ObamaCare Implosion

[jorjor]

Sincerely sorry for your situation.  That being said, your son is clearly an outlier statistically, and a mechanism to provide him care should exist alongside the system in which the average person receives care; we shouldn't tear the mainstream system down because it doesn't deal well with outliers.  We simply need to build a better system to accommodate the outliers.

What would you propose we do to accommodate the outliers?

[waltworks]

We need to stop half-assing and just try either:

A) No more gov't interference in the health care market at all. No medicare,  no medicaid, no VA, nothing. Employers/employees pay full taxes on any benefits given as compensation. Cancel EMTALA, if you don't have proof of insurance the hospital can just let you die.

B) Medicare for all, feel free to buy your own outside healthcare if you want to.

ACA is just a slight tweaking of the prior worst-of-both-worlds system in which profit motives trump health consideration AND many levels of stupid bureaucracy/rules create inefficiencies and perverse incentives/unintended consequences.

-W

[LeRainDrop]

Great.  None of that solves the problem that none of my doctors are on the provider lists for any of the open exchange plans.  I feel fortunate that I can afford COBRA for now.

Is this really a problem/concern people have? Why do people care so much who their doctor is? As long as they get the job done (and it's crazy or something) what's the difference? It's a person in a white coat that look at you for 45 seconds every few years, maybe. It's at least 4-5 years since I saw my doctor and I can't remember his name or what he looks like. I see my car mechanic way more often, and I don't care who that is as long as they do the job properly. This really seems like a non-issue.

Yes, it is a real concern.  My doctors are not people I see for 45 seconds every few years.  Some of them are people I see with great frequency for ongoing treatments.  I care because we have established a great relationship over the years and they are very familiar with my medical history and treatment plan.  Like I said, I am paying for COBRA to continue the benefits from my prior employer since none of the ACA plans in my state would accommodate what I need.

Well I guess you're special. My doctor is not my  shrink. He's just a guy who decide which pills, or surgery I may need. That's pretty much it, and most of the people who graduate medical school are able to do that just fine.

I've never met a doctor who wasn't cold, impersonal and seemed like he couldn't wait to get me outta there asap. And that's fair; it's a business transaction.

No, I don't think I am special.  That's kind of the point.  Lots of people are concerned about not being able to keep their doctors when they buy a plan on the open exchange.  That's why it was such a huge talking point in debate when the ACA was proposed, adopted, and reviewed.  My doctors aren't "my shrink" either -- they are informing me of options/risks and medically treating physical problems.  I'm so happy for you that you are quite healthy and do not even need annual check-ups, let alone treatments.  Many of us are not so fortunate.  On the other hand, I feel bad for you that you've only had cold, impersonal doctors, and not the kind who are truly invested in their patients' health, understanding, and buy-in on a treatment plan.

Again, I care only about getting from Point A (a system where not everyone can get the care they need for an affordable price) to Point B (a system where everyone can).  I care not whether the transformation is through something called Obamacare or has another name -- just that we get to that finish line for all people.

[mathlete]

We need to stop half-assing and just try either:

A) No more gov't interference in the health care market at all. No medicare,  no medicaid, no VA, nothing. Employers/employees pay full taxes on any benefits given as compensation. Cancel EMTALA, if you don't have proof of insurance the hospital can just let you die.

B) Medicare for all, feel free to buy your own outside healthcare if you want to.

ACA is just a slight tweaking of the prior worst-of-both-worlds system in which profit motives trump health consideration AND many levels of stupid bureaucracy/rules create inefficiencies and perverse incentives/unintended consequences.

-W

I would be fine with option B. I think that everyone having access to health care is an admirable goal for the United States to have.

That being said though, I was personally better off pre-ACA and I would have to imagine that I am personally better off pre-universal health care as well.

This is because I'm fortunate enough to both make a lot of money, and be a healthy person. The several years high deductible in the bank crowd stand to take a beating with every step we take in the universal healthcare direction because the current system works out pretty spectacularly for people like us.

So I understand the argument that people make against universal care. I don't think there can be a first principles argument that everyone is entitled to someone else providing a service to them. Of course we crossed that bridge a long time ago.

[MustachianAccountant]

Right.  Other developed countries have much lower rates of obesity, heart disease, car fatalities, gun violence, and other preventable causes of death.

If you look at what the health system does when presented with patients who need health care, the US does very well.

That is an excellent observation.  Lots of things unrelated to the health care system itself factor into life expectancy.
... As it turns out, the USA ranks pretty poorly. We have better outcomes than Mexico or Estonia, but we're much worse than say, Greece, Spain, Italy, or France.  Of the 31 OECD countries, we're down in the 20s somewhere, depending on how you figure.   

http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/HEA/WD/HWP=(2011)1&docLanguage=En

AND our health care costs are MUCH higher.

[waltworks]

So I understand the argument that people make against universal care. I don't think there can be a first principles argument that everyone is entitled to someone else providing a service to them. Of course we crossed that bridge a long time ago.

Yes, EMTALA (signed into law by Reagan!) effectively socialized healthcare in the US. Whether that's good or bad is open to interpretation (and depends on where you sit) but at that point we should have just gone full gov't/medicare for all. The last 30 or so years has all been fallout of that decision, for better or worse.

-W

[randymarsh]

Yes, EMTALA (signed into law by Reagan!) effectively socialized healthcare in the US. Whether that's good or bad is open to interpretation (and depends on where you sit) but at that point we should have just gone full gov't/medicare for all. The last 30 or so years has all been fallout of that decision, for better or worse.

-W

Not really. Socialized healthcare implies the government is paying the bill. EMTALA is a moral directive that has no provision for reimbursement that I'm aware of. If you have no insurance, you're personally billed. If you can't pay, the account is charged off. Costs increase for everyone.

[Jrr85]

It's not just this - 60% of bankruptcies in the US are due to medical expenses.  Of this proportion 75% HAVE HEALTH COVERAGE.  It's just that overall they have fight with their insurers tooth and claw.  It's a crappy, crappy system we have.  Unless you have a lot of money.   http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/index.html?_s=PM:HEALTH

That is possibly the most bullshitiest statistic of all bullshit statistics. 

I'm not criticizing you because it was put out there by two Harvard professors, one of whom was Elizabeth Warren, that were being intentionally dishonest about what they found.  What they really found was that a large percentage of bankruptcy claimants had medical bills.  They would basically take somebody who had a $400k house, $50k car, $60k in credit card debt and a $1500 medical bill and classify them as suffering from a medical bankruptcy.  And of course all the mediocrities in the media blared the result without event attempting to see if the authors were trying to mislead them because it gave them an outrageous headline, and now even intelligent people repeat the statistic because they don't have enough experience with bankruptcy to even determine whether the claim is plausible (but fyi, it's not). 

[RangerOne]

It's not just this - 60% of bankruptcies in the US are due to medical expenses.  Of this proportion 75% HAVE HEALTH COVERAGE.  It's just that overall they have fight with their insurers tooth and claw.  It's a crappy, crappy system we have.  Unless you have a lot of money.   http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/index.html?_s=PM:HEALTH

That is possibly the most bullshitiest statistic of all bullshit statistics. 

I'm not criticizing you because it was put out there by two Harvard professors, one of whom was Elizabeth Warren, that were being intentionally dishonest about what they found.  What they really found was that a large percentage of bankruptcy claimants had medical bills.  They would basically take somebody who had a $400k house, $50k car, $60k in credit card debt and a $1500 medical bill and classify them as suffering from a medical bankruptcy.  And of course all the mediocrities in the media blared the result without event attempting to see if the authors were trying to mislead them because it gave them an outrageous headline, and now even intelligent people repeat the statistic because they don't have enough experience with bankruptcy to even determine whether the claim is plausible (but fyi, it's not).

Would be cool if you have a link noting the poor statistical analysis they did. I would be somewhat surprised if someone like Warren would knowingly push a statistic with samples like you describe as representative of people bankrupted by medical expenses.

The sad truth that we all know is that the media and politicians often keep poor statistics alive for a long time that drive home a point, but under further scrutiny tend to make matters less clear.

[randymarsh]

It's not just this - 60% of bankruptcies in the US are due to medical expenses.  Of this proportion 75% HAVE HEALTH COVERAGE.  It's just that overall they have fight with their insurers tooth and claw.  It's a crappy, crappy system we have.  Unless you have a lot of money.   http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/index.html?_s=PM:HEALTH

That is possibly the most bullshitiest statistic of all bullshit statistics. 

I'm not criticizing you because it was put out there by two Harvard professors, one of whom was Elizabeth Warren, that were being intentionally dishonest about what they found.  What they really found was that a large percentage of bankruptcy claimants had medical bills.  They would basically take somebody who had a $400k house, $50k car, $60k in credit card debt and a $1500 medical bill and classify them as suffering from a medical bankruptcy. 

It doesn't sound that far fetched to me. I suspect a lot of CC debt in bankruptcy is actually medical debt people "paid". Even if the true number is 10 or 15% that are truly filing because of medical debt, that shows a huge flaw in our system.

[MustacheExplorer]

The other issue, it seems, is that prices are completely unregulated (much like education costs), so they're inflated to insane levels. How much is a standard GP visit there?

A $20 co-pay? Most doc visits are something like that.

You must have some decent insurance :) My office only offers high deductible plans which means we pay what is called the "negotiated rate" (what the insurance would pay to the doctor after we hit the deductible). Depending on which doctor we are able to get in to see our office visits usually cost about $100 - $130. We'll pay that until we hit a 3k deduct.

After we hit our deductible we pay a CoInsurance fee which is 30% of the negotiated rate. If we somehow then hit our Max Out of Pocket costs (which I believe are 9k this year) then the insurance will cover everything after that.

My understanding is that most small to medium businesses in the US are switching over to plans like what I have (my father works in insurance and I do some HR so we talk about this a lot :))

My deductible went from a $20 copay to a $5000 deducible.  The only real savings I get short of a major issue is that I only have to pay the agreed to allowable fee.  My last dermatologist visit that lasted less than ten minutes cost me almost $1000 including lab fees.   

[Jrr85]

Right.  Other developed countries have much lower rates of obesity, heart disease, car fatalities, gun violence, and other preventable causes of death.

If you look at what the health system does when presented with patients who need health care, the US does very well.

That is an excellent observation.  Lots of things unrelated to the health care system itself factor into life expectancy.

For that reason, I prefer other metrics to compare health care systems, for example  "mortality amenable to healthcare." In other words, measuring the number of people who die from treatable conditions.  It is a binary metric. If a patient has a treatable certain condition, say appendicitis, he either lives or he dies.  Appendicitis can kill you, but it is does it probably because of a failure of the medical system, unlike say a gunshot wound. 

So health care statisticians have developed lists of treatable conditions, and calculated the death rates from the conditions in various countries.  This comparison has been done a number of times and a meta study is linked below. As it turns out, the USA ranks pretty poorly. We have better outcomes than Mexico or Estonia, but we're much worse than say, Greece, Spain, Italy, or France.  Of the 31 OECD countries, we're down in the 20s somewhere, depending on how you figure.   

http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/HEA/WD/HWP=(2011)1&docLanguage=En

Also troubling is that while we are improving mortality amenable to health care, other countries are improving much faster.

Even that can be misleading though, as a lot of the mortality amenable to health care is still heavily influenced by personal behaviors.  Cancer may not be, but circulatory disease certainly is.  I suspect just like diabetes, a lot of our circulatory disease mortality is driven by or exacerbated by failure to exercise and eat reasonably healthy. 

If you look at subgroups of populations, the U.S. does very well on life expectancy.  People of Japanese descent in the U.S. have longer life expectancy than Japanese in Japan.  To my knowledge, that is true of just about any European sub-group that is defined enough to do a comparison.  As noted, that deals with a lot of factors other than healthcare, but it shows that for life expectancy and healthcare, a lot of the disparity is driven by demographics. 

The U.S. healthcare system certainly has problems, but they primarily derive from having not letting any sort of free market work and not letting anybody suffer from their bad decisions, but also not having the political will to ration care and limit compensation to physicians and nurses. 

[MarciaB]

I know mustachians are generally immune to advertising and propaganda but this seems to be one area most people completely buy into.

Nah, I think most US Mustachians know our health care isn't the best.

But yes, the average American, especially those who watch TV, have very over-inflated opinions of our healthcare (and country in general).

Hey Rebs,

Sorry if you've answered this before - but as you are travelling around the world are you required to have US insurance as well? I'm thinking that you return for family visits and such...what's the scoop on that for you?

[Jrr85]

It's not just this - 60% of bankruptcies in the US are due to medical expenses.  Of this proportion 75% HAVE HEALTH COVERAGE.  It's just that overall they have fight with their insurers tooth and claw.  It's a crappy, crappy system we have.  Unless you have a lot of money.   http://www.cnn.com/2009/HEALTH/06/05/bankruptcy.medical.bills/index.html?_s=PM:HEALTH

That is possibly the most bullshitiest statistic of all bullshit statistics. 

I'm not criticizing you because it was put out there by two Harvard professors, one of whom was Elizabeth Warren, that were being intentionally dishonest about what they found.  What they really found was that a large percentage of bankruptcy claimants had medical bills.  They would basically take somebody who had a $400k house, $50k car, $60k in credit card debt and a $1500 medical bill and classify them as suffering from a medical bankruptcy.  And of course all the mediocrities in the media blared the result without event attempting to see if the authors were trying to mislead them because it gave them an outrageous headline, and now even intelligent people repeat the statistic because they don't have enough experience with bankruptcy to even determine whether the claim is plausible (but fyi, it's not).

Would be cool if you have a link noting the poor statistical analysis they did. I would be somewhat surprised if someone like Warren would knowingly push a statistic with samples like you describe as representative of people bankrupted by medical expenses.

The sad truth that we all know is that the media and politicians often keep poor statistics alive for a long time that drive home a point, but under further scrutiny tend to make matters less clear.

Just a quick google (as a bonus, I included one talking about how she misrepresented some information in her book the Two Income Trap, changing how she presented some information to hide the amount of the income gains from women moving into the workplace being sucked up by increased local taxes. 

http://thehill.com/blogs/congress-blog/economy-a-budget/263547-the-myth-of-medical-bankruptcy
http://www.wsj.com/articles/SB10001424052748704523604575512060220672440
http://elizabethwarrenwiki.org/academic-research-controversy/
http://www.theatlantic.com/business/archive/2009/06/elizabeth-warren-and-the-terrible-horrible-no-good-very-bad-utterly-misleading-bankruptcy-study/18826/
http://www.theatlantic.com/business/archive/2010/07/considering-elizabeth-warren-the-scholar/60211/

[Eric]

I know mustachians are generally immune to advertising and propaganda but this seems to be one area most people completely buy into.

Nah, I think most US Mustachians know our health care isn't the best.

But yes, the average American, especially those who watch TV, have very over-inflated opinions of our healthcare (and country in general).

Hey Rebs,

Sorry if you've answered this before - but as you are travelling around the world are you required to have US insurance as well? I'm thinking that you return for family visits and such...what's the scoop on that for you?

Not Rebs, but you're not required to have ACA coverage if you're outside of the country for 330 days or more for the year.  (other exemptions here)  When you return for visits, non-complaint high deductible plans are still available for purchase for short term coverage.

[doggyfizzle]

No "I heard" stories from me. Rather real hard facts from my personal experience buying Obamacare on the CA exchange. Very high pricing (am just a hair >400% FPL; ~$1200/month for family coverage, $0 subsidy)

I've got employer-sponsored health care, and my premiums come out pre-tax.  Are premiums you buy on an exchange tax-deductible (I am completely ignorant about this)?  Are you self-employed?  The only reason I ask is that from my perspective, the $1200/month seems roughly in line with the 70/30 cost sharing ratio ($840/$360) common in employer-sponsored plans, so the total cost doesn't seem outrageous except for when you are 100% responsible for it.

[randymarsh]

No "I heard" stories from me. Rather real hard facts from my personal experience buying Obamacare on the CA exchange. Very high pricing (am just a hair >400% FPL; ~$1200/month for family coverage, $0 subsidy)

I've got employer-sponsored health care, and my premiums come out pre-tax.  Are premiums you buy on an exchange tax-deductible (I am completely ignorant about this)?  Are you self-employed?  The only reason I ask is that from my perspective, the $1200/month seems roughly in line with the 70/30 cost sharing ratio ($840/$360) common in employer-sponsored plans, so the total cost doesn't seem outrageous except for when you are 100% responsible for it.

Like a lot of tax things, maybe. http://www.cbsnews.com/news/can-i-get-a-tax-deduction-for-health-insurance/

But definitely not in the same way W2 employees pay for insurance pretax. Like you mentioned, these costs don't seem much higher than what employer provided plans charge. My last employer plan would have been $700 for a family plan. I just looked at the CO exchange and found silver level plans for $733-$950 for a family of 4. The ACA exchanges are providing transparency and suddenly people are realizing that US health insurance is expensive. Who knew?!?

[jorjor]

No "I heard" stories from me. Rather real hard facts from my personal experience buying Obamacare on the CA exchange. Very high pricing (am just a hair >400% FPL; ~$1200/month for family coverage, $0 subsidy)

I've got employer-sponsored health care, and my premiums come out pre-tax.  Are premiums you buy on an exchange tax-deductible (I am completely ignorant about this)?  Are you self-employed?  The only reason I ask is that from my perspective, the $1200/month seems roughly in line with the 70/30 cost sharing ratio ($840/$360) common in employer-sponsored plans, so the total cost doesn't seem outrageous except for when you are 100% responsible for it.

Like a lot of tax things, maybe. http://www.cbsnews.com/news/can-i-get-a-tax-deduction-for-health-insurance/

But definitely not in the same way W2 employees pay for insurance pretax. Like you mentioned, these costs don't seem much higher than what employer provided plans charge. My last employer plan would have been $700 for a family plan. I just looked at the CO exchange and found silver level plans for $733-$950 for a family of 4. The ACA exchanges are providing transparency and suddenly people are realizing that US health insurance is expensive. Who knew?!?

Yeah, $1200/mo for family coverage isn't surprising. "Is it affordable?" is a different question entirely.

Our total coverage cost is $915/mo all-in for employee + spouse for my HSA plan. The company only charges me $72/mo and provides the rest. In many cases, the the actual cost of coverage and what an employee pays is very different.

I also work as an actuary in the healthcare industry, so I get to see data on what stuff costs.

[doggyfizzle]

So in the case of Laserjet above, if he/she is just a hair above the $97,200/year subsidy threshold, the $1,200 a month is definitely deductible if self-employed and if you are employed but lack insurance (higher than 7.5% of AGI)?

Is it affordable?  Compared to the "tax burden" of other developed nations that offer single-payer systems, when health insurance premiums are factored into withheld pay along with state/federal taxes, it doesn't really seem like that great of a deal considering the costs still shouldered by individuals in the US for medical care even with private insurance compared to Canada, UK, France, Denmark, etc.

[BTDretire]

So this is what you've heard?

Everyone I know (brother, parent, close friends) who actually has experienced using Obamacare has seen their costs decrease from what they were paying before this new system,

I see you said their cost, is that avoiding the real cost? As in their plus the cost to taxpayers through the subsidies.
 I have a family of four, in 2010 my private policy yearly premium was $4,512 with a $10,000 deductible with the same Out Of Pocket cost.
Today for the same policy with forced ACA changes I'm paying $10,248 with a $10,000 and Out Of Pocket.
To get an Obamacare policy, and I just looked it up, the cost is $15,108. The true cost of the Obamacare policy is $4,860 more than my private BCBS policy. Note, the deductible is higher at $13,700 as is the OOP.
  However as you know the willing taxpayers will subsidize me with a check for $11,028, bringing my cost down to $4,080. That's based on a $72,000 income.
 Bottom line, you need to compare private policy costs to the real cost of an Obamacare policy after the subsidy.
We haven't even talked about the additional taxes imposed on taxpayers and healthcare use for Obamacare.

[beltim]

Right.  Other developed countries have much lower rates of obesity, heart disease, car fatalities, gun violence, and other preventable causes of death.

If you look at what the health system does when presented with patients who need health care, the US does very well.

That is an excellent observation.  Lots of things unrelated to the health care system itself factor into life expectancy.

For that reason, I prefer other metrics to compare health care systems, for example  "mortality amenable to healthcare." In other words, measuring the number of people who die from treatable conditions.  It is a binary metric. If a patient has a treatable certain condition, say appendicitis, he either lives or he dies.  Appendicitis can kill you, but it is does it probably because of a failure of the medical system, unlike say a gunshot wound. 

So health care statisticians have developed lists of treatable conditions, and calculated the death rates from the conditions in various countries.  This comparison has been done a number of times and a meta study is linked below. As it turns out, the USA ranks pretty poorly. We have better outcomes than Mexico or Estonia, but we're much worse than say, Greece, Spain, Italy, or France.  Of the 31 OECD countries, we're down in the 20s somewhere, depending on how you figure.   

http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/HEA/WD/HWP=(2011)1&docLanguage=En

Also troubling is that while we are improving mortality amenable to health care, other countries are improving much faster.

As I read it, your metric has the same problem that life expectancy does, namely that it includes data from the uninsured and people who don't seek medical care.  While a useful metric in principle, it's terrible for evaluating the US health system because of the uninsured population.  In contrast, metrics of health care provided rank the US much higher - like I said before, above Canada, France, and Germany:
http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last

[randymarsh]

As I read it, your metric has the same problem that life expectancy does, namely that it includes data from the uninsured and people who don't seek medical care.  While a useful metric in principle, it's terrible for evaluating the US health system because of the uninsured population.  In contrast, metrics of health care provided rank the US much higher - like I said before, above Canada, France, and Germany:
http://www.commonwealthfund.org/publications/press-releases/2014/jun/us-health-system-ranks-last

This I think is the same issue we have with global school rankings. The US is often low. But compare middle class Americans to middle class French/German/English/etc and we do pretty well. 

The US is so stratified on income that the poor are effectively living in another country in regards to healthcare, education, and probably a dozen other issues.

[Northwestie]

The findings for the US are not just limited to the poor:

Key findings related to the U.S. include:

Healthy lives: The U.S. does poorly, ranking last on infant mortality and on deaths that were potentially preventable with timely access to effective health care and second-to-last on healthy life expectancy at age 60.

Access to care: People in the U.S. have the hardest time affording the health care they need. The U.S. ranks last on every measure of cost-related access. More than one-third (37%) of U.S. adults reported forgoing a recommended test, treatment, or follow-up care because of cost.

Health care quality: The U.S ranks in the middle. On two of four measures of quality—effective care and patient-centered care—the U.S. ranks near the top (3rd and 4th of 11 countries, respectively), but it does not perform as well providing safe or coordinated care.

Efficiency: The U.S ranks last, due to low marks on the time and dollars spent dealing with insurance administration, lack of communication among health care providers, and duplicative medical testing. Forty percent of U.S. adults who had visited an emergency room reported they could have been treated by a regular doctor, had one been available. This is more than double the rate of patients in the U.K. (16%).



Equity: The U.S. ranks last. About four of 10 (39%) adults with below-average incomes in the U.S. reported a medical problem but did not visit a doctor in the past year because of costs, compared with less than one of 10 in the U.K., Sweden, Canada, and Norway. There were also large discrepancies between the length of time U.S. adults waited for specialist, emergency, and after-hours care compared with higher-income adults.

[MarciaB]

I know mustachians are generally immune to advertising and propaganda but this seems to be one area most people completely buy into.

Nah, I think most US Mustachians know our health care isn't the best.

But yes, the average American, especially those who watch TV, have very over-inflated opinions of our healthcare (and country in general).

Hey Rebs,

Sorry if you've answered this before - but as you are travelling around the world are you required to have US insurance as well? I'm thinking that you return for family visits and such...what's the scoop on that for you?

Not Rebs, but you're not required to have ACA coverage if you're outside of the country for 330 days or more for the year.  (other exemptions here)  When you return for visits, non-complaint high deductible plans are still available for purchase for short term coverage.

Thanks Eric. We plan on travelling 6-8 months a year, so will have to figure all this out the same way early retirees do who stay in the States I guess...

[Norioch]

I don't doubt the reports that premiums in some areas are skyrocketing, but the premiums in my area (Seattle area) are still very reasonable. I'm insured by my employer but from time to time check prices on WA's health exchange (just for curiosity, and to plan for my retirement) and I'm always surprised by how cheap the plans are.

[The Happy Philosopher]

In a nutshell the ACA cost shifts from the younger and healthier to the older and sicker. It is actually a great thing for the early retiree, but doubtful it is a great thing overall. It insures more people in a system that is too expensive and dysfunctional to begin with.

Here are the trends I see, prepare for them:

1. Insurance will get more expensive for younger and healthier people.
2. Deductibles and cost sharing will continue to increase until all affordable insurance is basically a high deductible plan. This will destroy frugal early retirees that live very lean and develop a serious medical condition.
3. Insurance networks will continue to become more 'narrow' (ie: limited provider options) in an effort to control costs. It will be more and more difficult to see a specialist that is actually covered by your insurance.
4. As you are forced to see out of network providers what you thought was your annual deductible will in reality be much higher as you get balance billed to death.

TL/DR: Don't get sick in America because it is very expensive.

[ShortInSeattle]

I don't doubt the reports that premiums in some areas are skyrocketing, but the premiums in my area (Seattle area) are still very reasonable. I'm insured by my employer but from time to time check prices on WA's health exchange (just for curiosity, and to plan for my retirement) and I'm always surprised by how cheap the plans are.

We had a good range of plans to choose from on the exchange. Paying $400/mo for 2 adults with no subsidy for a bronze plan. I did switch doctors, we would have needed a $550/mo plan for her network. We decided to go with a less expensive plan.

[MoneyCat]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

[Jrr85]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

[MoneyCat]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

Yeah, like you, I sometimes don't pay attention to some national events too. You missed out on the GOP Supreme Court blocking the federal government from punishing states for refusing to expand Medicaid and refusing to create and promote marketplaces to drive costs down. I missed out on some Olympic swimmer lying about peeing on a Brazilian convenience store.

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[randymarsh]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

Are you serious? The GOP has done nothing but disparage every part of the Affordable Care Act, lie about it, and waste taxpayer money on failed repealed attempts. In what world is refusing to expand medicaid and lies about "death panels" not sabotage?

This is the same basic plan the party LOVED in the 90s. The Democrats, as usual, cave and decide they can get behind it. Then suddenly the plan is unconstitutional and evil and literally destroying the country.

[ender]

We need to stop half-assing and just try either:

A) No more gov't interference in the health care market at all. No medicare,  no medicaid, no VA, nothing. Employers/employees pay full taxes on any benefits given as compensation. Cancel EMTALA, if you don't have proof of insurance the hospital can just let you die.

B) Medicare for all, feel free to buy your own outside healthcare if you want to.

ACA is just a slight tweaking of the prior worst-of-both-worlds system in which profit motives trump health consideration AND many levels of stupid bureaucracy/rules create inefficiencies and perverse incentives/unintended consequences.

-W

I think that (B) is the only long term viable option.

They should just get the whole thing over with and go to a fully government run, free system, and let an entirely separate private healthcare system run side by side. I'm pretty libertarian on most things but the racket that is insurance makes me loathe the entire system.

A highly intelligent and incredibly financially savvy person should be able to understand their healthcare billing process. It is astounding to me how complicated, convoluted, slow, and overall inefficient the insurance industry is when it comes to health insurance. It is infuriating for me to realize that the vast majority of people are simply getting screwed by the system because the entire system is setup to be complicated enough even hospital billing departments have no clue how it works.

Yeah, like you, I sometimes don't pay attention to some national events too. You missed out on the GOP Supreme Court blocking the federal government from punishing states for refusing to expand Medicaid and refusing to create and promote marketplaces to drive costs down.

Or, perhaps, the Supreme Court simply was upholding rights of the states?

[MustachianAccountant]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

Both the house and the senate have been controlled by Republicans since 2014.
Also, it's worth noting that many of the states where Obamacare "isn't working" are also Republican controlled, and have instituted state laws blocking the health exchanges.
Here, cross reference the list in this article of states blocking Obamacare: http://watchdog.org/225114/state-obamacare-exchanges/ against the Wikipedia list of which party controls which states: https://en.wikipedia.org/wiki/Political_party_strength_in_U.S._states

[Jrr85]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

Are you serious? The GOP has done nothing but disparage every part of the Affordable Care Act, lie about it, and waste taxpayer money on failed repealed attempts. In what world is refusing to expand medicaid and lies about "death panels" not sabotage?

This is the same basic plan the party LOVED in the 90s. The Democrats, as usual, cave and decide they can get behind it. Then suddenly the plan is unconstitutional and evil and literally destroying the country.

So, the GOP "sabotaged" Obamacare by hurting its feelings?

[Jrr85]

Both the house and the senate have been controlled by Republicans since 2014.

And the President has been Obama since 2014.  I may have missed it, but I'm pretty sure they haven't overridden any veto of Obama.

Also, it's worth noting that many of the states where Obamacare "isn't working" are also Republican controlled, and have instituted state laws blocking the health exchanges.
Here, cross reference the list in this article of states blocking Obamacare: http://watchdog.org/225114/state-obamacare-exchanges/ against the Wikipedia list of which party controls which states: https://en.wikipedia.org/wiki/Political_party_strength_in_U.S._states

No state laws have "blocked" obamacare exchanges.  The law allowed for states to choose to set up state exchanges or not.  Choosing among the options provided by the law cannot be "sabotaging" the law. 

Many places where Obamacare has been the most damaging are in republican controlled states, but because (1) they tend to be less densely populated, so the way the exchanges are set up by county is particularly damaging to what little bit of competition existed; lots of counties only have one insurer participating in the exchanges now and (2) their health insurance was not as screwed up to begin with; New York and New Jersey aren't going to be particularly hurt by ridiculous coverage mandates because they already have them while a lot of republican controlled states have allowed people to choose what they want to insure for and avoided stuff like mandatory coverage for acupuncture. 

[Jrr85]

Yeah, like you, I sometimes don't pay attention to some national events too. You missed out on the GOP Supreme Court blocking the federal government from punishing states for refusing to expand Medicaid and refusing to create and promote marketplaces to drive costs down. I missed out on some Olympic swimmer lying about peeing on a Brazilian convenience store.

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That rascally Supreme Court thinking that we still have limited government and federalism.  Why shouldn't the federal government be able to "punish" states when they try to act like sovereigns.  And the nerve of states to choose among the options provided to them by the legislation passed by democrats and signed by President Obama.  Don't they know that when Obamacare provided them the option to create state exchanges or to rely on a federal exchange, actually exercising that option would constitute sabotage?

[Metric Mouse]

Both the house and the senate have been controlled by Republicans since 2014.

And the President has been Obama since 2014.  I may have missed it, but I'm pretty sure they haven't overridden any veto of Obama.

Also, it's worth noting that many of the states where Obamacare "isn't working" are also Republican controlled, and have instituted state laws blocking the health exchanges.
Here, cross reference the list in this article of states blocking Obamacare: http://watchdog.org/225114/state-obamacare-exchanges/ against the Wikipedia list of which party controls which states: https://en.wikipedia.org/wiki/Political_party_strength_in_U.S._states

No state laws have "blocked" obamacare exchanges.  The law allowed for states to choose to set up state exchanges or not.  Choosing among the options provided by the law cannot be "sabotaging" the law. 

Many places where Obamacare has been the most damaging are in republican controlled states, but because (1) they tend to be less densely populated, so the way the exchanges are set up by county is particularly damaging to what little bit of competition existed; lots of counties only have one insurer participating in the exchanges now and (2) their health insurance was not as screwed up to begin with; New York and New Jersey aren't going to be particularly hurt by ridiculous coverage mandates because they already have them while a lot of republican controlled states have allowed people to choose what they want to insure for and avoided stuff like mandatory coverage for acupuncture.

Fully 55% of the country lives in a district where there are two or less insurers in the exchange.  A 'competitive' marketplace is considered 3 or more insurers.  There are still millions of uninsured Americans.  Costs continue to go up.  There are some great aspects to the ACA (like ensuring people with chronic conditions can access health insurance) but overall the ACA is failing to prove that it's a net positive for the country as a whole.

[GuitarStv]

And the nerve of states to choose among the options provided to them by the legislation passed by democrats and signed by President Obama.  Don't they know that when Obamacare provided them the option to create state exchanges or to rely on a federal exchange, actually exercising that option would constitute sabotage?

They should stop blaming the system, and start blaming the people who made those choices.  It's the results of those choices that have made things miserable.  Blaming the ACA is just a way of avoiding personal responsibility on the part of the people who decided poorly.

[MustachianAccountant]

Also, it's worth noting that many of the states where Obamacare "isn't working" are also Republican controlled, and have instituted state laws blocking the health exchanges.
Here, cross reference the list in this article of states blocking Obamacare: http://watchdog.org/225114/state-obamacare-exchanges/ against the Wikipedia list of which party controls which states: https://en.wikipedia.org/wiki/Political_party_strength_in_U.S._states

No state laws have "blocked" obamacare exchanges.  The law allowed for states to choose to set up state exchanges or not.  Choosing among the options provided by the law cannot be "sabotaging" the law. 

"But a lack of support for state Obamacare exchanges is reflected in the fact 18 of the 34 states defaulting to HealthCare.gov have state laws or constitutional amendments forbidding state-run exchanges..[these “Health Care Freedom” laws and constitutional amendments were enacted] specifically in response to Obamacare."

And I think we're all still waiting to hear the GOP's viable alternative. Being complainypants isn't really looked upon fondly around here, but I'm sure everyone here would at least *look* at a well reasoned plan to attack the US healthcare problem in the absence of Obamacare.

[StarBright]

And the nerve of states to choose among the options provided to them by the legislation passed by democrats and signed by President Obama.  Don't they know that when Obamacare provided them the option to create state exchanges or to rely on a federal exchange, actually exercising that option would constitute sabotage?

They should stop blaming the system, and start blaming the people who made those choices.  It's the results of those choices that have made things miserable.  Blaming the ACA is just a way of avoiding personal responsibility on the part of the people who decided poorly.

^ This.

I live in a reddish state where the repub governor took the extra funding and encouraged local insurers on the exchanges. I've been impressed by how relatively inexpensive the plans can be (compared to the last state I lived in that did not take the expansion) - about $500 a month (unsubsidized) for a family silver plan that are almost comparable to what I get through my job. You know what I don't hear people complain about here? Obamacare.

Where states are using the ACA as designed it seems to be working better (who'dve thunk?)

I still think that insurance is too expensive and I think high deductible plans are actually an awful idea. But i have definitely seen  a difference on the exchanges between a red state that worked with the ACA and one that didn't.

[goatmom]

Well, I am in New York.  I see plenty of uninsured people.  Uninsured by choice because it is better to pay the penalty than to purchase insurance.  I see plenty of people on Medicaid that are pretty high income.  They know how to play the system and have their AGI below the threshold.  I see others who even though on paper they are considered insured don't feel that way.  Why?  The deductibles are so high that they can't afford to every reach it.  Even after they get to the deductible, the medicine they need keeps getting denied coverage by the insurance company.  Then they feel once they are barely treading water, the clock resets and they have to meet the deductible again.  The only people I meet that are pretty happy are those with great insurance through an employer (unions, school teachers, etc) and those on Medicaid.

I am not sure what the answer is.  I still stand by the fact if I had something seriously wrong with me - I would want to be in the US.  Most rich people around the world feel this way too.    Go to any major hospital and see all the foreigners who come here to get the best care in the world.  Or Healthcare system is not good.  We need to get rid of the insurance companies.   Single payer might be the answer.  Not sure. 

[radram]

Following.

It sounds like most people seem to be in favor of coverage for all, but are really complaining about the costs to do it.  Does anyone have ideas to reduce costs for coverage?  If not, what current coverage would you eliminate?  I see single payer and Medicaid for all as 2 options thrown around.  Does anyone have estimates (more recent than 1991) as to how much those systems would cost?  If they are much cheaper, then why in the world do we not shift to them? Is it something other than profit motive?

To me the solution must include some sort of realistic safety net along personal responsibility.  I do not see $1000 monthly premiums and paying $12,000 in a "bad year" as a reasonable  safety net for the masses.  With the subsidies, the $1000 is reduced, but the $12,000 or so max OOP is not.  That is not a realistic long term solution.  For ME, this solution would work for the foreseeable future but I think we can and should do better.

Receiving care and not changing the reason the care was needed is also not a long term solution.  I know huge consumers of medical care who do not do what is asked of them. That also is not right or fair. 

I could see the US morphing into some sort of dual health system, with universal coverage including inexpensive basic wellness and catastrophic care, and a private system that is purchased by people who need/want more coverage.  Still not without its problems, but different ones.   Did I just describe Medicaid? 

What if max oop was also tied to income?

Thoughts?

[jorjor]

Both the house and the senate have been controlled by Republicans since 2014.
Also, it's worth noting that many of the states where Obamacare "isn't working" are also Republican controlled, and have instituted state laws blocking the health exchanges.
Here, cross reference the list in this article of states blocking Obamacare: http://watchdog.org/225114/state-obamacare-exchanges/ against the Wikipedia list of which party controls which states: https://en.wikipedia.org/wiki/Political_party_strength_in_U.S._states

I wouldn't call blocking a state-run Exchange the same thing as "blocking Obamacare." There is still a Marketplace, it's just the Federal Marketplace, and Obamacare is a hell of a lot more than a website. Not expanding Medicaid or continually extending Transitional Policies which screwed up the risk pool were far more harmful than not having your Marketplace be run by the state.

[jorjor]

Many places where Obamacare has been the most damaging are in republican controlled states, but because (1) they tend to be less densely populated, so the way the exchanges are set up by county is particularly damaging to what little bit of competition existed; lots of counties only have one insurer participating in the exchanges now and (2) their health insurance was not as screwed up to begin with; New York and New Jersey aren't going to be particularly hurt by ridiculous coverage mandates because they already have them while a lot of republican controlled states have allowed people to choose what they want to insure for and avoided stuff like mandatory coverage for acupuncture.

(1) is silly. Being rural is partially to blame, but far more because you commonly have smaller insurers there who can't afford to lose money, who then lost money because of the effed up risk pools. The effed up risk pools are partly because of shoddy ACA rollout backed by the Dems, and partly because of actions taken by the GOP to make it worse (no Medicaid expansion, Transitional Policies, etc.). It wasn't because "the way the exchanges are set up."

(2) Talk about begging the question. "Things suck here because they were great before and things changed, things don't suck there because their rules were already ridiculous."

[randymarsh]

Obamacare would be doing swimmingly well if the GOP didn't purposefully set out to sabotage it because they hate poor people. (Sorry if that's blunt, but it's the truth.) It's amazing how spiteful some people can be when something threatens their self-proclaimed superiority. My state fully implemented all aspects of Obamacare and guess what? We have nearly no uninsured people and ACA health plans are super cheap. Imagine that.

This is just completely uninformed. Obamacare was passed without any republican support. Democrats didn't have to do anything to cater to republicans and every compromise in the legislation was something to get democrats to agree on it. and since its been enacted, we've obviously had a democrat administration the entire time. And state administrations can only choose among the options permissible under the law.m, so there's not much of a way for them to sabotage it.

Are you serious? The GOP has done nothing but disparage every part of the Affordable Care Act, lie about it, and waste taxpayer money on failed repealed attempts. In what world is refusing to expand medicaid and lies about "death panels" not sabotage?

This is the same basic plan the party LOVED in the 90s. The Democrats, as usual, cave and decide they can get behind it. Then suddenly the plan is unconstitutional and evil and literally destroying the country.

So, the GOP "sabotaged" Obamacare by hurting its feelings?

Stop trying to be cute. You know exactly what I'm talking about. They've done everything they can to try to convince the public that it's a terrible idea. That has effects. Conservatives launched an ad campaign trying to convince young people not to sign up. If you don't think that's sabotage you're just being willfully ignorant. http://www.reuters.com/article/us-usa-healthcare-republicans-idUSBRE96O0EJ20130725

You glossed over refusing to expand Medicaid. Yes, states have the option to do that. But expansion was part of the ACA. It was assumed states would expand and more people would be covered. So now Republicans can tell people who fall into the gap between medicaid and subsidy eligibility "See, Obamacare is bad. It didn't even get you coverage! REPEAL REPEAL REPEAL!".

[jorjor]

It sounds like most people seem to be in favor of coverage for all, but are really complaining about the costs to do it.  Does anyone have ideas to reduce costs for coverage?  If not, what current coverage would you eliminate?  I see single payer and Medicaid for all as 2 options thrown around.  Does anyone have estimates (more recent than 1991) as to how much those systems would cost?  If they are much cheaper, then why in the world do we not shift to them? Is it something other than profit motive?

I think we accept that any new system will have to cut costs. Where do you cut?

Do you cut payments to providers and hospitals? That's going to be met with hard opposition from providers and hospitals.

Hospital administrators and support staff are commonly cited as wasteful. Plenty of perfectly fine middle class people work at insurers, another oft-cited source of waste. Who do you cut? What happens to them when you cut them? A huge number of middle-class folks just lost their jobs. Too bad, so sad?

If you overhaul, you're probably cutting out a huge portion of administrative expense, which isn't necessarily a bad thing. You're also probably getting some more fraud to offset some of that, and you're putting more people out than just the fat cat executives that everyone likes to rant about. Again, maybe worth it. You don't need to shed a tear for them if you don't want to. You can call any or all of that "profit incentive" The point is that it all adds up to a lot of inertia.

What if max oop was also tied to income?

It already is for some. Cost Sharing Reduction (CSR) plans are available to anyone earning less than 250% FPL, though the real savings isn't until below 200% FPL with the 87% and 94% CSR plans. Those have maximum limits on OOP maximums (and deductibles) that are lower than the maximum limits for standard plans.

[jim555]

Don't forget the House Republicans lawsuit to stop funding of the Silver plans Cost Sharing Reductions.  It is still in the courts right now.

[jorjor]

Don't forget the House Republicans lawsuit to stop funding of the Silver plans Cost Sharing Reductions.  It is still in the courts right now.

That would be pretty damn destructive too.

[jim555]

Well, I am in New York.  I see plenty of uninsured people.  Uninsured by choice because it is better to pay the penalty than to purchase insurance.  I see plenty of people on Medicaid that are pretty high income.  They know how to play the system and have their AGI below the threshold.

You contradict yourself "that are pretty high income" against "their AGI below the threshold".  The threshold of 138% FPL is not high at all, especially in New York.  So they are committing fraud by lying about true income?? 

[jim555]

Rubio helped to cut the risk corridor payments and undermine the ACA.  Republicans have constantly tried to break the ACA.

http://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html