Author Topic: Will ObamaCare Make Early Retirement More Difficult?  (Read 76766 times)

forummm

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #150 on: June 27, 2016, 11:21:51 AM »
What we had prior to 2014 was mostly a result of 50 years of regulation, licensing requirements, restrictions upon private pricing, and a growing percentage of public healthcare funding distorting the market.

In thread after thread you have made this claim, and said it's the reason our healthcare market is so expensive. I have challenged you to provide evidence several times, and you have not. The one time you responded (without evidence) I went through point by point to promote discussion on each of the points you raised. You never responded.

You have a fundamental problem with your argument. It's not true. The US has a huge private market component of the healthcare system. And it's crazy expensive. Doctors do need licenses, but those aren't hard to get (What do you call the person graduating at the bottom of their med school class? Doctor.). Prices in the private insurance market are set by negotiations between doctors/hospitals and insurance companies or private payers. The government is not involved in those. And even with public insurance (like Medicaid), the state (since Medicaid is a state-based program) frequently uses managed care (75% of Medicaid beneficiaries are in managed care) where they issue an RFP and private business bid for the contract to provide care for those beneficiaries. And Medicare has a large privatization program as well (guess what--it costs more).

On the other hand, every other major industrialized nation in the world has a MUCH more government regulated healthcare system. And every single one of them has DRAMATICALLY lower costs.

Out healthcare industry is very opaque. Although there is some semblance of free market, it is covered by a vaile of middlemen who like bookies take a piece of the action. A real free market has the cost for service readily available. Without knowing the cost how can we ever have a free market. Let's exclude emergency services which is a very small fraction of our healthcare dollars.

Yes, there are tons of middlemen making lots of money on healthcare. But it's people in private industry milking the system--mostly making their money from people on private insurance. If the private market was doing a great job, those people wouldn't exist because they couldn't be making so much money for providing little, no, or even negative value. There's nothing regulatory stopping prices from being publicized and transparent. It's the private insurers and private market providers who decide to keep prices secret. And actually, Medicare and Medicaid payments to providers are public.

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Also CMS dictates much of how medicine is practiced in the US. Often times wasting resources on regulations that do not increase patient safety. Such as forcing blood cultures on every pneumonia patient (research shows no benefit.) Or collecting patient satisfaction data and paying based on good satisfactory surveys (research shows happy patients don't get better care and actually some data shows poorer outcomes since increased unnecessary testing leads to better score.). One question in those surveys asks if pain has been adequately controlled. Today our healthcare system has created a narcotic drug dependence because we want to satisfy our patients.
Also, what CMS proposes as a payment model private health insurance follows shortly after.

CMS requires those things for CMS (Medicare and Medicaid) patients. But not for private insurance or self pay individuals. CMS certainly has inefficiencies and could cut costs more. But pre-ACA it's totally up to the private insurers what they do (post-ACA they have some requirements--but those requirements are clearly not to blame for all the pre-ACA insanely high prices). If private insurance and providers don't think CMS payments models make sense, they don't have to follow them.

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Here is where I see the free market working. Where I live free standing Energency departments are popping up all over the city. They do not take Medicare/medicaid and they cost about 1/3 -1/2 the cost of a regular ER visit. Another example is some of these surgical centers that do not take insurance. Again these have transparent pricing and the cost of service is much lower than going to a regular hospital.

Hospitals are very expensive. And the cost of care in a hospital is always higher regardless of the service. So if you shed the hospital (like in these free-standing service centers you mention), you cut costs a lot. It's easy to see why that's the case. I don't think it has anything to do with transparent pricing or taking insurance.

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I wish we had more free market in our healthcare industry because I believe costs would decrease. (I will repeat that "I believe.") I am awaiting the day that a full hospital will open up that does not take Medicare/Medicaid. I do believe that is the future since the cost of doing business with government is becoming more and more expensive every year.

Why do hospitals take Medicare/Medicaid? Because they make money. If Medicare is a money loser, then why to hospitals around Florida put out billboards to get more seniors to get their care at the advertising hospital? Medicaid is a mixed scenario. Fee for service Medicaid (about 25% of beneficiaries) tend to have very low reimbursement rates. However, 75% of Medicaid beneficiaries are on managed care plans, which are privately administered. And the ACA improves revenues for hospitals by providing the Medicaid expansion, so hospitals won't have as much uncompensated care to write off. Medicaid payments are better than no payments.

Shane

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #151 on: June 27, 2016, 12:01:41 PM »
Let's for one second ignore the actual number of people who FIRE. Mustachian beliefs of that actually exists is all about self reliance. MMM calls it badassity. Since when is badassity having someone else pay for your healthcare insurance when you can easily work an extra year or two and cover it yourself forever?

Also, although there are a very small percentage of rich people who are paying more for healthcare, the majority of the cost sits on the shoulders of the middle class. They get no subsidies and are now forced to pay higher premiums for worse coverage. This is a colossal failure for them. Yes increasing coverage for those who couldn't afford it or couldn't get it is indeed a benefit for those. Now when someone FIREs they and gets subsidies they are making it harder for every middle class American to save for their own retirement. This is a horrible system.  Being a physician I meet enough people on a regular basis who make just over the subsidies cutoff and now can't afford the higher cost of health insurance and opt for the penalty instead. I also meet people who get health insurance via subsidy but their deductibles are so high they can't afford to pay them making their insurance a useless plastic card in their wallets.

This is what usually happens in a socialist society. You find a few people who learn to game the system for their own selfish needs. This is indeed anti-mustachian. But how do I convince someone what they are doing is wrong when it will cost them an extra $250-$500 per month in health insurance costs. Impossible.

Lastly, people who FIRE add almost nothing into the system as they pay minimal taxes if any at all. Maybe they use their time to make their community better and maybe they don't but they definitely without a doubt add almost nothing via taxes. There is a great post on bogleheads how a family of two can live on $100k/yr and pay no taxes in retirement.

Two things:

1) Your argument seems to make the assumption that health care is a choice people make, just like buying a car or a new pair of shoes. I agree that it would be unfair for anyone to expect others to pay for their personal items like a new car or a pair of shoes, but healthcare is different. Healthcare is not something people choose to consume. At some point in almost everyone's life, he's going to end up having to consume some amount of healthcare. I know people who brag that they "never" go to a doctor, but the reality is that almost everyone will eventually end up being forced to buy healthcare, whether she wants to or not.

2) You keep bringing up these middle class people you know who are making just above the amount to qualify for subsidies and are therefore forced to pay higher premiums for worse coverage. I find it hard to believe that as many of those people exist as you're claiming.

ACA subsidies exist for anyone earning between 139% and 400% of the Federal Poverty Level (FPL). It depends on your perspective, but to me 400% of the FPL is a LOT of money, way more money than a family needs to live on anywhere in the U.S. People who are making "just above the cutoff for ACA subsidies," i.e., >400% of the FPL, are making plenty of money to be able to afford to pay for their own health insurance without any subsidies. Also, rather than whining about not being able to afford health insurance without ACA subsidies, everyone can choose how much money she makes. Anyone who wants to can choose to earn a little bit less money and therefore qualify for ACA subsidies. That many people apparently choose not to manage their incomes to maximize their ACA subsidies is a choice they are making. Some people just like to complain and want to blame Obamacare for their inability to budget their money.

Here's a quote from Obamacarefacts.com:

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ObamaCare subsidizes those with incomes ranging from 139% to 400% of the FLP (federal poverty level) and helps to make Medicaid and CHIP available for those below the 139% mark. in 2013 400% FPL is $45,960 for single person, $62,040 for a family of two, and $78,120 for a family of three. Subsidies are given as refundable tax credits. Subsidies are given as refundable tax credits.

jim555

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #152 on: June 27, 2016, 12:06:58 PM »
A totally free market has no answer to poor people who need health care.  Right now they can go to the emergency room and get looked at.  This is because the hospital is forced to do this by law.  But  that wouldn't happen in a free market.  The person would arrive, they would be asked for insurance, no insurance and they are escorted out the door.  Basically they will be told to drop dead.  Isn't that "morally wrong"? 

Old people in nursing homes with no Medicaid around, once they run out of money, would be put in the street to die.  That's a great system, and morally right?? 

The Republican answer is go to the ER, get treated, get bills, go bankrupt.  Not a solution.

Private charity could not even scratch the surface of what is needed when it comes to health care.

"Leave it to the states"- Please if we did that slavery would still exist.  We would have no SS, Medicare, Medicaid and a whole bunch of other programs.

bacchi

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #153 on: June 27, 2016, 12:20:07 PM »
I apologize if I come off saying doctors are superior in some way or another. Definitely not my intention. We all make our choices in life as a career. Not everyone can become a physician just like not everyone can become a professional football player or a nuclear physicist. The market decides on what to pay the profession.

Wha? You also wrote, on this very page,

Quote from: EnjoyIt
Out healthcare industry is very opaque. Although there is some semblance of free market,

How can the market decide what to pay the profession when the market is "very opaque" and only has "some semblance of free market?" By your own reasoning, the market is not deciding a doctor's pay at all.


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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #154 on: June 27, 2016, 12:29:38 PM »
We would have no SS, Medicare, Medicaid and a whole bunch of other programs.
Sounds good to me.  My taxes would be lower.

bacchi

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #155 on: June 27, 2016, 12:34:15 PM »
We would have no SS, Medicare, Medicaid and a whole bunch of other programs.
Sounds good to me.  My taxes would be lower.

Most Americans don't want to live in a world like that.

Schaefer Light

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #156 on: June 27, 2016, 12:45:22 PM »
We would have no SS, Medicare, Medicaid and a whole bunch of other programs.
Sounds good to me.  My taxes would be lower.

Most Americans don't want to live in a world like that.
Judging by the last two presidential elections, that much is obvious ;).

Erica

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #157 on: June 27, 2016, 01:31:41 PM »
If you retire early, it's cheaper on the taxpayers if yo qualify for Medicaid (or Medi-Cal in Calif). Just $50 a month dinged to taxpayers to keep you on the program.

Our friend was on a BPAP at night. What he did is keep the little filters, masks, hoses washed them and didn't replace them every 3 months as needed. Just washed them more often. He has 5 years worth built up now. Since they are completely healthy, eat organic and exercise pretty hard 3 days a week, they don't get sick. They are drawing very little money (in order to qualify for medi-cal) but they don't use it.

That's $600 a year for one person versus the hundreds of dollars which go to a subsidy. They didn't want to take hundreds from taxpayers so opted for Medi-Cal.

ooeei

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #158 on: June 27, 2016, 01:37:09 PM »
Let's for one second ignore the actual number of people who FIRE. Mustachian beliefs of that actually exists is all about self reliance. MMM calls it badassity. Since when is badassity having someone else pay for your healthcare insurance when you can easily work an extra year or two and cover it yourself forever?

You could make that same argument for oh so many things.  Having someone else pay for the army when you could work extra and pay for it forever.  Having someone else pay for pharmaceutical manufacturing oversight when you could work extra and pay for it forever.  Literally anything the federal (or in some cases, state) government does could have that argument made for it.  Are you saying early retirees should structure their lives to pay more taxes to make sure they pay their share?  I'm not sure why this criteria should only apply to early retirees though, why not everyone? 

Our country doesn't run on the honor system.  It runs on very specifically defined laws and rules.  Those laws and rules will screw you over sometimes, and help you out sometimes.  Sure it'd be great if everyone paid their share for everything and we all held hands and sang around the campfire. 

As is, early retirees who limit their income enough to receive subsidies are a rounding error in the federal healthcare budget.  If/when it becomes a problem, it will be dealt with.  As of now you paying extra for your healthcare won't change anything for anybody.  Even if every early retiree did it, it wouldn't change a thing.  The absolute number of early retirees DOES matter. 

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Also, although there are a very small percentage of rich people who are paying more for healthcare, the majority of the cost sits on the shoulders of the middle class. They get no subsidies and are now forced to pay higher premiums for worse coverage. This is a colossal failure for them. Yes increasing coverage for those who couldn't afford it or couldn't get it is indeed a benefit for those. Now when someone FIREs they and gets subsidies they are making it harder for every middle class American to save for their own retirement. This is a horrible system.  Being a physician I meet enough people on a regular basis who make just over the subsidies cutoff and now can't afford the higher cost of health insurance and opt for the penalty instead. I also meet people who get health insurance via subsidy but their deductibles are so high they can't afford to pay them making their insurance a useless plastic card in their wallets.

This is what usually happens in a socialist society. You find a few people who learn to game the system for their own selfish needs. This is indeed anti-mustachian. But how do I convince someone what they are doing is wrong when it will cost them an extra $250-$500 per month in health insurance costs. Impossible.

Lastly, people who FIRE add almost nothing into the system as they pay minimal taxes if any at all. Maybe they use their time to make their community better and maybe they don't but they definitely without a doubt add almost nothing via taxes. There is a great post on bogleheads how a family of two can live on $100k/yr and pay no taxes in retirement.

They add just as little to the system as a poor person who doesn't pay much/any taxes does.  Actually more because they paid taxes when they first earned the money (except what is in 401k/IRAs).  Is it morally wrong for a poor person to take the subsidy if they can "afford it" by moving their budget around elsewhere? 

Is it morally wrong for an early retiree to take a tax break on buying a home when they don't need it and would buy the home anyway?  Or to put money in a 401k if they can afford the capital gains taxes and would still invest in taxable if the 401k wasn't available?  Or take an energy credit if they would've bought the solar system anyway?  Is it wrong for them to try to optimize their tax strategy at all? Should they work a few extra years and just write a check to the federal government in the interest of fairness?
« Last Edit: June 27, 2016, 01:40:55 PM by ooeei »

Gin1984

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #159 on: June 27, 2016, 01:38:22 PM »
Also, there is nothing wrong to be adequately compensated for the work you put in. There are very few people in the world who have the aptitude and perseverance to become physicians.
...Look. Yes. It takes a lot of work the become a physician. Give yourself a round of applause for being such a badass. But feeling like ~$250k is "adequate compensation for the work you put in" is really quite arrogant. The average salary for a Physics researcher with a PhD in Physics, for example is $103k. Nothing against Physicians, but I doubt many Physicians have the mental chops to study physics at that level. $250k is a spectacular amount of money that those with exceptional privilege (and obviously hard work) are able to earn.

Quote from: EnjoyIt
Therefor due to supply and demand, it is fair to expect a high compensation for those services.

Here's the crux of the issue. Healthcare is not subject to true supply/demand. "Buyers" (patients) are not truly given a choice. If I break my femur in a car accident, I'm taken to a hospital. I cannot shop around for the best price. I cannot negotiate for a better price on morphine. I'm a hostage to whatever prices that hospital happens to charge. Healthcare is so obviously not subject to the same "suppy/demand" forces that buying a new cell phone is.

Rebuttal:
A physician does not just go to grad school they also require years of residency therefor put in my time than a physics doctorate. Also, the promise of solid compensation is one reason we choose medicine. I loved physics and was good at it, but I also knew that I had a better chance of financial success in medicine and chose that route.

As for supply and demand. I meant there is not enough physicians in the US and the market is forced to pay hem more to service an underserved region. It is why a physician makes twice as much in the midwestern US as compared to NYC or Bay Area.

Lastly,  I could have chosen a specialty in pediatrics making $100k-$120k a year but I knew it would not even come close to paying my loans and chose a more lucrative profession. The market makes its choices and if we cut salaries to physicians enough they will instead choose to do something else.

There is a reason why rich foreigners from all over the world come to US hospitals for medical care. We have some of the best doctors and technology in the world if you can afford it.
And a researcher with a PhD does a postdoctoral fellowship, just like residency is done for MDs so there is no time difference.

And most PhD programs require more than 4 years of post-graduate work. So the time requirement is actually higher for PhDs than MDs unless the MD decides to get multiple specialties or to get very time-consuming specialties that require multiple residencies. And MDs tend to get paid more on their residencies than PhDs do in a post doc.

I doubt you had to work 80-100 hour work weeks not getting paid anything extra? I doubt you have to make decisions on people's lives on a daily basis where the wrong move will kill them. That you have to tell a family member their kid has leukemia or grandma is dead. Maybe that deserves a few extra dollars.

Maybe you made the wrong choice in a careers. Maybe you didn't. You could have also chosen to be an actor spending decades in training making no money at all when you are done. Nice job not choosing to be an actor.

I chose my profession knowing its effort and rewards. You chose yours so please stop griping that you make less. Accept your decision and move on.
My post doc just spent 100 hours working last week and yes, he is salaried so he did not make more.  Should MDs be working 80-100 hrs and making decisions on people's lives, no, but that is about patient safety, not money.  No one is griping about how much money they make or don't, except you.

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #160 on: June 27, 2016, 01:39:36 PM »
I apologize if I come off saying doctors are superior in some way or another. Definitely not my intention. We all make our choices in life as a career. Not everyone can become a physician just like not everyone can become a professional football player or a nuclear physicist. The market decides on what to pay the profession.

Wha? You also wrote, on this very page,

Quote from: EnjoyIt
Out healthcare industry is very opaque. Although there is some semblance of free market,

How can the market decide what to pay the profession when the market is "very opaque" and only has "some semblance of free market?" By your own reasoning, the market is not deciding a doctor's pay at all.

Who is deciding physician compensation?
A physician in NYC makes as little as 50% less than a physician in the South.  Why is that?  It is supply  and demand for physicians.

As for the post above, I am not griping about my salary.  Actually I am very happy with my compensation and don't think it needs to increase.  But I also don't think it needs to decrease.

You know who I think is drastically underpaid?  Teachers.  They provide such an amazing service, but for some reason market forces and regulations keep those wages lower.  It is a shame.  Then again I see astroturf and jumbotrons being put up in athletic field at high schools instead of paying our teachers more.  Again what a shame.
« Last Edit: June 27, 2016, 01:44:16 PM by EnjoyIt »

Yaeger

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #161 on: June 27, 2016, 01:59:03 PM »
What we had prior to 2014 was mostly a result of 50 years of regulation, licensing requirements, restrictions upon private pricing, and a growing percentage of public healthcare funding distorting the market.

In thread after thread you have made this claim, and said it's the reason our healthcare market is so expensive. I have challenged you to provide evidence several times, and you have not. The one time you responded (without evidence) I went through point by point to promote discussion on each of the points you raised. You never responded.

You have a fundamental problem with your argument. It's not true. The US has a huge private market component of the healthcare system. And it's crazy expensive. Doctors do need licenses, but those aren't hard to get (What do you call the person graduating at the bottom of their med school class? Doctor.). Prices in the private insurance market are set by negotiations between doctors/hospitals and insurance companies or private payers. The government is not involved in those. And even with public insurance (like Medicaid), the state (since Medicaid is a state-based program) frequently uses managed care (75% of Medicaid beneficiaries are in managed care) where they issue an RFP and private business bid for the contract to provide care for those beneficiaries. And Medicare has a large privatization program as well (guess what--it costs more).

On the other hand, every other major industrialized nation in the world has a MUCH more government regulated healthcare system. And every single one of them has DRAMATICALLY lower costs.

No I did, I've defended this point on several other threads, including a thread I started on the untended effects of regulation on the economy. You quoted me above but I honestly don't understand how you could have a conflict with that quote. Pre-ACA the US healthcare market over a period of 50 years has become more regulated, licencing requirements for medical professionals has increased, government has imposed more and more limits on the free-range of private entities within healthcare to include insurers, hospitals, drug producers, medical device manufacturers.

Even if you think the net result of these changes has been for the better, I find it hard to understand why you think that as public healthcare spending eclipses private healthcare spending that somehow the diminishing amount of private healthcare interaction in our healthcare system is responsible for the rise in total costs. It's absurd and it feels like you're sticking your head in the ground and ignoring basic economic principles behind government intervention in a market and the distortions (good or bad) that it causes. If the federal government is the largest buyer, and it doesn't actively negotiate prices, how do you imagine that effects the other actors? The government either overpays, which sets a price floor for a lot of situations, or they underpay and the provider has to recoup costs. In both scenarios instead of paying an ever-changing 'market price' that price differential is shifted onto private customers.

More to the point, at what point of private vs public spending does a system cease being private? Private markets tend to rely on giving power on the consumer in placing downward pressure on prices and driving innovation, change, and increases in efficiency. I'd argue that the reduction in the role that a private consumer has in picking healthcare options, especially in regards to the limitations imposed on them post-ACA and the fact that the private consumer is the unintended recipient of the distortion effects of public spending, is responsible for mangling a 'private' market and I think it disingenuous to call it such. Even every other industrialized nation appreciates the role of private enterprise in healthcare and places like Sweden, Canada, and the UK have seen the growth of private healthcare options due to inadequate or incompetent public care and the explosion of healthcare costs relative to GDP.

I thought this talked reasonably well about the effects of regulation on healthcare costs:
https://mises.org/blog/how-government-regulations-made-healthcare-so-expensive

bacchi

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #162 on: June 27, 2016, 02:06:07 PM »
I apologize if I come off saying doctors are superior in some way or another. Definitely not my intention. We all make our choices in life as a career. Not everyone can become a physician just like not everyone can become a professional football player or a nuclear physicist. The market decides on what to pay the profession.

Wha? You also wrote, on this very page,

Quote from: EnjoyIt
Out healthcare industry is very opaque. Although there is some semblance of free market,

How can the market decide what to pay the profession when the market is "very opaque" and only has "some semblance of free market?" By your own reasoning, the market is not deciding a doctor's pay at all.

Who is deciding physician compensation?

You tell me; you're the one that wrote that the healthcare market is very opaque and only a semblance of a free market. Is it or is it not?

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #163 on: June 27, 2016, 02:07:16 PM »
What we had prior to 2014 was mostly a result of 50 years of regulation, licensing requirements, restrictions upon private pricing, and a growing percentage of public healthcare funding distorting the market.

In thread after thread you have made this claim, and said it's the reason our healthcare market is so expensive. I have challenged you to provide evidence several times, and you have not. The one time you responded (without evidence) I went through point by point to promote discussion on each of the points you raised. You never responded.

You have a fundamental problem with your argument. It's not true. The US has a huge private market component of the healthcare system. And it's crazy expensive. Doctors do need licenses, but those aren't hard to get (What do you call the person graduating at the bottom of their med school class? Doctor.). Prices in the private insurance market are set by negotiations between doctors/hospitals and insurance companies or private payers. The government is not involved in those. And even with public insurance (like Medicaid), the state (since Medicaid is a state-based program) frequently uses managed care (75% of Medicaid beneficiaries are in managed care) where they issue an RFP and private business bid for the contract to provide care for those beneficiaries. And Medicare has a large privatization program as well (guess what--it costs more).

On the other hand, every other major industrialized nation in the world has a MUCH more government regulated healthcare system. And every single one of them has DRAMATICALLY lower costs.

Out healthcare industry is very opaque. Although there is some semblance of free market, it is covered by a vaile of middlemen who like bookies take a piece of the action. A real free market has the cost for service readily available. Without knowing the cost how can we ever have a free market. Let's exclude emergency services which is a very small fraction of our healthcare dollars.

Yes, there are tons of middlemen making lots of money on healthcare. But it's people in private industry milking the system--mostly making their money from people on private insurance. If the private market was doing a great job, those people wouldn't exist because they couldn't be making so much money for providing little, no, or even negative value. There's nothing regulatory stopping prices from being publicized and transparent. It's the private insurers and private market providers who decide to keep prices secret. And actually, Medicare and Medicaid payments to providers are public.

Indeed this is bureaucracy allowing lobbying to allow this opaqueness.  Its complete bullshit that I have no idea what the hospital is charging for my services, and what my patients are expecting as a bill.  To be honest, I think the health insurance industry is the biggest problem.  If insurance was exactly what it was designed to be, insurance instead of paying for basic health related items.  I get home owners insurance incase my roof falls in.  I do not buy home owners insurance to repair my faucet when it leaks.  Health care should be the same.  You buy catastrophic insurance incase you develop cancer or other dangerous condition that will cost a ridiculous amount of money while at the same time paying for the minor items such as  simple doctors visits and minor procedures out of pocket.  This would create competition and market forces would cut costs.  Costs would also drop because we would not have to deal with the red tape of insurance and all its headaches.  Cost would be cut because there would be less middlemen sucking off the healthcare teat.
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Also CMS dictates much of how medicine is practiced in the US. Often times wasting resources on regulations that do not increase patient safety. Such as forcing blood cultures on every pneumonia patient (research shows no benefit.) Or collecting patient satisfaction data and paying based on good satisfactory surveys (research shows happy patients don't get better care and actually some data shows poorer outcomes since increased unnecessary testing leads to better score.). One question in those surveys asks if pain has been adequately controlled. Today our healthcare system has created a narcotic drug dependence because we want to satisfy our patients.
Also, what CMS proposes as a payment model private health insurance follows shortly after.

CMS requires those things for CMS (Medicare and Medicaid) patients. But not for private insurance or self pay individuals. CMS certainly has inefficiencies and could cut costs more. But pre-ACA it's totally up to the private insurers what they do (post-ACA they have some requirements--but those requirements are clearly not to blame for all the pre-ACA insanely high prices). If private insurance and providers don't think CMS payments models make sense, they don't have to follow them.

CMS creates and then private insurance follows shortly after.  CMS says you need to document 10 line items on your chart to bill and private insurance follows.   CMS makes these minor changes to temporarily cut costs.  For example when I work with a nurse practitioner I used to be able to jot a very brief note.  Starting in September CMS is dictating a more broad note which will take up more of my time even if the nurse practitioner's note was adequate.  If I do not write what they demand they will pay less. I believe 15% less. I predict there is a learning curve for proper implementation allowing CMS to pay less until others bridge that gap.  In the meantime I now have to spend an extra 2 minutes per patient every day.  Although these extra 2 minutes do not seam like a lot, but over the years as CMS keeps adding an extra minute or 2 per patient every 1-3 years, I find today I am spending more time on the computer than I am with my patients.  It sucks and it is killing my desire to be a doctor.  Honestly I just want to take care of patients, be there for them, explain their disease process, and get them to understand how to be healthier. With every demand, CMS is slowly killing my joy for my career.

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Here is where I see the free market working. Where I live free standing Energency departments are popping up all over the city. They do not take Medicare/medicaid and they cost about 1/3 -1/2 the cost of a regular ER visit. Another example is some of these surgical centers that do not take insurance. Again these have transparent pricing and the cost of service is much lower than going to a regular hospital.

Hospitals are very expensive. And the cost of care in a hospital is always higher regardless of the service. So if you shed the hospital (like in these free-standing service centers you mention), you cut costs a lot. It's easy to see why that's the case. I don't think it has anything to do with transparent pricing or taking insurance.

Hospitals are expensive because of all the garbage they have to do.  there is an entire department of compliance people, billing people, regulatory people that need to get paid.  Get rid of CMS and all of a sudden cost plummet.

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I wish we had more free market in our healthcare industry because I believe costs would decrease. (I will repeat that "I believe.") I am awaiting the day that a full hospital will open up that does not take Medicare/Medicaid. I do believe that is the future since the cost of doing business with government is becoming more and more expensive every year.


Why do hospitals take Medicare/Medicaid? Because they make money. If Medicare is a money loser, then why to hospitals around Florida put out billboards to get more seniors to get their care at the advertising hospital? Medicaid is a mixed scenario. Fee for service Medicaid (about 25% of beneficiaries) tend to have very low reimbursement rates. However, 75% of Medicaid beneficiaries are on managed care plans, which are privately administered. And the ACA improves revenues for hospitals by providing the Medicaid expansion, so hospitals won't have as much uncompensated care to write off. Medicaid payments are better than no payments.

That is today.  There will likely be a tipping point in the future where that will change.  We slowly see doctors opening up offices that don't accept medicare/medicaid.  I believe this trend will continue.  I believe that we will have small free standing ERs with small inpatient facilities.  I believe it will continue to build from there.  Currently a hospital's profit margin is about just a couple of percentage points.  2-3% is very common.  When CMS says it will cut payments by 1% if a hospital doesn't comply it is a very big deal and the hospital is forced to jump.  Someday we will see a hospital that is sick of jumping.
« Last Edit: June 27, 2016, 02:09:58 PM by EnjoyIt »

Yaeger

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #164 on: June 27, 2016, 02:16:19 PM »
They add just as little to the system as a poor person who doesn't pay much/any taxes does.  Actually more because they paid taxes when they first earned the money (except what is in 401k/IRAs).  Is it morally wrong for a poor person to take the subsidy if they can "afford it" by moving their budget around elsewhere? 

Is it morally wrong for an early retiree to take a tax break on buying a home when they don't need it and would buy the home anyway?  Or to put money in a 401k if they can afford the capital gains taxes and would still invest in taxable if the 401k wasn't available?  Or take an energy credit if they would've bought the solar system anyway?  Is it wrong for them to try to optimize their tax strategy at all? Should they work a few extra years and just write a check to the federal government in the interest of fairness?

Typically I see a 'tax break' as someone that pays a net positive amount of taxes, the break just reduces the amount of taxes they do pay. A 'subsidy' is a grant from the government and it's typically net negative, you're receiving more in benefits than you're paying into the system.

I'm fine with tax breaks because they're still contributing to society's burden. It should always be the government's role to actively work in minimizing its tax burden on the citizen. I'm not fine with someone receiving a subsidy when they have the means of providing for themselves without public assistance.

ooeei

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #165 on: June 27, 2016, 02:33:17 PM »
They add just as little to the system as a poor person who doesn't pay much/any taxes does.  Actually more because they paid taxes when they first earned the money (except what is in 401k/IRAs).  Is it morally wrong for a poor person to take the subsidy if they can "afford it" by moving their budget around elsewhere? 

Is it morally wrong for an early retiree to take a tax break on buying a home when they don't need it and would buy the home anyway?  Or to put money in a 401k if they can afford the capital gains taxes and would still invest in taxable if the 401k wasn't available?  Or take an energy credit if they would've bought the solar system anyway?  Is it wrong for them to try to optimize their tax strategy at all? Should they work a few extra years and just write a check to the federal government in the interest of fairness?

Typically I see a 'tax break' as someone that pays a net positive amount of taxes, the break just reduces the amount of taxes they do pay. A 'subsidy' is a grant from the government and it's typically net negative, you're receiving more in benefits than you're paying into the system.

I'm fine with tax breaks because they're still contributing to society's burden. It should always be the government's role to actively work in minimizing its tax burden on the citizen. I'm not fine with someone receiving a subsidy when they have the means of providing for themselves without public assistance.

For someone who's ER whether it's a tax break or tax subsidy is mathematically the same in most cases.  It's that much less revenue the government gets from that person. 

The only time the tax break/subsidy distinction matters is for people with incomes low enough they pay no taxes (and an inability to raise that income to capture additional tax breaks).

Spork

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #166 on: June 27, 2016, 02:37:14 PM »
If you do that... does the subsidy not still apply when you file taxes?  (Not trying to start a political firestorm again... trying to understand how it works.)

Nope. If you buy direct from any insurance company, or from a company or independant agent, you will not get any subsidy. To get the subsidy when you file, you have to buy the policy through either the Federal exchange or your state's exchange (if your state has one). And, I'm pretty sure, it has the be a Silver policy.
Not true.

Do you please have a good citation to back it up? Or is it from personal experience?

http://obamacarefacts.com/ contradicts you and says it has to be second cheapest Silver, and has to be bought through the federal or state exchange (whichever applies to the buyer).

From:

http://obamacarefacts.com/obamacare-subsidies/

“The amount of cost assistance you can get is based on the second-lowest-cost Silver plans in your state’s Marketplace.”

“Cost sharing reduction subsidies are only Available On Silver Plans.”

This is a dot com, not dot gov site, so I don't take it as gospel. If you have a .gov site reference that says it doesn't have to be Silver, I will gratefully stand corrected.

Try "healthcare.gov".  ;)

Make up some numbers and see what the plans are before/after subsidy for your state.

I can also tell you Bronze is subsidized from personal experience.  I had private insurance before ACA for myself/my wife at about the level of the Bronze plan for about $250/month.  After ACA approximately the same plan (before subsidy) is about $1200 a month and with subsidy applied it's about $550 a month.   

Silver is special though, and that's probably where the confusion comes in.  Silver has additional cost sharing subsidies.  Try reading our own SeatleCyclone's write up:  https://seattlecyclone.com/optimizing-the-affordable-care-act/

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #167 on: June 27, 2016, 03:32:38 PM »
Try "healthcare.gov".  ;)

Make up some numbers and see what the plans are before/after subsidy for your state.

I can also tell you Bronze is subsidized from personal experience.  I had private insurance before ACA for myself/my wife at about the level of the Bronze plan for about $250/month.  After ACA approximately the same plan (before subsidy) is about $1200 a month and with subsidy applied it's about $550 a month.   

Silver is special though, and that's probably where the confusion comes in.  Silver has additional cost sharing subsidies.  Try reading our own SeatleCyclone's write up:  https://seattlecyclone.com/optimizing-the-affordable-care-act/

You are the perfect example Spork.  Prior to ACA you payed $250 and now your insurance is $550.  How is this even a subsidy?  You are paying more than twice as much for the same plan.  Since you are getting a subsidy I will assume you are middle class America who now has to pay an extra $3600 a year after taxes for health insurance.  If you are middle class I will assume you are in the 25% tax bracket with maybe 5% state tax for a total of 30%.  You need to make an additional $5,142 to cover your family's health insurance costs.  That is $5,142 that you will not be able to save in a retirement account for your future.  For many middle class American's this is a massive hit on their future and current well being.  Much easier to just say fuck it and not have health insurance at all and pay the penalty.  Hope for the best, and if you get sick just go to the hospital and not pay your bills.

Spork

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #168 on: June 27, 2016, 03:47:23 PM »
Try "healthcare.gov".  ;)

Make up some numbers and see what the plans are before/after subsidy for your state.

I can also tell you Bronze is subsidized from personal experience.  I had private insurance before ACA for myself/my wife at about the level of the Bronze plan for about $250/month.  After ACA approximately the same plan (before subsidy) is about $1200 a month and with subsidy applied it's about $550 a month.   

Silver is special though, and that's probably where the confusion comes in.  Silver has additional cost sharing subsidies.  Try reading our own SeatleCyclone's write up:  https://seattlecyclone.com/optimizing-the-affordable-care-act/

You are the perfect example Spork.  Prior to ACA you payed $250 and now your insurance is $550.  How is this even a subsidy?  You are paying more than twice as much for the same plan.  Since you are getting a subsidy I will assume you are middle class America who now has to pay an extra $3600 a year after taxes for health insurance.  If you are middle class I will assume you are in the 25% tax bracket with maybe 5% state tax for a total of 30%.  You need to make an additional $5,142 to cover your family's health insurance costs.  That is $5,142 that you will not be able to save in a retirement account for your future.  For many middle class American's this is a massive hit on their future and current well being.  Much easier to just say fuck it and not have health insurance at all and pay the penalty.  Hope for the best, and if you get sick just go to the hospital and not pay your bills.

Caveat: I haven't read most of the back-n-forth arguing.  I always skip those bits.  I generally come to this site to find things I have in common with folks.  When arguments break out, I start ignoring/skipping threads.

That said: I did see you were a physician.  I grew up in a physician's family and I can generally see things through my Dad's eyes.  I understand your frustration in this.  I am also a pretty extreme Capitalist/Libertarian type.  I am not pro-ACA.  But... I do take the subsidies.  I take them because the market changed in such a way that it was sort of impossible not to.  It is my unprovable theory that this was the intent... to make the market tip in such a way that uniform healthcare seems the only viable option. 

I am FIRE'd and living in a state with no income taxes... so I would pretty much be one of the freeloaders people are complaining about.  If my calculations are correct, I think I'll be paying no income tax this year.  I can't say I like the system, but it's the one we have.  Being Libertarian puts me in the serious minority for effecting change.  Outside of voting Libertarian and sending them money, I'm sort of out of options.

randymarsh

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #169 on: June 27, 2016, 03:50:00 PM »
Is Social Security, healthcare, and everything provided by government. Income is a very inaccurate indicator of ability if your net worth is nearing seven figures and using subsidies meant for the poor is depriving poor families of legitimate aid, and that's deplorable.

A wealthy person using ACA subsidies doesn't prevent anyone from getting their own subsidy. AFAIK, ACA subsidies are like food stamps. If you qualify, you get them. No one is going to be told "Sorry, you applied too late and funds are exhausted".

Yes, wealthy one percenters getting Medicaid does make it more difficult for others to get what they need.  There is not an unlimited amount of money for these programs.  Rich people taking advantage means that others will have to carry a heavier burden to support this.

You're incorrect. There is, effectively, an unlimited amount of money. From what I've read, ACA subsidies (along with things like child tax credits, food stamps, and Medicaid) are part of mandatory spending. It is impossible for a "real" poor person to be deprived because a FIRE'd person takes advantage of a benefit they qualify for.

MoonShadow

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #170 on: June 27, 2016, 03:58:53 PM »

Out healthcare industry is very opaque. Although there is some semblance of free market, it is covered by a vaile of middlemen who like bookies take a piece of the action. A real free market has the cost for service readily available. Without knowing the cost how can we ever have a free market. Let's exclude emergency services which is a very small fraction of our healthcare dollars.


The economic term that you are looking for here is "transaction friction".  There is a relatively high overhead on transactions & settlements in our current, insurance dominated, health care access system.  (Health care is not a human right, but access to health care probably is.  A free person always has the right to engage in business, including the business of providing or consuming health care services)  Obamacare didn't improve this 'friction', and seems to have made it worse overall.  Single payer would actually improve this portion of our system, which is overregulated and seriously outdated.  There is no rational reason that, in the age of the Internet, I shouldn't be able to know exactly how much a given service will cost me and from whom. 

onlykelsey

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #171 on: June 27, 2016, 04:01:42 PM »

Out healthcare industry is very opaque. Although there is some semblance of free market, it is covered by a vaile of middlemen who like bookies take a piece of the action. A real free market has the cost for service readily available. Without knowing the cost how can we ever have a free market. Let's exclude emergency services which is a very small fraction of our healthcare dollars.


The economic term that you are looking for here is "transaction friction".  There is a relatively high overhead on transactions & settlements in our current, insurance dominated, health care access system.  (Health care is not a human right, but access to health care probably is.  A free person always has the right to engage in business, including the business of providing or consuming health care services)  Obamacare didn't improve this 'friction', and seems to have made it worse overall.  Single payer would actually improve this portion of our system, which is overregulated and seriously outdated.  There is no rational reason that, in the age of the Internet, I shouldn't be able to know exactly how much a given service will cost me and from whom.

My old pharmacist that I became buddy-buddy with used to joke that "the random number generator" had determined my price for the day was $X.

Eric

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #172 on: June 27, 2016, 04:01:58 PM »
If you do that... does the subsidy not still apply when you file taxes?  (Not trying to start a political firestorm again... trying to understand how it works.)

Nope. If you buy direct from any insurance company, or from a company or independant agent, you will not get any subsidy. To get the subsidy when you file, you have to buy the policy through either the Federal exchange or your state's exchange (if your state has one). And, I'm pretty sure, it has the be a Silver policy.
Not true.

Do you please have a good citation to back it up? Or is it from personal experience?

http://obamacarefacts.com/ contradicts you and says it has to be second cheapest Silver, and has to be bought through the federal or state exchange (whichever applies to the buyer).

From:

http://obamacarefacts.com/obamacare-subsidies/

“The amount of cost assistance you can get is based on the second-lowest-cost Silver plans in your state’s Marketplace.”

“Cost sharing reduction subsidies are only Available On Silver Plans.”

This is a dot com, not dot gov site, so I don't take it as gospel. If you have a .gov site reference that says it doesn't have to be Silver, I will gratefully stand corrected.

All of those statements are true, but the wording is confusing.  The amount of cost assistance is based on the 2nd lowest cost silver plan.  That doesn't mean that there isn't cost assistance on other levels of plans, only that the level of assistance doesn't increase if you increase to a Platinum plan, for example.  Notice that they said cost assistance.

Cost sharing reduction subidies are different than cost assistance.  They are above and beyond the basic subsidy that's available to everyone who qualifies based on income.  See here:
https://www.healthcare.gov/lower-costs/save-on-out-of-pocket-costs/

MoonShadow

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #173 on: June 27, 2016, 04:44:57 PM »
  I am also a pretty extreme Capitalist/Libertarian type.  I am not pro-ACA.  But... I do take the subsidies.  I take them because the market changed in such a way that it was sort of impossible not to.  It is my unprovable theory that this was the intent... to make the market tip in such a way that uniform healthcare seems the only viable option. 
.  Outside of voting Libertarian and sending them money, I'm sort of out of options.

From my point of view, you are not wrong to take the subsidies.  You paid into the system, and even with the subsidies, you are extremely unlikely to get back what you have already contributed in other ways.  You only lose your moral high ground if you vote to continue the fraud.  This is also how I look at Social Security.

Yaeger

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #174 on: June 27, 2016, 05:00:31 PM »
Is Social Security, healthcare, and everything provided by government. Income is a very inaccurate indicator of ability if your net worth is nearing seven figures and using subsidies meant for the poor is depriving poor families of legitimate aid, and that's deplorable.

A wealthy person using ACA subsidies doesn't prevent anyone from getting their own subsidy. AFAIK, ACA subsidies are like food stamps. If you qualify, you get them. No one is going to be told "Sorry, you applied too late and funds are exhausted".

Yes, wealthy one percenters getting Medicaid does make it more difficult for others to get what they need.  There is not an unlimited amount of money for these programs.  Rich people taking advantage means that others will have to carry a heavier burden to support this.

You're incorrect. There is, effectively, an unlimited amount of money. From what I've read, ACA subsidies (along with things like child tax credits, food stamps, and Medicaid) are part of mandatory spending. It is impossible for a "real" poor person to be deprived because a FIRE'd person takes advantage of a benefit they qualify for.

That's wrong, if you expand mandatory spending you're just shifting the cost to another area of government when they wrangle for a smaller pool of discretionary spending. You claiming ACA benefits in excess of the additional taxes created to support that spending in order to support your ER could, and effectively does, reduce funding available on discretionary items like roads, or education, or Defense or leads to greater annual deficits if no one's willing to reduce those programs.

There is a finite amount of government funding available, just like there are finite amounts that the government can effectively withdraw as tax revenue from its citizens. It's not unlimited and though you might feel like a flea on the back of government, it's the mass of fleas that are dragging us all down. Every dollar is important, and if it's not, then don't tax that dollar from my income.

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #175 on: June 27, 2016, 05:01:11 PM »

Caveat: I haven't read most of the back-n-forth arguing.  I always skip those bits.  I generally come to this site to find things I have in common with folks.  When arguments break out, I start ignoring/skipping threads.

That said: I did see you were a physician.  I grew up in a physician's family and I can generally see things through my Dad's eyes.  I understand your frustration in this.  I am also a pretty extreme Capitalist/Libertarian type.  I am not pro-ACA.  But... I do take the subsidies.  I take them because the market changed in such a way that it was sort of impossible not to.  It is my unprovable theory that this was the intent... to make the market tip in such a way that uniform healthcare seems the only viable option. 

I am FIRE'd and living in a state with no income taxes... so I would pretty much be one of the freeloaders people are complaining about.  If my calculations are correct, I think I'll be paying no income tax this year.  I can't say I like the system, but it's the one we have.  Being Libertarian puts me in the serious minority for effecting change.  Outside of voting Libertarian and sending them money, I'm sort of out of options.

I too am more libertarian leaning.  I as you being human would take the subsidy.  You would be a fool not to take the free cash.  Especially since without it your costs actually 120%.  You may be correct that the long standing plan is to make our system so intolerable that the only option is a one payer system.  I just fear that this system will be as poor as medicare/medicaid which will drag down the quality of our physicians.  This fear is just one more reason why I save as much as I do so that I don't have to rely on the government for my paycheck.  And you know what, if at that point I am offered a subsidy for my health insurance.  I sure as hell will jump right on it.  Even though I despise the whole system.

The economic term that you are looking for here is "transaction friction".  There is a relatively high overhead on transactions & settlements in our current, insurance dominated, health care access system.  (Health care is not a human right, but access to health care probably is.  A free person always has the right to engage in business, including the business of providing or consuming health care services)  Obamacare didn't improve this 'friction', and seems to have made it worse overall.  Single payer would actually improve this portion of our system, which is overregulated and seriously outdated.  There is no rational reason that, in the age of the Internet, I shouldn't be able to know exactly how much a given service will cost me and from whom. 

Right on, thanks for the terminology.  I believe your assessment is exactly what is going on.  I can call 3 surgeon buddies of mine and ask them how much to remove my gallbladder and not a single one will know without running numbers through their collection service.  BTW, this service isn't cheap and adds to the cost of my procedure.

If the single payer is our government, then I fear it will come with increased bureaucratic red tape and the same pathetically low reimbursement drastically altering the lives of many physicians in this country.  Some would have to close their practices since Medicaid covers about 80% of the cost of the service. Also, look at how horrible the government handles medical care via the VA. I have worked in a VA hospital and their documentation and bureaucracy is much worse than the private sector.  We all had a saying "everything takes longer at the VA."  I hated working there so much.

A few ways we need to cut costs is:
1) Stop incentivizing patient satisfaction.  This leads to unnecessary testing. Which costs more and leads to false positive results and increased risk of unnecessary procedures which also increase cost.
2) Stop incentivizing pain control financially.  This has created a slew of opiate addiction in the US also  costing a fortune.
3) No more lawsuits unless there was malicious intent while allowing peers to scrutinize practice methods and enforcing continuing medical education or revocation of licensure if no improvement in quality of care.  Eliminating the fear of lawsuits will allow us to practice evidence based medicine instead of cover our ass medicine.  This measure will be huge, but will take maybe a decade or more to see its full results as we are trained to protect ourselves and this is a hard habit to break.
4) Stop providing end of life care to the brain dead.  Last I read, end of life care is 28% of the CMS budget.  We need to stop keeping the grandpa if he eats through a tube in his stomach and hasn't moved or said a word in years.
5) Allow physicians to institute DNR (do not resuscitate) at will.  It will allow us to stop bringing the braindead back to life like grandpa I alluded to in #4.
6) Stop performing Chemotherapy on those that have minimal chance of survival.  Chemo is ridiculously expensive and causes a lot of discomfort.  Allow people to die with dignity.
7) Outside of real emergency services, allow medical practices to compete in the open market for their clients and the services they provide.  Competition is great at hedging prices.  When I say Emergency services I don't mean going to the ER when you have a cough.  I mean heart attacks, strokes, surgical infections and the likes.
8) To make #7 work, we need to eliminate a ton of the bearocratic bullshit primary care doctors deal with so that they have more time to open up their schedules and see a patient in a timely manor when they are sick.  Today most offices will tell the patient to just go to the ER.  Great idea, lets convert a $100 visit into a $3000K visit.
9) Eliminate the 3rd payer model and eliminate this friction from the transaction.  The costs of the third payer is placed directly onto the consumer.  Lets cut out the middle man.

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #176 on: June 27, 2016, 05:04:50 PM »

You're incorrect. There is, effectively, an unlimited amount of money. From what I've read, ACA subsidies (along with things like child tax credits, food stamps, and Medicaid) are part of mandatory spending. It is impossible for a "real" poor person to be deprived because a FIRE'd person takes advantage of a benefit they qualify for.

It is this attitude toward government spending that is dragging down the US.  The money supply is not unlimited.  it must come from somewhere.  There is also a finite amount of debt this country can tolerate before it will collapse under its own weight.

And as Yeager said, there is only so much that the government cat take as taxes.  There is a point where you increase the percent taken, but actually get less revenue due to decreased productivity and stifling of business.  The money supply is not unlimited.

Gin1984

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #177 on: June 27, 2016, 05:14:06 PM »

Caveat: I haven't read most of the back-n-forth arguing.  I always skip those bits.  I generally come to this site to find things I have in common with folks.  When arguments break out, I start ignoring/skipping threads.

That said: I did see you were a physician.  I grew up in a physician's family and I can generally see things through my Dad's eyes.  I understand your frustration in this.  I am also a pretty extreme Capitalist/Libertarian type.  I am not pro-ACA.  But... I do take the subsidies.  I take them because the market changed in such a way that it was sort of impossible not to.  It is my unprovable theory that this was the intent... to make the market tip in such a way that uniform healthcare seems the only viable option. 

I am FIRE'd and living in a state with no income taxes... so I would pretty much be one of the freeloaders people are complaining about.  If my calculations are correct, I think I'll be paying no income tax this year.  I can't say I like the system, but it's the one we have.  Being Libertarian puts me in the serious minority for effecting change.  Outside of voting Libertarian and sending them money, I'm sort of out of options.

I too am more libertarian leaning.  I as you being human would take the subsidy.  You would be a fool not to take the free cash.  Especially since without it your costs actually 120%.  You may be correct that the long standing plan is to make our system so intolerable that the only option is a one payer system.  I just fear that this system will be as poor as medicare/medicaid which will drag down the quality of our physicians.  This fear is just one more reason why I save as much as I do so that I don't have to rely on the government for my paycheck.  And you know what, if at that point I am offered a subsidy for my health insurance.  I sure as hell will jump right on it.  Even though I despise the whole system.

The economic term that you are looking for here is "transaction friction".  There is a relatively high overhead on transactions & settlements in our current, insurance dominated, health care access system.  (Health care is not a human right, but access to health care probably is.  A free person always has the right to engage in business, including the business of providing or consuming health care services)  Obamacare didn't improve this 'friction', and seems to have made it worse overall.  Single payer would actually improve this portion of our system, which is overregulated and seriously outdated.  There is no rational reason that, in the age of the Internet, I shouldn't be able to know exactly how much a given service will cost me and from whom. 

Right on, thanks for the terminology.  I believe your assessment is exactly what is going on.  I can call 3 surgeon buddies of mine and ask them how much to remove my gallbladder and not a single one will know without running numbers through their collection service.  BTW, this service isn't cheap and adds to the cost of my procedure.

If the single payer is our government, then I fear it will come with increased bureaucratic red tape and the same pathetically low reimbursement drastically altering the lives of many physicians in this country.  Some would have to close their practices since Medicaid covers about 80% of the cost of the service. Also, look at how horrible the government handles medical care via the VA. I have worked in a VA hospital and their documentation and bureaucracy is much worse than the private sector.  We all had a saying "everything takes longer at the VA."  I hated working there so much.

A few ways we need to cut costs is:
1) Stop incentivizing patient satisfaction.  This leads to unnecessary testing. Which costs more and leads to false positive results and increased risk of unnecessary procedures which also increase cost.
2) Stop incentivizing pain control financially.  This has created a slew of opiate addiction in the US also  costing a fortune.
3) No more lawsuits unless there was malicious intent while allowing peers to scrutinize practice methods and enforcing continuing medical education or revocation of licensure if no improvement in quality of care.  Eliminating the fear of lawsuits will allow us to practice evidence based medicine instead of cover our ass medicine.  This measure will be huge, but will take maybe a decade or more to see its full results as we are trained to protect ourselves and this is a hard habit to break.
4) Stop providing end of life care to the brain dead.  Last I read, end of life care is 28% of the CMS budget.  We need to stop keeping the grandpa if he eats through a tube in his stomach and hasn't moved or said a word in years.
5) Allow physicians to institute DNR (do not resuscitate) at will.  It will allow us to stop bringing the braindead back to life like grandpa I alluded to in #4.
6) Stop performing Chemotherapy on those that have minimal chance of survival.  Chemo is ridiculously expensive and causes a lot of discomfort.  Allow people to die with dignity.
7) Outside of real emergency services, allow medical practices to compete in the open market for their clients and the services they provide.  Competition is great at hedging prices.  When I say Emergency services I don't mean going to the ER when you have a cough.  I mean heart attacks, strokes, surgical infections and the likes.
8) To make #7 work, we need to eliminate a ton of the bearocratic bullshit primary care doctors deal with so that they have more time to open up their schedules and see a patient in a timely manor when they are sick.  Today most offices will tell the patient to just go to the ER.  Great idea, lets convert a $100 visit into a $3000K visit.
9) Eliminate the 3rd payer model and eliminate this friction from the transaction.  The costs of the third payer is placed directly onto the consumer.  Lets cut out the middle man.
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow. 

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #178 on: June 27, 2016, 05:45:24 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.

MoonShadow

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #179 on: June 27, 2016, 05:53:56 PM »

You're incorrect. There is, effectively, an unlimited amount of money. From what I've read, ACA subsidies (along with things like child tax credits, food stamps, and Medicaid) are part of mandatory spending. It is impossible for a "real" poor person to be deprived because a FIRE'd person takes advantage of a benefit they qualify for.

It is this attitude toward government spending that is dragging down the US.  The money supply is not unlimited.  it must come from somewhere.  There is also a finite amount of debt this country can tolerate before it will collapse under its own weight.

And as Yeager said, there is only so much that the government cat take as taxes.  There is a point where you increase the percent taken, but actually get less revenue due to decreased productivity and stifling of business.  The money supply is not unlimited.

This is the Laffer Curve.  The theory that there is an optimal rate of taxation that results in the maximum amount of revenue.  It's rooted in the premise that at the extremes (0% tax rate & 100% tax rate) any revenue is impossible; the lower end because no tax is due, the higher end because no one would bother to work, at least not in any legal capacity; and therefore there is a bell-like curve in the middle that must peak at some point before declining back to zero.

We are hitting a lot of economic topics here today.

Gin1984

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #180 on: June 27, 2016, 06:02:37 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

Northwestie

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #181 on: June 27, 2016, 06:08:46 PM »
Dial it back a bit -- the doc's response was reasonable.  Yours is not.

Yaeger

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #182 on: June 27, 2016, 06:09:54 PM »
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

I agree with you, except that the patient should personally bear at least some of the financial risk of that decision. Divorcing that risk/reward decision from the patient disconnects them from making an informed decision and instead pushes the financial penalty of that inherently risky decision to some faceless public. He's right in linking that to our disastrous healthcare and how those ballooning costs are eating away our ability to provide effective care to the populace.

randymarsh

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #183 on: June 27, 2016, 06:11:22 PM »
You're incorrect. There is, effectively, an unlimited amount of money. From what I've read, ACA subsidies (along with things like child tax credits, food stamps, and Medicaid) are part of mandatory spending. It is impossible for a "real" poor person to be deprived because a FIRE'd person takes advantage of a benefit they qualify for.

That's wrong, if you expand mandatory spending you're just shifting the cost to another area of government when they wrangle for a smaller pool of discretionary spending. You claiming ACA benefits in excess of the additional taxes created to support that spending in order to support your ER could, and effectively does, reduce funding available on discretionary items like roads, or education, or Defense or leads to greater annual deficits if no one's willing to reduce those programs.

There is a finite amount of government funding available, just like there are finite amounts that the government can effectively withdraw as tax revenue from its citizens. It's not unlimited and though you might feel like a flea on the back of government, it's the mass of fleas that are dragging us all down. Every dollar is important, and if it's not, then don't tax that dollar from my income.

I don't think I ever said it didn't increase spending. Obviously it does. But your very first reply stated that a rich person accepting ACA subsidies would take that support away from someone who actually needed it. That is not possible.

Besides, don't you want to reduce discretionary spending? ;-)


Gin1984

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #184 on: June 27, 2016, 06:15:35 PM »
Dial it back a bit -- the doc's response was reasonable.  Yours is not.
Saying a doctor gets to decide for you, when you die is one of the most outrageous things I have read here.  That is completely against the idea of bodily autonomy, so I think my response was perfectly reasonable in response to that attitude.  Add on the attitude of, if the patient disagrees with me, they must just not understand and my response would have been worse in person if that person had been my doctor.  That attitude is one reason why people don't go to doctors even when they need them and has been shown to also cause negative medical outcomes when people do go.  So I stand by every word I wrote and am frankly shocked no one else had an issue with his statements.

onlykelsey

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #185 on: June 27, 2016, 06:17:15 PM »
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

I agree with you, except that the patient should personally bear at least some of the financial risk of that decision. Divorcing that risk/reward decision from the patient disconnects them from making an informed decision and instead pushes the financial penalty of that inherently risky decision to some faceless public. He's right in linking that to our disastrous healthcare and how those ballooning costs are eating away our ability to provide effective care to the populace.

End of life care does seem particularly wrought with this tension.  As far as I can tell, though, it's rarely the actual patient who's insisting on all the most aggressive treatments and last ditch efforts.  It seems to be the family members, pretty often.  That is horrifying to me, the idea of being kept alive at great expense (to someone, me, the insurance company, the government, whatever) and in pain because my kids can't bear to see me go. 

Personally, I think the gradual move towards NPs and PAs as primary care providers is great.  It saves money, they are (as far as I can tell and the research I've seen can tell) eminently qualified, and they seem (no offense, MDs) much better at listening to the patient's concerns and finding the least intrusive option for the patient, while getting buy in from the patient.  Early in my pregnancy I met with an MD and with a certified nurse midwife, and the difference was really night and day.  It seems like MDs are more likely to look for treatments immediately, and that NPs/CNMs/etc take a more holistic view that often results in great patient satisfaction and adherence, for less money. Sign me up!

randymarsh

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #186 on: June 27, 2016, 06:20:43 PM »
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

I agree with you, except that the patient should personally bear at least some of the financial risk of that decision. Divorcing that risk/reward decision from the patient disconnects them from making an informed decision and instead pushes the financial penalty of that inherently risky decision to some faceless public. He's right in linking that to our disastrous healthcare and how those ballooning costs are eating away our ability to provide effective care to the populace.
Oh man, I agree with Yaeger (this never happens!) and Northwestie. End of life care is EXTREMELY expensive and also many times EXTREMELY useless. To pretend otherwise is insane. I'm not a doctor, but my understanding is that performing extraordinary measures is also painful. Are these actions really in the best interests of a 90 year old patient who will die in a few days/weeks anyway?

onlykelsey

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #187 on: June 27, 2016, 06:22:21 PM »
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

I agree with you, except that the patient should personally bear at least some of the financial risk of that decision. Divorcing that risk/reward decision from the patient disconnects them from making an informed decision and instead pushes the financial penalty of that inherently risky decision to some faceless public. He's right in linking that to our disastrous healthcare and how those ballooning costs are eating away our ability to provide effective care to the populace.
Oh man, I agree with Yaeger (this never happens!) and Northwestie. End of life care is EXTREMELY expensive and also many times EXTREMELY useless. To pretend otherwise is insane. I'm not a doctor, but my understanding is that performing extraordinary measures is also painful. Are these actions really in the best interests of a 90 year old patient who will die in a few days/weeks anyway?

For anyone interest in this end of life discussion, a neat approach a MD takes: http://www.theatlantic.com/magazine/archive/2013/05/how-not-to-die/309277/

iris lily

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #188 on: June 27, 2016, 06:24:20 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.
I am all for Gin1984's comatose-for-4 years grandfather getting extensive heroic measure treatment--if Gin  and her family pay 100% of the bill that is (even though I think it is cruel cruel cruel, and
I would never do that to a loved one.)

These end of life, and beginning of life high expenses tend to happen in families where education or sophisti with medical world is low.

Ive just read my second book about premature babies where the parents begged medical personnel not to save them. In one  book it didnt happen, babies lived, suffered many procedures (god, I  hate that word) and then died. A life of pain and confusion for these little ones. I would hate for my tiny babies to go through that.

The best treatments are those that have been mutally agreed upon by the patient, his family, his physician and medical standards, and yes funds available to pay.
« Last Edit: June 27, 2016, 06:37:17 PM by iris lily »

iris lily

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #189 on: June 27, 2016, 06:35:49 PM »




Quote
Oh man, I agree with Yaeger (this never happens!) and Northwestie. End of life care is EXTREMELY expensive and also many times EXTREMELY useless. To pretend otherwise is insane. I'm not a doctor, but my understanding is that performing extraordinary measures is also painful. Are these actions really in the best interests of a 90 year old patient who will die in a few days/weeks anyway?


I poked around Medline and there are articles on this topic.
One, published in the Journal of Public Health, refutes the popular idea that huge percentages of health care dollars are spent in the last year of life.

It is titled"The Myth Regarding the High Cost of End of Life Care" by Melissa Aldridge and says that their study showed 13% of health care dollars were spent on people in their last year of life.

Still, I Think 13% is a lot! They also had another interesting breakdown:  of the people who had very high healh care costs in the year of the study, 11% were in their last year of life.

If you Google this article it seems to be available several places on the web.
« Last Edit: June 27, 2016, 06:40:29 PM by iris lily »

Gin1984

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #190 on: June 27, 2016, 06:44:21 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.
I am all for Gin1984's comatose-for-4 years grandfather getting extensive heroic measure treatment--if Gin  and her family pay 100% of the bill that is (even though I think it is cruel cruel cruel, and
I would never do that to a loved one.)

These end of life, and beginning of life high expenses tend to happen in families where education or sophisti with medical world is low.

Ive just read my second book about premature babies where the parents begged medical personnel not to save them. In one  book it didnt happen, babies lived, suffered many procedures (god, I  hate that word) and then died. A life of pain and confusion for these little ones. I would hate for my tiny babies to go through that.

The best treatments are those that have been mutally agreed upon by the patient, his family, his physician and medical standards, and yes funds available to pay.
Then you have to decide, what is "heroic" and therefore the patient should pay all (not the insurance company).  My grandmother was told at 19 she could die at anytime because of a heart condition.  She was on the forefront of most heart related medical advances.  She was the first woman in California to get a triple bypass.  At the time, that was heroic.  But then she lived for another 13 years.  Should she have had to pay for the entire surgery?  Or is this just when someone is elderly? 

iris lily

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #191 on: June 27, 2016, 06:54:44 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.
I am all for Gin1984's comatose-for-4 years grandfather getting extensive heroic measure treatment--if Gin  and her family pay 100% of the bill that is (even though I think it is cruel cruel cruel, and
I would never do that to a loved one.)

These end of life, and beginning of life high expenses tend to happen in families where education or sophistication with the medical world is low.

Ive just read my second book about premature babies where the parents begged medical personnel not to save them. In one  book it didnt happen, babies lived, suffered many procedures (god, I  hate that word) and then died. A life of pain and confusion for these little ones. I would hate for my tiny babies to go through that.

The best treatments are those that have been mutally agreed upon by the patient, his family, his physician and medical standards, and yes funds available to pay.
Then you have to decide, what is "heroic" and therefore the patient should pay all (not the insurance company).  My grandmother was told at 19 she could die at anytime because of a heart condition.  She was on the forefront of most heart related medical advances.  She was the first woman in California to get a triple bypass.  At the time, that was heroic.  But then she lived for another 13 years.  Should she have had to pay for the entire surgery?  Or is this just when someone is elderly?

There are quite a lot of heroic procedures we as a society cannot afford. Of course, once they are performed regularly and physicians and surgeons get good at them, then they becme more rouine and are the standard of care, not the bleeding edge.

But to answer you question age would have something to do with stopping heroic measures but more importantly, functionality and quality of life are key. Your comatose  grandpa isnt enjoying life and expensive $100,000 a year care in a nursing home just so grandchildren can occasionally gather around his bed is a waste of taxpayer dollars. The grandkids can just as easily gather around a grave.
« Last Edit: June 27, 2016, 07:25:01 PM by iris lily »

Cassie

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #192 on: June 27, 2016, 06:56:16 PM »
When my Mom was just short of 90 she had been battling cancer for 3 years. When she had a month left to live a radiation doc came and tried to talk her into having it 5 times/week. He claimed it would improve her quality of life for the last month of her life. I am sure he just wanted to make $ and she said no. How ridiculous! She went home and 3 weeks later went to a hospice for one week and then died.

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #193 on: June 27, 2016, 10:17:03 PM »
Gin,
I still have no ill will or resentment from your remarks. I will state again if you and your family disagreed with my discussion with you, I would follow your lead with what you wanted. Unfortunately I see far too often bed ridden family members with absolutely no quality of life and the family just won't let them go. For some reason they stop thinking about their loved ones and how much suffering they are being subjected to. Family just wants them around a little bit longer.  CPR is very painful, daily needle sticks are painful, tubes in every orrifice are painful. Most people just don't realize how horrible this stuff is.

If you did a survey of medical professionals such as nurses and physicians. You will find the large majority do not want such measures performed on them. We see what it is, and we shudder the thought of having it done to us one day.

I just realized, and sorry for realizing it so late in this discussion, but maybe you and your family recently had to make tough decisions or are in the process of making such decision. If that is the case, I am truly sorry to not have empathized and been so calous with my remarks. If this is true I feel for you and what you are going through or recently went through. If this is a current process then the only item I can share with you is to look at your loved one, think back and ask yourself if this is what they would really want for themselves. You will know in your heart what the correct decision is. If you are honest with yourself and the person you care about I couldn't think of a single doctor that wouldn't support your decision.

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #194 on: June 27, 2016, 10:36:31 PM »
Your tax credit is based on the second lowest silver plan, but you are free to buy any plan shown on the healthcare.gov site to get that credit.

The silver plans are the only ones that offer the cost sharing subsidies, though. Those lower your copays and oop max, depending on your income.

You're right, geekette. I thought cost sharing subsidies and premium subsidies were the same thing. They're not.

Root of Good explains it very well here:

http://rootofgood.com/affordable-care-act-subsidy/

EnjoyIt

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #195 on: June 27, 2016, 10:36:58 PM »
Personally, I think the gradual move towards NPs and PAs as primary care providers is great.  It saves money, they are (as far as I can tell and the research I've seen can tell) eminently qualified, and they seem (no offense, MDs) much better at listening to the patient's concerns and finding the least intrusive option for the patient, while getting buy in from the patient.  Early in my pregnancy I met with an MD and with a certified nurse midwife, and the difference was really night and day.  It seems like MDs are more likely to look for treatments immediately, and that NPs/CNMs/etc take a more holistic view that often results in great patient satisfaction and adherence, for less money. Sign me up!

I am a big supporter of the allied health profession (NPs and PAs.) I work with them extensively and would not be able to function without them. Although there are some professionals that are simply amazing and will exceed in knowledge and skill of physicians, we need to discuss majority. The majority of PAs and NPs can manage 90-95% of what medicine requires of them. It is that other 5-10% that requires just a little more. I believe I work with some really bright NPs and PAs but in my experience, on average about once a day I get a presentation that just isn't right and requires a different way to handle that patient's care.

The conclusion I get is that the allied health professionals can help cut the costs of healthcare substantially but should be required to work under the supervision of a physician. At the very least to run questions by them and assist in a difficult diagnosis and therapy.

I understand this may sound like I am protecting my self interest. But my view is honest since I will be long capable of FIRE before anything I say will actually have any bearing on my own income.

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #196 on: June 27, 2016, 10:40:23 PM »
If health care is truly a human right, then what happens if we don't have enough doctors to serve everyone?

Train more doctors.

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #197 on: June 27, 2016, 11:00:31 PM »
If you do that... does the subsidy not still apply when you file taxes?  (Not trying to start a political firestorm again... trying to understand how it works.)

Nope. If you buy direct from any insurance company, or from a company or independant agent, you will not get any subsidy. To get the subsidy when you file, you have to buy the policy through either the Federal exchange or your state's exchange (if your state has one). And, I'm pretty sure, it has the be a Silver policy.
Not true.

Do you please have a good citation to back it up? Or is it from personal experience?

http://obamacarefacts.com/ contradicts you and says it has to be second cheapest Silver, and has to be bought through the federal or state exchange (whichever applies to the buyer).

From:

http://obamacarefacts.com/obamacare-subsidies/

“The amount of cost assistance you can get is based on the second-lowest-cost Silver plans in your state’s Marketplace.”

“Cost sharing reduction subsidies are only Available On Silver Plans.”

This is a dot com, not dot gov site, so I don't take it as gospel. If you have a .gov site reference that says it doesn't have to be Silver, I will gratefully stand corrected.

Try "healthcare.gov".  ;)

Make up some numbers and see what the plans are before/after subsidy for your state.

I can also tell you Bronze is subsidized from personal experience.  I had private insurance before ACA for myself/my wife at about the level of the Bronze plan for about $250/month.  After ACA approximately the same plan (before subsidy) is about $1200 a month and with subsidy applied it's about $550 a month.   

Silver is special though, and that's probably where the confusion comes in.  Silver has additional cost sharing subsidies.  Try reading our own SeatleCyclone's write up:  https://seattlecyclone.com/optimizing-the-affordable-care-act/

You are right. Thanks for the correction and the cite.

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #198 on: June 27, 2016, 11:14:37 PM »
OMG, your ideas are horrid.  What do you practice and what state so I can avoid it completely?  The patients decide what treatments to have, when to die etc.  You should be sued if you decide to not follow patient's wishes/requirements and don't hand of care to another.  Wow.

Of course I follow patient's wishes.  But please let the brain dead die with dignity instead of stuck to tubes, poked and prodded and suffer longer because their family just doesn't won't let them go.  Also, just because a patient wants a CT does not mean it is the best thing for them.  Patients get to decide in conjunction with discussing with the physician to make an educated decision and not in a vacuum. Just because a patient wants an MRI does not mean they get an MRI. 

I have seen enough times in my career when their primary care doctor finally convinces the family that further care is futile and they are OK with letting their loved one go, an oncologist shows up and gives them false hope.  Chemo pays a lot of money and the doctor is incentivized to give everyone chemo.  The patient who could have died at home in the care of their loved ones is instead tortured with caustic medication that makes them sick, hospitalized and instead die from a nasty infection costing 100s of thousands in the process.

Your comments above are completely understandable and I do not hold them against you.  If you or your family was my patient I would attempt to get you to understand and allow your loved one to stop suffering.  If you still chose to not understand I would proceed as you wished.  BTW, do you know what a DNR is? It keeps us from doing CPR if the heart stops.  Do you know that to perform proper CPR on an elderly person you will likely brake every rib in their chest.  Does that sound like torture to you?  it does to me.
I know what a DNR is and the choice of having one should be up to the patient, not the MD.  Your comments smack of "Doctor knows best" attitude and because of that, you would not be a MD for any family of mine.  I frankly don't care if you hold my comments against me or not.  Your attitude is despicable, a patient disagreeing with you is not "not understanding", one can understand and disagree.  And that choice is that of patient's, not the MDs.  And that lack of understanding on your part, makes you a poor Doctor and one who I would never have treat me or my family.

If you haven't already read it, you might find this interesting.

"How Doctors Die: Showing Others the Way"
http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?_r=0

I don't expect to change your position, but you might at least gain some understanding about the why of Enjoyit's opinion.

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Re: Will ObamaCare Make Early Retirement More Difficult?
« Reply #199 on: June 27, 2016, 11:24:02 PM »

Personally I don't like the way the ACA is structured and would rather see universal health insurance for everyone even if it had a premium (expanded Medicare) but it's better than before for most people in many ways. And being that there are probably very few early retirees they probably have a minimum impact.

I actually came up with a rather simple, rules based compromise between a full blown single payer system and a totally unregulated market that would cover everyone to a basic level without permitting politics to distort what is covered and what is not.  I can't recall anyone ever being able to poke a hole in it yet.  Anyone game for that one?

These are the rules...

1)  If a medical procedure, service or medication existed in any documented fashion 50 years prior to January 1st of the current year, they are covered by the national, taxpayer supported, single payer system.  Period.  No committee debates about what should be covered, and to what degree, etc.  If the wealthiest person in the United States could buy the medical procedure 50 years ago, it's covered, but modern substitutions are not.  For example, the system would pay for the cost of a leg cast in the fashion that existed 50 years ago, but if that method is no longer in use, the system does not pay for the modern waterproof, exothermic, quick-setting version that is in common use today.  Not even at a partial degree.  If your doctor doesn't have the old method, or refuses to use it because it's antiquated, there is no payment at all from the national system. The pricing of these procedures & medications would have matured decades ago, so there would be plenty of data to determine what is proper to charge.  Actuaries would have no problem making this work; and taxpayers are unlikely to lose much to fraud or quackery, because there would be too much data to defraud the national system with excessive charges for the condition being serviced and no actual medical professional is going to try to charge the government for bloodletting with leeches as a partial payment for dialysis.  (Just a ridiculous example of 'partial payment upgrading' that I could think of off the top of my head)

2)  For a particular person, anything that could be considered medical in nature; from a triple bypass heart surgery down to an individually packed  pair of aspirin from the gas station, is completely tax deductible for that person, so long as they are willing & able to provide documentation.  If this deduction is not consumed in a single year, it rolls over until it is consumed.

3)  Any person, business or corporation can donate directly to the medical debts/needs of another person at 100%, no matter the relationship, and deduct it at 100%, without having to funnel it through a charity first.  This also covers the parent-child relationship, regardless of the age of the child.  A greater degree of documentation might be required here.

4) Any person working in the medical field, with any accredited position; Doctors, nurses, nurse-pracs, medical techs, etc; may choose to donate their professional services to a charity or clinic, and deduct those in-kind donations at 100% without a limit.

This still leaves room for a dynamic, free market in medical innovations as well as traditional and non-traditional forms of insurance; but literally everyone is covered for medical care to a common, uncontroversial minimum standard.