I saw an interview many years ago with some American historian (of the labor movement?) who argued that establishing universal health care was on the table in the 1950s, but the unions opposed it because health care was the prime benefit they used to attract people to union membership. Wish I could remember the name of that historian.
Obviously it's not every union and they have different degrees of support or opposition. But Democrats won't pass any major health-care bill without the support of all the largest unions, and they're never getting that, especially as many unions are defecting to MAGAism now.
> Anyone I know that wants separation of employment and health insurance is also very pro-union.
Are they in labor unions? Or are they white-collar workers with college degrees who happen to support both of these things?
As we saw in the last election, there can be a significant disconnect between union members' views and the official unions themselves.
Unions are an often necessary hack to overcome some of capitalism's worst baked-in contradictions, but unfortunately they often bring their own set of complications. It seems like we should instead step back and go to the real source of the problem: capitalism
it's the same in EU (I'm from Poland). You work, you have health insurance. Kids are connected with their parents insurance. There is always someone who pays.
This is certainly not universal in the EU. And one of the main problems with this in the US is that you lose your health insurance when you lose your job.
You don't lose it in Germany when you lose your job, who pays for it changes though.
I'm not sure if you understand how it works in the US, but it's common for your employer to provide you health insurance as part of your employment.
This is different from (as far as I know) all countries in the EU. Either there is government-provided basic healthcare, like in the UK, or there is a heavily regulated, compulsory, privatized or partially privatized healthcare system (like Germany, afaik).
It's common to provide subsidized-health insurance as part of employment. Never worked anywhere that is was all covered. Where I used to work people had private health insurance in the UK as well as their NHS coverage.
So if you aren't employed in Poland you don't have access to emergency services or able to schedule an appointment to check a skin growth? That's rather odd.
it's complicated. When you are drunk you have access to emergency service. If you are sober you need insurance. Any skin growth or whatever worries you (which means you are in smaller part of population which cares about their own health) you check on private appointment right now or in two years in public health care.
The German healthcare system covers hospital care, emergency services, some preventative care, prescription medication, some dental care, mental health care, it includes maternity care, it even covers sick pay.
And you literally cannot be without health insurance unless you make a significant amount of money. If you're unemployed your health insurance will be paid by the state.
I hear this all the time, and I somewhat disagree. The problem is that unhealthy people do not want to pay the full amount of their risk-adjusted rate into the risk-pool. Therefore, they need healthy people to subsidize them. It makes sense that pooling a group of employees together would be uncorrelated to health status, and would therefore make a good proxy for a risk-pool.
Some of the most common jobs in the US are driving trucks and working in warehouses. Those people are not some kind of random sample of healthy and unhealthy people. They tend to have chronic pain and metabolic disease at young ages.
If you want to pool healthy and unhealthy people together, you use the system that has worked in every other developed country, some for almost 100 years: pool everyone together. The whole point of a functioning government is for all of us to pool resources together to reduce risk for ourselves in our daily lives. Private health insurance makes absolutely no sense.
110-140 years in Germany, depending on "how everyone" you want. The workers were getting restless (protesting) about some of their hardships, so the conservative emperor asked the conservative chancellor to do something about their welfare in order to keep them away from the bad people (communists, socialists).
Because not everyone wants to pay for the same class of service.
The lowest common denominator is something like the NHS, with its well documented problems.
Many people wish to pay the minimum possible, and many people wish to pay for higher service and lower wait times. There must be some way of deciding who is prioritized for access to limited resources, and incentivizing increasing supply.
> Because not everyone wants to pay for the same class of service.
You can still have choice for more service if you want even if there is a public option.
And even then, it's not like the current employment-tied plans really offer much choice. I either take the 1-2 plans my employer offers or I can go pay a fortune in the marketplace. Imagine if those 1-2 plans were not tied to employment, and if employers weren't expected to directly shoulder all that cost to have employees in the US
"Because not everyone wants to pay for the same class of service."
Countries with socialized healthcare systems usually mandate a basic level of service, but you can then buy additional insurance on top of that. That's what the NHS is, it's the basic mandatory service everybody has to have. But it's not all you have access to. You can get better healthcare if you want to.
In the UK, this type of additional healthcare is also sometimes provided as part of a job benefit.
Actually, having a national service + private insurance is quite good. That's what the UK does (well, except the NHS is possibly going bust).
Because in principle the state insurer provides you with every service, just possibly not very well or in appropriate time, the private insurers have to compete with it and demonstrate some added value.
Ironically, as the NHS is going downhill, the insurers in the UK, IME, are getting Americanised too.
But say in 2019, you could expect from the totally free, universal provider to treat anything: broken bones, medical emergencies, teeth, bad back, headaches, cancer, dementia, mental health... Even some cutting edge treatments were available. And yes, you'd wait longer than you'd like, but it would come in decent time. The hospital food would be so-so and you'd probably share a room with lots of people, but it would be free - you could spend not a penny.
Then the private insurers were cheap-ish and had to have good customer care. Now, the NHS is in disarray, private healthcare effectively doesn't have any competition and IME stopped trying.
You have to understand that after a certain point, the internal narrative has to shift for some people in a capitalist economy to one in which people who can't afford something because the price is too high means they simply don't want it enough. This allows the price setter to ignore their own part in the manufacturing of the suffering of another.
That there is such a thing as a base necessity that should be baked into the human condition is basically anathema to the theoretical worldview. This worldview tends to persist as long as one is lucky enough to never pick up one of those meddlesome chronic conditions of existence whereby one has to rely on others to merely exist.
I'm convinced the United States has attracted a type of psychopath that just thinks money is the end all be all of existence, instead of social cohesion, and we're all suffering for it.
People choose this all the time, if it saves them money. It's like some people will choose a risky job, or a job that comes with predictable negative health implications, if they can make sufficiently more money.
That makes logical sense in terms of grabbing onto a specific mechanism for risk hedging, which would be how we accidentally and naturally arrived at this system.
But it doesn't make sense within a larger society in that you drop out of the pool of insurance-eligible people as soon as you have a health issue that limits your employability.
In fact, that specific case makes it seem totally insane and backwards. Why would you link a thing like employment to your health when your ability to work is directly tied to your health? What a crazy catch-22.
As I understand it, a lot of reason was originally to end-run around wage controls and then got enshrined through some combination of collective bargaining and then generalized employee expectations. But to your point, even if you decouple from employment, it doesn't really help if you're paying $7K+ for individual health insurance as a person who is too ill to work. (Yes, larger companies in particular have disability insurance but this is hardly universal.)
There's definitely a psychological component of what people are willing to pay for and what costs get hidden- if the full insurance premium was shown to be directly taken out of your paycheck every month people would complain, but if the employer-paid premium isn't factored into your salary you don't know how much wages you're missing out on. Even if 100k salary with 10k of hidden premiums is the same as 110k with 10k taken out each month.
There are some tax effects as well. But, yeah, people don't really think of benefits as coming out their paychecks although they are, of course, at some level whether they personally would ever take advantage of them or not. A lot of cross-subsidies happen with benefits.
Shouldn't insurance risk pools be trying to move towards the large and average? This allows insurance to be more resilient to sudden changes in health by accepting that people are going to get sick. I don't know how having tiers of health care with low risk pool and high risk pools would be advantageous to anyone but the young and healthy who inevitably become the old and sick, which is painfully short term thinking for the former and unfairly punishing for the latter.
No, the risk pools should not be "trying to move towards large and average". The insurers should be utilizing their market position to incentivize both employers and employees to adopt practices that reduce healthcare needs.
One instance of this is smoking. Insurers charge more towards groups with smokers, and groups signing up based upon smoking policies of the employer (prohibition on smoking) can result in significant discounts to the group.
Ultimately, we are a rather unhealthy country. We really need to figure out effective ways to utilize financial incentives to either (1) get people healthier or (2) defray the increased costs due to characteristics which may be addressed through habit changes, such as smoking and obesity.
> The insurers should be utilizing their market position to incentivize both employers and employees to adopt practices that reduce healthcare needs.
They have no need to when they can simply deny claims or coverage. It seems strange to me that we should have private corporations shaming the public by acting as the arbiters of health. I agree that people have unhealthy habits, but some of these coverage items have nothing to do with personal choices. There are conditions people are born with or develop without being able to control them. The elderly need more care, and that's not fault of their own outside of simply living long enough.
> They have no need to when they can simply deny claims or coverage. It seems strange to me that we should have private corporations shaming the public by acting as the arbiters of health. I agree that people have unhealthy habits, but some of these coverage items have nothing to do with personal choices.
You can't deny claims to an obese person for a joint replacement. If it was part of the policy, you can't deny the treatment simply because someone had a condition they could have avoided if they had adopted different practices.
> I agree that people have unhealthy habits, but some of these coverage items have nothing to do with personal choices. There are conditions people are born with or develop without being able to control them. The elderly need more care, and that's not fault of their own outside of simply living long enough.
This is an area I do agree with to some extent: we should be much more discerning what we consider "preexisting" conditions; congenital heart defects from birth should be covered, but eating deep fried oreos every day for and washing it down with a handle of vodka shouldn't. This is generally not controversial to most laymen, however states such as CA (see: https://leginfo.legislature.ca.gov/faces/billVersionsCompare...) outright limit the ability of insurers to impact consumer behavior. There needs to be a much more clear-eyed view of mutable vs. immutable characteristics and how we permit insurers to underwrite risk, and how we as a society perceive things such as genetic defects verus excess alcohol consumption.
> The elderly need more care, and that's not fault of their own outside of simply living long enough.
In my view, one of the big problems with the risk pool is young (myself included) buy catastrophic instead of health because of the 3x max charge on elderly. This is a nice to say, but the costs don't pencil out and this needs to be handled out-of-band for standard healthcare. Elder care is a problem, but it is one that can't be solved by risk pooling and is a contributing factor to typical healthcare premium increases.
source for this: I work in the industry owning two (small) businesses in this area, and was looking to expand into insurance directly, and am running into the fact you can only do so much to limit costs on obesity and other things. It's a real problem that insurers can't actually reflect risk accurately.
> outright limit the ability of insurers to impact consumer behavior.
As it should be, why should we defer to corporations only following a profit motive the freedoms you have? You open a can of worms by allowing companies to control people's behaviour through how much they can pay for it. There's a limit where pricing is not about efficient markets but social control by corporations and you are leaning into it without a second thought, to me this sounds scary as fuck.
You need to balance freedoms with its costs, I'd much rather have the government using taxes to incentivise/disincentivise consumer behaviour rather than corporations controlling what freedoms you are allowed by pricing you out of them.
> In my view, one of the big problems with the risk pool is young (myself included) buy catastrophic instead of health because of the 3x max charge on elderly. This is a nice to say, but the costs don't pencil out and this needs to be handled out-of-band for standard healthcare. Elder care is a problem, but it is one that can't be solved by risk pooling and is a contributing factor to typical healthcare premium increases.
And one day you expect to be old, imagine if you don't make it, or lose it all, and now requires care without being able to pay for it. Is that humane? I prefer as a young person to pay my taxes knowing that the ones in need have access to universal healthcare where I live rather than the thought that my society allows disadvantaged people to die because they didn't make enough money so their life is worthless.
A society exists to make all of our lives better, it doesn't make sense to live in a society while being a hyper-individualistic freak; nothing you've achieved in life would be possible without the help of others, to educate you, to transport you, to grow the food you eat, to deliver that food, so on and so forth. Paying back to all of these other people, even if they don't make as much money and/or cost more to the system, averaging out through society is the fairest way to ensure everyone in it can have dignity.
Denying dignity as a society to save some cash is a frankly absurd thought to hold for me.
> As it should be, why should we defer to corporations only following a profit motive the freedoms you have? You open a can of worms by allowing companies to control people's behaviour through how much they can pay for it. There's a limit where pricing is not about efficient markets but social control by corporations and you are leaning into it without a second thought, to me this sounds scary as fuck.
> You need to balance freedoms with its costs, I'd much rather have the government using taxes to incentivise/disincentivise consumer behaviour rather than corporations controlling what freedoms you are allowed by pricing you out of them.
I don't quite understand this argument: nobody is obligated (federally) to purchase insurance, or otherwise participate in a particular health care plan. This isn't about "efficient markets"; this is about incentivizing healthy behavior for socially mandatory programs.
As far as "government intervention for consumer behavior": you wind up with the same problem with sugar taxes begin "inequitable" and opposed by many rights groups or academic publications. See https://nutr.uw.edu/wp-content/uploads/2022/08/UW-Tax-Equity.... In many cases, people simply don't want it because they feel government impacting behavior by mandatory taxes is worse than opt-in programs, but this may simply be American values.
> And one day you expect to be old, imagine if you don't make it, or lose it all, and now requires care without being able to pay for it. Is that humane? I prefer as a young person to pay my taxes knowing that the ones in need have access to universal healthcare where I live rather than the thought that my society allows disadvantaged people to die because they didn't make enough money so their life is worthless.
I'm going to be real: reading through your profile you hardly fit the definition of "young person" (you literally recall living through events before I was born) so I'll lay it out in plain terms: young people have zero guarantees, both in the US and EU nations. The elderly have benefitted from policies which have poorly invested the monies for social security in treasuries earning 3%. They have fought against building housing, resulting in inflated values. They vote themselves generous benefits, mortgaging the future to allow them to "age in place" -- which usually fails anyway -- rather than relocating to elder care communities for more efficient service delivery. So realistically, realize the youths' last benefit in society is their youth, and saying "sacrifice more" rings hollow.
> A society exists to make all of our lives better, it doesn't make sense to live in a society while being a hyper-individualistic freak; nothing you've achieved in life would be possible without the help of others, to educate you, to transport you, to grow the food you eat, to deliver that food, so on and so forth. Paying back to all of these other people, even if they don't make as much money and/or cost more to the system, averaging out through society is the fairest way to ensure everyone in it can have dignity.
This is just a thin veneer over reality: at any given point in time there are finite resources. If there aren't enough resources to address the issue in its totality (as it is with healthcare, where we spend massive money on obesity and alcoholism) nothing we do will make "enough", even at 17% of GDP. In the us, this manifests as price rationing; those can can pay, receive. In the EU, this manifests as physician bedside rationing (see https://pmc.ncbi.nlm.nih.gov/articles/PMC1831659/). Nothing you have stated ameliorates the rationing: it simply ignores the fact that it is already happening, even in socialized health systems.
And -- as far as a "hyper-individualistic freak" -- I grew up in a "disadvantaged" school district (I just checked) to immigrant parents. I didn't qualify for disadvantaged grants to attend better ranked colleges because I wasn't a URM, so I just went to a state school and worked in research labs during the year and local engineering firms to pay my tuition. That's my life. In the US, you can absolutely claw your way up. Technical skills and entrepreneurship are absolutely the engine of social mobility Europe wishes it has, and why we can actually provide immigrants integration and social mobility. I 100% prefer this over the sirens song of socialized care which simply doesn't exist, even in Europe.
> I don't quite understand this argument: nobody is obligated (federally) to purchase insurance, or otherwise participate in a particular health care plan. This isn't about "efficient markets"; this is about incentivizing healthy behavior for socially mandatory programs.
Which is absurd since everyone will need healthcare in their lives, spreading the risk pool across the whole society and providing the service as an averaged out resource for the benefit of all is the most logical way of doing it.
> In many cases, people simply don't want it because they feel government impacting behavior by mandatory taxes is worse than opt-in programs, but this may simply be American values.
Yes, this is simply American values, which individualism is a paramount one. And probably the value which may bring down American society one day as you can see from the erosion of empathy in American society.
> I'm going to be real: reading through your profile you hardly fit the definition of "young person" (you literally recall living through events before I was born) so I'll lay it out in plain terms: young people have zero guarantees, both in the US and EU nations. The elderly have benefitted from policies which have poorly invested the monies for social security in treasuries earning 3%. They have fought against building housing, resulting in inflated values. They vote themselves generous benefits, mortgaging the future to allow them to "age in place" -- which usually fails anyway -- rather than relocating to elder care communities for more efficient service delivery. So realistically, realize the youths' last benefit in society is their youth, and saying "sacrifice more" rings hollow.
For all accounts in the society I live in I'm still in the "young" cohort, mid-30s is not old and if you are younger than that you haven't contributed much to society yet, you basically sucked up resources for growing up and now wants to deny resources for others who have contributed to the society they helped build and which you live in.
> This is just a thin veneer over reality: at any given point in time there are finite resources. If there aren't enough resources to address the issue in its totality (as it is with healthcare, where we spend massive money on obesity and alcoholism) nothing we do will make "enough", even at 17% of GDP. In the us, this manifests as price rationing; those can can pay, receive. In the EU, this manifests as physician bedside rationing (see https://pmc.ncbi.nlm.nih.gov/articles/PMC1831659/). Nothing you have stated ameliorates the rationing: it simply ignores the fact that it is already happening, even in socialized health systems.
There are finite resources but human ingenuity has found ways to make resource usage more and more efficient through technology.
It's not because there's a public healthcare system that there aren't options in the private sector, a lot of European countries have a hybrid system (including in Sweden where I live). The public healthcare is available even if with deficiencies but it doesn't mean that you don't have access to treatment if you can pay for it... The system you live under is the worst of both worlds, extremely expensive, bureaucratic and selecting people's lives by how much money they have, I'm baffled you can't see that as anything other than absurd.
> And -- as far as a "hyper-individualistic freak" -- I grew up in a "disadvantaged" school district (I just checked) to immigrant parents. I didn't qualify for disadvantaged grants to attend better ranked colleges because I wasn't a URM, so I just went to a state school and worked in research labs during the year and local engineering firms to pay my tuition. That's my life. In the US, you can absolutely claw your way up. Technical skills and entrepreneurship are absolutely the engine of social mobility Europe wishes it has, and why we can actually provide immigrants integration and social mobility.
And I grew up in Brazil, with much worse schools than even your disadvantaged public school district. I didn't qualify for any disadvantaged program, the better ranked colleges in Brazil are public ones and only accessible through standardised entrance exams where the rich can go through a year or two of prep school to get into. I clawed my way up and moved to Sweden some 10 years ago after a brief sting living in the USA, all on my own, and I still believe in everything I said about hyper-individualism...
The social mobility engine of the USA only benefits a few, it's a pipe dream sold to make the masses believe that they can make it if only they are good enough. It's never brought up as "you can make it if you work a lot and are lucky enough" because that would tear up the American Dream as a whole, the belief one is in complete control of their destiny is the big fat lie needed for such an individualistic society to not tear itself apart.
> I 100% prefer this over the sirens song of socialized care which simply doesn't exist, even in Europe.
You simply don't know how socialised care works, you said yourself that you are young so you lack any life experience on that, and you only lived in the USA so you can't really know what you prefer, you just have a feeling based on your own American Exceptionalism bias.
The majority is somewhere between overweight and vastly obese, which is a choice (even in HN's latest boondoggle of "you lose weight if and only if you are injected the right drugs", obesity remains a choice). Similarly, the vast majority of people don't even meet the basic WHO guidelines on physical activity, which is even more obviously a choice. It is well-known that making these choices precipitates virtually every common, serious disease. Therefore, most people are unhealthy by choice.
That is an argument for mandatory healthcare, not tying it to employers.
The real challenge with employer-tied healthcare is the lowest wage workers would not be able to afford it otherwise.
High pay workers would receive a salary bump to compensate if healthcare were decoupled. Low paid workers wouldn't because they are already compensated above the market clearing rate for their labor.
Why would it be uncorrelated? It is not unheard of for people to lose their job due to health issues, which then means they lose health coverage too. It's like they never really had coverage at all.
There are lots of ways to have big risk pools. The bigger issue is that the things you most need insurance for are often so bad you won't be able to work or won't remain employed.
On top of that, historically the connection discouraged entrepreneurship.(With the exchanges I think that's maybe slightly less the case. Though risk pools issues with small businesses do favor larger businesses IMO.)
America is a land of inequality. There are many people (poor) which have bad healthcare, but for many others (the wealthy, stably employed), healthcare is excellent.
If you have a good job with a good PPO plan, this healthcare is just incredible. You are free to see any doctor you want, including specialists without any gatekeeping.
Want to see the best orthopedic surgeon in the world who just fixed Lebron James's knee? Make a call and get an appointment within a few weeks paying a 30 dollar fee. Want to see 10 more orthopedic surgeons to get 2nd, 3rd and 4th opinions? Same process.
Decide to have a surgery? Sure! Sign up to have that done in a few weeks, eventually paying $250 out of pocket for the whole experience, including overnight hospital stays and physical therapy.
Having spent some good time hanging out in facebook groups for my condition with international patients, its pretty much always evident that they dont have this kind of freedom in picking their doctor, getting a surgery quickly, and also often lack cutting edge and modern treatments that are offered in the states.
I totally understand that this system is very unfair, and there is whole subset of people that have no access to care, but it should be noted that if you are in the top 50% of society financially, and especially if you have a difficult health condition you manage there is no healthcare system better in the world to do that then the USA.
I'm pretty sure it can't be the top 50% of society that has this, because that would mean it was average or even median. I expect it can probably start to happen from the top 25% up
It’s unclear to me why the American government doesn’t change the laws and create a new system more like a European one. I don’t think hating any of the players makes sense. Those that set the rules are ultimately responsible.
>It’s unclear to me why the American government doesn’t change the laws and create a new system more like a European one
Because the regime decisions in the US. are much defined by the corporatocracy and lobbyists interests rather than the people's. Some further readings/videos on that:
Well, that gets us into the question of the influence of money on American politics. The incumbent players make a ton of money from the current system, and they use a lot of that money to lobby to maintain the system, and the system is responsive to their money. Made worse by Citizens United, but it's been a problem for a long time.
Combine this with a distrust of government that is encouraged by many of those same interests and you have, well, us.
Voters still control the ballot box, and have rejected single payer propositions. When polled, they say they want healthcare reform, but hate every option when they are described to them.
Yeah. There's a lot of fear-based marketing aimed at getting people to reject single-payer. It seems effective.
A lot of our voting seems to suffer from the "but it won't happen to me" fallacy, whether that be about health care and medical debt, conditions in jails, climate change, social services, etc. with the irony being that it often happens to most people in the long run.
It is extremely hard to get people to agree on any one alternative. Any system has pluses and minuses, and it's easy to scare people away from any particular choice.
It took superhuman effort, a once-in-a-lifetime political opportunity, and some outright shenanigans even to get the Affordable Care Act passed. It was a very minor tweak to the existing system, and half the country viewed it as an apocalypse. The political party that passed it ran away from it in the next election, and got massacred. But now that it is law, it too is nearly impossible to alter because the alternatives all terrify people.
At least making insurance available for people with pre-existing conditions was a pretty big win for some. And the penalties for just passing on it are pretty small. However, as I wrote elsewhere, Medicare is still expensive if you recently had a high-ish income. It's been perfectly fine insurance for me so far but it's probably what many would consider unreasonably expensive.
Isn't it just that there's too much money and too big an industry (with lobbyists and campaign contributions)? People are not happy with the system but they're less dedicated to pressuring politicians than companies who depend on the status quo.
We all also hate the overly complex tax system that obliges individuals to calculate their own taxes and get penalized if they do it wrong, but tax preparers like Intuit can kill efforts to simplify it. I think in general we all hate some subsidies but recipient industries are effective in lobbying to preserve them. Etc etc.
Scroll down that article to see that for the last 21 years of revisiting it by every legislative body, it always ends "Died in Committee". Every 2 years, some new representatives get elected, and yet it still dies. The proposal doesn't even make it out to the House floor to officially vote on.
Why? A lot of vested interests in keeping the current system. (Aka "money".)
The intuition is to think only the greedy health insurance companies are against it. But doctors' associations and many American workers with decent health insurance from their employers are against it too.
Doctors often are compensated for the money they bring to their hospitals by the treatments they prescribe. That is, there is an incentive for doctors to prescribe costly treatments because they will net more payments from insurance raising hospital revenues.
Surveys show that a majority of Americans support a single national government program for healthcare. The reason this does not exist is because it has become increasingly easy to distract people with wedge issues and make them focus on what divides them, rather than what unites them.
The root of the problem is that American health insurance is employer-sponsored so you don’t get to choose your carrier and your employer can choose entirely because of bribes if they so choose. As such, the vaunted American invisible hand doesn’t get to play its part.
> The requirement to have 60/100 votes in the senate makes it almost impossible to pass anything except the most uncontroversial bills.
The filibuster is not enshrined in the Constitution. It's only a Senate rule that could be abolished at any time via a simple majority vote in the Senate. The Senators have chosen not to abolish the filibuster.
> makes it almost impossible to pass anything except the most uncontroversial bills
It's actually worse than this.
Popular bills, like the Dreamers Act, become political footballs. Neither party wants to pass it while the other party is "in power" (in the minds of the electorate), and they want to keep it around as a bargaining chip, campaign promise, etc.
So the bills that get 60 votes aren't just uncontroversial, they're usually not even meaningful to voters.
Also fun rotation in jobs. Work on one side and then have expertise to work on the other. And wise-versa... Unless you are true idealist, which will get steered out, why would you ruin the good thing going on...
>I don’t think hating any of the players makes sense. Those that set the rules are ultimately responsible.
If it were legal in certain circumstances to kill someone and take all their stuff, you'd hold the people who arrange for those circumstances to arise as often as possible for the purposes of plundering from their former neighbors blameless because "they're just playing the game"? What if it were torture instead of just murder? Does there ever come a point when a person is responsible for their actions?
> Does there ever come a point when a person is responsible for their actions?
This is it right here. People have been holding out for an answer to that question and I think they are learning every day the answer is no. People can't watch families like the Sacklers inflict untold harm on the population and then get away with a fine less than what they made inflicting that harm, and come away to believe the system works, and that rich people's "due process" is the same as the rest of ours.
If I murder 1, 10, or 100 people I go to jail for life or get the death penalty. If I make a business that murders half a million people by pushing pills and I make a billion dollars doing that, absolute worst case scenario I get a relatively small fine compare to my earnings, and I continue the rest of my life in luxurious freedom. And that's only IF the issue goes to trial after I exhaust my endless resources to massage the justice system by choosing the venue, the judge, and the jury.
Lifetime jail and death isn't even on the table. I guess until now that is... maybe that changes the cost/benefit analysis in boardrooms. Maybe they need to start estimating the likelihood their decisions are so immoral they will actually radicalize their customers to murder them. Because it seems like that possibility doesn't even cross their minds and they feel they can race to the bottom with no repercussions except a fine.
I'm not asking about whether the legal system will hold someone responsible. I'm asking whether they are culpable, ethically speaking. The whole "don't hate the player; hate the game" thing seems to just be a total abdication of responsibility. Of course incentives shape behavior, but saying that only the incentive structure is to blame serves the interests of no one but the sort of person who would do absolutely anything they can get away with that makes them a buck and then insist that it wasn't bad because someone else would've done it if they hadn't.
In the American political system currently the reward for passing a large piece of legislation, even one which eventually becomes popular, is to be voted out at the next midterm elections. So why bother? Don’t worry about legislation, just tweet.
but which European system? in Poland we go private otherwise we wait two years (so you can die without a debt). In Sweden you need to pay for a doctor appoitnment. Netherlands you cover first few hundreds euros. Every country is little different.
Many European countries were able to implement universal healthcare without much of a fight because their economies were utterly devastated after WW2, along with their health care systems. (An exception that proves the rule: France nationalized its private insurance companies that survived the war.) So there weren't really any stakeholders arguing for the old system - notably this is not just hospitals and insurers, patients are also stakeholders. One problem with the US is that "universal healthcare" is popular in the abstract, but "we're gonna take away your BCBS plan and put you on Medicaid" is extremely unpopular.[1]
The US is actually closer to the Canadian example, though Canada started earlier and doesn't have a Big Pharma burden. But like the US, Canada is a hybrid private-public system with a lot of provincial variation. There wasn't a Canadian federal health law until the 80s, after 20 years of patchwork provincial laws, and Canada continues to have big gaps and inequities (e.g. mental health coverage is quite a bit worse in Canada than the US, dental isn't covered, and people on work visas get screwed). A large majority of Canadians have supplementary private insurance. So I think the US will get close to the Canadian system via slowly pushing up the Medicaid eligibility line and eating away at private insurance, and not a big sweeping law.
[1] "Medicare for all" is dishonest, it has to be Medicaid for all. But for classist political reasons nobody wants to say that.
Because the European market based insurance models like the ones in the Netherlands and Germany are completely redundant bureaucracy without any actual market mechanism, and Americans are typically above that kind of nonsense. Americans want choice, but that necessitates having choice.
I can't tell if you're serious or sarcastic, but you can get private health insurance in all European countries, and an important thing the "redundant bureaucracy" does is negotiate and/or control pricing, which keeps the overal healthcare cost down.
One of the issues with healthcare in the US is that every actor other than the patient benefits from higher cost and worse service. It increases revenue and decreases cost for healthcare providers, for pharma, and, importantly, also for insurance companies. There is no competition to improve service and decrease costs.
I don't know what you are talking about, but I have lived in both the Netherlands and Germany and in both instances, you have a "choice" of insurance providers, but the list of services and the pricing is mandated by law. There is virtually no difference between being with one insurer compared to the other, except for whom will process your application and handle the money. In that respect it's just a bunch of useless added bureaucracy compared to an NHS-style system with just one country-wide insurer.
Like I said, you can get private health insurance in both the Netherlands and Germany. Basic service is mandated by law, and will be the same across all providers, but you can get any additional insurance you want.
I do agree that it makes more sense to have basic healthcare covered by a single national government program, rather than mandating basic coverage and allowing private insurance companies to "compete" by offering the same mandatory coverage as each other. If that's specifically what you're referring to by "useless added bureaucracy", then I agree.
Somewhere along the way a firmware bug was discovered in the American psyche that judges whether or not something is “capitalism” by whether or not there are “companies” involved, but is completely insensitive to whether or not “competition” is involved: this is how you get a Vox piece that includes “private industry” and “legally allowed to negotiate prices” in the same paragraph but lacks “fucking ridiculous”.
The pharmaceutical companies have patents on the drugs and so they rent seek. The hospitals have geographic locations and generally don’t get built across the street from each other. The pharmacies are owned by the same parent companies as the insurers.
But somehow you can take this mess of central committee grift and pay some CEO 8 figures a year and now comrade, now we are doing the capitalism. We are rocking and rolling.
It’s also illegal to build new hospitals without permission, even if you have the demand and ability to build one across the street from the existing one.
There are MANY firms who would love to open discount clinics across the street from a bunch of existing medical centers and out-compete them on price and service and eat their lunch; anyone who has used the american medical system knows what a low bar that is to clear. The problem is that in most cases the supply of doctors is capped by law and the ability to open new hospitals and clinics is restricted, so prices remain astronomical and service remains terrible, just like your other public utilities.
Somehow this government-mandated lack of competition is blamed on “free market capitalism”.
This is a canonical example of an establishment media outlet steering (misdirecting?) the conversation into more "acceptable" directions.
"The killing of a human being is morally repugnant — full stop." Yup. But this industry's business model is predicated on withholding care, sometimes costing lives. So, by definition, it too is morally repugnant.
"But prices have continued to spiral upward, accelerated by the aging of the baby boomers and by important but costly advancements in medical science." Note how deftly this sidesteps profit taking as a driver. It's a big one, estimated to be nearly $2 Trillion in 2022 (as compared to other peer countries, who face the same aging population constraints and "costly" advances in medical science. https://www.msn.com/en-us/health/other/the-cost-of-corporate...).
"The passage of Obamacare over industry opposition..." I was around and paying close
attention when that happened. The industry practically wrote the ACA. Sure, they made some concessions, but anything they really opposed--like the Public Option--didn't stand a chance. And when the individual mandate went before SCOTUS it was of course upheld. The industry was happy to have people pay a penalty for not using its products!
This last is in fact the biggest sin of this piece: the obfuscation of the role that the industry's lobby plays in opposing change. Any attempt to get to a more rational system is met with full frontal opposition in the media and in our legislatures. People who advocate for systems like Medicare for All are labeled nuts, out of touch, and get the "Harry and Louise" treatment. There is no safety valve. So the pressure keeps rising and rising, until something really bad happens.
To be accurate it’s not the pharmaceutical companies, but the pharmacies and pharmacy benefit middlemen that influence pharmaceutical prices that are increasingly owned by the insurers.
Do any of us really care which of these mega-bureaucracies is to blame for each particular hurdle to receiving healthcare?
From the patient’s perspective, they are all conspiring to gouge us, deny us care, and perpetuate their gold-plated monopolies.
The constant factor is that the patient always loses.
It’d be nice if we could have a political system where politicians represented their constituents, rather than their financial backers. But I fear that the culture war has made that very unlikely. It’ll get worse before it gets better.
There's something that is often overlooked in discussions of the problems with and how to fix the American healthcare system.
Two of the biggest problems are that (1) America pays quite a bit more for a given level of care than they do in most other first world countries, and (2) the cost keeps going up significantly more than can be explained just be normal inflation.
The discussion then usually focuses on the differences between the American system and the systems of places like Europe and Japan, with people arguing about which of those differences are why we've got problems and whether or not adopting some ideas from those other systems would fix our high cost and rising cost problems.
The problem with that is while those other systems do indeed cost a lot less than the US, they also have a rising cost problem. For example here are the ratios the per capita costs when up in the US during the decades starting from the '70s [1]: 3.2, 2.6, 1.7, 1.7, 1.5. Pretty horrible.
Here are the numbers for the UK: 3.1, 2.0, 2.4, 1.8, 1.5. Here they are for France: 3.4, 2.2, 2.0, 1.4, 1.4. Also pretty horrible, and about the same level of horribleness as the US.
Here's the ratio of 2018 to 2000 per capita health care costs for a few countries: Japan 2.6, UK 2.6, US 2.3, Germany 2.1, Canada 2.0, France 1.8, Italy 1.7.
This suggests that perhaps the US problem with rising costs does not stem from the differences between the US system and those of most other places.
It also suggests that the problem with higher costs than those other places might not be due to relatively recent changes in the US system that much discussion often focuses on. Instead it might be we pay much more than Europe and Japan now mostly because we paid much more than Europe and Japan 50 years ago.
[1] My data came from https://data.oecd.org/healthres/health-spending.htm which used to have a wonderful interface that allowed you to easily generate various views and reports of OECD country health care costs from 1970 to almost the present that let me get the data I wanted in a convenient form.
The have since reorganized things and that now redirects to https://www.oecd.org/en/data/indicators/health-spending.html which has a different interface and still has, I think, the same data but I no longer know how to get it as conveniently.
America's problem are similar to elsewhere: to too much demand, overworked staff, long lines .
The NHS is not a particularly good example. I live in another Western European country. It's easy to get an appointment quickly and an appointment means an appointment (if the appointment is at 11:15, you typically have to wait 10 minutes at most). My experience has been the same in another Western/Northern European country when I had what turned out to be kidney stones when we were on vacation. It used to be different when I was young, but the system was made more efficient.
Both of my parents were/are dealing with a severe illness, but both were quick to get appointments for tests/surgery and they haven't paid a cent.
>It's easy to get an appointment quickly and an appointment means an appointment (if the appointment is at 11:15, you typically have to wait 10 minutes at most)
From the outside, it seems that many Americans are opposed to regulation in general and universal healthcare is seen as 'socialist'. This is fed by politicians lobbied by corporations with deep pockets. To make it worse, large employers have a stake in keeping the system, because it reduces employee mobility and makes employees more obedient (since they don't want to or can't risk losing health care).
It seems that these problems can only be resolved if Americans accept more broadly that regulation can be good and that even though regulation can be 'socialist' it does not necessarily mean bad.
Americans are fine with regulation but struggle with nuanced regulation and long term regulation that has a short term cost. Culturally we’ll also rush to a perceived moral high ground on various issues with a regional bias - for example cities will pass a minimum wage law on moral grounds and small towns will reject the same law on moral grounds (small business).
Like all thinks it’s nuanced and blanket statements don’t really help.
Thank you for the clarification! It's just something that I encounter a lot when talking to Americans, there is a lot of aversion to regulation, government support, etc.
So deep that we did absolutely nothing about it when we had the chance and now have elected someone that will make it even worse. Americans don’t realize that the country is exploitative in so many ways because they keep voting completely opposite from candidates that will help make their life better.
>John Steinbeck once said that socialism never took root in America because the poor see themselves not as an exploited proletariat but as temporarily embarrassed millionaires.
Historically exploitation is the back bone of America. Before we were even a country we were exploiting the British to clear the Ohio river valley for commercial gain. We didn’t want to pay for that so we took the opportunity to revolt which was paid for largely by the French. Then between manifest destiny and sniping half the continent from the French in the Louisiana purchase. Our early economy exploited hundreds of thousands of African slaves. And that’s just the first hundred years.
As an outsider what I see is that Trump claimed to stand for change, while the Democrats seemed to champion the status quo.
Just the fact Biden promised to run for one term, then they lied about him not being senile, then Harris was anointed saying she'll basically be Biden, and don't you dare not go along because Trump is the end of democracy - that is just incredibly astonishing to me. And people wonder why that didn't work out? To me that's like talking about why this car with perfectly good tires hasn't won the race, when it has no engine and no driver and it's not even on the racing track but at the bottom on the ocean. With perfectly good tires admittedly, which pundits are examining with microscopes.
From what I can tell all they ever offered is playing for time and rationalizations for why the boat should not be rocked, preaching to people who are treading water, who will never be in that boat. Basically "we're so proud of our achievements and excited to face even greater challenges with you" -- whereas Trump was screaming about making "them" pay and flipping tables. And even though "they" are a scapegoat, and even though he'll make it (so much) worse, at least the anger is something people vaguely recognize, whereas what came from the Democrats is mostly alien and alienating ivory tower talk.
At the end of the day, I think the US needs at least one more major party. Two sides hiding all their own flaws behind the other is just unworkable. It makes people incredibly lazy intellectually.
I like Grapes of Wrath, but I don't think that's a solid understanding of the current situation .
I think that almost all of my friends who voted for Trump did so precisely because they think the US is exploitative in a variety of ways. They are often quite subject to that exploitation and aware of many of its specifics.
From my position, which is anti-capitalist and anti-authoritarian (or left libertarian, or anarchist or whatever label you'd use), they have very misguided understandings of the specifics of that exploitation.
However, also from my position my many friends who voted for Harris also have similar shortcomings in their understandings of the world. My understanding is that 15M or so folks decided that Harris was not a candidate who wold make their lives better.
The fact that the Democrats absolutely did not fix this system begs the question of why it did not get fixed.
My understanding is that they did not want to fix the system, or that there are structural issues in the system which make it functionally impossible to reform. I believe that it could be reformed, but that since the donating classes to the parties did not want it the ACA became a massive handout to the insurance industry instead of some more universally solved solution.
Thus your position that folks aren't voting for "candidates that will help make their life better" could be read in a couple of ways and I find it a bit ambiguous as stated.
Like, I typically read stuff like that as saying "if they'd voted for KH, then this could at least maybe get fixed". But that feels internally contradictory given that when people did vote for a similar hope-and-change candidate it did not make things markedly better.
At the same time, I think that folks stopped voting largely not out of apathay but out of a real awareness that they aren't selecting from "candidates that will help make their life better".
So my position is that folks actually are voting for Trump for the same reasons they were previously voting for folks like Obama and not, for instance, for the Steinbeck-ian rational that led them to vote for Reagan or the Bush family.
> My understanding is that they did not want to fix the system, or that there are structural issues in the system which make it functionally impossible to reform.
I beg you, read one article on how the US legislature functions.
The bottom line is change is possible, if enough Americans vote as though they are not temporarily embarrassed millionaires.
I mean, "monkeys might fly out of my butt" is possible, I suppose. And it seems to be about the level of response merited by your comeback.
It's also possible, as you state in your comment, that I have literally never read one article (or book) in my time being ruled by the US on how their legislature functions, and that I'm wholly ignorant of the mechanisms of the US legislature.
It's also possible that you have your head up your ass because the fantasy that either party has the actual ability to fix what are deeply structural problems, much less has the will to do so, is more appealing than registering the depth of the problem.
I have in the past, believed that these reforms were possible, and I still believe that they are "possible" in the sense that literally anything is possible in this world. You don't respond to the question all that begs, which is why, if everyone in the US deeply hates the healthcare system, none of it has yet been fixed.
"Affordable" healthcare and not being tied to an employer are not necessarily the same thing. I have Medicare (with a couple add-ons) and I'm paying pretty much what I would pay for a marketplace plan (although that will presumably go down once I'm a year or two further out from full-time employment). I pay more today than when I was employed.
That would be true if the senate were perfectly democratic, but it’s not (for several reasons). How the senate votes is only weakly correlated with what most people want.
This is because Republicans are beholden to the companies profiting from the existing system, and Democrats are beholden to unions[1].
Our unions are a reason we have no actual labor movement in this country. They're socially conservative and oppose universal health-care because it invalidates hard-won health benefits in the contracts they've negotiated with employers.
They spent decades fighting brutal legal battles and taking hits to their pay from striking, and one of the things they got was health insurance. It's painful to feel like that was for nothing.
