What comes after the ACA?

[nereo]

A lot of Trumpets believed that he would replace it with something better.  Wait till they find out they get zilch.

Do you really think it will matter to them?  He can repeal the ACA outright and offer no replacement plan, and still declare victory even though 20 million people will be newly uninsured and millions more will have worse insurance at higher rates.  He'll just say he fixed it, and they will believe him.  Any media outlet that points out the problems will be labeled as fake news.
...  With Trump 's supporters, that is as easy as telling them you did it and anyone who fact checks him is lying and part of the liberal conspiracy.  Mission Accomplished, right?

Counter argument:  Trump is standing on a thin ledge. He's just 3 seats from losing the Senate, and 29 from the house.  He lost the popular vote and squeaked out a victory via the electoral college primarily because of a lack of enthusiasm for HRC combined with a bunch of people who became convinced that he'd be able to pull off these lofty promises AND that our national troubles would end once he does. Then there was the sizable contingent of GOP-leaning individuals who assumed, until now, that he was saying crap for shock value and wouldn't actually try to build a wall or start a muslim registry or

I absoltuely agree that his core trumpeters will swallow up any "alternative facts" presented to them, but it won't be enough. He's got to hold on to virtually every seat while simultaneously spouting this crap. He's got to be fortunate enough not to hit a recession or have a major attack occur on his watch. He's got to hope that his politically inexperienced cabinet doesn't get caught in some big scandal and that by some miracle he sidesteps them too despite his untold numerous yet poorly documented conflicts of interests.

Meanwhile, you've got an equally outraged group of democrats that will almost certainly turn out in higher than anticipated numbers in '18.  History shows its incredibly hard to hold on to seats during the midterm elections - I'm guessing a lot of people that didn't vote because they didn't like HRC or just assumed DJT didn't "actually mean what he said" will be think differently this time around.

[CDP45]

Then there was the sizable contingent of GOP-leaning individuals who assumed, until now, that he was saying crap for shock value and wouldn't actually try to build a wall or start a muslim registry or

...or outflank crooked Hillary by pulling out of TPP and incentivizing more auto production domestically.

Tough choices in Canada: http://www.cbc.ca/news/health/hepatitis-c-medication-expensive-cure-1.3359149

"But, whatever the price, it's steep enough that only those patients whose liver disease has progressed to Stage 2 will qualify for publicly funded medication."

Gee, money isn't unlimited in Canada to pay for healthcare? But it's "universal."

[Lagom]

Looks like the GOP isn't totally clueless that they are poised to look quite bad here:

https://www.washingtonpost.com/politics/behind-closed-doors-republican-lawmakers-fret-about-how-to-repeal-obamacare/2017/01/27/deabdafa-e491-11e6-a547-5fb9411d332c_story.html?utm_term=.2947e7a06b70

[powskier]

This is our country now.  You don't need to actually do anything you promised, you just need to create the public perception that you've done what you promised.    With Trump 's supporters, that is as easy as telling them you did it and anyone who fact checks him is lying and part of the liberal conspiracy.  Mission Accomplished, right?

This is a far bigger problem than health care, it underlies everything. Time to make reality and facts great again.

[scantee]

I have been telling anyone and everyone, for years, that the Republicans have no alternative to the ACA because there is no good, conservative alternative to the ACA. Republicans are smart enough (some of them at least, Paul Ryan is) to know that once you extend a social support to the middle-class it is extremely difficult to take that benefit away and doing so will result in political suicide. So they can't, and won't, go back to the pre-ACA system, but they also know there is no workable alternative to the ACA that doesn't drastically expand the government's role in health care.

In a sense, they've been in a good situation these past six years, because they've been able to successfully claim the ACA is horrible without having to really do anything about it, or propose any viable alternative. They, like everyone else, assumed Hillary would win and that they would be able to continue to avoid having to substantively deal with the issue. Now here we are, with Trump unexpectedly as president, and the public looking at them anxiously to hear their plan to improve on something they've been screaming is an absolute disaster for years.

They're screwed, and they know it. Will Americans pick up on it? Hard to say. Right now, Republicans are scrambling for time so they can figure out a strategy for how to politic and message their way out of this. If they can do that soon, they might be okay, but the longer they delay the greater the likelihood is that this will be politically terrible for them.

David Frum, who I think of as a pretty principled conservative, wrote this article over a year and a half ago, before Republicans found themselves in their current predicament, but I think it remains a good, pragmatic summation of the conundrum they now find themselves in. It offers some suggestions for how to tweak the ACA to be more in line with conservative thinking, while acknowledging that, yes, these are just tweaks rather than a major overhaul. The question is: will tweaks be enough, after all of the hyperbole about the horribleness of the ACA? I think most Republicans think no, they won't.

[Metric Mouse]

I think the larger point is that super-high deductible catastrophic plans are... probably worth having for many people. Doing away with those was IMO a mistake.

But again, that doesn't mean just throwing the whole healthcare system into chaos is the best way to handle it.

-W

The reason that the ACA couldn't allow those was that since lower to middle income people couldn't afford the high deductibles they needed higher income people to sign up for the lower deductible plans to shift some of the cost away from lower-middle income people. The ACA has been a total success if you look at it in terms of access to care at prices that are affordable (10% or less of income.) It's a complete failure if you look at it in terms of cost for higher income healthy people. Liberals judge it through the lens of the former and conservatives the latter. Since 17.7% of U.S. GDP is spent on healthcare the ACA has not placed a ridiculous burden on anyone. The true solution is lowering the percentage of GDP spent in this country on healthcare to typical 1st world levels. That would require single payer, prescription price controls and rationed care. These are completely unpalatable to conservatives so we are left with the ACA (originally a conservative idea) and no real long term options from conservatives. Once this iteration of conservatism collapses in this country (as early as 2020 in my opinion) we can get real solutions.

What are you on about? The ACA passed with 1 republican vote*. It wasn't even needed. The democrats could have passed any damn thing they wanted - and so to blame the faults of the ACA on the party that opposed it from the start is just incredible. The Democrats had an excellent opportunity to truly address healthcare in the country. They chose to go with a broken republican plan that subsidized massive insurance agencies, which were one of the biggest problems from before. So it would be quite reasonable to assume that the fixes you mentioned were unpalatable to Democrats as well.

Hopefully once this iteration of 'health insurance reform' collapses, we can indeed get real solutions.

[AdrianC]

My employer subsidized HDHP has a ~3k deductible and ~7k out of pocket maximum, for which we pay ~3700/yr in premiums.  My employer also pays another $11k/yr in employer contributions. 

Thanks.

Just for comparison, our Silver Obamacare plan has a deductible of $6,150 individual/$12,300 family, out of pocket limit of $7,000 individual/$14,000 family.

This does not qualify as a High Deductible plan. Premium is $990/mo for our family of 5.

We can cover this deductible amount no problem. As you say, it would be terrible for most Americans.

[Metric Mouse]

Tough choices in Canada: http://www.cbc.ca/news/health/hepatitis-c-medication-expensive-cure-1.3359149

"But, whatever the price, it's steep enough that only those patients whose liver disease has progressed to Stage 2 will qualify for publicly funded medication."

Gee, money isn't unlimited in Canada to pay for healthcare? But it's "universal."

That's so dumb. Wouldn't it be cheaper by far over the course of the person's life to treat it as early as possible to avoid more issues later?

[AdrianC]

True, it's a very high deductible compared with the "$40 co-pay" plans we've gotten used to, and too many families can't pony up $1,000 within 30 days to cover an emergency, but personally I don't think having to shell out a couple grand to pay for extensive and life-saving care (ICU, Chemo, etc) as being all that high.
'just sayin'

Me neither, but I thought you said you were on a "super-high deductible catastrophic plan"?

I'm not on a "super-high deductible catastrophic plan" and our family OOP max is $7,000 individual/$14,000 family.

If one of us needs care costing $7K we just write a check. We've done it (broken tibia). Many folks around here could do the same. Most Americans? Probably not.

[sol]

Just for comparison, our Silver Obamacare plan has a deductible of $6,150 individual/$12,300 family, out of pocket limit of $7,000 individual/$14,000 family.

This does not qualify as a High Deductible plan. Premium is $990/mo for our family of 5.

We can cover this deductible amount no problem. As you say, it would be terrible for most Americans.

So it looks like you pay a bit less than we do, for less coverage.  There are a bunch of details that might change that calculus, like if you have a prescription drug benefit, which I don't, or if there are differences in the coinsurance for hospitalizations or surgeries. 

But the big difference is probably the risk pools we're in.  I have federal employee insurance, so I'm in a risk pool with all 4.5 million federal employees and annuitants.  Every single one of us (who chooses my insurance coverage option) pays the exact same rate, regardless of income or age or health or even pre-existing conditions.  A 100 year old on their death bed pays the same (subsidized) ~$1200/month that the 19 year old intern pays, and so the rates tend to cancel out to a better average.   Private insurers on the individual market prefer to divide everyone up and make them pay a cost closer to their actual usage, which typically means older/sicker people pay much more for their insurance than they would if they were part of a larger risk pool, like an employer-sponsored plan or Medicare.

[Bucksandreds]

Tough choices in Canada: http://www.cbc.ca/news/health/hepatitis-c-medication-expensive-cure-1.3359149

"But, whatever the price, it's steep enough that only those patients whose liver disease has progressed to Stage 2 will qualify for publicly funded medication."

Gee, money isn't unlimited in Canada to pay for healthcare? But it's "universal."

That's so dumb. Wouldn't it be cheaper by far over the course of the person's life to treat it as early as possible to avoid more issues later?

Most cases of Hep C don't progress to terminal liver failure so in aggregate, it's probably cheaper to wait. I would hope that a healthcare worker acquiring Hepatitis through needlestick or anyone else acquiring it through no fault of there own would have access. Isn't that what conservatives preach?  Personal accountability and consequences for poor choices? Once the patent expires on that med it should be possible, in theory, to eradicate Hep C.

[Jammu]

Tough choices in Canada: http://www.cbc.ca/news/health/hepatitis-c-medication-expensive-cure-1.3359149

"But, whatever the price, it's steep enough that only those patients whose liver disease has progressed to Stage 2 will qualify for publicly funded medication."

Gee, money isn't unlimited in Canada to pay for healthcare? But it's "universal."

That's so dumb. Wouldn't it be cheaper by far over the course of the person's life to treat it as early as possible to avoid more issues later?

Most cases of Hep C don't progress to terminal liver failure so in aggregate, it's probably cheaper to wait. I would hope that a healthcare worker acquiring Hepatitis through needlestick or anyone else acquiring it through no fault of there own would have access. Isn't that what conservatives preach?  Personal accountability and consequences for poor choices? Once the patent expires on that med it should be possible, in theory, to eradicate Hep C.

The cost is C$150k. If you want it buy it yourself?

The price of this drug is what is most obscene. I don't know the economics of drug pricing but this is ridiculous.

[Roland of Gilead]

I did a stock screen and found 68 small cap (under 300 million) biotech drug companies trading below net cash on hand.  In one case the company has 125 million in cash, no debt, and is trading for 42 million!!!

Why?  If drug prices are so outrageous, why would investors let a company trade at 1/3 cash on hand?

Could it possibly be that developing a drug is horribly expensive and risk of total loss of investment?

[CDP45]

Anyone else could have come up with Solvaldi, like all those government researchers or European utopias...but they didn't. Guess that poor lady in Canada who has "universal single payer" healthcare is S.O.L.  Since when did reducing competition and only having 1 "single-payer" option become the only solution?

Think rationing/death-panels won't happen here? I wouldn't want to depend on luck to be part of the 500 that get treatment annually:

"The Oregon Health Authority told Senate investigators that the predicted cost of covering the hep C drugs for half of the 10,000 Medicaid patients who could benefit from them would have more than doubled the $600 million annual budget it had for all drugs the previous year. Oregon decided instead it would cover just 500 patients a year for the first 6 years."

About the pricing, lets say there was a law that all cell phones could only cost $100- think Apple would make the iPhone?

Going to add this about the single-payer ability to negotiate drug prices: "Germany has said it has a deal to buy Sovaldi at €41,000 for a 12-week course."  Wow, what a deal, and with an estimated 2,000,000 patients in Germany, it will only cost $80B for JUST this one treatment, let alone all the other co-morbidity costs that come with this disease.

That's like saying they got a 20% discount on Porsche's, still going to bankrupt the system.  Do you think banning the higher price of Porsches will lead to more Porsches being built?

There are no easy answers here folks, it's a lie that universal or single-payer will solve all the problems because this is an economic issue, and I think it's been proven that more choices for the individual yields the best solution. Do you want to make your health choices or do you want to let Donald Trump make them?

[Maenad]

Think rationing/death-panels won't happen here?

They already exist. What do you think it is when an insurance company denies coverage for serious pre-existing conditions? They already deny coverage for expensive treatments that could save lives, etc. Death Panels exist in spades, they're just the insurance companies rather than a government agency.

[nereo]

Think rationing/death-panels won't happen here?

They already exist. What do you think it is when an insurance company denies coverage for serious pre-existing conditions? They already deny coverage for expensive treatments that could save lives, etc. Death Panels exist in spades, they're just the insurance companies rather than a government agency.

CDP45 - are you completely comfortable with a for-profit company making these decisions without governmental regulations?  It's a serious question. Some argue that "market forces" will ensure that these companies will operate fairly an efficiently, whereas I believe that you need extensive regulation to combat the inherent conflict-of-interest that exists whenever a for-profit company is confronted with a situation where providing treatment will result in financial loss.

[CDP45]

Think rationing/death-panels won't happen here?

They already exist. What do you think it is when an insurance company denies coverage for serious pre-existing conditions? They already deny coverage for expensive treatments that could save lives, etc. Death Panels exist in spades, they're just the insurance companies rather than a government agency.

You mean the voluntary signed contract chosen by the consumer?

[nereo]

Think rationing/death-panels won't happen here?

They already exist. What do you think it is when an insurance company denies coverage for serious pre-existing conditions? They already deny coverage for expensive treatments that could save lives, etc. Death Panels exist in spades, they're just the insurance companies rather than a government agency.

You mean the voluntary signed contract chosen by the consumer?

yes.

[scottish]

Interesting.   Can you folks with pharma plans in the US get access to Sovaldi with only stage 1 fibrosis if you have hepatitis C?

Stage 1 fibrosis is actually very mild liver disease.   IIRC, the big problem is in accurately measuring the degree of liver fibrosis so you can tell when to start the treatment.    The most definitive test is a liver biopsy, but this has a significant mortality risk(something like 1 in 10,000).   Newer tests use a type of ultrasound, but they aren't very accurate.

So the problem then, is when do you spend the 90K on the drug?     If you were paying for it yourself, you probably wouldn't do it at stage 1, you'd wait and see.  Maybe you'd cut back on other sources of liver disease, such as alcohol consumption and obesity.    Why should the public system be any different?

There are many new drugs that are out of reach for people without insurance.    Some of them are expensive to manufacture (something about growing them in Chinese hamsters!) and the Phase 1, 2, and 3 trials cost the drug companies an arm and a leg as well.    In Ontario, there's a public drug insurance plan called the Trillium Drug Plan that will provide access to these drugs with a deductible equal to 4% of last year's gross income.    You have to go through an approval phase, but as long as the drug is warranted by current medical practices, you can generally get approved.

Overall, it seems like a reasonable level of health care to me.    I suspect only the very wealthy in the US can get significantly better health care, but I'd like to hear your stories on this.

[CDP45]

I would say all federal government employees would be provided the entire Solvaldi cure if they had Hep-C for less than $1,000 out of pocket.

I personally have gone to a local ER and spent 2 nights at a billed cost of $7,000 and I paid a $500 deductible a few years ago. Now my family deductible is $3,000 via HSA with OOP max $6,700, and I would say the vast majority of people with employer sponsored health care have similar best in the world treatments with no waiting.

The issue is that the 100MM working-class and up folks are suffering enormous cost increases in the past 5-6 years.   

[CDP45]

Think rationing/death-panels won't happen here?

They already exist. What do you think it is when an insurance company denies coverage for serious pre-existing conditions? They already deny coverage for expensive treatments that could save lives, etc. Death Panels exist in spades, they're just the insurance companies rather than a government agency.

CDP45 - are you completely comfortable with a for-profit company making these decisions without governmental regulations?  It's a serious question. Some argue that "market forces" will ensure that these companies will operate fairly an efficiently, whereas I believe that you need extensive regulation to combat the inherent conflict-of-interest that exists whenever a for-profit company is confronted with a situation where providing treatment will result in financial loss.

I would be most comfortable with contracts that were followed by both parties. A real problem is socializing losses via government bailout, but also people putting their faith in government to absorb risk and eliminate fraud, which in reality is shockingly deficient at preventing. At this point in time, many regulations are merely anti-competitive lobbying efforts for existing companies to prevent upstarts from entering the market. Luckily in the USA we're not at a point like many other countries that have nearly outlawed hard-work and profit, but that doesn't mean we still don't pay a high price of opportunity cost and prevent progress towards a more prosperous society.

[Metric Mouse]

Tough choices in Canada: http://www.cbc.ca/news/health/hepatitis-c-medication-expensive-cure-1.3359149

"But, whatever the price, it's steep enough that only those patients whose liver disease has progressed to Stage 2 will qualify for publicly funded medication."

Gee, money isn't unlimited in Canada to pay for healthcare? But it's "universal."

That's so dumb. Wouldn't it be cheaper by far over the course of the person's life to treat it as early as possible to avoid more issues later?

Most cases of Hep C don't progress to terminal liver failure so in aggregate, it's probably cheaper to wait. I would hope that a healthcare worker acquiring Hepatitis through needlestick or anyone else acquiring it through no fault of there own would have access. Isn't that what conservatives preach?  Personal accountability and consequences for poor choices? Once the patent expires on that med it should be possible, in theory, to eradicate Hep C.

Ahh, I suppose you're right about the disease not always progressing to the point that this medication would be a cost-effective treatment. Thank you for explaining.

[scottish]

I personally have gone to a local ER and spent 2 nights at a billed cost of $7,000 and I paid a $500 deductible a few years ago. Now my family deductible is $3,000 via HSA with OOP max $6,700, and I would say the vast majority of people with employer sponsored health care have similar best in the world treatments with no waiting.

What do you mean by "no waiting"?   If you have a non-urgent procedure - maybe a hernia repair for example - are you saying you can get it done the next day?

Just for comparison, the last time I was in the hospital was via the ER for an inflamed appendix.    They removed it late that night.   This was a few years ago, but IIRC, my total bill came to less than $200 and that because I asked for a private room for 2 nights.    This level of care is available to any resident of Canada.   Still think your employer sponsored plan is better?

[CDP45]

I personally have gone to a local ER and spent 2 nights at a billed cost of $7,000 and I paid a $500 deductible a few years ago. Now my family deductible is $3,000 via HSA with OOP max $6,700, and I would say the vast majority of people with employer sponsored health care have similar best in the world treatments with no waiting.

What do you mean by "no waiting"?   If you have a non-urgent procedure - maybe a hernia repair for example - are you saying you can get it done the next day?

Just for comparison, the last time I was in the hospital was via the ER for an inflamed appendix.    They removed it late that night.   This was a few years ago, but IIRC, my total bill came to less than $200 and that because I asked for a private room for 2 nights.    This level of care is available to any resident of Canada.   Still think your employer sponsored plan is better?

Correct on the non-urgent procedures, had a hand issue that was slightly annoying just a few times per year and finally went in and doc said he was open for surgery in 2 days if I wanted to do it that soon. I honestly have never heard of any sort of waiting in the US, like for anything. MRIs, kidney stones, most just call the specialist doctor directly for an appt. Any sort of medication or drug is never unavailable. I've lived in a 1MM+ person city for 30 years and ambulances arrive within minutes of the emergency call. My young daughter had a moderate fever one night and we call her doctors office at like 7pm and they said come in first thing 730am.

And yes I think my plan is better (and the 100+ million with employer sponsored plans/group health) because in the case of a major problem there wouldn't be any waiting or rationing of care. The best care would be provided or they would refer you to where you would need to go.

Just a simple google search on Canadian wait times yields this, and these waits are totally foreign (haha pun) to most Americans.
http://www.ctvnews.ca/health/healthcare-wait-times-hit-20-weeks-in-2016-report-1.3171718

 In terms of specialized treatment, national wait times were longest for neurosurgery (46.9 weeks) and shortest for medical oncology (3.7 weeks).

    Neurosurgery: 46.9 weeks
    Orthopaedic surgery: 38
    Ophthalmology: 28.5
    Plastic Surgery: 25.9
    Otolaryngology: 22.7
    Gynaecology: 18.8
    Urology: 16.2
    Internal medicine: 12.9
    Radiation oncology: 4.1
    General surgery: 12.1
    Cardiovascular: 8.4
    Medical oncology: 3.7

http://www.usnews.com/news/best-countries/articles/2016-08-03/canadians-increasingly-come-to-us-for-health-care

The three hospitals that use stem-cell therapy to treat patients with blood disorders and aggressive cancers like the one that Sharon Shamblaw battled are unable to keep up with the soaring demand. So patients are sent to medical facilities in Buffalo, Cleveland, Ohio, and Detroit, Michigan, for the potentially life-saving treatment.

"We don't yet have the capacity to serve all the patients who require allogeneic stem-cell transplants," says Dr. Michael Sherar, president and CEO of Cancer Care Ontario, referring to the treatment that uses donor stem cells.

Im just casually googling this stuff, and I don't know if it's a fair representation, but I have never heard anyone being sent OUT of the US for treatment. I've heard of cases where maybe the CLOSEST hospital might have a longer wait than another down the road, but there still wouldn't be any waiting.

[Paul der Krake]

Im just casually googling this stuff, and I don't know if it's a fair representation, but I have never heard anyone being sent OUT of the US for treatment. I've heard of cases where maybe the CLOSEST hospital might have a longer wait than another down the road, but there still wouldn't be any waiting.

Yes there are wait times. Sometimes long. This is what happens when decisions are made to consider the health of the nation as a whole, not just one patient's.

Despite that, it's pretty telling that virtually nobody who has experienced more than one system favors the US version of things.

[scottish]

If you dig down further into the weight times, you'll find that they vary by urgency as well as by treatment type.   For example, emergency surgery happens very quickly, but elective surgery can take longer - sometimes a great deal longer.   So I think the number's you've found are probably more representative of elective surgery.

Anyway, there's no question wait times for non-urgent surgery and care are a bit of a problem in Canada.    If you can really get immediate care for this stuff in the US, then I'd agree that you have better health care.   This goes a long way towards explaining why so many Americans prefer their health care system.    It still leaves a big gap for the people without employer-sponsored care though.

Something else to think about.    Waiting lists for care are essentially a priority queuing system.    If you can get rapid care for things that aren't urgent, this suggests that your queue resources are not very busy, i.e. your surgeons and specialists are idling  while they wait for patients.    This would help explain why US health care is so expensive.

I don't know what the right answer is.   I'd like to see our government put more resources into our health care system, but they seem to be busy paying US companies to build solar farms.    On the other hand, I think it's crazy for a wealthy country to not provide good health care for all of its citizens, so I don't really like the free market approach - and I'm someone who would be able to take advantage of it.

[Monkey Uncle]

Correct on the non-urgent procedures, had a hand issue that was slightly annoying just a few times per year and finally went in and doc said he was open for surgery in 2 days if I wanted to do it that soon. I honestly have never heard of any sort of waiting in the US, like for anything. MRIs, kidney stones, most just call the specialist doctor directly for an appt. Any sort of medication or drug is never unavailable. I've lived in a 1MM+ person city for 30 years and ambulances arrive within minutes of the emergency call. My young daughter had a moderate fever one night and we call her doctors office at like 7pm and they said come in first thing 730am.

And yes I think my plan is better (and the 100+ million with employer sponsored plans/group health) because in the case of a major problem there wouldn't be any waiting or rationing of care. The best care would be provided or they would refer you to where you would need to go.

I'll offer a couple of anecdotes as counterpoints to the bolded statements.

Regarding the no waiting: A few years ago my doctor ordered a MRI.  He and I argued with my employer-sponsored insurance company for nine months before they finally gave in and let me have the test.  In the meantime they diverted me to ineffective physical therapy (twice), and made me have x rays and other less expensive tests that were not effective in diagnosing my issue.  And I have pretty much the best employer provided health insurance in the country (federal employee insurance).

Regarding the no waiting or rationing in the case of a major problem:  My cousin battled cancer for several years, during which time she constantly had to argue with her employer-provided insurance to get them to cover needed treatments (surgeries, radiation, and chemotherapy).  Several times she waited months to get the treatments she needed.

I realize these are just individual anecdotes and not statistics.  But this kind of stuff does happen to fully insured people in the US.  Just read any health insurance policy; they are all full of mandatory precertifications for hospital admissions and most major procedures.  Presumably the reason they require precertification is because they want the opportunity to deny you access to the treatment.  We already have rationing of care, it is just enforced by the insurance companies rather than the government.  And I'm not saying that rationing at some level isn't needed.  Unlimited access leads to unlimited prices, so someone has to look out for the bottom line.  All I'm saying is that we shouldn't pretend that the private insurance system is capable of providing instant access to any and all treatments.

[sol]

Parts of my family are getting enormous amounts of quasi-elective surgery associated with aging, like replacement knees and heart surgery, and they routinely wait 6 months to two years for surgeries even with good American insurance.  It's absolutely false to claim that the American health care system can provide immediate care to anyone at any time. 

Wait times are solely determined by the balance between available doctors and available patients.  There is no reason why insurance format should have any bearing on wait times, unless it disproportionately changes one of those two things in relation to the other.

[AdrianC]

Just for comparison, our Silver Obamacare plan has a deductible of $6,150 individual/$12,300 family, out of pocket limit of $7,000 individual/$14,000 family.

This does not qualify as a High Deductible plan. Premium is $990/mo for our family of 5.

We can cover this deductible amount no problem. As you say, it would be terrible for most Americans.

So it looks like you pay a bit less than we do, for less coverage. 

Yeah, but neither of us has a "super-high deductible catastrophic plan".

A super-high deductible catastrophic plan might be a good solution for my family, though, if coupled with an unlimited HSA.

Put, say $500K into the HSA. At 4% that gives us $20K of inflation adjusted spending per year. That should cover any normal medical needs. As long as we get the insurance company negotiated rate at providers.

Of course, for most Americans there's one small teensy-weensy issue...

[rpr]

As long as we get the insurance company negotiated rate at providers.

This is what I don't get. Why can't everyone (all Americans) just get the negotiated rate -- not just the ones with the insurance company coverage.

[sol]

This is what I don't get. Why can't everyone (all Americans) just get the negotiated rate -- not just the ones with the insurance company coverage.

Because that would reduce profits for private insurance companies and health care providers. 

Hospitals don't want to charge everyone the same price, when there is 5% of the population out there that will voluntarily pay 20x as much for the same care.  Insurance companies don't want anyone else to pay prices as low as they negotiate for their customers, because that reduces your incentive to buy their product.

The free market system dictates that prices should be variable.  Capitalism demands unequal pricing.  Go America!

[Metric Mouse]

This is what I don't get. Why can't everyone (all Americans) just get the negotiated rate -- not just the ones with the insurance company coverage.

Because that would reduce profits for private insurance companies and health care providers. 

Hospitals don't want to charge everyone the same price, when there is 5% of the population out there that will voluntarily pay 20x as much for the same care.  Insurance companies don't want anyone else to pay prices as low as they negotiate for their customers, because that reduces your incentive to buy their product.

The free market system dictates that prices should be variable.  Capitalism demands unequal pricing.  Go America!

And the cherry on the cake is a law that demands everyone buy these company's product. Take the worst of the capitalistic system and add in the worst of the socialistic system and claim it makes things better. And then punish hospitals for providing more care to high-risk populations; no wonder prices aren't going down.

[rpr]

The free market system dictates that prices should be variable.  Capitalism demands unequal pricing.  Go America!

USA! USA! USA!

We're Number 1!!!!

[CDP45]

This is what I don't get. Why can't everyone (all Americans) just get the negotiated rate -- not just the ones with the insurance company coverage.

Because that would reduce profits for private insurance companies and health care providers. 

Hospitals don't want to charge everyone the same price, when there is 5% of the population out there that will voluntarily pay 20x as much for the same care.  Insurance companies don't want anyone else to pay prices as low as they negotiate for their customers, because that reduces your incentive to buy their product.

The free market system dictates that prices should be variable.  Capitalism demands unequal pricing.  Go America!

Uhm well back in reality like everyone other industry there are cost savings through volume and relationships. Most of the insurance companies and hospitals are non-profit anyway in this country, so what's their motive smart guy?

[sol]

And the cherry on the cake is a law that demands everyone buy these company's product.

Don't pretend that people were able to avoid buying healthcare before the ACA was passed.
 
The problem here is that everyone uses healthcare, whether they like it or not, often in emergency situations.  That prevents the type of comparison shopping that protects consumers in a normal market.  Hospitals can pretty much charge you any price at all, because if you are going to be dead in 10 minutes if you say no, you will agree to anything.  This is why healthcare isn't subject to the usual rules of the free market.  Buyers have no power.  There can be no competition in a market in which buyers have no choices.

Most of the insurance companies and hospitals are non-profit anyway in this country, so what's their motive smart guy?

How many non-profit insurance companies do you know of?  I dare you to name one without using google. 

Some hospitals are non-profit, that's true.  But don't forget that non-profit does NOT mean it is run at cost.  It just means it doesn't have shareholders or a private equity group behind it.  It still wants to generate as much "profit" as possible, it's just required to pay out most (not all) of that profit in salaries to it's executive board, or invest it into new equipment, departments, buildings, and land (and in exchange is exempted from most taxation).  The "non-profit" hospital near me is CONSTANTLY in a state of construction and expansion, because they spend those ridiculous profits on making the hospital bigger and fancier, regardless of what patients actually need.

[geekette]

Most of the insurance companies and hospitals are non-profit anyway in this country, so what's their motive smart guy?

How many non-profit insurance companies do you know of?  I dare you to name one without using google. 

I'm not arguing with you, but I have a question, if anyone knows.  Our insurance is through BCBS NC, which is "not for profit", and honestly, I'm not sure what that really means.  I know they fought to be "for profit" a few years ago and lost.  They do pay state and federal taxes, though.

They aren't cheap, and regardless of what they say about network size, we, under an ACA plan, are restricted to a smaller network in our county.  If we lived outside the county, we could have gotten a plan that included our doctor, whose office is in our county.  Confused?  So am I. 

[Erica]

Trump signed this executive order regarding healthcare. He is against the individual mandate, btw


Day 1: Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal
Hours after taking the oath of office, Trump issued an executive order aimed at rolling back Obamacare. The directive called on the secretary of health and human services, in addition to other agencies, to interpret regulations as loosely as possible to minimize the financial burden on individuals, insurers, health care providers and others.
Who will it affect? The order's language is somewhat vague and considering that Obamacare was passed through Congress, this presidential action can't change the law. The process of changing the law is underway, however. The House of Representatives recently approved a budget that would allow Congress to repeal parts of the Affordable Care Act and congressional Republicans and the White House are scrambling to develop a replacement. President Trump hopes to replace it with his own administration's health care law. All of that means this executive order's implications are unknown.

[Metric Mouse]

And the cherry on the cake is a law that demands everyone buy these company's product.

Don't pretend that people were able to avoid buying healthcare before the ACA was passed.
 
The problem here is that everyone uses healthcare, whether they like it or not, often in emergency situations.  That prevents the type of comparison shopping that protects consumers in a normal market.  Hospitals can pretty much charge you any price at all, because if you are going to be dead in 10 minutes if you say no, you will agree to anything.  This is why healthcare isn't subject to the usual rules of the free market.  Buyers have no power.  There can be no competition in a market in which buyers have no choices.

Most of the insurance companies and hospitals are non-profit anyway in this country, so what's their motive smart guy?

How many non-profit insurance companies do you know of?  I dare you to name one without using google. 

Some hospitals are non-profit, that's true.  But don't forget that non-profit does NOT mean it is run at cost.  It just means it doesn't have shareholders or a private equity group behind it.  It still wants to generate as much "profit" as possible, it's just required to pay out most (not all) of that profit in salaries to it's executive board, or invest it into new equipment, departments, buildings, and land (and in exchange is exempted from most taxation).  The "non-profit" hospital near me is CONSTANTLY in a state of construction and expansion, because they spend those ridiculous profits on making the hospital bigger and fancier, regardless of what patients actually need.

I think it's a bit late in the discussion to continue to pretend that health insurance = healthcare.

[CDP45]

And the cherry on the cake is a law that demands everyone buy these company's product.

Don't pretend that people were able to avoid buying healthcare before the ACA was passed.
 
The problem here is that everyone uses healthcare, whether they like it or not, often in emergency situations.  That prevents the type of comparison shopping that protects consumers in a normal market.  Hospitals can pretty much charge you any price at all, because if you are going to be dead in 10 minutes if you say no, you will agree to anything.  This is why healthcare isn't subject to the usual rules of the free market.  Buyers have no power.  There can be no competition in a market in which buyers have no choices.

Most of the insurance companies and hospitals are non-profit anyway in this country, so what's their motive smart guy?

How many non-profit insurance companies do you know of?  I dare you to name one without using google. 

Some hospitals are non-profit, that's true.  But don't forget that non-profit does NOT mean it is run at cost.  It just means it doesn't have shareholders or a private equity group behind it.  It still wants to generate as much "profit" as possible, it's just required to pay out most (not all) of that profit in salaries to it's executive board, or invest it into new equipment, departments, buildings, and land (and in exchange is exempted from most taxation).  The "non-profit" hospital near me is CONSTANTLY in a state of construction and expansion, because they spend those ridiculous profits on making the hospital bigger and fancier, regardless of what patients actually need.

Hmm, well the largest health insurer in the northwest would be Regence, a BCBS affiliate. And the largest hospitals are religiously afilliated...so I would say the vast majority of healthcare where you live is provided by non-profits.

Learn something new every day huh?

[sol]

Hmm, well the largest health insurer in the northwest would be Regence, a BCBS affiliate.

I'm assuming you're aware that BCBS isn't non-profit anymore?

Google tells me that there are approximately 100,000 Americans insured through non-profit health insurance companies.  That's great for that particular ~3.5% of Americans, but the other 96.5% of us aren't so lucky.

[sol]

I think it's a bit late in the discussion to continue to pretend that health insurance = healthcare.

Quite the contrary, they distinction is what (theoretically) makes plans like the ACA work. 

Healthcare will never be a viable market, for reasons we've already covered.  Sellers have all the power and buyers are held hostage, so no market can function.  Everyone is forced to buy care, in disadvantageous situations, by the nature of being mortal.

But health INSURANCE can be a viable market.  When shopping for insurance plans, people can compare rates and make decisions without the threat of immediate death hanging over their heads.  Theoretically, this decoupling is what allows capitalism to work in the healthcare market at all, but removing the care from the payment for care and then letting the free market work on the payment method.  This is the whole reason conservatives pushed so hard for Romneycare, because it's the only way to let capitalism control health care costs.  Without it, the only viable solution (which works so well in every other westernized nation) is basically another form of socialism, and conservatives hate all things socialist (army, roads, schools, post office, etc). 

Republicans killed universal health care in America in the 90s, and then eventually passed Romneycare as their preferred alternative "free market" solution.  Democrats expanded their idea to other states.  Now Republicans are going to kill their own idea, I guess.

[CDP45]

Hmm, well the largest health insurer in the northwest would be Regence, a BCBS affiliate.

I'm assuming you're aware that BCBS isn't non-profit anymore?

Let me know if you'd like to present any "alternative facts," but I choose reality.

I am aware of this (and so is wikipedia)

Cambia Health Solutions is a nonprofit health insurance corporation based in Portland, Oregon.[1] It sells health insurance through several subsidiaries, including Regence, a member of the Blue Cross Blue Shield Association operating in Oregon, Idaho, Utah, and Washington; Asuris Northwest Health; BridgeSpan Health; and LifeMap.[2] Cambia also invests in non-insurance healthcare technology and service companies, such as GNS Healthcare, Qliance, and True Link.

Before November 2013, Cambia was known as The Regence Group.[1]

Regence is licensed to sell health insurance plans under the Blue Cross Blue Shield name in Utah, and Oregon. It is licensed under the Blue Shield name in Idaho and western Washington. Its non-Blue subsidiary uses the Asuris name in eastern Washington, because Premera acquired that territory's Blue Shield license in 1998 when it merged with Spokane's Medical Services Corporation.

Regence has 2.5 million members in Idaho, Oregon, Utah and Washington. It has the largest enrollment of any health insurer in Oregon[3] and Washington.[4] It has offices in each state served, and employs 5,500 people.

[CDP45]

Hmm, well the largest health insurer in the northwest would be Regence, a BCBS affiliate.

I'm assuming you're aware that BCBS isn't non-profit anymore?

Google tells me that there are approximately 100,000 Americans insured through non-profit health insurance companies.  That's great for that particular ~3.5% of Americans, but the other 96.5% of us aren't so lucky.

Are you sure you're using google and not just pulling it out of your ass?

Founded in 1945, Kaiser Permanente is one of the nation's largest not-for-profit health plans, serving more than 10.6 million members, with headquarters in Oakland, California. It comprises: Kaiser Foundation Hospitals and their subsidiaries. Kaiser Foundation Health Plan, Inc.

[sol]

Let me know if you'd like to present any "alternative facts," but I choose reality.

I didn't say there weren't ANY non-profit health insurance plans.  There are even some BCBS plans that are still non-profit, just not most of them.

You said "most of the insurance companies are non-profit" and that's just not true.  You can call my facts "alternative" all day long and I won't be bothered.  Anybody here can spend 30 seconds on google researching this for themselves.  I will stand by that ~96% number unless somebody else would like to do more research than I have done.

And this is a weird argument for you to choose, out of the ten different ways you've been refuted in this thread.  Why are you so hard for non-profit insurance plans?  Isn't that leaning a little too close to socialism for you?

[CDP45]

https://www.providence.org/about

Where We Serve

We operate 34 hospitals, 600 physician clinics, 22 long-term care facilities, 19 hospice and home health programs and 693 supportive housing units in 14 locations. Our health plan serves our caregivers and other large employer groups covering 513,000 members.

I just found another half million people after a few seconds of search covered by non-profit insurers.

Can't seem to find any facts that more than 100,000 people in the US are covered by non-profits? Wow, you're just a master-debator...

Maybe I'm just hoping to break through your cognitive dissonance so that you might actually question your viewpoints instead of regurgitating statist lies?

Don't you think it's odd you're posting on a financial independence forum against capitalism, profit, and well against independence and dependence on the state?

But to your question no, I think non-profits are a wonderful examples of free-association and charity that is crowded out by the state.

[Metric Mouse]

I think it's a bit late in the discussion to continue to pretend that health insurance = healthcare.

Quite the contrary, they distinction is what (theoretically) makes plans like the ACA work. 

Healthcare will never be a viable market, for reasons we've already covered.  Sellers have all the power and buyers are held hostage, so no market can function.  Everyone is forced to buy care, in disadvantageous situations, by the nature of being mortal.

But health INSURANCE can be a viable market.  When shopping for insurance plans, people can compare rates and make decisions without the threat of immediate death hanging over their heads.  Theoretically, this decoupling is what allows capitalism to work in the healthcare market at all, but removing the care from the payment for care and then letting the free market work on the payment method.  This is the whole reason conservatives pushed so hard for Romneycare, because it's the only way to let capitalism control health care costs.  Without it, the only viable solution (which works so well in every other westernized nation) is basically another form of socialism, and conservatives hate all things socialist (army, roads, schools, post office, etc). 

Republicans killed universal health care in America in the 90s, and then eventually passed Romneycare as their preferred alternative "free market" solution.  Democrats expanded their idea to other states.  Now Republicans are going to kill their own idea, I guess.

But that is the point: there is no reason to 'let the market decide the cost of healthcare' - for all the reasons you mentioned.  If the government is already forcing people to buy health insurance, and has to both subsidize insurance companies AND the people buying the product they forced people to buy, all while strictly regulating the product, and strictly regulating the healthcare that is purchased with the forced-to-purchase-highly-regulate-product; how exactly does the market decide anything of meaning under this system?  And if we're already at this level of governmental intervention, how is it not preferable, and cheaper, to cut out the middle man (insurance - which was the fuckin' problem to begin with, and only made marginally better by the ACA)? Like roads and military and the post office, these things are not marketable, but needed, and thus should be shouldered by the government.

And rag on Republicans all you want. The Democrats had the opportunity to really change healthcare for the better. Like, really make it better - anything they could come up with they could pass.  Instead, the best they could come up with was to copy what Republicans were doing and ram rod it through with only minor changes. And when it didn't solve the issue (though it worked just as planned, because it was a Republican plan -seems like this one they did get to function as designed) the best thing they could say is "Well, it was Romney's plan to begin with."

And now the Democrats are defending a broken Republican plan while Republicans are arguing among themselves on how to make it better. Meanwhile costs continue to rise at similar rates to before the magic plan.  It's just madness. Time to scrap it and move towards healthcare.

[elysianfields]

This is what I don't get. Why can't everyone (all Americans) just get the negotiated rate -- not just the ones with the insurance company coverage.

Because that would reduce profits for private insurance companies and health care providers. 

Hospitals don't want to charge everyone the same price, when there is 5% of the population out there that will voluntarily pay 20x as much for the same care.  Insurance companies don't want anyone else to pay prices as low as they negotiate for their customers, because that reduces your incentive to buy their product.

The free market system dictates that prices should be variable.  Capitalism demands unequal pricing.  Go America!

Furthermore, the lack of transparent pricing information and customer knowledge/ability to interpret that pricing data, in addition to the inability to compare quality among providers, means that the medical providers have the advantage of more information.  They alone can tell whether their price is fair or not (of course it isn't!), whether the procedure you're considering is a worthwhile investment, and so on.  In fact, most providers cannot even tell you what a particular treatment or procedure will cost!

How many of you, seriously, compare doctor pricing and then visit the cheapest one?

[AdrianC]

Google tells me that there are approximately 100,000 Americans insured through non-profit health insurance companies.  That's great for that particular ~3.5% of Americans, but the other 96.5% of us aren't so lucky.

That's interesting. We're in the 3.5%! I was excited to go with a non-profit this year (Aetna dropped us after being with them for 9 years).

https://www.caresource.com/about-us/

We're finding out one reason why our plan was cheaper than the for-profit plans: a very narrow network.

My wife had a procedure scheduled for months now, and two days before it we found out that though the doctor is in network, the facility is not. Procedure cancelled. New doctor found. Now she's waiting to see the new specialist to then schedule the same procedure. Inefficiency ain't in it.

[okonumiyaki]

I don't think being frugal is equal to being mean spirited or selfishly only looking out for yourself while the community around you crumbles.

Thank you for for the wonderful thoughtful comment that I didn't have the words to say.

its a devils advocate statement ... can you not see that we could be slowing crumbling our society thru giving everyone medical treatment and not letting natural selection work in some instances.  i'm pretty sure Stephen Hawking didnt procreate and therefore continue on his disorder.  You guys cant see past this dude has this we must help everyone, assuming its for a better society as a whole.  well in 200 years they may look back and say WTF were these people thinking allowing the procreation of these genetic mutations that have lead to a crumbled society.  You're not looking past first quarter earnings so your stock price stays high like most companies in america do.  this doesnt fully fall under the ACA or anything like that but its a fully plausible situation which everyone here isnt really taking into account. 

I'm all for a single payer system.  but under such a system things like this can and should be considered when giving treatment to someone who may be selfish enough to procreate and continue a disorder that should be naturally selected away.

Just in case it wasn't answered.  Stephen Hawking has 3 middle aged healthy children. 

[maizefolk]

Hmm, well the largest health insurer in the northwest would be Regence, a BCBS affiliate.

I'm assuming you're aware that BCBS isn't non-profit anymore?

Google tells me that there are approximately 100,000 Americans insured through non-profit health insurance companies.  That's great for that particular ~3.5% of Americans, but the other 96.5% of us aren't so lucky.

There's a factor of ten 100 error somewhere in there. 100,000/320M american's is a lot closer to 0.35% 0.035% than it is to 3.5%.