Affordable Care - <AUTHOR> http://blog.samaltman.com/affordable-care <comment><USER3> 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).

<comment><USER4> 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.

<comment><USER5> So turn the entire population into H1B visa employees. Leave and you lose your health coverage forever?

</comment></comment></comment><comment><USER6> 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?

<comment><USER7> 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.

<comment><USER8> _while U.S. citizens convinced their employers._

During WWII the government imposed wage controls.. but fringe benefits did not count as wages. And with a shortage in labor because of the war, employers used health insurance and other fringe benefits to attract workers.

The unions jumped onboard later.

[https://en.wikipedia.org/wiki/Health_insurance_in_the_United...](https://en.wikipedia.org/wiki/Health_insurance_in_the_United_States#The_rise_of_employer- sponsored_coverage)

</comment></comment></comment><comment><USER9> 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.

<comment><USER10> 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.

<comment><USER11> _" ACA has got to be the largest tax increase ever foisted on the middle class."_

That's just Not Even Wrong.

Your health insurance premium is not a "tax". You're getting health insurance. Moreover, _not_ getting a subsidy for your health insurance is also not a tax. You can only use that logic when the tax credit is offsetting another tax. Which it isn't. It's offsetting your health insurance bill.

If, instead, you're trying to claim that every bit of increase in health insurance costs since the ACA is a "tax", that's maybe a bit more defensible, but still Wrong. Health insurance costs have been skyrocketing for decades. The ACA has probably _slowed down_ that trend.

Finally, if you're just complaining that you're healthy but you have to pay for health insurance now...take a walk, please. Eventually, we all get sick. Health insurance only works if healthy people foot the bill of the sick people. That's how insurance works.

<comment><USER10> It's simple economic fact that a subsidy or other government benefit which decreases as your income increases is exactly the same as an income tax.

It's called "Effective Marginal Tax Rate" if you want to Google it.

From the CBO; "The effective marginal tax rate (for brevity, hereafter referred to as the marginal tax rate) is the percentage of an additional dollar of earnings that is unavailable to an individual because it is paid in taxes or offset by reduced benefits from government programs."

I mean, it seems almost ridiculous to say that buying health insurance & health care is a tax, but when the government is paying over a trillion dollars a year to buy health care for everyone except those who are too young or earning too much money, that's exactly what it's become.

And I'm definitely not complaining that healthy people should not have to pay for health insurance. In fact the healthiest 50 percent of people who pay for health insurance use only 3.5 percent of services, it's what allows the entire system to work!

<comment><USER11> Health insurance is not a government benefit, unless you're on Medicare or Medicaid. Your health insurance premium is not a tax. It doesn't go to the government.

Being required to pay for a service doesn't make that service a tax. The _only_ thing about the ACA that has been characterized as a tax is the penalty you pay if you don't buy insurance.

</comment></comment></comment></comment></comment><comment><USER12> 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

<comment><USER13> I'm confused, is Colorado Care actually working in CO right now? Quick search seems to indicate that Amendment 69 has failed:

[http://www.denverpost.com/2016/11/08/coloradocare- amendment-...](http://www.denverpost.com/2016/11/08/coloradocare- amendment-69-election-results/)

<comment><USER12> Sry... I'm new to CO. Your'e right... Amendment 69 failed (72% against or something?!?! who knows... I voted in favor).

The correct name is "Health First Colorado". I signed up the day I was hurt, they backdated the signup to the month prior. It took less than 15 minutes to become covered.

I've been working for 20+ years, with spats of insured or not-insured throughout... mostly uninsured. After I left my SF gig, I gave up my insurance & didn't get any more since I'd already had 6 months for the year.

By the end of December, I needed it.

Edit - link: [https://www.colorado.gov/hcpf/colorado- medicaid](https://www.colorado.gov/hcpf/colorado-medicaid)

<comment><USER8> I'm in colorado.. just to be clear, we definitely do not have any type of universal coverage here, and Health First Colorado is not open to everyone. It's just normal medicaid.

They didn't care if you signed up when you were injured because you would have qualified for it anyway... you just didn't complete the paperwork. You definitely cannot do this when you exceed the income limit for medicaid and have to get normal health insurance.

The ACA increased the limits to qualify for medicaid. I know there were a few states balking at increased medicaid costs.. but you could have gotten this in most states, including CA.

<comment><USER12> Hey CO! Thanks for the details.

Yeah... my income === 0. Hopefully, not for too much longer.

</comment></comment></comment></comment></comment><comment><USER14> Here's a counter-point, Mr. Altman:

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?

<comment><USER15> Are you saying that if Obamacare did not exist you would be better off?

<comment><USER16> I know I can say it.

Married, two kids. Everybody reasonably healthy, have a decent job.

Healthcare costs have become expensive as shit because of the ACA. That's not a partisan talking-point: that's the bottom line in our household budget.

The happy-face anecdotes the ACA's advocates trot out are lovely, but there are far more people in my position.

<comment><USER17> How could you possibly just assert there are far more people in your position? There are tens of millions of people who had no access to health care that now have it. And can you explain exactly how the ACA has made healthcare unaffordable for tens of millions, since you assert more are disaffected by it than helped?

<comment><USER14> And there are hundreds of millions of people who have seen their premiums and health care costs go up.

<comment><USER18> As they did every year, pre- and post-ACA.

<comment><USER14> Excuse me, "go up by a larger factor year-over-year than had previously been the norm."

<comment><USER18> Because they started lower, apparently.

[https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyro...](https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyrocketing- obamacare-premiums-still-lower-than-employer-sponsored-insurance/)

> A new analysis from the Urban Institute found that the average unsubsidized > premiums in the Affordable Care Act exchanges, commonly known as Obamacare, > are actually 10 percent lower than the full premiums in the average employer > plan nationally in 2016.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER19> 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.

</comment><comment><USER20> 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.

<comment><USER21> Labor unions as well, who picked up on negotiating health care benefits for their workers. It's an interesting bit of history.

Still, we all know what it's like to have a major design flaw in the legacy codebase.

<comment><USER22> Labor unions... we also know what it's like to be dependent on a crucial services that are no longer being supported...

</comment></comment></comment><comment><USER23> 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?

<comment><USER24> > _What 's special about healthcare except that it's expensive?_

Great question. Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item.

My opinion is because the system we have today is basically a wealth transfer from the taxpayers to large interest groups (nurses' unions, big pharma, etc).

<comment><USER25> > Everyone needs food, everyone needs shelter, everyone needs medical care, > but this deep passion only exists for the last item.

Programs exist to make food and shelter universally available, as well, and while imperfect, the proportion of the population unable to afford food or shelter is lower than the pre (or even post) ACA rate of people being unable to afford healthcare.

The fact that the problem is less solved for healthcare is probably why there is more visible passion on the issue.

</comment></comment></comment><comment><USER26> 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.

</comment><comment><USER27> 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.

<comment><USER28> 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.

<comment><USER7> Not when you factor in _more_ insured people means _less_ expensive medical costs - i.e. more preventative care and less emergency room visits.

<comment><USER29> > Not when you factor in more insured people means less expensive medical > costs - i.e. more preventative care and less emergency room visits.

Well, you can make the argument for preventive care on medical grounds or even moral ones, but you can't say it actually saves money. When people have access to preventive care, they also tend to consume more, which means greater costs (although better overall care)[0].

This has borne out with the ACA[1], as the data shows that preventive costs increased faster than chronic and acute care costs dropped, by a very significant margin.

[0] [https://prescriptions.blogs.nytimes.com/2009/09/03/when- prev...](https://prescriptions.blogs.nytimes.com/2009/09/03/when-preventive- care-costs-more/)

[1] [https://www.nytimes.com/2015/08/06/upshot/no-giving-more- peo...](https://www.nytimes.com/2015/08/06/upshot/no-giving-more-people- health-insurance-doesnt-save-money.html)

<comment><USER7> You should really read articles before you cite them, because neither use data after 2014, when the ACA provisions took effect.

The ACA report last month shows the opposite of what you're saying, that oupatient costs have dropped more than inpatient costs have risen, and that medical prices have not risen more than inflation.

Page 58+ here: [https://www.whitehouse.gov/sites/default/files/page/files/20...](https://www.whitehouse.gov/sites/default/files/page/files/20161213_cea_record_healh_care_reform.pdf)

<comment><USER29> > The ACA report last month shows the opposite of what you're saying, that > oupatient costs have dropped more than inpatient costs have risen

That's not actually the opposite of what I said. Outpatient vs. inpatient isn't the same comparison as preventive vs. responsive care. You're comparing apples and oranges.

> You should really read articles before you cite them

From the Hacker News guidelines:

> Avoid gratuitous negativity.... Please don't insinuate that someone hasn't > read an article. "Did you even read the article? It mentions that" can be > shortened to "The article mentions that."

<comment><USER7> The majority of outpatient treatments are preventative healthcare, e.g. check- ups, x-rays, rehab, minor procedures, blood draws, etc.

The majority of inpatient treatments are responsive healthcare, e.g. emergency, major surgeries, ICU/NICU, burn unit, etc.

Also, when you present an article as a source for something that it is not, then it is valid to question if you read it and present why, like I did. The _full sentence_ of what I said is valid by HN rules, even if you attempt to quote it out of context:

>You should really read articles before you cite them, _because neither use data after 2014, when the ACA provisions took effect._

<comment><USER29> > The majority of outpatient treatments are preventative healthcare, e.g. > check-ups, x-rays, rehab, minor procedures, blood draws, etc

This is absolutely not true, and in fact some of the things you list aren't even preventive care.

<comment><USER7> [https://en.wikipedia.org/wiki/Ambulatory_care](https://en.wikipedia.org/wiki/Ambulatory_care)

>Many Medical Investigations and treatments for acute and chronic illnesses and _preventive health_ care can be performed on an ambulatory basis

<comment><USER29> I'm well aware of what ambulatory care is. But not all ambulatory care is preventive care; in fact, the majority is not, which is directly contrary to your previous claim.

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER30> 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.

</comment><comment><USER31> 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.

<comment><USER32> Then if you're still on it, pay COBRA for the year. Based on what I can see without making up fake info to look at the Minnesota exchange[1], a Silver plan for a family of 4 went from $905 in 2016 to $1405 in 2017, but with $68k/year in income there'd be a $725 tax credit so the monthly premium would have gone from $622 to $680. I assume since your numbers were a bit lower that you were looking at the Bronze plans instead.

Just take hope! If you can just make it through this year you won't have to worry about the question of purchasing insurance as an individual, because as a family with several preexisting conditions (fertile female, children/disease and injury vectors) without the ACA you'll be effectively uninsurable unless you can grow your startup fast enough to make a group plan feasible.

[1] [https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare- cov...](https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-coverage- plan-rates.pdf)

<comment><USER31> I was seeing premiums way lower than $905/mo back when I was first shopping for plans. With my current income 2015 I do not qualify for any federal subsidies. I have no idea what my income is going to be for 2016 but I can keep a majority of my income in my business so that my personal income is well below the level I need it to be to qualify for medical assistance. It doesn't feel right to me to be going on medical assistance with my earning power, but I guess this is the reality we live in.

I've been on hold with MNSure for 2 hours so far today and I can't start an application until I talk to customer support because of some problem in their system. The whole thing has been a giant comedy of errors so far. I'm definitely not a fan of the ACA.

<comment><USER32> If this is your first year looking at Exchange plans it's worth doing a spreadsheet with some auto-calculating fields based on guesstimates of your number of primary care and specialist visits per year.

One thing that I discovered when I did that my first year was that the big difference between some of the Gold plans and the Silver plans was pretty much only in the minimum amount I'd be paying per month as premiums - the maximum out of pocket was pretty much the same and there wasn't that much variation in my "expected" out of pocket - I was just paying it as higher copays IF we did go to the doctor or as a higher premium regardless of whether we went to the doctor.

Something to watch out for is "coinsurance after deductible" aka "you get bupkis until you've used a lot of care." With school-age kids and probably a minimum of one checkup/physical per year per child plus vaccinations, etc. you might be better off looking for a plan with copays even if the premium is a bit higher. It's also worth looking at the emergency coverage, there can be some variation in there.

Oh, and check the provider network - BCBSIL at least has different provider network levels, so if you see seemingly-similar plans from the same carrier with a significant price difference it may mean that most providers or hospitals are going to be out-of-network which means you pay more.

Good luck

</comment></comment></comment></comment><comment><USER33> 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.

<comment><USER34> Here's my complaint with the ACA, and it has nothing to do with insurance premiums.

My job ended in January '16\. I got a large severance and left the US for 7 months. I sold some stock in July, but other than that, my income was $0 each month. Looking forward, my income was likely to be just as erratic, with most months being $0. After spending way too much time talking with the folks at CoveredCA trying to figure out just how to fill out the forms for such an uncertain income level, I finally got all the information on my application and got denied. I couldn't even buy an unsubsidized plan. The exchange failed hard for my scenario and I ended up having to buy insurance directly from the health insurance company I was with when I was employed. It was quick and easy and _cheaper_ than it would have been on the exchanges. And now, to add insult to injury, I'm probably going to have to pay a penalty for not having US health insurance for all those months that I wasn't living in the US, since I'm pretty sure I didn't pass the threshold for being a non-resident.

As a programmer, I'm all to familiar with code that handles the 90% case and just assumes those other edge cases don't exist. It's lazy and error prone and a sign of an amateur programmer. The ACA feels like the legislative equivalent of that sort of code. In their hurry to create a system where the majority of those without health coverage could get it, they created a system that's truly terrible for edge cases like me.

<comment><USER33> Interesting, I haven't heard of someone getting denied coverage for applying to an ACA plan before. What was the reason for the denial?

<comment><USER34> The denial letter looked like it was making two separate, independent eligibility determinations. One, for CoveredCA insurance and one for MediCal. I was denied by CoveredCA because my monthly income was $0, which would normally push me towards MediCal. But I was denied by MediCal because I made six figures in both months that I reported taxable income.

The MediCal denial makes sense. I don't see why I should have the state pay the entirety of my medical insurance costs when I'm making that much money. I also would like more choice when it comes to my doctor and treatment than MediCal allows and I'm willing to pay for it. The CoveredCA part is baffling to me. Why I'm not allowed to purchase health insurance with no premium assistance because I don't have a steady income leads me to believe that the ACA is poorly-written legislation.

</comment></comment></comment></comment><comment><USER35> ""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.

<comment><USER36> I'm not entirely sure that's true. I think a lot of the anti-ACA lobby is doing it for purely partisan reasons. If the ACA succeeds then its a counted as a big win for your opponents, so you fight like the dickens to make sure it doesn't work out.

Similarly, a lot of people that support the ACA don't support the ideas behind it, as much as they support _something_ being done from the previous, untenable situation. Obama took mostly Republican ideas and ran with them, now the Republicans have disavowed any involvement with them, and Democrats have adopted them as good (or at least better than what was there before, even ACA supporters acknowledge that it's a deep compromise from what anybody wanted.)

I think that the attitude of "it's going to help my side or nobody" is a much stronger driving force than the desire to prevent people from taking entrepreneurial risks.

<comment><USER35> Tactically you are right, but the people who fund the think tanks that fuel the fires you are describing, are playing a longer game. Same people and motivations behind the de-education of Americans kicked off by Reagan.

</comment></comment></comment><comment><USER37> 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 - <USER2> 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.

</comment><comment><USER38> 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.

<comment><USER39> This was what I did, until I got married. Now we've got a potential baby in the next ~ 1 year, so "uninsured" is not an option.

So, to pursue some things on my own time I had to negotiate a sabbatical with my company (which they generously allowed), so I could stay on employer health insurance.

If I wasn't able to do that, I'd be up shit creek, because there's no way in hell I'd risk my wife getting pregnant without health insurance.

I hope more and more people decide they feel no social obligation to things. Mass peaceful "law breaking" is really the best option, imo.

<comment><USER40> > I hope more and more people decide they feel no social obligation to things.

This is incredibly naive and ignores a lot of the political and theoretical underpinnings of our society and our country. [https://en.wikipedia.org/wiki/Social_contract](https://en.wikipedia.org/wiki/Social_contract)

<comment><USER41> There is not one single social contract that we all must subscribe to. It's much more nuanced than that, with lots of little obligations here and there. Some are more valid than others, and the individual should have a right to decide which to be a part of. Not paying taxes is a much different violation of a social contract than not paying for health insurance, especially considering the very legitimate argument that the ACA penalty is unconstitutional in itself.

</comment></comment></comment></comment><comment><USER42> 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.

<comment><USER39> > The ACA enshrines insurance, pharma, and hospital companies, including those > that are the biggest parts of the problem in health care in the USA.

Absolutely agree. The ACA (or repealing the ACA) are both "solutions" to the wrong problem. So much potential innovation in the health care space is illegal. If it wasn't illegal, someone might (gasp!) find a way to provide a valuable service for less money than in the current system.

It will not, and cannot, be fixed by regulation, because of what you said - any regulation MUST be approved by the big companies. They'll never approve something that goes against their interests.

</comment></comment><comment><USER43> 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"

[http://www.wsj.com/articles/health-cares-bipartisan- problem-...](http://www.wsj.com/articles/health-cares-bipartisan-problem-the- sick-are-expensive-and-someone-has-to-pay-1484234963)

<comment><USER44> Here's a non-paywalled version: [https://www.msn.com/en- us/money/healthcare/health-cares-bipa...](https://www.msn.com/en- us/money/healthcare/health-cares-bipartisan-problem-the-sick-are-expensive- and-someone-has-to-pay/ar-AAlNV6S)

</comment></comment><comment><USER45> 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.

</comment><comment><USER46> 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.

<comment><USER47> The exchanges are terrible. In Texas, the only options available on the exchanges are HMOs, and in large chunks of the state, only a single provider is available.

If you don't have employer-provided health insurance, you're still basically screwed even under the ACA.

<comment><USER46> Texas. Need I say more? The state chose to make ACA as unworkable as possible.

</comment></comment></comment><comment><USER48> People seem to think that without ACA, the US healthcare market is free, which is why it has so many problems.

This could not be further from reality. We have more government distortions in our healthcare market than countries with completely socialized healthcare. For example:

Medicare: socialized medicare for the elderly, which alone creates more distortion than a universal program would cause by inflating demand/prices for non-qualifying citizens.

Medicaid: socialized healthcare for specially qualifying poor people, which creates the same distortion as Medicare.

An oppressive FDA: which, coupled with overly-powered IP laws, grants de-facto monopolies in the medical product industry. We have an incredibly expensive and subjective medical equipment pre-approval process (as compared to a less- terrible FDA that would just be in charge of labeling, preventing fraud, and maintaining accountability in the event of incidents). Then there's the length and flexibility of patent protections in our current system (maybe we could cut those protection times in half, and patent trolling would not be a lucrative industry).

Oppressive occupational licensing: It's way too hard to become a doctor of any kind, even the kinds that don't manually put things into your heart. This will be a major battle as AI comes to the point where it can better diagnose conditions and largely replace generic/non-specialized pediatrics. Of course, the government will not make this easy.

Plus a slew of more minor things like malpractice regulation, and now the ACA (which is not so minor).

If we cleaned up/removed all of the problems in the above and replaced it with single payer, it would be OK and we would have something similar to Canada/other countries with long wait times, not much access to specialists, and a system where the government gets to decide who gets the last liver transplant and who dies.

Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL.

<comment><USER33> > Or we could try going the free-ish market approach and try to find a much > freer balance with the FDA/USDA/occupational-licensing/scrap > Medicare/Medicaid,etc., which we do not currently have AT ALL.

Is there any country that has implemented this successfully?

<comment><USER48> Unfortunately not, but I'd love for our country to be the first.

<comment><USER33> Why do you believe such an approach would work? Is there any evidence behind this position?

<comment><USER48> Is this so radical? There's ample evidence that our healthcare bureaucracies are NOT working. And there's ample evidence that free markets are more efficient at providing value, when held to a legal framework that maximizes freedom (for everyone, consumers and proprietors alike). I'm not even suggesting a fully 'free' market -- just reducing the size and scope of our bureaucracies which have gotten out of control, and see how much prices drop/ health-care improves before we commit ourselves to eternal government-quality care with minimal innovation.

Just ask any veterans relying on the VA how satisfied they are. On a tangent, universal health care is not 'great' anywhere, and the bigger the country, the less compelling the evidence (diseconomies of scale -- see Canada/England vs. Switzerland for example). And our country benefits from another order of magnitude of diseconomies of scale/bureaucratic bloat in trying to institute such a program.

So, moral of the story is that if it somehow did not end up making our healthcare system significantly better than universal healthcare countries, then we could still let states that lean a certain direction handle the bureaucracy of a universal healthcare system with slightly more efficiency.

<comment><USER33> > And there's ample evidence that free markets are more efficient at providing > value, when held to a legal framework that maximizes freedom (for everyone, > consumers and proprietors alike).

I don't think there is. I think in many cases, what starts out as a "free market" is ultimately overtaken by a few large corporations (as others fold or get acquired) which then proceed to abuse their position of dominance to engage in monopolistic rent-seeking behavior to maximize their profits at the expense of everyone else. Think Microsoft abusing their dominance of Windows, or Intel abusing their position to prevent PC manufacturers from using AMD products. We're starting to get there with iOS and Android being the only two remaining choices for mobile, and Facebook for social.

My concern is even if you could hit a magic reset switch and turn the health care industry into a free market, it would trend the same way. Insurance companies would grow in size and squeeze the health care industry from both ends, charging patients more and more money, while paying doctors less and less, all so they can squeeze out a larger profit. Pharmaceutical companies would jack up the prices of their drugs because they have a captive audience, they know you're going to pay up because your life is at stake, all so they can squeeze out a larger profit.

It's questionable to me if the medical system could ever act like a free market:

1\. In emergency situations you often don't have the opportunity to "shop around" for care.

2\. If a pharmaceutical company is the sole manufacturer of a life-saving drug, what stops them from jacking up the price of said drug to maximize their profits, at the expense of patient lives?

3\. If paying for someone's medical treatment is unprofitable, insurance companies have an incentive to drop that person's coverage instead of paying for treatment. (And often did pre-ACA.) How could a free market possibly address this situation?

Universal health care systems around the world are not perfect, but many countries have implemented them successfully and as a result spend less money on health care (as a percentage of GDP) than the US while simultaneously having better health outcomes. Why not move towards the known quantity which has already been tested and proven by every other modern country in the world, instead of this hypothetical free market system which we've never seen before, and frankly, sounds rather dubious in light of my questions above (especially (3))?

<comment><USER48> > I don't think there is. I think in many cases, what starts out as a "free > market" is ultimately overtaken by a few large corporations (as others fold > or get acquired) which then proceed to abuse their position of dominance to > engage in monopolistic rent-seeking behavior to maximize their profits at > the expense of everyone else.

Yes, that's crony capitalism, not a free market. There is no such thing as a natural, malevolent monopoly (except for governments). They require special government privileges to maintain dominance for long, or they will fall to competition in a free market (or have to become benevolent enough so that they still maintain market share with consumers).

Corruption isn't something you just "solve" in any part of government. Except, maybe, in a government made up solely of AI/programs. But anyway, for now it's fair to assume that it's an eternal problem that plagues government, and in fact it is the problem with our current FDA. So do we just give in? No, let's continuously reset it, be vigilant, and avoid giving the government "privilege-granting" powers that allow it to enable rent-seeking in the first place, so that we don't need to do frequent resetting.

> It's questionable to me if the medical system could ever act like a free > market:

Whether healthcare can be a free market is a different issue, and I've heard people even say it's inherently an immoral industry. I think healthcare is perhaps the MOST moral industry inherently, but the idea of medical insurance specifically is terrible to me, because for many people, healthcare is something they access frequently throughout their lives. I don't think health insurance is compatible with a free market, and probably constitutes fraud. The whole business plan of insurance is that people are hedging against risk/accidents, and will end up paying in more on average than they take out, but in reality health insurance is intended to cover WAY more than that as it currently stands. "Accident" insurance makes a lot more sense to me, and it's compatible with the idea of insurance (broken arms/trauma/etc.). But even serious illnesses are not really unexpected, because almost everyone gets them -- it's just a question of when. I think all medical expenses should be paid out of pocket. This is completely unreasonable in our current expensive, heavily and unfairly subsidized system, but if we refactor the system and take health insurance out of the equation, it's hard to imagine just how much costs would come down. Looking at the costs of raw materials and labor, there is absolutely no reason this should be so unattainable, and it's far more "fair." Yes, some poor people who got bad genes all around are going to have a more difficult time than a healthy or wealthy person and will have to pick and choose healthcare options that would be in their body's best interest, but such is life. Scarcity exists, and even the entire healthcare industry cannot keep one person alive forever. Side note: the majority of a person's lifelong medical expenses are incurred in the final two years of his or her life. There is finite medical care, and there is diminishing return (measured in hours/$) for how long you can keep a dying person alive another day. This is not a solvable problem with a socialist system -- there is INFINITE demand, so we need to let the market increase the supply as best it can (which is via competition, freedom, and profit motive).

So I think that answers number 3, where I very much agree with you. Number 1 as well, because you had the option to "shop around" for your accident insurance which should have you covered wherever your insurance is valid. Number 2 is solved by the free market and my additional post on reducing patent lengths. But what if the drug was just invented and they are still the only ones allowed to manufacture it?? Here is the real misunderstanding I think you share with many of my liberal friends. _THIS COMPANY JUST INVENTED A LIFE SAVING DRUG -- WITHOUT ITS INNOVATION, EVERYONE WITH THE CONDITION WOULD DIE, AND NOW SOME ARE LIVING WHO CAN AFFORD TO HELP THE COMPANY RECOUP THE R &D COSTS + INCENTIVES OF MAKING A LIFE SAVING DRUG._ And eventually, when its protections expire, the price will come down as others enter the market. In fact, it would probably not be in the company's long term interests to price gouge because people will remember that when competitors enter (who hasn't heard Shkreli's name?). Basically, well-intentioned people like yourself would benefit people who depend on this drug in the short term, through government intervention, at the expense of innovation in the long term as fewer corporations are attracted by the riches that await them for furthering the medical field and saving people's lives.

I apologize for the length of this post -- this topic is near and dear to my heart.

<comment><USER33> > Yes, that's crony capitalism, not a free market.

You're getting close to "no true scotsman" territory here. Microsoft abusing its position in the PC market: crony capitalism, not a free market? Intel bullying AMD in the processor market: crony capitalism, not a free market? Are there any examples anywhere in the world of a truly free market then?

> "Accident" insurance makes a lot more sense to me, and it's compatible with > the idea of insurance (broken arms/trauma/etc.). But even serious illnesses > are not really unexpected, because almost everyone gets them -- it's just a > question of when. I think all medical expenses should be paid out of pocket.

The problem is serious illnesses tend to be the most expensive. Even if health care costs were magically cut in half, cancer treatment would still bankrupt the vast majority of the population. So, tough luck for them?

> Basically, well-intentioned people like yourself would benefit people who > depend on this drug in the short term, through government intervention, at > the expense of innovation in the long term as fewer corporations are > attracted by the riches that await them for furthering the medical field and > saving people's lives.

Yeah... I'm not necessarily convinced that medical research should be a for- profit enterprise either, for exactly the reasons you mention. ("Should we research a cure for this disease?" "Our projections indicate it won't be profitable" "Ok, moving on then...")

I get that you believe free markets will solve the problem of expensive health care, I just don't see the mechanism behind it. So far it seems very hand-wavy to me. 1) Free markets. 2) ... 3) Cheap health care. What exactly happens in step 2? How do you prevent it from turning into an abusive "crony capitalism" situation?

<comment><USER48> > You're getting close to "no true scotsman" territory here.

The free market is an ideal -- I do see where you're coming from. But the market is never free so long as there are corruptible people in government or the framework does not fairly protect freedoms, but does that mean we shouldn't strive to get as close to the 'ideal' of a free market?

For the Microsoft example in particular, they didn't benefit from government intervention until the government "punished" them, by forcing them to provide a more inclusive platform. Makes you wonder if 90% of the PC market would still belong to Microsoft if the government had not gotten involved... might have pushed us toward open source/Mac OS sooner. In the other case, Intel just plagued AMD with legal bills, which perhaps says something about the way our legal framework is set up (can't countersue to cover legal costs), but Intel always provided a superior product so it's a quite stretch to say it was a "malevolent" monopoly. So you're right, neither of those are really crony capitalist examples, but that doesn't mean they contradict my points on market freedom and ill-willed monopolies.

I challenge you to provide an example of a longstanding, malevolent monopoly that did not rely on government privilege.

As to the points on medical care, I assume you agree?

<comment><USER33> I think we need to accept that much like communism is an ideal that might work in small groups (literally communes) but quickly falls apart when dealing with large groups (because people are terrible and will find ways to abuse the system), pure capitalism is also an ideal that might work in small groups but also quickly falls apart when dealing with large groups (because again, people are terrible and will find ways to abuse the system).

I think "free markets" will inevitably trend towards "crony capitalism" as long as 1) government exists and consists of, as you say, corruptible people, and 2) money exists, and therefore can be used to influence said corruptible people. Therefore, even if you managed to hit a reset switch and turn health care into a "free market" and ran the experiment over and over again, 100% of the time it will turn back into the same "crony capitalism" mess that we're in now. What can I say, I'm a cynic at heart.

And I've already mentioned this, but it also seems kind of silly to advocate for this theoretical experiment (which may not actually be possible to implement) when there are already many other countries around the world that have successfully implemented universal health care (either single-payer or two-tiered systems) with better health outcomes than the US.

<comment><USER48> Communism is flawed in theory because it relies on people not acting in their own personal interests, which is not a declared assumption (because it would be so ridiculous). The free market you often hear about is sound in theory when it makes clear assumptions about the government, but those assumptions are idealistic because they require government officials to not be persuaded by rent-seekers.

But you've taken this way off topic to be honest, because I am not advocating the ultra-pure free market ideal. I am advocating scaling back and reducing the scope of our excessive USDA/FDA (which would cause the same problems in a universal healthcare system regardless), reducing IP protections (same problems regardless of universal healthcare system), making it easier to become a doctor (also a problem regardless of whether we have universal healthcare) and getting rid of our existing lop-sided "universal" healthcare systems which would be irrelevant in a universal health-care system.

To my original point, we have the most government distorted healthcare market in the world so it really should not be so surprising that our system is the worst per dollar. You can't just add another "universal healthcare program" and expect all of the problems to go away -- there's a lot of cleanup to do. And even after that cleanup, I think it would be silly to resign ourselves to the mediocrity of other systems instead of seeking progress.

<comment><USER33> Yeah I did not mean to go so far off topic, just wanted to point out that I think a free market approach to health care will lead to an abusive system due to for-profit entities like insurance companies behaving in ways that are good for itself, but ultimately bad for patients.

I agree that reducing IP protections is a good idea. I'm not sure I would call other systems mediocre. They're not perfect but they're far, far ahead of what we have in the US. I don't think that our country is so different from others that implementing a similar system wouldn't lead to an improved outcome as well. Anyways, thanks for the discussion.

</comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment></comment><comment><USER49> Nice post, the stories echo multiple people I know as well. Having health insurance tied exclusively to a job is anti-entrepreneurial. That should be fairly obvious.

The ACA has flaws but it also has some great features that need to persist: minimum care requirements, pre-existing condition exclusions banned (having a pulse is a pre-existing condition BTW), no lifetime caps on treatment.

What's the alternative? Still haven't heard anything.

<comment><USER50> There is none: [http://krugman.blogs.nytimes.com/2017/01/10/there-will-be- no...](http://krugman.blogs.nytimes.com/2017/01/10/there-will-be-no-obamacare- replacement/)

</comment></comment><comment><USER51> Something of note - not a single woman on here. Pregnancy, birth control... so many expensive, and common medical procedures that are very relevant to all female founders have been overlooked or neglected.

</comment><comment><USER10> Faced with a similar decision pre-ACA, the fact is that CA already had guaranteed issue small business health insurance. ACA roughly tripled the cost of the same plan, but made it more accessible to people by putting a web front-end on top of what was otherwise a fairly opaque process.

But it's untrue to claim ACA provided benefits to any CA startup in terms of coverage, guaranteed issue or pre-existing conditions.

If you wanted to start a company in CA pre-ACA and you had prior credible coverage, you could get a great plan at a competitive price (the so-called "rating adjustment factor" was capped for the guarantee issue plans) with immediate coverage for pre-existing conditions.

</comment><comment><USER52> I am unconvinced that healthcare affects the number of startups as this have been going down also after Obama got on board and is going down also in Europe (ex Denmark where healthcare is completely free)

But I am all for an alternative to what we have now or what we had.

The most important thing IMO is to make sure that people don't get hit by pre- existing conditions.

[https://www.washingtonpost.com/opinions/why-is-the-number- of...](https://www.washingtonpost.com/opinions/why-is-the-number-of-us-start- ups- falling/2016/05/19/53fe8e04-1ded-11e6-9c81-4be1c14fb8c8_story.html?utm_term=.3786a4f853de)

</comment><comment><USER53> If only Mr. Altman had a pre-existing relationship with someone very close to Mr. Trump. He could then perhaps raise these arguments with that person.

</comment><comment><USER54> ACA works. But it seems to me that young people just starting out have it so much worse when it comes to healthcare.

Example. Out of college. Got job. Had insurance and didn't think much of it. $2 all RX

Mid '80s had kid. 5 days in hospital (C section) and it cost $500. Insurance was 59 per month. (I making $36k)

Got thrown out of tech into federal job with federal insurance. Excellent coverage. Got $102k prostetic from New york hospital for< $5000 out of pocket.

My life with health insurance was been charmed. I am so glad I dont have to start like these young people.

</comment><comment><USER55> That's a pity american people have to think about healthcare that much and as far as i can see not long time ago didn't even have a backup plan in case their employment goes wrong. Post soviet countries all enjoy pretty affordable health care, free in most cases. Govermment pays all the salaries so it is pretty simple. Of course it is overused, as every public good is, but maybe that is not actually the problem. Sick people with huge debts because ot their sickness looks far worse in comparison.

</comment><comment><USER56> I am a Republican. More in fact, Fiscal Constitutional conservative.

Now that thats out of the way.

I hate the ACA. Its overreach by what the government should be doing. No where in the constitution does it say the government is allowed to force law abiding citizens to do something. ACA does exactly that. It forces people to do things against their will. Or they will be forced to pay a fine. Alright, don't down vote me just yet.

Lets repeal the ACA. But I certainly see things that should be quickly made into law.

* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.

* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.

* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.

* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.

* Lastly, I want hospital prices published. I want to shop around.

* I am business friendly, but these are common sense laws.

I think EVERY Republican can get behind these thoughts as every other Democrat, but forcing me to pay for it, when I just want to live off the land in some small town somewhere. Complete overreach and strictly unconstitutional.

<comment><USER57> Your solutions rely on something that does not exist in health care: information parity. A true free market requires information parity. Health care is complicated, thus information parity does not exist. Regulation is the answer to dealing with that lack of information parity.

A hospital cannot "publish prices" because prices vary wildly based on many factors. Even if they did, how am I supposed to know what I need for my healthcare? If I go to the doctor and they say "you need a surgery and it will cost 10,000" the posted prices do not tell me if I need that surgery at all, just what they cost. And, of course, the most expensive medical care is emergency, a time when price shopping is not possible.

> Remove the boundries of the state borders. This is regulation. Not allowing > companies to work and provide across state lines is ridiculous and again > government overreach that could quickly drive down costs.

I'm not opposed to this, but it does remove state control over insurance regulation, which is an anathama to Republicans. I also have no idea how it will drive down costs? Are some states that much healthier than others?

> Birth Control, yes and no. We should be able to opt out paying for it, > especially if it goes against my religion and frankly it does, but I won't > stop others from opting in and paying for it.

I don't even know where to start. If I can opt out of paying for some medically approved procedures, where does it end? Can I say that I want to opt out of ob/gyn care for unmarried women?

<comment><USER58> > A hospital cannot "publish prices" because prices vary wildly based on many > factors.

Here's a question: Dentists routinely publish prices. If you ask them how much some procedure will cost, they will tell you. If there is uncertainty, they will give you a range (e.g. to account for the possibility that complications will arise during an oral surgery). What is different in the hospital situation, apart from some rather extreme measures taken to obfuscate pricing?

> And, of course, the most expensive medical care is emergency

Is it? Or is it end-of-life? Genuinely curious to see numbers here!

> I also have no idea how it will drive down costs

Prices, not costs. The current situation is that in a lot of states there are somewhere on the order of 1-3 companies offering insurance of certain types at all. For example, for Maryland, I believe there is only one company offering an ACA-compatible PPO (everyone else has HMOs or even EPOs). See [https://news.ycombinator.com/item?id=13393287](https://news.ycombinator.com/item?id=13393287) for where I got that data.

Of course in a monopoly situation there is absolutely no incentive for a monopolist to cut prices. Why would they? So to the extent that prices represent excessive profits (as opposed to the actual costs of health care), allowing cross-state insurance sales should drive them down. People who believe insurance companies are price-gouging should be _very_ in favor of removing restrictions on such sales.

<comment><USER59> So should they explain the pricing schedule while you're still unconcious from the accident at the crash site or when your eyes are fluttering in the ambulance? Then at the E.R., they can talk you through your various choices in surgery, a menu of blood products, and let you peruse through a catalog of doctor histories. If you decide this isn't the place you'd like to have the steering wheel removed from your rectum, you can always go online and browse a few local options from the dozens of hospitals in your area until you find a price point and payment plan that's right for you and your intestinal needs.

Similarly, when your diagnosis comes in and surgery is required, you can take time off from your three jobs to carefully research the pros and cons of various procedures to determine which is most financially appropriate for you. I mean, it's not exactly heart surgery we're talking about here. Well, technically and literally it is, but it shouldn't be too hard for anyone to understand the pros and cons of different surgical equipment and procedures to evaluate the risks and cross-compare with the clear apples-to-apples data sets to arrive at a medically and economically responsible decision while blood is pouring out of your extremities and your body feels like it's on fire. Take the time and shop carefully. You are a model fiscal actor and will make the right call.

Free market forces will make this system work and work well. The invisible hand has been after all such a huge success in setting health care prices and has proven to be the model every modern industrial country has taken because it's so intuitive and has great proven results.

<comment><USER58> > So should they explain the pricing schedule while you're still unconcious

A lot of hospital care is non-emergency, but they don't explain pricing schedules for _that_ either, now do they? I think everyone understands the impossibility of comparison-shopping on emergency care.

> I mean, it's not exactly heart surgery we're talking about here

No, it's hip replacement surgery. And people _already_ do comparison shopping on things like that as much as they can, including comparing to and shopping in other countries. See medical tourism.

More to the point, people do comparison shop just like that for oral surgery. Yes, they may not have all the data they might like. Yes, they don't always make the right decisions. But by and large, dentistry works OK.

Again, the "stuff that must be done RIGHT NOW" thing is a strawman: there's plenty of hospital care that is not that sort.

> The invisible hand has been after all such a huge success in setting health > care prices

The invisible hand has absolutely nothing to do with most health care prices today (at least in the US). There are some exceptions: plastic surgery, laser eye surgery, dentistry, some forms of occupational therapy, and maybe family medicine.

> and has proven to be the model every modern industrial country has taken > because it's so intuitive

Various industrial countries have price transparency for their medical care. If want to know how much my hip replacement will cost in the UK not via the NHS, I go to [http://www.privatehealth.co.uk/conditions-and- treatments/hip...](http://www.privatehealth.co.uk/conditions-and- treatments/hip-replacement-total/costs/) and I get all the data I could want, including prices and the hospitals charging those prices. Importantly, those hospitals publish their prices. If I did go via the NHS, I suspect there is no real difference in the pricing, but would welcome data on how it really works.

Anyway, knowing how much medical procedures will cost you is not an uncommon situation. Except in the US, of course, where hospitals will never tell you ahead of time how much a procedure will cost.

Note that price transparency is necessary, but not sufficient, for some sort of sanity in the discretionary medical care market.

</comment></comment></comment></comment></comment><comment><USER60> As someone that has worked for myself for 16 years, I will sorely miss the the ACA. Let me know if you have any recommendations because surely I'm missing something.

\- Before the ACA we had Blue Cross and I inquired about maternity coverage. My wife was looking at a shoulder surgery so we were locked in. Blue Cross offered us a $1000/month rider that had to be in place for 21 months before birth and then they would cover anything over our high deductible. It worked out to about $25,000 on top of our regular premiums before they would pick up the bill. We jokingly priced getting an apartment in another city instead.

\- Then the ACA came out. Maternity was included free and the premiums are about the same. We had a baby and had to cover twice the deductible. The marketplace gave us some trouble due to stupid bureaucracy so we priced out getting a plan directly (non-ACA) but the price was so much higher and it covered less. So, even with the marketplace, the coverage and affordability made it an easy decision.

Anyway, I could live without the subsidies (we haven't qualified for them every year) and I wish the marketplace was a little easier to work with. Though I feel like our coverage is so much better now. Why take it all away?

</comment><comment><USER61> Isn't the biggest part of health cost is from drug company and insurance company?

If that's the case, addressing the cost is the foremost issue, instead of forcing everyone to join a universal plan. That does not help addressing the root problem above.

<comment><USER62> So basically, your argument is to do nothing to help anybody unless you have a magical fix-everything-in-one-go plan?

Good luck trying to get political support for anything that hurts the insurance companies.

<comment><USER61> Isn't there plenty of fixes demonstrated many places already?

</comment></comment></comment><comment><USER63> The health system in the US is a total mess. Single payer is the only sane way to go. That too will be imperfect and ragged but it is provenly absurdly cheaper - practically all advanced industrial countries are single payer and all spend far less as a percentage of their GNP - as in half to a third - whilst covering everybody. The admin savings are staggering, the drug costs are lower etc etc.

<comment><USER64> We've eliminated the possibility of Single Payer in the US, and the reason for this is stupid: Nobody on the left can criticize the ACA anymore. Due to our ridiculously partisan shitshow that we've got going on, any criticism by Democratic Party politicians of the ACA will bring a shunning from the party leaders. The only thing they are allowed to do anymore is gloss over the ACA's failings with flowery language, and say they want to "improve" it.

But you can't "improve" the ACA into single payer. You can only get single payer by starting over from scratch.

The pathetic thing is that a public option, the original plan, could quite easily be improved into single payer. And despite the largest Democratic majorities in both the house and senate for several decades, with a sparkly new progressive Democratic president that campaigned primarly on health care reform, they couldn't pass it. It seems the Democratic party has something to learn from the Republican party on how to get shit done.

<comment><USER65> Single payer is considered socialism by half the population due to decades of Republican rhetoric.

<comment><USER66> That's because single payer IS socialism. The problem is that not all socialism is bad :) .

We have single-payer here in my country, and anecdotal evidence is that it works incredibly better than healthcare in the U.S. for 99% of cases (the U.S. is far better at treating complicated health problems, but at staggering costs).

</comment></comment></comment></comment><comment><USER67> I would like to see prices published and anti-trust exemptions for the industry scrapped. There is absolutely no transparency in the pricing.

</comment><comment> c-slice Having health insurance be offered by employers/ tied to employment is one of the biggest mistakes in American healthcare policy. It encourages a "consume as much as possible" mindset for employees and disguises the true cost of care. Creating clarity of price and cost in healthcare would be one of the most beneficial shifts.

</comment><comment><USER68> Of course, it's better to have a nationwide health service, now that ACA is toast, may be it is time for states to start considering health care systems within their borders. Many states have populations multiple the size of many countries which have universal health care. It could be very possible.

</comment><comment><USER69> I went full-time in my business in 2010-2011. I got denied for months for health insurance. I was in my early 30s, wife, and one child with no major health issues and barely ever used insurance. I got denied from the same companies I previously had insurance working full-time non-stop for years and years from. Finally I did get some by putting me and my family on differing plans across companies. It was insane, I was actually taken back at how messed up that seemed. It caused more panic than it needed to.

The ACA (or similar basic rules: no pre-existing, must cover, supports small business and self proprietors as the market goes more that way) is needed for entrepreneurship and in cases where you can't get it through a job, it is a must for starting business today. Other places have a competitive advantage to starting a company in a country that has healthcare figured out and away from the job.

We should be able to get insurance as a pool of individuals. The current insurance companies are not setup for non employer based healthcare and need to either change or go. They group based on company or individual not pools of people across companies and individuals, which is a broken legacy system. We need consumer facing companies to be in healthcare if private healthcare is the main thing, companies in auto insurance and other insurance are more consumer focused (Geico, Progressive, Nationwide etc). I wish for more competition in this area that is consumer focused not employer focused.

Insurance needs to be remove from employment (probably through legislation or market benefits) to ultimately solve this consumer facing insurance problem for healthcare. We also probably need a separate health insurance plan for catastrophic events and a healthcare plan that handles day to day healthcare needs, bundling them is a bit wrong when compared with other insurance i.e. car maintenance is not covered under auto insurance, home maintenance is not covered under home insurance.

Ultimately, fixing healthcare is needed for business and quality of life reasons. Our system is becoming a competitive disadvantage to businesses in the US.

<comment><USER70> >Insurance needs to be remove from employment

ding ding we have a winner. This is a no brainer that anyone, Republican or Democrat, should agree on.

</comment></comment><comment><USER71> Regarding the concern about health insurance being tied to an employer, it is important to consider why employers have historically been the source of health insurance in US. A primary reason is the higher marginal income tax rates, which makes it hard for companies to effectively reward valuable employees with heavily-taxed salaries. So the companies instead resort to providing non-salary benefits such as health insurance. If mid-to-high marginal tax rates weren't so high, then employees would be paid more in salary and could purchase insurance themselves so they aren't "locked-in" to their company for providing essential needs.

<comment><USER72> Health insurance became tied to employment in WWII, when the government imposed wage controls. To attract employees while getting around wage controls, fringe benefits were added instead of increased pay. [1]

[1] [http://www.nber.org/papers/w14839.pdf](http://www.nber.org/papers/w14839.pdf)

<comment><USER71> Sure that was one of many contributing factors. A couple sentences later that study affirms the point I was making:

"Finally, in a landmark 1954 ruling, the Internal Revenue Service clarified an earlier administrative court ruling regarding the income tax status of ESI by exempting such benefits from income taxation and adding this provision to the tax code."

</comment></comment></comment><comment><USER73> There were many issues with health insurance prior to Obamacare. Obamacare did not fix very many of these things, and broke a great deal of other things.

Sure, it's nice that pre-existing conditions are covered better and 26 and under people can get insurance with their parents, but those kinds of benefits could have been covered by a one or two page bill. What's in the rest of it? Special deals for corporations such as AARP.

The law does nothing about making malpractice insurance more affordable, or making the malpractice lawsuit environment more rational. Why is that?

Why is my employer still involved in my health insurance? Why not move the tax benefits from my employer (it's a company, and cannot get sick) to me? My employer doesn't need the insurance. I do.

Why can't I buy insurance across state lines like other insurances?

Why are there separate 'risk pools'? The US is a single market - there should only be one risk pool. This would put maximal pressure on the insurance companies in terms of cost as they would have to compete for my business instead of negotiating cozy deals with companies (and companies don't get sick).

Why does the gov't get to tell me what's in my plan? If I'm a single male, why do I need to buy a plan that covers ObGyn? Why can't I buy a high deductable plan anymore?

Why does Obamacare think its wrong for doctors to own medical facilities?

If controlling cost is so important, why is it practically impossible to find out the cost of anything ahead of time? This makes making decisions based on cost impossible. Why is the price one person pays radically different than what another person pays? Why does cost have no relationship to quality? I can get an MRI with a brand new machine or with a 15 year old machine that produces crap images, and the crap will cost more. Why not require publication of prices?

Why is it that my dad, a wounded combat veteran, cannot get decent health care at the VA in a major metropolitan area? The VA is completely controlled by the gov't. It is the gov't. And yet, if he goes to a private hospital to get decent care, he gets penalized.

<comment><USER59> Let me just answer this one: Why can't I buy insurance across state lines like other insurances?

Because then pretty much EVERY insurance company will pick up and move to the one most desperate state that writes laws in their favor, doesn't tax them, allows them to sell substandard insurance, gives them liability protection and forced arbitration and in every way abuse the customer.

And the industry will become abusive, fraudulant, manipulative, and untouchable. Every state will lower its standards and revenue streams to keep insurers from leaving and taking jobs with them. And the customer will have very few if any good choices and no recourse when screwed over. Over time, the industry's power over the state will become even more entrenched. Exhibit one: The credit card industry, and south dakota. Go watch the Frontline episode I refer to in another thread.

I'd like to answer some of your other questions like "why do I have to buy a plan that covers obgyn" but I'm too pissed over having to pay for rear seatbelts I'll never wear, a space program I'll never use, fire hydrants I'll probably never need, and taxes for schools I'll never attend. Living in a society sucks. I mean, I have to pay for roads I'll never drive on. It's bullshit. I mean even my freaking insurance-- I have to pay for all these diseases that it'll cover! I'm NEVER gonna get ALL of them at once. And only one of them can even possibly kill me, maybe two max. Why should I pay for protection from a heart attack AND cancer treatment?!!! Bullshit, man. That's how they get you. I mean, I saw tonsilectimy on the list and I don't even have tonsils any more. Tyranny. I want an a la cart health insurance plan where I can figure out what I'm likely to get and only get insurance against that specific disease!!!

<comment><USER71> > "Because then pretty much EVERY insurance company will pick up and move to > the one most desperate state that writes laws in their favor, doesn't tax > them, allows them to sell substandard insurance, gives them liability > protection and forced arbitration and in every way abuse the customer."

By that same logic, people would also move to the state most beneficial to them or would vote for laws in their state that they think is best for the people.

Competition benefits everyone.

</comment></comment></comment><comment><USER74> GWB upped the age of coverage to 25 and the ACA only moved it a bit but gets all the credit. DJT wants to keep the preexisting conditions part and do away with the fines for not having insurance and increased costs of forcing insurers into the ACA by repealing it and replacing it with interstate insurance competition without the bureaucracy of a government managed program. Too bad everyone thinks Obama was a holy man for putting together the garbage that is the ACA, and thinks of any improved solution as an assault on his legacy.

<comment><USER75> GWB most certainly did not up the age of coverage to 25.

Prior to the ACA, nearly every employer-based coverage plan stopped dependent coverage at 19-years old or upon college graduation. Those that allowed older children would refuse dependent coverage if the children's employer offered health care, which meant that if you got a entry-level job out of high school at a company that offered insurance _at any price_ , you couldn't use your parents' insurance.

After the ACA, every plan, employer-sponsored or exchange-based, must offer dependent care up until 26-years of age.

2.5 million <25-year olds gained health insurance in the first year after the expansion, which was _before the mandate was in place_.

The ACA gets credit for the expansion since it caused the expansion.

</comment></comment><comment><USER28> Many of these stories suggest that you'll have less overhead (and more runway) as a 25 year old found than as a 27 year old founder.

I'm not convinced that's providing productive selection criteria.

<comment><USER76> The anecdotes illustrate that there were two main benefactors: young people without formal full-time employment and those with pre-existing conditions that had allowed insurance coverage to lapse.

From someone too old to be on their parent's insurance, while I'm 100% behind the reform that disallows previous conditions from affecting ability to get coverage, the ACA was effectively a shake-down that made me delay taking the risk to go full time on my startup -- the options for coverage in my state were expensive and very low-quality, and the penalty for opting-out would have been $4000 for my domestic partner and I (on top of the additional taxes we paid to support ACA).

<comment><USER28> Thanks for sharing. I alluded to this in another thread but got downvoted and stirred controversy.

My claim is this: For the median entrepreneur, there is more financial drag due to insurance now than there was before the ACA. For those who are sick or young, there is less financial drag. Your story anecdotally supports that claim.

<comment><USER76> Yeah, I think that there's a political type that is just a zealot scared of anything that will challenge his/her worldview and feels a need to flag/downvote/hide.

The reform surrounding pre-existing conditions for people that let their health coverage lapse is the only good thing that came out of the ACA, and it was _very_ expensive for the taxpayers and continues to be. This should have just been a piece of legislature and not a terrible government shakedown of the American public; a simple reform was needed, not another way to subsidize the non-working while compelling the public to give money to private corporations.

</comment></comment></comment></comment><comment><USER77> A few years back, I quit my job and founded an (ultimately unsuccessful) startup. A big factor in deciding to do it was that the ACA would go into effect before my Cobra coverage expired.

</comment><comment><USER78> Damn. I saw the title and thought YC was starting a healthcare company. That would have been awesome.

</comment><comment><USER79> > One thing the ACA definitely did was help a lot of founders start their > companies--without it, being a founder would make sense for less people

Hmm. I've heard many small companies could not afford to provide health insurance for their employees after ACA passed ( I don't know the details of exactly the causal chain there ). So they stop providing it and pushed people to use ACA which had ridiculous price hikes and also in some states companies withdrawing from the exchanges.

In other cases I've heard companies have pushed people part time status in order to avoid having to provide health insurance and other benefits. I think that is mostly lower wage employment.

My own rates working for a small company a few years before the ACA and after went up much high even before ACA was about to pass in anticipation. There the insurance representative who we talk to every year stated clearly why there is an increase -- because of the volatility and unknown effects of ACA they decided to increase prices. After it passed and was being phased in our rates were going up much high.

Some things were nicer, like no pre-existing conditions, no lifetime maximum, some free preventative checks overall it has been worse.

Now, no doubt it has helped many people, but I am not sure if small businesses and their employees (especially in the tech sector) saw a benefit.

<comment><USER80> > I don't know the details of exactly the causal chain there...

This is a really sincere recommendation: if I were you, I would research that and figure out if it's true or not. There is plenty of propaganda going around on this subject from all sides; it's dangerous to rely on things you've heard.

<comment><USER79> Have you? What do you think is the reason?

<comment><USER80> The reason for what? I can't even seem to validate the original claims, so...

<comment><USER79> >>> . I've heard many small companies could not afford to provide health insurance for their employees after ACA passed ( I don't know the details of exactly the causal chain there )

>> if I were you, I would research that and figure out if it's true or not.

> I can't even seem to validate the original claims, so...

I was just asking if you knew the reason already or have looked into it.

<comment><USER80> Right. I'm saying I don't know if "many small companies could not afford to provide health insurance..." is accurate. I don't know how we're defining small companies (if they're under 25 full time employees, the mandates don't apply). I don't know how we're defining "couldn't afford to." What effects count? Are we saying that the rate of businesses going out of business has increased? Etc., etc.

Once there's some data, we can have the perhaps more interesting question of whether or not it's worth it. No question but that increasing the number of people with health insurance costs money and that has to have some effect.

<comment><USER79> Makes sense. Sorry, I think my question sounded snippy. I didn't mean it that way. I ask for opinion here often because I trust users here more than any other online forum.

</comment></comment></comment></comment></comment></comment></comment><comment><USER81> One of the best experiences I had was actually going through a different site which seemed to have even more options than Healthcare.gov, [https://www.policygenius.com/health- insurance](https://www.policygenius.com/health-insurance)

I'm sure there's more as well, but this definitely helped several friends of mine. Seems like these kind of things would have been impossible without large swaths of the ACA.

</comment><comment><USER82> Perhaps I am being overly simplistic, and I do support ACA reform, but I don't believe there is a silver bullet to reforming ACA. If there was Republicans would already have come up with it and would have been publicizing it for the last 8 years.

The fact remains - covering pre-existing conditions, kids till 26, and low income households is expensive. You can pay it by increasing the insured pool - which is what ACA tries to do via the individual mandate, or by introducing a single payer system whose buying power would be so big that they will substantial leverage over healthcare provider. As a society we have decided that a single payer system is socialist, so it cannot be adopted here (and it has its own problems - wait times, lack of R&D incentive etc.). So now we have to choose between not providing healthcare to 40-50 million people or pay increased premiums to cover for those.

Some reforms that may somewhat bring down the premiums: \- Offer subsidies to even middle income people, not just poor. May be set the income limit by geography \- Make the individual mandate more expensive to incentivize healthier people join the pool \- Offer a public option

</comment><comment><USER83> We need something like the ACA. Shit, we need more than that, but the very imperfect ACA is a good start.

I look at it this way: Right now, I'm with a large company - I have a wife who left corporate life to raise our daughter. It's all riding on me. And on that, I have some ideas, one has become a small side gig, but if they grow enough to become my focus, that essentially opens the basic question of how I'd provide health insurance to my family.

Thankfully, I have a backup plan to some degree, as I happen to be a citizen of a European country as well as the US, but it's an imperfect backup plan as my "other" nationality is a place with notoriously difficult small business bureaucracy, and while I could live in another EU country, I'd need to establish the ability to support myself before anyone's going to let me stay.

Ideally, we'd stay in the US, because let's face it, this is a pretty great country to found a company, warts and all. But we have to not be having to worry about something as basic as healthcare if we're to take the kinds of risks that lead to innovation.

</comment><comment> temp-dude-87844 Healthcare is a touchy subject because people's quality-of-life and their actual lives (vs. death) are on the line. But food and shelter are similarly crucial to existence, yet they aren't provided at no cost, but must be acquired through their own labor, or reliance on family, charity, etc.

It's interesting to me that we as a society have long accepted that people have to work for food and shelter, leaving a permanent underclass in the dust, while we're uncomfortable to say the same about healthcare.

But of course, it doesn't matter. Those who oppose the ACA or the individual mandate or employer requirements or the notion of healthcare subsidies are dancing around their justifications and are reluctant to come out and say that people with health complications should just be out of luck. Instead, they'll dismantle, maybe introduce an alibi entitlement scheme to save some political face, and leave a status quo with the exact same result.

<comment><USER84> There are a lot of social programs for food and shelter in the US. The food one works fine, the shelter one is more hit or miss.

<comment><USER25> The shelter one may be hit and miss, but it's a lot better than healthcare support (even under, but much moreso prior to, the ACA.)

</comment></comment></comment><comment><USER85> ACA doubled or quadrupled my monthly insurance costs, which actually put a strain on my budget when doing a startup at the time.

</comment><comment><USER86> I love this idea that we can "save the best parts". What part would that be, exactly? The part where insurance companies can't deny you coverage? And the part to get rid of would be the part where you are required to carry insurance? Are people really so dense that they can't see how one absolutely requires the other?

</comment><comment> gm-conspiracy I disagree this is a "party" doing.

Mitt Romney had similarly reformed Massachusetts law in 2006 as Governor.

[https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...](https://en.wikipedia.org/wiki/Massachusetts_health_care_reform)

I see the article briefly touched upon the American notion of health insurance being tied to employment.

Nobody seems to want to really solve this problem, just band-aids and lip- service. Neither mainstream party would consider a single-payer system, nor direct government negotiation with drug companies.

It's as though the drug and insurance companies are better represented (and have more rights) than its citizens.

Heck, even Medicare is divided into at least four regions to "negotaiate" regional prices.

How do other countries perceive this?

The US falls further and further behind in healthcare and affordable and available high-speed internet. Let's see some real progress.

<comment><USER87> > just band-aids

INSURANCE EXPLANATION OF BENEFIT

Adhesive bandage. . . . . . $300 | Covered: $.02 | You Owe: $299.98

</comment></comment><comment><USER88> I think the point most of the people that Sam referred to where basically saying that they would like others to subsidize their health insurance. That's what insurance is. We all put money into a bucket and some people will use it and some not so much and others a lot. The people who use it a lot want to pay the same amount as those who are healthy and have the healthy subsidize their health issues. That is what is currently going on and why prices have gone through the roof. All those "unisurables" are on the same insurances as healthy but now the bucket of money needs to be much larger to cover the cost of the "unisurables".

If this is how the government wants to do it, don't call it insurance. Just call it socialized medicine, because I am definitely not getting what I paid for.

</comment><comment><USER89> I am optimistic that we have a chance for real solutions here:

* Pricing: How about transparent pricing up front for all non-emergency services? That means the price you pay, and that your insurance pays. Not some mystery of "you are responsible for some unknowable amount if the insurance company doesn't pay" or "we might make you pay your entire deductible".

* More effective implementation of high deductible health plans that's simpler for people.

* Medical expenses and insurance tax-deductible, full stop. No messing with HSA, FSA.

* When you are diagnosed with a condition, your current insurance is responsible for the rest of your life for related expenses. No new insurance company would deny you because it wouldn't cost them anything for your preexisting condition.

* Subsidize normal health insurance for poor people.

</comment><comment><USER90> As a European watching from afar I feel like the US government should rather come after the insane pricing schemes of hospitals and pharma companies that make insurance so expensive in the first place.

Need your appendix removed? Better get a loan from the bank. Just because they can.

</comment><comment><USER91> "I had heart surgery when I was 18. I was virtually uninsurable. I now have health insurance. Why we need the ACA is no more complicated than that."

I am a bit confused by this story. Was Zach not covered under his families' health coverage? He also went to: Westminster School - one of the most expensive private high schools in the US.

Now, one could argue he had a pre-existing condition and thus, was not covered under any health care providers plan, but he states: "I was virtually uninsurable." This tells me there were options, but none that covered the entire cost of the surgery. Honestly, this story alone makes me seriously question the purpose of this post.

<comment><USER92> A serious heart condition in one's youth (infancy, even), regardless of insurance coverage at the time, could exclude one from all future private insurance (as in: there are zero options, they will not do business with you) leaving only incredibly-expensive state-provided (but privately administered , of course—profit over all) insurance as an "option", _i.e._ leaving the only actual options as being employed with a large company, going without insurance at all, or being poor enough to qualify for medicaid (so, avoiding employment).

Source: I know someone for whom this was the case pre-ACA.

</comment></comment><comment><USER93> Altman acts like buying insurance was impossible when self employed pre-ACA. Give me a break.

I shopped online and bought a sensible plan just like anything else. There were tons of choices and plenty of competition.

This whole notion that we'll all be doomed without it is utter rubbish. The entire Healthcare system is broken, starting from our agricultural subsidies to our ridiculous prescription drug prices (which many pharma-lobbied Democrats just voted to keep high) to the artificially low supply of doctors (you don't need 12 years of school to prescribe penicillin).

ACA is just 2000 pages of nonsense on top of all of that. We can do better at all facets.

<comment><USER33> > Altman acts like buying insurance was impossible when self employed pre-ACA. > Give me a break.

It was impossible if you had any pre-existing conditions, no matter how trivial.

<comment><USER93> So, is the argument here that more expensive healthcare shouldn't make for more expensive insurance?

<comment><USER33> I'm not making any argument except pointing out that for many people with pre- existing conditions, buying health insurance pre-ACA was indeed actually impossible.

</comment></comment></comment></comment><comment><USER94> I tried running a startup in 2010 before the ACA took effect. What ultimately made me give up? My only health care option was Cobra, and I ran out of time.

At the time, I had sleep apnea and had to pay almost $500 a month for health insurance. That was more then I spent on food, almost as much as I paid for rent. (It was more than my car payment, which I paid off two years prior.)

18 months is a very short time period when you're trying different things to see what sticks.

If the ACA was an option, I'd probably had another 4-6 months to go. Would I have found something that "stuck?" I'll never know.

</comment><comment><USER47> The flip side is that the ACA has enabled small businesses to screw over and exploit their employees by exempting businesses under a certain size from having to provide health insurance to their employees.

</comment><comment><USER95> It's a balancing act though, no? Health Insurance is stupid expensive in the US. In Bolivia I used to pay $300/month for my entire family full coverage, no copay. But they did screen for preexisting conditions when I signed up.

So what's the answer? How can health insurance providers help people with pre- existing conditions, and also not gouge young healthy customers?

Is the healthcare industry just charging too much money?

<comment><USER43> Asking everyone to pay into a shared risk pool is not gouging. That's simply the nature of insurance. We're going to have to pay for people with pre- existing conditions one way or another, whether it's structured as a tax, penalty, or insurance premium.

Certainly there is _some_ waste, fraud, and abuse in the healthcare system which could be cut. But ultimately the only way to significantly cut costs would be to ration care. It's a hard issue and no one likes to talk about it.

<comment><USER96> > _But ultimately the only way to significantly cut costs would be to ration > care._

As far as I know, Western European countries spend about half (per capita) on health care as what USA spends. I don't know if US health care is that much better. And if it's not, then in theory there is a way to get the same results cheaper.

<comment><USER97> My experience with the USA healthcare system has been utterly phenomenal. Almost no waits for procedures of any kind, top-tier care. My last hospital stay was 5 days with many lab tests and two ER visits and an ambulance ride preceding it. Out of pocket I paid $100, $50 of which was later refunded to me.

Parts of the ACA are necessary but I can't help but feeling, based on the price increases, the Act itself is horribly inefficient. We didn't increase the supply, we just increased the demand for a product which is very inelastic, resulting in skyrocketing premiums. A reform must involve increasing the supply of care.

</comment></comment></comment></comment><comment><USER98> I twitch a little every time I read something like this:

> Precision CNC milled from aircraft grade aluminum to 1/1000ths of an inch > tolerance

What you need aicraft-grade aluminum for? And a 1-mil tolerance? Are you building a really tiny aircraft?

"Premium design" stops when the design choices are the best you could ever need. Beyond that, it's no longer a matter of engineering, it's about far less respectable traits.

</comment><comment><USER99> Why can't the national health be handled as infrastructure?

I mean, we pay taxes for streets, so people can get everywhere. We pay taxes for schools, so people learn everything. Why not pay taxes, so people are kept healthy?

The whole public healthcare stuff doesn't even work like a real insurance, so why not throw this stuff away, make a health tax everyone pays, call it exactly that, and be done with it?

</comment><comment><USER68> I posted a comment already, but I have another thing to say, or rather ask: honest question to sama and the rest of the YC people, why don't you lobby congress to keep parts of the ACA? Money in politics is the reason we are here, and until we fix that, the only way it seems you can play is to pay. I'm curious is people from SV have considered lobbying congress.

</comment><comment><USER100> If you have to read this thread then call your rep. It litterly is about a 30 second call. [http://www.house.gov/representatives/find/](http://www.house.gov/representatives/find/)

Even if you have a rep that favors the ACA it gives them an idea how much effort in to saving it.

</comment><comment><USER101> Simple question:

Why is there little or no start up innovation in the insurance space? Why aren't YC17 companies able to attack this?

</comment><comment><USER102> the seen: people it helps the (mostly) unseen: the higher burden on everybody else

Is the tradeoff worth it? That's the question.

</comment><comment><USER103> Trump aims to be a job creator. As a member of the uncountable funemployed, and while I may be working on the Next Big Thing(tm), it doesn't count. But take away my affordable, subsidized, health insurance policy and force me to seek shelter under the corporate umbrella? Then I'm +1 job.

</comment><comment><USER104> My last four insurance companies have gone under since the ACA. I get fewer worse choice every year. My plan is now 5 times the cost as it was before the ACA. Entrepreneurs are clearly hurt worse than the largest companies who werr hit by ACA later. The subsidies are unsustainable and will end soon.

</comment><comment><USER105> Easy fix is to require all insurers to provide ACA plans. Also cross state plans sound nice in theory but then you need cross state normalization of insurance regulators. That may only happen at a Fdderal level and will be an interesting constitutional issue. Same with Medicare and Medicaid.

</comment><comment><USER106> I'm still left wondering how our government manages to spend more money on healthcare than the vast majority of countries, but we have the highest out of pocket expenses of any country and our life expectancy and infant mortality still look a bit worse than other developed countries.

</comment><comment><USER107> sam, i'd like the choice to buy or not buy health insurance. thats a little thing called freedom

</comment><comment><USER41> The healthcare and health insurance system in the United States is a complete mess. There are multiple distinct problems, but politicians like to group them all together into one single problem. The way I see it, all the problems fall into one of two major categories: (1) Healthcare costs are out of control, and (2) Health insurance costs are out of control.

1) Healthcare costs are out of control.

In the US, healthcare spending is 17% of GDP, the highest of any country in the world; the next highest is France, at 11% GDP. [0] The reasons for this are very complex and intertwined, but there are a few major issues:

(1a) Intellectual Property protections: When only one company can sell a drug for the first 10 years of its existence, they effectively have a monopoly and can set the price to whatever they want.

(1b) R&D costs: If it costs $10mm to develop a new drug to treat a deadly disease that affects less than 1% of the population, then naturally the company must set a high price for the drug to cover costs of R&D; this is related to (1a).

(1c) Primary care providers and pharmaceutical companies are accountable to nobody when setting their prices. Because the majority of people pay for healthcare via insurance, they are price insensitive. After all, if insurance is paying for your healthcare, what do you care if the cost is $100k or $1k? (As an example: A family friend of mine ran a "compounding pharmacy," where he compounded multiple drugs into a single pill, so people who are prescribed 15+ pills to only need to take one. The insurance companies considered the resulting compound to be a "new drug" and therefore he was able to set its price to literally _whatever he wanted._ )

2) Health insurance costs are out of control.

This is a complex issue but it comes down to a few major factors:

(2a) Risk pools cannot cross state lines. As far as I can see there is literally no reason for this.

(2b) The requirement to cover pre-existing conditions increases insurance costs for everyone. As many have mentioned in this thread, it makes no sense to call coverage for pre-existing conditions "insurance." If you already have a disease, you aren't insuring against it; you're just paying for it. I do think that people have a right to healthcare, and even as a republican I think that taxpayers have a duty to subsidize those with pre-existing conditions. But I don't think we should be including this obligation in the cost of insurance from private companies. It should be a separate budget item, like social security or medicare or medicaid (or better yet, take it out of the defense budget...). If private companies need to insure (read: pay for) pre- existing conditions, then they effectively become the gatekeepers for this tax, and they have every incentive to make it as high as possible.

[0] [http://www.commonwealthfund.org/publications/issue- briefs/20...](http://www.commonwealthfund.org/publications/issue- briefs/2015/oct/us-health-care-from-a-global-perspective)

</comment><comment><USER108> isn't there a bit of a broken-windows fallacy here? How many founders can't afford to leave their normal 9-5 / and do a startup because their premiums have gotten more expensive and they can't build up a runway?

</comment><comment><USER109> Sam Altman should get a list of all YC startup employees insurance data made public, maybe with a a small questionnaire form with objective questions.

That way analysis becomes easier and all perceived sample biases can be alieviated.

</comment><comment><USER110> It seemed weird to me that ycombinator wasn't at Trump's Tech meeting (considering they're at the center of silicon valley in a sense). This post makes me wonder if that was not an accident...

</comment><comment><USER111> Thanks for writing this. Whatever your view on the ACA, you can probably agree that health is important. It's a tough problem, how we handle it will define the US more than anything else in the future.

</comment><comment><USER112> I don't understand why we don't have Universal Healthcare? Every other first world country has it. They also spend a lot less money than us. We should borrow what works best from around the world.

</comment><comment><USER113> Can someone explain the benefits of a US-style healthcare system vs nationalised tax funded healthcare?

All I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now.

What happens if you don't have insurance? To me any system where you make sick people pay more than rich people seems bonkers no? If most people's employers already pay it on their behalf, isn't it a business tax already?

<comment><USER114> > Can someone explain the benefits of a US-style healthcare system vs > nationalised tax funded healthcare?

None.

> I see from threads like this is a lot of Americans bickering over their own > healthcare, and as an outsider I don't really know how how it works, and why > everyone is so invested in how it works now.

Because actual change is near impossible these days. (Ultimately this is largely a result of flaws in our electoral system. Most notably, gerrymandering gives Republicans a near permanent lock on the House.)

> What happens if you don't have insurance?

You die.

> To me any system where you make sick people pay more than rich people seems > bonkers no?

Republican congressmen are bonkers and/or evil.

> If most people's employers already pay it on their behalf, isn't it a > business tax already?

That's a large part of the problem. It got tied to employment in during WWII when the government mandated salary caps for some industries so firms competed on benefits. I think almost everyone agrees this is bad but it's impossible to change because of gridlock.

</comment></comment><comment><USER115> Id only people cared about the Affordable Care Act this much, before! The election...

</comment><comment><USER116> These individual stories are nice. But when are you Americans going to fight to save your healthcare?

<comment><USER40> Many, many people have been calling their elected representatives every day and otherwise lobbying behind the scenes

</comment></comment><comment><USER40> I'm currently working as a consultant and I'd not be able to do it without the ACA.

</comment><comment><USER117> Arguments against ACA:

\- It cost me money

\- It's not perfect

Arguments in favor of ACA:

\- It literally saved my life

Regarding increasing premiums, the complaints tend to be anecdotal. According to the National Conference of State Legislatures, in 2016, the average monthly net premium increased just $4 -- or 4% -- from 2015 to 2016 among the insured that take advantage of subsidies.[1]

Furthermore, premiums have gone up year-over-year every year almost every year since I've been paying for my own insurance -- and that's well before ACA.

There's an interesting chart on the Kaiser Foundation website, where it shows the average plan prices and percent increase year-over-year broken down by state. It also shows that, after tax credits and with very few exceptions, plan prices have remained stable (0% change) between 2015 and 2016.

I understand and sympathize with the high premium prices, but I have serious reservations about the assertion that the high premiums are due to the ACA and not external factors.

[1] [http://www.ncsl.org/research/health/health-insurance- premium...](http://www.ncsl.org/research/health/health-insurance- premiums.aspx)

[2] [http://kff.org/health-reform/issue-brief/2017-premium- change...](http://kff.org/health-reform/issue-brief/2017-premium-changes-and- insurer-participation-in-the-affordable-care-acts-health-insurance- marketplaces/)

<comment><USER118> As a non US Citizen, I have a question:

If Obamacare is repelled at the Federal level, could a state just implement its local ACA? what prevents California for instance of giving health coverage for its residents? California is a good example since it "the world's sixth- largest economy" (If California was a country) I'm sure healthcare companies wouldn't want to cut themselves out of this market?

This would give California and SV an even bigger advantage regarding what is described in Sam's post.

<comment><USER25> > If Obamacare is repelled at the Federal level, could a state just implement > its local ACA?

Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. It's also likely that a repeal would be accompanied or followed by federal policies which would make state- specified versions of the ACA less practical than they are now.

> what prevents California for instance of giving health coverage for its > residents?

California already provides state-run send healthcare beyond the requirements of the federal programs it participates in.

<comment><USER118> > Some parts of the ACA could be implemented in state law, some would be > either illegal or impractical at the state level.

That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, what would be impractical? If a state ACA is challenged in court, couldn't they use the supreme courts rulings of Obamacare as a strong defense?

Other comments here mentions that Massachusetts already had it (and I assume would likely keep it even after Obamacare is repealed), Couldn't California copy the Massachusetts implementation?

> California already provides state-run send healthcare beyond the > requirements of the federal programs it participates in.

But I assume those state-run programs aren't providing as strong of a coverage as Obamacare was? Now would seem a good time to update it to match Obamacare?

<comment><USER119> > That's my poor understanding of U.S. Federal vs State government that fails > me here: what exactly would be illegal,

Mandating coverage, which is basically a requirement of affordable universal healthcare.

"What happens if I don't pay the fee?

The IRS will hold back the amount of the fee from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee."

[https://www.healthcare.gov/fees/fee-for-not-being- covered/](https://www.healthcare.gov/fees/fee-for-not-being-covered/)

<comment><USER120> Massachusetts did this in the program that Obamacare was modeled after, so clearly that's not (currently) illegal at the state level.

The fee structure is different (just a missed deduction on the state taxes, not a separate monthly charge), but it still works.

<comment><USER119> I'm not saying it _can 't_ be done; I'm saying its a pain in the ass due to the political climate in the US. Apologies that wasn't clear.

</comment></comment></comment></comment></comment></comment></comment><comment><USER121> When my wife and I looked for insurance just before ACA, the private plan without subsidies, because they didn't exist, was $250. It was a basic plan with a high deductible and an HSA. It was pretty much what my employer offered. After the ACA, same plan, by name, now cost $530. Sure it had more bells and whistles, but I didn't want nor need them. This priced me out. This same plan today is $780 a month without subsidies.

We are now on an ACA plan. $270 with subsidies. Think about that. The government doubled the price of the plan or more, and is paying with our tax dollars the difference between my $270 and $780.

The ACA helped many people. It helped people under 26. It helped people with pre-existing conditions. It helped give free or low-cost health care to people that couldn't afford it because now the government is picking up the lion's share of the tab.

As much as people like to rag on the Republicans, and they deserve it, I don't think they will throw out the good parts. I think they will look at the industrial recommendations such as expanding risk pools across states (Commerce Clause allows this regulation), and other rational plans. Will it be perfect? No. Will it be better than the current ACA? Maybe.

<comment><USER15> > I don't think they will throw out the good parts

You are mistaken. The good parts, like covering pre-existing conditions is exactly what causes your insurance to go up. It's basic economics. The Republicans do not have a plan to fix that.

If there was a way to fix it, don't you think it would already be implemented? You think they're purposefully keeping your rates high just to fuck with you? Not to mention suffer all the political fallout of it?

Don't forget. Obamacare is the Republican plan. This repeal and objection to Obamacare is all politics, not an attempt to fix a broken system.

<comment><USER122> Seconded. ACA puts a cap on the profits of insurers. They are not just increasing the premiums and pocketing the difference. Most, if not all of the difference is going towards medical care by law.

"MLR measures the share of health care premium dollars spent on medical benefits, as opposed to company expenses such as overhead or profits. For example, if an insurer collects $100,000 in premiums and spends $85,000 on medical care, the MLR is 85%. In general, the higher the MLR, the more value a policyholder receives for his or her premium dollar. The ACA requires an annual, minimum 80% MLR for individual and small group insurance plans, and an annual, minimum 85% MLR for large group plans." [1]

Source: [https://fas.org/sgp/crs/misc/R42735.pdf](https://fas.org/sgp/crs/misc/R42735.pdf)

<comment><USER123> So insurance is bounded by cost plus pricing now. They have no problem if actual health care costs go up, their bottom line profits go up too! The insurance companies interests are now misaligned. Yeah they want to keep costs down to increase their spread, but if the spread is limited and allowed now they have no problem if hospitals charge $200 for what was a $100 procedure last year because $30 is more than $15 and they'll just increase premiums!

<comment><USER124> I never understood why this is not glaringly obvious before anyone implements such a plan. Or maybe it was and this was intended? Seems just as likely at this point.

I mean, this is a constant joke in professional circles. If you are hourly billing and you can use your shitty talent to create something in 8 hours that your good talent would create in 1 - it's usually economically beneficial to have the worse employees do the work as it's more profitable overall. Up until the point where you lose the customer - but in this case that's not a concern.

<comment><USER125> It's right up there with excess taxes on gambling and tobacco. Governments become dependent on those excesses and are disincentivized to decrease the activities they're ostensibly trying to lower.

<comment><USER126> > excess taxes on gambling and tobacco

You may be mishearing the term "excise tax". An excise tax is a tax on any specific good, such as tobacco or gasoline. Those taxes are included in the cost of the good (it just costs more at the pump or on the shelf). Yes, they are typically used to reduce consumption, or to pay for costs associated with consumption (eg roads).

<comment><USER125> I'm aware of what excise taxes are, but I see why it might seem like that's what I meant, because I wasn't really explaining what I meant by that phrase. By "excess tax", I mean taxes in excess of the cost of the behavior they're trying to regulate. Both of these examples are both excise taxes, the rates of which are in excess of the costs borne to society of those activities.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER127> A fine example of confirmation bias: ACA aligns with Sam's ideological position, so he hand picks some examples to support it. Don't get me wrong, I think it's great that people with preexisting conditions can't be denied coverage. But is it OK that plans are three times more expensive now, with three times the deductible? I don't think so. Seems like a trillion dollar money trough for Big Pharma and Big Insurance to me.

<comment><USER128> Well strictly speaking, if Obama could have passed single payer, he would have. He went with a compromise based on a republican idea and negotiated with the insurers to get their support. The thing is, expensive as it is, you have the ability to get health coverage. The ACA made health care affordable to people who previously couldn't afford it at all, particularly the working poor through medicaid expansions.

<comment><USER129> He had two years of full Democratic control of Congress. He didn't even _try_ to get single payer, didn't even try to get the "public option".

Obama's disastrous politics are a result of going into every debate _starting_ at the "compromise" position, and then getting dragged further right. Just go back to his 2004 DNC speech, it lays out exactly how he's going to fail.

<comment><USER130> He had just a couple of months of full Democratic control. Due to Al Franken not being seated right away, Robert Byrd being ill, and Ted Kennedy dying, the Democrats didn't have a supermajority until September of 2009. They then lost that supermajority in February 2010 when Scott Brown was sworn in.

I do agree that Obama tended to negotiate badly by compromising before it was even needed, but that "two years of full Democratic control" thing gets repeated so often, and it's annoyingly wrong.

<comment><USER131> As they proved later, they didn't _need_ a Supermajority in the Senate -- they just changed Senate rules. It was passed with a simple majority.

<comment><USER130> Are you talking about the use of reconciliation to get the final version through?

</comment></comment></comment></comment></comment></comment><comment><USER132> Affordable Care Act?

[https://ycharts.com/indicators/us_health_care_inflation_rate](https://ycharts.com/indicators/us_health_care_inflation_rate)

Health care is not becoming more affordable. The rate of inflation in health care is significantly higher than the US inflation rate.

[https://fred.stlouisfed.org/series/T5YIFR](https://fred.stlouisfed.org/series/T5YIFR)

How is that affordable? How are $600 epi-pens affordable?[1] How is a 4000% price hike on a 62 year old generic affordable?[2] Google for "snake bite hospital bill." $153,000. That's not affordable. That sounds downright fraudulent.

It seems they should have named it something more appropriate, like the Universal Health Insurance Act. Insurance that is no more affordable than the overpriced health care available in the country. But point this out, and everyone starts their partisan bickering and nothing gets done at all.

[1][https://www.bloomberg.com/news/articles/2016-08-29/mylan- to-...](https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-sell- generic-epipen-to-quell-outcry-over-600-cost)

[2] [https://www.washingtonpost.com/news/to-your- health/wp/2015/0...](https://www.washingtonpost.com/news/to-your- health/wp/2015/09/22/turing-ceo-martin-shkreli-explains-that-4000-percent- drug-price-hike-is-altruistic-not-greedy/)

<comment><USER133> Wrt to your first link[1], the very first sentence in the overview tab states, "US Health Care Inflation Rate is at 3.98%, compared to 4.26% last month and 2.95% last year. This is lower than the long term average of 5.40%."

I don't intend any snarkiness, but am I somehow misreading those numbers? I'm reading that statement as "an inflation rate of 2.95% for the last year compared to the long term average of 5.40% could be equated with 'more affordable'".

[1] [https://ycharts.com/indicators/us_health_care_inflation_rate](https://ycharts.com/indicators/us_health_care_inflation_rate)

<comment><USER132> The long term inflation rate of the US is much lower than that as a whole. That's the point. Inflation in health care exceeds inflation in the US as a whole.

That is the core issue. That was not solved by the ACA. How do we solve it? Ideas? Oh yeah, you know what? Let's argue about Obama and Trump instead. That will surely work. Look at the comments in this thread.

If I asked you how to solve a sorting problem, I'd have a dozen good solutions presented. If I ask how to solve a healthcare cost problem that many other countries don't seem to have, everyone's brain switches off and they go into arguing about politics.

<comment><USER134> "Health care inflation" isn't directly comparable to the overall inflation rate, as the quality and amount of health care has been rising alongside the increasing percentage of GDP we spend on it. Compared to when the only available remedies were bloodletting and leeches, I bet we spend a lot more on the health care sector.

<comment><USER132> Are you seriously making excuses for the overpriced health care in the US? Every other country has the same procedures we have in the US at lower prices.

[http://ritholtz.com/2012/03/comparing-medical-procedure- cost...](http://ritholtz.com/2012/03/comparing-medical-procedure-costs-in-us- vs-overseas/)

</comment></comment></comment></comment></comment><comment><USER135> Sorry, but Sam Altman (and many others) are missing the point.

Without actual PRICE DISCOVERY nothing(in terms of reform) works.

I got a tetanus shot (booster as an adult, Tdap) and called around to different clinics. Prices ranged from $131 to $39. For what is _required by law_ to be exactly the same thing.

That "well your insurance might mean you will pay a different amount" is EXACTLY the problem. No one can easily determine the price of anything.

Is there a base-model Chevy that is sold at one dealership for $35K and at another dealership in the same city, for $65K?

No, because people would very quickly do price discovery...

</comment><comment><USER136> Countries that offer universal care such as Canada, The UK, France (also also NY State/NY City where I live) have a tobacco tax in the $5 to $7 range or more that helps to pay for the higher health care costs of smokers. NYC tax is $6.85 for city+state+fed. The US Federal tax is about $1. If the tax were increased by $5 for the 13 billion packed smoked each year it would yield approx $30 to $35 billion which could be used to mitigate the high cost of insurance for others.

Also, the medical ratio of youth to elderly is 1:6 and before the ACA, youth would pay about 1/6 of elderly costs. Congress unfairly mandated that ratio to be 1:3 meaning youth pay 75% more than they should. They already have to pay for student loans, save for a house, and now they have additional burdens paying for smokers and those who drink daily sugar Cokes and thus obese.

Tax tobacco like other countries and NYC/NYS and use that money to make premiums for youth and middle class more fair.

<comment><USER29> > Tax tobacco like other countries and NYC/NYS and use that money to make > premiums for youth and middle class more fair.

Tobacco taxes are incredibly regressive (they very disproportionately tax the poor). So you're essentially proposing taxing the poor in order to pay for the middle class.

<comment><USER136> > "Tobacco taxes are incredibly regressive (they very disproportionately tax > the poor)."

They disproportionately tax smokers making smokers at least pay a portion of the additional health care costs they incur by smoking.

Taxing tobacco contributes over half the effect of ensuring teens never start and smokers quit smoking.

</comment></comment></comment><comment><USER137> The fact that Obamacare was mandatory meant it had to go. Obamacare was really a fascist's wet dream and why the insurance companies ended up being pretty giddy about it.

Good riddance!

</comment><comment><USER138> I have nothing to say for or against Republicans, Dems, Trump or any other political entity.

BUT

If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts.

It's inhumane for the wealthiest country in the world to take away basic healthcare for it's most vulnerable citizens.

If you are so 'smart' and so 'great' \- then figure out a way to introduce efficiencies, pricing intelligence etc. to get people more and better coverage - instead of just smashing some law because it's not perfect and it was written by 'Obama'.

<comment><USER139> >If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts.

Which should be a very strong indication that's not going to happen.

Despite the endless propaganda, Republican lawmakers are neither stupid nor evil.

People are not going to be left uncared for, that's just political fearmongering, and we don't have to fall for it.

<comment><USER138> They can definitely be stupid, and they can sometimes be borderline evil - making jail time for crack 80x greater than for cocaine because of the offender demographics, that's pretty evil (and stupid).

1) They are voting to repeal ACA in real time.

2) They have not offered even a hint of an alternative.

This is not only going to be potentially damaging those who will lose their coverage - but it's also incredibly difficult for business: there is no roadmap. Insurers, and all other businesses small and large now are left in the dark with respect to their future. Introducing such ambiguity is definitely stupid, and it's 'anti businesses'.

They have at least two years of unlimited power, they should debate solutions, narrow it down to an actionable plan, and then modify ACA in a well thought out process.

As it stands, they're just rolling back laws and haven't discussed anything else, which I think is irresponsible. They don't need to be in such a panic.

<comment><USER139> Neither of your points 1 or 2 are accurate, instead they reflect the political fearmongering I mentioned.

People lament that our politics are so divided. Mis-stating the situations we're in and exaggerating for political gain are a root cause of that. Do not be part of the problem. Stop spreading the fear.

<comment><USER138> This is false.

1) They are repealing ACA as we speak - the legislative process has been introduced. They are voting today. This is fact.

2) _There is no alternative_. Neither Republicans nor Trump have offered any plan. There are no white papers, working groups, coordinated policy plans, and certainly no legislation. This is also a fact.

So what you're dismissing as 'fear mongering' is reality.

I don't have a problem with a total re-factor of ACA - but it needs to be done responsibly, thoughtfully, with diligence and transparency.

They're screwing it up on a day one: rolling back legislation that affects 100% of Americans and 100% of business - without a plan. It's totally irresponsible. They are doing it quickly (and recklessly) for political reasons, instead of an underlying impetus of 'good governance'.

Which is too bad, because it's a complex issue and there's work to be done.

<comment><USER139> You can keep restating the same things, but they still aren't accurate.

The ACA is not being repealed today. This simply is not true. It's not what is happening. Saying that it is is in fact fearmongering.

The ACA will still be in place tomorrow. It will be in place next week. It is not being repealed as we speak.

<comment><USER138> "The ACA is not being repealed today"

Yes, it is. The Congressional process was started today:

[http://www.businessinsider.com/obamacare-repeal-process- sena...](http://www.businessinsider.com/obamacare-repeal-process-senate- vote-2017-1)

This is a fact.

And it is also a fact that the GOP has no plans whatsoever in terms of what it will be replaced with.

If you have access to any working groups, white-papers, or legislation otherwise - provide a link.

You can't - because there is nothing.

Obviously it will take some time to clawback all of the legislation, but it is being repealed as we speak.

"The ACA will still be in place tomorrow. It will be in place next week."

Obviously - but what are businesses around American doing now? They have no way to make plans, they have no idea what the future holds.

This is 'anti business' and 'anti responsibility'.

The responsible thing to do would be to craft a _plan_ \- and then put the gears in motion so that people know what is going to happen, and individuals and businesses have insight as to what will invariably affect everyone in America.

The Republicans have full control of Congress and they can expedite the repeal at least parts of ACA fairly quickly - once that is done - there is no ACA. Boom, it's gone. Insurers will have to make fluctuating, ambiguous ongoing changes to their polices. With no alternative.

It's laughably irresponsible.

There should be a plan, not a scramble into the void.

<comment><USER139> From your linked article- "...what is expected to be a long, winding process of repealing the Affordable Care Act"

So, not being repealed in real time, as you claimed. Not being repealed today, as you claimed. Instead, "the long, winding process" has begun.

From your linked article- "Though the repeal is on the top of the legislative agenda, Trump is unlikely to put his pen into action on it anytime soon."

It will be quite some time before the actual repeal happens. Not anytime soon. No need for panic. No need to sow fear.

From your linked article- GOP leaders' comments that they want to replace the bill at the same time they repeal it suggest that a seamless transition may take time. House Speaker Paul Ryan said replacement and repeal would happen "concurrently," and Trump has pledged it will be "simultaneously."

So by the Republicans own words, there will not be a time when there is no plan in place.

In fact, Republicans are going to vote to continue funding for the present plan. [http://www.politico.com/story/2017/01/republicans- obamacare-...](http://www.politico.com/story/2017/01/republicans-obamacare- subsidies-233618)

Again, no need to spread fear.

</comment></comment></comment></comment></comment></comment></comment></comment><comment><USER140> I don't like subsidizing poor lifestyle choices to _any_ degree. I hope whatever comes next takes things like choosing to drink, smoke, and eat too much into account.</comment>