Author Topic: What comes after the ACA?  (Read 772968 times)

radram

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Re: What comes after the ACA?
« Reply #800 on: January 30, 2017, 09:52:38 AM »
I am having trouble researching the recent debate as to whether for-profit or non-profit entities ensure more americans.

Can someone show sources?

Is it possible that some of these conglomerates are similar to the NFL, a non-profit with 31 for-profit entities, plus the Green Bay Packers (GO PACK) within it?

Does that or should that change the conversation?

nereo

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Re: What comes after the ACA?
« Reply #801 on: January 30, 2017, 10:01:56 AM »
I am having trouble researching the recent debate as to whether for-profit or non-profit entities ensure more americans.


I've been wondering how, practically speaking, this even matters. If a substantial portion of people get their health insurance through for-profit entities, and if even a portion of our nation's health care facilities are for-profit, then we have to consider how they fit into the broader discussion.


NESailor

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Re: What comes after the ACA?
« Reply #802 on: January 30, 2017, 10:15:31 AM »
I am having trouble researching the recent debate as to whether for-profit or non-profit entities ensure more americans.


I've been wondering how, practically speaking, this even matters. If a substantial portion of people get their health insurance through for-profit entities, and if even a portion of our nation's health care facilities are for-profit, then we have to consider how they fit into the broader discussion.

In fact, it does not.  I'm a CPA and a former CPA colleague of mine is a VP of Finance at a non-profit hospital. (I've also audited non-profits in the past and sit on the board of one today).  This distinction means nothing for prices.  Profits aren't distributed but they are ALWAYS maximized.  We literally talk about margins and how to increase them at non-profit board meetings.  This non-profit is also in the healthcare biz.

Let's move on from this point.

radram

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Re: What comes after the ACA?
« Reply #803 on: January 30, 2017, 10:46:36 AM »
I am having trouble researching the recent debate as to whether for-profit or non-profit entities ensure more americans.


I've been wondering how, practically speaking, this even matters. If a substantial portion of people get their health insurance through for-profit entities, and if even a portion of our nation's health care facilities are for-profit, then we have to consider how they fit into the broader discussion.

In fact, it does not.  I'm a CPA and a former CPA colleague of mine is a VP of Finance at a non-profit hospital. (I've also audited non-profits in the past and sit on the board of one today).  This distinction means nothing for prices.  Profits aren't distributed but they are ALWAYS maximized.  We literally talk about margins and how to increase them at non-profit board meetings.  This non-profit is also in the healthcare biz.

Let's move on from this point.

I would largely agree regarding why it would even matter.

Sol and CDP45 have both made a claim. One might be correct, or they both may be correct,  due to complex structure like the NFL example I described up-thread. If one of them is not giving correct information and passing that off as data, that will be very helpful to me moving forward. I would even give benefit of the doubt that both are presenting accurate data, with one being more current. Sources would help with that distinction.

It sounds like an extremely easy question to answer, but yet is is hard to find out. Whenever I find it difficult to find an answer, I always wonder why. There is usually an answer that makes the confusion clear.

partgypsy

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Re: What comes after the ACA?
« Reply #804 on: January 30, 2017, 11:09:11 AM »
Quote
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

Quote
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.
As others have noticed, there are wait times and rationing for private insurance as well.
I paid additional for dental insurance. After being on it a couple years, a tooth developed a crack; I needed to remove it and according to both my dentist and oral surgeon, the best and appropriate care was a dental implant. However my insurance would only cover a bridge, not an implant. When I spoke to the representative they admitted that even though what my providers suggested I do was the standard of care, it was not covered soley due to economic reasons. So my insurance paid $100 to remove my tooth and I paid the other 5K out of pocket.

A year or two ago I was having increasing discomfort with my eyes. from February to August, I tried multiple times to schedule an appointment with my opthamologist. I would either be offered an appointment literally 3 months out, or was told to call the following month to see if there were any openings. Finally I gave up and scheduled with a doctor the next town over.
My children's provider, we got a letter that she was being moved to another location (again the next town over) and to contact them to let them know if we wanted our children to continue to see that provider (and move locations) or be seen by someone closer. I sent a message to them months ago, letting them know we wanted to stick with the original provider, no response, no information how to do so.
 
These stories are from a very good federal insurance. I'm not complaining; the horror stories I know most are the people who are self-employed, contractors who are trying to get on insurance. It truly is a land of haves and have nots; usually if you get insurance through employer, get more coverage and more standard care. If you have to get it outside that, well good luck.

Reynold

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Re: What comes after the ACA?
« Reply #805 on: January 30, 2017, 11:58:04 AM »
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.

I point out that in the U.S., in addition to a pretty strong patient lobby that would be unhappy with this idea, there is a rather strong doctor viewpoint that nobody should be interfering with their doctor/patient relationship in terms of what they are recommending for the patient.  In practice, of course, insurance companies "interfere" by not covering everything, but I have almost never seen medical care providers in the US self regulate.  I've seen lazy or incompetent doctors who didn't recommend things, but never one who said "we could do this procedure, but I wouldn't recommend it because it because it isn't worth it." 

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

Back in 2008, I ran into a woman at a party who was pretty liberal and progressive, until it came to a discussion of health care.  She had had a relative die in the UK, and saved another by bringing him to the U.S. for a diagnosis he wasn't going to get in time there.  She said she would never use the UK health care system.  It is an anecdote, and perhaps she is in the "virtually nobody" category. For more numbers behind this, I found this article;

http://www.gallup.com/poll/8056/healthcare-system-ratings-us-great-britain-canada.aspx

Which says the percentage of people satisfied with the quality of their care is identical at 31% in the U.S. and the UK, though many more in the UK are satisfied with the affordability of their care.  Of course most of their cost in the UK is in taxes, which may not occur to someone drafting or responding to a poll.  Also the numbers are from 2003, I would be surprised if they have not changed by now, especially since the health care system has been under heavy debate and through many changes in last few years.  Finally, I have never seen systematic polls questioning only people who actually have experience with both systems. 

nereo

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Re: What comes after the ACA?
« Reply #806 on: January 30, 2017, 12:44:17 PM »

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

I didn't see this until just now.
I've seen and lived with both the US and Quebec (Canada) system now.  The US system has large flaws but I certainly wouldn't recommend the Canadian systems for Americans.*  Both systems could be substantially improved for their constituents.


* I wouldn't recommend the US system for Canadians either.  What's good for one group of people often won't fly with a different demographic.

NoStacheOhio

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Re: What comes after the ACA?
« Reply #807 on: January 30, 2017, 01:08:49 PM »
Back in 2008, I ran into a woman at a party who was pretty liberal and progressive, until it came to a discussion of health care.  She had had a relative die in the UK, and saved another by bringing him to the U.S. for a diagnosis he wasn't going to get in time there.  She said she would never use the UK health care system.  It is an anecdote, and perhaps she is in the "virtually nobody" category. For more numbers behind this, I found this article;

The American system has many, many flaws, but acute care isn't one of them. If you get to the right center, we're insanely good at fixing problems (or correctly diagnosing mysteries) that nobody else can handle. The problem is that not everybody can geographically get to the right tertiary center, and then they may not be able to pay for it either. If we ignore money, the best hospitals in the U.S. are among the best in the world.

JLee

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Re: What comes after the ACA?
« Reply #808 on: January 30, 2017, 01:17:31 PM »
Another way is to finally get to single payer and cover most healthcare costs through our progressive tax system. 

Everyone here keeps saying this, and it totally makes sense, but it's never going to happen.  Republicans will never allow the US government to destroy an industry that employs millions of people (and spends billions of dollars on lobbying).

The fact that many of those people would need to be re-employed by the government's version of insurance does not soothe Republicans, because their concern is for the business and not the worker.  Unemployment would go up, as all of those redundant insurance adjusters and claims processors were fired from insurance companies suddenly made obsolete.  You can argue that efficiency is a good thing for the economy overall, but Republicans care more about protecting corporate profits than they do about advancing the economy.  They would make the same last stand for buggy whip manufacturers.

Bingo.  I don't think it's so much the people employed as it is the people running the show, making absurd quantities of dollars.

http://www.ibtimes.com/healthcare-pharma-ceos-paid-more-top-execs-any-other-industry-analysis-finds-2374013

Those guys aren't going to let their cash cow get slaughtered.

nereo

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Re: What comes after the ACA?
« Reply #809 on: January 30, 2017, 01:44:17 PM »
Back in 2008, I ran into a woman at a party who was pretty liberal and progressive, until it came to a discussion of health care.  She had had a relative die in the UK, and saved another by bringing him to the U.S. for a diagnosis he wasn't going to get in time there.  She said she would never use the UK health care system.  It is an anecdote, and perhaps she is in the "virtually nobody" category. For more numbers behind this, I found this article;

The American system has many, many flaws, but acute care isn't one of them. If you get to the right center, we're insanely good at fixing problems (or correctly diagnosing mysteries) that nobody else can handle. The problem is that not everybody can geographically get to the right tertiary center, and then they may not be able to pay for it either. If we ignore money, the best hospitals in the U.S. are among the best in the world.

This to me the heart of the strength of the US health care system.*  Patient outcomes for complex conditions are better here than almost anywhere else. The survival rate for heart surgeries, cancer treatments, organ transplants etc are at or among the best in the world. Wait time for quality of life procedures in urban markets are a fraction of what they are in many G-20 countries.

*That, to me, are the strengths.  The biggest weakness is that these only apply to people who have coverage and are near urban centers to have access to this care, and the cost of insurance in the US is overly prohibitive to a large segment of its population.

CDP45

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Re: What comes after the ACA?
« Reply #810 on: January 30, 2017, 01:54:59 PM »
As others have noticed, there are wait times and rationing for private insurance as well.
I paid additional for dental insurance. After being on it a couple years, a tooth developed a crack; I needed to remove it and according to both my dentist and oral surgeon, the best and appropriate care was a dental implant. However my insurance would only cover a bridge, not an implant. When I spoke to the representative they admitted that even though what my providers suggested I do was the standard of care, it was not covered soley due to economic reasons. So my insurance paid $100 to remove my tooth and I paid the other 5K out of pocket.

A year or two ago I was having increasing discomfort with my eyes. from February to August, I tried multiple times to schedule an appointment with my opthamologist. I would either be offered an appointment literally 3 months out, or was told to call the following month to see if there were any openings. Finally I gave up and scheduled with a doctor the next town over.
My children's provider, we got a letter that she was being moved to another location (again the next town over) and to contact them to let them know if we wanted our children to continue to see that provider (and move locations) or be seen by someone closer. I sent a message to them months ago, letting them know we wanted to stick with the original provider, no response, no information how to do so.
 
These stories are from a very good federal insurance. I'm not complaining; the horror stories I know most are the people who are self-employed, contractors who are trying to get on insurance. It truly is a land of haves and have nots; usually if you get insurance through employer, get more coverage and more standard care. If you have to get it outside that, well good luck.

Would you rather make these decisions by reading your policy upfront and understand what is and isn't covered, and having an insurance agent help you navigate this...

Or would you rather have Trump make these decisions for you?

nereo

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Re: What comes after the ACA?
« Reply #811 on: January 30, 2017, 02:02:21 PM »

Would you rather make these decisions by reading your policy upfront and understand what is and isn't covered, and having an insurance agent help you navigate this...



I don't trust an insurance agent salesman to help me navigate anything. Why would I possibly assume that someone who makes money selling me a policy would have my own best interests at heart, especially when they make MORE money denying my claims?
Contracts are intentionally written to be as confusing as hell to the layperson and to offer multiple ways for the insurance company to deny coverage.

scottish

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Re: What comes after the ACA?
« Reply #812 on: January 30, 2017, 03:14:14 PM »
Paul Krugman (for once) posted a clear analysis on this topic.

Quote
So here we go: providing health care to those previously denied it is, necessarily, a matter of redistributing from the lucky to the unlucky. And, of course, reversing a policy that expanded health care is redistribution in reverse. You canít make this reality go away.

Left to its own devices, a market economy wonít care for the sick unless they can pay for it; insurance can help up to a point, but insurance companies have no interest in covering people they suspect will get sick. So unfettered markets mean that health care goes only to those who are wealthy and/or healthy enough that they wonít need it often, and hence can get insurance.

If thatís a state of affairs youíre comfortable with, so be it. But the public doesnít share your sentiments. Health care is an issue on which most people are natural Rawlsians: they can easily imagine themselves in the position of those who, through no fault of their own, experience expensive medical problems, and feel that society should protect people like themselves from such straits.

The thing is, however, that guaranteeing health care comes with a cost. You can tell insurance companies that they canít discriminate based on medical history, but that means higher premiums for the healthy ó and you also create an incentive to stay uninsured until or unless you get sick, which pushes premiums even higher. So you have to regulate individuals as well as insurers, requiring that everyone sign up ó the mandate, And since some people wonít be able to obey such a mandate, you need subsidies, which must be paid for out of taxes.

Before the passage and implementation of the ACA, Republicans could wave all this away by claiming that health reform could never work. And even now theyíre busy telling lies about its collapse. But none of this will conceal mass loss of health care in the wake of Obamacare repeal, with some of their most loyal voters among the biggest losers.

Unique User

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Re: What comes after the ACA?
« Reply #813 on: January 30, 2017, 04:31:58 PM »
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?

It's difficult to get doctor's offices to actually give you a price, but I've done this each place I've lived in the last 25 years - four different towns/cities in three different states.  It takes a lot of phone calls, but I eventually got prices at all locations except my current location.
« Last Edit: January 30, 2017, 04:37:40 PM by Unique User »

CDP45

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Re: What comes after the ACA?
« Reply #814 on: January 30, 2017, 05:28:50 PM »
Paul Krugman (for once) posted a clear analysis on this topic.

Quote
So here we go: providing health care to those previously denied it is, necessarily, a matter of redistributing from the lucky to the unlucky. And, of course, reversing a policy that expanded health care is redistribution in reverse. You canít make this reality go away.

Left to its own devices, a market economy wonít care for the sick unless they can pay for it; insurance can help up to a point, but insurance companies have no interest in covering people they suspect will get sick. So unfettered markets mean that health care goes only to those who are wealthy and/or healthy enough that they wonít need it often, and hence can get insurance.

If thatís a state of affairs youíre comfortable with, so be it. But the public doesnít share your sentiments. Health care is an issue on which most people are natural Rawlsians: they can easily imagine themselves in the position of those who, through no fault of their own, experience expensive medical problems, and feel that society should protect people like themselves from such straits.

The thing is, however, that guaranteeing health care comes with a cost. You can tell insurance companies that they canít discriminate based on medical history, but that means higher premiums for the healthy ó and you also create an incentive to stay uninsured until or unless you get sick, which pushes premiums even higher. So you have to regulate individuals as well as insurers, requiring that everyone sign up ó the mandate, And since some people wonít be able to obey such a mandate, you need subsidies, which must be paid for out of taxes.

Before the passage and implementation of the ACA, Republicans could wave all this away by claiming that health reform could never work. And even now theyíre busy telling lies about its collapse. But none of this will conceal mass loss of health care in the wake of Obamacare repeal, with some of their most loyal voters among the biggest losers.

I'll go back to my denial of the Hep-C cure by Canada, I'm sure Krugman "the state can do no wrong unless my team isn't in-charge" would happily carry water for this decision.

But insurance is risk transfer, and that's what insurance does in other lines of coverage (auto, home, liability, etc) and there doesn't seem to be a crisis there...hmm wonder what the difference could be.

scottish

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Re: What comes after the ACA?
« Reply #815 on: January 30, 2017, 06:02:17 PM »
I usually think of him as Paul "If I use enough economic jargon people will have to believe me" Krugman.

So what do you think the feds will do then?   Just eliminate the ACA and that's it?   I can't believe the US can switch to single payer.   Is there an alternative other than something similar to the ACA?

sol

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Re: What comes after the ACA?
« Reply #816 on: January 30, 2017, 06:17:06 PM »
So what do you think the feds will do then?   Just eliminate the ACA and that's it?   I can't believe the US can switch to single payer.   Is there an alternative other than something similar to the ACA?

Sure, I proposed one back on page four of this thread:  http://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg1372352/#msg1372352

Nobody seemed terribly excited about it, but I still think it's the easiest fix.

jim555

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Re: What comes after the ACA?
« Reply #817 on: January 30, 2017, 06:19:02 PM »
Pre ACA was horrible.  Would they do it?  Maybe.  Seems like they want maximum chaos.

scottish

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Re: What comes after the ACA?
« Reply #818 on: January 30, 2017, 07:05:11 PM »
Well that's outside the box!   I like it.   It's vaguely possible the private insurance companies the government would be paying would be more efficient cost effective than a government bureaucracy doing the same thing.

Metric Mouse

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Re: What comes after the ACA?
« Reply #819 on: January 31, 2017, 05:54:46 AM »
So what do you think the feds will do then?   Just eliminate the ACA and that's it?   I can't believe the US can switch to single payer.   Is there an alternative other than something similar to the ACA?

Sure, I proposed one back on page four of this thread:  http://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg1372352/#msg1372352

Nobody seemed terribly excited about it, but I still think it's the easiest fix.
No body was terribly excited about it because it keeps the worst part of the system (insurance) and does nothing to address costs or increase healthcare outcomes. It's the same system as we have now, only you get a bill from the government when the insurance company denies your claim instead of a bill from the hospital.

thenextguy

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Re: What comes after the ACA?
« Reply #820 on: January 31, 2017, 12:31:51 PM »
So what do you think the feds will do then?   Just eliminate the ACA and that's it?   I can't believe the US can switch to single payer.   Is there an alternative other than something similar to the ACA?

Sure, I proposed one back on page four of this thread:  http://forum.mrmoneymustache.com/welcome-to-the-forum/what-comes-after-the-aca/msg1372352/#msg1372352

Nobody seemed terribly excited about it, but I still think it's the easiest fix.

I guess I don't really see much of a difference between this and the ACA. The only major difference is the additional step of collecting taxes to pay premiums rather than the consumer paying less in taxes and paying premiums themselves. How would that bring about different results?

NESailor

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Re: What comes after the ACA?
« Reply #821 on: January 31, 2017, 02:50:01 PM »


But insurance is risk transfer, and that's what insurance does in other lines of coverage (auto, home, liability, etc) and there doesn't seem to be a crisis there...hmm wonder what the difference could be.

I'd say there are quite a few differences but let's just start with one.  Most of the other lines of coverage are required one way or another.  Either by statute (auto), the lender (home...since most people finance their homes), or business contracts (liability).

With health insurance...we had no such mandate pre-ACA.  Left to their own devices, we know people make the sub-optimal choice to go without and stiff the system and conversely you and I, the premium payers.  I understand that the mandate is not ideologically palatable to some folks but how else do you prevent a death spiral if we refuse to deny care.   Or should we start denying care based on ability to pay?

scottish

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Re: What comes after the ACA?
« Reply #822 on: January 31, 2017, 03:22:15 PM »
Once the government is paying the insurers the game of inches begins.   

Aggressive, cost conscious government negotiators start removing the worst of the entitlements and egregious over-charging.    Things get better every year.

In an alternative scenario, experienced negotiators for the insurance companies slowly start jacking up premiums with individual justifications that are hard to argue.   Lobbying reaches new lows with bribes being provided to committee members responsible for health care.   The US tax-payer gets shafted.

I prefer to believe in the first scenario.


Metric Mouse

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Re: What comes after the ACA?
« Reply #823 on: February 01, 2017, 09:42:58 PM »


But insurance is risk transfer, and that's what insurance does in other lines of coverage (auto, home, liability, etc) and there doesn't seem to be a crisis there...hmm wonder what the difference could be.

I'd say there are quite a few differences but let's just start with one.  Most of the other lines of coverage are required one way or another.  Either by statute (auto), the lender (home...since most people finance their homes), or business contracts (liability).

With health insurance...we had no such mandate pre-ACA.  Left to their own devices, we know people make the sub-optimal choice to go without and stiff the system and conversely you and I, the premium payers.  I understand that the mandate is not ideologically palatable to some folks but how else do you prevent a death spiral if we refuse to deny care.   Or should we start denying care based on ability to pay?
How exactly did the ACA solve this death spiral? Now the priemuim payers are still paying for care through taxes and higher premiums - the people who can't pay still don't. Only now instead of the profits going to the hospitals who had to charge more to cover write-offs, they are going to the insurances companies. It's just shifted the money around, without changing the system meaningfully, except that now people that would have been too sick to get coverage before are now able to not pay into the system, which they never did anyway. From a financial standpoint the ACA didn't improve things much.

sol

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Re: What comes after the ACA?
« Reply #824 on: February 01, 2017, 10:30:52 PM »
From a financial standpoint the ACA didn't improve things much.

I agree that the ACA didn't do much to improve the financial arrangements of American healthcare.  It did some, and was built to phase in more changes over time, but it didn't dramatically reshape the payment landscape.

But it did provide health insurance, and thus better care, to tens of millions of Americans who were previously unable to see a doctor except by visiting an emergency room.  That's not nothing.  That legitimately Made America Greater.

Maybe we need to return to valuing something other than just dollars.  America isn't only great because it is wealthy.

Monkey Uncle

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Re: What comes after the ACA?
« Reply #825 on: February 02, 2017, 04:32:25 AM »
So the news this morning is that the Republicans now want to "repair" the ACA rather than replace it.  Or if you listen to Paul Ryan, they want to "repeal, replace, AND repair."  Wonder what that means.  The floundering would be comical if there weren't so much at stake.

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Re: What comes after the ACA?
« Reply #826 on: February 02, 2017, 05:44:43 AM »
So the news this morning is that the Republicans now want to "repair" the ACA rather than replace it.  Or if you listen to Paul Ryan, they want to "repeal, replace, AND repair."  Wonder what that means.  The floundering would be comical if there weren't so much at stake.

How can you repair something you've repealed?

jim555

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Re: What comes after the ACA?
« Reply #827 on: February 02, 2017, 06:49:19 AM »
Kinda hard to do anything without 60 votes, besides de-funding.  I don't think they want to de-fund since it will cause hardship and they will be blamed. 
They got themselves into a quagmire.

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Re: What comes after the ACA?
« Reply #828 on: February 02, 2017, 06:57:40 AM »
I think the GOP's best strategy at this point is just to hope the public gets distracted with other things for the next 3.8 years. They've vilified the existing law and over-promised about what they'll do, how much it will cost and what it will cover.

Going forward they'll need to defend on those three fronts: Cost, Coverage and Care.
You can be great on two of those, but not all three.


NESailor

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Re: What comes after the ACA?
« Reply #829 on: February 02, 2017, 07:18:22 AM »


But insurance is risk transfer, and that's what insurance does in other lines of coverage (auto, home, liability, etc) and there doesn't seem to be a crisis there...hmm wonder what the difference could be.

I'd say there are quite a few differences but let's just start with one.  Most of the other lines of coverage are required one way or another.  Either by statute (auto), the lender (home...since most people finance their homes), or business contracts (liability).

With health insurance...we had no such mandate pre-ACA.  Left to their own devices, we know people make the sub-optimal choice to go without and stiff the system and conversely you and I, the premium payers.  I understand that the mandate is not ideologically palatable to some folks but how else do you prevent a death spiral if we refuse to deny care.   Or should we start denying care based on ability to pay?
How exactly did the ACA solve this death spiral? Now the priemuim payers are still paying for care through taxes and higher premiums - the people who can't pay still don't. Only now instead of the profits going to the hospitals who had to charge more to cover write-offs, they are going to the insurances companies. It's just shifted the money around, without changing the system meaningfully, except that now people that would have been too sick to get coverage before are now able to not pay into the system, which they never did anyway. From a financial standpoint the ACA didn't improve things much.

I think you're jumping to conclusions.  I never claimed the ACA did prevent a death spiral.  My argument is that while the mandate may be unpopular - it is also necessary in whatever new system will be enacted.  Otherwise you'll have pretty much the same setup we had before - healthy and wealthy get care and pay and the rest of the population suffers until they are forced to consume extremely expensive care that they cannot afford - so it's absorbed and the rates increase for the payers at an above inflation pace.

I will say that the mandate DID make ACA viable at least temporarily.  Since the law didn't really address cost drivers, we are still at risk of a death spiral and rates are still increasing rather fast. 

jim555

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Re: What comes after the ACA?
« Reply #830 on: February 02, 2017, 07:44:17 AM »
There are a record number of signups this year.  I think the fine is getting large enough to compel the side liners to come in.  May help the premiums come down a bit.

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Re: What comes after the ACA?
« Reply #831 on: February 02, 2017, 08:21:08 AM »
So the news this morning is that the Republicans now want to "repair" the ACA rather than replace it.  Or if you listen to Paul Ryan, they want to "repeal, replace, AND repair."  Wonder what that means.  The floundering would be comical if there weren't so much at stake.

How can you repair something you've repealed?

It's all just messaging and probably has little to no connection to whatever path they actually plan to take.  Apparently Paul Ryan has now clarified that the "repair" of the healthcare system (as the Republican efforts have apparently now been rebranded) still means the "repeal and replacement" of the ACA.

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Re: What comes after the ACA?
« Reply #832 on: February 02, 2017, 08:42:38 AM »
I don't think they want to de-fund since it will cause hardship and they will be blamed. 

But do they care about that? Will their voting base care about that?

They'll brand it as short term pain for long term gain and the base will eat it up as usual.

I hope not. I really want to believe there are some Republicans who care and want to find an equitable solution.

GuitarStv

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Re: What comes after the ACA?
« Reply #833 on: February 02, 2017, 09:01:03 AM »
They'll brand it as short term pain for long term gain and the base will eat it up as usual.

They can just report that there is no pain and their base will eat up the alternative facts as usual.

AdrianC

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Re: What comes after the ACA?
« Reply #834 on: February 02, 2017, 09:59:37 AM »
Here's another plan:

http://www.vox.com/policy-and-politics/2017/2/1/14460348/conservative-republican-obamacare-plan-phil-roe

For me personally, tax credits and an HSA that I can put enough money into might work well. As long as the high deductible insurance that goes with it is actually worth a damn.

NESailor

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Re: What comes after the ACA?
« Reply #835 on: February 02, 2017, 10:29:50 AM »
Here's another plan:

http://www.vox.com/policy-and-politics/2017/2/1/14460348/conservative-republican-obamacare-plan-phil-roe

For me personally, tax credits and an HSA that I can put enough money into might work well. As long as the high deductible insurance that goes with it is actually worth a damn.

Aw man I tried reading the whole thing but couldn't get past the "advanceable refundable tax credit" for poor folks to then go out and shop for insurance "like I am" (Phil Roe, that is).   What a crock of $hit - excuse my language. 

Just like most people on here, this would probably work out great for me.  I know my way around money and have a lot of it to start.  But why do we keep pushing this ridiculous narrative that more choices are somehow a good thing for everyone.  Those poor folks who do not have an income tax liability today are likely to make a sub-optimal choice when purchasing cheese, buying Kraft "processed cheese product" instead of the real thing.  How in the world can we expect average people to understand insurance contracts?  I know not everyone is stupid.  But shopping for insurance is something only a small fraction of the population can do effectively.  Any plan that touts "access" and "shopping for insurance" will cause some serious harm to those who need the most help.

Schaefer Light

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Re: What comes after the ACA?
« Reply #836 on: February 02, 2017, 02:07:08 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.

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Re: What comes after the ACA?
« Reply #837 on: February 02, 2017, 02:58:41 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.
Stereotypes much?

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nereo

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Re: What comes after the ACA?
« Reply #838 on: February 02, 2017, 03:12:33 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.

In the context of this thread, who is making that suggestion?

Personally I think there's a more fundamental reason why the government should be responsible for providing health care to its citizens, and that's because for-profit companies have an inherent conflict of interest against providing insurance to sick people and against paying out claims in general.  It's not in a private insurer's best interests to insure individuals that have a high likelihood of costing them a lot of money.

We could minimize these conflicts by placing strict regulations and oversight of private companies, but then we are already moving towards a system that is controlled by the government. This argues for some level of government care.

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Re: What comes after the ACA?
« Reply #839 on: February 02, 2017, 05:07:35 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.

I think the aspect of the conservative mindset that pisses me off the most is the idea that people are simply too immoral to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should make decisions about a person's actions or body.

thenextguy

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Re: What comes after the ACA?
« Reply #840 on: February 02, 2017, 06:22:48 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.

I think the aspect of the conservative mindset that pisses me off the most is the idea that people are simply too immoral to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should make decisions about a person's actions or body.


Metric Mouse

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Re: What comes after the ACA?
« Reply #841 on: February 02, 2017, 07:27:52 PM »
From a financial standpoint the ACA didn't improve things much.

I agree that the ACA didn't do much to improve the financial arrangements of American healthcare.  It did some, and was built to phase in more changes over time, but it didn't dramatically reshape the payment landscape.

But it did provide health insurance, and thus better care, to tens of millions of Americans who were previously unable to see a doctor except by visiting an emergency room.  That's not nothing.  That legitimately Made America Greater.

Maybe we need to return to valuing something other than just dollars.  America isn't only great because it is wealthy.
While I agree that money should not be a primary driver in healthcare in theory, the fact remains that any plan does have to be financially feasible, at a minimum. The ACA did not address this - though, as you have pointed out, it did attempt to, just did so poorly.

And there were clearly some positive ideas in the ACA. Thankfully the controlling party states they want to keep them in the reform. (Though, who knows, I guess.)

Metric Mouse

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Re: What comes after the ACA?
« Reply #842 on: February 02, 2017, 07:37:26 PM »
I think the aspect of the liberal mindset that pisses me off the most is the idea that people are simply too stupid to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should take care of everyone.

I think the aspect of the conservative mindset that pisses me off the most is the idea that people are simply too immoral to take care of themselves.  I see this all the time.  They use it to justify the idea that the government should make decisions about a person's actions or body.


Please don't Troll.

Here's another plan:

http://www.vox.com/policy-and-politics/2017/2/1/14460348/conservative-republican-obamacare-plan-phil-roe

For me personally, tax credits and an HSA that I can put enough money into might work well. As long as the high deductible insurance that goes with it is actually worth a damn.

Aw man I tried reading the whole thing but couldn't get past the "advanceable refundable tax credit" for poor folks to then go out and shop for insurance "like I am" (Phil Roe, that is).   What a crock of $hit - excuse my language. 

Just like most people on here, this would probably work out great for me.  I know my way around money and have a lot of it to start.  But why do we keep pushing this ridiculous narrative that more choices are somehow a good thing for everyone.  Those poor folks who do not have an income tax liability today are likely to make a sub-optimal choice when purchasing cheese, buying Kraft "processed cheese product" instead of the real thing.  How in the world can we expect average people to understand insurance contracts?  I know not everyone is stupid.  But shopping for insurance is something only a small fraction of the population can do effectively.  Any plan that touts "access" and "shopping for insurance" will cause some serious harm to those who need the most help.

I don't automatically assume poor people are dumb, or are incapable to making good choices when presented with options, or are likely to make sub-optimal choices based on an arbitrary metric. I hardly see why people who think that others can't make good choices should be allowed to make choices for those people that they look down upon. It is a very narrow view that seems pretty is incredibly condescending, and does not do anything to address the underlying problem of why some people sometimes make sub-optimal choices. The correct answer is not to remove access to choices that are good for some people and only offer choices that are ok for everyone. The answer is to educate people on their choices and to simplify the complex system to the point that more people can make good choices.

Big Boots Buddha

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Re: What comes after the ACA?
« Reply #843 on: February 02, 2017, 09:10:50 PM »
^^^^^

Payday loans? 27% credit card interest rates. 3 liter bottles of soda pop.

I don't think you have a good understanding of how stupid the bottom of the USA has become. Luckily (?) I am related to some of them and its much worse than people expect. I would not trust many people I know to pick out insurance. I found out recently that one of my relatives forgot to pay their car insurance for almost a year, crashed into another car after going across the median, totaled the car, seriously injured, found out that they hadn't filled out the paperwork correctly for the low income medical insurance and decided that getting really drunk for the next few weeks was the right response to this. Its anecdotal, but humanity is made of humans.

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Re: What comes after the ACA?
« Reply #844 on: February 03, 2017, 05:42:13 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

nereo

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Re: What comes after the ACA?
« Reply #845 on: February 03, 2017, 05:52:14 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

Hmm... either I'm not understanding your argument Jim or I just disagree.  I don't share your attitude that 'most people are idiots', nor agree that your SS analogy does much to prove your point.
Specifically regarding SS payments; we've been telling people for over eight decades that SS was their money, that it was guaranteed, and that they 'paid into the system' and would would be taken care of by Uncle Sam.  Dependence on SS doesn't really show they are idiots, only that they trusted their government.
Regarding the "most people are idiots" - by and large people base their decisions on what is benefitial in the short term. We've evolved this way - that doesn't make people necessarily stupid.

jim555

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Re: What comes after the ACA?
« Reply #846 on: February 03, 2017, 05:59:14 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

Hmm... either I'm not understanding your argument Jim or I just disagree.  I don't share your attitude that 'most people are idiots', nor agree that your SS analogy does much to prove your point.
Specifically regarding SS payments; we've been telling people for over eight decades that SS was their money, that it was guaranteed, and that they 'paid into the system' and would would be taken care of by Uncle Sam.  Dependence on SS doesn't really show they are idiots, only that they trusted their government.
Regarding the "most people are idiots" - by and large people base their decisions on what is benefitial in the short term. We've evolved this way - that doesn't make people necessarily stupid.
I was thinking more on the lines of they don't save for retirement or plan for the future, which is idiocy.  MMM types are exceptions.

GuitarStv

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Re: What comes after the ACA?
« Reply #847 on: February 03, 2017, 06:05:18 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

Hmm... either I'm not understanding your argument Jim or I just disagree.  I don't share your attitude that 'most people are idiots', nor agree that your SS analogy does much to prove your point.
Specifically regarding SS payments; we've been telling people for over eight decades that SS was their money, that it was guaranteed, and that they 'paid into the system' and would would be taken care of by Uncle Sam.  Dependence on SS doesn't really show they are idiots, only that they trusted their government.
Regarding the "most people are idiots" - by and large people base their decisions on what is benefitial in the short term. We've evolved this way - that doesn't make people necessarily stupid.
I was thinking more on the lines of they don't save for retirement or plan for the future, which is idiocy.  MMM types are exceptions.

There have been a number of studies that show that people in poor financial situations tend to make worse decisions about what to do with their money.  Removing someone from the poor financial situation for a while will improve their decision making.  I'm not sure that you can blame stupidity . . . it just appears to be a natural human reaction to the social and economic stresses that apply to the people who are worse off.

nereo

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Re: What comes after the ACA?
« Reply #848 on: February 03, 2017, 06:34:32 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

Hmm... either I'm not understanding your argument Jim or I just disagree.  I don't share your attitude that 'most people are idiots', nor agree that your SS analogy does much to prove your point.
Specifically regarding SS payments; we've been telling people for over eight decades that SS was their money, that it was guaranteed, and that they 'paid into the system' and would would be taken care of by Uncle Sam.  Dependence on SS doesn't really show they are idiots, only that they trusted their government.
Regarding the "most people are idiots" - by and large people base their decisions on what is benefitial in the short term. We've evolved this way - that doesn't make people necessarily stupid.
I was thinking more on the lines of they don't save for retirement or plan for the future, which is idiocy.  MMM types are exceptions.
two points:  first, bascially what GuitarStv said about it being linked to low social-economic status rather than general idiocy. That needs to be fixed and i think the best way of doing it is vastly improved education for these communities.  Second, precisely *because* we have these programs in place and have spent literally generations talking about how they are the core of retirement explains a lot of why people have depended on them so much.  We shouldn't be surprised when we tell people "we promise you this stream of income regardless of how long you live" and then be surprised when they depend on that stream of income. Cynics will call it welfare dependence, realists/defendants might say they weren't given the full story. Either way SS is overwhelmingly viewed as a government pension (guranteed and relied upon), not as a social safety net (something best not to rely on, but will be there as a last resort).

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Re: What comes after the ACA?
« Reply #849 on: February 03, 2017, 06:43:19 AM »
Look at the number of elderly who live entirely on Social Security.  Imagine what would happen without it.  Most people are idiots who need to be told what to do.  I hate to say it, but it is true.  Personally I would love to make my own plans and be left alone but I realize I am not like most people.

Hmm... either I'm not understanding your argument Jim or I just disagree.  I don't share your attitude that 'most people are idiots', nor agree that your SS analogy does much to prove your point.
Specifically regarding SS payments; we've been telling people for over eight decades that SS was their money, that it was guaranteed, and that they 'paid into the system' and would would be taken care of by Uncle Sam.  Dependence on SS doesn't really show they are idiots, only that they trusted their government.
Regarding the "most people are idiots" - by and large people base their decisions on what is benefitial in the short term. We've evolved this way - that doesn't make people necessarily stupid.
I was thinking more on the lines of they don't save for retirement or plan for the future, which is idiocy.  MMM types are exceptions.

So paying Social Security tax with the reasonable expectation of receiving Social Security (at least for workers in the past) can't be counted as retirement planning?

I'm not advocating relying 100% on SS for income in retirement, but how is it any different than paying into a pension at your factory job in 1957?

Is it optional? No. Does it provide income in retirement? Yes.