What comes after the ACA?

[MrGreen]

There are some real problems to the ACA.  Many insurance companies have pulled out of offering plans on the state exchanges.  This is getting worse after the congress removed the penalty for the individual mandate.  If you aren't forcing everyone (including the health folks) to buy into it, the insurance companies don't want to offer any plans.

Of the plans that are on state exchanges, a very large number of them are pretty terrible -- having upwards of $15,000 family out of pocket maximums, having $7000 deductibles, having extremely small networks of doctors, etc.  In my city, none of the plans on the ACA include ANY physicians from the two main research/educational hospitals here.

The big expenses in terms of actual health care spending dollars are:
- ridiculous end-of-life care
- diabetes
- cardiovascular disease
- cancer

Insulin resistance causes high blood sugar levels which causes cancer, inflammation, CVD and obviously diabetes -- and I think the nutritional guidelines in this country over the past several decades have been catastrophic.  Focusing on blaming LDL cholesterol instead of high carb diets and insulin-resistance has been devastating to our general population's health.  It's absolutely batshit insane.  Dealing with the fallout of the standard american diet of high carb, high sugar, highly processed foods -- this is a huge cause of chronic conditions and the money being flushed down the toilet of the american healthcare system.

It just depends on where you are. Our ACA insurance is phenomenal and new insurers are joining the state exchange. Our plan, which is the most basic Blue Cross Blue Shield plan covers a very nice sized network, and extends to all other BCBS groups in the country so it's basically a national insurance plan.

[pecunia]

I think the Affordable Care Act is a partial interim solution.  This link from Kaiser explains that there are over 20 million not covered.

https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

It's really hard for these political candidates to argue to keep the status quo when it comes to medicine.  it's kind of fun to watch some of them squirm.  The guys that paid to get them in office want them to keep it the same.  The people that vote them in want them to fix things.

[jim555]

Medicaid work requirements AGAIN struck down...

"A federal judge expanded the legal obstacles Monday to the Trump administration’s efforts to compel certain poor people to get jobs in exchange for Medicaid, ruling that New Hampshire cannot move ahead with such new requirements.

The ruling marks the third state for which U.S. District Judge James E. Boasberg has held that federal health officials were “arbitrary and capricious” when they approved the state plans, failing to consider the requirements’ effects on low-income residents who rely on Medicaid for health coverage."

https://www.washingtonpost.com/health/federal-judge-strikes-down-new-hampshires-medicaid-work-requirements/2019/07/29/a8e7fb6c-b237-11e9-951e-de024209545d_story.html?noredirect=on&utm_term=.d51ef4b3f283

[Threshkin]

Medicaid work requirements AGAIN struck down...

"A federal judge expanded the legal obstacles Monday to the Trump administration’s efforts to compel certain poor people to get jobs in exchange for Medicaid, ruling that New Hampshire cannot move ahead with such new requirements.

The ruling marks the third state for which U.S. District Judge James E. Boasberg has held that federal health officials were “arbitrary and capricious” when they approved the state plans, failing to consider the requirements’ effects on low-income residents who rely on Medicaid for health coverage."

https://www.washingtonpost.com/health/federal-judge-strikes-down-new-hampshires-medicaid-work-requirements/2019/07/29/a8e7fb6c-b237-11e9-951e-de024209545d_story.html?noredirect=on&utm_term=.d51ef4b3f283

Judicial activism. 

[jim555]

Medicaid work requirements AGAIN struck down...

"A federal judge expanded the legal obstacles Monday to the Trump administration’s efforts to compel certain poor people to get jobs in exchange for Medicaid, ruling that New Hampshire cannot move ahead with such new requirements.

The ruling marks the third state for which U.S. District Judge James E. Boasberg has held that federal health officials were “arbitrary and capricious” when they approved the state plans, failing to consider the requirements’ effects on low-income residents who rely on Medicaid for health coverage."

https://www.washingtonpost.com/health/federal-judge-strikes-down-new-hampshires-medicaid-work-requirements/2019/07/29/a8e7fb6c-b237-11e9-951e-de024209545d_story.html?noredirect=on&utm_term=.d51ef4b3f283

Judicial activism.

Don't agree.  The Repubs tried and failed to change the law in 2017.  So they try to change the law outside of the Congress, Paul Ryan actually had a whole slide show for the strategy.  The law does not have any mention of a work requirement.  They are using the 1115 waivers as a tool to change the law, but these waivers are only for the improvement of innovation for Medicaid, not as a way to add burdens and take away care from a vast majority of recipients.  In short, the judge is correct, it is arbitrary, capricious and unlawful.  If they want these changes they need to change the law.

[freya]

I'd prefer if they eliminated the problem by outlawing private-only insurance, and instituting another payroll tax to cover everyone with Medicare!  The private companies could continue to offer Medicare-Advantage-type programs if they wish.

Other than the new payroll tax, this would be a nice simple solution.  I think we need to get away from tying health insurance to jobs though.  That is essentially what caused a lot of our current problems.

However - what about limiting this coverage to high expense conditions (by diagnosis code), and let most outpatient care revert to the cash-basis system that it was prior to the 1970s and the era of health insurance job benefits?  It's a very tight and low-margin environment, and coopting it into a payment-sharing scheme (which is what insurance has become) simply makes it much more expensive and complicated than it needs to be.  If office visits, routine labs, and "core" generic meds were taken off insurance, permitting innovations like expanded use of telemedicine for followups and removing a huge unnecessary layer of billing and documentation requirements, the prices would go down to the point where going to the doctor would be hardly more expensive than going to a movie.  Movie tickets can cost up to $50, yet no one is clamoring for "movie insurance".    We've just been trained to believe that we should never pay out of pocket for health care, and maybe that's the problem.

[pecunia]

I'd prefer if they eliminated the problem by outlawing private-only insurance, and instituting another payroll tax to cover everyone with Medicare!  The private companies could continue to offer Medicare-Advantage-type programs if they wish.

Other than the new payroll tax, this would be a nice simple solution.  I think we need to get away from tying health insurance to jobs though.  That is essentially what caused a lot of our current problems.

However - what about limiting this coverage to high expense conditions (by diagnosis code), and let most outpatient care revert to the cash-basis system that it was prior to the 1970s and the era of health insurance job benefits?  It's a very tight and low-margin environment, and coopting it into a payment-sharing scheme (which is what insurance has become) simply makes it much more expensive and complicated than it needs to be.  If office visits, routine labs, and "core" generic meds were taken off insurance, permitting innovations like expanded use of telemedicine for followups and removing a huge unnecessary layer of billing and documentation requirements, the prices would go down to the point where going to the doctor would be hardly more expensive than going to a movie.  Movie tickets can cost up to $50, yet no one is clamoring for "movie insurance".    We've just been trained to believe that we should never pay out of pocket for health care, and maybe that's the problem.

I can choose not to go to a movie.  Going to a doctor even for a few stitches is rather essential.  Many of us have paid for our doctor bills out of pocket because insurance did not cover these things.  In fact, it is difficult to determine what insurance does cover even for those in the billing office at doctor's offices.  I think the system is now too tainted to ever be like going to any other business.  I doubt whether the cost would go down.  How many things have you seen the cost go down?  Only when there is a replacement product (or process) will drive costs down.

Seems like there are fewer and fewer folks out there that want to keep things "as is."

[DaMa]

There are some real problems to the ACA.  Many insurance companies have pulled out of offering plans on the state exchanges.  This is getting worse after the congress removed the penalty for the individual mandate.  If you aren't forcing everyone (including the health folks) to buy into it, the insurance companies don't want to offer any plans.

Of the plans that are on state exchanges, a very large number of them are pretty terrible -- having upwards of $15,000 family out of pocket maximums, having $7000 deductibles, having extremely small networks of doctors, etc.  In my city, none of the plans on the ACA include ANY physicians from the two main research/educational hospitals here.

Maybe they could just add a public option to the ACA, where people could buy into Medicare at the average cost.  Then if Medicare really was a lower cost option, people would eventually leave their high-cost private plans for Medicare, gradually phasing into a single payer system.

Too bad that our politicians caved to the demands of the insurance industry and took that out of the ACA.  I always thought that was the best way to lead the country to a single payer system in a way that would happen slowly enough that most health insurance employees could shift into other jobs.  It also allowed people to choose to get what they pay for -- opting to pay to keep their private plans as long as they could. 

[zolotiyeruki]

There are some real problems to the ACA.  Many insurance companies have pulled out of offering plans on the state exchanges.  This is getting worse after the congress removed the penalty for the individual mandate.  If you aren't forcing everyone (including the health folks) to buy into it, the insurance companies don't want to offer any plans.

Of the plans that are on state exchanges, a very large number of them are pretty terrible -- having upwards of $15,000 family out of pocket maximums, having $7000 deductibles, having extremely small networks of doctors, etc.  In my city, none of the plans on the ACA include ANY physicians from the two main research/educational hospitals here.

Maybe they could just add a public option to the ACA, where people could buy into Medicare at the average cost.  Then if Medicare really was a lower cost option, people would eventually leave their high-cost private plans for Medicare, gradually phasing into a single payer system.

Too bad that are politicians caved to the demands of the insurance industry and took that out of the ACA.  I always thought that was the best way to lead the country to a single payer system in a way that would happen slowly enough that most health insurance employees could shift into other jobs.  It also allowed people to choose to get what they pay for -- opting to pay to keep their private plans as long as they could.

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

[Roland of Gilead]

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

If we are going to force big pharma to sell drugs at certain price levels I do not see any reason why we can't also force providers to accept new Medicare patients at the standard reimbursement rate.   If you don't take the patients, you don't get to practice in the USA.

[zolotiyeruki]

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

If we are going to force big pharma to sell drugs at certain price levels I do not see any reason why we can't also force providers to accept new Medicare patients at the standard reimbursement rate.   If you don't take the patients, you don't get to practice in the USA.

And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

WRT Big Pharma, I'd be more comfortable if they simply offered drugs at the same price everywhere in the developed world.

[ysette9]

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

If we are going to force big pharma to sell drugs at certain price levels I do not see any reason why we can't also force providers to accept new Medicare patients at the standard reimbursement rate.   If you don't take the patients, you don't get to practice in the USA.

And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

WRT Big Pharma, I'd be more comfortable if they simply offered drugs at the same price everywhere in the developed world.

The rest of the developed world gets better prices because they have price controls

[zolotiyeruki]

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

If we are going to force big pharma to sell drugs at certain price levels I do not see any reason why we can't also force providers to accept new Medicare patients at the standard reimbursement rate.   If you don't take the patients, you don't get to practice in the USA.

And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

WRT Big Pharma, I'd be more comfortable if they simply offered drugs at the same price everywhere in the developed world.

The rest of the developed world gets better prices because they have price controls

Yes, they do...only because the pharmaceuticals can jack the price up in the US to compensate, *and* because the expensive pharmaceuticals are not commoditized.  It's the same issue with the proposal with Medicare--once you've slain the cash cow (i.e. private insurance which is effectively subsidizing Medicare), that extra cost has to come from somewhere.

[pecunia]

Ker-snip-


And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

Nah - There is now a two tier pay system in the auto industry.  Lots of people have been laid off and have had to accept lower pay.  Why should these health care professionals be immune from the economy around them?  I'll bet in 2008 when all those folks lost their jobs that the health care people  weren't impacted one bit.  Those folks have a lot of time invested in experience and training.  They will still be one of the highest paid professions in the US.  They ain't gonna run out and work in a convenience store instead of doing the medical thing.

They ain't gonna like it.  Too bad.  Let them bitch.  They'll still be making a ton of money even with a pay cut.  We can smile when they bitch and say "too bad."  One more thing.  Those folks are smart and hard working.  I am sure they will figure out some way to do like all other businesses do.  They will improve their business to make up for the "lost" revenue.  It will end up being a win win for us all.

[Paul der Krake]

I have two questions/concerns:
1) When you way "average cost," do you mean "average cost to the taxpayer of covering someone via Medicare"?
2) Medicare's reimbursement rates are significantly lower than those paid by private insurance (to the point that a fair number of providers no longer accept new MC patients), which means that Medicare patients are effectively being subsidized by private insurance.  What happens if a large percentage of patients switch to a (presumably) cheaper Medicare plan, and providers are now facing far slimmer (or negative) margins?

If we are going to force big pharma to sell drugs at certain price levels I do not see any reason why we can't also force providers to accept new Medicare patients at the standard reimbursement rate.   If you don't take the patients, you don't get to practice in the USA.

And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

WRT Big Pharma, I'd be more comfortable if they simply offered drugs at the same price everywhere in the developed world.

The rest of the developed world gets better prices because they have price controls

Yes, they do...only because the pharmaceuticals can jack the price up in the US to compensate, *and* because the expensive pharmaceuticals are not commoditized.  It's the same issue with the proposal with Medicare--once you've slain the cash cow (i.e. private insurance which is effectively subsidizing Medicare), that extra cost has to come from somewhere.

Medicare. Does. Not. Underpay.

Its prices are well in line with the rest of costs of the rest of the developed world. They just aren't as big suckers as the private insurance market, and there are enough of larger suckers that some providers decide they would rather deal with the biggest suckers instead of the moderate suckers.

Makes sense?

I get it, it's totally natural. I've found a sucker employer willing to pay me a ton of money, so I've decided not to deal with the others employers willing to pay less. If my current sucker stops being a sucker, I'll fall back to the second biggest sucker.

[zolotiyeruki]

Medicare. Does. Not. Underpay.

Its prices are well in line with the rest of costs of the rest of the developed world. They just aren't as big suckers as the private insurance market, and there are enough of larger suckers that some providers decide they would rather deal with the biggest suckers instead of the moderate suckers.

Makes sense?

I get it, it's totally natural. I've found a sucker employer willing to pay me a ton of money, so I've decided not to deal with the others employers willing to pay less. If my current sucker stops being a sucker, I'll fall back to the second biggest sucker.

The demand curve in the healthcare market may not have as much elasticity to it as other markets, and in the short term, the supply curve may also be less elastic.  But you better believe in the long term, it'll be affected.

As to whether Medicare underpays, I don't have an answer for that, nor did I claim that it does.  What I stated is that because Medicare reimbursement rates are significantly lower than for private insurance, Medicare patients are being effectively subsidized by those with private insurance.

[former player]

Medicare. Does. Not. Underpay.

Its prices are well in line with the rest of costs of the rest of the developed world. They just aren't as big suckers as the private insurance market, and there are enough of larger suckers that some providers decide they would rather deal with the biggest suckers instead of the moderate suckers.

Makes sense?

I get it, it's totally natural. I've found a sucker employer willing to pay me a ton of money, so I've decided not to deal with the others employers willing to pay less. If my current sucker stops being a sucker, I'll fall back to the second biggest sucker.

The demand curve in the healthcare market may not have as much elasticity to it as other markets, and in the short term, the supply curve may also be less elastic.  But you better believe in the long term, it'll be affected.

As to whether Medicare underpays, I don't have an answer for that, nor did I claim that it does.  What I stated is that because Medicare reimbursement rates are significantly lower than for private insurance, Medicare patients are being effectively subsidized by those with private insurance.

Not necessarily.  "Less profitable" does not mean "subsidized" - every business has some contracts that are more profitable than others, that doesn't mean one contract is subsidising another as long as both are profitable.  And even if Medicare patients are running at a loss that might be because of inefficiencies in the organisation rather than Medicare paying below a reasonable cost.  One test would be what if any medical services which are run for profit refuse Medicare patients - if there are few or none then the "subsidized" argument starts to look pretty weak.

[Bateaux]

Ker-snip-


And watch the price controls gut the industry?  You'll have to forgive me if I'm not enthusiastic about the idea.

Nah - There is now a two tier pay system in the auto industry.  Lots of people have been laid off and have had to accept lower pay.  Why should these health care professionals be immune from the economy around them?  I'll bet in 2008 when all those folks lost their jobs that the health care people  weren't impacted one bit.  Those folks have a lot of time invested in experience and training.  They will still be one of the highest paid professions in the US.  They ain't gonna run out and work in a convenience store instead of doing the medical thing.

They ain't gonna like it.  Too bad.  Let them bitch.  They'll still be making a ton of money even with a pay cut.  We can smile when they bitch and say "too bad."  One more thing.  Those folks are smart and hard working.  I am sure they will figure out some way to do like all other businesses do.  They will improve their business to make up for the "lost" revenue.  It will end up being a win win for us all.

Slam dunk!  Well said.

[DavidAnnArbor]

The website acasignups.net goes into great detail about Biden's improvement of the ACA, expanding subsidies, getting rid of surprise billing from out of network providers, etc.  There's also a comparison with Warren's ACA 2.0 bill (before Warren decided to go all Bernie and decide she prefers Medicare for All)

Here's the link:

http://acasignups.net/19/07/19/joe-biden-picks-aca-20-bill-elizabeth-warren-seems-have-set-aside-adds-public-option-it?te=1&nl=paul-krugman&emc=edit_pk_20190723%3Fcampaign_id%3D116&instance_id=11110&segment_id=15472&user_id=3b17fc640dfd053a0092ebb0ae92c95e&regi_id=2945323

[DaMa]

I'll repeat Paul der Krake.  Medicare does not underpay.  This is just one of many misleading sound bites perpetuated by the health insurance industry. 

Why do I say that?  Because I worked in the industry analyzing claims and revenue for Medicare Advantage (MA) plans for 10 years.  Part of my job was to sit down with a side by side comparison of Medicare and my plan payment rates.  There was certainly variation, but overall the rates were within 1%. 

I'm sure it's the areas where the variation is high that the press focuses on.  I remember a news story about some areas that had issues with OBs not taking Medicare, but the real issue was there was such a low number of OBs that they could take only the highest paying plans.  That's a supply and demand issue, and one of the reasons why Medicare has regional payment rates. The OB Medicare rates went up in that area eventually.

BTW, that "within 1%" was after removing our admin+profit load.  Which is how we did our analysis.  Which is why I keep writing about how much we could save by eliminating insurance company admin+profit.

[DavidAnnArbor]

Democrats Are Having the Wrong Health Care Debate
https://nyti.ms/2YCwxSZ

This opinion piece by Ezekiel Emanuel, a health care economist, goes into great detail about the problems with high costs.

"Four policies can effectively tackle the affordability issue.

First, we need to address drug prices. - Despite a lot of talk about cutting drug prices, the Trump administration has taken no substantive action.

Second, hospital prices are soaring and must be contained. - The main culprit behind this price escalation appears to be the mergers of hospital systems, which creates local monopolies.

Third, we need a policy that targets wasteful insurance billing practices. - which is what DaMa said already. - The simplest approach is to empower an independent commission to create a clearinghouse for processing all medical bills with uniform standardized electronic formats for all insurers - like Germany and Japan.

Fourth - push even harder on switching from fee-for-service payment to value-based alternatives. As it stands, when physicians avoid an unnecessary test or deliver the same outcomes for less money, they suffer financially."

"For the other 295 million Americans who have some form of health insurance, the problem is high costs. Even with health insurance, high premiums, deductibles and co-pays, surprise hospital bills and exorbitant drug prices inhibit people from accessing care and taking their medications, threaten to drain their savings, or even force Americans into bankruptcy. Democrats need a plan to deal with this problem. "

[Roland of Gilead]

I have now exited all of my stock positions in drug stocks.   I do not see any good reason an investor interested in a reasonable return on their investment based on the high risk would invest in pharma right now.

Pull up a chart of any major drug company right now and compare it to any major tech company and the tech company has blown away the returns from the drug company.

[DavidAnnArbor]

I don't recommend doing market timing and trying to time sectors of the stock market - recipe for disaster for you.

[Roland of Gilead]

I don't recommend doing market timing and trying to time sectors of the stock market - recipe for disaster for you.

I wouldn't quite say disaster, but yeah this year I only have about a 14% return compared to the 19% return of the overall market.

Last year though I had a 141% return, which handily beat the market.

[DavidAnnArbor]

A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check)
https://nyti.ms/2ZVBp3n

Wow, American hospitals are so ridiculously priced that one could get a check for having the surgical procedure done in Mexico.

[Exflyboy]

Works for me.

My buddy in the Philippines recently hurt himself.. Xrays, ER visit, several hours in the hospital. Total cost Thirteen bucks.. Total out of pocket cost!

Geez, for that price I think I'd find reasons to actually visit the ER to give them some business and show my appreciation!

[Roland of Gilead]

The average salary in the Phillippines for a doctor/surgeon is $489,000 peso, or about $9300 USD a year

We can get these low prices in the USA if we pay our doctors at that rate!

[Exflyboy]

The average salary in the Phillippines for a doctor/surgeon is $489,000 peso, or about $9300 USD a year

We can get these low prices in the USA if we pay our doctors at that rate!

Like I said.. Works for me..;)

[Roland of Gilead]

The average salary in the Phillippines for a doctor/surgeon is $489,000 peso, or about $9300 USD a year

We can get these low prices in the USA if we pay our doctors at that rate!

Like I said.. Works for me..;)

And we pay our aircraft mechanics a similar rate to Phillippines (about $3500 a year)

[Exflyboy]

The average salary in the Phillippines for a doctor/surgeon is $489,000 peso, or about $9300 USD a year

We can get these low prices in the USA if we pay our doctors at that rate!

Like I said.. Works for me..;)

And we pay our aircraft mechanics a similar rate to Phillippines (about $3500 a year)

Now you're scaring me..:)

[stoaX]

Democrats Are Having the Wrong Health Care Debate
https://nyti.ms/2YCwxSZ

This opinion piece by Ezekiel Emanuel, a health care economist, goes into great detail about the problems with high costs.

"Four policies can effectively tackle the affordability issue.

First, we need to address drug prices. - Despite a lot of talk about cutting drug prices, the Trump administration has taken no substantive action.

Second, hospital prices are soaring and must be contained. - The main culprit behind this price escalation appears to be the mergers of hospital systems, which creates local monopolies.

Third, we need a policy that targets wasteful insurance billing practices. - which is what DaMa said already. - The simplest approach is to empower an independent commission to create a clearinghouse for processing all medical bills with uniform standardized electronic formats for all insurers - like Germany and Japan.

Fourth - push even harder on switching from fee-for-service payment to value-based alternatives. As it stands, when physicians avoid an unnecessary test or deliver the same outcomes for less money, they suffer financially."

"For the other 295 million Americans who have some form of health insurance, the problem is high costs. Even with health insurance, high premiums, deductibles and co-pays, surprise hospital bills and exorbitant drug prices inhibit people from accessing care and taking their medications, threaten to drain their savings, or even force Americans into bankruptcy. Democrats need a plan to deal with this problem. "

Well said - thanks for posting this.

As a retired health insurance underwriter my hope is that whoever the voters of the United States elect to the presidency and congress end up implementing meaningful improvements to the ACA.  I kinda doubt we'll hear anything like this during the run-up to the elections, I expect more extreme rhetoric.  I just hope cooler heads prevail when the work is actually being done.   

[pecunia]

Sounds kind of like as those health companies merge, there will be less of them.  Their operations will be streamlined to enable the huge profits.  So - It might be easy for the government to take over the operation, eliminate the profits and save us money.  Alternatively, they could keep a few around and bid the job out of providing health care for various areas.  This would still incentive streamlined operations as they could lose a contract to a competitor.  It would also allow the monitoring of their expenses so they wouldn't run rampant.

I wouldn't want it to turn out like defense contractors.  Sometimes, that's a bad deal for the taxpayer.

[rantk81]

Edit: Removed my own post.  It was way too snarky.

I would just say that I don't think "Health Insurance" jobs should exist.  For something that (many of us) believe should be a "public good" or a "right" -- access to health care -- there shouldn't be some private company middle-man skimming off billions and billions of dollars per year.  We would be better off as a society if those folks found employment in some other industry.

[stoaX]

Edit: Removed my own post.  It was way too snarky.

I would just say that I don't think "Health Insurance" jobs should exist.  For something that (many of us) believe should be a "public good" or a "right" -- access to health care -- there shouldn't be some private company middle-man skimming off billions and billions of dollars per year.  We would be better off as a society if those folks found employment in some other industry.

While a number of the jobs would disappear in "medicare for all" or other nationalized arrangement, many of them wouldn't.  Those health insurance jobs that adjudicate claims, negotiate and maintain reimbursement rates; create, monitor and enforce clinical standards; pursue waste fraud and abuse issues, do customer service, etc.. would all still exist in some form or another.   But you are right that the total number of workers doing this would be substantially less. 

[pecunia]

Here's the thing about the jobs.  Right now, in my ignorant opinion, I don't think the health insurance industry is doing a big chunk of what they should be doing.  This Marianne Williamson lady makes some sense to me.  There ought to be an effort at preventive medicine.  In fact, I'll bet a lot of people agree with her.  Why not help people do the things that stop you from being sick in the first place?

As a great junk food epicure, I love my greasy Cheetos and other crunchy delights.  I know they are bad for me and slap my hand before I eat them.  I also know that there are beau coup people out there that don't even know this stuff is bad for you.  Does the food industry help?  Nah - Good money to be made.

To cut this short, if the health industry had a bit of an overhaul, there would (should) be jobs created to help us not to get sick in the first place.  There's lots of diseases like heart disease and diabetes that can be prevented by people if they just had a little help.  OK - Who is going to pay for it?  I kinda figure it will pay for itself.  It will eventually get to the "Don't fix it if it ain't broke."  Or to make it obvious, "Don't doctor us if we ain't sick."

[SugarMountain]

Here's the thing about the jobs.  Right now, in my ignorant opinion, I don't think the health insurance industry is doing a big chunk of what they should be doing.  This Marianne Williamson lady makes some sense to me.  There ought to be an effort at preventive medicine.  In fact, I'll bet a lot of people agree with her.  Why not help people do the things that stop you from being sick in the first place?

As a great junk food epicure, I love my greasy Cheetos and other crunchy delights.  I know they are bad for me and slap my hand before I eat them.  I also know that there are beau coup people out there that don't even know this stuff is bad for you.  Does the food industry help?  Nah - Good money to be made.

To cut this short, if the health industry had a bit of an overhaul, there would (should) be jobs created to help us not to get sick in the first place.  There's lots of diseases like heart disease and diabetes that can be prevented by people if they just had a little help.  OK - Who is going to pay for it?  I kinda figure it will pay for itself.  It will eventually get to the "Don't fix it if it ain't broke."  Or to make it obvious, "Don't doctor us if we ain't sick."

Great point.  The original food pyramid was designed by the food industry not nutritionists and as a result is very heavy on grains which are really just carbs which is really just sugar.  This is one of the many reasons we've become fat in America.

[Monkey Uncle]

Here's the thing about the jobs.  Right now, in my ignorant opinion, I don't think the health insurance industry is doing a big chunk of what they should be doing.  This Marianne Williamson lady makes some sense to me.  There ought to be an effort at preventive medicine.  In fact, I'll bet a lot of people agree with her.  Why not help people do the things that stop you from being sick in the first place?

As a great junk food epicure, I love my greasy Cheetos and other crunchy delights.  I know they are bad for me and slap my hand before I eat them.  I also know that there are beau coup people out there that don't even know this stuff is bad for you.  Does the food industry help?  Nah - Good money to be made.

To cut this short, if the health industry had a bit of an overhaul, there would (should) be jobs created to help us not to get sick in the first place.  There's lots of diseases like heart disease and diabetes that can be prevented by people if they just had a little help.  OK - Who is going to pay for it?  I kinda figure it will pay for itself.  It will eventually get to the "Don't fix it if it ain't broke."  Or to make it obvious, "Don't doctor us if we ain't sick."

Right now health insurers have no incentive to help their customers stay healthy.  Insurance companies are mandated by law to spend at least 80% of their revenue on health care claims.  So the only way they can make more money is to pay out more money in claims (i.e., allow health care costs to keep spiraling upward).  This is a well-intentioned part of the ACA that had the unforeseen consequence of setting up a perverse incentive.

[rantk81]

The original food pyramid was designed by the food industry not nutritionists and as a result is very heavy on grains which are really just carbs which is really just sugar.  This is one of the many reasons we've become fat in America.

I could not agree more!  It's no coincidence that the obesity/diabetes epidemic came on after all of these carb-heavy diets were pushed on the populace.  People blowing out their pancreases from insulin-resistance is a primary factor, if not root cause, of most modern first-world diseases.  CVD, Diabetes, Obesity, Cancer, probably Alzheimer's too.

The Lipid Hypothesis is an outright lie -- and has duped several generations -- and the worst part is, most doctors still believe it.  It sure made Pfizer shareholders pretty rich though from selling Lipitor. 

A diet full of healthy fats (that humans ate for thousands of years) was replaced (in just the last couple generations) with a diet full of insulin-spiking cheap carbs/sugars.

[ecchastang]

The original food pyramid was designed by the food industry not nutritionists and as a result is very heavy on grains which are really just carbs which is really just sugar.  This is one of the many reasons we've become fat in America.

I could not agree more!  It's no coincidence that the obesity/diabetes epidemic came on after all of these carb-heavy diets were pushed on the populace.  People blowing out their pancreases from insulin-resistance is a primary factor, if not root cause, of most modern first-world diseases.  CVD, Diabetes, Obesity, Cancer, probably Alzheimer's too.

The Lipid Hypothesis is an outright lie -- and has duped several generations -- and the worst part is, most doctors still believe it.  It sure made Pfizer shareholders pretty rich though from selling Lipitor. 

A diet full of healthy fats (that humans ate for thousands of years) was replaced (in just the last couple generations) with a diet full of insulin-spiking cheap carbs/sugars.

Most healthcare professionals make more money by treating symptoms than by curing the cause.

[roomtempmayo]

No mention of how much higher salaries are in the USA for medical professionals than they are in other comparable countries or how much higher our legal malpractice costs are than other countries or how much more we pay for administration than other countries.

The problem with really cutting costs is that health care is 20% of our economy, and to cut that even close to in half so that we're aligned with the most of western Europe wouldn't just mean the specialists making $300k+ would take a pay cut, a large number of upper middle class workers would get a briss.  If, for example, we reel RNs making 70-100k+ back to typical bachelor's salaries of 40-65k, there are going to be a whole lot of pissed off nurses out there, not to mention the economic and social fallout that would occur.  Health care is the new "too big to fail" industry.

I do think that in the long run the pain of realignment in the industry would be worth it.

The key, I think, to making a Medicare for All or single payer system work is flooding the medical labor market with foreign workers to increase supply enough to cover all the rural hospitals while simultaneously driving down prices enough to make rural care affordable.  Open a really basic Federal residency program to ensure competence, and then let everyone who is qualified go practice.  Yes, some people who came up under the old system expecting a big payout would feel hosed, but the health industry has so overplayed its hand that an industry shakeup is a known hazard for anyone going into it.  Nobody is entitled to a distorted and protected market in perpetuity. 

[roomtempmayo]

The money just doesn't just disappear, though. If premiums go down by 50%, that means extra money each month for other purchases.

Oh, I totally agree, which is why I think the pain would be worth it in the long run.  Further, though, productivity would be increased because those cuts would increase efficiency.  Insurance is almost entirely transaction cost/friction compared with the Medicare/Medicaid billing system, so doing away with it seems like a clear efficiency gain.  Likewise, if labor costs would be reduced by 1/4 or 1/3 while the same work gets done, that's a net efficiency gain.

If we could get past the short term pain of displaced and/or disgruntled workers, we'd be in a much better place as a society.

In the bigger picture, health care seems to be a perfect example of how we are biased toward known but suboptimal outcomes, and biased against optimal but unknown outcomes.

If we could move $5k/capita in employee compensation from health costs to wages, the stimulus effect would be fantastic.  Even better, for thrifty savers, imagine saving and investing an additional $5k/year over the typical 35-45 year career.  It would be huge.

AMA ad:

"This is a medical school in India.
<shot of some POS clinic in rural India>
Do you want someone trained there to save your child?
<shot of a child's coffin with a brown skinned doctor in the background>
Call your representative today."

I almost wish we were in a place where the AMA had to become the public scaremonger.  At least then we'd be having the conversation.  As it is, that conversation isn't even on the table because (a) most people have given zero thought to how the American residency system reduces the supply of doctors and drives up the price of services, and (b) cannot fathom voluntarily consuming medical services provided by someone for whom English isn't their first language (and, for anything not OBGYN, someone who is a white male).

[pecunia]

You don't need to flood the country with health professionals from other places.  You don't need to rob those places of their needed health professionals.  There just needs to be a concerted effort to train more here.  Change the rules so it doesn't require an MD to perform a lot of the tasks.  There's plenty of young people who would like a decent job in medicine.

[roomtempmayo]

You don't need to flood the country with health professionals from other places.  You don't need to rob those places of their needed health professionals.  There just needs to be a concerted effort to train more here.  Change the rules so it doesn't require an MD to perform a lot of the tasks.  There's plenty of young people who would like a decent job in medicine.

I agree with the idea that we should train far more people here, and we should lower every barrier to entry reasonable.  But the AMA and others have managed to perpetuate a protectionist racket that we don't seem able to confront.  There isn't a path within the existing paradigm to the sorts of cost reductions (25-50%) we need to see.

Regardless of whether we do it, western Europe and Australia will continue to mine the world for health professionals to subsidize their health systems.  The choice is just whether or not we participate.

[iris lily]

I will briefly  relate our saga of staying on an ACA policy for the last few months until DH can get on the government teat of Medicare.

Briefly, he has zero income. He had  zero income a few months ago when the ACA allowed him to have an ACA policy.

A few months ago I qualified for an ACA policy because I had appropriate income. He was on “my” ACA account. Then I moved to Medicare. He will soon be eligible for Medicare but
ACA threatened to drop him when I dropped our AC?a policy.

The phone drones at ACA Central asked him how much his income is and he truthfully answered $0. He has the same income he had four  months ago which is a household income. I share it with him. We file taxes jointly,  and come tax time we will file exactly as we did last year. ACA subsidies will be determined on that basis.

But the phone drones couldn’t wrap their heads around it and determined he was a Medicaid eligible person except that we don’t have expanded Medicaid in my state. And him being on Medicaid is ridiculous anyway, so ridiculous I cannot even contemplate that. That aint gonna happen, We would go private insurance before doing Medicaid.

So after several weeks of back-and-forthing with some paperwork, one of the phone drones suggested we send our last 1040 form. So we did, and that seem to satisfy them. Keep in mind this is all for income estimates anyway. The rubber meets the road when the IRS determines income eligibility and subsidies.

I know this is a first world problem but damn it was annoying.

[Exflyboy]

@iris lily I have often wondered what happens when one of you qualifies for Medicare and the other has to remain on the ACA.

As I suspected, this will be another nightmare to look forward to!

This assumes of course the ACA even survives the attacks of the GOP until I qualify 7 years from now.

[seattlecyclone]

@iris lily I have often wondered what happens when one of you qualifies for Medicare and the other has to remain on the ACA.

My understanding of what should happen is that you still use the overall household income to calculate what the net cost of the second-cheapest silver plan should be after subsidies, but since you're only covering one person with that amount rather than two the amount of subsidy you get (if any) will go way down. Meanwhile you're paying Medicare premiums as well so your overall health care costs will probably go up for those years.

I'm not aware of any circumstance where a person's individual income factors into ACA or Medicaid coverage, it's all about the household income. If they asked @iris lily's husband for an individual income specifically, I'd sure like to know why. Otherwise, next time they ask "what's your income," you should probably just respond with the household income to avoid a bunch of confusion.

[iris lily]

@iris lily I have often wondered what happens when one of you qualifies for Medicare and the other has to remain on the ACA.

My understanding of what should happen is that you still use the overall household income to calculate what the net cost of the second-cheapest silver plan should be after subsidies, but since you're only covering one person with that amount rather than two the amount of subsidy you get (if any) will go way down. Meanwhile you're paying Medicare premiums as well so your overall health care costs will probably go up for those years.

I'm not aware of any circumstance where a person's individual income factors into ACA or Medicaid coverage, it's all about the household income. If they asked @iris lily's husband for an individual income specifically, I'd sure like to know why. Otherwise, next time they ask "what's your income," you should probably just respond with the household income to avoid a bunch of confusion.

I wasn’t listening in to the conversation with the ACA representative and DH. But I assume they asked him how much his income is and he he replied zero and then ensued a long conversation about household income. So it’s not as though they did not, in multiple phone calls with multiple people, know he had a household income.

Fortunately there won’t be any more of this in six weeks. It was just a short time where he needed
 ACA coverage after my Medicare coverage kicked in.

I don’t know how much it will cost but I’m confident it’s cheaper than private insurance and I just want to get everything set up on Medicare and supplemental programs. We have had 4 transitions in the past four years since I retired and every transition is tricky.

[Roadrunner53]

@iris lily I have often wondered what happens when one of you qualifies for Medicare and the other has to remain on the ACA.

As I suspected, this will be another nightmare to look forward to!

This assumes of course the ACA even survives the attacks of the GOP until I qualify 7 years from now.

My spouse and I were on ACA until he went on Medicare. It is based on household income. When the two of us were on it with subsidy, it cost us around $510 a month for two people. When spouse dropped off ACA to go onto Medicare I was expecting the price to go down by half and that did not happen. It only dropped around $20. So for one person on ACA with the same household income the price is basically the same for one as it was for two. Made me crazy but could have been worse if we had not gotten the subsidy. Got to be very careful to control household income so you stay under the radar screen. Any unexpected income can throw you off the rails. Like overtime, winning some money in the lotto, dipping into IRA's. We were exceptionally careful to not exceed income limits and it worked for us. Now I am on Medicare too and that is a whole other can of worms and is more expensive than ACA if you buy the supplemental Medicare things you need. People don't realize that basic Medicare pays for hospital and there is a huge deductible if you are admitted. Part B you have to pay for and that is for Doctor visits, tests but there is a deductible for that too per year. Then there is Plan D for prescription drugs. Then you have to realize that Medicare only pays 80% of doctor visits, tests and things. You pay the other 20%. That is where a supplemental plan comes in. There are various programs that pay 50%, 75% and one that pays 100% (of the 20% you will owe). If you think ACA is making your head spin, wait till you get on Medicare!

[Exflyboy]

yeah that 80% part B coverage is a 20% unlimited liability.. How is Chemo paid?

That looks like Part B to me and with some chemo's costing north of $1M/year.. Yeah you need a Medigap policy or similar.

[seattlecyclone]

yeah that 80% part B coverage is a 20% unlimited liability.. How is Chemo paid?

That looks like Part B to me and with some chemo's costing north of $1M/year.. Yeah you need a Medigap policy or similar.

This is one reason why I'm rather wary of the calls for "Medicare for All." The parts of Medicare that you actually buy directly from the government (A and B) have no out-of-pocket maximum, and if you make less than 400% of the poverty level your premiums for a bronze-level ACA plan (with an out-of-pocket maximum!) could well be lower than just the Medicare Part B premiums.

If you're on Medicare and want to limit your financial downsides, you need to buy a supplemental plan from...you guessed it...a private insurance company! These plans don't seem to have any income-based subsidies available, so the difference in premiums only gets bigger.

As much as there is to dislike about the system of private insurance carriers acting under the ACA, simply lowering the Medicare eligibility age without changing the program in other ways seems like it could be one step forward, two steps back for many of us.