What comes after the ACA?

[MrGreen]

I'm very encouraged by the questioning we've heard so far, particularly from Roberts and Kavanaugh, that make it seem like striking the whole law is not going to happen. It's early, of course, but it is very encouraging nonetheless.

[AdrianC]

Key Justices Signal Support for Affordable Care Act
At a Supreme Court argument Tuesday, Chief Justice Roberts and Justice Kavanaugh suggested that striking down one provision would not doom the balance of the law.
https://www.nytimes.com/2020/11/10/us/supreme-court-obamacare-aca.html?campaign_id=60&emc=edit_na_20201110&instance_id=0&nl=breaking-news&ref=cta&regi_id=93871742&segment_id=44112&user_id=51b0c9c24bd2dd2f56f41e7a59b7089a

WASHINGTON — The bulk of the Affordable Care Act, the sprawling 2010 health care law that is President Barack Obama’s defining domestic legacy, appeared likely to survive its latest encounter with the Supreme Court in arguments on Tuesday.

Very encouraging.

[jim555]

I listened to the whole hearing and I didn't get the impression they wanted to strike the entire law.

Pete Williams take on it...
Supreme Court Hears Arguments In Challenge To Affordable Care Act | Andrea Mitchell | MSNBC
https://www.youtube.com/watch?v=0yJ3fYRrI8U

[iris lily]

In the ACA case the Plaintiffs have no standing since they are suffering no harm from a $0 penalty, the case should be dismissed.

Standing to Challenge the Individual Mandate
https://reason.com/volokh/2020/11/09/standing-to-challenge-the-individual-mandate/

At the end of the day the supreme court justices were nominated because of their political leanings and with few exceptions voting goes along party lines.

ACA will only be saved if the law is changed to remove the individual mandate or there are at least 2 conservative supreme court justices that decide to save the law and strike down just portion of the law that is problematic.  The odds of a fix are better with Biden in the white house, but if republicans think it helps their chances in 2022 they will obstruct any attempts to save ACA.

I guess chief justice Roberts was one of those “few exceptions “ when he cast the determining vote that the mandate was a tax not a fee. A Republican appointee.

[stoaX]

Here are some tidbits from this morning's oral argument:

1. “I think it’s hard for you to argue that Congress intended the entire act to fall if the mandate were struck down, when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the act...I think frankly, they wanted the court to do that. But that’s not our job.” C.J. Roberts


2. “I tend to agree with you this a very straightforward case for severability under our precedents, meaning that we would excise the mandate and leave the rest of the act in place.” Kavanaugh

“It does seem fairly clear that the proper remedy would be to sever the provision...and leave the rest in place.”  Kavanaugh

3. “Because there could have been many choices between invalidating the entire ACA and just zeroing out the tax...Congress’s choice was just zero out the tax, correct?” Sotomayor

4. “In the first case, there was a strong reason to believe the individual mandate was...essential to keep the plane flying. Now the part has been taken out and the plane has not crashed...How would we explain why the individual mandate in its present form is essential to the operation of the act?” Alito

Thanks for taking the time to post the above.  Nothin' better than hearing what the judges have to say themselves.

[friedmmj]

Here are some tidbits from this morning's oral argument:

1. “I think it’s hard for you to argue that Congress intended the entire act to fall if the mandate were struck down, when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the act...I think frankly, they wanted the court to do that. But that’s not our job.” C.J. Roberts


2. “I tend to agree with you this a very straightforward case for severability under our precedents, meaning that we would excise the mandate and leave the rest of the act in place.” Kavanaugh

“It does seem fairly clear that the proper remedy would be to sever the provision...and leave the rest in place.”  Kavanaugh

3. “Because there could have been many choices between invalidating the entire ACA and just zeroing out the tax...Congress’s choice was just zero out the tax, correct?” Sotomayor

4. “In the first case, there was a strong reason to believe the individual mandate was...essential to keep the plane flying. Now the part has been taken out and the plane has not crashed...How would we explain why the individual mandate in its present form is essential to the operation of the act?” Alito

Thanks for taking the time to post the above.  Nothin' better than hearing what the judges have to say themselves.

If the ruling is not happening until June, then it seems there might be time for the new Congress to pass a more bullet-proof law in the meantime.  That's VERY optimistic though if Turtle boy is still Majority leader in the Senate.

[billy]

So if they do remove just individual mandate, does that mean all states with individual mandate, with financial penalty currently like California, get removed as well?

[Paul der Krake]

Finally listened to the arguments later today (didn't feel like waking up at 5am to listen to it live), and was struck by how little focus on the reliance argument there was. It was nearly all technical explorations on severability, and some odd lines of questioning. Someone compared the mandate to the government mandating that all Americans should flying the country's flag on their houses?!

Both counsels played the game of "you said the exact opposite last time around" when discussing the importance of the mandate, which was exhausting to listen to. I also thought the respondents were staking a very hard line on standing (this cost us at least $1 in increased costs, we can sue).

But overall an interesting 2 hours.

[reeshau]

So if they do remove just individual mandate, does that mean all states with individual mandate, with financial penalty currently like California, get removed as well?

This is only about the ACA, and its (now) $0 mandate.  It's not about mandates in general, or about any state law.

[American GenX]

Here are some tidbits from this morning's oral argument:

1. “I think it’s hard for you to argue that Congress intended the entire act to fall if the mandate were struck down, when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the act...I think frankly, they wanted the court to do that. But that’s not our job.” C.J. Roberts


2. “I tend to agree with you this a very straightforward case for severability under our precedents, meaning that we would excise the mandate and leave the rest of the act in place.” Kavanaugh

“It does seem fairly clear that the proper remedy would be to sever the provision...and leave the rest in place.”  Kavanaugh

3. “Because there could have been many choices between invalidating the entire ACA and just zeroing out the tax...Congress’s choice was just zero out the tax, correct?” Sotomayor

4. “In the first case, there was a strong reason to believe the individual mandate was...essential to keep the plane flying. Now the part has been taken out and the plane has not crashed...How would we explain why the individual mandate in its present form is essential to the operation of the act?” Alito

I listened to some of the arguments while at work today and caught up on some of these comments later that I missed.  It definitely sounds promising.  It's about time something went right for me.  The question now is whether this gives me enough confidence to take a risk and retire in April rather than waiting for a possible June 2021 ruling for certainty.

[John Galt incarnate!]

Here are some tidbits from this morning's oral argument:

1. “I think it’s hard for you to argue that Congress intended the entire act to fall if the mandate were struck down, when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the act...I think frankly, they wanted the court to do that. But that’s not our job.” C.J. Roberts


2. “I tend to agree with you this a very straightforward case for severability under our precedents, meaning that we would excise the mandate and leave the rest of the act in place.” Kavanaugh

“It does seem fairly clear that the proper remedy would be to sever the provision...and leave the rest in place.”  Kavanaugh

3. “Because there could have been many choices between invalidating the entire ACA and just zeroing out the tax...Congress’s choice was just zero out the tax, correct?” Sotomayor

4. “In the first case, there was a strong reason to believe the individual mandate was...essential to keep the plane flying. Now the part has been taken out and the plane has not crashed...How would we explain why the individual mandate in its present form is essential to the operation of the act?” Alito

I listened to some of the arguments while at work today and caught up on some of these comments later that I missed.  It definitely sounds promising.  It's about time something went right for me.  The question now is whether this gives me enough confidence to take a risk and retire in April rather than waiting for a possible June 2021 ruling for certainty.

Today, Professor  Little made a statement to the effect that he expects the ACA opinion to be handed down this spring or even as early as January. 

Prof. Rory Little - The Federalist Society
fedsoc.org › contributors › rory-little
May 28, 2014 — Professor Rory Little began teaching at UC Hastings in 1994 after a ... has been awarded the “Best Professor” designation by the UC Hastings third-year class. ... annually publishes a Review of the Supreme Court's Term: Criminal Cases ... Little also clerked for Justices Powell, Stevens, and Chief Justice ...

[dresden]

In the ACA case the Plaintiffs have no standing since they are suffering no harm from a $0 penalty, the case should be dismissed.

Standing to Challenge the Individual Mandate
https://reason.com/volokh/2020/11/09/standing-to-challenge-the-individual-mandate/

At the end of the day the supreme court justices were nominated because of their political leanings and with few exceptions voting goes along party lines.

ACA will only be saved if the law is changed to remove the individual mandate or there are at least 2 conservative supreme court justices that decide to save the law and strike down just portion of the law that is problematic.  The odds of a fix are better with Biden in the white house, but if republicans think it helps their chances in 2022 they will obstruct any attempts to save ACA.

I guess chief justice Roberts was one of those “few exceptions “ when he cast the determining vote that the mandate was a tax not a fee. A Republican appointee.

Indeed Justice Roberts clearly put the court's reputation ahead of political leanings and I think he is right in wanting to protect the court from politics.

Let's face it, Justice Barrett's nomination was in large part due to her publicly known views on ACA - this case was brought to the court by the person that nominated her just weeks ago right before the case started.  She should have recused herself.  She should recuse herself from any election related cases as well.

[Paul der Krake]

Let's face it, Justice Barrett's nomination was in large part due to her publicly known views on ACA - this case was brought to the court by the person that nominated her just weeks ago right before the case started.  She should have recused herself.  She should recuse herself from any election related cases as well.

That may very well be true, but it doesn't matter anymore. She's now at the pinnacle of the legal profession, there's no higher job in the cards for her. There is no incentive for her to act like a political hack now, quite the contrary.

I will read her opinion (if there is one) closely. Maybe she'll make good points, maybe she won't.

[American GenX]

Here are some tidbits from this morning's oral argument:

1. “I think it’s hard for you to argue that Congress intended the entire act to fall if the mandate were struck down, when the same Congress that lowered the penalty to zero did not even try to repeal the rest of the act...I think frankly, they wanted the court to do that. But that’s not our job.” C.J. Roberts


2. “I tend to agree with you this a very straightforward case for severability under our precedents, meaning that we would excise the mandate and leave the rest of the act in place.” Kavanaugh

“It does seem fairly clear that the proper remedy would be to sever the provision...and leave the rest in place.”  Kavanaugh

3. “Because there could have been many choices between invalidating the entire ACA and just zeroing out the tax...Congress’s choice was just zero out the tax, correct?” Sotomayor

4. “In the first case, there was a strong reason to believe the individual mandate was...essential to keep the plane flying. Now the part has been taken out and the plane has not crashed...How would we explain why the individual mandate in its present form is essential to the operation of the act?” Alito

I listened to some of the arguments while at work today and caught up on some of these comments later that I missed.  It definitely sounds promising.  It's about time something went right for me.  The question now is whether this gives me enough confidence to take a risk and retire in April rather than waiting for a possible June 2021 ruling for certainty.

Today, Professor  Little made a statement to the effect that he expects the ACA opinion to be handed down this spring or even as early as January. 

Prof. Rory Little - The Federalist Society
fedsoc.org › contributors › rory-little
May 28, 2014 — Professor Rory Little began teaching at UC Hastings in 1994 after a ... has been awarded the “Best Professor” designation by the UC Hastings third-year class. ... annually publishes a Review of the Supreme Court's Term: Criminal Cases ... Little also clerked for Justices Powell, Stevens, and Chief Justice ...

Thanks.  I listened to the interview where he said January to early spring.  It looks like a decision could be rendered sooner than the commonly mentioned June time frame, particularly if there's more agreement about it among the justices.

[jim555]

When Roberts said basically "its not our job" to strike the law, basically you are not going to use the court to do your dirty work, he tipped his hand on this case.

[iris lily]

In the ACA case the Plaintiffs have no standing since they are suffering no harm from a $0 penalty, the case should be dismissed.

Standing to Challenge the Individual Mandate
https://reason.com/volokh/2020/11/09/standing-to-challenge-the-individual-mandate/

At the end of the day the supreme court justices were nominated because of their political leanings and with few exceptions voting goes along party lines.

ACA will only be saved if the law is changed to remove the individual mandate or there are at least 2 conservative supreme court justices that decide to save the law and strike down just portion of the law that is problematic.  The odds of a fix are better with Biden in the white house, but if republicans think it helps their chances in 2022 they will obstruct any attempts to save ACA.

I guess chief justice Roberts was one of those “few exceptions “ when he cast the determining vote that the mandate was a tax not a fee. A Republican appointee.

Indeed Justice Roberts clearly put the court's reputation ahead of political leanings and I think he is right in wanting to protect the court from politics.

Let's face it, Justice Barrett's nomination was in large part due to her publicly known views on ACA - this case was brought to the court by the person that nominated her just weeks ago right before the case started.  She should have recused herself.  She should recuse herself from any election related cases as well.

Oh I absolutely agree that the court needs to be above politics.

This morning on the radio one of the local law professors reviewed Roberts’  decision from 2012. He had a factual an account of it that I truly do not remember, and I’ve been holding a grudge against Roberts all these years for it. I was wrong.

This legal pundit said that Roberts did not rule on the mandate being a tax. He ruled on the penalty being a tax. And THAT I can see as a tax.  I could never see how the fee for insurance I was required by law to pay could be constitutionally determined to be a tax.

[sherr]

This morning on the radio one of the local law professors reviewed Roberts’  decision from 2012. He had a factual an account of it that I truly do not remember, and I’ve been holding a grudge against Roberts all these years for it. I was wrong.

This legal pundit said that Roberts did not rule on the mandate being a tax. He ruled on the penalty being a tax. And THAT I can see as a tax.  I could never see how the fee for insurance I was required by law to pay could be constitutionally determined to be a tax.

I don't understand your point, these are the same thing. The "mandate" is just the bit of the law that says "if you don't have insurance you have to pay this fee/penalty/tax".

[jim555]

Argument analysis: ACA seems likely to survive, but on what ground?
https://www.scotusblog.com/2020/11/argument-analysis-aca-seems-likely-to-survive-but-on-what-ground/

"After roughly two hours of oral argument in the Supreme Court on Tuesday, it appeared likely that the Affordable Care Act will survive yet another effort in the courts to dismantle it. Although there may be five votes to strike down the ACA’s individual mandate – the provision in the law that directs virtually all Americans to buy health insurance – a majority of the court in California v. Texas seemed to agree with the ACA’s defenders that even if the mandate is unconstitutional, the rest of the ACA can survive. That determination would effectively leave in place the status quo, because Congress in 2017 eliminated the penalty for failing to obtain insurance, and the ACA has continued to operate without any enforceable individual mandate.

It’s not even clear if the court will get that far. Any ruling on the constitutionality of the mandate – or the rest of the law – will hinge on whether at least five justices believe that the challengers in the case have a legal right to sue."  ...continues

[toocold]

So what comes after the ACA, assuming that SC upholds the law?  Here is an excellent article about how difficult it would be to add a public option or reduce Medicare to 60.  Both would help me personally, but not holding my breath.

https://www.mprnews.org/story/2020/11/11/npr-biden-wants-to-lower-medicare-eligibility-age-to-60-but-hospitals-push-back

Just for context, "charge rates" which are amounts that a hospital would charge you and me individually are about ~100% higher than commercial rates and ~400% more than medicare rates (e.g. charge = $100, commercial = $50, medicare is $25).  And these are rising higher than inflation.

Fundamentally, ACA did nothing to address the cost of healthcare, only the "access" to healthcare.

[Exflyboy]

Actually if you set your income to around $32k per year, then the subsidised rate for us on the ACA is about $10/month.

Its going to be WAY higher than that when we hit Medicare!

Around $10k/year to protect ourselves properly.

[Monkey Uncle]

Actually if you set your income to around $32k per year, then the subsidised rate for us on the ACA is about $10/month.

Its going to be WAY higher than that when we hit Medicare!

Around $10k/year to protect ourselves properly.

My wife just signed up for Medicare.  Due to some recent health issues, she chose the broadest possible part B supplement plan.  She also signed up for a part D drug plan.  Her all-in premium cost (part B, part B supplement, and part D) will be a little under $3k.  And the only health care expense she will have to pay out of pocket is the Part B deductible, which is currently $298.  Yes, this is more expensive than fully subsidized ACA insurance, but it's nowhere near 10 grand.

Of course, part B supplements and part D plans are sold on a state-by-state basis, so costs can vary a lot depending on where you live.

[Exflyboy]

Actually if you set your income to around $32k per year, then the subsidised rate for us on the ACA is about $10/month.

Its going to be WAY higher than that when we hit Medicare!

Around $10k/year to protect ourselves properly.

My wife just signed up for Medicare.  Due to some recent health issues, she chose the broadest possible part B supplement plan.  She also signed up for a part D drug plan.  Her all-in premium cost (part B, part B supplement, and part D) will be a little under $3k.  And the only health care expense she will have to pay out of pocket is the Part B deductible, which is currently $298.  Yes, this is more expensive than fully subsidized ACA insurance, but it's nowhere near 10 grand.

Of course, part B supplements and part D plans are sold on a state-by-state basis, so costs can vary a lot depending on where you live.

Right, I was saying that $10k was for a couple like us in our location. You may be right in that we might be able to do better than $10k though.

[John Galt incarnate!]

It’s not even clear if the court will get that far. Any ruling on the constitutionality of the mandate – or the rest of the law – will hinge on whether at least five justices believe that the challengers in the case have a legal right to sue."  ...continues

 To have standing to sue in federal courts

1. The plaintiff must show  imminent or actual injury to a particular, legally protected interest.

2. The plaintiff must demonstrate a specific nexus between the injury and the action or inaction of the party(s) who caused the injury.

3.The plaintiff must show  likelihood of prevailing.


The gravamen of the injury complained of here seemed flimsy to me after my cursory read of it months ago.

[iris lily]

This morning on the radio one of the local law professors reviewed Roberts’  decision from 2012. He had a factual an account of it that I truly do not remember, and I’ve been holding a grudge against Roberts all these years for it. I was wrong.

This legal pundit said that Roberts did not rule on the mandate being a tax. He ruled on the penalty being a tax. And THAT I can see as a tax.  I could never see how the fee for insurance I was required by law to pay could be constitutionally determined to be a tax.

I don't understand your point, these are the same thing. The "mandate" is just the bit of the law that says "if you don't have insurance you have to pay this fee/penalty/tax".

Assuming I understood the point, he made a point between the mandate being one thing and the penalty for it being something else. The way he described it Roberts made a distinction between the two.

Right now I’m too lazy to go back and look into that, but it made sense upon hearing it this morning.

Edited later to add: thinking about it later this is the distinction this law professor made and it makes sense to me. He claims that Roberts believed the mandate was unconstitutional ( as it clearly is!!!)  However,  the ACA law gives me as a citizen a choice:  I don’t have to follow the mandate. I can pay money to the IRS instead.

That alternative payment can be considered a tax, which the gubmnt has authority to levy.

[sherr]

This morning on the radio one of the local law professors reviewed Roberts’  decision from 2012. He had a factual an account of it that I truly do not remember, and I’ve been holding a grudge against Roberts all these years for it. I was wrong.

This legal pundit said that Roberts did not rule on the mandate being a tax. He ruled on the penalty being a tax. And THAT I can see as a tax.  I could never see how the fee for insurance I was required by law to pay could be constitutionally determined to be a tax.

I don't understand your point, these are the same thing. The "mandate" is just the bit of the law that says "if you don't have insurance you have to pay this fee/penalty/tax".

Assuming I understood the point, he made a point between the mandate being one thing and the penalty for it being something else. The way he described it Roberts made a distinction between the two.

Right now I’m too lazy to go back and look into that, but it made sense upon hearing it this morning

Okay, sure. The argument against the "mandate" was that the federal government doesn't have the ability to just order you to purchase insurance. But they do have the ability to tax you if you don't have insurance, which is what the ACA does (and what the Supreme Court previously upheld). So yes in that sense they are different, in that one interpretation is "the mandates orders people to have insurance" and the other (correct) interpretation is "the mandate says that you have to have insurance or you'll get taxed", and those are two different things.

However both of those interpretations are completely unrelated to your insurance premiums, which it sounded like you were tying in there somehow.

[iris lily]

This morning on the radio one of the local law professors reviewed Roberts’  decision from 2012. He had a factual an account of it that I truly do not remember, and I’ve been holding a grudge against Roberts all these years for it. I was wrong.

This legal pundit said that Roberts did not rule on the mandate being a tax. He ruled on the penalty being a tax. And THAT I can see as a tax.  I could never see how the fee for insurance I was required by law to pay could be constitutionally determined to be a tax.

I don't understand your point, these are the same thing. The "mandate" is just the bit of the law that says "if you don't have insurance you have to pay this fee/penalty/tax".

Assuming I understood the point, he made a point between the mandate being one thing and the penalty for it being something else. The way he described it Roberts made a distinction between the two.

Right now I’m too lazy to go back and look into that, but it made sense upon hearing it this morning

Okay, sure. The argument against the "mandate" was that the federal government doesn't have the ability to just order you to purchase insurance. But they do have the ability to tax you if you don't have insurance, which is what the ACA does (and what the Supreme Court previously upheld). So yes in that sense they are different, in that one interpretation is "the mandates orders people to have insurance" and the other (correct) interpretation is "the mandate says that you have to have insurance or you'll get taxed", and those are two different things.

However both of those interpretations are completely unrelated to your insurance premiums, which it sounded like you were tying in there somehow.

I am not tying insurance premiums into today’s discussion.

[MrGreen]

Actually if you set your income to around $32k per year, then the subsidised rate for us on the ACA is about $10/month.

Its going to be WAY higher than that when we hit Medicare!

Around $10k/year to protect ourselves properly.

My wife just signed up for Medicare.  Due to some recent health issues, she chose the broadest possible part B supplement plan.  She also signed up for a part D drug plan.  Her all-in premium cost (part B, part B supplement, and part D) will be a little under $3k.  And the only health care expense she will have to pay out of pocket is the Part B deductible, which is currently $298.  Yes, this is more expensive than fully subsidized ACA insurance, but it's nowhere near 10 grand.

Of course, part B supplements and part D plans are sold on a state-by-state basis, so costs can vary a lot depending on where you live.

So someone in their mid-60s has a max out of pocket of ~$3,300 a year for all healthcare expenses other than some prescriptions? That seems like a pretty dang good deal to me. I wonder if there's a way to see those state-to-state variations without having to live there.

[MrGreen]

So what comes after the ACA, assuming that SC upholds the law?  Here is an excellent article about how difficult it would be to add a public option or reduce Medicare to 60.  Both would help me personally, but not holding my breath.

https://www.mprnews.org/story/2020/11/11/npr-biden-wants-to-lower-medicare-eligibility-age-to-60-but-hospitals-push-back

Just for context, "charge rates" which are amounts that a hospital would charge you and me individually are about ~100% higher than commercial rates and ~400% more than medicare rates (e.g. charge = $100, commercial = $50, medicare is $25).  And these are rising higher than inflation.

Fundamentally, ACA did nothing to address the cost of healthcare, only the "access" to healthcare.

The next step should certainly be an attempt to reign in cost. Making that a priority will make insurance more affordable for those not able to receive subsidies, and should help to lower deductibles and max out of pocket amounts as the cost of care comes down.

[toocold]

So what comes after the ACA, assuming that SC upholds the law?  Here is an excellent article about how difficult it would be to add a public option or reduce Medicare to 60.  Both would help me personally, but not holding my breath.

https://www.mprnews.org/story/2020/11/11/npr-biden-wants-to-lower-medicare-eligibility-age-to-60-but-hospitals-push-back

Just for context, "charge rates" which are amounts that a hospital would charge you and me individually are about ~100% higher than commercial rates and ~400% more than medicare rates (e.g. charge = $100, commercial = $50, medicare is $25).  And these are rising higher than inflation.

Fundamentally, ACA did nothing to address the cost of healthcare, only the "access" to healthcare.

The next step should certainly be an attempt to reign in cost. Making that a priority will make insurance more affordable for those not able to receive subsidies, and should help to lower deductibles and max out of pocket amounts as the cost of care comes down.

Yes, and we need to keep in mind that these subsidies are paid for the taxpayers.  If the government can contain medical costs, that would be great. 

We need to recognize that hospitals run margins close to breakeven.  Labor is the biggest driver of cost and have one of the strongest unions around.  And often times, hospitals are the largest employers in a town, especially rural settings. 

In a scenario like this, it's tough for government to drive costs down.  They have been trying for the past 30 years and haven't been very successful.

 

[DavidAnnArbor]

In a scenario like this, it's tough for government to drive costs down.  They have been trying for the past 30 years and haven't been very successful.

One way to drive down costs is to investigate whether some medical procedures actually provide any benefit.  Also, the standard of medical care for a specific disease can differ from region to region, and the federal government can investigate which standard works most effectively.

[Paul der Krake]

The idea that hospitals break even and have nothing to cut is insulting.  If I ran a T-shirt store and sold them for $20 a pop, there is no way in hell I could write off $50 for each t-shirt that gets shoplifted. Yet this is exactly what happens with hospitals. All those losses are just a matter of accounting. Where else would the money come from for the never ending expansion and consolidation in the industry? Do these new wards just build themselves?

Regulate the shit of them.

[toocold]

In a scenario like this, it's tough for government to drive costs down.  They have been trying for the past 30 years and haven't been very successful.

One way to drive down costs is to investigate whether some medical procedures actually provide any benefit.  Also, the standard of medical care for a specific disease can differ from region to region, and the federal government can investigate which standard works most effectively.

Yes, they have been looking at this. When the ARRA (2009 stimulus package) had funds to pursue this.  There has been no noticeable impact of this on cost of care.  Too long to explain why this hasn't been successful.

https://www.hsph.harvard.edu/comparative-effectiveness-research-initiative/definition/

The idea that hospitals break even and have nothing to cut is insulting.  If I ran a T-shirt store and sold them for $20 a pop, there is no way in hell I could write off $50 for each t-shirt that gets shoplifted. Yet this is exactly what happens with hospitals. All those losses are just a matter of accounting. Where else would the money come from for the never ending expansion and consolidation in the industry? Do these new wards just build themselves?

Regulate the shit of them.

Healthcare is one of the most regulated industries now, and it should since the government pays about 50% of healthcare spend directly or through subsidies, which benefits many people on this forum. 

I am not advocating that there isn't waste -- there is so much waste in the system. 

I'm just saying that when the biggest cost driver is highly unionized labor, it's tough for government to do much.  We can always point fingers toward CEO compensation or insurance middle men if that makes people feel better.

Of course no one wants their piece of the pie to be taken away from them.

[katsiki]

The idea that hospitals break even and have nothing to cut is insulting.  If I ran a T-shirt store and sold them for $20 a pop, there is no way in hell I could write off $50 for each t-shirt that gets shoplifted. Yet this is exactly what happens with hospitals. All those losses are just a matter of accounting. Where else would the money come from for the never ending expansion and consolidation in the industry? Do these new wards just build themselves?

Regulate the shit of them.

+1000000000000000000

I always chuckle at the non-profit aspect some promote.

[Monkey Uncle]

Actually if you set your income to around $32k per year, then the subsidised rate for us on the ACA is about $10/month.

Its going to be WAY higher than that when we hit Medicare!

Around $10k/year to protect ourselves properly.

My wife just signed up for Medicare.  Due to some recent health issues, she chose the broadest possible part B supplement plan.  She also signed up for a part D drug plan.  Her all-in premium cost (part B, part B supplement, and part D) will be a little under $3k.  And the only health care expense she will have to pay out of pocket is the Part B deductible, which is currently $298.  Yes, this is more expensive than fully subsidized ACA insurance, but it's nowhere near 10 grand.

Of course, part B supplements and part D plans are sold on a state-by-state basis, so costs can vary a lot depending on where you live.

So someone in their mid-60s has a max out of pocket of ~$3,300 a year for all healthcare expenses other than some prescriptions? That seems like a pretty dang good deal to me. I wonder if there's a way to see those state-to-state variations without having to live there.

Yup, it's a pretty good deal.  Maybe that's why the Medicare trust fund is going to go broke in a few years, LOL.

It's pretty easy to get a rough idea of costs for your locality using the tools at medicare.gov. 

[Monkey Uncle]

In a scenario like this, it's tough for government to drive costs down.  They have been trying for the past 30 years and haven't been very successful.

One way to drive down costs is to investigate whether some medical procedures actually provide any benefit.  Also, the standard of medical care for a specific disease can differ from region to region, and the federal government can investigate which standard works most effectively.

Yes, they have been looking at this. When the ARRA (2009 stimulus package) had funds to pursue this.  There has been no noticeable impact of this on cost of care.  Too long to explain why this hasn't been successful.

https://www.hsph.harvard.edu/comparative-effectiveness-research-initiative/definition/

The idea that hospitals break even and have nothing to cut is insulting.  If I ran a T-shirt store and sold them for $20 a pop, there is no way in hell I could write off $50 for each t-shirt that gets shoplifted. Yet this is exactly what happens with hospitals. All those losses are just a matter of accounting. Where else would the money come from for the never ending expansion and consolidation in the industry? Do these new wards just build themselves?

Regulate the shit of them.

Healthcare is one of the most regulated industries now, and it should since the government pays about 50% of healthcare spend directly or through subsidies, which benefits many people on this forum. 

I am not advocating that there isn't waste -- there is so much waste in the system. 

I'm just saying that when the biggest cost driver is highly unionized labor, it's tough for government to do much.  We can always point fingers toward CEO compensation or insurance middle men if that makes people feel better.

Of course no one wants their piece of the pie to be taken away from them.

This argument always comes back to the fact that the rest of the civilized world gets better health care outcomes than we do for half the cost.  That's the ultimate proof that somebody somewhere is making out like a bandit while the rest of us get screwed.  Specialist providers, hospital administrators and executives, and insurance company executives are all very highly compensated and are prime culprits in my view.

[American GenX]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

[GuitarStv]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

Weird that hospitals in Canada can stay open with so much less money being thrown at them than in the US.

I guess the free market isn't all that efficient in this sector?

[billy]

The price for goods and services is just out of whack in the US, my lady works for Bio farm and their wholesale prices are unbelievable, one way to fix the issue like other developed countries do is to put caps, not just relying on tax dollars sliding scale Band-Aid. Why should the US bear the brunt of pharmaceutical r&d recoup for the whole world?

[Exflyboy]

And don't forget it is illegal for Medicare to negotiate drug prices... $1million/ year chemo treatments anyone?

[Paul der Krake]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

Sorry, but that's not a good argument. Businesses going out of business when they can't operate in a market is the normal course of things. Sucks for the people who live out in the sticks, too bad so sad, this is the cost of living in the sticks. And I say this as someone who lives in the sticks!

The hospitals who go out of business aren't the big shiny ones in urban centers with brand recognition. They're the small ones in the middle of nowhere who have most of their patients on Medicaid, a lot of them uninsured, and some with private insurance. They're trying to run a private business in a market that fundamentally cannot support them. Yet all hospitals act like they're all in this together despite having nothing in common.

I live in a very small town on the north shore of Oahu, which is the most populated island (roughly 1 million people) in the state of Hawaii. This is a good case study for a health market, because the nearest large city to us is San Francisco, a cool 2,500 miles away. So we're very self contained. What are my options for hospitals?

- drive 30 minutes to Wahiawa General Hospital, a struggling private hospital in the sticks
- drive 30 minutes to Kahuku Medical Center, another struggling private hospital, also in the sticks
- drive 45 minutes to the southern side of the island, where most people live, and all the big boys (Queen's, Straub, Kaiser) have their shiny facilities

Guess what, I'm never choosing option #1 or #2. Nobody with any money would. As a result, they're only getting the desperate patients and the occasional overconfident surfer who hit the reef and that's where EMTs took them. Is it taxpayers' responsibility to prop up those two private hospitals on an island of 20 by 30 miles where there are other options? I don't think so.

[Shane]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

Weird that hospitals in Canada can stay open with so much less money being thrown at them than in the US.

I guess the free market isn't all that efficient in this sector?

Recently, I was talking with a neighbor who told me he was really concerned about a Biden/Harris administration ruining the US. When I asked him what he was most worried Joe and Kamala might do, he replied, "socialized healthcare." I said, "So...you're concerned they might help more people to be able to go to a doctor if they get sick?" He said, "There's no way we could ever possibly afford to give healthcare to everyone in the US. The country would go broke." It's amazing to me that there are still Americans who actually seem to believe this type of drivel. I told my friend, "Every. single. other. rich. country in the world provides all of its citizens with some version of universal healthcare, and most of them spend 40%, 50%, 60%, 70% less the we do in the United States." My neighbor said, "Oh, well, that's because those other countries are much smaller than the US. There's no way we could ever afford to provide all Americans with healthcare. We've got too many people!" I told him, "No, because the US has a higher population than most other developed countries, we should be able to provide all of our people with good quality healthcare for MUCH LESS than smaller countries. Have you heard of economies of scale?" :(

Health expenditure as share of GDP

[the_fixer]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

Weird that hospitals in Canada can stay open with so much less money being thrown at them than in the US.

I guess the free market isn't all that efficient in this sector?

Recently, I was talking with a neighbor who told me he was really concerned about a Biden/Harris administration ruining the US. When I asked him what he was most worried Joe and Kamala might do, he replied, "socialized healthcare." I said, "So...you're concerned they might help more people to be able to go to a doctor if they get sick?" He said, "There's no way we could ever possibly afford to give healthcare to everyone in the US. The country would go broke." It's amazing to me that there are still Americans who actually seem to believe this type of drivel. I told my friend, "Every. single. other. rich. country in the world provides all of its citizens with some version of universal healthcare, and most of them spend 40%, 50%, 60%, 70% less the we do in the United States." My neighbor said, "Oh, well, that's because those other countries are much smaller than the US. There's no way we could ever afford to provide all Americans with healthcare. We've got too many people!" I told him, "No, because the US has a higher population than most other developed countries, we should be able to provide all of our people with good quality healthcare for MUCH LESS than smaller countries. Have you heard of economies of scale?" :(

Health expenditure as share of GDP

I had this same discussion with my FIL who claims the same socialism/ we cannot afford it line and in addition to your points I also mentioned.

When people are sick and can not get care they are less productive and not producing for the economy and can end up on more social programs why not get them healthy and back to work?

If problems go undiagnosed it costs us more in the long run, why not be proactive and provide basic healthcare and avoid paying more in the long run for a chronic or end stage care

People end up seeking care at some point at a ER or free clinic and when they cannot afford to pay someone somewhere has to pay the bill.

I also asked him how he is enjoying his socialized medicine now that he has reached social security age. (A low blow I know)

People fail to see that the cost to society is still there, you can pay now or you can pay later but the cost is still there.

And since we are paying either way why not be decent and allow people health care and dignity?

He calls me a flaming liberal now...


Sent from my iPhone using Tapatalk

[Shane]

Not sure if anyone else here has worked in health care.  I have.

Medicare and Medicaid don't pay enough for hospitals to keep the lights one.  Despite cutting to the bone, even more so during the pandemic, many hospitals have gone out of business, even before the pandemic.  I mentioned this earlier in the thread with links to more information on that.

Weird that hospitals in Canada can stay open with so much less money being thrown at them than in the US.

I guess the free market isn't all that efficient in this sector?

Recently, I was talking with a neighbor who told me he was really concerned about a Biden/Harris administration ruining the US. When I asked him what he was most worried Joe and Kamala might do, he replied, "socialized healthcare." I said, "So...you're concerned they might help more people to be able to go to a doctor if they get sick?" He said, "There's no way we could ever possibly afford to give healthcare to everyone in the US. The country would go broke." It's amazing to me that there are still Americans who actually seem to believe this type of drivel. I told my friend, "Every. single. other. rich. country in the world provides all of its citizens with some version of universal healthcare, and most of them spend 40%, 50%, 60%, 70% less the we do in the United States." My neighbor said, "Oh, well, that's because those other countries are much smaller than the US. There's no way we could ever afford to provide all Americans with healthcare. We've got too many people!" I told him, "No, because the US has a higher population than most other developed countries, we should be able to provide all of our people with good quality healthcare for MUCH LESS than smaller countries. Have you heard of economies of scale?" :(

Health expenditure as share of GDP

I had this same discussion with my FIL who claims the same socialism/ we cannot afford it line and in addition to your points I also mentioned.

When people are sick and can not get care they are less productive and not producing for the economy and can end up on more social programs why not get them healthy and back to work?

If problems go undiagnosed it costs us more in the long run, why not be proactive and provide basic healthcare and avoid paying more in the long run for a chronic or end stage care

People end up seeking care at some point at a ER or free clinic and when they cannot afford to pay someone somewhere has to pay the bill.

I also asked him how he is enjoying his socialized medicine now that he has reached social security age. (A low blow I know)

People fail to see that the cost to society is still there, you can pay now or you can pay later but the cost is still there.

And since we are paying either way why not be decent and allow people health care and dignity?

He calls me a flaming socialist now...


Sent from my iPhone using Tapatalk

It's amazing that even when it's pointed out to them how providing everyone in the US with healthcare would save us a shit ton of money in the long run, they still double down on their "socialism bad" narrative.

[toocold]

I agree with almost all the posts about how expensive the US healthcare system is (and as a result, the high cost of insurance against that spend). 

With that said, given the current administration and the divided government, what realistic things do you think will be accomplished by the Biden administration outside of the tons of incremental things that have been tried? 

My perspective is, not much.  So what comes after the ACA?  Not much.

(But I hope for the best... you never know).

[rab-bit]

I am curious about the next steps after a ruling on severability.

Suppose it comes down to severability and the SC rules that the individual mandate is severable from the rest of the law. What happens next? Do Congress and the President have to do anything, like pass an amended law? If yes, is it possible the the GOP-controlled Senate refuses to cooperate and what would happen in that case?

[GuitarStv]

With that said, given the current administration and the divided government, what realistic things do you think will be accomplished by the Biden administration outside of the tons of incremental things that have been tried? 

My perspective is, not much.  So what comes after the ACA?  Not much.

(But I hope for the best... you never know).

Realistically, with Republican control of the senate I don't think McConnell will permit President Biden to do much of anything.  Certainly nothing in the way of health care improvements.

[bacchi]

I am curious about the next steps after a ruling on severability.

Suppose it comes down to severability and the SC rules that the individual mandate is severable from the rest of the law. What happens next? Do Congress and the President have to do anything, like pass an amended law? If yes, is it possible the the GOP-controlled Senate refuses to cooperate and what would happen in that case?

No, the Court removes the unconstitutional part of the law and it rides on.

I would caution everyone that, in 2012, the NFIB v. Sebelius oral arguments sounded like it would be bad for the ACA. It obviously wasn't but the point is that oral arguments aren't always an indicator of how a decision is made.

[rab-bit]

I am curious about the next steps after a ruling on severability.

Suppose it comes down to severability and the SC rules that the individual mandate is severable from the rest of the law. What happens next? Do Congress and the President have to do anything, like pass an amended law? If yes, is it possible the the GOP-controlled Senate refuses to cooperate and what would happen in that case?

No, the Court removes the unconstitutional part of the law and it rides on.

I would caution everyone that, in 2012, the NFIB v. Sebelius oral arguments sounded like it would be bad for the ACA. It obviously wasn't but the point is that oral arguments aren't always an indicator of how a decision is made.

Thanks, @bacchi. Knowing that McConnell et al. are not in the picture on this scenario is a relief.

Also, your point about oral arguments is well taken. I was just trying to understand what seems like a likely (but by no means guaranteed) possibility on how this plays out.

[pecunia]

Would it be possible to "shame" the Republicans into incremental healthcare law improvements?  Biden will have the bully pulpit.  Healthcare affects everyone.

I remember a few years back when Republicans were trying to repeal the ACA and replace it with the ACHA, there were videos of Town Halls that would practically bring you to tears.  Constituents would tell their representatives in all seriousness that the law change would kill their wives and ask them if they really wanted to do this.  People in those Town hall meetings were very very angry.  Could the force of the public be channeled into positive changes

Maybe, Mitch has no shame.

[wenchsenior]

Would it be possible to "shame" the Republicans into incremental healthcare law improvements?  Biden will have the bully pulpit.  Healthcare affects everyone.

HAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAHAAHAAA!!!!

:wipes tears: