If I start a fire insurance company, and I have a policy that you can sign up even if your house is currently on fire, I'm unlikely to stay in business.
Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact.
This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered.
Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand.
Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).
I don't understand why people are so opposed to the "mandate". We have the same thing in so many other places, only those are handled by paying taxes for things you might not need.
I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different?
If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.
> Either we deny coverage to those that are already ill, or we force everyone to have insurance
This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
Insurance with pre-existing condition is just health care. You are not insuring against anything.
My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.
The problem is that you have a tripple system. You have the insurance for unlikely but expensive accidents/cancer/etc which is what insurance is good for; you have subscriptions for things like annual health screenings, common care etc and finally you have subsidies for those who have shit health.
It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children.
There is no need to require everybody to buy an overprized service bundle.
With regards to pre-existing conditions, Ryan's plan talks about continuous coverage policies. Under a "continuous coverage" policy, a person with a pre-existing condition would need to avoid having any gap in insurance coverage in order to avoid paying more for insurance or being denied outright.
So if you lose your job and your health coverage, insurers would be able to deny you coverage.
But if you never have a gap, then you can't be discriminated against.
Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.
Why don't we have two systems? One of guaranteed healthcare for the expensive conditions and one of insurance against everyday issues and accidents. So single payer towards things like cancer and insurance for getting checkups, having a cold, going to the ER, etc. Could some middle ground solution like that work?
It's more like winning a state lottery, where the monthly payout will be terminated if you leave the country for any reason.
There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time).
This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
I think it's much more complicated then that. Perhaps a different analogy is better:
There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance.
Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them.
Then there are the people who prefer paying for things out of their pocket as they go.
The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.
The ACA in it's current form is probably comparable to a fire department in your analogy.
As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.
As a Canadian, I hit CTRL+F and searched for "Canada" in this thread with over 600 comments and didn't find a single result. (Edit: My mistake, missed one other Canadian!) I searched for a few other nations with universal healthcare and couldn't find any references to them, either.
It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.
Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with.
I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?
Many Americans and many politicians often do look to other countries for examples of how to do something right. The problem is we have a loud-mouthed national-pride movement that believes in American exceptionalism and can constantly think of excuses as to why Canada's system wouldn't work here, or the NHS wouldn't work here, or every other country's system wouldn't work here. We're unique, so those other systems won't work here.
We also have a large contingent of people who take immense pride in voting against their own self-interest. They'll look to Canada's system and say "yeah but they wait for days to get an x-ray for a broken arm" ignoring the fact that they themselves couldn't even afford to get an x-ray. But it's worth it because even though I can't get healthcare, the people I hate can't get it either.
As shown by the most recent election, it's political suicide to imply that America isn't the single greatest nation in the world. It's even worse to suggest that we should be asking some other country for help. Those other countries are communists, and the only communist we like is Russia.
Australian here, same opinion. It seems, watching from afar, that the american public is somehow being convinced that free health care is impossible. We have free health care here and there are some issues here and there but in general it works and is not burdensome tax wise. If you want you can pay additional for private insurance and get private coverage in private hospitals, which means a room to yourself and so on, and you can choose your doctor. In the public system you get the doctor available, but when it comes to specialists, they're the same doctors usually, because there's only so many specialists.
Recent experience - my daughter sprained her ankle, so went to the hospital for x-rays. I live outside the city so the doctor we saw was coincidentally our local GP. The price $0, time waited - about half an hour, this was on a Sunday night.
One thing that may be a factor here is the medical practices are run by doctors - no professional manager people which, from what I understand, seem to be in the US health system. The doctors, in general, really are people who want to make people well and thats what they do. Sure they like to make a buck and they do but not at the expense of everyone else.
If you let non medical people into the system to manage it then, I'd look closely at their motives, I suspect you'll find sometimes their motives aren't pure.
In the early 20th century, both Canadians and U.S. citizens formed unions to push for better living/working conditions in their country.
The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers.
This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less.
Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.
Yes. It's absurd that this is even a debated topic when dozens upon dozens of countries around the world have successfully implemented universal health care systems which have resulted in better health outcomes than the US.
> It is really interesting how the American mindset is to never look abroad to see what works and what doesn't.
Oh we definitely look abroad. In fact that's one of the major arguments for a single-payer system in the U.S. - such a system exists successfully in every other capitalist democracy. So why can't we make it work here?
And this looking abroad is not a tonic against bad thinking. Conservatives routinely look at health systems in other countries and decry them: long waiting lists for elective procedures, high marginal income tax rates, etc., etc. Any flaw in another system is magnified and considered a non-starter.
Obamacare was based on an older Republican plan which had been implemented by Mitt Romney in Massachusetts. But in the run-up to Obamacare conservatives hyperventilated about "death panels" and how the ACA was going to destroy the economy. None of which came to pass.
One way the US could look to Europe is by not forcing a single one-size-fits-all solution on every state, but rather leave health care to the individual states, which allows for more experimentation, variety, and competition. This would require congress repeal ACA and replace it with no federal health care law, just like is done with Europe's central government.
> There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.
Everyone understands the healthcare systems in Canada and most of Europe. There is no point mentioning it because for most of Republicans it's a non-starter. It's incredibly niece of you to think a bunch of liberals have never thought to look elsewhere, at best. At worst you wanted to just blanket insult the US.
The problem is that middle class Americans are charged outlandish rates for the plans.
The plan for my family last year cost over $1200 per month, and this year rose to $1400/month.
Previously, with employer-provided plans I paid at most $400/month for my family.
Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.
A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month.
In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan.
The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what.
I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price.
I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment.
One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.
ACA has got to be the largest tax increase ever foisted on the middle class.
We already have a progressive tax, but let's add an individual mandate, tax credits that phase out at 400% FPL, and cost sharing subsidies which phase out after 250% of FPL.
The maximum value of the tax credits for your family would be nearly the full cost of the premiums at 133% FPL, let's say $12,000. Then on top of that the cost sharing reductions would reduce your out-of-pocket maximum -- which if you're truly unlucky could run your family another $14,300 -- to a maximum of $4,500, so that's worth potentially another $10k.
What this means is ACA is a $12,000 - $22,000 tax on your family depending on your health care utilization, as income rises from 133% - 400% FPL.
For a family of 4 the 133% FPL = $32,250 and 400% = $97,000. So as you make that extra $64,750, in addition to all the other taxes you are paying, you are also phasing in $12,000 - $22,000 of increased payments for the same exact health care. Now that is one hell of a tax.
So while you and your spouse are working your asses off to earn $150k, you can look back and appreciate how $10k went to the town, $10k to the state, $30k to the Fed and ~$15k to the SSA. So it's really just the cherry you're being charged an extra $15k for insurance, come on, you can afford it!
I won't mention all the other subsidies you lose out on for being a productive member of society. Because when you realize the real tax rate approaches 100% on the first $97,000 it's a bit of a buzz kill.
It's meaningless to compare employer funded plans to ACA plans without knowing what amount was being subsidized by your company. It's also a different risk pool.
The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage.
If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.
> Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.
Isn't this just because now insurance companies have to cover preexisting conditions and also not charge them exorbitant prices? Naturally, they would be taking a loss in order to do this so that burden is instead shifted onto the healthy people. To prevent healthy people from just not buying insurance, the mandate was made because it's economically unfeasible without them.
If you're the type of person who would normally use a high deductible plan, you're worse off, but that's the way it was supposed to be. Presumably if one day you get very sick though, you will still be able to get insurance.
I quit my job and moved to Colorado ("Health First Colorado" === medicaid). Over the winter holiday I broke my collarbone.
If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else.
Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes.
* - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about.
edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P
I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible.
I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off.
Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?
It's frustrating to see so much energy wasted in fragmenting health coverage solutions in the US. This makes it so costly, that it _looks_ like it's too expensive or inefficient, making right wing politicians justify the fact that it should be everyone for themselves.
As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly.
Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts.
In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.
The prevalence of employer-offered, private health insurance is – like many facets of American life and institutions – an interesting path dependency of WW2.
The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.
Something just seems wrong about a lot of these stories citing the provision that they're allowed to remain on their parents insurance until they're 26. Because the story is really, "not having to worry about the high cost of health insurance afforded me the luxury of taking more financial and career risks." Surely we can do better for people who are older than 26 or who don't have the option of getting insurance through their parents. If we wanted to give everyone this kind of benefit we would just have universal healthcare with the state acting as everyone's 'parent'.
The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?
Chiming in to say that we wouldn't have been able to start our last company or this most recent one without the ACA. One of these YC stories had a founder who was rejected because they had a sleep study done. Most people have never interacted with the individual insurance market, and so don't realize that virtually any interaction with the health care system beyond a strep throat test would, prior to the ACA, get you declined automatically: you were uninsurable at any price. That's what happened to us; for instance: my daughter had an unexplained seizure when she was 4 (she's a healthy 15 year old now), and was thus declined.
I've always disliked how right-wing parties automatically get to enjoy the assumption that they are "business-friendly". That's not the case -- their policies tend to be friendly to existing big businesses, but may be deeply hostile to new or merely potential businesses.
This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.
There is also the mantra that Republicans are the party of small government and fiscal responsibility. Nope, the difference between Democrats and Republicans is what they want to spend the money on. This is just a fact, easily verified by looking at the debt across decades of various administrations and congressional alignments.
A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this:
Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.
I see it as part of the DC bubble effect. What is considered "pro business" is defined by corporate lobbyists, what is "pro labor" by the unions with the largest bureaucracies, and so on.
These problems are all a result of the huge tax benefit given to employer-provided healthcare; if we got rid of that or extended it to apply to individual plans as well (and hopefully allowed people to purchase out-of-state insurance), it would reduce costs, and allow for more job freedom.
I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.
The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment.
Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit.
There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\
The ACA increases the opportunities for young people and people with chronic illnesses. By distributing those costs, healthy individuals pay more in premiums, which limit their opportunities. If we are optimizating for overall economic productivity, far more people benefit from not having the ACA.
I comment rarely, but had to chime in as the ACA was very important to me in terms of starting a company.
The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture.
What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk!
For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1.
I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it.
Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it.
Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.
I recently quit my six figure salary job at a startup here in Minnesota to start my own startup. Just before I quit I was looking at around $650/month premiums for my family of four as the absolute cheapest plan with the highest deductible. Right after I quit, the two largest health insurance providers in MN pulled out of our MNSure health insurance exchange, causing premiums to spike up across the board. Now I am faced with a $1200/month premium which is more than I'd pay for my former employer's health plan through COBRA. Having to cover such a high premium expense is significantly impacting my ability to start my company.
So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses.
What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.
A lot of complaints about the ACA seem related to monthly premiums going up compared to pre-ACA plans. It goes something like this: prior to the ACA I was paying $X, now I'm paying more, therefore the ACA is bad.
But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA.
Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place.
So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement.
It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations.
This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.
""my only option was to work for a large employer with an established health plan that would provide me with the appropriate benefits to support my situation""
I think the anti-ACA lobby sees this as a feature not a bug.
The ACA passed on a purely partisan vote and will be repealed on a purely partisan vote.
The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster.
In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn.
There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome.
I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be.
Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece).
Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows.
Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.
As a young, healthy male in my 20's pursuing entrepreneurship, the best health insurance for me is the ability to declare bankruptcy. I have chosen to go uninsured and pay the ACA penalty because it's so much cheaper than paying for a catastrophic health insurance plan. Why would I pay $4000 per year for a $6000 deductible? I do not see any benefit from that except in the case of catastrophe. It's just flushing money (that I don't have) down the toilet.
If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years.
This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.
This post, especially presented as it is through the voices of these founders, makes an important point.
However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores:
Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA.
The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA.
For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.
For those with a Wall Street Journal subscription, they had an excellent unbiased article on the economics of providing healthcare for people with serious medical conditions. Anyone trying to reform or repeal the ACA will have to address this issue.
"Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay"
Had ACA existed when I graduated from college, I would've been able to remain on my parent's health insurance plan until 26 (5 extra years). This would have allowed me to take a job with a startup company that could not offer health insurance instead of joining a large multi-national corporation that offered good health coverage. Wow...thinking how different my path could have been with that opportunity. I heard about YC two years out of college (it started the year I graduated), all I wanted to do was apply and talked myself out every time as I am unable to go without health coverage and would not have qualified for an individual plan due to past health history.
I have no pre-existing conditions, but being able to sign-up using the exchange was a big reason I was able to go full-time in a small business rather than continuing to work part-time for a large company to keep health benefits. The monthly premium is too high in my opinion, but one hospital visit made it worth it.
Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.
[+] [-] jakewins|9 years ago|reply
Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact.
This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered.
Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand.
Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).
[+] [-] lutorm|9 years ago|reply
I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different?
If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.
[+] [-] losvedir|9 years ago|reply
This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
[+] [-] bentruyman|9 years ago|reply
Insurance with pre-existing condition is just health care. You are not insuring against anything.
My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.
[+] [-] tomjen3|9 years ago|reply
It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children.
There is no need to require everybody to buy an overprized service bundle.
[+] [-] platz|9 years ago|reply
So if you lose your job and your health coverage, insurers would be able to deny you coverage.
But if you never have a gap, then you can't be discriminated against.
Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.
[+] [-] enknamel|9 years ago|reply
[+] [-] ctdonath|9 years ago|reply
There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time).
This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
[+] [-] gwbas1c|9 years ago|reply
There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance.
Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them.
Then there are the people who prefer paying for things out of their pocket as they go.
The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.
[+] [-] bduerst|9 years ago|reply
[+] [-] iaw|9 years ago|reply
As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.
[+] [-] brandon272|9 years ago|reply
It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.
Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with.
I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?
[+] [-] freehunter|9 years ago|reply
We also have a large contingent of people who take immense pride in voting against their own self-interest. They'll look to Canada's system and say "yeah but they wait for days to get an x-ray for a broken arm" ignoring the fact that they themselves couldn't even afford to get an x-ray. But it's worth it because even though I can't get healthcare, the people I hate can't get it either.
As shown by the most recent election, it's political suicide to imply that America isn't the single greatest nation in the world. It's even worse to suggest that we should be asking some other country for help. Those other countries are communists, and the only communist we like is Russia.
[+] [-] chadcmulligan|9 years ago|reply
Recent experience - my daughter sprained her ankle, so went to the hospital for x-rays. I live outside the city so the doctor we saw was coincidentally our local GP. The price $0, time waited - about half an hour, this was on a Sunday night.
One thing that may be a factor here is the medical practices are run by doctors - no professional manager people which, from what I understand, seem to be in the US health system. The doctors, in general, really are people who want to make people well and thats what they do. Sure they like to make a buck and they do but not at the expense of everyone else.
If you let non medical people into the system to manage it then, I'd look closely at their motives, I suspect you'll find sometimes their motives aren't pure.
[+] [-] bduerst|9 years ago|reply
The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers.
This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less.
Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.
[+] [-] nodamage|9 years ago|reply
[+] [-] leepowers|9 years ago|reply
Oh we definitely look abroad. In fact that's one of the major arguments for a single-payer system in the U.S. - such a system exists successfully in every other capitalist democracy. So why can't we make it work here?
And this looking abroad is not a tonic against bad thinking. Conservatives routinely look at health systems in other countries and decry them: long waiting lists for elective procedures, high marginal income tax rates, etc., etc. Any flaw in another system is magnified and considered a non-starter.
Obamacare was based on an older Republican plan which had been implemented by Mitt Romney in Massachusetts. But in the run-up to Obamacare conservatives hyperventilated about "death panels" and how the ACA was going to destroy the economy. None of which came to pass.
[+] [-] em3rgent0rdr|9 years ago|reply
https://mises.org/blog/how-us-states-compare-foreign-countri...
[+] [-] plandis|9 years ago|reply
Everyone understands the healthcare systems in Canada and most of Europe. There is no point mentioning it because for most of Republicans it's a non-starter. It's incredibly niece of you to think a bunch of liberals have never thought to look elsewhere, at best. At worst you wanted to just blanket insult the US.
[+] [-] grandalf|9 years ago|reply
The plan for my family last year cost over $1200 per month, and this year rose to $1400/month.
Previously, with employer-provided plans I paid at most $400/month for my family.
Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.
A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month.
In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan.
The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what.
I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price.
I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment.
One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.
[+] [-] zaroth|9 years ago|reply
We already have a progressive tax, but let's add an individual mandate, tax credits that phase out at 400% FPL, and cost sharing subsidies which phase out after 250% of FPL.
The maximum value of the tax credits for your family would be nearly the full cost of the premiums at 133% FPL, let's say $12,000. Then on top of that the cost sharing reductions would reduce your out-of-pocket maximum -- which if you're truly unlucky could run your family another $14,300 -- to a maximum of $4,500, so that's worth potentially another $10k.
What this means is ACA is a $12,000 - $22,000 tax on your family depending on your health care utilization, as income rises from 133% - 400% FPL.
For a family of 4 the 133% FPL = $32,250 and 400% = $97,000. So as you make that extra $64,750, in addition to all the other taxes you are paying, you are also phasing in $12,000 - $22,000 of increased payments for the same exact health care. Now that is one hell of a tax.
So while you and your spouse are working your asses off to earn $150k, you can look back and appreciate how $10k went to the town, $10k to the state, $30k to the Fed and ~$15k to the SSA. So it's really just the cherry you're being charged an extra $15k for insurance, come on, you can afford it!
I won't mention all the other subsidies you lose out on for being a productive member of society. Because when you realize the real tax rate approaches 100% on the first $97,000 it's a bit of a buzz kill.
[+] [-] jbarciauskas|9 years ago|reply
The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage.
If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.
[+] [-] rifung|9 years ago|reply
Isn't this just because now insurance companies have to cover preexisting conditions and also not charge them exorbitant prices? Naturally, they would be taking a loss in order to do this so that burden is instead shifted onto the healthy people. To prevent healthy people from just not buying insurance, the mandate was made because it's economically unfeasible without them.
If you're the type of person who would normally use a high deductible plan, you're worse off, but that's the way it was supposed to be. Presumably if one day you get very sick though, you will still be able to get insurance.
[+] [-] amluto|9 years ago|reply
Would that still be true if you had to pay retail for all your care?
[+] [-] mr_spothawk|9 years ago|reply
If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else.
Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes.
* - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about.
edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P
[+] [-] kobeya|9 years ago|reply
I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible.
I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off.
Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?
[+] [-] RRRA|9 years ago|reply
As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly.
Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts.
In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.
[+] [-] nooron|9 years ago|reply
The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.
[+] [-] beat|9 years ago|reply
Still, we all know what it's like to have a major design flaw in the legacy codebase.
[+] [-] Spivak|9 years ago|reply
The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?
[+] [-] tptacek|9 years ago|reply
[+] [-] pavlov|9 years ago|reply
This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.
[+] [-] tasty_freeze|9 years ago|reply
A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this:
http://www.patheos.com/blogs/dispatches/2017/01/11/republica...
Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.
[+] [-] resfirestar|9 years ago|reply
[+] [-] BurningFrog|9 years ago|reply
There is a big distinction between "pro free enterprise" and "pro business". The former supports capitalism, the latter crony capitalism.
> Under Republican policies, these businesses would not exist
I think the GOP has yet to figure out what their health care policy even is. They really need to figure out how to be for something again.
[+] [-] nickff|9 years ago|reply
I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.
[+] [-] misnome|9 years ago|reply
[+] [-] k__|9 years ago|reply
The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment.
Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit.
There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\
[+] [-] adrianparsons|9 years ago|reply
[+] [-] phamilton|9 years ago|reply
[+] [-] mas644|9 years ago|reply
The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture.
What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk!
For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1.
I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it.
Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it.
Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.
[+] [-] marknutter|9 years ago|reply
So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses.
What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.
[+] [-] nodamage|9 years ago|reply
But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA.
Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place.
So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement.
It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations.
This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.
[+] [-] jchrisa|9 years ago|reply
I think the anti-ACA lobby sees this as a feature not a bug.
[+] [-] grellas|9 years ago|reply
The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster.
In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn.
There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome.
I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be.
Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece).
Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows.
Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.
[+] [-] WhatIsThisIm12|9 years ago|reply
If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years.
This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.
[+] [-] jMyles|9 years ago|reply
However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores:
Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA.
The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA.
For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.
[+] [-] nradov|9 years ago|reply
"Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay"
http://www.wsj.com/articles/health-cares-bipartisan-problem-...
[+] [-] clbrook|9 years ago|reply
[+] [-] alphabettsy|9 years ago|reply
Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.