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No, it's not "almost free". It's paid for by the company.

You are correct, but large companies get dramatically better rates and better coverage than small companies. My family's small business has seen healthcare premiums increase more than 20% each year for the past few years. We have had to cut benefits (increase deductibles and copays, etc). It's a sad state of affairs that employees of large companies are insulated from (for now).

More or less because reasonably-priced health insurance requires a risk pool in which membership isn't voluntary, and large companies provide such a pool by requiring that all their employees enroll in the company health insurance as a condition of employment (and pay their portion of the coverage fee with no opt-out allowed). The insurers assume that the number of people who'll turn down the job solely due to disagreeing with the mandatory-insurance aspect is small, so the coverage pool is in effect a large, mandatory-coverage pool selected for mostly-health-unrelated reasons, which is the kind that works as a risk pool.

Entrepreneurs don't have anything similar unless there is a way to aggregate themselves into a pool where the opt-ins don't correlate with health condition too strongly, which currently there isn't. Insurers for good reason don't give good terms to non-mandatory-coverage risk pools, because of the strong bias towards high-risk people in such pools. And good luck if you have any congenital health issues; my friend who has a from-birth heart defect is essentially banned from ever doing a startup due to the employment-tied nature of the U.S. healthcare system and the preexisting-condition rules that make the health-insurance-via-corporate-job approach the only one open to him.

The insurance company inherently pools everyone that it insures, whether they work in 10 large companies, or 1000 small ones.

So I fail to see a legit statistical/risk-model reason why health insurers MUST gouge small companies/entrepreneurs.

I think it's mostly due to small companies having less negotiating leverage.

Large employer insurance plans are often self-funded, meaning that the insurance company charges administration fees but does not truly insure the plan financially.

Certainly small employers are worse at negotiating health care plans, but I'm not sure how much leverage they could possibly have in negotiations given economies of scale and switching costs.

(in a past life, I worked for a benefits consulting firm which specialized in union plans - one positive of how these plans operated was that they disclosed their benefits costs as $/hr rate per member.)

The issue is whether opting in is correlated with worse health. When one large company opts in, it's usually not because the company's CEO is himself sick: it's just a general policy decision to offer employees health insurance, and then thousands of people with overall "average" levels of health are non-voluntarily enrolled (the only way to opt out is to quit their job). But the decisions of individuals and small companies to choose or not choose to buy health insurance are much more strongly driven by their own personal health, with less-healthy people and people who suspect they're likely to have health problems soon more likely to buy in, and healthy entrepreneurs more likely to opt out / self-insure.

Google adverse selection

The US and Canadian government spend the same amount per person on healthcare but Canada has universal health care. On average the US and Canadian healthcare systems provide vary similar outcomes on average.

So, clearly more government involvement is an option. But, so is less the US could save a ridiculous amount of money if we could stop wasting it on end of life care that proves little to no benefit. Healthcare is an endless money sink and because the US government agrees to hand over money with little veto power we have are left with the worst healthcare system money can buy.

Just think about this for a second would you rather have an extra 250,000$ to spend when your young, or have a 50/50% shot of spending an extra 2 months on your death bead in a semi lucid state?

Canadian here: Your post is kind of at odds with the final question you posed.

You can have the money AND not sacrifice health outcomes. As you said, Cdn and US governments spend the same amount of money for the same outcomes.

Also Canada has dramatically less ethnic diversity, at least if I'm reading Wikipedia correctly.

Are you really suggesting that a few ethnic diseases would render the Canadian healthcare system unworkable? I find it very hard to believe that a few more cases sickle cell or whatever would have that kind of effect.

> Are you really suggesting that a few ethnic diseases

It isn't a "few ethnic diseases", but you are underestimating the cost of high-blood pressure and the like.

I think you are underestimating the prevalence of high-blood pressure in ethnicities technically less inclined to have it.

Canada also has a lower obesity rate.

I'm suggesting that a U.S. healthcare dollar is statistically not going to go as far as a Canadian one, even if the U.S. had universal health care.

> The US and Canadian government spend the same amount per person on healthcare but Canada has universal health care.

As does the US, it just doesn't go by that name.

Yes, there is free healthcare in the US. It isn't unlimited and you can buy better, but the same is true of Canada.

However, I'll note that the US govt directly pays for about half of US healthcare (employees, etc.). If US govt healthcare will be so good, why isn't it? (Half of the population is enough to prove what it can do.)

However, I'm willing to give Obama free rein over US govt paid healthcare to show how much better it can be. All I ask is that he spends the same per-person this year, 10% less per person the 2nd year, and 20% less the third year. (Since govt healthcare advocates claim far more savings to be had, this should be easy.)

FWIW, pointing out how the US govt can't do healthcare isn't much of an argument for more US govt involvement in healthcare....

Going to the emergency room when you're on the brink of death doesn't count as "free healthcare," no matter how many times they beat their chest claiming it is. Emergency room healthcare is significantly more expensive than getting your blood pressure checked every couple of months.

The right to healthcare isn't something that only applies to the emergency room.

> Going to the emergency room when you're on the brink of death doesn't count as "free healthcare,"

So?

You're ignoring medicaid and the free clinics that are in many areas. Medicaid is especially interesting because the vast majority of the "poor uninsured" are eligible and get signed up as soon as they actually need care.

Both programs are fairly well publicized, so it's interesting that you mentioned emergency care as if it's the only option.

And there's a third option which is less well known. With the possible exception of much of Alaska (due to population density), every county has a public hospital that provides free healthcare.

why isn't it?

Because in the vast majority of cases the US government does not provide heath care it provides heath insurance. The only large scale government healthcare in the US is the VA which costs a lot less than the rest of the US healthcare system because they pay for the doctors directly and cut out a lot of middle men that drive up costs everywhere else in the US system. They also have more leverage when it comes to malpractice and doctor pay etc.

Now, your rhetorical idea that prices can drop 10% the first year and 10% the second would probably not be far off the mark. (Just compare VA costs with the average hospital etc.) But, in the end it's only going to save around 40% because until we see some real automation there is only so much costs you can cut before quality is impacted.

> But, in the end it's only going to save around 40% because until we see some real automation there is only so much costs you can cut before quality is impacted.

How can that be? After all, we have all these stories about significantly lower costs in other countries. Do they have automation that we don't?

Umm a 40% discount on healthcare is huge is ~16% of US GDP which is significantly higher than the rest of the world. For reference that's savings is larger than the interest on the national debt. In other words the money we waste on healthcare is like doubling the national debt. Or twice what we spend on oil.

http://en.wikipedia.org/wiki/File:International_Comparison_-...

PS: Japan spends 1/2 what we do on healthcare despite a rapidly aging population. But, I would assume we would end up somewhere between them an Canada, because a significant portion of Canada's costs relate to it's vary low population density.

Actually canada only spends about %66 the amount of money that the USA does as percentage of GDP.

http://en.wikipedia.org/wiki/File:International_Comparison_-...

> I've actually paid for health insurance out of pocket as an "older american". Rent was more expensive.

I think you were very lucky. As a "young & healthy american," that was not my experience.

It's not luck, just state by state differences. Some states are much better than others.

What the fuck, downvoters. Seriously, health insurance is regulated differently on a state to state level, and some states have more consumer-friendly laws than others on the matter.

It's hard to believe that CA is one of the better ones.

And no, it wasn't a bare-bones policy, let alone an HSA. Either of those options would have reduced the cost significantly.

Being cheaper than rent is a pretty low bar.

> healthcare could be a lot less expensive, but since much of that expense comes from govt involvement

Citation please.

(In other words, you're wrong. And you know it.)

> Citation please.

Govt mandates that "health insurance" cover things for which I have no interest. Those things increase the cost. Govt mandates that I can't buy health insurance across state lines, which reduces competition.

There are so many ways in which govt increases the cost of healthcare that I could post large numbers of citations and not even scratch the surface.

> (In other words, you're wrong. And you know it.)

Are you claiming that govt involvement hasn't increased the cost of healthcare at all, or just quibbling about the size of the net increase?

Those are opinions, not citations.

I'm surprised you didn't mention "tort reform" too, another one of the debunked talking points.

If government is so bad, why does Medicare/Medicaid help more people at less cost than private insurance?