Supreme Court challenge to the ACA

[Exflyboy]

Anyone have any thoughts about this?

I was of course pleased to see the court didn't gut the ACA subsidies outright, but it looks like they will make a final ruling in June.

I guess it would be interesting if subsidies suddenly became unavailable but low income folks were suddenly responsible for an extra $681 a month in HC premiums.

Thoughts?

[sol]

My understanding is that the worst case scenario would only gut subsidies for people who live in states that didn't set up their own exchange (most Republican governors who did so to protest the Presidency).

I think I'm fine with that outcome.  If your state government doesn't want you to have subsidized health insurance, you can either pay full price or move to a better state.  It's not like you'd be exempt from the requirement to have insurance, you'd just be denied the reduced price.

We're already heading towards two distinct Americas.  This would just be one more step in that direction, and I think it will be pretty clear in a few decades which one will have become more prosperous.  I won't even attempt to predict which one it is, I'm just saying that over time some sort of pattern will emerge that reflects the outcome of these decisions.

[Exflyboy]

Two Americas.. yes I really must dust off the Gulfstream V to make my escape to my tropical island when the 99% revolt.. Oh wait.. I'm not in THAT America..:)

[Monkey Uncle]

I'm definitely rooting for the ACA to pull through on this one.  If the subsidies are struck down, my ER will have to wait at least until DW is eligible for Medicare.

[UnleashHell]

its pretty clear that the intent was that the subsidies were intended for everyone. However the supreme court doesn't need to rule on that. it can rule that the wording is unclear. I understand the challenge - but this isn't about people and how they are affected - its all about politics. I don't even mind the politics but for the ACA its just no, no, no from the republicans. Challenge away as to how this thing works - but in the meantime how about some solutions or alternatives as well.
They have nothing - its all well and good to spout off about affordable insurance but they aren't actually doing anything to make this happen. Its all about destructive politics and most of the party would rather see the act fail than actually do anything about any sensible healthcare policy. The healthcare costs are out of control and something positive has to be done - just destroying whats in places because you have called it obamacare is failing the people they represent.

"four legs good, two legs bad" is what I'm reminded of here. which of course will change to four legs good, two legs better when it suits them.

[Norioch]

It's not like you'd be exempt from the requirement to have insurance, you'd just be denied the reduced price.

This isn't correct. If the plaintiffs win, then nobody in states with federal exchanges would be required to pay the penalty for not having insurance. Ostensibly, this is the reason why the plaintiffs sued to begin with - they didn't want to buy insurance even with the subsidies, and they didn't want to pay the penalties either. It's disingenuous because all four of the plaintiffs were already exempt from the penalties for various reasons - the conspicuously under addressed issue of standing - yet, here we are.

[brooklynguy]

My understanding is that the worst case scenario would only gut subsidies for people who live in states that didn't set up their own exchange (most Republican governors who did so to protest the Presidency).

The Supreme Court case imperils the continued viability of the ACA for all Americans, as discussed in this thread (which has become the central clearing house for discussion on this topic in the forum and, through a rare moderator misstep, has been buried in the Off Topic subforum).

[CaveDweller]

My understanding is that the worst case scenario would only gut subsidies for people who live in states that didn't set up their own exchange (most Republican governors who did so to protest the Presidency).

34 out of 50 states use federal exchanges - that's most of the country, and a pretty horrible 'worst case scenario.' Also when states made the decision whether or not to set up their own exchanges, they did so thinking that there wouldn't be any downside to using the federal exchange. Otherwise they might have made a different decision.

Also, most people affected actually WOULD become exempt from the mandate, because without the subsidy it would become 'unaffordable' (if insurance costs more than 9.5% of your income, you don't have to buy or pay any penalty). Hence fewer healthy people would choose to buy insurance, the insured pool would be made up of much sicker people, hospitals would go back to treating a lot more uninsured people and eating the cost, and rates would go up for everyone.

Unfortunately people who say the entire law would unravel if the Court sides with the plaintiffs are not exaggerating.

[seattlecyclone]

It's not like you'd be exempt from the requirement to have insurance, you'd just be denied the reduced price.

This isn't correct. If the plaintiffs win, then nobody in states with federal exchanges would be required to pay the penalty for not having insurance.

This isn't quite correct either. The penalty will still apply to people who have access to a plan that costs less than 8% of their income. Currently the lowest-priced plan in my area for a 40-year-old married couple costs $387.68/month, meaning 40-year-old couples earning more than $58k would still have to pay a penalty. The limit would be less for younger people ($45k for a 25-year-old couple) and more for older people ($120k for a 60-year-old couple), but the penalty would still apply to quite a lot of people in a country with median household income of $52k.

At least it would apply for a while. It's reasonable to assume that an "adverse selection death spiral" could occur when lower-income healthy people drop out of the insurance system, raising premiums for the remaining customers and causing more healthy people to quit buying insurance. This death spiral would presumably happen slower than if everyone was exempt from penalties all at once, but it would still likely happen.

My understanding is that the worst case scenario would only gut subsidies for people who live in states that didn't set up their own exchange (most Republican governors who did so to protest the Presidency).

34 out of 50 states use federal exchanges - that's most of the country, and a pretty horrible 'worst case scenario.' Also when states made the decision whether or not to set up their own exchanges, they did so thinking that there wouldn't be any downside to using the federal exchange. Otherwise they might have made a different decision.

If the Supreme Court sides with the plaintiffs, nothing is stopping these states from establishing their own exchanges, aside from continued Republican obstructionism. And if the citizens of these states allow their Republican state representatives to keep their jobs after their inaction costs their constituents a valuable federal tax credit that costs the state government nothing, I'd say the people of these states are getting the government they deserve. I won't shed too many tears for them if that happens.

Meanwhile, the ACA isn't going anywhere. As strongly as the Republicans oppose it, the Democrats aren't willing to repeal it. As long as Democrats retain the presidency or filibuster power in the Senate, the law stays.

[retired?]

My understanding is that the worst case scenario would only gut subsidies for people who live in states that didn't set up their own exchange (most Republican governors who did so to protest the Presidency).

I think I'm fine with that outcome.  If your state government doesn't want you to have subsidized health insurance, you can either pay full price or move to a better state.  It's not like you'd be exempt from the requirement to have insurance, you'd just be denied the reduced price.

We're already heading towards two distinct Americas.  This would just be one more step in that direction, and I think it will be pretty clear in a few decades which one will have become more prosperous.  I won't even attempt to predict which one it is, I'm just saying that over time some sort of pattern will emerge that reflects the outcome of these decisions.

"better" is in the eye of the beholder.  Here is a map from the Washington Post around the time states had to declare whether they would set up their own exchange or not.  It would be interesting to compare this to the the general fiscal responsibility of each state....e.g. Illinois and CA get a fail.

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/02/18/its-official-the-feds-will-run-most-obamacare-exchanges/

But, to the OP's question, I am a little torn on this.  I will benefit, but I think it is a poor law.  I think govt is inefficient.  Along the lines of all the talk about Iran/Israel the same saying applies "No deal is better than a bad deal".  I wouldn't be surprised of Roberts pusses out again and cannot judge the law as written. 

If you want to look at which states are currently more prosperous, it is those that are pro business and anti-regulation.  But, you are right I think.  In a few decades we'll see which states are "right".  I can just imagine people moving from states that are producing more jobs to states that are not, but which have exchanges.

[Tyler]

The subsidies may well get struck down, but the old system will not magically return.  Grossly unaffordable healthcare will be far too politically radioactive on both sides, and something will get done to fix it. My prediction is that Congress will agree to extend subsidies through the end of the year while they negotiate a long-term reform. The rhetoric will be at full blast, but both sides will eventually compromise before the election year.

In any case, most articles I've read about the Supreme Court oral arguments yesterday (even from conservative blogs) predict, based on reading the tea leaves of the justices, that the subsidies will ultimately be upheld.

For prospective early retirees, I believe the important lesson here is to count on laws you may depend on today to change several times during your lifetime. Don't get pissed or discouraged, and don't plan a retirement that depends on a very narrow set of circumstances to be viable. Be like water, my friend.

[brooklynguy]

If the Supreme Court sides with the plaintiffs, nothing is stopping these states from establishing their own exchanges, aside from continued Republican obstructionism. And if the citizens of these states allow their Republican state representatives to keep their jobs after their inaction costs their constituents a valuable federal tax credit that costs the state government nothing, I'd say the people of these states are getting the government they deserve. I won't shed too many tears for them if that happens.

Meanwhile, the ACA isn't going anywhere. As strongly as the Republicans oppose it, the Democrats aren't willing to repeal it. As long as Democrats retain the presidency or filibuster power in the Senate, the law stays.

If the insurance markets in a majority of the states collapse in an adverse-selection death spiral, that would disrupt insurance markets nationwide.  Even though each state represents a separate market with a distinct risk pool, most insurance companies operate across state lines.  A relatively sudden drop-out of a significant number of states from the ACA framework would destroy the underlying financial models used by the insurance companies coming into this.  In addition, the financial modeling that underpins the ACA itself assumed nationwide participation; the cost of the subsidies was intended to be sustainable, among other reasons, partly due to revenue from the individual mandate penalty (which would no longer be collected as projected in states without their own exchanges) and partly due to the effect on health care costs that would be caused by near-universal nationwide coverage (which would no longer be the case).  Also, the unavailability of subsidies in states that fail to establish their own exchanges could lead to an adverse selection problem for states that do have their own exchanges if less healthy people begin fleeing to those states en masse, but I won't speculate as to how likely that is to actually happen.  But I do think it is unrealistic to believe that the implosion of the ACA in a majority of the states would leave the remainder of the country wholly unaffected.

[retired?]

its pretty clear that the intent was that the subsidies were intended for everyone. However the supreme court doesn't need to rule on that. it can rule that the wording is unclear. I understand the challenge - but this isn't about people and how they are affected - its all about politics. I don't even mind the politics but for the ACA its just no, no, no from the republicans. Challenge away as to how this thing works - but in the meantime how about some solutions or alternatives as well.
They have nothing - its all well and good to spout off about affordable insurance but they aren't actually doing anything to make this happen. Its all about destructive politics and most of the party would rather see the act fail than actually do anything about any sensible healthcare policy. The healthcare costs are out of control and something positive has to be done - just destroying whats in places because you have called it obamacare is failing the people they represent.

"four legs good, two legs bad" is what I'm reminded of here. which of course will change to four legs good, two legs better when it suits them.

Paul Ryan has a plan.  You have to recall - no alternative to ACA would go through prior to Nov 2014.  But, again, a bad plan isn't better than no plan.....the common refrain that "obamacare is better than doing nothing". 

We have to pass it first so we can see what's in it.

It will go bankrupt (not that there are funds) like SS and be eroded or covered by inflation.  Let's print money to make the peasants happy.

[MoneyCat]

If the ACA subsidies are struck down for states with federal exchanges, then my state will immediately start a state exchange.  The only reason we don't have one now is because we have a Republican governor with delusions that he is going to be US President and he's trying to appeal to ultraconservatives.  If the subsidies are struck down, he will be forced to start a state exchange or he will face a revolt from both parties in the state legislature.

[Exflyboy]

Well fingers crossed that the subsidies stay.

We could always got back to our native UK with very well run nationalised HC system.

Would rather not do that for other reasons but at least its an option, as is moving to another low HC cost country.

[dragoncar]

We're already heading towards two distinct Americas.  This would just be one more step in that direction, and I think it will be pretty clear in a few decades which one will have become more prosperous.  I won't even attempt to predict which one it is, I'm just saying that over time some sort of pattern will emerge that reflects the outcome of these decisions.

Hasn't this already happened?  Isn't the pattern clear?

[sol]

We're already heading towards two distinct Americas.  This would just be one more step in that direction, and I think it will be pretty clear in a few decades which one will have become more prosperous.  I won't even attempt to predict which one it is, I'm just saying that over time some sort of pattern will emerge that reflects the outcome of these decisions.

Hasn't this already happened?  Isn't the pattern clear?

Wrt subsidized universal healthcare availability, I don't think one year is long enough to see any significant results.

[retired?]

The subsidies may well get struck down, but the old system will not magically return.  Grossly unaffordable healthcare will be far too politically radioactive on both sides, and something will get done to fix it. My prediction is that Congress will agree to extend subsidies through the end of the year while they negotiate a long-term reform. The rhetoric will be at full blast, but both sides will eventually compromise before the election year.

For prospective early retirees, I believe the important lesson here is to count on laws you may depend on today to change several times during your lifetime. Don't get pissed or discouraged, and don't plan a retirement that depends on a very narrow set of circumstances to be viable. Be like water, my friend.

They certainly won't disappear mid-year.  At "worst", they'd disappear at the end of a calendar year.

RE bold part - it seems much of the guidance on healthcare on MMM posts is simply 'hey, we now have subsidies'.  Saw lots of 'hey, now I can retire'.

You are also right that it simply won't revert to the old system.  I prefer the SC judges to enforce it as written (i.e. not legislate from the bench) and force Congress to write a clear law (not a 'gotta pass it to know what is in it').

[MrMoogle]

But, to the OP's question, I am a little torn on this.  I will benefit, but I think it is a poor law.  I think govt is inefficient.  Along the lines of all the talk about Iran/Israel the same saying applies "No deal is better than a bad deal".  I wouldn't be surprised of Roberts pusses out again and cannot judge the law as written. 

I too will benefit.  With the subsidies, I may get to RE a year or two earlier.  But someone retiring at 33 isn't what the subsidies are designed for.

I disagree with the law, I don't think I need as much coverage as they're requiring, if I got some low-cost catastrophic plan, that would be fine with me.  And yes, I think government is stepping in where they don't have any need to, but that is out of my control.  But since it is now required, I will use the system to get as much of a subsidy that I can. 

Luckily I'm waiting a couple more years to RE, so some of this can get a little more hammered out.

[brooklynguy]

But someone retiring at 33 isn't what the subsidies are designed for.

Yes it is.  You could almost say that is exactly what the subsidies are designed for.  They are designed to make health insurance more affordable for people who lack employer-sponsored coverage and who satisfy the specified income thresholds and limitations.  They are designed to partially untether the availability of health insurance from the possession of employment, artificially knotted together in the United States only by reason of historical accident in the way the labor markets and insurance industries co-evolved in this country.  They are designed to give American workers the freedom to leave their jobs without fear of losing access to affordable health care, whether they do so in order to pursue other gainful employment or, as in our case, extremely early retirement (and, in the process, open up a job opportunity for another individual who would love to take it).

[retired?]

But, to the OP's question, I am a little torn on this.  I will benefit, but I think it is a poor law.  I think govt is inefficient.  Along the lines of all the talk about Iran/Israel the same saying applies "No deal is better than a bad deal".  I wouldn't be surprised of Roberts pusses out again and cannot judge the law as written. 

I too will benefit.  With the subsidies, I may get to RE a year or two earlier.  But someone retiring at 33 isn't what the subsidies are designed for.

I disagree with the law, I don't think I need as much coverage as they're requiring, if I got some low-cost catastrophic plan, that would be fine with me.  And yes, I think government is stepping in where they don't have any need to, but that is out of my control.  But since it is now required, I will use the system to get as much of a subsidy that I can. 

Luckily I'm waiting a couple more years to RE, so some of this can get a little more hammered out.

As you should.  The govt is horrible at foreseeing unintended consequences.  Congress really, to a large extent, is a bunch of idiots.  Rather to be more precise, probably somewhat intelligent people, but entirely uneducated in economics or logic.  They study things like public policy, international law, etc.

For the most part, they do not know how to think critically.

[retired?]

But someone retiring at 33 isn't what the subsidies are designed for.

Yes it is.  You could almost say that is exactly what the subsidies are designed for.  They are designed to make health insurance more affordable for people who lack employer-sponsored coverage and who satisfy the specified income thresholds and limitations.  They are designed to partially untether the availability of health insurance from the possession of employment, artificially knotted together in the United States only by reason of historical accident in the way the labor markets and insurance industries co-evolved in this country.  They are designed to give American workers the freedom to leave their jobs without fear of losing access to affordable health care, whether they do so in order to pursue other gainful employment or, as in our case, extremely early retirement (and, in the process, open up a job opportunity for another individual who would love to take it).

You are missing the point.  Yes, separating healthcare from employment is a key aspect(and a good goal), but I don't expect any member of Congress or the general public thinks the subsidies should go to people at 33 who can afford to not work.  Or 45, or 55, etc.  As written, an multi-millionaire living off assets can claim the subsidies.  I advocate playing by the rules, but I am 100% certain no one aimed to subsidize millionaires....which, for the most part, by definition, includes RE people.  Just another example of govt not anticipating the consequences of policy. 

Have to pass it so we can see what it says.

side note - it was the govt in the early 60s that made healthcare premiums deductible (i.e. taxes are paid on income net of healthcare premiums) and tied it to employment.  Now, trying to undo what they had done.

[Exflyboy]

I would just like to state that I have every intention of managing my income to obtain the maximum possible subsidy.. If they are stupid enough to write it that way then I don't feel too bad at clawing back some of the subsidies I have been paying for.. like for my waste space in laws who's first thought every day is how to screw the tax payer so they don't have to work.

Somehow long term I doubt the ACA will exist so we can game the system this way.. Then I see living overseas as a real option.

[brooklynguy]

Just another example of govt not anticipating the consequences of policy. 

That's why I said "almost," but I now take back the almost.  Subsidizing millionaires who meet the income test is not an unforeseen consequence of the law.  It is a consequence that was recognized and accepted when the legislature decided to adopt a straight income-based test instead of a form of means-testing with an asset-based component (a decision that was fully intentional).  And before you bemoan the absurdity (or stupidity, to use Exflyboy's words) of that result, consider that the various tax policies promoting leisure over labor that we in the early retiree community exploit (such as the 0% federal tax rate on LTCG and QD) actually treat passive income more favorably than earned income.  At least the ACA looks at all income equally instead of giving income received from your million-dollar nest egg better treatment than income earned from actual labor.  And even though I personally oppose our regressive tax system that has the effect of benefiting rich people like us and assisting our own early retirement plans, I, like you, do not intend to reject any of those benefits for which I legally qualify for as long as that system remains in place.

[Tyler]

Like the ACA, Medicare is also means tested by income but not by wealth. The reason is quite logical -- discouraging retirement savings is very bad public policy. I personally see no reason why ACA coverage should be any different. 

My advice to those who feel strongly about it is to claim the absolute maximum in subsidies to which you are legally entitled and to donate them to charity. That will also allow you to deduct the donation from your taxes.

[Doulos]

I do not understand.
The government paying for some people's premium is not lowering costs.
It is only moving the costs from some % of the people to everyone's tax dollars.

If anything needs to be done it is attempts to fix the actual costs. 
   Just to make up ideas that is probably bad;
   -  Ensure that all health care costs (estimates) are provided to customers by providers up front. 
   -  Enforce non-monopoly rules upon emergency services like ambulances and hospitals. 

Point is, this is about making tax payers paying for other people's bills.  It has nothing to do with lowering the actual costs of the health care.

[Tyler]

I think you meant Medicaid - health insurance for poor people - and not Medicare, which is for old people and isn't means tested at all.

I meant Medicare.  Since 2007, Medicare Part B (outpatient care) and Part D (prescription drugs) are means tested by income.

http://jaredbernsteinblog.com/medicare-is-means-tested/

[Eric]

The Supreme Court case imperils the continued viability of the ACA for all Americans, as discussed in this thread (which has become the central clearing house for discussion on this topic in the forum and, through a rare moderator misstep, has been buried in the Off Topic subforum).

Hear Hear!

[Eric]

But, to the OP's question, I am a little torn on this.  I will benefit, but I think it is a poor law.  I think govt is inefficient.  Along the lines of all the talk about Iran/Israel the same saying applies "No deal is better than a bad deal".  I wouldn't be surprised of Roberts pusses out again and cannot judge the law as written. 

I too will benefit.  With the subsidies, I may get to RE a year or two earlier.  But someone retiring at 33 isn't what the subsidies are designed for.

I disagree with the law, I don't think I need as much coverage as they're requiring, if I got some low-cost catastrophic plan, that would be fine with me.  And yes, I think government is stepping in where they don't have any need to, but that is out of my control.  But since it is now required, I will use the system to get as much of a subsidy that I can. 

Luckily I'm waiting a couple more years to RE, so some of this can get a little more hammered out.

As you should.  The govt is horrible at foreseeing unintended consequences.  Congress really, to a large extent, is a bunch of idiots.  Rather to be more precise, probably somewhat intelligent people, but entirely uneducated in economics or logic.  They study things like public policy, international law, etc.

For the most part, they do not know how to think critically.

It's not like you can just write a perfect law and submit it for vote.  The opposing party has to get their concessions, which work to distort the final effects of any law.  No matter how much economics or logic you study, or how smart you are, it's nearly impossible to write good policy when it's essentially pre-determined that you will have to change at least parts of said policy to get it to pass simply for political reasons.  You could write the best law in the history of the world and the opposing party would find fault with it every time.  This is the current state of our contentious political discourse.

Case in point, there's a current bill to help human trafficking victims that should be a slam dunk, but the Republicans are worried that some underaged sex slaves may end up with abortions so they added language to stop that from happening and now the Democrats are threatening to block it.  When we can't even get a goddamn bill on slavery passed because of some ideologs, it's not a stretch to realize that the current state of politics has nothing to do with studying economics.

http://www.usnews.com/news/politics/articles/2015/03/11/reid-strip-abortion-from-trafficking-bill-or-it-fails

[okonumiyaki]

I do not understand.
The government paying for some people's premium is not lowering costs.
It is only moving the costs from some % of the people to everyone's tax dollars.

If anything needs to be done it is attempts to fix the actual costs. 
   Just to make up ideas that is probably bad;
   -  Ensure that all health care costs (estimates) are provided to customers by providers up front. 
   -  Enforce non-monopoly rules upon emergency services like ambulances and hospitals. 

Point is, this is about making tax payers paying for other people's bills.  It has nothing to do with lowering the actual costs of the health care.

That's why it is called insurance.  Making everyone pay home insurance is also moving costs from some % of people to everyone, and doesn't reduce the cost of having your house burn down.

[brooklynguy]

Point is, this is about making tax payers paying for other people's bills.  It has nothing to do with lowering the actual costs of the health care.

The ACA did implement measures designed to reduce the cost of health care in the US, completely separate from the redistributive tax credit system that makes the insurance coverage more affordable for people receiving the tax credits.  It implemented a series of structural changes intended to cut costs and reduce waste in the health care system--for example, it instituted penalties for hospital readmissions to remove one of the existing financial incentives for performing unnecessary medical procedures.  Economists are debating the extent of the impact these measures have had on reduction of healthcare costs, but there is general consensus that they have had some impact.  Here's one example of an article discussing this effect:

http://www.bloomberg.com/news/articles/2014-09-05/obamacare-effect-linked-to-lower-medical-cost-estimates

When we can't even get a goddamn bill on slavery passed because of some ideologs, it's not a stretch to realize that the current state of politics has nothing to do with studying economics.

Indeed.  It's one thing to disagree with the ACA on the merits, but it is ludicrous to believe that the enormously complex, 900+ page law completing overhauling the United States health care system is simply the product of a bunch of uninformed liberal arts majors dabbling in an area beyond their understanding.

[brooklynguy]

The Supreme Court case imperils the continued viability of the ACA for all Americans, as discussed in this thread (which has become the central clearing house for discussion on this topic in the forum and, through a rare moderator misstep, has been buried in the Off Topic subforum).

Hear Hear!

Ok, mods, now that the entire forum seems to be under renovation and we have at least one person seconding my motion to reinstate the referenced thread back where it belongs, how about moving it back to a more appropriate home than "Off Topic" in light of this topic's extreme importance to many early retirees and aspiring early retirees?

[waltworks]

Just do one of the following:
-Repeal EMTALA and make all medical care completely private. You pay for your services, no subsidies, no nothing.
-Medicare for all/universal healthcare.

I personally think a super rich society should just guarantee health care for everyone, pay up, and reap the benefits of people going and starting cool new businesses and creating awesome stuff because they don't have to worry about their kid getting sick and bankrupting them. But I can see the argument for making everything private and letting market pressures drive down prices.

Problem is, we've got neither of those things. We've got a system where really life threatening emergencies and serious problems are treated for free, but the preventative/basic/ongoing care that might prevent them are not. That's maybe the dumbest way to run things I can imagine and it creates a ton of misery and throws otherwise useful members of society into poverty essentially for being unlucky.

-W

[sol]

We've got a system where really life threatening emergencies and serious problems are treated for free, but the preventative/basic/ongoing care that might prevent them are not. That's maybe the dumbest way to run things I can imagine and it creates a ton of misery and throws otherwise useful members of society into poverty essentially for being unlucky.

It's not dumb at all, when viewed from the perspective of the for-profit healthcare industry.  Capitalism demands profit margins, and wealthy industries lobby to protect their markets.  In America, medical care is literally a profit-driven business with a powerful lobby, which has effectively asked for and been granted the system you describe above, which helps ensure their future profitability.

It's no different for any other major sector of the economy.  America is a business more than it is a philosophy.  Politicians come and go, but our plutocracy reigns supreme.

[RootofGood]

Just do one of the following:
-Repeal EMTALA and make all medical care completely private. You pay for your services, no subsidies, no nothing.
-Medicare for all/universal healthcare.

I'm with you there. 

We need to put on our philosophical big boy pants and say we're comfortable letting people die a screaming, writhing death on the hospital doorsteps if they can't provide proof of ability to pay (insurance, adequate assets, cosigner, underwriter, surety, etc).  Or accept that these costs will be born by society and figure out a way to pay for it (and prevent it to the extent possible). 

I'll take your first bullet point a step farther and suggest repealing the megabillion dollar tax break on employer provided health insurance and get rid of government employer provided health insurance.  Get government out of the health insurance biz.  All the way.

Or, come up with some workable healthcare for all. 

[planner10]

I do not understand.
The government paying for some people's premium is not lowering costs.
It is only moving the costs from some % of the people to everyone's tax dollars.

If anything needs to be done it is attempts to fix the actual costs. 
   Just to make up ideas that is probably bad;
   -  Ensure that all health care costs (estimates) are provided to customers by providers up front. 
   -  Enforce non-monopoly rules upon emergency services like ambulances and hospitals. 

Point is, this is about making tax payers paying for other people's bills.  It has nothing to do with lowering the actual costs of the health care.

That's why it is called insurance.  Making everyone pay home insurance is also moving costs from some % of people to everyone, and doesn't reduce the cost of having your house burn down.

Yes but home insurance is not paid by the government with your taxes. 
Home insurance is voluntary (if you own your home), and required by banks who put up a large stake of money against your home as an asset. 
If the ACA was not bank rolled by people's taxes then we wouldn't be having this argument.

Having something run or funded by the government is the least efficient and least effective way of solving a problem.

[sol]

Having something run or funded by the government is the least efficient and least effective way of solving a problem.

That must be why we entrust our national defense to private militias?

[waltworks]

Don't forget the interstate tollway system. Or the Angie's List food safety experts. Or all those ham radio kids who do air traffic control in exchange for tips!

-W

Having something run or funded by the government is the least efficient and least effective way of solving a problem.

That must be why we entrust our national defense to private militias?

[Exflyboy]

Actually I believe the most cost effective way we buy medical care in this country is the Medicare program.. Government run.

Just about every other HC system in the modern World costs costs close to half what the USA pays (on a GDP basis).. Most of those are Government run, and very high quality care despite what the scare mongering press will tell you.

I agree the ACA is not so much about lowering the total cost of care (although the data seems to imply that it is beginning to work in this regard).. Its about insuring the 50M uninsured in the US.

So if this basically come down to "we can't trust the Government".. What is wrong with our government compared to Governments overseas?

I would suggest our Government is in the pockets of the corporations who have no interest in seeing costs come down.

Apart from that, which is really somewhat off topic.. the question is will the ACA be there as a tool that enables us to retire early, whether you agree with it or not.

[DavidAnnArbor]

The ACA provides funding to research whether medical procedures are effective and safe. The ACA is comparing different regions of the country to determine why some hospitals charge five times more for the same procedures than hospitals in other regions. Government plays a vital role in the health and well-being of our society. Social security, Medicare, Medicaid are lifelines to many people, and the government provides these programs extremely efficiently. Compared to the overhead that health insurance companies incur to provide health insurance (after all the CEO of United Health Care needs four Mercedes, not just three) I'd say government is a great bargain.

[sol]

Social security, Medicare, Medicaid are lifelines to many people, and the government provides these programs extremely efficiently.

Nonsense!  Healthcare is obviously best when it is 100% privately run. 

Unless you're a veteran.  Or senior citizen.  Or disabled.  Or a child, or poor.  In those cases socialized healthcare is fine.

But between the ages of 18 and 62 for healthy people outside of the military, socialized healthcare is clearly the devil's work.

[Exflyboy]

Social security, Medicare, Medicaid are lifelines to many people, and the government provides these programs extremely efficiently.

Nonsense!  Healthcare is obviously best when it is 100% privately run. 

Unless you're a veteran.  Or senior citizen.  Or disabled.  Or a child, or poor.  In those cases socialized healthcare is fine.

But between the ages of 18 and 62 for healthy people outside of the military, socialized healthcare is clearly the devil's work.

Of course.. the UK, Sweden, Germany,Japan, Taiwan and several others provide HC for its citizens at half the cost using Government run systems.. According to Newt Gingrich (so it MUST be true) "they have death panels over there!"... Pure concentrated evil!

Gee, Newt, considering I doubt you know where the UK is, let alone ever lived there, your word must be gospel.. I called up my Dad who is still back in the UK and told him to emigrate immediately.. he sees a cardiologist every month for free.. Surely his "Death panel" appointment must be coming up soon!

Wit a minute.. Not American = the Devil's work.. wow, glad I have been enlightened.

[brooklynguy]

Wit a minute.. Not American = the Devil's work.. wow, glad I have been enlightened.

Exflyboy, either you or I (or both of us) must have a broken sarcasm detector.

Mine is working well enough to tell me that you and sol are in agreement that the government indeed possesses the ability to efficiently run healthcare programs, but not well enough to tell me whether or not you recognize that you are in agreement.

[Blonde Lawyer]

Two thoughts:

1.) For those that oppose the ACA, do you oppose the mandate that health insurers insure people with pre-existing conditions?  For me personally, that was the biggest win of the law. I have Crohn's disease so my only options are (a) work for large employer that has group health care and pray I don't get sick enough to lose my job or (b) marry someone that works for a large employer that has group health care and pray I don't get divorced.  I chose B during law school, A for awhile post law school and now I'm back to B. 

I just think it is absurd that we had a system where you could get sick, then lose your insurance, then get sicker, and not be able to get back to work.  There are many people with medical conditions through no fault of their own.  It isn't all alcoholics with liver disease and diabetics that "eat too much junk" (lines I frequently hear.)  I also understand that insurance companies will lose a ton of money if they are forced to insure those with chronic conditions.  What's the solution then?  Someone actually once told me - Darwinism, let them die off.

2.) EMTALA.  Emtala has a lot of problems.  It is certainly abused.  However, we absolutely need some kind of law in place that you can get emergency medical care without proving your ability to pay.  How many of you run and bike with your insurance card in your pocket? You get hit by a car and show up at the ER in a coma.  They don't know if you are insured or if you have assets? Do you want them to treat you?

Those that want EMTALA repealed just want people to stop using the ER for primary care.  The law is already written in that way.  The ER's are just afraid of being sued though and will very rarely turn someone away.  If you show up at an ER with something that is not actually defined as an emergency, they don't have to treat you.  The solution would be for ER's to do a better job of screening out what is and isn't an EMTALA emergency.

The non-EMTALA cases should be referred to FQHC community health centers.  These centers receive a higher medicaid reimbursement to help compensate for the number of uninsureds they see.  Where other facilities lose money on medicaid patients, FQHC's are sustainable treating medicaid patients.  Almost every community has one.

[Exflyboy]

Haha.. Well I'm English and the HC system "Over there" is very well run indeed. Is it perfect? of course not! Do Brits complain about it?.. yes they do, buts its very easy to complain about something when you have never had to pay for it out of pocket.

So either the UK Government (along with dozens of other governments) has super powers far in excess of the USA's or.. the Tea Party view of government is more about proselytising a belief system based on fear mongering and complete nonsense.

I.e big government = socialism= evil=Dad is about to be knocked off at any minute!

Bottom line yes I am in full agreement that the Government should run the healthcare system in the USA.. In fact it is such a vast market the discounts the Government could negotiate would in theory be very impressive.

[brooklynguy]

Yep, I got that message from your original post.  My only point was that sol's post about socialized healthcare equaling the devil's work to which you were responding was itself sarcastic (meaning that your sarcastic response was in agreement with sol), and I wasn't sure whether or not you were aware of that (and I'm still not sure...)

Damn this medium of communication and its inability to properly transmit sarcasm!

[FIPurpose]

There are several problems that the US faces that European countries just don't consider.

The UK may have a well run system for healthcare, but the UK is also roughly 1/5 the population of the US, and the UK has 10x the population density. There are several problems that would have to be addressed concerning how to scale similar operations in Europe, and at the same time deal with a sparse population much like Canada.

If states decided healthcare for themselves, it would be much easier to implement. At a federal level, the simple fact of the matter is that it hasn't been done before at this size to an American quality of life.

[Exflyboy]

There are several problems that the US faces that European countries just don't consider.

The UK may have a well run system for healthcare, but the UK is also roughly 1/5 the population of the US, and the UK has 10x the population density. There are several problems that would have to be addressed concerning how to scale similar operations in Europe, and at the same time deal with a sparse population much like Canada.

If states decided healthcare for themselves, it would be much easier to implement. At a federal level, the simple fact of the matter is that it hasn't been done before at this size to an American quality of life.

Great! this is exactly the kind of dialogue we should be having IMHO. I.e what are the differences and what would and would not work here?

The problem I think is we have a whole bunch of yelling and wilingness to look at options. The fact of the matter is that HC costs should not be double most other industrialised nations.. so what can we do to reduce?

Rather than.. We'll all go to Hell if we have socialised medicine! I find it very sad that a large part of the population take this as gospel even though there is not a shred of evidence to support it.

[Exflyboy]

Yep, I got that message from your original post.  My only point was that sol's post about socialized healthcare equaling the devil's work to which you were responding was itself sarcastic (meaning that your sarcastic response was in agreement with sol), and I wasn't sure whether or not you were aware of that (and I'm still not sure...)

Damn this medium of communication and its inability to properly transmit sarcasm!

I'm not sarcastic!...;)

[Abe]

The UK also has strict controls on admission to intensive care (and thus have much fewer ICU beds per capita). They also strictly control use of expensive medications, especially chemotherapy or antibodies treatments with costs that run into the tens of hundreds of thousands. Those are the two most expensive parts of medical care in the US, and also the least cost effective. In fact, all other developed countries with modern healthcare systems have costs controls of some type in these two aspects.