Again, the premiums you're referencing are taking into account specific demographics-- usually the average 27-year-old white male. As a woman my premium was innately higher than a man's living in the same area. Looking at the full demographic average is more important than looking at the lowest possible number; we've all seen sales 'starting from' a particular price and know that, in practice, nobody is getting away that cheap.
Additionally, my issue with the cost is also based on that base cost. I think it's a better situation for everybody to pay less on average than it is for some people to pay nothing while others are paying out the nose for an equivalent product. Of course there are always going to be discrepancies between the needs of demographics and the cost of insurance should be adjusted because of it-- that same 27-year-old man is much less likely to use his insurance for ongoing health care than a 60-year-old man.
However, two 27-year-old men with different income levels shouldn't be paying such a massively different price. The ACA's subsidies (for a Bronze tier plan) will cover the full cost of insurance up to 150% of the poverty line-- currently $22500 for a single individual. Once you start making more than that the subsidies rapidly drop off and the premiums rise, which is the 'donut hole' I referred to earlier-- people making enough money that they no longer qualify for subsidies (thus eating the full cost of the premium) but for whom spending an extra $400 a month on insurance is still untenable. Between grocery shopping, utilities, credit card bills, loan payments, and rent/mortgage, that $400 is a lot of money going toward a service they might not want or feel they need.
Regarding the foundational costs--
We have issues with both the cost of health insurance and the underlying cost of health care. As far as the cost of insurance:
Government guarantees -- when the government guarantees payment then there's no incentive to keep cost down. When you're dealing with individuals you have to make sure your services are affordable to as many people as possible within your target demographic (in this case, you're appealing to every adult in the country). When the government assures you that they're good for payment, you have carte blanche to charge pretty much whatever you want because the government will just make money happen. On the front end this is fine for people who qualify for assistance, but if you don't, you're now saddled with the inflated cost.
Limited Competition -- This is in regards to both overall competition and to the plans offered by each provider. Health care could only be sold within state lines, limiting the available competition off the bat and limiting it even more when smaller companies collapsed when the ACA went into effect, limiting marketplace options to only a couple of providers or, sometimes, only one, meaning there was no competition and no need to offer better services or better prices.
Limited Options -- The options for plans were reduced; where a healthy young adult could previously buy low-deductible disaster insurance (no coverage for doctors or meds but good coverage for emergency hospitalizations) or somebody with a severe condition could get a plan that was specifically made to cover the needs of that condition, the ACA enforced bare minimum coverage. You can no longer buy an emergency plan; you must pay for a plan that will (eventually) cover doctors and medication when you reach the (very high, for Bronze plans) deductible. Women are also forced to buy plans that cover maternity and child care, even if they won't or can't have children, increasing the cost of insurance. Limited options were generally an issue before the ACA s well, as most providers have package deals for plans instead of letting you customize according to your needs, but the government mandates restricting these options even more didn't help.
As for the cost of health care:
Limited Competition -- Again. Only certain drug manufacturers in the US are allowed to manufacture certain drugs. While there are obvious safety concerns to be taken into account to make sure medications are as safe as possible for as many people as possible, in practice this often results in favors being done for a small number of manufacturers, authorizing them to produce medications while preventing competition. Insulin, for instance, is actually a very cheap thing to produce, and we've known how to produce for a century now-- but only one manufacturer was allowed to produce insulin in the United States, allowing them to charge exorbitant rates because they were the only option. The solution here isn't necessarily deregulation (of all the things that have high regulation, medicine definitely needs it) but looking into why only certain manufacturers are given the right to produce these medications and making avenues for others to do the same.
Subsidizing Other Nations -- There's an international drug pricing index that the vast majority of industrialized nations are part of. This index regulates the cost of drugs and caps them at a certain level. For some reason, the United States is not part of this index, meaning that the drug companies make up the profit they're losing in other countries by overcharging the US consumer. I don't know if you recall this but Trump was trying to actually get the US signed on this scheme, which would have dramatically lowered the price of drugs in the US in exchange for raising it in other countries. (The German Prime Minister actually cried about how unfair this would be.) I remember talking about this to a pharmacy wholesaler around 2018-2019 and hearing about Trump's intentions shortly thereafter, so if I'm being charitable it was probably disrupted by COVID. Why it wasn't revisited afterward, I can only speculate.
Doctors are Expensive -- And there are multifaceted reasons for this. Part of it is that the up-front cost of becoming a doctor and opening a practice is very high, between the rising cost of medical school and the regulations that have to be followed to do so, meaning that doctors have to pass their own costs on to consumers. (Another point where regulation and certification are obviously extremely important, but the costs should be easier to mitigate-- but the obscene price of higher education is its own issue.) This winds up also contributing to not having enough doctors for the population at large; offices are packed with people and doctors basically have to address a conga line of patients through the day, leading to higher costs, less specified care, and a probably knock-on effect of sick people not seeking help early in their illness, when it would be easier to deal with, causing greater complications and an increased strain on resources.
General Issues with Individual Health -- We have an unhealthy population and a lot of people actively pushing for people to be and remain unhealthy, which causes an increased strain on resources and leads to overall higher costs. This is a bit more esoteric, but I think we would go a long way toward improving both costs and general health by teaching proper nutrition and cooking to a broader sect of the population. Fixing people's underlying health reduces pressure on the system and mitigates the need for more medical intervention.
We Need Less Medical Intervention -- Kind of related to the above but we also have an over-reliance on medication to fix problems. Reducing a reliance on medication when other options are available should be prioritized. I think this partially ties in to how we have too many patients per doctor; it's easier to throw pills at somebody than to assess their individual needs.
Follow the Money -- This ties in to everything, on every level. A lot of issues are caused by a prioritization of money over health. This can't be entirely avoided and I don't really begrudge manufacturers from wanting to make a profit (especially because R&D is extremely expensive and if they don't recoup the costs, guess what? No more medicine), but there are incentives and blockades up and down the chain that must be addressed. From the aforementioned companies that have exclusive manufacturing rights to government incentives prioritizing medical intervention and higher-cost treatments, there are loads of pressure points where money is used as an incentive to force more expensive (and ongoing) care.
Retail Rates -- This is wildly variable but during my pharmacy work I got to see the price of drugs, from wholesale to retail. My favorite places to work were the ones where I saw both simultaneously. Most common drugs have a minor markup. More specialized drugs might see a markup between 50% and 700%. Some markup is necessary -- you have to compensate for the cost of the distributor buying the drug, transporting it, storing it, the labor involved in processing, it makes sense -- but more specialized drugs almost universally are outrageously expensive on the consumer side. The pharmacy techs would often be appalled when I asked for a price reference. And the reason they can do this?
Obfuscation -- I think this is maybe the most insidious. The fact is, people don't know what health care actually costs. During my work in pharmacies I would see the difference between what a person was paying versus what the drug cost. There's a huge difference in attitude when you see "You pay $0" versus "Your insurance saved you $1970"; they both mean the same thing in this case, but the latter really makes you wonder why is it so expensive? This applies to things like ER stays and testing. How expensive is an ultrasound? An MRI? An EKG? I've recently gone through an extensive gauntlet of medical testing and I have no idea what it cost because my insurance pays for it and we say nothing else. Even my doctors have no idea what it costs. This is almost certainly by design; if everybody knew what the underlying cost of their treatment actually was, they would be furious. That said, I have overheard some of the reasons things cost so much, and one of them surprised me.
Foreign Nationals Getting Elective Surgery -- I believe this only applies to specialized and elective surgery, but we as a nation have many of the best medical facilities in the world. Many foreign nationals prefer to have their surgeries done by doctors in the States than in their own countries. To dissuade this, the base cost of these surgeries is made prohibitively expensive, with the understanding that foreigner trying to use our resources will have to pay the full cost of the surgery while our own citizens who are seeking these services will have them covered almost entirely by insurance. This one I'm less familiar aware of than anything else on this list, but given the above tendency for obfuscation I can believe it. This is probably a pretty minimal issue in the grand scheme, but it does explain why certain procedures have such a high up-front cost when it seems like it shouldn't be necessary.
People Taking Advantage of the System -- I don't mean the downtrodden of our own country. Apparently there's an issue near the border where foreign nationals will cross over the border and take advantage of our emergency rooms (where you cannot be denied treatment even if you cannot pay). What I heard specifically is that thousands of people use this to get free dialysis treatments-- done three times a week for thousands of dollars each session. Because it's done through an emergency room there's no up-front payment, because they aren't citizens they don't have social security numbers to track, and because they just run back into Mexico they can't be tracked down and charged. This is tens of millions of dollars every year being bled from these facilities, and the cost winds up being put on our own citizens to make up the difference. I'm sure this is taken advantage of all across the nation in different ways, so the people who play by the rules wind up paying for those who refuse to.
I actually put this at the bottom of the list because, while it's certainly a problem, it's hard for me to justify refusal of medically necessary services to those who can't afford them. While I think that not letting people run across the border to take advantage of our services would be, you know... great... you wind up with situations like how would you enforce that? If a foreign tourist suffers a heart attack do you deny them service because they aren't a citizen, even though they're here legitimately? Do you make people provide some kind of collateral? Do they have to have an address to bill? Then then you can't help the homeless. On and on and... maybe there's a way to address this in a humane and sensible way. Maybe.
However, the addressing the bevy of other reasons that health care is so expensive (and I'm sure this list isn't exhaustive) would go such a long way to helping regulate costs that it would make eating the costs of those abusing the system would be much more tolerable. If treatment itself cost half of what it does now then that's already half the cost mitigated.
And all of that said, I don't think the ACA was an unmitigated disaster. Removing the individual mandate went a long way to easing the burden on people. I think making it illegal to deny coverage for people with preexisting conditions is fantastic. I think that subsidies should be available under certain conditions, but as a separate program rather than baked into the system (to discourage people taking advantage of government guarantees).
But the actual scope and implementation of the ACA was a bandage applied to a snake bite. You're covering up a wound when you need to drain the venom.
