What's especially weird is the number of people here who are fiercely defensive of the arrangement, with the only rationale being it's the status quo. See also car-centric urban design.
Just because it's not ideal doesn't mean it couldn't be worse. It's not like the constant stream of federal management disasters over the past 20 years has been inspiring.
> What's especially weird is the number of people here who are fiercely defensive of the arrangement, with the only rationale being it's the status quo
Most Americans (roughly 70%) are happy with their health insurance. That's a reason to be defensive other than it "being the status quo".
There's quite a difference between being happy with your insurance and being happy with it being tied to your job. My insurance is fine. The fact that if I were fired tomorrow, my partner and I would suddenly need to either start paying thousands of dollars a month to maintain it via COBRA or scramble to find an entirely new set of doctors and therapists is not fine.
Who are these Americans? I have never once been happy with my health insurance; I mean, sure, it beats not having it in this country, but I constantly get billed the wrong amount because someone at the hospital didn't code it exactly the way the insurance company requires, or suddenly my health insurance decides that my doctor or dentist isn't covered so now I have to pay up front and do a song and dance to get reimbursed for some smaller fraction of the price, or whatnot. If I go to the ER (even accidentally, when I asked for urgent care but got directed to the ER instead), I've got a $500 dollar bill waiting for me regardless of what the treatment I needed was. Oh, or I'm on a medication that's prescribed by my doctor, but suddenly the insurance company decides it's not covered and I have to pay hundreds of dollars out of pocked while I chase my doctor down to send them more documentation that yes, they tried other alternatives first and they weren't effective, yes I really do need this medication.
And I pay more for this, just in terms of my monthly premiums, not to mention all of the out of pocket and deductible costs, than I would in taxes for healthcare in just about any other developed country.
I don't know what metric people are using when saying that they are "happy" with their health insurance, other than comparing it to being uninsured in this country, in which case, sure, it beats that.
Kaiser in California is pretty great. It's like an all-in-one thing[1] with the general doctors, pharmacies, specialists etc all under one roof. It's bureaucracy heavy, but sensible, sort of thing.
[1]: this arrangement is also technically illegal in California, but worked around with a Three Corporations In a Nonprofit Trenchcoat sort of deal. The seams mostly don't show.
What is even more especially weird is that a relativiely new country with 330 million people stretching 2800 miles have different thoughts and opinions. See also group think.
Is it tied to employment or is it tied to insurance companies who make it punitively expensive to get insurance without being in a group, and that group is typically "employers" ?
My wife runs a business and employs, typically, only 1 or 2 people; when they started asking for health insurance we found that getting insurance (as a business) was actually not terribly expensive; at the same time my insurance plans have gotten progressively more crappy.
I can't remember, or be bothered to find out -- how expensive is it these days to just get private insurance in the USA if you've got 3 hideously expensive pre existing conditions? I have some vague recollection that the obamacare thing requires that insurance companies offer coverage to people without regard to those preexisting conditions, and intuitively that seems "fair" but it's all such a pile of crap it's frustrating to dig through and demotivating. I assume "that's the way they like it."
> I can't remember, or be bothered to find out -- how expensive is it these days to just get private insurance in the USA if you've got 3 hideously expensive pre existing conditions? I have some vague recollection that the obamacare thing requires that insurance companies offer coverage to people without regard to those preexisting conditions, and intuitively that seems "fair" but it's all such a pile of crap it's frustrating to dig through and demotivating. I assume "that's the way they like it."
Take a look at your state's healthcare marketplace site. You should be able to browse plans if you put in your county/zip code and participant ages. Marketplace plans can't charge based on health history, and at least in my area, they all seem to cover the minimum required services and nothing else; they compete on networks and copay/coinsurance.
It's not the giant morass of pain that it used to be, but it's still somewhat of a pain, and often employer based plans are better; especially in terms of networks and out of area coverage.
The US has government provided healthcare as well for people without jobs or with a low enough income level. It isn’t “tied to your work” that’s just one of many ways in which people choose to get healthcare.
Medicaid is pretty complex and runs afoul of you accidentally having too much income or assets despite being functionally low income. When used car prices started trending upward during the pandemic people actually got kicked off medicaid rolls because their vehicle was now too valuable of an asset to make them eligible for benefits.
Means-testing is just a very inefficient, clumsy way of providing benefits to people and functionally operates as a tax on those who would benefit from the service but would fail the test.
I've never understood how the right-wing thinks that having a government agency work to determine if people are 'poor enough' to 'earn the right' to have healthcare provided is an efficient use of resources. Seems backwards to me. If we want people to be able to work, basic health is a requirement.
A cynic would say that the right-wing isn't about efficient use of resources, it's about a justice where some people deserve to be kept trodden down even if it costs more to do so.
What's weird actually is how unified for such a young and populous country are the opinions of people with money and political power. You know, the ones that actually make the rules everybody else is forced to obey.
Seems like easy solution would be to ban that entirely. So everyone would be forced to get health insurance from free market. The compensation could be moved to regular pay. And tax deduction given.
That would be a double whammy of positive side effects.
Besides decoupling the insurance from employment to facilitate career changes and even quitting, it would also bring down the average price of insurance for people who currently get it on the individual market as the average corporate worker is statistically healthier than the rest of the population.
Eliminating the tax deduction is not enough as even at break even the company offering health insurance is a net win from the lower risk pool. It had to be an additional penalty / tax.
> Seems like easy solution would be to ban that entirely
It’s not really “easy” to reform/change anything this significant in the US. It is not like a European country with a functioning modern parliament that can make laws. In the US system both major parties have to agree in order to pass anything of substance, which due to hyper-polarization means essentially nothing gets passed.
To some extent, that would just move the problem around rather than solving it. In the US, the individual States have a lot of control over how healthcare is implemented, as a Constitutional matter. Every time a State looks into eliminating employment-based insurance, rudimentary analysis shows systemic risk due to arbitrage and adverse selection that is nearly impossible to design out of the system legally. Due to fundamental differences in how individual States are governed and funded, and their respective Constitutions, this is a durable feature of trying to change the way the system works (i.e. harmonizing it is infeasible).
The US healthcare system is stuck in a deep local minima. The cost of transitioning to a different equilibrium is so high that it is obviously politically infeasible any most if not all States. I don't like the current system but if there was a viable path to a different model, at least some States would have taken it.
These conversations never consider that the US does offer pretty robust welfare programs for cases just like this. He would undoubtedly meet the case for 'disabled' as defined by the Social Security Administration if he lost his insurance and had low/no income. Pennsylvania also offers additional medical assistance if you meet that guideline.
I don't know if you've ever had to try to get that designation by SSA, but in my (second and third hand) experience it is extremely difficult to qualify. SSA regularly denies and then you have to get a lawyer and sue them for benefits and restitution. There are also asset and income tests that at this point are effectively punitive.
I don't know anything about Pennsylvania, maybe it's easier there.
The fact that you have to spend time trying to get yourself designated such whilst you are probably looking for a job, struggling to pay your rent or mortgage, and dealing with other stressors is ridiculous.
At least in PA, having a disability (I'd assume MS with motor difficulties would qualify) makes it pretty straightforward, based on my experience. Like most government interaction, there's lots of paperwork, but the employees administering it are generally helpful, competent, and pleasant.
I'm sure the bar is higher without a disability, but the asset tests in PA are reasonable, considering they exempt your residence and 1 vehicle.
There's probably horror stories of people falling through cracks, but I just find it disingenuous when people breathlessly proclaim that the US callously let's people die on the street from a loss of employer health care.
"Robust", good joke. The purpose of these laws is to do what you're doing: mention they exist. But there is a huge process to actively demotivate the applicant to succeed. I know someone who actively tried to get benefits and was first denied and had to reapply (while she won lawsuit against her former employer). I was there when she did the paperwork. It is huge, and it has large legal ramifications. And it is the same in The Netherlands.
My father had MS, and he was considered a fraud (back in the 70s). Of course, such is easily said if there are no repercussions (I, parent of two young children, have been called a pedophile by my neighbors ...). It is very likely he also had autism, like me, a burden to function in society and a mark on your forehead cause "you're weird".
I've been suffering from a burnout (related to my neighbor's behavior) since start last year and when I applied for benefits because I got fired I've been told I should've reported myself fully healed earlier. I've also been asked questions to which the answers weren't written down because (and I quote) "I'm not allowed to ask that question".
If you apply for any social benefits, society considers you a fraud and you have to prove you're not. This is immense work, more so for people who suffer from disabilities (likely those who rightfully apply).
I deal with parolees coming out of prison in the USA and try to get them set up with healthcare under the State plan here in Illinois. It is a pain. Most of these guys would have a lot of trouble getting set up and qualified if left to their own devices. Very complicated system that is tangled up in the fact that it is socialized healthcare sitting on top of mostly privatized healthcare. At least Chicago (Cook County) has its own healthcare system that plugs in to the system and offers a great backstop.
Oh please. For any local/state/fed program, there's MONTHS of means testing, multiple assessments of various kinds, multiple times to prostrate yourself to show that you *really* are in need of help.
Oh, and then you get denied. Multiple times.
This country would rather "useless" (read: cant make money for capitalists) people die.
It's very intentional. A strong leverage on the side of the employer to further skew the employer–employee """balance""" of power in favour of the former.
Procuring health insurance is not tied to a job in the US, since 2011 or so. Anyone can buy health insurance at healthcare.gov.
They just usually cannot afford it, even though there are subsidies available, most people will not earn or save enough to pay the deductibles / out of pocket max.
And when I looked at COBRA ( which is basically your employer insurance without the company payins) it looked to be about the same as a similar marketplace plan.
I ended up waiting for Medicare eligibility anyway which, with supplemental and prescription drug coverage is probably not nearly as much cheaper as a lot of people assume.
It's by design; we had salary caps during WWII so employers offered benefits.
In the 1960s when healthcare costs began to rise there was a conversation around changing it, but by 1970s it was concluded that on balance tying it to employment had benefits in reducing labor action (strikes), which was a big concern back then. We've stuck with it since.
It’s sort of the same in Japan, though I can get the same health insurance without a job, every time you switch jobs (or from job to jobless, or vice versa) you need to go to city hall to get a new card.
On the other hand, as long as you have that card everything is really cheap, which is definitely not true in the US.
No, because health insurance has always been available to individuals (and families). We've never needed to go through our employers to get it. But back before WWII health insurance was pretty much not used at all; health care was so cheap that it cost less than food or clothes. During WWII Congress passed laws that fixed the price of goods, services, and wages. This started to lead to shortages. Combined with the draft, many industries were competing over fewer and fewer employees, but legally they could not raise wages. Instead they started offering perks such as tips from the customers or “free” health insurance. Even companies that don’t offer free insurance usually split the cost with their employees, and often they do get a slightly lower rate because all their employees are shopping from the same company. And it’s not like you can raise your salary by negotiating out of the insurance; the employer likely pays the same amount to the insurance company regardless. The insurance lowers our salaries no matter what we do; might as well take it.
Gradually these perks started to become as important of a consideration as the salary itself. Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care.
In fact, I think this guy overstated the risk to his health. If you get fired you don’t actually lose your insurance. You sign up for continuation of coverage from COBRA, taking over payments for the insurance from your employer, and then purchase an individual or family insurance plan of your own before COBRA runs out. Or get hired somewhere else and sign on to one of their insurance plans. Either way you’ve lost nothing, at least in terms of health care.
> Unfortunately health insurance is easily misused. We started relying on it to pay for all health care, rather than to actually mitigate the risk of a sudden medical bill. The result has been a rapid and continual increase in the price of health care over the last 70–80 years caused directly by the fact that nobody pays for the services they use, but instead pays into insurance plans that then pay for the care.
I don't think it's as simple as that. Empirically, lots of countries have health insurance systems whose incentive structure could be described in the same way, yet the US is an extreme outlier in healthcare costs. Something else must be going on.
I don’t think any other national system offers the same un-rationed, low-wait access to
- top-skill, top-paid specialists
- world-class research hospitals with near-luxury-level amenities
- cutting edge pharmaceuticals, including absurdly expensive novel biologics
that is enjoyed by, say, a junior Microsoft developer and her family in Seattle.
One example of how this plays out as GP described is childbirth: There’s something like a 5X cost disparity for a typical birth process between a perfectly competent regional hospital and an elite research institution. But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food.
Obviously, this is not every American’s experience with the system, but for the portion of outlier costs that aren’t related to outlier US population health trends (e.g. obesity), it’s an important part of the story.
> But the typical well-insured US mother-to-be doesn’t spend a moment thinking about that difference vs., say, the reported quality of the food.
Your definition of "typical" apparently is very different from my own, or we are thinking about "well insured" very differently. Every pregnant person that I've ever talked to, if they have a choice at all, has weighed the projected cost heavily in their decision on where to give birth.
The typical person in the US has a deductible that runs well past several thousand dollars and then they have to pay a coinsurance amount, which could be up to 25% of the cost, up to absurdly high out of pocket maxes.
Also, his definition of "low-wait" is different than others'. Last time I tried to get a new-patient appointment with a doctor, every doctor in my area had a 4-8 month waiting list.
And yes, the cost weighs highly in mind every time we make a decision about whether we need to go to the doctor or not. Not knowing if this trip to the doctor is going to be the one that bankrupts us (cancer diagnosis?), I tend to simply not go unless a limb is falling off. My wife on the other hand came from a country with socialized health care, and can't shake the habit of just going to the doctor whenever she feels ill or injured. Then I have to be the bad guy with the "honey I know you feel sick but do you feel that sick? We're looking at a minimum bill of many hundreds of dollars out of pocket every time you go."
COBRA is Where you need to start paying for the full cost of the insurance plan your employer was paying most of while your income has been entirely removed. It's such a dumb law.
The alternative is no income, no insurance, and no mechanism to continue your coverage. The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor.
> The point of COBRA is to continue your existing benefits, soaking the total cost yourself, so you do not have to find a new doctor.
Just a new source of income to pay the rent, or a free place to sleep since you can’t afford rent anymore, now that you’re paying for health insurance instead.
COBRA is an artifact of pre Affordable Care Act health insurance, when you could be denied for pre existing conditions and it simply was not sold as easily to individuals.
It can easily be dispensed of and nothing would change, people would simply need to go to healthcare.gov.
When I looked at it I’d probably have gone with COBRA but just because it was short-term and it meant I basically wouldn’t have had to think about anything.
In those countries, your taxes pay for the health care. If you don’t have a job, you are freeloading. Your health care raises the amount of taxes that must be collected from everyone else.
Your last paragraph suggests your understanding of US healthcare is entirely theoretical. In practice, COBRA is frequently so much more expensive that it wouldn't be affordable even if you hadn't just lost your job. In practice, millions of people are trapped in jobs they don't want but can't leave because they need healthcare and will lose access to healthcare if they lose the job. It's a stupendously shitty system that gives US employers even more of an upper hand than they would otherwise have.
I’ve paid for my own insurance via CORBA. I wish those checks had been entirely theoretical, but the fact is that my employer had been writing those same checks on my behalf and then they stopped. The insurance company isn’t going to give me anything for free.
Yes, the ACA made it so everyone can go to healthcare.gov and buy health insurance.
Health insurance and healthcare is NOT tied to your employer in the US.
However, many employers pay 50% to 70% or even 100% of the health insurance premiums for their employees, and employees can use pre tax income to pay health insurance premiums if purchased by their employer.
The problem has always been this tax advantage of your employer purchasing it, AND most Americans opting to not purchase it due to cost.
Note that there are significant subsidies available if you earn less than 400% of the federal poverty level, although that may still leave many unable to purchase it (or the deductible/oop max is so high it would not make any difference).
The other problem is that ACA plans are garbage compared to group plans, with no out of state or out of network coverage available. If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by.
I have been able to find equivalent plans in 3 states, usually BCBS ones that are the same as any self insured or employer group plan. Might not be as good as the employers with especially high portions of young, healthy, higher paid office workers, but for most people, it should be comparable.
> If you end up needing a hospital stay, you could be in trouble if the "wrong" doctors do a drive-by.
This is not true since the No Surprises Act went into effect Jan 1, 2022. Everything is considered in network in an emergency, and if a doctor works in an in network hospital, then the doctor is considered in network too.
Interesting. In the few states I looked, there were no PPO plans (including by BCBS). As for hospitals, I guess it's important to know which hospitals are in network near home and anywhere you might be traveling?
Usually in an emergency I don't have the presence of mind to direct the ambulance to the right hospital (in case the emergency turns into an overnight stay), and it's all the more important if the plan doesn't have good (or any) out of network benefits.
In an emergency, all hospitals/doctors/facilities are treated as if in network, so you would not have to direct the ambulance to the in network hospital.
I don’t think so, if you get discharged from the hospital under your own recognizance, you are no longer in an emergency. If you are not discharged, then how could they argue it is not an emergency?
Out of pocket maximums and simply being able to get insurance regardless of your health is pretty huge.
Also, the age rating factors being capped at 3 allows older people’s health insurance premiums to be much lower before age 65, although I maintain that this young to old wealth transfer is not beneficial for society.
Not entirely true. You have COBRA after losing employment for some time
COBRA is good insofar that it lets people know the real cost of health insurance.
Thats the cost for covering everything under the sun + every bad habit + risky behavior. Instead of you know: emergencies, no fault accidents, and unexpected genetic problems. (Like, say car insurance)
Not only is this a strange opinion, that you want some kind of entity to decide whether or not each of our health conditions are at-fault, your analogy to car insurance isn't even true in no-fault states, of which there are many.
