What comes after the ACA?

[Classical_Liberal]

Let's say you are on your catastrophic plan and are diagnosed with a disease and your medicine cost just under 6 figures (my family has this situation).  Your 50 something and you have 10 or 15 years to go until you are eligible for medicare.  Now you will be part of the high risk group and because everyone else is on one of those catastrophic plans your premiums are $3000.00 a month (twice the cost of this plan now) for a plan with a $7000.00 annual deductible.  You now get to pay $43,000.00 a year for coverage or pay nearly 6 figures for medicine and pay for the catastrophic plan. 

Unfortunately, you will soon be low income and qualify for subsidies or medicare once you run out of money.

This single statement encapsulates all that is wrong with our healthcare system. 

A)You can pay premiums through various employers or independently for decades, then the moment you file a claim you're screwed.  Why would any sane person want to pay the premiums to begin with in this system?

B)Healthcare is too expensive in the US (this is a topic in itself)

C)When an uninsured person gets sick it becomes a problem for all of us.  In the US it's not morally OK to let sick people suffer simply because they don't have money.

It's identical to the retirement problem.  We don't want seniors living in the streets or starving... enter in SS.  A basic level backstop.  Everyone has to pay in because too many people are too stupid to do it for themselves. Stupid people's decisions cost the whole society.  The only way for it to remain solvent is for some wealth distribution.  This wealth distribution is worth it to the "well off" because it keeps the society in which they thrive functional.

If we really believe healthcare is a right in this country, we need to pony up and create a backstop.  You don't get the Cadillac care (just like SS recipients don't get million dollar pensions), but you do get preventative care to promote wellness and basic cares required to treat illness.  Private insurance and HSA's can fill the gap for people who want private-room birthing centers with massage treatments and catered meals.  Just like annuities and IRA's do for retirement.

Will the system be inefficient and wrought with crony capitalism? Absolutely!  It's big government!

But whats the alternative at this point?  At least once the gov't is directly paying the bills for all basic medical care our legislatures will be more motivated to figure out ways (with regulated capitalism) to reduce costs.

[Exflyboy]

The problem is that to those that matter (billionaires who use $$ to influence the government through lobbying groups) there is almost zero motivation to reduce the cost of HC.

Why?.. Well HC is 15% of the US economy. So 15% of their rather large dividend payments from their enormous portfolios comes from the HC industry.

So tell me what possible incentive is there to do anything other than let the HC industry gouge money from their captive market.. What does it matter if a few die along the way, thats just chump change. Heck we even have the FDA to act like the drug company lapdog that will one day soon start cracking down on Grandma buying her meds from Canada.

Fantastic system.. Nothing wrong with it as far as I can see!

[Radagast]

But whats the alternative at this point?  At least once the gov't is directly paying the bills for all basic medical care our legislatures will be more motivated to figure out ways (with regulated capitalism) to reduce costs.

I'd like to see an 80%-90% flat subsidy of all healthcare costs. Not free or universal. Also a requirement that prices must be displayed up front not less clearly than an average McDonald's or Apple website, and the provider cannot tack things on later except in emergency situations. Nobody gets free health care, but it is very, very cheap. That way there is still price competition. It still leaves room for charities, HSA's, and catastrophic insurance, but they are not generally necessary.

I thought of a graded scale by means and income, but decided that is too complicated and redundant with income tax.

[TheMCP]

I hope getting rid of the individual mandate will open up lower cost health insurance options to those who do not need everything the ACA offers. 

No disrespect meant, but I feel this is a little short sighted. 

Let's say you are on your catastrophic plan and are diagnosed with a disease and your medicine cost just under 6 figures (my family has this situation).  Your 50 something and you have 10 or 15 years to go until you are eligible for medicare.  Now you will be part of the high risk group and because everyone else is on one of those catastrophic plans your premiums are $3000.00 a month (twice the cost of this plan now) for a plan with a $7000.00 annual deductible.  You now get to pay $43,000.00 a year for coverage or pay nearly 6 figures for medicine and pay for the catastrophic plan. 

Unfortunately, you will soon be low income and qualify for subsidies or medicare once you run out of money.

The way things stand right now, wouldn't one just be able to sign up for a normal ACA marketplace plan at that point, since the preexisting condition protections still apply there?

[maizefolk]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

Essentially, it sounds like there is a major problem with many medical procedures which have been shown to provide no actual benefit to patients continue to be widely performed for years or decades after the science is in.

“Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”... Estimates vary about what fraction of the treatments provided to patients is supported by adequate evidence, but some reviews place the figure at under half. ...One study of [a campaign to encourage MDs to adopt evidence based medicine] examined seven procedures that have widely been shown to be ineffective, including imaging tests for “uncomplicated” headaches, cardiac imaging for patients without a history of heart problems, and routine imaging for patients with low-back pain. In the two-to-three-year period leading up to 2013, only two of the seven practices targeted for reduction showed any decrease at all in the US. (And the declines were tiny: The use of scans for those uncomplicated headaches decreased from 14.9 percent to 13.4 percent, for instance.)

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

[Exflyboy]

Yup as long as we keep paying they will keep providing!

[NaturallyHappier]

I hope getting rid of the individual mandate will open up lower cost health insurance options to those who do not need everything the ACA offers. 

No disrespect meant, but I feel this is a little short sighted. 

Let's say you are on your catastrophic plan and are diagnosed with a disease and your medicine cost just under 6 figures (my family has this situation).  Your 50 something and you have 10 or 15 years to go until you are eligible for medicare.  Now you will be part of the high risk group and because everyone else is on one of those catastrophic plans your premiums are $3000.00 a month (twice the cost of this plan now) for a plan with a $7000.00 annual deductible.  You now get to pay $43,000.00 a year for coverage or pay nearly 6 figures for medicine and pay for the catastrophic plan. 

Unfortunately, you will soon be low income and qualify for subsidies or medicare once you run out of money.

The way things stand right now, wouldn't one just be able to sign up for a normal ACA marketplace plan at that point, since the preexisting condition protections still apply there?

This is using an ACA Plan.

[Exflyboy]

Yes but that is not true as of today.. i.e you cannot be charged more for an ACA plan based on medical history (smoking not withstanding).

[freya]

Spreading risk among healthy and sick people is exactly the point of insurance.  How I wish universal coverage could become a reality, e.g. Medicare for all.

How about this for an idea:  Have Medicare kick in not just for age 65+ and people needing dialysis, but automatically for anyone who incurs more than $50,000 of medical expenses in a year.  In other words, government would backstop private insurers above this threshold.  This effectively increases the "very sick" risk pool to a nationwide one, which spreads risk around optimally.  Private insurers would have less excuse to increase rates, because now they don't have to plan for the relatively rare but catastrophic payouts that make it difficult to predict expenses.

This might be a form of universal coverage that even Republicans could stomach.  I'd be willing to see an increase in the Medicare tax to make this happen.

[protostache]

Spreading risk among healthy and sick people is exactly the point of insurance.  How I wish universal coverage could become a reality, e.g. Medicare for all.

How about this for an idea:  Have Medicare kick in not just for age 65+ and people needing dialysis, but automatically for anyone who incurs more than $50,000 of medical expenses in a year.  In other words, government would backstop private insurers above this threshold.  This effectively increases the "very sick" risk pool to a nationwide one, which spreads risk around optimally.  Private insurers would have less excuse to increase rates, because now they don't have to plan for the relatively rare but catastrophic payouts that make it difficult to predict expenses.

This might be a form of universal coverage that even Republicans could stomach.  I'd be willing to see an increase in the Medicare tax to make this happen.

This is called reinsurance. Alaska and Minnesota have state-based reinsurance programs, where the state backstops policies at $50k of claims. They have proven to reduce premiums by multiple tens of percents. The Federal government could easily implement this nationwide, and in fact there was a temporary nationwide reinsurance program that ended at the beginning of the 2017 plan year.

[rockeTree]

Would this run into the government-can’t-negotiate-drug-prices problem? If it’s the backstop for essentially everyone with a condition that’s very expensive to treat, any drug used only for that condition would become a blank check from the government for the developer (who will not, I can assure you, fill it out for “costs plus a reasonable margin”). But I’m not expert in this rule so may be wildly misunderstanding it...


Sent from my iPhone using Tapatalk

[DavidAnnArbor]

Spreading risk among healthy and sick people is exactly the point of insurance.  How I wish universal coverage could become a reality, e.g. Medicare for all.

How about this for an idea:  Have Medicare kick in not just for age 65+ and people needing dialysis, but automatically for anyone who incurs more than $50,000 of medical expenses in a year.  In other words, government would backstop private insurers above this threshold.  This effectively increases the "very sick" risk pool to a nationwide one, which spreads risk around optimally.  Private insurers would have less excuse to increase rates, because now they don't have to plan for the relatively rare but catastrophic payouts that make it difficult to predict expenses.

This might be a form of universal coverage that even Republicans could stomach.  I'd be willing to see an increase in the Medicare tax to make this happen.

This is called reinsurance. Alaska and Minnesota have state-based reinsurance programs, where the state backstops policies at $50k of claims. They have proven to reduce premiums by multiple tens of percents. The Federal government could easily implement this nationwide, and in fact there was a temporary nationwide reinsurance program that ended at the beginning of the 2017 plan year.

The advantage of reinsurance is that not only does the government cover the very sickest with very high health care costs, but the insurance companies then lower the cost of health insurance premiums, which means the federal government has lower subsidies to shell out. Those that don't qualify for subsidies at least can benefit from the lowered cost of health insurance.

[freya]

I didn't know about the Alaska plan, protostache.  It's by designated medical condition not a dollar amount, but same idea.  The immediate impact is impressive:  a 7% insurance rate increase instead of 42%, with insurers paying for the reinsurance.  So it works - why isn't everyone getting on that bandwagon???

Doing it through Medicare taxes instead of billing it to private insurance would be even better, as that means everyone paying FICA contributes to the reinsurance cost, and premiums would be still lower.  It would also provide a way for hospitals to recoup losses from caring for uninsured people who end up on their doorstep with a catastrophic condition - perhaps reducing hospital costs.  That and prescription drugs are far and away the biggest ticket items in health care costs, outside of billing & regulatory-related overhead.  Trying to reduce healthcare spending by cutting physician reimbursements for office visits is like trying to fund your grocery spending by fishing coins out of a soda machine.

I hope fixing the prescription drug issue is on the GOP's todo list, but with the amount of big pharma money flowing into campaign chests on both sides of the aisle, I'm not holding my breath.

[EnjoyIt]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims.  In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

As for over ordering tests.  I will agree we order too many studies in this country.  The reason is because physicians can't be wrong.  They can't miss anything. It is not just about being sued but also the risk of loosing your privileges at a hospital or losing your license. No one faults a physician for ordering too many tests.  But have a few misses by not ordering a CT and you will be forced out of your hospital.

[NoStacheOhio]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims.  In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

Maizeman just misinterpreted the article. Appropriate cardiac stenting doesn't include stenting when you're not having a cardiac event. Hopefully you know this, given that you have letters after your name.

[Gin1984]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims.  In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

Maizeman just misinterpreted the article. Appropriate cardiac stenting doesn't include stenting when you're not having a cardiac event. Hopefully you know this, given that you have letters after your name.

Actually the research article does not say that.  The research article said that stents do not increase exercise even though they increase blood flow.  Therefore given the risk of surgery, if you can stabilize with drugs, it may be a better choice to do so.  That is not always possible and there are other risk factors that may make waiting and trying with drugs contracindicated.  I hate to agree with EnjoyIt on anything but I have to agree with him here.  Rarely do popular news get research articles correctly (I've only seen it happen five times in my short career).

[NoStacheOhio]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims.  In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

Maizeman just misinterpreted the article. Appropriate cardiac stenting doesn't include stenting when you're not having a cardiac event. Hopefully you know this, given that you have letters after your name.

Actually the research article does not say that.  The research article said that stents do not decrease pain even though they increase blood flow.  Therefore given the risk of surgery, if you can stabilize with drugs, it may be a better choice to do so.  That is not always possible and there are other risk factors that may make waiting and trying with drugs contracindicated.  I hate to agree with EnjoyIt on anything but I have to agree with him here.  Rarely do popular news get research articles correctly (I've only seen it happen five times in my short career).

"Stable chest pain" isn't a cardiac event, and stents aren't indicated. We're talking about unstable chest pain.

[Gin1984]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims.  In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

Maizeman just misinterpreted the article. Appropriate cardiac stenting doesn't include stenting when you're not having a cardiac event. Hopefully you know this, given that you have letters after your name.

Actually the research article does not say that.  The research article said that stents do not decrease pain even though they increase blood flow.  Therefore given the risk of surgery, if you can stabilize with drugs, it may be a better choice to do so.  That is not always possible and there are other risk factors that may make waiting and trying with drugs contracindicated.  I hate to agree with EnjoyIt on anything but I have to agree with him here.  Rarely do popular news get research articles correctly (I've only seen it happen five times in my short career).

"Stable chest pain" isn't a cardiac event, and stents aren't indicated. We're talking about unstable chest pain.

There were two articles it referenced, I was editing.  The first article it referred then referred to pain.

[NoStacheOhio]

There were two articles it referenced, I was editing.  The first article it referred then referred to pain.

OK. Nobody really cares about pain. "Death" is really the primary focus for cardiac treatments. Stents are really good at preventing death related to unstable chest pain (aka heart attack).

If your doctor wants to schedule you a stent, run.

[golden1]

How about this for an idea:  Have Medicare kick in not just for age 65+ and people needing dialysis, but automatically for anyone who incurs more than $50,000 of medical expenses in a year.  In other words, government would backstop private insurers above this threshold.  This effectively increases the "very sick" risk pool to a nationwide one, which spreads risk around optimally.  Private insurers would have less excuse to increase rates, because now they don't have to plan for the relatively rare but catastrophic payouts that make it difficult to predict expenses.

I like this a lot, and I could see this appealing to both liberals and conservatives. 

[maizefolk]

To touch on the question of how you reduce healthcare costs again, it was fascinating to read this recent article, which appears to have been inspired by a recent study which demonstrated that inserting stents into arteries to treat chest pain works no better than a placebo surgery.

https://www.vox.com/the-big-idea/2017/12/28/16823266/medical-treatments-evidence-based-expensive-cost-stents

The bolded is some obnoxious drivel.  This article does not point to a single study that allows one to verify those claims. In fact appropriate cardiac stenting has been shown to decrease the incidence of heart attacks and prolong life.  It has also decreased the need for open heart surgery for bypass grafts.  It is articles like this that dumb down our population to make idiotic decisions like not vaccinating their kids.

You're correct that you have to click through a couple of layers of links to get to the actual primary literature, but when you do, you do find real studies in reputable scientific journals. One example is this paper* which was published in the New England Journal of Medicine (with is a rather reputable journal in the field), and describes a randomized study that looked at a population of about 2,300 people who had stable coronary artery disease (which produces chest pain) but not acute coronary artery disease (essentially heart attacks) who either received a stent + medical intervention, or medical intervention alone. Both looking at only the results of their study, or a meta-analysis including this study and several others which increased the total number of patents to ~5,000, the authors find no evidence that treating patents with stable chest pain with stents decreases their risk of later progressing to having heart attacks.

To be clear, no one is saying that stenting is never appropriate or never saves lives. They are using large scale studies to identify when stenting is or isn't an appropriate treatment. In this case they found that using stenting to treat a specific condition (stable coronary artery disease, which produces stable chest pain) doesn't appear to provide significant health benefits, yet, at least at the time this study was conducted they estimate 85% of stents were being inserted to treat this condition rather than for patents acute coronary systems (where the statistical evidence is clear that stents save lives).

* http://www.nejm.org/doi/full/10.1056/NEJMoa070829

[radram]

There were two articles it referenced, I was editing.  The first article it referred then referred to pain.

OK. Nobody really cares about pain. "Death" is really the primary focus for cardiac treatments. Stents are really good at preventing death related to unstable chest pain (aka heart attack).

If your doctor wants to schedule you a stent, run.

Don't they schedule an angioplasty based on test results, and then insert stints only based on the results of angioplasty? In effect there is never a "planned stint" surgery. Is this correct?

 Base on this conversation it seems to be an important distinction.

[nereo]

How about this for an idea:  Have Medicare kick in not just for age 65+ and people needing dialysis, but automatically for anyone who incurs more than $50,000 of medical expenses in a year.  In other words, government would backstop private insurers above this threshold.  This effectively increases the "very sick" risk pool to a nationwide one, which spreads risk around optimally.  Private insurers would have less excuse to increase rates, because now they don't have to plan for the relatively rare but catastrophic payouts that make it difficult to predict expenses.

I like this a lot, and I could see this appealing to both liberals and conservatives.

Hmm.... trying to think this one through.  Currently the most expensive portion of health insurance is paying for very rare but very expensive acute traumatic or severe chronic conditions.  There are really two ways that an individual can run up a 5 or 6 figure medical bill; very rapidly with an acute (e.g. 'emergency', e.g. 'trauma') condition, or over many years with a severe chronic condition. For an acute condition (e.g. car accident, major-organ surgery etc) the above proposal would be effective in 'backstopping' private insurance at the expense of the federal government.  However, what it would do little to change insurance markets for chronic conditions which require annual medical care of $10k-$50k for the duration of the patient's life. These would be the people who need to see their doctor every few weeks, who require expensive medications and who must undergo monthly treatments such as dialysis or blood transfusions. They are still in this "high-risk" pool; their annual medical bills may never rise to the $50k cap, but they can easily require $1-3k of care per month for many decades.

I think a hybrid system is our best hope in the US, where the population currently won't tolerate a completely government run health-care system. 'Backstops' may be part of the solution but they're just a brick int he wall. As discussed here, oh, 50+ pages ago I still believe that basic services should be available to all for a small regulated fee, including annual exams and vaccinations. Where and when private insurance comes in is tough part.

[EnjoyIt]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack. 

[radram]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack.

So the angiogram is the test that confirms the need for the angioplasty, which may lead to a stent on the spot or a schedule to add one? Just trying to get as close to a medical degree as I can without paying for one :)

[soccerluvof4]

Washington needs to be on whatever plan they put in place. Then maybe, just maybe they will figure something out that works . But I am not going to hold my breath and pass out and go to the hospital because my deductible is to high.

[NoStacheOhio]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack.

So the angiogram is the test that confirms the need for the angioplasty, which may lead to a stent on the spot or a schedule to add one? Just trying to get as close to a medical degree as I can without paying for one :)

#2 is what the studies are pointing away from at this point, but lots of places still do it

[Paul der Krake]

Washington needs to be on whatever plan they put in place. Then maybe, just maybe they will figure something out that works . But I am not going to hold my breath and pass out and go to the hospital because my deductible is to high.

By and large, they already are:
https://www.washingtonpost.com/apps/g/page/politics/which-senators-and-representatives-have-signed-up-for-obamacare/646/

[Gin1984]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack.

So the angiogram is the test that confirms the need for the angioplasty, which may lead to a stent on the spot or a schedule to add one? Just trying to get as close to a medical degree as I can without paying for one :)

#2 is what the studies are pointing away from at this point, but lots of places still do it

Do you have any links to those studies, because you can be able to exercise (which is what the linked study was testing) and still get a heart attack.    Now I am not saying that we don't need more evidence based medicine, we do and part of the issue is how we train our MDs, but the data does not always support changing standard practice.

[maizefolk]

The study I linked to was looking at both rates of death and rates of non-fatal heart attacks in patents in that second category who received stents plus non-surgical treatment and patients who just received non-surgical treatment.

[freya]

As discussed here, oh, 50+ pages ago I still believe that basic services should be available to all for a small regulated fee, including annual exams and vaccinations. Where and when private insurance comes in is tough part.

Agree!

Back in the 1960s, insurance didn't cover routine medical costs, only big ticket items like hospitalizations.  This changed when employers were incentivized to provide benefits instead of direct wages.  From there, prices of everything - especially pharmaceuticals - went up because the normal market forces were no longer there to keep them in check.  It was made worse when CMS started mandating a pile of expensive billing and documentation requirements for office visits in order to get control over reimbursements.  That's how we got into this mess. 

Having people pay out of pocket for office visits, thus dispensing with the need to get reimbursements paid through insurance, would instantly cut the costs by half or more.  Plus reduce insurance premiums.  And you'd get more face to face time with your doctor.

[GettingClose]

There were state-to-state variations, but I can corroborate that everything bacchi says was true.

[boarder42]

Anyone else see the report in the book Trump was in favor of Medicare expansion for all. Then was shut down by the Republican machine. Is it possible he is mildly less dumb the most of us think and is destroying it and putting it in a bad place so if dems take control he can help push Medicare expansion or a better plan thru ? 

[Gin1984]

Anyone else see the report in the book Trump was in favor of Medicare expansion for all. Then was shut down by the Republican machine. Is it possible he is mildly less dumb the most of us think and is destroying it and putting it in a bad place so if dems take control he can help push Medicare expansion or a better plan thru ?

No, I don't think he is less dumb.

[wenchsenior]

Anyone else see the report in the book Trump was in favor of Medicare expansion for all. Then was shut down by the Republican machine. Is it possible he is mildly less dumb the most of us think and is destroying it and putting it in a bad place so if dems take control he can help push Medicare expansion or a better plan thru ?

No, I don't think he is less dumb.

I don't either.  Trump was/voted Dem at times and was also pro choice.  He's held all sorts of positions on all sorts of issues.  He supported the wars, then he withdrew that support.  Who knows what he actually believes, if anything?  He might actually be in favor of Medicare expansion, but he obviously doesn't care enough one way or the other to act on it if he is.  He has the attention span of a gnat.

[fuzzy math]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack.

Uum what? You think patients are having angiograms and then being taken out of the cath lab, woken up and told they have blockages, so they can then consent to go back to the cath lab to receive a stent or a balloon angioplasty? Are you insane? Every consult I've seen allows the cardiologist to just balloon or stent at the time of the angiogram. If you're referring to CT angiograms, they are by far not the norm yet in most hospital settings.

[EnjoyIt]

I hate to agree with EnjoyIt on anything but I have to agree with him here. 

I almost fell over reading this.


A patient gets coronary stents in one of two ways.
1) They show up in an emergency department with a heart attack
2) They have angina, get a stress test or coronary angiogram, or sometimes both which shows significant vessel disease and then they get scheduled for a stent with the goal of preventing a heart attack.

Uum what? You think patients are having angiograms and then being taken out of the cath lab, woken up and told they have blockages, so they can then consent to go back to the cath lab to receive a stent or a balloon angioplasty? Are you insane? Every consult I've seen allows the cardiologist to just balloon or stent at the time of the angiogram. If you're referring to CT angiograms, they are by far not the norm yet in most hospital settings.

Of course not. I meant CT angio and you are correct that they are not offered everywhere. I practice in a big city and I see it used often enough.

Yes stenting or balloon angioplasty happens at the time of the acath lab angiogram. I have seen a few times a cardiologist place a stent in the worst vessel during an emrgency and then reschedule again for a future angiogram to open up the other vessels. This could happen if the first stent was difficult and they do not want to exceed the dye load/radiation load, or the patient is unstable for other reasons. I suspect maybe some do it to pad the billing which is unscrupulous in my opinion.

[Monkey Uncle]

Looks like the Republicans' next target may be the employer mandate:

http://www.msn.com/en-us/news/politics/individual-mandate-now-gone-gop-targets-the-one-for-employers/ar-AAuGUsV

I think this would actually be a good thing because it likely would generate new business for the exchanges and help diversify the risk pool.

Of course the people who would get screwed by this move are more of the same people who are currently getting screwed: upper middle class workers who make too much to qualify for ACA tax credits.

[iris lily]

Looks like the Republicans' next target may be the employer mandate:

http://www.msn.com/en-us/news/politics/individual-mandate-now-gone-gop-targets-the-one-for-employers/ar-AAuGUsV

I think this would actually be a good thing because it likely would generate new business for the exchanges and help diversify the risk pool.

Of course the people who would get screwed by this move are more of the same people who are currently getting screwed: upper middle class workers who make too much to qualify for ACA tax credits.

You guys are already on the chopping block. Forgetabout the 1%, it is now the top tier of upper-middles who are in line to receive societal wrath.

The book Dream Hoarders: How the American Upper Middle Class is leaving Everyone Else in the Dust, Why that is a Problem, and What to Do About it   lays out the case as to why “income inequality” is killing America.

By the way, this author defines his target group at a household income of $112,000.

I am so happy to be out of the line of fire now that we are FIRED. Our income is $30,000 annually and there aint no way the social justice warriors will be coming after us, based on this income, while I am still alive.

I read only the first chapter of this book  and may soon abandon it. It makes me laugh. The author earnestly explained how I as a former target group member (before I retired doncha know) deliberately kept birth control out of the hands of those who need it.

I cant even make this stuff up.

He also commits sins of the Eastern Seaboard Elite where he dwells on the problems of rich people guarding coveted positions in exclusive schools, holding them hostage to those of their class. Others cannot break into that world! Tragic!

Dude, Come join me in  flyover country where State U is fine for us, we dont GAF about getting into The Right Schools. And imagine this, we manage to earn enough with our paltry State U degrees to break the Upper Middle Class barrier. Of course, we will never participate in  other societal norms that also Eastern Seaboard Elites consider de rigour such as fencing lessons and summer houses on the Cape.

This crap makes me crazy. I do forgive the author somewhat, he was raised in
England. Class distinction is part of his upbringing and he is comfortable in a world where it exists regardless of his claim otherwise.

[Exflyboy]

One great thing about being FIRED.. Don't like the income group your in? Simply change it..:)

[iris lily]

One great thing about being FIRED.. Don't like the income group your in? Simply change it..:)

so cool, agreed!

[MrGreen]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

[DavidAnnArbor]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

Disturbing. and everyone is temporarily able-bodied, everyone in Idaho should ponder their future health care needs.

[jim555]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

That would be immediately challenged in court since it is illegal.

[MrGreen]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

That would be immediately challenged in court since it is illegal.

The article says the enforcing body is DHHS. I suppose it wouldn't matter if it was illegal if DHHS was going to overlook that fact, and judging from the actions of the DHHS over the past year it wouldn't surprise me if they turned a blind eye.

[bacchi]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

Ffs. We can't have anything good without some money grubbing asshole fucking things up.

No worries, though. It's a temporary problem that'll be fixed in 2020, at the latest.

[MrGreen]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

Ffs. We can't have anything good without some money grubbing asshole fucking things up.

No worries, though. It's a temporary problem that'll be fixed in 2020, at the latest.

You really think so? I'm not holding my breath.

[Inaya]

Hey now, I'm sure the insurance companies will do the right thing and not charge extra for preexisting conditions just because they can and will make money doing so.

Just like the cable companies won't throttle consumers' Internet or create fast lanes now that Net Neutrality is gone.

[Tyson]

Hey now, I'm sure the insurance companies will do the right thing and not charge extra for preexisting conditions just because they can and will make money doing so.

Just like the cable companies won't throttle consumers' Internet or create fast lanes now that Net Neutrality is gone.

But what's good for business is good for America, dontchanknow?  /snark

[ketchup]

http://amp.slate.com/news-and-politics/2018/01/idaho-ignoring-obamacare-pre-existing-condition-rules.html

This is a bummer. Hopefully nothing comes of it but it could open the floodgates.

That would be immediately challenged in court since it is illegal.

Ehh.  It's tricky.  Pot is still "illegal" federally; it's just not enforced anymore in certain states that have "legalized" it.  Laws have to be enforced to really be laws.