So was mine.
ACA forced the insurance companies to insure those with pre-existing conditions. It allowed kids under 25 (or thereabouts) to go on their parents’ insurance. And it expanded Medicaid, and would have expanded it more except for asshole Republican governors.
The tax was to encourage those who chose not to get insurance enrolled. The penalty wasn’t enough to make that happen a lot. But ACA did get millions of Americans insured, so you can’t fault it for not forcing everyone to be insured, like it or not.
Just to double-check, when one of your family members needed a $200,000+ surgery how easy was it to clear up that huge bill from the anesthesiologist who happened to be out-of-network? Or to get the recommended rehab outside insurer’s parameters?
Since you’re commenting on how satisfied you are with your insurance, I’m sure you’ve used it for a major expense at least once. (As other opponents of the healthcare models in the developed world will tell you, routine medicines and doctor visits are almost irrelevant to financial appraisal.)
I’d liken it to a feudal relationship rather than outright slavery. Kind of like tenant farmers. Your feudal lord holds a resource that you or your family may need to live. You are free to leave but at the cost of losing access to that resource.
It is what US businesses get for all those dollars they spend on health benefits that other nations businesses don’t have to spend. Workers who have severely reduced ability to go off and start lean new businesses competing with them.
Your objection is, for lack of a better term, out-of-context. Public approval would be relevant if it was an issue of deciding between two equal alternatives. Or some kind of reform of a government program. But that is not the issue.
The issue is that the US healthcare system is a failure in objective terms. Public approval is not relevant to that.
The US spends 3.3 % of GDP on the military and 18 % on healthcare, where other first world nations average about 9 %. With a national debt of 16 trillion you overspend on healthcare by 1.5 trillion or more per year. You can’t afford that and public approval makes no difference. I am sure the public approved of Maduros spending Venezuelan oil money on the public -until the money ran out.
I think you have to be cautious with that assumption. Plenty of people living in, say, New York City, Chicago, LA, etc. on Medicaid, in cities with world-class medical care. The real question is whether or not they can access that care.
Why do you assume that ALL of that 3/4 is going to be less rather than more satisfied with such a change? As pointed out, you might actually wind up with even better coverage and even less hassle than you presently have.
Seems to me my fellow Americans are afraid simply because it would be a change without consideration of whether they’d be better or worse off.
Yes, the ACA was responsible for cutting the uninsured rate in the US by almost half. I would note that in the ages 18-64 crowd, the uninsured rate is about half in expansion states as it is in non-expansion states. And the overall uninsured rate across the entire nation is now stable at around 9%. Some work is left to be done, likely starting in blue states. But the ACA has made an enormously good impact in the US.
Here’s the latest from the CDC:
I didn’t make that assumption that all of us will be angry. But there will be some people that will be “afflicted” by the change. Disruptions cause problems.
I’m not quite sure what assumptions to make from this, though. Is it mostly larger companies that offer health plans and thus higher numbers of participants (than 50%)? What does this say about job creation and entrepreneurial efforts? In any case, trying to improve ACA to get those last 9% of Americans covered yet still paying half again as much as other industrialized countries seems to be a very low bar to shoot for.
It means that smaller businesses cannot afford to offer a health plan to their employees, making it harder to attract and retain those employees.
I think it would be very difficult to quantify how much small business creation would be enhanced by single payer and thus really hard to factor into the overall economic benefits of its imposition. But personally I think it’s a non-negligible amount.
In a normal country, that would be a way to go about it.
However, the ACA barely got passed, and only because the dems had a 60 seat majority for a couple weeks.
Without bipartisan support, the ACA has been locked in stone since it was created, with the only changes being republican attempts to chip away at it.
A healthy congress would see the problems and adjust legislation to reduce or eliminate them.
Our congress is not healthy.
Prior to ACA, health coverage for myself and my employees was the biggest thing holding me back from setting out on my own.
Even with the imperfections of the ACa, it still gave me the confidence and freedom to go out and open up my own place.
Now that the ACA is being dismantled bit by bit by the republicans, that becomes less and less viable, and becomes more of a concern.
IMHO, I think that your “non-negligible” estimate is more than a bit of an understatement. Fear of losing health benefits, especially if one has a family, prevents quite a bit of mobility, but when it comes to small businesses and start-ups, it’s a much more daunting undertaking. With people freed from depending on their employer for their healthcare, they can afford to take risks in either starting up, or just at working for a small business.
Thanks for responding to my points. To make my responses clearer, I’ve added the title of each of my original points just prior to your responses. I think I can be brief, because one thing we can agree on is that most of these principles are “not rocket science”. I’m just astonished that you can come to such radically different conclusions based on the same facts.
1. Costs.
IPAC? You probably mean IPAB, the (non-existent) Independent Payment Advisory Board. That was really just a defunct proposal for constraining Medicare spending, not controlling provider costs, and raised fears that it would result in service cuts. Posting prices? Don’t see how that’s possible in a situation where there are no “prices”, just a range where radically different fees are charged to different insurers and the uninsured. And it’s not likely to have much effect anyway. And “alliances” by definition means “networks”, and while these may help the costs of certain insurers, they limit patient access without having any effect on costs in the system overall.
You can’t effectively control costs (without also cutting patient access to essential services) when provider costs are high due to factors like item #2 below, and in the absence of any centralized means of cost control. Where I live the public single-payer system periodically negotiates the fee schedule with the physicians’ medical association, so there is one uniform fee schedule for all providers in the entire province, and costs can be kept low because their overhead is low. Simple. “Simple” is the recurring message here. Whenever I read about almost any aspect of US health care, pretty soon my head is spinning from the sheer complexity that patients and doctors all have to endure, all for the benefit of insurers.
2. Administrative overhead and paperwork.
No doubt some things can be made more efficient. But as long as there are many different private insurers, along with Medicare and Medicaid, each with their own plans, forms, and policies, and each scrutinizing each and every claim form with a view to denying the claim or reducing it and/or substituting a different medical procedure, the entire relationship between provider and insurer is going to be a quagmire and a nightmare of bureaucratic complexity.
Again, to contrast with how it works in single-payer, or multi-payer UHC where for medically necessary services each payer looks exactly the same, there is in reality or in effect only one insurer to deal with. When I see a doctor there are no forms involved at all from my standpoint, and from the doctor’s standpoint, he submits an electronic form containing little more than the health card number and one or more billing codes. Simple, efficient, and low cost. But it requires the kind of standardized simple interface between provider and insurer that is characteristic of single-payer or its regulated multi-payer equivalent. So I disagree – it has everything to do with single-payer, and nothing to do with the providers.
**
3. Bureaucratic meddling and denials.**
That simplistic statement misses the fundamental difference between health care in the US and in other first-world countries, where insurance bureaucracy never comes between doctor and patient and for all practical purposes denials do not exist and in fact cannot exist in ordinary circumstances. Looking at Medicare a little more closely, one observes some interesting things about that. It doesn’t do away with that problem, so patients are subject to denials because of the way that the claims process is administered. Medicare denial rates are still far lower than those of private insurers, and when they do occur, they occur either because some rule or condition was not satisfied in a complex and arcane claims system reflecting the absence of the “unconditional coverage” doctrine.
Furthermore, even so, denial rates for original Medicare, as opposed to Medicare overall, are the lowest of all and practically negligible; most of the denials come from the self-serving decisions of the third-party contractors in Medicare Advantage plans. Single-payer, and properly administered equivalent systems, have none of these obstacles, complications, and self-interested parties. I’ve never even heard of a denial in my health care system, and in normal circumstances it’s not even possible. If my doctor or specialist or surgeon feels that I need a certain procedure, there is never an insurance bureaucrat there to say “no”. You need to understand that this is a fundamentally different approach to health care.
4. [Risk- vs. community-rating]
The ACA mandates adjusted community rating (ACR), not real community rating. Some risk factors can no longer be used, but certain others can, and it doesn’t apply to all plans.
That said, given the legislative will and some miraculous ability to prevail against the private insurance lobby, true community rating is something that actually could be legislatively achieved. But by itself it’s just a prerequisite to the ability to provide straightforward, unconditional and non-adjudicated coverage to all patients at all times, as per the previous points. And your fixes are a very long way from being able to do that.
Fixing the system requires much more fundamental changes than you seem to think, so that the resulting system embodies the major elements that I indicated above.
But even in cities people are not going to go too far to get primary care. I grew up in
Queens. My grandmother went to Flushing Hospital, which was fine, but if it wasn’t they weren’t going to shlep her to Mt. Sinai.
Not all hospitals are created equal, and the less than equal ones aren’t going to be in La Jolla. I’ve been to that hospital. I’d gladly vacation there. 
Just to be fair, my wife had $50K in retinal surgery and I think I paid $100 out of pocket. Top flight private insurance can work - but not nearly often enough to be something we shouldn’t change.
And I jumped through the proper hoops - pre-approval, in network hospitals, etc. to get such a good result.
Wouldn’t it be far better to have a system in which, because of the way it’s structured, you never have to jump through hoops to get pre-approvals because there’s no such process; there are no “in-network” or “out of network” hospitals because there’s no such thing as a restricted “network”; coverage is always guaranteed; and you don’t have to marvel at how low your co-pay is compared to the total cost because there are no co-pays and you’re not even aware of what your medical procedure cost. I know you probably agree, I’m just saying.
On a different topic, and what I came in here to say, is that I was just reading an article that underscores the fact that the private insurance system is not only a useless and parasitical drain on health care costs, but it’s often actively malignant and counterproductive. Here is one of the nation’s largest insurers, Anthem, engaged in total slimeball tactics for which they’re being sued.
Short version: patients being treated at mental health and addiction centers are being paid directly by Anthem, often receiving multiple large checks with no explanation, instead of the company paying the providers. Why? Because many such providers are not in Anthem’s network, and Anthem refuses to deal with them as a pressure tactic to get them to join their network. Meanwhile, since many of these people are not in the best state of mind, and may be confused, forgetful, or just simply dishonest, some of these big windfall payments never make it to the provider. But at least the providers know that payments have been issued and can request them from the patient, right? Wrong – Anthem deliberately refuses to notify the providers, something that Anthem considers a bonus in their campaign to screw with their payments and get them to join their network and drop their rates.
Also linked in that article as relevant related stories:
Woman who needed a life-saving liver transplant was denied coverage by UnitedHealthcare until, desperate and with no options left, she went public and pleaded for her life with the CEO himself.
California Supreme Court lets stand a lower court decision assessing $91 million in fines against UnitedHealthCare for wrongful and unfair denial of claims; initially they were assessed $173 million in fines by the California insurance commissioner for 908,547 violations.
Aetna successfully sued for $25.5 million for “recklessly” denying coverage for a cancer patient who subsequently died.
These are not isolated cases. Claim denials are a systemic problem, as I noted before.
What a complete clusterfuck this whole overpriced mercenary system is, overburdened with paperwork, devoid of compassion, ineffective in operation. Not as good in the World Health Organization rankings as Costa Rica or virtually every first-world nation in the world, but by golly, better than Slovenia!
Yeah, I’ve had a hospital stay when I got a virus and dehydrated. I’ve had a colonoscopy. I’ve had my daughter sprain an ankle and get a forehead gash that required stitches. I think my wife had her sinuses scraped once. I mentioned that one of my family has diabetes. I have another family member with some major complications that has required a lot of doctor visits, tests, labs, etc. We’ve had many brushes with the health care system outside of routine care. No problems. No hassle. Reasonable co-pays. I think when my daughter sprained her ankle, I had to fork out $100 for the ER visit or something.
I know it’s not popular on this board. But I think my level of satisfaction with my healthcare and health insurance is in the decided majority in the US. Not even close.
You paid $100 and got pre-approvals? OMG? You slave. LOL.
I’m on Medicare now, and I’m not on Medicare Advantage specifically to not be in the situation of having out of network doctors and hospitals. I was on a trip around the country for six weeks, and it was comforting to know that I could pop into just about any doctor or hospital, show my medicare cards, and get treatment without co-pays. Sound familiar?
The reason I posted what I did was not to say our system is great (even a superficial look at my posts will show that) but to try to keep anyone from saying that every interaction with the current system is awful. If they do, anyone with good experiences will reject the need for a better system. That need is obvious from the cost and number of uninsured in our current system.
As for your point, my kid and her husband had a job basically rejecting claims. I’m happy to say they quit it and are now gainfully and morally employed.