Why doesn’t America join the first world and provide Universal Health Care?

At its very core, an insurance company operates by: 1) pooling policyholder’s risks together and 2) collecting premiums from the policyholders based on actuarial data, to pay claims and maybe make a small profit. But looking broader, an insurance market exists when: a) policyholders voluntarily or are obliged to obtain policies, b) insurers are willing and able to accept the risks in exchange for a premium expected to support the insurance pool, and c) the actuarial risks are calculable and prove true, on average.

The loss of any of A, B, or C will substantially impact a healthy insurance market, or can prevent the insurance market from ever getting started. For some examples of market failures, the ongoing California homeowner insurance crisis shows how losing B (starting with insurers refusing to renew policies near the wildland-rural interface) and C (increase in insured losses due to climate change) results in policies becoming unaffordable or impossible to obtain.

As a broader nationwide example, an established business sector that operates wholly without insurance availability is cannabis. A majority of US States have decriminalized marijuana for medical use, and a near-majority have legalized recreational consumption. Yet due to unyielding federal law, no insurer will issue policies for marijuana businesses, to protect from risks that any business would face, such as losses from fire, due to a product recall or product liability, or for liability to employees. These risks are calculable and there’s a clear need for such policies – thus meeting criteria A and C – but no commercial insurer is willing to issue. Accordingly, the formal market for cannabis business insurance is virtually non-existent in the USA.

With these examples, we can see that the automobile insurance market meets all three criteria for a healthy market, but it’s how these criteria are met which is noteworthy. Motorists in the USA are obliged to insure in every state except New Hampshire and Virginia: it is a criminal offense to drive a car without third-party liability insurance, meaning the motorist might spend time in jail. Note: NH and VA won’t send a motorist to jail, but they do have administrative penalties for driving without “financial responsibility”, which includes insurance or a bond at the DMV.

The exact requirement varies per state, with some requiring very low amounts of coverage and others requiring extra coverage like Personal Injury Protection (PIP, aka no-fault insurance). The point is that criteria A is easily met: motorists want to avoid jail, but also want to avoid the indignity of being sued after having caused a road incident, in addition to protecting their apparently only viable mode of transportation.

Insurers can take into account the overall trends in national risks trends for automobiles (eg new car safety, through the Insurance Institute for Highway Safety, IIHS) as well as local or hyper-local risks (eg hail damage in the southeast, property crime in a particular zip code). And as a large country with nearly as many cars as people, many insurers are willing to meet the demand. This satisfies criteria B and C.

So well-organized is the automobile insurance market that you could almost say that it’s vertically integrated: the largest nationwide insurers have contracts in place with every dealership network, auto collision chain, new and used parts dealers, as well as automatic data sharing with state DMVs, plus with firms like CarFax that buy information. Despite each state being slightly different, the insurers have overcome and achieved a level of near uniformity that allows an efficient market to exist.

Things are drastically different for the American healthcare system and for American health insurance companies. While most think of their healthcare provider as a national name like Anthem Blue Cross or Kaiser Permanente, the reality is that each state is an island, and sometimes counties in a state are enclaves. Even federal programs like Medicaid and Medicare are subject to state-level non-uniformities. For example, hospitals can be either privately operated (eg religion-affiliated, or for-profit) or run by a public entity (eg county or state), and can exist as a single entity or form part of a regional hospital network. Some entities operate both the insurance pool as well as providing the health care (eg HMOs like Kaiser Permanente) while others dispatch to a list of contracted providers, usually being doctor’s own private practices or specialist offices.

With so many disparate entities, and where healthcare is a heavily-regulated activity by each state, the cost of insurable risks – that is, for routine healthcare services – is already kinda difficult to compute. Hospitals and doctors go through intense negotiations with insurers to come to an agreement on reimbursement rates, but the reality is that neither has sufficient actuarial data to price based on what can be borne by the market. So they just pass their costs on, whatever those may be, and insurers either accept it into their calculations, or drop the provider.

Suffice it to say, there are fewer pressure to push the total cost of healthcare down, given this reality, and more likely prices will continue to climb. This fails criteria C.

Source

Briefly speaking, it’s fairly self explanatory why people would want health insurance, since the alternative is either death or serious health repercussions, paying out-of-pocket rates for service, or going to the ER and being burdened by medical debt that will somehow haunt even after death. Criteria A is present.

As for Criteria B, that was actually resolved as part of the Affordable Care Act (ACA). During discussions with the drafters, insurers bargained for an obligation for everyone to have insurance (aka the individual mandate, bolstering criteria A), in exchange for an obligation to issue policies for anyone who applies, irrespective of pre-existing health conditions. Thus, Criteria B is present for all ACA-compliant policies in the USA, even though the individual mandate was later legislatively repealed.

So to answer your question directly, the costs for healthcare in the USA continue to spiral so far out of control that it causes distortions in the health insurance market, to everyone’s detriment. Specific issues such as open-enrollment periods, employer subsidies, and incomprehensible coverage levels all stem from – and are attempts to reduce – costs.

Enrollment periods prevent people from changing plans immediately after obtaining an expensive service, like a major surgery. Employer subsidies exist due to a federal tax quirk decades ago, which has now accidentally become an essential part of the health insurance and health care situation. And coverage levels try to provide tiered plans, so people can still afford minimal coverage for “catastrophic” injuries while others can buy coverage for known, recurring medical needs.

But these are all bandaging the bleeding which is unchecked costs. It would take an act of Congress – literally – or of state legislatures to address the structural issues at play. The most prominent solution to nip costs is the bud is to achieve the same near-vertical integration as with automobile insurance. This means a single or very few entities which have contracts in place with every provider (doctors and hospitals), negotiated at once and uniformly, so as to achieve criteria C. The single-payer model – which Medicare already uses – is one such solution.

Going further would be the universal healthcare model, which discards the notion of health insurance entirely and creates an obligation for a government department to provide for the health of the citizens, funded by taxes. This means doctors and hospitals work at the behest of the department for the citizenry, or work privately outside the system entirely, with no guarantee of a steady stream of work. Substantial administrative savings would arise, since the number of players has been reduced and thus simplifies things, including the basic act of billing and getting paid for services rendered.

These models could be approached by individual states or by the nation as a whole, but it’s unclear where the Overton window for that idea currently is.

So many explanations, but here’s a summary: The concept of the efficiency of free markets is an illussion. Especially in conditions of guaranteed damand

By tying insurance to employment (side effect of some economic policy) the option to shop around was removed. When people are already forced to use the insurance provided by employment so that they can afford it, there is no way for some other insurance agency to be competitive. Then it just got worse over the years.

The ACA attempting to make a competitive market was a half assed substitute for just going all in on single payer, but at least people with the jobs that don’t provide insurance have the possibility of affording it now so it is better. Just getting stabbed instead of being shot better.

You, don’t have any bargaining power regarding your health. Let’s say you broke a arm, a Mundane thing. You’re in pain, and would do anything to make it stop. Once they give you some morphine, you’re high and can’t take any reasonable decision.

Moreover, you can decide to thrash away a car, it happens all the time, you can’t do it with your life.

Because it’s rigged against you. US has the most expensive health care in the world - It’s not natural, this is crafted oligopoly to gouge the prices

(easier for health insurance companies to double-dip this way)

Because Americans care about cars.

It is effective and efficient, just not for the consumer.

Not all cars and drivers have accidents, but everybody in his/hers life WILL need health care of some kind

Can only shop during a specific enrollment period.

With most other insurance, it only pays out of something unplanned happens. With health insurance, there are medical issues that can be known about in advance of them being to be addressed. So you might know you have a heart condition that needs to be operated on soon, but not immediately. This is known as a medical precondition.

Before the ACA was passed, health insurance companies would always exclude medical preconditions. So, if you switched insurance while needing that heart operation, you would find that you weren’t covered and have to pay all the costs.

The ACA got rid of being able to limit coverage of medical preconditions, but it needed to provide a way for insurance companies to limit their exposure to people switching from a bad plan to an amazing plan that covered everything and would have to pay out immediately. To handle that, it made it a requirement for all people to get a minimum amount of medical insurance and to restrict when people could shop for insurance.

universal health cover is also realtively simple too…

Regulatory capture

Because the customer and user are not the same people and insurance is keeping the costomer happy. High prices mean I cannot afford to quit my job or retire early. I have to have a job to have any form of insurance at all. It is great for the hr department that buys my insurance. In theory I can buy my own on the market but that means the thousand dollars a month my employer is paying gets thrown away.

Can only shop during a specific enrollment period

With cars it’s relatively easy to determine if a particular collision occurred before or after you bought insurance. It’s also very hard to predict exactly when these commissions will occur. Consequently, it is not so easy to delay and only buy a policy when you already have a claim ready to go.

With many progressive diseases, it’s much easier to wait and only buy insurance if you think it’s going to be expensive, but haven’t been diagnosed with anything yet. That’s why health insurance has open enrollment periods.