Author Topic: What comes after the ACA?  (Read 387520 times)

CDP45

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Re: What comes after the ACA?
« Reply #1900 on: April 11, 2017, 12:00:03 PM »
What's the rationale for treating cancer in those 75+? The Federal government is spending a $600B on people over 65 and is causing prices to skyrocket for everyone, does it make sense to spend hundreds of thousands on treatment for the elderly?

Children aged 0-14, and teenagers and young adults aged 15-24, each account for less than one per cent of all new cancer cases in the UK (2011-2013).[1-4] Adults aged 25-49 contribute a tenth (10%) of all new cancer cases, with twice as many cases in females as males in this age group.[1-4] Adults aged 50-74 account for over half (53%) of all new cancer cases, and elderly people aged 75+ account for over a third (36%), with slightly more cases in males than females in both age groups. There are more people aged 50-74 than aged 75+ in the population overall, hence the number of cancer cases is higher in 50-74s, but incidence rates are higher in 75+.

For most cancer types, incidence increases with age. This largely reflects cell DNA damage accumulating over time. Damage can result from biological processes or from exposure to risk factors. A drop or plateau in incidence in the oldest age groups often indicates reduced diagnostic activity perhaps due to general ill health.

http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age#heading-Zero

NoStacheOhio

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Re: What comes after the ACA?
« Reply #1901 on: April 11, 2017, 12:25:55 PM »
It's not cut-and-dried. A 78-year-old who is otherwise healthy may be an excellent candidate for treatment, even aggressive treatment.
The first step is acknowledging you have a problem, right?

https://forum.mrmoneymustache.com/journals/digging-out-of-a-hole/

sol

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Re: What comes after the ACA?
« Reply #1902 on: April 11, 2017, 12:32:32 PM »
What's the rationale for treating cancer in those 75+? The Federal government is spending a $600B on people over 65 and is causing prices to skyrocket for everyone, does it make sense to spend hundreds of thousands on treatment for the elderly?

You sound like a prime candidate to sit on your neighborhood's DEATH PANEL.  Fiscal responsibility clearly demands that we refuse treatment to the elderly when they get sick.  Hurry up and die already, folks, and make some room for those young consumers who actually contribute to our economy, because that's all that matters in America. 

Wait, was that a step too far?  How about we compromise, and you DON'T join your neighborhood death panel, and just serve as the administrator of your own family's death panel instead.  You can tell your parents when they are too old to receive any additional medical treatment.  Just keep in mind that some day your kids will make the same decision for you!

Jrr85

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Re: What comes after the ACA?
« Reply #1903 on: April 11, 2017, 12:42:58 PM »
What's the rationale for treating cancer in those 75+? The Federal government is spending a $600B on people over 65 and is causing prices to skyrocket for everyone, does it make sense to spend hundreds of thousands on treatment for the elderly?

You sound like a prime candidate to sit on your neighborhood's DEATH PANEL.  Fiscal responsibility clearly demands that we refuse treatment to the elderly when they get sick.  Hurry up and die already, folks, and make some room for those young consumers who actually contribute to our economy, because that's all that matters in America. 

Wait, was that a step too far?  How about we compromise, and you DON'T join your neighborhood death panel, and just serve as the administrator of your own family's death panel instead.  You can tell your parents when they are too old to receive any additional medical treatment.  Just keep in mind that some day your kids will make the same decision for you!

I don't get your reaction.  Most people on the forum seem to want government funded single payer.  How do you think government should make decisions on treatments if not a cost/benefit analysis?  You can either let people make their own decisions with their own resources, or you can let the government make decisions with taxpayer money.  (Or you can do some combination, with government making economic funding decisions for relatively basic care and the individual deciding whether he/she wants to spend their own resources to receive more than basic care). 

sol

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Re: What comes after the ACA?
« Reply #1904 on: April 11, 2017, 01:30:53 PM »
I don't get your reaction. 

I typically respond to all of CDP's posts with outrage and sarcasm because I've read too many of his posts to see anything except bigotry and hatred written between the lines.  He's been a thorn in the side of this forum for too long, and I will continue to make him as unwelcome as possible because I don't think he adds anything of value to these conversations.  Go ahead and ask him about climate change sometime, and you'll get the same answer you're seeing here about healthcare: government is evil and need to be abolished so that freedom can ring out for all white people across this great christian nation.

So forgive me if my post seemed like an overreaction.  I'm reacting not only to the specific point being made in his latest post, but also to the corrosive and disgusting opinions that created it.  I wish I could just address the specific arguments currently before us, but I can't because I know from experience that they are part of a larger subversive narrative and are being made in the context of advancing that ugly and destructive agenda, not to advance the current specific debate.

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You can either let people make their own decisions with their own resources, or you can let the government make decisions with taxpayer money. 

Here's a thought, how about we let doctors decide what is best for each patient given their unique individual circumstances, instead of arbitrarily denying care to people who would benefit from it (death panels!) or denying care to poor people just because they can't afford it (free markets!). 

This isn't a binary choice between only those two options.  We don't need the government dictate what care a patient can receive regardless of circumstances, and we don't need to let a patient's ability to pay dictate what care they can receive.  Both of the options you've presented remove the doctor-patient discussion of appropriate treatment options from the table.  Both lead to worse patient outcomes.

PiobStache

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Re: What comes after the ACA?
« Reply #1905 on: April 11, 2017, 02:25:49 PM »
Here's a thought, how about we let doctors decide what is best for each patient given their unique individual circumstances, instead of arbitrarily denying care to people who would benefit from it (death panels!) or denying care to poor people just because they can't afford it (free markets!). 

This isn't a binary choice between only those two options.  We don't need the government dictate what care a patient can receive regardless of circumstances, and we don't need to let a patient's ability to pay dictate what care they can receive.  Both of the options you've presented remove the doctor-patient discussion of appropriate treatment options from the table.  Both lead to worse patient outcomes.

Speaking of arbitrary choices, denying care does not have to be arbitrary.  For instance, a bed ridden, end stage dementia patient and a PEG tube (percutaneous endoscopic gastrostomy) better known as a "feeding tube."  Medicare will pay to place one and Medicaid will pay to sustain this unfortunate person within the long term care setting.  Will the advanced dementia be cured?  No.  Do families insist that this is course of treatment?  Daily.

I just can't find the justification for a public system to pay for this.  Maybe others can, but I can't on several levels.  It's not even a quality of life thing as research shows "comfort care" hand feeding not only yields qualitative benefits for the patient but also quantitative outcomes such as lower incidence of aspiration and aspiration pneumonia (something that also is not cheap to treat.)

People do not always "benefit" from all modalities of treatment at all points in their lives.  A close friend, that is a highly respected hospice and palliative care physician, describes as knowing when to cease interventional treatment and move to a companionship/partnership regimen.

Just something to think about.

sol

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Re: What comes after the ACA?
« Reply #1906 on: April 11, 2017, 02:35:55 PM »
Speaking of arbitrary choices, denying care does not have to be arbitrary. 

I have no problem with denying care, even when it hastens death, but I think that decision should be made by consultation between the doctor, the patient, and the family, and not by the government or an insurance company.

I didn't mean to argue for unlimited healthcare for everybody all the time.  I meant to say that doctors and patients should have control over these decisions, without being forced down one specific path because you are poor (if conservatives get their way and strip away coverage for everyone but the rich) or because the death panel says so (if the conservative's horror vision of socialized medicine were to actually exist).

PiobStache

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Re: What comes after the ACA?
« Reply #1907 on: April 11, 2017, 02:40:50 PM »
Speaking of arbitrary choices, denying care does not have to be arbitrary. 

I have no problem with denying care, even when it hastens death, but I think that decision should be made by consultation between the doctor, the patient, and the family, and not by the government or an insurance company.

I didn't mean to argue for unlimited healthcare for everybody all the time.  I meant to say that doctors and patients should have control over these decisions, without being forced down one specific path because you are poor (if conservatives get their way and strip away coverage for everyone but the rich) or because the death panel says so (if the conservative's horror vision of socialized medicine were to actually exist).

LOL, you really hate "conservatives," don't you?  But glad to hear you're not for unlimited healthcare all the time.

EnjoyIt

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Re: What comes after the ACA?
« Reply #1908 on: April 11, 2017, 02:41:05 PM »
Here's a thought, how about we let doctors decide what is best for each patient given their unique individual circumstances, instead of arbitrarily denying care to people who would benefit from it (death panels!) or denying care to poor people just because they can't afford it (free markets!). 

This isn't a binary choice between only those two options.  We don't need the government dictate what care a patient can receive regardless of circumstances, and we don't need to let a patient's ability to pay dictate what care they can receive.  Both of the options you've presented remove the doctor-patient discussion of appropriate treatment options from the table.  Both lead to worse patient outcomes.

Speaking of arbitrary choices, denying care does not have to be arbitrary.  For instance, a bed ridden, end stage dementia patient and a PEG tube (percutaneous endoscopic gastrostomy) better known as a "feeding tube."  Medicare will pay to place one and Medicaid will pay to sustain this unfortunate person within the long term care setting.  Will the advanced dementia be cured?  No.  Do families insist that this is course of treatment?  Daily.

I just can't find the justification for a public system to pay for this.  Maybe others can, but I can't on several levels.  It's not even a quality of life thing as research shows "comfort care" hand feeding not only yields qualitative benefits for the patient but also quantitative outcomes such as lower incidence of aspiration and aspiration pneumonia (something that also is not cheap to treat.)

People do not always "benefit" from all modalities of treatment at all points in their lives.  A close friend, that is a highly respected hospice and palliative care physician, describes as knowing when to cease interventional treatment and move to a companionship/partnership regimen.

Just something to think about.

I fully agree. People want everything done regardless of the cost since it is free to them. We can not provide immediate healthcare with the latest and greatest tech, with the newest meds without increasing cost. Rationed care is but one of the few ways that must be instituted.

Sol, today doctors do not have a choice on denying healthcare to those people or risk for either abandonment or malpractice.

Sol, I now understand why you are so pro government for everything. You work for the federal government and therefor your income depends on taxes. Although your ideals are sound , unfortunately I feel you don't quite understand how health care is administered, documented and then paid for in this country. When someone in the field of medicine tries to explain how it works you tend to ignore their responses. In the US the answer is not as simple as single payer.

Paul der Krake

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Re: What comes after the ACA?
« Reply #1909 on: April 11, 2017, 02:56:06 PM »
You could argue that people also want everything done to them because they've already paid so much into premiums and want to get their money back out.

If everything was free people may not care as much to try and optimize their years when they max out their deductibles or whatever stupid games we all find ourselves doing.

sol

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Re: What comes after the ACA?
« Reply #1910 on: April 11, 2017, 03:00:33 PM »
LOL, you really hate "conservatives," don't you?  But glad to hear you're not for unlimited healthcare all the time.

Specifically, I really hate people who are actively trying make our broken healthcare system even worse.  I was briefly hopeful that Donald Trump was actually going to try to improve things, based on his campaign rhetoric, but then all of the republican plans that were put forward seemed like steps backwards. 

Rationed care is but one of the few ways that must be instituted.

Can we start by giving doctors the authority to ration that care, instead of insurance companies? 

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You work for the federal government and therefor your income depends on taxes.

I work for the federal government because it's the place I feel like I can do the most good in the world with my skill set.  I assure you that this decision came with a considerable pay cut compared to doing the same work in the private sector.  And as an aside, I find your casual judgment of my moral sensibilities to be condescending and offensive.  You're entitled to be both of those things, though, so you go right ahead and judge me and I'll go right ahead and judge you for it.  Deal?

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In the US the answer is not as simple as single payer.

Definitely not!  Have I somewhere suggested that single payer was a panacea for American healthcare?  There are a whole host of associate issues that would have be simultaneously addressed if we tried to institute a single payer option.  I'm also fine with private healthcare existing as a supplement to guaranteed basic services for everyone, and I'm even fine with corporations profiting off of being the middle man between people who need care and the government that ultimately pays for it.  What I'm not fine with, and what pisses me off the most, is how the current American system deliberately exploits some groups of people while denying necessary and life saving care to others.  Can we talk about ways to address some of those problems?

PiobStache

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Re: What comes after the ACA?
« Reply #1911 on: April 11, 2017, 03:03:28 PM »
LOL, you really hate "conservatives," don't you?  But glad to hear you're not for unlimited healthcare all the time.

Specifically, I really hate people who are actively trying make our broken healthcare system even worse.  I was briefly hopeful that Donald Trump was actually going to try to improve things, based on his campaign rhetoric, but then all of the republican plans that were put forward seemed like steps backwards. 

That's fair enough and actually why I was against Obamacare.  I was against it as all it did was further entrench a fatally flawed system by buying enough support to sustain it.  That and I knew it would get dismantled the first time the Repubs got power.  Don't have the answer for the woes of the US but I knew the fix was not Obamacare.

sol

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Re: What comes after the ACA?
« Reply #1912 on: April 11, 2017, 03:29:33 PM »
That's fair enough and actually why I was against Obamacare.  I was against it as all it did was further entrench a fatally flawed system by buying enough support to sustain it.  That and I knew it would get dismantled the first time the Repubs got power.  Don't have the answer for the woes of the US but I knew the fix was not Obamacare.

Let's talk about why Obamacare is broken.  I agree there are some things about it that aren't working as intended, and there are some problems with American healthcare that Obamacare wasn't designed to address.  I still think it's an improvement over what we had before.  The primary problem with it, from my perspective, is that it has failed rural red states. 

Obamacare seems to work great where I live, and in New York and California and Minnesota and basically any other place with enough population to support enough hospitals and insurers to provide a functioning competitive market.  My local state healthcare exhange has like 25 silver plans for sale, they are all reasonably priced, and they offer good coverage.  I have lots of doctors to choose from.  Obamacare works here.

But in some states, healthcare providers are too rare and spread out to be economically viable on their own.  They just don't have the customer base to support competing networks.  They can't provide volume discounts, or specialist facilities, because there isn't enough demand to support them.  This is the exact same problem the country initially had with the spread the postal service to rural areas, and then electricity, and then municipal water systems, and then high speed internet.  The benefits of civilization are easy to provide in places where people live densely, and expensive and difficult to provide in places where people live far apart.  We have always solved this problem, as a nation, by using the federal government (taxes from cities) to subsidize the expansion of these services into rural areas.  Why can't we do the same for healthcare?

Obamacare took some steps in the right direction.  It expanded access to healthcare by adding people to Medicaid.  It controlled the cost of premiums to consumers by offering income based subsidies.  It rid the market of predatory insurance practices like cost-based rescission.  It tried to guarantee basic health services to everyone, so that people didn't need to die despite having "insurance".  And it expanded the pool of paying customers to spread the costs around and increase the customer demand in rural areas that need more customers to support functioning markets.  I thought these were all positive steps, though you are free to disagree.

We've already proposed a handful of fixes to the ACA, in this very thread, that we all seemed to think would make things better.  We've also exhaustively discussed the republican proposals that we all seem to think would make things worse.  Obamacare has become such a political football that I fear republicans are unwilling to recognize and accept the positive steps it took, and will actively work to undermine that progress just to spite the name of their former political opponent regardless of the impact those actions may have on their own constituents.

But I don't think republicans actually hate Obamacare just because they put Obama's name on it.  They hate it because they don't believe poor people should have insurance.  All of their recent proposals seem to back me up on this one.  They only care about corporate profits and motivating their core voters to turn out for elections with fake outrage. 

We've yet to see a Republican plan that would improve the healthcare system in America over what Obamacare offers.  I am absolutely open to seeing that plan, and I would personally vote to repeal Obamacare if they actually came up with something better to replace it.  Have any ideas for me?

desertadapted

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Re: What comes after the ACA?
« Reply #1913 on: April 11, 2017, 03:44:26 PM »
It seems that the simpler course with respect to end-of-life care is for Medicare and Medicaid to reimburse doctors and social workers for meeting with patients to discuss end-of-life planning.  I suspect many people, when faced with compassionate discussion about their wishes, will elect to sign advanced directives that clarify the scope of desired care.  I and my family members have.  Advanced directives provide simple guidance from the patient to the physician, without interference from distraught family members who want to do anything they can to prolong a loved one’s life.  Frequently, patients do not seek “all in” care, and express the desire most of us have for death with dignity.   Who decides?  The patient in consultation with their health providers.  When should they address the issue?  Early and often.  I know, however, that where I see "mature discussion about the inevitability of mortality" others see "Death Panel."   Consider reading the attached article.

http://www.cbsnews.com/news/patients-seek-end-of-life-talks-once-labeled-death-panels/

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1914 on: April 11, 2017, 03:53:59 PM »
I see both testing ordered that is not appropriate, as well as testing not ordered that should be. Medicine is still very much the wild west when it comes to individual practice, and so much bad behavior (of the overtesting financial sort) can be waved away with so-called community standards. We are starting to see standardization of diagnosis and treatment in the cancer realm, I can't speak to other areas of medicine, but I think creation and enforcement of standards based on evidence is what will truly curb unnecessary testing/treatment more so than the constant whittling away of reimbursement that CMS, followed by the commercial carriers, has used as their primary tool to curb costs for the past few decades.

I totally agree with this. One of the things that Obamacare/ACA did was to fund research into this very issue of comparing standards of care.

Also, I have a friend who is in internal medicine at a VA Hospital, and aside from the understaffing problems, there's also the problem of "testing ordered that is not appropriate, as well as testing not ordered that should be." 

Yes sadly it definitely is the wild west when it comes to the way some physicians practice medicine - and not very good oversight.

CDP45

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Re: What comes after the ACA?
« Reply #1915 on: April 11, 2017, 04:00:49 PM »
I don't get your reaction. 

I typically respond to all of CDP's posts with outrage and sarcasm because I've read too many of his posts to see anything except bigotry and hatred written between the lines.  He's been a thorn in the side of this forum for too long, and I will continue to make him as unwelcome as possible because I don't think he adds anything of value to these conversations.  Go ahead and ask him about climate change sometime, and you'll get the same answer you're seeing here about healthcare: government is evil and need to be abolished so that freedom can ring out for all white people across this great christian nation.

Call me Moby-Dick... 

It's amazing to see your commitment to discourse and facts and of course your superior judgment on behalf of everyone here to decide what ideas are valuable or not.

Because any question about giving away free stuff is just evil.

dividendman

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Re: What comes after the ACA?
« Reply #1916 on: April 11, 2017, 05:54:09 PM »
Because any question about giving away free stuff is just evil.

This is where I lose a lot of conservatives... nobody is talking about "giving away free stuff". We are talking about what societal minimums we want to have for everyone in this society.

Somehow we have decided that you get police protection. You meaning everyone. Anyone can call the police and get protection and investigative services. The police don't come to your door and ask if you paid taxes or how much you paid in taxes, or bill you for their service. You get police services as a minimum in this society.

Why is giving away that "free stuff" just fine, but saying that unless you are rich you can be bankrupt and destitute due to health issues?

Why as a society have we decided that protecting someone from murder, assault and robbery are important but protecting someone who gets cancer not?

Why do US travelers get consular services and military protection as "free stuff"? Why is it more important to evacuate (usually) rich citizens from countries in turmoil when they have CHOSEN to go there than ensuring a broken limb doesn't put a family out of their home right here in the USA?

Why do areas impacted by hurricanes, flooding, and tornadoes get "free stuff" like temporary housing, food rations and rebuilding funds?

I don't have answers to how society has deemed some "free stuff" OK. I do think it is stupid to think of it as "free stuff" though.

jim555

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Re: What comes after the ACA?
« Reply #1917 on: April 11, 2017, 07:03:30 PM »
Healthcare funded by taxation makes sure no one free rides since all pay taxes and all use healthcare services.  If you are not alive you can't have freedom, so life protection would seem to have a higher priority than mere liberty.  Someone who is dead has no liberty, it is a moot point.

Lagom

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Re: What comes after the ACA?
« Reply #1918 on: April 11, 2017, 07:39:18 PM »
Because any question about giving away free stuff is just evil.

This is where I lose a lot of conservatives... nobody is talking about "giving away free stuff". We are talking about what societal minimums we want to have for everyone in this society.

Somehow we have decided that you get police protection. You meaning everyone. Anyone can call the police and get protection and investigative services. The police don't come to your door and ask if you paid taxes or how much you paid in taxes, or bill you for their service. You get police services as a minimum in this society.

Why is giving away that "free stuff" just fine, but saying that unless you are rich you can be bankrupt and destitute due to health issues?

Why as a society have we decided that protecting someone from murder, assault and robbery are important but protecting someone who gets cancer not?

Why do US travelers get consular services and military protection as "free stuff"? Why is it more important to evacuate (usually) rich citizens from countries in turmoil when they have CHOSEN to go there than ensuring a broken limb doesn't put a family out of their home right here in the USA?

Why do areas impacted by hurricanes, flooding, and tornadoes get "free stuff" like temporary housing, food rations and rebuilding funds?

I don't have answers to how society has deemed some "free stuff" OK. I do think it is stupid to think of it as "free stuff" though.

Well put, although I have yet to see a "taxes are theft" type actually acknowledge any of the above unless they are especially committed to stretching the "free market can solve any problem" narrative. Cognitive dissonance, I suppose.

CDP45

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Re: What comes after the ACA?
« Reply #1919 on: April 11, 2017, 11:10:03 PM »
I should elaborate. I don't think we're having the conversation about questioning the limits or the consequences of the spending on free stuff. If certain free stuff is so important and worthwhile, then it should easy be to justify.

And I think you gave some great examples of what doesn't make sense.

Obviously I am not against being safe, but I am against some of the costs and methods purported to do so such as bulk domestic surveillance. Asserting the protections of the 4th amendment doesn't mean you want to let in terrorists, just like questioning how much spending and taxing for Medicare doesn't mean you hate sick people and it's a dishonest charge to make.

If the aim of Medicare is to provide old people who are poor healthcare, seems like outside of the scope for the government to pick up the tab for millionaires. Why isn't there a means test? Wouldn't a high bar of $5MM be fair? And if you dip below have a sliding scale. Medicaid does this to an extreme point, and that seems like a fairer way to go.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1920 on: April 12, 2017, 04:30:41 AM »
Here's an idea:  instead of piling on me for whatever my transgressions are how about if we all agree Germany and France have great systems and start moving the national conversation that way?

Just a thought.

Well, I think we can agree on that point. 

But surely you can see that the reason for the piling on was your waving around of superficial details in an attempt to demonstrate your encyclopedic knowledge on the subject.  Instead of impressing everyone with your intellectual superiority, you came across as a petty nitpicker who knows all the meaningless trivia but is oblivious to the real subject of the discussion.

By the way, your posts after the quoted one above were quite constructive.  Glad to see those.

They are not superficial nor meaningless trivia.  Paradigms are highly important particularly in public policy.  As to intellectual superiority...well, I'm sort of slow so nothing to worry about there.

Please explain the importance of the particular paradigms you cited.
"Take this job and shove it" - David Allan Coe

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1921 on: April 12, 2017, 10:51:33 AM »
If the aim of Medicare is to provide old people who are poor healthcare, seems like outside of the scope for the government to pick up the tab for millionaires. Why isn't there a means test? Wouldn't a high bar of $5MM be fair? And if you dip below have a sliding scale. Medicaid does this to an extreme point, and that seems like a fairer way to go.

There is a fundamental problem with drawing lines in the sand in means testing for social programs.  It provides little incentive for a recipient to improve their situation.  If a program (like medicaid) is 100% cut off once a household income reaches a level above federal poverty, then the household completely loses the programs which helped them overcome poverty in the first place.  The end result is a lower overall standard of living.  From a theoretical macro-standpoint, no sane actors would choose to work harder for less.  This is why, IMO, progressive taxes can be justified from a more conservative economic perspective.  They are necessary to provided a level playing field.  Related, this is why the ACA (from a standpoint of premium credits and max out of pocket) is a smart system, because it is slowly progressive.  OTOH, if I will lose all medicare benefits if I have 5 Million in net worth, you can be damned sure I will manage to fall just short of that level. 

As a disclaimer to my thoughts on this, they are also from anecdotal experiences.  I have seen many frustrated people who are struggling to get by reach some of these "lines in the sand".  They get stung and then back pedal to to more dependence on social programs to regain a previously higher standard of living, for less personal effort.

PiobStache

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Re: What comes after the ACA?
« Reply #1922 on: April 12, 2017, 11:22:19 AM »
We've yet to see a Republican plan that would improve the healthcare system in America over what Obamacare offers.  I am absolutely open to seeing that plan, and I would personally vote to repeal Obamacare if they actually came up with something better to replace it.  Have any ideas for me?

As the last thing I am is Republican I have absolutely no comprehension why I would have any idea of what they might propose.

PiobStache

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Re: What comes after the ACA?
« Reply #1923 on: April 12, 2017, 11:26:20 AM »
Please explain the importance of the particular paradigms you cited.

I already stated the basics of why.  Please quote back to me where I said the basics and I'll know you're not just trolling me.

sol

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Re: What comes after the ACA?
« Reply #1924 on: April 12, 2017, 11:42:44 AM »
As the last thing I am is Republican I have absolutely no comprehension why I would have any idea of what they might propose.

This isn't about you, it's about the party currently in control of the US government and all of the proposals they have put forward since gaining power.  Several of them have been actual bills in congress, others are more like white paper outlines of plans.  Do you watch the news at all?

The most recent and most serious republican plan to replace the ACA would have given a multibillion dollar tax break to the wealthiest Americans by cutting healthcare benefits to millions of poor people.  I didn't think this plan was better than what we currently have. 

PiobStache

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Re: What comes after the ACA?
« Reply #1925 on: April 12, 2017, 12:30:36 PM »
As the last thing I am is Republican I have absolutely no comprehension why I would have any idea of what they might propose.

This isn't about you, it's about the party currently in control of the US government and all of the proposals they have put forward since gaining power.  Several of them have been actual bills in congress, others are more like white paper outlines of plans.  Do you watch the news at all?

The most recent and most serious republican plan to replace the ACA would have given a multibillion dollar tax break to the wealthiest Americans by cutting healthcare benefits to millions of poor people.  I didn't think this plan was better than what we currently have.

If it's not about me then your question to me is even more curious.  Possibly it was rhetorical?  Dunno.

Also, no, I don't want the news much, but I do get a host of industry publications and email blasts which I suspect are more insightful and contextualized than anything Scott Pelley is going to present. I knew a 100 day repeal was not going to happen and the Repubs are going to lose seats "bigly" in the mid-terms.  The most likely course will be defunding what they can through budget reconciliation, big mid-term losses, and then enough Repubs join Dems to stop a wholesale repeal or defunding. 

Jrr85

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Re: What comes after the ACA?
« Reply #1926 on: April 12, 2017, 02:44:56 PM »
Because any question about giving away free stuff is just evil.

This is where I lose a lot of conservatives... nobody is talking about "giving away free stuff". We are talking about what societal minimums we want to have for everyone in this society.

Somehow we have decided that you get police protection. You meaning everyone. Anyone can call the police and get protection and investigative services. The police don't come to your door and ask if you paid taxes or how much you paid in taxes, or bill you for their service. You get police services as a minimum in this society.

Why is giving away that "free stuff" just fine, but saying that unless you are rich you can be bankrupt and destitute due to health issues?

Why as a society have we decided that protecting someone from murder, assault and robbery are important but protecting someone who gets cancer not?

Why do US travelers get consular services and military protection as "free stuff"? Why is it more important to evacuate (usually) rich citizens from countries in turmoil when they have CHOSEN to go there than ensuring a broken limb doesn't put a family out of their home right here in the USA?

Why do areas impacted by hurricanes, flooding, and tornadoes get "free stuff" like temporary housing, food rations and rebuilding funds?

I don't have answers to how society has deemed some "free stuff" OK. I do think it is stupid to think of it as "free stuff" though.

Well put, although I have yet to see a "taxes are theft" type actually acknowledge any of the above unless they are especially committed to stretching the "free market can solve any problem" narrative. Cognitive dissonance, I suppose.

You've never seen a definition of public good by anybody?  Really?  I think the "taxes are theft" statement is inaccurate and not effective as a rhetorical ploy, but there's so much discussion out there in different straings of libertarian and/or conservative thought about what the proper role of government is, I'm not sure how you could avoid it without trying to stay in a bubble. 

Jrr85

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Re: What comes after the ACA?
« Reply #1927 on: April 12, 2017, 03:01:47 PM »
You can either let people make their own decisions with their own resources, or you can let the government make decisions with taxpayer money. 

Here's a thought, how about we let doctors decide what is best for each patient given their unique individual circumstances, instead of arbitrarily denying care to people who would benefit from it (death panels!) or denying care to poor people just because they can't afford it (free markets!). 

This isn't a binary choice between only those two options.  We don't need the government dictate what care a patient can receive regardless of circumstances, and we don't need to let a patient's ability to pay dictate what care they can receive.  Both of the options you've presented remove the doctor-patient discussion of appropriate treatment options from the table.  Both lead to worse patient outcomes.

You want to give doctors a blank check tied to the federal government's finances?  I'm just guessing that would not turn out to great.  Even if currently practicing doctors are saints, I suspect we'd see a different strain of doctors starting to practice from one to eight years after they were given a blank check to earn their way into a lear jet. 

Is just a practical fact that somebody is going to have to make cost benefit decisions.  You can't do away with that fact by pretending doctors are saints without a shred of self interest.   

Classical_Liberal

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Re: What comes after the ACA?
« Reply #1928 on: April 12, 2017, 03:24:08 PM »
You want to give doctors a blank check tied to the federal government's finances?  I'm just guessing that would not turn out to great.  Even if currently practicing doctors are saints, I suspect we'd see a different strain of doctors starting to practice from one to eight years after they were given a blank check to earn their way into a lear jet. 

Is just a practical fact that somebody is going to have to make cost benefit decisions.  You can't do away with that fact by pretending doctors are saints without a shred of self interest.

I think you are wrong.  In general, it's the providers who often have frank discussions with the patients and families regarding NOT doing additional testing/interventions when it's not indicated with best practice or evidence based.  The true risk of a "blank check" is that providers give in to those ill-advised requests/demands from the consumption side. This is why a universal, basic, best practice care model would work.  If the consumption side wants more or different than what is evidenced based standard of care, they can pay out of pocket or have private insurance coverage for their perceived needs, which are discretionary.

If there are two (or more) options which are equally valid, cost should not be the determining factor.  It should be the choice of the well informed patient and her doctor. 

Lagom

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Re: What comes after the ACA?
« Reply #1929 on: April 12, 2017, 03:35:31 PM »
You've never seen a definition of public good by anybody?  Really?  I think the "taxes are theft" statement is inaccurate and not effective as a rhetorical ploy, but there's so much discussion out there in different straings of libertarian and/or conservative thought about what the proper role of government is, I'm not sure how you could avoid it without trying to stay in a bubble.

Sounds like you aren't a "taxes are theft" type so my statement doesn't apply to you. I know many libertarians/conservatives that don't spout that nonsense with whom I have had great discussions about the "proper role of government." I myself lean libertarian-ish. No bubble here, mate. You can stand down.

gerardc

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Re: What comes after the ACA?
« Reply #1930 on: April 12, 2017, 10:47:43 PM »
I have no problem with denying care, even when it hastens death, but I think that decision should be made by consultation between the doctor, the patient, and the family, and not by the government or an insurance company.

This assumption that the doctor knows best and government/insurance company does not is ridiculous... You seem to forget that the government and insurance companies include doctors, medical experts, etc. who can provide guidelines in terms of evidence needed to receive a treatment in specific circumstances. That's necessary for a single-payer system to work out. Otherwise, doctors having the authority to decide if a treatment is necessary / reimbursed by the single-payer, would create an incentive for overtreatment. Certain doctors will become known to give the best treatment possible. If a single-payer is viable, the government needs to oversee medical practice standards!

jim555

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Re: What comes after the ACA?
« Reply #1931 on: April 13, 2017, 03:05:22 AM »
A story about the Silver plans cost sharing reductions House lawsuit...

Trump dangles Obamacare payments to force Dems to the table
Cutting off a key subsidy program could send Obamacare’s insurance markets into a tailspin.
http://www.politico.com/story/2017/04/donald-trump-obamacare-subsidies-negotiate-237174

Monkey Uncle

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Re: What comes after the ACA?
« Reply #1932 on: April 13, 2017, 04:43:29 AM »
Please explain the importance of the particular paradigms you cited.

I already stated the basics of why.  Please quote back to me where I said the basics and I'll know you're not just trolling me.

No, you did not.  I went back and read all of your posts, and nowhere did you compare a Bismarck, beverage, or whatever system to true "single payer" in terms of the ultimate impact on costs.  I'm not going to go to the trouble of quoting all of those posts here.  But that's fine; I'm done dicking around with you since you obviously have nothing meaningful to contribute.
"Take this job and shove it" - David Allan Coe

Jrr85

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Re: What comes after the ACA?
« Reply #1933 on: April 13, 2017, 08:31:23 AM »
You want to give doctors a blank check tied to the federal government's finances?  I'm just guessing that would not turn out to great.  Even if currently practicing doctors are saints, I suspect we'd see a different strain of doctors starting to practice from one to eight years after they were given a blank check to earn their way into a lear jet. 

Is just a practical fact that somebody is going to have to make cost benefit decisions.  You can't do away with that fact by pretending doctors are saints without a shred of self interest.

I think you are wrong.  In general, it's the providers who often have frank discussions with the patients and families regarding NOT doing additional testing/interventions when it's not indicated with best practice or evidence based.  The true risk of a "blank check" is that providers give in to those ill-advised requests/demands from the consumption side. This is why a universal, basic, best practice care model would work.  If the consumption side wants more or different than what is evidenced based standard of care, they can pay out of pocket or have private insurance coverage for their perceived needs, which are discretionary.

If there are two (or more) options which are equally valid, cost should not be the determining factor.  It should be the choice of the well informed patient and her doctor.

You apparently missed what I was talking about.  If the patient is paying for it, then the patient can make decisions.  If the government pays for it, there is going to be a cost benefit analysis done by some entity associated with the government.  "Death panel" is somewhat inflammatory, but it's not necessarily inaccurate.  There is going to be a government board that says they are going to let people die rather than pay for treatments that they don't think are cost effective.  Which is basically what the individual (or individual's family) would be doing if they were paying for it and making the decision (or more likely, what the insurance company would be doing, as most family's would not reach into their own pocket if an insurance company denied a treatment, but attack/lobby the insurance company to change their determination). 

dividendman

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Re: What comes after the ACA?
« Reply #1934 on: April 13, 2017, 09:30:57 AM »
Not to thread hijack, but you know what I'm sick and tired of? Government funded police protection... let's call it Police Care. Police Care is basically the Government MANDATING that everyone gets police protection, whether they want it or not. That's crazy.

Some people may want no police protection.
Others may want police protection from assault, but not from  trespassing or robbery. This "one size fits all" police protection model is just ridiculous.

On top of this, we could have private police forces on the market that give police protection to people who want it, and they could choose which police protections they want through individually tailored police insurance.

Do you know what else is ridiculous? That in the event of numerous calls to the police, the GOVERNMENT decides who to help, these Police Death Panels aren't how it's supposed to work. It should be between me and my police what protection I get through my private police insurance, not some Government Bureaucrat.

Another advantage is this will also stop all of those free loaders who call the police when they don't need them, since now it'll be money out of their pocket instead of them free loading off of real tax payers.

The above will give everyone access to police protection, to the level they want. Maybe we should give some tax credits to help people buy police insurance but really even that is kind of a hand out.

This plan will utilize the free market to bring down policing costs overall and lead to a healthier, more efficient, police protection system. We'll even let them buy police insurance across state lines.

Let's use this private market approach to policing and get out of this Government mandated mess we're in!

Mr Mark

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Re: What comes after the ACA?
« Reply #1935 on: April 13, 2017, 09:46:40 AM »
^ too true. Super nice post.
Mr. Mark

radram

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Re: What comes after the ACA?
« Reply #1936 on: April 13, 2017, 09:47:00 AM »
Not to thread hijack, but you know what I'm sick and tired of? Government funded police protection... let's call it Police Care. Police Care is basically the Government MANDATING that everyone gets police protection, whether they want it or not. That's crazy.

Some people may want no police protection.
Others may want police protection from assault, but not from  trespassing or robbery. This "one size fits all" police protection model is just ridiculous.

On top of this, we could have private police forces on the market that give police protection to people who want it, and they could choose which police protections they want through individually tailored police insurance.

Do you know what else is ridiculous? That in the event of numerous calls to the police, the GOVERNMENT decides who to help, these Police Death Panels aren't how it's supposed to work. It should be between me and my police what protection I get through my private police insurance, not some Government Bureaucrat.

Another advantage is this will also stop all of those free loaders who call the police when they don't need them, since now it'll be money out of their pocket instead of them free loading off of real tax payers.

The above will give everyone access to police protection, to the level they want. Maybe we should give some tax credits to help people buy police insurance but really even that is kind of a hand out.

This plan will utilize the free market to bring down policing costs overall and lead to a healthier, more efficient, police protection system. We'll even let them buy police insurance across state lines.

Let's use this private market approach to policing and get out of this Government mandated mess we're in!

Can we do the same thing with roads. Do you have any idea how many roads I pay for, and I haven't even been on them. What a crock. And I even have a car. What about those that don't?

bacchi

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Re: What comes after the ACA?
« Reply #1937 on: April 13, 2017, 10:01:37 AM »
Let's use this private market approach to policing and get out of this Government mandated mess we're in!

The L.P.D. is on the case!

http://www.newyorker.com/humor/daily-shouts/l-p-d-libertarian-police-department

rpr

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Re: What comes after the ACA?
« Reply #1938 on: April 13, 2017, 10:12:27 AM »
Let's use this private market approach to policing and get out of this Government mandated mess we're in!

The L.P.D. is on the case!

http://www.newyorker.com/humor/daily-shouts/l-p-d-libertarian-police-department

That was fricking hilarious. Thank you for that link :)

tyort1

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Re: What comes after the ACA?
« Reply #1939 on: April 13, 2017, 11:15:02 AM »
Let's use this private market approach to policing and get out of this Government mandated mess we're in!

The L.P.D. is on the case!

http://www.newyorker.com/humor/daily-shouts/l-p-d-libertarian-police-department

Awesome!  Favorite quote:

"Our country needs a private-sidewalk voucher system, but, thanks to the incestuous interplay between our corrupt federal government and the public-sidewalk lobby, it will never happen."
Frugalite in training.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1940 on: April 13, 2017, 12:47:38 PM »
Let's use this private market approach to policing and get out of this Government mandated mess we're in!

The L.P.D. is on the case!

http://www.newyorker.com/humor/daily-shouts/l-p-d-libertarian-police-department

The private market is always right - it's just another religion.

Jrr85

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Re: What comes after the ACA?
« Reply #1941 on: April 13, 2017, 01:03:12 PM »
Not to thread hijack, but you know what I'm sick and tired of? Government funded police protection... let's call it Police Care. Police Care is basically the Government MANDATING that everyone gets police protection, whether they want it or not. That's crazy.

Some people may want no police protection.
Others may want police protection from assault, but not from  trespassing or robbery. This "one size fits all" police protection model is just ridiculous.

On top of this, we could have private police forces on the market that give police protection to people who want it, and they could choose which police protections they want through individually tailored police insurance.

Do you know what else is ridiculous? That in the event of numerous calls to the police, the GOVERNMENT decides who to help, these Police Death Panels aren't how it's supposed to work. It should be between me and my police what protection I get through my private police insurance, not some Government Bureaucrat.

Another advantage is this will also stop all of those free loaders who call the police when they don't need them, since now it'll be money out of their pocket instead of them free loading off of real tax payers.

The above will give everyone access to police protection, to the level they want. Maybe we should give some tax credits to help people buy police insurance but really even that is kind of a hand out.

This plan will utilize the free market to bring down policing costs overall and lead to a healthier, more efficient, police protection system. We'll even let them buy police insurance across state lines.

Let's use this private market approach to policing and get out of this Government mandated mess we're in!

Not to thread hijack, but you know what I'm sick and tired of? People proudly displaying (hopefully feigned) ignorance about what a public good is and smugly acting as if that feigned ignorance makes them superior. 

But the New Yorker thing was funny even if it was based on the same ignorance.  I think the “Subway™ Eat Fresh and Freeze, Scumbag!" line was probably the best line.

rpr

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Re: What comes after the ACA?
« Reply #1942 on: April 13, 2017, 01:16:34 PM »

Not to thread hijack, but you know what I'm sick and tired of? People proudly displaying (hopefully feigned) ignorance about what a public good is and smugly acting as if that feigned ignorance makes them superior. 


Due to my obvious superiority, things I believe the government should spend money on are a "public good" ;)

PiobStache

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Re: What comes after the ACA?
« Reply #1943 on: April 13, 2017, 01:30:02 PM »
No, you did not.  I went back and read all of your posts, and nowhere did you compare a Bismarck, beverage, or whatever system to true "single payer" in terms of the ultimate impact on costs.  I'm not going to go to the trouble of quoting all of those posts here.  But that's fine; I'm done dicking around with you since you obviously have nothing meaningful to contribute.

Go read where I described the difference between regular Medicare (single payer) and Medicare Advantaged plans (function like a Bismark system.)

Based on your posts to me, and other posts of yours I've read, "nothing meaningful to contribute" is your way of saying, "Doesn't 100% agree with me; can't present facts to disprove him." 

Have a good life.

PiobStache

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Re: What comes after the ACA?
« Reply #1944 on: April 13, 2017, 01:57:47 PM »
So to others willing to accept that when France says it's not a single payer, it's not a single payer, here's a nicely done but not too detailed write up from the US NIH.  I would encourage folks to read the whole article, but here's a key high light.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447687/

Quote
First, the French experience demonstrates that it is possible to achieve universal coverage without a “single-payer” system. To do this, however, will still require a statutory framework and an active state that regulates NHI financing and provider reimbursement. Of course, French NHI was not designed from scratch as a pluralistic, multipayer system providing universal coverage on the basis of occupational status. It is the outcome of sociopolitical struggles and clashes among trade unions, employers, physicians associations, and the state. This suggests that NHI in the United States could similarly emerge from our patchwork accumulation of federal, state, and employer-sponsored plans so long as we recognize the legitimate role of government in overseeing the rules and framework within which these actors operate.

The final sentence shows agreement with me that a Bismarck system, not a single payer system such as Canada uses, seems to fit the US.  If you read the article you'll see France, although not perfect, excels and has been ranked #1 in the world by the WHO.  But that's just me, the World Health Organization, and the National Institute of Health talking so take it with a grain of salt.

mm1970

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Re: What comes after the ACA?
« Reply #1945 on: April 13, 2017, 02:55:38 PM »
What's the rationale for treating cancer in those 75+? The Federal government is spending a $600B on people over 65 and is causing prices to skyrocket for everyone, does it make sense to spend hundreds of thousands on treatment for the elderly?

Children aged 0-14, and teenagers and young adults aged 15-24, each account for less than one per cent of all new cancer cases in the UK (2011-2013).[1-4] Adults aged 25-49 contribute a tenth (10%) of all new cancer cases, with twice as many cases in females as males in this age group.[1-4] Adults aged 50-74 account for over half (53%) of all new cancer cases, and elderly people aged 75+ account for over a third (36%), with slightly more cases in males than females in both age groups. There are more people aged 50-74 than aged 75+ in the population overall, hence the number of cancer cases is higher in 50-74s, but incidence rates are higher in 75+.

For most cancer types, incidence increases with age. This largely reflects cell DNA damage accumulating over time. Damage can result from biological processes or from exposure to risk factors. A drop or plateau in incidence in the oldest age groups often indicates reduced diagnostic activity perhaps due to general ill health.

http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age#heading-Zero
This may be a reasonable point and the answer is: it depends.

When I met my husband, his grandmother was undergoing treatment for cancer.  If I am able to do the math correctly, then she was 74, and declared in remission when she was 75.

She lived to be 95, just a hair shy of 96.  More than 20 more years.  In fact, in her last two years of life, her cancer recurred.

The doctor gave my FIL the choice to treat it aggressively or not, because of her age and declining health.  Well, he opted to not treat.  She lived through 2 years of increasing pain and suffering, that drugs could only partially help.  To be honest, though it seemed like the right idea at the time, he regrets that decision.  He was not expecting her to live 2 more years.  But there's some serious longevity in the women in that family.

So...I guess it depends. Reasonably healthy people can live to be 90+.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1946 on: April 13, 2017, 07:13:47 PM »
So to others willing to accept that when France says it's not a single payer, it's not a single payer, here's a nicely done but not too detailed write up from the US NIH.  I would encourage folks to read the whole article, but here's a key high light.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447687/

Quote
First, the French experience demonstrates that it is possible to achieve universal coverage without a “single-payer” system. To do this, however, will still require a statutory framework and an active state that regulates NHI financing and provider reimbursement. Of course, French NHI was not designed from scratch as a pluralistic, multipayer system providing universal coverage on the basis of occupational status. It is the outcome of sociopolitical struggles and clashes among trade unions, employers, physicians associations, and the state. This suggests that NHI in the United States could similarly emerge from our patchwork accumulation of federal, state, and employer-sponsored plans so long as we recognize the legitimate role of government in overseeing the rules and framework within which these actors operate.

The final sentence shows agreement with me that a Bismarck system, not a single payer system such as Canada uses, seems to fit the US.  If you read the article you'll see France, although not perfect, excels and has been ranked #1 in the world by the WHO.  But that's just me, the World Health Organization, and the National Institute of Health talking so take it with a grain of salt.

Very interesting. I think the Obamacare/ACA was a partial step in the direction of a Bismarck system.

And here's an excellent article about how states can insulate themselves from Trump's sabotage.

http://www.vox.com/policy-and-politics/2017/4/13/15262614/obamacare-alaska-reinsurance
« Last Edit: April 13, 2017, 08:23:33 PM by DavidAnnArbor »

PiobStache

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Re: What comes after the ACA?
« Reply #1947 on: April 14, 2017, 09:49:40 AM »
Very interesting. I think the Obamacare/ACA was a partial step in the direction of a Bismarck system.

And here's an excellent article about how states can insulate themselves from Trump's sabotage.

http://www.vox.com/policy-and-politics/2017/4/13/15262614/obamacare-alaska-reinsurance

The ACA just had too many flaws.  From the "market place" Medicaid coverage, that everyone knew was going to blow up in multiple states, to "the mandate" and playing games as to whether or not it was a tax, it was doomed to failure.  It was clearly constructed in an echo chamber as the Jonathan Gruber videos substantiate.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #1948 on: April 14, 2017, 10:25:37 AM »
to "the mandate"

If we are going to have community rating whereby everyone can get insurance regardless of medical condition, then the mandate is needed so that the risk pool of insured is not only people who are sick, and this insures that the price insurers charge is not catastrophic. Combine this mandate with the premium subsidies and the cost sharing enables healthy people with lower incomes to be able to afford it.

PiobStache

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Re: What comes after the ACA?
« Reply #1949 on: April 14, 2017, 10:41:46 AM »
to "the mandate"

If we are going to have community rating whereby everyone can get insurance regardless of medical condition, then the mandate is needed so that the risk pool of insured is not only people who are sick, and this insures that the price insurers charge is not catastrophic. Combine this mandate with the premium subsidies and the cost sharing enables healthy people with lower incomes to be able to afford it.

You misunderstand my comment and I'm pretty solid on the economic theory so don't need an explanation.  I can see your internal landscape here due to your selective editing.  Why did you edit out:

Quote
and playing games as to whether or not it was a tax..

If you did not quote me out of context it would be clear what the intent of mentioning the mandate was.
« Last Edit: April 14, 2017, 10:44:35 AM by PiobStache »