Author Topic: What comes after the ACA?  (Read 1916290 times)

Exflyboy

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Re: What comes after the ACA?
« Reply #3650 on: October 10, 2017, 04:28:24 PM »
yeah and Flovent inhaler at $205 for a stupid inhaler... All neatly protected by patents..

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3651 on: October 10, 2017, 04:31:17 PM »
And cardiologists making a ridiculous $400,000 a year.

lbmustache

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Re: What comes after the ACA?
« Reply #3652 on: October 10, 2017, 07:15:44 PM »
And cardiologists making a ridiculous $400,000 a year.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

nereo

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Re: What comes after the ACA?
« Reply #3653 on: October 11, 2017, 04:14:35 AM »
And cardiologists making a ridiculous $400,000 a year.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially.  Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #3654 on: October 11, 2017, 04:48:46 AM »
I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially.  Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

I don't disagree with anything you've said, but now we have to drill another level deeper and figure out (1) why medical school costs so much, and (2) why the insane working hours exist.  I haven't researched it, but I'm wondering if med schools are experiencing the same kind of price inflation that is going on at most institutions of higher learning.  If so, that means we need to take a hard look at eliminating the ballooning layers of non-instructor administration, and controlling inflated salaries in the administration that remains.  I don't have a clue about the insane working hours - maybe one of the physicians who have been participating in this thread could enlighten us.

ZiziPB

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Re: What comes after the ACA?
« Reply #3655 on: October 11, 2017, 04:55:53 AM »
And cardiologists making a ridiculous $400,000 a year.

It's much more than that.  20+ years ago, I worked for an estate planning lawyer.  One of his clients was a cardiologist making $800,000 a year.  Back in the early 1990s.

Anyway, another issue with our system here is how many expensive specialists we have and how often we see them.  Countries that keep their medical costs care down rely a lot more on primary physicians.  Think about how NHS operates and the ratio of GPs to consultants.

ketchup

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Re: What comes after the ACA?
« Reply #3656 on: October 11, 2017, 07:52:28 AM »
And cardiologists making a ridiculous $400,000 a year.
And how much is their malpractice insurance?

farmecologist

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Re: What comes after the ACA?
« Reply #3657 on: October 11, 2017, 07:54:48 AM »
And cardiologists making a ridiculous $400,000 a year.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I think salaries are a very big part of the fundamental problem that our health care costs too damn much per person. The counterargument for why physicians, parituclarly specialists, sohuld be compensated so highly are the factors you mention (extensive schooling, training, hours) in addition to the huge cost of going to medical school in teh first place. If we addressed how much it cost to go ot medical school physicians' salaries could be reduced substantially.  Our current psuedo-free makret approach leads to more people choosing highly specialized fields (rather than primary care) precisely because the 'trade-off' is worth the extra couple years of residency when the up-front financial burden (med-school) is so great and the increased end payoff (extermely high salary) is several times larger.

It's worth noting that many other developed countries have similar trainning requirements (4 years of medical school + residency) and doctor's salaries are 30-50% less, but the patient outcome is remarkably similar. Eliminate or reduce the up-front medical school debt and address the insane working hours (particulary for residents) and we could have doctors who make a more healthy and wel compensated living on $80-125k/year.

I had an interesting observation this summer when our daughter visited a former exchange student friend in Argentina ( tip : if your kid wants to travel the world...tell them to get to know the exchange students! ). 

Anyway, the mother of this friend is an ER surgeon.  However, they live what we would call a 'middle class' life.  They live in a small two bedroom apartment, etc... Nothing extravagant at all.  In fact the average physician salary in argentina is only around 40K USD.  On the other hand, medical training is top notch..and very low cost for the individual.  And they are actually working to control medical costs...imagine that.

    https://teleport.org/cities/buenos-aires/salaries/

So expectations will need to change if we ever go the 'socialized medicine single payer' route.  This will be a tough nut to crack.  First of all, our entire system of medical training will have to change.  Most medical students go into incredible debt...and even worse debt for specialist training.  However, they easily pay that back due to the expectation of large salaries, etc...  And by looking at the homes and lifestyles of many doctors around here, they are doing incredibly well ( we live at the home of the Mayo Clinic ). 

No good answers here ( and I'm not sure there are any)..but I just wanted to share this personal observation.


GuitarStv

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Re: What comes after the ACA?
« Reply #3658 on: October 11, 2017, 08:12:26 AM »
And cardiologists making a ridiculous $400,000 a year.

That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

sol

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Re: What comes after the ACA?
« Reply #3659 on: October 11, 2017, 08:58:47 AM »
That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

That's Canadian money, it doesn't count. 

Most medical students go into incredible debt...and even worse debt for specialist training.  However, they easily pay that back due to the expectation of large salaries

I don't see this as any different from any other market bubble.  Real estate prices are so high because rents are so high!  Salaries are so high because profits are so high!  Gold is so high because everyone is buying it!  It will pop eventually, and not just for doctors.  All higher education has to come down in relative price.

And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration.  Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries.  They are what we need to bring down health care costs in America.  Wildly unrestricted immigration policies for anyone with an MD would be a good start.  Let's import some of that foreign talent. 

Restrictive immigration policies are part of the reason why American healthcare costs so much.  We pay our doctors too much, in part because American medical training costs so much.  But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage.  All we have to do is stop refusing them permission to immigrate.


Inaya

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Re: What comes after the ACA?
« Reply #3660 on: October 11, 2017, 09:06:49 AM »
Yeah but nobody wants stupid, lazy brown people performing medical procedures on them. (I say this sarcastically, but I know there are plenty of people with this mindset.)

nereo

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Re: What comes after the ACA?
« Reply #3661 on: October 11, 2017, 12:34:16 PM »
That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

That's Canadian money, it doesn't count. 

Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.

...
And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration.  Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries.  They are what we need to bring down health care costs in America.  Wildly unrestricted immigration policies for anyone with an MD would be a good start.  Let's import some of that foreign talent. 

Restrictive immigration policies are part of the reason why American healthcare costs so much.  We pay our doctors too much, in part because American medical training costs so much.  But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage.  All we have to do is stop refusing them permission to immigrate.
Immigration could certainly lower costs here, but the doctors and their lobbies have put up the mother of all protective moats. You cannot be a trained doctor in, say, the UK (or Canada!), move to the US and continue practicing as a doctor right away. In most cases it takes several years to become board-certified should your medical degree come from another country, even when everyone openly admits that your country has essentially identical medical standards and practices.  It's even harder if you get your degree in a country where the general population has skin darker than Nikki Haley.  For most, the main option available to practice medicine in the US involves going back to medical school in the US - even if they've been a practicing cardiologist for the last two decades in their home country.

In short - US doctors don't want to compete with foreign-trained doctors, and the system is set up explicitly to prevent this from happening.
« Last Edit: October 11, 2017, 12:46:38 PM by nereo »

GuitarStv

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Re: What comes after the ACA?
« Reply #3662 on: October 11, 2017, 12:42:13 PM »
That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

That's Canadian money, it doesn't count. 


Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.


I got a chuckle out of it.  :P

Paul der Krake

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Re: What comes after the ACA?
« Reply #3663 on: October 11, 2017, 01:25:57 PM »
Also, did sol just make the case for systematically draining talent from other countries at their expense? That's quite out of character.

maizefolk

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Re: What comes after the ACA?
« Reply #3664 on: October 11, 2017, 02:05:33 PM »
Note we already do this with nursing staff. If you go to lower income countries where english is widely spoken (think the Philippines) the USA draws off a lot of their most experienced and talented nurses. It's not a oneway street as the remittances from Filipinos working overseas contribute a significant fraction of the countries overall economy, but I gather we're still not too popular with hospital administrators over there.

For MDs I think the the board exams, which practicing physicians generally aren't able to pass without taking a lot of time off to restudy the material, plus the requirement to go back through the residency process in the USA along the difficulty of even getting a residency slot as a foreign trained MD, acts as the most significant barrier to bringing in more foreign trained MDs to bring down the cost of healthcare in the USA.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3665 on: October 11, 2017, 02:20:45 PM »
That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

That's Canadian money, it doesn't count. 

Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.


I think you are misunderstanding Sol's humor, he is playing the role of a Stephen Colbert who is imitating Bill O'Reilly in the Colbert Report.

nereo

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Re: What comes after the ACA?
« Reply #3666 on: October 11, 2017, 02:33:36 PM »
ok, maybe i misplaced my sense of humor this morning when i whacked my head on the boat in rough seas (true story).
I'll reinterpret Sol's comment as dry humor.

sol

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Re: What comes after the ACA?
« Reply #3667 on: October 11, 2017, 03:07:54 PM »
Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.

Jokes!  Just jokes.  I love our Canadian neighbors, their food, their women, their landscapes, their accents, and their civility.  And their healthcare.  But what kind of neighbour would I be if we couldn't trade a little light ribbing?

The other comments above about non-federal restrictions to importing more medical professionals are well taken, but those rules come from the same slightly racist and overtly protectionist mindset responsible for our immigration restrictions.  Doctors know they can command outrageous salaries only as long as they are a scarce resource, so they created barriers to entry in their field.  I know other professions have done the same.  That doesn't make it right.

And in a moment like this one, when the national conversation centers on improving access and lowering costs for Americans seeking healthcare, I think that reevaluating our protectionist policies is a good place to start. 

If you really want to solve this enormous and intractable problem that has so efficiently divided the nation, which has stymied congress and spawned so many pages of this very thread and thousands of others like it across the internet, maybe consider just talking to the AMA about changing those rules?

Also, did sol just make the case for systematically draining talent from other countries at their expense? That's quite out of character.

Yes I did.  We do it with programmers and engineers.  We do it with agricultural workers, and manicurists, and drywall mudders, and taxi drivers.  In previous generations we did it with police officers and nuclear scientists.  America was built by stealing the most talented and motivated people from every other country and offering them a chance at a better life here, with more freedoms and more opportunity and hopefully with more prosperity.  I see no reason to deny this part of our history.  Our diversity is a big part of our success.

So yes, by all means drain those foreign talent pools.  They also get to try to drain ours.  May the best country win.
« Last Edit: October 11, 2017, 04:09:32 PM by sol »

Exflyboy

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Re: What comes after the ACA?
« Reply #3668 on: October 11, 2017, 03:33:23 PM »
Exactly! If we hadn't whitewashed the Nazi war records and given them jobs in the US we wouldn't have NASA!

https://en.wikipedia.org/wiki/Operation_Paperclip

If it worked for the space program using thoroughly unpleasant people I'm sure we could do it with Doctors.. Human body is the same the World over.

EnjoyIt

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Re: What comes after the ACA?
« Reply #3669 on: October 11, 2017, 08:39:10 PM »
I love this talk about cost reduction and doctor salaries.  Kudos to everybody.  My thoughts are likely very biased considering I get a doctors salary but here are my comments on some of the topics above:

Doctors have the potential to make a high income.  Not all doctors.  Salaries range by geography and specialty.  Some doctors make slightly over $100k while others can make over $1 million.  In fact the average income for a physician is under $250k/yr which in my opinion is not to absurd for the education and work that they do (remember I am biased.)  Don't forget because of our progressive tax code, making $250k/yr is not twice as good as make $125k/yr.  Also doctors pay steep licensing and continuing medical education fees as well as malpractice insurance which lowers that income substantially.  Also of note many physicians work well over 40 hours a week.  It is not uncommon for 60-80 hour work weeks which allows them to make such a large income.  Lastly most physician salaries have gone down comparative over the decades.  Cardiologist don't make $800k like they used to.  Actually the MACRA reimbursement model has a programed in rise in reimbursement that is below inflation.  Which means compensation will continue to decrease as the years go by. I promise you it is not all roses for everyone.

I fully agree that the cost of becoming a doctor is outrageous.  It is not uncommon to come out of residency with over $300k+ in school debt.  Speaking of education.  Many countries have medical school as part of undergrad and then they do a residency.  This saves 4 years of education and debt as compared to the US. I'm sure physicians would be more amicable to lower wages if their education was fully funded. And BTW, because of the progressive tax code the interest rate on school loans is not tax deductible.

It is idiotic, but physicians are expected to live the "physician lifestyle." Therefor you can not judge how well a physician is doing financially by the car they drive or the latest vacation they went to. I know plenty of physicians who are broke despite driving a BMW to work every day.  Very un-mustachian.

Someone brought up the AMA which in my opinion is a joke and in bed with CMS and lobbyists.  They do not advocate for physicians and I refuse to give them money. I doubt anyone can get any positive leeway with that organization.

Regarding foreign doctors:  The US has a very robust foreign trained doctor program. Currently 25% of our physician workforce is a foreign graduate.  Many are Middle Eastern, Indian, Pakistani and Asian. The only time I have an issue with a foreign doctor is when their English is so bad that their patients have a hard time understanding them.  It is rare, but it happens.  You can't treat a patient if they can't follow your recommendations. More immigrant physicians would definitely help with the supply demand curve and the free market would lower their compensation naturally over time.  For example doctors in NY and California are some of the lowest paid while working in Wisconsin or Alaska they can make a fortune. 

TLDR, most docs do not make the crazy income described.  This is especially true when considering the amount of overtime they work, their higher tax bracket, their school debt, their malpractice insurance, and all those licensing fees. Also, physician reimbursement has been on the chopping block for decades and continues to go down adding to the burnout and dissatisfaction of our physicians.  In reality, to curb the cost of healthcare salaries will also have to go down, but so should education costs, licensing fees, malpractice insurance and maybe even taxes for those who provide unreimbursed care to the poor.  I think we want our docs to be compensated well not obscene, but well enough so that bright young minds choose to do medicine instead of wall street.

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Re: What comes after the ACA?
« Reply #3670 on: October 12, 2017, 04:44:29 AM »
EnjoyIt, thanks for giving us your physician's perspective on the compensation issue.  Just out of curiosity, how much are we talking about on an annual basis for licensing fees, malpractice insurance, and unreimbursed costs of treating indigent patients?  I'm sure those costs vary a lot from place to place and from specialty to specialty, but can you give us some ballpark ranges?

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Re: What comes after the ACA?
« Reply #3671 on: October 12, 2017, 05:31:48 AM »
And cardiologists making a ridiculous $400,000 a year.

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference.  Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

nereo

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Re: What comes after the ACA?
« Reply #3672 on: October 12, 2017, 07:19:33 AM »

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference. 

Interesting.  Source?

farmecologist

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Re: What comes after the ACA?
« Reply #3673 on: October 12, 2017, 08:05:57 AM »
And cardiologists making a ridiculous $400,000 a year.

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference.  Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality. 

I could say 'oh thats only x% of healthcare costs' for many other things.  They add up....

nereo

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Re: What comes after the ACA?
« Reply #3674 on: October 12, 2017, 08:30:42 AM »
And cardiologists making a ridiculous $400,000 a year.

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference.  Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality. 

I could say 'oh thats only x% of healthcare costs' for many other things.  They add up....
I'd have to agree, assuming the 10% cost stated above is correct.  In order to have the US's health care system be more in line with other developed nations, we need to cut per-capita cost by roughly 25-40%.† Obviously we aren't going to have physicians work for free, but a 30% reduction in salaries would get us about 10% of the way to that goal, and would put physicians salaries more in line with what they earn elsewhere.  Of course as EnjoyIt and others have noted it would take a wholesale change in the system, including altering the upfront cost of medical school and hours worked.


† The US spent $9,451 per person in 2015; the 'next 9' (all developed nations in Europe) & had a median cost of $5,267 and a max of $7,765.  Shooting "low" at a 25% reduction would put costs at $7,088 and leave the US still as the 2nd most expensive (after Luxembourg).  A 40% reduction ($5,670 per person) would still leave the US in the top 5 and still way ahead of Canada, the UK and Japan on a per-capita basis. Of course its never an apples-apples comparison due to differences in population, demographics etc but I think those 'goals' are a fair target

maizefolk

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Re: What comes after the ACA?
« Reply #3675 on: October 12, 2017, 09:10:24 AM »
We spend $3.2 trillion on healthcare each year. If 10% of that goes to MDs, that's $320 billion. The first estimate I found for the number of active doctors in the USA was about 850,000, or about $375,000 in spending per MD, which seems like it's in the right ballpark once you factor in the cost of fringe benefits (retirement and, or course, health insurance ;-) ). So it seems like the 10% number is plausible.

nereo

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Re: What comes after the ACA?
« Reply #3676 on: October 12, 2017, 09:27:03 AM »
We spend $3.2 trillion on healthcare each year. If 10% of that goes to MDs, that's $320 billion. The first estimate I found for the number of active doctors in the USA was about 850,000, or about $375,000 in spending per MD, which seems like it's in the right ballpark once you factor in the cost of fringe benefits (retirement and, or course, health insurance ;-) ). So it seems like the 10% number is plausible.
cut $10B here, $5B there... soon enough it adds up to some real money!

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Re: What comes after the ACA?
« Reply #3677 on: October 12, 2017, 09:32:46 AM »
And cardiologists making a ridiculous $400,000 a year.

I don't have a problem with their salary. Extensive schooling, extensive hours worked, extensive specialized knowledge. Other stuff is the problem.

I almost added this to one of my comments above, but I didn't want to seem like I was endorsing it: I predict that the first target of the inevitable cost reductions in healthcare, when they arrive, will be physician salaries.  Though they are a 10% piece of the health care pie, they are a highly visible one.  Plus, I think that people tend to direct their ire to the more visible targets that they see all around them (the rich doctor in the gated part of your upper middle class subdivision whose kids go to school with your kids) rather than the more egregious targets they don't have any contact with (the pharma CEO who you never see because he has an army of people to do his errands for him).  Also, physicians will be way less organized than the lobbying interests protecting CEOs, hospitals, insurance companies, etc.  Don't worry-they'll all be happy to blame doctors to take the heat off themselves.

Physician salaries are higher in the US, and they will inevitably come down.  But we can also hope that they come down together with treatment expenditures.  Perhaps some doctors will  see that their indifference to drug and other treatment prices will eventually lead to outcomes that personally affect them.  When you prescribe a drug because you think the pharma rep is hot, and it's 60x the cost of the first line treatment, that serves to destabilize the entire system.  Eventually, it will catch up to you.  That's not every doctor (and many doctors are wonderful about being honest about the dubious benefits of newer me-too drugs). 


nereo

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Re: What comes after the ACA?
« Reply #3678 on: October 12, 2017, 09:33:33 AM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

radram

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Re: What comes after the ACA?
« Reply #3679 on: October 12, 2017, 09:45:37 AM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


Also, why didn't he do this day 1?

farmecologist

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Re: What comes after the ACA?
« Reply #3680 on: October 12, 2017, 10:17:33 AM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


Also, why didn't he do this day 1?

Seems like it is about time for someone to test the limits of the executive order in court.  Or is that already happening?  Seems illogical that EOs can so easily undermine an act of congress like this.  But when has our government ever been logical?  :-)



JLee

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Re: What comes after the ACA?
« Reply #3681 on: October 12, 2017, 10:51:22 AM »
And cardiologists making a ridiculous $400,000 a year.

Physician salaries make up ~10% of healthcare spending, if they all worked for free it wouldn't be a huge difference.  Nevertheless, there are some MD salaries that are out of whack, but cardiologist are probably the last one's I'd complain about, they actually deal with high stakes life/death situations, I have no problem with their pay.

10% is a big chunk...thinking like this is the 'death by 1000 cuts' mentality. 

I could say 'oh thats only x% of healthcare costs' for many other things.  They add up....

Meanwhile, the top 14 pharma CEOs made $281.8 million in 2015.

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Re: What comes after the ACA?
« Reply #3682 on: October 12, 2017, 10:54:38 AM »
Speaking of studying medicine at the Bachelor's level. My niece is currently in Medical school in the UK (Mostly state funded).

She met her Cadaver in her first week at 18 years old.. fellow 18 year old car crash victim, especially chosen I'm sure.

Three of the class walked out and were never seen again, which if you're spending state resources to train them makes perfect sense in a harsh brutal sort of way.

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Re: What comes after the ACA?
« Reply #3683 on: October 12, 2017, 11:13:10 AM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA).  Once again people will be able to buy health insurance that doesn't cover much and costs less.  The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available.  Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance).  This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").

Quote
Also, why didn't he do this day 1?
Not even god can say why Trump does what he does, but I'm guessing its because thought the GOP, with control of both legislative branches, would unveil the wonderful plan they had been promising for 7 years and get it passed within the first 100 days.

Gin1984

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Re: What comes after the ACA?
« Reply #3684 on: October 12, 2017, 11:18:34 AM »
That doesn't sound too crazy.  In Canada's socialized system cardiologist salary starts at 174,000 with most experienced cardiologists making 348,000$  (https://neuvoo.ca/salary/cardiologist/).

That's Canadian money, it doesn't count. 

Most medical students go into incredible debt...and even worse debt for specialist training.  However, they easily pay that back due to the expectation of large salaries

I don't see this as any different from any other market bubble.  Real estate prices are so high because rents are so high!  Salaries are so high because profits are so high!  Gold is so high because everyone is buying it!  It will pop eventually, and not just for doctors.  All higher education has to come down in relative price.

And in an interesting twist that is rarely mentioned around these parts, the solution to this thread's problem is already being discussed in other threads: more immigration.  Those top notch doctors from Argentina, or Canada, or the UK will work for normal middle class salaries.  They are what we need to bring down health care costs in America.  Wildly unrestricted immigration policies for anyone with an MD would be a good start. Let's import some of that foreign talent. 

Restrictive immigration policies are part of the reason why American healthcare costs so much.  We pay our doctors too much, in part because American medical training costs so much.  But it's not a chicken-and-egg problem, because we already have access to millions of highly trained (on someone else's dime) medical professionals who desperately want to move to America and work for half of the typical US doctor's wage.  All we have to do is stop refusing them permission to immigrate.
Please don't.  I work with MDs from other countries who can't practice here because their standard of care is so different than the US.  And some of it, yes, would be ok but some of it would cause adverse outcomes.

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Re: What comes after the ACA?
« Reply #3685 on: October 12, 2017, 11:25:14 AM »
This rule change will be going to court.  Trying to change law by EO when you fail in congress is disgraceful, no matter who does it.

nereo

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Re: What comes after the ACA?
« Reply #3686 on: October 12, 2017, 11:45:45 AM »
This rule change will be going to court.  Trying to change law by EO when you fail in congress is disgraceful, no matter who does it.

You are not alone in believing this EO will wind up in the courts.  The article linked up-thread predicts as much, and both Trump's public statements and his actions appear to intentionally undermine federal law. 

More broadly speaking, such actions could be interpreted as further evidenec of DJT being unwilling to uphold the duties of his office.

protostache

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Re: What comes after the ACA?
« Reply #3687 on: October 12, 2017, 12:13:56 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

radram

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Re: What comes after the ACA?
« Reply #3688 on: October 12, 2017, 12:15:53 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA).  Once again people will be able to buy health insurance that doesn't cover much and costs less.  The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available.  Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance).  This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").


Thank you for the comment nero. Doesn't the death spiral only apply to ACA recipients that do NOT qualify for subsidies. I agree that those that remain in ACA plans will necessarily have more expensive plans since presumably the healthy people will leave, but aren't those on the subsidy protected to the tune of something like 90% of all cost increases? So if my subsidized plan for a family of 4 costs a total of $1200 per month, and my non-subsidized portion is $250 per month, and my plan then doubles in real dollars to $2400, won't my premium only increase something like another $50, or even not at all?

protostache

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Re: What comes after the ACA?
« Reply #3689 on: October 12, 2017, 12:26:39 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

I am very confused with this signing. Am I reading this right that it will now be possible to offer a health plan that covers less and then therefore theoretically costs less then a current ACA plan? If that is true, then many healthy people currently on ACA can leave it for one of these cheaper plans that cover less? At the same time, those with health problems on an ACA plan seemingly would want to stay on their plan, and could as long as that plan is still offered?
Wouldn't this lead to healthy people that do not get a subsidy leaving ACA, while sick subsidized people staying? Won't this cost the government MORE, not less?


What this does is allow small businesses and (potentially) individuals to skirt the ACA requirements for minimum coverage (the "essential benefits" listed in the ACA).  Once again people will be able to buy health insurance that doesn't cover much and costs less.  The fear (shared by most medical insurance companies as well as just about every patient group out there) is that we'll suddenly have lots of these plans available.  Health and young individuals will start buying those plans (skirting the insurance penalty for not having medical insurance).  This in turn will drive up the cost for those with ACA-style coverage, most notably those with a chronic health condition as well as the elderly, leading to much higher costs for those people (the so-called "rising premium death-spiral").


Thank you for the comment nero. Doesn't the death spiral only apply to ACA recipients that do NOT qualify for subsidies. I agree that those that remain in ACA plans will necessarily have more expensive plans since presumably the healthy people will leave, but aren't those on the subsidy protected to the tune of something like 90% of all cost increases? So if my subsidized plan for a family of 4 costs a total of $1200 per month, and my non-subsidized portion is $250 per month, and my plan then doubles in real dollars to $2400, won't my premium only increase something like another $50, or even not at all?

Correct. Premium subsidies are tied to your income in relation to the 2nd least expensive Silver plan (the benchmark) in your rating area. If you're eligible for subsidies at all you won't pay more than a legally mandated percentage of your income for the benchmark plan, no matter how much it costs. Table 2 here explains the breakdown, but say you're paying 2% of your income for health insurance (which is like $200 in that 100%-133% bracket) and the unsubsidized premium of the 2nd least expensive Silver plan goes from $1000 to $2000, your subsidy amount goes from $800 to $1800. This gets really weird when CSR offsets are loaded onto just Silver plans like what California is doing for 2018, because all of the sudden the Silver plans are way more expensive than anything else. People will be steered toward Gold plans with the same subsidized premium cost or Bronze plans with a zero dollar premium instead of the Silver plans.

Inaya

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Re: What comes after the ACA?
« Reply #3690 on: October 12, 2017, 12:31:08 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

Interesting...

I wonder if Trump even read it. He probably thinks he's signing the End of Obamacare (EO)--and nobody bothered to tell him the order was just to consider proposing some stuff. His base will eat it up, they'll not notice or care when nothing materially changes, and little damage is ultimately done--right? I wonder who was the actual power behind this EO.
« Last Edit: October 12, 2017, 12:32:40 PM by Inaya »

Exflyboy

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Re: What comes after the ACA?
« Reply #3691 on: October 12, 2017, 12:31:20 PM »
Yes the 90% of cost increases... Devil is in the details of course. in Oregon apparently costs have only risen by 15% from 2017 to 2018.

The way I see that my HC provider got around that was to simply cancel my policy..

"Oh we don't offer that policy anymore.. But you might be interested in THIS policy which offers slightly worse coverage than before".. The slightly worse coverage is not a big deal but then cost of the new plan is then +30% compared to the old one.

So while on aggregate costs may have increased 15%, in reality individual policies can be way off that mark.

So if as a subsidy payer you might be protected against cost increases, the question becomes is that in aggregate or for individual policy holders?

I.e do they protect you against the 30%, or do they protect you against the 15%.. but then stick you with the other 15%.. Big difference.


protostache

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Re: What comes after the ACA?
« Reply #3692 on: October 12, 2017, 12:34:48 PM »
Trump just signed an EO negating the ACA insurance rules. Directly undermines the ACA

So now we have no ACA replacement, nor is it repealed (the "repeal and replace" mantra of the GOP). Instead the WH continues to actively sabotage what health care we do have.  Seems the gameplan (basically admitted to by DJT) is to inflict as much pain and suffering as possible until they get their way.


https://www.washingtonpost.com/national/health-science/trump-to-sign-executive-order-to-gut-aca-insurance-rules-and-undermine-marketplaces/2017/10/11/40abf774-ae97-11e7-9e58-e6288544af98_story.html?hpid=hp_hp-more-top-stories_aca-execorder-615am%3Ahomepage%2Fstory&utm_term=.d2368a01f0c2

They released the actual text of the executive order just a few minutes ago. My reading says that this is a complete nothing burger. It's just another piece of paper for Trump to sign to make him feel like he's doing something.

The "order", such as it is, instructs the relevant departments to "consider" proposing new regulations and opinions that could expand access to AHPs and short term non-regulated insurance. The former will impact some small groups but that won't impact the risk pool substantially because the relevant law (ERISA) doesn't allow sole proprietors to join AHPs. The latter is a little bit more worrisome, but it only rolls the clock back to 2016. Up until Dec 31, 2016 short term non-regulated plans could last 364 days and that didn't meaningfully impact the risk pools at all.

Basically unless the Department of Labor breaks the law by allowing individuals (sole proprietors) to join AHPs, this doesn't significantly change the risk pools in a way that will impact subsidy eligible people. Unsubsidized participants are screwed but that's true generally absent state or federal reinsurance programs.

Interesting...

I wonder if Trump even read it. He probably thinks he's signing the End of Obamacare (EO)--and nobody bothered to tell him the order was just to consider proposing some stuff. His base will eat it up, they'll not notice or care when nothing materially changes, and little damage is ultimately done--right? I wonder who was the actual power behind this EO.

He didn't read it. If he did he didn't understand the impact of using the words "shall consider" instead of just "shall".

This is the president that didn't know what the 25th amendment was until Steve Bannon told him. He is not a detail oriented person.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3693 on: October 12, 2017, 09:42:45 PM »
Trump to Scrap Critical Health Care Subsidies, Hitting Obamacare Again

https://nyti.ms/2kKn0GP

Roland of Gilead

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Re: What comes after the ACA?
« Reply #3694 on: October 12, 2017, 10:18:28 PM »
Orange Asshole

mosprott

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Re: What comes after the ACA?
« Reply #3695 on: October 12, 2017, 11:55:54 PM »
Petulant baby.

The next few weeks are going to be a mad scramble.

ZiziPB

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Re: What comes after the ACA?
« Reply #3696 on: October 13, 2017, 05:34:16 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.

Mr. Green

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Re: What comes after the ACA?
« Reply #3697 on: October 13, 2017, 06:24:53 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.

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Re: What comes after the ACA?
« Reply #3698 on: October 13, 2017, 06:52:51 AM »
Sol - I generally find your comments to be a very high edition to this forum.  But the above is just snarky and mean.

Jokes!  Just jokes.  I love our Canadian neighbors, their food, their women, their landscapes, their accents, and their civility.  And their healthcare.  But what kind of neighbour would I be if we couldn't trade a little light ribbing?

The other comments above about non-federal restrictions to importing more medical professionals are well taken, but those rules come from the same slightly racist and overtly protectionist mindset responsible for our immigration restrictions.  Doctors know they can command outrageous salaries only as long as they are a scarce resource, so they created barriers to entry in their field.  I know other professions have done the same.  That doesn't make it right.

And in a moment like this one, when the national conversation centers on improving access and lowering costs for Americans seeking healthcare, I think that reevaluating our protectionist policies is a good place to start. 

If you really want to solve this enormous and intractable problem that has so efficiently divided the nation, which has stymied congress and spawned so many pages of this very thread and thousands of others like it across the internet, maybe consider just talking to the AMA about changing those rules?

Also, did sol just make the case for systematically draining talent from other countries at their expense? That's quite out of character.

Yes I did.  We do it with programmers and engineers.  We do it with agricultural workers, and manicurists, and drywall mudders, and taxi drivers.  In previous generations we did it with police officers and nuclear scientists.  America was built by stealing the most talented and motivated people from every other country and offering them a chance at a better life here, with more freedoms and more opportunity and hopefully with more prosperity.  I see no reason to deny this part of our history.  Our diversity is a big part of our success.

So yes, by all means drain those foreign talent pools.  They also get to try to drain ours.  May the best country win.

I used to pick on Canadians because I thought people from Alberta were just like my native Texas.

Then I learned about the maritime provinces, and how the party there basically never stops. Now, I just want to figure out how to move to one of those ;-)

ZiziPB

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Re: What comes after the ACA?
« Reply #3699 on: October 13, 2017, 07:09:33 AM »
The end of subsidies will effectively kill off the individual marketplaces, right?  I don't even have words for this.
The ACA is still the law of the land so insurance companies still have to give reduced premiums for those that qualify for subsidies. I believe everyone is locked in now for 2018. However, all insurance companies could walk away in 2019 if everyone making enough that they don't qualify for subsidies balk at the exchanges and insurance companies know they aren't being reimbursed for the subsidies any longer. If no legislation is passed I suspect the 2019 healthcare year will be a total shit show.

Thanks for the explanation.  I also heard on NPR this morning that the open enrollment period is being shortened this year and that the website where you sign up will be shut down weekly for maintenance.  So clearly significant effort is being made to ensure that the individual marketplace implodes as soon as next year.