Not to mention that tying your insurance to your job is a *huge* pain. If you switch jobs or get fired you need to deal with coverage gaps, considering individual coverage for the duration, and you may need to switch care providers depending on what your new coverage is.

It is just a really awful system overall.

It's really tough on people with a particular health condition and it can turn into an additional expense if a critical provider is suddenly out-of-network. Employers have definitely given me side eye when I've asked for details on the health insurance plan.

United Healthcare is pretty big in the US, they are also famous for forcing people to spend a lot of time on the phone, waiting on hold or advocating for care. I expect this ends up taking time that the employee would otherwise have been working as well as negatively impacting morale.

Markets require information to operate efficiently, but it's not actually in the interest of the companies involved. Who wants to have to endlessly ruthlessly compete? They would much prefer monopolies or cartels - however governments regulate against those.

Hence the "Confusopoly".

The more complex and opaque the system is, the more opportunities for value extraction by those on the inside.

The main reason health insurance matters so much is it can't be bought. No amount of money can "upgrade" your employer plan to a good one if it sucks. If you have a nice PPO with a low deductible and low out of pocket max, that's a diamond in the rough. If you switch to an HMO, now you can't arbitrarily see specialists. Yes you could maybe cover the deductible cost or whatever, but your actual care will be impacted. And money can't fix that.

Most people don't care, including me. Until I got cancer, then I cared, because suddenly this was the stuff that could make the difference between me living and dying.

While I am incredibly privileged, it shouldn't be this way. Beyond the waste it's horribly anti-competitive for consumers. Consumers want better plans, and they have the money. They can't get them. That's a huge smell for "the market is fucked". And fucked it is, beyond belief.

My workplace has made health insurance a competitive point: zero employee premium, zero copays except for an ambulance call which does not result in an admission, zero Rx costs. Full family coverage.

The dental coverage was screwed up for the first 4 months of the year. An assumption was made that all dental plans were basically the same in terms of payments to dentists. This turned out not to be the case.

Everyone should have this, but until we do, it will be a reasonable negotiating point. Why should non-health-care employers be in the healthcare business?

I don't think think I've ever had a job offer where this wasn't a topic of conversation. its further down the flow signing bonus, salary + bonus/equity/incentive are obviously the big ones, but I've always seen vacation, 401k+match, summary health care, relo package, etc care before accepting an offer admittedly its never been a obstacle and probably only moves the total comp needle a couple of percent. honestly its always been the easiest place for me to pick up money with little push back (extra week vacation, 5 years seniority at start for full 401k vesting/match etc.)

> Though I think the private health insurance system is a dumb waste of overhead and paperwork and misaligned incentives

There are countries where private health insurance works great. The problem in US is how it is regulated.

Chiming in to say that health insurance and benefits are a huge part of what I look for in job listings, and all of my friends currently looking for new jobs too. It may feel less relevant when we were young, but approaching middle age and it becomes a huge driver of continuing in a shitty job and in accepting an offer.

>- there's no standard metric on "how much do our employees pay on healthcare" (i.e. employee premium contributions, deductibles, copays), "how much time do employees spend on the phone with the insurance company", and certainly no way to feed in your last year's records of health-care to see "on plan Y you would have paid C"

"how much companies/employees pay for healthcare" is a poor metric too, because it would depend on the demographics of the company. You'd expect a startup of 30-somethings would have lower premiums than a company of boomers, even for the same coverage.

And in the US a new worker can only join the healthcare plan during certain times of year! New workers often have to wait months with a health insurance gap before they can get on the new plan.

I can only speak to my own experiences with salaried work. I'll also preface that I don't like healthcare being tied to employment.

All the job interviews that went to the point of discussing compensation, healthcare benefits were almost always included when negotiating what actual compensation would be. A difference of them covering several hundred dollars a month in premiums and them matching some % of HSA contributions is several thousand dollars a year in compensation differences. When multiple job offers are pretty close, that can make a difference.

Also, the few times employers have offered healthcare concierge as a benefit it was definitely mentioned in the overall compensation package.

At the high end in tech it’s just assumed it’s all good plus you can make choices on what plan of several offered.

But for many normal jobs it’s very normal to use health care coverage as a negotiation or decision point.

It may just be a me thing, but when discussing a job offer I always ask for details about the health insurance. I want to see the premiums, what is covered, the networks, etc. All the details given to current employees when they go through open enrollment. And I can count on one hand the times where it was difficult to obtain from the recruiter or "HR lady".

That being said, nothing tells me the plans won't completely change in a few months of course. That's just the "game" and I also hate it.

Just give me the money directly and let me pick my plan from a marketplace that doesn't suck balls. If employers still want to give some incentives to be more competitive fine, but I shouldn't have to time my job switching to avoid coverage gaps.

> job offers generally do not want to get into details on the health insurance offering. it's not a main "competition" point

Health insurance has been a primary topic in every job offer I’ve had, my entire career.

If a company won’t discuss the insurance situation or provide details about the employee contribution, that’s a warning sign. This is a routine topic for negotiations and any company hiding this data is not a company you want to be working with.

Yes, the title gave me whiplash because I went in expecting an argument for socialized healthcare, then read a couple paragraphs and realized the article was actually presenting an argument against government meddling in the healthcare industry, then read further and realized it was actually using the problems created by government meddling in the healthcare industry to argue for more government meddling.

You can deduct some of your medical expenses. I think it’s over 7.5% of your AGI.

But tax deduction or not isn’t what makes individual health insurance so expensive. When you have employer provided health insurance you’re in a completely different risk pool than people buying on the open market.

I don't get why decoupling insurance from employment isn't a bigger part of the healthcare reform discourse. It's the most obvious, easiest, lowest hanging fruit for improving the US healthcare system, and almost uniquely politically acceptable to both Democratic and Republican voters. Decoupling also doesn't entail disrupting any of the established incumbents (pharma, AMA, insurance companies, etc.) who typically kill any reform. The policy is also arguably market-oriented, or at least is not a form of government intervention that would otherwise offend Republicans, yet benefits individuals over large companies so can appeal to Dems too.

The Republicans have utterly failed to offer *any* alternative at all to Obamacare after 16 years, which is insane for many reasons, but especially considering that they could have put decoupling insurance from employment at the heart of an alternative (even more than the ACA) market-oriented reform. Letting individuals choose their own insurance would put more pressure on insurance companies to actually deliver quality care because, unlike employers, individuals are highly sensitive to the quality of care they receive and are more likely to switch insurers if the insurer unreasonably denies claims or otherwise fails to deliver a decent product. On the other side, individuals are also more sensitive to costs so with greater control over their plan choices would be more able to pick plans that are structured to match their anticipated costs.

In other words, individual insurance would improve the functioning of the market, which should in theory appeal to Republicans. Instead, they only focus on making individuals pay more at the point of care, on the theory that cost-sharing discourages insured people from over-consuming healthcare. Yet they don't think about how the current system makes it impossible for individuals to be truly cost sensitive when selecting plans.

I would guess the Republicans haven't adopted the idea because they are not really in favor of free markets, they are in bed with big business, and employer-provided insurance tends to favor larger companies that can demand better terms from insurers, that can amortize the HR overhead over a larger number of employees, and that tend to benefit disproportionately from lower labor mobility compared to small business (people are more likely to be involuntarily locked into a big company job for security than at a small business, and it's harder for people who are worried about maintaining quality healthcare access to move to a startup, reducing the competition experienced by the bigger companies).

It is also frustrated that this was meant to be a temporary hack during WWII that never went away. People should just get $$ into their HSA from their employer and but whatever plan they want.

it's connected via vicious cycle

private healthcare is getting more and more expensive due to private prices available to bulk insurers but not for private person

even if this is not completely deliberate, effect is that you are "serf of whomever pays your insurance" or go bankrupt the moment you have any kind of emergency

in europe some private healthcare providers are showing their colors from different perspective, they outright refuse or cancel private contracts when you are above certain age

You can get healthcare outside of employers and it's incredibly expensive. The cost of private healthcare (either employer sponsored or not) is what is responsible for what the article is talking about, it's certainly not just employer provided plans. Are you saying that if employers didn't provide health insurance that it would help the situation somehow?

Yeah, the article sort of conflates the two.

It's funny that he (accurately) quotes the Cato Institute as being opposed to employer-provided health insurance... and then implies that the sole alternative is the NHS. Um, I'm pretty sure that's not what the libertarian Cato Institute was suggesting!

There are just so many middle steps that are unnecessary, though I think the easiest policy lever is simply mandatory price transparencies, with zero exceptions.

So how would private healthcare happen without employer provided insurance?

> the experience has been […] uniformly poor […] Any positive interactions and outcomes have felt like happy accidents

Which is to say, not uniformly poor?

> I'd also love to do away with tax prep — the government knows what is owed

Sometimes! We would probably have to simplify the tax code first. Otherwise instead of spreading out the work of identifying income and tax credit eligibility amongst taxpayers and such upon them who are most proximal to this knowledge, we would have a centralized body need to know all of the things that you and I know about ourselves, such as how many kids we have, what kind of car we drive, whether we use solar power, whether we invest in crypto, whether we earned money from gifts or gambling or dividends or farming. Or we could just simplify the code, which I would like.

I see a bunch of comments with this same theme but to me it’s splitting hairs.

The term “private healthcare” is mostly referring to the fact that there is no such thing as non-private healthcare for the majority of Americans.

I agree with you about Infant genital mutilation (circumcision) but disagree the issue is the doctors themselves. I think the shrinking pool of competition is the major issue. (Hospitals being privatized with VC money etc)

The U.S. has waitlists too? The U.S. makes people wait based on how much money they have, socialized healthcare systems make people wait based on an assessment of need. The latter is obviously better, even though it is not perfect. You’ll find that most everyone living with socialized healthcare believes it to be adequate when compared to the U.S. system. Adequate does not mean without flaws, adequate doesn’t mean available on demand, adequate means has good outcomes. Very few countries with a similar economy have as poor healthcare outcomes as the U.S.

I have a very simple and easy solution: allow any person with any medical education from any country around the world to practice medicine in their field of study, and relieve them from any medical malpractice responsibility (apart from criminal). Let them prescribe medicine, no paperwork, no regulation.

Anybody can choose to which hospital they go, the “state-licensed” crazy expensive one or the “unlicensed” one for 50 dollars a visit.

As far as I understand, currently the pool of people in the US who are allowed to do medical work is artificially limited, and doctors’ salaries are inflated. Just look around the world, there’s a huge supply of doctors with no student debt who would be happy to work for 60k a year. Also tens of thousands of US citizens will just go get a cheap medical degree from other countries, come back, and open private practice.

> You have X doctors who can see (just a guess) 30X patients

FWIW, it's about 1500X plus or minus.

> How can we make sure there's enough staff to provide adequate healthcare for everyone?

The solution now seems to be headed towards using FNP's and similar in place of fully licensed MDs. Which for things like primary care makes good sense IMO.

Forced labour? Poland has doctors on 32 hour shifts. Worker comes on monday morning, leaves tuesday evening. The night is spend on ER, with a few naps between patients. Perfectly legal!

The whole thing is a racket. The amount of doctors is artificially constrained by the AMA. It's also why the US medical school system is so competitive compared to other countries. For example, in England one does not need an undergrad degree then medical school. One just goes straight into medical school at university. It's a 5-6 year long program compared to the US's 8 year program.

Of course, doctors do not earn nearly as much in England as the USA, thus good luck ever getting something like to change in the USA. In America, most people go to medical school for the prestige and the paycheck, and our system utterly reflects both.

I'm not sure which country you're from, but many EU countries do have private health insurance. The Netherlands, for example, has a system of subsidized private insurance, and a mandate that everyone buy a policy.

(If Americans are thinking, "huh, that sounds like Obamacare / the ACA marketplace!" then you're right.)

The European/"Socialist" solutions are never obvious to Americans.

It is like parliamentarianism, campaign financing regulations, gun control, multiple political parties, etc. Americans call these things "Socialism" and then freak out about them and refuse to see any good on them.

> But I can’t imagine it happening nationwide. Maybe cities can create their own public options, say a flat 3% income tax and you get health insurance.

It's interesting: 3 states (Vermont, Colorado, and Massachusetts) did recently try to make state-level single-payer systems. https://www.thirdway.org/report/single-payer-health-care-a-t...

That “lazy people” getting something they didn’t absolutely earn is a core right wing narrative that has been very successfully propagandized for decades. People are still going to need work to pay for everything else. No one is going to stop working once the crushing weight of medical debt is lifted. It’s easy to debunk but I don’t see much effort going into this right now.

The reason the "myth" persists is because there are some folks who take advantage of the system like this. In fact, many people personally know someone who's doing this. We can debate what percentage of recipients it is and whether we should worry about it or not, but it's a non-zero number. Framing it like some kind of racist trope is disingenuous and only works because of America's existing racial tensions. In Canada, for example, folks I've known doing this kind of thing are all white.

At the most basic level, this shows up as folks avoiding working more than a certain amount to avoid losing some government benefits. This is a result of "benefit cliffs"[1] that actually reduce net income as you work harder. It's "lazy" in the sense that you're maximizing your earnings at others' expense by working less than you otherwise could, but it's also a perfectly rational decision given the incentives.

My preferred solution is to have all benefits taper off gradually with income instead of having hard "cut offs". Done right this ensures there's never a financial penalty for working more. It does make the tax system more complicated though.

[1] https://en.wikipedia.org/wiki/Effective_marginal_tax_rate

Why do governments steer clear from performing clinical trials for new medicines?

The cost reduction alone from everyone paying the same price (for the same service at the same facility of course) must be staggering. I agree - I don't see any need to ban any private insurance or providers and that's also aligned with a traditionally (lower case c) conservative free market view too.

Single payer maybe, but single provider? Never.

Nothing is free. We want both low cost and high quality healthcare.

This means we need to have ways in incentivize innovation (AI diagnostics, robotic procedures, drug discovery, deeper R&D).

Free Markets (with government controls against monopoly) are generally better than governments at delivering cost and quality improvements, but healthcare in most countries is somewhere between “100% not a market” and “70% not a market” (the US). In many cases, governments also actively create and enforce monopolies (eg AMA or local hospitals in the US).

There are a million other things but part of what is required for markets to work is skin in the game, which the UK, Canada, and the US all do bad jobs of in their own ways.

Some say medicine has no elasticity. I don’t think that is true for 90% of spend (for gunshot wounds, maybe, but most spending is on chronic diseases where multiple providers and approaches are available and people could price shop).

I would like to see more countries experiment with more free market healthcare. It’s remarkably effective for many pieces of healthcare.

Americans have been propagandized like crazy and don't really understand what can actually be done. "Single-payer" is treated as a synonym for "universal health care." "Private" is seen as mutually exclusive. People will say we should/shouldn't have something like Europe, then describe a system that only a handful of countries have.

All doctor's offices in Canada are in fact private businesses. It's not actually a fully socialized system.

It's just there's a single payer. Those businesses bill the provincial government instead of you. Most of the dysfunctions in the Canadian system come down to provinces screw around with billing and payment and funding.

Take your dissatisfaction with the way the government manages payments to the voting booth instead of advocating dismantling what is on the whole a quite equitable system that has a history of actually producing very good health outcomes.

I actually have on the whole extremely pleasant experiences here in my corner of Ontario. And then I hear horror stories.

The system is underfunded and inconsistent. The province is to blame for that.

Yup. Recently drove 6 hours (each way, twice) to get to a Canadian private clinic to get treatment. This saved approximately a year (or more) of waiting in the public system for a routine outpatient procedure that takes 30 minutes to perform. I was lucky this option was even available within driving distance though.

Canada's public healthcare system is massively overloaded and it seems to be getting worse.

I really didn't appreciate how much of a problem this is in my 20s and 30s (while I didn't need much healthcare) and it was easy to assume the bellyaching from older folks was overblown. Time makes fools of us all.

I'm guessing you aren't aware how much of that innovation comes from academic research instead of direct private investment by pharma companies, or that there is a thriving pharmaceutical industry in places like Europe. Ironically your chosen examples are based on innovations pioneered by a German biotech (BioNTech) and a Danish pharmaceutical company (Novo Nordisk). What relevance the Soviet Union might have 34 years after it's collapse is something of a mystery.

> Soviet programmers invented it in their spare time when they had access to computers, as enthusiasts. What did capitalism add?

Capitalism created the computers whose Soviet copies were Tetris' native platform, it made the languages Pajitnov used and the machines he ported it to. It incentivized people to bring Tetris to the rest of the world, and who knows, it might have spread on its own eventually, just for free, but maybe not.

> All of the inflation we've seen from the pandemic has been the "raising prices" part.

Superficially true, but vacuous. In anyway that matters this is flagrantly and amazingly false. But maybe you weren't aware of the $931 billion US dollars of stimulus paid to individuals, or you may not be familiar with the principle of supply and demand. More dollars in supply, the less the value of each dollar. Prices change to match the devalued currency.

> Being expensive to access out of employment is a feature not a bug.

I think this may qualify as a bug, to which you can credit the Revenue Act of 1954 for codifying the tax break given to companies who provide healthcare directly rather than pay that money as income to the employee. Classic example of a stale law. Now, vested interests may be keeping it in place, but I also see no significant awareness on the voter side of this issue nor the will to reform this discriminatory tax policy.