There's a multitude of evidence that points to the success of the ACA from a cost perspective (among other things).

Cost of healthcare for individuals is not a good metric to judge by. The ecosystem of hospitals, patients, doctors, insurers, health systems, and the federal government is complex and you're not going to get a clear picture of the overall impact of the ACA by looking as something as simple as cost savings.

One example, hospitals are required to treat patients whether or not they hold insurance. The hospital foots the bill for that care and it's a major reason why hospitals shut down (especially in underserved communities). Getting more people on insurance plans was a direct factor is keeping many struggling hospitals and health systems afloat.

https://www.statnews.com/2019/03/22/affordable-care-act-cont...

https://www.networkforphl.org/news-insights/the-affordable-c...

https://www.cbpp.org/research/health/chart-book-accomplishme...

1. Do any of the cost savings recommendations you address come close to $1T/yr impact? This is the scale we should be aiming for.

2. If you think this modeling is inaccurate or incomplete you can directly discuss that. That would be a much more interesting discussion than "it might be incorrect."

I think the high upfront capital required to start out in the industry is a much much bigger hurdle than the regulation.

You see the same problem in IT with hardware startups vs purely software ones. The moment you need to own something more than 1s and 0s, the risk grows exponentially.

Reducing regulation doesn’t solve that problem.

And that’s without even considering all the shady tactics that the incumbents can do to drive new ventures out of business.

It's also caused by absurd nonsense like how doctors can't tell you how much anything they're proposing to do actually will cost (a necessary condition for entering into a contract!), but then the system makes up arbitrary bills after the fact - with fraudulent amounts that nobody actually pays! No other industry works like that, as it's not the foundation of a market in the first place. Imagine if going to the grocery store involved "paying" some token amount at the cashier for their time to put your items in bags, then for the food you received shakedown bills for years afterwards, that you had to spend time going through your old documentation to refute and bargain down. Absurd.

Regardless of "insurance", who is ultimately paying, or subsidies to provide a baseline of care - there needs to be reform that mandates simple up-front prices, constant per-provider regardless who is paying, and ruling out any other theory of billing. Doctors throw up their hands and act like they're dealing with some special problems, but there are plenty of other industries we can look at for the dynamics of how to handle routine procedures versus emergencies (and knowns vs unknowns) in a consensual and market-responsive manner.

You're actually talking about the same problem. Competition in healthcare is heavily restricted by stuff like certificates of need because there is little cost-sharing with utilizers so you get overutilization & induced demand. This is Roemer's law [0]. A large part of the reason for competition restrictions is because of a hacky attempt to control overutilization without direct cost-sharing.

0: https://en.wikipedia.org/wiki/Roemer%27s_law

The wonders of American healthcare really mean that it's all more expensive, and at the same time, more is consumed, because so much of what is paid is done past deductible. If you look at so many standard of care situations vs, say, Spain, the American system will do a whole lot more. Even for preventive care: For instance America wants colonoscopies every 10 years from 45. Spain will give you a non invasive fecal test every 2 years, and only consider colonoscopies after the test is positive. Every time I send my american prescribed intervention list, given my symptoms, to my family members working in the Spanish public caresystem, they look at it with their hair on fire. Very different standards. You might think US insurance is restrictive regarding what needs to be done, but most public care system are significantly more restrictive than that. It'll be for better reasons, instead of defaulting to no on everything, but ultimately still far more cautious regarding their spending.

So we fail both ways at the same time: We avoid interacting with the medical system, but when we do, far more is done, at far higher price per intervention, so we end up with more interventions for the same outcome, even though we avoid doctors more!

I think a citation is needed for "Americans regularly avoid care ... because they can’t afford it."

I think there are other reasons, e.g. they don't like doctors, or it's too inconvenient, or waiting times are too long. I have good insurance and haven't seen a doctor in probably 20 years.

I know people who are visiting the doctor for every sore throat, ache and pain or sneeze and sniffle, and that's not me at all.

The people who avoid care they need because they can't afford it are a very small portion of the population that gets an outsized share of attention on the issue.

Until public healthcare advocates understand this and make actual attempts to convince the majority of people who are satisfied with the current system that there are benefits, the status quo will remain.

Let’s try and deal with actual facts here. If you disagree then you should be able to post some actual data in terms of lifespans or costs that says otherwise.

There’s multiple healthcare systems around the world, single payer results in vastly less administrative and thus overall spending and equal or better outcomes overall. So by objective criteria the average person massively benefits from single payer healthcare.

I think that’s a reasonable model to want, but it’s what we call “preauthorization”, and many patients along with most doctors absolutely hate it. In order to know with certainty what your care will cost and how much your insurance company will pay, the doctor has to contact them in between deciding what treatment you should have and giving you the treatment.

You can and I do solve that annoyance with an HMO, where the doctors and insurance can communicate more effectively because they’re part of the same organization. But that also means it’s difficult or impossible for me to get the kind of care that a normal insurance company would hesitate to approve.

>theres an argument for removing private insurance companies in favor of thr government

I don't see why you'd need to do that. Just expand medicare to everyone and if people want to also buy private insurance they can.

They'd just need to be more competitive and add significant value, which they don't currently do.