I've always thought the biggest "root cause" issue of what we see is that our political system doesn't handle trial and error well at all...anymore.
In the last 100 years the US has moved much more towards consolidated federal policy. Federal level policy comes with a lot of issues.
First, combining politics with trial and error doesn't work in a 2 party system. 1 party will point out its flaws, while the other party will pretend they don't exist or be defensive about those flaws. The country will be left with people who feel the pain of that problem and those who do not. The ones who feel the pain will vote to end the pain, regardless of anything else. The ones who don't feel the pain won't see the big deal and will focus on other issues...and those other issues will be seen as issues that the other party was voting "against".
The other issue is that with federal policy, the entire country suffers from the consequences of issues. Once the legislation is in place, it's nearly impossible to change or remove so if you think there MIGHT be an issue you're better off voting staunchly against it.
State level policy doesn't suffer from this issue. With 50 states and a national idea that all policy should be state level, we'd have 50 experiments. If one state tried something and it worked, other states would research what they did and follow suit. If it didn't work, they'd stay away. Or try something new. County/City level is even better.
That's why when people were selling the ACA as "what Romney did in his state" were missing the point. The point was that was state level...so other states could follow if they wanted. It didn't mean that should be the policy at a federal level. The entire point was that it was a state level policy.
At the federal level and in the election, Hillary wouldn't even acknowledge there were problems with the ACA and IMO that is what cost her the election, because new premium letters started coming out just before election and there was a lot of pain to go around.
>The point was that was state level...so other states could follow if they wanted.
When it comes to cost-sharing schemes the bigger the pool the better -- costs are more predictable the more people are in the pool.
I agree with the general idea that laboratory democracy is a good idea but health care costs, 'insurance' etc. are well understood and best handled at the largest level possible.
Hillary acknowledged problems with the ACA but believed that it needed to be patched, not re-written from scratch.
I agree. A few patches that would have a big impact:
A national public option to force competition (along with cross-state selling of insurance -- but not one without the other or at least that cross-state selling of insurance must be done across all states if offered that way) would go a long way to pushing competition and reducing perverse incentives that the ACA created with the 'profits based on percentage spent on care' scheme.
Redefining full-time employees as full-time equivalents for defining thresholds within the law. This was a flat-out mistake that pushed some employers to do some very silly things.
Create incentives for patients to shop around for the best cost of care.
Require some level of transparency in pricing even if it is only common treatments and tests.
The mandate would have to stay. The choice is, have a mandate and force people to buy insurance they need or don't have a mandate and force people who buy insurance to pay for the health risk of those who mistakenly believe they shouldn't have to pay for their own.
I tend to agree with you on all of those point, for a cost sharing scheme.
When a lot of people don't want the policy at all it becomes a cost forcing scheme though...and that's the crux of the problem.
If this was California legislation and it had problems, local politicians in California would be campaigning to make the changes right now. The question of how long we're going to be stuck with the current issues is where the federal flaw lies. It removes the ability of people to adapt and react to problems. The larger pool is a negative when the pool size expands the scope of issues.
Unless we are going to, as a society, agree that people who don't pay don't get treated for disease, then it is a cost-forcing scheme whichever path is chosen.
Before the ACA those that paid for insurance were forced to shoulder the cost of those that didn't. Now, those who think they don't want to pay for health insurance are forced to pay one way or another (though I think the penalty is too small).
I find it hard to feel bad for people that don't want to pay for their own health risk or who think they don't have any.
I lean heavily towards the libertarian side of things, but it didn't take that long for me to come to the conclusion that unless "we" (as a society) were going to let people die in the streets from curable diseases, we are all going to pay for everyone's health insurance, in some way/shape/form anyway.
I still believe a more open market would be a "better" solution, with a tight safety net to maintain standards across economic levels, but as that is unlikely, fixing the glaring issues with the ACA seems like a good starting point.
There is no reason we can't pursue both simultaneously. Nothing in the ACA prevents posting of price lists or incentivizing patients with cash payouts for finding cheaper than average care.
That is what has driven me crazy about politics -- it is more about making noise about the other side than actually doing something that might push things forward. Republicans could have pushed open market reforms the moment ACA was passed. If they did it on a state by state level they could even point to data of success vs pure ACA states to bolster their agenda.
Trump seems to think it will lead to the ACA falling apart. He might be right but only as part of the entire current insurance system falling apart around it. I really don't know what the intention was, there. As simple as fulfilling a campaign promise no matter the cost?
The issue is that based on the reasoning that people who were paying for insurance before were already bearing the costs. If that’s the case then it doesn’t make much sense for those same people to see dramatic cost increases.
In the last 100 years the US has moved much more towards consolidated federal policy. Federal level policy comes with a lot of issues.
First, combining politics with trial and error doesn't work in a 2 party system. 1 party will point out its flaws, while the other party will pretend they don't exist or be defensive about those flaws. The country will be left with people who feel the pain of that problem and those who do not. The ones who feel the pain will vote to end the pain, regardless of anything else. The ones who don't feel the pain won't see the big deal and will focus on other issues...and those other issues will be seen as issues that the other party was voting "against".
The other issue is that with federal policy, the entire country suffers from the consequences of issues. Once the legislation is in place, it's nearly impossible to change or remove so if you think there MIGHT be an issue you're better off voting staunchly against it.
State level policy doesn't suffer from this issue. With 50 states and a national idea that all policy should be state level, we'd have 50 experiments. If one state tried something and it worked, other states would research what they did and follow suit. If it didn't work, they'd stay away. Or try something new. County/City level is even better.
That's why when people were selling the ACA as "what Romney did in his state" were missing the point. The point was that was state level...so other states could follow if they wanted. It didn't mean that should be the policy at a federal level. The entire point was that it was a state level policy.
At the federal level and in the election, Hillary wouldn't even acknowledge there were problems with the ACA and IMO that is what cost her the election, because new premium letters started coming out just before election and there was a lot of pain to go around.