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PaperclipPerfector  6d ago (text post)   27042 thread views

Culture War Roundup for the week of July 7, 2025

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Posted this in the comments last week, but was curious to get some more thoughts on a potential path forward on the healthcare front that isn't just single-payer across the board:

I do occasionally wonder if you could get to a decent place via:

  1. Get rid of Medicaid. It maybe made sense at one point, but it's current incarnation is, as far as I can tell, such a disgusting mess for all involved parties that it's better to just kill it with fire.
  2. People who would be on Medicaid can now get insurance via the ACA exchanges - they'll get a 94% CSR plan for 2% of their income. There's some annoyance around how they will enter their income, but much less paperwork than it takes to interface with Medicaid. There would need to be a small legislative tweak to allow this to happen (let <138% FPL income people get subsidies), but in practice they should trade a bunch of annoying documentation and everything is free for a functional network (ie a blues plan) and everything is very cheap + 2% of their income.
  3. Expand Medicare to more disease categories other than just end stage renal disease (in addition to the elderly). In practice I think you want to try to capture an additional several million of the sickest people. Hemophiliacs, organ transplant, some cancers, some rare genetic disease perhaps, that sort of thing. This will dramatically lower premiums in the ACA. However power-law distributed you think healthcare costs are, the reality is they are likely more power law distributed than you think.

That's going to create some winners and losers, hospitals will be upset that more high cost people are on Medicare, but shifting people from Medicaid to commercial reimbursement rates should help out with that. The amount of bureaucratic nonsense saved by getting rid of Medicaid should be huge.

All a bit of pie in the sky dreaming anyways...

My preferred solution is that Medicare or Medicaid covers everybody for catastrophic illnesses and injuries. Everything else you buy on the ACA exchanges. The large pool of 330 or so Americans paying into this via taxes should help keep costs reasonable, and the lack of those coverages on other plans for those same illnesses would probably lower costs of those plans as well. It also allows people to decide how much risk they’re willing to bear in their health insurance. If you’re 21, you probably don’t need much besides the catastrophic health care package. You are not likely to get sick, and thus you can skip the rest. If you’re 45 you might want more coverage for drugs or doctor visits or whatever else you think you need.

The reasons this is unworkable are political- the ‘thé government should cover ozempic/IVF/whatever’ platform is always going to be more popular than the ‘keep universal healthcare only for catastrophic’ platform.

My preferred solution- all children on Medicare, hospitals get guaranteed reimbursement for EMTALA care, low-coverage plans and low-risk pools are legal again.

the government should cover ozempic

Given how much obesity costs the US healthcare system/economy, this might be a positive EV move.

Sure, willing to believe that. But the point is the government is going to start adding non-catastrophic care they cover, often through rational cost-benefit analysis(vaccines etc) and then expanding the list will become a political issue with a ratchet that only goes one way.

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