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This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection for these exploitative middlemen when the necessary solution was to blow up the entire industry with a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.
Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
The ACA was the best compromise that could be struck at the time, with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
This is the dirty part of the political process: people sacrifice better outcomes for all, merely for the pursuit of more power in the future. And those who want better outcomes for all must somehow gather a coalition that can achieve those outcomes.
Nobody, least of all the architects of the ACA, thought it was the best possible system. It was merely the best system that could get through the democratic process of our government.
Which means we need iterative design on these programs. It's not pass once and done forever. We need maintenance legislation for bug fixes and feature improvements. However, every culture war battle that we fight can be used to distract from actual reform, like a nefarious form of bike-shedding.
I wish we'd just say ok, people like Medicare, let's drop the age of enrollment by 1 year every year for ten years and see how that goes. If that works out, drop the age of enrollment by 2 years every year for the next ten years. Then figure it out from there. Could start as a paid option rather than just lowering the age when you get coverage based on work history, too.
Maybe something for children too, start with making Medicaid or something automatic for the first N months of life, and increase it every year too.
We'd still be waiting for healthcare with this kind of plan.
Before the ACA it simply was not a choice to be an independent professional and have health insurance.
If people could understand why it is unacceptable to force independent professionals and entrepreneurs to give up healthcare they would see the ACA was necessary in whatever form it could be passed.
You don't need to have insurance for the vast majority of care, yet it gets used as such. Let's drop that nonsense, it tangles up the billing process.
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Everyone I know on Medicare does not like it and would prefer something else.
I think people like Medicare like they like Comcast. They have it, it performs a service they want, they hate everything about it, and would never leave.
Some 30% of NY state and ~48% CA population is already on medicaid. Are you gonna make a whole middle-america flyover town work an extra shift to pay for that plan?
> with a large portion of the population being dead set against better healthcare if it meant allowing Obama to be able to take credit for it.
This is a fiction people repeat with no citation. A large portion of the population wants m4a when it is explained to them. This "system" failure was specifically our elected reps - bipartisanly - ignoring the needs and wants of the people at the behest of their donors. The democratic process failure was when the two parties solidified.
It wasn't pitchfork wielding illiterate rubes (or whatever undoubtedly out of touch "data driven" parody of what an average person is we're operating with) trying to deny a Black man his legacy, it was that Black man's party collectively wanting to be reelected that gave us the "Buy Insurance Or We Fine You Through Taxes" Act.
As silly as agile government sounds, if it forces our legislators to take part in the misery of a daily standup, I'm all for it.
Legislation is literally the code of society.
Sort of. It’s more akin to design guidelines.
By "literally" I mean that the name for it is the Code of Law, with a civil code, and a criminal code. And this usage of "code" predates computer programming by many centuries!
is it safe?
Absolutely not. It regularly performs invalid rights on unallocated memory and even kills people.
> This is a real concern for me because people credit the ACA with making a big dent in the healthcare problem here in the US, but it feels more like it just created a massive legal protection...
Both are true! The ACA is a literal life-saver and bankrupcy-avoider for a significant percentage of the population. So it is a huge win for the common person.
At the same time, yes, it perpetuates the corrupt insurance system, which is bad. But at least makes it more widely available, which is good.
> Not every system becomes more efficient with profit incentives, and this really seems like just such a case.
Health care can only ever get worse with profit incentives. The best way would be to eject all the profiteering out of the system so that only the people who provide actual care (doctors, nurses, medical technicians,etc) get paid. Remove all profit from the hangers-on that do nothing useful (insurance middlemen).
The path to get there is obvious, but politically quite impossible in the US (and only in the US, since every other country has it figured out.)
> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven
We can solve pharmaceuticals without bringing in the miasma of the broader healthcare debate.
Three things:
1. Let Medicare directly negotiate pricing on all drugs;
2. Make it easier for generics producers, including foreign manufacturers, to sell into America; and
3. Reform PBMs [1]. Transparency on pricing. Spun out of monoliths.
While we’re at it, maybe someone can figure out how to cut the $1bn it costs to get a drug to approval to something lower.
[1] https://www.congress.gov/bill/118th-congress/senate-bill/297...
Nothing in this article was a byproduct of ACA and it all predated it. But also in no way did it reduce costs, that’s a lie. Who even says that? Unless you’re only considering very specific benefits like birth control. Overall it increased costs, even when Medicare of any government program announces a reduction or sequestration the industry just raises prices everywhere else to offset. I’ve been in those decisions when I worked in the industry. We never let it flow through to bottom line, we always found a way.
Profit-chasing never makes systems more efficient. It’s competition.
As if a "public option" would not have a middle tier that evaluated, and then approved or denied claims?
That doesn’t matter when it’s subsidized by the government. When people talk for a public option all they’re really talking about is one option, because no company would be able to compete.
We have free at point of need healthcare here in the UK, and still have a lot of choice in private healthcare if you want it.
In the nearest city to me there are 3 major private hospitals, and if you head into London there are loads of them.
Private is still able to compete and to be profitable. Just no one needs to die from preventable diseases.
(not saying NHS is perfect, it is a shadow of what it should be right now)
Sort of. My understanding is that private hospitals largely opt out of most of the difficult stuff, because the NHS is there to take it on. So they're good if you're waiting around for a hip replacement but not so much for other things.
Right, essentially every private hospital's response if, say, a patient they're giving a boob job suddenly becomes unresponsive is to... call the NHS. Yeah, the medical staff will be better than your neighbour or some random passing guy in the street when it comes to knowing how to put you in recovery position or attempt CPR but those hospitals won't have a crash protocol beyond too bad call the NHS.
I spent eight hours at an Accident & Emergency department at my city's hospital a couple of weeks ago (Those electric scooters look easy enough, I have a driving license, I watch the training video, then at midnight I thought I'd try one, signed it out, crashed into a lamp post within seconds, broke my hand and busted my head open. Oops. Signed the scooter back in, walked to the Urgent Care, it shuts late at night, walked towards hospital, saw a cop - "Hey, I can't see my head, I can feel the wound, is it bad?" "You should get a taxi to A&E. I'll call you one"). There is no private emergency care, private cosmetic surgery sure, and lots of private non-urgent care, like knee replacement or whatever - but no emergency care.
> a true public option that could out-compete every profit-driven money-extraction system by simply not being profit-driven.
Much like amazon did in the early days.
When the problem is incentive structures -- of profit seeking corporations or compensation seeking individuals -- what options do you have? (IMO its only regulatory enforcement with democratic oversight and transparenct.)
I think we as a society still have to figure out ways to restructure sprawling institutions and i dont like it when people only put the blame on public or private ones while ignoring the other.
Love how people try to rationalize these vultures. The elite and their PMC toadies are just corrupt. That’s it. The united states is corrupt to it’s core because we allowed the elite to run things.
> because we allowed the elite to run things
By definition, a society’s elites always run things…
True. How's that worked out so far?
> How's that worked out so far?
Pretty damn well in the long run!
Worked great for the French too, right up to the Revolution.
> Worked great for the French too, right up to the Revolution
Each of the French Revolution’s successive governments had their own sets of elites. (La Révolution itself had its elites.) Arguing against elites as a category is arguing against hierarchical sociology. It’s inchoate. We don’t have an example of a society without elites; we barely have examples of social animals without hierarchies. (Zebra herds.)
And speaking of the French Revolution, the elites ex post facto were not only mostly the same as before, they escaped with so much money and wealth that it’s actually debated if they increased their wealth share through the chaos [1].
Nah, one day we'll just have flat societies with AIs to replace the beaurocracy and elites and manage everything for us. Nothing could go wrong with that! </sarcasm>.
Public option would lead to pure fraud like in the ABMT treatment for breast cancer. Asking for trouble. Especially in the US where people believe that no one should trade grandma for a dollar.
In the UK, they fortunately have a notion of money spent for QALYs earned (adjusted to boost life extension at end of life) but in the US everyone believes that we should spend arbitrary amounts of money on people and if we don't, we should pay their relatives extraordinary amounts to compensate for the fact that we didn't spend a few aircraft carriers worth of money on them.
Put simply, so long as US ethics remains "there is no sum of money that is too high to save an arbitrary person's life", we have to oppose the public option.
I'd like to see proof that Medicare does not evaluate QALY and spends unlimited money in general.
The percentage of the federal budget that is spent on dialysis and the life of the patient preceding when they're put on dialysis.
Even without that, when Cuomo in NY said he wouldn't trade grandma for a dollar, there was thunderous applause across the US. And many here argued that the economy isn't as important as any life lost. That's enough to cement it for me.
Typical US profit margins are somewhere in the area of 8%. If dropping healthcare costs by 8% is what people are arguing over then I've been badly mislead about the problems with the US healthcare system.
There is a real issue with regulatory capture. Making the system purely public is not going to result in the regulators suddenly purging their souls of all corruption. It'll still be a disaster just without any pretence of an alternative. There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.
That's nominal profit margins. It doesn't take into account the way that different parts of these conglomerates take money from one pocket and put it in the other (e.g. insurance and Healthcare providers), which means it doesn't show up in the profits for your first pocket. This is why the fact that Healthcare platforms are vertical monopolies (not just horizontal monopies) is important to this conversation.
(separately, profit capping rules means that once a monopoly is cemented, once a company has moved as much as it can from one pocket to the other, there's an internal incentive to spend money on bureaucracy).
Because the regulations encourage vertical monopolies. Replacing that with a state mandated vertical monopoly unconstrained by market forces isn't going to help. In fact it'll probably make the situation worse. There is no reason for there to be monopolies in healthcare and if they are emerging that strongly suggests misregulation. Giving the regulators more power in that sort of situation is the opposite of helping.
The profit margins are not the only thing. There are tens or hundreds of thousands of people working on billing jobs at doctors and insurances that shouldn’t exist.
And you think a government run system would be more efficient? It’s still going to have people in each side verifying claims, preauthorizing stuff, etc. To do otherwise invites massive fraud.
Government run systems are alot cheaper all across Europe. So yes.
Unless you are saying there is something exception about the US and profit extractions?
> There are literally people on HN every day who would happily improve on the US healthcare system's costs and outcomes if well meaning busybodies hadn't banned them from doing so by overregulating.
I trust the market to provide healthcare about as much as I expect america to suddenly blast off to join the moon. And i trust vc/finance a hell of a lot less than that.
Do you feel the Trump & Musk dynamic duo are going to do a better job of handling it? They're cut from similar cloth.
high cost of healthcare can be solved overnight: just mandate insurance companies to pay for healthcare for foreign hospitals (at rates not exceeding US rates).
so that Americans could travel overseas and get healthcare expenses reimbursed over there.
watch prices drop...
Does that include airfare and living expenses? I figured out that if I needed two crowns, it would be cheaper to fly to Estonia and use my friend's dentist than to go to a US dentist.
On prescriptions, reimbursement for drugs bought from cost plus would also help drive down pharma prices
The whole system is infuriating. Even when you assume a free market is what you want, it's pretty clear that this is far away from a free market. Unless you view non-competitive monopolies as free market.
I don't understand why vertical integration is not made illegal. An insurer should not own a PBM or providers. They all should have an adverse relationship so they put cost pressure on each other.
Also, providers should charge the same prices for the same procedures no matter who pays. Ideally everybody should be mandated to follow Medicare prices. If these prices are too low to survive, then there should be a discussion about adjusting the prices.
The whole system is basically a huge bureaucracy that wastes a lot of money but some of the waste is enough profit for a lot of people to fight tooth and nail to keep the status quo.
I can't speak for all providers, but I can say that, in many cases they're getting squeezed by the insurance companies, too. My girlfriend is a provider of services for young people with disabilities. The insurance companies fully dictate how much she can charge (how much the insurance companies will pay) and even what specific services she can provide (what they'll specifically pay for). It's infuriating. Up until about 7 years ago, she was fully funded by the state through the California Department of Education, and it was simple. She met with a single person from the state monthly, they reviewed her billable hours, made some corrections here and there, and she got paid. Simple. When private insurance was introduced it became a nightmare. She had to hire a full-time employee just to manage billing with the insurance companies. One insurer won't even talk to providers at all. Nothing. Nada. She has to fax them. Yes, fax. And their fax machine only answers during business hours; it's powered-off outside of business hours. Why? Because fuck you, that's why. It's obvious that the insurance companies make it as difficult as possible for providers to get paid, which is not too different from patients. Weird...not.
I dunno, I used to have Kaiser which is vertically integrated and the nice thing was there wasn't the thing where the Doctor says we should do X, but your insurance won't pay for it, so we'll do Y. Or my favorite where the doctor writes a prescription, and the pharmacy doesn't fill it because it's not covered, and you have to convey what is covered to the doctor so they can write that instead.
Kaiser would sometimes tell me that we have to try X first before we do Y, but then the X's worked sometimes, so it seemed like they were asking for reasonable things to reduce cost.
> I don't understand why vertical integration is not made illegal.
Well I decided that would be extremely inconvenient for me if that was the case, so I’m going to call this “bad regulation”, and say it’s against the “Free Market” so if you support it you are a communist.
If later on I decide this is good for me, then I will call it “good regulation” that supports the “Free Market” and you are in the clear.
All sarcasm aside, if you don’t define what your minimum set of regulations are for you to consider it a “Free Market”, then you are consigning yourself to endless bike shedding over what a “Free Market” really is
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lol. No we’re dealing with unregulated capitalism.
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I think you are describing free markets, not capitalism. Capitalism means accumulation of capital through any means possible. Sometimes monopolies are examples of capitalism.
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> This makes it extremely difficult for new competitors to enter the space. Which means the existing players can collude to raise prices.
> That's not capitalism. Capitalism requires heavy competition. Think restaurants for example. Extreme competition drives prices down and keeps prices fair for consumers.
No, that absolutely is capitalism. No True Scotsmanning capitalism when we see this as an end result of capitalism doesn't work as an argument.
For example, in the gig economy which is largely unregulated we see incumbents to the market get destroyed by economy of scale. Did you know Austin had its own non-profit ride-sharing app called RideAustin? Did you know that it blew up after Uber and Lyft completely pushed it out of the market?
I could go on with other examples of these issues. Like for example Bartells in Seattle being bought out by Rite Aid only to be decimated by Rite Aids shitty practices, with little to no ability for incumbents to fill the void due to the costs of rent and rising bootstrap costs. Or the way grocery companies merge and combine until we have five different brands all operating under the same owner.
Capitalism is controlled by the winners who have the most capital. Competition only vaguely exists as a way for capital to exert control.
My dad used to have a job where he’d basically go around to failing small-time family practices and help the doctors there figure out their financials. I remember him telling me that in an extremely typical scenario, he’d walk into their office and somewhere in there he would find a huge stack of unfiled insurance claims.
Usually when he’d ask them about this, the process of filing these claims with the insurance companies was so onerous, they just fell way behind on the process. Typically you could resolve this by bringing in someone with a LOT of experience filing these claims I believe.
This was back in the 90s, so maybe the advent of computers has improved this particular part of the game (I’m not in the industry myself), but at least back then, it was infuriating doctors too.
I am not surprised in the least to hear that, like every other system in this economy, it seems to have gotten massively more complicated for approximately zero real-world improvement
One of the rare bipartisan areas of agreement in Congress right now is the need to rein in these Pharmacy Benefit Managers (PBMs). Both Republicans and Democrats had rallied around reforms to increase PBM transparency, which could lower costs for employers and, eventually, consumers.
But just as a major PBM reform bill was set to pass last December, Elon Musk fired off a series of tweets opposing it. Within hours, what had been near-unanimous support collapsed. Five days later, Musk tweeted, "What is a pharmacy benefit manager?"—as if he had only just learned about the issue.
This isn’t about whether Musk was right or wrong on PBMs (though evidence suggests reform would lower costs). The bigger issue is how a single billionaire’s influence can derail democratic processes that were functioning as intended. When a reform has broad bipartisan support, expert backing, and clear public benefits, yet can still be nuked by one well-placed tweet, that’s not just a policy failure—it’s a governance problem.
Tech billionaires reshaping policy via social media whims should concern anyone who cares about democratic accountability. If Musk can tank a bill that helps millions save on prescriptions, what else can be undone with a midnight tweetstorm?
I worked for a PBM in the late-90s. I wish I would've sold crack cocaine and guns to children. I would've felt better about myself. ... Hyperbole, indeed, but wow, that company, and PBM industry, was shady as fuck.
I'd love to hear some of the horror stories
> just as a major PBM reform bill was set to pass last December, Elon Musk fired off a series of tweets opposing it
Source? (Not doubting you.)
Hold on. That bill contained the PBM stuff, but that doesn’t mean he was wrong about it being full of pork - though I don’t know one way or the other.
They certainly could have just done the PBM reforms in a separate bill instead of shoving it into something else…but then they potentially wouldn’t be able to get their own choice cuts of pork passed.
Anyways, seems odd to blame Musk directly for that even if his tweet did kill the bill.
> seems odd to blame Musk directly for that even if his tweet did kill the bill
Musk tanked a bill he obviously didn't read with zero plans for its replacement. So instead of a $1.7 trillion bill in December, we get roughly the same bill (that's what a continuing resolution is) plus $100bn in giveaways in March minus the PBM reforms.
Musk killed PBM reform. The fact that he was too high to know what he was doing isn't exactly redemption.
> what else can be undone with a midnight tweetstorm?
I'm sure we'll find out soon enough.
Such a pity that this is "easily" remedied via campaign finance reform and revoking Citizens United.
It's not that easy. The deeper issue is plurality voting and duverger's law, with people being incentivized not to vote for something but to vote against a perceived evil, as that's what the campaigns get more traction with on the whole.
Plurality voting applied to the tragedy of the commons, i.e. the nash equilibrium decision matrix, results in the worst possibility if there's no basis for trust. If we could vote on the results of that matrix, by replacing {+1, 0, 0, 0...} voting with {+1, +0.5, -0.5, 0, 0, 0...} voting, things might actually improve with 3-4 viable, local parties, with smart selection of candidates actually representing districts constructively and campaigning accordingly.
But we don't have that. I fear its absence at all scales from local right on up to resolution of international conflict may end up being the Great Filter: The coordination problem of solving the tragedy of the commons in all its forms.
The billing system has cancer, it's time to schedule a biopsy.
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Biopsy? I think you mean amputation.
You heard him doc, amputate the brain
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