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What will the future of the US healthcare system look like?
The current system is a patchwork of primarily employer-sponsored healthcare (60% of non-elderly Americans), the ACA marketplace (offering government-approved plans through private insurance companies), Medicare for the elderly, and Medicaid for the poor, disabled, and children. About 8-9% of the population is uninsured. Prices are higher and health outcomes worse than comparable developed countries.
Obamacare attempted to reduce the uninsured population by, among other things, implementing Medicaid expansion to all adults under 138% of the federal poverty level and granting tax credits to help defray the cost of marketplace plans (for incomes up to 400% of the FPL). During COVID, these subsidies were increased and expanded to higher income levels, but Congress allowed them to expire this year, resulting in average premium increases of ~114% for about 22 million people, although an additional vote is scheduled this month.
In addition, low-income adults utilizing expanded Medicaid will be required to demonstrate 80 hours of work per month starting in 2027. Mike Johnson framed this as kicking out unemployed young men mooching off the system - even the old welfare queen trope has been de-DEIified. Georgia already implemented a similar work-requirements program as part of their Medicaid expansion in 2023, resulting in the bulk of the money going to administrative costs and only about 9k out of 250k low-income adults enrolled.
As a result of all of this, the uninsured population will likely increase this year, which may even cause premiums for people with health insurance to rise due to a death spiral effect - if more people are uninsured and can't pay their medical bills, the costs may be shifted to covered patients.
The above article takes the pessimistic view that the system is unlikely to improve significantly, because tying healthcare to employment is such a nice perk for employers (the system started during WW2 when companies offered health insurance as a replacement for wage increases due to federal wage freezes). European or Canadian style universal healthcare certainly seems less likely than ever.
The blackpill moment for me came about five or six Christmases ago.
I was came home to see mom, dad, and my siblings a few days before Christmas. At this time of year, every year, my dad finalizes his books. He has always run the household finances top to bottom, even though my mom had her own entrepreneurial career since I was little. This year, however, dad had extra time on his hands because, well, he'd been retired for the full year. Probably to keep busy, he was self-auditing the family's entire financial history since my oldest sibling was born (if you haven't figured it out by now, my dad was a finance nerd).
Coming into his office to greet him after, of course, hugging my mom first and learning about all the amazing Christmas cookie recipes she had shared with the other church ladies, I found my dad looking a bit sullen. Nothing catastrophic, but definitely something there. I perked up at once. Had he miscalculated their retirement forecast? Impossible, he'd been thinking about that daily for over a decade before he retired. What was it? Had mom started splurging on fur coats or trinkets for the grandkids?
I asked him what the matter was and his response was direct, "We should've never paid for heath insurance. We came out behind."
This was beyond stunning to hear. It was like finding out that I was adopted all these years later. Why? Because one of my siblings, in her teenage years, had had five major surgeries that required; A specialist-of-specialist surgeon to actually do each one, multi week hospital stays each time, weekly (later monthly) checkups locally, and prescriptions for all sorts of exotic medications. The whole saga actually played out over 4 years. Complications, poor recovery, etc. I was fairly young so I don't remember the worse of it, but this has always been cited as why my mother went prematurely grey.
I asked my father to explain. Pulling up the World's Greatest Excel Spreadsheet, he walked me through historical premiums, deductibles, out of pocket expenses. At the end, the =SUM() function told the tale; had mom and dad paid out of pocket instead for all that time, they would've saved money.
Two important caveats
Still in all, this was my helathcare blackpill moment. The normie narrative around healthcare is "yeah, it's too damn expensive, but if you really need it it's worth it." Well, like, no. My sister's bills probably put us into about the top 5% of expenditure for the years she was in the middle of everything. And yet, the numbers still didn't crunch.
Since then, I've learned that the top 1% of healthcare "users" (that is, people who are consuming care) represent about 50% of overall healthcare spending. It's a crazy power law. But that actually isn't the problem. As others have pointed out, it's all of the off book spending that gets done for defectors. This then gets passed up the chain to the middle and top. For every deadbeat who uses the ER as his or her primary care physician, many of them as "frequent fliers", that's thousands to tens of thousands of unpaid costs that have to get paid somewhere. And that somewhere is you, the dutiful policy holder. It is the ponzi schemes of ponzi schemes because the pyramid is upside down -- the people at the top aren't actually capturing a bunch of value and then playing slight of hand with those lower, it's that those at the very bottom are pushing all the cost up.
This is one of the moral dilemmas I actually think about most. If I, god forbid, ever need some sort of major procedure done, do I just defect and refuse to pay? They can't send me to jail. Maybe my credit score goes to shit forever, maybe I even go bankrupt. Eh, but then I'm just going to be a cash-only vagabond and live as free as I please.
But it would be wrong and immoral. As much as it is a totally rigged game, I see the only hope for society to be to continue to at least observe the rules of the game. Defecting in a collective action problem shifts immediate personal cost to prolonged socialized cost. It's inherently anti-social.
You make the case like you have and if it doesn't (can't) get heard - you defect. The longer you play along the longer you incentivise the status quo. But I probably wouldn't have the balls to defect also.
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