Author Topic: What comes after the ACA?  (Read 237538 times)

sol

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What comes after the ACA?
« on: January 06, 2017, 06:39:08 PM »
Who knows what the Republicans will propose after they repeal the ACA?   One hint:  look at what they say they will replace it with.

The bullet points below are taken from the current GOP "replace" plan called "A Better Way".  They've had seven years of hating Obamacare to put this alternative plan together, and this is the current state of the art version.

1.  Remove the "guaranteed issue" clause so people with pre-existing conditions can be denied private insurance, then provide federal dollars in support of high-risk pools for people denied coverage because of pre-existing conditions.  Trump has waffled on this point, but this is what the Republicans in Congress want.

This plan just redistributes how the deficit will be used to pay health insurance companies, giving it to them through a concentrated sub-market of sick people instead of giving it to them distributed over all buyers.  Unless we increase deficit spending on healthcare, this will increase costs for healthy people (by reducing the average subsidy) while potentially lowering costs for sick people.  This seems like a backwards incentive to me, like Uncle Sam saying "it's okay to be an overweight smoker, we've got your back."  High risk pools have consistently failed everywhere they've been tried, but we can make anything pencil out if we throw enough deficit spending at it.

(As a side note, I should mention that every penny of the ACA was paid for with new taxes and spending cuts.  Democrats showed an uncharacteristic level of restraint on that one, and the cost-controls reduce future deficits, but I don't expect a Republican-controlled Congress to follow suit.  I'm expecting radical new deficit spending for the next four years.)

2.  Remove the individual mandate, which hurts insurance companies because they will lose customers.  But not to worry, those companies can be soothed with higher government subsidies for healthcare.

All the insurers care about is their bottom line staying in the black, so as long as the GOP plan keeps them profitable without an individual mandate, they'll be happy.  Millions of Americans will lose insurance, though.  Under the ACA, the individual mandate is used to offset the costs of "guaranteed issue", so in theory you can repeal them both and end up with the same costs to taxpayers, but fewer people who have insurance.  Or you can keep the same number of people insured by increasing deficit spending to prop up insurer profit margins.  The ACA is the lowest-cost fix to get the most people insured, which is why Republicans proposed it in the first place.

3.  Segregate health insurance regulations down to the state by state level, removing federal protections and letting each state decide what rules to enforce.  This includes passing continuous coverage protection so you don't get dinged for losing coverage when you switch between insurance plans (just like employer plans currently have under HIPAA).

Note that this is NOT the same as the oft-touted GOP line about "buying insurance across state lines."  Insurers can already sell insurance across state lines, but most of them don't because it's not cost effective for them. 

This suggestion is purely an attempt to shrink the federal regulatory framework that keeps fraudulent insurers from selling garbage insurance and then refusing to pay claims, instead letting each state bear responsibility for keeping insurers solvent and effective.  Some states (CA, MA, TX) can totally do this.  Some states (WY, MS, AL) will fail miserably, and some of their residents will get screwed.  I feel like regulating markets is one of those things that is better done federally, for the protection of people who live in shitty states, but if they really want to screw over poor red states I'm inclined to let them.

4.  Expand access to HSAs by making them available to everyone regardless of plan type, giving them higher contribution limits, and allowing more more costs (like OTC medications) to be deductible. 

This is a plan I could maybe get behind!  We have an HSA, and we love it.  It's a great tax shelter for rich folks like me, though I admit it is totally worthless to the majority of Americans who already pay little or no taxes and who don't have any surplus income to sock away in a tax shelter.  This bullet point is effectively just another tax cut for the rich.  Hey I'm rich, sign me up!  The GOP thinks that all you poor folks can suck it, apparently.

5.  Provide "refundable advanced tax credits" for people without employer insurance, regardless of income.

This is just like the ACA plan except they're calling them "credits" instead of "subsidies" but the idea is the same.  Uncle Sam will foot the bill for some portion of your insurance coverage (though they would shutter the exchanges that currently allow you to shop for insurance, so get used to calling around for rate quotes).  The key difference here is that under the GOP plan, Uncle Sam will provide that subsidy to everyone, instead of just for poor people.  This bullet point is effectively just another tax cut for the rich.  Hey I'm rich, sign me up!  The GOP thinks that all you poor folks can suck it, apparently.

6.  "Enact medical liability reform"

This is a meaningless phrase, without some specifics.  Any state can already do this at any time, and several states already have.  For example by placing maximum caps on jury awards for malpractice cases, so you only get a quarter million instead of a million dollars if a doctor removes the wrong kidney by mistake.  Unfortunately, these changes don't seem to make any difference in the cost of insurance in the states that have done it.  It's a fine idea, but it doesn't provide anyone with insurance or reduce anyone's costs.

7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

8.  Change Medicaid to block-grant funding.  This fundamentally alter the nature of this program from an entitlement, available as a social safety net to anyone who meets the criteria, to a blank check for each state to spend as they see fit.  Maybe they'll expand coverage to pregnant women and children (WIC), or maybe they'll cancel medicaid entirely and use the money on tax breaks for rich people.  Each state would get to decide.  Red states have been pushing hard to reduce medicaid eligibility, because they don't like helping poor people.

Medicaid is currently the country's largest single insurer, providing low-cost insurance to tens of millions of low-income families and people with disabilities.  It's also one of the most expensive things our government does.

Most Democrats strongly oppose ending this 54 year old program, in part because the GOP plan to dismantle medicaid (which benefits the poor and disabled) is just the first step in their plan to also dismantle medicare and social security (programs that benefit senior citizens).  The GOP hates all of the entitlement programs, and medicaid is the easiest one to attack because poor people and the disabled don't vote with quite the same power that senior citizens do. 

If they successfully kill medicaid, everyone's retirement plans are about to get a lot more complicated.
« Last Edit: January 06, 2017, 08:45:17 PM by sol »

Knaak

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Re: What comes after the ACA?
« Reply #1 on: January 06, 2017, 08:23:50 PM »
7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

It has been several years since I read articles about this, but IIRC, the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.  When the ACA went into effect it capped the max at a 3:1 ratio.  This is forcing the youngest group to pay an extra 75% over what their costs really are so the oldest group can get a discount.  Considering the Boomers never had to pay that extra amount when they were younger, they are now getting one hell of a deal.

The Democrats think all of you young folks can suck it, apparently.

Disclaimer:  I'm not a Republican and I'm in favor of single payer.  I just wanted to point out the 3:1 ratio really fucked over young people.

protostache

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Re: What comes after the ACA?
« Reply #2 on: January 06, 2017, 08:41:14 PM »
So essentially everything is worse for people who are not rich, and even rich people will get screwed unless they're really really rich because of the Medicaid changes.

It seems like the overriding message is to get a job and work until you die and never get disabled or have bigger ambitions. It just seems so... small minded.

Lagom

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Re: What comes after the ACA?
« Reply #3 on: January 06, 2017, 08:43:20 PM »
7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

It has been several years since I read articles about this, but IIRC, the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.  When the ACA went into effect it capped the max at a 3:1 ratio.  This is forcing the youngest group to pay an extra 75% over what their costs really are so the oldest group can get a discount.  Considering the Boomers never had to pay that extra amount when they were younger, they are now getting one hell of a deal.

The Democrats think all of you young folks can suck it, apparently.

Disclaimer:  I'm not a Republican and I'm in favor of single payer.  I just wanted to point out the 3:1 ratio really fucked over young people.

I mean I agree with you, but then the rest of Sol's post still stands. Would love to hear a measured response from a Republican (seriously). That said, wealthy boomers are definitely among the most entitled individuals out there and the Dems in their own way kowtow to them as much as anyone.

Knaak

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Re: What comes after the ACA?
« Reply #4 on: January 06, 2017, 09:24:30 PM »
I mean I agree with you, but then the rest of Sol's post still stands. Would love to hear a measured response from a Republican (seriously). That said, wealthy boomers are definitely among the most entitled individuals out there and the Dems in their own way kowtow to them as much as anyone.

Oh yeah, sol's post was an entertaining summary of what the Republicans are proposing and most of their plans are somewhere between bad and terrible.  I just really took issue with the ratio change back when it first happened.  It was absolutely ridiculous to push the ratio so far away from the true costs.

I'm guessing sol didn't know what the real cost ratios were between the age bands, otherwise he would have realized 5:1 is still a great deal for the oldest band.  He made it sound like the young were putting such a huge burden on the old ("...transferring the cost of coverage away from the young and onto the old.") when in fact the heavy burden is so far in the opposite direction right now.

Quidnon?

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Re: What comes after the ACA?
« Reply #5 on: January 06, 2017, 09:25:59 PM »
I don't agree with most of your commentary, Sol, so I'm going to ignore that part for now, and focus on the actual proposals.

Who knows what the Republicans will propose after they repeal the ACA?   One hint:  look at what they say they will replace it with.

The bullet points below are taken from the current GOP "replace" plan called "A Better Way".  They've had seven years of hating Obamacare to put this alternative plan together, and this is the current state of the art version.

1.  Remove the "guaranteed issue" clause so people with pre-existing conditions can be denied private insurance, then provide federal dollars in support of high-risk pools for people denied coverage because of pre-existing conditions.

I'm in favor of this one, I consider it a necessary step towards reviving true insurance.  I'm also somewhat in favor of some support for high risk pools, but the devil is in the details there.  I will assume that they would manage to screw that up, somehow, until I see evidence to the contrary.

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2.  Remove the individual mandate,

I'm definitely in favor of this one.  I consider the idea that individuals can get taxed for not purchasing a product from private business to be fundamentally wrong in many ways.
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3.  Segregate health insurance regulations down to the state by state level, removing federal protections and letting each state decide what rules to enforce.


I'm mostly neutral on this issue.  Generally, I'm in favor of letting state governments manage public policy whenever possible, but I can take it or leave it.

Quote

4.  Expand access to HSAs by making them available to everyone regardless of plan type, giving them higher contribution limits, and allowing more more costs (like OTC medications) to be deductible. 


I'm in favor of this one.  I think that my HSA is the best thing to ever happen in the health care industry, and I believe that once enough people have them, at a certain point health care providers will be forced to publish their pricing or offer binding estimates for most non-critical care or quality-of-life maintenance issues.  That may, or may not, lower costs due to reviving local competition, but I can't see how it could actually make it worse.

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5.  Provide "refundable advanced tax credits" for people without employer insurance, regardless of income.


I'm straight up opposed to this one.  I agree that, mathematically, it's not much different from subsidies.  Maybe worse, since this would mostly favor the self-employed, not the unemployed.

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6.  "Enact medical liability reform"


Neutral without more details.  Like you said, a meaningless statement.

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7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.


I'm straight up in favor of this one.  I'm starting to get up there, and I have always consider forcing companies to price the young and healthy high in order to subsidize the older people in the same risk pool to be wrong.  Insurance should be priced to reflect the real risks of the insured during the term covered under the policy, just like life insurance, homeowners' insurance, auto collision insurance and flood insurance are.  It would reduce the tendency of the childless, single and young to skip out on health insurance while "rolling the dice" because their insurance is too expensive.  Perhaps a bit of public education on the matter coupled with #4 above would be a good public policy, and help convince those same young adults to both pay their true cost of premiums, while contributing to their HSA so they can afford to pay the true cost of their premiums in 30+ years as well.

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8.  Change Medicaid to block-grant funding.

I'm neutral on this one, simply because I don't know enough about the idea to have an opinion.

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sol

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Re: What comes after the ACA?
« Reply #6 on: January 06, 2017, 10:16:39 PM »
the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.

I think the young are supposed to subsidize the old, just like the healthy are supposed to subsidize the sick.  That's how insurance works.  Everyone pays more than their actual costs, unless they have sudden large costs and then they pay less.  That's the whole point of insurance.

The shift from the ACA's 3:1 ratio to a 5:1 ratio means old people will pay more and young people will pay less.  It's theoretically the same deal as unsubsidized high risk pools.  If being old were considered high risk.

(allowing insurers to deny coverage for pre-existing conditions) I'm in favor of this one, I consider it a necessary step towards reviving true insurance.

If you're in favor of letting insurance companies deny people coverage, are you also okay with millions of people not having health insurance, and only getting medical care when they go to the ER?  The whole point of this guaranteed issue clause was to reduce overall costs by getting people into more cost effective preventative care, instead of letting them go uninsured and thus untreated until they had some sort of catastrophic malfunction.

If we revoke guaranteed issue, lots of people who want insurance will be unable to get it, at any price.  For now, Republicans are publicly saying they DON'T want this to happen, despite it being their official written policy.

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(individual mandate) I'm definitely in favor of this one.  I consider the idea that individuals can get taxed for not purchasing a product from private business to be fundamentally wrong in many ways.

That seem exactly backwards.  I consider it fundamentally wrong that an individual can weasel out of paying for a service that they are 100% guaranteed to use.  Everyone uses healthcare at some point of their lives, no exceptions.  Some folks just get it for free because they don't buy insurance, and those people are freeloaders.

And to be clear, the individual mandate doesn't force everyone to buy insurance.  Only the ~10% of folks who don't already have insurance, and it offers them financial incentives to help them do it, and VERY light tax penalties for turning down the financial incentives.  I consider those tax penalties to be a great deal, since those folks are still going to get unlimited amounts of free healthcare anyway.

Would the individual mandate be more or less palatable to you if people were buying insurance directly from the government, for example by enrolling in expanded medicaid/medicare programs?  Is it the "private companies" part that upsets you?  Because that part infuriates me too, I see no reason for Uncle Sam to be giving money to inefficient insurance companies as middle men when they could just provide the same service themselves at a lower cost, with no profit motive.

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(change age-related premiums from 3:1 to 5:1) I'm straight up in favor of this one. I'm starting to get up there, and I have always consider forcing companies to price the young and healthy high in order to subsidize the older people in the same risk pool to be wrong.

I've always considered forcing the young and healthy into the same risk pool as the old and sick to be the defining characteristic of insurance plans.  My employer-provided insurance does this, for example.  Every employee is in the same pool, regardless of age or health.  We all pay the same amount.  I think the individual market should work the same way.

Otherwise, it's not really insurance.  Why not take this argument to its logical extreme, and put each person into a risk pool of one, with an appropriate weighted premium based on their unique characteristics?    At that point, every person would pay their actual costs and it's no longer insurance.  Segregating risk pools is just taking the first step in this direction, and it's designed to deliberately undermine the very idea of insurance. 

I do appreciate the feedback from a contrary perspective.  I'm still trying to decide if Republicans even care whether or not Americans can actually get affordable insurance, or just care about protecting insurance company profits regardless of what is best for Americans.

calimom

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Re: What comes after the ACA?
« Reply #7 on: January 06, 2017, 10:22:46 PM »
So essentially everything is worse for people who are not rich, and even rich people will get screwed unless they're really really rich because of the Medicaid changes.

It seems like the overriding message is to get a job and work until you die and never get disabled or have bigger ambitions. It just seems so... small minded.

Pretty much this. The Republican Heath Plan, such as it it is, is "don't get sick".

Happy now, Trump voters?

Quidnon?

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Re: What comes after the ACA?
« Reply #8 on: January 06, 2017, 10:30:01 PM »

Happy now, Trump voters?

Yes.  So  far, I'm upbeat.  I'm truly sorry that life went so sideways for you, but it's still not my fault.
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gimp

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Re: What comes after the ACA?
« Reply #9 on: January 06, 2017, 10:31:08 PM »
Don't worry, they'll still have social security and medicare for old people.

I mean, some old people.

I mean, people who are currently old, or will be very shortly.

They'll gut it for anyone under 50 or 55, but don't worry, if you already have it, they won't gut it, because they know you have nothing better to do than vote and write lots of letters.

Raeon

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Re: What comes after the ACA?
« Reply #10 on: January 06, 2017, 11:32:04 PM »
Younger middle class here, and I feel the pinch of ACA very hard.  31 years old. 

For the past 10 years I have had private health insurance to the tune of roughly $250/ month.  I am a non-smoker with no history of disease or illness in my family. I almost never get sick; last doctor visit was roughly 8 years ago for a z-pack.  My wife's has been about $300; she's a little higher maintenance but no glaring illnesses or disease.  $550 total.  For 2017, both of our plans were cancelled.  For the cheaper bronze level coverage a new plan together this year is going to cost us $1250/ month.  Our combined income puts us just outside of the subsidy brackets. 

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"every penny of the ACA was paid for with new taxes and spending cuts"

Maybe there's no extra line in the tax code, but I see an increase of $700/month...  Makes me sick to my stomach.

There are people I know working 20 hours a week at a gas station, going home to smoke and drink their paycheck away, and qualifying for insurance payments around $100/month.  Now, I don't mind the principle of pitching in a little to help my fellow man (an extra 50-100 a month maybe?), but when I work 80 hours a week trying to get ahead, I don't do it so I can pay an insurance bill larger than my mortgage and utilities combined.

My situation is the broken side of the ACA.  I won't be sorry to see it go.  Unfortunately, I don't see prices ever coming back down.  As it sits now, the extra cost is going to come out of my IRA contributions.  I just can't quite find the words to describe my frustration with this. 
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rpr

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Re: What comes after the ACA?
« Reply #11 on: January 07, 2017, 12:51:22 AM »

You've missed the parts of the "A Better Way" document that directly address this.  Long story short -- you can never be denied coverage for preexisting conditions or have your rates jacked up when you switch plans PROVIDED you maintain continuous coverage.  High risk pools are only for people who do not maintain continuous coverage and then want insurance once they get sick.  This basically is a commonsense replacement for the individual mandate, and notably is very similar to the way the current system works for corporate health coverage.  They also propose a one-time grace signup period where anyone can bypass the high risk pools and start continuous coverage at the normal rates right away.
I admit I have not read the document you mention. What happens when, with current preexisting conditions, you lose your job with health care benefits (at a small company with less than 20 employees) and are then are able to find a job that does not offer health care benefits.  Since there is no COBRA you will have to buy private individual insurance. I would assume that your rates would either be sky high since you will be in the high risk pool. Are you saying that this is not the case?

sol

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Re: What comes after the ACA?
« Reply #12 on: January 07, 2017, 01:01:36 AM »
you can never be denied coverage for preexisting conditions or have your rates jacked up when you switch plans PROVIDED you maintain continuous coverage.

I think the details of this plan are severely lacking.  Everyone gets one and only one sign up period, but what about the people who can't sign up then?  Say they are currently bankrupt and can't afford insurance.  Or homeless.  Or in jail, or rehab, or travelling abroad.  Or under age 18.  Or legal immigrants.  Or they have employer insurance and get laid off.  There are about a million ways for a person to have a gap in their insurance coverage (or miss the one-time-only sign up period) through no fault of their own.  The Republican plan, like most Republican plans, works out okay for straight white people with 9-5 jobs, and kind of ignores everyone who is less fortunate.

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High risk pools are only for people who do not maintain continuous coverage and then want insurance once they get sick. 

Technically, it looks like the high risk pools are for people to whom insurance companies have denied coverage, for any reason.  You don't need to be sick to end up there.

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This basically is a commonsense replacement for the individual mandate, and notably is very similar to the way the current system works for corporate health coverage.

I think making comparisons to employer-sponsored insurance is only a valid strategy if you're also willing to adopt the rest of that model, namely "everyone pays the same rates for insurance regardless of age or health."  Personally I'm fine with this.  The federal government could just stop giving tax breaks to corporations to provide insurance, and give them directly to individuals instead, in the same amount.  Don't subsidize people who don't buy insurance (no  mandate), just like employers.  Put everyone into one risk pool, just like employers do, and let the government subsidize the insurers.  Better yet, go one farther and just let the government 100% subsidize the insurers and skip the tax breaks entirely!

The risk here is that some people will go without insurance, and end up back in the ER as freeloaders again, receiving care and expecting the rest of us who DO buy insurance to subsidize those healthcare providers with our inflated premiums.  This system really only works if you do it for everyone, or are willing to refuse service to folks who don't pay. 

rpr

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Re: What comes after the ACA?
« Reply #13 on: January 07, 2017, 01:15:18 AM »

I think making comparisons to employer-sponsored insurance is only a valid strategy if you're also willing to adopt the rest of that model, namely "everyone pays the same rates for insurance regardless of age or health."  Personally I'm fine with this.  The federal government could just stop giving tax breaks to corporations to provide insurance, and give them directly to individuals instead, in the same amount.  Don't subsidize people who don't buy insurance (no  mandate), just like employers.  Put everyone into one risk pool, just like employers do, and let the government subsidize the insurers.  Better yet, go one farther and just let the government 100% subsidize the insurers and skip the tax breaks entirely!

The risk here is that some people will go without insurance, and end up back in the ER as freeloaders again, receiving care and expecting the rest of us who DO buy insurance to subsidize those healthcare providers with our inflated premiums.  This system really only works if you do it for everyone, or are willing to refuse service to folks who don't pay.

+1. I agree. We should get rid of the tax breaks for workplace obtained health insurance both employee and employer portions.  This is basically a subsidy for health care insurers and ultimately the providers.   

bacchi

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Re: What comes after the ACA?
« Reply #14 on: January 07, 2017, 04:11:50 AM »

I think making comparisons to employer-sponsored insurance is only a valid strategy if you're also willing to adopt the rest of that model, namely "everyone pays the same rates for insurance regardless of age or health."  Personally I'm fine with this.  The federal government could just stop giving tax breaks to corporations to provide insurance, and give them directly to individuals instead, in the same amount.  Don't subsidize people who don't buy insurance (no  mandate), just like employers.  Put everyone into one risk pool, just like employers do, and let the government subsidize the insurers.  Better yet, go one farther and just let the government 100% subsidize the insurers and skip the tax breaks entirely!

The risk here is that some people will go without insurance, and end up back in the ER as freeloaders again, receiving care and expecting the rest of us who DO buy insurance to subsidize those healthcare providers with our inflated premiums.  This system really only works if you do it for everyone, or are willing to refuse service to folks who don't pay.

+1. I agree. We should get rid of the tax breaks for workplace obtained health insurance both employee and employer portions.  This is basically a subsidy for health care insurers and ultimately the providers.

That would definitely solve some budgetary problems from the other proposed ideas.

Re: 1.  Remove the "guaranteed issue" clause, they'll do this by underfunding the high risk pools. Look at the numbers being thrown around for the pools -- it's extremely low and won't be anywhere near enough. The end result will be either people dying because they can't afford the $2000/month coverage or states running deficits to make up for the fed's negligible contribution.

boarder42

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Re: What comes after the ACA?
« Reply #15 on: January 07, 2017, 04:33:06 AM »
The issue with the pre existing conditions clause is that isn't how any other insurance works. If my house burns down and I don't have insurance I can't go buy it to fix my house. No insurance company would do that for less than the rebuild price.

If I choose to not have insurance and get cancer I shouldn't be able to wait till November and go sign up  so if you don't require everyone to always have it or pay a penalty then you must drop this clause also those 2 go hand in hand
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Re: What comes after the ACA?
« Reply #16 on: January 07, 2017, 04:34:04 AM »
I still curse Obama for taking single payer off the table at the very beginning of the health care debate.  Simplicity, and better health outcomes, at about half the cost of our current fucked up system.  Couldn't we have at least talked about it?
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boarder42

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Re: What comes after the ACA?
« Reply #17 on: January 07, 2017, 04:35:53 AM »
Also while I fully support HSA expansion. Isn't this just the 401k all over again and will be severely under utilized by the avg incompetent American who doesn't understand money.
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Re: What comes after the ACA?
« Reply #18 on: January 07, 2017, 04:43:16 AM »
What comes after the ACA? Universal health care would be the ideal option, but since the Republicans control all three branches of government nothing will. The results will likely cause millions of deaths overall, but it'll be ignored and forgotten.

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Re: What comes after the ACA?
« Reply #19 on: January 07, 2017, 06:02:30 AM »
The expansion of 3:1 to 5:1 could work, provided an individual mandate is enforced.

The reality is its not enforced now, so any "repeal the individual mandate" is just a waste of time.
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brooklynguy

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Re: What comes after the ACA?
« Reply #20 on: January 07, 2017, 06:12:24 AM »
5.  Provide "refundable advanced tax credits" for people without employer insurance, regardless of income.

This is just like the ACA plan except they're calling them "credits" instead of "subsidies" but the idea is the same.

It's just like the ACA in name as well as in substance.  The primary "subsidies" conferred by the ACA are "refundable tax credits" and are referred to as such in the provision of the ACA that implements the statutory changes to the Internal Revenue Code that make them available.

StarBright

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Re: What comes after the ACA?
« Reply #21 on: January 07, 2017, 06:28:21 AM »


I think the details of this plan are severely lacking.  Everyone gets one and only one sign up period, but what about the people who can't sign up then?  Say they are currently bankrupt and can't afford insurance.  Or homeless.  Or in jail, or rehab, or travelling abroad.  Or under age 18.  Or legal immigrants.  Or they have employer insurance and get laid off.  There are about a million ways for a person to have a gap in their insurance coverage (or miss the one-time-only sign up period) through no fault of their own.  The Republican plan, like most Republican plans, works out okay for straight white people with 9-5 jobs, and kind of ignores everyone who is less fortunate.


I'm pretty sure "qualifying life event" would still apply right? - so getting laid off and getting released from prison both would count as a qualifying event and you can purchase coverage on the exchange.

The other options (homeless, gaps, etc) are a problem but there are definitely ways of navigating around  some of them - primarily medicaid based.

That said, I think switching to single payer is such a no brainer and I think it would actually help US businesses become more competitive - we are basically the only country that relies on employer provided health insurance and it if you can remove that benefit cost from US businesses it could be a huge boon.

Can't Wait

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Re: What comes after the ACA?
« Reply #22 on: January 07, 2017, 06:34:13 AM »
Younger middle class here, and I feel the pinch of ACA very hard.  31 years old. 

For the past 10 years I have had private health insurance to the tune of roughly $250/ month.  I am a non-smoker with no history of disease or illness in my family. I almost never get sick; last doctor visit was roughly 8 years ago for a z-pack.  My wife's has been about $300; she's a little higher maintenance but no glaring illnesses or disease.  $550 total.  For 2017, both of our plans were cancelled.  For the cheaper bronze level coverage a new plan together this year is going to cost us $1250/ month.  Our combined income puts us just outside of the subsidy brackets. 

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"every penny of the ACA was paid for with new taxes and spending cuts"

Maybe there's no extra line in the tax code, but I see an increase of $700/month...  Makes me sick to my stomach.

There are people I know working 20 hours a week at a gas station, going home to smoke and drink their paycheck away, and qualifying for insurance payments around $100/month.  Now, I don't mind the principle of pitching in a little to help my fellow man (an extra 50-100 a month maybe?), but when I work 80 hours a week trying to get ahead, I don't do it so I can pay an insurance bill larger than my mortgage and utilities combined.

My situation is the broken side of the ACA.  I won't be sorry to see it go.  Unfortunately, I don't see prices ever coming back down.  As it sits now, the extra cost is going to come out of my IRA contributions.  I just can't quite find the words to describe my frustration with this.


That's crazy that your bronze level plan is $1250 a month for both of you. I just signed my wife up for a gold and its $377 a month. For shits and giggles I added myself to it to see how much it would be and it was like $600 or so. We also do not qualify for any subsidies.

protostache

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Re: What comes after the ACA?
« Reply #23 on: January 07, 2017, 07:53:44 AM »
The thing that baffles me about this forum in particular is the disdain for ACA. If your goal is FIRE, how does that square with the probability of getting some disqualifying condition after leaving work and having to pay the price for a high risk pool or preexisting condition rider, if you even have access so such things? Doesn't that torpedo everyone's FIRE plans?

Iplawyer

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Re: What comes after the ACA?
« Reply #24 on: January 07, 2017, 08:13:17 AM »
The expansion of 3:1 to 5:1 could work, provided an individual mandate is enforced.

The reality is its not enforced now, so any "repeal the individual mandate" is just a waste of time.

It is enforced in that your penalty is taken out of any tax refund or check from the government.  That will catch up with everyone eventually - maybe not until social security time - but it will.

mathlete

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Re: What comes after the ACA?
« Reply #25 on: January 07, 2017, 08:18:34 AM »
What comes after the ACA? Universal health care would be the ideal option, but since the Republicans control all three branches of government nothing will. The results will likely cause millions of deaths overall, but it'll be ignored and forgotten.

Come on now...

Iplawyer

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Re: What comes after the ACA?
« Reply #26 on: January 07, 2017, 08:36:16 AM »
I am only 54 but I think the younger people here with any disdain of the ACA are short sighted.  You can exercise, eat right, not smoke, etc. and get a disease or have an accident that has a permanent consequence.  As much as you would like to think so - you simply are not in control of this.  I was paying over $1000 per month for insurance when we had our own business 20 years ago before any conditions that are now issues to getting health insurance. I began working outside of our business so had access to employer insurance when I had such a health issue that is now considered a permanent pre-existing condition.  I could not get health insurance on the private market if I tried through absolutely no fault of my own.  Even with my employer's insurance - neither my husband nor I have consumed over the deductible amount of insurance in the last 10 years - but that doesn't mean that we could get private insurance now.  (That doesn't count some annual tests that are required to be provided before the deductible.)

Without some guarantee that I can get health insurance - I cannot afford to retire even with a NW of almost $4M.  Now that is sad and it wouldn't happen in any other top 30 country on earth. 

And while I don't think everything about the ACA is right or good - I think it at least provided health insurance for people who couldn't afford it before - or who simply could not get it at all.  And for most already retired on this board - it provided a way for them to retire.   

And no, since I've worked for 35 years paying into social security and medicare, and at the maximum level for most of those, I want them in place for me. (Thanks you Mr. Black, for encouraging me to become an electrical engineer.)  AND THAT DOES NOT MAKE ME A BABY BOOMER SUCKING ON YOUNG PEOPLES TEAT.  I sincerely doubt I will get back what I have paid in, what my employer has paid in, and conservative returns on that money.  And, frankly, I have paid far more into these systems than most ERs on this board did or ever will. And I have paid in more federal, state, local, and property tax than most ERs on this board.  Don't tell me this Baby Boomer is sucking on anyone's tit.  And I'm not finished paying yet.  The sale of my principle residence will come with  medicare taxes (unless they are repealed) and I will owe income tax on my 401K withdrawals. 

I don't want a government subsidy for health insurance - and I'm not asking for one.  I just want to be able to purchase a high deductible policy that will reliably pay after I've self-insured the high deductible for any health issue (predictable or otherwise) that I might have with no lifetime cap.  That is simply not a lot to ask for living and contributing, in one of the most affluent countries in the world, for 35 years so far - and likely 37 before I retire.   Otherwise - no amount of NW will be enough. 
« Last Edit: January 07, 2017, 08:42:08 AM by ddmesser »

mathlete

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Re: What comes after the ACA?
« Reply #27 on: January 07, 2017, 08:37:16 AM »
I don't think the Republicans have a plan. Not a plan that addresses sick/poor people who can't get insurance anyway.

Block-grant and state lines might as well be pixie dust. They were non-solutions proposed just so they could sort of say they had a plan ready to replace ACA at any of the 30 times that they tried to do it.

We've had high risk pools at the state level for years and that still left tens of millions without insurance. I don't know if Federal money is going to help. Not in the amounts they're talking about anyway.

HSAs are great for folks like us. Expanding access to them will help very few people that need help though. Poor people have (surprise) not a lot of money to save. They also see a much smaller marginal benefit from saving pre-tax/tax-deferred dollars.


rpr

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Re: What comes after the ACA?
« Reply #28 on: January 07, 2017, 09:41:50 AM »
Also while I fully support HSA expansion. Isn't this just the 401k all over again and will be severely under utilized by the avg incompetent American who doesn't understand money.
+1. I agree that it will be the 401k all over again.

I am totally against the HSA system. Why in the heck should there be a tax break for health expenses? Get rid of it completely.

Knaak

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Re: What comes after the ACA?
« Reply #29 on: January 07, 2017, 09:52:48 AM »
the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.

I think the young are supposed to subsidize the old, just like the healthy are supposed to subsidize the sick.  That's how insurance works.  Everyone pays more than their actual costs, unless they have sudden large costs and then they pay less.  That's the whole point of insurance.

The shift from the ACA's 3:1 ratio to a 5:1 ratio means old people will pay more and young people will pay less.  It's theoretically the same deal as unsubsidized high risk pools.  If being old were considered high risk.

By compressing the ratios you are forcing young healthy people to not only subsidize young unhealthy people and old unhealthy people, but old healthy people as well.  The ones that can most afford to subsidize others -- old people that are healthy and have the highest incomes -- are given a discount while the healthy young people just starting their careers are forced to pick up the difference.  Do you honestly think that's fair?  That's about as regressive a policy as you can get.

rpr

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Re: What comes after the ACA?
« Reply #30 on: January 07, 2017, 10:15:24 AM »
One way to apportion costs could be based on incomes. The income ratio between old people and young is likely to be less than 3:1. It is definitely not 5:1.

Knaak

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Re: What comes after the ACA?
« Reply #31 on: January 07, 2017, 10:59:11 AM »
One way to apportion costs could be based on incomes. The income ratio between old people and young is likely to be less than 3:1. It is definitely not 5:1.

That's one way.  Another way is to finally get to single payer and cover most healthcare costs through our progressive tax system.  Just like our income taxes now, the heaviest burden will fall on rich old people.  Those making the lowest amounts (which is where most young people starting out will fall) won't be expected to shoulder such a big portion of the burden just because of their age.

sol

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Re: What comes after the ACA?
« Reply #32 on: January 07, 2017, 11:24:54 AM »
Another way is to finally get to single payer and cover most healthcare costs through our progressive tax system. 

Everyone here keeps saying this, and it totally makes sense, but it's never going to happen.  Republicans will never allow the US government to destroy an industry that employs millions of people (and spends billions of dollars on lobbying).

The fact that many of those people would need to be re-employed by the government's version of insurance does not soothe Republicans, because their concern is for the business and not the worker.  Unemployment would go up, as all of those redundant insurance adjusters and claims processors were fired from insurance companies suddenly made obsolete.  You can argue that efficiency is a good thing for the economy overall, but Republicans care more about protecting corporate profits than they do about advancing the economy.  They would make the same last stand for buggy whip manufacturers.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #33 on: January 07, 2017, 11:40:26 AM »
Why should people who get coverage through their employer continue to get a subsidy (through the tax exempt nature of that compensation) while others not?

Knaak

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Re: What comes after the ACA?
« Reply #34 on: January 07, 2017, 11:52:52 AM »
Another way is to finally get to single payer and cover most healthcare costs through our progressive tax system. 

Everyone here keeps saying this, and it totally makes sense, but it's never going to happen.  Republicans will never allow the US government to destroy an industry that employs millions of people (and spends billions of dollars on lobbying).

The fact that many of those people would need to be re-employed by the government's version of insurance does not soothe Republicans, because their concern is for the business and not the worker.  Unemployment would go up, as all of those redundant insurance adjusters and claims processors were fired from insurance companies suddenly made obsolete.  You can argue that efficiency is a good thing for the economy overall, but Republicans care more about protecting corporate profits than they do about advancing the economy.  They would make the same last stand for buggy whip manufacturers.

So because Republicans don't want single payer, your answer (and the ACA's answer) is to implement a system that pushes the burden from old healthy people onto young healthy people?  I don't quite follow that logic.  It's an idea I would expect from a bunch of old Republicans.

v8rx7guy

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Re: What comes after the ACA?
« Reply #35 on: January 07, 2017, 12:01:55 PM »
Also while I fully support HSA expansion. Isn't this just the 401k all over again and will be severely under utilized by the avg incompetent American who doesn't understand money.
+1. I agree that it will be the 401k all over again.

I am totally against the HSA system. Why in the heck should there be a tax break for health expenses? Get rid of it completely.

I think that if everyone had an HDHP and HSA's we will begin to make care providers have to be more competitive with their pricing.  When your average person knows they are paying for a procedure, medication, visit etc. with their HSA they shop around a bit bringing more pricing competition into the market and I believe that will make costs more reasonable over time.  I know for our family certainly shops around more and thinks things thru more often now that we are on an HDHP paying with our HSA.  Before there was essentially no thinking involved because we knew it would just be a small deductible.

seattlecyclone

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Re: What comes after the ACA?
« Reply #36 on: January 07, 2017, 12:49:53 PM »
Why should people who get coverage through their employer continue to get a subsidy (through the tax exempt nature of that compensation) while others not?

They shouldn't. It's crazy that an employer paying me $10k in the form of health insurance is taxed differently than if they paid me $10k in cash and I bought my own health insurance. It's time for that to end, so that companies have less incentive to pay their employees in the form of health insurance that is often different from what the employee would choose if they were using their own money.
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Davids

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Re: What comes after the ACA?
« Reply #37 on: January 07, 2017, 02:54:08 PM »
A few things I want to see happen.

1) Remove the individual mandate, no one should be forced to purchase health insurance or pay a tax penalty if they do not. That is ridiculous.

2) Being charged based on your individual risk. No offense but a younger healthy person should pay much less than what they are paying now and an older person who has a preexisting condition should pay more than what they are paying now for coverage. With that I would keep the mandate that an insurance company cannot deny coverage for preexisting conditions but they can at least properly price for it.

3) Expand the HSA - It should be available for everyone who has health insurance coverage regardless of deductible amount, instead of just those with high deductible. I would also increase the HSA MAX contribution rate to $15,000.00 for family and $7,500.00 for Individual and have the MAX increase at a rate of 3% annually. Yes it can be seen as benefiting the rich with a bigger tax cut but I say so what, this can only help, not hurt people. 

4) Do not get rid of Medicaid - We should not get rid of Medicaid. What needs to be done is a better review of those who are on Medicaid (or any other Government Welfare program) to ensure those who are on it are truly the ones who qualify/need it and not just milking the system.

Lagom

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Re: What comes after the ACA?
« Reply #38 on: January 07, 2017, 02:57:43 PM »
I think that if everyone had an HDHP and HSA's we will begin to make care providers have to be more competitive with their pricing.  When your average person knows they are paying for a procedure, medication, visit etc. with their HSA they shop around a bit bringing more pricing competition into the market and I believe that will make costs more reasonable over time.  I know for our family certainly shops around more and thinks things thru more often now that we are on an HDHP paying with our HSA.  Before there was essentially no thinking involved because we knew it would just be a small deductible.

Perhaps, but this falls apart in the case of an emergency (major accident, heart attack, stroke, etc.). No time to price shop in those scenarios.


Iplawyer

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Re: What comes after the ACA?
« Reply #39 on: January 07, 2017, 02:59:35 PM »
A few things I want to see happen.

1) Remove the individual mandate, no one should be forced to purchase health insurance or pay a tax penalty if they do not. That is ridiculous.

2) Being charged based on your individual risk. No offense but a younger healthy person should pay much less than what they are paying now and an older person who has a preexisting condition should pay more than what they are paying now for coverage. With that I would keep the mandate that an insurance company cannot deny coverage for preexisting conditions but they can at least properly price for it.

3) Expand the HSA - It should be available for everyone who has health insurance coverage regardless of deductible amount, instead of just those with high deductible. I would also increase the HSA MAX contribution rate to $15,000.00 for family and $7,500.00 for Individual and have the MAX increase at a rate of 3% annually. Yes it can be seen as benefiting the rich with a bigger tax cut but I say so what, this can only help, not hurt people. 

4) Do not get rid of Medicaid - We should not get rid of Medicaid. What needs to be done is a better review of those who are on Medicaid (or any other Government Welfare program) to ensure those who are on it are truly the ones who qualify/need it and not just milking the system.

So you think insurance companies will price insurance for a person who has had cancer before at any rate that anybody could reasonably pay?  No - they won't unless forced. 

I hope for your sake you never get a disease or have an accident that gives you a pre-existing condition.

protostache

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Re: What comes after the ACA?
« Reply #40 on: January 07, 2017, 03:09:40 PM »
A few things I want to see happen.

1) Remove the individual mandate, no one should be forced to purchase health insurance or pay a tax penalty if they do not. That is ridiculous.

2) Being charged based on your individual risk. No offense but a younger healthy person should pay much less than what they are paying now and an older person who has a preexisting condition should pay more than what they are paying now for coverage. With that I would keep the mandate that an insurance company cannot deny coverage for preexisting conditions but they can at least properly price for it.

3) Expand the HSA - It should be available for everyone who has health insurance coverage regardless of deductible amount, instead of just those with high deductible. I would also increase the HSA MAX contribution rate to $15,000.00 for family and $7,500.00 for Individual and have the MAX increase at a rate of 3% annually. Yes it can be seen as benefiting the rich with a bigger tax cut but I say so what, this can only help, not hurt people. 

4) Do not get rid of Medicaid - We should not get rid of Medicaid. What needs to be done is a better review of those who are on Medicaid (or any other Government Welfare program) to ensure those who are on it are truly the ones who qualify/need it and not just milking the system.

So you think insurance companies will price insurance for a person who has had cancer before at any rate that anybody could reasonably pay?  No - they won't unless forced. 

I hope for your sake you never get a disease or have an accident that gives you a pre-existing condition.

Based on the rate I pay for a simple $250k term life insurance policy because I happened to survive cancer ($339/mo), I would expect to pay more than $4,000 per month for a bronze-equivalent plan. This is what happens when you force coverage without price controls. And my cancer was one of the random survivable kinds! I can only imagine someone with worse prospects would be priced completely out.

Boxcat

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Re: What comes after the ACA?
« Reply #41 on: January 07, 2017, 03:29:48 PM »
What comes after the ACA? Universal health care would be the ideal option, but since the Republicans control all three branches of government nothing will. The results will likely cause millions of deaths overall, but it'll be ignored and forgotten.

Come on now...
I realize it's bold claim, but I try not to underestimate the glory of Republican governance anymore.

Here's a scenario: 3,121 people die this year due to lacking healthcare, do the powers that be clamor for a War on Health and spend trillions? I don't see that happening, instead they'll make some joke policies that weaken the bottom 90% and engage in corporate plundering.

Quidnon?

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Re: What comes after the ACA?
« Reply #42 on: January 07, 2017, 03:31:50 PM »


(allowing insurers to deny coverage for pre-existing conditions) I'm in favor of this one, I consider it a necessary step towards reviving true insurance.

If you're in favor of letting insurance companies deny people coverage, are you also okay with millions of people not having health insurance, and only getting medical care when they go to the ER?  The whole point of this guaranteed issue clause was to reduce overall costs by getting people into more cost effective preventative care, instead of letting them go uninsured and thus untreated until they had some sort of catastrophic malfunction.

I don't agree that was the point of it at all, but if it was, it failed.  And in a predictable way, because that is contrary to human nature.  The main reason that so many people over-use emergency care services is not because they neglect their preventative care, so much as it is that they are in the habit of doing whatever is most convenient for themselves, and never bothering to attend a general prac for a regular checkup is more convenient than doing so.  Even forcing people to get an ACA compliant plan won't solve this problem, even if it worked to an absolute degree, because then you just moved the responsible party from the taxpayer to the taxpayer subsidized insurance plan.  Irresponsible people are irresponsible people because they can get away with it in our modern society without much consequence.

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If we revoke guaranteed issue, lots of people who want insurance will be unable to get it, at any price.  For now, Republicans are publicly saying they DON'T want this to happen, despite it being their official written policy.

<sigh> This is false, as I have shown in many ways before.  I am not going to repeat myself in full, but in short, there were solutions to these problems before ACA.  Some were expensive, some required a waiting period for pre-existing conditions, sometimes a state subsidized high risk pool was the only solution.  Often it was a combination of things, and often the solution could not be identified by the unfortunate seeker of solutions; but they existed.
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(individual mandate) I'm definitely in favor of this one.  I consider the idea that individuals can get taxed for not purchasing a product from private business to be fundamentally wrong in many ways.

That seem exactly backwards.  I consider it fundamentally wrong that an individual can weasel out of paying for a service that they are 100% guaranteed to use.  Everyone uses healthcare at some point of their lives, no exceptions.  Some folks just get it for free because they don't buy insurance, and those people are freeloaders.
Okay, I can see your perspective here, but I don't agree that insurance is the only way to pay for health care.  In fact, I don't consider it the best way.  If the mandate could be satisfied with an emergency hospitalization only plan, or a true catastrophic plan (such as I could get before the ACA, that didn't cover annually reoccurring expenses that everyone should expect, nor regular care for which it is actually impossible for me to need), then I would be okay with such a mandate.  Still wouldn't like that as a solution, but okay with it.  Such as it is, the ACA regulations don't compare to requiring legally mandated liability insurance in order to drive a car; but both comprehensive auto insurance with a plan that paid for free oil changes every three months and a new set of brake pads every few years.  I should have the option of a minimalist plan and have that qualify for the penalty exemption.

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And to be clear, the individual mandate doesn't force everyone to buy insurance.  Only the ~10% of folks who don't already have insurance, and it offers them financial incentives to help them do it, and VERY light tax penalties for turning down the financial incentives.  I consider those tax penalties to be a great deal, since those folks are still going to get unlimited amounts of free healthcare anyway.

I think that we both know that doesn't really happen in practice.  With or without the ACA.

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Would the individual mandate be more or less palatable to you if people were buying insurance directly from the government, for example by enrolling in expanded medicaid/medicare programs?  Is it the "private companies" part that upsets you?


On some level, yes.  If it was a default enrollment for the lazy, with an opt-out option, I could see a minimalist version of a single payer system being acceptable.  I doubt that it would work well, but I wouldn't find it as offensive on ideological grounds.
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(change age-related premiums from 3:1 to 5:1) I'm straight up in favor of this one. I'm starting to get up there, and I have always consider forcing companies to price the young and healthy high in order to subsidize the older people in the same risk pool to be wrong.

I've always considered forcing the young and healthy into the same risk pool as the old and sick to be the defining characteristic of insurance plans.  My employer-provided insurance does this, for example.  Every employee is in the same pool, regardless of age or health.  We all pay the same amount.  I think the individual market should work the same way.

It has become that, but it doesn't need to be that.  Your's can work that way at your employer without requiring the entire industry to operate in that manner. 

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Otherwise, it's not really insurance.  Why not take this argument to its logical extreme, and put each person into a risk pool of one, with an appropriate weighted premium based on their unique characteristics?    At that point, every person would pay their actual costs and it's no longer insurance.  Segregating risk pools is just taking the first step in this direction, and it's designed to deliberately undermine the very idea of insurance. 
It is most certainly insurance.  And your HSA certainly can be a risk pool of one, but spread over a lifespan instead spread across a risk pool during a single calendar year.  The defining character of insurance is that it is a contract to limit risk of economic destruction, not that the insurance company spreads that risk over a broad group of people.  The latter is just one way of doing it.

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I do appreciate the feedback from a contrary perspective.  I'm still trying to decide if Republicans even care whether or not Americans can actually get affordable insurance, or just care about protecting insurance company profits regardless of what is best for Americans.

I couldn't really say.  I'm not a Republican.  I'm a conservative, and I'm not registered as affiliated with any political party.  I don't agree that conservative equates to Republican today.
"When plunder becomes a way of life for a group of men living together in society, they create for themselves in the course of time a legal system that authorizes it and a moral code that glorifies it."
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Paul der Krake

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Re: What comes after the ACA?
« Reply #43 on: January 07, 2017, 03:39:41 PM »
My ideal ACA replacement magically punishes people that I, Benevolent Health Overlord, deem unworthy of receiving care. Everyone will be graded by an impartial algorithm of my choosing, and placed into different pools.

Some criteria used to be placed in the naughty pool:
- proven pattern of smoking while sober or before 10pm
- BMI over 25
- has injured themselves more than twice over the last decade in their own kitchen

Some criteria used to be placed in the fabulous pool:
- meets or exceeds general attractiveness standards as defined by the yearly report of the specially anointed Swedish Immigration Task Force
- ability to convincingly talk about triathlon training regimens for more than 10 minutes
- have kids who can behave in a restaurant

 Doctors will be prohibited by law to cater to patients outside of the risk pool they have been assigned to. The worst offenders are to be relocated to Wyoming and placed on a non-heated reservation where they will be compelled to reflect on their lifestyle choices and do hard labor.

-------

But failing that, I will take higher HSA contribution limits, please.

Quidnon?

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Re: What comes after the ACA?
« Reply #44 on: January 07, 2017, 04:02:25 PM »
I think that if everyone had an HDHP and HSA's we will begin to make care providers have to be more competitive with their pricing.  When your average person knows they are paying for a procedure, medication, visit etc. with their HSA they shop around a bit bringing more pricing competition into the market and I believe that will make costs more reasonable over time.  I know for our family certainly shops around more and thinks things thru more often now that we are on an HDHP paying with our HSA.  Before there was essentially no thinking involved because we knew it would just be a small deductible.

Perhaps, but this falls apart in the case of an emergency (major accident, heart attack, stroke, etc.). No time to price shop in those scenarios.

This is true, but these are the very low risk, very high consequence events that true insurance is properly designed to deal with.  That is why a high-deductable health plan is a requirement for an HSA while contributing, to force the owner to have such a policy in order to benefit from the tax favorable savings vehicle.
"When plunder becomes a way of life for a group of men living together in society, they create for themselves in the course of time a legal system that authorizes it and a moral code that glorifies it."
~ Frederic Bastiat

Quidnon?

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Re: What comes after the ACA?
« Reply #45 on: January 07, 2017, 04:14:05 PM »
What comes after the ACA? Universal health care would be the ideal option, but since the Republicans control all three branches of government nothing will. The results will likely cause millions of deaths overall, but it'll be ignored and forgotten.

Come on now...
I realize it's bold claim, but I try not to underestimate the glory of Republican governance anymore.

Here's a scenario: 3,121 people die this year due to lacking healthcare, do the powers that be clamor for a War on Health and spend trillions? I don't see that happening, instead they'll make some joke policies that weaken the bottom 90% and engage in corporate plundering.

Hold on, now.  Let's clarify a bit.  While people can die prematurely due to lack of health care services, no one dies as a direct result of lack of insurance coverage.  No one dies because they don't have a particular type of contract in effect, but people really do die because they don't get necessary care.  Please don't mix the two concepts, it promotes a deceptive thought process.  These people die because they have diseases or injuries that kill them.  Sol complains that not having insurance (often) leads to bankruptcy in the event of a major health problem, which (often) ends up costing taxpayers money due to health care write-offs and increased insurance costs for others.  This much is true enough, but bankruptcy never actually killed anyone, as far I know.  Killed the realistic possibility of a retirement, sure.  But retirement, early or not, has always been a luxury feature of modern society.  No one deserves to quit working and still eat.  Hopefully most/all of us will be able to afford to quit working and still eat, but none of us are entitled to that simply because we are still alive when we reach any special age.
"When plunder becomes a way of life for a group of men living together in society, they create for themselves in the course of time a legal system that authorizes it and a moral code that glorifies it."
~ Frederic Bastiat

Beardog

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Re: What comes after the ACA?
« Reply #46 on: January 07, 2017, 04:17:30 PM »
I am only 54 but I think the younger people here with any disdain of the ACA are short sighted.  You can exercise, eat right, not smoke, etc. and get a disease or have an accident that has a permanent consequence.  As much as you would like to think so - you simply are not in control of this.  ...

+1  The cause of many horrible diseases is unknown and can strike anyone.  Look at Lou Gehrig, and Ann Romney (wife of Mitt Romney, who has MS).  Certainly you can't blame these people for their illnesses. 

A major overhall of our health care system is needed so that insurance can be provided at a reasonable cost.  The profit motive has taken over the 'health care' industry.  I don't go to see a doctor unless I have an acute infection that requires antibiotics or something.  There is little to no scientific foundation to justify many regular screening procedures such as mamograms and colonoscopies for most ordinary people.  And there is no evidence that life spans are actually being extended by performing many of these procedures.  The medical system is crammed full of expensive procedures and pharmaceuticals of minimal or no benefit.  Americans expect to receive all possible diagnostic procedures and treatments, no matter how expensive and how small the likely benefit.  Unless there is some way to deal with this, I think the health care system is sunk.

marion10

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Re: What comes after the ACA?
« Reply #47 on: January 07, 2017, 04:34:12 PM »
I am particularly worried about Medicaid- I think one of the largest ( if not largest) uses for Medicaid is nursing home care after assets are exhausted. My MIl who had Alzheimer's lived for six years in a very good nursing home after she exhausted her assets ( which took about 18 months). With that - what would we do- her care was over 100,000  a year.

Cassie

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Re: What comes after the ACA?
« Reply #48 on: January 07, 2017, 05:10:45 PM »
SOL: you make some excellent points and it is really scary that we will go backwards instead of forward in regard to health care.  I am a guardian for a friend with early onset alzheimer's and she could afford her care between pension and SS but now she needs more care and the cost has doubled and we applied for Medicaid. No clue what would happen to her without it. She has no family left.

bacchi

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Re: What comes after the ACA?
« Reply #49 on: January 07, 2017, 05:35:03 PM »

Quote
If we revoke guaranteed issue, lots of people who want insurance will be unable to get it, at any price.  For now, Republicans are publicly saying they DON'T want this to happen, despite it being their official written policy.

<sigh> This is false, as I have shown in many ways before.  I am not going to repeat myself in full, but in short, there were solutions to these problems before ACA.

<sigh> This is false, as has been shown before. I'm not going to repeat others but, in short, there weren't what anyone sane would call solutions to these problems before ACA.

Before ACA, if you lost your job because you were throwing up from cancer and couldn't go to work, you could go on COBRA.

Before ACA, if you got cancer and had an individual policy (you didn't work at a corporation that provided a group plan), you could be rescinded.

After COBRA/rescission, you could apply and apply and NO MONEY would give you a policy. You could call and offer thousands a month (if you had thousands a month to offer) and you wouldn't get a policy.

Unbelievably, these companies wouldn't take your money -- yeah, I offered lots of money, offered to sign an exclusionary rider, and got nada, zilch, nothing.

Then you could turn to the state health pools, after being denied several times. Ahh, but there's a waiting list. You don't just sign up and, 2 weeks later, get approved and start receiving benefits. The state has limited funds in its pool and doesn't accept every sick, sad, sack that turns up. You get in when, presumably, a previous insured person is planted 6 feet under. The premiums are also a multitude what regular premiums are for your age group.

It's not a solution anyone sane or civilized would create.

"Fuck you, you're sick" as a health policy is a cruel policy.