Author Topic: What comes after the ACA?  (Read 687118 times)

Exflyboy

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Re: What comes after the ACA?
« Reply #4250 on: April 11, 2018, 07:42:04 PM »
So general ACA question..

Do we think the Washington GOP swamp is going to have another go at repealing the ACA? I know the individual senators got a lot of townhall pushback when they tried it last time.

Paul der Krake

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Re: What comes after the ACA?
« Reply #4251 on: April 11, 2018, 08:05:07 PM »
So general ACA question..

Do we think the Washington GOP swamp is going to have another go at repealing the ACA? I know the individual senators got a lot of townhall pushback when they tried it last time.
Why would they? They already repealed the individual mandate. Much easier to let insurers leave the market instead of putting their sabotaging efforts back in the spotlight. There are reports that they are already focused on reforming the other entitlement programs.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4252 on: April 11, 2018, 09:28:20 PM »
So general ACA question..

Do we think the Washington GOP swamp is going to have another go at repealing the ACA? I know the individual senators got a lot of townhall pushback when they tried it last time.

I don't think they will at this point.  Trump is taking a victory lap saying that Obamacare is dead because they repealed the individual mandate.  And a bunch of states are filing suit that the ACA is unconstitutional due to the repeal.  Since I'm not set to FIRE until 2019, I'll have a chance to see what develops the rest of this year with that, the outcome of the midterm elections, and the 2019 ACA marketplace before I pull the trigger.  If I can't rely on ACA & subsidies for FIRE, I will probably OMY on the job to make up for it.

Why would they? They already repealed the individual mandate. Much easier to let insurers leave the market instead of putting their sabotaging efforts back in the spotlight. There are reports that they are already focused on reforming the other entitlement programs.

I can't see them making much head-way on that (entitlements) for any significant changes considering their difficulties with repeal and replace of the ACA.  Medicare changing to a voucher system?  It's hard for me to imagine that passing.

Paul der Krake

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Re: What comes after the ACA?
« Reply #4253 on: April 11, 2018, 09:40:25 PM »
Why would they? They already repealed the individual mandate. Much easier to let insurers leave the market instead of putting their sabotaging efforts back in the spotlight. There are reports that they are already focused on reforming the other entitlement programs.

I can't see them making much head-way on that (entitlements) for any significant changes considering their difficulties with repeal and replace of the ACA.  Medicare changing to a voucher system?  It's hard for me to imagine that passing.
I have no opinion on the feasibility of significantly reforming entitlements, just that it's what they will be focusing on. Cutting taxes and social programs are the sacred cows of the Republican party, whereas the ACA was just a convenient temporary boogeyman.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #4254 on: April 12, 2018, 05:11:34 AM »
Can you convert from a silver plan to a bronze plan mid year and then fund a HSA?

I have been wildly successful with trading this year and rapidly approaching the subsidy cutoff (currently have made $43,000 in short term capital gains on a $100,000 account and it isn't even May yet).   We are signed up for a silver plan and I had estimated our MAGI to be $25,000 for the year.   I really don't know quite how one could estimate how lucky they will be in a given year trading stock.

I don't think you can switch plan levels outside open enrollment without a life changing event, like moving or getting a job...

Perhaps if I were to file as a professional trader, that would count as a job change...

A HSA would save me some $3,000 on taxes and subsidy.

No, you can't change plans mid-year without a qualifying event.  I don't think filing as a professional trader would count, as that does not affect insurance availability.  Not the same thing as losing your employer-provided health coverage.

And you are supposed to be updating your MAGI estimate to reflect the increased income, so they can reduce your PTC and cost sharing.  Otherwise you'll have to pay back the disallowed PTC when you file your taxes.  Which is fine, I guess, as long as you're prepared for it.
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boarder42

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Re: What comes after the ACA?
« Reply #4255 on: April 12, 2018, 12:45:39 PM »
go get a job with health insurance and then quit. boom dual life event.
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DreamFIRE

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Re: What comes after the ACA?
« Reply #4256 on: April 12, 2018, 09:19:09 PM »
So, what do you think is going to happen with the ACA now that the penalty for the individual mandate has been repealed effective at the beginning of 2019? Will too many healthy people drop out?  Will insurers drop out in 2020 if not 2019?  Will ACA go into a downward spiral due to this sabotage?  Also, 20 states are filing suit that the ACA is now unconstitutional without the penalty for the individual mandate.  It sucks if you are relying on this for FIRE.  I didn't save >$1M to pay for my own health insurance!

Exflyboy

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Re: What comes after the ACA?
« Reply #4257 on: April 13, 2018, 12:21:25 AM »
Well depends on where you live too.

I suspect that blue states would step in to either shore the ACA up in their own state or develop their own plans.

Thats my theory anyway.

Oh there is nothing keeping a FIRE'ee in the USA either.. Lots of other nice places to live and ALL of them have much lower HC costs.
« Last Edit: April 13, 2018, 12:42:24 AM by Exflyboy »

jim555

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Re: What comes after the ACA?
« Reply #4258 on: April 13, 2018, 07:02:24 AM »
Expatriate until Medicare begins is my backup plan.

Mr. Green

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Re: What comes after the ACA?
« Reply #4259 on: April 13, 2018, 01:54:43 PM »
So, what do you think is going to happen with the ACA now that the penalty for the individual mandate has been repealed effective at the beginning of 2019? Will too many healthy people drop out?  Will insurers drop out in 2020 if not 2019?  Will ACA go into a downward spiral due to this sabotage?  Also, 20 states are filing suit that the ACA is now unconstitutional without the penalty for the individual mandate.  It sucks if you are relying on this for FIRE.  I didn't save >$1M to pay for my own health insurance!
Barring additional tweaking that makes it applicable to more people I see it continuing for a while. Call it "Medicaid+" or "Not-quite-Medicare." Even if all the non-subsidized people drop out it is still insuring millions and the public opinion is finally realizing that people having access to healthcare not tied to a job is a good thing. Insurers have largely figured out the pricing and subsidies are guaranteed money for them because the government is footing the bill. I think that is a strong incentive for insurers to stay in play, especially in states where there is only one and they can monopolize the market.

People will argue that the cost of the program is expensive for only insuring a small part of the population but I think it will be too unpopular now to actually pass legislation that takes away insurance from the poorest, sickest part of the population. Republicans are already on the ropes for 2018. If Democrats take control of the House or Congress it could easily be almost a decade before anyone could pass meaningful legislation hurting or improving the ACA.

This is what I hope happens so the markets have a chance to settle and people can take stock of what's working, and what needs tweaking, but at the end of the day the ability to get insurance not tied to a job is only going to get more popular as the numbers of people working non-traditional jobs (gigs) increases and technology and automation replace the need for humans

Perhaps a legislative "stalemate period" would allow our representatives to turn their attention to the bigger problem, which is why healthcare costs so much. I would think that is an issue both parties could get behind and create a bipartisan win that affects every citizen in the country.
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Roland of Gilead

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Re: What comes after the ACA?
« Reply #4260 on: April 13, 2018, 02:24:06 PM »
Perhaps a legislative "stalemate period" would allow our representatives to turn their attention to the bigger problem, which is why healthcare costs so much. I would think that is an issue both parties could get behind and create a bipartisan win that affects every citizen in the country.

Why healthcare costs so much? 

People living longer such that many health issues need treating to sustain mobility and quality of life

Drug use

Obesity

Those are the main factors.

Smaller factors are doctor/nurse/care giver salaries and investment/R&D costs for new drugs to treat the above three main factors.

sol

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Re: What comes after the ACA?
« Reply #4261 on: April 13, 2018, 02:34:43 PM »
Why healthcare costs so much? 

People living longer such that many health issues need treating to sustain mobility and quality of life

Drug use

Obesity

Those are the main factors.

While I agree that those factors contribute, it's hard to call them deterministic when so many other westernized nations facing the same headwinds manage to provide better health outcomes at lower cost than we do. 

There is really only one unique factor that makes American healthcare so expensive compared to other similar nations: we have minimally-regulated for-profit corporations sitting between sick people and their care.  Every nation that has fixed this specific problem sees their costs drop, but we're not really as interested in lowering costs as we are in increasing profits.  You can get rich screwing sick people, and in America nothing is more important than getting rich.

That's a kind of sickness too, when you think about it.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #4262 on: April 13, 2018, 02:51:34 PM »
While I agree that those factors contribute, it's hard to call them deterministic when so many other westernized nations facing the same headwinds manage to provide better health outcomes at lower cost than we do. 

There is really only one unique factor that makes American healthcare so expensive compared to other similar nations: we have minimally-regulated for-profit corporations sitting between sick people and their care.  Every nation that has fixed this specific problem sees their costs drop, but we're not really as interested in lowering costs as we are in increasing profits.  You can get rich screwing sick people, and in America nothing is more important than getting rich.

That's a kind of sickness too, when you think about it.

Well I was kind of thinking more general than USA specific but yes we do seem to have higher costs per citizen than other countries.

We are a more obese nation though.

Higher drug use?  Not sure about that...maybe?

The greed thing is a tough nut.   Perhaps the carrot is too much for attracting investors, doctors, care givers but I am unsure if people want everything to be state run (currently a pretty low opinion of state run medical facilities out there).   Could it all be done non-profit?

Exflyboy

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Re: What comes after the ACA?
« Reply #4263 on: April 13, 2018, 03:15:34 PM »
Its a bit more than "seem".. It IS more expensive by a factor of 2 at least.


Mr. Green

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Re: What comes after the ACA?
« Reply #4264 on: April 13, 2018, 03:21:38 PM »
While I agree that those factors contribute, it's hard to call them deterministic when so many other westernized nations facing the same headwinds manage to provide better health outcomes at lower cost than we do. 

There is really only one unique factor that makes American healthcare so expensive compared to other similar nations: we have minimally-regulated for-profit corporations sitting between sick people and their care.  Every nation that has fixed this specific problem sees their costs drop, but we're not really as interested in lowering costs as we are in increasing profits.  You can get rich screwing sick people, and in America nothing is more important than getting rich.

That's a kind of sickness too, when you think about it.

Well I was kind of thinking more general than USA specific but yes we do seem to have higher costs per citizen than other countries.

We are a more obese nation though.

Higher drug use?  Not sure about that...maybe?

The greed thing is a tough nut.   Perhaps the carrot is too much for attracting investors, doctors, care givers but I am unsure if people want everything to be state run (currently a pretty low opinion of state run medical facilities out there).   Could it all be done non-profit?
Healthcare in the US is basically twice as expensive, per capita, than the rest of the developed world. If we cut current health insurance and healthcare costs in half I think most people would find that cost reasonably fair for a system that covers sick people and healthy people alike. Sure some of the healthy ones will still complain that it's more than they used to pay, but I think most that have had either direct or indirect exposure to someone more than a little sick in need of healthcare would be okay with that system. It might not be great yet but it's not a bad place to start.
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TrudgingAlong

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Re: What comes after the ACA?
« Reply #4265 on: April 13, 2018, 05:25:26 PM »
The greed thing is a tough nut.   Perhaps the carrot is too much for attracting investors, doctors, care givers but I am unsure if people want everything to be state run (currently a pretty low opinion of state run medical facilities out there).   Could it all be done non-profit?

As someone who has had to rely on state run hospitals (military) for the last 15 years, I always find this a weird opinion when it comes from people who have never used state care. They mostly just connect state care with their opinion of government. Personally, I have very few complaints.
« Last Edit: April 14, 2018, 08:33:58 PM by TrudgingAlong »

Exflyboy

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Re: What comes after the ACA?
« Reply #4266 on: April 13, 2018, 06:57:44 PM »
And most of the people in Europe are happy with their care.. Of course a few complain until you tell then what it costs in the USA.. Then they seem absolutely delighted with their care!

I love the way Europeans give you that "WTF?" look when you say the words "Medical bankruptcy"... Cus they have no idea what you're talking about.

sol

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Re: What comes after the ACA?
« Reply #4267 on: April 13, 2018, 07:28:35 PM »
I love the way Europeans give you that "WTF?" look when you say the words "Medical bankruptcy"... Cus they have no idea what you're talking about.

We're talking about survival of the fittest, you euro bastards!  Social Darwinism at its finest!  In America, only the strong prosper and in so doing they make America stronger.  We let our sick and infirm wither and die like the dead wood they are, to make room for vigorous new growth.

Which is... um... immigrants?  Because Americans are not making babies anywhere near fast enough and our population would quickly start diminish without immigration.  As long as they're healthy and vigorous immigrants, maybe it's okay?  No brown ones, though, because they're apparently all rapists and drug dealers.  The President told me so.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4268 on: April 13, 2018, 07:50:48 PM »
the CBO now projects much lower health care spending than it used to, at least partly bc of Obama cost-control efforts

fuzzy math

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Re: What comes after the ACA
« Reply #4269 on: April 13, 2018, 08:03:33 PM »
The greed thing is a tough nut.   Perhaps the carrot is too much for attracting investors, doctors, care givers but I am unsure if people want everything to be state run (currently a pretty low opinion of state run medical facilities out there).   Could it all be done non-profit?

As someone who has had to rely on state run hospitals (military) for the last 15 years, I always find this a weird opinion when it comes from people who have never used state care. They mostly just connect state care with their opinion of goevernemtn. Personally, I have very few complaints.

Thank you. For the record, VA hospitals and public or private hospitals pay their regular "caregivers" roughly the same. The amount does vary more for doctors, with VA and state / public hospitals usually paying much lower. The health care system is stretched very thin attempting to recruit physicians, nurses and other specialists. A physician I work with mentioned how residencies in his speciality are going unfilled because there are no qualified applicants (this is a terrifying prospect for any of us who hope to live into our 70s and utilize this specialty). Try being a hospital trying to recruit a physician with good outcomes (i.e., not that guy who has had a billion medical claims due to poor care and killing their patients). Many medical schools are accepting higher numbers of foreign students simply because there aren't enough American applicants. Why would you want to go into medicine if you can make just as much as an IT guy and post on the MMM forums all day? Nurses at my hospital are so chronically understaffed due to lack of applicants that the hospital cannot maintain safe nursing ratios. If you are on a light medical / surgical floor, your nurse who is supposed to have 4 patients might have 6. If you are on a ventilator in the ICU, your nurse who is supposed to only have 1 patient - YOU - might have 1-2 other patients.  Then talk about how healthcare is expensive due to salaries. Nurses make on average $40-80k a year - much of that coming from overtime, night, weekend or holiday pay which means that they miss out on many things that traditional 9-5 workers take for granted. They bust their ass, have really high rates of work place injuries (lifting and moving 300 lb patients), and are frequently harassed and assaulted by patients. They are the first line of people available who will perform CPR on you when you lay in a hospital bed. If you think a physician is always around to do that, you are mistaken (see above).


There is a huge disconnect between people who work in other industries who have no issue taking huge salaries (I forum searched and learned that your wife made over $250k a year a few years back working for a publicly traded company with stock options), and those people turning around and lamenting that people in health care make too much. You want to have a high standard of living, but somehow want to deny that to the people who will literally save your life someday. Your family's high salary causes the product that your wife's former company produces to be more expensive. And guess what, it's probably a product that hospitals purchase. I wonder what drives up those prices.  Your wife's high salary makes it more expensive for consumers (such as nurses in the $40-80k range) to be able to afford consumer goods AND HEALTHCARE. I find the greed and dangling of carrot analogies of attracting doctors and caregivers to be hilarious. If we are going to go all socialized medicine (which I support) and cut salaries (which I don't support), there needs to be an across the board (European socialized society) taxed and flattened salary range for all of society. Otherwise we are just asking health care workers to be serfs.


Ask any health care worker what drives up the cost of health care and they will tell you its insurance, hospital administrators (who often pull in > $2 MM per year) and unreasonable expectations of patients and families ("please save my 89 yr old granny!!! Do whatever it takes!"). I'm pretty sure its not paying nurses an extra $2 per hour to work overnight on Christmas eve Saturday.
« Last Edit: April 13, 2018, 08:18:33 PM by fuzzy math »
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EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #4270 on: April 13, 2018, 08:10:37 PM »
I love the way Europeans give you that "WTF?" look when you say the words "Medical bankruptcy"... Cus they have no idea what you're talking about.

We're talking about survival of the fittest, you euro bastards!  Social Darwinism at its finest!  In America, only the strong prosper and in so doing they make America stronger.  We let our sick and infirm wither and die like the dead wood they are, to make room for vigorous new growth.

Any world traveler knows that America unleashed obesity upon the rest of the world.  KFC, TacoBell, and heaven forbid, Ronald Mc.D.- American pop culture basically clogged the arteries of every up and coming economy.   The fact that immigrants would put themselves in harms way, subjecting themselves now to unhealthy lifestyles for a quick buck while being unprotected medically really speaks to the human condition.  Nothing good ever happens when you eat healthy and have plenty of healthcare, apparently!
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Roland of Gilead

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Re: What comes after the ACA
« Reply #4271 on: April 13, 2018, 10:59:35 PM »

There is a huge disconnect between people who work in other industries who have no issue taking huge salaries (I forum searched and learned that your wife made over $250k a year a few years back working for a publicly traded company with stock options), and those people turning around and lamenting that people in health care make too much. You want to have a high standard of living, but somehow want to deny that to the people who will literally save your life someday. Your family's high salary causes the product that your wife's former company produces to be more expensive. And guess what, it's probably a product that hospitals purchase. I wonder what drives up those prices.  Your wife's high salary makes it more expensive for consumers (such as nurses in the $40-80k range) to be able to afford consumer goods AND HEALTHCARE. I find the greed and dangling of carrot analogies of attracting doctors and caregivers to be hilarious. If we are going to go all socialized medicine (which I support) and cut salaries (which I don't support), there needs to be an across the board (European socialized society) taxed and flattened salary range for all of society. Otherwise we are just asking health care workers to be serfs.


Ask any health care worker what drives up the cost of health care and they will tell you its insurance, hospital administrators (who often pull in > $2 MM per year) and unreasonable expectations of patients and families ("please save my 89 yr old granny!!! Do whatever it takes!"). I'm pretty sure its not paying nurses an extra $2 per hour to work overnight on Christmas eve Saturday.

I didn't say doctor salaries were the main issue, just that I thought doctors and nurses are paid a bit more in the USA than some other countries (we have already established these other countries have half the health care costs of the USA).   $250K as a senior software engineer after decades of work on the west coast is pretty easy but plenty of other professions with similar education (Stanford, Harvard, MIT, Brown) as my wife make far more than that in management, sales, legal, etc.     Doctors who work at drug companies make fat buck...on the order of millions per year, even if the drug fails.   They also get stock options so for those few drugs that work, the doctors at the drug company make tens or hundreds of millions.

A nurse makes 50k a year and a baseball player makes 10 million a year.   $250k falls somewhere in-between.

Insurance companies are making some serious profit here but if it were at obscene levels then the best investment for any of us would be a insurance ETF, which has not been true at all (FANG anyone?).   You could probably knock out the insurance companies from the equation and the USA would still have 1.9x the cost of other countries on healthcare instead of 2x.


Edit:  I did look it up and it looks like for GP, the USA is the highest paid doctor salary in the world at roughly 35% higher than the next highest country ($161k in the USA vs $118k in the UK).   So it is a factor even if a minor factor.    Just toss it in the mix with all the other stuff like insane drug prices, insurance company profiteering,  high malpractice costs from lawsuits, overpaid hospital executives, a very unhealthy USA population in general and there you go, 2x the price of everyone else.   Simple.

Oh one more edit:   Why are nurses paid so much less than doctors?   If you can answer that, then you can figure out why a senior software engineer with 20 years of experience in a hot field might make $250k while another IT worker who graduated last year from a 2 year online degree might make $50k.    Also cost of living on the west coast can make salaries double.   I bet a nurse in Silicon valley makes more than $50k a year.   Hah I just looked it up on glassdoor:

The average salary for a Registered Nurse is $123,762 in San Francisco, CA. Salaries estimates are based on 694 salaries submitted anonymously to Glassdoor by Registered Nurse employees in San Francisco, CA.
« Last Edit: April 13, 2018, 11:22:13 PM by Roland of Gilead »

Paul der Krake

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Re: What comes after the ACA?
« Reply #4272 on: April 13, 2018, 11:50:50 PM »
Salaries are higher across the board in the US. No nurse in the UK comes anywhere near making six figures, not even in London.

bacchi

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Re: What comes after the ACA
« Reply #4273 on: April 14, 2018, 12:02:22 AM »
Edit:  I did look it up and it looks like for GP, the USA is the highest paid doctor salary in the world at roughly 35% higher than the next highest country ($161k in the USA vs $118k in the UK).   So it is a factor even if a minor factor.    Just toss it in the mix with all the other stuff like insane drug prices, insurance company profiteering,  high malpractice costs from lawsuits, overpaid hospital executives, a very unhealthy USA population in general and there you go, 2x the price of everyone else.   Simple.

Good summary. And this is why nothing gets changed -- one hand is in the pot o' gold and the other hand is waving money in front of a politician's nose.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4274 on: April 14, 2018, 09:15:58 AM »
Well depends on where you live too.

I suspect that blue states would step in to either shore the ACA up in their own state or develop their own plans.

Thats my theory anyway.

Oh there is nothing keeping a FIRE'ee in the USA either.. Lots of other nice places to live and ALL of them have much lower HC costs.

Expatriate until Medicare begins is my backup plan.

I can't see myself doing that just to get lower cost healthcare insurance / healthcare.  It's a pretty drastic change to leave my country, my family and friends, my home,... and I'm not a citizen of any other country.  If I FIREd with the ACA, and then lost it, I suppose I would just have to pay the higher cost out of pocket or try to get a job with good healthcare insurance until Medicare kicks in.

Exflyboy

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Re: What comes after the ACA?
« Reply #4275 on: April 14, 2018, 12:18:45 PM »
Its a personal decision of course.

You don't have to be a citizen of almost anywhere else to live there.. Heck I am not a US citizen and have been here for 22 years.. Although I am in the process of getting my citizenship now.

Leaving this country is not a huge deal for me (except I would either have to sell or rent out the house) but my Wife would find that pretty hard I think. So for her going back to work would be preferable to living abroad.

There are at least options despite them being somewhat un-palatable.

Roadrunner53

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Re: What comes after the ACA?
« Reply #4276 on: April 14, 2018, 12:51:10 PM »
Leaving ACA August 1, 2018! Got my Medicare card today! YIPPIE!

DreamFIRE

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Re: What comes after the ACA?
« Reply #4277 on: April 14, 2018, 01:10:30 PM »
You don't have to be a citizen of almost anywhere else to live there.

My citizenship comment was in relationship to the healthcare benefits which aren't necessarily available to immigrants, based on some past comments I've read.  I only know what I've read from other people commenting on the matter as I haven't researched it myself since I didn't see that as a likely path for myself.

maizeman

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Re: What comes after the ACA?
« Reply #4278 on: April 14, 2018, 01:27:28 PM »
You don't have to be a citizen of almost anywhere else to live there.

My citizenship comment was in relationship to the healthcare benefits which aren't necessarily available to immigrants, based on some past comments I've read.  I only know what I've read from other people commenting on the matter as I haven't researched it myself since I didn't see that as a likely path for myself.

The expat option (if you go that direction) has a lot less to do with public or single payer healthcare and a lot more to do with the fact that the cost of paying for all your healthcare out of pocket most places in the world can be much less than the cost of health insurance premiums in the USA.

iris lily

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Re: What comes after the ACA?
« Reply #4279 on: April 15, 2018, 03:08:09 PM »
Leaving ACA August 1, 2018! Got my Medicare card today! YIPPIE!
I am 13 months behind you!

Roadrunner53

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Re: What comes after the ACA?
« Reply #4280 on: April 16, 2018, 04:24:06 AM »
Leaving ACA August 1, 2018! Got my Medicare card today! YIPPIE!
I am 13 months behind you!

Kind of mixed feelings. So glad to get the card and get off ACA (August 1) which seems to be on the chopping block every other week with our president threatening to destroy it. But, sort of sad to be turning 65! Seems like I was only 35 years old...a few years ago! Where did all those years go!

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4281 on: April 17, 2018, 07:52:43 PM »
Leaving ACA August 1, 2018! Got my Medicare card today! YIPPIE!
I am 13 months behind you!

Kind of mixed feelings. So glad to get the card and get off ACA (August 1) which seems to be on the chopping block every other week with our president threatening to destroy it. But, sort of sad to be turning 65! Seems like I was only 35 years old...a few years ago! Where did all those years go!

I met a 65 year old guy today who said he was training for a triathlon so I guess you're only as old as you feel.

rantk81

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Re: What comes after the ACA?
« Reply #4282 on: April 19, 2018, 06:49:20 AM »
The expat option (if you go that direction) has a lot less to do with public or single payer healthcare and a lot more to do with the fact that the cost of paying for all your healthcare out of pocket most places in the world can be much less than the cost of health insurance premiums in the USA.

+1000


DreamFIRE

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Re: What comes after the ACA?
« Reply #4283 on: April 19, 2018, 04:13:33 PM »
The expat option (if you go that direction) has a lot less to do with public or single payer healthcare and a lot more to do with the fact that the cost of paying for all your healthcare out of pocket most places in the world can be much less than the cost of health insurance premiums in the USA.

+1000
-1000

You can get an even better deal if you qualify for free healthcare rather than having to pay out of pocket.  I don't see see any incentive to move to another country if I have to pay for the actual healthcare, even if it's 1/2 as much total cost for healthcare services as the U.S. (based on previous comments on price comparisons.)

I'm only paying about $60/mo for my healthcare premiums here in the U.S. and have a $100 deductible.

maizeman

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Re: What comes after the ACA?
« Reply #4284 on: April 19, 2018, 04:24:35 PM »
You can get an even better deal if you qualify for free healthcare rather than having to pay out of pocket.  I don't see see any incentive to move to another country if I have to pay for the actual healthcare, even if it's 1/2 as much total cost for healthcare services as the U.S. (based on previous comments on price comparisons.)

I'm only paying about $60/mo for my healthcare premiums here in the U.S. and have a $100 deductible.

That's a pretty sweet plan. Yeah, if I was able to get a deal like that in FIRE, I wouldn't see any benefit to moving out of the country to control my healthcare spending either.

That doesn't mean others with much higher premiums and deductibles than yours might not still see savings from moving to a country with a much lower cost of care, even if they do have to pay out of pocket for treatment.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4285 on: April 19, 2018, 04:29:39 PM »
You can get an even better deal if you qualify for free healthcare rather than having to pay out of pocket.  I don't see see any incentive to move to another country if I have to pay for the actual healthcare, even if it's 1/2 as much total cost for healthcare services as the U.S. (based on previous comments on price comparisons.)

I'm only paying about $60/mo for my healthcare premiums here in the U.S. and have a $100 deductible.

That's a pretty sweet plan. Yeah, if I was able to get a deal like that in FIRE, I wouldn't see any benefit to moving out of the country to control my healthcare spending either.

That doesn't mean others with much higher premiums and deductibles than yours might not still see savings from moving to a country with a much lower cost of care, even if they do have to pay out of pocket for treatment.
I agree.  I only keep that deal as long as I work at least 24 hr. /week.  I'm not a government employee, so no sweet healthcare benefits after I FIRE completely.  :)

sol

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Re: What comes after the ACA?
« Reply #4286 on: April 19, 2018, 04:52:18 PM »
  I'm not a government employee, so no sweet healthcare benefits after I FIRE completely.  :)

Just for the record, federal government employees only get subsidized healthcare in retirement if they work until normal (old) retirement age.  Early retirees are out of luck.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4287 on: April 19, 2018, 05:13:18 PM »
  I'm not a government employee, so no sweet healthcare benefits after I FIRE completely.  :)

Just for the record, federal government employees only get subsidized healthcare in retirement if they work until normal (old) retirement age.  Early retirees are out of luck.
Same with many states too. I would have had to work about 15 years longer to get retiree medical and even then it was super expensive compared to even an unsubsidized plan I could have bought on the exchange. And of course the cost increases every year too and there are no "partial" medical insurance plans.  My sister, in a private sector job, is entitled to retiree medical once 55 but the cost is high also ends she would be better off using the ACA even if unsubsidized. Just because an employer, private or public, offer retiree medical doesn't mean its inexpensive.

I actually had my own state in mind.  Lawmakers tried to cut back on the healthcare benefits, but the courts ruled that they were protected by the state's constitution.

Exflyboy

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Re: What comes after the ACA?
« Reply #4288 on: April 19, 2018, 08:47:21 PM »
The expat option (if you go that direction) has a lot less to do with public or single payer healthcare and a lot more to do with the fact that the cost of paying for all your healthcare out of pocket most places in the world can be much less than the cost of health insurance premiums in the USA.

+1000
-1000

You can get an even better deal if you qualify for free healthcare rather than having to pay out of pocket.  I don't see see any incentive to move to another country if I have to pay for the actual healthcare, even if it's 1/2 as much total cost for healthcare services as the U.S. (based on previous comments on price comparisons.)

I'm only paying about $60/mo for my healthcare premiums here in the U.S. and have a $100 deductible.

I think that works OK on Medicaid (maybe) but remember if you are on an ACA plan or an employer plan and you have to go to the ER out of network you will be balanced billed and could still see a bill in the $100k's + after a stint in the ICU.

So even though premiums might be low for you there are still huge structural problems with the US HC system that don't exist in other countries.. It depends on what benefits you would qualify for too of course.

DreamFIRE

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Re: What comes after the ACA?
« Reply #4289 on: April 19, 2018, 09:07:57 PM »
I'm only paying about $60/mo for my healthcare premiums here in the U.S. and have a $100 deductible.

I think that works OK on Medicaid (maybe) but remember if you are on an ACA plan or an employer plan and you have to go to the ER out of network you will be balanced billed and could still see a bill in the $100k's + after a stint in the ICU.

So even though premiums might be low for you there are still huge structural problems with the US HC system that don't exist in other countries.. It depends on what benefits you would qualify for too of course.

Mine is an employer plan.  I wasn't sure on the out of network, but I didn't think it was that extreme with my plan.  So I just looked it up.  Our out of network emergency services (including ambulance) says $100 co-pay.  Hospital services out of network are covered at 50%.  But the maximum yearly out of pocket for out of network says $10,000.  So, that's pretty high, but at least it's not $100K.  As far as the ACA plans, I haven't investigated it that deeply since that's a year+ out for me.  I have some relatives on it - no horror stories yet.

Exflyboy

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Re: What comes after the ACA?
« Reply #4290 on: April 19, 2018, 09:26:18 PM »
I think you'll find that ACA out of network is close to zero to none! What they do say is that OON is covered for emergencies.

But what that means is the insurance company will pay the same as what it does to in network providers.. The problem is the hospital and all its sub contractors will balance bill the patient for the rest of their BS bill.

So yes a road accident plus a few days in the ICU could easily be $100k OOP.

Are you sure your employer plan doesn't work the same way??

DreamFIRE

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Re: What comes after the ACA?
« Reply #4291 on: April 19, 2018, 09:44:13 PM »
I think you'll find that ACA out of network is close to zero to none! What they do say is that OON is covered for emergencies.

But what that means is the insurance company will pay the same as what it does to in network providers.. The problem is the hospital and all its sub contractors will balance bill the patient for the rest of their BS bill.

So yes a road accident plus a few days in the ICU could easily be $100k OOP.

Are you sure your employer plan doesn't work the same way??
Yes, our plan has in network and out of network benefits.  The numbers I gave above were for out of network.   Maximum out of pocket is $10,000 for out of network.   It was much lower for in network.
« Last Edit: April 19, 2018, 09:46:26 PM by DreamFIRE »

maizeman

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Re: What comes after the ACA?
« Reply #4292 on: April 19, 2018, 09:47:01 PM »
Yup. The OOP max is the maximum your insurance company is going to charge you. In states that allow balance billing that doesn't protect you from an out of network provider coming after you for all the money they think your insurance company should have paid, but didn't.

Google "balance billing".

DreamFIRE

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Re: What comes after the ACA?
« Reply #4293 on: April 19, 2018, 10:07:58 PM »
We have a separate out of pocket maximum which is based on the fact that an out of network provider will cost the insurance company more.   That's also why they only cover 50% of the hospital bill, not 100% like in network.   But at $10,000, my insurer will pay 100%, so the provider won't bill me directly for higher costs as the insurance company will pay for anything above that.  That's how our plan works.  I've worked with hundreds of people on the same plan for over 17 years, and I haven't heard of a single complaint.

There are also laws/regulations in my state addressing balance billing.

Psychstache

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Re: What comes after the ACA?
« Reply #4294 on: April 24, 2018, 10:07:18 AM »
We have a separate out of pocket maximum which is based on the fact that an out of network provider will cost the insurance company more.   That's also why they only cover 50% of the hospital bill, not 100% like in network.   But at $10,000, my insurer will pay 100%, so the provider won't bill me directly for higher costs as the insurance company will pay for anything above that.  That's how our plan works.  I've worked with hundreds of people on the same plan for over 17 years, and I haven't heard of a single complaint.

There are also laws/regulations in my state addressing balance billing.

That is the part that makes all of the difference. If you are in a state with basically no regs on balance billing, it is a crapshoot. Our state dept of insurance offers a mediation process, but that is a plan on hope. Also given the literature on their website, they seem a little...out of touch with current realities:

"Balance billing Ė or a surprise medical bill Ė happens when you get a bill from a doctor, hospital, or other health care provider who isnít part of your health planís network. Often, consumers didnít know they were getting care from out-of-network providers.

For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the $600 that the health plan didnít pay, as well as any copays, deductibles, and coinsurance."

bold mine.

Out of network emergency doc with a $1000 bill? Yeah, I think they missed a zero.

Exflyboy

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Re: What comes after the ACA?
« Reply #4295 on: April 24, 2018, 10:59:34 AM »
Here in Oregon they have a halfway measure they just passed this year.

If you go to an in-network hospital then an OON provider from within that hospital can't balance bill.

If you go to an OON hospital, even for emergency care they can (and will) balance bill.

Knowing this of course the insurance company have severely restricted the area to about 5 miles from my front door for anything to ne in network.

So travelling on one of these plans leaves you wide open to a big fat bill. I don't think we will be taking any driving across the USA type vacation with this level of HC.

MDM

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Re: What comes after the ACA?
« Reply #4296 on: April 24, 2018, 11:49:04 AM »
I'm looking at adding ACA tax effects to the case study spreadsheet.

Current plan is to add Form 8962 calculations, assuming all months for Form 1095-A were the same.

Thus one would enter
- Monthly enrollment premiums, and
- Monthly advance payment of premium tax credit
in the "Monthly Average Expenses" section, and
- Annual second lowest cost silver plan (SLCSP) premium in a Form 8962 section.

For those with more ACA knowledge: any suggestions for additions, deletions, or other changes to that plan?

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #4297 on: April 24, 2018, 01:47:59 PM »
I'm looking at adding ACA tax effects to the case study spreadsheet.

Current plan is to add Form 8962 calculations, assuming all months for Form 1095-A were the same.

Thus one would enter
- Monthly enrollment premiums, and
- Monthly advance payment of premium tax credit
in the "Monthly Average Expenses" section, and
- Annual second lowest cost silver plan (SLCSP) premium in a Form 8962 section.

For those with more ACA knowledge: any suggestions for additions, deletions, or other changes to that plan?

Does this calculation take into account that circular issue that if you get a subsidy it lowers health insurance expense, which raises AGI, which then lowers the subsidy, which then in turn raises the AGI ?

MDM

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Re: What comes after the ACA?
« Reply #4298 on: April 24, 2018, 01:56:44 PM »
I'm looking at adding ACA tax effects to the case study spreadsheet.

Current plan is to add Form 8962 calculations, assuming all months for Form 1095-A were the same.

Thus one would enter
- Monthly enrollment premiums, and
- Monthly advance payment of premium tax credit
in the "Monthly Average Expenses" section, and
- Annual second lowest cost silver plan (SLCSP) premium in a Form 8962 section.

For those with more ACA knowledge: any suggestions for additions, deletions, or other changes to that plan?

Does this calculation take into account that circular issue that if you get a subsidy it lowers health insurance expense, which raises AGI, which then lowers the subsidy, which then in turn raises the AGI ?
Not yet.  That's only for self-employment income and associated health insurance deduction on Form 1040 line 29.  For W-2, pension, SS benefits, etc., health costs might be itemized deductions but that would not affect AGI.

The iterative calculations for the self-employment situation might be worth doing in a later version, but one step at at time....

MDM

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Re: What comes after the ACA?
« Reply #4299 on: April 24, 2018, 04:19:02 PM »
I'm looking at adding ACA tax effects to the case study spreadsheet.

Current plan is to add Form 8962 calculations, assuming all months for Form 1095-A were the same.

Thus one would enter
- Monthly enrollment premiums, and
- Monthly advance payment of premium tax credit
in the "Monthly Average Expenses" section, and
- Annual second lowest cost silver plan (SLCSP) premium in a Form 8962 section.

For those with more ACA knowledge: any suggestions for additions, deletions, or other changes to that plan?
Online now.  See this post.  Suggestions welcomed.