One of the biggest disappointments for me about the ACA was that it didn't address one of the most obvious problems with the American healthcare system -- the significant discount for employer-provided healthcare.
The biggest disappointment about the ACA is that the discussion completely ignores the cost of care.
In other words: the healthcare discussion in America revolved around "how can we make it so everyone can afford this $300 asprin?" rather than, "Why are we letting hospitals charge $300 for asprin?"
There's a simple reason they charge whatever they want and generally can't even be bothered to disclose those prices ahead of time: because they can.
To critics of the ACA, the relevant question is, who or what is in an effective position to put downward pricing pressure on hospitals? Because to date, it has clearly not been individuals or insurance companies.
Single-payer systems have a track record for being much better at putting downward pressure on pricing. Not only can they secure drug discounts of ~50% due to their ability to bargain as a bloc against much smaller insurance companies in the US, but they lack perverse incentives to allow costs to rise. Insurance companies don't care about reducing costs, only reducing costs relative to competitors. Since their "cut" is a fraction of overall expenditures, they're quite happy to see costs rise, as long as they rise in tandem for their competitors.
Nobody who is familiar with the market is surprised that single-payer systems are so much cheaper.
> they lack perverse incentives to allow costs to rise
But, of course, they also lack incentive to actually provide all that much care, so long as those who are inconvenienced are politically unimportant (e.g. disabled newborns), and they have plenty of incentive to provide more care for the politically connected.
In practice, we can just look at existing single payer systems and see how they're doing. Would you rather be a poor parent of a disabled child in the US or the UK?
The person best in the position to apply pricing pressure is the person paying the bills. Since individuals do not pay the bills, of course they haven't been put pricing pressure on hospitals.
The ACA pretty much doubles down on employer-provided health insurance that covers many routine costs, which doesn't address that issue.
Well, if you really wanted to de-couple health insurance from employment, you'd have been better off voting for John McCain, whose health plan transformed the tax-advantaged status of employer health care into an individual tax credit available regardless of how your health care was purchased.
Neither President Obama nor Sen. Baucus (the real author of what became "Obamacare") ever had that in mind: If you weren't going to get single-payer, there was no way you were going to cut government worker and blue collar labor unions away from the very cushy tax-advantaged plans they'd negotiated with their employers for current and retired members. They're already extremely upset about just the "Cadillac" tax.
Is employer-provided healthcare discounted, or merely subsidized by the employer (or both)? The plan through my employer seemed inexpensive, but they were paying a significant portion of the premium.
It depends on exactly what you mean by discounted, but in a very real way the answer is both.
First there's the obvious, and quite significant, tax benefits to employer provided healthcare over private purchased healthcare. In the former case, neither the employer nor the employee pay payroll taxes on their contributions and the employee portion is also exempted from income tax (the employer also doesn't pay income tax on its contribution, but it wouldn't for cash salary either).
Second, more subtly, the group market faces much more favorable underwriting than the individual market. Even if non-employer group health insurance were allowed (which it isn't anymore under ACA) such groups are always subject to self-selection bias and thus are unlikely to be underwritten as as favorably. However, this point is somewhat tricky because there are both cross-subsidies and gross economic surpluses, which can be hard to untangle.
It's tax deductible for the company to offer employees health care, but individual plans bought by individuals on the exchanges are not. So it's effectively subsidized in one case but not the other.
She single biggest disappointment of the ACA is how few people understand what could be passed in the american system of governance, which combines a huge number of veto points with the republican party that plainly couldn't give a fuck less about people unable to afford healthcare.
