Conservatives expect a red-state paradise of unregulated health insurance, but they would actually recreate the dysfunctional blue-state insurance markets that prevailed before the ACA.
The part that confuses me, is why post-Roe repeal showing the huge political downsides of "catching the car" on an issue where you are massively underwater with the public, the GOP want to try it again.
There are many other priorities they could pursue in terms of lowering taxes, or regulations that make the economy more efficient, but they keep focusing on the area where if they succeed they will lose Senate seats and the house.
I know it’s considered “extreme” in the US (even though every other rich country has had it for decades or more) but universal healthcare is still the obvious solution here. Private health insurance companies are, well, private companies who are obligated to maximize value to their shareholders. For most companies, that works just fine. But for health insurance it results in some truly abhorrent practices. The profit incentives of the industry often are in direct opposition to what provides patients the best care and outcomes.
Additionally, about 15-30% (it varies depending on the study) of healthcare costs are purely for navigating the behemoth system of different healthcare policies and providers that are the result of our current patchwork system. We could get rid of almost all of that by just having one provider with one system of rules in place. A public provider could focus entirely on the public good rather than its bottom line, which would also decrease the cost of healthcare for pretty much everyone. Would your taxes go up? Sure, they’d go way up. But it would be more than made up for by the fact that you wouldn’t need private insurance anymore.
There is no way to finance a single-payer system within the political constraint that Republicans won’t raise taxes and Democrats won’t raise taxes on people who make less than $400,000. This is why the Massachusetts approach is inevitable: the math cannot add up in the system without substantial premium payments made by employers, employees and individuals; you can’t raise enough tax revenue to avoid the use of premiums. By the way, while 15-30% of health care expenditure is on administration, the administrative expense in a single payer system would not be zero. You would still need claims, approvals, etc.
Also most people like their employer-provided healthcare plans and don't want to change them!
That said, the amount we spend per capita on healthcare compared to other rich countries where people live longer is ridiculously high. Leftist Euro-worship is annoying, but running healthcare systems is clearly something like subway design that the Europeans do better than us.
We could probably cut out health spending in half and have outcomes that were not really that much worse, and it would probably be a trade-off we'd make soberly, but when someone's got brain cancer they want the best care even if its benefits are marginal.
Yes, as I said, the US probably wouldn't be that much worse off. Have less choice and noticeably lower spending and the effect might be so small it's not even measurable.
But no one wants *their* choice and spending reduced.
That describes the difference between our system and single-payer or nationalized systems like in Canada or the UK, but there’s a ton of fancy private healthcare in France or Germany or Switzerland if you want to pay for it (or your employer will pay for it). In Lausanne if you want a private room while recovering from surgery, they tell you how much it costs and you sign on the dotted line. It is seldom that simple in the USA.
There is maybe a bit more high-end care here then elsewhere, and quite a bit more medical research. But I simply don’t believe that our weird morass of subsidized insurance and complex hospital billing is a sign that we either get better healthcare or more meaningful choice for our extra spending.
I totally agree. I’m under no illusion that universal healthcare has any chance of actually happening, barring a major change in our political climate. It’s just unfortunate that a policy that has been shown to work in all the countries that are the most similar to us is such a non-starter with so many people.
Probably no way to do it within the constraint that Republicans won’t raise taxes and Democrats won’t raise taxes on people who make less than $400,000, but you could get closer by making people 55 and older eligible for medicaire and allow employers to provide medigap for those employees.
This is a serious question: what is the cadence with which we can expect posts from Josh? This last one was September 18. Matt Yglesias’ Substack is daily and only costs a few dollars more. I am having a hard time justifying supporting this endeavor when it produces such little content, even with the Presidential election a month away! I can’t be the only one who feels this way.
Late to this but I have been wondering the same question. A couple posts a month is a far cry from…what was it initially, two posts plus the Mayo Clinic plus a podcast, every week? I totally get that that pace is probably unsustainable. Indeed, I remember when Matt Lewis of the DMZ podcast had a job that required him to write three columns a week he complained about how hard it was almost constantly. But it would be nice to have more transparency about the plan/expectations.
I ended up not renewing this one, especially after the lack of an explanation. My other substack write 3-5 per week, I think once per week is a reasonable expectation given the cost. Even some of those user generated “mailbag” type columns would be nice. It doesn’t have to be all substance all the time. I enjoyed Josh’s weird hobby horses about grilling. But I didn’t get much value add compared to his Twitter feed.
Hi Josh – enjoyed reading this very much and had a quick question. The individual marketplace market got off to a rocky start but (by my understanding) was functioning pretty well by the late 2010s, even as enrollment was declining slightly under Trump. Under Biden, subsides were expanded significantly and enrollment has since doubled to >20m. My question is: if those ADDITIONAL Biden-era subsidies were to be removed, would the market not simply return to the pre-Biden levels/functionality, without necessarily entering a death spiral? Or is your point that, once enrollment is expanded, it’s effectively impossible to walk it back without entering a death spiral from adverse selection?
I don’t think reverting to the lower subsidies would lead to a death spiral in the market, though enrollment would fall. It’s eliminating the subsidies entirely that would cause a death spiral.
What a great explainer, and a good reminder of how completely unhinged the discourse around Obamacare was.
The part that confuses me, is why post-Roe repeal showing the huge political downsides of "catching the car" on an issue where you are massively underwater with the public, the GOP want to try it again.
There are many other priorities they could pursue in terms of lowering taxes, or regulations that make the economy more efficient, but they keep focusing on the area where if they succeed they will lose Senate seats and the house.
I know it’s considered “extreme” in the US (even though every other rich country has had it for decades or more) but universal healthcare is still the obvious solution here. Private health insurance companies are, well, private companies who are obligated to maximize value to their shareholders. For most companies, that works just fine. But for health insurance it results in some truly abhorrent practices. The profit incentives of the industry often are in direct opposition to what provides patients the best care and outcomes.
Additionally, about 15-30% (it varies depending on the study) of healthcare costs are purely for navigating the behemoth system of different healthcare policies and providers that are the result of our current patchwork system. We could get rid of almost all of that by just having one provider with one system of rules in place. A public provider could focus entirely on the public good rather than its bottom line, which would also decrease the cost of healthcare for pretty much everyone. Would your taxes go up? Sure, they’d go way up. But it would be more than made up for by the fact that you wouldn’t need private insurance anymore.
There is no way to finance a single-payer system within the political constraint that Republicans won’t raise taxes and Democrats won’t raise taxes on people who make less than $400,000. This is why the Massachusetts approach is inevitable: the math cannot add up in the system without substantial premium payments made by employers, employees and individuals; you can’t raise enough tax revenue to avoid the use of premiums. By the way, while 15-30% of health care expenditure is on administration, the administrative expense in a single payer system would not be zero. You would still need claims, approvals, etc.
Also most people like their employer-provided healthcare plans and don't want to change them!
That said, the amount we spend per capita on healthcare compared to other rich countries where people live longer is ridiculously high. Leftist Euro-worship is annoying, but running healthcare systems is clearly something like subway design that the Europeans do better than us.
The US is rich, which both gives us more money to spend on stuff as well as making labor costs high (you gotta pay me a lot to get off the couch).
https://randomcriticalanalysis.com/why-conventional-wisdom-on-health-care-is-wrong-a-primer/
We could probably cut out health spending in half and have outcomes that were not really that much worse, and it would probably be a trade-off we'd make soberly, but when someone's got brain cancer they want the best care even if its benefits are marginal.
You can get excellent brain cancer care (and you can pay extra to make sure you get a top surgeon and a private room) in France, Japan or Switzerland.
The US "market" for healthcare is sufficiently distorted that I don't really buy free market arguments for our system.
Yes, as I said, the US probably wouldn't be that much worse off. Have less choice and noticeably lower spending and the effect might be so small it's not even measurable.
But no one wants *their* choice and spending reduced.
That describes the difference between our system and single-payer or nationalized systems like in Canada or the UK, but there’s a ton of fancy private healthcare in France or Germany or Switzerland if you want to pay for it (or your employer will pay for it). In Lausanne if you want a private room while recovering from surgery, they tell you how much it costs and you sign on the dotted line. It is seldom that simple in the USA.
There is maybe a bit more high-end care here then elsewhere, and quite a bit more medical research. But I simply don’t believe that our weird morass of subsidized insurance and complex hospital billing is a sign that we either get better healthcare or more meaningful choice for our extra spending.
I totally agree. I’m under no illusion that universal healthcare has any chance of actually happening, barring a major change in our political climate. It’s just unfortunate that a policy that has been shown to work in all the countries that are the most similar to us is such a non-starter with so many people.
Probably no way to do it within the constraint that Republicans won’t raise taxes and Democrats won’t raise taxes on people who make less than $400,000, but you could get closer by making people 55 and older eligible for medicaire and allow employers to provide medigap for those employees.
This is a serious question: what is the cadence with which we can expect posts from Josh? This last one was September 18. Matt Yglesias’ Substack is daily and only costs a few dollars more. I am having a hard time justifying supporting this endeavor when it produces such little content, even with the Presidential election a month away! I can’t be the only one who feels this way.
Late to this but I have been wondering the same question. A couple posts a month is a far cry from…what was it initially, two posts plus the Mayo Clinic plus a podcast, every week? I totally get that that pace is probably unsustainable. Indeed, I remember when Matt Lewis of the DMZ podcast had a job that required him to write three columns a week he complained about how hard it was almost constantly. But it would be nice to have more transparency about the plan/expectations.
I ended up not renewing this one, especially after the lack of an explanation. My other substack write 3-5 per week, I think once per week is a reasonable expectation given the cost. Even some of those user generated “mailbag” type columns would be nice. It doesn’t have to be all substance all the time. I enjoyed Josh’s weird hobby horses about grilling. But I didn’t get much value add compared to his Twitter feed.
Hi Josh – enjoyed reading this very much and had a quick question. The individual marketplace market got off to a rocky start but (by my understanding) was functioning pretty well by the late 2010s, even as enrollment was declining slightly under Trump. Under Biden, subsides were expanded significantly and enrollment has since doubled to >20m. My question is: if those ADDITIONAL Biden-era subsidies were to be removed, would the market not simply return to the pre-Biden levels/functionality, without necessarily entering a death spiral? Or is your point that, once enrollment is expanded, it’s effectively impossible to walk it back without entering a death spiral from adverse selection?
I don’t think reverting to the lower subsidies would lead to a death spiral in the market, though enrollment would fall. It’s eliminating the subsidies entirely that would cause a death spiral.