What comes after the ACA?

[rantk81]

I have a question about the sound-bites from the Democrat candidates -- the ones who want "Medicare for All" or "Medicare for All who want it" --

When they say Medicare, are they just using that as a generic phrase to refer to government-sponsored (single payer or single-payer'ish) healthcare in general?

Or does it refer to offering the actual parts of Medicare as available for purchase (parts A, B, D) for people at any age?  Would the prices be at the same price-schedule as those who reach the regular Medicare age of 65?  Would Part A be "free" for those, who aren't yet 65, but have accumulated enough working years to qualify?

Do these "Medicare for All" plans include the option to purchase an "Advantage" plan from a private insurer -- where you might get a smaller network of doctors, but also might have lower premiums (presumably with the government subsidizing part of the cost of the premiums?)

I'm just curious how this is supposed to work.  "Medicare for all" is a nice phrase -- but I haven't really heard of what the details are for these proposals, other than the headline sound-bites.

If a "Government" (or Medicare?) plan is available by default on the Healthcare.gov exchange, would it have cost sharing the same as the cost sharing is in Medicare?  Regular Medicare plans right now are not compliant with the ACA (in terms of the ACA requiring certain restrictions on out-of-pocket maximums.)

[sherr]

It sounds like we agree that you can't blame them for anything that happened during Obama's presidency.  With Trump elected, the program had metastasized and so they couldn't simply repeal it and pull the rug out.  So it has really become an impossible situation--you've got a terrible, complicated, unwieldy, inefficient system, but people are dependent on it.  Unwinding it in such a way as to minimize the pain is extremely delicate, and any measures you want to enact have to be incremental.

[rolls eyes]

You still haven't answered my question (or anyone else's) and actually linked anyone to these "market-driven cost reduction approaches" that Republicans favor. Letting sick people die because they can't get insurance for their pre-existing conditions is a "market-driven cost reduction approach", sure, and again that's the closest that anything's actually come to passing in a Republican Senate. Anything else?

[sherr]

I have a question about the sound-bites from the Democrat candidates -- the ones who want "Medicare for All" or "Medicare for All who want it" --

When they say Medicare, are they just using that as a generic phrase to refer to government-sponsored (single payer or single-payer'ish) healthcare in general?

Or does it refer to offering the actual parts of Medicare as available for purchase (parts A, B, D) for people at any age?  Would the prices be at the same price-schedule as those who reach the regular Medicare age of 65?  Would Part A be "free" for those, who aren't yet 65, but have accumulated enough working years to qualify?

Do these "Medicare for All" plans include the option to purchase an "Advantage" plan from a private insurer -- where you might get a smaller network of doctors, but also might have lower premiums (presumably with the government subsidizing part of the cost of the premiums?)

I'm just curious how this is supposed to work.  "Medicare for all" is a nice phrase -- but I haven't really heard of what the details are for these proposals, other than the headline sound-bites.

If a "Government" (or Medicare?) plan is available by default on the Healthcare.gov exchange, would it have cost sharing the same as the cost sharing is in Medicare?  Regular Medicare plans right now are not compliant with the ACA (in terms of the ACA requiring certain restrictions on out-of-pocket maximums.)

Well first of all it would be government-sponsered health insurance; health care would still be provided by private hospitals and doctors and pharmaceutical companies like it is today. Which I know you understand, but is an important distinction that often gets lost in the shouting.

But to actually answer your question, it varies by the candidate. Bernie's plan for example seems to be using "Medicare" as a stand-in for government-sponsered single payer insurance, so the existing actual Medicare system would probably change a lot. It's impossible to say at this stage what would actually get passed though, I'd say the "plans" at this point are more a signal for whether they support single-payer or public-option than they are actual plans.

[rantk81]

Thanks for the reply.

Kind of related questions I've had in the back of my mind for a while (with respect to Medicare, as it exists today):

To set up my question.... So there are different "Parts" with different costs (premiums, deductibles, co-insurances).  But the cost sharing for Medicare parts is not structured exactly the same as how cost-sharing is structured on private insurance plans.

A) Hospital Insurance
- No premium for this if you worked a certain number of years
- Has deductibles that aren't applied on an annual basis
- Does not have out of pocket maximum

B) Medical Insurance
- Has a premium for this
- Has a deductible and co-insurance (that is applied on an annual basis?)

D) Prescription coverage
- Has a monthly premium
- Is administered by a private insurance company (?) so that cost-sharing schedules can vary widely.


And then there is Part (C) Medicare "Advantage" which has cost sharing that is structured similar to private insurance plans, where there is a premium, an annual deductible, co-insurance, and an out-of-pocket maximum.

My question is: Often, Medicare Part (C) Advantage plans are offered for "Free" to people who are eligible for Medicare.  These plans are administered by private insurance companies.  Is the "premium" for these plans essentially funded by the Government? --

e.g. Uncle Sam says "Hey John Doe, you're eligible for Medicare because you worked xx years and are 65 years old.  But instead of getting Medicare parts A & B directly from the government, you can instead get this private insurance company to administer your health insurance.  And the Govt will give that private insurance company some money -- which will pay for part or all of the plan. But you'll probably have a smaller network of doctors."

Is that basically how it goes?

[waltworks]

It sounds like we agree that you can't blame them for anything that happened during Obama's presidency.  With Trump elected, the program had metastasized and so they couldn't simply repeal it and pull the rug out.  So it has really become an impossible situation--you've got a terrible, complicated, unwieldy, inefficient system, but people are dependent on it.  Unwinding it in such a way as to minimize the pain is extremely delicate, and any measures you want to enact have to be incremental.

That's moving the goalposts a little. I can have a great plan for reforming healthcare, and simultaneously know that it needs to be incrementally implemented. Is that what you're arguing is the case here? Because I haven't seen any actual concrete/comprehensive policy proposals on this front from the GOP (to be clear, I don't find most of the Democratic proposals all that plausible).

The only legislative proposals from the GOP related to healthcare in the last decade have involved repealing the ACA and returning to the pre-ACA status quo, right? Or did I miss something?

Again, to be clear: I agree that there are significant practical hurdles to implementing *any* comprehensive healthcare legislation. That doesn't prevent anyone, including the GOP, president Trump (who did promise an amazing plan once elected, back in 2016), or anyone else from making a proposal. The total lack of such proposals from the GOP says to me that they don't actually have a plan they can agree on and that Americans will support. Given the number of years that have passed since the ACA was implemented, I suspect that the GOP will never construct such a plan.

-W

[sherr]

My question is: Often, Medicare Part (C) Advantage plans are offered for "Free" to people who are eligible for Medicare.  These plans are administered by private insurance companies.  Is the "premium" for these plans essentially funded by the Government? --

e.g. Uncle Sam says "Hey John Doe, you're eligible for Medicare because you worked xx years and are 65 years old.  But instead of getting Medicare parts A & B directly from the government, you can instead get this private insurance company to administer your health insurance.  And the Govt will give that private insurance company some money -- which will pay for part or all of the plan. But you'll probably have a smaller network of doctors."

Is that basically how it goes?

Yes, it looks like that is exactly how it works. Some critics actually contend that the government subsidy for Medicare Advantage plans is actually larger than the government would spend if they enrolled in traditional Medicare part A/B instead, because the people who are healthier tend to self-select into MA.

[rantk81]

Yes, it looks like that is exactly how it works. Some critics actually contend that the government subsidy for Medicare Advantage plans is actually larger than the government would spend if they enrolled in traditional Medicare part A/B instead, because the people who are healthier tend to self-select into MA.

Thanks. Yeah, that's what I always thought, but I wasn't sure.

I can easily see how people who are "healthier" would opt for a "zero premium private insurance plan" instead of paying premiums for Medicare Part B.  One would hope that the government would take this into account, when it is determining how much money to throw at those private Medicare Advantage plans though.

For me, my primary concern would be that Medicare Parts A & B don't have annual "out of pocket maximums", which would make me lean toward the private Advantage plans.  I'm a long way off from age 65... but I'm interested in these topics, since phrases like "Medicare for All" are being thrown around in the headlines.

[American GenX]

For me, my primary concern would be that Medicare Parts A & B don't have annual "out of pocket maximums", which would make me lean toward the private Advantage plans.

It's common for people to get a Medicare "supplement" policy to cover costs not covered by A & B.

Earlier in the thread, Roadrunner(?) and maybe some others posted some examples of what they are paying for the various Medicare parts and supplement.

[American GenX]

The Supreme Court has refused to fast track the Obamacare case currently winding it's way through the court system.

I haven't seen anymore updates posted about this, but that's not been decided yet.

"The U.S. Supreme Court signaled it will use its Feb. 21 private conference to discuss whether to consider the fate of the Affordable Care Act on a fast-track schedule that would mean a decision by the end of June. "

https://thehill.com/policy/healthcare/481635-supreme-court-to-consider-taking-obamacare-case-at-feb-21-conference

"Democrats are urging the justices to hold arguments during the last week of April -- the court’s last scheduled week to hear cases -- or during a highly unusual special sitting in May."

https://www.bloomberglaw.com/document/X581H6QS000000

It takes 5 justices to vote for expediting the case this term.
It takes 4 justices to vote to take the case for review next term.
Otherwise, it continues back down to the district court regarding the severability of the mandate from the other components of the ACA, where it was previously ruled the entire law falls along with the mandate.

Just a follow-up on the above post.  They kicked the can down the road a little, so we don't know if they're going to take the case yet.

UPDATE: Feb. 24, 2020: The Supreme Court is now scheduled to review the ACA case during a conference date set for Friday, Feb. 28.

https://www.healthcaredive.com/news/supreme-court-mum-on-aca-case/572823/

Here's a confirmation of the above:

https://www.healthaffairs.org/do/10.1377/hblog20200221.66921/full/

"But the delay makes it highly unlikely that the case will be considered during the Court's current term. If the Court agrees to hear the appeal, Texas is expected to be decided during the Court's next term (with a decision in summer 2021)."

[sherr]

You still haven't answered my question (or anyone else's) and actually linked anyone to these "market-driven cost reduction approaches" that Republicans favor. Letting sick people die because they can't get insurance for their pre-existing conditions is a "market-driven cost reduction approach", sure, and again that's the closest that anything's actually come to passing in a Republican Senate. Anything else?

The crickets are deafening.

[Exflyboy]

You still haven't answered my question (or anyone else's) and actually linked anyone to these "market-driven cost reduction approaches" that Republicans favor. Letting sick people die because they can't get insurance for their pre-existing conditions is a "market-driven cost reduction approach", sure, and again that's the closest that anything's actually come to passing in a Republican Senate. Anything else?

The crickets are deafening.

Well obviously there is no point in keeping poor people alive, they can't afford HC so there is no point! MAGA!

[freya]

You still haven't answered my question (or anyone else's) and actually linked anyone to these "market-driven cost reduction approaches" that Republicans favor. Letting sick people die because they can't get insurance for their pre-existing conditions is a "market-driven cost reduction approach", sure, and again that's the closest that anything's actually come to passing in a Republican Senate. Anything else?

The crickets are deafening.

Actually, there is data that you can use to get an idea of the added cost that insurance layers onto medical spending:  prices of direct-to-consumer lab tests vs. the same tests ordered by an MD that are eligible for insurance reimbursement.  There's about a 5 fold price difference - pretty amazing.  In fact, if you have a typical high deductible policy, you may be better off financially using direct to consumer lab services for routine tests (offered by LabCorp for example).  Unless you live in a nanny state like NY or MD, where these are prohibited - presumably in order to eliminate competition.

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

[waltworks]

Freya, that's certainly true. But it's not (to my knowledge) a GOP proposal that we eliminate insurance.

We sort of have the worst of a free market and the worst of socialism in the current system. #winning!

-W

[pecunia]

- SNIP -

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

In most any product or service, a market cannot do "it's thing," unless there are alternatives that a consumer can choose between.  Frankly, I just don't see that for medicine.  It has been noted before within this forum.

[seattlecyclone]

- SNIP -

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

In most any product or service, a market cannot do "it's thing," unless there are alternatives that a consumer can choose between.  Frankly, I just don't see that for medicine.  It has been noted before within this forum.

In theory I don't see any reason a market couldn't work for most medical needs, the low-cost low-urgency things. Even though we all need food to survive, we usually have the time to comparison shop and become familiar with who tends to offer the foods we need for reasonable prices. Why could the same not work for most medical services? Emergency rooms are a different beast, but if I know I need a lab test and could get that test at any of 20 different labs in town, and prices were transparent to allow me to do reasonable comparison shopping, why couldn't it work?

As I see it our current system is basically the worst of both worlds. Insurance is the least efficient way to pay for anything due to the middlemen involved, but we use it even for cheap stuff that should be affordable out-of-pocket for most people. At the same time we have the illusion of market competition for the expensive stuff that people don't have the time or information needed for market pricing to work. One way to bring this closer to sanity is to simply switch to single-payer health care and have the central payer dictate lower prices to doctors whether they like it or not. If we want to go in the other direction and try to improve the market-based pricing, I'm not really sure what the solution is. Maybe move deductibles from a year-long thing to a per-day thing so that you don't have any reason to involve your insurance company unless you go to the hospital or something?

[FireLane]

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

The biggest danger of this is that it would incentivize people, especially poor people, to skip routine preventative care to save money. They'll end up only going to the doctor when a small problem becomes a crisis, which means more pain and suffering and drives up costs for everyone.

[Omy]

And instead of getting checked out and staying home when they get (insert latest pandemic virus here) symptoms, they will go to work and infect everyone in their path for the several days they are contagious. You would think that a pandemic would motivate Americans to come up with a plan that takes everybody into account - or the poorest/sickest have the potential of taking us all out.

[pecunia]

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

The biggest danger of this is that it would incentivize people, especially poor people, to skip routine preventative care to save money. They'll end up only going to the doctor when a small problem becomes a crisis, which means more pain and suffering and drives up costs for everyone.

Isn't that the way it is now?

And instead of getting checked out and staying home when they get (insert latest pandemic virus here) symptoms, they will go to work and infect everyone in their path for the several days they are contagious. You would think that a pandemic would motivate Americans to come up with a plan that takes everybody into account - or the poorest/sickest have the potential of taking us all out.

Isn't that the way it is now?

I guess the market is working the way we expect.

Side note - I read a few years ago that tuberculosis was coming back.  People get it and don't complete treatment.  It's expensive.  Some with the disease are migrant workers.   The TB gets immune to the old drugs.  It spreads.  My grandfather died of tuberculosis.  It's a horrible way to go. 

The market works fine for those with money.  Those without the money share their diseases with all.  It gives full meaning to what Bill Clinton used to say about feeling your pain.

[American GenX]

I haven't seen any other reference to confirm this, but this website has a Feb 28th update that says:

"The U.S. Supreme Court said it will not fast-track a request by 19 states to take on a decision by a federal appeals court that ruled Obamacare’s individual mandate is unconstitutional

Instead, the Supreme Court sent the case back to a U.S. district court to decide whether the entire law needs to be thrown out."

https://www.heartland.org/news-opinion/news/supreme-court-sidelines-review-of-aca-constitutionality-as-law-approaches-ten-years

I wasn't expecting a fast-track at this point, but if this is true, they aren't even taking up the case, at least not until it makes it way back from the lower courts on appeal.

[freya]

Assuming the same applies to outpatient office visits, you can make a pretty good case for taking all those routine medical encounters off insurance entirely, and letting the market do its thing.  This is actually how it worked in the 1960s, before insurance became a popular job perk and started expanding coverage, and people managed just fine.  It would be most interesting to see what happens just in that sphere, and what happens to insurance premiums when coverage is limited to truly catastrophic conditions/expenses.  Unfortunately, to get the maximum benefit you have to make this universal - if just one small group of patients requires massive documentation and all the other tripe that's inflating costs, then it's effectively required for everyone.

The biggest danger of this is that it would incentivize people, especially poor people, to skip routine preventative care to save money. They'll end up only going to the doctor when a small problem becomes a crisis, which means more pain and suffering and drives up costs for everyone.

This is the usual argument put forward to support the idea of insurance for routine care, but it doesn't hold up.  My day is too short to explain why, but there are quite a number of excellent books on the subject (start with "Doctoring Data" by Malcolm Kendrick).

Most preventive care programs are about selling drugs and services, not improving health.  The main one that's worthwhile is getting your blood sugar checked, and that's super easy to do - drugstores and workplaces are always offering free checks for example.  Or you can buy a glucose meter and do it yourself.

It is true that the GOP is not proposing to take routine services off insurance, but oh how I wish they would!

[DavidAnnArbor]

Under the ACA there are a lot of basic routine care that is already free and covered by insurance including vaccinations, general check up once a year, a free colonoscopy starting at age 50, and other things. This free care enables poor and low income to get care that is preventive in nature.
Also, poorer people can qualify for Medicaid which is free health care.

[pecunia]

Under the ACA there are a lot of basic routine care that is already free and covered by insurance including vaccinations, general check up once a year, a free colonoscopy starting at age 50, and other things. This free care enables poor and low income to get care that is preventive in nature.
Also, poorer people can qualify for Medicaid which is free health care.

I've been learning bits and pieces about medical care.  I've paid more attention since the inception of the ACA because I had to buy my own insurance for a while.  I find the strangest thing about the preventive medicine that is offered is that the stuff that will give you the most bang for the buck is not stressed.  My doctor is willing to dole out pills and is happy to prescribe tests.  However, on nutritional and exercise advise he is strangely silent.  So, one of the bits and pieces I've learned is not to put too much faith in these people.

[waltworks]

The medical profession in general has always been terrible about giving out useful diet/exercise advice, so that's not new or a feature of the ACA, really.

To be fair, it's not like everyone doesn't already know that sugar and being sedentary are bad. Most people just don't care and are unhealthy/obese, hence the emphasis on drugs and tests.

-W

[iris lily]

Under the ACA there are a lot of basic routine care that is already free and covered by insurance including vaccinations, general check up once a year, a free colonoscopy starting at age 50, and other things. This free care enables poor and low income to get care that is preventive in nature.
Also, poorer people can qualify for Medicaid which is free health care.

I've been learning bits and pieces about medical care.  I've paid more attention since the inception of the ACA because I had to buy my own insurance for a while.  I find the strangest thing about the preventive medicine that is offered is that the stuff that will give you the most bang for the buck is not stressed.  My doctor is willing to dole out pills and is happy to prescribe tests.  However, on nutritional and exercise advise he is strangely silent.  So, one of the bits and pieces I've learned is not to put too much faith in these people.

Good nutritional and exercise advice is all over the internet. A complete health program for a general exercise and reducing diet would require hours of instruction  from the doc. 
I wouldnt expect a physician to give me this instruction..

[geekette]

I wouldn't go to a dietitian for a sprained ankle or a gym for a persistent cough, so going to an MD for diet and exercise advise seems similarly ill-advised.  Although I've certainly been referred!

[American GenX]

The Supreme Court has refused to fast track the Obamacare case currently winding it's way through the court system.

I haven't seen anymore updates posted about this, but that's not been decided yet.

"The U.S. Supreme Court signaled it will use its Feb. 21 private conference to discuss whether to consider the fate of the Affordable Care Act on a fast-track schedule that would mean a decision by the end of June. "

https://thehill.com/policy/healthcare/481635-supreme-court-to-consider-taking-obamacare-case-at-feb-21-conference

"Democrats are urging the justices to hold arguments during the last week of April -- the court’s last scheduled week to hear cases -- or during a highly unusual special sitting in May."

https://www.bloomberglaw.com/document/X581H6QS000000

It takes 5 justices to vote for expediting the case this term.
It takes 4 justices to vote to take the case for review next term.
Otherwise, it continues back down to the district court regarding the severability of the mandate from the other components of the ACA, where it was previously ruled the entire law falls along with the mandate.

Just a follow-up on the above post.  They kicked the can down the road a little, so we don't know if they're going to take the case yet.

UPDATE: Feb. 24, 2020: The Supreme Court is now scheduled to review the ACA case during a conference date set for Friday, Feb. 28.

https://www.healthcaredive.com/news/supreme-court-mum-on-aca-case/572823/

Here's a confirmation of the above:

https://www.healthaffairs.org/do/10.1377/hblog20200221.66921/full/

"But the delay makes it highly unlikely that the case will be considered during the Court's current term. If the Court agrees to hear the appeal, Texas is expected to be decided during the Court's next term (with a decision in summer 2021)."

I'm surprised no one has mentioned this already, but here's some breaking news that I read earlier this morning:

Supreme Court to Hear Obamacare Appeal

"WASHINGTON — The Supreme Court on Monday agreed to hear a third major case on the Affordable Care Act, President Barack Obama’s health care law, granting petitions from Democratic state officials and the House of Representatives in a case with the potential to wipe out the entire law."

This is the case we've been talking about where the district court judge ruled that the ACA is unconstitutional by way of the mandate after the penalty was reduced to zero.   So, instead of letting it play out in the lower courts, dragging it out even longer, it looks like SCOTUS will hear the case next term, which begins in October, and we should get a final ruling by summer 2021.

https://www.nytimes.com/2020/03/02/us/supreme-court-obamacare-appeal.html

https://news.bloomberglaw.com/us-law-week/supreme-court-to-hear-democrats-obamacare-appeal-in-next-term

https://www.cnbc.com/2020/03/02/supreme-court-says-it-will-hear-cases-over-obamacare-constitutionality.html

[iris lily]

That news was mentioned on another thread, but this gives me opportunity to voice my question: didn’t the Supreme Court already rule on the mandate? Justice Roberts made the final call, that it was a tax and therefore constitutional.

That is what I remember.

So tell me,if my memory is correct, what are the Supremes doing by bringing it in front of them again?
Is the point of law slightly different? Or—?

[American GenX]

That news was mentioned on another thread, but this gives me opportunity to voice my question: didn’t the Supreme Court already rule on the mandate? Justice Roberts made the final call, that it was a tax and therefore constitutional.

That is what I remember.

So tell me,if my memory is correct, what are the Supremes doing by bringing it in front of them again?
Is the point of law slightly different? Or—?

It's been discussed upthread, but basically, this case came about because the penalty was reduced to zero, so the plaintiffs argue that it's no longer a tax, so if that's the reason ACA was upheld before, they argue the change now makes the mandate unconstitutional and that the rest of the law is unseverable.

[iris lily]

That news was mentioned on another thread, but this gives me opportunity to voice my question: didn’t the Supreme Court already rule on the mandate? Justice Roberts made the final call, that it was a tax and therefore constitutional.

That is what I remember.

So tell me,if my memory is correct, what are the Supremes doing by bringing it in front of them again?
Is the point of law slightly different? Or—?

It's been discussed upthread, but basically, this case came about because the penalty was reduced to zero, so the plaintiffs argue that it's no longer a tax, so if that's the reason ACA was upheld before, they argue the change now makes the mandate unconstitutional and that the rest of the law is unseverable.

Hunh, ok, thanks!

[iris lily]

Ok, but now I wonder how a mandate that isnt a mandate (no one has to pay) can still be viewed as a mandate.

Oh well, I guess this is the tricky bizness of The Law..

[MrGreen]

The Supreme Court has refused to fast track the Obamacare case currently winding it's way through the court system.

I haven't seen anymore updates posted about this, but that's not been decided yet.

"The U.S. Supreme Court signaled it will use its Feb. 21 private conference to discuss whether to consider the fate of the Affordable Care Act on a fast-track schedule that would mean a decision by the end of June. "

https://thehill.com/policy/healthcare/481635-supreme-court-to-consider-taking-obamacare-case-at-feb-21-conference

"Democrats are urging the justices to hold arguments during the last week of April -- the court’s last scheduled week to hear cases -- or during a highly unusual special sitting in May."

https://www.bloomberglaw.com/document/X581H6QS000000

It takes 5 justices to vote for expediting the case this term.
It takes 4 justices to vote to take the case for review next term.
Otherwise, it continues back down to the district court regarding the severability of the mandate from the other components of the ACA, where it was previously ruled the entire law falls along with the mandate.

Just a follow-up on the above post.  They kicked the can down the road a little, so we don't know if they're going to take the case yet.

UPDATE: Feb. 24, 2020: The Supreme Court is now scheduled to review the ACA case during a conference date set for Friday, Feb. 28.

https://www.healthcaredive.com/news/supreme-court-mum-on-aca-case/572823/

Here's a confirmation of the above:

https://www.healthaffairs.org/do/10.1377/hblog20200221.66921/full/

"But the delay makes it highly unlikely that the case will be considered during the Court's current term. If the Court agrees to hear the appeal, Texas is expected to be decided during the Court's next term (with a decision in summer 2021)."

I'm surprised no one has mentioned this already, but here's some breaking news that I read earlier this morning:

Supreme Court to Hear Obamacare Appeal

"WASHINGTON — The Supreme Court on Monday agreed to hear a third major case on the Affordable Care Act, President Barack Obama’s health care law, granting petitions from Democratic state officials and the House of Representatives in a case with the potential to wipe out the entire law."

This is the case we've been talking about where the district court judge ruled that the ACA is unconstitutional by way of the mandate after the penalty was reduced to zero.   So, instead of letting it play out in the lower courts, dragging it out even longer, it looks like SCOTUS will hear the case next term, which begins in October, and we should get a final ruling by summer 2021.

https://www.nytimes.com/2020/03/02/us/supreme-court-obamacare-appeal.html

https://news.bloomberglaw.com/us-law-week/supreme-court-to-hear-democrats-obamacare-appeal-in-next-term

https://www.cnbc.com/2020/03/02/supreme-court-says-it-will-hear-cases-over-obamacare-constitutionality.html

Well at least we have some kind of certainty about when this legal challenge will be finished. I just hope it goes in the ACA's favor. At least the way it's going to be hear will make it a headline issue running up to the election.

[Exflyboy]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

[MrGreen]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

That is an excellent point I had not considered before!

[Exflyboy]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

That is an excellent point I had not considered before!

Right.. We have a precedent right there in the existing tax code.

Lets just hope the Justices are not so highly compensated that they don't know this..:)

[American GenX]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

I've seen that argument before, I think upstream in this thread.  But the plaintiffs' argument is the mandate penalty of zero now doesn't generate any revenue, at all, from anyone, for the government, which would be difference than capital gains and dividends taxes.

Of course, I thought the defendants had a more compelling argument in the case.

[waltworks]

The weird thing is, if I was the GOP, I'd want the ACA to stay on the books forever. It's a great scapegoat and talking point, it's easy to get your base riled up about, and best of all - it absolves you, effectively, from doing anything.

If the ACA gets thrown out, and 19 million people lose their health insurance, that will be pretty chaotic, and everyone will know exactly who to blame. The pressure will immediately be on to propose new legislation, which, again, the GOP doesn't seem able to do at this stage.

I guess they could basically write up ACA 2.0, call it the Health Freedom and Tiny American Flags for Everyone act, and just claim it as their own? I don't see another option, really. If they just write up a bill guaranteeing coverage for pre-existing conditions, it'll just collapse the insurance industry completely in short order and that's a fast road to single payer.

It seems sort of like a dog-catches-car situation to me. Am I missing something?

-W

[sherr]

I guess they could basically write up ACA 2.0, call it the Health Freedom and Tiny American Flags for Everyone act, and just claim it as their own? I don't see another option, really. If they just write up a bill guaranteeing coverage for pre-existing conditions, it'll just collapse the insurance industry completely in short order and that's a fast road to single payer.

It seems sort of like a dog-catches-car situation to me. Am I missing something?

No I think you're exactly right, this is precisely what they'd do. See also NAFTA and the attempt at a Republican healthcare bill that actually passed the Republican House. The hard part though would be how they actually handle the bits they've been very public about hating.

If the ACA is bad because of the individual mandate, how on earth do they preserve the pre-existing conditions clause without it? I think likely they can't. It is very much a dog-catches-car situation. Which is why they couldn't figure out a better solution in Trumps first 2 years when they actually had a chance. It won't be different this time around, they still are currently not able to figure anything out and that won't change just because they managed to kill the ACA.

[MrGreen]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

I've seen that argument before, I think upstream in this thread.  But the plaintiffs' argument is the mandate penalty of zero now doesn't generate any revenue, at all, from anyone, for the government, which would be difference than capital gains and dividends taxes.

Of course, I thought the defendants had a more compelling argument in the case.

What about the 2.9% tax on high income earners? I think that's still there, which would mean some revenue to the govt.

[American GenX]

Easy counter argument....

Qdivs and Capital gains are taxed, but if you are in the 12% or lower tax bracket they are taxed at zero%.

Therefore taxes of zero% are still taxes..

End of argument. Of course the whole thing is a political football and repealing just kicks 19million POOR people off healthcare and the GOP doesn't give a shit... Thats the only reason this is go to the Supremes.

I've seen that argument before, I think upstream in this thread.  But the plaintiffs' argument is the mandate penalty of zero now doesn't generate any revenue, at all, from anyone, for the government, which would be difference than capital gains and dividends taxes.

Of course, I thought the defendants had a more compelling argument in the case.

What about the 2.9% tax on high income earners? I think that's still there, which would mean some revenue to the govt.

But the argument is about the mandate penalty not being a tax since it's 0%, therefore making the mandate unconstitutional, since the ACA was held up previously by SCOTUS on the grounds of the penalty being a tax.

[seattlecyclone]

I agree that a 0% tax isn't really a tax, but I also think that a mandate with a $0 penalty for violators isn't really a mandate. Seems like they want to argue that the former is true but not the latter. Not a very consistent argument I think.

[sherr]

I agree that a 0% tax isn't really a tax, but I also think that a mandate with a $0 penalty for violators isn't really a mandate. Seems like they want to argue that the former is true but not the latter. Not a very consistent argument I think.

It doesn't make any sense on any number of levels. And yet we have Republican judges rubber-stamping it. This is what you get when Republicans have a stranglehold on the judiciary, law and order go out the window and they just do whatever they want to. And to think that *they* are the ones whining about "legislating from the bench"...

[freya]

Doesn't make sense, but I suspect the ACA is history.  So far, the GOP & Trump are saying they will keep the part about not excluding pre-existing conditions - hopefully that will be the case.

I would not worry about this either way though.   There is a lot of baggage in the ACA law that has been driving medical and insurance costs up, and getting rid of that would frankly be a good thing.  Also, catastrophic policies would no longer be outlawed.   It would be interesting to price out one of those, with the highest deduction you can find, combined with a health sharing ministry subscription if you're not inclined to want to self-insure.

Also, there's an interesting trend developing: self-directed care replacing regular primary care visits.  Between direct to consumer labs, your ability to do your own checks at home for glucose, BP, even sleep disorders, and easy availability of online, on-demand telemedicine plus urgent care clinics popping up everywhere, you don't really need your health insurance for routine stuff.  All these except urgent care and preventative procedures (which don't require a referral) are cash-pay only and a lot cheaper than going the traditional route.  So you could opt for this for the routine stuff, and save insurance for those rare situations when you really need the backstop - i.e. what insurance is REALLY supposed to be for.   True, most people probably are better off relying on MD guidance, but those of us on this forum are smart enough to figure this out for themselves.  It's not rocket science.

[John Galt incarnate!]

It doesn't make any sense on any number of levels. And yet we have Republican judges rubber-stamping it. This is what you get when Republicans have a stranglehold on the judiciary, law and order go out the window and they just do whatever they want to. And to think that *they* are the ones whining about "legislating from the bench"...

"An activist court is a court that makes a decision you don't like." Justice Kennedy



If legislation is not facially unconstitutional the Supreme Court's review of it  commences with a presumption of constitutionality.

Sometimes the high Court does "rewrite" legislation, or "legislates from the bench," to shape   legislation  so that it fits within the bounds of constitutionality.

The reason the Supreme Court does so is to observe the cardinal rule of statutory construction which is "to save and not to destroy," an observation that  effects the principle of judicial restraint.

[waltworks]

Doesn't make sense, but I suspect the ACA is history.  So far, the GOP & Trump are saying they will keep the part about not excluding pre-existing conditions - hopefully that will be the case.

If the goal is short term chaos/the end of private insurance and long term single payer, then keeping the pre-existing condition protections and getting rid of the rest of the law is a great strategy. I can tell you exactly what I'd do in that situation - drop my health insurance, pay out of pocket for routine stuff, and buy insurance again if I get cancer.

-W

[bacchi]

The reason the Supreme Court does so is to observe the cardinal rule of statutory construction which is "to save and not to destroy," an observation that  effects the principle of judicial restraint.

I think you're going to be surprised and saddened at the decisions this term and next. Some of the Justices don't believe in precedent as much as you think they do.

[John Galt incarnate!]

The reason the Supreme Court does so is to observe the cardinal rule of statutory construction which is "to save and not to destroy," an observation that  effects the principle of judicial restraint.

I think you're going to be surprised and saddened at the decisions this term and next. Some of the Justices don't believe in precedent as much as you think they do.

Doubtless I've   consistently opined that the Supreme  Court will not overturn the A.C.A.

Time will tell if my prediction is correct.

I've been thinking about starting a thread that includes all of the Court's rationales that support  my opinion.

This thread already includes a sprinkling of them.

It's a lot of work  to write an opening post that includes all of them.

 Lately I'm feeling lazy due to the springlike weather.

Maybe next fall?

Maybe next winter?

For now, Justice Harlan's dissent in Plessy v. Ferguson (1896) provides a cogent  rationale in support of judicial restraint.


Is it meant that the determination of questions of legislative power depends upon the inquiry whether the statute whose validity is questioned is, in the judgment of the courts, a reasonable one, taking all the circumstances into consideration?

A statute may be unreasonable merely because a sound public policy forbade its enactment.

But I do not understand that the courts have anything to do with the policy or expediency of legislation.

A statute may be valid and yet, upon grounds of public policy, may well be characterized as unreasonable.

Mr. Sedgwick correctly states the rule when he says that, the legislative intention being clearly ascertained,


the courts have no other duty to perform than to execute the legislative will, without any regard to their views as to the wisdom or justice of the particular enactment.


There is a dangerous tendency in these latter days to enlarge the functions of the courts by means of judicial interference with the will of the people as expressed by the legislature.

 Our institutions have the distinguishing characteristic that the three departments of government are coordinate and separate.

Each must keep within the limits defined by the Constitution.

And the courts best discharge their duty by executing the will of the lawmaking power, constitutionally expressed, leaving the results of legislation to be dealt with by the people through their representatives.

Statutes must always have a reasonable construction. Sometimes they are to be construed strictly; sometimes liberally, in order to carry out the legislative will.

But however construed, the intent of the legislature is to be respected, if the particular statute in question is valid, although the courts, looking at the public interests, may conceive the statute to be both unreasonable and impolitic.

If the power exists to enact a statute, that ends the matter so far as the courts are concerned.

The adjudged cases in which statutes have been held to be void because unreasonable are those in which the means employed by the legislature were not at all germane to the end to which the legislature was competent.
 

[American GenX]

Doesn't make sense, but I suspect the ACA is history.  So far, the GOP & Trump are saying they will keep the part about not excluding pre-existing conditions - hopefully that will be the case.

They don't want to keep pre-existing conditions or any other part of the ACA.  They've made that clear in the ACA lawsuit that they think the entire ACA should fall along with the mandate.  They are being dishonest about wanting to protect pre-existing conditions - they are trying to eliminate them.

There is a lot of baggage in the ACA law that has been driving medical and insurance costs up, and getting rid of that would frankly be a good thing.  Also, catastrophic policies would no longer be outlawed.   It would be interesting to price out one of those, with the highest deduction you can find, combined with a health sharing ministry subscription if you're not inclined to want to self-insure.

ACA helps keep healthcare costs down.  Those pre-ACA low cost "junk" policies and healthcare share ministries have left too many people holding the bill, not covering pre-existing conditions, getting dropped from their insurance, low coverage caps, having ridiculously high co-pays and deductibles, etc.  With subsidies, you can get some very affordable plans on the ACA marketplace that have required protections, and poor people can get FREE coverage through the ACA Medicaid expansion.

The ACA isn't perfect and can be improved on, but Trump/GOP are doing just the opposite, trying to dismantle it, removing funding, etc.  We're going to need a democrat in the White House as well as democratic majorities in Congress to see the improvements made.

[freya]

ACA helps keep healthcare costs down.  Those pre-ACA low cost "junk" policies and healthcare share ministries have left too many people holding the bill, not covering pre-existing conditions, getting dropped from their insurance, low coverage caps, having ridiculously high co-pays and deductibles, etc.  With subsidies, you can get some very affordable plans on the ACA marketplace that have required protections, and poor people can get FREE coverage through the ACA Medicaid expansion.

The ACA may help keep YOUR healthcare costs down, but overall costs have increased.  Where do you think the subsidies come from?  It doesn't fall from the sky.

I think that a cash pay, private system will continue to develop alongside traditional insurance, which is limited to a fixed, severely over-regulated health-care delivery system that will become unable to cope with the healthcare needs of an increasingly sick population.  The analogy here is how commerce used to work in the Soviet Union:  there were mostly empty cheap, government-run stores, with long lines forming every time a store restocked.  Outside in the street, there was a thriving Wild-west of makeshift stalls where goods were sold at market prices with zero government oversight.  That's what happens when a centralized government tries to engineer a large segment of the economy.

Fortunately this is already happening -  the paleo/keto movement, DIY healthcare, online telemedicine etc.  If not for that, healthcare costs would be increasing even more.  I personally don't care whether the cost comes in the form of higher premiums/deductibles/copays, or increased taxes.  It'll come out the same either way.

[Tyson]

ACA helps keep healthcare costs down.  Those pre-ACA low cost "junk" policies and healthcare share ministries have left too many people holding the bill, not covering pre-existing conditions, getting dropped from their insurance, low coverage caps, having ridiculously high co-pays and deductibles, etc.  With subsidies, you can get some very affordable plans on the ACA marketplace that have required protections, and poor people can get FREE coverage through the ACA Medicaid expansion.

The ACA may help keep YOUR healthcare costs down, but overall costs have increased.  Where do you think the subsidies come from?  It doesn't fall from the sky.

I think that a cash pay, private system will continue to develop alongside traditional insurance, which is limited to a fixed, severely over-regulated health-care delivery system that will become unable to cope with the healthcare needs of an increasingly sick population.  The analogy here is how commerce used to work in the Soviet Union:  there were mostly empty cheap, government-run stores, with long lines forming every time a store restocked.  Outside in the street, there was a thriving Wild-west of makeshift stalls where goods were sold at market prices with zero government oversight.  That's what happens when a centralized government tries to engineer a large segment of the economy.

Fortunately this is already happening -  the paleo/keto movement, DIY healthcare, online telemedicine etc.  If not for that, healthcare costs would be increasing even more.  I personally don't care whether the cost comes in the form of higher premiums/deductibles/copays, or increased taxes.  It'll come out the same either way.

[snark]Yes, I see what you mean!  Which is why we see such long lines outside of power stations.  Or the water plants.  [/snark]

Hell, we actually have a fully socialized system already set up - the military.  The military is certainly a model we could use to provide healthcare to all. 

Seriously, it's obviously possible for the government to do a fine job regulating and providing services on a large scale.  As someone who is concerned about the best outcomes for the highest number of people, that makes sense to me.  I should mention I'm a registered Democrat so that tells you where I am politically. 

But on the other hand, I realize there's a tradeoff.  With the free market approach to medicine, huge amounts of money get poured in to innovating medical solutions to things like cancer. 

My mom was just diagnosed with lung cancer, so this hits home for me.  Looking at the survival stats over the past few decades, her chances are a LOT better now than they would have been in the 60's or 70's.  Why?  Because there's been a ton of money poured into cancer research, including much better early detection tools.

With a socialized medicine approach, those types of innovations will slow down significantly and maybe stop completely in some areas.  That's the tradeoff.  Is it worth it?  Dunno.  But we should know what we are losing if we fully embrace socialized medicine.

[American GenX]

ACA helps keep healthcare costs down.  Those pre-ACA low cost "junk" policies and healthcare share ministries have left too many people holding the bill, not covering pre-existing conditions, getting dropped from their insurance, low coverage caps, having ridiculously high co-pays and deductibles, etc.  With subsidies, you can get some very affordable plans on the ACA marketplace that have required protections, and poor people can get FREE coverage through the ACA Medicaid expansion.

The ACA may help keep YOUR healthcare costs down, but overall costs have increased.  Where do you think the subsidies come from?  It doesn't fall from the sky.

Subsidies can help lower premiums and out of pocket costs, but I'm talking about total healthcare spending.  The increases in healthcare spending were reduced under the ACA, saving the country 2.3 trillions dollars.  Healtcare costs would have gone up a lot more without the ACA, and more people would be uninsured.  And the answer is not just preventative by going on a keto diet and getting exercise.  Healthcare is far more complex than that.

https://www.statnews.com/2019/03/22/affordable-care-act-controls-costs/