What comes after the ACA?

[brooklynguy]

It's DOA anyway, everyone on all sides basically hates it. IMO, no point in discussing it.

It's nevertheless the new baseline.  Moreover, in my view, the equal hostility it faces from contingents on opposite ends of the political spectrum actually bodes well for its chances of more or less resembling what will ultimately be adopted (on the theory that a good compromise is one that leaves both sides dissatisfied).

[waltworks]

It's DOA anyway, everyone on all sides basically hates it. IMO, no point in discussing it.

So you think we're keeping Obamacare?

No, I think we're just going to get a series of random proposals like this one that get immediately shot down by various groups within the GOP. When you simultaneously have Lisa Murkowski and Rand Paul opposing something, but for wildly different reasons, you have no chance of passing that thing. Ever.

I don't know what the endgame is. Anything that will get any democratic votes will have to be, at the very most, a few minor rule tweaks. I have no idea what on earth could get 80%+ of the GOP behind it, let alone unanimity, let alone any democrats... so that means probably nothing will happen.

I've been wrong before, but I'd be shocked if we see any healthcare legislation passed at all in the next couple of years.

-W

[jim555]

Other thoughts...

The new continuous coverage provision penalizes people who go more than two months without coverage.  Any bets on how many people will buy health insurance for one month out of every three?

I'm also not sure if the new bill contains the home equity exclusion rule, which would allow states to deny expanded Medicaid to folks with too much home equity, even if their income is low enough.  That could really hurt a lot of folks here.  That would be a good reason to take out a new mortgage.

I am puzzled by that since resources are not considered for MAGI Medicaid.  Maybe this applies to traditional Medicaid?

[jim555]

Other thoughts...

The new continuous coverage provision penalizes people who go more than two months without coverage.  Any bets on how many people will buy health insurance for one month out of every three?

I'm also not sure if the new bill contains the home equity exclusion rule, which would allow states to deny expanded Medicaid to folks with too much home equity, even if their income is low enough.  That could really hurt a lot of folks here.  That would be a good reason to take out a new mortgage.

I am puzzled by that since resources are not considered for MAGI Medicaid.  Maybe this applies to traditional Medicaid?

That may be if they revert to means testing for medicaid but I don't think they ever counted your primary residence's equity before. Could be something new (and scary) for the future. Even if a low income person could get a loan (I know I couldn't even with an expensive paid off house) then they'd have to sell the place and woyld have too many cash assets to qualify for medicaid anyways. Guess that's a way to keep them off medicaid and use their home to pay for medical insurance to supplement then income pushing them further into poverty.

This has to be for traditional Medicaid.
"Require states to limit home equity to federal minimum (removes the option to expand the limit from $500,000 to $750,000 (adjusted for CPI), effective six months after the bill is enacted or longer if states must pass legislation to change. "
http://kff.org/interactive/proposals-to-replace-the-affordable-care-act/

[Metric Mouse]

Other thoughts...

The new continuous coverage provision penalizes people who go more than two months without coverage.  Any bets on how many people will buy health insurance for one month out of every three?

I'm also not sure if the new bill contains the home equity exclusion rule, which would allow states to deny expanded Medicaid to folks with too much home equity, even if their income is low enough.  That could really hurt a lot of folks here.  That would be a good reason to take out a new mortgage.

Wouldn't they be hampered by open enrollment timelines?

[SwordGuy]

What comes after the ACA?

[EnjoyIt]

I always love this statement. An oldie, but a goodie. The Government. Who do you think votes for that Government? And then they complain that it's awful...wash and repeat.

Yep, it's like the "Government" is some sort of weird mysterious body of people that sprung out of the ground instead of, you know, consisting of people that were voted for and the people they hired.   Also, most people know government employees who aren't evil people and who go to work everyday and do their jobs.  My dad was one of those people. 

So far the roll out of this bill is going over like a lead balloon.

Fine, let me rephrase it.  The crony capitalism, the corruption and special interests have been screwing the middle class for too long. And us idiots vote for democrats and republicans.  There is very little difference between the two.  Both sides are exactly the same, they just have different cronies puling their strings.  No health care plan will survive until we begin talking about cost.  Instead we just keep arguing about who will pay for it. 

[Exflyboy]

What comes after the ACA?

Yup.. Or the ER's flooded with uninsured people. Which will them pay for with increased rates.

[Radagast]

From that perspective, the whole "repeal and replace" plan is basically just tax cuts for the rich, slashing welfare, and banning abortion.  There is nothing new under the sun, this is the same old GOP platform they've been pushing since the 80s.

Did you expect something different? Honestly it was exactly how I imagined it.

Fine, let me rephrase it.  The crony capitalism, the corruption and special interests have been screwing the middle class for too long. And us idiots vote for democrats and republicans.  There is very little difference between the two.  Both sides are exactly the same, they just have different cronies puling their strings.  No health care plan will survive until we begin talking about cost.  Instead we just keep arguing about who will pay for it. 

I agree. The problem isn't that the rich pay more or the poor pay more, or the young versus the old, though that is a perfectly fine discussion to have. The problem is that the entire system sucks. In fact I'd say that right now the "insurance" part is the shitty part. Any law that continues to require insurance will guarantee the system continues to suck. The opaque behind the scenes interactions, massive paperwork, and indeterminate prices result in the perfect combination of low efficiency, high cost, and general confusion. Some posters have spoken about insurance as if it was somehow the desirable part, but no, "insurance" is the part that is making it suck most. It impedes the debate. The goal is not insurance, the goal is efficient, quality health care.

My schtick is that we need to combine government subsidies with direct price and quality competition among healthcare providers. Everybody should have to pay at least some percentage for all of their own medical care, with government subsidies for the remaining amount based on means, from government pays 99% to government pays 0%. Prices made clear in advance. Choose whatever doctor, practice, or center you think is best. For any medical want or need, if you pony up your percentage the government will pay the rest, no questions. That way there will be incentive to keep things fast, inexpensive, and high quality. People won't go see the doctor unnecessarily no matter their income, because it will cost them at least some amount of money every time so there will not be unnecessary freeloading. Providers will need to act smart because every single patient can choose to go elsewhere for any reason. It will still leave room for charities at the bottom and insurance at the middle-top.

[protostache]

Y'know, there's another way the system could work without insurance companies while providing quality care to everyone.

We could just expand Medicare to cover everyone. I would gladly pay higher taxes if I didn't have to pay an insurance company and medical providers a combined $21,000 per year.

[BeanCounter]

Y'know, there's another way the system could work without insurance companies while providing quality care to everyone.

We could just expand Medicare to cover everyone. I would gladly pay higher taxes if I didn't have to pay an insurance company and medical providers a combined $21,000 per year.

This is exactly what I've been saying for years. If we expanded Medicare to let everyone buy in if they want to (at appropriate pricing for premiums), but allow people to also buy private insurance if they choose. I believe it would help. The Medicare pricing is already in place. Care providers know how to operate under that system (and yes still make money). And the insurance companies would be forced to build private products that are BETTER than Medicare so there would be actual competition.

[BeanCounter]

From that perspective, the whole "repeal and replace" plan is basically just tax cuts for the rich, slashing welfare, and banning abortion.  There is nothing new under the sun, this is the same old GOP platform they've been pushing since the 80s.

Did you expect something different? Honestly it was exactly how I imagined it.

Fine, let me rephrase it.  The crony capitalism, the corruption and special interests have been screwing the middle class for too long. And us idiots vote for democrats and republicans.  There is very little difference between the two.  Both sides are exactly the same, they just have different cronies puling their strings.  No health care plan will survive until we begin talking about cost.  Instead we just keep arguing about who will pay for it. 

I agree. The problem isn't that the rich pay more or the poor pay more, or the young versus the old, though that is a perfectly fine discussion to have. The problem is that the entire system sucks. In fact I'd say that right now the "insurance" part is the shitty part. Any law that continues to require insurance will guarantee the system continues to suck. The opaque behind the scenes interactions, massive paperwork, and indeterminate prices result in the perfect combination of low efficiency, high cost, and general confusion. Some posters have spoken about insurance as if it was somehow the desirable part, but no, "insurance" is the part that is making it suck most. It impedes the debate. The goal is not insurance, the goal is efficient, quality health care.

My schtick is that we need to combine government subsidies with direct price and quality competition among healthcare providers. Everybody should have to pay at least some percentage for all of their own medical care, with government subsidies for the remaining amount based on means, from government pays 99% to government pays 0%. Prices made clear in advance. Choose whatever doctor, practice, or center you think is best. For any medical want or need, if you pony up your percentage the government will pay the rest, no questions. That way there will be incentive to keep things fast, inexpensive, and high quality. People won't go see the doctor unnecessarily no matter their income, because it will cost them at least some amount of money every time so there will not be unnecessary freeloading. Providers will need to act smart because every single patient can choose to go elsewhere for any reason. It will still leave room for charities at the bottom and insurance at the middle-top.

I agree with your overall statement regarding transparency in pricing inhibiting a true free market economy with providers. I don't agree with the bolded statement. Insurance, whether it's private or Medicare/Medicaid relies on a risk pool to be successful. If healthy people don't buy in, then there isn't enough money to cover the sick. Even if the pricing for care got better this would be an issue. We saw this in the ACA. Most of the people that came on were sick, and hadn't had medical care in years. The insurance company can't survive if members who have only paid $1k or so in premiums then go and get $50k in care and there aren't enough healthy people paying premiums to cover the difference. It's just basic math.

[AdrianC]

But I still disagree with your assessment that the ACA was failing.  Republicans have been repeating this line on television often, as their justification for needing to change the law, but it doesn't hold up under scrutiny.  The ACA has been seeing record sign ups, and lots of insurance companies have had to refund money to ratepayers because they exceeded the ACA profit caps.  Millions more people have insurance, the industry is profitable, and cost controls are working (slower than most of us would like, but still working).  Where is the evidence of failure?

Well, insurance companies have been pulling out. There were many areas where only one company participated on the exchange for 2017.

So you think that insurance companies pulling out of the ACA when they are getting $8,000 to $10,000 in subsidies from a poor family and somehow they are going to agree to stay in this new plan when they are only going to get $5,000 from the poor family?

Several insurance companies have pulled out, yes? Do we agree on that fact?

http://www.npr.org/sections/health-shots/2017/03/08/519059382/republicans-health-plan-may-not-fix-the-problems-they-want-to-fix?utm_medium=RSS&utm_campaign=news

The Affordable Care Act's markets have been struggling, no doubt. Several insurance companies have dropped out, leaving some states and counties with only one company offering plans. At the same time, premiums have risen in many markets. Last year, premiums rose an average 22 percent — though individual cost increases varied because federal subsidies for many people rose in tandem with premiums.

I make no claims that this new plan will be any better, overall.

It looks like it will be somewhat better for my family, probably better for most early-retire types. It's a work in progress, though.

[Well Respected Man]

From that perspective, the whole "repeal and replace" plan is basically just tax cuts for the rich, slashing welfare, and banning abortion.  There is nothing new under the sun, this is the same old GOP platform they've been pushing since the 80s.

Did you expect something different? Honestly it was exactly how I imagined it.

Fine, let me rephrase it.  The crony capitalism, the corruption and special interests have been screwing the middle class for too long. And us idiots vote for democrats and republicans.  There is very little difference between the two.  Both sides are exactly the same, they just have different cronies puling their strings.  No health care plan will survive until we begin talking about cost.  Instead we just keep arguing about who will pay for it. 

I agree. The problem isn't that the rich pay more or the poor pay more, or the young versus the old, though that is a perfectly fine discussion to have. The problem is that the entire system sucks. In fact I'd say that right now the "insurance" part is the shitty part. Any law that continues to require insurance will guarantee the system continues to suck. The opaque behind the scenes interactions, massive paperwork, and indeterminate prices result in the perfect combination of low efficiency, high cost, and general confusion. Some posters have spoken about insurance as if it was somehow the desirable part, but no, "insurance" is the part that is making it suck most. It impedes the debate. The goal is not insurance, the goal is efficient, quality health care.

My schtick is that we need to combine government subsidies with direct price and quality competition among healthcare providers. Everybody should have to pay at least some percentage for all of their own medical care, with government subsidies for the remaining amount based on means, from government pays 99% to government pays 0%. Prices made clear in advance. Choose whatever doctor, practice, or center you think is best. For any medical want or need, if you pony up your percentage the government will pay the rest, no questions. That way there will be incentive to keep things fast, inexpensive, and high quality. People won't go see the doctor unnecessarily no matter their income, because it will cost them at least some amount of money every time so there will not be unnecessary freeloading. Providers will need to act smart because every single patient can choose to go elsewhere for any reason. It will still leave room for charities at the bottom and insurance at the middle-top.

I agree with your overall statement regarding transparency in pricing inhibiting a true free market economy with providers. I don't agree with the bolded statement. Insurance, whether it's private or Medicare/Medicaid relies on a risk pool to be successful. If healthy people don't buy in, then there isn't enough money to cover the sick. Even if the pricing for care got better this would be an issue. We saw this in the ACA. Most of the people that came on were sick, and hadn't had medical care in years. The insurance company can't survive if members who have only paid $1k or so in premiums then go and get $50k in care and there aren't enough healthy people paying premiums to cover the difference. It's just basic math.

It is basic math: the profits of insurance companies are a drain on the overall system. Medicare for all with the addition of negotiated prices removes that drain. With Medicare, there is no person who goes without health care for decades. There is no buying in; if you are unlucky to be an outlier cost-wise, your care is paid for by everyone's taxes (plus a percentage from your pocket based on means, according to Radagast's proposal). If you are at the mean, cost-wise, you probably grumble that it costs too much to get health care, but the mean is lower without the siphon of the insurance companies.

[pbkmaine]

A friend in health care consulting sent me this:

http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/

[brooklynguy]

It looks like it will be somewhat better for my family, probably better for most early-retire types.

Putting aside any policy flaws with the proposed law that would have adverse effects on the entire individual health insurance market (and make things worse for early retirees along with everybody else), the proposed law would, as noted several times above, be significantly worse for most early retirees cut from the mustachian cloth (i.e., having low incomes to accompany low expenses).

[jim555]

It looks like it will be somewhat better for my family, probably better for most early-retire types.

Putting aside any policy flaws with the proposed law that would have adverse effects on the entire individual health insurance market (and make things worse for early retirees along with everybody else), the proposed law would, as noted several times above, be significantly worse for most early retirees cut from the mustachian cloth (i.e., having low incomes to accompany low expenses).

Bogelheads will like it and those with a 3 million stasche everyone else, not so much.

[AdrianC]

It looks like it will be somewhat better for my family, probably better for most early-retire types.

Putting aside any policy flaws with the proposed law that would have adverse effects on the entire individual health insurance market (and make things worse for early retirees along with everybody else), the proposed law would, as noted several times above, be significantly worse for most early retirees cut from the mustachian cloth (i.e., having low incomes to accompany low expenses).

Bogelheads will like it and those with a 3 million stasche everyone else, not so much.

I guess I'm more of a Boglehead than I am a mustachian :-)

I like that I will be able to buy a catastrophic plan (not allowed currently). I will get significant tax credits to help buy it (get none right now). I will be able to stash much more money into an HSA. These are all positives, and I'm an optimistic guy.

But don't get me wrong, I think this is tinkering around the edges of a terribly flawed system. Single payer is the right way to go.

[MMMarbleheader]

Ironically it seems like this plan will help people in wealthy blue states on the coasts and hurt those in the poor red states.

[MrGreen]

From a USA Today article:

"GOP bill: Repeals the penalties. Would keep people from jumping into the market only when they need care by allowing insurers to charge them 30% higher premiums for a year."

http://www.usatoday.com/story/news/politics/2017/03/07/4-key-ways-house-republicans-health-care-bill-changes-obamacare/98851094/

That's somewhat of a catastrophic insurance plan without having to buy one. It doesn't help in a true emergency where care is required immediately but if one simply had a day it seems like you could cover major issues by just paying more for the first year. I suppose the actual bill could have an elimination period in it but that seems kinda generous to me.

[infogoon]

Ironically it seems like this plan will help people in wealthy blue states on the coasts and hurt those in the poor red states.

I've been saying since the election that the Trump supporters in the south and midwest are going to be the ones who find themselves tied to the tracks once the Paul Ryan Express really gets up to speed.

[ZiziPB]

I like that I will be able to buy a catastrophic plan (not allowed currently). I will get significant tax credits to help buy it (get none right now). I will be able to stash much more money into an HSA. These are all positives, and I'm an optimistic guy.

Where are you seeing this?  According to the summaries I read, insurance companies are still required to offer the same preventative services and maternity care as under the ACA.  There has been no change to that. 

As far as I understand it, the new bill is designed to work under the budget reconciliation procedures (allowing it to pass with a simple majority in the Senate), so it can only change the ACA's financial aspects (subsidies, taxes, etc.) but cannot affect the substantive provisions of the ACA relating to health services, contents of the policy, etc.

[Metric Mouse]

But I still disagree with your assessment that the ACA was failing.  Republicans have been repeating this line on television often, as their justification for needing to change the law, but it doesn't hold up under scrutiny.  The ACA has been seeing record sign ups, and lots of insurance companies have had to refund money to ratepayers because they exceeded the ACA profit caps.  Millions more people have insurance, the industry is profitable, and cost controls are working (slower than most of us would like, but still working).  Where is the evidence of failure?

Well, insurance companies have been pulling out. There were many areas where only one company participated on the exchange for 2017.

So you think that insurance companies pulling out of the ACA when they are getting $8,000 to $10,000 in subsidies from a poor family and somehow they are going to agree to stay in this new plan when they are only going to get $5,000 from the poor family?

Several insurance companies have pulled out, yes? Do we agree on that fact?

http://www.npr.org/sections/health-shots/2017/03/08/519059382/republicans-health-plan-may-not-fix-the-problems-they-want-to-fix?utm_medium=RSS&utm_campaign=news

The Affordable Care Act's markets have been struggling, no doubt. Several insurance companies have dropped out, leaving some states and counties with only one company offering plans. At the same time, premiums have risen in many markets. Last year, premiums rose an average 22 percent — though individual cost increases varied because federal subsidies for many people rose in tandem with premiums.

I make no claims that this new plan will be any better, overall.

It looks like it will be somewhat better for my family, probably better for most early-retire types. It's a work in progress, though.

I love how some people continue to claim that the current system is working, despite all evidence to the contrary.

[Metric Mouse]

Ironically it seems like this plan will help people in wealthy blue states on the coasts and hurt those in the poor red states.

I've been saying since the election that the Trump supporters in the south and midwest are going to be the ones who find themselves tied to the tracks once the Paul Ryan Express really gets up to speed.

Maybe this would motivate more people to think positively about a more comprehensive system like single payer?

[Paul der Krake]

Ironically it seems like this plan will help people in wealthy blue states on the coasts and hurt those in the poor red states.

I've been saying since the election that the Trump supporters in the south and midwest are going to be the ones who find themselves tied to the tracks once the Paul Ryan Express really gets up to speed.

Ironically it seems like this plan will help people in wealthy blue states on the coasts and hurt those in the poor red states.

I've been saying since the election that the Trump supporters in the south and midwest are going to be the ones who find themselves tied to the tracks once the Paul Ryan Express really gets up to speed.

Maybe this would motivate more people to think positively about a more comprehensive system like single payer?

Doubtful. Red states have been voting against their own interests for a very long time. If I were starting a cult, I'd study the crap out of the conservative playbook.

[sol]

I love how some people continue to claim that the current system is working, despite all evidence to the contrary.

I'm one of those people!  The ACA is working!

Yes, some insurers have pulled out of some markets, but that has always happened and can't be blamed on the ACA.  If anything, the ACA slows down this process by expanding the customer pool in rural areas, incentivizing insurers to offer coverage in sparsely populated counties that otherwise would have only one outrageous plan.

Under the ACA, tens of millions of new people have affordable healthcare.  This is a good thing.  In some markets, insurers have had to literally refund money for being too profitable.  Costs of care have come down by moving more people into Medicaid's pay structure.  And all of it done without increasing the deficit, 100% paid for with new taxes and reductions in fraud and waste.

Even republicans like most of what the ACA does, though they don't admit it.  Their plan keeps most of the ACA intact (pre-existing conditions, lifetime caps, age 26, insurance subsidies, penalties for not buying insurance, basic plan minimum requirements, etc.)

So yes, I will continue to say the ACA is working.  It could certainly be improved, but it is a far cry from failing.

[ZiziPB]

Even republicans like most of what the ACA does, though they don't admit it.  Their plan keeps most of the ACA intact (pre-existing conditions, lifetime caps, age 26, insurance subsidies, penalties for not buying insurance, basic plan minimum requirements, etc.)

They don't, it's just because of a procedural issue that this stuff stays in for now.  A lot of people, apparently including senators and representatives, do not seem to realize that the Republican bill is the budget reconciliation bill which is filibuster proof in the senate. It cannot include things like the repeal of the "mandates and basic benefits" only repeal of taxes and expenditures.

A bill to repeal the entire ACA would have to get 60 votes in the senate to be passed and it is very doubtful there are eight Senate Democrats and independents who would support an outright repeal.

[protostache]

I love how some people continue to claim that the current system is working, despite all evidence to the contrary.

I'm one of those people!  The ACA is working!

Yes, some insurers have pulled out of some markets, but that has always happened and can't be blamed on the ACA.  If anything, the ACA slows down this process by expanding the customer pool in rural areas, incentivizing insurers to offer coverage in sparsely populated counties that otherwise would have only one outrageous plan.

Under the ACA, tens of millions of new people have affordable healthcare.  This is a good thing.  In some markets, insurers have had to literally refund money for being too profitable.  Costs of care have come down by moving more people into Medicaid's pay structure.  And all of it done without increasing the deficit, 100% paid for with new taxes and reductions in fraud and waste.

Even republicans like most of what the ACA does, though they don't admit it.  Their plan keeps most of the ACA intact (pre-existing conditions, lifetime caps, age 26, insurance subsidies, penalties for not buying insurance, basic plan minimum requirements, etc.)

So yes, I will continue to say the ACA is working.  It could certainly be improved, but it is a far cry from failing.

Never forget that companies have pulled out and co-ops have failed because the GOP refused to appropriate the funds that were promised to them as part of the risk corridor program. If those appropriations had been statutory instead of discretionary the system as a whole would be far better off today. This was, of course, intentional.

[Exflyboy]

The ACA is working somewhat but its a far cry form an effective solution. The Trump plan looks to be worse but will cost the tax payer less.

To me this looks like "round 2" of trying to fix a fundamentally flawed system.. Re-arranging the deck chairs on the Titanic if you will.

In my Native UK the total cost of HC is a little over one third of what the US spends. Most European countries are in the one third to one half price range.

Unless we can get away from this "everything is a business" mentality then HC costs will remain barely affordable.. or worse no matter what system we have in place.

[sol]

They don't, it's just because of a procedural issue that this stuff stays in for now.  A lot of people, apparently including senators and representatives, do not seem to realize that the Republican bill is the budget reconciliation bill which is filibuster proof in the senate. It cannot include things like the repeal of the "mandates and basic benefits" only repeal of taxes and expenditures.

This is a smokescreen and I think you know it.  They could absolutely repeal the whole thing by budget reconciliation, by just removing the penalties for not complying with provisions they don't like.  If they wanted a return of lifetime caps, for example, they could just repel the penalties on insurers for having lifetime caps.  They did it for the mandates, and they could do it for anything else they wanted to get rid of.  The purse controls all.

But republicans admit that these provisions of the ACA are popular, so they want to keep them.  For some reason, they don't admit that the individual mandate is also popular (50% in favor, 48% opposed) with the American people, or that expanded Medicaid is both popular and an effective cost control measure, because they hate entitlement programs on principle.

[thenextguy]

The Trump plan looks to be worse but will cost the tax payer less.

Well sure, because more people will forego insurance because they can't afford it.

[thenextguy]

I love how some people continue to claim that the current system is working, despite all evidence to the contrary.

I'm one of those people!  The ACA is working!

Yes, some insurers have pulled out of some markets, but that has always happened and can't be blamed on the ACA.  If anything, the ACA slows down this process by expanding the customer pool in rural areas, incentivizing insurers to offer coverage in sparsely populated counties that otherwise would have only one outrageous plan.

Under the ACA, tens of millions of new people have affordable healthcare.  This is a good thing.  In some markets, insurers have had to literally refund money for being too profitable.  Costs of care have come down by moving more people into Medicaid's pay structure.  And all of it done without increasing the deficit, 100% paid for with new taxes and reductions in fraud and waste.

Even republicans like most of what the ACA does, though they don't admit it.  Their plan keeps most of the ACA intact (pre-existing conditions, lifetime caps, age 26, insurance subsidies, penalties for not buying insurance, basic plan minimum requirements, etc.)

So yes, I will continue to say the ACA is working.  It could certainly be improved, but it is a far cry from failing.

Never forget that companies have pulled out and co-ops have failed because the GOP refused to appropriate the funds that were promised to them as part of the risk corridor program. If those appropriations had been statutory instead of discretionary the system as a whole would be far better off today. This was, of course, intentional.

Honestly, the whole risk corridor issue was overblown. Yes, it allowed Marco Rubio to claim a "victory" in harming the ACA, but the risk corridors were always temporary anyway. It wouldn't make sense for insurers to pull out because of that when they were never going to be ongoing anyway. By pulling the risk corridors, they caused insurers to suffer one-time losses.

[Schaefer Light]

Unless I'm missing something, I don't see anything in this bill that makes health care any more affordable.  So what's the point in passing it?

[BeanCounter]

I love how some people continue to claim that the current system is working, despite all evidence to the contrary.

I'm one of those people!  The ACA is working!

Yes, some insurers have pulled out of some markets, but that has always happened and can't be blamed on the ACA.  If anything, the ACA slows down this process by expanding the customer pool in rural areas, incentivizing insurers to offer coverage in sparsely populated counties that otherwise would have only one outrageous plan.

Under the ACA, tens of millions of new people have affordable healthcare.  This is a good thing.  In some markets, insurers have had to literally refund money for being too profitable.  Costs of care have come down by moving more people into Medicaid's pay structure.  And all of it done without increasing the deficit, 100% paid for with new taxes and reductions in fraud and waste.

Even republicans like most of what the ACA does, though they don't admit it.  Their plan keeps most of the ACA intact (pre-existing conditions, lifetime caps, age 26, insurance subsidies, penalties for not buying insurance, basic plan minimum requirements, etc.)

So yes, I will continue to say the ACA is working.  It could certainly be improved, but it is a far cry from failing.

Never forget that companies have pulled out and co-ops have failed because the GOP refused to appropriate the funds that were promised to them as part of the risk corridor program. If those appropriations had been statutory instead of discretionary the system as a whole would be far better off today. This was, of course, intentional.

Honestly, the whole risk corridor issue was overblown. Yes, it allowed Marco Rubio to claim a "victory" in harming the ACA, but the risk corridors were always temporary anyway. It wouldn't make sense for insurers to pull out because of that when they were never going to be ongoing anyway. By pulling the risk corridors, they caused insurers to suffer one-time losses.

I disagree. The risk corridors were needed because of the unhealthy members that hadn't been insured and came on to the plans with major health problems, needing expensive care. Some plans in some regions were hit harder than others. The idea was that RC would help fund those losses temporarily while the insurer could build up their risk pools (from healthy member's premiums) and get the sick members back to being healthy (or at least manage their care).

[BeanCounter]

From that perspective, the whole "repeal and replace" plan is basically just tax cuts for the rich, slashing welfare, and banning abortion.  There is nothing new under the sun, this is the same old GOP platform they've been pushing since the 80s.

Did you expect something different? Honestly it was exactly how I imagined it.

Fine, let me rephrase it.  The crony capitalism, the corruption and special interests have been screwing the middle class for too long. And us idiots vote for democrats and republicans.  There is very little difference between the two.  Both sides are exactly the same, they just have different cronies puling their strings.  No health care plan will survive until we begin talking about cost.  Instead we just keep arguing about who will pay for it. 

I agree. The problem isn't that the rich pay more or the poor pay more, or the young versus the old, though that is a perfectly fine discussion to have. The problem is that the entire system sucks. In fact I'd say that right now the "insurance" part is the shitty part. Any law that continues to require insurance will guarantee the system continues to suck. The opaque behind the scenes interactions, massive paperwork, and indeterminate prices result in the perfect combination of low efficiency, high cost, and general confusion. Some posters have spoken about insurance as if it was somehow the desirable part, but no, "insurance" is the part that is making it suck most. It impedes the debate. The goal is not insurance, the goal is efficient, quality health care.

My schtick is that we need to combine government subsidies with direct price and quality competition among healthcare providers. Everybody should have to pay at least some percentage for all of their own medical care, with government subsidies for the remaining amount based on means, from government pays 99% to government pays 0%. Prices made clear in advance. Choose whatever doctor, practice, or center you think is best. For any medical want or need, if you pony up your percentage the government will pay the rest, no questions. That way there will be incentive to keep things fast, inexpensive, and high quality. People won't go see the doctor unnecessarily no matter their income, because it will cost them at least some amount of money every time so there will not be unnecessary freeloading. Providers will need to act smart because every single patient can choose to go elsewhere for any reason. It will still leave room for charities at the bottom and insurance at the middle-top.

I agree with your overall statement regarding transparency in pricing inhibiting a true free market economy with providers. I don't agree with the bolded statement. Insurance, whether it's private or Medicare/Medicaid relies on a risk pool to be successful. If healthy people don't buy in, then there isn't enough money to cover the sick. Even if the pricing for care got better this would be an issue. We saw this in the ACA. Most of the people that came on were sick, and hadn't had medical care in years. The insurance company can't survive if members who have only paid $1k or so in premiums then go and get $50k in care and there aren't enough healthy people paying premiums to cover the difference. It's just basic math.

It is basic math: the profits of insurance companies are a drain on the overall system. Medicare for all with the addition of negotiated prices removes that drain. With Medicare, there is no person who goes without health care for decades. There is no buying in; if you are unlucky to be an outlier cost-wise, your care is paid for by everyone's taxes (plus a percentage from your pocket based on means, according to Radagast's proposal). If you are at the mean, cost-wise, you probably grumble that it costs too much to get health care, but the mean is lower without the siphon of the insurance companies.

I totally agree. I just think that most Americans will always want some sort of private option or maybe even just a private "buy up" plan.

[jim555]

The big change no one is talking about is the block granting of Medicaid.  That is for the whole program, not just the expansion.  Medicaid is a HUGE part of any state's budget and shifting costs back to states means less care and more taxes at the state level.  Repubs like block grants so they can take the money and use it for purposes not related to medicine.  Hospitals should, and are, fighting against this bill.

[sol]

I just think that most Americans will always want some sort of private option or maybe even just a private "buy up" plan.

Private insurance will always be available, even if we someday get single payer universal healthcare.  These things are not mutually exclusive. 

Single payer covers some basic services, but not others (like plastic surgery or laser eyes) so I think there will always be a market for people who want additional coverage.  Maybe you'll want to pay for faster service, or experimental drugs/procedures, or a private doctor who operates outside the single payer system.  Private insurance isn't going away, but it could be made secondary to universal basic coverage for all citizens.

And honestly, it's likely that the only way we'll ever get "universal healthcare" is if the universal coverage is pretty stingy.  Like one physical per year that comes with free advice to quit smoking, ER services, a limited set of prescription services that covers common ailments like diabetes with hefty copays, and then rationed care for catastrophic events.  It would be insufficient by itself for most people, but would still save thousands of lives per year. And it would b cheap to provide and administer.

[BeanCounter]

I just think that most Americans will always want some sort of private option or maybe even just a private "buy up" plan.

Private insurance will always be available, even if we someday get single payer universal healthcare.  These things are not mutually exclusive. 

Single payer covers some basic services, but not others (like plastic surgery or laser eyes) so I think there will always be a market for people who want additional coverage.  Maybe you'll want to pay for faster service, or experimental drugs/procedures, or a private doctor who operates outside the single payer system.  Private insurance isn't going away, but it could be made secondary to universal basic coverage for all citizens.

And honestly, it's likely that the only way we'll ever get "universal healthcare" is if the universal coverage is pretty stingy.  Like one physical per year that comes with free advice to quit smoking, ER services, a limited set of prescription services that covers common ailments like diabetes with hefty copays, and then rationed care for catastrophic events.  It would be insufficient by itself for most people, but would still save thousands of lives per year. And it would b cheap to provide and administer.

Yes. Totally agree and I would be very happy with this solution. Basically single payer/universal for Medicare part A, B and D and private for part f (gap insurance).

[Classical_Liberal]

I just think that most Americans will always want some sort of private option or maybe even just a private "buy up" plan.

Private insurance will always be available, even if we someday get single payer universal healthcare.  These things are not mutually exclusive. 

Single payer covers some basic services, but not others (like plastic surgery or laser eyes) so I think there will always be a market for people who want additional coverage.  Maybe you'll want to pay for faster service, or experimental drugs/procedures, or a private doctor who operates outside the single payer system.  Private insurance isn't going away, but it could be made secondary to universal basic coverage for all citizens.

And honestly, it's likely that the only way we'll ever get "universal healthcare" is if the universal coverage is pretty stingy.  Like one physical per year that comes with free advice to quit smoking, ER services, a limited set of prescription services that covers common ailments like diabetes with hefty copays, and then rationed care for catastrophic events.  It would be insufficient by itself for most people, but would still save thousands of lives per year. And it would b cheap to provide and administer.

This is the true solution and what most of the world operates under.  Part of the problem with healthcare today is that everyone expects a "Cadillac", but only wants to pay for a "Hyundai".  I put myself on the far right of fiscal conservatism.  I would complexly get behind a progressive, but separate (ie Medicare/SSDI) tax to provide a clearly defined "Hyundai" coverage for all.  No more unless you want to pay for it privately. I really don't see any other way to make healthcare work.

[AdrianC]

I like that I will be able to buy a catastrophic plan (not allowed currently). I will get significant tax credits to help buy it (get none right now). I will be able to stash much more money into an HSA. These are all positives, and I'm an optimistic guy.

Where are you seeing this?  According to the summaries I read, insurance companies are still required to offer the same preventative services and maternity care as under the ACA.  There has been no change to that. 

As far as I understand it, the new bill is designed to work under the budget reconciliation procedures (allowing it to pass with a simple majority in the Senate), so it can only change the ACA's financial aspects (subsidies, taxes, etc.) but cannot affect the substantive provisions of the ACA relating to health services, contents of the policy, etc.

http://healthaffairs.org/blog/2017/03/07/examining-the-house-republican-aca-repeal-and-replace-legislation/

The repeal of the AV levels would allow plans to be sold with AVs of less than 60 percent, although the maximum out-of-pocket limit in the ACA is retained so insurers would not be able to sell plans less generous than the current catastrophic plans.

Catastrophic plans are available currently, but only for young people.

https://www.healthcare.gov/choose-a-plan/plans-categories/

From what various Republicans have said - that we should be able to buy a catastrophic plan and fund the rest of our care via an HSA - I expect that catastrophic plans will be available for older people and will qualify for tax credits (they don't right now).

I could have it wrong...in which case my family loses due to the change in age ratios, but wins due to the tax credit of $12k and higher HSA limits. Probably still a little better off. And no more Obamacare taxes.

Bear in mind that even if it passes it is temporary. They'll keep on tinkering with it for years.

[EnjoyIt]

Under the ACA, tens of millions of new people have affordable healthcare.  This is a good thing.  In some markets, insurers have had to literally refund money for being too profitable.  Costs of care have come down by moving more people into Medicaid's pay structure.  And all of it done without increasing the deficit, 100% paid for with new taxes and reductions in fraud and waste.

The healthcare is not affordable.  Although they get subsidies their deductible is $6000 and then they cover 20%  There is nothing affordable about that.  It is not a good thing.

[fasteddie911]

With everyone mentioning universal healthcare, the question is whether providers would be onboard.  If nothing else were to change, and everyone went on medicare, I doubt they would.  Doctors are already stingy with how many medicare/medicaid patients they take, the amount of resources these patients can use exceeds the financial gain.  Government and insurance involvement in dictating healthcare is already too much for many providers and having more government involvement, in its current form, is not going to help.

[waltworks]

If you want to address costs, probably the fact that US doctors make a ton of money is the place to start. The AMA is not going to be happy about any sort of reform that cuts their pay, though.

-W

[Psychstache]

With everyone mentioning universal healthcare, the question is whether providers would be onboard.  If nothing else were to change, and everyone went on medicare, I doubt they would.  Doctors are already stingy with how many medicare/medicaid patients they take, the amount of resources these patients can use exceeds the financial gain.  Government and insurance involvement in dictating healthcare is already too much for many providers and having more government involvement, in its current form, is not going to help.

If 90+% of the population chooses not to buy private insurance and only uses the public option, what choice would most providers have except to play ball?

[sol]

The healthcare is not affordable.  Although they get subsidies their deductible is $6000 and then they cover 20%  There is nothing affordable about that.  It is not a good thing.

Maybe it depends on where you live?  Because around here, ACA plans for a family making the median income are about $400/mo with s $1k deductible and $2.5k OOP max, and that's with only getting $160/mo in ACA subsidy.  And if you earn less than $38k/yr you get free coverage under expanded Medicaid.  What's not affordable about free?

Maybe you meant "affordable" for people too rich for the ACA subsidies?  If your family of five makes more than $114k/year you don't currently get subsidies on the individual market, just like you didn't before the ACA was passed.  But you also make more than double the median household income, so I don't feel too bad for you.

[jodelino]

With everyone mentioning universal healthcare, the question is whether providers would be onboard.  If nothing else were to change, and everyone went on medicare, I doubt they would.  Doctors are already stingy with how many medicare/medicaid patients they take, the amount of resources these patients can use exceeds the financial gain.  Government and insurance involvement in dictating healthcare is already too much for many providers and having more government involvement, in its current form, is not going to help.

You underestimate many health care providers. Check out Physicians for a National Healthcare Program:

http://www.pnhp.org

Many, many doctors would welcome a single payer plan, for many reasons: the morality of it; the simplicity of not having to wrangle with an array of health care companies and plans; the higher quality for patients and more reliable payment for themselves (doctors I know say that Medicare is a much better and more reliable payer than most insurance companies, both to them and to the labs etc. whose services they order).

[sol]

Doctors are already stingy with how many medicare/medicaid patients they take, the amount of resources these patients can use exceeds the financial gain. 

We can make more doctors.  They are only stingy because they can be, bc private insurance is so much more profitable for them.

I agree that doctors will make less money.  This is a good thing, and is the way that other countries manage to provide healthcare so much more cost effectively than the US does.  They use a lot more nurse practitioners instead of MDs to look at runny noses and prescribe antibiotics.

Step two, then, will be to figure out how to lower the cost of training new medical staff so that doctors who only make $150k instead of $300k per year don't start out their practices with $400k of debt.

[Paul der Krake]

If you want to address costs, probably the fact that US doctors make a ton of money is the place to start. The AMA is not going to be happy about any sort of reform that cuts their pay, though.

-W

I don't give two shits what doctors think. We can import some that are just as qualified who don't have 300k in student loans and won't bitch about not having 3 vacations homes.

Same goes for the billing department of any hospital, and 90% of the medical-industrial complex. There is no reason to have thousands of administrative staff who don't provide direct medical support. This shit costs everyone thousands of dollars because every single fucking claim needs to go through a bazillion people and endless phone trees. If there's ever been a middle-man tax, this is it.

Burn this shit to the ground.

[waltworks]

Agreed, I was just pointing out that the AMA is (yet another) significant barrier to any real cost reduction efforts.

The whole concept of the doctor as the highest educated/paid professional in society is a little ridiculous IMO. 95% of stuff doctors do can be done by nurse practitioners with just a few years of school, because it's dead easy.

But everyone wants their doctor to basically have a PhD for some reason, c'est la vie.

-W

[sol]

If you want to address costs, probably the fact that US doctors make a ton of money is the place to start.

The ACA has already addressed some other potential cost saving measures.  It penalizes providers for fraudulent claims, it encourages market competition by established insurance exchanges where plans can be comparison shopped, it incentives new cost saving therapies, expanded reinsurance programs, covered free preventative care, promoted ACOs, and (this is the big one) moved more people into the Medicaid pay structure.  All of these things lower the actual cost of care.  I just wish the republicans hadn't gutted the provision to allow negotiation of drug prices.

Republicans have wisely decided to keep every one of these cost control provisions.  They didn't do anything new to make care more affordable on the provider side, but at least they didn't make it worse either.

Again, allowing drug prices to be negotiated would be a huge one, and would spread the pain from doctors to big pharma.  But republicans hate that idea, because it benefits American citizens instead of the biggest American corporations.  It's easy to see who their real constituents are.