Author Topic: What comes after the ACA?  (Read 655474 times)

NoStacheOhio

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Re: What comes after the ACA?
« Reply #3950 on: November 15, 2017, 09:53:10 AM »
Just curious, I'd assume the folks worried about this are not FIRE yet right?  Because if you're FIRE, you're not working so you have $0 AGI and would qualify for Medicaid in most states, no?

Capital gains, dividends, retirement withdrawals and passive income all counts toward AGI.
The first step is acknowledging you have a problem, right?

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Exflyboy

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Re: What comes after the ACA?
« Reply #3951 on: November 15, 2017, 09:57:52 AM »
Just curious, I'd assume the folks worried about this are not FIRE yet right?  Because if you're FIRE, you're not working so you have $0 AGI and would qualify for Medicaid in most states, no?

Capital gains, dividends, retirement withdrawals and passive income all counts toward AGI.

Plus rent.. Many retirees have rentals as part or all of their income.. And don't forget pensions.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3952 on: November 15, 2017, 10:03:08 AM »
The ACA puts a cap on the most the Feds will pay in subsidies and CSRs to 0.504% of GDP.  Starting in 2019 the subsidy percentages are adjusted if the total exceeds 0.504%, causing the amount paid by person to increase.  This will become a big factor over the next several years.

I didn't realize that. Yikes! Does anyone have data on where current payouts are relative to that cap? Subsidy payouts are obviously going to go up significantly next year although the should be partially offset by the absence of CSRs.

(Learning stuff like this is why I really enjoy participating in these discussions.)

I'm pretty confident that the subsidies and CSR's are nowhere near $75 billion a year.

protostache

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Re: What comes after the ACA?
« Reply #3953 on: November 15, 2017, 10:09:29 AM »
The ACA puts a cap on the most the Feds will pay in subsidies and CSRs to 0.504% of GDP.  Starting in 2019 the subsidy percentages are adjusted if the total exceeds 0.504%, causing the amount paid by person to increase.  This will become a big factor over the next several years.

Can you provide a cite for that? I don’t see it in a quick read of PPACA Section 1402.36B and gross domestic product only appears once in reference to Medicare target growth rates.

NoStacheOhio

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Re: What comes after the ACA?
« Reply #3954 on: November 15, 2017, 10:13:33 AM »
Just curious, I'd assume the folks worried about this are not FIRE yet right?  Because if you're FIRE, you're not working so you have $0 AGI and would qualify for Medicaid in most states, no?

Capital gains, dividends, retirement withdrawals and passive income all counts toward AGI.

Plus rent.. Many retirees have rentals as part or all of their income.. And don't forget pensions.

I filed that under "passive income" ;)

Though I suppose that underestimates the business of landlording.
The first step is acknowledging you have a problem, right?

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jim555

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Re: What comes after the ACA?
« Reply #3955 on: November 15, 2017, 10:21:53 AM »
The ACA puts a cap on the most the Feds will pay in subsidies and CSRs to 0.504% of GDP.  Starting in 2019 the subsidy percentages are adjusted if the total exceeds 0.504%, causing the amount paid by person to increase.  This will become a big factor over the next several years.

Can you provide a cite for that? I don’t see it in a quick read of PPACA Section 1402.36B and gross domestic product only appears once in reference to Medicare target growth rates.
See page 3:
https://www.gpo.gov/fdsys/pkg/PLAW-111publ152/pdf/PLAW-111publ152.pdf
See page 6 (page 2 on doc):
http://www.ncsl.org/documents/health/hlthinspremcredits.pdf

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #3956 on: November 15, 2017, 10:42:02 AM »
1.  Subsidies aren't keeping up with insurance premium increases, and certainly not offsetting the reductions in coverage and deductible increases.  2.  Do you really think the government is going to pay more in the future to support a subsidized system through 2020?  They can't wait for it to crash and burn (as it is currently doing in a slow train-wreck that is accelerating, if you hadn't noticed).

The worst possible place to be going forward is 'too much income to be on Medicaid' but too little wealth and/or income to have options.

I don't think #1 is supported by the data. People who qualify for subsidies are actually seeing their prices come down this year (for bronze and gold level plans anyway, silver plans are generally flat), and deductibles are basically maxed out for plans at each insurance level, so as far as I know deductibles aren't actually increasing.

#2 is certainly a valid concern. The premium subsidy increases are automatic process that would require a vote of congress to change. Right now our government is so dysfunctional that I doubt it could get a consensus to actually successfully pass ANYTHING. But I'll stipulate that is certainly subject to change in each coming election.

That's one piece of it, just where is the comprehensive data?  I have seen lots of anecdotes ('increased rate' datapoints in MMM's comments section, for instance).  Hard to make any sense of it, since it varies state by state, individual by individual. 

What I think should be of bigger concern to people depending on subsidies is that they can be reduced or taken away at any time.  It's pretty easy to get the IRS to back charge you for your 2018 benefit, since they already have the paperwork.  The current administration is trying really hard to come up with savings to offset their tax cuts, which create larger defects as the corporate rates drop going forward.  I, personally, would not be expecting subsidies to successfully offset increases for 2019, and maybe not even for all of 2018 if you brush up on the tax reform proposals.   
Transitioning to FIRE'd albeit somewhat cautiously...

jim555

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Re: What comes after the ACA?
« Reply #3957 on: November 15, 2017, 10:57:56 AM »
They are not looking at ACA overhaul, only the individual mandate in the tax proposals.  So for now things will stay the same.

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #3958 on: November 15, 2017, 10:58:07 AM »
The ACA puts a cap on the most the Feds will pay in subsidies and CSRs to 0.504% of GDP.  Starting in 2019 the subsidy percentages are adjusted if the total exceeds 0.504%, causing the amount paid by person to increase.  This will become a big factor over the next several years.

I didn't realize that. Yikes! Does anyone have data on where current payouts are relative to that cap? Subsidy payouts are obviously going to go up significantly next year although the should be partially offset by the absence of CSRs.

(Learning stuff like this is why I really enjoy participating in these discussions.)

I'm pretty confident that the subsidies and CSR's are nowhere near $75 billion a year.

How confident are you?  75 billion divided by the 10 million people participating is $7,500 per plan. 

Quote
"Repealing the individual mandate without a workable alternative will reduce enrollment, further destabilizing an already fragile individual and small group health insurance market on which more than 10 million Americans rely," the coalition wrote. "Eliminating the individual mandate by itself likely will result in a significant increase in premiums, which would in turn substantially increase the number of uninsured Americans."
Transitioning to FIRE'd albeit somewhat cautiously...

AdrianC

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Re: What comes after the ACA?
« Reply #3959 on: November 15, 2017, 11:30:49 AM »
What I think should be of bigger concern to people depending on subsidies is that they can be reduced or taken away at any time.
It should be clear to everyone by now that our FIRE budget needs to include health insurance cost without subsidy. The subsidy is a bonus.

Trede

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Re: What comes after the ACA?
« Reply #3960 on: November 15, 2017, 11:42:59 AM »
Regarding the current subsidies and CSR annual payouts, I was curious so looked them up.

This article estimates the 2017 premium subsidies at $42.6 billion: https://www.cbsnews.com/news/obamacare-subsidies-to-jump-10-billion-in-2017/

This article cites a CBO estimate for the 2017 CSR payments at $7 billion: http://www.foxnews.com/politics/2017/10/13/cost-sharing-reduction-payments-what-are-subsidies-trump-cut.html

So, close to $50 billion in 2017.

protostache

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Re: What comes after the ACA?
« Reply #3961 on: November 15, 2017, 12:25:31 PM »
How confident are you?  75 billion divided by the 10 million people participating is $7,500 per plan. 

  • GDP in 2016 was $18.46 trillion. 0.504% of that is $93 billion
  • KFF counts 10 million people enrolled in the marketplaces in 2017 but only 8 million receive the premium tax credit.
  • KFF further estimates that the Federal government will spend $38 billion on premium tax credits in 2017. Add in about $7 billion for CSRs gets us to $45 billion

To get anywhere close to the limit the average premium for the second lowest cost silver plan nationwide would have to more than double while simultaneously GDP and income growth holding steady. Possible, yes, but highly unlikely in the next 10 years, even with individual mandate repeal.

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #3962 on: November 15, 2017, 12:34:18 PM »
Thanks for the info and links Trede.  Your number seems to line up with this:



What melts my brain is trying to figure out what happens when the individual mandate is removed.  Healthy and younger people drop out (reducing CSR + subsidy spending) which causes insurers to raise rates on the smaller remaining pool of people (some of whom cause CSR + subsidy spending to increase). 
Transitioning to FIRE'd albeit somewhat cautiously...

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #3963 on: November 15, 2017, 12:36:40 PM »
By the way, thanks for the informed discussion everyone, I'll be the first to admit that I'm not all that well plugged in since this doesn't affect me (yet).... what kicked me off on looking deeper into this at this time is the repeated claim that all of this tax + ACA reform is 'helping the middle class'...
Transitioning to FIRE'd albeit somewhat cautiously...

geekette

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Re: What comes after the ACA?
« Reply #3964 on: November 15, 2017, 01:08:18 PM »
Just curious, I'd assume the folks worried about this are not FIRE yet right?  Because if you're FIRE, you're not working so you have $0 AGI and would qualify for Medicaid in most states, no?

Capital gains, dividends, retirement withdrawals and passive income all counts toward AGI.

Most states /= all states.  Map

protostache

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Re: What comes after the ACA?
« Reply #3965 on: November 15, 2017, 01:08:44 PM »
Regarding the current subsidies and CSR annual payouts, I was curious so looked them up.

This article estimates the 2017 premium subsidies at $42.6 billion: https://www.cbsnews.com/news/obamacare-subsidies-to-jump-10-billion-in-2017/

This article cites a CBO estimate for the 2017 CSR payments at $7 billion: http://www.foxnews.com/politics/2017/10/13/cost-sharing-reduction-payments-what-are-subsidies-trump-cut.html

So, close to $50 billion in 2017.

Just FYI, the CBS article is from December 2016 while KFF's numbers are based on actual enrollment for plan year 2017 through February.

Thanks for the info and links Trede.  Your number seems to line up with this:

EscapeVelocity2020 that image is President Obama's requested 2017 budget and doesn't line up with what actually ended up getting passed in September.

Quote
What melts my brain is trying to figure out what happens when the individual mandate is removed.  Healthy and younger people drop out (reducing CSR + subsidy spending) which causes insurers to raise rates on the smaller remaining pool of people (some of whom cause CSR + subsidy spending to increase). 

Yeah, it's really confusing. CBO is basically projecting that the non-subsidized market is going to evaporate and a large number of people are going to drop off of Medicaid (I don't quite understand why). Also some people with employer-sponsored insurance are going to lose it, but again I don't understand why. Subsidies are going to go up both because the pool will be sicker and because nobody is expecting CSRs to get paid ever again, but the government will save $338 billion over 10 years, primarily in reduced Medicaid spending.

jim555

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Re: What comes after the ACA?
« Reply #3966 on: November 15, 2017, 01:22:43 PM »
I am puzzling over why Medicaid spending would drop.  I guess because without a penalty people won't sign up for Medicaid?

BigRed

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Re: What comes after the ACA?
« Reply #3967 on: November 15, 2017, 01:30:00 PM »
No, it's because many people only find out they are eligible for Medicaid when they go to the exchanges and shop for healthcare.  Without the mandate, and with the premiums rising due to the reduction in unsubsidized healthy buyers, many won't go look on the exchanges, and won't find out they are eligible.  Presto, fewer on Medicaid.

protostache

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Re: What comes after the ACA?
« Reply #3968 on: November 15, 2017, 01:32:24 PM »
No, it's because many people only find out they are eligible for Medicaid when they go to the exchanges and shop for healthcare.  Without the mandate, and with the premiums rising due to the reduction in unsubsidized healthy buyers, many won't go look on the exchanges, and won't find out they are eligible.  Presto, fewer on Medicaid.

That makes perfect sense and also makes me very sad.

ZiziPB

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Re: What comes after the ACA?
« Reply #3969 on: November 15, 2017, 01:58:35 PM »
No, it's because many people only find out they are eligible for Medicaid when they go to the exchanges and shop for healthcare.  Without the mandate, and with the premiums rising due to the reduction in unsubsidized healthy buyers, many won't go look on the exchanges, and won't find out they are eligible.  Presto, fewer on Medicaid.

That makes perfect sense and also makes me very sad.

Yes, I think throwing in the mandate repeal is making a lot of people sad and angry.  Here is one exchange quoted in this article: https://www.bloomberg.com/news/articles/2017-11-15/senate-plan-guts-obamacare-sunsets-many-cuts-tax-debate-update

Quote
In one notable exchange, Democratic Senator Claire McCaskill of Missouri sparred with Hatch by disputing his comment that ending the Obamacare mandate wouldn’t harm health-care coverage.

“Where do you think the $300 billion is coming from? Is there a fairy that’s dropping it on the Senate?” she said. “This is such a scam. So don’t trot out your righteous indignation saying you’re helping poor people by repealing this tax penalty.”



DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3970 on: November 15, 2017, 02:13:23 PM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

maizeman

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Re: What comes after the ACA?
« Reply #3971 on: November 15, 2017, 02:18:48 PM »
Regarding the current subsidies and CSR annual payouts, I was curious so looked them up.

This article estimates the 2017 premium subsidies at $42.6 billion: https://www.cbsnews.com/news/obamacare-subsidies-to-jump-10-billion-in-2017/

This article cites a CBO estimate for the 2017 CSR payments at $7 billion: http://www.foxnews.com/politics/2017/10/13/cost-sharing-reduction-payments-what-are-subsidies-trump-cut.html

So, close to $50 billion in 2017.

Thanks so much for digging this up Trede!

Exflyboy

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Re: What comes after the ACA?
« Reply #3972 on: November 15, 2017, 02:43:50 PM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

Looks like this might be another Republican clusterfuck.

Normally I would be rubbing my hands with glee but the market will tank if tax reform falls apart.. At least in the short term

AdrianC

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Re: What comes after the ACA?
« Reply #3973 on: November 15, 2017, 06:05:57 PM »
To get anywhere close to the limit the average premium for the second lowest cost silver plan nationwide would have to more than double while simultaneously GDP and income growth holding steady. Possible, yes, but highly unlikely in the next 10 years, even with individual mandate repeal.
Our silver plan is going up 80% for 2018. With this, our health insurance cost would have quintupled over the last ten years.

We're going back to Bronze for 2018 and should get a subsidy, so no problem. But, I totally can see nationwide rates more than doubling in the next ten years. Probably more like the next two years.

protostache

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Re: What comes after the ACA?
« Reply #3974 on: November 15, 2017, 07:01:33 PM »
To get anywhere close to the limit the average premium for the second lowest cost silver plan nationwide would have to more than double while simultaneously GDP and income growth holding steady. Possible, yes, but highly unlikely in the next 10 years, even with individual mandate repeal.
Our silver plan is going up 80% for 2018. With this, our health insurance cost would have quintupled over the last ten years.

We're going back to Bronze for 2018 and should get a subsidy, so no problem. But, I totally can see nationwide rates more than doubling in the next ten years. Probably more like the next two years.

The massive 2018 increases should be a one time thing. CSR offsets will almost certainly be baked exclusively into on-exchange Silver plans in every state for plan year 2019, which means off-exchange Silver and all Bronze and Gold plans should only see medical inflation rate changes. If more states are able to institute reinsurance waivers like MN and AK then those states should see corresponding decreases.

GuitarStv

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Re: What comes after the ACA?
« Reply #3975 on: November 16, 2017, 08:26:56 AM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

Looks like this might be another Republican clusterfuck.

Normally I would be rubbing my hands with glee but the market will tank if tax reform falls apart.. At least in the short term

You should be rubbing your hands with glee then (assuming you're still in the accumulation phase).

radram

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Re: What comes after the ACA?
« Reply #3976 on: November 16, 2017, 08:35:01 AM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

He is my Senator, and I know his work pretty well. I don't read very much into what he is saying right now. He is not really a no in the most common sense. In reality, he is saying no because taxes for some businesses are not cut enough. He will end up a yes. It still might not pass, but not due to a no from him. He is no McCain.

tyort1

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Re: What comes after the ACA?
« Reply #3977 on: November 16, 2017, 10:42:39 AM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

Looks like this might be another Republican clusterfuck.

Normally I would be rubbing my hands with glee but the market will tank if tax reform falls apart.. At least in the short term

This is why diversifying into something like real estate with renters providing you cash flow can be a good idea. 
Frugalite in training.

GettingClose

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Re: What comes after the ACA?
« Reply #3978 on: November 16, 2017, 11:18:28 AM »
Something needs to happen.  In our county we have one option on the exchange (in gold/silver/bronze varieties).  There are no other companies offering health insurance in our county, even going outside the exchange (we checked the websites of every major insurer in our state and consulted with an insurance agent).  For a Bronze plan, it will be approximately $1750/month for my husband and me.  Fortunately, my work covers $515/month of my premium, and his practice will pay all of his.

We've been toying with the idea of FIRE next year, but $21000 a year for very bad health insurance?  We'd have to add $30k a year to the budget to be safe.  One case where costs are going to go up in retirement, rather than down.  No way our income is going to be below the amount for subsidies.  We've decided to move.

Exflyboy

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Re: What comes after the ACA?
« Reply #3979 on: November 16, 2017, 11:49:38 AM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

Looks like this might be another Republican clusterfuck.

Normally I would be rubbing my hands with glee but the market will tank if tax reform falls apart.. At least in the short term

You should be rubbing your hands with glee then (assuming you're still in the accumulation phase).

I'm not..:)

Exflyboy

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Re: What comes after the ACA?
« Reply #3980 on: November 16, 2017, 11:54:57 AM »
This whole tax cut scheme may be doomed if Senator Ron Johnson won't even vote for it.

Sen. Ron Johnson (R., Wis.) said he opposes the Senate Republican tax package, saying it unfairly benefits corporations more than other types of businesses.
“If they can pass it without me, let them,” Mr. Johnson said in an interview Wednesday. “I’m not going to vote for this tax package.”

Looks like this might be another Republican clusterfuck.

Normally I would be rubbing my hands with glee but the market will tank if tax reform falls apart.. At least in the short term

This is why diversifying into something like real estate with renters providing you cash flow can be a good idea.


I have...:).. Actually I have had renters since I bought my property in 1997. The rent allowed me to pay off the mortgage in 6 years and 3 months. Now we are FIRED the rent pays basically 2/3rds of our base spend.

I don't particularly enjoy the rental business (even though we have had great renters). I get a pension in 4 years time that should equal the rent so that might be a good time to get out of the landlord game.. Or not..:)

Bateaux

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Re: What comes after the ACA?
« Reply #3981 on: November 17, 2017, 04:11:20 AM »
I'm back to thinking in a post ACA United States it may be best to move after FIRE.  It's much cheaper in the rest of the world.
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Exflyboy

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Re: What comes after the ACA?
« Reply #3982 on: November 17, 2017, 12:56:57 PM »
I'm back to thinking in a post ACA United States it may be best to move after FIRE.  It's much cheaper in the rest of the world.

Could well be. We could afford the current rates (unsubsised) if we wanted to stay here.. but, holy cow $20k (its $14k now) for basically a catastrophic plan, thats just hard to stomach!

Of course selling everything (or renting out the house) and emigrating is not exactly inconsequential either!

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #3983 on: November 17, 2017, 01:32:14 PM »

In Virginia those that don't qualify for subsidies are experiencing sticker shock at the price of health insurance on the exchange
Middle-Class Families Confront Soaring Health Insurance Costs
https://nyti.ms/2jxoZhM

In another article the range of costs for medical procedures is mind-boggling:
"The price of an M.R.I., for example, is 12 times higher in the most expensive markets than in the least expensive ones, and can vary by a factor of nine even within the same area."
"Mississippi’s infant mortality rate puts it on par with Botswana and Bahrain."
"If all states were to improve to the level of top performers, we’d see gains across the country: 20 million more people insured and 14 million fewer skipping care because of cost; 12 million more adults screened for cancer and 500,000 more children vaccinated; 124,000 fewer hospital readmissions and 90,000 fewer premature deaths."
What States Can Learn From One Another on Health Care
https://www.nytimes.com/2017/11/16/upshot/what-states-can-learn-from-one-another-on-health-care.html

gerardc

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Re: What comes after the ACA?
« Reply #3984 on: November 17, 2017, 05:34:28 PM »
End the mandate.  Rates rise since only the sick will buy insurance and not the young and healthy.  Those over the 400% line get screwed while those under 400% get mostly made whole by subsidies.  Federal government pays billions more.  Sounds like another sabotage backfire.

I'm not convinced about that statement. Even young/healthy people would buy at least high-deductible insurance to protect themselves from catastrophic scenarios, no? Not everyone has a $1m+ stash and willing to self insure. Plus, they're not doing away with the credits IIUC so it seems removing the mandate will only affect a small minority.

Exflyboy

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Re: What comes after the ACA?
« Reply #3985 on: November 17, 2017, 06:48:28 PM »
I know several young (invincible) people who earn too much to qualify for Medicaid but decide to pay the fine rather than pay for insurance because "Its too expensive".

Take away the penalty and that can only get worse.
« Last Edit: November 17, 2017, 07:03:00 PM by Exflyboy »

ixtap

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Re: What comes after the ACA?
« Reply #3986 on: November 17, 2017, 06:54:18 PM »
End the mandate.  Rates rise since only the sick will buy insurance and not the young and healthy.  Those over the 400% line get screwed while those under 400% get mostly made whole by subsidies.  Federal government pays billions more.  Sounds like another sabotage backfire.

I'm not convinced about that statement. Even young/healthy people would buy at least high-deductible insurance to protect themselves from catastrophic scenarios, no? Not everyone has a $1m+ stash and willing to self insure. Plus, they're not doing away with the credits IIUC so it seems removing the mandate will only affect a small minority.

They didn't before the ACA, why would they once the penalty is removed? As a nomadic academic, I know I spent a lot of 3-4 month gaps hoping nothing happened, well into my 30s. I couldn't even afford COBRA coverage when it was offered.

gerardc

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Re: What comes after the ACA?
« Reply #3987 on: November 17, 2017, 07:55:49 PM »
I know several young (invincible) people who earn too much to qualify for Medicaid but decide to pay the fine rather than pay for insurance because "Its too expensive".

Take away the penalty and that can only get worse.

Right, I understand the rationale, but it sounds like speculation to me that the number of people who will forego insurance will be appreciable. What if it is 1% and turns out to be negligible? I think that's what is implied by that proposal...

There is still an annual open-enrollment window, so someone who becomes sick with no insurance won't be able to jump in right away, and can be wrecked financially in the meantime. So I'm not convinced the pool of "invincible" will be large enough to make a difference.

GuitarStv

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Re: What comes after the ACA?
« Reply #3988 on: November 18, 2017, 06:51:54 AM »
So, if you're an invincible person and go in to an ER . . . who pays for your treatment?  Do you just go into tremendous debt, get left to die, or does everyone else pick up the tab through increased fees?

ixtap

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Re: What comes after the ACA?
« Reply #3989 on: November 18, 2017, 08:43:45 AM »
So, if you're an invincible person and go in to an ER . . . who pays for your treatment?  Do you just go into tremendous debt, get left to die, or does everyone else pick up the tab through increased fees?

Both, actually. The debt is on your record, but the hospital has to make up the loss. And don't forget some tax dollars thrown in because we don't want the hospitals to fail.

This scenario was actually a huge part of the need for reform. Hospitals are not allowed to turn emergencies away, and in exchange for requiring this, the government subsidizes indigent patients.

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Re: What comes after the ACA?
« Reply #3990 on: November 18, 2017, 08:49:02 AM »
So if they get rid of the mandate...  Go naked.  If you get sick quit your job and apply for Medicaid, since it has no open enrollment.  Make sure you are in a state that has expanded.  Have enough money to cover the initial ER visit and visits in the first month.  This will cover you until the next open enrollment.

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Re: What comes after the ACA?
« Reply #3991 on: November 18, 2017, 10:55:08 AM »
Hospitals will do the bare minimum to get you back on your feet and out the door.

Then they will write off the care you received and never paid at the BS sticker price.

nereo

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Re: What comes after the ACA?
« Reply #3992 on: November 18, 2017, 11:07:18 AM »
Hospitals will do the bare minimum to get you back on your feet and out the door.

Then they will write off the care you received and never paid at the BS sticker price.
^this.
I'm so tired of this false narrative that hospitals will give comprehensive care to people in need regardless of their ability to pay.  What hospitals will do is stabilize a life threatening condition and then send you on your merry way (with debt around you neck and creditors on your heels). 

For example, if you are in a car crash they will stitch you up and splint your bones. You'll leave with a script for pain killers and antibiotics, but those are meaningless if you can't pay for them.  You will not be given physical therapy to rehabilitate injured muscles nor will they perform surgery to repair and reset joints (so called: 'quality of life' procedures necessary to return to pre-accident range of motion and function).  The official plan for anyone without an ability to pay is to 'stabilize and discharge' even when that leads to future problems down the road (inability to walk properly, potential for infection etc.)
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Nightwatchman9270

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Re: What comes after the ACA?
« Reply #3993 on: November 20, 2017, 08:55:20 AM »
Hospitals will do the bare minimum to get you back on your feet and out the door.

Then they will write off the care you received and never paid at the BS sticker price.
^this.
I'm so tired of this false narrative that hospitals will give comprehensive care to people in need regardless of their ability to pay.  What hospitals will do is stabilize a life threatening condition and then send you on your merry way (with debt around you neck and creditors on your heels). 

For example, if you are in a car crash they will stitch you up and splint your bones. You'll leave with a script for pain killers and antibiotics, but those are meaningless if you can't pay for them.  You will not be given physical therapy to rehabilitate injured muscles nor will they perform surgery to repair and reset joints (so called: 'quality of life' procedures necessary to return to pre-accident range of motion and function).  The official plan for anyone without an ability to pay is to 'stabilize and discharge' even when that leads to future problems down the road (inability to walk properly, potential for infection etc.)

That's complete bullsh!t.  If you fracture your femur in a car accident they aren't going to "splint" it.  You are getting surgery if it's indicated in the United States.  Period.  The hospital and doctors suck up the loss.  If they are lucky there's a CAT fund that will at least cover the 10's of thousands worth of equipment needed to internally fixate a femur.  I'm not saying our medical system is flawless but talk about a false narrative....


To the Original Post:  I would speculate that Single-Payer is going to be a reality within 10 years once the exchanges implode.
« Last Edit: November 20, 2017, 09:08:49 AM by Nightwatchman9270 »

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Re: What comes after the ACA?
« Reply #3994 on: November 20, 2017, 09:07:03 AM »
Hospitals will do the bare minimum to get you back on your feet and out the door.

Then they will write off the care you received and never paid at the BS sticker price.
^this.
I'm so tired of this false narrative that hospitals will give comprehensive care to people in need regardless of their ability to pay.  What hospitals will do is stabilize a life threatening condition and then send you on your merry way (with debt around you neck and creditors on your heels). 

For example, if you are in a car crash they will stitch you up and splint your bones. You'll leave with a script for pain killers and antibiotics, but those are meaningless if you can't pay for them.  You will not be given physical therapy to rehabilitate injured muscles nor will they perform surgery to repair and reset joints (so called: 'quality of life' procedures necessary to return to pre-accident range of motion and function).  The official plan for anyone without an ability to pay is to 'stabilize and discharge' even when that leads to future problems down the road (inability to walk properly, potential for infection etc.)

That's complete bullsh!t.  If you fracture your femur in a car accident they aren't going to "splint" it.  You are getting surgery if it's indicated in the United States.  Period.  The hospital and doctors suck up the loss.  If they are lucky there's a CAT fund that will at least cover the 10's of thousands worth of equipment needed to internally fixate a femur.  Stick with subjects you know something about.  Medicine obviously ain't it.

It's not BS.  Yes, if you fracture your femur - which is considered a life-threatening condition - they will give you surgery.  But the hospital will not give you physical therapy, post-discharge medicine,  follow up care etc.  A hospital's directive is to stabilize and discharge.  Yes the doctors and hospital 'suck up' the loss for that patient but its not comprehensive care, as is being frequently alleged upthread.  The level of care and the end result if you are uninsured and unable to pay is not even remotely comparable to an individual with health insurance. And yes, this is a subject I have firsthand knowledge in.
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Re: What comes after the ACA?
« Reply #3995 on: November 23, 2017, 09:50:38 AM »
Hospitals will do the bare minimum to get you back on your feet and out the door.

Then they will write off the care you received and never paid at the BS sticker price.
^this.
I'm so tired of this false narrative that hospitals will give comprehensive care to people in need regardless of their ability to pay.  What hospitals will do is stabilize a life threatening condition and then send you on your merry way (with debt around you neck and creditors on your heels). 

For example, if you are in a car crash they will stitch you up and splint your bones. You'll leave with a script for pain killers and antibiotics, but those are meaningless if you can't pay for them.  You will not be given physical therapy to rehabilitate injured muscles nor will they perform surgery to repair and reset joints (so called: 'quality of life' procedures necessary to return to pre-accident range of motion and function).  The official plan for anyone without an ability to pay is to 'stabilize and discharge' even when that leads to future problems down the road (inability to walk properly, potential for infection etc.)

That's complete bullsh!t.  If you fracture your femur in a car accident they aren't going to "splint" it.  You are getting surgery if it's indicated in the United States.  Period.  The hospital and doctors suck up the loss.  If they are lucky there's a CAT fund that will at least cover the 10's of thousands worth of equipment needed to internally fixate a femur.  Stick with subjects you know something about.  Medicine obviously ain't it.

It's not BS.  Yes, if you fracture your femur - which is considered a life-threatening condition - they will give you surgery.  But the hospital will not give you physical therapy, post-discharge medicine,  follow up care etc.  A hospital's directive is to stabilize and discharge.  Yes the doctors and hospital 'suck up' the loss for that patient but its not comprehensive care, as is being frequently alleged upthread.  The level of care and the end result if you are uninsured and unable to pay is not even remotely comparable to an individual with health insurance. And yes, this is a subject I have firsthand knowledge in.

This isn't completely true either.  It depends on the hospital, but there is a significant risk management strategy going on in each individual case.

True: If you are deemed safe to go home by providers and hospital PT/OT, you will be discharged.   Resource information (for any available nationally or locally) will be provided to help with payment for any outpatient services that are being recommended and therapies will be scheduled.  The preferred method of rehab is outpt or at a skilled nursing facility.  Outcomes are better in these settings because they are designed to get you back on your feet (literally and figuratively), so are more intensive and longer in duration  Whereas these services in hospitals, tend to be designed only for the short term (ie make sure you don't get worse, evaluate for appropriate placement in next level of care, and provide basic education); hence are limited in number and duration.  An exception to this would be an acute rehab unit in a hospital; generally very limited in beds and for specific purposes only. 

Not True:  Hospitals do not generally"street" an uninsured patient who is not safe to return home based on hospital PT/OT evaluations AND does not have any means with which to pay out of pocket for SNF care.  This is a significant liability risk, and frankly, unethical.  Hence uninsured patients often end up with longer hospital stays while placement/payment (for SNF)  options are worked out with very hard working case managers and social workers.  Hospitals eat the cost of these longer stays.  This is not ideal as the inpatient PT and OT are not designed for longer term care.  Outcomes can suffer, although hard working therapy and nursing staff often try to find extra time in their days (forgoing breaks and lunches) to help these people who are stuck "in limbo" get at least some of the progressive therapy they need.
« Last Edit: November 23, 2017, 09:53:22 AM by Classical_Liberal »

accolay

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Re: What comes after the ACA?
« Reply #3996 on: December 03, 2017, 12:58:18 AM »
This isn't completely true either.  It depends on the hospital, but there is a significant risk management strategy going on in each individual case.

Think it also depends on the state. But right, we're not going to send a patient who can't care for themselves from hospital to home. We don't want people to come back especially within that 30 day window for readmission under Obamacare. Bad for liability, bean counters dislike those penalties and it looks bad on hospital reviews.

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Re: What comes after the ACA?
« Reply #3997 on: December 21, 2017, 12:25:19 PM »
Some potentially good news. The Administration has indicated they do not intend to go after Obamacare beyond the elimination of the individual mandate. So the ACA will most likely be around at least a few more years in its current condition, which is fine for anyone receiving a subsidy as long as an insurer is available.

https://amp.thedailybeast.com/trump-white-house-signals-it-will-abandon-obamacare-repeal
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jim555

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Re: What comes after the ACA?
« Reply #3998 on: December 21, 2017, 02:40:29 PM »
Some potentially good news. The Administration has indicated they do not intend to go after Obamacare beyond the elimination of the individual mandate. So the ACA will most likely be around at least a few more years in its current condition, which is fine for anyone receiving a subsidy as long as an insurer is available.

https://amp.thedailybeast.com/trump-white-house-signals-it-will-abandon-obamacare-repeal
Would be good news, but one minute to another and everything can change with this Administration.  I don't trust anything they say.

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Re: What comes after the ACA?
« Reply #3999 on: December 21, 2017, 04:56:40 PM »
Some potentially good news. The Administration has indicated they do not intend to go after Obamacare beyond the elimination of the individual mandate. So the ACA will most likely be around at least a few more years in its current condition, which is fine for anyone receiving a subsidy as long as an insurer is available.

https://amp.thedailybeast.com/trump-white-house-signals-it-will-abandon-obamacare-repeal

I hope they really do back off.  But I'm not letting my guard down.  This administration has shown time and again that it has no qualms about abandoning promises and telling outright lies.

And Susan Collins got rolled big time when she fell for Mitch McConnell's promise to take up the ACA stabilization measures in the budget bill.  Once the tax bill passed, it was, "oh, nevermind."  I saw that coming a mile away; I can't imagine why she didn't.
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