Author Topic: What comes after the ACA?  (Read 747504 times)

ZiziPB

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Re: What comes after the ACA?
« Reply #3700 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 #3701 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 #3702 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 #3703 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 #3704 on: October 13, 2017, 08:17:44 AM »
Quick question to make sure Iím understanding the impacts correctly.  (1) Insurers are still required to pay the CSRís 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 thatís 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 #3705 on: October 13, 2017, 08:40:47 AM »
Quick question to make sure Iím understanding the impacts correctly.  (1) Insurers are still required to pay the CSRís 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 thatís 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 #3706 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 #3707 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 #3708 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#ß10 Surgeons are most expensive, at $28000 a year, while a "normal" doctor pays $3200 a year.

Rcc

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Re: What comes after the ACA?
« Reply #3709 on: October 13, 2017, 09:42:53 AM »
Happy Friday.

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

Į\_(ツ)_/Į

sol

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Re: What comes after the ACA?
« Reply #3710 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#ß10 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 #3711 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 #3712 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#ß10 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 #3713 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 #3714 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.

sol

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Re: What comes after the ACA?
« Reply #3715 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 #3716 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.

jorjor

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Re: What comes after the ACA?
« Reply #3717 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 #3718 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 #3719 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 #3720 on: October 13, 2017, 11:55:24 AM »
Quick question to make sure Iím understanding the impacts correctly.  (1) Insurers are still required to pay the CSRís 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 thatís 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 #3721 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.

Mr. Green

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Re: What comes after the ACA?
« Reply #3722 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 »

Bucksandreds

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Re: What comes after the ACA?
« Reply #3723 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.  Itís 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 #3724 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 #3725 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 #3726 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 #3727 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 #3728 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 #3729 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 #3730 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 #3731 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 #3732 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 #3733 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 #3734 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 CBOís 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 #3735 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 #3736 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.

MDM

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Re: What comes after the ACA?
« Reply #3737 on: October 13, 2017, 05:26:25 PM »
...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.
Obama and Trump have both used executive orders to do things that congress "is supposed to" do.  Whether one thinks that is good or bad seems to depend, in many cases, on whether one agrees with what Obama or Trump did.  Or one could be happy or unhappy that the executive branch is usurping the legislative branch's function, regardless of the specific case.

seattlecyclone

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Re: What comes after the ACA?
« Reply #3738 on: October 13, 2017, 06:08:22 PM »
...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.
Obama and Trump have both used executive orders to do things that congress "is supposed to" do.  Whether one thinks that is good or bad seems to depend, in many cases, on whether one agrees with what Obama or Trump did.  Or one could be happy or unhappy that the executive branch is usurping the legislative branch's function, regardless of the specific case.

I've long been unhappy about the president's ever-increasing power. Even when it was a president taking actions I mostly agreed with, I was always aware that we could get someone who could abuse that power and that granting such a large amount of power to one man is just asking for trouble when you pick the wrong man.

ixtap

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Re: What comes after the ACA?
« Reply #3739 on: October 13, 2017, 06:26:27 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.

He said he had a plan. He has not put forward any plan.

sol

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Re: What comes after the ACA?
« Reply #3740 on: October 13, 2017, 07:38:56 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.

He said he had a plan. He has not put forward any plan.

And while we're picking nits, he was elected by the electoral college (on that promise).  The American people mostly voted against him.

But I do agree that he deserves a chance to offer something better.  It's been 11 months, and I'm still waiting to see it.  Today's developments were a step in the wrong direction, though.

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #3741 on: October 14, 2017, 12:26:25 AM »
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.

He said he had a plan. He has not put forward any plan.

And while we're picking nits, he was elected by the electoral college (on that promise).  The American people mostly voted against him.

But I do agree that he deserves a chance to offer something better.  It's been 11 months, and I'm still waiting to see it.  Today's developments were a step in the wrong direction, though.

Honestly - let's just be honest for a minute - Trump likes to make others do the impossible.  Maybe it worked for him in the past, pushing his brinkmanship to the edge and getting all the last crumbs he could even if he had to declare bankruptcy, but US government is not a pyramid like it was in his business world.  He puts up a ridiculous ultimatum and the Legislature looks at him like, WTF.  We wanted this to work, many of them even thought this would work and be amicable, but Trump unexpectedly throws friends under the bus and works with the opposition.  I don't see how this gets any better going forward; Trump has used all the plays in his limited playbook and he's not exactly at an age to learn new tricks.

nereo

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Re: What comes after the ACA?
« Reply #3742 on: October 14, 2017, 06:30:37 AM »
Honestly - let's just be honest for a minute - Trump likes to make others do the impossible.  Maybe it worked for him in the past, pushing his brinkmanship to the edge and getting all the last crumbs he could even if he had to declare bankruptcy, but US government is not a pyramid like it was in his business world.  He puts up a ridiculous ultimatum and the Legislature looks at him like, WTF.  We wanted this to work, many of them even thought this would work and be amicable, but Trump unexpectedly throws friends under the bus and works with the opposition.  I don't see how this gets any better going forward; Trump has used all the plays in his limited playbook and he's not exactly at an age to learn new tricks.

Let's be clear for a moment - Trump has a long history of over-promising and under-delivering, and it has worked for him int he past.  Further, he has an incredibly long list of people he's chummed up to and then thrown under the bus when he decided it would give him an edge.  Bankruptcy wasn't a unintended consequence for the Trump brand, it was part of the intitial blueprints of his 'deals'; pay a premium using borrowed money with high interest rates, default, and then negotiate for pennies-on-the-dollar under the threat that otherwise the whole system would just crumble and - hey, wouldn't that be a shame?  He followed this playbook for his failed casinos.

This echos in his current dealings with the ACA.  He promised glitz and glamour ("great healthcare for everyone at a much lower cost!"), drummed up expectations at debates, rallies and on twitterverse, got a bunch of hapless sods (the GOP) to give him the political capitol he required, and then when it turned out that his initial promises turned out to be bat-shit-crazy-land-impossible he threw everyone under the bus (it;s "mean"!; "It's not surprising McConnel FAILED"; ), and now that its clear his promises will not bear fruit he's in full sabotage mode ("Let O-Care Fail!"; Trump signs EO undermining ACA; HHS cuts funding, time frame for ACA enrollment) which he explicitly admits is to force others to cut a deal. Then as now he's leveraging the pain and suffering of everyday people to get his way. Before it was the workers and economy of New Jersey; now it's the healthcare for millions. His expectation is that the other parties will eventually cut a deal because they have a moral compass and will (eventually) reach a point where the current state of affairs (with his sabotage) is simply ethically unpalatable.  One true danger here is he's playing this game with career politicians who are responsible for just a small constituancy and are - at times - unwilling to follow their own moral compasses in favor of survival (re-election).

70+ year olds rarely change their ways or suddenly develop a completely different outlook on life. What Trump was before he is now, and there will be no "Presidential Pivot" or Billionaire Fighting for the little guy.  He's out to "win" based on his own definition, and he tallies it as a win anytime he loses less than the other folks in the room.

...now that we're temporarily off-focus from the ACA and on to tax reform, watch how this is starting to play out.  Trump has made lofty (many would say "bat-shit crazy") promises of 6% growth, tax cuts for the middle class and huge gains for the upper quartile of society.  He's promised this won't add a penny to the deficit over 10 years which almost every credible economist has called ludicrous. Assuming he follows his playbook his next step will be to start throwing people under the bus when his crazy promises cannot be obtained (DEM obstructionists! Ryan can't get it done!...) and then, somehow inflict pain to extract leverage.  He'll veto spending bills and budgets while signing EOs to stall the economy or push it into a recession in the hopes that Congress will pass a "stimulus package" that, curiously, has tax cuts for the right, the end fo teh estate tax and a number of his other priorities which will help Trump Inc.

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Re: What comes after the ACA?
« Reply #3743 on: October 14, 2017, 11:19:34 AM »
I donít know if Iíve articulated it out loud, but since he announced Iíve had a sneaking suspicion that Trumpís ultimate goal, his best ďwin,Ē is to get the estate tax repealed and then die in office. I donít know he can consciously think of such a thing but it definitely seems like a possible path for this train wreck of a presidency.

scottish

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Re: What comes after the ACA?
« Reply #3744 on: October 14, 2017, 01:33:25 PM »
On a lighter note, this was in the Onion today:

Quote
BEAVER DAM, WIóIn an effort to justify the recent set of executive orders the president signed earlier this week to dismantle the Affordable Care Act, exhausted Trump supporter Phil Holt reportedly just decided Friday that massive cuts to healthcare subsidies were the reason he voted as he did. ďUltimately increasing the cost of healthcare for me, my family members, and others like me is why I voted for Trump the first place,Ē said the completely drained Holt, 56, who reportedly has spent the last nine months since Trump took office rationalizing every step the White House has made as his motivation for casting his ballot for the president. ďWhen I went to the polls, I based my vote solely on the hope that insurance would be allowed to skirt around Obamacare policies that protect the elderly and those with pre-existing conditions from being discriminated against. Destabilizing the nationís healthcare system is exactly what I wanted from Trump and exactly what I got. Yes, exactly.Ē At press time, a weary Holt had determined that getting a second job just to afford healthcare was always a part of making America great again.

nereo

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Re: What comes after the ACA?
« Reply #3745 on: October 14, 2017, 02:10:46 PM »
I donít know if Iíve articulated it out loud, but since he announced Iíve had a sneaking suspicion that Trumpís ultimate goal, his best ďwin,Ē is to get the estate tax repealed and then die in office. I donít know he can consciously think of such a thing but it definitely seems like a possible path for this train wreck of a presidency.

I find it bizarre that his calls to repeal the estate tax haven't triggered more widespread condemnation about self-dealing and hubris.  This could (depending on his actual net worth) save him and his estate half a billion dollars.  It's the ultimate windfall for his heirs, and a singularly compelling reason why they should continue to endure any level of media scrutiny if there's even a chance it will come to fruition. 

It's the height of hypocrisy to claim that "rich people like me won't benefit at all" and that his tax proposals "are no good for me." This could be the only reason left why he continues to want to be president.

tl/dr: If Trump gets the tax deal he wants, he and his heirs will receive >$500,000,000 in tax savings. That's one hell of a paycheck.

radram

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Re: What comes after the ACA?
« Reply #3746 on: October 15, 2017, 07:14:05 AM »


tl/dr: If Trump gets the tax deal he wants, he and his heirs will receive >$500,000,000 in tax savings. That's one hell of a paycheck.

I think it is an interesting point to mention that Trump is correct that a full elimination of the estate tax would not benefit HIM. He, of course, would be dead (believe me).

iris lily

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Re: What comes after the ACA?
« Reply #3747 on: October 15, 2017, 07:57:05 AM »
...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.
Obama and Trump have both used executive orders to do things that congress "is supposed to" do.  Whether one thinks that is good or bad seems to depend, in many cases, on whether one agrees with what Obama or Trump did.  Or one could be happy or unhappy that the executive branch is usurping the legislative branch's function, regardless of the specific case.

I've long been unhappy about the president's ever-increasing power. Even when it was a president taking actions I mostly agreed with, I was always aware that we could get someone who could abuse that power and that granting such a large amount of power to one man is just asking for trouble when you pick the wrong man.
Ahreed, I dont care who is subverting Congress' authority with regulatory action, but it is written ng. The creeping power of the executive office is worrisome.

sol

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Re: What comes after the ACA?
« Reply #3748 on: October 15, 2017, 08:56:07 AM »
Ahreed, I dont care who is subverting Congress' authority with regulatory action, but it is written ng. The creeping power of the executive office is worrisome.

The "creeping power of the executive" really started to take off under Dick Cheney.  If you're looking for a reason to lament the disintegration of moral boundaries between public and private interests, you need look no further than the CEO of a private government contracting firm becoming Vice President.  As it turns out, ignoring conflicts of interest in the pursuit of personal profit from public office didn't start with our current President.  Expanding the power of the executive branch by removing the normal checks and balances is all part of the "get rich quick from public office" playbook. 

Trump is just following chapter two.  Chapter five is "start international conflict that directly benefits your personal business model."

MDM

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Re: What comes after the ACA?
« Reply #3749 on: October 15, 2017, 09:39:01 AM »
Although, one could also make a reasonable case that Trump's CSR ruling actually returns power to the legislative branch, because Congress had not appropriated those funds in the first place.