Your comment about states running marketplaces reminded me of the ill-fated Clinton-era welfare "reform". This moved Federal funds to state block grants and states managing programs and eligibility (ie TANF) [1]. The result? The system became significantly less efficient in terms of how much of each Federal dollar resulted in aid as well as how many people received assistance and how much assistance recipients got.
I'm not sure what the basis was for state marketplaces for the ACA but the history of involving states seems to make everything worse. Adding an intermediary allows programs to be scuttled and money diverted (if not outright stolen) by other programs and participants.
As an example, Texas refused free money from the Federal government for Medicaid expansion, amounting to $5-6 billion per year [2].
To be fair, there is no such thing as "free money". Every "free" dollar the feds give out is that much more inflation and devaluation of the dollar, and it's been skyrocketing every since the Feds started giving out this type of free money to the states.
I doubt Texas refused on this principal, but states viewing Federal money as free is irksome. It's not free. It's a hidden tax on both your current citizens in terms of devaluation of their savings, and future citizens to pay off the debt the Feds are creating with this "free" money.
Talking about inefficiency - it'd probably be significantly more efficient to stop requiring this money to funnel through DC. But it's more about power than efficiency.
Some people don't have the intellectual capacity to grasp the fact that a healthy populationin working age brings more wealth to everyone in the long run
This is always what amuses me from my European perspective. Large parts of the insurance systems where created for ensuring workers are healthy and productive. And it is an understanding that bad care causes permanent reduction in work output.
It's part of the "if you are successful it is because you worked hard and deserved what you get" and the "if you are a failure, it is because you are stupid and lazy".
There are no unfortunates in the USA, there are only losers and winners.
If more welfare spending creates more wealth, then wouldn’t you expect the median Western European to be wealthier than the median American? Yet the opposite is true. How do you reconcile this?
First we talk about Healthcare Spending.
The US spends the most and get the worst outcomes in G7. Also you have universal health insurance for Elder People (Medicare).
It just doesn't make any sense to have perfectly capable workers to loose their ability to work because they couldn't get a treatment for 10.000$ in real cost (not the marked up price for Uninsured people, because the insurance companies want a rebate from the sticker price)
Also if you look at GDP measured in PPP the US doesn't really have an advantage. In other measurements as HDI they trail even behind
Just because you don't use "free" federal money doesn't mean you can't provide for those people.
We don't live in a black and white world where Medicaid alone is the answer to all our problems. If anything, these centralized mandates have caused significant price increases and less competition, in multiple sectors, including thr currently apparent housing shortage and affordability crisis.
I'm not sure what the basis was for state marketplaces for the ACA but the history of involving states seems to make everything worse. Adding an intermediary allows programs to be scuttled and money diverted (if not outright stolen) by other programs and participants.
As an example, Texas refused free money from the Federal government for Medicaid expansion, amounting to $5-6 billion per year [2].
[1]: https://www.cbpp.org/research/income-security/lessons-from-t...
[2]: https://www.statesman.com/story/news/politics/politifact/202...