15 votes

Why US health insurance reform is difficult

19 comments

  1. [6]
    eggpl4nt
    Link
    Okay, so don't do that. Start "small." Instead, propose what Obamacare (ACA) originally wanted to do, which was include a public option. Then there's much less avenue for them to fearmonger with...

    [A]nyone proposing a radical reform like Medicare for all is in effect saying to large numbers of voters, “We’re going to take away insurance that you like, that you believe works for you, and replace it with something different. It will be better! Trust us!”

    Okay, so don't do that. Start "small." Instead, propose what Obamacare (ACA) originally wanted to do, which was include a public option.

    Then there's much less avenue for them to fearmonger with claims of "they're going to take away the private plans you like!" because the response can be "no, we're providing another choice Americans can make, we are increasing choices and competition in the healthcare 'market.'"

    Don't get me wrong, I'll promote any instances of "healthcare for all" I come across, but I know big sweeping change is "scary" to many people. I want to see proposals for incremental changes, that are easier to explain and justify, that large majorities of the population can get behind. Besides, big changes are composed of many small changes. Rome was not built in a day.

    23 votes
    1. NaraVara
      Link Parent
      This was basically Buttigieg’s “Medicare for all who want it” plan, and that essentially became the root of Kamala Harris’ plan in 2024. Over the long term this would create ground for single...

      This was basically Buttigieg’s “Medicare for all who want it” plan, and that essentially became the root of Kamala Harris’ plan in 2024.

      Over the long term this would create ground for single payer because you’d be able to outcompete private insurers on price, especially if you make political hay around no longer subsidizing millionaires and their “Cadillac healthcare plans.”

      16 votes
    2. lou
      (edited )
      Link Parent
      Brazil has universal Healthcare. There's also private Healthcare. You can literally pick and choose. Why is that so hard to understand? In the US you can already choose between private and public...

      Brazil has universal Healthcare. There's also private Healthcare. You can literally pick and choose. Why is that so hard to understand? In the US you can already choose between private and public education. It's the same thing. No one's forced to go to public institutions, and many (in Brazil) don't.

      If a public alternative served only as competition, reducing prices in the private sector, it would be helpful already.

      13 votes
    3. AnthonyB
      Link Parent
      I had that exact passage copied when I came to the comments. I don't think its something that should scare legislators away from advocating for big changes. Sure, plenty of insured people are...

      I had that exact passage copied when I came to the comments. I don't think its something that should scare legislators away from advocating for big changes. Sure, plenty of insured people are happy with their insurance. Technically, I am happy with my insurance. I have plenty of local doctors and pharmacies in my network, and like a lot of people, I haven't had to deal with a denied claim yet. But, that doesn't mean I support the healthcare industry. In fact, most people dislike the healthcare and pharmaceutical industries.

      Here are some figures from that poll:

      Very/somewhat positive view of healthcare industry: 31% (51% negative)

      Very/somewhat positive view of pharmaceutical industry: 20% (61% negative)

      Most urgent health problem facing country [open ended]: Cost 23% / Access 14% / Obesity, drugs, cancer 23%

      Satisfied with cost of healthcare: 19%

      Which would you prefer: government-run or private run system? 46% government 49% private

      This is without any meaningful mainstream persuasion efforts over the past four years. Lean into it!

      I think it's a mistake to give any legitimacy to private insurance because it inherently undermines the position that a public option or government-based system is better and it puts you on defense when you try to make that case. Instead, they should be laser-focused on highlighting the many flaws and evils of the health insurance industry. Any time this nonsense about positive ratings is brought up, it should be met with something along the lines of, "Sure, until the provider drops them, denies a claim, or the person loses their job." Or shit, highlight some of the gross inefficiencies that Krugman laid out. Whatever it is, just stay on the attack!

      A public option should the floor of what is acceptable, not the starting point. Unfortunately, the likelihood of us hearing that type of messaging from anyone outside of the most progressive wing of the Democratic Party is very slim, thanks to the millions and millions of dollars the insurance and pharmaceutical companies spend in campaign contributions and lobbying efforts. Kind of weird how that wasn't mentioned at all when discussing the reasons for why health insurance is so difficult to reform.

      5 votes
    4. [2]
      teaearlgraycold
      Link Parent
      At this point I'd be happy to see it become illegal to offer health insurance. That would be an improvement over what we're getting. I'd just put my premiums into a savings account - then pay a...

      At this point I'd be happy to see it become illegal to offer health insurance. That would be an improvement over what we're getting. I'd just put my premiums into a savings account - then pay a non-inflated market rate for care.

      2 votes
      1. lou
        Link Parent
        Public healthcare has issues anywhere it exists. It is good to have another option. But they must be regulated.

        Public healthcare has issues anywhere it exists. It is good to have another option. But they must be regulated.

        4 votes
  2. [2]
    vord
    Link
    I think the problem is that there is a lack of transparency. If employers were mandated to provide a report about their health coverage, including things like "here's how much you pay, here's how...

    The more important problem is that most Americans with employer-sponsored health insurance are happy with their coverage

    I think the problem is that there is a lack of transparency. If employers were mandated to provide a report about their health coverage, including things like "here's how much you pay, here's how much we pay, and here's how much it will cost you out of pocket for common treatments". Have that list side-by-side with Medicare's offerings.

    It's very telling that satisfaction with health insurance has an inverse relationship with how much you need to use it.

    The answer is the public option. Let anybody opt out of their employer's insurance in favor of Medicare/Medicaid. Your taxes go up the corresponding amount (IIRC it was something like up to 80% of what paying your private insurer now), and you no longer pay insurance premiums. You want to keep your insurance? Go ahead. When that report comes around that shows you're paying double what your coworkers do for typical treatments, that'll speed up adoption real quick.

    It's been decades since we've properly evaluated what Medicare provides as well. A solid reform which wraps in most of the needed benefits we've come to expect in the last 40ish years, and it'll look even more attractive.

    • Free non-cosmetic dental care: cleanings, fillings, surgeries
    • Free vision exams, with free basic frames/lenses
    • A HSA which doesn't expire annually for covering luxury, cosmetic, and OTC health stuff.

    Then, after a few years of phase in, start tightening things up by making people who opt into medicare later have to pay higher taxes for it, to get around the "pay nothing for garbage insurance then switch to Medicare when you're old and you need to start using it."

    17 votes
    1. Habituallytired
      Link Parent
      As someone who has gotten more and more sick over the last decade, I have definitely become more and more upset with the health insurance industry as a whole. Even today, I was expecting a phone...

      It's very telling that satisfaction with health insurance has an inverse relationship with how much you need to use it.

      As someone who has gotten more and more sick over the last decade, I have definitely become more and more upset with the health insurance industry as a whole. Even today, I was expecting a phone call from my insurer, and they assured me I would receive one, and no one has called. They keep lying to keep me from complaining. I also have become so disillusioned with the entire industry. Literally everyone who touches the health insurance companies is in my burn book.

      And yes, vision and dental absolutely need to be rolled into health insurance. It's insane to me that in 2024, they still aren't.

      10 votes
  3. skybrian
    Link
    An opt-in arrangement (the "public option" that didn't make it into Obamacare) seems more politically promising than starting from scratch. It's easier and less risky to start small and grow a new...

    An opt-in arrangement (the "public option" that didn't make it into Obamacare) seems more politically promising than starting from scratch. It's easier and less risky to start small and grow a new system than to do it in a big-bang way.

    However, in effect, a public option already exists for Medicare. Figuring out whether straight Medicare or a Medicare Advantage plan would be better (and which one?) is very difficult, because in part it requires guessing about what health care you will need. How do you predict what coverage will be better for problems that come as a surprise?

    10 votes
  4. [9]
    NaraVara
    Link
    He’s right about healthcare and has been all along. He also doesn’t mention that there is literally no other way it can be if you have private companies in the mix. They can’t make a profit if...

    He’s right about healthcare and has been all along. He also doesn’t mention that there is literally no other way it can be if you have private companies in the mix. They can’t make a profit if they don’t deny care, and their every incentive is to not have to pay out.

    Also, unrelated to the article itself but I’m very disappointed that Paul Krugman decided to host his blog via substack. Krugman came to speak at my college once and, when asked where he got his news and commentary because the media was so reflexively conservative (this was right before he became a Time columnist) he suggested trying the, then nascent, blogs and rattled off a list of blogs he read that included DailyKos and Atrios.

    This plugged me into a whole world of the political blogosphere, up until then I only knew of blogs as basically open personal diaries. This also had a significant impact on my politics, and took me from being a generally politically disaffected person to an ardent progressive Democrat. So seeing him on Substack, while I assume is something of a path of least resistance, feels disappointing being as how it’s yet another of the platform monopolist, blitzscaling, value-sucking vampires that adds nothing to the ecology of online discourse but the promise of discovery and simplified hosting. There’s gotta be a better way to get the latter on an open platform.

    8 votes
    1. [8]
      skybrian
      Link Parent
      Why do you believe that? Seems to me that sometimes insurance is profitable and other times, it isn't.

      They can’t make a profit if they don’t deny care, and their every incentive is to not have to pay out.

      Why do you believe that? Seems to me that sometimes insurance is profitable and other times, it isn't.

      3 votes
      1. [7]
        DefinitelyNotAFae
        Link Parent
        This is so broad a statement as to be meaningless.

        Seems to me that sometimes insurance is profitable and other times, it isn't.

        This is so broad a statement as to be meaningless.

        5 votes
        1. [6]
          skybrian
          Link Parent
          Yes, I'll try again: I'm doubtful that the government set up health insurance rules so that there's no way to run a business that's both ethical and profitable. If that's the case then it would be...

          Yes, I'll try again: I'm doubtful that the government set up health insurance rules so that there's no way to run a business that's both ethical and profitable. If that's the case then it would be interesting to know why that is.

          2 votes
          1. DefinitelyNotAFae
            Link Parent
            I'd argue that the lack of regulation is the problem, because it's not about whether you're profitable, it's whether you're maximally profitable. That's why we have large deductibles and co-pays,...

            I'd argue that the lack of regulation is the problem, because it's not about whether you're profitable, it's whether you're maximally profitable. That's why we have large deductibles and co-pays, ostensibly so the consumer is more "invested" in keeping costs of care low.

            It's never been an issue of "the government isn't letting them be profitable if they're ethical"

            4 votes
          2. [4]
            NaraVara
            Link Parent
            If you don’t deny care, which is to say, say “no” from time to time when a doctor, nurse, patient or whomever wants to charge for something, costs will spiral out of control. You will have created...

            If you don’t deny care, which is to say, say “no” from time to time when a doctor, nurse, patient or whomever wants to charge for something, costs will spiral out of control. You will have created incentives for the healthcare system, including for profit hospital networks, medical practices, and big pharmaceutical companies, to jack up prices as high as the market can bear. It’s not unethical to set up standard practices and limits it’s just bad for patients to have that done through a paperwork ridden 3 way arbitration process where the one with the most on the line (the patient) is the least informed about what’s going on and the other two are for profit entities deciding how much of the pie to eat.

            4 votes
            1. [3]
              skybrian
              Link Parent
              Okay, it sounds like you’re saying that denying claims (that is, not always paying) is a necessary part of what health insurers do, which seems reasonable. For example, I think we would all agree...

              Okay, it sounds like you’re saying that denying claims (that is, not always paying) is a necessary part of what health insurers do, which seems reasonable. For example, I think we would all agree that if Medicare refuses to pay in cases of fraud, that’s actually the right thing to do. (We can’t have too much taxpayer money going to grifters, after all.)

              And it seems that this is the main job that insurers do for the government? If it were just like running payroll with no real decision to make, it would be easy and efficient.

              The structure of the system could be changed so that decision-making happens somewhere else. For example, an HMO might make it the doctors’ responsibility to not approve marginal treatments too often.

              When there’s a limited supply, it seems like someone needs to say “no” somewhere? If it doesn’t happen earlier, there will be a queue so that procedures get scheduled for many months out. (As an example, the pandemic resulted in a huge backlog, and I don’t know if they’ve worked through it yet.)

              I sometimes wonder if it wouldn’t be better to have more of everything? For example, add MRI facilities until nobody has to wait for an MRI.

              3 votes
              1. Minori
                Link Parent
                That's basically what Japan did!

                I sometimes wonder if it wouldn’t be better to have more of everything? For example, add MRI facilities until nobody has to wait for an MRI.

                That's basically what Japan did!

                3 votes
              2. NaraVara
                Link Parent
                The way they’d do this is just give the doctor’s a flat amount of money per patient and it’s up to them to make the most of it. But then you get the problem of doctor’s preferentially stacking...

                The structure of the system could be changed so that decision-making happens somewhere else. For example, an HMO might make it the doctors’ responsibility to not approve marginal treatments too often.

                The way they’d do this is just give the doctor’s a flat amount of money per patient and it’s up to them to make the most of it. But then you get the problem of doctor’s preferentially stacking their patient roster with healthy people and leave the unhealthy (expensive) people for others to deal with.

                Yeah more supply of anything would be ideal, but you’d have to pay for it. MRI machines are expensive, and you need to make sure they’re put where they’re needed.

                1 vote
  5. skybrian
    Link
    From Krugman's blog post: ... ...

    From Krugman's blog post:

    [W]hile private companies account for 29 percent of payments by insurers, a significant part of that effectively comes from taxpayers. Premiums on employer-sponsored care are exempt from income and payroll tax, which is a “tax expenditure” — a de facto subsidy — of about $300 billion a year. And most individuals who purchase plans through the Obamacare exchanges receive significant subsidies as well, totaling around $90 billion a year.

    So we really have a system in which taxpayers foot the bill for around 80 percent of health insurance. Yet much of that money flows through private insurance companies. In fact, a majority of Medicare recipients now have Medicare Advantage plans, which means that even Medicare passes through the private insurance industry [...]

    ...

    The big problem isn’t the political power of the insurance industry [...] the more important problem is that most Americans with employer-sponsored health insurance are happy with their coverage.

    ...

    [A]nyone proposing a radical reform like Medicare for all is in effect saying to large numbers of voters, “We’re going to take away insurance that you like, that you believe works for you, and replace it with something different. It will be better! Trust us!”

    That’s a very difficult pitch to make. In a way, it’s what Bill Clinton tried in 1993 — and he failed badly. If Harry Truman had managed to add health insurance to Social Security in 1947, Americans would take single-payer for granted and be furious if anyone proposed privatizing health insurance. But we are where we are; Obamacare was designed to expand coverage while doing as little as possible to disrupt existing health arrangements — and as some older readers may remember, it barely made it through Congress even so.

    5 votes