What comes after the ACA?

[MrGreen]

If by some miracle, Congress did pass positive health care legislation, how long would it take to implement?
https://www.congress.gov/bill/115th-congress/house-bill/676

Unless the legislation has a specific future start date it would begin the next year. If it was some kind of sweeping change I could see the start being delayed a year to prepare for the administrative running of whatever is passed.

[EnjoyIt]

As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.

The size of my stache isn't the most important thing to me.

Sure definitely not the most important thing, but I'm sure it will be a big priority if you plan on a tight FIRE withdrawing 4% while the market only gives you 2-3%

Don't kid yourself, the stache is a huge item of concerns to an early retiree.

[DavidAnnArbor]

Trump’s Sabotage of Obamacare Is Illegal  https://nyti.ms/2Mncdz2
A president doesn’t have the right to dispense with laws he dislikes.
By Nicholas Bagley and Abbe R. Gluck
Mr. Bagley and Ms. Gluck are law professors.
Aug. 14, 2018

Excerpt:

"Never in modern American history has a president so transparently aimed to destroy a piece of major legislation. What makes Mr. Trump’s sabotage especially undemocratic is that Congress has repeatedly considered repealing the law — and repeatedly declined to do so. In addition, the Supreme Court has twice sustained the Affordable Care Act in the face of major legal challenges. Mr. Trump’s attempt to destroy the law any way he can is an unconstitutional usurpation of power.
That is also the message of a lawsuit — the first of its kind — filed this month in federal court in Maryland. Brought by several plaintiffs including the cities of Chicago, Cincinnati and Columbus, the lawsuit recounts the “relentless and unlawful campaign to sabotage and, ultimately, to nullify” the Affordable Care Act. Taken individually, some of the Trump administration’s actions may be defensible. Taken together, they amount to a derogation of his constitutional duties.
The lawsuit asks the court to strike down the administration’s new rules and to enjoin the president from further sabotage. To prevail, the plaintiffs may have to overcome some procedural hurdles, including questions about whether the courts have the authority or the institutional competence to prevent violations of Article II’s requirement that the president “take care that the laws be faithfully executed” — especially given the wide discretion that presidents traditionally have to implement the laws."

[MrGreen]

I will be following that case with interest. Sure seems like the defence will have a hard time arguing that he is faithfully executing the law. Seems like a slam dunk, even though nothing ever is with the law. Of course if they're able to repeal the law the whole case would become moot.

[Paul der Krake]

Eh, the executive branch has a long history of ignoring the laws they find inconvenient. Can the plaintiffs make the case that this is above and beyond? Maybe. Maybe not. I have a hard time seeing much more than a super narrow ruling.

[MrGreen]

Eh, the executive branch has a long history of ignoring the laws they find inconvenient. Can the plaintiffs make the case that this is above and beyond? Maybe. Maybe not. I have a hard time seeing much more than a super narrow ruling.

The thing is I think we're well past ignoring and into active sabotage. I don't know if a court will see it that way or not.

[simonsez]

As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.

The size of my stache isn't the most important thing to me.

Sure definitely not the most important thing, but I'm sure it will be a big priority if you plan on a tight FIRE withdrawing 4% while the market only gives you 2-3%

Don't kid yourself, the stache is a huge item of concerns to an early retiree.

I generally do not think there is a strong connection between the POTUS and the size of your portfolio but will indulge a little bit.  Obama inherited the S&P 500 in the 800s.  When he left it was at 2300.  Do you really think the S&P 500 will perform better over 8 years with Trump at the helm compared to Obama?  The S&P 500 would need to be 6500+ after 8 years if Trump is re-elected.

Do I personally believe Obama (if there weren't term limits) or another Democrat President instead of Trump would have the market higher?  Hell no, it could be true or it might be but it wouldn't be due to who is sitting in the Oval Office.  I'm not complaining about my own accounts the past 18 months, but the prior 96 weren't too shabby, either.

Yes, there is ridiculous nuance to the situations under a sitting President as it pertains to the economy, but that's my point - an early retiree choosing to re-elect Trump based on the expected better market performance doesn't seem like a sound strategy.  The market factors external to a President are much more important to the economy than a single person's "pro-business" appearance.  It is basically a coin flip with each new administration if the market will perform better or worse than it did under the prior admin.

For early retirees, I think choosing a candidate with the best long-term affordable healthcare plan would be more impactful than attaching market performance to a president.  Or if you are going to endorse Trump for his economic prowess and how that might benefit early retirees, at least talk about lower short-term taxes or something they are directly responsible for rather than a nebulous relationhsip.

[EnjoyIt]

All I said is historically whe the markets do well during a presidential election the incumbent is very likely to win. I also said that corporate profits are essential to a sustainable withdrawal strategy in retirement. Each statement was written separately and do not imply one should vote for Trump or that a president has any significant impact on market performance.

I will admit that the corporate tax break has likely been one of the most pro corporate legislations in decades that I can think of. One would assume lower taxes will equal increased profits and increased profits will equal improved market performance but who knows if that will be a reality.

if you had to give me a choice between having enough money to pay for healthcare vs hoping the government gets these policies right I will choose the cash. Our healthcare industry is so fucked up and no insurance oriented legislation will ever fix the underlying problem since insurance isn't the real issue. Cost is the problem and no legislator is willing to discuss it and address it.

[sol]

Cost is the problem and no legislator is willing to discuss it and address it.

Can you really blame them?

Imagine a politician lobbying to lower the cost of some other good, say soybeans.  He goes to the annual soybean convention, and tells the farmers and distributors that he wants to stem the rising cost of soyeans.  People will be happier, he says, if only soybeans didn't cost so much.  It's for the good of the country!  Oh and btw, half of you are going to go out of business because you're making too much money from soybeans.

We live in a capitalist system in which higher higher costs means higher profit margins means means higher standard of living for suppliers.  That would be fine on its own, if we didn't also allow those same suppliers in the medical industry to set their own prices in noncompetitive ways, essentially subverting the market forces that are supposed to keep this system in balance.  Right now, all of the incentive is on raising costs and the rest of us just have to accept it.  Literally no one except the consumer wants prices to go down, and the consumer is the least influential party involved because we don't get to choose whether or not we participate in the market.  By virtue of being living human beings, we each have a guaranteed need for healthcare.

The politicians were supposed to be the influential voice of the people, but in today's political environment "the people" now means "corporations and wealthy donor organizations with good lobbyists" and not "consumers".  Elizabeth Warren literally tried to create the Consumer Financial Protection Bureau to address this specific problem in one specific industry, but (and don't be too shocked here) Republicans vehemently opposed it and managed to effectively shut it down, by refusing to appoint anyone to lead it, defunding it, and then exempting the worst-offending firms from the very laws the CFPB was supposed to enforce.  So just in case you're looking for someone to blame for this sort of thing, you could start there.

Is it a coincidence that the same congressional republicans who hate the CFPB also hate the ACA?  Financial regulation and healthcare seem to share a common problem of misaligned incentives and subverted market forces that make some rich people even richer, and republicans seem absolutely bent on preserving those distortions. 

[EnjoyIt]

Sol,
You are completely correct with every word you said above. I also agree that many republicans are to blame but so are the democrats. What you described is why our healthcare system is falling apart and will continue to get worse for many years to come. Real change will lead to hundreds of thousands of people to be out of work because their services simply won't be needed. A single payer model would accomplish similar unemployment rates.

Personally I think the first step needs to be transparent pricing being mandatory. Simply making pricing transparent would force all the providers, hospital and private alike to simply pricing away from the convoluted BS we have today. Transparent pricing is not the fix. It would be a good start. But again no group of politicians will do that and have the fortitude to get it to pass.

[pecunia]

Sol,
You are completely correct with every word you said above. I also agree that many republicans are to blame but so are the democrats. What you described is why our healthcare system is falling apart and will continue to get worse for many years to come. Real change will lead to hundreds of thousands of people to be out of work because their services simply won't be needed. A single payer model would accomplish similar unemployment rates.

Personally I think the first step needs to be transparent pricing being mandatory. Simply making pricing transparent would force all the providers, hospital and private alike to simply pricing away from the convoluted BS we have today. Transparent pricing is not the fix. It would be a good start. But again no group of politicians will do that and have the fortitude to get it to pass.

Would that many jobs be lost?  I have worked on Federal contracts where a new contract took effect.  We changed hats and worked for the new contractor.

We would still need the nurses, doctors and health technicians.  People would still need to go to the doctor.  In fact, people reluctant to go to the doctor today due to the "falling apart" nature of our current system would now go to a health care facility.  This may prompt additional employment.  I think many of the people currently administering insurance would be still needed by Uncle Sam to keep the health care wheels turning.  However, I think the administrative people may have an easier job as the rules would be consistent for everyone.

Some jobs would definitely be lost if a transition was made to something similar to other countries as those systems are more efficient.  Is this that different than the job losses that other American industries have suffered over the last thirty years?   We have built automated factories for steel production and automotive assembly that are more efficient and have eliminated many jobs.

I would guess a lot of these health care CEOs would take their golden parachutes and leave. 

[FIRE@50]

I'm with pecunia on this.

Rip off the band-aid already!

[maizefolk]

Would that many jobs be lost?  I have worked on Federal contracts where a new contract took effect.  We changed hats and worked for the new contractor.

We would still need the nurses, doctors and health technicians.  People would still need to go to the doctor.  In fact, people reluctant to go to the doctor today due to the "falling apart" nature of our current system would now go to a health care facility.  This may prompt additional employment.  I think many of the people currently administering insurance would be still needed by Uncle Sam to keep the health care wheels turning.  However, I think the administrative people may have an easier job as the rules would be consistent for everyone.

Either you can believe that the transition to a medicare for all system would bring down costs or that it wouldn't cause a fair number of folks to lose their jobs, but it's basically impossible for both to be true at the same time.

Private insurance spends 6-9 time more of each dollar of total spending on administration/overhead than medicare. In absolute dollar terms that is on the order of $70-150 billion dollars more overhead spending than delivering the same amount of healthcare spending to hospital and doctors would cost through the medicare system.* If you figure the average payment processing/claims evaluation/etc health care worker costs their employer $100k/year when you factor in fringe benefits (employer payroll taxes, retirement contributions, and yes, employer provided healthcare), that works out to 700,000 - 1.5M jobs where the need for someone to do that work would vanish in an instant if we switched to medicare for all.

Now I don't think "we should stick with this much more expressive and less efficient system because the reason it is inefficient is that it is paying people to do work that doesn't need to be done) is a particularly reasonable argument.** But it is important to realize that a big increase in the efficiency of either healthcare or health insurance in the USA is, essentially by definition, going to mean putting a lot of people out of work.***

*Note that this doesn't do anything to take into account the difference in reimbursement rates between public and private health insurance providers which is what was being talked about up thread.

**And if it was, it'd probably make even more sense to apply it to stopping the development of self driving trucks which are likely to put many of the 3.5M americans who drive trucks for a living out of business over the next decade.

***Hopefully it'll also mean a lot of new jobs get created because the cost of hiring employees will decline, and more people will be willing to take the risk of starting a new company if they don't have to hold on to their big company job in order to make sure they'll have health insurance. But even if so, that change will take time, and the people qualified for the new jobs won't necessarily be the same people who lost the old jobs.

[rantk81]

Those medical-middle-men are jobs that SHOULD BE "LOST"!

They aren't providing delivery of medical services. I have nothing against those individuals personally... but I wouldn't shed a tear of all those jobs went away so that our health care system was cheaper.

[seattlecyclone]

Right, of course cutting costs will lead to job losses. Most of the money paid for medical care goes to people in the end. If you cut costs you either cut people's pay or eliminate jobs, but most likely is a mix of both.

[Paul der Krake]

"Oh man I can't believe they axed 1,000 paper pushing experts in the billing department, it's a tragic loss of tradition and expertise that couldn't possibly be replaced" -- no one ever

We kill jobs all the time. Heck, a lot of people on this forum automate other people's jobs for a living and nobody bats an eye.

[PathtoFIRE]

Either you can believe that the transition to a medicare for all system would bring down costs or that it wouldn't cause a fair number of folks to lose their jobs, but it's basically impossible for both to be true at the same time.

Sorry to be a little contrarian, and this doesn't necessarily have to happen with a national health system, but if you replaced doctors with (more) mid-level providers, you could have both; cost savings along with a preservation or even increase in jobs (and perhaps even an increase in the provision of health/medicine on top of that).

[pecunia]

[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

[former player]

[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

Yes, governments keeping economically irrational industries in place for reasons of political stability and kleptocracy is a dishonourable tradition in socialist authoritarian countries.

[EnjoyIt]

[
-SNIP-

And again folks, I'm not arguing that this is a reason to avoid reforming healthcare. Just that it is a consequence it is important to be aware of.

I wonder if this is different than a mill closing.  There are some protective laws that are on the books that give people a little extra help when industrial facilities close.  I doubt whether there are similar laws for someone being laid off from an insurance company.

Should goodness and mercy be a part of any legal change?  Maybe, some retraining money could be included.  It seems to me that bookkeepers, actuarial people and others employed by insurance companies could be retrained for other work.  This would lessen any economic disruption.

Businesses may also have insurance experts that would no longer be required under the new system.

Actually, I think the money saved by business would be akin to a Keynesian shot in the arm for the US economy.  This health care thing has been dragging us down like an anchor.

Yes, governments keeping economically irrational industries in place for reasons of political stability and kleptocracy is a dishonourable tradition in socialist aut  horitarian countries.

In the US we also see it in the taxation industry.  Hundreds of thousands of jobs exist because our tax system is so complex.

Unfortunately when bureaucracy gets involved there is a good chance to have inefficiencies due to paper pushing. When the incentive isn't profit, there is less need for efficiency.  Generally speaking, the bigger something gets, the less efficient it becomes.  This is in corporations and government alike.

Upthread someone said replace physicians with mid levels.  We have discussed it before on this thread.  I am a huge proponent of mid level providers who by the way now are called Advanced Practicing Clinicians (APCs).  But, and this is a big but, they are not doctors.  I work with some amazing and very bright APCs. They can do just about anything a physician can do maybe up to 95% of what a doc does and knows. Unfortunately they sometimes have no clue that they don't know that 5% and can and will make mistakes there unless having appropriate assistance from a physician.  Trust me.  I see this all the time and why we have supervising physicians helping them out.  So....a more efficient practice of a physician assisting a few APCs is a cost effective way to practice medicine and is already being utilized in many practices.  It was something that many practices had to implement just to stay profitable due to decreasing reimbursement and increased regulatory documentation.

[pecunia]

Enjoy It:

Unfortunately when bureaucracy gets involved there is a good chance to have inefficiencies due to paper pushing. When the incentive isn't profit, there is less need for efficiency.  Generally speaking, the bigger something gets, the less efficient it becomes.  This is in corporations and government alike.

Now, I've given that a little thought in the past.  I have garbage pickup on Thursdays.  There are about 5 separate garbage companies that come down the road I live on and pick up selected garbage.  I have thought that it would be more efficient to have one big truck pick up the garbage.

Henry Ford built the River Rouge plant.  I guess he had iron ore go in one end and cars come out the other.  It was better than having lots of little cottage industries.  He also had people do one particular task all day.  It was boring, but they learned to do it well and do it quickly.

There's a term called the "economy of scale" where reduced costs per unit that arise from increased total output of a product.

I think that medical paperwork could actually have greater efficiencies if handled by one organization with the principles of "economy of scale" applied.  Processes could be streamlined.  Special software could be created and refined for this specialized and standardized work practice.  Rather than each insurance company having unique forms and processes, standard government forms and processes could be created.  Medical staff would become familiar with the one way to do the work rather than the many individual insurance company methods.  Deming methods could be applied for greater quality.

The real life examples that this is true is the medicare program in the United States and many of the government run health care programs in other countries.

[Paul der Krake]

Re: re: re: FWD: re: re: [urgent]: re: re: balance billing

(maybe this was discussed in the 90+ pages of this thread, not sure)

You may have heard of the story of the school teacher stuck with a 6 figure bill that made the rounds this week:
https://khn.org/news/the-109k-heart-attack-bill-is-down-to-332-what-about-other-surprise-bills/

What surprised me most was that even if you have an emergency in a state with balance billing protections, they are null and void if the plan is self-insured (the insurance company provides administrative services, but the cost is assumed directly by the corporation, usually the case for large employers). For those plans, only federal law applies, not state law.

AFAICT, this doesn't apply to ACA plans though. Just about 50% of us working stiffs with employer coverage.

[DreamFIRE]

Earlier in the thread I linked to a column that mentioned that in reference to the NY law but didn't state that in the thread itself.  I don't know if anyone else did.

Also, some states' laws regarding balance billing don't apply those protections to PPO plans, so that will exclude ACA PPO plans from those protections.

This article mentions the self-insured plans being covered by federal law and the insured not receiving balance billing protection (61% of plans) and shows a list of some states that don't provide balance billing protections for PPO plans, either.

https://www.commonwealthfund.org/publications/issue-briefs/2017/jun/balance-billing-health-care-providers-assessing-consumer?redirect_source=/publications/issue-briefs/2017/jun/balance-billing-consumer-protections-states

[Paul der Krake]

Nice article. For the lazy who don't want to read it all, it boils down to this:



Another anecdote:
I was scheduled for an outpatient procedure at a small local hospital in WA, which doesn't have balance billing protections (apparently it's making its way through the legislature now). I work for one of the largest employers in the state with a generous, no referrals or pre-autorization needed, self-insured PPO plan administrated by the local Blue Cross affiliate. I consider myself an informed consumer.

I get a call from the hospital 2 days before assuring me that they are in fact in-network and no pre-autorization is needed, and because I've already hit my deductible for the year, I will only need to pay them 10% of the bill when I come in, which is about $70. Sounds a little "cheap", so I assume this is only the hospital facility fee, and will get a bill from the in-network doctor too. Whatever.

The day of at check-in, I am given a mountain of the standard disclaimers to sign. And I notice the following (rough wording):
" I/the undersigned understand that anaesthesiologists who may perform services are contractors and as such will bill you directly".

At this point alarm bells start ringing in my head.
1) Do I even need an anaesthesiologist? The receptionist can't tell me. My procedure requires sedation, but it's not clear whether an actual anaesthesiologist will be present, or will they get called in only if something goes wrong? Well it all really depends, you see. Maybe they'll be there, maybe not.
2) Will this anaesthesiologist be in-network? I don't want surprises. Yes she assures me, if the hospital is in-network then the anaesthesiologist will be.
3) How do I know you're not just saying this to make me sign an open-ended legal document that has much more weight than "well I was told the opposite"? Cryptic smile.

Of course they have all the leverage. I've already taken time off from work for both me and my designated driver (can't drive after being sedated), and I would probably get hit with a no-show fee if caving this late, so I roll the dice. Guess we'll know the outcome in a few weeks when everything is processed.

[Monkey Uncle]

Best of luck with that, Paul.  That's a shining example of the lack of price transparency in our so-called "system."

Cal Thomas recently did an opinion column in which he (or rather a friend of his he was quoting) lambasted the medical system for that kind of stuff.  Rarely do I ever agree with anything Cal Thomas says, but in this case I think he (or again, his friend) hit, if not "the" nail on the head, at least one of the big nails.  Here's the quote from his doctor friend:

https://calthomas.com/columns/the-future-of-medicine

“In 2018, ‘Medicine’ is a nationwide system of financial obfuscation, in which the ruling denizens are huge corporate entities that control scores of hospitals, or health insurance for millions of ‘subscribers,’ or pharmaceutical benefits, or psychiatric benefits, or physical therapy, or a hundred other niche ‘benefits’ for millions of people, who are paying exorbitant ‘premiums’ to support thousands of ‘vendors’, and have no idea what they are paying for.

“And this entire ‘system’ is run by an endless network of interconnected computer programs, which are continually being ‘upgraded’, or swapped out for newer, more complex systems that always promise (but never deliver) ‘better medical care.’ And, needless to say, NO ONE HAS ANY IDEA WHAT ANYTHING COSTS! [Clearly it costs A LOT, because a few new billionaires are generated every year.]

“Meanwhile, the interests of patients (which used to be the main driver of medical care) have been replaced by concern for the bottom line. And physicians, who used to be the substance of medical care, now find themselves no more than compliant (and replaceable) cogs in the machinery. [‘Get me two more instrument sterilizers, another MRI, 12 ward nurses, two ENTs and another hospitalist!’]

But then, of course, Thomas has to muck up the argument by claiming, completely without evidence, that government overinvolvement is the root of the problem, and he even goes on to imply that Medicare should not be "second-guessing" providers on how much they charge.  Excuse me, but can you imagine how expensive health care would be if no one was even attempting to negotiate the price on behalf of the patient?

[PiobStache]

Do folks here realize Medicare has no concurrent review but only retrospective?  Also that they must pay claims within 14 days of receiving a "clean" billing statement?  This is part of why their admin overhead is low relative to commercial plans and also is why you see fraud cases with such big numbers.  The retrospective reviews are also less than efficient for all aspects:  https://en.wikipedia.org/wiki/Recovery_Audit_Contractor

Also, do folks realize there are more universal models than single payer?  That the countries that tend to score the highest in world rankings for healthcare tend not to have single payer systems?  I only ever see M4A and single payer conversations here.

[Exflyboy]

I'm surprised nobody has raised a question around the likely survival of the ACA after John McCain's passing.

Thoughts?

[Paul der Krake]

I'm surprised nobody has raised a question around the likely survival of the ACA after John McCain's passing.

Thoughts?

I think the full legislative ship has sailed. They already claimed victory for killing the individual mandate and will continue the death by a thousand cuts approach. No need to spend even more political capital this close to the midterms.

[maizefolk]

I'm surprised nobody has raised a question around the likely survival of the ACA after John McCain's passing.

Thoughts?

When McCain gave the thumbs down that ended the last effort to repeal the ACA, the republicans had a 52-48 majority in the house, plus the tiebreaker vote with VP Pence. The reason his vote was decisive was that Murkowski (R-Alaska) and Collins (R-Maine) were already opposed to the appeal.

Since then Doug Jones won the special election in Alabama as a Democrat, so the the Republicans had a 51-49 majority (still with the tie breaker) and three of those republicans  still opposed to repeal without replacement (Murkowski, Collins, and McCain), which left the republicans two votes short of what they'd need to repeal the ACA.

So regardless of who Doug Ducey appoints to replace McCain in the senate, repeal is still at least one vote short until the new batch of senators elected this fall take their seats early next year. At that point all bets are off. Republicans who have  much safer majority in the senate. Republicans might lose the senate. Republicans might increase their majority in the senate while also losing the house.

[Paul der Krake]

Do folks here realize Medicare has no concurrent review but only retrospective?  Also that they must pay claims within 14 days of receiving a "clean" billing statement?  This is part of why their admin overhead is low relative to commercial plans and also is why you see fraud cases with such big numbers.  The retrospective reviews are also less than efficient for all aspects:  https://en.wikipedia.org/wiki/Recovery_Audit_Contractor

Also, do folks realize there are more universal models than single payer?  That the countries that tend to score the highest in world rankings for healthcare tend not to have single payer systems?  I only ever see M4A and single payer conversations here.

Yes, very aware. I was hospitalized at a private hospital in Kensington for a week, while on a supplemental policy that was employer provided. It was fucking great, I had a hospital room to myself, nurses at my beck and call, and watched test rugby on Sky Sports the entire time. Had I only used the NHS, I would have been treated just fine, but definitely not gotten the 5 star experience.

Germany similarly has a dual speed, where everybody gets basic coverage, but you can purchase supplemental things, and probably should. France is similar, except now the supplemental coverage is even mandatory. If you can't afford it, you go on the Medicaid equivalent.

Switzerland is probably the closest model to the US, where you must buy all of your coverage (with serious consequences if you don't, unlike the US), and their per capita spending is still significantly less.

Politicians on the left use "single payer" as a rallying cry, but anyone who's spent even 30 minutes researching this knows very well it's a lot more nuanced than that.

[jim555]

The minute the Republicans get the votes the ACA will be effectively destroyed.  Razor thin margin keeping it in place.

[PiobStache]

Do folks here realize Medicare has no concurrent review but only retrospective?  Also that they must pay claims within 14 days of receiving a "clean" billing statement?  This is part of why their admin overhead is low relative to commercial plans and also is why you see fraud cases with such big numbers.  The retrospective reviews are also less than efficient for all aspects:  https://en.wikipedia.org/wiki/Recovery_Audit_Contractor

Also, do folks realize there are more universal models than single payer?  That the countries that tend to score the highest in world rankings for healthcare tend not to have single payer systems?  I only ever see M4A and single payer conversations here.

Yes, very aware. I was hospitalized at a private hospital in Kensington for a week, while on a supplemental policy that was employer provided. It was fucking great, I had a hospital room to myself, nurses at my beck and call, and watched test rugby on Sky Sports the entire time. Had I only used the NHS, I would have been treated just fine, but definitely not gotten the 5 star experience.

Germany similarly has a dual speed, where everybody gets basic coverage, but you can purchase supplemental things, and probably should. France is similar, except now the supplemental coverage is even mandatory. If you can't afford it, you go on the Medicaid equivalent.

Switzerland is probably the closest model to the US, where you must buy all of your coverage (with serious consequences if you don't, unlike the US), and their per capita spending is still significantly less.

Politicians on the left use "single payer" as a rallying cry, but anyone who's spent even 30 minutes researching this knows very well it's a lot more nuanced than that.

Good to hear.  I spend a lot of breath, and get very few people to believe, there are more choices than the status quo in the US vs. a Canadian style single payer.  Folks actually often try to say Bismarck/Bismarck hybrids like Germany, France, and Japan are actually single payer systems when I raise the issue.

[swampwiz]

As of today unemployment is low and the market is way up. Unless the market tanks between now and election time, history dictates that Trump will have a 2nd term.  Frankly the last 18 months have been very positive for most of the staches on this forum.

Frankly, the last 60 months have been very positive for most of the staches. (Really about the last 112 since the bottom in April 2009.)  But your point is valid, low unemployment will help get Trump get re-elected if he hasn't been impeached by then.  There are definitely some negatives out there - real wages have been dropping and the trade war does threaten to have an impact.  We'll see.

To get re-election, Trump better do something about his 60% disapproval number:

https://www.politico.com/story/2018/08/31/trump-approval-rating-poll-washington-post-abc-805563

[DreamFIRE]

I'm surprised nobody has raised a question around the likely survival of the ACA after John McCain's passing.

Thoughts?

No real concerns in regard to John McCain but much more so in regard to the midterm elections.  The republicans will try repeal again next year if they think they can get it through.

[DavidAnnArbor]

Good to hear.  I spend a lot of breath, and get very few people to believe, there are more choices than the status quo in the US vs. a Canadian style single payer.  Folks actually often try to say Bismarck/Bismarck hybrids like Germany, France, and Japan are actually single payer systems when I raise the issue.

Yes I expect the ACA and Medicare to ultimately morph into the Switzerland model.

[swampwiz]

I'm surprised nobody has raised a question around the likely survival of the ACA after John McCain's passing.

Thoughts?

I think the full legislative ship has sailed. They already claimed victory for killing the individual mandate and will continue the death by a thousand cuts approach. No need to spend even more political capital this close to the midterms.

Agreed.  And the Democratic takeover of the House will be our protection from this rearing its ugly head in the next Congress.

[sol]

Agreed.  And the Democratic takeover of the House will be our protection from this rearing its ugly head in the next Congress.

I think that the ACA, like medicaid and social security, is here to stay in one form or another but that won't stop Republicans from spending entire legislative careers preaching about how evil it is.  It will just be another "entitlement" that they want to "reform" by privatization. 

Of course, the memory of the "privatized" version we had before the ACA will quickly fade, and conservatives will spend the next century singing the praises of the free market panacea as if the ACA ruined a perfectly functioning capitalist utopia.  They already do it with every other part of the social safety net, up to and including public education.

[MrGreen]

Agreed.  And the Democratic takeover of the House will be our protection from this rearing its ugly head in the next Congress.

I think that the ACA, like medicaid and social security, is here to stay in one form or another but that won't stop Republicans from spending entire legislative careers preaching about how evil it is.  It will just be another "entitlement" that they want to "reform" by privatization. 

You're probably right. There are several other big legislative items on the horizon like social security reform that will require substantial effort. Combine that with the increasing popularity of a healthcare solution and the small percentage of the population the ACA affects and I think it will become a simple matter of more pressing issues to deal with. The clamor around healthcare costs is only going to get louder and that's a whole other ballgame Congress is going to have to deal with.

[Exflyboy]

I doubt Republicans will ever "deal with" high HC costs. You only have to have an ETF stock portfolio of say $2M where your earnings from the Healthcare sector will outweigh anything your family will have to pay for your own HC.

Namely rich people are better off the more expensive HC is. The bigger the portfolio the better off you are. Add in the backhanders from the lobbyests and the motivation to reduce HC costs is effectively zero.

It won't be until the great unwashed wake up and realise they are being screwed that anything will change.

Probably why all powerful societies throughout history collapse from the inside.

[DavidAnnArbor]

This mid-term election is make or break for ACA.

[MrGreen]

I doubt Republicans will ever "deal with" high HC costs. You only have to have an ETF stock portfolio of say $2M where your earnings from the Healthcare sector will outweigh anything your family will have to pay for your own HC.

Namely rich people are better off the more expensive HC is. The bigger the portfolio the better off you are. Add in the backhanders from the lobbyests and the motivation to reduce HC costs is effectively zero.

It won't be until the great unwashed wake up and realise they are being screwed that anything will change.

Probably why all powerful societies throughout history collapse from the inside.

I think that depends on the public outcry. If it gets loud enough they'll do something. You can only ignore a tidal wave so long before it drowns you. But that assumes it becomes that important to the citizenry.

[Paul der Krake]

I think that depends on the public outcry. If it gets loud enough they'll do something. You can only ignore a tidal wave so long before it drowns you. But that assumes it becomes that important to the citizenry.

The citizenry was already consulted, and by and large they DGAF. But Corporate America is getting tired of spending 10k per worker with nothing to show for it, and they have influence with lawmakers. Sadly, I think it's our best hope for some sort of cost control. Fix the cost and all the other problems will hopefully disappear.

[EnjoyIt]

I doubt Republicans will ever "deal with" high HC costs. You only have to have an ETF stock portfolio of say $2M where your earnings from the Healthcare sector will outweigh anything your family will have to pay for your own HC.

Namely rich people are better off the more expensive HC is. The bigger the portfolio the better off you are. Add in the backhanders from the lobbyests and the motivation to reduce HC costs is effectively zero.

It won't be until the great unwashed wake up and realise they are being screwed that anything will change.

Probably why all powerful societies throughout history collapse from the inside.

I think both republicans and democrats alike have no vested interest in decreasing the cost of delivering healthcare.  all they do is argue who will foot the expensive bill.

[MrGreen]

I think that depends on the public outcry. If it gets loud enough they'll do something. You can only ignore a tidal wave so long before it drowns you. But that assumes it becomes that important to the citizenry.

The citizenry was already consulted, and by and large they DGAF. But Corporate America is getting tired of spending 10k per worker with nothing to show for it, and they have influence with lawmakers. Sadly, I think it's our best hope for some sort of cost control. Fix the cost and all the other problems will hopefully disappear.

They may not seem to care now, but the concern is growing. It doesn't take much to push something to the forefront of everyone's attention. Just look at healthcare in general. Before Trump was elected it wasn't a hot topic but now it's all I hear about from people. Maybe it won't reach a critical mass, but as more people start to realize that it's actually costs driving the cost of their health insurance I think the focus will shift.

[pecunia]

- SNIP SNIP -

I think both republicans and democrats alike have no vested interest in decreasing the cost of delivering healthcare.  all they do is argue who will foot the expensive bill.

Medicare for all, Single Payer and other plans look to save the individual and businesses money as has been noted previously.  In the past these have been conservative mantras.  It would certainly help business if the burden of paying a share of health insurance was lifted.  Although they have taken some extremely bizarre turns as of late, the Republicans have been known as the conservative party.  They have been known as the party of business. 

It just seems odd that not a single Republican has got on board with a contrary view to their status quo.  In recent polls I seem to recall seventy percent of the populace were on board with the single payer health plan.  It seems like it could be an easy sell for the GOP guaranteeing power for years to come.

I would think the Christian conservatives would get on board as it saves lives.  They could place and anti abortion ad on the same page as single payer with the statement, "Save Lives."  They could place an ad showing some sort of germ with the statement, "This is America's Biggest Terrorist!"  It would be followed up with a clear explanation of how single payer eliminates the problem of this terror.  This would help sell the program to defense oriented people.

Some diseases such as tuberculosis are coming back.

https://www.consultant360.com/articles/tuberculosis-old-disease-returns

A side benefit of allowing more people to get medical treatment is that these types of diseases which the current populace has not had to worry about for several generations can be kept away.  At the present time when medical treatment is not financially feasible for many of us, diseases such as this cannot be treated and so have a greater propensity to spread.

My grandfather died of tuberculosis.  I was told about it.  It isn't pretty.

This is a program that would give the nation as a whole better health.  It just seems bizarre on a humanitarian basis that is argued with.  Owners of slaves on plantations had the sense to get medical treatment for their slaves.  Are the one percenters that own our country not able to see this advantage?

The statement has been made that if you have a decent sized portfolio that you will make more money from health care stocks than you pay in a premium.  I think with all of the advantages the country would have with good health returns the stock market would be higher.  Productive companies would replace parasitic insurance companies.  I believe a higher yield would come from companies that perform an actual service for people rather than simply be a middle man transferring money.

People often seem to vote against their better interests.  I think the GOP may be doing that today.  They are on the wrong side of history regarding this issue.

[EnjoyIt]

No one thinks about long term solution in this country.  it is about short term.  Realistically single payer would accomplish very little without curtailing delivery and regulatory costs.  Sure it will go down a little but I think it would be a small dent to the overlying problem.  Getting everyone on a single payer system is also very problematic of a transition costing hundreds of thousands of jobs which is also political suicide.  Opening up current standards to everyone is very expensive.  instead we need have cheap/affordable options easily available and then universal provide them for everybody.  No private rooms in hospitals, no expensive cutting edge medication, no expensive robotic surgeries and no costly prolonged end of life care for those who are practically dead to begin with.  Then add a capitalist system on top of it to allow for all those extra emanates to be covered out of pocket or through a high deductible catastrophic insurance plan. This should fit the democrat stance of providing healthcare to everyone with the conservative pro capitalist twist to allow for a for profit motive.

Before we even consider enacting this we need to make the healthcare system transparent today.  Step one is mandate all pricing available and easily accessible to everyone.  We will never have lower costs when health care delivery is double blind.  The provider and the receiver of healthcare have no clue what the cost is.  Next, we need to allow the government to negotiate on rates for purchasing pharmaceuticals as well as equipment.  Those two measures alone would cost cost dramatically and open up a way to provide cheap affordable healthcare to the population.

[EnjoyIt]

No one thinks about long term solution in this country.  it is about short term.  Realistically single payer would accomplish very little without curtailing delivery and regulatory costs.  Sure it will go down a little but I think it would be a small dent to the overlying problem.  Getting everyone on a single payer system is also very problematic of a transition costing hundreds of thousands of jobs which is also political suicide.  Opening up current standards to everyone is very expensive.  instead we need have cheap/affordable options easily available and then universally provide them for everybody.  No private rooms in hospitals, no expensive cutting edge medication, no expensive robotic surgeries and no costly prolonged end of life care for those who are practically dead to begin with.  Then add a capitalist system on top of it to allow for all those extra amenities to be covered out of pocket or through a high deductible catastrophic insurance plan. This should fit the democrat stance of providing healthcare to everyone with the conservative pro capitalist twist to allow for a for profit motive.

Before we even consider enacting this we need to make the healthcare system transparent today.  Step one is mandate all pricing available and easily accessible to everyone.  We will never have lower costs when health care delivery is double blind.  The provider and the receiver of healthcare have no clue what the cost is.  Next, we need to allow the government to negotiate on rates for purchasing pharmaceuticals as well as equipment.  Those two measures alone would cost cost dramatically and open up a way to provide cheap affordable healthcare to the population.

[pecunia]

Enjoy It, That was a good post and probably worth repeating.

-SNIP-

Before we even consider enacting this we need to make the healthcare system transparent today.  Step one is mandate all pricing available and easily accessible to everyone.  We will never have lower costs when health care delivery is double blind.  The provider and the receiver of healthcare have no clue what the cost is.  Next, we need to allow the government to negotiate on rates for purchasing pharmaceuticals as well as equipment.  Those two measures alone would cost cost dramatically and open up a way to provide cheap affordable healthcare to the population.

That seems like a great first step.  As I've probably stated before, I've been to the doctor and asked what the cost will be and have been met with this odd look and reaction as though, "Why are you even asking this?"  I think it would even help the insurance companies.  I guess I've never considered their perspective before, but the job of determining payments may be quite difficult.

[EnjoyIt]

Enjoy It, That was a good post and probably worth repeating.

-SNIP-

Before we even consider enacting this we need to make the healthcare system transparent today.  Step one is mandate all pricing available and easily accessible to everyone.  We will never have lower costs when health care delivery is double blind.  The provider and the receiver of healthcare have no clue what the cost is.  Next, we need to allow the government to negotiate on rates for purchasing pharmaceuticals as well as equipment.  Those two measures alone would cost cost dramatically and open up a way to provide cheap affordable healthcare to the population.

That seems like a great first step.  As I've probably stated before, I've been to the doctor and asked what the cost will be and have been met with this odd look and reaction as though, "Why are you even asking this?"  I think it would even help the insurance companies.  I guess I've never considered their perspective before, but the job of determining payments may be quite difficult.

It is not just difficult but frankly impossible because every insurance company has different nuances for each and every plan it sells.  Plus, sometimes they agree to pay, sometimes they pay a portion and sometimes they just don't like how you billed and refuse to pay all together.  One would think that single payer would fix this, but the same thing happens with medicare and medicaid. If the cost for a service was fixed irrespective of insurance then the cost of billing would drop as well as all the back door negotiations that occur making the system so complex. 

Remember, most of our healthcare is not set in the emergency department and the consumer has some ability to shop around. According to the American College of Emergency medicine, the ER encompasses only 2% of healthcare dollars spent.  I'm sure those figures are a bit biased but even if they are 2 or 3 times as large, the numbers point that emergency care is not where all the healthcare dollars are going. This also means consumers do have the option to shop around. http://newsroom.acep.org/2009-01-04-costs-of-emergency-care-fact-sheet

[pecunia]

EnjoyIt:

"Remember, most of our healthcare is not set in the emergency department and the consumer has some ability to shop around. According to the American College of Emergency medicine, the ER encompasses only 2% of healthcare dollars spent.  I'm sure those figures are a bit biased but even if they are 2 or 3 times as large, the numbers point that emergency care is not where all the healthcare dollars are going. This also means consumers do have the option to shop around. http://newsroom.acep.org/2009-01-04-costs-of-emergency-care-fact-sheet"

I don't get sick very much but when I do I certainly don't want to spend time "shopping around."  Hey doc - How much for a broken leg.  It's a compound fracture.  Do you guys happen to be running a special this week?  I've been saving coupons.  Do you take them?

I don't like doctors so it doesn't make much difference to me which one does the poking and prodding, but many people want to deal with their primary physician.  I'll bet they don't want to shop either.

I guess if you shop around the old adage, "Let the Buyer Beware" could have some serious consequences.

I just don't think this capitalism thing works very well for medicine.