Author Topic: What comes after the ACA?  (Read 727454 times)

sol

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Re: What comes after the ACA?
« Reply #2850 on: June 23, 2017, 03:46:45 PM »
Reading these comments, its interesting the term "spending money" on people who make more than $250,000 is used.  I'm curious how letting someone keep money is an expense...

Wouldn't it have been better to leave tax rates where they are, and kill a bunch of poor people by taking away their insurance so that we could apply the savings to balancing the budget? Republicans are arguing that instead of balancing the budget, they want to direct that money into the pockets of our wealthiest citizens.

The government also spends money on subsidized oil and gas leases for energy companies.  It's the same sort of deal.  Instead of getting market rates for those leases, they reduce federal revenue by selling them at cut rates.  Is that federal spending, or is that giving money "back" to energy companies by charging them less?  Does it matter, when either interpretation had the same impact on the budget?
« Last Edit: June 23, 2017, 04:12:40 PM by sol »

jim555

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Re: What comes after the ACA?
« Reply #2851 on: June 23, 2017, 03:54:02 PM »
They are using the whole ACA thing as a front to destroy traditional Medicaid.  Traditional Medicaid has nothing to do with the ACA.  This will destroy state budgets and cause huge tax increases at the state level or granny will be put out on the street and left to die. 

Traditional Medicaid requires a total spend down before it kicks in and any remaining assets are subject to estate recovery.  It is the LEAST they can do for the elderly.  Least is not small enough apparently.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2852 on: June 23, 2017, 04:04:47 PM »

Medicaid is for poor and disabled people. The biggest single use of Medicaid funds is for old age nursing home care for poor seniors. Do you understand how they got to be poor?

By spending all of their money on nursing homes.


You are completely correct which goes back to what I was saying.  The cost of delivering healthcare is way too high.  It should not cost ~$250/day to provide nursing home services.  It is insane. Some patients will require more expensive care such as a skilled nursing facility.  Patients on vents or with open wounds and the such.  Most patients get assistance with hygiene, medication implementation, and feeding themselves. Some get rehab.  None of that should cost $250/day.

I'm sorry to hear about your immediate family.  It must be hard to see what they are and have gone through.  I can't fathom throwing old people out on the streets.  Hopefully this is just some scare tactic against the bill as opposed to what will really happen.  It appears the republicans are going to pass something.  How much good vs harm it does is speculation. I remember when Obamacare was being proposed and all the republicans spewing bullshit and scare tactics about it.  Almost all of those scare tactics did not come to fruition.

The comment that 10,000+ people will die in the streets is a scare tactic.

Ohh, Yes, the ACA lifted people from the streets and made other people pay for it.  Terrific for those people and not so terrific for some others. People with no insurance still show up in the Emergency Departments and received care which was subsidies by the insured. Now that same care is subsidized by the tax payer via expanded medicaid. That is the cost shifting I am describing. Again, I am not saying what the ACA did was bad as whole, I am saying it did little to nothing addressing the real problem of ever increasing cost.

jim555

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Re: What comes after the ACA?
« Reply #2853 on: June 23, 2017, 04:11:15 PM »
You are completely correct which goes back to what I was saying.  The cost of delivering healthcare is way too high.  It should not cost ~$250/day to provide nursing home services.  It is insane. Some patients will require more expensive care such as a skilled nursing facility.  Patients on vents or with open wounds and the such.  Most patients get assistance with hygiene, medication implementation, and feeding themselves. Some get rehab.  None of that should cost $250/day.

I'm sorry to hear about your immediate family.  It must be hard to see what they are and have gone through.  I can't fathom throwing old people out on the streets.  Hopefully this is just some scare tactic against the bill as opposed to what will really happen.  It appears the republicans are going to pass something.  How much good vs harm it does is speculation. I remember when Obamacare was being proposed and all the republicans spewing bullshit and scare tactics about it.  Almost all of those scare tactics did not come to fruition.
Who are you to say what price is too high for care per day?  Isn't that a free market pricing mechanism?  Are you admitting to a market failure?  In my area it is $480 a day. 
So who will be paying for the care if the Feds cut way back, charity?  No one will be giving that much charity.  And the result is people will not be cared for.  This is not a scare tactic, it is a reality.

marty998

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Re: What comes after the ACA?
« Reply #2854 on: June 23, 2017, 04:17:33 PM »
Reading these comments, its interesting the term "spending money" on people who make more than $250,000 is used.  I'm curious how letting someone keep money is an expense...

Wouldn't it have been better to leave tax rates where they are, and kill a bunch of poor people by taking away their insurance so that we could apply the savings to balancing the budget? Republicans are arguing that instead of balancing the budget, they want to direct that money into the pockets of our wealthiest citizens.

The government also spends money on subsidized oil and gas leases for energy companies.  It's the same sort of deal.  Instead of getting market rates for those leases, they reduce federal revenue by selling them at cut rates.  Is that federal spending, or is that giving money "back" to energy companies by charging them less?  Does it matter, when either interpretation had the same impact on the budget?

We call them tax expenditures. It's the cost to the budget of not taxing all types of income on the same basis. Or charging the same rate for the same service / lease to all users.

Some are easy to cost. Some a very difficult to estimate. Because if the tax expenditure / concession did not exist it is likely the taxpaying population's behaviour will change accordingly.


mm1970

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Re: What comes after the ACA?
« Reply #2855 on: June 23, 2017, 04:29:38 PM »
Quote
You are completely correct which goes back to what I was saying.  The cost of delivering healthcare is way too high.  It should not cost ~$250/day to provide nursing home services.  It is insane. Some patients will require more expensive care such as a skilled nursing facility.  Patients on vents or with open wounds and the such.  Most patients get assistance with hygiene, medication implementation, and feeding themselves. Some get rehab.  None of that should cost $250/day.

Why shouldn't it cost $250 a day?  I mean, I'm no expert or anything (hubby's grandma was in a very depressing Medicaid paid for home for at least a decade).

First of all there's rent.  You are taking up space.
You are paying for nursing, cooks, housekeeping, laundry.  Assistants to help people bathe and eat.  (They get crappy pay, by the way.)
There's overhead, insurance costs, insurance premiums and salaries, electricity, gas, water.

In any event, I guess I'm lucky my parents are dead?  Can they use a filial law for a step-child?  Probably not.  There are no filial laws in the state where my in-laws live.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2856 on: June 23, 2017, 04:30:34 PM »
Let me be clear...I am human and I make mistakes.
Please give me permission to make those mistakes without abetting me up too much.

Fuck that. You don't get to come in here and make these grand pronouncements and take devils advocate positions without knowing the barest minimum about the topic at hand. I'll take your word that you're a well educated medical professional, but every single post you've made in this thread reveals just a little more that you know nothing about how the macro system works, nor what an ordinary person actually experiences while navigating the system.

We're talking about at least tens of millions of people's financial and bodily well being. Maybe this is just some game to you because you've got doctor money, but it's life and death for so many people, probably including people in this thread. Please have some respect and educate yourself before continuing to post.

Let me be clear, I new perfectly well that Medicaid covered long term care but misunderstood what the person meant who I was replying to because I skimmed through and thought I noticed something.  Just as I am clear that medicare covers the first 100 days of nursing care which covers about 30% of the people requiring such care.  I know those facts.  My mistake was not reading thoroughly what that person said and I got lambasted for it.  I deserved it to some extent and admit to my mistake. 

If we can't have reasonable intelligent conversation on the subject then what is the point.  If you look around this thread I have some serious competition to what I say despite me agreeing with much of the views here. What I am trying to do is open up the view of everyone as a whole and not blindly think that the ACA is the best thing since sliced bread which it is not.  Many real lives were harmed by the law making their healthcare unaffordable where once before it was. In return 10 million people received health insurance some of which still can't afford their unsubsidized parts and their unsibsidized deductibles. How many people who once afforded healthcare now can't? Is it 100, 1,000, or is it 10 million? These statistics are impossible to find but I meet these real life people on a regular basis.  Because it is not a game to those people either.  Hard working, tax paying Americans with chronic disease that now have to pay a lot more money than they used to and now can't afford to service their mortgage, their school loans, their car loans, their medical bills and still put food on the table. Do you want to ignore them and the harm the law has caused them? What these people and the 10 million who may lose their health insurance isn't more cost shifting.  We need a less expensive delivery system.

I don't think the AHCA will make things better.  I am still curious to see what will really come of all this because much of the conversation regarding its outcome is mere speculation.

jim555

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Re: What comes after the ACA?
« Reply #2857 on: June 23, 2017, 04:53:09 PM »
Why do you keep creating the straw man that we all think the ACA is the best thing since sliced bread?  I don't know where you are getting this from. 

EnjoyIt

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Re: What comes after the ACA?
« Reply #2858 on: June 23, 2017, 06:04:10 PM »

Who are you to say what price is too high for care per day?  Isn't that a free market pricing mechanism?  Are you admitting to a market failure?  In my area it is $480 a day. 
So who will be paying for the care if the Feds cut way back, charity?  No one will be giving that much charity.  And the result is people will not be cared for.  This is not a scare tactic, it is a reality.

Healthcare is not a free market system. It is riddled with regulation and cost is hidden from the person buying those services.

Why do you keep creating the straw man that we all think the ACA is the best thing since sliced bread?  I don't know where you are getting this from. 

Because whenever I bring up something bad I get trounced with examples of 10 million people now have insurance story while denying the examples of bad.  BTW, these are not straw men.  These are real live people with real live expenses.  This is also hospital system balance sheets that are showing poor reimbursement from these new plans due to people not paying copays and healthcare.gov paying medicaid rates which tend to be 80%-90% of what it costs to take care of those patients.  I also get this from physicians who are starting to refuse to take healthcare.gov insurance in their private practice. I get this from patients who are having a hard time finding a specialist in their area willing to take their insurance.

The first step is agreeing there is a problem.  The next step is to look for solutions.  More taxes and more spending is not the answer.  Cost shifting which the republicans are looking to do is not the answer. Controlling overall costs is only solution.

fuzzy math

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Re: What comes after the ACA?
« Reply #2859 on: June 23, 2017, 06:26:57 PM »


You are completely correct which goes back to what I was saying.  The cost of delivering healthcare is way too high.  It should not cost ~$250/day to provide nursing home services.  It is insane. Some patients will require more expensive care such as a skilled nursing facility.  Patients on vents or with open wounds and the such.  Most patients get assistance with hygiene, medication implementation, and feeding themselves. Some get rehab.  None of that should cost $250/day.



$250 a day won't even cover the expense for 24 hrs of a CNA's care at $10 - 16 an hr.
Granted the CNA's take care of more than 1 pt, but that same patient will be assigned an RN and others. There also have to be RN shift managers, registered dietitians, pharmacists, MDs and others who aren't visible in the patient's room even though they're providing care. They are all making more than $10 an hr.

These ppl require benefits - health insurance, retirement, vacation, shift differential (because no one wants to wipe grandpa's butt at 2 am unless they're getting an extra $1.75 an hr), weekend and holiday pay, etc. These aren't free things. They cost the facility. The facility has to pay taxes too.

Resourceful ppl leave bad employment situations. The people who stay are those who have no options or those who don't give a fuck. These people get resentful and then you get those stories on the news of people in nursing homes being abused.

protostache

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Re: What comes after the ACA?
« Reply #2860 on: June 23, 2017, 06:31:10 PM »
[Controlling overall costs is only solution.

You keep saying this thing. Over the course of 58 pages nobody has disagreed with you. Not once. It's not a contentious point.

accolay

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Re: What comes after the ACA?
« Reply #2861 on: June 23, 2017, 08:46:38 PM »
And this Senate bill will make it so that last part doesn't actually happen, so elderly people will rely on children to take care of them, 24/7/365, until they die. Or the children will pay out of pocket for nursing home care. It's a literal nightmare even today and I don't understand how anyone would even fathom making it worse, but here we are.

This is exactly what I'm afraid of, since my MIL and grandmother are in nursing homes and other grandmother in assisted living. Fortunately I'm in a Blue State....but oh fuck our state legislature is now run by Republicans-nevermind. I don't think EnjoyIt has any skin in the game, therefore doesn't really know the implications of this shit show bill.
$250 a day won't even cover the expense for 24 hrs of a CNA's care at $10 - 16 an hr.
Granted the CNA's take care of more than 1 pt, but that same patient will be assigned an RN and others. There also have to be RN shift managers, registered dietitians, pharmacists, MDs and others who aren't visible in the patient's room even though they're providing care. They are all making more than $10 an hr.
These ppl require benefits - health insurance, retirement, vacation, shift differential (because no one wants to wipe grandpa's butt at 2 am unless they're getting an extra $1.75 an hr), weekend and holiday pay, etc. These aren't free things. They cost the facility. The facility has to pay taxes too.
Resourceful ppl leave bad employment situations. The people who stay are those who have no options or those who don't give a fuck. These people get resentful and then you get those stories on the news of people in nursing homes being abused.
$16/hr? Holy shit, where do you make that much at a nursing home as an aide? I worked at one for three and a half years while in nursing school starting at $11.45 ending pay $11.70. 2008-2012 four days a week, every other weekend. And this was a decent nursing home. There was no vacation or benefits unless you were full time. If I didn't work, I didn't get payed. Not to hijack the political discussion at hand but in respect to immigrants that's who works in these facilities. The majority of who work there care about the residents (some don't, but true of any industry) but you also only have so much time in the day for every person. I left for a hospital position I'd been applying to for much over a year for less than half as much work for over 16/hr...but I digress.

$250/day? Stuck in 1980s prices...

chasesfish

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Re: What comes after the ACA?
« Reply #2862 on: June 24, 2017, 07:03:47 AM »
Reading these comments, its interesting the term "spending money" on people who make more than $250,000 is used.  I'm curious how letting someone keep money is an expense...

Wouldn't it have been better to leave tax rates where they are, and kill a bunch of poor people by taking away their insurance so that we could apply the savings to balancing the budget? Republicans are arguing that instead of balancing the budget, they want to direct that money into the pockets of our wealthiest citizens.

The government also spends money on subsidized oil and gas leases for energy companies.  It's the same sort of deal.  Instead of getting market rates for those leases, they reduce federal revenue by selling them at cut rates.  Is that federal spending, or is that giving money "back" to energy companies by charging them less?  Does it matter, when either interpretation had the same impact on the budget?

So I'm not a fan of the replacement plan or a lot of things about the ACA, but some of these politicians are getting absurd posting about "killing" people.  The US provided healthcare for years before the ACA, people were never turned away from ERs, we have charitable clinics all over the country.   That isn't what this is about.   This is about getting healthcare and not being bankrupt, which is still an issue for 10-20% of the population that don't buy the ACA and the additional people who drop insurance because of affordability under the ACA.  My comment is the government needs to figure out how to provide coverage to those 10-20% that will always been in deep poverty then figure out how to cover the rest. 

We argue a bit, but I don't think our thoughts are that different.   Regarding the taxes, that's a different debate for me, I think the US should have a progressive system that maximize revenue with the least economic waste possible.  Either do a 2-3 bracket income tax with no deductions or a flat sales tax with a rebate up to the poverty limit paid monthly.  We spent billions per year between accountants and IRS, change the tax laws, then still collect the same revenue.  I disagree with a reduction in revenue being classified as an expense.  If you or I go part time, its not an expense, but it is a budget reduction.

https://en.wikipedia.org/wiki/Hauser%27s_law




rpr

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Re: What comes after the ACA?
« Reply #2863 on: June 24, 2017, 07:35:27 AM »

So I'm not a fan of the replacement plan or a lot of things about the ACA, but some of these politicians are getting absurd posting about "killing" people.  The US provided healthcare for years before the ACA, people were never turned away from ERs, we have charitable clinics all over the country.  That isn't what this is about.   This is about getting healthcare and not being bankrupt, which is still an issue for 10-20% of the population that don't buy the ACA and the additional people who drop insurance because of affordability under the ACA.  My comment is the government needs to figure out how to provide coverage to those 10-20% that will always been in deep poverty then figure out how to cover the rest. 

Just curious if emergency room care can be use to get treatment for chronic conditions or for cancer treatment etc.I have known cases where unpaid ER bills were turned over to collection agencies which had no qualms about harassing very sick people.

For the 10-20% in deep poverty, there was the Medicaid expansion which they want to gut.

Quote
We argue a bit, but I don't think our thoughts are that different.   Regarding the taxes, that's a different debate for me, I think the US should have a progressive system that maximize revenue with the least economic waste possible.  Either do a 2-3 bracket income tax with no deductions or a flat sales tax with a rebate up to the poverty limit paid monthly.  We spent billions per year between accountants and IRS, change the tax laws, then still collect the same revenue.  I disagree with a reduction in revenue being classified as an expense.  If you or I go part time, its not an expense, but it is a budget reduction.

https://en.wikipedia.org/wiki/Hauser%27s_law

Regarding taxes, I agree that we need to simplify considerably. To start with I'd get rid of all itemized deductions and give every person a standard deduction of some amount with some total family cap (say 30-50K). Have only three brackets 15, 25, 35%. Also get rid of tax breaks for everything including mortgage and student loan interest, employer provided medical insurance premiums. Also get rid of 401ks, IRAs, HSAs. Also tax capital gains and dividends at the same rate as ordinary income. Also no deductions for charitable contributions. This will simplify the  code considerably.

chasesfish

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Re: What comes after the ACA?
« Reply #2864 on: June 24, 2017, 09:05:19 AM »
rpm - Agree with you on most.

If Medicaid expansion fixed this for people in deep poverty, how are there still 27 million people uninsured (9%) uninsured in 2016?   I don't think Medicaid expansion goes far enough, open the VA hospitals up to provide baseline care.

protostache

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Re: What comes after the ACA?
« Reply #2865 on: June 24, 2017, 09:06:04 AM »
So I'm not a fan of the replacement plan or a lot of things about the ACA, but some of these politicians are getting absurd posting about "killing" people.

The New England Journal of Medicine published a massive meta-study yesterday (Vox explainer) (pdf link to actual journal article) that showed that one life is saved for every 300-800 people that gain insurance coverage. Inverting that, that means that one life is lost for every 300-800 people that lose insurance coverage. Going by CMS's own estimate that 14 million people will lose coverage in 2018, which is pretty conservative compared to the CBO's AHCA score of 23 million in the first year, that means that between 17,500 and 46,000 people will die solely because they lose health insurance coverage. Just for 2018, not even projecting for future coverage losses.

These are your friends. Your kids' friends. Your neighbors. People you see in the grocery store. People who shake your hand at church. Fifty one Republican Senators, two hundred and eighteen Republican Members of Congress, and one clueless President will have those people's blood on their hands when they vote for this bill.

jim555

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Re: What comes after the ACA?
« Reply #2866 on: June 24, 2017, 09:23:13 AM »
rpm - Agree with you on most.

If Medicaid expansion fixed this for people in deep poverty, how are there still 27 million people uninsured (9%) uninsured in 2016?   I don't think Medicaid expansion goes far enough, open the VA hospitals up to provide baseline care.
Don't forget the red states that didn't expand creating a coverage gap.

dividendman

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Re: What comes after the ACA?
« Reply #2867 on: June 24, 2017, 09:29:50 AM »
Fifty one Republican Senators, two hundred and eighteen Republican Members of Congress, and one clueless President will have those people's blood on their hands when they vote for this bill.

The people actually responsible are all of the people who voted for these people. Half or more of whom will be affected by the loss of these programs, so they will feel the impact.

What I don't understand is why Republicans in the federal government are going half way. I have said this numerous times but they should just cut *all* federal anti-poverty programs and cut federal taxes to match the savings. Then the states can raise their own taxes for their own programs. Some states will have good programs, some states will have none.

Yes, people will die, but those people want to die.

Paul der Krake

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Re: What comes after the ACA?
« Reply #2868 on: June 24, 2017, 09:34:45 AM »
If Medicaid expansion fixed this for people in deep poverty, how are there still 27 million people uninsured (9%) uninsured in 2016?
Because the decision-making abilities of the target population leaves a lot to be desired, or they don't qualify.


There's about 10 million people who don't live in the country legally and are not eligible, with narrow exceptions.

There are people stuck in the coverage gap, not poor enough for Medicaid, and not rich enough for ACA subsidies.

There are people who have no idea that the program is available to them, or what it does. It's incredibly hard and expensive to reach them. They don't follow the legislative process in the newspaper. They rely on word of mouth from other poor people. Even if you sit them down and give them a presentation, they may not understand it.

There are people who have deluded themselves into thinking that they are strong, independent, red-blooded Americans. They refuse to get coverage, even if it's at no charge or next-to no charge to them. My wife's cousin is one of them. He don't need no stinkin government telling him what to do, even though he is in debt up to his eyeballs and lives with grandma.

chasesfish

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Re: What comes after the ACA?
« Reply #2869 on: June 24, 2017, 10:19:53 AM »
If Medicaid expansion fixed this for people in deep poverty, how are there still 27 million people uninsured (9%) uninsured in 2016?
Because the decision-making abilities of the target population leaves a lot to be desired, or they don't qualify.


There's about 10 million people who don't live in the country legally and are not eligible, with narrow exceptions.

There are people stuck in the coverage gap, not poor enough for Medicaid, and not rich enough for ACA subsidies.

There are people who have no idea that the program is available to them, or what it does. It's incredibly hard and expensive to reach them. They don't follow the legislative process in the newspaper. They rely on word of mouth from other poor people. Even if you sit them down and give them a presentation, they may not understand it.

There are people who have deluded themselves into thinking that they are strong, independent, red-blooded Americans. They refuse to get coverage, even if it's at no charge or next-to no charge to them. My wife's cousin is one of them. He don't need no stinkin government telling him what to do, even though he is in debt up to his eyeballs and lives with grandma.

This is exactly why I think the ACA/Replacement Plan for all approach is wrong.  Open up the government run hospitals to those without insurance/coverage then compel everyone who files taxes to buy insurance or not get a refund.

chasesfish

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Re: What comes after the ACA?
« Reply #2870 on: June 24, 2017, 10:21:03 AM »
So I'm not a fan of the replacement plan or a lot of things about the ACA, but some of these politicians are getting absurd posting about "killing" people.

The New England Journal of Medicine published a massive meta-study yesterday (Vox explainer) (pdf link to actual journal article) that showed that one life is saved for every 300-800 people that gain insurance coverage. Inverting that, that means that one life is lost for every 300-800 people that lose insurance coverage. Going by CMS's own estimate that 14 million people will lose coverage in 2018, which is pretty conservative compared to the CBO's AHCA score of 23 million in the first year, that means that between 17,500 and 46,000 people will die solely because they lose health insurance coverage. Just for 2018, not even projecting for future coverage losses.

These are your friends. Your kids' friends. Your neighbors. People you see in the grocery store. People who shake your hand at church. Fifty one Republican Senators, two hundred and eighteen Republican Members of Congress, and one clueless President will have those people's blood on their hands when they vote for this bill.

Devils Advocate here - This is assuming these people aren't going to loose coverage anyways due to insurers dropping out and states being left with no markets.  The CBO's estimates assumes insurance companies will continue to absorb losses or the government will continue to subsidize it.

protostache

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Re: What comes after the ACA?
« Reply #2871 on: June 24, 2017, 10:33:11 AM »
Devils Advocate here - This is assuming these people aren't going to loose coverage anyways due to insurers dropping out and states being left with no markets.  The CBO's estimates assumes insurance companies will continue to absorb losses or the government will continue to subsidize it.

Insurers are dropping out almost entirely because of the uncertainty surrounding the next few years. Insurance companies hate legislative uncertainty because it makes it impossible to estimate risk.

In any case, the 1 death per 300-800 people losing coverage number holds regardless of the reason for loss. Makes no difference if it's due to ratfucking by the executive over the mandates and CSRs or due to direct legislative action, thousands of people are going to die stupid avoidable deaths because of the actions of this government.
« Last Edit: June 24, 2017, 10:36:13 AM by protostache »

EnjoyIt

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Re: What comes after the ACA?
« Reply #2872 on: June 24, 2017, 12:35:08 PM »
Regarding nursing home care and payments I found a pretty good link regarding cost
https://www.payingforseniorcare.com/longtermcare/paying-for-nursing-homes.html

http://news.morningstar.com/articlenet/article.aspx?id=564139

This could be a good resource of mustachians who plan on retiring and want to make sure they won't be a burden to their families when requiring nursing home care:

1) The average cost of a shared nursing home room is $222/day or $81k/yr (which varies greatly based on location.)  Please see first link above to asses cost in your own state.
2) The average length of stay for a nursing home patient is 2.44 years or 892 days.
3) 30% of the nursing home stays are under 100 days and fully covered by medicare with supplemental which I think every person should have.
4) 40% of all population who reaches 65 will spend some time in a nursing home.
5) 10% of the population stays in a nursing home over 5 years.

So what does all this math mean?  You have a 70%*40% = 28% chance of being in a nursing home for more than 100 days of which the rest will need to be paid out of pocket or medicaid if qualified. 2.8% of that population has the chance of being in the nursing home for > 5 years which can destitute most people.  25.2% of the population will stay in a nursing home for 5 years or less which will cost on average $81k/yr or $405k or less (please check your state for costs in your area.) Remember that we all will get social security in some form or another which may offset some of those costs. You can expect that most of us even early retirees will get about 20k in social security at 70.  Therefor we will have to come up with $81k-$20k over a potential 5 years.  That is the equivalent of $61k or ~$305k.  Saving an extra $100k prior to retirement should grow into $305k by the time we may need it if we are to retire early in our 40s. Saving an extra $100k can take 1-3 years depending on the growth of your FIRE number and yearly contributions.  For someone with a FIRE of $1 million and 18k yearly contribution it will take an extra 18 months.  If you are maxing out 2 401ks or $36k/yr then it will take about 14-15 months to get there.  I think it is worth working an extra 14-18 months to give yourself a 97.2% chance of not needing medicaid for your nursing home needs.

Personally I think we have too many people in nursing homes who have no quality of life and are provided unnecessary procedures and medication to sustain them. I would rather be dead than to live bed ridden with pressure ulcers and a feeding tube to my stomach.  Luckily my wife and I agree that is not how we want to live and will do everything in our power to minimize the other person's suffering.  The same exists for our parents.  I think if we convinced our population into similar thinking it would drastically decrease medicaid expenses and allow that money to be used more usefully. On the poor that actually has a life to live. Cutting medicaid spending on this subset of the population could potentially save enough money to be able to expand medicaid and cover just about every poor person in the country.
« Last Edit: June 24, 2017, 12:51:29 PM by EnjoyIt »

sol

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Re: What comes after the ACA?
« Reply #2873 on: June 24, 2017, 01:17:12 PM »
I would rather be dead than to live bed ridden with pressure ulcers and a feeding tube to my stomach. 

We all say that now, when we're healthy, but in my experience people's views tend to change when they actually face that situation.  Bed sores are a minor inconvenience, and speaking as someone who has been bedridden in my life, I would definitely not consider that situation a reason to end my life.

Losing control of your bowels sucks, but I guarantee you that there are hundreds of people on this board with that problem who are productive contributing members of this community.  You deal with it.

Feeding tubes and oxygen tubes suck, but if they let you watch tv in comfort and visit with you family a few more times before you shuffle off, they're worth it.  The alternative is a slow and painful death by starvation or suffocation, and nobody really wants to experience that.  These treatments are designed to make your life less miserable, not more.

I've watched young and healthy people die suddenly, like in car accidents, and considered it a tragedy they were gone so suddenly.  I've watched old and decrepit people die slow lingering deaths, some alone and depressed and some surrounded by loving family.  I've also watched people spend 20 years with Alzheimer's, physically too healthy to die, but absolutely miserable because they are constantly terrified by everything around them, including their own children. 

Death always sucks.  We all need to be prepared to deal with that.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2874 on: June 24, 2017, 01:58:09 PM »
I would rather be dead than to live bed ridden with pressure ulcers and a feeding tube to my stomach. 

We all say that now, when we're healthy, but in my experience people's views tend to change when they actually face that situation.  Bed sores are a minor inconvenience, and speaking as someone who has been bedridden in my life, I would definitely not consider that situation a reason to end my life.

Losing control of your bowels sucks, but I guarantee you that there are hundreds of people on this board with that problem who are productive contributing members of this community.  You deal with it.

Feeding tubes and oxygen tubes suck, but if they let you watch tv in comfort and visit with you family a few more times before you shuffle off, they're worth it.  The alternative is a slow and painful death by starvation or suffocation, and nobody really wants to experience that.  These treatments are designed to make your life less miserable, not more.

I've watched young and healthy people die suddenly, like in car accidents, and considered it a tragedy they were gone so suddenly.  I've watched old and decrepit people die slow lingering deaths, some alone and depressed and some surrounded by loving family.  I've also watched people spend 20 years with Alzheimer's, physically too healthy to die, but absolutely miserable because they are constantly terrified by everything around them, including their own children. 

Death always sucks.  We all need to be prepared to deal with that.

Some good points if your brain is with it.  Many of these bed ridden, bed sored people have no expectation of improvement. They will continue being bed ridden with no quality of life. You had the potential to improve.  I too was bedridden but only for a short time after an accident and surgery.  Obviously I would not off myself. I am talking about those with no expectation and no quality of life.  These people have little to no idea the TV is even on or if family comes to visit.  There is no need to sustain that type of life.

People who have a medical back ground such as physicians, NP, PA and nurses see these patients and realize what entails in keeping them alive. The majority do not want that for themselves or their families.  There are a few studies that ask these questions which I am too lazy to try and dig up for you. You will probably skip and ignore them like everything else I have sent you such as insurance profits a few posts up. Also, there is no need to starve to death as we have options of hospice providing sufficient pain medication to relieve some of that suffering. We really should have TV commercials that educate the US population on end of life care and when it is appropriate and when it is ok to minimize the suffering of their loved ones and to allow them to die with dignity.  I believe such education would drastically change those nursing home percentages.

May I ask, are you simply looking for points of contention with these comments trying to find exceptions just because they are coming from me or do you really believe we should be spending inordinate amount of money on the almost brain dead with no quality of life?

gerardc

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Re: What comes after the ACA?
« Reply #2875 on: June 24, 2017, 02:00:31 PM »
It feels unfair that a Mustachian who saved $1M and needs end-of-life skilled care will slowly deplete their savings before getting on Medicaid while a spendypants with $10k savings will use that in a month;  both will leave no inheritance. A workaround for the saver would be to give the inheritance to their children before they die, which may be what this bill is trying to avoid.

But more importantly, it feels unfair that a Mustachian who lived their whole life frugally would get the same end result as a careless spender who enjoyed a life with less work, less stress or more indulgences. Liberals often try to push their ideal of giving from the rich to the poor, with the argument that the rich are born into wealth and the poor simply got unlucky to be stuck in shitty jobs, but high earners pay a lot in terms of quality of life, and it doesn't seem fair to favor the poor too much just because "poor them, they got unlucky". Kinda like parents giving more inheritance to one child (the spender, low education, low income, or high debt one) because the other child was more frugal and serious with their career and doesn't need the money. Is that what we want our tax system to incentivize? We have a good thing with the US economy in general and some people don't realize the full consequences and side effects of introducing changes in that running system.

chasesfish

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Re: What comes after the ACA?
« Reply #2876 on: June 24, 2017, 02:11:09 PM »
Devils Advocate here - This is assuming these people aren't going to loose coverage anyways due to insurers dropping out and states being left with no markets.  The CBO's estimates assumes insurance companies will continue to absorb losses or the government will continue to subsidize it.

Insurers are dropping out almost entirely because of the uncertainty surrounding the next few years. Insurance companies hate legislative uncertainty because it makes it impossible to estimate risk.

In any case, the 1 death per 300-800 people losing coverage number holds regardless of the reason for loss. Makes no difference if it's due to ratfucking by the executive over the mandates and CSRs or due to direct legislative action, thousands of people are going to die stupid avoidable deaths because of the actions of this government.

Actions of the various governments over the past 10 years, insurers were dropping in 2016 too even when the election of HRC was a certainty.  All these politicians are spineless.

If I were a political advisor, I'd tell the republicans to drop the bill immediately and let the economics of obamacare unravel, then maybe somebody will pass real compulsory insurance requirements or open up the VA to the uninsured.

sol

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Re: What comes after the ACA?
« Reply #2877 on: June 24, 2017, 02:11:25 PM »
They will continue being bed ridden with no quality of life. You had the potential to improve.

Yes I did, but that doesn't mean I didn't think about it.  My extended stay in a nursing home at age 28 gave me plenty of opportunity to lay around and think, and one of the things I thought about was what I would do if my situation were permanent.  What if I wasn't going to get better?

I decided that life is complicated, and there are lots of different arenas you can live in.  Had I been confined to a bed permanently, I would clearly have to give up mountaineering, and biking, and the front yard slip and slide with my kids (today's activity).  But I could still write, and I would be excited about the chance to have uninterrupted time to crank out a few books I've had kicking around in my head but can't currently make time for.  I could still watch movies, and I love great movies and dissecting them.  I could still participate in internet forums, and offer people helpful advice about their finances.  There are lots of ways to keep busy and engaged, even without your mobility.

Quote
May I ask, are you simply looking for points of contention with these comments trying to find exceptions just because they are coming from me or do you really believe we should be spending inordinate amount of money on the almost brain dead with no quality of life?

I'm repeating the assertion I have made three times in this thread, that people who claim they don't want to live that way often change their minds when they arrive at that decision.  We are all stronger than we think we are.  We can and will learn to cope with difficulties that we once thought insurmountable.

I hang with climbers.  They always talk about the absolute necessity of having a detailed plan.  Logisitics, route beta, equipment support, contingency plans, emergency and medical evac plans, weather delay plans, gear repair or substitution plans, team re-assignment plans, everything has to be planned out ahead of time.  But when you're at nineteen thousand feet and the wind starts to blow, you have to be prepared to throw your plans to the wind.  You never really know what the right decision will be, until right in that moment when you have to make it.  Yes, it's valuable to think these things through ahead of time.  Just don't legally bind yourself to a decision you can't change, because when you get there you need to have all of your options on the table.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2878 on: June 24, 2017, 02:20:40 PM »
They will continue being bed ridden with no quality of life. You had the potential to improve.

Yes I did, but that doesn't mean I didn't think about it.  My extended stay in a nursing home at age 28 gave me plenty of opportunity to lay around and think, and one of the things I thought about was what I would do if my situation were permanent.  What if I wasn't going to get better?

I decided that life is complicated, and there are lots of different arenas you can live in.  Had I been confined to a bed permanently, I would clearly have to give up mountaineering, and biking, and the front yard slip and slide with my kids (today's activity).  But I could still write, and I would be excited about the chance to have uninterrupted time to crank out a few books I've had kicking around in my head but can't currently make time for.  I could still watch movies, and I love great movies and dissecting them.  I could still participate in internet forums, and offer people helpful advice about their finances.  There are lots of ways to keep busy and engaged, even without your mobility.

Quote
May I ask, are you simply looking for points of contention with these comments trying to find exceptions just because they are coming from me or do you really believe we should be spending inordinate amount of money on the almost brain dead with no quality of life?

I'm repeating the assertion I have made three times in this thread, that people who claim they don't want to live that way often change their minds when they arrive at that decision.  We are all stronger than we think we are.  We can and will learn to cope with difficulties that we once thought insurmountable.

I hang with climbers.  They always talk about the absolute necessity of having a detailed plan.  Logisitics, route beta, equipment support, contingency plans, emergency and medical evac plans, weather delay plans, gear repair or substitution plans, team re-assignment plans, everything has to be planned out ahead of time.  But when you're at nineteen thousand feet and the wind starts to blow, you have to be prepared to throw your plans to the wind.  You never really know what the right decision will be, until right in that moment when you have to make it.  Yes, it's valuable to think these things through ahead of time.  Just don't legally bind yourself to a decision you can't change, because when you get there you need to have all of your options on the table.

People who are almost brain dead do not make these decisions. Their family decide for them. I think if you can make those decisions for yourself then you are not brain dead and you have a quality of life. Even sitting in bed watching TV all day can provide joy to that person.  But when you are at a point where you don't even know the TV is on, maybe it is time your family stops forcing you to have needless surgeries and expensive life sustaining expensive measures. I am sure you agree with that. I'm sure you agree that keeping those people alive is very expensive.  I'm sure you would agree that money could be used more productively somewhere else like expanding medicaid for the poor. Am I wrong?

Luck12

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Re: What comes after the ACA?
« Reply #2879 on: June 24, 2017, 03:31:19 PM »
We have a good thing with the US economy in general and some people don't realize the full consequences and side effects of introducing changes in that running system.

It seems to me you are bemoaning the ACA and want to restore the system to how it was before:

Many other countries have "a good thing" with their economies too and also have a much better health care system than the U.S.  Even putting aside the cruel nature of this bill with respect to those who are poorer, is it fair an MMM'er who's been frugal has to continue working for many more years (even to Medicare age) just because they have a pre-existing condition?   

America only does the right thing after it has tried everything else. 

former player

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Re: What comes after the ACA?
« Reply #2880 on: June 24, 2017, 03:31:45 PM »
It feels unfair that a Mustachian who saved $1M and needs end-of-life skilled care will slowly deplete their savings before getting on Medicaid while a spendypants with $10k savings will use that in a month;  both will leave no inheritance. A workaround for the saver would be to give the inheritance to their children before they die, which may be what this bill is trying to avoid.

But more importantly, it feels unfair that a Mustachian who lived their whole life frugally would get the same end result as a careless spender who enjoyed a life with less work, less stress or more indulgences. Liberals often try to push their ideal of giving from the rich to the poor, with the argument that the rich are born into wealth and the poor simply got unlucky to be stuck in shitty jobs, but high earners pay a lot in terms of quality of life, and it doesn't seem fair to favor the poor too much just because "poor them, they got unlucky". Kinda like parents giving more inheritance to one child (the spender, low education, low income, or high debt one) because the other child was more frugal and serious with their career and doesn't need the money. Is that what we want our tax system to incentivize? We have a good thing with the US economy in general and some people don't realize the full consequences and side effects of introducing changes in that running system.
All the government is doing is ensuring provision of the minimum care necessary in order to be called a civilised society, at the minimum cost.  If the State doesn't require people with money (in this case, capital) to pay for the care they get, where does the money for that care come from?  It can only come from people who don't have capital (ie a tax on income).  It's got to be one or the other, right?   And you can't reasonably expect the government to pick up the whole of the tab on someone who spends 10 years in a nursing home with Alzheimers just so their kids can get an inheritance (funny how it often seems to be the right-wingers who want that sort of big government/big tax solution to preserving private inheritance).  The unfairness, if there is one, comes from the unequal distribution of ill health before death, which is hardly the government's fault.

GuitarStv

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Re: What comes after the ACA?
« Reply #2881 on: June 24, 2017, 03:56:32 PM »
It feels unfair that a Mustachian who saved $1M and needs end-of-life skilled care will slowly deplete their savings before getting on Medicaid while a spendypants with $10k savings will use that in a month;  both will leave no inheritance. A workaround for the saver would be to give the inheritance to their children before they die, which may be what this bill is trying to avoid.

But more importantly, it feels unfair that a Mustachian who lived their whole life frugally would get the same end result as a careless spender who enjoyed a life with less work, less stress or more indulgences. Liberals often try to push their ideal of giving from the rich to the poor, with the argument that the rich are born into wealth and the poor simply got unlucky to be stuck in shitty jobs, but high earners pay a lot in terms of quality of life, and it doesn't seem fair to favor the poor too much just because "poor them, they got unlucky". Kinda like parents giving more inheritance to one child (the spender, low education, low income, or high debt one) because the other child was more frugal and serious with their career and doesn't need the money. Is that what we want our tax system to incentivize? We have a good thing with the US economy in general and some people don't realize the full consequences and side effects of introducing changes in that running system.

Yep.  It's unfair.

Someone who is genetically lucky enough to avoid needing spendy medical care in his life having to pay little, while someone else who wasn't so lucky needs to spend a lot is also patently unfair.  Someone who was born into circumstances that allowed him to succeed making more money at a job than someone who was born with a crippling mental illness is also patently unfair.  Life is, unfortunately, full of unfair things that happen.

I don't know a way to develop a rule that benefits those who should be rewarded, and punishes those who fail some sort of moral test.  I don't even know if there's a straight-forward way that everyone would agree upon to classify actions as moral or immoral.  I do know that denying old people medical care that they want/need (effectively sentencing them to death) because of a lack of money seems fundamentally wrong.


FWIW - It also feels wrong to me that someone needs to deplete savings at all for health care.  That's like needing to give police officers cash to investigate a robbery that happened at your house, or having the firefighters save your house from burning down - only to realize that you're losing the house because you can't afford their bill.

jim555

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Re: What comes after the ACA?
« Reply #2882 on: June 24, 2017, 04:13:11 PM »
People who are almost brain dead do not make these decisions. Their family decide for them. I think if you can make those decisions for yourself then you are not brain dead and you have a quality of life. Even sitting in bed watching TV all day can provide joy to that person.  But when you are at a point where you don't even know the TV is on, maybe it is time your family stops forcing you to have needless surgeries and expensive life sustaining expensive measures. I am sure you agree with that. I'm sure you agree that keeping those people alive is very expensive.  I'm sure you would agree that money could be used more productively somewhere else like expanding medicaid for the poor. Am I wrong?
You are treading a very thin line with this topic.  A person without mental capability can't give consent to voluntary suicide.  What it sounds like could easily be called murder.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2883 on: June 24, 2017, 04:47:20 PM »
People who are almost brain dead do not make these decisions. Their family decide for them. I think if you can make those decisions for yourself then you are not brain dead and you have a quality of life. Even sitting in bed watching TV all day can provide joy to that person.  But when you are at a point where you don't even know the TV is on, maybe it is time your family stops forcing you to have needless surgeries and expensive life sustaining expensive measures. I am sure you agree with that. I'm sure you agree that keeping those people alive is very expensive.  I'm sure you would agree that money could be used more productively somewhere else like expanding medicaid for the poor. Am I wrong?
You are treading a very thin line with this topic.  A person without mental capability can't give consent to voluntary suicide.  What it sounds like could easily be called murder.

Not subjecting your family member to costly medical procedures that does nothing but prolong suffering is not murder. it is compassion. Families make those choices every day.  Some make the right choice, while others prolong their suffering because they can't bear to lose what is left of their loved one.  The "do everything" family needs to be educated. Most families don't realize that performing CPR will likely break several ribs and may puncture a lung. The results of delayed CPR is not what you see on TV. We may save the heart but the brain suffers permanent injury due to oxygen deprivation. Families don't realize that putting their 85 year old loved one with extensive metastatic cancer on chemo may prolong their life for a few extra months at the cost of pain, nausea, vomiting, and high risk of infections.  Sometimes I see something even worse: a family bringing in their decrepit bed ridden no brain function elderly relative. This relative lives at home and the family takes care of them. The patient is very poorly managed at home, not fed, barely gets water, comes in wearing dirty diapers, and not bathed.  The family is practically torturing this person, wanting everything done to keep them alive because they get to keep and use their Social Security and/or Pension.

jim555

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Re: What comes after the ACA?
« Reply #2884 on: June 24, 2017, 05:10:29 PM »
This is why Advance Directives are so vital, so situations like this can be handled in a way that the patient has agreed to.  The whole problem comes in when no instructions have been laid out and it falls on the family to make these hard choices.  I would not want a government to be making these choices for vulnerable persons, they should always default to survival in absence of instructions.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2885 on: June 24, 2017, 05:29:09 PM »
This is why Advance Directives are so vital, so situations like this can be handled in a way that the patient has agreed to.  The whole problem comes in when no instructions have been laid out and it falls on the family to make these hard choices.  I would not want a government to be making these choices for vulnerable persons, they should always default to survival in absence of instructions.

And we do.  It is the law. But I would advocate better education for the population regarding advanced directives as well as the risk vs benefit on some of these procedures.  It would save Medicare/Medicaid billions.  I would also advocate making it easier for doctors to deny futile care.  The current process involves an Ethics Board which is necessary to assist in making those decisions. Most common example I see is a patient with no advanced directive suffers pulmonary failure requiring intubation and now placed on a vent.  After a few days they are found to have anoxic brain injury and they have no brain function left.  The heart, kidneys, Liver, GI tract are working just fine, but they are brain dead. I need to repeat and clarify, not comatose, but actual brain death. The only rational thing to do now is remove them from the respirator and allow their heart to stop.  Some families will fight that decision threatening law suit. We usually get the Ethics Board involved to help evaluate the case which can take a a few weeks.  A few weeks in the ICU at about $10k/day adds up pretty quickly.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #2886 on: June 24, 2017, 09:50:27 PM »
Hospital system balance sheets are showing poor reimbursement from these new plans due to people not paying copays and healthcare.gov paying medicaid rates which tend to be 80%-90% of what it costs to take care of those patients.

More false information here. ACA increased the reimbursement rate that Medicaid pays out. It's not just 80-90% of what it costs.
http://thehill.com/policy/healthcare/236603-hhs-hospitals-saved-billions-under-obamacare

More taxes and more spending is not the answer.  Cost shifting which the republicans are looking to do is not the answer. Controlling overall costs is only solution.

Why do physicians do unneccesary medical tests, why do specialists get paid such absurd amounts of money, why in some areas of the country the standard of care for atrial fibrillation requires treatment costing $5,000 and in another part of the country it is a different medical approach with worse outcomes but cost $15,000?

The ACA at least had research efforts into these areas to help figure out how to control costs. The ACA was moving toward reimbursements that are outcome based, not merely paying for procedures/tests. Just paying doctors who order tests in a private practice, motivates them to do testing to make more money.


The US provided healthcare for years before the ACA, people were never turned away from ERs, we have charitable clinics all over the country.   That isn't what this is about.   This is about getting healthcare and not being bankrupt, which is still an issue for 10-20% of the population that don't buy the ACA and the additional people who drop insurance because of affordability under the ACA.  My comment is the government needs to figure out how to provide coverage to those 10-20% that will always been in deep poverty then figure out how to cover the rest. 

I'm not sure what you were saying, but the reason why the ACA didn't reach out to the other 10% still uncovered is because:

The Republican appointees on the Supreme Court allowed states to opt out of the Medicaid expansion. Consequently, states like Texas ruled by Republicans, didn't expand it, millions of poor people have no Medicaid, and no access to healthcare, except maybe they use an emergency room when things get to an extreme.

Others are not covered under the ACA because they are illegal aliens and though they may work as dishwashers at the restaurant, or work on farms to keep prices low for us, these workers won't be able to get insurance under the ACA nor Medicaid.

I would advocate better education for the population regarding advanced directives as well as the risk vs benefit on some of these procedures.  It would save Medicare/Medicaid billions.  I would also advocate making it easier for doctors to deny futile care. 

It's ironic you should bring up this issue that the ACA/Obamacare addressed by providing a paid for visit with a physician to discuss end of life care options. Of course the Republicans jumped on this and cried, "Death Panels."
« Last Edit: June 24, 2017, 10:03:00 PM by DavidAnnArbor »

EnjoyIt

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Re: What comes after the ACA?
« Reply #2887 on: June 25, 2017, 10:09:09 AM »
Davidannarbor,
Providing care should have some price variation based on location and cost of doing business. But a $5k-$15k discrepancy is rediculous.

The pay for quality measure offered through our current reimbursement model is a sound idea with poor half ass implementation. Maybe over the years it will change to reflect quality and not some half arbitrary measure of success that may or may not produce better outcomes to patients. Also currently to be able to prove good outcomes providers and hospitals must spend a fortune in computer software and hardware as well as comply with extra time documenting. This cost is then laid out to the consumer through increased prices.

Just because I have disagreements on some aspects of the ACA does not make me a republican. The death panel conversation you alluded to was run through by lobbyist and regurgitated by republicans. These are the same lobbyists who quelled the public option because both hurt the revenue of the healthcare industry. It is bullshit and I despise most of our elected officials republican and democrat alike.

accolay

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Re: What comes after the ACA?
« Reply #2888 on: June 25, 2017, 10:13:45 AM »
People who are almost brain dead do not make these decisions. Their family decide for them. I think if you can make those decisions for yourself then you are not brain dead and you have a quality of life. Even sitting in bed watching TV all day can provide joy to that person.  But when you are at a point where you don't even know the TV is on, maybe it is time your family stops forcing you to have needless surgeries and expensive life sustaining expensive measures. I am sure you agree with that. I'm sure you agree that keeping those people alive is very expensive.  I'm sure you would agree that money could be used more productively somewhere else like expanding medicaid for the poor. Am I wrong?
You are treading a very thin line with this topic.  A person without mental capability can't give consent to voluntary suicide.  What it sounds like could easily be called murder.

I have to agree with EnjoyIt here. Is it murder, or is it letting nature take it's course? Most don't want to hear "rationing care" but the truth is, it already happens. We can spend hundreds of thousands keeping someone "alive."

And to Sol's point about pressure ulcers- if you've ever seen a Stage IV ulcer up close...hell, if you've ever smelled a pressure ulcer like that... realize the cost of managing such a wound I daresay it might make you reconsider.

But it really all comes back to preventative care (pressure ulcers almost always preventable) and having those hard discussions with your provider, both of which the ACA provided. Not everyone wants to languish in a care setting and others want any possibility of the miracle.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #2889 on: June 25, 2017, 01:15:09 PM »
Senate bill subsidies screenshot:

The benchmark is no longer the second lowest cost Silver plan (SLCSP), but a benchmark plan rated at 58% actuarial value.  The current Silver plans are rated at 70% AV (with additional CSRs).

The employer mandate and individual mandate fines are reduced to $0.  Say goodbye to employer health coverage.

O.K., so does anyone know how to apply the numbers in the subsidies table?  For example, for someone who is 40 years old with an AGI that is 200% of FPL, does this mean that the premium for a bronze plan can't exceed 6.3% of income?  If that is the case, this would actually be a pretty sweet deal for a healthy mustachian FIREee living off of investment income.

jim555

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Re: What comes after the ACA?
« Reply #2890 on: June 25, 2017, 02:00:26 PM »
It means the subsidy is hinged to a benchmark.  You can have plans that will cost you more than 6.3% but it is up to you if you want to spend on those.
AHCA Senate proposal gives less subsidy than the ACA since the benchmark is lower, also gives less with age.  ACA has no age brackets, it is strictly income based.



« Last Edit: June 25, 2017, 04:05:16 PM by jim555 »

EnjoyIt

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Re: What comes after the ACA?
« Reply #2891 on: June 25, 2017, 07:40:33 PM »
Senate bill subsidies screenshot:

The benchmark is no longer the second lowest cost Silver plan (SLCSP), but a benchmark plan rated at 58% actuarial value.  The current Silver plans are rated at 70% AV (with additional CSRs).

The employer mandate and individual mandate fines are reduced to $0.  Say goodbye to employer health coverage.

O.K., so does anyone know how to apply the numbers in the subsidies table?  For example, for someone who is 40 years old with an AGI that is 200% of FPL, does this mean that the premium for a bronze plan can't exceed 6.3% of income?  If that is the case, this would actually be a pretty sweet deal for a healthy mustachian FIREee living off of investment income.

It could as long as you have enough money saved to cover maximum out of pocket expenses for that year if your medical catastrophe actually occurs. An HSA with a nice chunk of cash in it would be the perfect solution.  I believe the max out of pocket for bronze is about $6900. 

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #2892 on: June 25, 2017, 08:06:19 PM »
Looks like a few Republican Senators are not too thrilled with the Senate Healthcare Repeal/Replace effort, notably so far Susan Collins of Maine, Bill Cassidy of Louisiana, Lisa Murkowski of Alaska, and of course the 5 extremist Republican Senators who want to ditch health care altogether, Rand Paul, Ted Cruz and 3 others.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2893 on: June 25, 2017, 08:31:30 PM »
Looks like a few Republican Senators are not too thrilled with the Senate Healthcare Repeal/Replace effort, notably so far Susan Collins of Maine, Bill Cassidy of Louisiana, Lisa Murkowski of Alaska, and of course the 5 extremist Republican Senators who want to ditch health care altogether, Rand Paul, Ted Cruz and 3 others.

I don't know much about the other names you have listed, but attached is Rand Paul's healthcare law he recommended
https://www.paul.senate.gov/imo/media/doc/ObamacareReplacementActSections.pdf
Dr. Rand Paul is a physician who feels like he understands the issues involved in our overpriced healthcare system.  Just a few items he recommends:
1) Allow the same tax deductions for employees for purchasing health insurance as employers get.
2) Provide tax credits for those who contribute to an HSA and increase the maximum limit
3) remove deductible limits from being able to utilize an HSA plan
4) remove the obamacare pre-existing conditions and re-implement the HIPAA pre-existing conditions protections (I have not evaluated if this is actually reasonable)
5) Allow interstate purchases of insurance to increase completion and one up the market.
6) Allow physicians to negotiate together with insurance companies regarding rates
7) Allow small businesses to pool together across state lines and create pooled insurance plans.

I don't particularly think it is too extreme, but despite all his talk over the years regarding regulatory burdens and unnecessary cost, his plan does very little to help that.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #2894 on: June 25, 2017, 09:34:34 PM »
Looks like a few Republican Senators are not too thrilled with the Senate Healthcare Repeal/Replace effort, notably so far Susan Collins of Maine, Bill Cassidy of Louisiana, Lisa Murkowski of Alaska, and of course the 5 extremist Republican Senators who want to ditch health care altogether, Rand Paul, Ted Cruz and 3 others.

I don't know much about the other names you have listed, but attached is Rand Paul's healthcare law he recommended
https://www.paul.senate.gov/imo/media/doc/ObamacareReplacementActSections.pdf
Dr. Rand Paul is a physician who feels like he understands the issues involved in our overpriced healthcare system.  Just a few items he recommends:
1) Allow the same tax deductions for employees for purchasing health insurance as employers get.
2) Provide tax credits for those who contribute to an HSA and increase the maximum limit
3) remove deductible limits from being able to utilize an HSA plan
4) remove the obamacare pre-existing conditions and re-implement the HIPAA pre-existing conditions protections (I have not evaluated if this is actually reasonable)
5) Allow interstate purchases of insurance to increase completion and one up the market.
6) Allow physicians to negotiate together with insurance companies regarding rates
7) Allow small businesses to pool together across state lines and create pooled insurance plans.

I don't particularly think it is too extreme, but despite all his talk over the years regarding regulatory burdens and unnecessary cost, his plan does very little to help that.

As you've noted before, most people aren't going to be doing a whole lot of saving, so HSA's are nice for mustachians, but not a health care policy does it make.

Add Republican Senator Dean Heller of Nevada to the list of the disgruntled.

And then there's Medicaid:

Medicaid Cuts May Force Retirees Out of Nursing Homes https://nyti.ms/2t3J2Hd

How Medicaid Works, and Who It Covers https://nyti.ms/2t0TbEK
« Last Edit: June 25, 2017, 09:57:57 PM by DavidAnnArbor »

Monkey Uncle

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Re: What comes after the ACA?
« Reply #2895 on: June 26, 2017, 04:37:51 AM »
It means the subsidy is hinged to a benchmark.  You can have plans that will cost you more than 6.3% but it is up to you if you want to spend on those.
AHCA Senate proposal gives less subsidy than the ACA since the benchmark is lower, also gives less with age.  ACA has no age brackets, it is strictly income based.

Yes, it's not as sweet of a deal as the ACA, but still less expensive than my current employer-provided insurance.  Out of pocket costs for a bronze plan are higher, which about balances out with the lower premiums.

The bill is a shit sandwich for most of America, but it doesn't seem like the end of the world for us.

chasesfish

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Re: What comes after the ACA?
« Reply #2896 on: June 26, 2017, 05:44:15 AM »
I saw this short analysis posted on CNBC - Its one of the first news stories that removed a lot of emotion and rhetoric related to the senate bill (at least until you get to the last couple paragraphs with people's opinions quoted):

http://www.cnbc.com/2017/06/24/winners-and-losers-of-the-senates-health-care-proposal.html

Looks net neutral for the early retiree, might be slightly lower on the cost of insurance based on the bands, keeps pre-existing conditions.  It may hurt some of the subsidies some ER folks get based on the income test.  Higher HSA limits help people leading up to retirement.

brooklynguy

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Re: What comes after the ACA?
« Reply #2897 on: June 26, 2017, 07:32:08 AM »
Looks net neutral for the early retiree

If you look only at first-order effects, frugal early retirees who can easily manipulate their income levels would be largely insulated from the damage this bill would inflict (except perhaps Californians and New Yorkers, who would have limited to nonexistent options for obtaining cost-subsidizing tax credits).  But if you zoom out in your perspective, it becomes clear that this legislation would be disastrous for virtually everyone.  For one thing, its defective structural design would virtually ensure the occurrence of death spirals in the individual insurance markets, and no amount of cost subsidization will help individuals purchase coverage on markets that have ceased to function entirely.

chasesfish

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Re: What comes after the ACA?
« Reply #2898 on: June 26, 2017, 07:40:57 AM »
@brooklynguy - I agree with you and think the ACA has the same issues.  Opening the band up to 5x vs. 3x may buy a little time, but the death spiral is there without compulsory requirements for insurance.

We need to move towards Switzerland's model of compulsory insurance or Costa Rica's of a public/private provider model (open the VA to the poor) quickly. 

wenchsenior

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Re: What comes after the ACA?
« Reply #2899 on: June 26, 2017, 09:43:05 AM »
What's weird is the GOP talking points (including Ryan and McConnell on various talk shows etc) since Trump's election have been that the ACA is shit because 1) premiums are too high (definitely true for some middle income people); 2) deductibles are too high (definitely true in some cases); because 3) there are too many things insurance is mandated to cover and 4) not enough incentive for healthy people to buy in. (And this doesn't even address the majority of people that got covered under the ACA, the poor...just the smaller higher income segment).  The only thing they consistently praised about Obamacare was keeping young people on parents' plans, and making sure pre-existing conditions didn't exclude people from buying insurance.

So then they present this absolute SHIT SHOW of a bill that 1) decreases subsidies to buy insurance, resulting in higher percentage of premiums having to be paid out of pocket (OPPOSITE of what people want); 2) allows states to drop 'standard of care' requirements for the plans offered, which effectively will allow insurance companies to sell shittier plans with higher deductibles (MAYBE people want this because they think it will mean much cheaper insurance, but I'm skeptical); which then 3) opens the door for insurance companies to be allowed to sell insurance to people with pre-existing conditions THAT DOES NOT COVER THEIR PRE-EXISTING CONDITION. Sure, Mr. Cancer Survivor, this law dictates I must offer you some sort of insurance plan...so I'm offering you a plan that does not cover chemotherapy.  Pay up.  And finally, 4) this bill includes ZERO provision that incentivizes buy-in from healthy people, which means they are setting up a bill prone to immediate death spiral.

And of course, this doesn't even address the bulk of the people newly covered under Medicaid, who will be gradually kicked off their coverage over time.

And for the icing on the cake, they are ALSO gutting the funding for Medicaid that was present BEFORE the ACA expansion, so they can spread the pain over even MORE of the poor, elderly, and disabled.

So, the richest 400 families in the U.S. will get a tax cut equivalent to the cost of health care for the poor in FOUR STATES.

I cannot wrap my head it.  I am seriously starting to think Paul Ryan (who has actually been quoted describing how he used to be the guy in the corner at fraternity keggers, talking about his dreams of ending Medicaid funding) is an honest to god sociopath.