It truly is shocking that health insurance is tied to employment status.
I really think this is a large part of the trend towards overt ruthlessness in the USA, no one has their back so they have no ones back, as people age and experience medical bankruptcy (or narrowly avoid it at great cost) they are realizing this ruthlessness in our system.
Health insurance is not tied to employment status. Anyone can go to healthcare.gov and buy an equivalent BCBS or Kaiser or whatever gold/silver/bronze insurance. Unless you are in a particularly shitty state.
What employers do have is the ability to sell you health insurance with pre tax dollars, which is also available to self employed individuals. But the people who are screwed are those who are employed by employers that do not offer health insurance. They have to buy insurance with post tax dollars.
There is similar bullshit with retirement funding, where employer sponsored retirement account limits are drastically more than individual ones (401k vs IRA), and especially if you are a married couple with 1 spouse with 401k access and one spouse without.
>Health insurance is not tied to employment status. Anyone can go to healthcare.gov and buy an equivalent BCBS or Kaiser or whatever gold/silver/bronze insurance. Unless you are in a particularly shitty state.
Out of curiosity, I went and looked up the plans in NJ for a 32 year old person(56k salary). This is someone in a lower risk pool. The bronze plans are in the upper ~280$/month and include a $6000 deductible. There are three plans out of 36 that are ~380 a month that have a $2500 deductible. Everything else is more. This is NJ, one of the better states and definitely not a shitty state. These plans are garbage. Every time someone on HN extols the virtues of Healthcare.gov, I recheck my options and they always come back much worse than what I get working for a private employer (typical S&P 500 corp). I wish people would look up their possible plans on Healthcare.gov before tossing it out as something other than a scam.
ACA compliant health insurance pricing is pretty commodified since all the rating factors are codified in law (age, location, smoking status, and that is it I think).
Edit:
>These plans are garbage
The plans simply reflect the cost of healthcare. The companies that sell the healthcare have profit margins in the sub 5% range. Mechanisms to bring the cost down would be to have taxpayer funded medicine in the public domain so the medicine is sold without patent, increasing number of doctors by greatly expanding residency positions and reducing training requirements so that you can start practicing before age 28, reducing the need for "certificates of need" so more hospitals can open and compete, etc.
> The plans simply reflect the cost of healthcare.
Anyone who works in healthcare and looks at billing can tell you this is not actually the case, prices are not based on any reasonable metric and are rarely actually paid by insurers anyway.
>The companies that sell the healthcare have profit margins in the sub 5% range.
Point of contention here, these companies aren't selling healthcare, they're reselling it. Which is a service which should ideally not have any profit margins, and would be best suited for a large, collective entity that everyone paid into according to their financial ability, as opposed to smaller social-class exclusive pools.
What you are talking about is taxpayer funded healthcare, with the large collective entity being the government.
Seeing as how that is not politically possibly, middlemen with sub 5% profit margins was the compromise. Obviously not the best situation, but still better than before.
5% profit isn't the whole story here - If you can't increase profit, increase revenue. These middlemen have a lot of power and an incentive to use it in making the system less efficient.
All businesses would like to increase profit and revenue, but they cannot just will it. There are at least 7 major publicly traded competing managed care organizations (MCOs, aka health insurance comapanies) plus Kaiser Permanente among many others.
Is there any evidence that these companies are concluding to increase revenue by making the system less efficient?
Low profit margins plus multitude of competitors generally means there is not much juice left to squeeze.
Correct, that was what I was alluding to. There's lots of good reasons to move to such a system, and no good reasons to keep our current system.
>Seeing as how that is not politically possibly
Basically every other liberal democracy has taxpayer funded healthcare, and even many US states have successful programs. It's extraordinarily silly to call that impossible, or to call what we have now a "compromise" rather than a clear case of corporate welfare being put before the welfare of the citizens.
There literally was a compromise in 2009 during the passage of ACA that nixed the “public option” (taxpayer funded) healthcare in order to win the votes of necessary Senators to pass the bill.
Seeing as how Republicans have zero interest in taxpayer funded healthcare, and they have held enough Senate seats to stymie any Democrat led effort for the past 20 years and probably next 20, I do not see why it is “silly” to call it politically impossible.
Seems like Texas will go blue as the population changes. They almost elected one in 2018. They may also flip North Carolina and Pennsylvania to permanent blue as well.
> Your employer is probably just paying a lot for your coverage.
Yes but they get to deduct this, unlike an individual for whom no such deduction exists. Repeat after me: "a tax deduction is a subsidy." That is, welfare. An extremely biased, discriminatory welfare at that.
This just feels like a ‘well ackshually’ retort to health insurance being tied to employment. This is an extra added expense and often times the barebones insurance is garbage with high deductibles and out of pocket maximums.
How is it an “extra added expense”? Just because you do not pay for 50% of the premium out of your own pocket directly does not mean you are not paying implicitly. Your employer is obviously counting it in the total cost of employing you, and the figure is given to you in box 12 code DD on your W-2.
You can also buy a platinum level BCBS health plan yourself, without an employer, and get the same low deductible and low oop max.
It is still a headache to have to register for a plan after losing your job and possibly transfer/link your information to a new account. COBRA is better than nothing, but it is often more expensive than makes sense.
Furthermore you cannot use the exchanges if your employer offers plans IIRC. So your employer can control which plans you have access to.
The subsidies should just be given directly to the person who needs healthcare. There is no need to involve a third party. It just complicates the situation for no gain.
> Furthermore you cannot use the exchanges if your employer offers plans IIRC. So your employer can control which plans you have access to.
I do not think this is true. Everyone can sign up on healthcare.gov. Employers will want you to opt into the subsidized plans they offer, especially if you are a lower compensated employee, in order to pass their non discrimination testing requirements, but they have to make the portion they are paying for high enough to make it enticing enough, they cannot force you.
> The subsidies should just be given directly to the person who needs healthcare. There is no need to involve a third party. It just complicates the situation for no gain.
Absolutely. The whole employer tax benefit situation should be abolished, and all individuals dumped on healthcare.gov. Same with retirement benefits. Employers should not receive any beneficial tax treatment for providing benefits, and it would make compensation much more transparent and easier for employees to compare from one employer to another.
Hmm you're right on that first part. I don't know where I got that from. I seemed to remember playing around on CoveredCA and it said I couldn't get a plan because my employer offered plans, but I can't reproduce that now.
I'm assuming this is by design to keep the US population "on their toes" and at work doing productive things. Otherwise why would it be tied to employment?
Health insurance is "tied to employment" because of wage controls that were implemented in WWII. Employers still had trouble hiring people, and because they were prohibited from raising wages, they had to find other ways to attract people: benefits. Health insurance then became a popular benefit.
Also, note that you can buy your own health insurance in the US. You are not required to use health insurance provided by an employer.
> Health insurance is "tied to employment" because of wage controls that were implemented in WWII.
If that was the only or even dominant reason, then the removal of those controls in 1945 would have seen that tie rapidly unravel, instead, health care has become more, not less, tied to employment since the end of that policy, reinforced by deliberate policy choices like tax policy and explicit mandates.
The historical reason a thing first became common and the reason the thing is still common are often not all the same.
Having had both, this is not my experience. My experience is that employer plans have fewer choices and similar or higher rates. They're cheap because my employer is paying most of the bill.
Just a note for those who may not know, either because they've grown up under a different regulatory regime or they never shopped for private insurance before the ACA:
Pre-ACA, I was once a much healthier early-twenty something applying for private coverage. I have a genetic condition that has never manifested in a health consequence that has required treatment, and technically it was illegal even at the time to reject someone based on their genetic information. Despite that, I was denied coverage by every private insurer in the market because I had a preexisting condition. The only reason the private market functions at all for anyone with so much as a history of a sprained ankle is because of the ACA.
Insurance companies would routinely (and retroactively!) deny coverage and payment based on preexisting conditions. They would accept premium payments for years, then when you came down with breast cancer would dig up an old photo of you with a cigarette in your mouth and refuse to pay for your treatment because you claimed to be a non-smoker when you applied for coverage. This was considered normal.
Varies a lot state-by-state. Ours has no individual plans offered outside the "marketplace", which most years only has a couple companies offering plans on it, all with bad networks, bad coverage, and terrible rates. A fairly bad employer plan is a much better value than the marketplace plans while a middling employer-provided group plan will be way better than the best plans on the marketplace, and there are, I repeat, no other providers that will sell you an individual plan in this state (I've checked, both with brokers and with major providers around, all said the same thing: "no-one sells individual plans in this state anymore, your only options are whatever's on the marketplace")
Is it available off-market? That's how I bought my insurance (in another state). My state has a marketplace too, but I found better plans directly through the insurer's website.
>I haven't had insurance for five years because the (major, national) providers who cover what I need aren't available on my state's marketplace (NY).
As someone who purchases insurance from the NY marketplace, that hasn't been my experience.
Initially, I had a plan from one of those (Anthem/BCBS), which provided pretty good coverage because they increased my premiums by more than 50%.
Now I have a local (New York State) provider (Fidelis Care) which costs less and has a (fairly) low deductible through the state's marketplace.
That said, many providers are actively hostile to marketplace plans. Back when I still had an employer-based plan, my company changed insurance providers. I called up my GP to make sure they accepted insurance from the new company, but before I could even describe the scenario, the office person at my doctor's office raised her voice and said, "We don't take any Obamacare plans!"
Which was quite interesting, since back then many of the major national insurance companies were offering such plans, including the companies (both old and new) my employer was contracting with.
All in all, I've been fairly satisfied with Fidelis Care, although I wish I could do database queries of their "Explanation of Benefits" records rather than having to wade through PDFs for each visit to a provider.
All that said, I don't know your circumstance (none of my business) so you may have needs that I don't. I wonder what those might be that a "national" insurer might offer than an in-state provider doesn't, especially since the ACA specified requirements for all health insurance plans, not just those on marketplaces.
Although I'm not sure how no insurance could be better than some, unless you're against medical care in general. But my use case isn't yours and I'm sure you make decisions that are best for you.
Edit: Added a few thoughts to address parent's issues, clarified my point about coverage to be more clear that I'm emphatically not calling anyone a liar.
> As someone who purchases insurance from the NY marketplace, that just isn't true.
So have I, and I stopped purchasing insurance because I cannot find the coverage I want. I need a specific variant of a certain operation which is only performed by a few surgeons in the country, and the one surgeon in New York who offers it only takes Aetna for that operation. Aetna reentered marketplaces starting 2022, but I'm moving and the operation has a year-plus waitlist, so I'm SOL. It has made a ton of sense for me to have no insurance because I'm fairly young and in fantastic health, making it cheaper to just pay out-of-pocket for primary care once or twice a year. Please don't call people liars.
>So have I, and I stopped purchasing insurance because I cannot find the coverage I want. I need a specific variant of a certain operation which is only performed by a few surgeons in the country, and the one surgeon in New York who offers it only takes Aetna for that operation. Aetna reentered marketplaces starting 2022, but I'm moving and the operation has a year-plus waitlist, so I'm SOL. It has made a ton of sense for me to have no insurance because I'm fairly young and in fantastic health, making it cheaper to just pay out-of-pocket for primary care once or twice a year.
That seems reasonable. As I said, "my use case isn't yours and I'm sure you make decisions that are best for you."
>Please don't call people liars.
My intent wasn't to call you (or anyone else) a liar. My apologies if you felt I was attacking you. Nothing could be further from the truth. I've edited my comment to explicitly reflect that.
I'd also add that I had a similar experience with physical therapy (PT) after surgery. When I changed insurers from BCBS to Fidelis (just a month or so after surgery), I found that the PT group I was using didn't accept my new insurance.
It's sad that we have to jump through all sorts of hoops just to get the medical care we need. Which is often the case even when it isn't an edge case like yours (or mine with my PT -- my situation was, of course, much less consequential since there are many PT providers out there).
Because previously all social services, including police and fire safety, were privatized, and were only taken over by the state when it became clear there wasn't enough economic incentive to keep such services running without the operators doing stuff like roughing people up, burning down buildings, etc. But everyone decomposes as they age, and people fear illness and death enough that you can charge them however much you like, so it stays private and eventually employers start pitching in to attract talent without having to offer better wages, more holiday leave, or a shorter work week.
Now, there's a whole administrative system that drives up prices and puts a ceiling on availability and quality of care; with most Americans being (relatively) ill-traveled, ill-read, and fed a news product that beneath the packaging is some combination of entertainment and fear-mongering, it's easy for one to believe there's just something in the air that makes an NHS-style or even a German-style system impossible here.
Then, if you were around for the 2008, 2012, and 2016 elections, you'd have seen presidential candidates arguing about whether someone should have to pay for someone else's well-being. And it's not a debate along the lines of class—it's tied up with identity politics and a broader debate around the welfare state. Advantaged and disadvantaged communities alike are full of people who see how things are, and, knowing that it takes a lottery win to move up the economic ladder and a bad week to fall down, are skeptical that next time it'll be different.
Doesn't help that most Americans will never have the opportunity to get even an hour of education in macroeconomics, unless it's buried in disconnected lessons about individual economic downturns, nor that education on probability doesn't happen until second-year calculus (which is similarly rare in high schools), nor that most Americans don't learn about the mechanics of Medicare until their fifties or sixties
> all social services, including police and fire safety, were privatized
I think enforcing the law has been a government function from the times the first laws were laid down. Fire services were a private function, and this actually works fine in sparsely populated areas where fires are not likely to spread in temperate climates. The only reason fire services are public is because of the inherent risk to everyone that a fire poses in a dense, substantially flammable, city.
If a fire affects you and only you, then why not cover it under normal, optional, property insurance like every other disaster?
This is generally the model of government intervention I support - intervene when the actions of one group of people directly affect others. This covers regulation around rights of way, fire services, environmental protection, waste management, water supply, pandemic/disease control, police, and the military. It however does not cover supplying the personal necessities of life like food, shelter, clothing, medical care, entertainment, companionship, sex, fulfillment, etc.
These are fundamentally individual needs, and I therefore hold that meeting them should be an individual responsibility. Any cooperation to meet these needs should be strictly voluntary and consensual, not compulsory. I think this is where, to greatly simplify, "the left" and "the right" fundamentally disagree. For instance, in spite of the now well-studied and crushing effects of loneliness, it would be absolutely tyrannical for the government to mandate friendship. Similarly it is tyrannical for the government to mandate participation in public health care/insurance. Let people figure out how to meet their needs for themselves, and let them figure out how to cooperate voluntarily. Charity is exactly the virtue of helping those in need, but mandatory charity is indistinguishable from slavery.
I'm not sure what you mean "private police" - the Boston night watch, which predated the 1838 professional police force, were given powers by the town government[1]. I can't find any references to how the night watch was funded, but surely the town government was involved.
Edit:
> The duties of the Watch, as appears by the order, were to be performed in turn by the inhabitants; they were not "citizen soldiers," but citizen Watchmen, and having an interest in their work, no doubt did it well.
- A chronological history of the Boston watch and police
by Savage, Edward H.[2]
Savage seems to indicate that the night watch was performed in turn by the inhabitants of the community, by order of the government, and there is no mention they were paid. This doesn't seem like a private service to me.
sure, just pointing out that the _funding and availability_ of a social service wasn't a point of contention there. unintuitive as it is, the discourse around public health and health care aren't really related. anyway i was just giving people some background, not opining. if i was feeling saucy i might say something incoherent about people feeling entitled to a service they previously resented as soon as it's useful to them
Well, you made the case that police were previously privatized. I'm not sure that's true exactly. You also compare healthcare to police and fire services. I was just elaborating as to why that comparison may not be apt. Public health, insofar as controlling the spread of communicable disease, has always been a function requiring government authority.
The idea that people who set bones and cure cancer should be included in this category is a more modern take, one that requires much more careful discussion of what should and should not be a "public service".
> people feeling entitled to a service they previously resented as soon as it's useful to them
I think we should expect people to prefer suffering and death with dignity, rather than greedily and desperately peering into the pockets of strangers, but that's just my take.
uh i cant edit this anymore but i wanted to clarify to all the ppl spazzing out over the police thing that i was speaking in a broader historical sense and only got specific to america in the transition to the second paragraph
The origin of the tie between US employment and healthcare was during the Second World War when wage controls were put into place. Employers competed for workers by adding benefits packages, which later became ossified and further entrenched with exemptions in the tax code.
I knew an individual named Ron Hillhouse, he sold life insurance and built a large insurance company in Texas twice.
He sold it each time to a group in NY (MetLife each time if memory serves). He told me that his insight was that construction companies would have variable revenue and compensation requirements across TX building contracts (private vs government mostly) and to avoid discontent they would dump the difference into life insurance and other alternative compensation because as long as the take home paycheck was the same no one really complained about being put on lower compensation jobs.
Not sure if that was a similar origin for health insurance but I've always assumed it was.
I think you are framing it as a top down objective, but I think it's the opposite. Employers themselves offer healthcare because it's a way to attract employees. You can get other health plans (e.g. Obamacare) but they are not as competitive as employer-sponsored plans. To not have employer-sponsored plans, you would have to either 1) ban employer-sponsored plans 2) offer other plans that are competitive. #1 seems unrealistic, #2 is possible but would have to probably be done by the state, which the US doesn't really love.
I want to point out that the above analysis is completely ahistorical and does not track the path dependence and latent contexts of the development of the modern US healthcare system. The above is not an explanation, it is a post-hoc rationalization.
Any argument that claims anything is "the way it is" because of the ways people act today is only talking about current incentive structures and has nothing whatsoever to do with the systems and tendencies that have created what we see today. Current incentive structures are a product of the system they are expressed from, not the other way around.
There are competitive plans on the individual market. (Your local insurance market may vary.)
I could get approximately equivalent insurance for about 40% cheaper if I went on the individual market. But, my employer pays 75% of my employer sponsored plan.
The real problem is how expensive healthcare is in the US.
Compare Cignas global plan with and without US coverage. Somehow they can easily cover essentially all of the rest of the world for far less than the US.
Last I checked, pretty much the entire rest of the OECD was between 40% and 70% of US per-capita spending on healthcare. Some spend less total, per capita, than we do just from public spending that we already do (medicare, medicaid, CHIP, public employee healthcare plans, military care like VA and Tricare, et c.) without even having universal care like ~everyone else does
> Last I checked, pretty much the entire rest of the OECD was between 40% and 70% of US per-capita spending on healthcare.
Per capita numbers can be misleading on healthcare as health is labor intensive, so countries with higher wages will have higher per capita costs with otherwise similar systems.
OTOH, the US spends the second highest share of GDP on healthcare, globally, behind Tuvalu, and about a time and half the GDP share of the second highest large, developed state (Germany). [0]
Yeah, like part of the reason Taiwan, say, is so much cheaper, is that wages are lower across the board.
Canada? Switzerland? Germany? Yes they pay a lot worse for some jobs (software developer, and, more relevantly, doctor) but ordinary fully-loaded employee costs aren't that different from the US. Admittedly, the countries more comparable to the US tend to be more in the 60-70%-of-US-spending range, than on the lower end.
That does mean that even allowing a generous premium over the most-comparable peers, we should be able to cut total healthcare spending 20% while covering everyone and removing a major drag from our economy, and a major factor reducing overall US QoL. As it is, we're struggling (and largely failing) to even keep cost increases to merely the inflation rate.
I was recognizing the potential problem with per capita numbers only for the purpose of specifically pointing out that they aren't misleading in this case because the same thing is there in the per-GDP numbers.
IMO, the population covered by employer-sponsored group policies is significantly healthier than the population shopping on the exchanges. The biggest weakness of the ACA was that it didn’t ban employer-sponsored coverage as a means to force everyone into the same free market.
Such mechanism give corporations the power to decide who gets terminated and loses health insurance. It's very effective at discouraging people from doing anything that goes again the grain, like getting into an union.
Bosses absolutely do not love healthcare costs if that's what you're suggesting. But even legal mandates for larger firms aside, if you're trying to hire white collar workers while not having a decent healthcare plan, you're going to find it's a challenge.
Give me a break. Bosses can add and subtract, and so can employees. They both know healthcare is getting paid for from the paycheck regardless. And with company plans, bosses may pay less or may pay more. Probably less. Either way, bosses love that employees know quitting their job is going to require switching health insurance plans, which is a dicey process. Bosses like holding that power in the same way they like holding visas over H1B visa holders heads.
And the most obnoxious part of it all is that you knew this.
>Bosses can add and subtract, and so can employees. They both know healthcare is getting paid for from the paycheck regardless.
It's not clear to me that most employees do know that, actually. I see a ridiculous number of people that oppose nationalized healthcare "because they'd have to pay taxes", not realizing that there is already a deduction from their total compensation to pay for their healthcare (i.e. a tax).
THIS is for real. If I don’t have a job with good benefits, I can’t pay our medical bills anymore, and we could lose everything. So even though I’ve had the “team player” personality from birth, I cannot allow myself to put my faith in any employer. The moment they start turning the screw on benefits, I’m out.
As an American who has worked closely with the Federal government, I'm significantly more afraid of the idea that the government would be responsible for my medical care.
Medicare (single payer healthcare in the US for everyone over age 65) has a lower fraud rate than private insurance, serves millions of seniors and has for decades, and as an American there is a big discontinuity in actuarial data where your life expectancy literally goes up at 65 because you get access to it.
Maybe don't generalize from a few personal anecdotes to the functioning of the entire 4 million employee federal government?
A common right-wing criticism of Medicare that I was trying to pre-empt is that it is rife with waste, fraud, and abuse.
But to directly answer your question: if you want your dollars spent effectively, you should care about fraud rates in services you pay for (public or private).
Alright, well I guess I'll take your comment as an attempt at a real conversation. But fraud in the medical industry isn't really something that crosses my mind, nor is it part of my concern about the government dictating my healthcare.
Medicare not only covers the most at risk of our population, but is also by far the cheapest per capita beside medicaid. Yes, American health care is expensive, but medicare is the cheapest way to deliver it.
Most of the world does not have government run health care, what they have is government run health insurance. Hospitals, doctors, health care providers in general are privately operated and anyone with the right credentials can go ahead and start their own practice/clinic, but the government provides single payer and universal health insurance.
That's not what anyone in the US is proposing though. Even medicare for all would still have the same private companies responsible for your care, they would just be paid by the federal government.
It would transition away from employer-provided health insurance, to employer-subsidized insurance, having instead individuals choose their health care plan from state-approved private insurers. It sought to make the cost of health insurance more transparent to consumers, with the expectation being that this would increase market pressures to drive health insurance costs down.
Health insurance is one of the least concerning things for the government to get involved in with healthcare, really. Worst thing that happens is they don't insure you or the procedure, and you have to pay for it yourself somehow.
I would question the viability of government for handling many things, but collecting taxes and distributing funds is one of the things they usually are pretty good at. Some of the leanest health insurers in the US in terms of overhead are public enterprises, e.g. the VA and various state assistance programs.
In Germany, health insurance is also tied to your employer. If you're a freelancer in Germany you pay out of your own pocket every month (around 500 bucks).
It's a very similar system, the real difference is that it's illegal to not have insurance, so you are "forced" to always be insured, and unemployment support is more generous.
They are either included in your insurance (if you are employed and have public health insurance), or you'd have to add them to the insurance at extra cost, if you have private health insurance (for example freelancer).
I have no problem believing that other nations governments do a great job. I also do not live there nor am I a citizen of those countries.
American government is a uniquely incompetent form of government. Despite being one of the largest & most expensive governments it gets little to nothing done. Anything that is 'done' is often done far over the original projected budget.
> American government is a uniquely incompetent form of government.
Objectively untrue by any serious metric you'd like to go for, and in particular government-run health insurance programs (Medicare chief among them, but also the VA) are notably well-run and have low incidence of fraud while maintaining remarkably low overhead.
It's interesting to me that you're lumping together Medicare and the VA. Because while I here almost nothing but positive things about Medicare, I hear lots of stories of people not getting the care they need from the VA (and "slipping through the cracks"). Granted, those seem to be mostly older anecdotes, have things changed in the past decade or so?
You're conflating things like physical infrastructure and defense contracts with welfare. The welfare that we do give, for the most part, is exceptionally well run and effective.
Because giving individuals money, targeted or otherwise, is given/spent to enhance an individual or families life in some way. It is a direct benefit to them.
And yes, SS is absolutely welfare and it is extremely effective. It reduces the poverty rate of the elderly by nearly 30%. It also reduces, directly and indirectly, child and young adult poverty by meaningful amounts as well, 1.5% and 3% respectively.
Regarding your first point, I disagree. I think the intention is clearly to provide a direct benefit, but that isn’t always the effect. One example which seems to be entering the zeitgeist now is student aid. The presence of additional student aid has a high correlation with the rise in tuition over time, but I think we’d all struggle to say it was commensurate with to the cost.
Addressing your second point re: social security and perhaps generalizing my first point slightly, I think the statistics you cite are reductions in poverty vs simply abolishing the benefit. I don’t think they measure the counterfactual scenario of there never having been social security to begin with, and those current seniors having had their take home pay increase by some portion of the 15% of their gross pay which otherwise went to SS. Additionally, it doesn’t take into account the future debt servicing cost of current SS recipients on future generations.
As to your point about SS, you are right, but the counterfactuals have been measured. We didn't have SS in this country for the majority of its history and elder poverty was terrible prior to its existence, reaching well over 40% in the 1920's.
SS also has always been a Pay Go system and doesn't have any debt servicing, actually the reverse is true, SS is owed money from the US government. That is, SS lent the US government money. That government debt would exist with or without SS as federal government spending is not constrained in any way by tax receipts, so SS's impact here is moot.
To your point about student aid, that is far more complicated. While it is likely true that the existence of the aid has resulted in some upward pressure on tuition, it is not the only factor. Increased demand both in quantity and quality of services, reduction in direct public aid to institutions, and increasing administrative costs among other things all play a part. Without student aid, it is likely true that prices would be lower, but probably not nearly as much as one would assume, and we would have a far less educated populace. The latter being a substantial negative in a world where the best paying work is and continues to be more knowledge based.
doctors would be responsible for your medical care; taxes would foot the bill. The primary involvement of the government is the logistics involved in getting from A to B.
As people age they do get “free” insurance from Medicare. And if a white collar worker experiences downward mobility they can qualify for free or cheap insurance through the Medicaid and Affordable Care Act provisions.
Every single one of those programs comes with a laundry list of asterisks that make them far worse than any employer provided insurance I have ever had.
Also, medicare doesn't kick in until 65, which pretty much guarantees that most workers won't be able to retire until then; even if they're otherwise eligible / able.
To offer a contrasting anecdote, my government health insurance (MediCal) was the best I ever had, including my current 6-figure job. It can be done well.
it shouldn't be! From an ethical standpoint, housing should be guaranteed as a human right. Obviously if you're living in a mansion paid by an executive job and you get laid off you might have to downsize, but nobody should have to fear homelessness in the wealthiest countries on earth.
> It truly is shocking that health insurance is tied to employment status.
I think "annoying" is a better description. It's not shocking at all, it was a fairly predictable outcome given the situation. It is really annoying that we haven't managed to walk it back to something more reasonable since then.
“Annoying” for me would be stepping on a small LEGO. As a Canadian, I think that the US healthcare system exists in a first world country is absolutely “shocking”.
As someone who has experienced both systems, the fact Canada covers all is great but there are big issues with wait times and coverage gaps (in some provinces).
Oh absolutely. If you don't have an emergency you will have to wait.
But man, when you do have a medical emergency, it's great not having to think about whether you're going to have to remortgage your house, sell your kidneys, put your kids up for adoption or reconsider all of your life plans.
Personally I think Canada is a little bit over-dogmatic about rejecting a parallel private system entirely: I know there are problems with running two systems (mainly around inequity and brain-drain incentives for healthcare workers to move out of the public system), but IMO, nothing that can't be fixed by sufficiently high prices/taxes.
The US system is a huge mess, but but the reason why it hasn't changed is because it works "barely" for most people.
Keep in mind that medical bankruptcy isn't unknown in Canada either - not being able to work is a bigger cause of medical bankruptcy than medical bills themselves.
Tying your personal health and that of your loved ones to your employer gives your boss unduly leverage over yourself, particularly when there are life and death decisions to be made.
Wages were frozen during WWII (Stabilization Act of 1942), and insurance was exempt from this freeze. At the time, it was a way to compete for employees. Eventually, you just weren't in the running if you weren't providing insurance.
historically Protestant work ethic
+ unrestrained pursuit of profit
+ weak labor protections and domination of corporate interests in the halls of legislation
= predictable outcome.
This is not historically accurate. Insurance through employers came out of the federally mandated price controls during WW2, and was later solidified by massive tax breaks for corporations for providing said insurance (under the eager endorsement by unions among others). Changing the system would require changing the tax incentive. Changing the deduction to apply to individuals could be a path forward.
Federal mandates and tax incentives are created in the halls of legislation. This was mentioned above, albeit concisely. You even mention "massive tax breaks for corporations" which really only happens with intense pressure (backchannel or otherwise) on Congress. We call that "corporate lobbying" today, just as we called it back then.
Recall the intense pressures on FDR from both sides. Eventually the unions won some important concessions, but the corporations still had sufficient representation to ensure the system calcified into one that continues to funnel capital upward.
I am old enough to remember families (my own included) being destroyed by this same reality pre-ACA. Insurance being tied to your job was a pre-aca reality.
I was born with heart defects, pre-aca it was literally impossible for me to get private, non-corporate coverage, I tried for years.
At least denying coverage for pre-existing conditions means that getting diagnosed between jobs isn't a complete family destroying death sentence like it was for mine.
The ACA ossified the existing system a bit, but employer-provided care was the norm before the ACA. That or just not having any insurance, especially for young people working for small companies.
ACA did not ossify it. If anything, ACA allowed non employers to purchase insurance. Previously, the options were to work for a deep pocketed employer or just not have insurance.
Plans that would cover pre-existing conditions was one very important change for a lot of people. What ACA didn't really solve was the "affordable" part for people who aren't fairly high income. Between the marketplaces in most states and COBRA for those in between jobs or near 65, insurance is available but it's expensive with no one else chipping in a big chunk of the premium.
Nothing will solve the affordable part other than massive wealth transfers (which ACA did, but obviously not massive enough), and increased supply of healthcare (more docs, hospitals, medication manufacturers - or medicines in public domain), and tort reform.
But ACA did what it could with the political compromises that had to be made at the time. It provided out of pocket maximums, maximum age rating factor (age 64 only pays 3x age 21), and required coverage for all applicants (removing risk of disqualification from pre existing condition).
It is unfortunate the mandate was repealed and state level participation in functioning marketplaces was politically hampered.
Yeah, even if you just arbitrarily chop 20-30% off of US healthcare costs--which aren't just from the pockets of fairly low margin insurance companies, the money still needs to come from somewhere. So maybe a random individual can get a decent insurance plan for $5K/year with a family plan something north of $10K without a company paying. I expect a lot of people would still not find that reasonable and would want someone else to pay for it.
I really think this is a large part of the trend towards overt ruthlessness in the USA, no one has their back so they have no ones back, as people age and experience medical bankruptcy (or narrowly avoid it at great cost) they are realizing this ruthlessness in our system.