Author Topic: What comes after the ACA?  (Read 729291 times)

runewell

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Re: What comes after the ACA?
« Reply #3300 on: July 21, 2017, 01:46:53 PM »
As a corollary, look at the economic booms that have resulted every time the US has had sharply rising birth rates.  We need to make more consumers and taxpayers to at least replace the ones who are dying.  Immigration helps, since Americans are currently not making enough babies on their own.

"Pyramid scheme" suggests indefinite growth, which is not what we're shooting for by asking for more babies. 

It's true that the fertility rate is indeed below the replacement level, but "not dramatically so"

Regarding pyramid scheme, you didn't exactly convince me there.  A pyramid scheme hopes to recruit additional people to support the existing population.  And I would expect additional babies to result in indefinite growth.  You could make the argument that an increased population does come with increased costs but also some economies of scale.  or you could be arguing that we are already relying on future generations to pick up our tab and the more people, the easier that would be.

What's wrong with having a steady state with a constant number of inhabitants?

Which is exactly why your second point is so misguided.  Government should absolutely be subsidizing procreation, because paying that cost up front generates more revenue for the country over time.  Consider it an investment in our future success, like public education or highways or healthcare.  If individuals won't improve the country because the personal costs of doing so are too high, then it makes sense for government to subsidize that cost up front and then recoup it later (in this case with a lifetime of taxes).

If the government doesn't have enough revenue, perhaps it should collect more taxes rather than viewing the next generation as a solution. If the US population were to level out at 300M or so inhabitants we wouldn't need many more roads, we could just maintain existing infrastructure.  I would agree that a declining population does bring some challenges with it, but I don't think we need to worry about that just yet.

Quote
Would you also tell private corporations they can't sell stock, because they should pay the full cost of their business expansions up front?

Companies can issue stock or debt.  Maybe you'll need to get a childbirth loan. 

runewell

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Re: What comes after the ACA?
« Reply #3301 on: July 21, 2017, 01:49:01 PM »

Incidentally, my 1 hour outpatient surgery cost my insurance company $20k.  That's unconscionable.

And either we or our employers are paying for it. 

nereo

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Re: What comes after the ACA?
« Reply #3302 on: July 21, 2017, 01:51:14 PM »

If we could use the consumer model to drive down the costs of non-emergency care in addition to other methods to drive down the overall costs maybe we could get somewhere.

If I understand you correctly, you are advocating for more consumer responsibility when choosing non-emergency medical procedures.
I think that would be a very large mistake.

For starters, it would place more of the burden on the individuals, who know far less about the procedures, their costs and their risks. It would also slow down care when a core focus of medicine over the last several decades has been to reduce the time from diagnosis to treatment.

Here's a not uncommon scenario as an example; you start having pain in one side, fatigue and a rash, so you make an appointment with your doctor.  Upon examination, the doctor thinks it could be one of three different things, A, B or C.  A is somewhat common, no life threatening but the test is often inconclusive and takes several days. B is uncommon but potentially severe; its test is expensive but you get the results immediately. C is somewhat rare, the diagnosis is inexpensive but often painful (an injection with acute muscle soreness lasting for days).

If we ask the patient to take responsibility for the financial decisions, s/he will have to start calling around to various clinics asking for the costs of A/B/C. This patient would need to call several places and get quotes on three different proceedures - s/he might make a matrix showing which place has the best cost for which proceedure. Since the cheapest test might be someplace else, it delays a diagnosis. Given human nature, the patient will typically avoid test B even though its the first test a doctor would recommend because a doctor will want to rule out the worst things first. When forced to make decisions based on economics a patient will go with the cheapest options first in the hopes that this will solve the problem - often putting themselves at risk if it is something else. Patients also tend to avoid tests that are painful simply because we have an aversion to pain - importantly the likelihood of someone going through with this test (C) goes down if they are given lots of time to procrastinate.  That's why a doctor's bedside manner training involves coaching a patient to take a test that is unpleasant.

All of this is for something that's fairly routine, and when the tests are simple.  Often one test won't give a definitive answer, but will lead to the next test - an x-ray will rule out a fractured rib, suggesting it could be an infection (requiring a blood panel) or acute inflammation (a sonogram).  Again the patient would need to start calling clinics to get prices for each procedure, then make a decision about which one to test for first. This diagnostic train can go on for several steps, and if the patient were responsible each step creates the potential for the individual to delay care and make the wrong decision.

runewell

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Re: What comes after the ACA?
« Reply #3303 on: July 21, 2017, 01:54:31 PM »
It's not just the cost that matters, it's the quality of the care you're going to get. Different settings could have different outcomes, you could acquire an infection in a poor quality setting. A birth can be botched by a poor performance of the obstetrician.

But, higher spending is no guarantee of improved outcome.

Midwest

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Re: What comes after the ACA?
« Reply #3304 on: July 21, 2017, 02:04:16 PM »
I agree with you a consumer driven model is irrelevant for most emergencies.  What percentage of patient care, however, is true emergency care?  If my family is a model, emergency care is a small portion of medical care.

If my family is a model, emergency care is a small portion of the care provided, but a clear majority of the cost.

That hasn't been the case in my family.  Tonsils, planned orthopedic work and pregnancies have been the big ones.  Clearly however, informing the consumer and incentivizing is only part of the solution.

Sure it hasn't been the case in your family because you haven't had a real emergency situation occur. My wife had two recent emergency surgeries that also required around 4-5 days of recovery in the hospital. The combined bill was around 250k, which fortunately we didn't have to pay because of insurance.

Lagom - I'm not arguing against insurance.  Your wife's $250k bill is precisely why we need insurance.  Johnny's trip to the doctor, not so much.

Hope your wife is ok.

shenlong55

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Re: What comes after the ACA?
« Reply #3305 on: July 21, 2017, 02:05:33 PM »
It's not just the cost that matters, it's the quality of the care you're going to get. Different settings could have different outcomes, you could acquire an infection in a poor quality setting. A birth can be botched by a poor performance of the obstetrician.

But, higher spending is no guarantee of improved outcome.

You may be right that higher spending does not guarantee an improved outcome, but that is not the same as saying that higher spending will not lead to an improved outcome.  Sometimes higher spending does lead to improved outcomes.

Midwest

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Re: What comes after the ACA?
« Reply #3306 on: July 21, 2017, 02:08:59 PM »

If we could use the consumer model to drive down the costs of non-emergency care in addition to other methods to drive down the overall costs maybe we could get somewhere.

If I understand you correctly, you are advocating for more consumer responsibility when choosing non-emergency medical procedures.
I think that would be a very large mistake.

For starters, it would place more of the burden on the individuals, who know far less about the procedures, their costs and their risks. It would also slow down care when a core focus of medicine over the last several decades has been to reduce the time from diagnosis to treatment.

Here's a not uncommon scenario as an example; you start having pain in one side, fatigue and a rash, so you make an appointment with your doctor.  Upon examination, the doctor thinks it could be one of three different things, A, B or C.  A is somewhat common, no life threatening but the test is often inconclusive and takes several days. B is uncommon but potentially severe; its test is expensive but you get the results immediately. C is somewhat rare, the diagnosis is inexpensive but often painful (an injection with acute muscle soreness lasting for days).

If we ask the patient to take responsibility for the financial decisions, s/he will have to start calling around to various clinics asking for the costs of A/B/C. This patient would need to call several places and get quotes on three different proceedures - s/he might make a matrix showing which place has the best cost for which proceedure. Since the cheapest test might be someplace else, it delays a diagnosis. Given human nature, the patient will typically avoid test B even though its the first test a doctor would recommend because a doctor will want to rule out the worst things first. When forced to make decisions based on economics a patient will go with the cheapest options first in the hopes that this will solve the problem - often putting themselves at risk if it is something else. Patients also tend to avoid tests that are painful simply because we have an aversion to pain - importantly the likelihood of someone going through with this test (C) goes down if they are given lots of time to procrastinate.  That's why a doctor's bedside manner training involves coaching a patient to take a test that is unpleasant.

All of this is for something that's fairly routine, and when the tests are simple.  Often one test won't give a definitive answer, but will lead to the next test - an x-ray will rule out a fractured rib, suggesting it could be an infection (requiring a blood panel) or acute inflammation (a sonogram).  Again the patient would need to start calling clinics to get prices for each procedure, then make a decision about which one to test for first. This diagnostic train can go on for several steps, and if the patient were responsible each step creates the potential for the individual to delay care and make the wrong decision.

I would shop around for A, B or C depending on the Dr's recommendation and my risk assessment. 

Let's look at MRI's.  I had 2 on the same body part last year.  One was $1300.  One was $400.  The $400 one had a better report.  The only reason for the $1300 bill was that one was associated with a hospital and one wasn't.  If I could shop up front, I would have saved $900.

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Re: What comes after the ACA?
« Reply #3307 on: July 21, 2017, 02:19:35 PM »
There are also benefits to receiving all your care from a single provider. They get to know you, you get to know them, they are more familiar with your history, etc. If you shop around for care and get each of your services from a different provider, you no longer have a long-term relationship with your primary provider and the benefits thereof. Sure, electronic health records are easy to transfer but 1) it's still not the same as having a provider who knows all of the details of your history, and 2) health care providers tend to have very bad cybersecurity practices, and the more you spread your PHI around, the more susceptible it is to ending up in a breach situation.

nereo

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Re: What comes after the ACA?
« Reply #3308 on: July 21, 2017, 02:21:47 PM »

I would shop around for A, B or C depending on the Dr's recommendation and my risk assessment. 

Let's look at MRI's.  I had 2 on the same body part last year.  One was $1300.  One was $400.  The $400 one had a better report.  The only reason for the $1300 bill was that one was associated with a hospital and one wasn't.  If I could shop up front, I would have saved $900.

I think, somehow, you missed my point.  Perhaps it is my fault for trying to make it detailed.
I simply think that placing the burden of reducing costs on the patient is exactly the wrong direction to go.  I'm all for greater transparency in pricing, and I concur that a large percentage of Americans have absolutely no idea how much their medical care or medical insurance costs, and why
But I just don't think a good solution is to the have patient be responsible for seeking out the lowest cost treatments.  IMO that's bad medicine, and ultimately our solutions should both reduce costs and improve care. I'm skeptical it can do much for the former for all the reasons listed above (and several others), and I'm certain it will harm care.

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Re: What comes after the ACA?
« Reply #3309 on: July 21, 2017, 02:30:34 PM »

I would shop around for A, B or C depending on the Dr's recommendation and my risk assessment. 

Let's look at MRI's.  I had 2 on the same body part last year.  One was $1300.  One was $400.  The $400 one had a better report.  The only reason for the $1300 bill was that one was associated with a hospital and one wasn't.  If I could shop up front, I would have saved $900.

I think, somehow, you missed my point.  Perhaps it is my fault for trying to make it detailed.
I simply think that placing the burden of reducing costs on the patient is exactly the wrong direction to go.  I'm all for greater transparency in pricing, and I concur that a large percentage of Americans have absolutely no idea how much their medical care or medical insurance costs, and why
But I just don't think a good solution is to the have patient be responsible for seeking out the lowest cost treatments.  IMO that's bad medicine, and ultimately our solutions should both reduce costs and improve care. I'm skeptical it can do much for the former for all the reasons listed above (and several others), and I'm certain it will harm care.

You aren't placing the burden on the patient, you are empowering the patient to make an informed decision.  Right now, you need the test and can choose to get the test or not get the test.  You have almost no idea what the test will cost.  If you are concerned enough, you get the test.

My ideal, you can choose to get the test (or not).  If you care about price, you can do some price comparison.

I've had a high deductible health plan for several years.  I can assure you it has never impacted my decision to have a necessary medical procedure one way or the other.  YMMV.

Either way, we need to reduce the cost of care in the US.

Dabnasty

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Re: What comes after the ACA?
« Reply #3310 on: July 21, 2017, 02:38:36 PM »
It's true that the fertility rate is indeed below the replacement level, but "not dramatically so"

Regarding pyramid scheme, you didn't exactly convince me there.  A pyramid scheme hopes to recruit additional people to support the existing population.  And I would expect additional babies to result in indefinite growth.  You could make the argument that an increased population does come with increased costs but also some economies of scale.  or you could be arguing that we are already relying on future generations to pick up our tab and the more people, the easier that would be.

What's wrong with having a steady state with a constant number of inhabitants?
Nothing, in fact I think that would be ideal. I'm guessing you didn't check the link provided earlier so I'll post the image. Apologies for not knowing how to size images, if it's even possible. Edit: the thumbnails big enough to see...close enough

What you're suggesting would almost certainly deter people from having children so the bottom of this chart would taper down further.
« Last Edit: July 21, 2017, 03:01:39 PM by Dabnasty »

nereo

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Re: What comes after the ACA?
« Reply #3311 on: July 21, 2017, 02:44:28 PM »

You aren't placing the burden on the patient, you are empowering the patient to make an informed decision.  Right now, you need the test and can choose to get the test or not get the test.  You have almost no idea what the test will cost.  If you are concerned enough, you get the test.

My ideal, you can choose to get the test (or not).  If you care about price, you can do some price comparison.

I've had a high deductible health plan for several years.  I can assure you it has never impacted my decision to have a necessary medical procedure one way or the other.  YMMV.

Either way, we need to reduce the cost of care in the US.

Saying that you are "empowering the patient to make an informed decision" just sounds like political spin to me. If it costs the patient the same amount regardless of which lab they use I don't see much empowerment nor incentive for the patient to shop around.  If you are going to structure health care in such a way where the patient pays more if s/he uses anything less than the lowest-cost provider around - that's a burden.  It requires the patient to do the leg work... make the calls, understand the outcomes, drive to a different clinic, etc.  It also places more risk on the patient, as s/he now must make a medical decision absent his/her doctor, and increase the time from diagnosis to treatment.

As I said before, I'm all for more knowledge of costs and transparency, but I would stress cost reduction from the top down, not from the bottom up. Limiting profits at all stages is certainly one of many ways this could be accomplished, but there's little political desire right now for that kind of fight.

runewell

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Re: What comes after the ACA?
« Reply #3312 on: July 21, 2017, 02:50:26 PM »
There are also benefits to receiving all your care from a single provider. They get to know you, you get to know them, they are more familiar with your history, etc. If you shop around for care and get each of your services from a different provider, you no longer have a long-term relationship with your primary provider and the benefits thereof.

I probably go to the doctor once a year, and never feel that any knowledge of my history greatly affects my current situation.  Sure, there are some instances where this could be valued by I feel it is generally overrated.

Dabnasty

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Re: What comes after the ACA?
« Reply #3313 on: July 21, 2017, 02:56:20 PM »
There are also benefits to receiving all your care from a single provider. They get to know you, you get to know them, they are more familiar with your history, etc. If you shop around for care and get each of your services from a different provider, you no longer have a long-term relationship with your primary provider and the benefits thereof.

I probably go to the doctor once a year, and never feel that any knowledge of my history greatly affects my current situation.  Sure, there are some instances where this could be valued by I feel it is generally overrated.
The relationship is more than just them knowing your history. People are more honest with people they're familiar with. Getting patients to be honest about embarrassing things is a big hurdle for doctors.

Midwest

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Re: What comes after the ACA?
« Reply #3314 on: July 21, 2017, 03:01:08 PM »

You aren't placing the burden on the patient, you are empowering the patient to make an informed decision.  Right now, you need the test and can choose to get the test or not get the test.  You have almost no idea what the test will cost.  If you are concerned enough, you get the test.

My ideal, you can choose to get the test (or not).  If you care about price, you can do some price comparison.

I've had a high deductible health plan for several years.  I can assure you it has never impacted my decision to have a necessary medical procedure one way or the other.  YMMV.

Either way, we need to reduce the cost of care in the US.

Saying that you are "empowering the patient to make an informed decision" just sounds like political spin to me. If it costs the patient the same amount regardless of which lab they use I don't see much empowerment nor incentive for the patient to shop around.  If you are going to structure health care in such a way where the patient pays more if s/he uses anything less than the lowest-cost provider around - that's a burden.  It requires the patient to do the leg work... make the calls, understand the outcomes, drive to a different clinic, etc.  It also places more risk on the patient, as s/he now must make a medical decision absent his/her doctor, and increase the time from diagnosis to treatment.

In the case of an HSA, it does cost me more.  Regarding risk, my Dr. orders an MRI.  I make the appointment.  That's how it works now.  The only difference is I can now shop for the cheapest MRI should I so choose.

As I said before, I'm all for more knowledge of costs and transparency, but I would stress cost reduction from the top down, not from the bottom up. Limiting profits at all stages is certainly one of many ways this could be accomplished, but there's little political desire right now for that kind of fight.

I would like to see cost reduction from both the top and bottom in medical care.  The current increases are unsustainable.  Regarding the political desire comment, completely agree no appetite for dealing with the cost side of the issue.

nereo

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Re: What comes after the ACA?
« Reply #3315 on: July 21, 2017, 03:04:13 PM »
There are also benefits to receiving all your care from a single provider. They get to know you, you get to know them, they are more familiar with your history, etc. If you shop around for care and get each of your services from a different provider, you no longer have a long-term relationship with your primary provider and the benefits thereof.

I probably go to the doctor once a year, and never feel that any knowledge of my history greatly affects my current situation.  Sure, there are some instances where this could be valued by I feel it is generally overrated.
The relationship is more than just them knowing your history. People are more honest with people they're familiar with. Getting patients to be honest about embarrassing things is a big hurdle for doctors.

It gets more important as you get older as well as for people with complicated medical histories.
A doctor who has known you for many years can also pick up on changes that a new doctor wouldn't realize was any different. Depression is a good example - to someone who has never met me I might just appear introverted, but normal. But my regular doctor realized was a big change in my mood from previous visits, and ultimately tied it to a side effect of some long-term medication.  This actually happened to me.

nereo

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Re: What comes after the ACA?
« Reply #3316 on: July 21, 2017, 03:10:24 PM »

You aren't placing the burden on the patient, you are empowering the patient to make an informed decision.  Right now, you need the test and can choose to get the test or not get the test.  You have almost no idea what the test will cost.  If you are concerned enough, you get the test.

My ideal, you can choose to get the test (or not).  If you care about price, you can do some price comparison.

I've had a high deductible health plan for several years.  I can assure you it has never impacted my decision to have a necessary medical procedure one way or the other.  YMMV.

Either way, we need to reduce the cost of care in the US.

Saying that you are "empowering the patient to make an informed decision" just sounds like political spin to me. If it costs the patient the same amount regardless of which lab they use I don't see much empowerment nor incentive for the patient to shop around.  If you are going to structure health care in such a way where the patient pays more if s/he uses anything less than the lowest-cost provider around - that's a burden.  It requires the patient to do the leg work... make the calls, understand the outcomes, drive to a different clinic, etc.  It also places more risk on the patient, as s/he now must make a medical decision absent his/her doctor, and increase the time from diagnosis to treatment.

In the case of an HSA, it does cost me more.  Regarding risk, my Dr. orders an MRI.  I make the appointment.  That's how it works now.  The only difference is I can now shop for the cheapest MRI should I so choose.


For something like an MRI - maybe. In many situations you can now have an MRI done the same visit in house.
What I"m talking about though is any of the thousands of procedures that can be run the day of my visit. If my doctor recommends test X, I don't want to go home, comparison shop, then call back and make an appointment with someone entirely new.  After I complete the test I have to decide whether to go back to my original doctor for a consult on the results I just had done with a different clinic.
That to me is moving medicine in the wrong direction.


Mr. Green

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Re: What comes after the ACA?
« Reply #3317 on: July 21, 2017, 04:11:28 PM »

Incidentally, my 1 hour outpatient surgery cost my insurance company $20k.  That's unconscionable.

And either we or our employers are paying for it.
No one should be paying it, that's the point. Read the following Time article. If you're an actuary I assume you know what a Chargemaster is. I'd love to see someone logically justify the numbers in this extensive research piece covering multiple patients, procedures, and states. I'm dying to see the business math behind the $7 alcohol swab when one can be bought for 0.955 cents. "We require this 732% markup in order to cover our costs and make a reasonable profit."

https://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf

jim555

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Re: What comes after the ACA?
« Reply #3318 on: July 21, 2017, 06:21:15 PM »
The Senate Parliamentarian has ruled against several provisions of the repeal and replace bill.  Meaning some changes would require 60 votes.
"https://www.budget.senate.gov/imo/media/doc/Background%20on%20Byrd%20Rule%20decisions_7.21[1].pdf"
« Last Edit: July 21, 2017, 07:35:19 PM by jim555 »

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3319 on: July 23, 2017, 07:02:13 PM »
The Senate Parliamentarian has ruled against several provisions of the repeal and replace bill.  Meaning some changes would require 60 votes.
"https://www.budget.senate.gov/imo/media/doc/Background%20on%20Byrd%20Rule%20decisions_7.21[1].pdf"

That's good news.

Regarding lowering the cost of health care in this country, one of the best ways to do it is tackle the issues of the 5% of patients that are responsible for a majority of health care costs. In many cases simply using a social worker to help insure these patients do a better job at taking prescribed medications, make basic lifestyle choices, etc. would yield a lowering of health care needed.

Additionally, standards of care for certain medical issues need to be researched. Prostate cancer treatments may in fact turn out to be largely unneeded. Research might determine that prostate surgery/radiation ultimately led to practically no change in outcomes for patient death rates, and in fact led to more disability.
Another example, is how cardiologists love to give stress tests to elderly above and beyond what is needed, in order to milk Medicare for money.

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Re: What comes after the ACA?
« Reply #3320 on: July 25, 2017, 01:07:42 PM »
One step closer to the ACA being repealed: the votes to proceed to debate split 50/50 and Pence will be casting the deciding vote.


DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3321 on: July 25, 2017, 01:17:10 PM »
Yuck. Not sure what happens now.

runewell

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Re: What comes after the ACA?
« Reply #3322 on: July 25, 2017, 02:17:28 PM »

No one should be paying it, that's the point. Read the following Time article. If you're an actuary I assume you know what a Chargemaster is. I'd love to see someone logically justify the numbers in this extensive research piece covering multiple patients, procedures, and states. I'm dying to see the business math behind the $7 alcohol swab when one can be bought for 0.955 cents. "We require this 732% markup in order to cover our costs and make a reasonable profit."

https://www.uta.edu/faculty/story/2311/Misc/2013,2,26,MedicalCostsDemandAndGreed.pdf

The only thing I can tell you is that the chargemaster values rarely came into play - sometimes they did.  Usually it was a % (more than 100%) of Medicare rates.  I don't think there is any rhyme or reason to it.  The patient simply doesn't get any say.  It's a ludicrous system.  Medicare provides useful information on the amount of effort required to provide medical services and that is a good starting point. 

Sort of like when you get your car worked on, at least in the past there would be a manual telling you that an axle change would require 1.5 hrs of labor, so you paid 1.5 x hourly charge + parts + shop supplies. 

They have the capability to do the same thing but I couldn't tell you exactly where their rates come from.

sol

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Re: What comes after the ACA?
« Reply #3323 on: July 25, 2017, 02:21:20 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.

ZiziPB

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Re: What comes after the ACA?
« Reply #3324 on: July 25, 2017, 03:09:37 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.
The whole thing is beyond ridiculous at this point.  What a waste of time and effort, only to satisfy Trump's insane desire for a "win". 

jim555

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Re: What comes after the ACA?
« Reply #3325 on: July 25, 2017, 03:32:48 PM »
They want to pass anything to get to the conference committee.  Then the Freedumb caucus in the committee can shape the final bill and they can try to cram it through.

katsiki

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Re: What comes after the ACA?
« Reply #3326 on: July 25, 2017, 03:40:56 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.

How do more people become uninsured if this bill doesn't change anything?  Those two seem in conflict.  What am I missing?

Lagom

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Re: What comes after the ACA?
« Reply #3327 on: July 25, 2017, 03:42:37 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.

Well the good news is, we may soon not have to worry about such pesky FAKE NEWS details like a CBO score:

https://www.washingtonpost.com/news/powerpost/wp/2017/07/24/congressional-budget-office-is-freedom-caucuss-target-in-spending-bill/?utm_term=.019b9435a010

Optimiser

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Re: What comes after the ACA?
« Reply #3328 on: July 25, 2017, 03:43:10 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.

How do more people become uninsured if this bill doesn't change anything?  Those two seem in conflict.  What am I missing?

Some healthy people will choose not to buy insurance because the penalty is gone. This will raise the cost of insurance for everyone else, which will result in additional people not being able to afford insurance, or choosing not to purchase it at the higher price.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3329 on: July 25, 2017, 03:44:51 PM »
Moreover less people will be directed to Medicaid because without the mandate being enforced, these individuals will not find out that would have qualified for Medicaid.

sol

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Re: What comes after the ACA?
« Reply #3330 on: July 25, 2017, 03:55:47 PM »
Newest GOP health care proposal being pitched today is called a "skinny bill" because it does nothing except change the penalties for violating the mandates to zero dollars.  But doesn't touch Medicaid.

CBO scoring of a previous version of this proposal suggests 15 million additional uninsured people and a 20% spike in premiums, which makes it the best republican idea floated so far because it does the least damage.  It also doesn't fix any of the current problems and enhances the death spiral, but it is at least less stupidly and unnecessarily cruel to people.

How do more people become uninsured if this bill doesn't change anything?  Those two seem in conflict.  What am I missing?

Some healthy people will choose not to buy insurance because the penalty is gone. This will raise the cost of insurance for everyone else, which will result in additional people not being able to afford insurance, or choosing not to purchase it at the higher price.

Right, the point of the mandates was to get everyone paying into the insurance pools in order to lower costs for everyone.  Without a mandate, some people who do not buy insurance will still receive medical care, and everyone who does buy insurance ends up paying for it.  The mandate was designed to fix the freeloader problem. 

Repealing the mandates will cause fewer people to have insurance, and premiums to rise for those people who do have it.

The skinny bill proposal doesn't do nothing, it does one very specific thing.  It repeals the mandates (and some of the taxes).
« Last Edit: July 25, 2017, 03:57:43 PM by sol »

Lagom

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Re: What comes after the ACA?
« Reply #3331 on: July 25, 2017, 04:27:56 PM »
If any of you clicked on the links in that spam post, I hope your computer is recently backed up.  Google docs links are spreading ransomware like wildfire these days.  Do not touch.

Man, that was an especially lazy one too. Terribly written.

Optimiser

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Re: What comes after the ACA?
« Reply #3332 on: July 25, 2017, 04:31:45 PM »
If any of you clicked on the links in that spam post, I hope your computer is recently backed up.  Google docs links are spreading ransomware like wildfire these days.  Do not touch.

Man, that was an especially lazy one too. Terribly written.

I've heard that stuff like that is poorly written on purpose to weed out intelligent people. People who don't notice poor grammar and spelling apparently make better targets.

shuffler

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Re: What comes after the ACA?
« Reply #3333 on: July 25, 2017, 04:53:10 PM »
Can we get the mods to delete this or at least deactivate the links?
Gah.  Don't quote the spam.

katsiki

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Re: What comes after the ACA?
« Reply #3334 on: July 25, 2017, 04:53:22 PM »
I did the report to mod button.  I am sure one of them will zap it pretty soon.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3335 on: July 25, 2017, 06:29:07 PM »
And the spam is gone. Wish we could get rid of the Republican efforts

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3336 on: July 26, 2017, 07:46:09 AM »
I think the penalty on the individual mandate was supposed to get higher over time.

While currently at $695, the penalty seems to be toothless, but if someone discovers that the penalty is not much less than the cost of having an insurance plan for the year after subsidies kick in, then it might just be worth having the insurance anyway. This individual is likely to be a healthier young person who doesn't make a high income, and this group probably helps to stabilize the risk pool of the insurance market.

Also, if you scroll down to the middle of page 56 I posted a graph (from a healthcare journalist's blog) of how the ACA requires all three legs of the stool to exist in order to have a stable health insurance market. It shows where the mandate fits into that.
https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/2750/
« Last Edit: July 26, 2017, 07:51:26 AM by DavidAnnArbor »

shenlong55

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Re: What comes after the ACA?
« Reply #3337 on: July 26, 2017, 07:57:05 AM »
I think the penalty on the individual mandate was supposed to get higher over time.

While currently at $695, the penalty seems to be toothless, but if someone discovers that the penalty is not much less than the cost of having an insurance plan for the year after subsidies kick in, then it might just be worth having the insurance anyway. This individual is likely to be a healthier young person who doesn't make a high income, and this group probably helps to stabilize the risk pool of the insurance market.

Also, if you scroll down to the middle of page 56 I posted a graph (from a healthcare journalist's blog) of how the ACA requires all three legs of the stool to exist in order to have a stable health insurance market. It shows where the mandate fits into that.
https://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/2750/

I thought the penalty was $695 OR 2.5% of your AGI, whichever is higher.

jim555

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Re: What comes after the ACA?
« Reply #3338 on: July 26, 2017, 07:59:57 AM »
I believe the tax is the greater of $695 or 2.5% of income.  That is not a small tax.  A $50,000 income would have a $1,250 tax.
As long as you never get a tax refund the IRS has no way to collect it.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3339 on: July 26, 2017, 08:06:18 AM »
Oh yes I stand corrected about the penalty.

DarkandStormy

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Re: What comes after the ACA?
« Reply #3340 on: July 26, 2017, 08:23:08 AM »
https://www.vox.com/policy-and-politics/2017/7/25/15880262/republicans-health-hearings-repeal

There were 22 public Senate hearings in 2009 on the ACA (and 22 public House hearings as well).

In 2017, the GOP held ZERO public Senate hearings on Repeal/Repeal & Replace/Trumpcare.

**** the GOP.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3341 on: July 26, 2017, 08:29:41 AM »
The NY Times editorial really spells out the sabotage of health care repeal,

"Republican senators sent a troubling message to insurers, doctors and hospitals. Many insurers must soon finalize rates and policies for next year, and experts say some might decide not to participate because they think the A.C.A. insurance marketplaces will go away, or jack up premiums due to the political uncertainty."

The Senate’s Health Care Travesty
https://nyti.ms/2tI9BDe

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3342 on: July 26, 2017, 08:41:44 AM »
Today Senators have to vote on spur of the moment amendments that they barely understand and which have not been vetted by independent experts nor scored by the CBO.
It's a vote a rama effort by McConnell to get 50 votes on a "skinny" repeal/replace.

WhiteTrashCash

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Re: What comes after the ACA?
« Reply #3343 on: July 26, 2017, 08:50:21 AM »
On the plus side for us, I think that Vanguard's health sector index fund could be deeply discounted soon after the shenanigans in Congress crush healthcare stocks, so we could all get some cheap shares. Silver linings and everything.

DarkandStormy

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Re: What comes after the ACA?
« Reply #3344 on: July 26, 2017, 08:55:04 AM »
On the plus side for us, I think that Vanguard's health sector index fund could be deeply discounted soon after the shenanigans in Congress crush healthcare stocks, so we could all get some cheap shares. Silver linings and everything.

Haha legitimately just texted a friend I was considering cashing out on VHT today and waiting for it to drop to buy back in.

sol

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Re: What comes after the ACA?
« Reply #3345 on: July 26, 2017, 11:02:57 AM »
As of right now, it looks like the Senate Republicans will successfully pass some version of the skinny bill, repealing only the most unpopular parts of the ACA (the mandates that make the premiums affordable).  Not because that's what they want, but because that allows them to take the bill to conference committee, behind closed doors, where they can then "resolve the differences" between the Senate and the House bills and produce pretty much any bill they want to without needing a majority.

This tactic hinges on them being able to pass something, anything, through the Senate with 51 votes.  It looks like they could pass a bill changing the name from the ACA to the AHCA and making no other changes, and still get to take it to conference committee.

So yea, I'm still predicting they pass a "repeal" and then declare victory, regardless of what actually changes in the law.

brooklynguy

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Re: What comes after the ACA?
« Reply #3346 on: July 26, 2017, 11:32:25 AM »
Not because that's what they want, but because that allows them to take the bill to conference committee, behind closed doors, where they can then "resolve the differences" between the Senate and the House bills and produce pretty much any bill they want to without needing a majority.

The end-product of conference committee reconciliation negotiations would still need to be approved by a majority of both chambers.  By all logic, one would think that if Senate Republicans can't come up with a plan amongst themselves that can win the approval a majority of their members, then there's no way a joint committee with the House (with which Senate Republicans have even bigger policy differences than amongst themselves) can either.  However, logic and reason appear to have lost all predictive power in this process, so I won't rule anything out.

GenXbiker

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Re: What comes after the ACA?
« Reply #3347 on: July 26, 2017, 11:35:50 AM »
Another thing, they can stop paying CSR at anytime.   The failed Senate bill would have extended those payments for two years, and the last I heard, they are going to be paid this month.   If that stops, that's another negative effect on premiums and providers withdrawing from specific markets.

Mr. Green

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Re: What comes after the ACA?
« Reply #3348 on: July 26, 2017, 02:10:34 PM »
So the vote didn't pass on repeal only. With all the last minute changes, I'm confused as to what exactly they voted on. Was this the "skinny repeal"?

sol

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Re: What comes after the ACA?
« Reply #3349 on: July 26, 2017, 02:25:21 PM »
So the vote didn't pass on repeal only. With all the last minute changes, I'm confused as to what exactly they voted on. Was this the "skinny repeal"?

No, skinny vote will come at the end iff they can't manage to pass anything else more severe.  I think that what just failed was "full ACA repeal with a 2 year delay to come up with a replacement".