What comes after the ACA?

[chasesfish]

So, where does it go from here?  I'm a soon to be early retiree

I'm disappointed again that both sides can't work together, this thing is a long way from finished.

Is the ACA currently good for early retirees?  Heck yes. 
Is it sustainable?  Questionable.

I don't see how this works without requiring everyone to pay into the system.   You either need a two tiered system with baseline care provided by the government, or an enforced requirement for everyone to buy health insurance.   Withhold tax refunds until they have it and don't process all the refundable tax credits for the really poor.

We also still need to require medical providers to have one service, one price.  Period.   Uninsured, insured, Medicare, its all one price.

 Hell, the deficit run in 2016 would have required each man/woman/child to pay roughly $1500 more in federal taxes.  The solution of "make someone else pay for it" via tax this person, this company, isn't sustainable either.

Reality sucks

.

[EscapeVelocity2020]

At this point, now that I'm back in the US and things didn't get as bad as I ranted about, I'm actually very happy.  In a way, it's a little sad that I was braced for the worst (given the rapid descent of Airline USA) and now I'm happy the best airline in the world didn't crash although the pilot is balls.  I'm still wondering if I want to be a passenger on this 4-year flight, but at least I'm flying the best airline money can buy (for the time being).

[DavidAnnArbor]

What are some of the ways they might do that [i.e., sabotage the ACA] without Democratic support?

Today's NY Times outlines some of the available options on the menu:  "Trump's Choice on Obamacare: Sabotage or Co-opt?"

Scary

[EscapeVelocity2020]

What are some of the ways they might do that [i.e., sabotage the ACA] without Democratic support?

Today's NY Times outlines some of the available options on the menu:  "Trump's Choice on Obamacare: Sabotage or Co-opt?"

Scary

It is quite troublesome that, instead of this administration learning anything from this episode, things will only get more polarized (within the fractious GOP especially).  This is, as Trump naively conceded, a complex issue, but it's something that you delve in to, then use some of your powers as President to determine a preferable path forward and bring Congress on board. 

I fear that nothing was learned and the GOP is becoming more desperate to show influence.

[jim555]

I was wondering about the enforcement of the Individual Mandate and the penalty tax.  The law is still on the books so I don't see how they can simply not enforce the law.  I read that a tax return that leaves blank the section on health insurance will not be rejected now.  But I don't see how that absolves the tax liability.  I think it is a Trump trap and people will find out later they are still on the hook for the penalty.

[Gin1984]

So, where does it go from here?  I'm a soon to be early retiree

I'm disappointed again that both sides can't work together, this thing is a long way from finished.

Is the ACA currently good for early retirees?  Heck yes. 
Is it sustainable?  Questionable.

I don't see how this works without requiring everyone to pay into the system.   You either need a two tiered system with baseline care provided by the government, or an enforced requirement for everyone to buy health insurance.   Withhold tax refunds until they have it and don't process all the refundable tax credits for the really poor.

We also still need to require medical providers to have one service, one price.  Period.   Uninsured, insured, Medicare, its all one price.

 Hell, the deficit run in 2016 would have required each man/woman/child to pay roughly $1500 more in federal taxes.  The solution of "make someone else pay for it" via tax this person, this company, isn't sustainable either.

Reality sucks

.

If one group wants to destroy something that is good for your constituents with no solution except harming them, how exactly are you suppose to compromise?  This is a serious question.

[chasesfish]

I thought there was some good and some bad in the new plan, just like there is with the ACA.  Tying the penalty to continuous coverage and having it go into the insurance pool for example was a positive. 

I think the ACA is doomed as soon as states loose all of the big 4 carriers.  Maybe that happens in 2018, maybe its 2019, but its coming.   Not enough payers, too many takers.

I stand by my prediction of one of two outcomes:

Switzerland style mandatory insurance OR Costa Rica style two tiered medicine with public providers and private providers.  Its the only two politically obtainable options.  I'm indifferent on which route we end up with.

[DavidAnnArbor]

I think the ACA is doomed as soon as states loose all of the big 4 carriers.  Maybe that happens in 2018, maybe its 2019, but its coming.   Not enough payers, too many takers.

There are many states where the ACA individual marketplace is doing well, like California, and states with larger population. Where I am in Michigan there are lots of health insurance companies participating in the exchange.

The problem with losing carriers is generally in rural counties with few participants and not many hospitals.

[protostache]

I was wondering about the enforcement of the Individual Mandate and the penalty tax.  The law is still on the books so I don't see how they can simply not enforce the law.  I read that a tax return that leaves blank the section on health insurance will not be rejected now.  But I don't see how that absolves the tax liability.  I think it is a Trump trap and people will find out later they are still on the hook for the penalty.

The only thing Trump's executive order changed was the IRS' timeline for automatically rejecting returns without a box checked, just as they've done since TY2014.

Filers who don't check a box and don't carry qualified coverage are absolutely still on the hook for the penalty. The IRS will generate a notice for every single one of them that demands they produce a 1095 or cold hard cash.

[teen persuasion]

I think the ACA is doomed as soon as states loose all of the big 4 carriers.  Maybe that happens in 2018, maybe its 2019, but its coming.   Not enough payers, too many takers.

Health insurance is regional.  Who are the big 4 carriers?  In my area it is Independent Health, Univera, and BCBS.  Other parts of the state have different players.  I see insurance companies mentioned by posters from other parts of the country that seem to be big players, but don't exist in my state at all, and my market is said to be healthy.

[Tyson]

I think the ACA is doomed as soon as states loose all of the big 4 carriers.  Maybe that happens in 2018, maybe its 2019, but its coming.   Not enough payers, too many takers.

There are many states where the ACA individual marketplace is doing well, like California, and states with larger population. Where I am in Michigan there are lots of health insurance companies participating in the exchange.

The problem with losing carriers is generally in rural counties with few participants and not many hospitals.

Between farm subsidies, sucking up all those Federal benefits dollars, and not even being able to carry their own weight on health insurance, the rural parts of this country sure are a bunch of takers.

[sol]

Between farm subsidies, sucking up all those Federal benefits dollars, and not even being able to carry their own weight on health insurance, the rural parts of this country sure are a bunch of takers.

Wait, you mean it's NOT unwed teenage mothers who are destroying America?

[Tyson]

Between farm subsidies, sucking up all those Federal benefits dollars, and not even being able to carry their own weight on health insurance, the rural parts of this country sure are a bunch of takers.

Wait, you mean it's NOT unwed teenage mothers who are destroying America?

Nope.  Here's the map, you can see for yourself - the red states get more federal $$ than they contribute and the blue states take less federal $$ than they contribute.  Purple states are about net zero.  You might see a pattern here...

[stoaX]

Between farm subsidies, sucking up all those Federal benefits dollars, and not even being able to carry their own weight on health insurance, the rural parts of this country sure are a bunch of takers.

Wait, you mean it's NOT unwed teenage mothers who are destroying America?

Nope.  Here's the map, you can see for yourself - the red states get more federal $$ than they contribute and the blue states take less federal $$ than they contribute.  Purple states are about net zero.  You might see a pattern here...

Cool map - am I right that it is from 2005, like it says in the bottom right hand corner?  I wonder how things have changed now that we are more than a decade later.

[Tyson]

Cool map - am I right that it is from 2005, like it says in the bottom right hand corner?  I wonder how things have changed now that we are more than a decade later.

2014 Data:

[PathtoFIRE]

That's not exactly the same info as the 2005 graphic

[DavidAnnArbor]

That's not exactly the same info as the 2005 graphic

That's true but the two graphs taken together illustrate a trend.

[stoaX]

That's not exactly the same info as the 2005 graphic

and it only gets us up to 2012.   Things have changed since then such as the money moving around between the feds and the states for ACA / Medicaid expansion. 

[MrGreen]

One of the things I'm concerned about is the potential for the Congress to cease funding for cost sharing in the ACA. The big 4 insurers have said if that goes away then they will no longer participate. We're in the verge of making some decisions about work that affect health insurance and I'm nervous about the prospect of giving up employer-based insurance right before a pregnancy and child birth, to potentially find ourselves in a situation where we now have to try and find jobs just for health insurance because it's other wise unaffordable or we're some how denied coverage.

[DavidAnnArbor]

One of the things I'm concerned about is the potential for the Congress to cease funding for cost sharing in the ACA. The big 4 insurers have said if that goes away then they will no longer participate. We're in the verge of making some decisions about work that affect health insurance and I'm nervous about the prospect of giving up employer-based insurance right before a pregnancy and child birth, to potentially find ourselves in a situation where we now have to try and find jobs just for health insurance because it's other wise unaffordable or we're some how denied coverage.

I agree and sympathize. It's so chaotic, wish we had two parties that actually wanted to fix the ACA and improve on it.

[Tyson]

That's not exactly the same info as the 2005 graphic

and it only gets us up to 2012.   Things have changed since then such as the money moving around between the feds and the states for ACA / Medicaid expansion.

Here's more recent data:  https://wallethub.com/edu/states-most-least-dependent-on-the-federal-government/2700/

The point is this - we could fix the deficit if the red states just stopped taking the money.  People talk about "welfare queens", but the true welfare queens seem to be farmers, small towns and rural America. 

[sol]

People talk about "welfare queens", but the true welfare queens seem to be farmers, small towns and rural America.

We've discussed this disparity before.  "Welfare queens" are a tiny tiny fraction of the free handouts that the US government gives out.  Most of those handouts go to rich people, not poor people.  Most of that tiny fraction that goes to poor people goes to rural white communities.

[Tyson]

People talk about "welfare queens", but the true welfare queens seem to be farmers, small towns and rural America.

We've discussed this disparity before.  "Welfare queens" are a tiny tiny fraction of the free handouts that the US government gives out.  Most of those handouts go to rich people, not poor people.  Most of that tiny fraction that goes to poor people goes to rural white communities.

Interesting.  Thanks sol.

[DavidAnnArbor]

"Wyoming’s cowboy mythology has helped its residents ignore the dynamic of federal reliance."

http://www.gillettenewsrecord.com/news/article_e9b925fc-8518-5326-a4db-bf5c01d67933.html

[Paul der Krake]

The press is now reporting that there is another version of the replacement bill in the works.

https://www.nytimes.com/2017/03/28/us/politics/health-care-obamacare-freedom-caucus.html

This is going to be fun.

[Bateaux]

Woo hoo!  Louisiana here at number 2 and we love us some Trump no doubt.

[scantee]

The press is now reporting that there is another version of the replacement bill in the works.

https://www.nytimes.com/2017/03/28/us/politics/health-care-obamacare-freedom-caucus.html

This is going to be fun.

Not going to happen. McConnell has already said, definitively, that the Senate will not be considering health care reform bills. These calls for new bills from House members are pure ass covering since they spent the last seven years crowing about repealing ACA only to give up the effort after a mere few weeks.

[gerardc]

We've discussed this disparity before.  "Welfare queens" are a tiny tiny fraction of the free handouts that the US government gives out.  Most of those handouts go to rich people, not poor people.  Most of that tiny fraction that goes to poor people goes to rural white communities.

That's not really fair accounting. So you take $100k from rich people then cut them some slack for $4k back; and you tax poor people $5k then give them back $1k in food stamps. You're still taxing the rich 96k and the poor 4k for the same societal benefits, yet you claim that the rich got more in return! That's just laughable.

[accolay]

That's not really fair accounting. So you take $100k from rich people then cut them some slack for $4k back; and you tax poor people $5k then give them back $1k in food stamps. You're still taxing the rich 96k and the poor 4k for the same societal benefits, yet you claim that the rich got more in return! That's just laughable.

That's pretty disingenuous. The reason the poor don't get taxed that much is because, well, they're poor. You need to be making quite a bit more than 100k if you're in that tax bracket. Not that I have anything against the very rich, but pardon me if I don't feel anything for someone who has that much money. 1000 in food stamps doesn't go very far.

Your example doesn't even compare apples to oranges though. More like apples to, I dunno, fucking space meatballs or something.

Edited for clarity.

[radram]

1000k in food stamps doesn't go very far.

I am quite sure I could make 1 million dollars in food stamps go pretty far :)

Now THAT would be a welfare queen.

/sarcasm

[DavidAnnArbor]

We've discussed this disparity before.  "Welfare queens" are a tiny tiny fraction of the free handouts that the US government gives out.  Most of those handouts go to rich people, not poor people.  Most of that tiny fraction that goes to poor people goes to rural white communities.

That's not really fair accounting. So you take $100k from rich people then cut them some slack for $4k back; and you tax poor people $5k then give them back $1k in food stamps. You're still taxing the rich 96k and the poor 4k for the same societal benefits, yet you claim that the rich got more in return! That's just laughable.

We should be more like Guatemala or Kazakhstan where income taxes are low.

[infogoon]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

[gerardc]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

You guys are missing the point as usual. The point is not that taxation is theft. Taxation need not be linear, it can be anything from constant to sub-linear, linear, and supra-linear in progressive taxation systems. Let's assume that an optimal tax rate (however you define optimality) ends up between 5% and 75%. We don't really know what that number is. So when we give a tax break to set one's rate from 35% back to 33%, and another one from 15% to 14%, we can't really look at the correction (the delta) and whine about it. We need to look at the big picture. We might actually get closer to the optimum. The point is nobody knows, and unless we have specific data about optimal taxation, we're just speculating / whining / wasting our time.

[Scortius]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

You guys are missing the point as usual. The point is not that taxation is theft. Taxation need not be linear, it can be anything from constant to sub-linear, linear, and supra-linear in progressive taxation systems. Let's assume that an optimal tax rate (however you define optimality) ends up between 5% and 75%. We don't really know what that number is. So when we give a tax break to set one's rate from 35% back to 33%, and another one from 15% to 14%, we can't really look at the correction (the delta) and whine about it. We need to look at the big picture. We might actually get closer to the optimum. The point is nobody knows, and unless we have specific data about optimal taxation, we're just speculating / whining / wasting our time.

If you're talking about the Laffer Curve, I believe there is a wide body of evidence demonstrating that we are left of the optimum.

[DavidAnnArbor]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

You guys are missing the point as usual. The point is not that taxation is theft. Taxation need not be linear, it can be anything from constant to sub-linear, linear, and supra-linear in progressive taxation systems. Let's assume that an optimal tax rate (however you define optimality) ends up between 5% and 75%. We don't really know what that number is. So when we give a tax break to set one's rate from 35% back to 33%, and another one from 15% to 14%, we can't really look at the correction (the delta) and whine about it. We need to look at the big picture. We might actually get closer to the optimum. The point is nobody knows, and unless we have specific data about optimal taxation, we're just speculating / whining / wasting our time.

If you're talking about the Laffer Curve, I believe there is a wide body of evidence demonstrating that we are left of the optimum.

This thought experiment by Paul Krugman illustrates that the optimum tax rate has a lot to do with the effects of rising wages, leisure, and one's earnings status.

https://krugman.blogs.nytimes.com/2010/08/10/the-laffer-test-somewhat-wonkish/

[Mr Mark]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

What about a country where tax rates are the same but the public services are way better, like in terms of healthcare,  public education,  care of the old and indigent,  lower insurance,  and almost no capital gains tax at all?

It amazes me how much of the "debate" is about who pays what, rather than how much y'all pay and what you get for it.

[marty998]

We should be more like Guatemala or Kazakhstan where income taxes are low.

It's really strange how the "taxation is theft!" crowd never wants to move to a country with little or no taxation.

What about a country where tax rates are the same but the public services are way better, like in terms of healthcare,  public education,  care of the old and indigent,  lower insurance,  and almost no capital gains tax at all?

It amazes me how much of the "debate" is about who pays what, rather than how much y'all pay and what you get for it.

Sounds like New Zealand.

Our old friend Gooki must out enjoying life. Haven't seen her around in a while...

[Mr Mark]

^ well spotted!

[jim555]

Nice article on the lawsuit to stop CSRs:

The bizarre lawsuit that could still blow up the ACA insurance markets
http://www.vox.com/the-big-idea/2017/3/29/15107836/lawsuit-aca-payments-reimbursement-unconstitutional

[DavidAnnArbor]

The overall costs for Medicare as well as for Medicaid/CHIP/individual insurance marketplace subsidies have come in lower than expected thanks to the reforms of Obamacare/ACA. The Republicans would have risked these cost savings by repealing ACA just so that they can get a tax cut to the top 1% earners using "Reconciliation" to pass budget legislation.

https://www.americanprogress.org/issues/economy/news/2017/03/30/429602/new-data-deliver-good-news-health-care-bad-news-speaker-ryans-tax-reform-plan/

[infogoon]

It amazes me how much of the "debate" is about who pays what, rather than how much y'all pay and what you get for it.

As someone posted earlier in this thread, watching Americans argue about risk pools and selling insurance policies across state lines while the rest of the world has long settled these problems is like watching us argue over whether a '74 Dart _really_ needs a catalytic converter while everyone in Europe drives electric cars.

[Glenstache]

It amazes me how much of the "debate" is about who pays what, rather than how much y'all pay and what you get for it.

As someone posted earlier in this thread, watching Americans argue about risk pools and selling insurance policies across state lines while the rest of the world has long settled these problems is like watching us argue over whether a '74 Dart _really_ needs a catalytic converter while everyone in Europe drives electric cars.

I feel like this thread peaked with this post. Pithy and pretty much sums it up.

[MrMoneySaver]

"Here’s a big roadblock for your dreams of early retirement"
http://www.marketwatch.com/story/how-washington-just-upended-your-dreams-of-early-retirement-2017-03-29

[Bateaux]

That's the delima I'm currently facing.   Want to FIRE but can't trust our health care system.

[DavidAnnArbor]

"Here’s a big roadblock for your dreams of early retirement"
http://www.marketwatch.com/story/how-washington-just-upended-your-dreams-of-early-retirement-2017-03-29

The article even cites MrMoneyMustache ideas of early retirement

[EnjoyIt]

It amazes me how much of the "debate" is about who pays what, rather than how much y'all pay and what you get for it.

You are so point on.  The healthcare industry would rather us fight over who pays as opposed to having real transparency, and decreasing the cost of medical care.  Healthcare has no ceiling in cost when it comes free once deductibles are met.  It is no different in the cost of higher education.  Since it is subsidized by unlimited loans, the cost just keeps rising.  In medicine there will always be more research, more medicine, more tech that will cost more and more and more.  Like fools we keep yelling at each other "who will pay for it all?"  We are having the wrong discussion here people. It shouldn't be who will pay, but how much we pay and what we get for it.

[Mr Mark]

I hope the collapse of the GOP's crazy tax cut health bill will enable a more considered law that is underpinned by some kind of public option, based on medicaid I guess. But I presume the industry  - insurance, hospitals, doctors - will squeal like crazy at that.

[Monkey Uncle]

I hope the collapse of the GOP's crazy tax cut health bill will enable a more considered law that is underpinned by some kind of public option, based on medicaid I guess. But I presume the industry  - insurance, hospitals, doctors - will squeal like crazy at that.

Ain't gonna happen until the Democrats control the presidency, House, and at least 60 votes in the Senate.  To do that, they'll have to take back all the state legislatures and governorships they've lost so they can undo all the gerrymandering that the republicans did when the 2010 census coincided with the Tea Party wave.  Next opportunity for major re-districting is 2021.  So they need to win a lot of state races in 2018 and 2020, fix the gerrymandering in 2021, then they might be able to take Congress during the 2022 mid-terms.  If they happen to also win the presidency in 2020, then we might be looking at real health care reform in 2023.  Sigh.

[EnjoyIt]

I hope the collapse of the GOP's crazy tax cut health bill will enable a more considered law that is underpinned by some kind of public option, based on medicaid I guess. But I presume the industry  - insurance, hospitals, doctors - will squeal like crazy at that.

Ain't gonna happen until the Democrats control the presidency, House, and at least 60 votes in the Senate.  To do that, they'll have to take back all the state legislatures and governorships they've lost so they can undo all the gerrymandering that the republicans did when the 2010 census coincided with the Tea Party wave.  Next opportunity for major re-districting is 2021.  So they need to win a lot of state races in 2018 and 2020, fix the gerrymandering in 2021, then they might be able to take Congress during the 2022 mid-terms.  If they happen to also win the presidency in 2020, then we might be looking at real health care reform in 2023.  Sigh.

Don't you get it, there is no healthcare reform from democrats or republicans.  Its a bunch of bullshit.  Real reform will happen only when the prices are so outlandish that no one can afford it.  Until then it will be the same old same old.  Let the people argue about who will pay for it in the meantime.  It really makes no difference if it is a republican or democrat.  If the Rich pay more or the old pay more or the middle class pay more, someone has to pay while the price keeps going up.  And it will continue to rise until we stop this stupid battle about who will pay and switch to real transparency in cost cutting measures.

As I see it, the only cost cutting measures I see create more hoops to jump though in the medical industry which actually increases cost to the hospitals and physicians with the threat of decreasing reimbursement.  But the cost just keeps rising in the meantime.

You can keep increasing premiums for some group of people, the rich for example, but it will not contain the actual price, prices will go up until premiums need to go up again and again and again.  Our hunger for the latest and greatest medicine, technology, research, etc is never ending and therefor price has only one way to go especially when so many get it for "free," or "free" after deductible.

[DavidAnnArbor]

I hope the collapse of the GOP's crazy tax cut health bill will enable a more considered law that is underpinned by some kind of public option, based on medicaid I guess. But I presume the industry  - insurance, hospitals, doctors - will squeal like crazy at that.

Ain't gonna happen until the Democrats control the presidency, House, and at least 60 votes in the Senate.  To do that, they'll have to take back all the state legislatures and governorships they've lost so they can undo all the gerrymandering that the republicans did when the 2010 census coincided with the Tea Party wave.  Next opportunity for major re-districting is 2021.  So they need to win a lot of state races in 2018 and 2020, fix the gerrymandering in 2021, then they might be able to take Congress during the 2022 mid-terms.  If they happen to also win the presidency in 2020, then we might be looking at real health care reform in 2023.  Sigh.

Don't you get it, there is no healthcare reform from democrats or republicans.  Its a bunch of bullshit.  Real reform will happen only when the prices are so outlandish that no one can afford it.  Until then it will be the same old same old.  Let the people argue about who will pay for it in the meantime.  It really makes no difference if it is a republican or democrat.  If the Rich pay more or the old pay more or the middle class pay more, someone has to pay while the price keeps going up.  And it will continue to rise until we stop this stupid battle about who will pay and switch to real transparency in cost cutting measures.

As I see it, the only cost cutting measures I see create more hoops to jump though in the medical industry which actually increases cost to the hospitals and physicians with the threat of decreasing reimbursement.  But the cost just keeps rising in the meantime.

You can keep increasing premiums for some group of people, the rich for example, but it will not contain the actual price, prices will go up until premiums need to go up again and again and again.  Our hunger for the latest and greatest medicine, technology, research, etc is never ending and therefor price has only one way to go especially when so many get it for "free," or "free" after deductible.

The public option if it were allowed to happen in the ACA is real reform that the Democrats tried to create and it was almost accomplished save 1 or 2 Senate votes. So let's try to get that through.

I do agree that the costs need to stabilize, and it will have to come down to rationing of health care - using health care technology in a more smart, sensible, and useful way.
And the ACA included significant reforms to slow the growth of Medicare spending.
ACA reform is trying to change the model of reimbursement based on outcomes rather than the number of medical procedures performed.

https://www.americanprogress.org/issues/economy/news/2017/03/30/429602/new-data-deliver-good-news-health-care-bad-news-speaker-ryans-tax-reform-plan/