Author Topic: What comes after the ACA?  (Read 724157 times)

maizeman

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Re: What comes after the ACA?
« Reply #4550 on: July 17, 2018, 05:51:29 PM »
As for pre-existing conditions.  I highly doubt that part of the ACA will ever disappear.  It will be political suicide to push for it.

The problem is that it would be economic suicide to bring back disqualification based on pre-existing conditions (and the potential for health insurance rescission if you ever got sick enough to need your insurance) without the individual mandate.

And it would also be political suicide to have the individual mandate without subsidies to help people in the bottom half or so of incomes afford insurance.

And those three policies form the core of the whole ACA bill. So either the republicans will ultimately have to give up on repealing obamacare, or if they repeal any one of the three, all three are ultimately going to go away.

pecunia

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Re: What comes after the ACA?
« Reply #4551 on: July 17, 2018, 05:52:25 PM »
Swampman:
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Well, it sounds like you are angry that you are not getting your money's worth.  Here's hoping you get that big cancer diagnosis so you can get your "bang for the buck"!

Please do not wish that on me nor on anyone.

I don't mind paying what I consider a "fair share."  I just don't like being ripped off.  In fact I don't like being ripped off for anything.  It is particularly easy to get miffed about insurance, because it does seem like you are getting nothing for the money.  I mean nothing.  They just take the money and run.  Maybe, they could have testimonials on their website from unfortunate Cancer patients who have been helped.  It would give people like me some good will.

I just imagine I am writing a check to go in some insurance executive's pockets.  Opinions on this will certainly differ, but if I paid a similar amount in a tax, I would probably feel better.  I would think the money would have a better chance of helping someone in need. 

Now I expect a lot of responses to those who have been brainwashed with right wing anti government propaganda during their formative years and really think John Galt existed.

maizeman

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Re: What comes after the ACA?
« Reply #4552 on: July 17, 2018, 05:54:07 PM »
Quote
But please do remember the relatively young relatively healthy people who are subsidizing your healthcare are indeed people too.

Yes - Here's another fact.  Some of us older people do not get sick either and end up paying a great deal of money for nothing.  I believe I still can share your pain.  I've paid for it for many years and have received little.  They don't even give out a glossy calendar.  They just take the money.

Well, it sounds like you are angry that you are not getting your money's worth.  Here's hoping you get that big cancer diagnosis so you can get your "bang for the buck"!

I don't know if your comment was directed at me or pecunia, but in either case I would say the statement "here's hoping you get cancer" crosses the line of civilized discourse in either case (and not in the fun face punchy way many of us enjoy on this board).

For what it's worth, I'd really be happier if none of us got cancer, thank you very much.

Roadrunner53

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Re: What comes after the ACA?
« Reply #4553 on: July 17, 2018, 06:01:29 PM »
Why is ACA any different from car insurance? Some people have many accidents causing deaths, totaled cars, damage to buildings and cost insurance companies big bucks. These accident prone people have to pay thru the nose to get insurance but it also increases all of our policies too. There are some good drivers that drive for 40 years and never get in an accident.  So we can compare someone who gets cancer to some other people who are healthy. Some get sick and some do not. Some people have multiple car accidents and others never do. Some people are healthy and others are not. That is what insurance is all about. It is a gamble. We get insurance to HOPE we never use it. Babies get sick, toddlers get sick, young people get sick and old people get sick. So no one is protected. We just never know. Read the obituary's regularly and you will see how many young people die prematurely. My feeling is that no one should begrudge paying for insurance because no one knows when any of us will get sick. I just wish they could control the costs for all of us. Young and old.

pecunia

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Re: What comes after the ACA?
« Reply #4554 on: July 17, 2018, 06:56:07 PM »
Roadrunner:
Quote
Why is ACA any different from car insurance?

You have control as to how you drive.  You have some limited control over your health.

Mostly it's "There but by the grace of God go I," in regards to many forms of sickness.

maizeman

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Re: What comes after the ACA?
« Reply #4555 on: July 17, 2018, 07:08:05 PM »
Why is ACA any different from car insurance? Some people have many accidents causing deaths, totaled cars, damage to buildings and cost insurance companies big bucks. These accident prone people have to pay thru the nose to get insurance but it also increases all of our policies too. ...

My feeling is that no one should begrudge paying for insurance because no one knows when any of us will get sick. I just wish they could control the costs for all of us. Young and old.

I think the difference is is the very point you highlighted about car insurance. People who drive poorly and get in lots of accidents pay more. A lot less of their costs gets passed on to everyone else than in the case of health insurance.

Car insurance companies also use a lot of statistical models to try to predict individual risk of accidents based on all sorts of factors from age to sex to marital status to GPA in high school or college. The net result is that while you pay come out ahead or behind on car insurance, without knowing the future the expected value of car insurance is only slightly negative (insurance always has to have at least a slightly negative value to cover overhead and profits) while reducing your risk of extremely bad outcomes. Health insurance used to be the same way, which meant a lot of people at risk of extremely expensive procedures either couldn't get insurance at all, or it was unaffordable (just like some people with enough accidents cannot buy car insurance anymore).

So we set out to fix that. Because people shouldn't be unable to receive healthcare just because they're unlucky enough to be born with the wrong allele of the BRCA gene or type I diabetes, or needed an organ transplant when they were a child. But instead of switching to single payer or subsidizing the insurance of people unlucky enough to be born with pre-existing conditions (or come into them later in life), either of which would ultimately have been funded by income tax revenue which takes the most from the wealthy and the least from the poor, we legislated that insurance companies had to do a much much worse job of charging people what they expected their medical care to cost. It's better than the old situation were lots of folks were just left without any options after losing the genetic lottery. But it also means if you are relatively healthy, the expected value of health insurance is substantially negative rather than slightly negative, even though it still reduces your risk of extremely bad outcomes, just like car insurance. 

So that's my best guess as to why lots of people feel differently about health insurance today than they do about car insurance.

protostache

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Re: What comes after the ACA?
« Reply #4556 on: July 17, 2018, 07:26:48 PM »
Why is ACA any different from car insurance? Some people have many accidents causing deaths, totaled cars, damage to buildings and cost insurance companies big bucks. These accident prone people have to pay thru the nose to get insurance but it also increases all of our policies too. ...

My feeling is that no one should begrudge paying for insurance because no one knows when any of us will get sick. I just wish they could control the costs for all of us. Young and old.

I think the difference is is the very point you highlighted about car insurance. People who drive poorly and get in lots of accidents pay more. A lot less of their costs gets passed on to everyone else than in the case of health insurance.

Car insurance companies also use a lot of statistical models to try to predict individual risk of accidents based on all sorts of factors from age to sex to marital status to GPA in high school or college. The net result is that while you pay come out ahead or behind on car insurance, without knowing the future the expected value of car insurance is only slightly negative (insurance always has to have at least a slightly negative value to cover overhead and profits) while reducing your risk of extremely bad outcomes. Health insurance used to be the same way, which meant a lot of people at risk of extremely expensive procedures either couldn't get insurance at all, or it was unaffordable (just like some people with enough accidents cannot buy car insurance anymore).

So we set out to fix that. Because people shouldn't be unable to receive healthcare just because they're unlucky enough to be born with the wrong allele of the BRCA gene or type I diabetes, or needed an organ transplant when they were a child. But instead of switching to single payer or subsidizing the insurance of people unlucky enough to be born with pre-existing conditions (or come into them later in life), either of which would ultimately have been funded by income tax revenue which takes the most from the wealthy and the least from the poor, we legislated that insurance companies had to do a much much worse job of charging people what they expected their medical care to cost. It's better than the old situation were lots of folks were just left without any options after losing the genetic lottery. But it also means if you are relatively healthy, the expected value of health insurance is substantially negative rather than slightly negative, even though it still reduces your risk of extremely bad outcomes, just like car insurance. 

So that's my best guess as to why lots of people feel differently about health insurance today than they do about car insurance.

This is where a national reinsurance program would come in. Capping medical loss to, say, $50k, lets insurers charge much smaller premiums. The government would step in behind the scenes for the small percentage of people with outsized claims. Could be easily paid for by buying slightly fewer F-35s.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4557 on: July 17, 2018, 07:59:33 PM »
I think some states do in fact have that reinsurance program which is successful at lowering the premiums.

The ACA could be made into a robust insurance marketplace with moderate premiums if we implement several fixes to it, reinsurance program being one of them.

sol

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Re: What comes after the ACA?
« Reply #4558 on: July 17, 2018, 08:25:38 PM »
This is where a national reinsurance program would come in. Capping medical loss to, say, $50k, lets insurers charge much smaller premiums. The government would step in behind the scenes for the small percentage of people with outsized claims. Could be easily paid for by buying slightly fewer F-35s.

The ACA had a reinsurance program.  Congressional Republicans sabotaged it in late 2016.

It's almost like they want premiums to skyrocket...

maizeman

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Re: What comes after the ACA?
« Reply #4559 on: July 17, 2018, 08:36:45 PM »
A highly subsidized federal reinsurance program would definitely bring down prices for everyone.

Essentially it'd just another way of shifting more of the cost of healthcare from insurance premiums to federal income taxes, but it could be framed as using income tax dollars only to subsidize insurance for people with extremely high costs which might be a lot more politically palatable than broader subsidies even if the end result was the same.

former player

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Re: What comes after the ACA?
« Reply #4560 on: July 18, 2018, 01:49:17 AM »
I agree that we'll be better off after the change, but there will still be some short term pain.  We have lots of healthcare freeloaders right now, people making crazy salaries to do jobs that probably should not exist, and are therefore effectively just parasites on the national economy.

Having worked in the healthcare sector quite a bit in the past on the IT side, I wouldn't call the workers who get educated and take jobs, pay taxes, etc. to be parasites merely because they are working in the healthcare sector.  Parasites sounds like a description more appropriate for the able-bodied people who are living on government handouts who have never contributed to society and of course government workers.

What sort of rabbit hole thinking leads to "government workers are parasites"?   Why are government workers parasites when health insurance workers aren't?  It's all (mostly) admin that makes a civilised world go around.   


And what counts as "contributing to society?  Does "government handouts" include social security?  People on unemployment between jobs?  Someone laid off from a dying industry in a dying town?  How about tax credits, do they count as "government handouts"?

DreamFIRE

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Re: What comes after the ACA?
« Reply #4561 on: July 18, 2018, 05:25:54 AM »
I agree that we'll be better off after the change, but there will still be some short term pain.  We have lots of healthcare freeloaders right now, people making crazy salaries to do jobs that probably should not exist, and are therefore effectively just parasites on the national economy.

Having worked in the healthcare sector quite a bit in the past on the IT side, I wouldn't call the workers who get educated and take jobs, pay taxes, etc. to be parasites merely because they are working in the healthcare sector.  Parasites sounds like a description more appropriate for the able-bodied people who are living on government handouts who have never contributed to society and of course government workers.

What sort of rabbit hole thinking leads to "government workers are parasites"?   Why are government workers parasites when health insurance workers aren't?  It's all (mostly) admin that makes a civilised world go around.   

You'll notice the post I responded to and my response said "healthcare", *NOT* "healthcare insurance".  I never worked in healthcare insurance.

Quote
And what counts as "contributing to society?  Does "government handouts" include social security?  People on unemployment between jobs?  Someone laid off from a dying industry in a dying town?  How about tax credits, do they count as "government handouts"?

SS is not a government handout as those people had to contribute to society over 40 quarters before getting a return in benefits decades later.

FIRE@50

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Re: What comes after the ACA?
« Reply #4562 on: July 18, 2018, 09:11:23 AM »
Being required to by auto insurance is not the same as being required to buy medical insurance. Owning a car is optional, owning a body is not.

seattlecyclone

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Re: What comes after the ACA?
« Reply #4563 on: July 18, 2018, 10:30:57 AM »
Why is ACA any different from car insurance? Some people have many accidents causing deaths, totaled cars, damage to buildings and cost insurance companies big bucks. These accident prone people have to pay thru the nose to get insurance but it also increases all of our policies too. ...

My feeling is that no one should begrudge paying for insurance because no one knows when any of us will get sick. I just wish they could control the costs for all of us. Young and old.

I think the difference is is the very point you highlighted about car insurance. People who drive poorly and get in lots of accidents pay more. A lot less of their costs gets passed on to everyone else than in the case of health insurance.

Car insurance companies also use a lot of statistical models to try to predict individual risk of accidents based on all sorts of factors from age to sex to marital status to GPA in high school or college. The net result is that while you pay come out ahead or behind on car insurance, without knowing the future the expected value of car insurance is only slightly negative (insurance always has to have at least a slightly negative value to cover overhead and profits) while reducing your risk of extremely bad outcomes. Health insurance used to be the same way, which meant a lot of people at risk of extremely expensive procedures either couldn't get insurance at all, or it was unaffordable (just like some people with enough accidents cannot buy car insurance anymore).

So we set out to fix that. Because people shouldn't be unable to receive healthcare just because they're unlucky enough to be born with the wrong allele of the BRCA gene or type I diabetes, or needed an organ transplant when they were a child. But instead of switching to single payer or subsidizing the insurance of people unlucky enough to be born with pre-existing conditions (or come into them later in life), either of which would ultimately have been funded by income tax revenue which takes the most from the wealthy and the least from the poor, we legislated that insurance companies had to do a much much worse job of charging people what they expected their medical care to cost. It's better than the old situation were lots of folks were just left without any options after losing the genetic lottery. But it also means if you are relatively healthy, the expected value of health insurance is substantially negative rather than slightly negative, even though it still reduces your risk of extremely bad outcomes, just like car insurance. 

So that's my best guess as to why lots of people feel differently about health insurance today than they do about car insurance.

This, and there's an easy way to get out of the requirement to buy car insurance: don't own a car. There was no analogous opt-out for the medical insurance mandate. Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

maizeman

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Re: What comes after the ACA?
« Reply #4564 on: July 18, 2018, 10:34:41 AM »
That's a good point, seattlecyclone.

Where I grew up, owning a car was essentially mandatory to be able to function as an adult in society, and I think I managed to inherit that same mindset even after living lots of places where you could get by perfectly well without one. But now that you point it out, I'd imagine most people in the USA today live in places they can avoid buying auto insurance simply by choosing not to own/operate a car.

pecunia

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Re: What comes after the ACA?
« Reply #4565 on: July 18, 2018, 10:39:04 AM »
SeattleTornado:
Quote
Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

You did have the choice of paying the fine.  If the health coverage was covered by Uncle Sam, it would be a tax.  The taxpayers would have some control over it.

The in between thing of having the health insurance tax "privatized" was not the best.  It may be a first that the Republicans took out privatization of something.  Of course, they didn't replace the lost revenue with anything.  Sabotage, at it's finest.

sol

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Re: What comes after the ACA?
« Reply #4566 on: July 18, 2018, 11:38:08 AM »
This, and there's an easy way to get out of the requirement to buy car insurance: don't own a car. There was no analogous opt-out for the medical insurance mandate. Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

The reason you shouldn't be able to opt out of health insurance isn't because you can't opt out of owning a body, it's because you can't opt out of incurring medical bills.  Everyone gets sick eventually, and in the United States hospitals are required by law to treat you.  They legally HAVE to spend money to save you're life, and you are asking for the right to refuse to pay for it.

I would be much more comfortable with repealing the individual mandate of we also repealed EMTALA and the Hippocratic Oath.  But with those in place, every person who doesn't buy heath insurance is exploiting the rest of society, like a damn freeloader.  It baffles me that on this one specific topic, conservatives demand the right to leach.  What ever happened to rugged individualism?

Besides, the whole "don't force me to buy from a private company" argument is patently ridiculous anyway.  You are forced to buy thousands of things from private companies, both personally and as government spending on private companies, unless you are homeless or otherwise off the grid.  In which case, you don't need to buy health insurance either.  The mandate is only for people plugged into the matrix, collecting benefits, paying taxes, owning property, etc.  You always have the option of not earning enough money to pay taxes, just like you have the option of not owning a car.  No taxes, no mandate.

If you choose to profit handsomely by participating in our advanced western democracy and it's attendant economy, then you choose to have guaranteed healthcare and should also choose to pay for it.  Or, you can choose to avoid the obligation by opting not to participate.  But IMO, you shouldn't be allowed to claim the benefit but refuse to pay the cost.

Threshkin

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Re: What comes after the ACA?
« Reply #4567 on: July 18, 2018, 11:41:37 AM »
SeattleTornado:
Quote
Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

You did have the choice of paying the fine.  If the health coverage was covered by Uncle Sam, it would be a tax.  The taxpayers would have some control over it.

The in between thing of having the health insurance tax "privatized" was not the best.  It may be a first that the Republicans took out privatization of something.  Of course, they didn't replace the lost revenue with anything.  Sabotage, at it's finest.
But the fine was a tax.  The Supremes said so.

fuzzy math

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Re: What comes after the ACA?
« Reply #4568 on: July 18, 2018, 12:33:55 PM »
This, and there's an easy way to get out of the requirement to buy car insurance: don't own a car. There was no analogous opt-out for the medical insurance mandate. Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

The reason you shouldn't be able to opt out of health insurance isn't because you can't opt out of owning a body, it's because you can't opt out of incurring medical bills.  Everyone gets sick eventually, and in the United States hospitals are required by law to treat you.  They legally HAVE to spend money to save you're life, and you are asking for the right to refuse to pay for it.

I would be much more comfortable with repealing the individual mandate of we also repealed EMTALA and the Hippocratic Oath.  But with those in place, every person who doesn't buy heath insurance is exploiting the rest of society, like a damn freeloader.  It baffles me that on this one specific topic, conservatives demand the right to leach.  What ever happened to rugged individualism?

Besides, the whole "don't force me to buy from a private company" argument is patently ridiculous anyway.  You are forced to buy thousands of things from private companies, both personally and as government spending on private companies, unless you are homeless or otherwise off the grid.  In which case, you don't need to buy health insurance either.  The mandate is only for people plugged into the matrix, collecting benefits, paying taxes, owning property, etc.  You always have the option of not earning enough money to pay taxes, just like you have the option of not owning a car.  No taxes, no mandate.

If you choose to profit handsomely by participating in our advanced western democracy and it's attendant economy, then you choose to have guaranteed healthcare and should also choose to pay for it.  Or, you can choose to avoid the obligation by opting not to participate.  But IMO, you shouldn't be allowed to claim the benefit but refuse to pay the cost.

Word. For the record people can opt out for religious reasons (see: the Amish), but the Amish also pay also prepared to pay cash when they need hospital care.

Insurance should not be optional as long as bankruptcy exists since Medical bills are exempted from bankruptcy and healthcare providers canít recoup costs.

Better yet if you donít want insurance, donít go to the hospital. Stay home and tough it out.

Here are some fine examples of why insurance / public goods services shouldnít be optional:

http://www.nbcnews.com/id/39516346/ns/us_news-life/t/no-pay-no-spray-firefighters-let-home-burn/

https://www.cbsnews.com/news/firefighters-watch-home-burn-owners-didnt-pay/

« Last Edit: July 18, 2018, 08:50:53 PM by fuzzy math »

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4569 on: July 18, 2018, 12:36:47 PM »
It simply baffles my mind that someone would have millions invested and then not want to have insurance.

FIRE@50

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Re: What comes after the ACA?
« Reply #4570 on: July 18, 2018, 12:41:31 PM »
This, and there's an easy way to get out of the requirement to buy car insurance: don't own a car. There was no analogous opt-out for the medical insurance mandate. Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

The reason you shouldn't be able to opt out of health insurance isn't because you can't opt out of owning a body, it's because you can't opt out of incurring medical bills.  Everyone gets sick eventually, and in the United States hospitals are required by law to treat you.  They legally HAVE to spend money to save you're life, and you are asking for the right to refuse to pay for it.

I would be much more comfortable with repealing the individual mandate of we also repealed EMTALA and the Hippocratic Oath.  But with those in place, every person who doesn't buy heath insurance is exploiting the rest of society, like a damn freeloader.  It baffles me that on this one specific topic, conservatives demand the right to leach.  What ever happened to rugged individualism?

Besides, the whole "don't force me to buy from a private company" argument is patently ridiculous anyway.  You are forced to buy thousands of things from private companies, both personally and as government spending on private companies, unless you are homeless or otherwise off the grid.  In which case, you don't need to buy health insurance either.  The mandate is only for people plugged into the matrix, collecting benefits, paying taxes, owning property, etc.  You always have the option of not earning enough money to pay taxes, just like you have the option of not owning a car.  No taxes, no mandate.

If you choose to profit handsomely by participating in our advanced western democracy and it's attendant economy, then you choose to have guaranteed healthcare and should also choose to pay for it.  Or, you can choose to avoid the obligation by opting not to participate.  But IMO, you shouldn't be allowed to claim the benefit but refuse to pay the cost.
Are you opposed to government provided healthcare?

seattlecyclone

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Re: What comes after the ACA?
« Reply #4571 on: July 18, 2018, 01:41:49 PM »
This, and there's an easy way to get out of the requirement to buy car insurance: don't own a car. There was no analogous opt-out for the medical insurance mandate. Being required by law to buy a product from a private companyónot as a condition of some optional activity like driving, but just as a condition of being aliveórubs a lot of people (including me) the wrong way.

The reason you shouldn't be able to opt out of health insurance isn't because you can't opt out of owning a body, it's because you can't opt out of incurring medical bills.  Everyone gets sick eventually, and in the United States hospitals are required by law to treat you.  They legally HAVE to spend money to save you're life, and you are asking for the right to refuse to pay for it.

I would be much more comfortable with repealing the individual mandate of we also repealed EMTALA and the Hippocratic Oath.  But with those in place, every person who doesn't buy heath insurance is exploiting the rest of society, like a damn freeloader.  It baffles me that on this one specific topic, conservatives demand the right to leach.  What ever happened to rugged individualism?

Besides, the whole "don't force me to buy from a private company" argument is patently ridiculous anyway.  You are forced to buy thousands of things from private companies, both personally and as government spending on private companies, unless you are homeless or otherwise off the grid.  In which case, you don't need to buy health insurance either.  The mandate is only for people plugged into the matrix, collecting benefits, paying taxes, owning property, etc.  You always have the option of not earning enough money to pay taxes, just like you have the option of not owning a car.  No taxes, no mandate.

If you choose to profit handsomely by participating in our advanced western democracy and it's attendant economy, then you choose to have guaranteed healthcare and should also choose to pay for it.  Or, you can choose to avoid the obligation by opting not to participate.  But IMO, you shouldn't be allowed to claim the benefit but refuse to pay the cost.

I basically agree with all of that. I understand that healthy people need to buy insurance (priced at well above expected value) in order for covering sick people at well below expected value to be feasible. I understand that a rational person might choose not to buy insurance priced well above expected value in the absence of a fine for not doing so. The requirement still rubs me the wrong way. For whatever reason the individual mandate just feels wrong to me, in a way that either Medicare for All or repealing EMTALA would not.

If we want to have free market health care, let's do that. If we want to have taxpayer-funded health care, let's do that. In my opinion Obamacare gives us some of the worst of both worlds. What it does do, very well, is ensure the survival of the health care cartel, as you described very well in a previous post.

sol

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Re: What comes after the ACA?
« Reply #4572 on: July 18, 2018, 01:53:45 PM »
Are you opposed to government provided healthcare?

I am not opposed to government provided healthcare (e.g. Medicaid, Medicare, Tricare, etc).  I'm not opposed to expanding these programs, or adding new ones.  I'm also not opposed to government provided health insurance, the republican's proposed alternative, though as currently implemented I think it has some serious shortcomings.

Healthcare is never a free market.  Buyers can't comparison shop, prices are not transparent or consistent, competition is basically non-existent, and supply and demand are essentially uncoupled from the amount of care provided.  If there was ever an ironclad case for government intervention in an industry, I think this is it.  Every other western nation seems to agree.

pecunia

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Re: What comes after the ACA?
« Reply #4573 on: July 18, 2018, 05:31:03 PM »
Quote
Healthcare is never a free market.  Buyers can't comparison shop, prices are not transparent or consistent, competition is basically non-existent, and supply and demand are essentially uncoupled from the amount of care provided.  If there was ever an ironclad case for government intervention in an industry, I think this is it.  Every other western nation seems to agree.

I do not think it is remotely possible to write a concise rebuttal to this excellent paragraph.

The best response may be to do what politicians do and discuss some insignificant piece of minutia regarding the issue or to just write about something else and call it a response.

Radagast

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Re: What comes after the ACA?
« Reply #4574 on: July 18, 2018, 11:30:26 PM »
https://www.propublica.org/article/health-insurers-are-vacuuming-up-details-about-you-and-it-could-raise-your-rates
https://www.propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills

A couple articles I just read on this topic. I maintain that health insurance is the problem, not the solution. Mandatory insurance introduces a third party into the system whose best interests are counter to the interests of both patient and provider, while skimming a profit and introducing administration losses. I agree with seattlecyclone. Only stupid "compassionate conservatives" of the 2000's era would have dreamed up this terrible system, and only an ignorant and weak "liberal" like Obama would have tried to implement it. So long as we have mandatory health insurance, we will always pay substantially more for healthcare than we need to.
If we want to have free market health care, let's do that. If we want to have taxpayer-funded health care, let's do that. In my opinion Obamacare gives us some of the worst of both worlds. What it does do, very well, is ensure the survival of the health care cartel, as you described very well in a previous post.

katsiki

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Re: What comes after the ACA?
« Reply #4575 on: July 19, 2018, 07:42:24 AM »
I basically agree with all of that. I understand that healthy people need to buy insurance (priced at well above expected value) in order for covering sick people at well below expected value to be feasible. I understand that a rational person might choose not to buy insurance priced well above expected value in the absence of a fine for not doing so. The requirement still rubs me the wrong way. For whatever reason the individual mandate just feels wrong to me, in a way that either Medicare for All or repealing EMTALA would not.

If we want to have free market health care, let's do that. If we want to have taxpayer-funded health care, let's do that. In my opinion Obamacare gives us some of the worst of both worlds. What it does do, very well, is ensure the survival of the health care cartel, as you described very well in a previous post.

I think you just summed up my current position as well.  I also don't like the mandate and was very against it initially.  However, I am coming around to it being a necessary evil. 

This thread has been very educational.  I wish our congresspeople and other "experts" would put 10% as much thought into this issue as some of the posters here.

Jrr85

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Re: What comes after the ACA?
« Reply #4576 on: July 19, 2018, 07:53:10 AM »
Are you opposed to government provided healthcare?

I am not opposed to government provided healthcare (e.g. Medicaid, Medicare, Tricare, etc).  I'm not opposed to expanding these programs, or adding new ones.  I'm also not opposed to government provided health insurance, the republican's proposed alternative, though as currently implemented I think it has some serious shortcomings.

Healthcare is never a free market.  Buyers can't comparison shop, prices are not transparent or consistent, competition is basically non-existent, and supply and demand are essentially uncoupled from the amount of care provided.  If there was ever an ironclad case for government intervention in an industry, I think this is it.  Every other western nation seems to agree.

Health care is never a free market because the government has prevented it from being a free market.  They put a stranglehold on the supply.  Provide a huge portion of third party payments, make employer provided plans tax advantaged (further increasing the percent of third party payment), and then outlaw high deductible plans (basically ensuring that nobody will get basic healthcare without involving third party payment). 

Emergency care needs to be regulated like a utility since people can't really comparison shop in an emergency.  The rest doesn't actually have to have government involvement, although I think after so many decades of the government preventing any pricing mechanism from working, it would probably take some moderately heavy handed government intrusion to get a freeish market going. 

Maybe mandate that binding pricing be published and available online or over the phone.   Require that total cost be agreed to up front by consumer prior to care for all non-emergency care.  Require that consumers pay at least 5-20% of costs of all non-emergency care subject to an out of pocket maximum.  Require that all states receiving medicaid allow NPs and PAs practice on their own without doctor supervision.  That wouldn't fix all problems, but it would give market mechanisms a chance to work. 

But if you're not going to allow market mechanisms to work, they really need to do something like medicaid for all and just have a two tier health system, with everybody guaranteed some basic minimum care, and people who want to can pay for private care either for more cutting edge care or just to avoid wait times.  Not sure how much that will help though as long as we put a stranglehold on the number of doctors.   

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Re: What comes after the ACA?
« Reply #4577 on: July 19, 2018, 07:57:11 AM »
I basically agree with all of that. I understand that healthy people need to buy insurance (priced at well above expected value) in order for covering sick people at well below expected value to be feasible. I understand that a rational person might choose not to buy insurance priced well above expected value in the absence of a fine for not doing so. The requirement still rubs me the wrong way. For whatever reason the individual mandate just feels wrong to me, in a way that either Medicare for All or repealing EMTALA would not.

If we want to have free market health care, let's do that. If we want to have taxpayer-funded health care, let's do that. In my opinion Obamacare gives us some of the worst of both worlds. What it does do, very well, is ensure the survival of the health care cartel, as you described very well in a previous post.

I think you just summed up my current position as well.  I also don't like the mandate and was very against it initially.  However, I am coming around to it being a necessary evil. 

This thread has been very educational.  I wish our congresspeople and other "experts" would put 10% as much thought into this issue as some of the posters here.

Congresspeople are generally wealthy.. Wealthy people own stocks.. Stocks make money.. The more expensive HC is the more money those stocks make.. There is no incentive for congresspeople to make HC cheaper.

Not until we as a people are prepared to vote them out.. Enough of our population are so conditioned to "We don't want any socialist HC system here.. Socialism.. Baaad!" dogma thats not going not going to happen anytime soon.

So we will continue to pay until there people start to die in large numbers because they can't afford insurance.

protostache

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Re: What comes after the ACA?
« Reply #4578 on: July 19, 2018, 08:37:18 AM »
Congresspeople are generally wealthy.. Wealthy people own stocks.. Stocks make money.. The more expensive HC is the more money those stocks make.. There is no incentive for congresspeople to make HC cheaper.

Not until we as a people are prepared to vote them out.. Enough of our population are so conditioned to "We don't want any socialist HC system here.. Socialism.. Baaad!" dogma thats not going not going to happen anytime soon.

So we will continue to pay until there people start to die in large numbers because they can't afford insurance.

I mean... yes, but almost all of us here own stocks as well. If you own a US index fund you own stock in United Healthcare, Aetna, Humana, Cigna, etc. The companies work within the system that Congress gives them while exercising considerable influence on what that system will look like. Congress being wealthy a small part of the problem, but Congress, particularly the leadership, being old is a much bigger problem.

I think the reflexive hate toward socialist systems is going to taper off as the Boomers start dying off in mass numbers. People born after the Regan years grew up watching the success of the European systems and the failure of our own. Ocasio-Cortez's win, while not indicative, is certainly suggestive that people are starting to feel fed up with the current system.

sol

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Re: What comes after the ACA?
« Reply #4579 on: July 19, 2018, 09:11:26 AM »
But if you're not going to allow market mechanisms to work, they really need to do something like medicaid for all and just have a two tier health system, with everybody guaranteed some basic minimum care, and people who want to can pay for private care either for more cutting edge care or just to avoid wait times.  Not sure how much that will help though as long as we put a stranglehold on the number of doctors.

This is such an easy fix, though!  Just allow doctors to immigrate!  There are tens of thousands of doctors and nurses in other countries who would kill for the chance to come to America and make half of what their US counterparts make.  Just let them.  Even if they have brown skin.

Wages would come down in the medical field.  I'm okay with that.  Every hospital around me is constantly under construction because they are such cash cows these days.

Quote
Emergency care needs to be regulated like a utility since people can't really comparison shop in an emergency.

I suspect this is where we're headed.  I'm predicting they'll expand medicaid to provide something to everyone, but it will be pretty shitty coverage.  Bare minimum on procedures (like ER visits but not vision/dental/cosmetic, maybe one preventative visit per year because that reduces overall costs), relatively high out of pocket maximums, but guaranteed issue and premiums fully covered by tax deductions.  Essentially a federally insured catastrophic plan.  That might satisfy people who want universal coverage, but it wouldn't eradicate the private insurance industry either.  And it solves the freeloader problem we currently face from conservatives who refuse to pay.

AdrianC

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Re: What comes after the ACA?
« Reply #4580 on: July 19, 2018, 09:19:13 AM »
I'm predicting they'll expand medicaid to provide something to everyone, but it will be pretty shitty coverage.  Bare minimum on procedures (like ER visits but not vision/dental/cosmetic, maybe one preventative visit per year because that reduces overall costs), relatively high out of pocket maximums, but guaranteed issue and premiums fully covered by tax deductions.

Sounds exactly like my ACA plan.

(Minus the $1600/mo premium, of course).

Exflyboy

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Re: What comes after the ACA?
« Reply #4581 on: July 19, 2018, 09:22:45 AM »
Yes I too make more from the HC sector in my index funds than the cost of our care.. That would be true even if we didn't get an ACA subsidy. My point of course is that the people that have the power to influence the system have way more more money than I do so are motivated to make HC as expensive as possible.

The humanitarian in me says "Would I be prepared to give up 10% of my NW if everybody could have access to universal HC?".. Honestly the answer would be a resounding YES! If only from the selfish perspective of the fact that should I get something expensive I know I will be covered.

My Mum and Dad are on the equivilent of Medicare in the UK and they pay NOTHING for HC, no co pays for drugs, eyeglasses .. all of it at zero cost to them. If they get cancer or MS there is zero cost.

Not saying the UK system is perfect by any means but dear God its light years better than we have.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4582 on: July 19, 2018, 09:33:43 AM »
My Mum and Dad are on the equivilent of Medicare in the UK and they pay NOTHING for HC, no co pays for drugs, eyeglasses .. all of it at zero cost to them. If they get cancer or MS there is zero cost.

Much better than Medicare then.  They would be paying more like $10,000 per year for Medicare.

Roadrunner53

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Re: What comes after the ACA?
« Reply #4583 on: July 19, 2018, 09:37:12 AM »
Exflyboy, just curious, are you an American Citizen? Why did you leave UK?

Exflyboy

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Re: What comes after the ACA?
« Reply #4584 on: July 19, 2018, 10:03:13 AM »
Exflyboy, just curious, are you an American Citizen? Why did you leave UK?

I got my US Citizenship a few weeks ago... I now have dual citizenship with the UK.

I worked for an American company in the UK and they headhunted me for a job in the US. I managed to convert this to a permanent position in 1997.

It was a great opportunity to come here as I have had a fabulous engineering career..:)

Roadrunner53

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Re: What comes after the ACA?
« Reply #4585 on: July 19, 2018, 10:07:10 AM »
Exflyboy, just curious, are you an American Citizen? Why did you leave UK?

I got my US Citizenship a few weeks ago... I now have dual citizenship with the UK.

I worked for an American company in the UK and they headhunted me for a job in the US. I managed to convert this to a permanent position in 1997.

It was a great opportunity to come here as I have had a fabulous engineering career..:)

CONGRATULATIONS on your US Citizenship! Yay for you!

Excuse my ignorance but what does dual citizenship provide? Do you get a UK pension like SS or can you get UK healthcare if you go there to be treated?

Exflyboy

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Re: What comes after the ACA?
« Reply #4586 on: July 19, 2018, 11:11:57 AM »
Exflyboy, just curious, are you an American Citizen? Why did you leave UK?

I got my US Citizenship a few weeks ago... I now have dual citizenship with the UK.

I worked for an American company in the UK and they headhunted me for a job in the US. I managed to convert this to a permanent position in 1997.

It was a great opportunity to come here as I have had a fabulous engineering career..:)

CONGRATULATIONS on your US Citizenship! Yay for you!

Excuse my ignorance but what does dual citizenship provide? Do you get a UK pension like SS or can you get UK healthcare if you go there to be treated?

Yes I can get a small UK Government pension but I believe its taxed very heavily as the US doesn't like you getting US and UK Social security. Its a very small amount anyway so I have not looked into it much.

I do get a UK company pension that I can draw now ($16.5k/yr) or wait till I'm 60 in 3 years and get $20.5k.. That will be taxed as normal income either in the US or UK.

The only way I can get treated in the UK is if I go back to live there.. So I'd have to show a rental agreement/ utility bill/ shipping manifest of household belongings etc. I do however have the right to go back and live in the UK.. as does my US born DW, she would have to pay $260/year to get full HC coverage for 5 years until she established residency.. Chump change in reality.

If I did go back I would still have to file US taxes, but only pay the greater of the UK or US taxes, i.e you are not taxed twice.

Note anyone (even overseas visitors to the UK) are treated for emergency care plus primary care and medicines are covered by the National health service for free.. There is a small copay for prescritptions.
« Last Edit: July 19, 2018, 11:16:31 AM by Exflyboy »

Roadrunner53

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Re: What comes after the ACA?
« Reply #4587 on: July 19, 2018, 11:24:41 AM »
Exflyboy, just curious, are you an American Citizen? Why did you leave UK?

I got my US Citizenship a few weeks ago... I now have dual citizenship with the UK.

I worked for an American company in the UK and they headhunted me for a job in the US. I managed to convert this to a permanent position in 1997.

It was a great opportunity to come here as I have had a fabulous engineering career..:)

CONGRATULATIONS on your US Citizenship! Yay for you!

Excuse my ignorance but what does dual citizenship provide? Do you get a UK pension like SS or can you get UK healthcare if you go there to be treated?

Yes I can get a small UK Government pension but I believe its taxed very heavily as the US doesn't like you getting US and UK Social security. Its a very small amount anyway so I have not looked into it much.

I do get a UK company pension that I can draw now ($16.5k/yr) or wait till I'm 60 in 3 years and get $20.5k.. That will be taxed as normal income either in the US or UK.

The only way I can get treated in the UK is if I go back to live there.. So I'd have to show a rental agreement/ utility bill/ shipping manifest of household belongings etc. I do however have the right to go back and live in the UK.. as does my US born DW, she would have to pay $260/year to get full HC coverage for 5 years until she established residency.. Chump change in reality.

If I did go back I would still have to file US taxes, but only pay the greater of the UK or US taxes, i.e you are not taxed twice.

Note anyone (even overseas visitors to the UK) are treated for emergency care plus primary care and medicines are covered by the National health service for free.. There is a small copay for prescritptions.

Interesting! Thank you!

jim555

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Re: What comes after the ACA?
« Reply #4588 on: July 19, 2018, 11:36:40 AM »
UK as a Plan B is nice to have.

Jrr85

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Re: What comes after the ACA?
« Reply #4589 on: July 19, 2018, 11:49:48 AM »
But if you're not going to allow market mechanisms to work, they really need to do something like medicaid for all and just have a two tier health system, with everybody guaranteed some basic minimum care, and people who want to can pay for private care either for more cutting edge care or just to avoid wait times.  Not sure how much that will help though as long as we put a stranglehold on the number of doctors.

This is such an easy fix, though!  Just allow doctors to immigrate!  There are tens of thousands of doctors and nurses in other countries who would kill for the chance to come to America and make half of what their US counterparts make.  Just let them.  Even if they have brown skin.

Wages would come down in the medical field.  I'm okay with that.  Every hospital around me is constantly under construction because they are such cash cows these days.
  Allowing doctors to immigrate and not have to start a residency at square one (if they can even get a residency) to get licensed would be good, but I suspect depending on what country your talking about, our Nurse practitioners and physician assistants are as well trained as their doctors.  It would probably be more helpful to foreign trained doctors if there was some sort of formal certification for them; it just needs to be something like passing a written test to show they have the basics, and then some sort of hands on test that doesn't require three years or more to complete. 

Quote
Emergency care needs to be regulated like a utility since people can't really comparison shop in an emergency.

I suspect this is where we're headed.  I'm predicting they'll expand medicaid to provide something to everyone, but it will be pretty shitty coverage.  Bare minimum on procedures (like ER visits but not vision/dental/cosmetic, maybe one preventative visit per year because that reduces overall costs), relatively high out of pocket maximums, but guaranteed issue and premiums fully covered by tax deductions.

I think any further move to government provided universal coverage is guaranteed to be pretty shitty.  There are already a lot of doctors who won't accept new medicare patients, and we definitely can't afford to extend medicare to everyone.  Granted if we offered Medicaid for all would, I think it would drive compensation down so much that doctor's would jump at today's medicare rates, but that won't change the fact that the basic medicaid option will be relatively shitty.   

  Essentially a federally insured catastrophic plan.  That might satisfy people who want universal coverage, but it wouldn't eradicate the private insurance industry either.
  I don't think we'll be so lucky.  I think just saying once you exceed X% of your income (and preferably have some sort of asset test), you get government provided care, or alternatively provide government reinsurance for a qualifying high deductible plan would be pretty decent.  I think the voting populace is going to demand that the government be involved from something close to first dollar coverage, and which means we're going to get something closer to medicaid. 


  And it solves the freeloader problem we currently face from conservatives who refuse to pay.

I seriously doubt you'd find that conservatives are over represented in those who refuse to pay.  Probably much more likely that it's over represented by "young invincibles" who as a group would lean left. 

EnjoyIt

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Re: What comes after the ACA?
« Reply #4590 on: July 19, 2018, 07:49:03 PM »
A few comments to the above:
1) Healthcare cost are currently not transparent but should be 100% of the time.

2) Outside of Emergency care which is a small fraction of all healthcare dollars being spent, shopping for healthcare is very feasible if there was 100% transparency.  Most of the reasons why people go to the ER isn't because it is an emergency but because they don't have any other reasonable options.  Such as a doctor who takes walk ins or they don't have money and know they will get free care at the local ER. http://www.politifact.com/truth-o-meter/statements/2013/oct/28/nick-gillespie/does-emergency-care-account-just-2-percent-all-hea/

Quote
The group used figures from 2008 collected by the Medical Expenditure Panel Survey, a study undertaken by a division of the Department of Health and Human Services. The survey found that the total amount of money spent on emergency care -- including physician and other emergency-room services -- was $47.3 billion. Thatís slightly less than 2 percent of the same surveyís $2.4 trillion estimate of total health care expenditures that year.

3) Socialism sucks.  I grew up in socialism and the only people doing well are those in power while most of society live in poverty.  A social democracy sounds good but you still end up with socialism.  My family and I escaped to the US from socialism just to find people 20 years later preaching for it here.  BTW, here is a little fact about socialism.  When the socialists gain power, historically, the first thing they do is kill all those who got them there.  Jackasses.

4) NP and PAs have decent training but they are not physicians and need a physician to help out from time to time.  They are not a replacement for doctors but are very useful in making the doctors more efficient by helping in managing patient care. I love our NPs and PAs but don't fool yourself thinking they are equally qualified as a physician. A well oiled team can see more patients safely at a lower cost.


swampwiz

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Re: What comes after the ACA?
« Reply #4591 on: July 19, 2018, 09:20:32 PM »
Quote
But please do remember the relatively young relatively healthy people who are subsidizing your healthcare are indeed people too.

Yes - Here's another fact.  Some of us older people do not get sick either and end up paying a great deal of money for nothing.  I believe I still can share your pain.  I've paid for it for many years and have received little.  They don't even give out a glossy calendar.  They just take the money.

Well, it sounds like you are angry that you are not getting your money's worth.  Here's hoping you get that big cancer diagnosis so you can get your "bang for the buck"!

I don't know if your comment was directed at me or pecunia, but in either case I would say the statement "here's hoping you get cancer" crosses the line of civilized discourse in either case (and not in the fun face punchy way many of us enjoy on this board).

For what it's worth, I'd really be happier if none of us got cancer, thank you very much.

I'm sorry, but this gets real personal with me.  Everyone who is healthy thinks that they are paying too much.  This canned statement of mine is a like a big slap in the face to realize just how ridiculous the statement is - i.e., that paying for sick folks but being healthy is not a deal with having!

swampwiz

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Re: What comes after the ACA?
« Reply #4592 on: July 19, 2018, 09:24:39 PM »
Car insurance companies also use a lot of statistical models to try to predict individual risk of accidents based on all sorts of factors from age to sex to marital status to GPA in high school or college.

GPA?  What, does a customer have to submit his transcript?

swampwiz

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Re: What comes after the ACA?
« Reply #4593 on: July 19, 2018, 09:25:19 PM »
This is where a national reinsurance program would come in. Capping medical loss to, say, $50k, lets insurers charge much smaller premiums. The government would step in behind the scenes for the small percentage of people with outsized claims. Could be easily paid for by buying slightly fewer F-35s.

The ACA had a reinsurance program.  Congressional Republicans sabotaged it in late 2016.

It's almost like they want premiums to skyrocket...

DING DING!  We have a winner!

maizeman

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Re: What comes after the ACA?
« Reply #4594 on: July 19, 2018, 09:26:57 PM »
Car insurance companies also use a lot of statistical models to try to predict individual risk of accidents based on all sorts of factors from age to sex to marital status to GPA in high school or college.

GPA?  What, does a customer have to submit his transcript?

If you want the discount, yes you do. The case I'm familiar with is state farm, where you can get discounts up to age 25 if you submit high school or college transcripts with a sufficiently high GPA.

maizeman

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Re: What comes after the ACA?
« Reply #4595 on: July 19, 2018, 09:28:22 PM »
Quote
But please do remember the relatively young relatively healthy people who are subsidizing your healthcare are indeed people too.

Yes - Here's another fact.  Some of us older people do not get sick either and end up paying a great deal of money for nothing.  I believe I still can share your pain.  I've paid for it for many years and have received little.  They don't even give out a glossy calendar.  They just take the money.

Well, it sounds like you are angry that you are not getting your money's worth.  Here's hoping you get that big cancer diagnosis so you can get your "bang for the buck"!

I don't know if your comment was directed at me or pecunia, but in either case I would say the statement "here's hoping you get cancer" crosses the line of civilized discourse in either case (and not in the fun face punchy way many of us enjoy on this board).

For what it's worth, I'd really be happier if none of us got cancer, thank you very much.

I'm sorry, but this gets real personal with me.  Everyone who is healthy thinks that they are paying too much.  This canned statement of mine is a like a big slap in the face to realize just how ridiculous the statement is - i.e., that paying for sick folks but being healthy is not a deal with having!

This gets real personal for me to. Wishing cancer on anyone, even strangers on the internet is not an okay thing to do.

swampwiz

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Re: What comes after the ACA?
« Reply #4596 on: July 19, 2018, 09:29:17 PM »
That's a good point, seattlecyclone.

Where I grew up, owning a car was essentially mandatory to be able to function as an adult in society, and I think I managed to inherit that same mindset even after living lots of places where you could get by perfectly well without one. But now that you point it out, I'd imagine most people in the USA today live in places they can avoid buying auto insurance simply by choosing not to own/operate a car.

This has only become semi-feasible with Uber, and will become the cost-efficient system once autonomous cars get going.

swampwiz

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Re: What comes after the ACA?
« Reply #4597 on: July 19, 2018, 09:37:16 PM »
Only stupid "compassionate conservatives" of the 2000's era would have dreamed up this terrible system, and only an ignorant and weak "liberal" like Obama would have tried to implement it. So long as we have mandatory health insurance, we will always pay substantially more for healthcare than we need to.

Obama did the absolutely best he could to barely ram through RomneyHeritageCare; there were still some insurance-company-corrupted Democratic senators like Liebermann & Landrieu that would not allow the Public Option.  The real win though is that now that the stupid Americans who have been exposed to it like the idea of the government guaranteeing coverage.  That and the absolutely pathetic attempt at "repeal & replace" by the Republicans.

pecunia

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Re: What comes after the ACA?
« Reply #4598 on: July 19, 2018, 09:51:42 PM »
Time to show the free market really works:

We import Japanese, German and Korean cars.  People like these cars.  They have a choice of buying these or American makes.

How about allowing these countries to open Japanese, German and Korean health clinics? These would be subject only to the foreign regulations in order not to corrupt the experience.  True competition would take place. 

I'll bet the foreign docs would love to come here on 6 month stints.  It would be good for them and good for their patients.  True win - win capitalism. 

American workers are the best in the world.  Our doctors would truly respond.

Radagast

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Re: What comes after the ACA?
« Reply #4599 on: July 19, 2018, 11:32:17 PM »
My thought on why mandatory health insurance wouldn't work originated with an investing book, Unconventional Success by Swenson. (I learned a lot of new ways of thinking about the world once I learned about investing.) In it Swensen argues that stocks are good investments because management's interests are mostly aligned with shareholder interests. Government bonds are OK investments, because the government wants to promote stability and prosperity, and yet it doesn't really want to pay you back, so it is neither for nor against you. Corporate bonds are bad because management's interests are opposite of yours.

I applied the same method to health care. First, I realized that universal health insurance is like corporate bonds: bad for you. The insurers make money by taking as much as possible from you, and paying as little as possible to health care providers. At every point it is in their interest to delay, obfuscate, negotiate, and make lower money they owe while continuing to demand ever greater payments up front. Opportunity for shady deals with providers, manufacturers, and suppliers abound so you will never be able to get a free market effect by competition through insurers. There is no alignment of interests between mandatory insurers and you, what so ever. The very best theoretical outcome is that you get the same care for the same price plus the labor, materials, and profit of of the insurers. In other words, the same care for a higher price is the best outcome as a system (Obamacare did extend healthcare to people who couldn't have it otherwise, which was good, but it made the system overall worse).

Next, obviously you are interested in your own health. This is the free market we all know and love. But I was surprised to realize that government is, if any thing, at least as interested in your health as you are. Not always or in exactly in the same way as you personally, but in aggregate it is in the interest of the government to keep its citizens mentally and physically fit so that they can maximize GDP and be good little soldiers if needed. That war on drugs, mandatory vaccines, seat belts, the cigarette and sugar and booze taxes? Not actually judgementalism for its own sake. The forces of big government are concerned that many citizens are losing their health edge. At that point I realized that the government would probably be more incentivized to provide effective and efficient health care as measured by aggregate data than the private free market would. You might argue against government health care simply because you are against big government, but if you say you oppose it because it would be less efficient than the individual free market you will be wrong. The government has strong incentives to provide the best aggregate care for the lowest cost in a timely manner, quite likely stronger than your own personal incentives.

Now to the problem that the government's interests are mostly but not entirely aligned with your own. The government only cares if you function well. You want to enjoy life, which in health care terms is maybe about 80% the same. We still need to give individuals the chance to get more, less, none, specialized, or different healthcare whenever they want and are able without barriers beyond availability and their own ability to pay. So we need a way to work that in. The problem with unconstrained government health care isn't inefficiency, it is overefficiency.

I worked for a few weeks with a poor Canadian guy who had a hernia, but his system couldn't schedule him for surgery for months for any reason. He was walking around in pain and on meds. To me that is a little bit of a failing. It's nice that he got low cost surgery, but the long delay leaves a little to be desired in my book.

My favorite (from my very shallow perspective) health care system is China (I have heard South Korea is similar but never been there). Obviously it is highly subsidized. It is astoundingly fast, you get same day service for virtually anything, and if you show up with an ear infection and no appointment you will see a PA/NP equivalent and walk out with a prescription within 30 minutes for the entire process. To my mind, beyond heavy subsidies, the defining characteristic of the Chinese system is that you must pay up front in cash before you receive any health care at all. Sure the cost is very small, but you don't get in if you aren't prepared to pay it. Pay $3 to see the doctor-type-person. Need lab tests? Take $3 to the payment window then get them done. Then return to the doctor, who gives a prescription. Back to the payment window with $2 and then go get the prescription filled. To my mind the cash-only pay-in-advance-as-you-go system keeps prices transparent, patients attentive, and generally acts like grease on an axle. I see it as beneficial. There are some problems though, for example apparently the providers get paid based on the cost of what they provide. This has made doctors almost always recommend C-sections over natural births because they get paid more for them. It is not a system I would want in its entirety, but there are many parts I like.

Then there is what the USA has. Slow like Canada. Perverse incentives like China. No price transparency to consumers. No price negotiation by government. It seems to have copied the worst elements from all of the world's other systems into a giant mess. If I had $10,000 to spend, I bet the quality(times)quantity of care it would buy in the US would be the actual worst in the world. To fix that I propose that a system that is roughly 80% government, 20% private/individual will be best. I have no idea of details needed to implement that, but that's where I would like to go.