What comes after the ACA?

[Jenny1974]

Mustachianism and early retirement aside . . . what passed the House yesterday is frightening for me on a personal level.  My 14 year old daughter has Crohn's disease.  She could end up hosed financially before her adult life even begins under a plan like this.  I was sickened by Congressman Brooks comments on CNN . . .

“My understand is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all of these costs thereby reducing the costs to those people who lead good lives. They’re healthy. They’ve done the things to keep their bodies healthy, and right now, those are the people who have done things the right way, who are seeing their costs skyrocketing.”

Ignorant people like that are making our healthcare decisions!  I suspect he might feel a little differently if it was his child facing a chronic condition they were GENETICALLY PREDISPOSED to!

[ZiziPB]

What Republicans did is beyond shameful.  And I agree with Sol that the destruction of Medicaid built into this bill is an even greater outrage than other parts of the bill.  This country is definitely moving in the wrong direction.

[FrugalToque]

You just have get it through your heads:

Poor people don't deserve health care.
Sick people don't deserve to get healed.
Children don't deserve to be fed.
It's all for the good of society.

Duh.

Toque.

[AdrianC]

Health insurance is your stash insurance. You built up that stash, but it will be for naught if you don't have health insurance.

Agreed. Going without health insurance opens you up to being ripped-off by the health care industry. You've got to have some basic coverage, if only to get the discount rate for services.

My wife was recently sick. The hospital charges of $14K were immediately cut in half by insurance discounts. We owe about $6K (deductible). Without insurance we'd be on the hook for the full amount.

[jim555]

They went after traditional Medicaid, which has nothing to do with the ACA.  They will get to wrecking Medicare, SS, and SSDI next.

[nereo]

They went after traditional Medicaid, which has nothing to do with the ACA.  They will get to wrecking Medicare, SS, and SSDI next.

I'm sorry, but no.  The lions share of the ACA was about expanding who was eligible to be on Medicaid.  The insurance marketplaces, etc. are just small subsets of the law.

[ZiziPB]

They went after traditional Medicaid, which has nothing to do with the ACA.  They will get to wrecking Medicare, SS, and SSDI next.

I'm sorry, but no.  The lions share of the ACA was about expanding who was eligible to be on Medicaid.  The insurance marketplaces, etc. are just small subsets of the law.

Right, but the Republicans not only dialed back the expansion but also gutted Medicaid as it was prior to ACA.  Nobody is focusing on that but it is there, in that shameful bill.

[nereo]

They went after traditional Medicaid, which has nothing to do with the ACA.  They will get to wrecking Medicare, SS, and SSDI next.

I'm sorry, but no.  The lions share of the ACA was about expanding who was eligible to be on Medicaid.  The insurance marketplaces, etc. are just small subsets of the law.

Right, but the Republicans not only dialed back the expansion but also gutted Medicaid as it was prior to ACA.  Nobody is focusing on that but it is there, in that shameful bill.

Fair enough, I was reading Jim's comment a bit differently. My apologies if i misinterpreted it.
It just irks me that the ACA has so many detractors who know absolutely nothing about what it actually did.  Chief among that is how most people simply do not know that the largest financial cost within the ACA was expansion of medicaid.

[dude]

Personally, I think all of this focus on removing the protections for pre-existing conditions, essential health benefits, and lifetime caps (while terrible) is basically small potatoes to what this bill really does, which is to give a huge tax break to the wealthiest Americans and pay for it by taking Medicaid away from millions of poor people.

Sure, disassembling ACA protections gets people riled up, because yes it definitely makes American healthcare worse.  But really the headlines on every major news outlet today should be REPUBLICANS VOTE TO STEAL FROM POOR PEOPLE TO PAY FOR TAX BREAK FOR THE RICH.  That's where all the real action is, that's what this bill actually does in terms of immediate dollars and cents changes.  It kicks millions of Americans off of Medicaid, and uses that money to lower taxes on people earning more than $250k/year (the capital gains and medicare surtaxes).  It's literally robbing the poor to pay the rich.

There are other problems, of course.  It looks like the current language prohibits the proposed federal tax credits from being used to buy insurance that includes any abortion-related services, which means that states like NY and CA that mandate abortion coverage in all of the insurance plans would get no federal tax credits.  Which the Republicans must just LOVE, because they love sticking it to liberals and are always trying to find laws that disproportionately hurt the blue states (see state income tax deduction on the chopping block, for example). 

Plus all the usual problems, like kicking tens of millions of people off of their current insurance instead of fulfilling the President's promise of "insurance for everybody" and the inevitable spike in premiums that will result from high risk pools being woefully underfunded instead of folded into the larger ratepayer population.  But really none of that bothers me as much as destroying Medicaid so they can give a tax break to the wealthiest households, that's just evil.

Exactly right, and let's not kid ourselves, they've got Medicare (and SS) in their crosshairs, too.  Obviously, the poor are a much easier target than the AARP crowd, but they've been pushing a private insurance voucher system to replace Medicare for a while now.  Did you see the smug bastards' faces (esp. Ryan and Pence) when they announced this shit yesterday.  Evil is right.  The depths of their greed and contempt for the poor is just astounding in its inhumanity.

[dude]

now that ACA is likely to be destroyed by the Republicans.

it  casts enormous doubt on the viability of the ACA's future, which itself will further destabilize the market and very possibly render the GOP's claims of the ACA's imminent collapse a self-fulfilling prophecy.

This has been their intent all along. They've gaslighted millions of people into believing the ACA ("OMABAcare!!!") was evil and not in their best interests, and they fucking succeeded in driving that message home to the mouthbreathers.  They have been doing the same with SS for years now, and they are succeeding there as well -- ask a millennial what they think the chances of SS being around when they retire is, and they'll tell you they don't expect it to be around.  That is completely fucked seeing as how 77% of benefits can be funded with projected receipts out to as far as the eye can see.  But the Koch Bros. are winning the propaganda war, and it's been a long time in the works (read "Dark Money" to see how they've done this). But most people are vapidly stupid and easily led astray.

[CBnCO]

Wow, one of the longest threads I've ever seen here!

I wonder why it is that most posters here take as gospel that our health must be administered by the federal government and via a massive, mandatory, and all encompassing program that combines care and charity/welfare into a single multi-thousand page piece of legislation. I know that the federal government has proven itself to be a lean, mean operating machine in respect to efficiency (ha!); but, it occurs to me that the general sentiment here on this issue is a bit anti-mustachian.

I've always view the MMM philosophy as alternative  and individual lifestyle choice that is largely counter to what the masses are doing. And, by having the insight and fortitude to swim upstream you can create a better path for yourself. With respect to health care, I try to make good choices with nutrition and exercise and it should be my decision how much or how long I work to save money to cover the what ifs.

I think the lesson in this entire debate is that no matter what mainstream political party architects such a plan they will certainly take care of themselves, their votes, and their corporate donors (Insurance companies, pharma, etc..) first. I love the direct primary care model and it's only one of the innovative possibilities that could exist if the regulators where removed from the picture.

And, as for those that can't afford to pay for needed care, including those with pre-existing conditions, its simply a question of how and how much society and each of us wants to help the poor out with getting a reasonable level of care and no different than food stamps, housing, or any other subsidy we give to the poor to help them out.

I'm sure I've disappointed many by not showing up to decry the Republicans or Democrats; but, I'm pretty certain I'd like the behemoth of government completely removed from architecting complex and politically motivated plans related to my health. Next they'll tell me I have to wear a seatbelt in the privacy of my own car, or limit the amount of soda I drink, or contribute money to fund the bombing of foreign countries...yep, a slippery slope.

[jim555]

They went after traditional Medicaid, which has nothing to do with the ACA.  They will get to wrecking Medicare, SS, and SSDI next.

I'm sorry, but no.  The lions share of the ACA was about expanding who was eligible to be on Medicaid.  The insurance marketplaces, etc. are just small subsets of the law.

Traditional Medicaid does not include the expansion and has nothing to do with the ACA.

[NESailor]

And, as for those that can't afford to pay for needed care, including those with pre-existing conditions, its simply a question of how and how much society and each of us wants to help the poor out with getting a reasonable level of care and no different than food stamps, housing, or any other subsidy we give to the poor to help them out.

I'm sure I've disappointed many by not showing up to decry the Republicans or Democrats; but, I'm pretty certain I'd like the behemoth of government completely removed from architecting complex and politically motivated plans related to my health. Next they'll tell me I have to wear a seatbelt in the privacy of my own car, or limit the amount of soda I drink, or contribute money to fund the bombing of foreign countries...yep, a slippery slope.

You're certainly more articulate than most who bash the big bad gubment's involvement in anything with the same tired arguments about inefficiency and free markets but what you're advocating is still not really a viable solution.  Why don't we have free market policing, firefighting, military, border patrol?  Certain industries just don't produce the best results when left to free and unregulated markets.

Healthcare for the poor is nothing like food stamps.  If you're ineligible for other forms of social services you simply don't get the money.  Not so with health care.  We've already decided that EVERYBODY gets care.  The conservative superhero (Reagan) himself signed that into law.  So you have no choice but to pay for that care.  And pay you do.  Everytime an uninsured defaults on a medical bill it makes all the other payers have to pitch in a little more.  So on and so forth in an accelerating spiral of increasing costs.  Any solution that results in fewer rate payers in risk pools is going to be worse for everyone.  That's where we're headed right now.

And specifically about leaving regulators out of the picture - this one also baffles me.  The government, as inefficient as it may be, is supposed to work for you.  It may fail but it still answers to you.  If you leave the administration of the system to private for profit entities, they will do everything possible to deliver a return to their shareholders - not you.  It is in the for profit business' interest to charge you as much as possible for everything.  Free market theories are based on the assumption that the participants are willing and well informed.  That's not what you've got in health care.  The elective stuff is already subject to competition but it's also not what drives up the costs.  When you're in cardiac arrest you're not going to debate the docs on which brand defibrillator to use.  In fact, you will happily pay your entire net worth and then some to use ANY one of them at that moment.  Same with insurance companies.  It is in their interest to sell you policies you will not use, and try to get out of paying if you do try to use them.  You may be well equipped to deal with that - is the average Joe?  You can still say - f*&k them, they should educate themselves.  Valid point...but you're still going to pay THEIR bill if they buy a policy that only covers care on every second Thursday of every second month and they default on care that they will get.

This isn't about eating your veggies. Chances are every one of us will have a major unanticipated health event in our lives, no matter how careful you are.  Are we going to accept risk of ruin because we can't ideologically agree on the method of payment? (since we're not debating whether we'll pay...we will). Seems ridiculous.

[PathtoFIRE]

The point is that you cannot have a truly free and independent marketplace for healthcare, we've never had such in many many decades coinciding with the advent of modern medicine, and you cannot point to one existing anywhere in the developed world. The onus is on you to prove it can be done. Until then, the rest of us will deal with the practicalities at hand, and this current bill is a giant leap backwards for the people of the USA, that is an unassailable fact.

[Glenstache]

The point is that you cannot have a truly free and independent marketplace for healthcare, we've never had such in many many decades coinciding with the advent of modern medicine, and you cannot point to one existing anywhere in the developed world. The onus is on you to prove it can be done. Until then, the rest of us will deal with the practicalities at hand, and this current bill is a giant leap backwards for the people of the USA, that is an unassailable fact.

Unless you are rich, already have a cadillac-plan, and felt like you wanted a tax cut. The rest of us can "eat cake" so to speak.

[jim555]

AHCA effects on Medicaid:

The enhanced federal match (90%) for the expansion group becomes a traditional federal (50-75%) match after 12/31/2019.

Expanded enrollees as of 12/31/2019 continue with enhanced federal match (90%) as long as they do not have a break in eligibility for more than one month.  If a break occurs the federal match gets reduced to the traditional federal (50-75%) match level.

Ends the ACA’s special hospital presumptive eligibility program, under which hospitals can temporarily enroll patients who appear to be eligible and begin to get paid for their care while their full applications are pending.

End a states option to cover expansion adults over 138% FPL.  Some states have elected this option.

Ends personal attendant services funding for children and adults with severe disabilities 1/1/2020.

Ends scheduled reductions in payments to hospitals for uncompensated care unless the state did not expand.

Makes lottery winners income be spread out over months and will make them ineligible due to a break in eligibility.

Ends retroactive eligibility.  Currently eligibility can be back dated up to three months, would change this to the month the application was made.

Ends attestation of citizenship or eligible legal immigration status and would require documentary proof of citizenship or legal status before eligibility begins.

Traditional Medicaid a state can exclude up to $750,000 of home equity, would reduce it to $500,000.

Provides a $10 billion pool ($2 billion annually) between calendar year (CY) 2018 and 2021 for allocation among states that have not expanded Medicaid for safety net funding.

Eligibility redetermination every six months verses every year.

Completely changes the way the federal match is calculated for all of Medicaid.  Instead of matching based on actual expenses it would be based on a per capita allotment.  States would have to make up the difference.  Shifts back hundreds of billions back to the states to pay.

[PathtoFIRE]

AHCA effects on Medicaid:
...
Completely changes the way the federal match is calculated for all of Medicaid.  Instead of matching based on actual expenses it would be based on a per capita allotment.  States would have to make up the difference.  Shifts back hundreds of billions back to the states to pay.

I'd put that last one first, that's the real substantial change

I think there are a number of truly principled conservative ideas for how to address healthcare, and while I don't necessarily agree with many aspects of them, I don't think you can honestly say that the AHCA has any real conservative principle except tax reduction. My family is in the young, healthy, wealthy grouping that this is supposed to support. I'm estimating my extra Medicare tax for 2017 to be above $1700. Would I pay $1700 a year in order to maintain a ban an lifetime caps, exclusion for existing conditions, and a healthcare funding safety net? Absolutely, it's not even something I need to think too hard about, I'd pay multiple of that at our income levels to keep those things around, plus all of the other features of the ACA.

[brooklynguy]

There are other problems, of course.  It looks like the current language prohibits the proposed federal tax credits from being used to buy insurance that includes any abortion-related services, which means that states like NY and CA that mandate abortion coverage in all of the insurance plans would get no federal tax credits.   

This might be the single most under-discussed aspect of the entire AHCA debacle (though, as you point out, certainly not the worst one).  As a resident of one of these states who's been following the health care legislation saga quite closely, I've seen virtually no mention in the press of the fact that the tax credits would be literally unuseable to anyone in these states (and, incredulously, that fact didn't stop every single Congressional Republican from California nor almost every one from New York from voting in favor of this bill).

[ZiziPB]

There are other problems, of course.  It looks like the current language prohibits the proposed federal tax credits from being used to buy insurance that includes any abortion-related services, which means that states like NY and CA that mandate abortion coverage in all of the insurance plans would get no federal tax credits.   

This might be the single most under-discussed aspect of the entire AHCA debacle (though, as you point out, certainly not the worst one).  As a resident of one of these states who's been following the health care legislation saga quite closely, I've seen virtually no mention in the press of the fact that the tax credits would be literally unuseable to anyone in these states (and, incredulously, that fact didn't stop every single Congressional Republican from California nor almost every one from New York from voting in favor of this bill).

I posit that the vast majority of Republicans voting on that bill yesterday have not read it.  In fact, some of them admitted as much.

[nereo]

I posit that the vast majority of Republicans voting on that bill yesterday have not read it.  In fact, some of them admitted as much.

Of that I have no doubt. The latest revision wasn't widely circulated, even among Republicans, until a week ago.  It's a thousand pages long, and written in legal-ese. It's a huge undertaking to read and understand the bill in such a short time period. Over the next several days we'll see small provisions come to the surface as people get the proper amount of time to study it.

Most legislatures don't have the time (or often even the background) to read all the legislation that comes across their desk.  They rely on staffers who rely on committee heads and lobbyists to tell them what's in a bill and whether its good or bad.

[jim555]

I posit that the vast majority of Republicans voting on that bill yesterday have not read it.  In fact, some of them admitted as much.

Of that I have no doubt. The latest revision wasn't widely circulated, even among Republicans, until a week ago.  It's a thousand pages long, and written in legal-ese. It's a huge undertaking to read and understand the bill in such a short time period. Over the next several days we'll see small provisions come to the surface as people get the proper amount of time to study it.

Most legislatures don't have the time (or often even the background) to read all the legislation that comes across their desk.  They rely on staffers who rely on committee heads and lobbyists to tell them what's in a bill and whether its good or bad.

I read the first versions of the bill and it is not thousands of pages and is readable.  The recent changes are not that long either. 

https://www.congress.gov/bill/115th-congress/house-bill/1628/text

[Bateaux]

My class of 2019 Fire plans are in jeopardy due to health-care.   Probably indefinitely now.  Could be extending to 2023 when I'd be eligible for company subsidized health care plan.

[Gin1984]

Anyone that contemplates retiring before 65 I hope you have a plan for health insurance now that ACA is likely to be destroyed by the Republicans.

At least until 2021, when Democrats will possibly be back in charge and change the system again.

The problem is, you can't switch from having health insurance to not having insurance every 4-8 years.  I too, would not retire in this system.

Thats why they make this thing called health share. 

we should build a mustachian Healthshare company with Mustachianism being our religious grounds for development and exclusion.

We dont want to play your dumb games we're going to self insure our pool of people. thru our faith in mustachianism.

Actually no, it is not why and we have already discussed why health share (which is not insurance and does not guarantee coverage even if you pay nor is it regulated) will not work for those of us with pre-existing conditions.  You can take all the risks you want, I won't.

[NESailor]

There are other problems, of course.  It looks like the current language prohibits the proposed federal tax credits from being used to buy insurance that includes any abortion-related services, which means that states like NY and CA that mandate abortion coverage in all of the insurance plans would get no federal tax credits.   

This might be the single most under-discussed aspect of the entire AHCA debacle (though, as you point out, certainly not the worst one).  As a resident of one of these states who's been following the health care legislation saga quite closely, I've seen virtually no mention in the press of the fact that the tax credits would be literally unuseable to anyone in these states (and, incredulously, that fact didn't stop every single Congressional Republican from California nor almost every one from New York from voting in favor of this bill).

I'm from Elise Stefanik's district in NY.  I have some choice words for her performance during her short tenure that aren't even appropriate on an anonymous internet forum.  Judging from the responses on her official facebook page yesterday and today - her vote did most likely NOT reflect the wishes of the majority of her district.  I hope those impassioned enough to give her a good scolding online will pull through next election.  I suspect there were dozens of Reps who voted in direct contradiction to what their district would have done in a referendum.  Why exactly is entirely beyond me. 

[dividendman]

I've looked around but can't seem to answer a question perhaps because it is too basic maybe someone here can help me:

Are the refundable tax credits the republicans are proposing for everyone or only people who buy health plans off of the individual market (i.e. don't have employer coverage)?

[jim555]

I've looked around but can't seem to answer a question perhaps because it is too basic maybe someone here can help me:

Are the refundable tax credits the republicans are proposing for everyone or only people who buy health plans off of the individual market (i.e. don't have employer coverage)?

“(f) Eligible health insurance.—For purposes of this section—

“(1) IN GENERAL.—The term ‘eligible health insurance’ means any health insurance coverage (as defined in section 9832(b)) if—

“(A) such coverage is either—

“(i) offered in the individual health insurance market within a State, or

“(ii) is unsubsidized COBRA continuation coverage,

[OurTown]

http://www.aarp.org/politics-society/advocacy/info-2017/healthcare-bill-will-increase-premiums.html?intcmp=AE-POL-ADV-EOA2

We might need an extra $200k or so just for health insurance through age 65.

[talltexan]

posting to follow

[itsallgood]

As an (former) early retiree (at age 48, not terribly early but still early) who retired with free retiree healthcare in 2001, (which is now $300 per month)...and will go on medicare this fall, I have to say that I feel sorry for early retiree wannabes.  If this Trumpcare gets passed there is no way one can retire early...especially if you still have children you are responsible for.  One serious illness or accident could wipe out all your savings.  Looking at the list of pre-existing conditions, I have to say that everyone in my family (including my grown children) have at least one of them (some are so minor).  And if you are female, that in itself is a pre-existing condition.  I could sit back and say it doesn't affect me, we are on medicare now.  But I am enraged that this is happening to our country and I don't understand why more people aren't enraged. 

Truly in 2001, we had about $1.6M in savings, with a paid off house and free medical benefits.  We would not have retired without the medical benefits.  I was 48 at the time, and thankfully have been healthy since then, but I have seen many of my age group suffer serious illnesses that would decimate anyone without good health insurance. 

Who elected these idiots that are doing this to our country?  Come on younger folks (especially women), something has to be done to stop this.

If any of you on here who think they can retire early in this environment, you need to think again.  In fact if this Trumpcare goes through, you might as well shut down this website.

[Jrr85]

http://www.aarp.org/politics-society/advocacy/info-2017/healthcare-bill-will-increase-premiums.html?intcmp=AE-POL-ADV-EOA2

We might need an extra $200k or so just for health insurance through age 65.

In fairness though, it's not that costs are really being driven up by this bill.  It's that those costs will not be pushed off to other people as much.  I really don't get how the AARP can push their position with a straight face.  I think everybody can understand wanting to subsidize insurance based on ability to pay, even if they disagree as to how much (or whether at all) to do so, everybody can at least understand the position. 

But I really don't understand why young people should be forced to subsidize the cost of richer, older people.  Hell, some of these young people may not even make it to 50, and they are having to pay higher rates so richer, older people can enjoy lower rates?  I mean I get AARP is an advocacy organization, but surely they are a little bit embarrassed by this argument. 

[Classical_Liberal]

But I really don't understand why young people should be forced to subsidize the cost of richer, older people.  Hell, some of these young people may not even make it to 50, and they are having to pay higher rates so richer, older people can enjoy lower rates?  I mean I get AARP is an advocacy organization, but surely they are a little bit embarrassed by this argument.

People who don't need to utilize (or under utilize) coverage subsidizing those who do is the definition of any insurance.  In something like term life, you can just opt out, don't buy the policy, who cares.  However, with medical insurance if you opt out, get sick, and can't pay.  Well... you get the treatment anyway and society as a whole has to pay for you.  This is why healthcare has to change in one of two ways.  A) If you opt out and get sick, you don't get treatment and die.  Is this morally acceptable to most of our country?  or  B) Everyone has to join the risk pool, some will win (if you call getting sick a win), some will lose, but everyone pays their (progressive tax) fair share.

Edit: for clarity

[Classical_Liberal]

If any of you on here who think they can retire early in this environment, you need to think again.  In fact if this Trumpcare goes through, you might as well shut down this website.

I believe this to be over the top pessimistic and I tend to be a pessimist.  There are other options.  I'm afraid of a complete thread derail with explanations of the ones I can think of off of the top of my head, but I think you have a good start to a new thread.  Best ways to handle medical if ACHA or other garbage healthcare bills pass. :)

[HPstache]

Anyone that contemplates retiring before 65 I hope you have a plan for health insurance now that ACA is likely to be destroyed by the Republicans.

At least until 2021, when Democrats will possibly be back in charge and change the system again.

The problem is, you can't switch from having health insurance to not having insurance every 4-8 years.  I too, would not retire in this system.

Thats why they make this thing called health share. 

we should build a mustachian Healthshare company with Mustachianism being our religious grounds for development and exclusion.

We dont want to play your dumb games we're going to self insure our pool of people. thru our faith in mustachianism.

I said this a while back and it didn't get much interest.  With the dropping of the mandate, this might open a new door for a Mustachian Healthshare program!

[teen persuasion]

There are other problems, of course.  It looks like the current language prohibits the proposed federal tax credits from being used to buy insurance that includes any abortion-related services, which means that states like NY and CA that mandate abortion coverage in all of the insurance plans would get no federal tax credits.   

This might be the single most under-discussed aspect of the entire AHCA debacle (though, as you point out, certainly not the worst one).  As a resident of one of these states who's been following the health care legislation saga quite closely, I've seen virtually no mention in the press of the fact that the tax credits would be literally unuseable to anyone in these states (and, incredulously, that fact didn't stop every single Congressional Republican from California nor almost every one from New York from voting in favor of this bill).

I'm from Elise Stefanik's district in NY.  I have some choice words for her performance during her short tenure that aren't even appropriate on an anonymous internet forum.  Judging from the responses on her official facebook page yesterday and today - her vote did most likely NOT reflect the wishes of the majority of her district.  I hope those impassioned enough to give her a good scolding online will pull through next election.  I suspect there were dozens of Reps who voted in direct contradiction to what their district would have done in a referendum.  Why exactly is entirely beyond me.

I'm from Chris Collins' district.  He was crowing yesterday, he was so thrilled he got his amendment in to stick Cuomo with the counties' Medicaid unfunded mandates.  It's going to save property owners taxes!  Uh huh - who is going to magically pay for that portion of Medicaid?

Your comment about Facebook prompted me to see if Collins has a FB page (he's been refusing to hold town hall meetings or respond to constituents at all for months).  Oh boy, it's blowing up because Collins admitted to CNN that he didn't read the bill.  The Buffalo News asked if he realised the bill would cost the state another $3B by cutting the Essential Health Plan.  "Explain that to me."  The comments are amazing - all 1700 of them so far - are essentially "You are disgusting, resign now.  We will replace you Nov 2018."

[nereo]

If any of you on here who think they can retire early in this environment, you need to think again.  In fact if this Trumpcare goes through, you might as well shut down this website.

I believe this to be over the top pessimistic and I tend to be a pessimist.  There are other options.  I'm afraid of a complete thread derail with explanations of the ones I can think of off of the top of my head, but I think you have a good start to a new thread.  Best ways to handle medical if ACHA or other garbage healthcare bills pass. :)

I thought that statement was overly pessimistic too.  Don't get me wrong, I share teh frustration that this bill could even pass the house, but there were early retirees before the ACA and there will be early retirees regardless of what happens.  Part of FIRE is accepting certain risks in favor of the absolute certainty that your time is limited.

OurTown calculated that s/he might need an extra $200k to cover insurance/medical should the AHCA go through as written and my back of the envelope shows the same.  It sucks but hardly insurmountable... that would boost what I could spend on healthcare/insurance by ~$8k/year indefinitely, and we're already planning on $6k while we're young(ish) and $8k later.  With a robust HSA for out of pocket expenses this doesn't seem out of the realm of mustachianism.

One aspect the AHCA probably will bring back is bare-bones plans with very high deductibles... the sort of thing that is very bad for the broader public that a responsible mustachian nearing FI/RE should be able to handle.

[boarder42]

Does everyone forget pre ACA we could get catastrophic coverage.  And self insure.  I see those plans coming back with the mandate gone. 

[sol]

The provision in this bill that allows states to get exemptions from the pre-existing condition guarantee will absolutely destroy the entire insurance marketplace.

Think about how this would work.  Red states will ask for exemptions from the Obamacare rule and blue states will not.  People who get sick in red states will immediately be unable to afford health insurance in their own state, but will still be guaranteed coverage in their neighboring blue state.  Sick people will flock to blue states, driving up their coverage costs while reducing costs for healthy folks back in the red states by leaving their risk pool at the first sign of trouble.

End result: insurance gets cheaper and cheaper over time in red states, as long as you don't have to use it.  Insurance gets more and more expensive over time in blue states, which will have to suck up all of the country's sickest people who can't get insurance anywhere else.

It's the same number of people buying the same total amount of healthcare, but the PEC exemption provision effectively bifurcates the market into a healthy pool of conservatives that gets cheap useless insurance, and an unhealthy pool for everyone else that gets guaranteed coverage paid for only by liberals.  The red state insurance becomes craptastic coverage, and the blue state insurance is guaranteed a death spiral.

Who thought up this genius idea?

[brooklynguy]

The provision in this bill that allows states to get exemptions from the pre-existing condition guarantee will absolutely destroy the entire insurance marketplace.

It's not a flat exemption from guaranteed issue that the states can get.  Rather, they can allow insurers to get an exemption to charge higher premiums based on pre-existing conditions for people who have had a lapse in coverage (and only people who have had a lapse in coverage), in lieu of charging the 30% surcharge that would normally be imposed, and that increased premium would only apply for the same period of time that the surcharge would've applied (generally, one plan year).  So the effect you describe would exist only to the limited extent of people who get sick enough that it becomes worth it for them to flee their home state in order to avoid one year's worth of increased premiums (which is still a significant effect).

But the bigger structural defect, in my view, is the relatively toothless 30% surcharge, which exists not just in states that opt out, but everywhere.  It provides a much weaker disincentive for healthy people to forgo purchasing insurance until they get sick than does the ACA's individual mandate, because it imposes the same penalty regardless of how long you've been out of the insurance market before deciding to jump back once you actually need immediate coverage.  So that makes a death spiral much more likely than today, when that likelihood is low (contrary to GOP claims).

[Classical_Liberal]

One aspect the AHCA probably will bring back is bare-bones plans with very high deductibles... the sort of thing that is very bad for the broader public that a responsible mustachian nearing FI/RE should be able to handle.

Does everyone forget pre ACA we could get catastrophic coverage.  And self insure.  I see those plans coming back with the mandate gone. 

Right.  Not only that, but many(most) states preACA had some type of income based coverage that filled the gaps between medicaid and median household incomes.  If your home state does not provided something, geographic arbitrage is always a reasonable possibility, many folks talk about FIRE'ing to different areas for purposes of reduced housing costs.  Why would healthcare be different?. 

Speaking of geographic arbitrage, this may come as a surprise, but many (most) healthcare conditions do not require immediate & emergent treatment.  Many developing countries provide Western style care at a much lower cost.   

Let's assume a horrible case...  Say you suddenly have excruciating chest pain, go to the ER and they diagnosis a STEMI (common life threatening heart attack).  You are completely uninsured!  You're quickly carted of the the cardiac cath lab where a very expensive cardiologist places two stents in your LAD which had 85% blockage, effectively saving your life.  Now you need a day to recover in the hospital and are place on two or three new medications which you must take or virtually guarantee re-occurrence.  How much will this life-saving emergent procedure cost?
Source

Look for separate charges from the hospital, doctors and laboratory. For patients without health insurance, total costs are typically $11,000-$41,000 or more, depending on the type of stent and length of hospital stay. Legacy Health, an operator of hospitals and clinics in Portland, OR, charges $11,298-$36,221 for an average heart stent placement surgery; the company reported an average charge of $36,221. At Aurora Sinai Medical Center[2] in Wisconsin, placement of one cardiac stent that is coated with long-release medication to prevent scar tissue from reclogging the artery carries a median hospital charge of $41,228, according estimates from the Wisconsin Hospital Association.

Plus a couple grand in meds over the next year or so.

Sucks, yes!  End of a Mustachian FIRE?  Doubtful.

It's the unsubsidized  insurance premiums after something like this that are FIRE killers.  Chronic conditions are more expensive due to reoccurring cost, but in these cases geographic arbitrage should be considered. 

[DavidAnnArbor]

One aspect the AHCA probably will bring back is bare-bones plans with very high deductibles... the sort of thing that is very bad for the broader public that a responsible mustachian nearing FI/RE should be able to handle.

Does everyone forget pre ACA we could get catastrophic coverage.  And self insure.  I see those plans coming back with the mandate gone. 

Right.  Not only that, but many(most) states preACA had some type of income based coverage that filled the gaps between medicaid and median household incomes.  If your home state does not provided something, geographic arbitrage is always a reasonable possibility, many folks talk about FIRE'ing to different areas for purposes of reduced housing costs.  Why would healthcare be different?. 

Speaking of geographic arbitrage, this may come as a surprise, but many (most) healthcare conditions do not require immediate & emergent treatment.  Many developing countries provide Western style care at a much lower cost.   

Let's assume a horrible case...  Say you suddenly have excruciating chest pain, go to the ER and they diagnosis a STEMI (common life threatening heart attack).  You are completely uninsured!  You're quickly carted of the the cardiac cath lab where a very expensive cardiologist places two stents in your LAD which had 85% blockage, effectively saving your life.  Now you need a day to recover in the hospital and are place on two or three new medications which you must take or virtually guarantee re-occurrence.  How much will this life-saving emergent procedure cost?
Source

Look for separate charges from the hospital, doctors and laboratory. For patients without health insurance, total costs are typically $11,000-$41,000 or more, depending on the type of stent and length of hospital stay. Legacy Health, an operator of hospitals and clinics in Portland, OR, charges $11,298-$36,221 for an average heart stent placement surgery; the company reported an average charge of $36,221. At Aurora Sinai Medical Center[2] in Wisconsin, placement of one cardiac stent that is coated with long-release medication to prevent scar tissue from reclogging the artery carries a median hospital charge of $41,228, according estimates from the Wisconsin Hospital Association.

Plus a couple grand in meds over the next year or so.

Sucks, yes!  End of a Mustachian FIRE?  Doubtful.

It's the unsubsidized  insurance premiums after something like this that are FIRE killers.  Chronic conditions are more expensive due to reoccurring cost, but in these cases geographic arbitrage should be considered.

You forgot to figure in the cardiac rehabilitation - another $20 grand.

[DavidAnnArbor]

[rantk81]

Sucks, yes!  End of a Mustachian FIRE?  Doubtful.

The earliest comments to that article date back to 2012.  Five years down the road (2017) I bet that it's more. A lot more.

Anecdotally, an ER visit for chest pains that resulted in them running a few tests, finding no problems and making no real diagnosis, and leaving within 3 hours, racked up bills of nearly $20k in pre-insurance adjusted billing.

[zing12]

We need some kind of medical-tourism-insurance plan. High deductible, catastrophic, covers the cost of going abroad for medical care. boycott US system entirely, at least for anything big.

[NaturallyHappier]

The provision in this bill that allows states to get exemptions from the pre-existing condition guarantee will absolutely destroy the entire insurance marketplace.

Think about how this would work.  Red states will ask for exemptions from the Obamacare rule and blue states will not.  People who get sick in red states will immediately be unable to afford health insurance in their own state, but will still be guaranteed coverage in their neighboring blue state.  Sick people will flock to blue states, driving up their coverage costs while reducing costs for healthy folks back in the red states by leaving their risk pool at the first sign of trouble.

End result: insurance gets cheaper and cheaper over time in red states, as long as you don't have to use it.  Insurance gets more and more expensive over time in blue states, which will have to suck up all of the country's sickest people who can't get insurance anywhere else.

It's the same number of people buying the same total amount of healthcare, but the PEC exemption provision effectively bifurcates the market into a healthy pool of conservatives that gets cheap useless insurance, and an unhealthy pool for everyone else that gets guaranteed coverage paid for only by liberals.  The red state insurance becomes craptastic coverage, and the blue state insurance is guaranteed a death spiral.

Who thought up this genius idea?

The guys from the red states!

[JLee]

One aspect the AHCA probably will bring back is bare-bones plans with very high deductibles... the sort of thing that is very bad for the broader public that a responsible mustachian nearing FI/RE should be able to handle.

Does everyone forget pre ACA we could get catastrophic coverage.  And self insure.  I see those plans coming back with the mandate gone. 

Right.  Not only that, but many(most) states preACA had some type of income based coverage that filled the gaps between medicaid and median household incomes.  If your home state does not provided something, geographic arbitrage is always a reasonable possibility, many folks talk about FIRE'ing to different areas for purposes of reduced housing costs.  Why would healthcare be different?. 

Speaking of geographic arbitrage, this may come as a surprise, but many (most) healthcare conditions do not require immediate & emergent treatment.  Many developing countries provide Western style care at a much lower cost.   

Let's assume a horrible case...  Say you suddenly have excruciating chest pain, go to the ER and they diagnosis a STEMI (common life threatening heart attack).  You are completely uninsured!  You're quickly carted of the the cardiac cath lab where a very expensive cardiologist places two stents in your LAD which had 85% blockage, effectively saving your life.  Now you need a day to recover in the hospital and are place on two or three new medications which you must take or virtually guarantee re-occurrence.  How much will this life-saving emergent procedure cost?
Source

Look for separate charges from the hospital, doctors and laboratory. For patients without health insurance, total costs are typically $11,000-$41,000 or more, depending on the type of stent and length of hospital stay. Legacy Health, an operator of hospitals and clinics in Portland, OR, charges $11,298-$36,221 for an average heart stent placement surgery; the company reported an average charge of $36,221. At Aurora Sinai Medical Center[2] in Wisconsin, placement of one cardiac stent that is coated with long-release medication to prevent scar tissue from reclogging the artery carries a median hospital charge of $41,228, according estimates from the Wisconsin Hospital Association.

Plus a couple grand in meds over the next year or so.

Sucks, yes!  End of a Mustachian FIRE?  Doubtful.

It's the unsubsidized  insurance premiums after something like this that are FIRE killers.  Chronic conditions are more expensive due to reoccurring cost, but in these cases geographic arbitrage should be considered.

That's the real problem, IMO.

The United States has the most expensive health care in the world by a dramatic margin - without a corresponding improvement in care.

Until the health care system ceases to be a for-profit industry, we will constantly be plagued by problems.

[sol]

Until the health care system ceases to be a for-profit industry, we will constantly be plagued by problems.

I'd like to believe that we can keep for-profit health care, and for-profit health insurance.

We just can't have them be ONLY for-profit, as the only option.  There clearly needs to be some basic level of healthcare coverage available to everyone, regardless of income, and paid for with taxes.  This is how we handle disability and old-age insurance, for example.  Everyone pays a percentage of their income.  Everyone is covered.  And if you want MORE disability insurance, or MORE old-age insurance, you are free to seek out those products on the for-profit market to supplement the minimum coverage the government provides to everyone.

This is such an easy fix for so many other things that people need.  Why is this one so hard?

[former player]

My understanding is that Medicaid pays the bills for the poor elderly in nursing homes.  What happens if the cuts to Medicaid mean that those bills can no longer be paid by Medicaid?

ETA apparently about 62% of nursing home bills in the USA are paid by Medicaid.  How can that be capped/limited?  Nursing homes go bankrupt?  Sick old people get dumped on the streets?

[BeanCounter]

Until the health care system ceases to be a for-profit industry, we will constantly be plagued by problems.

I'd like to believe that we can keep for-profit health care, and for-profit health insurance.

We just can't have them be ONLY for-profit, as the only option.  There clearly needs to be some basic level of healthcare coverage available to everyone, regardless of income, and paid for with taxes.  This is how we handle disability and old-age insurance, for example.  Everyone pays a percentage of their income.  Everyone is covered.  And if you want MORE disability insurance, or MORE old-age insurance, you are free to seek out those products on the for-profit market to supplement the minimum coverage the government provides to everyone.

This is such an easy fix for so many other things that people need.  Why is this one so hard?

Yes! Yes! And Yes!
I would gladly pay more taxes if it gave me access to Medicare at any age. It's not hard. The system is already built, they just need to expand it. The answer is right there in front of our faces and it's relatively easy. There are just too many people with selfish interests standing in the way. Makes me so angry.

[jim555]

My understanding is that Medicaid pays the bills for the poor elderly in nursing homes.  What happens if the cuts to Medicaid mean that those bills can no longer be paid by Medicaid?

ETA apparently about 62% of nursing home bills in the USA are paid by Medicaid.  How can that be capped/limited?  Nursing homes go bankrupt?  Sick old people get dumped on the streets?

Probably means the states will have to raise taxes to make up the cuts.

[radram]

Until the health care system ceases to be a for-profit industry, we will constantly be plagued by problems.

I'd like to believe that we can keep for-profit health care, and for-profit health insurance.

We just can't have them be ONLY for-profit, as the only option.  There clearly needs to be some basic level of healthcare coverage available to everyone, regardless of income, and paid for with taxes.  This is how we handle disability and old-age insurance, for example.  Everyone pays a percentage of their income.  Everyone is covered.  And if you want MORE disability insurance, or MORE old-age insurance, you are free to seek out those products on the for-profit market to supplement the minimum coverage the government provides to everyone.

This is such an easy fix for so many other things that people need.  Why is this one so hard?

Yes! Yes! And Yes!
I would gladly pay more taxes if it gave me access to Medicare at any age. It's not hard. The system is already built, they just need to expand it. The answer is right there in front of our faces and it's relatively easy. There are just too many people with selfish interests standing in the way. Makes me so angry.

You are forgetting that the system in place already covers the WORST,MOST EXPENSIVE POPULATION IT POSSIBLY COULD. Everyone that goes on it, including the "high Risk" pre-existing people will LOWER per person costs, when compared to covering the old population alone.

To me, the answer is beyond right in front of their faces. If you are missing it, you are doing so ON PURPOSE for some other reason. Special interests perhaps?