What comes after the ACA?

[Lorna2287]

7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

It has been several years since I read articles about this, but IIRC, the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.  When the ACA went into effect it capped the max at a 3:1 ratio.  This is forcing the youngest group to pay an extra 75% over what their costs really are so the oldest group can get a discount.  Considering the Boomers never had to pay that extra amount when they were younger, they are now getting one hell of a deal.

The Democrats think all of you young folks can suck it, apparently.

Disclaimer:  I'm not a Republican and I'm in favor of single payer.  I just wanted to point out the 3:1 ratio really fucked over young people.

Just to clear up some misconceptions. I work in public health and have advocated for the ACA since the beginning. I have a personal investment in it too since my daughter is a two-time childhood cancer survivor and faces an uninsurable future without the ACA. Unlike 99.9% of the people who speak with absolute authority about something they know nothing about, I’ve read the ACA from beginning to end and have worked on programs funded by the ACA. I keep trying to explain to people that the current crappy version of the ACA with the health exchanges was a Republican idea in the first place. Obama and health care reform activists wanted a public option but couldn’t make that happen due to Republican obstructionism, so they turned to The Massachusetts model (“RomneyCare”...has everyone conveniently forgotten that?!) So the ACA, in its current iteration, IS a Republican program. But the Republicans with their extreme partisanship love to blame any failures of the ACA on the Democrats and take credit for any success. Please be careful when assigning blame.

[GuitarStv]

As an aside, wtf is up with people wanting to stay at the Ritz when they go in for some routine surgery? I don't want a fancy hospital room, I want my damn ACL or hernia or whatever competently fixed and then as long as I'm not in danger of dying, yes, send me the fuck home or let me sit in the hall and dick around on my computer or whatever. And if I'm 90 and need a new heart, yes, I should have to pay out of pocket, because that's ridiculous.

-W

Oh, this brings up another point to add to the earlier discussion - shifting more procedures to outpatient drastically reduces costs. We have a history and custom in the US to try to keep patients in hospitals much longer than other countries, and often much longer than is optimal. Surgery, stabilize and send them home (with follow-up care) and we'd save a lot.

Related side note . . . a couple years ago I was rushing to do some work in the garden early in the morning and managed to slice my right index finger very deeply.  Cleaned the wound, bandaged it up, went on my way to my job.  It was painful but everything seemed fine.  That night I woke up in excruciating pain, noticed bright red streaks on my arms going from where my cut was up my arm, and decided that I needed to go to the ER.

The ER figured out that I had developed blood poisoning.  The stuck me on an IV cocktail of ultra powerful antibiotics and I spent the night there.  The next day I was feeling fine aside from a little throbbing in my hand.  They told me I needed to stay on IV antibiotics for at least a week . . . which really bummed me out that I'd be a prisoner in the hospital.  BUT - then they told me that they had an outpatient program.  I could recover at home, they would show me how/when to swap the IV bags and send a nurse over every day to make sure I was doing everything right.  So that's what I did.

My experience is that it's infinitely better to recover at home where you're comfortable (and it's just a bonus that I managed to save our health care system some cash).

[Schaefer Light]

7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

It has been several years since I read articles about this, but IIRC, the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.  When the ACA went into effect it capped the max at a 3:1 ratio.  This is forcing the youngest group to pay an extra 75% over what their costs really are so the oldest group can get a discount.  Considering the Boomers never had to pay that extra amount when they were younger, they are now getting one hell of a deal.

The Democrats think all of you young folks can suck it, apparently.

Disclaimer:  I'm not a Republican and I'm in favor of single payer.  I just wanted to point out the 3:1 ratio really fucked over young people.

Just to clear up some misconceptions. I work in public health and have advocated for the ACA since the beginning. I have a personal investment in it too since my daughter is a two-time childhood cancer survivor and faces an uninsurable future without the ACA. Unlike 99.9% of the people who speak with absolute authority about something they know nothing about, I’ve read the ACA from beginning to end and have worked on programs funded by the ACA. I keep trying to explain to people that the current crappy version of the ACA with the health exchanges was a Republican idea in the first place. Obama and health care reform activists wanted a public option but couldn’t make that happen due to Republican obstructionism, so they turned to The Massachusetts model (“RomneyCare”...has everyone conveniently forgotten that?!) So the ACA, in its current iteration, IS a Republican program. But the Republicans with their extreme partisanship love to blame any failures of the ACA on the Democrats and take credit for any success. Please be careful when assigning blame.

And how many Republicans voted for the ACA?

[accolay]

My experience is that it's infinitely better to recover at home where you're comfortable (and it's just a bonus that I managed to save our health care system some cash).

This has been studied. There is a sweet spot for hospital stay, don't remember if it's tailored to specific illness. If I recall three days is the magic number. Less or more than that is associated with worse outcomes. I'll find cold hard fact if I have time.

[Schaefer Light]

I don't want the government deciding what's bad for me.

We'll then I'll fucking tell you: Cigarettes, too much alcohol, too much sugar are bad for you. Everything in moderation. Eat vegetables and fruits. Exercise.

I get that.  What I don't want is the government deciding some items get a "sin" tax while others do not.  If one beer a day is okay from a health perspective, then why can't I buy one beer a day without paying any extra tax?  And why is there no extra tax on a cheeseburger at McDonald's?  Surely a cheeseburger per day is worse for me than a beer per day.

[bacchi]

I have lived in Germany for the last 5 years I often here arguments about the need to have socialized medicine. The problem is Americans have to decide if they want to pay European tax rates for socialized benefits or not.

Americans already pay for it! In fact, we pay more per capita for health care than any other country.

Plus Physicians make 20-30% what a U.S. physician makes

No, they don't. PCPs make $185k in the US and $131k in Germany. That's 1/3 less, not 1/3 of.

Stop spreading FUD.

[boarder42]

7.  Loosen the cost controls on age-related premium pricing, so that old people will pay more for insurance.

The ACA caps the ratio of max to min premiums at 3:1, so that old folks can never pay more than 300% as much as young healthy folks pay.  The GOP plan wants to change this ratio to 5:1, effectively transferring the cost of coverage away from the young and onto the old.  The GOP thinks all of you poor old folks can suck it, apparently.

It has been several years since I read articles about this, but IIRC, the actual healthcare costs are a 6:1 ratio and most states had a cap at 5:1 pre-ACA.  This means our old plans already had the youngest age band subsidizing the oldest age band.  When the ACA went into effect it capped the max at a 3:1 ratio.  This is forcing the youngest group to pay an extra 75% over what their costs really are so the oldest group can get a discount.  Considering the Boomers never had to pay that extra amount when they were younger, they are now getting one hell of a deal.

The Democrats think all of you young folks can suck it, apparently.

Disclaimer:  I'm not a Republican and I'm in favor of single payer.  I just wanted to point out the 3:1 ratio really fucked over young people.

Just to clear up some misconceptions. I work in public health and have advocated for the ACA since the beginning. I have a personal investment in it too since my daughter is a two-time childhood cancer survivor and faces an uninsurable future without the ACA. Unlike 99.9% of the people who speak with absolute authority about something they know nothing about, I’ve read the ACA from beginning to end and have worked on programs funded by the ACA. I keep trying to explain to people that the current crappy version of the ACA with the health exchanges was a Republican idea in the first place. Obama and health care reform activists wanted a public option but couldn’t make that happen due to Republican obstructionism, so they turned to The Massachusetts model (“RomneyCare”...has everyone conveniently forgotten that?!) So the ACA, in its current iteration, IS a Republican program. But the Republicans with their extreme partisanship love to blame any failures of the ACA on the Democrats and take credit for any success. Please be careful when assigning blame.

And how many Republicans voted for the ACA?

haha 0... hard to stick it to the "republicans" as their plan when they didnt vote for it... they could have passed whatever they chose to.

[sol]

At least one!

Arlen Specter, lifelong Republican from PA, changed his party affiliation specifically for the purpose of giving Democrats a 60 vote filibuster-proof supermajority in the Senate, so that they could pass the ACA.

There were also a whole bunch of Republicans working on subcommittees that drafted the ACA, who not only wrote the text but also then attached amendments.  In the end, they were compelled to vote against the law they helped create by Republican leadership, mostly because Mitch McConnell had a raging hard-on for undermining Obama's agenda in every possible way, democracy be damned.

So let's review.  Republicans came up with the idea.  Republicans pased it in MA and really liked it.  Republicans introduced the idea to Congress, where Democrats actually agreed with them that something needed to change, and in the interest of getting changes passed they agreed to try the Republican's idea that seemed to be working really well in MA.  Republicans helped write the new law, including passing amendments to make it better.  Some Republicans even voted for the final bill, along with a supermajority of our elected officials.  Obama declined to veto it, and it was thus named "Obamacare" and now Republicans hated it with the heat of a thousand suns.

[bacchi]

I don't want the government deciding what's bad for me.

We'll then I'll fucking tell you: Cigarettes, too much alcohol, too much sugar are bad for you. Everything in moderation. Eat vegetables and fruits. Exercise.

I get that.  What I don't want is the government deciding some items get a "sin" tax while others do not.  If one beer a day is okay from a health perspective, then why can't I buy one beer a day without paying any extra tax?  And why is there no extra tax on a cheeseburger at McDonald's?  Surely a cheeseburger per day is worse for me than a beer per day.

Cheeseburgers should have a sin tax.

I see your point. What do you propose, then? What's the free market solution? Because right now, the healthy all pay for people who don't exercise and who eat 3 cheeseburgers/day. It's also one of the major reasons that our health costs are so high. Is the free market solution "nothing"?

[SuperMex]

Average Salary for People with Jobs as Physicians / Doctors


People with Jobs as Physicians / Doctors Median Salary by Job
Job
National Salary Data
€0   €50K   €100K   €150K
Physician / Doctor, General Practice
21 salaries
€39,866               
Physician / Doctor, Internal Medicine
13 salaries
€50,083   
Family Physician / Doctor
8 salaries
€50,829   
Physician / Doctor, Neurologist
8 salaries
€60,000   
Physician / Doctor, Radiologist
7 salaries
€39,600   
Physician / Doctor, Plastic Surgeon
6 salaries
€103,846   
Physician / Doctor, Oncologist
4 salaries
€65,000   
Country: Germany | Currency: EUR | Updated: 2 Jan 2017 | Individuals Reporting: 81


People with Jobs as Physicians / Doctors Median Salary by Job
Job
National Salary Data
$0   $100K   $200K   $300K
Family Physician / Doctor
1133 salaries
$167,468               
Physician / Doctor, Internal Medicine
1091 salaries
$181,831   
Physician / Doctor, General Practice
686 salaries
$135,133   
Physician / Doctor, Emergency Room (ER)
551 salaries
$208,256   
Physician / Doctor, Radiologist
460 salaries
$286,989   
Physician / Doctor, Neurologist
364 salaries
$201,899   
Obstetrician / Gynecologist (OB/GYN)
322 salaries
$204,951   
Country: United States | Currency: USD | Updated: 7 Jan 2017 | Individuals Reporting: 7,075

[accolay]

I don't want the government deciding what's bad for me.

We'll then I'll fucking tell you: Cigarettes, too much alcohol, too much sugar are bad for you. Everything in moderation. Eat vegetables and fruits. Exercise.

I get that.  What I don't want is the government deciding some items get a "sin" tax while others do not.  If one beer a day is okay from a health perspective, then why can't I buy one beer a day without paying any extra tax?  And why is there no extra tax on a cheeseburger at McDonald's?  Surely a cheeseburger per day is worse for me than a beer per day.

I don't know. I wont put a moral equivalence on it all, and I suppose some people have a "food addiction" but I'd bet without even looking up numbers that problems with cigarettes and alcohol cost us more than obesity, and obesity costs a lot. Unsure of stats on car crashes from eating cheeseburgers and driving though.

Some cities have a sugary drink tax. Before we tax cheese burgers though, maybe we should just ditch some agriculture subsidies and stop artificial pricing.

[bacchi]

Country: Germany | Currency: EUR | Updated: 2 Jan 2017 | Individuals Reporting: 81

Seriously?

[SuperMex]

OK how about this Bacchi I'll get several German physicians I know to give me their annual pay report and I'll black out their name. If they make more than 33% of what the average U.S. physician makes with similar qualifications you win.

I'll bet you $10,000 are you in?????

[bacchi]

OK how about this Bacchi I'll get several German physicians I know to give me their annual pay report and I'll black out their name. If they make more than 33% of what the average U.S. physician makes with similar qualifications you win.

I'll bet you $10,000 are you in?????

Seriously? Dude, it's not about one physician; it's about the median. Throwing out "this guy I know" means squat.

There is, admittedly, a Euro-USD conversion issue. The Euro used to be much stronger.

[nereo]

I see your point. What do you propose, then? What's the free market solution? Because right now, the healthy all pay for people who don't exercise and who eat 3 cheeseburgers/day. It's also one of the major reasons that our health costs are so high. Is the free market solution "nothing"?

One proposal I'd make is to focus less on taxing individual items and instead levy some sort of penalty on individuals who aren't healthy.  Overweight? you pay more.  Obese? you pay more still.  Maybe people will start taking their health more seriously if there's more of a financial penalty* instead of, you know, just an increased risk of dying and having a poor quality of life.

*yeah, in some regards this is already done by charging smokers and drinkers a higher premium.  And the ADA will probably fight tooth and nail to keep "obesety" from being monitarily penalized.

[bacchi]

I see your point. What do you propose, then? What's the free market solution? Because right now, the healthy all pay for people who don't exercise and who eat 3 cheeseburgers/day. It's also one of the major reasons that our health costs are so high. Is the free market solution "nothing"?

One proposal I'd make is to focus less on taxing individual items and instead levy some sort of penalty on individuals who aren't healthy.  Overweight? you pay more.  Obese? you pay more still.  Maybe people will start taking their health more seriously if there's more of a financial penalty* instead of, you know, just an increased risk of dying and having a poor quality of life.

*yeah, in some regards this is already done by charging smokers and drinkers a higher premium.  And the ADA will probably fight tooth and nail to keep "obesety" from being monitarily penalized.

That makes sense. It doesn't help those who can't afford it, though. If ya can't afford $200/month, you can't afford $250/month when you're obese and still poor.

[SuperMex]

that 123K you quoted is pre-tax after tax you are looking at mid 50's in Germany if you are lucky.

[Monkey Uncle]

Plus 5.5% solidarity tax, 7.5% Health tax plus an equal tax to the employer, 8-9% church tax.

Church tax?  WTF?  Most Germans don't even believe in god any more...

[bacchi]

that 123K you quoted is pre-tax after tax you are looking at mid 50's in Germany if you are lucky.

True, it is pre-tax and their taxes are high.

[Monkey Uncle]

So let's review.  Republicans came up with the idea.  Republicans pased it in MA and really liked it.  Republicans introduced the idea to Congress, where Democrats actually agreed with them that something needed to change, and in the interest of getting changes passed they agreed to try the Republican's idea that seemed to be working really well in MA.  Republicans helped write the new law, including passing amendments to make it better.  Some Republicans even voted for the final bill, along with a supermajority of our elected officials.  Obama declined to veto it, and it was thus named "Obamacare" and now Republicans hated it with the heat of a thousand suns.

Seriously, you ought to write copy for late-night comedians.  You'd clean up.

[nereo]

that 123K you quoted is pre-tax after tax you are looking at mid 50's in Germany if you are lucky.

well that's sort of the thing here... Germany has high taxes and a corresponding high level of services.  In the US you have lower taxes and less services.
Both have their advantages depending on the case and personal preference, but it's not fair to compare post-tax salaries unless you also consider what post-tax services one recieves (or would have to pay for).

[SuperMex]

I have 31 German employees only two are Church goers yet they all pay Church tax. I asked them why that is and they said the process is so onerous to get out of it that almost no one does it.

[sol]

interesting article out today commenting on DJT's pledge of 'insurance for everybody'.

tl/dr: Trump's setting the bar pretty high by promising coverage for everyone that's 'much less expensive and much better' with 'much lower deductibles'. He says it will not have cuts to Medicare.
Curious to see how this could happen without costing a fortune and requiring some sort of coersion/mandate to get everyone to participate.

That whole article is a mess of contradictions. 

Trump is promising lower premiums AND lower deductibles, and I don't see any way to do that without
    A)  making insurance crappy, so it doesn't pay for anything, or
    B)  using federal dollars to subsidize insurance companies.  This is what the ACA is already doing. 

Trump is promising "insurance for everybody" and said "There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”   This suggests to me he is either going to offer health care providers (not insurers) federal subsidies for providing emergency medical care to uninsured people, or he is going to increase health insurance subsidies to poor people (which seems contrary to his previous plans to decrease subsidies to the poor and increase subsidies to the elderly).

Trump is promising that nobody who gained access under the ACA will lose coverage.  This seems like an easy fix, just grandfather everyone in and then reinstate the exclusion of people with pre-existing conditions going forward.  He could truthfully claim that no one lost coverage when they repealed the ACA, without the burden of having to provide insurance to any newly sick people. 

Trump is promising not to cut Medicare.  Yay, I guess?  This isn't really surprising because lots of GOP voters are elderly and use Medicare.  What he is doing instead is cutting MedicAID.  Very few young, poor, or disabled people are GOP voters, after all, so the party doesn't lose much by screwing those folks over.

[nereo]

So let's review.  Republicans came up with the idea.  Republicans pased it in MA and really liked it.  Republicans introduced the idea to Congress, where Democrats actually agreed with them that something needed to change, and in the interest of getting changes passed they agreed to try the Republican's idea that seemed to be working really well in MA.  Republicans helped write the new law, including passing amendments to make it better.  Some Republicans even voted for the final bill, along with a supermajority of our elected officials.  Obama declined to veto it, and it was thus named "Obamacare" and now Republicans hated it with the heat of a thousand suns.

Seriously, you ought to write copy for late-night comedians.  You'd clean up.

Reading some of Sol's posts, the voice of John Oliver occasionally takes over in my head...

[waltworks]

SuperMex, you need to back up your numbers. You are digging yourself a quick credibility hole.

I will eat my hat if German physicians (GPs, no cherrypicking plastic surgeons or something) make 33% of what US physicians do.

I'm assuming you googled this and misinterpreted the NPR quote at the top of the results page:
http://www.npr.org/templates/story/story.php?storyId=91931036
"In some parts of Germany, doctors are going on strike over what they get paid. It's not that German doctors live in poverty. The average German primary-care doctor makes around $123,000 a year before taxes. That's about one-third less than the U.S. average."

That means they make 66% of what a US physician does, not 33%.

-W

[SuperMex]

Nereo I totally agree and that was my point Americans have to come to terms with which they prefer.

However politicians saying they are going to give you something for free is total bull.

[bacchi]

I'm assuming you googled this and misinterpreted the NPR quote at the top of the results page:
http://www.npr.org/templates/story/story.php?storyId=91931036

An interesting part of that story,

On top of that, administrative costs are almost 50 percent lower. That's not because the German health system is simple and streamlined. With its employer-based system, multiple insurers and ever-changing rules, German health care is as complicated in many ways as the U.S. system. But administration is much simpler because nearly everybody gets the same benefits, payment rates are uniform and virtually everybody is covered.

[SuperMex]

your right if you are counting pre-tax wages and don't take into account the difference in taxes.

[nereo]

Nereo I totally agree and that was my point Americans have to come to terms with which they prefer.

However politicians saying they are going to give you something for free is total bull.

I agree on both points emboldened above.
In general the US population sucks at understanding their level of service is tied to the amount we pay.  A stupidly large percentage of people seem to think we can increase services while decreasing taxes, all while paying down the deficit.
Partly I blame this drum-beat of "fraud and waste are to blame for everything!" as well as "increased growth will more than make up for loss in tax revenue when we cut taxes."

[waltworks]

your right if you are counting pre-tax wages and don't take into account the difference in taxes.

At $180k income (roughly) a US single doctor not doing any clever tax-avoidance (ie pretax retirement/health accounts) would pay (roughly) $70k in total taxes (state taxes vary a lot, but that's probably close). So $110k.

German taxes on $123k would break down as roughly:
First $8k = $0
Next $45k = $8k
Last $70k = $29k

The Euro is close enough to the dollar right now that I'm just going to ignore doing any careful converting back and forth.

That leaves us with a total compensation after income tax of about $86k. Even if you tack on some of the other taxes you mention (which I know nothing about) you are not going to get to $55k after tax, let alone ~$36k (which would be one third of US after-tax money).

You may have misunderstood how marginal tax rates work.

-W

[Gal2016]

You know who also is a large country that has simpler healthcare than us, fucking Russia... They are about half our size, yet we have about 18x the GDP...

I have yet to meet a single person who has come to the US from another major nation that isn't absolutely baffled by our health care system and the staggering costs to the individual.

There is no doubt that having state governments and a fairly large population ensures that creating our system will bear some extra degree of complexity and uncertainty but it is far from impossible to improve on what we have.

You've had people come from Russia and complain about our healthcare?

How about we ask natives of China and India  (the only two countries with higher populations than the US) how they're managing "universal healthcare" for ALL of their many citizens? -- Yeah. Comparing the US to any other country regarding "universal healthcare" is disingenuous. We're kind of unique and some cookie cutter, "well it worked for Canada" proposal just isn't going to work.

I work in healthcare (RN and then in management, which is where I am currently).  The ACA has made a mess of things. It didn't fix the things that were previously broken and things that were running relatively smoothly (those who already had insurance) it royally screwed up.

And Trump's promises sound an awful lot like Obama's "you can choose your own doctor and you don't have to change providers" line.  bleh.

[SuperMex]

I think your 86K is right before they take out the rest of the taxes. I picked my number of in the 50's based on the fact that all of the people I work with pay about 50% of their income in taxes. I also know that the more you make the higher rate you end up paying.

[waltworks]

I think your 86K is right before they take out the rest of the taxes. I picked my number of in the 50's based on the fact that all of the people I work with pay about 50% of their income in taxes. I also know that the more you make the higher rate you end up paying.

Ah, you "picked" a number.

Again, your picked number is very obviously wrong. And you'd need to tax your $86k (after tax) money by more than another 50% before you'd get to the $36k you need to get to 33% of US physician income.

Even if you use your 50% in taxes number, you're at $61k. That's 55% of what a US physician would make after taxes (as I showed) not 33%.

Don't make shit up, please.

-W

[mm1970]

I have lived in Germany for the last 5 years I often here arguments about the need to have socialized medicine. The problem is Americans have to decide if they want to pay European tax rates for socialized benefits or not.

Germany individual income tax rates, 2016

Tax %   Tax Base (EUR)
0           Up to 8,652
14%           8,653-53,665
42%           53,666-254,446
45%           254,447 and over

Plus 5.5% solidarity tax, 7.5% Health tax plus an equal tax to the employer, 8-9% church tax.

19% flat vat tax on almost all purchases, TV tax, radio tax, dog tax, road tax, and a ton I haven't thought of.

Plus Physicians make 20-30% what a U.S. physician makes and you get worse access to care and it is no frills care. After you have a surgery they roll you into the hall and leave you with your family to recover, 2-3 patients to a room, there is a cost benifits analysis on care when you are older.

Sounds great to me.

As an aside, wtf is up with people wanting to stay at the Ritz when they go in for some routine surgery? I don't want a fancy hospital room, I want my damn ACL or hernia or whatever competently fixed and then as long as I'm not in danger of dying, yes, send me the fuck home or let me sit in the hall and dick around on my computer or whatever. And if I'm 90 and need a new heart, yes, I should have to pay out of pocket, because that's ridiculous.

-W

Ha ha funny.  When I had my second kid, I had him in the new wing of the hospital.  The birthing rooms and the patient rooms after were a VAST improvement.  Twice the size, soaking tubs for the labor and delivery rooms, a large couch that opened to a bed for the spouse.

But the doctors and staff are SO GOOD at saving you some dough.  After one night in the hospital, literally being woken every 1.5 hours (half by the baby wanting to nurse, the other half by...someone taking my blood pressure, or taking out the trash, or checking the baby's vitals)... it all came to a head at 8:20 am the next morning, when I had FOUR people in there in the space of 10 minutes (custodian, breakfast, pediatrician, nurse to take the vitals)...when the OB came in 5 minutes later (two people still there!) and asked if I wanted the option to leave that day (baby was not even 24 hours old), I said YES!!

I got better sleep at home with a newborn right next to me.

[mm1970]

You know who also is a large country that has simpler healthcare than us, fucking Russia... They are about half our size, yet we have about 18x the GDP...

I have yet to meet a single person who has come to the US from another major nation that isn't absolutely baffled by our health care system and the staggering costs to the individual.

There is no doubt that having state governments and a fairly large population ensures that creating our system will bear some extra degree of complexity and uncertainty but it is far from impossible to improve on what we have.

You've had people come from Russia and complain about our healthcare?

How about we ask natives of China and India  (the only two countries with higher populations than the US) how they're managing "universal healthcare" for ALL of their many citizens? -- Yeah. Comparing the US to any other country regarding "universal healthcare" is disingenuous. We're kind of unique and some cookie cutter, "well it worked for Canada" proposal just isn't going to work.

I work in healthcare (RN and then in management, which is where I am currently).  The ACA has made a mess of things. It didn't fix the things that were previously broken and things that were running relatively smoothly (those who already had insurance) it royally screwed up.

And Trump's promises sound an awful lot like Obama's "you can choose your own doctor and you don't have to change providers" line.  bleh.

Honestly reading this makes me cringe.

Everyone says this like it's truth, it's truth!  Or when people say that the ACA made their costs go up, and it's horrible.

Do people not understand that it DEPENDS??

it depends on where you live
it depends on how your state implemented the ACA
it depends on how much money you make
it depends on whether or not you were even insurable before.

I have a very good friend who is a NP and has done a LOT of work in public health.  For her, in her city in her state, she's been thrilled because FINALLY a lot of hard working people have access to care, are getting checkups, and are able to afford necessary medications (these are NOT people living in poverty - they were already covered).  "It's been a slog seeing a lot of new patients but has been SO WORTH IT."

And my neighbor, self employed and middle class who requires a fair bit of medication due to a genetic disease - ACA is literally the best insurance she's had as an adult.  Better than any employer sponsored insurance she had before becoming self employed.

And my friends who were uninsurable due to preexisting conditions - saved their bacon.

My husband's insurance costs went down, mine went up.

IT DEPENDS PEOPLE!!

[waltworks]

Yeah, we had to do c-sections for both kids - but my wife is a former professional athlete and all-around badass, so we managed to get discharged ASAP in both cases. 2 nights both times, they "recommended" 4 or something but... no way. Everyone did better at home.

-W

[Lance Burkhart]

Even the most conservative among us recognize that the US military is superior to every alternative on the planet.  It is a lumbering behemoth, hugely inefficient and wasteful, and yet it enjoys bipartisan support for the sole reason that it is better than the privately-operated alternative, despite all of its flaws.  Highlighting those flaws doesn't change the fact that is still better than the alternative.

I recommend you read Bill Lind and Martin Van Creveld.

[CDP45]

So let's review.  Republicans came up with the idea.  Republicans pased it in MA and really liked it.  Republicans introduced the idea to Congress, where Democrats actually agreed with them that something needed to change, and in the interest of getting changes passed they agreed to try the Republican's idea that seemed to be working really well in MA.  Republicans helped write the new law, including passing amendments to make it better.  Some Republicans even voted for the final bill, along with a supermajority of our elected officials.  Obama declined to veto it, and it was thus named "Obamacare" and now Republicans hated it with the heat of a thousand suns.

Seriously, you ought to write copy for late-night comedians.  You'd clean up.

Reading some of Sol's posts, the voice of John Oliver occasionally takes over in my head...

This must be a case where it's funny because it's not true.
Not 1 republican senator voted for Obamacare
Not 1 republican congressman voted for Obamacare

It was passed only on partisan lines by Dem party controlling house, senate, and white house....hmm...

Here's the facts that Sol thinks everyone is to dumb to find, or he's such a partisan hack he's ignoring reality now:
http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396
http://clerk.house.gov/evs/2010/roll165.xml

[Erica]

Younger middle class here, and I feel the pinch of ACA very hard.  31 years old. 

You may want to check into one of the healthcare sharing ministries. They satisfy the ACA mandate but are much less expensive.

[Alps]

I have 31 German employees only two are Church goers yet they all pay Church tax. I asked them why that is and they said the process is so onerous to get out of it that almost no one does it.

Well apparently they're stupid. I did it when I was 14 (legal adult regarding religion) and it absolutely was not more complicated than going to the local municipal office with your ID and signing some forms.

I will say that I know a bunch of folks who don't consider themselves religious, yet feel that their church tax is being put to good use and are content still paying it.

[boarder42]

I see your point. What do you propose, then? What's the free market solution? Because right now, the healthy all pay for people who don't exercise and who eat 3 cheeseburgers/day. It's also one of the major reasons that our health costs are so high. Is the free market solution "nothing"?

One proposal I'd make is to focus less on taxing individual items and instead levy some sort of penalty on individuals who aren't healthy.  Overweight? you pay more.  Obese? you pay more still.  Maybe people will start taking their health more seriously if there's more of a financial penalty* instead of, you know, just an increased risk of dying and having a poor quality of life.

*yeah, in some regards this is already done by charging smokers and drinkers a higher premium.  And the ADA will probably fight tooth and nail to keep "obesety" from being monitarily penalized.

That makes sense. It doesn't help those who can't afford it, though. If ya can't afford $200/month, you can't afford $250/month when you're obese and still poor.

well and multiple studies done have shown the obese and smokers actually cost the system less than healthy people on a per year basis due to the costs to take care of a person who was healthy when they get really old

[Schaefer Light]

I don't want the government deciding what's bad for me.

We'll then I'll fucking tell you: Cigarettes, too much alcohol, too much sugar are bad for you. Everything in moderation. Eat vegetables and fruits. Exercise.

I get that.  What I don't want is the government deciding some items get a "sin" tax while others do not.  If one beer a day is okay from a health perspective, then why can't I buy one beer a day without paying any extra tax?  And why is there no extra tax on a cheeseburger at McDonald's?  Surely a cheeseburger per day is worse for me than a beer per day.

Cheeseburgers should have a sin tax.

I see your point. What do you propose, then? What's the free market solution? Because right now, the healthy all pay for people who don't exercise and who eat 3 cheeseburgers/day. It's also one of the major reasons that our health costs are so high. Is the free market solution "nothing"?

In its purest form, the free market solution would be no insurance.  Each person would pay the full cost of his own health care with no help from anyone else.  That would surely discourage a person from eating, drinking, or smoking too much.  I realize this is a step too far for most people, as they aren't going to be okay with not having any form of health insurance.  In my opinion, the next best thing is for people who are out of shape to pay higher premiums.  The insurance companies would have to decide what "out of shape" means to them.  They should know which health indicators typically lead to higher costs better than anyone.

I also believe that people should be allowed to have no insurance.  They should have to sign some sort of waiver indicating that they understand the risk - from both a health and financial perspective.  They should not get a taxpayer bailout.  If they get sick, they'll be relying on their own resources and the charity of others to help them out.  If they can't get the help they need, then they'll pass away the same way people have died for most of human history (i.e. without insurance).

[GuitarStv]

I also believe that people should be allowed to have no insurance.  They should have to sign some sort of waiver indicating that they understand the risk - from both a health and financial perspective.  They should not get a taxpayer bailout.  If they get sick, they'll be relying on their own resources and the charity of others to help them out.  If they can't get the help they need, then they'll pass away the same way people have died for most of human history (i.e. without insurance).

This idea is great in theory, the problem is when it comes to application.

You're effectively saying that health care workers and family have to sit by and watch someone die, knowing full well that there is a cure . . . but simply not being able to pay the money for the cure.  It will never happen.  Regardless of the documents and forms signed, most people will see it as patently unfair to make someone suffer/die in this manner and will lobby to change the system.

[KaizenSoze]

In its purest form, the free market solution would be no insurance.  Each person would pay the full cost of his own health care with no help from anyone else.  That would surely discourage a person from eating, drinking, or smoking too much.  I realize this is a step too far for most people, as they aren't going to be okay with not having any form of health insurance.  In my opinion, the next best thing is for people who are out of shape to pay higher premiums.  The insurance companies would have to decide what "out of shape" means to them.  They should know which health indicators typically lead to higher costs better than anyone.

How about accidents or injuries caused by another party and that other party has no money? Kids with cancer?

This is a completely unrealistic idea.

[sol]

Not 1 republican senator voted for Obamacare
Not 1 republican congressman voted for

Technically, exactly one lifelong Republican voted for it, immediately after changing his  party affiliation.  His name was Arlen Specter.  Look him up.

There were a bunch of other Republicans who helped craft the bill though, including the ones at the heritage foundation who wrote most of the original text, and the ones in Congress who attached a bunch of Republican amendments to try to strengthen it.  I won't count the ones in MA that wrote and then passed and then successfully implemented Romneycare.

[farmecologist]

How about accidents or injuries caused by another party and that other party has no money? Kids with cancer?

This is a completely unrealistic idea.

I agree...ever heard of the Hippocratic Oath?  Doctors are required to abide by ethical standards. They will not throw someone out on the street..even if they have "signed a waiver". 

Again..this all seems to come back to the various forms of the silly "I'm not sick - I don't need insurance" argument.  And yes, you can get ill even if you "are in shape", "take care of yourself", etc... It happens to millions of people every year.  Amazing revelation..eh?  Many of these conditions are then classified as "pre-existing".   Thus the need for insurance.  This is not a difficult concept to understand.  Maybe it is denial/rationalization ...i.e. - "it will never happen to me"?

And to throw people that have a pre-existing condition under the bus...well that is just a complete lack of empathy...which I see in droves around here.  In fact, I think some of you need a healthy dose of empathy to "understand" where some of us are coming from.  Either that or have it happen to yourself or someone in your family ( god forbid )...that will build 'empathy' really fast.

[jim555]

Where I worked, one person got prostate cancer, one got a tumor on the kidneys, one got leukemia, one has sleep apnea, another has Crohn's disease.  These are all in their late 40s and 50s.  It CAN happen to you, no matter what you eat or how much you exercise.

[mathlete]

In its purest form, the free market solution would be no insurance.

How is this more of a free market than one in which individuals can freely buy insurance and firms can freely sell it?

In my opinion, the next best thing is for people who are out of shape to pay higher premiums.  The insurance companies would have to decide what "out of shape" means to them.  They should know which health indicators typically lead to higher costs better than anyone.

This existed prior to ACA in the individual market. It was called Medical underwriting. As it turns out, the best indicators of morbidity were that the person was currently sick, had been sick before, is taking expensive prescriptions, etc.

Insurers also already impose an extra surcharge on tobacco users. I suppose they could start doing something similar for obesity, but I'm not sure there is a reliable indicator for that. There are some obviously healthy people who have a BMI that would call them overweight, etc.

Besides, healthy and fit non-smokers who live forever eventually become a huge burden on the healthcare system too.

I also believe that people should be allowed to have no insurance.  They should have to sign some sort of waiver indicating that they understand the risk - from both a health and financial perspective.  They should not get a taxpayer bailout.  If they get sick, they'll be relying on their own resources and the charity of others to help them out.  If they can't get the help they need, then they'll pass away the same way people have died for most of human history (i.e. without insurance).

I think that letting people die is a politically impossible thing to propose. No matter how financially irresponsible the person was.

Think of it this way; We feed, clothe, and house murders and rapists, but the non-violent but kind of deadbeatish dude doesn't get emergency surgery when his appendix bursts?

[sol]

How is this more of a free market than one in which individuals can freely buy insurance and firms can freely sell it?

By definition, insurers collectivize risk.  That's the nature of their product, but some people oppose it on philosophical grounds because it seems contrary to our American "rugged individualism".  This is exactly why so many conservatives like the idea of high risk pools.  By dividing everyone up into different premium categories, and lumping people of similar risks together, we move incrementally closer to having risk pools of one person each.  In that end-member case, each person pays their own costs and ignores everyone else, which is the conservative ideal but is definitely not insurance.

[Gal2016]

You know who also is a large country that has simpler healthcare than us, fucking Russia... They are about half our size, yet we have about 18x the GDP...

I have yet to meet a single person who has come to the US from another major nation that isn't absolutely baffled by our health care system and the staggering costs to the individual.

There is no doubt that having state governments and a fairly large population ensures that creating our system will bear some extra degree of complexity and uncertainty but it is far from impossible to improve on what we have.

You've had people come from Russia and complain about our healthcare?

How about we ask natives of China and India  (the only two countries with higher populations than the US) how they're managing "universal healthcare" for ALL of their many citizens? -- Yeah. Comparing the US to any other country regarding "universal healthcare" is disingenuous. We're kind of unique and some cookie cutter, "well it worked for Canada" proposal just isn't going to work.

I work in healthcare (RN and then in management, which is where I am currently).  The ACA has made a mess of things. It didn't fix the things that were previously broken and things that were running relatively smoothly (those who already had insurance) it royally screwed up.

And Trump's promises sound an awful lot like Obama's "you can choose your own doctor and you don't have to change providers" line.  bleh.

Honestly reading this makes me cringe.

Everyone says this like it's truth, it's truth!  Or when people say that the ACA made their costs go up, and it's horrible.

Do people not understand that it DEPENDS??

it depends on where you live
it depends on how your state implemented the ACA
it depends on how much money you make
it depends on whether or not you were even insurable before.

I have a very good friend who is a NP and has done a LOT of work in public health.  For her, in her city in her state, she's been thrilled because FINALLY a lot of hard working people have access to care, are getting checkups, and are able to afford necessary medications (these are NOT people living in poverty - they were already covered).  "It's been a slog seeing a lot of new patients but has been SO WORTH IT."

And my neighbor, self employed and middle class who requires a fair bit of medication due to a genetic disease - ACA is literally the best insurance she's had as an adult.  Better than any employer sponsored insurance she had before becoming self employed.

And my friends who were uninsurable due to preexisting conditions - saved their bacon.

My husband's insurance costs went down, mine went up.

IT DEPENDS PEOPLE!!

If you're working in "public health", you're probably highly subsidized by the government or other funding (grant funding, state run programs, etc).  Not necessarily unbiased.  Let me state that during the last 10 years I have worked for 3 different hospitals.  1 was a small local community hospital. 2 are large healthcare systems.  These hospitals and hospital systems covered 4 states. I've worked in both inpatient and outpatient settings. I've come into contact with literally thousands of patients and their families. From a care delivery perspective, the ACA (which is much more than "universal healthcare") has been terrible for hospitals , making it incredibly difficult to actually provide care and get paid for it.  Hospitals are going bankrupt and its become far more about what the ACA requires than what's good for the patient or their family. Everyone know someone or even a couple of people that the ACA "helped". I live everyday within a system that now has to look at what we are allowed to do rather than what we should do for the patient. If their insurance won't pay, how can we justify doing something when we know it will result in a huge bill for the patient? -- we give them the options that their insurance tells us they will cover. It's a monumental change in how medical care is being practiced.

From a consumer standpoint, my health insurance premiums have increased, my co-pays have increased, I am now charged for having my working spouse on my insurance (because he could get his through his employer) and the coverage has decreased.  I and everyone else in my healthcare system (10,000 or more employees) is paying more for less.  And this same thing was happening in the other hospital system I worked for (another 10,000 employees).  So, there's 20,000 people who's insurance deteriorated due to the ACA.