Comment by tptacek | Hacker News Reader

Comment by tptacek | Hacker News Reader

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How are you not describing the ACA system? The ACA makes health insurance compulsory (not as effectively as the Swiss system, to be sure), mandates a minimum health plan (quite effectively, and quite similarly to the LAMal), guarantees issuance, and prices through community rating, the same way the Swiss system does. US spending on health insurance is 6% of income, 8% if you include expenditures outside insurance.

I'm not arguing the US system is better or even close to as good as the Swiss system. We have a lot of problems, and overpay flagrantly. I'm saying the Swiss have a system that closely resembles ours (unsurprisingly, since ours is patterned on theirs) and theirs appears to work. That tells me our problems are orthogonal to the issue of private versus public insurance.

I think the weak penalties for not carrying insurance are a serious problem with our system, but you are going to have a difficult argument to make if you want to attribute the hundreds of billions of dollars we overspend in health care to just that factor, or even significantly to that factor.

I basically agree with you that we overfocus on the single-payer vs. private distinction. But I think there's more to it than that: when you get down to it, most Americans who want to reform the US health care system don't really care whether it's public or private. They care whether it's universal or not. The Swiss system is universal health care because the basic plan is capped at 8% of income at the federal level, with cash subsidies given to those with incomes lower than that.

By contrast, Medicaid in the United States is administered to the states, who have broad leeway in determining who is and who is not eligible for the system, especially after National Federation of Independent Business v. Sebelius. Income level alone does not necessarily qualify one for Medicaid. Medicaid is not considered universal health care, even with the ACA, and that makes a huge difference.

It's not so much that Americans don't want the Swiss system as that we're missing the crucial part of the Swiss system that makes people feel secure that they'll be insured.

Medicaid isn't the only option for premium-controlled health insurance in the US. As far as I'm aware, everyone in the US is able to purchase health insurance for at most 9.86% of their income in 2019, except:

- Those who earn less than 100% of the federal poverty level ($12k/year for an individual, $25k/year for a family of 4) in states that haven't expanded Medicaid (~2.2 million people [0])

- Those who earn more than 400% of the federal poverty level ($48k/year for an individual, $100k/year for a family of 4) but aren't offered health insurance through an employer (e.g., because they're self-employed or work for a small business) (~900 thousand people [1])

Both are legitimate and significant coverage gaps, but they only affect ~1.5% of non-elderly adults in the US. For comparison, the number of adults that qualify for free or subsidized coverage but chose not to enroll is about 4x larger as of 2016 [2].

[0] https://www.kff.org/medicaid/issue-brief/the-coverage-gap-un...

[1] https://www.commonwealthfund.org/publications/issue-briefs/2...

[2] https://www.kff.org/uninsured/issue-brief/estimates-of-eligi...

Sure, it's similar (no coincidence, as you point out). Most people in the US don't directly participate in the ACA marketplace. For all the talk about freedom of choice, i'd venture that the majority of Americans have no real choice in what insurance they'll get (apart from their freedom to switch jobs or pay a higher price on the exchange by forfeiting their employer's contribution).

We also have a significant population (~15%) on a public system that has an influence on prices that everyone pays but no authority to negotiate drug prices.

I don't think that any one of these differences is an explanation for the gap between ~11% of GDP and ~17% but there are enough of them that it's hard for me to decide public vs private is orthogonal.

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