Author Topic: What comes after the ACA?  (Read 728799 times)

SugarMountain

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Re: What comes after the ACA?
« Reply #4700 on: August 10, 2018, 09:27:26 AM »
As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.

Frankly, the last 60 months have been very positive for most of the staches. (Really about the last 112 since the bottom in April 2009.)  But your point is valid, low unemployment will help get Trump get re-elected if he hasn't been impeached by then.  There are definitely some negatives out there - real wages have been dropping and the trade war does threaten to have an impact.  We'll see.

Zap

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Re: What comes after the ACA?
« Reply #4701 on: August 12, 2018, 08:31:53 PM »
COSAR (Colorado Search and Rescue) cards are a good thing, but they aren't insurance. They are essentially a donation to the state search and rescue fund, which helps offset costs to SAR groups in the state.

pecunia

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Re: What comes after the ACA?
« Reply #4702 on: August 13, 2018, 08:27:11 AM »
If by some miracle, Congress did pass positive health care legislation, how long would it take to implement?
https://www.congress.gov/bill/115th-congress/house-bill/676


Mr. Green

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Re: What comes after the ACA?
« Reply #4703 on: August 13, 2018, 12:56:11 PM »
If by some miracle, Congress did pass positive health care legislation, how long would it take to implement?
https://www.congress.gov/bill/115th-congress/house-bill/676
Unless the legislation has a specific future start date it would begin the next year. If it was some kind of sweeping change I could see the start being delayed a year to prepare for the administrative running of whatever is passed.

EnjoyIt

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Re: What comes after the ACA?
« Reply #4704 on: August 14, 2018, 10:57:32 AM »
As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.
The size of my stache isn't the most important thing to me.

Sure definitely not the most important thing, but I'm sure it will be a big priority if you plan on a tight FIRE withdrawing 4% while the market only gives you 2-3%

Don't kid yourself, the stache is a huge item of concerns to an early retiree.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4705 on: August 14, 2018, 01:55:26 PM »
Trump’s Sabotage of Obamacare Is Illegal  https://nyti.ms/2Mncdz2
A president doesn’t have the right to dispense with laws he dislikes.
By Nicholas Bagley and Abbe R. Gluck
Mr. Bagley and Ms. Gluck are law professors.
Aug. 14, 2018

Excerpt:

"Never in modern American history has a president so transparently aimed to destroy a piece of major legislation. What makes Mr. Trump’s sabotage especially undemocratic is that Congress has repeatedly considered repealing the law — and repeatedly declined to do so. In addition, the Supreme Court has twice sustained the Affordable Care Act in the face of major legal challenges. Mr. Trump’s attempt to destroy the law any way he can is an unconstitutional usurpation of power.
That is also the message of a lawsuit — the first of its kind — filed this month in federal court in Maryland. Brought by several plaintiffs including the cities of Chicago, Cincinnati and Columbus, the lawsuit recounts the “relentless and unlawful campaign to sabotage and, ultimately, to nullify” the Affordable Care Act. Taken individually, some of the Trump administration’s actions may be defensible. Taken together, they amount to a derogation of his constitutional duties.
The lawsuit asks the court to strike down the administration’s new rules and to enjoin the president from further sabotage. To prevail, the plaintiffs may have to overcome some procedural hurdles, including questions about whether the courts have the authority or the institutional competence to prevent violations of Article II’s requirement that the president “take care that the laws be faithfully executed” — especially given the wide discretion that presidents traditionally have to implement the laws."

Mr. Green

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Re: What comes after the ACA?
« Reply #4706 on: August 15, 2018, 02:00:50 PM »
I will be following that case with interest. Sure seems like the defence will have a hard time arguing that he is faithfully executing the law. Seems like a slam dunk, even though nothing ever is with the law. Of course if they're able to repeal the law the whole case would become moot.

Paul der Krake

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Re: What comes after the ACA?
« Reply #4707 on: August 15, 2018, 02:11:03 PM »
Eh, the executive branch has a long history of ignoring the laws they find inconvenient. Can the plaintiffs make the case that this is above and beyond? Maybe. Maybe not. I have a hard time seeing much more than a super narrow ruling.

Mr. Green

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Re: What comes after the ACA?
« Reply #4708 on: August 15, 2018, 02:31:26 PM »
Eh, the executive branch has a long history of ignoring the laws they find inconvenient. Can the plaintiffs make the case that this is above and beyond? Maybe. Maybe not. I have a hard time seeing much more than a super narrow ruling.
The thing is I think we're well past ignoring and into active sabotage. I don't know if a court will see it that way or not.

simonsez

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Re: What comes after the ACA?
« Reply #4709 on: August 15, 2018, 03:43:47 PM »
As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.
The size of my stache isn't the most important thing to me.

Sure definitely not the most important thing, but I'm sure it will be a big priority if you plan on a tight FIRE withdrawing 4% while the market only gives you 2-3%

Don't kid yourself, the stache is a huge item of concerns to an early retiree.
I generally do not think there is a strong connection between the POTUS and the size of your portfolio but will indulge a little bit.  Obama inherited the S&P 500 in the 800s.  When he left it was at 2300.  Do you really think the S&P 500 will perform better over 8 years with Trump at the helm compared to Obama?  The S&P 500 would need to be 6500+ after 8 years if Trump is re-elected.

Do I personally believe Obama (if there weren't term limits) or another Democrat President instead of Trump would have the market higher?  Hell no, it could be true or it might be but it wouldn't be due to who is sitting in the Oval Office.  I'm not complaining about my own accounts the past 18 months, but the prior 96 weren't too shabby, either.

Yes, there is ridiculous nuance to the situations under a sitting President as it pertains to the economy, but that's my point - an early retiree choosing to re-elect Trump based on the expected better market performance doesn't seem like a sound strategy.  The market factors external to a President are much more important to the economy than a single person's "pro-business" appearance.  It is basically a coin flip with each new administration if the market will perform better or worse than it did under the prior admin.

For early retirees, I think choosing a candidate with the best long-term affordable healthcare plan would be more impactful than attaching market performance to a president.  Or if you are going to endorse Trump for his economic prowess and how that might benefit early retirees, at least talk about lower short-term taxes or something they are directly responsible for rather than a nebulous relationhsip.


EnjoyIt

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Re: What comes after the ACA?
« Reply #4710 on: August 16, 2018, 12:17:35 AM »
All I said is historically whe the markets do well during a presidential election the incumbent is very likely to win. I also said that corporate profits are essential to a sustainable withdrawal strategy in retirement. Each statement was written separately and do not imply one should vote for Trump or that a president has any significant impact on market performance.

I will admit that the corporate tax break has likely been one of the most pro corporate legislations in decades that I can think of. One would assume lower taxes will equal increased profits and increased profits will equal improved market performance but who knows if that will be a reality.

if you had to give me a choice between having enough money to pay for healthcare vs hoping the government gets these policies right I will choose the cash. Our healthcare industry is so fucked up and no insurance oriented legislation will ever fix the underlying problem since insurance isn't the real issue. Cost is the problem and no legislator is willing to discuss it and address it.

sol

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Re: What comes after the ACA?
« Reply #4711 on: August 16, 2018, 09:13:26 AM »
Cost is the problem and no legislator is willing to discuss it and address it.

Can you really blame them?

Imagine a politician lobbying to lower the cost of some other good, say soybeans.  He goes to the annual soybean convention, and tells the farmers and distributors that he wants to stem the rising cost of soyeans.  People will be happier, he says, if only soybeans didn't cost so much.  It's for the good of the country!  Oh and btw, half of you are going to go out of business because you're making too much money from soybeans.

We live in a capitalist system in which higher higher costs means higher profit margins means means higher standard of living for suppliers.  That would be fine on its own, if we didn't also allow those same suppliers in the medical industry to set their own prices in noncompetitive ways, essentially subverting the market forces that are supposed to keep this system in balance.  Right now, all of the incentive is on raising costs and the rest of us just have to accept it.  Literally no one except the consumer wants prices to go down, and the consumer is the least influential party involved because we don't get to choose whether or not we participate in the market.  By virtue of being living human beings, we each have a guaranteed need for healthcare.

The politicians were supposed to be the influential voice of the people, but in today's political environment "the people" now means "corporations and wealthy donor organizations with good lobbyists" and not "consumers".  Elizabeth Warren literally tried to create the Consumer Financial Protection Bureau to address this specific problem in one specific industry, but (and don't be too shocked here) Republicans vehemently opposed it and managed to effectively shut it down, by refusing to appoint anyone to lead it, defunding it, and then exempting the worst-offending firms from the very laws the CFPB was supposed to enforce.  So just in case you're looking for someone to blame for this sort of thing, you could start there.

Is it a coincidence that the same congressional republicans who hate the CFPB also hate the ACA?  Financial regulation and healthcare seem to share a common problem of misaligned incentives and subverted market forces that make some rich people even richer, and republicans seem absolutely bent on preserving those distortions. 




EnjoyIt

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Re: What comes after the ACA?
« Reply #4712 on: August 16, 2018, 12:13:41 PM »
Sol,
You are completely correct with every word you said above. I also agree that many republicans are to blame but so are the democrats. What you described is why our healthcare system is falling apart and will continue to get worse for many years to come. Real change will lead to hundreds of thousands of people to be out of work because their services simply won't be needed. A single payer model would accomplish similar unemployment rates.

Personally I think the first step needs to be transparent pricing being mandatory. Simply making pricing transparent would force all the providers, hospital and private alike to simply pricing away from the convoluted BS we have today. Transparent pricing is not the fix. It would be a good start. But again no group of politicians will do that and have the fortitude to get it to pass.

pecunia

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Re: What comes after the ACA?
« Reply #4713 on: August 16, 2018, 12:57:26 PM »
Sol,
You are completely correct with every word you said above. I also agree that many republicans are to blame but so are the democrats. What you described is why our healthcare system is falling apart and will continue to get worse for many years to come. Real change will lead to hundreds of thousands of people to be out of work because their services simply won't be needed. A single payer model would accomplish similar unemployment rates.

Personally I think the first step needs to be transparent pricing being mandatory. Simply making pricing transparent would force all the providers, hospital and private alike to simply pricing away from the convoluted BS we have today. Transparent pricing is not the fix. It would be a good start. But again no group of politicians will do that and have the fortitude to get it to pass.

Would that many jobs be lost?  I have worked on Federal contracts where a new contract took effect.  We changed hats and worked for the new contractor.

We would still need the nurses, doctors and health technicians.  People would still need to go to the doctor.  In fact, people reluctant to go to the doctor today due to the "falling apart" nature of our current system would now go to a health care facility.  This may prompt additional employment.  I think many of the people currently administering insurance would be still needed by Uncle Sam to keep the health care wheels turning.  However, I think the administrative people may have an easier job as the rules would be consistent for everyone.

Some jobs would definitely be lost if a transition was made to something similar to other countries as those systems are more efficient.  Is this that different than the job losses that other American industries have suffered over the last thirty years?   We have built automated factories for steel production and automotive assembly that are more efficient and have eliminated many jobs.

I would guess a lot of these health care CEOs would take their golden parachutes and leave. 

FIRE@50

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Re: What comes after the ACA?
« Reply #4714 on: August 16, 2018, 01:02:36 PM »
I'm with pecunia on this.

Rip off the band-aid already!

maizeman

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Re: What comes after the ACA?
« Reply #4715 on: August 16, 2018, 01:19:26 PM »
Would that many jobs be lost?  I have worked on Federal contracts where a new contract took effect.  We changed hats and worked for the new contractor.

We would still need the nurses, doctors and health technicians.  People would still need to go to the doctor.  In fact, people reluctant to go to the doctor today due to the "falling apart" nature of our current system would now go to a health care facility.  This may prompt additional employment.  I think many of the people currently administering insurance would be still needed by Uncle Sam to keep the health care wheels turning.  However, I think the administrative people may have an easier job as the rules would be consistent for everyone.

Either you can believe that the transition to a medicare for all system would bring down costs or that it wouldn't cause a fair number of folks to lose their jobs, but it's basically impossible for both to be true at the same time.

Private insurance spends 6-9 time more of each dollar of total spending on administration/overhead than medicare. In absolute dollar terms that is on the order of $70-150 billion dollars more overhead spending than delivering the same amount of healthcare spending to hospital and doctors would cost through the medicare system.* If you figure the average payment processing/claims evaluation/etc health care worker costs their employer $100k/year when you factor in fringe benefits (employer payroll taxes, retirement contributions, and yes, employer provided healthcare), that works out to 700,000 - 1.5M jobs where the need for someone to do that work would vanish in an instant if we switched to medicare for all.

Now I don't think "we should stick with this much more expressive and less efficient system because the reason it is inefficient is that it is paying people to do work that doesn't need to be done) is a particularly reasonable argument.** But it is important to realize that a big increase in the efficiency of either healthcare or health insurance in the USA is, essentially by definition, going to mean putting a lot of people out of work.***

*Note that this doesn't do anything to take into account the difference in reimbursement rates between public and private health insurance providers which is what was being talked about up thread.

**And if it was, it'd probably make even more sense to apply it to stopping the development of self driving trucks which are likely to put many of the 3.5M americans who drive trucks for a living out of business over the next decade.

***Hopefully it'll also mean a lot of new jobs get created because the cost of hiring employees will decline, and more people will be willing to take the risk of starting a new company if they don't have to hold on to their big company job in order to make sure they'll have health insurance. But even if so, that change will take time, and the people qualified for the new jobs won't necessarily be the same people who lost the old jobs.

rantk81

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Re: What comes after the ACA?
« Reply #4716 on: August 16, 2018, 01:24:43 PM »
Those medical-middle-men are jobs that SHOULD BE "LOST"!

They aren't providing delivery of medical services. I have nothing against those individuals personally... but I wouldn't shed a tear of all those jobs went away so that our health care system was cheaper.

maizeman

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Re: What comes after the ACA?
« Reply #4717 on: August 16, 2018, 01:32:49 PM »
I don't disagree, but hopefully it's helpful to realize that's an additional potential source of resistance to changing the current system (or basically an entrenched inefficient part of an economy), particularly from congresspeople in districts where insurance companies are significant employers.

"Eliminating the middleman is never as simple as it sounds. 'Bout 50% of the human race is middlemen, and they don't take kindly to being eliminated."

seattlecyclone

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Re: What comes after the ACA?
« Reply #4718 on: August 16, 2018, 02:08:38 PM »
Right, of course cutting costs will lead to job losses. Most of the money paid for medical care goes to people in the end. If you cut costs you either cut people's pay or eliminate jobs, but most likely is a mix of both.

Paul der Krake

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Re: What comes after the ACA?
« Reply #4719 on: August 16, 2018, 02:28:23 PM »
"Oh man I can't believe they axed 1,000 paper pushing experts in the billing department, it's a tragic loss of tradition and expertise that couldn't possibly be replaced" -- no one ever

We kill jobs all the time. Heck, a lot of people on this forum automate other people's jobs for a living and nobody bats an eye.

PathtoFIRE

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Re: What comes after the ACA?
« Reply #4720 on: August 16, 2018, 03:16:37 PM »
Either you can believe that the transition to a medicare for all system would bring down costs or that it wouldn't cause a fair number of folks to lose their jobs, but it's basically impossible for both to be true at the same time.

Sorry to be a little contrarian, and this doesn't necessarily have to happen with a national health system, but if you replaced doctors with (more) mid-level providers, you could have both; cost savings along with a preservation or even increase in jobs (and perhaps even an increase in the provision of health/medicine on top of that).

maizeman

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Re: What comes after the ACA?
« Reply #4721 on: August 16, 2018, 03:21:53 PM »
Either you can believe that the transition to a medicare for all system would bring down costs or that it wouldn't cause a fair number of folks to lose their jobs, but it's basically impossible for both to be true at the same time.

Sorry to be a little contrarian, and this doesn't necessarily have to happen with a national health system, but if you replaced doctors with (more) mid-level providers, you could have both; cost savings along with a preservation or even increase in jobs (and perhaps even an increase in the provision of health/medicine on top of that).

That might sustain or increase total jobs while reducing spending (and I think it is definitely something we need to do, our healthcare system seems to be moving in the opposite direction, requiring more and more expensive training in order to treat the same straightforward conditions and injuries), but even in that scenario a lot of MDs would end up losing their jobs.

So I'm not saying total jobs necessarily have to go down (particularly in the long term). Just that a lot of people who currently have jobs end up without them.

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

pecunia

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Re: What comes after the ACA?
« Reply #4722 on: August 16, 2018, 05:13:11 PM »
[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

former player

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Re: What comes after the ACA?
« Reply #4723 on: August 17, 2018, 01:58:02 AM »
[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

Yes, governments keeping economically irrational industries in place for reasons of political stability and kleptocracy is a dishonourable tradition in socialist authoritarian countries.

EnjoyIt

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Re: What comes after the ACA?
« Reply #4724 on: August 18, 2018, 09:11:58 PM »
[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

Yes, governments keeping economically irrational industries in place for reasons of political stability and kleptocracy is a dishonourable tradition in socialist aut  horitarian countries.

In the US we also see it in the taxation industry.  Hundreds of thousands of jobs exist because our tax system is so complex.

Unfortunately when bureaucracy gets involved there is a good chance to have inefficiencies due to paper pushing. When the incentive isn't profit, there is less need for efficiency.  Generally speaking, the bigger something gets, the less efficient it becomes.  This is in corporations and government alike.

Upthread someone said replace physicians with mid levels.  We have discussed it before on this thread.  I am a huge proponent of mid level providers who by the way now are called Advanced Practicing Clinicians (APCs).  But, and this is a big but, they are not doctors.  I work with some amazing and very bright APCs. They can do just about anything a physician can do maybe up to 95% of what a doc does and knows. Unfortunately they sometimes have no clue that they don't know that 5% and can and will make mistakes there unless having appropriate assistance from a physician.  Trust me.  I see this all the time and why we have supervising physicians helping them out.  So....a more efficient practice of a physician assisting a few APCs is a cost effective way to practice medicine and is already being utilized in many practices.  It was something that many practices had to implement just to stay profitable due to decreasing reimbursement and increased regulatory documentation.

pecunia

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Re: What comes after the ACA?
« Reply #4725 on: August 18, 2018, 10:29:56 PM »
Enjoy It:

Quote
Unfortunately when bureaucracy gets involved there is a good chance to have inefficiencies due to paper pushing. When the incentive isn't profit, there is less need for efficiency.  Generally speaking, the bigger something gets, the less efficient it becomes.  This is in corporations and government alike.

Now, I've given that a little thought in the past.  I have garbage pickup on Thursdays.  There are about 5 separate garbage companies that come down the road I live on and pick up selected garbage.  I have thought that it would be more efficient to have one big truck pick up the garbage.

Henry Ford built the River Rouge plant.  I guess he had iron ore go in one end and cars come out the other.  It was better than having lots of little cottage industries.  He also had people do one particular task all day.  It was boring, but they learned to do it well and do it quickly.

There's a term called the "economy of scale" where reduced costs per unit that arise from increased total output of a product.

I think that medical paperwork could actually have greater efficiencies if handled by one organization with the principles of "economy of scale" applied.  Processes could be streamlined.  Special software could be created and refined for this specialized and standardized work practice.  Rather than each insurance company having unique forms and processes, standard government forms and processes could be created.  Medical staff would become familiar with the one way to do the work rather than the many individual insurance company methods.  Deming methods could be applied for greater quality.

The real life examples that this is true is the medicare program in the United States and many of the government run health care programs in other countries.