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).
