Author Topic: What comes after the ACA?  (Read 403444 times)

nereo

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Re: What comes after the ACA?
« Reply #3700 on: October 12, 2017, 11:45:45 AM »
This rule change will be going to court.  Trying to change law by EO when you fail in congress is disgraceful, no matter who does it.

You are not alone in believing this EO will wind up in the courts.  The article linked up-thread predicts as much, and both Trump's public statements and his actions appear to intentionally undermine federal law. 

More broadly speaking, such actions could be interpreted as further evidenec of DJT being unwilling to uphold the duties of his office.
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protostache

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Re: What comes after the ACA?
« Reply #3701 on: October 12, 2017, 12:13:56 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

radram

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Re: What comes after the ACA?
« Reply #3702 on: October 12, 2017, 12:15:53 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA).  Once again people will be able to buy health insurance that doesn't cover much and costs less.  The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available.  Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance).  This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").


Thank you for the comment nero. Doesn't the death spiral only apply to ACA recipients that do NOT qualify for subsidies. I agree that those that remain in ACA plans will necessarily have more expensive plans since presumably the healthy people will leave, but aren't those on the subsidy protected to the tune of something like 90% of all cost increases? So if my subsidized plan for a family of 4 costs a total of $1200 per month, and my non-subsidized portion is $250 per month, and my plan then doubles in real dollars to $2400, won't my premium only increase something like another $50, or even not at all?

protostache

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Re: What comes after the ACA?
« Reply #3703 on: October 12, 2017, 12:26:39 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA).  Once again people will be able to buy health insurance that doesn't cover much and costs less.  The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available.  Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance).  This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").


Thank you for the comment nero. Doesn't the death spiral only apply to ACA recipients that do NOT qualify for subsidies. I agree that those that remain in ACA plans will necessarily have more expensive plans since presumably the healthy people will leave, but aren't those on the subsidy protected to the tune of something like 90% of all cost increases? So if my subsidized plan for a family of 4 costs a total of $1200 per month, and my non-subsidized portion is $250 per month, and my plan then doubles in real dollars to $2400, won't my premium only increase something like another $50, or even not at all?

Correct. Premium subsidies are tied to your income in relation to the 2nd least expensive Silver plan (the benchmark) in your rating area. If you're eligible for subsidies at all you won't pay more than a legally mandated percentage of your income for the benchmark plan, no matter how much it costs. Table 2 here explains the breakdown, but say you're paying 2% of your income for health insurance (which is like $200 in that 100%-133% bracket) and the unsubsidized premium of the 2nd least expensive Silver plan goes from $1000 to $2000, your subsidy amount goes from $800 to $1800. This gets really weird when CSR offsets are loaded onto just Silver plans like what California is doing for 2018, because all of the sudden the Silver plans are way more expensive than anything else. People will be steered toward Gold plans with the same subsidized premium cost or Bronze plans with a zero dollar premium instead of the Silver plans.

Inaya

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Re: What comes after the ACA?
« Reply #3704 on: October 12, 2017, 12:31:08 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

Interesting...

I wonder if Trump even read it. He probably thinks he's signing the End of Obamacare (EO)--and nobody bothered to tell him the order was just to consider proposing some stuff. His base will eat it up, they'll not notice or care when nothing materially changes, and little damage is ultimately done--right? I wonder who was the actual power behind this EO.
« Last Edit: October 12, 2017, 12:32:40 PM by Inaya »
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Exflyboy

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Re: What comes after the ACA?
« Reply #3705 on: October 12, 2017, 12:31:20 PM »
Yes the 90% of cost increases... Devil is in the details of course. in Oregon apparently costs have only risen by 15% from 2017 to 2018.

The way I see that my HC provider got around that was to simply cancel my policy..

"Oh we don't offer that policy anymore.. But you might be interested in THIS policy which offers slightly worse coverage than before".. The slightly worse coverage is not a big deal but then cost of the new plan is then +30% compared to the old one.

So while on aggregate costs may have increased 15%, in reality individual policies can be way off that mark.

So if as a subsidy payer you might be protected against cost increases, the question becomes is that in aggregate or for individual policy holders?

I.e do they protect you against the 30%, or do they protect you against the 15%.. but then stick you with the other 15%.. Big difference.


protostache

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Re: What comes after the ACA?
« Reply #3706 on: October 12, 2017, 12:34:48 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

Interesting...

I wonder if Trump even read it. He probably thinks he's signing the End of Obamacare (EO)--and nobody bothered to tell him the order was just to consider proposing some stuff. His base will eat it up, they'll not notice or care when nothing materially changes, and little damage is ultimately done--right? I wonder who was the actual power behind this EO.

He didn't read it. If he did he didn't understand the impact of using the words "shall consider" instead of just "shall".

This is the president that didn't know what the 25th amendment was until Steve Bannon told him. He is not a detail oriented person.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3707 on: October 12, 2017, 09:42:45 PM »
Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again

https://nyti.ms/2kKn0GP

Roland of Gilead

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Re: What comes after the ACA?
« Reply #3708 on: October 12, 2017, 10:18:28 PM »
Orange Asshole

mosprott

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Re: What comes after the ACA?
« Reply #3709 on: October 12, 2017, 11:55:54 PM »
Petulant baby.

The next few weeks are going to be a mad scramble.

ZiziPB

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Re: What comes after the ACA?
« Reply #3710 on: October 13, 2017, 05:34:16 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.



Mr. Green

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Re: What comes after the ACA?
« Reply #3711 on: October 13, 2017, 06:24:53 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.
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talltexan

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Re: What comes after the ACA?
« Reply #3712 on: October 13, 2017, 06:52:51 AM »
Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.

Jokes!  Just jokes.  I love our Canadian neighbors, their food, their women, their landscapes, their accents, and their civility.  And their healthcare.  But what kind of neighbour would I be if we couldn't trade a little light ribbing?

The other comments above about non-federal restrictions to importing more medical professionals are well taken, but those rules come from the same slightly racist and overtly protectionist mindset responsible for our immigration restrictions.  Doctors know they can command outrageous salaries only as long as they are a scarce resource, so they created barriers to entry in their field.  I know other professions have done the same.  That doesn't make it right.

And in a moment like this one, when the national conversation centers on improving access and lowering costs for Americans seeking healthcare, I think that reevaluating our protectionist policies is a good place to start. 

If you really want to solve this enormous and intractable problem that has so efficiently divided the nation, which has stymied congress and spawned so many pages of this very thread and thousands of others like it across the internet, maybe consider just talking to the AMA about changing those rules?

Also, did sol just make the case for systematically draining talent from other countries at their expense? That's quite out of character.

Yes I did.  We do it with programmers and engineers.  We do it with agricultural workers, and manicurists, and drywall mudders, and taxi drivers.  In previous generations we did it with police officers and nuclear scientists.  America was built by stealing the most talented and motivated people from every other country and offering them a chance at a better life here, with more freedoms and more opportunity and hopefully with more prosperity.  I see no reason to deny this part of our history.  Our diversity is a big part of our success.

So yes, by all means drain those foreign talent pools.  They also get to try to drain ours.  May the best country win.

I used to pick on Canadians because I thought people from Alberta were just like my native Texas.

Then I learned about the maritime provinces, and how the party there basically never stops. Now, I just want to figure out how to move to one of those ;-)

ZiziPB

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Re: What comes after the ACA?
« Reply #3713 on: October 13, 2017, 07:09:33 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.

Thanks for the explanation.  I also heard on NPR this morning that the open enrollment period is being shortened this year and that the website where you sign up will be shut down weekly for maintenance.  So clearly significant effort is being made to ensure that the individual marketplace implodes as soon as next year.



jim555

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Re: What comes after the ACA?
« Reply #3714 on: October 13, 2017, 07:28:35 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The CSRs are not PTC subsidies so this won't kill the exchanges.  In fact it will cost the Feds more since the PTC subsidies are hinged to the SLCSP.

farmecologist

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Re: What comes after the ACA?
« Reply #3715 on: October 13, 2017, 07:42:29 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.

Thanks for the explanation.  I also heard on NPR this morning that the open enrollment period is being shortened this year and that the website where you sign up will be shut down weekly for maintenance.  So clearly significant effort is being made to ensure that the individual marketplace implodes as soon as next year.

Trump and his cohorts are clearly in scorched-earth mode since they didn't get their way by working with congress. 

This may be an attempt to 'punish' congress...but the collateral will be those who can least afford it.

The lack of empathy of Trump and his ilk boggles the mind.




brooklynguy

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Re: What comes after the ACA?
« Reply #3716 on: October 13, 2017, 07:53:58 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The CSRs are not PTC subsidies so this won't kill the exchanges.  In fact it will cost the Feds more since the PTC subsidies are hinged to the SLCSP.

Ending the CSR payments will have a disproportionately adverse impact in New York, possibly killing the Essential Plan (which I know has particular relevance to you, Jim, and to me as well) as explained in this thread.

I'm cautiously optimistic that Congress will strike a deal to appropriate funds for the CSR payments, thereby neutering Trump's ability to terminate them.

desertadapted

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Re: What comes after the ACA?
« Reply #3717 on: October 13, 2017, 08:17:44 AM »
Quick question to make sure Im understanding the impacts correctly.  (1) Insurers are still required to pay the CSRs even if not reimbursed by the feds; (2) Insurers will raise rates on everyone in the individual market to compensate for the lack of CSR payments (I think ~20% increase has been the average); (3) lower income folks entitled to federal subsidy on their insurance will just have their subsidy increased by the feds using a funding mechanism thats already in place; and (4) the increased ~20% hit falls entirely on earners who make too much to qualify for a subsidy (and the taxpayer, but the taxpayer had to pay for the CSR anyway).  Am I getting this right?

jim555

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Re: What comes after the ACA?
« Reply #3718 on: October 13, 2017, 08:40:47 AM »
Quick question to make sure Im understanding the impacts correctly.  (1) Insurers are still required to pay the CSRs even if not reimbursed by the feds; (2) Insurers will raise rates on everyone in the individual market to compensate for the lack of CSR payments (I think ~20% increase has been the average); (3) lower income folks entitled to federal subsidy on their insurance will just have their subsidy increased by the feds using a funding mechanism thats already in place; and (4) the increased ~20% hit falls entirely on earners who make too much to qualify for a subsidy (and the taxpayer, but the taxpayer had to pay for the CSR anyway).  Am I getting this right?
It depends how each state decides to pass on the increase.  If it is confined to the Silvers then pick a non-Silver plan if you are over 400%. 

Roland of Gilead

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Re: What comes after the ACA?
« Reply #3719 on: October 13, 2017, 08:51:00 AM »
If they get rid of cost sharing, we will just go to Medicaid.   No asset test on that and no estate clawback if you are younger than 55 I believe.

So instead of paying $150 a month, we will actually pay $0.  Take that!

jim555

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Re: What comes after the ACA?
« Reply #3720 on: October 13, 2017, 08:54:46 AM »
If they get rid of cost sharing, we will just go to Medicaid.   No asset test on that and no estate clawback if you are younger than 55 I believe.

So instead of paying $150 a month, we will actually pay $0.  Take that!
That is what I did, so glad I don't have to worry about all this.

gaja

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Re: What comes after the ACA?
« Reply #3721 on: October 13, 2017, 09:10:20 AM »
EnjoyIt, thanks for giving us your physician's perspective on the compensation issue.  Just out of curiosity, how much are we talking about on an annual basis for licensing fees, malpractice insurance, and unreimbursed costs of treating indigent patients?  I'm sure those costs vary a lot from place to place and from specialty to specialty, but can you give us some ballpark ranges?

It sounds like this malpractice thing is very expensive? To compare - all malpractice stuff in Norway is handled by one governmental agency, and everyone who employs medical personell (or runs a private office) has to pay into the system. The price list is here, divide by 8 to get from NOK to USD: https://lovdata.no/dokument/SF/forskrift/2008-10-31-1166/%C2%A710#10 Surgeons are most expensive, at $28000 a year, while a "normal" doctor pays $3200 a year.
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Rcc

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Re: What comes after the ACA?
« Reply #3722 on: October 13, 2017, 09:42:53 AM »
Happy Friday.

After watching this thread grow to 75 pages,  Ive come to the same conclusion I initially had when I read the question...

\_(ツ)_/

sol

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Re: What comes after the ACA?
« Reply #3723 on: October 13, 2017, 09:48:11 AM »
EnjoyIt, thanks for giving us your physician's perspective on the compensation issue.  Just out of curiosity, how much are we talking about on an annual basis for licensing fees, malpractice insurance, and unreimbursed costs of treating indigent patients?  I'm sure those costs vary a lot from place to place and from specialty to specialty, but can you give us some ballpark ranges?

It sounds like this malpractice thing is very expensive? To compare - all malpractice stuff in Norway is handled by one governmental agency, and everyone who employs medical personell (or runs a private office) has to pay into the system. The price list is here, divide by 8 to get from NOK to USD: https://lovdata.no/dokument/SF/forskrift/2008-10-31-1166/%C2%A710#10 Surgeons are most expensive, at $28000 a year, while a "normal" doctor pays $3200 a year.

Isn't malpractice insurance tax deductible?  I always feel like these physician complaints about how their outrageous salaries aren't really that outrageous to be somewhat misleading.  Those are salaries AFTER business expenses like overhead and billing, and things like licensing and practice insurance should be billed as deductible business expenses.

Plus it pisses me off to hear rich people say things like "I don't really make twice as much as you because of our progressive tax code."  Fuck that BS.  If your salary is so beaten down by taxes, then surely you wouldn't mind trading it for my much lower salary instead, because the taxes will be lower?  No?  Then just admit you're rich as hell and stop complaining.

keyvaluepair

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Re: What comes after the ACA?
« Reply #3724 on: October 13, 2017, 09:55:42 AM »
I believe that you should be rich because you took some risks and made something worthwhile. Just going to med school shouldn't be enough. It only works because the AMA is a cartel - yeah, I realize that this might be flamebait.

Bucksandreds

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Re: What comes after the ACA?
« Reply #3725 on: October 13, 2017, 10:23:29 AM »
EnjoyIt, thanks for giving us your physician's perspective on the compensation issue.  Just out of curiosity, how much are we talking about on an annual basis for licensing fees, malpractice insurance, and unreimbursed costs of treating indigent patients?  I'm sure those costs vary a lot from place to place and from specialty to specialty, but can you give us some ballpark ranges?

It sounds like this malpractice thing is very expensive? To compare - all malpractice stuff in Norway is handled by one governmental agency, and everyone who employs medical personell (or runs a private office) has to pay into the system. The price list is here, divide by 8 to get from NOK to USD: https://lovdata.no/dokument/SF/forskrift/2008-10-31-1166/%C2%A710#10 Surgeons are most expensive, at $28000 a year, while a "normal" doctor pays $3200 a year.

Isn't malpractice insurance tax deductible?  I always feel like these physician complaints about how their outrageous salaries aren't really that outrageous to be somewhat misleading.  Those are salaries AFTER business expenses like overhead and billing, and things like licensing and practice insurance should be billed as deductible business expenses.

Plus it pisses me off to hear rich people say things like "I don't really make twice as much as you because of our progressive tax code."  Fuck that BS.  If your salary is so beaten down by taxes, then surely you wouldn't mind trading it for my much lower salary instead, because the taxes will be lower?  No?  Then just admit you're rich as hell and stop complaining.

In theory, I agree with you. I think that some physicians may be employed at hospitals that pay them a salary and expect them to pay their own malpractice with income that may or may not be tax deducted. I totally was thinking the same thing when I read the part claiming that double income isn't really double income. I was thinking that he's correct that making double does not equal double net.  But really we should consider how much money one has left after paying taxes and cost of basic living.  If I make double what you do then I should have more than double what you do after accounting for both parties paying for the necessities. Even after considering the higher marginal taxes on the added income.  Being a doctor or dentist (I am a dentist) in the US is somewhat of a cartel job that keeps it's own salaries artificially high. Subsidized medical/dental school with incomes more inline with engineering could be a good way to take several percent off of the cost of healthcare in the US. I obviously see that there is not one big change that will make healthcare more affordable but 20 or more small ones that each may only lower the cost of healthcare a percent or two.

bacchi

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Re: What comes after the ACA?
« Reply #3726 on: October 13, 2017, 10:29:46 AM »
Isn't malpractice insurance tax deductible?  I always feel like these physician complaints about how their outrageous salaries aren't really that outrageous to be somewhat misleading.  Those are salaries AFTER business expenses like overhead and billing, and things like licensing and practice insurance should be billed as deductible business expenses.

Of course it's after. A ob/gyn couldn't have $250k revenue, pay $100k malpractice, pay $100k for staff, and make only $50k.

https://www.cunninghamgroupins.com/historic-medical-malpractice-insurance-rates/

Internists pay about $27k in Miami for malpractice.

Look at Texas, in particular. Malpractice rates have gone down because of tort reform. Great! A way to control costs, we think. Lowering business costs doesn't always translate to lowered customer costs, though. There are studies about -- that I'm too lazy to find right now -- that analyze whether patient costs dropped and, surprise, they didn't. Tort reform only served to increase doctor's incomes.

In other words, tort reform doesn't do shit for lowering our costs for health care.

Mr. Green

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Re: What comes after the ACA?
« Reply #3727 on: October 13, 2017, 11:23:13 AM »
This latest development has me wondering if I should return to work. I'm from an industry where once you're out for a year it's extremely difficult to come back. Our FIRE budget can't handle an extra 10-15k in healthcare costs permanently. Not going back means trusting lawmakers will fix this mess. Based on the recent past, I question if that would be a sound decision on my part. My wife could just work indefinitely but that's not what we've been talking about for years now, quite the opposite.
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sol

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Re: What comes after the ACA?
« Reply #3728 on: October 13, 2017, 11:30:36 AM »
Maybe the ACA sabotage will be the missing catalyst this latent recession has been waiting for.  Trump has certainly been doing his best to put a stop to our current economic prosperity, surely one of these times he'll find the right button to push.

Mr. Green

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Re: What comes after the ACA?
« Reply #3729 on: October 13, 2017, 11:35:46 AM »
Maybe the ACA sabotage will be the missing catalyst this latent recession has been waiting for.  Trump has certainly been doing his best to put a stop to our current economic prosperity, surely one of these times he'll find the right button to push.
He just yanked the Iran deal too. I'm sure that won't help, as stability goes.
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jorjor

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Re: What comes after the ACA?
« Reply #3730 on: October 13, 2017, 11:36:13 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.

re: CSRs getting removed. You say they still have to give reduced premiums, but the new changes only affect cost sharing subsidies, not premium subsidies. Still a big deal though.

To the rest of your post, yes carriers have already submitted rates and are theoretically locked in, but many states allowed carriers to file two sets of rates, one to use if CSR funds got axed (with higher rates to compensate) and one if it was status quo so some will have planned this into the rates that end up going live. Still others are allowing insurers to refile rates quickly to get them in before they have to go live. Finally, while carriers are locked into rates, they can theoretically just drop out of the individual market and never actually sell those policies. State regulators can make that option unsavory by locking them out of other markets if they do that, but the individual market itself is not a huge part of business for a good number of carriers and they are more likely to just take their ball and go home.

jim555

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Re: What comes after the ACA?
« Reply #3731 on: October 13, 2017, 11:39:22 AM »
The insurers will certainly sue for the payments.  NY is suing.  They will probably win in the end.  Big fat mess for no good reason.

Bucksandreds

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Re: What comes after the ACA?
« Reply #3732 on: October 13, 2017, 11:52:30 AM »
This latest development has me wondering if I should return to work. I'm from an industry where once you're out for a year it's extremely difficult to come back. Our FIRE budget can't handle an extra 10-15k in healthcare costs permanently. Not going back means trusting lawmakers will fix this mess. Based on the recent past, I question if that would be a sound decision on my part. My wife could just work indefinitely but that's not what we've been talking about for years now, quite the opposite.

If you're healthy then the new "short term" plans will be cheap. It sounds like Trump's workaround is that since he can't change the law he can just change what a short term plan means. These plans don't have to meet any ACA standards.  Maybe you have to get a new short term plan every few years. As long as you stay healthy then you'd have cheap insurance. i do not agree with Trump doing this, however.

jorjor

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Re: What comes after the ACA?
« Reply #3733 on: October 13, 2017, 11:55:24 AM »
Quick question to make sure Im understanding the impacts correctly.  (1) Insurers are still required to pay the CSRs even if not reimbursed by the feds; (2) Insurers will raise rates on everyone in the individual market to compensate for the lack of CSR payments (I think ~20% increase has been the average); (3) lower income folks entitled to federal subsidy on their insurance will just have their subsidy increased by the feds using a funding mechanism thats already in place; and (4) the increased ~20% hit falls entirely on earners who make too much to qualify for a subsidy (and the taxpayer, but the taxpayer had to pay for the CSR anyway).  Am I getting this right?
It depends how each state decides to pass on the increase.  If it is confined to the Silvers then pick a non-Silver plan if you are over 400%.

Yeah, states will dictate this. It works best if you layer it onto silvers for the reason you mentioned: Low incomes don't care because they are subsidized anyway, high incomes can choose something else. That said, I know some states are requiring it spread over all metal levels.

Mr. Green

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Re: What comes after the ACA?
« Reply #3734 on: October 13, 2017, 12:07:49 PM »
This latest development has me wondering if I should return to work. I'm from an industry where once you're out for a year it's extremely difficult to come back. Our FIRE budget can't handle an extra 10-15k in healthcare costs permanently. Not going back means trusting lawmakers will fix this mess. Based on the recent past, I question if that would be a sound decision on my part. My wife could just work indefinitely but that's not what we've been talking about for years now, quite the opposite.

If you're healthy then the new "short term" plans will be cheap. It sounds like Trump's workaround is that since he can't change the law he can just change what a short term plan means. These plans don't have to meet any ACA standards.  Maybe you have to get a new short term plan every few years. As long as you stay healthy then you'd have cheap insurance. i do not agree with Trump doing this, however.
The problem with short term policies is that everyone is healthy until they're not. No one knows when they're going to get cancer of be in a life-altering accident, etc. Those policies also typically have lifetime caps and other items that make them not a good substitute for traditional health insurance. We could go that route only to become sick and put in a bad position due to short term policy restrictions. This is especially important for an early retiree who might have significant assets they don't want to see depleted over one medical emergency.
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Mr. Green

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Re: What comes after the ACA?
« Reply #3735 on: October 13, 2017, 12:14:47 PM »
re: CSRs getting removed. You say they still have to give reduced premiums, but the new changes only affect cost sharing subsidies, not premium subsidies. Still a big deal though.
I don't know what the percentage is but I believe is is significant how many people get CSRs. That cost will become a direct loss to insurers in 2019 if they are unable to recoup it through premium subsidies alone. Skyrocketing rates will cause most of the people not getting subsidies of any kind to drop out. If insurers are unable to mitigate those costs through premium subsidies they'll just drop out, leaving everyone on the exchanges with no options for healthcare. I'm not confident that insurers will be able to remain profitable with the loss of CSRs and the waterfall effect it has on how the rest of the system works.
« Last Edit: October 13, 2017, 12:37:00 PM by Mr. Green »
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Bucksandreds

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Re: What comes after the ACA?
« Reply #3736 on: October 13, 2017, 02:22:25 PM »
This latest development has me wondering if I should return to work. I'm from an industry where once you're out for a year it's extremely difficult to come back. Our FIRE budget can't handle an extra 10-15k in healthcare costs permanently. Not going back means trusting lawmakers will fix this mess. Based on the recent past, I question if that would be a sound decision on my part. My wife could just work indefinitely but that's not what we've been talking about for years now, quite the opposite.

If you're healthy then the new "short term" plans will be cheap. It sounds like Trump's workaround is that since he can't change the law he can just change what a short term plan means. These plans don't have to meet any ACA standards.  Maybe you have to get a new short term plan every few years. As long as you stay healthy then you'd have cheap insurance. i do not agree with Trump doing this, however.
The problem with short term policies is that everyone is healthy until they're not. No one knows when they're going to get cancer of be in a life-altering accident, etc. Those policies also typically have lifetime caps and other items that make them not a good substitute for traditional health insurance. We could go that route only to become sick and put in a bad position due to short term policy restrictions. This is especially important for an early retiree who might have significant assets they don't want to see depleted over one medical emergency.

If all other signup conditions stay the same then you could buy short term insurance and then upgrade to an ACA plan within months of getting any serious medical condition.  Its a sham and it will destroy the ACA (as Trump wants to) but it may work for you.

jim555

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Re: What comes after the ACA?
« Reply #3737 on: October 13, 2017, 02:33:49 PM »
Crap short term / association policies will siphon off the healthy, leaving the ACA for the sick.  Death spiral in rates could result.  Only those in the subsidy range or Medicaid will be ok.  The Feds will be paying massive subsidies in the destabilized market.

Hope you never get sick with a junk policy.

The sabotage has a big chance of backfiring on the orange dunce. 

Exflyboy

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Re: What comes after the ACA?
« Reply #3738 on: October 13, 2017, 02:40:58 PM »
This latest development has me wondering if I should return to work. I'm from an industry where once you're out for a year it's extremely difficult to come back. Our FIRE budget can't handle an extra 10-15k in healthcare costs permanently. Not going back means trusting lawmakers will fix this mess. Based on the recent past, I question if that would be a sound decision on my part. My wife could just work indefinitely but that's not what we've been talking about for years now, quite the opposite.

The additional problem is it might be $10-15k now but HC costs are going to rocket 20%+ per year going forward.

Personally I think if they really did gut the ACA (and Medicaid) that it would affect people so badly that it really just wouldn't happen.. OK that maybe a starry eyed view of the situation but if you are at a point of FI then you have a significant moat insulating you from the worst of the effects.

You could of course go back to work for say 2 years and build a bigger buffer of stash.. And then they may stick with the ACA anyway and you just have more money to spend.

v8rx7guy

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Re: What comes after the ACA?
« Reply #3739 on: October 13, 2017, 02:45:18 PM »
I am still hopeful that it gets replaced with something better, as promised...  And I think Trump deserves the chance to do so.  He was elected by the American people on that promise.

sol

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Re: What comes after the ACA?
« Reply #3740 on: October 13, 2017, 02:49:52 PM »
If he manages to end the CSR payments, it will only cost the government more money in the end.  Where is the master negotiator here?  What kind of deal is this?  Doesn't look so great to me.

It looks like he's doing it primarily for the purpose of motivating congressional democrats to revisit repeal and replace, which seems very backwards.  Every single republican plan offered thus far is waaay worse than just ending the CSR payments, so democrats in congress are probably thrilled that he is openly and brazenly making health insurance worse for millions of Americans while simultaneously converting it from an Obama policy to a Trump policy.  He's taking ownership of it, by deliberately and publicly making changes to the law by unilateral action.  It has now become his (handicapped) baby.

This looks like the same playbook he used on DACA, the TPP, the fiduciary rule for financial advisors, the ban on civil forfeiture, the clean power plan, transgender troops, gun sales to the mentally ill, and soon on the Iran deal.  He finds an existing Obama era rule that appears to be working fine, unilaterally overturns it by EO, then leaves his own republican congress scrambling to come up with some sort of replacement.  Except he's doing it so fast, and congress is so dysfunctional, that nothing gets fixed even when republicans hate what he's doing.

Republicans in Congress don't really want to ruin healthcare coverage for their constituents.  For the most part, they expect to be in office long after Trump is relegated to the history books as "worst US President ever."  I think they mostly want to fix healthcare, but feel boxed in by their campaign rhetoric and an infantile tweeter with no grasp of policy subtleties. 

Meanwhile, the president is feverishly stoking resentment among the minority of Americans who supported him in the hopes of shoring up his base, without any consideration of how his actions are impacting the country as a whole.  He doesn't care about what is good for the country, only what gets applause at rallies.  He's more entertainer than politician, and his impulsive pursuit of that resentful minority's applause is only weakening the country, not restoring it as he promised.
« Last Edit: October 13, 2017, 03:02:06 PM by sol »

jorjor

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Re: What comes after the ACA?
« Reply #3741 on: October 13, 2017, 02:57:18 PM »
re: CSRs getting removed. You say they still have to give reduced premiums, but the new changes only affect cost sharing subsidies, not premium subsidies. Still a big deal though.
I don't know what the percentage is but I believe is is significant how many people get CSRs. That cost will become a direct loss to insurers in 2019 if they are unable to recoup it through premium subsidies alone. Skyrocketing rates will cause most of the people not getting subsidies of any kind to drop out. If insurers are unable to mitigate those costs through premium subsidies they'll just drop out, leaving everyone on the exchanges with no options for healthcare. I'm not confident that insurers will be able to remain profitable with the loss of CSRs and the waterfall effect it has on how the rest of the system works.

The portion of people getting CSRs is significant. About 50-60% depending on whether a state expanded Medicaid (expansion siphons off some of low income 94% CSR members). But it is only a direct loss if you can't recoup it elsewhere. They will recoup by raising the underlying rates. About 85% of members get APTCs, so the amount they pay is related to their income and not the rate itself since they pay up to x% of income and premium subsidies (which are not being impacted here) make up the rest. That vast majority sees almost no change as a result of rates increasing to cover the CSRs funding being axed. There just ends up being higher premium subsidies paid, which is funny because the government doesn't actually save any money that way, they just end up paying a different kind of subsidy.

That leaves 15% who are price sensitive. So if you increase rates then some of them may leave. But states are letting carrier load the entire cost onto silver plans. That leaves other metal levels largely unaffected. Don't get subsidies? Just buy another plan that didn't get the load. Extra fun fact: Since subsidies are tied to the second lowest silver, and the second lowest silver rates are going to go up way more as these costs are loaded onto sliver plans, so does the premium tax credits. So the people who are between 250%-400% FPL (too much for CSRs but still get premium subsidies) just saw would see their raw subsidy go way up, making a buy-up to bronze or gold cheaper than before.

So if handled right by the states (and states have been handling it that correctly for the most part) then most consumers end up being be mostly unaffected, some may be better off, insurers could be mostly unaffected, and the real big change is that the government could end up paying more in subsidies than they were before.

The real problem for the markets themselves is if insurers can't price for the loss in CSR revenue (which might happen in some states, I'm not familiar with all), or if there are other changes that hit premium subsidies. But the CSR thing itself isn't this disastrous problem that will bring down the insurance companies and send the individual market crashing. Honestly, the short-term medical EO would have far bigger implications on anti-selective lapse if it ends up being implemented by HHS.
« Last Edit: October 13, 2017, 03:02:38 PM by jorjor »

jorjor

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Re: What comes after the ACA?
« Reply #3742 on: October 13, 2017, 03:18:38 PM »
I should expand on how important the timing on the CSR news. 2018 rates have been filed and and it's probably too late to go back (though I know a couple states are allowing a quick change). States had to make a bet on what might happen and decide what they would allow in the rates. What happens in a market is dependent on how the state dealt with it when approving 2018 rates.

If a state required insurers to assume CSRs would be paid in 2018, then the loss of revenue is not recouped elsewhere and there will be turmoil in those states. Carriers dropping out, etc.

If a state allowed insurers to price the loss of CSRs in and to load onto silver only or some other splitting of on/off-Exchange rates so that insurers could price in a way that recouped costs while minimally impacting non-premium subsidy members, then those markets won't have much impact.

Here is a nice table of what path each state took: http://acasignups.net/17/10/13/sword-damocles-falls-trump-officially-cutting-csr-reimbursements. That leftmost column is where you will see the most turmoil. There will be minimal impacts in the silver load only and silver switcheroo columns, which includes a majority of states.
« Last Edit: October 13, 2017, 03:22:03 PM by jorjor »

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3743 on: October 13, 2017, 03:19:40 PM »
Short-term medical plans are essentially what existed before Obamacare, because any plan you got, would go up in price so much, that you would have to start all over again looking for a new plan, filling out an application yet again claiming that you have no medical problems whatsoever.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3744 on: October 13, 2017, 03:56:25 PM »
Here is a nice table of what path each state took: http://acasignups.net/17/10/13/sword-damocles-falls-trump-officially-cutting-csr-reimbursements. That leftmost column is where you will see the most turmoil. There will be minimal impacts in the silver load only and silver switcheroo columns, which includes a majority of states.

Great article. I really like the quote, "Yes, that's right: Once again, Donald J. Trump is stiffing contractors out of their contractually-owed payments. So what else is new?"

sol

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Re: What comes after the ACA?
« Reply #3745 on: October 13, 2017, 04:01:09 PM »
Jorjor's link suggests that ending the CSR payments will cost the federal government an extra $2.4 billion, because it will just have to pay larger APTC subsidies in place of the CSR subsidies. It's an interesting read.

jorjor

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Re: What comes after the ACA?
« Reply #3746 on: October 13, 2017, 04:06:00 PM »
Here is a nice table of what path each state took: http://acasignups.net/17/10/13/sword-damocles-falls-trump-officially-cutting-csr-reimbursements. That leftmost column is where you will see the most turmoil. There will be minimal impacts in the silver load only and silver switcheroo columns, which includes a majority of states.

Great article. I really like the quote, "Yes, that's right: Once again, Donald J. Trump is stiffing contractors out of their contractually-owed payments. So what else is new?"

I thought it was a pretty good summary and could be understood by those who aren't in the industry. Here is a more explanation of each of the paths: http://acasignups.net/17/10/12/there-will-be-math-silver-switcharoo-how-make-trumps-csr-sabotage-backfire.


jorjor

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Re: What comes after the ACA?
« Reply #3747 on: October 13, 2017, 04:06:39 PM »
Jorjor's link suggests that ending the CSR payments will cost the federal government an extra $2.4 billion, because it will just have to pay larger APTC subsidies in place of the CSR subsidies. It's an interesting read.

Also, Kaiser Family Foundation did an article when CSRs were being talked about a while back: https://www.kff.org/health-reform/issue-brief/the-effects-of-ending-the-affordable-care-acts-cost-sharing-reduction-payments/

They came to a similar conclusion  of minimal impact to the member and increased cost to the Federal government, provided the state allows rates to be filed to handle the CSR funding removal:

Quote
Any systematic increase in premiums for silver marketplace plans (including the benchmark plan) would increase the size of premium tax credits. The increased tax credits would completely cover the increased premium for subsidized enrollees covered through the benchmark plan and cushion the effect for enrollees signed up for more expensive silver plans. Enrollees who apply their tax credits to other tiers of plans (i.e., bronze, gold, and platinum) would also receive increased premium tax credits even though they do not qualify for reduced cost-sharing and the underlying premiums in their plans might not increase at all.

We estimate that the increased cost to the federal government of higher premium tax credits would actually be 23% more than the savings from eliminating cost-sharing reduction payments. For fiscal year 2018, that would result in a net increase in federal costs of $2.3 billion. Extrapolating to the 10-year budget window (2018-2027) using CBOs projection of CSR payments, the federal government would end up spending $31 billion more if the payments end.

MrMoneySaver

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Re: What comes after the ACA?
« Reply #3748 on: October 13, 2017, 04:09:51 PM »
with no grasp of policy subtleties.

It's beyond that. I don't think he grasps even the broad strokes.

Mr. Green

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Re: What comes after the ACA?
« Reply #3749 on: October 13, 2017, 05:18:26 PM »
I am still hopeful that it gets replaced with something better, as promised...  And I think Trump deserves the chance to do so.  He was elected by the American people on that promise.
This is humorous in the saddest way possible because a President doesn't make laws. They can talk all they want about changing things but if Congress doesn't want to do it, it doesn't matter what the President says.
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