This is why I'm interested why so many people are obsessed with the idea that we need to completely burn down our system and start anew to improve it.
I'm not only not obsessed with the idea, but I'm not sure that would be a desirable way to go. That said, the healthcare system in the US is way beyond broken, and I don't see how it can possibly be fixed by half measures. Something really drastic is required. It's not hard to see why some people reach the "burn it all down" position.
Tactically speaking, it could conceivably be achieved by enacting a series of what some might consider "half measures":
- Simply getting rid of the Federal employer mandate as well as the payroll tax deductibility for group health insurance premiums could go a long way. A lot of employers really don't want to be in the business of hiring monster HR teams that spend the majority of their time becoming health insurance experts...
- Expanding ICHRAs (https://news.ycombinator.com/item?id=22527102) can also go a long way.
The only annoying part is after your first ER / doctor visits each year, you end up with a bunch of different random charges from people that you have to pay separately. It's an annoyance, but hardly one that requires us to 'burn it all down'.
This year I have an HDHP and an HSA, so I have more of those, but I also have an HSA.
As an example, my wife's first pregnancy probably cost about $200k nominally, but I paid... $2000-3000 at most.
The only real 'issue' I see is the tying of health insurance to employment, but there are straightforwards ways to get around that (federal incentives to purchase your own health insurance, and then employers can pass along savings so employees can purchase themselves). For me, I've never been unemployed longer than COBRA so it's not been an issue.
There are a lot of good things about America's system. My wife's pregnancies are extremely complicated. Many doctors said to give up. However, we searched and searched for a doctor to help, and we figured out what works. Basically, for unknown reasons (although many plausible ones that cannot be confirmed), she needs to take an expensive blood thinner during pregnancy or the baby dies. Since her tests don't come back for the 'standard' conditions this works for, it is difficult finding a doctor willing to prescribe. In fact, we didn't even know it was an option, until we went all over the country to various experts. Due to the free market, we were able to get to these experts in a matter of weeks. Similar experts in countries with socialized systems have long queues.
When it comes to the medication, due to the fact that we are the ones that pay (via insurance), not the government, as long as we can pay, we can continue to live our lives and have our children. Based on our conversations with other women in my wife's position in countires with socialized medicine, they have to really advocate for themselves in ways we do not in order to get their government to even provide the medication or pay for it. Many wait months before they are able to get someone. Every once in a while the government revokes access because some bureaucrat says it's not medically indicated. We've never had that. Should her doctor decide to do that and sentence our child to certain death, we have several backup doctors willing to prescribe the medication. Some moms in other countries we're in contact with have been cut off from the medication and subsequently had miscarriages in the second or third trimester. This is insane. I'm glad to live here.
We recently moved, and just scheduled a bunch of appointments and asked the doctors point blank whether they'd consider it based on her history. Some said no, others said yes. In a few weeks, we figured out what her friend over in Canada took many, many months to figure out. When it comes to pregnancy, months matter. 24 months of waiting can drastically change the spectra of outcomes in a women's pregnancy, especially given the age at which many women have children these days.
Same with things like surgeries and such. My relatives in countries with socialized care are waiting many months for things Americans get in a few days.
I'll give a couple of ancedotes about insurance, though. I've had two family members suffer major medical problems, both fully insured with what was considered excellent insurance. The struggles they had with the insurance companies rivaled the struggles they had with their conditions, essentially doubling their misery and requiring them to make very difficult (and intentionally hard to understand) decisions at exactly the time when they're least able to.
In both cases, they ended up bankrupt because of medical bills -- exactly the sort of thing that, if nothing else, insurance should prevent. Both now express that in hindsight, the insurance companies did more harm than good.
But there's also the problem of quality of care. If you have the money, the quality of care you get in the US is extremely good. If, however, you aren't wealthy, then the quality of care you get is, generally speaking, substantially lower than what you get in most other modern nations. This is not because doctors and nurses here suck, but it's because they're overworked. Which ties into another issue...
There's a shortage of doctors and nurses. Here, I can give my own personal story: I've been trying to find a primary care physician since before the pandemic (I did pause for most of the last year, but started again a couple of months ago) Apparently, there isn't a single one in my general area that is accepting new patients. Even though I have better-than-average health insurance, if I need to see a doctor, my only option is urgent care or the emergency room.
And the pricing is simply crazy. Another meaningless anecdote: A coworker had a dental emergency in Taiwan and had to have a crown replaced. The dentist there was very apologetic that he had to charge my coworker (because he's not a citizen and so isn't covered by their health care system). The thing is, he still paid substantially less for the new crown, and the quality of the work and the crown itself amazed him. He remarked that if you need two crowns done, you'll save money by flying to Taiwan and having them done there, and you'll end up with a better end result.
Now, I'm not saying that you can't have really excellent experiences in the US health care system. I am saying that they aren't the norm.
You're still being robbed of a ton of money (US healthcare procedure costs, i.e. pregnancy, have no actual bearing on what it costs to provide that service), but the system is so opaque and convoluted that there's no personal benefit for you to track down how much. You and I and many others live in more or less ignorant bliss about how much money is being redirected from our pockets to parasites in the insurance/provider system because we don't know any better.
We're still losing in this situation, it just doesn't feel as acutely painful to us as it does to those who are outside the upper middle class bubble.
Obviously, some healthy man or woman somewhere is making up for me, but that's the nature of insurance.
Anyway, you said the system doesn't work and is broken. If it works for 1/3 of people, the system works and the question is how to make it work for everyone.
That's because of inflated provider costs. We are drastically overpaying for each medical visit and it's coming out of all our of pockets, to the benefit of a small few.
Replaced? Not so sure.
But the status quo isn't acceptable.
I don't see how the current system can be reformed realistically. There are way too many well funded groups who benefit from the current situation and will fight any kind of change tooth and nail.
In my view Medicare for All is the only realistic path. It works already and could be tweaked to accept more people. Unfortunately Biden doesn't want it so that opportunity is gone for the next decades probably.
> Unfortunately Biden doesn't want it so that opportunity is gone for the next decades probably.
These two sentences are at odds with one another.
There are clearly other more realistic paths, in that case.
Name another more realistic path besides leaving things the way they are and keeping f…ing over the country with outrageous costs.
And all the systems are there already to implement a Swiss-style system (universal private healthcare with an individual mandate, sliding cost subsidies, and protection for pre-existing conditions). The only difference between Switzerland and the US is that the health insurance is predominately purchased on the individual market and is decoupled from employment.
That’s the realistic path: decoupling health insurance from employment. In fact, all the systems are there already.
That’s one thing we can agree on. Employer based health insurance needs to go.