I think the status quo is not better. Better half was switched to a "defined contribution plan" at work. They pay up to $300 per month, you pick the plan. Cheapest is $450 per month with a $12,000 deductible sky high co-pays and 30% co insurance at in network providers, meaning you have to Shell out the other 30% IF your care is in network. Of course, you cannot control that. Once you get to the ER, if any of the specialists are out of network you get no warning and have no recourse but to pay.

I mean, they make you insure a $2000 car, but they call a $12,000 deductible "insurance." It's bananas. And the cost increases by double digits every year. And we're professionals with fancy degrees and professional jobs. What are regular people supposed to do in this environment? Die? It seems from the life expectancy data, that's what's happening.

So, I guess my way of looking at it changed. I thought 10 or 15 years ago that we could find real solutions outside of universal care. I even worked 15 years ago on a state level program that would have cost about $600 per year per capita to provide a private insurance option to everyone with a reasonable plan and only $40 per month premiums by drastically reforming Medicaid and shifting accounting for uncompensated care and doing a host of other things. A competing plan would have considered a private single payer. Either way it hinged on state regulated prices. Then Romney Care came along and sucked all the oxygen out of the room. It had harsh mandates and no cost controls with teeth. Obamacare is similar, save for the Medicaid expansion. Mass is still better off than many states. It has lower taxes than some places with 5 times the uninsured rate. But it's a wealthy state. And the cost increases are pushing the system to the point of crisis.

So, where I'm at now is a state of short term hopelessness. One side wants single payer. The other side wants no change or worse, changes that will just exacerbate the cost problem and the coverage gaps. I suspect that the short term outcome will be that nothing gets done, and coverage gaps expand, bankruptcies explode (both especially in a downturn), and life expectancy drops much harder and faster than it already has in recent years. All the while, 12% annual premium increases and deductibles and co-pays and co-insurance rates will soar. I mean, this is all but certain if no major productive legislation that the med industrial complex doesn't like passes. I don't see that happening barring a massive wave election the likes of which happens maybe twice per century.

So, barring that, crisis comes anyways. And it comes at a time we'll be loading tens of millions annually onto the Medicare rolls, all the while the structural deficits created by 40 years of persistent tax cuts starve the beast. It's not hard to imagine maybe 20% of the discretionary budget going to debt service in 10 years' time.

Ok. So say this happens. Some folks will see it as a golden opportunity to claim crisis and kick grandma and grandpa off their Medicare and Johnny unemployed off his Medicaid. What then? You solved the budget problem, but old folks are desperate hopeless and dying. The truth is the free market cannot price health insurance plans for 80 year olds. Plans for 64 year olds already carry premiums that would cost you upwards of $20,000 per year for garbage coverage. Could be $35,000 ten years from now with robust price increases. If wages stay flat, which they will barring other massive legislative changes, it's game over. Companies won't be able to offer anything any more to anyone but the six figure crew. Pooling with younger workers will take some of the sting out. But they won't be able to offer much. Maybe a couple hundred off the top per month.

So at this point healthcare will eat up over a quarter of the US economy, heading for a third. It's already a fifth. And the top 20% already capture more than half of it, and that will only get worse without major changes too.

So, basically, we're looking at a scenario by 2030 where the bottom 80% shovels at least half their collective income into healthcare, or goes without. I'm guessing, given the real world pressures of commuting, paying rent or mortgages, eating, and all that, most will chose to go without.

In a way, what Obamacare really did was delay the inevitable. In the 10 years between 78 and 88, the uninsured rate soared from 12% to 17%. It peaked somewhere between 18 and 19%. Obamacare knocked it back to 10 or 11%. But we're going to be right back to 20% or so by 2030. And we'll be staring down a much steeper curve. Meanwhile, the coverage people do have will be so expensive they won't use it, and if they do, they'll increasingly go bankrupt as a result.

This is just the reality if we do nothing, and minor tinkering around the edges ain't gonna cut it. There's good odds this is our future. But I think there's increasingly good odds we see a wave election between now and then. So I'm not sure which way to bet. But I'm damn sure it's a crisis that's gonna have to be resolved in relatively short order either way. Doing nothing will lead to massive change just as surely, and just about as quickly now, as doing something. Doctors themselves will soon find the system intolerable. And for all the faults of single payer, and faults do exist, there are no other serious proposals to address the problem right now. Whacky plans to re-import drugs from Canada because they're sane enough to do something about prices and we can't seem to control ourselves, are not going to be enough, nor do I think they're serious proposals, since we wouldn't have to ship a pill made in New Jersey to Ontario and back again if we'd be willing to regulate prices ourselves. And just negotiating might do some good for Part D, but it will never help working people stuck with private plans. There are no easy answers. There is no free lunch. And it cannot be fixed without there being some major pain to many players. But it is a real problem. It's not going to go away on its own. So unless and until I see some new serious, large scale, major plan to tackle the issue head on, the options are going on the single payer diet or letting the healthcare sector get so fat it collapses under its own weight.

I think the central problem is that many people in America are dancing on the railroad tracks and they don't see this train coming. People on Medicare and Medicaid aren't necessarily directly dealing with the fallout yet. People working for Fortune 500s feel the pain a bit less. But people running and working at small businesses already can feel that train rumbling. And the poor bastards buying individual insurance can see it in the distance.

An 18% combined payroll tax for healthcare is only scary if your healthcare spend is equal to or less than 18% of your income. Americans already average 20%. It's going to look a whole lot better as that 20% approaches 30%. That's the other piece of this puzzle. It's moving. Healthcare costs are rising every day, faster than inflation, faster than other countries. The train is picking up steam. While folks are dancing to the house remix of taxes are theft with sunglasses on. And as much as slashing Medicare and Social Security seem like a wonderful alternative to some than getting off the tracks, there will be blood.

At least that's my grim view of it.

It's one thing to say nobody wants the train to hit anybody. That's probably true for the most part. It's another thing to have a plan to stop the damn train before there's carnage.

And to get back to the original point, I think maybe we disagree on whether there's a train coming...