Author Topic: Obamacare Blues: But I don't want Medicaid...  (Read 35294 times)

TheDudeReturns

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Obamacare Blues: But I don't want Medicaid...
« on: July 05, 2015, 12:21:18 AM »
Okay, looking at some options, and Obamacare is confusing the hell out of me.

I keep seeing that below a certain MAGI, you are *INELIGIBLE* for the tax credits on Healthcare.gov and they tell you to get Medicaid. Sure, you are free to get a plan and pay 100% out of pocket, but I'm looking at the plans and they're more than my mortgage on a monthly basis. Nice that we completely got rid of the $50 a month catastrophe plans I saw a few years ago. You know, the ones that actually operated as insurance and were pretty cheap...

So, aside from keeping myself cushioned in bubblewrap in my bubble-boy ball and hoping to never go to the hospital, is there are way to pay for a plan and get the tax credits/subsidies? Let's try some scenarios:

(1) Income below the MAGI cutoff, but put in higher income at sign-up, pay the extra, and get some back at tax time
(2) Income above MAGI cutoff, but falls over the year, and MAGI at tax time is in Medicaid territory

I'm sure there are others, but these 2 come to mind. I guess if you put in a higher income and then get back extra, then can force you to repay them since you didn't get enrolled in Medicaid and you're forced to do so for the future?

Honestly, it seems if you're around the cutoff, you are screwed. You are either forced to get crappy Medicaid and have no one in a 100 mile radius take you as a patient, or you have the benefit of paying $359 monthly ($4308 yearly) for junk catastrophe plan. Sorry, but add $50 more a month and I can double my mortgage payments thanks.

Thanks to those who can shed light on this topic :)

MDM

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #1 on: July 05, 2015, 12:34:28 AM »
There are a bunch of links at http://forum.mrmoneymustache.com/ask-a-mustachian/information-on-the-affordable-care-act-with-a-focus-on-early-retirees/.

As noted in that thread, you are doing the right thing by posting your specific question in your own thread.  It might be worthwhile, however, to check there for possible answers.

amberfocus

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #2 on: July 05, 2015, 12:47:34 AM »
The simplest way to push your MAGI above 138% FPL and stay off Medicaid is to do Roth conversions. Is that not an option for you?

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #3 on: July 05, 2015, 06:21:10 AM »
Medicaid is a state-based plan, so the details vary by state. However, in general, outcomes for people on Medicaid are about the same for people on private insurance, when adjusting for the health of the people prior to enrolling. Translation: Medicaid is great coverage.

And about 75% of all people on Medicaid around the country are actually enrolled in private insurance--it's called Medicaid managed care. The state is just paying a private insurer to take care of all your healthcare needs. Translation: Medicaid is actually private insurance for 75% of enrollees--and that number is growing rapidly.

But you can increase your income to 138% of FPL and just get a private plan. There are many ways to do that, including IRA conversions, earning a little money on the side and reporting it, taking fewer pre-AGI write-offs, etc.

Also, those pre-ACA catastrophic coverage plans you mention weren't really so great. They were generally only available to healthy people with no pre-existing conditions, or with exclusions for any care related to that pre-existing condition. They also had the ability to drop you from coverage if you got sick (so it really wasn't insurance) and they had caps for how much they would pay out in a year or cumulatively over your lifetime (so it really wasn't full insurance). And any plan is going to cost more now because of medical cost inflation. That's just a fact of economics. Hopefully we can some day adopt a system in this country that actually cuts out all that waste in the industry (most of which is in the private sector). Until then, this is what we've got.

Another Reader

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #4 on: July 05, 2015, 06:38:31 AM »
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

Roland of Gilead

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #5 on: July 05, 2015, 06:50:01 AM »
I am not seeing the difference between your $50 catastrophic plan and you going on Medicaid...except that you actually save $50 a month.

Your $50 plan would pay zilch for most things you would actually go to the doctor for....it might kick in when you have a $40,000 procedure.

Can you just pay your bills out of pocket like you would have with the $50 plan while you are on Medicaid?  I guess most doctors who don't accept Medicaid do accept cash?

It is really pretty easy to get your income up to $12,000 a year or whatever for a super subsidized silver plan with cheese.   You could do the opposite of tax loss harvesting and harvest only the gainers in your portfolio.  You can do IRA to Roth conversions.

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #6 on: July 05, 2015, 07:12:07 AM »
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

I have been on Medi-Cal before actually. I'd be fine going back on Medicaid again if needed.

I mentioned that the situation varies by state. Medi-Cal is going through some huge growing pains because they just had about 3.2 million new enrollees in just over a year. That's a 35% increase. That's too much growth to digest quickly. And California has the 3rd-lowest Medicaid reimbursement rate in the nation, so it is harder to get doctors to participate there. The situation will get better in the state, but it will take some time. Their budget process is really difficult to fix quickly due to needing 2/3 of both chambers to approve any budget.

There is a lot of research that shows similar outcomes for Medicaid vs private insurance, adjusted for health prior to entering the system. There is also research showing that people have improved outcomes after getting Medicaid from being uninsured.

And things are very different in other states. Surveys of doctors are showing that around the nation providers were taking new Medicaid patients at a higher rate than in prior years.

startingsmall

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #7 on: July 05, 2015, 07:17:38 AM »
My mom was put on Medicaid when she was diagnosed with lung cancer ~ 10 years ago and stayed on it until she passed away about 5 years later.  I was amazed at the excellent quality of care that she received... despite the fact that she was an incredibly non-compliant patient and very difficult to deal with.  Multiple surgeries, chemo, radiation, you name it... and never any significant delays in care.  The ONLY complaint she had was that she had to go to a nursing home for rehab at one point and her options there were limited.  The rest of her care, though, was spectacular - minimal waits, all of her specialists were conveniently located in her town, etc.  This was in Florida, so again it may vary by state.

wenchsenior

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #8 on: July 05, 2015, 08:18:08 AM »
My mom was put on Medicaid when she was diagnosed with lung cancer ~ 10 years ago and stayed on it until she passed away about 5 years later.  I was amazed at the excellent quality of care that she received... despite the fact that she was an incredibly non-compliant patient and very difficult to deal with.  Multiple surgeries, chemo, radiation, you name it... and never any significant delays in care.  The ONLY complaint she had was that she had to go to a nursing home for rehab at one point and her options there were limited.  The rest of her care, though, was spectacular - minimal waits, all of her specialists were conveniently located in her town, etc.  This was in Florida, so again it may vary by state.

Medicaid in WI (which I was familiar with until a few years ago) was also excellent. It really is a state-by-state situation.

sol

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #9 on: July 05, 2015, 08:24:28 AM »
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.

Bracken_Joy

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #10 on: July 05, 2015, 09:01:17 AM »
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.

+1. As someone who has been on both sides- I've been on Oregon Health Plan (OR's medicaid) and as a healthcare worker, it's a good plan. They put you in managed care networks and while the "HMO feel" gets a bad rap, it makes it easier to navigate in a lot of ways to be totally honest... I don't have to worry about someone saying they take my insurance, and then my insurance refusing to pay, etc. At least not that I ever experienced. And that happened several times with my previous insurance(s). 

I will say it's less ideal when you're in a very rural area. If your area has one General Practitioner, and they don't take your care network... well. That sucks. But then, that's why OR is increasing nurse practitioner roles.

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #11 on: July 05, 2015, 09:17:29 AM »
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.

Even in Calif it's not all bad as I think it highly depends on your county. Here in Orange County you have a choice of several different private policies where you can pick from a wide range of doctors in pretty much every specialty, hospitals and medical clinics in the area (100's of choices). I think it's called Opticare or something like that.

That's another good point. CA is really several huge markets, so there is even significant intra-state variation. Even private insurers specialize in one region or another. Since Medicaid is a state-based program, states organize things differently. I don't recall if CA parcels it out to the counties to implement, but that would fit with their other public health practices.

Axecleaver

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #12 on: July 06, 2015, 10:51:56 AM »
Quote
(1) Income below the MAGI cutoff, but put in higher income at sign-up, pay the extra, and get some back at tax time
(2) Income above MAGI cutoff, but falls over the year, and MAGI at tax time is in Medicaid territory

I wanted to respond to OP's questions.
1. Lie about your income. No, this won't work. During signup there are required documentation checks. In the state systems I've worked on, including the federal exchange, the system will check your tax return, and if this doesn't match (within a certain tolerance) what you enter, you'll be required to send in proof of income (pay stubs). So, don't try to lie about your income, it won't work.

2. Variable income which ends up in Medicaid territory after estimating it above 138%. This is somewhat complex, but a fairly common scenario as many low-income folks have extremely variable incomes. You may end up paying penalties depending on how this is calculated. There are IRS rules for how to do this, but I haven't gotten into them very deeply.

That said - Medicaid is an extremely high quality plan that pays for things private insurance doesn't (dental, taxi rides to the doctor, preventive care); I'd love to have Medicaid insurance. If you have problems with provider coverage, you can call the Medicaid agency and they will work with you to find providers that will take your insurance. Some specialties have very thin networks, but that's true in lots of areas of the country and for private plans, too. Most psychiatrists don't take insurance of any kind.

catccc

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #13 on: July 06, 2015, 12:31:55 PM »
Medicaid is a state-based plan, so the details vary by state. However, in general, outcomes for people on Medicaid are about the same for people on private insurance, when adjusting for the health of the people prior to enrolling. Translation: Medicaid is great coverage.

So I see many noting that this depends on the state.  I can say when DD was on medicaid as an infant it was great.  I didn't feel limited at all in who provided her care.  I'm in PA.  I would have loved to have qualified for it myself but I did not.  So I carried a low cost indemnity plan for a stretch of time.

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #14 on: August 18, 2015, 06:23:36 PM »
I did some research today and for the Medicaid expansion states, I think all but 2 or 3 (AR and CT were ones I could identify) are using private insurance to fulfill the coverage. So if you get "Medicaid" through the expansion, you are probably just getting private insurance that the state contracts with the private insurer to provide to beneficiaries. And anecdotally, the private insurers pay the providers more than the state FFS Medicaid program does, so providers take this Medicaid more readily. In fact, the state contracts with the insurer requires the insurer to ensure that there are sufficient providers available in each area of the state. So access to doctors and hospitals should typically not be a problem for Medicaid beneficiaries going forward.

EscapeVelocity2020

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #15 on: August 18, 2015, 06:26:33 PM »
What is your age, are you eligible for Medicare yet?

sol

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #16 on: August 18, 2015, 07:11:00 PM »
I did some research today and for the Medicaid expansion states, I think all but 2 or 3 (AR and CT were ones I could identify) are using private insurance to fulfill the coverage.

That's how it looks here, too.  When you go to your regular doctor and they ask for your insurance information, you just tell them Medicaid instead of blue cross or whatever.  We see it often from other patients when we're checking in the kids.

We also get asked frequently after that if we qualify, because there are apparently a bunch of additional services that doctors push that our regular insurance doesn't cover, for things like developmental specialists or nutrition counseling.  They seem much more focused on preventative care for Medicaid recipients.

Eric

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #17 on: August 18, 2015, 07:19:04 PM »
The simplest way to push your MAGI above 138% FPL and stay off Medicaid is to do Roth conversions. Is that not an option for you?

Agreed.  Another option is to take out a second mortgage on your house and invest it, which would artificially increase your expenses/income. 

Gin1984

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #18 on: August 18, 2015, 07:25:43 PM »
Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.

You've mentioned this here before, but I think it may be a problem specific to California.  Around here the state version of Medicaid is great.  All of my family's doctors take it.  It's just another insurance company.
Eh, I had a friend with lupus in Northern California and had great docs including specialists.  I know because she could not drive and I drove her a couple of times.  They even let her get a same day appointment when something weird happened during school.

EscapeVelocity2020

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #19 on: August 18, 2015, 08:11:45 PM »
...and another idea, if you really want to think outside the box, is that many other countries have better healthcare at much more reasonable prices.  Hence the advent of 'medical tourism', which is also a nice way of saying that, if you have concerns about ongoing healthcare cost, then you are probably better living elsewhere.  Even countries with universal coverage will give you a much better deal on more comprehensive private treatment than the US gives it's insured citizens on anything, just go to a 'private healthcare facility' over there.

It is ridiculous that Capitalism totally failed in such an important market, but it really did.  Undeniably.  And that really raises 'red flags' (but wait, doesn't red mean 'communism', which might get me flagged?  Oops, I said flag and red again.  Shit).  Damn :)

FIRE me

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #20 on: August 18, 2015, 09:04:59 PM »
It is ridiculous that Capitalism totally failed in such an important market, but it really did.  Undeniably.  And that really raises 'red flags' (but wait, doesn't red mean 'communism', which might get me flagged?  Oops, I said flag and red again.  Shit).  Damn :)

Capitalism in health care didn't fail at all. Capitalism is making huge profits for insurance companies, drug companies, and hospitals. In the eyes of capitalism, beyond lip service the patient was never any priority.

EscapeVelocity2020

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #21 on: August 18, 2015, 10:00:05 PM »
Capitalism in health care didn't fail at all. Capitalism is making huge profits for insurance companies, drug companies, and hospitals. In the eyes of capitalism, beyond lip service the patient was never any priority.
Sorry FM, I was just thinking of myself, as I sometimes do on this forum :)  Seriously, there should be a balance struck between the basic health of the nation paying taxes to a central government and the benefits paid out in terms of reasonable coverage against preventable disease.  Too many people in the US end up in the emergency room and don't have and insurance. 

sol

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #22 on: August 18, 2015, 10:11:24 PM »
Capitalism in health care didn't fail at all.

Agreed. I might even go so far as to say that American health care is one of the greatest examples of capitalism ever implemented.  Think of all the profits!

The key is that capitalism doesn't care about people.  It cannot value saving lives or minimizing suffering or curing disease, only making money.  By definition, it is about maximizing profits at the expense of all other considerations.

But I'm secretly kind of a pinko who thinks capitalism isn't always the best choice for managing some of our social systems.  Health care. Environmental protection. Civil rights.  Representative democracy.  All of these things have been ruined in America by capitalism, yet capitalism is still the nation's one defining feature and the one reason our government exists.

I don't expect to see an election in my lifetime that isn't primarily about "the economy" aka promoting capitalist profits above all else.

Hamster

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #23 on: August 19, 2015, 12:13:20 AM »
Medicaid is a very mixed bag - and varies a lot by state. My experience, with about 35% of my patients being on Medicaid, is it does a good job of giving patients access to unnecessary stuff (free Tylenol!) and major stuff (hospitalizations, major surgeries, etc), but it drops off a lot of services in the middle, and it adds a lot of work to providers and dumps a lot of costs off on others.

I get paid the same regardless of what insurance my patients have, but I have have to do way more fighting with our Medicaid plans than with any other insurer to get patients what they need.

Medicaid is oriented toward people with low income so there are no co-pays - whatever gets covered is fully covered, and there are things like taxis to appointments and OTC meds like Tylenol, and infant vitamin D drops that Medicaid will cover, but private insurance won't. They try to minimize these costs by making you fill out tons of paperwork though.

On the other hand, there are many things that are much harder to get covered. The WA State Medicaid plans (Molina) have very restrictive and often arbitrary formularies for prescription medications. For example, they cover the mildest topical medication for acne, but if that's not strong enough, the doc has to jump through hoops to get stronger medication, even though it doesn't cost any more. And here, no durable medical equipment is covered, meaning if a doc gives a sling, walking boot, or crutches, Medicaid won't pay for it. In practice, the provider's office ends up giving the equipment away because they can almost never collect from the patient either. Medicaid dumps the cost on the doctor's office.

Also Medicaid is exempt from many of the ACA requirements for covered services. So while the ACA mandates that plans cover certain preventive developmental screenings, our Medicaid plan doesn't pay for them. What a nightmare trying to figure out how to bill certain (non-grandfathered) private plans, but not Medicaid or grandfathered plans. It is pretty much impossible, so we just don't bill for these services, and eat the costs.

Average Medicaid reimbursement is about 60% that of private insurance, so many providers won't accept it. There was a time in the greater Seattle area that no orthopedists accepted Medicaid other than Univ of Washington and Seattle Children's. It was an access nightmare. That said, I only have so much sympathy for guys making as much as the orthopedists make...

Where we are, mental health contracting with Medicaid is also a mess. They have the state divided into regions, so someone with the exact same Medicaid plan in county A where wait times are months, can't see a psychiatrist in county B where wait times are a few days, even though both psychiatrists accept the exact same Medicad plan.

Dental can also be variable. In many cases they will pay for extraction, but not implants. So you can get dental care, for free, but that means a hole in your smile where they pull a tooth, but nothing to fill that hole. Many dentists here accept Medicaid when they first open their practices, but once they start filling up they don't take Medicaid any longer because it reimburses much lower.

Anyway. Despite all of the above, I would gladly take a single payer system in the U.S.   If everyone had Medicaid, things would even out, and Medicaid reimbursement would have to go up since there wouldn't be anyone else to eat those costs. The variability is a nightmare, so having one uniform plan, at least we would know what is covered consistently, and not have to deal with so many different players who all follow different rules.

Cressida

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #24 on: August 19, 2015, 12:19:08 AM »
...useful commentary...

Thanks for this - as a WA resident I appreciated the info. My coverage is with Group Health, and I vastly prefer it to any other provider (I've had several, thank you batshit employer-based health care system), but my understanding is that they don't accept Medicaid. So if I were to retire and ended up in the Medicaid window, I wouldn't be able to use my preferred provider, which stinks.

Yes, single-payer is definitely the answer. What an utter mess this is.

edit: terminology
« Last Edit: August 19, 2015, 12:20:59 AM by Cressida »

sol

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #25 on: August 19, 2015, 12:47:13 AM »
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

Axecleaver

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #26 on: August 19, 2015, 08:48:37 AM »
Hamster, that was a quality post, thanks for the provider side of the story.

Regarding admin costs for providers, the estimates I've seen are around 1/3rd of a provider's overhead goes toward managing the billing  process. I've done some work in this area with EHR's, which promised to help lower costs, but ended up making things worse for most providers. Some of the high end provider practices I've worked with have steadfastly refused to go to an EHR, giving up significant incentives, because they're such a nightmare to deal with. Single payer would fix this.

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #27 on: August 19, 2015, 09:00:58 AM »
Medicaid is oriented toward people with low income so there are no co-pays - whatever gets covered is fully covered

It depends on the state and whether you are part of a group exempt from copays (like children) or getting services exempt from copays (like family planning). Otherwise states can charge copays at their discretion. WA may be one of the smart ones that doesn't.

Also Medicaid is exempt from many of the ACA requirements for covered services. So while the ACA mandates that plans cover certain preventive developmental screenings, our Medicaid plan doesn't pay for them. What a nightmare trying to figure out how to bill certain (non-grandfathered) private plans, but not Medicaid or grandfathered plans. It is pretty much impossible, so we just don't bill for these services, and eat the costs.
Traditional Medicaid is exempt from the preventive services requirements (with the exception for tobacco cessation for pregnant women and pharmacotherapy tobacco cessation products for non-pregnant women). But beneficiaries of the Medicaid expansion get all of the same preventive services (over 100 including newborn screening) as non-grandfathered health plans without cost sharing.

Mr. Green

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #28 on: August 19, 2015, 10:09:38 AM »
"Medicaid is great coverage."

I hope you get the chance to be covered by Medicaid someday.  Same outcomes?  Maybe, for the few people that get to see a doctor.  Medicaid in California, called Medi-Cal, is pretty much the same as no health insurance.  Few doctors take it, even fewer specialists. 

Lay off the Kool-Aid.  All that sugar is not good for you, or the people you are telling Medicaid is great coverage.
My father is on Medicaid in North Carolina and it has been a wonderful experience compared to no insurance. As the person who has to manage his money, I have been pleasantly surprised with how well Medicaid has worked out.

EscapeVelocity2020

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #29 on: August 19, 2015, 11:04:58 AM »
It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance. 

Coming in to this discussion as an engineer, I agree that it is totally insane.  Nobody, in this day and age, should ever subject our citizenry to such a duplicitous, ridiculous system without being called a traitor to our country :)   Unfortunately, many seem to want to opt back in to the patchwork, unregulated fleecing that came before it.  That is the beauty of having a truly horrific third-world system (except it insults other countries that do healthcare better, sorry Djibouti...)

forummm

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #30 on: August 19, 2015, 12:35:04 PM »
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

EscapeVelocity2020

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #31 on: August 19, 2015, 12:53:41 PM »
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #32 on: August 19, 2015, 01:17:33 PM »
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

beltim

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #33 on: August 19, 2015, 01:25:58 PM »
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #34 on: August 19, 2015, 01:36:38 PM »
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.

I'd be happy to save the $1T we both agree on and work towards the extra $500B :)

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #35 on: August 19, 2015, 01:39:11 PM »
Since you are so good with numbers Forummm, what would think is a 'reasonable' cost per person on average per year for healthcare (which should roughly equal the insurance figure)?  200B (for 230M people) is about 10x what a large complicated new-field hydrocarbon project costs in a sophisticated, 30-year, high risk industry (which companies are only willing to pay for because they expect the outlay to pay itself off in anywhere from 1 - 3 years, and then provide pure profit).  And yes, I am talking about providing all of the 'energy resources' for this population for 30 years.

If America got realistic about what is demanded to provide healthcare, there would be an uprising to demand more for the 'middle' and complain about how inexpensive the rich have it.  But I know of no study that sheds light on things like what Steve Jobs paid out of pocket.  On the other hand, reporting on how horrible the middle class are treated are simply too heavy to digest (http://www.upmc.com/about/why-upmc/changing-health-insurance-market/Documents/time-article-2015.pdf). 

I'm not sure what you're asking. If you're asking how much I think we *should* be paying, I would say about half of what we pay now. If we had the system working like in other industrialized nations and scale it for our GDP, the other countries can get outcomes better or the same as ours for about half of what we pay now. In addition to all the waste we have with overhead, we also waste a lot by not coordinating care, having policies (like the farm bill) that make health much worse and more expensive, etc. If we had a single payer system or otherwise made the taxpayer on the hook for everything we could align incentives to make things cost less and make investments in bringing down long term costs. In the current system, the incentive is mostly to make things cost more (and the result has been a wild success for decades).

Forummm and I have disagreed on this before, and I've argued that the US should be spending more like 2/3 of what we pay now, because we're significantly richer than most of the comparison countries (http://forum.mrmoneymustache.com/welcome-to-the-forum/obamacare-survives/msg761407/#msg761407).  This works out to be about $6,000 per person per year.

I'd be happy to save the $1T we both agree on and work towards the extra $500B :)

Agreed.  I just thought it would be useful to give EV another number.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #36 on: August 19, 2015, 04:03:14 PM »
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)

To OP, if you can get Medicaid at no cost to you, you would be crazy not to unless it is causing you a moral dilemma (You ask yourself whether you want to take money that is meant to be a safety net for the poor, not a financially independent person.) I don't pass judgement. I think it is up to you. Just don't trash ACA, thinking that your $50 pre-Obamacare policy was actually an insurance policy (as others have described it was essentially worthless for all intents and purposes). 

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #37 on: August 19, 2015, 04:33:01 PM »
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)


Many years ago, I came up with a very simple plan that would have made the ACA entirely unnecessary, as well as had effects similar to a single payer system without the downsides of the political screw-ups.

It hinged on one simple tax rule change...

That any individual, corporation, institution or legal entity within the United States could donate towards the medical bills of any particular individual, either physically located within the United States, or otherwise a US citizen abroad.  All such donated funds would be 100% deductible for the donator so long as the medicine, procedure, whatever was a recognized medical practice for the malady in question, and was documented as available as an experimental procedure at least 50 years prior.

We can quibble about the actual time frame or details about the recognition of a deductible medical bill, but in practice there would be a whole new medical industry that popped up just to be able to both avoid paying the government taxes and get some political good will out of major corporations and high-income earning individuals.  Medical insurance would gravitate towards covering the 'gap' that the delay creates, as well as negotiating reasonable rates for the non-deductible portion.  This is the same effect that compelled businesses to offer medical insurance in the US to begin with, because it was all deductable to them anyway, and a better than average medical plan could be used to attract employees.  At present, it's actually quite difficult for an individual to deduct medical expenses for himself, much less for another person.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #38 on: August 19, 2015, 04:37:17 PM »
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #39 on: August 19, 2015, 04:49:14 PM »
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

EDIT: Think about it like this.  Groceries (i.e. unprepared food) is exempt from sales taxes just about everywhere, under the argument that food is a basic human need.  A similar argument applies to actual health care, but not health insurance.  It's not the actual insured rate that's important, but the access to health care.  If almost everyone could reasonablely expect to either 1) pay for their own medical expenses or if they couldn't afford it 2) get someone else to pay for it; then there really wouldn't be a need to worry about the rate of insured.
« Last Edit: August 19, 2015, 04:55:31 PM by MoonShadow »

beltim

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #40 on: August 19, 2015, 04:51:47 PM »
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

Sure, that might work if people would get more money back than they donated - it would be an instant profit to do so. But then it's costing the government just as much as a single payer program would.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #41 on: August 19, 2015, 05:12:29 PM »
Yes, single-payer is definitely the answer. What an utter mess this is.

It seems to me that a significant part of the costs of American healthcare are related the overly complicated billing processes we have to deal with so many different types of insurance.  If there was one type of insurance, with one set of payment rules, and everyone had it by default (but could then also buy additional insurance if they so desired) I think several million Americans who currently work in hospital billing would thankfully be out of a job.

The overhead is easily $200 billion per year when you consider the physician time, the office staff time, the insurer time, and the patient time. Probably more than that. In general, about 15-20% of premium dollars for private plans go to non-care costs (Medicare's rate is around 3-6% IIRC). And the total health expenditures are around $3T per year. Some of the overhead is not billing stuff.

One of the "amazing that they needed to include in the law" features of ACA is that insurance companies have to spend 80-85% of premium dollars on actual care. Unfortunately, the robbers that health insurance companies are have not really followed through... http://www.pnhp.org/news/2015/march/health-law-hasn%E2%80%99t-cut-insurers%E2%80%99-rate-of-overhead-spending-study

I am a huge proponent of ACA. Single-payer would be better but I think the law is doing a lot of good for a lot of people, and the FIRE crowd probably benefits more than anyone else.  I hate how people treat Obamacare as if it is some bogeyman.  It has been amazingly successful at many things (not all things however...)

To OP, if you can get Medicaid at no cost to you, you would be crazy not to unless it is causing you a moral dilemma (You ask yourself whether you want to take money that is meant to be a safety net for the poor, not a financially independent person.) I don't pass judgement. I think it is up to you. Just don't trash ACA, thinking that your $50 pre-Obamacare policy was actually an insurance policy (as others have described it was essentially worthless for all intents and purposes).

It's pretty easy to game the MLR.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #42 on: August 19, 2015, 05:14:00 PM »
Why do you think people would donate trillions of dollars per year in order to save at most 43% or whatever of their contribution on taxes?

Because it already occurs in limited contexts.  Surgeons, doctors & nurses donate time & expertise to civic health clinics.  Corporations donate to charities for both the deduction as well as the "goodwill equity" such actions create.  Religious institutions have benefited from such a wide open deduction for a very long time, and many of them are health care related.  If more incentive is actually necessary, than a 103% or 105% deduction rate might help motivate the tight-fisted.  But the way that I imagine it is that people who actually know someone who needs the help will give what they can, and benefit from the tax deduction in the following year.  The delay in deductable procedures would function mostly to limit deduction fraud, preventing people from inventing new procedures just to create new tax shelters.

Sure, that might work if people would get more money back than they donated - it would be an instant profit to do so. But then it's costing the government just as much as a single payer program would.

Maybe, but the ideological objection to single payer plans, including my own (libertarian) objection, ceases to exist.  If your desire is to reduce the overhead of medical care, and hopefully extend health care access to as many people as possible; then a single payer system should not be your only path under consideration.  However, there are those who have a political motive to promote single payer, and those who have a political motive to oppose it; so it's really a non-starter already.  Single payer will never survive long in the United States, simply because it's too divisive an issue here; no matter how badly each party screws up the medical services market in the meantime.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #43 on: August 19, 2015, 05:30:10 PM »
Single payer will never survive long in the United States, simply because it's too divisive an issue here; no matter how badly each party screws up the medical services market in the meantime.

I'm not convinced of that.

Single payer doesn't have to displace private health insurance, it just has to be available to everyone as their base insurance.  The Medicaid expansion already covers a significant portion of the country.  Medicare and tricare cover most of the rest.  It's just this little slice of people in the middle that don't yet have access to subsidized health care, and the ACA gives those people access to subsidized health insurance instead, which is almost the same thing but retains our nightmarish billing bureaucracy.

Private health insurance will always exist for people who want it, but I don't think anyone should be allowed to suffer and die by virtue of being too poor to afford it.  We could effectively negotiate a quasi-single-payer system by raising the income limit for Medicaid and lowering the age limit for Medicare.  The only people left would be young wealthy people who don't need either anyway, and at that point they would probably cry foul for being singled out, so we could just extend it to them too.  Make the new higher tax rates required to pay it all less progressive than the current system so the rich get proportionally cheaper care than the dirty poor, and they still get to buy as much Cadillac plan coverage as they want on the remaining private market.  Everyone wins!

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #44 on: August 19, 2015, 05:56:49 PM »
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it.  Just subsidizing health care for everyone still forces other people to pay for it.  In the current case, it's the young and not yet born generation that is going to be saddled with the debt, which is morally unacceptable in my view.  Also, the use of legalized coercion that is the largest issue for myself, not the end result.  Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it as convincing conservatives to support single payer without repeal, without coercion.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #45 on: August 19, 2015, 06:11:16 PM »
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it, check out this article in the Atlantic. You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:
On average, a person will contribute 1.8 million dollars over a lifetime to health care (as of 2009, with very conservative future growth estimates). Much of this is wasted on administration and price distortions which we have discussed before and are outlined in the first 3/4 of the article.
To fix this, he proposes that we address the pricing dilemma caused by our current system of health insurance which combines indeminity insurance and routine costs (What we have now in health "insurance" is akin to auto insurance that pays for oil changes and brake repair), and the opacity of a system where nobody knows what they are paying:

1) For catastrophic coverage (i.e. real insurance needs) - everyone would have the same insurance that is basically a VERY high-deductible plan. Since the deductible would be so high (e.g. $50,000), premiums would be very low. 
2) For routine care, everyone would be mandated to contribute to an HSA - (as we are now mandated to contribute to Medicare). People who earn below a certain amount would have the government contribute on their behalf. Price could be around $5000 per year, for example, and would accumulate for life. If you got above a certain threshold based on age, you could stop contributing (or withdraw the amount in excess), and any funds left when you die could become part of your estate (eliminate the 'use it or lose it' issue we have with much care now).
3) All of your medical care is paid directly by you, from your HSA, until you meet your VERY high deductible, then the catastrophic plan takes over. If there is a gap - costs above the HSA balance, but below the Catastrophic deductible, then you borrow against the future contributions to your HSA.
4) To ensure that people actually performed preventive services - one option would be that vouchers would be issued for preventive care that had evidence that it is beneifical.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #46 on: August 19, 2015, 06:11:53 PM »
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Why impossible?  I suggested expanding entitlements and raising taxes to pay for it, as a mechanism for reducing wasteful overhead costs we've already agreed plague our current system.  Remove some of the profit motive from healthcare, and maybe we can get back to improving outcomes for the patients instead just making money for the shareholders.

Quote
]Just subsidizing health care for everyone still forces other people to pay for it.

But we already do that under the current system.  Anybody who pays for insurance is currently subsidizing all those folks who are legally guaranteed care even if they can't afford it.  My proposed version just makes this discrepancy more obvious to everyone, instead of letting conservatives believe that a private health insurance market is somehow more equitable because they can pretend EMTALA doesn't exist.

Quote
Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it

I'm not comfortable making health care access dependent on charity.  What about unpopular people with no friends?  What about persecuted religious minorities? 

I'm fine with the notion of granting tax deductions for medical donations, but I'd rather those donations go into supporting/subsidizing a single payer system available to everyone than have it be the mechanism by which some people are granted care and others are denied it.  That just seems like a recipe for abuse.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #47 on: August 19, 2015, 06:23:10 PM »

Agreed.  I just thought it would be useful to give EV another number.


Thanks, and interesting.  Let's just say that, in terms of raw numbers, there are whole countries of difference between where the estimates stand.  At a number like 6k pp, I imagine people are shocked.  Yet this (or probably more) is what us youngsters are paying toward Medicare recipients without even knowing it...
« Last Edit: August 19, 2015, 06:27:39 PM by EscapeVelocity2020 »

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #48 on: August 19, 2015, 06:24:25 PM »
If you want to read a fantastic summary of why our healthcare is so expensive, why our insurance system results in such distorted pricing, and the most interesting proposal I have heard to reform it, check out this article in the Atlantic. You have to scroll through 3/4 of the article to "A Way Forward" before the author proposes his solution.

The basic idea is:


That would work also.  Another way would be to automaticly open HSA's for every child born, which are not accessible by parents alone, and are partially funded by tax dollars at certain life stages; say $10k at birth, another $10K at age 10, and again at 15 or so.  While this would not remove the coercion issue, one can make the argument that those funds are advances on the future income taxes of a healthy and productive adult.

My root argument is that the current (and recent past) state of the medical industry is so riddled with counterproductive tax rules, regulations and opaque financing schemes that it can't be fixed.  It simply must be replaced wholesale, but that I (and many others) cannot support single payer for ideological reasons.  It may survive anyway, but as divided as this nation is right now, I doubt that the ACA survives the next Republican presidency intact.  It will be "reformed" in some fashion or another.

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Re: Obamacare Blues: But I don't want Medicaid...
« Reply #49 on: August 19, 2015, 06:38:25 PM »
  Everyone wins!

Except not everyone wins.  That is mathmatically impossible, and you know it. 

Why impossible?  I suggested expanding entitlements and raising taxes to pay for it, as a mechanism for reducing wasteful overhead costs we've already agreed plague our current system.  Remove some of the profit motive from healthcare, and maybe we can get back to improving outcomes for the patients instead just making money for the shareholders.

Because, using your own example, shareholders won't win.  Somebody has to pay the bill, and that will fall upon someone; no matter how the taxes are raised.  BTW, we are those shareholders.  Shareholders are not typically fat-cats, but aspiring retirees.

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]Just subsidizing health care for everyone still forces other people to pay for it.

But we already do that under the current system.  Anybody who pays for insurance is currently subsidizing all those folks who are legally guaranteed care even if they can't afford it.  My proposed version just makes this discrepancy more obvious to everyone, instead of letting conservatives believe that a private health insurance market is somehow more equitable because they can pretend EMTALA doesn't exist.


Yes, I know.

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Do it my way, and those who can't pay for it themselves have as good a chance at convincing someone else to pay for it

I'm not comfortable making health care access dependent on charity.  What about unpopular people with no friends?  What about persecuted religious minorities? 

What about them?  We have a history of doing exactly this kind of thing in this country, quite successfully, prior to World War 1.  Mostly via "mutual assistance societies", which were the model for union health plans not long afterwards.  Notice, if you will, that persecuted minorities of every sort had their own societies.  Despite the bigoted nature of the age, the groups that formed these societies did fairly well.

https://en.wikipedia.org/wiki/Benefit_society

They were eventually undermined because they were typically discriminatory towards their own groups, and their success tended to undermine the 'collective bargaining' power of the AMA.  Also, they were ad hoc compared to a modern system, but some similar systems still exist.

http://christianpf.com/christian-health-insurance-alternative/
http://www.chministries.org/

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I'm fine with the notion of granting tax deductions for medical donations, but I'd rather those donations go into supporting/subsidizing a single payer system available to everyone than have it be the mechanism by which some people are granted care and others are denied it.  That just seems like a recipe for abuse.

How do you see such a system working under my proposal?  And why would you expect that it would be a worse problem than it already is?