What comes after the ACA?

[Monkey Uncle]

So based on the blurb in last night's speech, it sounds like Trump has signed on to RyanCare hook, line, and sinker, with a little added bluster about bringing down drug prices.  Some form of pre-existing condition protection, "access" to coverage with no standards on what has to be covered, tax credits, Medicaid block grants to states, selling insurance across state lines, and tort "reform" (i.e., you can't sue your doctor if he fucks up and maims you for life).

Blech.

[AdrianC]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Not only retire, some people started businesses and became self-employed. But that was back when the individual insurance market was stable. It's a bit unsettling right now.

It wasn't really stable for an early retiree buying their own plan as you always felt that your plan could be cancelled at any time and you are fompletely uninsurable, or the price could be jacked up to astronomical levels, at the whim of the insurance company if you actually got sick or injured due to the preexisting condition clause.

We had that concern but it never happened to us, but then none of us got seriously sick. Broken leg was the worst. We had much lower deductibles, much lower premiums, much better choice, worse coverage.

[AdrianC]

So based on the blurb in last night's speech, it sounds like Trump has signed on to RyanCare hook, line, and sinker, with a little added bluster about bringing down drug prices.  Some form of pre-existing condition protection, "access" to coverage with no standards on what has to be covered, tax credits, Medicaid block grants to states, selling insurance across state lines, and tort "reform" (i.e., you can't sue your doctor if he fucks up and maims you for life).

Blech.

My thoughts too. Trump will sign it if Ryan and Price can shove it through. The hard right reps in the "Freedom Caucus" don't like the tax credit proposals - another "entitlement program".

Our own rep is in the "Freedom Caucus". I'll ask his office if he agrees with:

"...Americans who can’t afford health insurance aren’t entitled to it, just as people are not entitled to own a home."

https://www.nytimes.com/2017/02/28/opinion/the-fight-for-obamacare-has-turned.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region

[NoStacheOhio]

These people probably have Medicaid, or are uninsured. Cutting their insurance is not going to make them suddenly less dumb or mentally ill, won't make them more employable, and they're still going to be seeking out the ER for their care, except now the hospital is going to have to write it off (if they aren't already).

Anecdotally, hospitals are already writing off increased amounts year-over-year. Not so much because of ER misuse/Medicaid volume (though it's a factor), but more because of bad debt on HDHPs (people don't pay their portion of the costs). My hospital does a ton of volume, and has a generally solid payor mix. We got hammered this year.

[BeanCounter]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Not only retire, some people started businesses and became self-employed. But that was back when the individual insurance market was stable. It's a bit unsettling right now.

It wasn't really stable for an early retiree buying their own plan as you always felt that your plan could be cancelled at any time and you are fompletely uninsurable, or the price could be jacked up to astronomical levels, at the whim of the insurance company if you actually got sick or injured due to the preexisting condition clause.

Also before the ACA many policies had a lifetime cap. With cancer care requiring the kind of spend that it does now, this is a problem. It's pretty easy to hit $1M in expenses and then your insurer can dump you and you've got nowhere to go. It's pay it out of your pocket until you go broke and on Medicaid or qualify for Medicare. The ACA fixed these issues by allowing pre-existing conditions and doing away with lifetime caps. But that is part of why it increased the cost of insurance for everyone. That and the fact that the so many of the ACA plan members were previously uninsurable and they came onto the plans sick. The loss ratio on the ACA plans have been huge and the government cut some of the funding (risk corridors) to help the plans. That's why so many insurers got out of the ACA business.
IMHO we need an ACA type solution for everyone to have access, but I don't think the way it is currently constructed is sustainable.
Personally I would be for expanding Medicare to everyone that wants to pay the premiums to CMS. Let private insurance still be an option for those who want that, but Medicare for everyone that wants it. The system is already built (well at least the fee schedules and processing etc). It is not perfect, but I think it's an option that's worth exploring.
I want access to insurance that is not tied to my job. And I want to be able to plan for these costs, stable premiums and reasonable deductibles (I'm all for HDHPs though).
I don't want to play the network game anymore. I don't want to worry about if I give birth or have surgery in a hospital if all the providers I receive care from are in network.
I want to know that if I get sick I won't lose my insurance or be subject to lifetime caps.

[NoStacheOhio]

Also before the ACA many policies had a lifetime cap. With cancer care requiring the kind of spend that it does now, this is a problem. It's pretty easy to hit $1M in expenses and then your insurer can dump you and you've got nowhere to go. It's pay it out of your pocket until you go broke and on Medicaid or qualify for Medicare.

It was even better when you got cancer at age 6, then had the rest of your life to get screwed by insurance. Never mind that it generally makes really good sense to treat kids with cancer (high cure rates, lots of time to contribute to society).

[BeanCounter]

Also before the ACA many policies had a lifetime cap. With cancer care requiring the kind of spend that it does now, this is a problem. It's pretty easy to hit $1M in expenses and then your insurer can dump you and you've got nowhere to go. It's pay it out of your pocket until you go broke and on Medicaid or qualify for Medicare.

It was even better when you got cancer at age 6, then had the rest of your life to get screwed by insurance. Never mind that it generally makes really good sense to treat kids with cancer (high cure rates, lots of time to contribute to society).

Yes. There you go. Perfect example. At least you have places like St. Jude that will treat them for free. But then they are SOL the rest of their life.

[stoaX]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Yes at 65 when they became eligible for Medicare.   

For early retirees it was more difficult unless you had early retiree coverage from your former employer (rare in the private sector, more common in the public sector), VA coverage or enough money and good health to get individual coverage.

[Gin1984]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Yes at 65 when they became eligible for Medicare.   

For early retirees it was more difficult unless you had early retiree coverage from your former employer (rare in the private sector, more common in the public sector), VA coverage or enough money and good health to get individual coverage.

My mom's plan was to COBRA starting at 62 because california has Cal-COBRA that lasts an extra 18 months then move to medicare.  Then the ACA happened. She was able to retire 58, four year prior to her expectation and she is so much healthier now.  She does not get the subsidies, she does not need them (and she wants to spend more) but she is so happy for access. 

[stoaX]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Yes at 65 when they became eligible for Medicare.   

For early retirees it was more difficult unless you had early retiree coverage from your former employer (rare in the private sector, more common in the public sector), VA coverage or enough money and good health to get individual coverage.

My mom's plan was to COBRA starting at 62 because california has Cal-COBRA that lasts an extra 18 months then move to medicare.  Then the ACA happened. She was able to retire 58, four year prior to her expectation and she is so much healthier now.  She does not get the subsidies, she does not need them (and she wants to spend more) but she is so happy for access.

Thanks - I forgot all about COBRA and Cal-COBRA (and I live in California!). As  you point out, that buys you a few years before Medicare at age 65.

[jim555]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Yes at 65 when they became eligible for Medicare.   

For early retirees it was more difficult unless you had early retiree coverage from your former employer (rare in the private sector, more common in the public sector), VA coverage or enough money and good health to get individual coverage.

Where I worked retiree medical was 1/2 the COBRA price, you needed years of service plus age to be 75+ with a min age of 55.  Most companies have phased it out and no longer offer pensions.  I retired at 49 too young to qualify.

[NoStacheOhio]

Could normal people retire before the ACA? I seem to remember that they did, but I may be mis remebering.

Yes at 65 when they became eligible for Medicare.   

For early retirees it was more difficult unless you had early retiree coverage from your former employer (rare in the private sector, more common in the public sector), VA coverage or enough money and good health to get individual coverage.

I just looked up my benefits: retiree medical coverage, largely similar to current employee coverage, eligible beginning at age 55 with 10 years on continuous service, or age 65 with (I think 2-3 years service). You also have to be on the employee plan at the time you retire. Who knows what it'll look like 25 years from now. I doubt I'll be at the same company, and I don't really want to work full-time that long.

[Roland of Gilead]

If a large portion of the early retirees go back to work, will that totally screw the younger generation with little experience but loads of college debt?

[NoStacheOhio]

If a large portion of the early retirees go back to work, will that totally screw the younger generation with little experience but loads of college debt?

That's already been called a contributing factor to Millennial struggles, though I don't think it's been rigorously examined. True early retirees are a small enough demographic that I don't think it would be a significant change compared to the number of people at traditional retirement age with no savings who continue to work.

[jim555]

A lot of Boomers near retirement, but shy of 65 will have to stick it out if they have no good options on health insurance.  Those spots would have opened to Millennials.

[JLee]

Seems like we can answer the question of price transparency by looking at other developed countries who have better outcomes with lower costs.  Do they have price transparency?  (Serious question - I don't know.)

Well in Canada each province has its own universal health care system administered by the Province. We know from tax revenue that the total amount spent on health care is roughly half what is spent per capita in the US, and outcomes are pretty comparable.

Strange thing is: NOBODY has a CLUE what anything costs (except accounting, i guess).  Not the patients, not the nurses who do most of the care, and certainly not he doctors.  Proceedures are all billed out, almost* everything is approved, and you don't pay anything out of pocket.  Many of my Canadian friends think paying $40 "just to see a doctor" is outrageous. The only time you learn what something costs is when you are denied coverage and/or don't have the provincial health care card.  At which point there's lots of fumbling around to get you an invoice, and it's about as expensive (in my eyes) as paying out of pocket in the US.

Anecdote - I had a corneal ulcer when I was in AB, Canada (as a US resident with no Alberta health insurance).  My emergency eye doctor visit and prescription was about $60 USD combined (including a second visit for followup).  My followup (just to make sure everything had healed) in the US (with insurance) was over $100 USD.

[Roland of Gilead]

If a large portion of the early retirees go back to work, will that totally screw the younger generation with little experience but loads of college debt?

That's already been called a contributing factor to Millennial struggles, though I don't think it's been rigorously examined. True early retirees are a small enough demographic that I don't think it would be a significant change compared to the number of people at traditional retirement age with no savings who continue to work.

I just figured if "millionaires getting subsidies" was such a big deal then that group returning to work would have a significant impact.

[NoStacheOhio]

If a large portion of the early retirees go back to work, will that totally screw the younger generation with little experience but loads of college debt?

That's already been called a contributing factor to Millennial struggles, though I don't think it's been rigorously examined. True early retirees are a small enough demographic that I don't think it would be a significant change compared to the number of people at traditional retirement age with no savings who continue to work.

I just figured if "millionaires getting subsidies" was such a big deal then that group returning to work would have a significant impact.

Are we talking rhetorically or statistically significant? ;)

[dragoncar]

You (and I) don't know the "right" people. I follow a lot of medical blogs, and have read some...interesting rants on those who will call for an ambulance to take them to the hospital for a pregnancy test (and other such nonsense, but that one really stuck with me).

True, I did discount this segment of the population. But this is the segment who will never change their behaviors even if they "have skin in the game" like the previous poster was alluding to.
These people probably have Medicaid, or are uninsured. Cutting their insurance is not going to make them suddenly less dumb or mentally ill, won't make them more employable, and they're still going to be seeking out the ER for their care, except now the hospital is going to have to write it off (if they aren't already).

I don't really understand what any of this has to do with the ACA.  If people are making emergency calls for non-emergency matters, shouldn't the fix be to bill them for the services?  If that's not feasible, the problem is going to happen whether or not they have ACA, Medicaid, or no insurance at all.  Even before the ACA, all my insurance plans had a small/no copay for emergency services if admitted, but higher/full responsibility otherwise.  Preventing people from abusing emergency services seems to be a completely orthogonal issue.

[BeanCounter]

You (and I) don't know the "right" people. I follow a lot of medical blogs, and have read some...interesting rants on those who will call for an ambulance to take them to the hospital for a pregnancy test (and other such nonsense, but that one really stuck with me).

True, I did discount this segment of the population. But this is the segment who will never change their behaviors even if they "have skin in the game" like the previous poster was alluding to.
These people probably have Medicaid, or are uninsured. Cutting their insurance is not going to make them suddenly less dumb or mentally ill, won't make them more employable, and they're still going to be seeking out the ER for their care, except now the hospital is going to have to write it off (if they aren't already).

I don't really understand what any of this has to do with the ACA.  If people are making emergency calls for non-emergency matters, shouldn't the fix be to bill them for the services?  If that's not feasible, the problem is going to happen whether or not they have ACA, Medicaid, or no insurance at all.  Even before the ACA, all my insurance plans had a small/no copay for emergency services if admitted, but higher/full responsibility otherwise.  Preventing people from abusing emergency services seems to be a completely orthogonal issue.

Most of the time, the people who abuse the emergency services DON'T have money to pay anyway. So Medicaid or sometimes Medicare will pay what they are going to pay and the hospital/ambulance writes off the rest. A bill won't matter one bit. They won't/can't pay.
Some of it is an access issue, they can't get to primary care. Or don't have consistent primary care. A community health center might help with that.
Some of it is education, they are just doing what they know to do because that's how they grew up or that's what their neighbors do.
So they need access and education.
Some of it is mental illness. Mental illness (including substance abuse) is actually a huge drain on the system.

[mm1970]

Also before the ACA many policies had a lifetime cap. With cancer care requiring the kind of spend that it does now, this is a problem. It's pretty easy to hit $1M in expenses and then your insurer can dump you and you've got nowhere to go. It's pay it out of your pocket until you go broke and on Medicaid or qualify for Medicare.

It was even better when you got cancer at age 6, then had the rest of your life to get screwed by insurance. Never mind that it generally makes really good sense to treat kids with cancer (high cure rates, lots of time to contribute to society).

Or how about a preemie that racks up bills in the millions before they are even out of the hospital?

[EscapeVelocity2020]

I'm reading up on Trump's idea to sell health insurance policies across state lines, seems like a quagmire to me!  Does anyone out there think that this is a good idea?

http://www.benefitspro.com/2016/05/12/why-selling-insurance-across-state-lines-might-be

One biggie is the whole network idea. A person who lives in Florida, for example, and wants to buy a plan sold in North Dakota, is going to have a problem when it comes to finding doctors and hospitals in the network in his state. After all, the network was constructed for North Dakota residents and therefore Florida doctors and hospitals will be in short supply. / And if the kind of coverage in questions is something that a lot of people actually might need — diabetes, say, or cancer — and only healthy people buy the policies from states that don’t require such coverage to be offered so that they can save money, that means that all the people who actually need treatment for diabetes or cancer will have to buy in their home states, thus driving up the price of coverage for everyone in that state. / Last but not least, there’s the fact that if you have a problem with that South Dakota policy, good luck getting any help from your Florida insurance commissioner; he won’t be able to help you with a policy sold in another state.

http://galen.org/2016/selling-health-insurance-across-state-lines-a-really-dumb-idea/

This is nothing more than an attempt to take the market back to the days of cherry picking risk––figuring out how to sell policies to only the healthy people. If this were ever enacted it would only serve to shuffle the healthy people into one set of health insurance policies and the sick into another thereby driving down costs for the healthy and in return just driving costs up for the sick––and accomplishing nothing toward fundamentally making insurance cheaper.

People who promote the idea are targeting the many state benefit mandates that drive health insurance policy prices up. The idea is, after the federal Obamacare mandates are repealed, to allow the sale of cheaper policies from states with the fewest benefit mandates to be able to be sold in high mandate states––thereby encouraging the state with more mandates to curtail them.

But if their aim is to eliminate many of these “excessive” state benefit mandates with a federal law, why not just curtail these mandates in all of the states with a federal law? If they are going to stick their federal noses into some of the states that have traditionally regulated insurance, why not just go ahead and stick their noses in all of the states at once and create a level playing field while they are at it?

[Cassie]

I was watching RAchel Maddox last night and she said that the Repubs don't have enough votes to repeal the ACA. They have some Repubs that would refuse to vote for it without a suitable alternative and some won't vote for an alternative but only if it is completely repealed. That leaves them short of the votes they need.

[DavidAnnArbor]

I was watching RAchel Maddox last night and she said that the Repubs don't have enough votes to repeal the ACA. They have some Repubs that would refuse to vote for it without a suitable alternative and some won't vote for an alternative but only if it is completely repealed. That leaves them short of the votes they need.

If the Republicans don't have the votes to repeal ACA, and they don't replace it with something and allow ACA to continue, but at the same the Trump administration does not require the health insurance mandate via a tax penalty, then the whole health insurance marketplace will explode.

[jim555]

I was watching RAchel Maddox last night and she said that the Repubs don't have enough votes to repeal the ACA. They have some Repubs that would refuse to vote for it without a suitable alternative and some won't vote for an alternative but only if it is completely repealed. That leaves them short of the votes they need.

If the Republicans don't have the votes to repeal ACA, and they don't replace it with something and allow ACA to continue, but at the same the Trump administration does not require the health insurance mandate via a tax penalty, then the whole health insurance marketplace will explode.

That is what they are hoping for.

[Cassie]

Ugh!  I feel so sorry for people that need the ACA.

[Metric Mouse]

I was watching RAchel Maddox last night and she said that the Repubs don't have enough votes to repeal the ACA. They have some Repubs that would refuse to vote for it without a suitable alternative and some won't vote for an alternative but only if it is completely repealed. That leaves them short of the votes they need.

If the Republicans don't have the votes to repeal ACA, and they don't replace it with something and allow ACA to continue, but at the same the Trump administration does not require the health insurance mandate via a tax penalty, then the whole health insurance marketplace will explode.

This.

There are strong arguements this would have happened anyway, but the actions taken by the current administration have certainly not delayed this.

[jim555]

I was watching RAchel Maddox last night and she said that the Repubs don't have enough votes to repeal the ACA. They have some Repubs that would refuse to vote for it without a suitable alternative and some won't vote for an alternative but only if it is completely repealed. That leaves them short of the votes they need.

If the Republicans don't have the votes to repeal ACA, and they don't replace it with something and allow ACA to continue, but at the same the Trump administration does not require the health insurance mandate via a tax penalty, then the whole health insurance marketplace will explode.

This.

There are strong arguements this would have happened anyway, but the actions taken by the current administration have certainly not delayed this.

Doubtful.  Maybe in isolated pockets only.  That is the Repub BS machine spouting its BS. 

[jim555]

Repub strategy, underhandedly undermine and blame Obama:
Don't fund the risk corridors.
Don't expand Medicaid in many states.
Lawsuits to stop cost sharing reductions in the Silvers.
Create a constant stream of threats to scare insurers.
Don't enforce the individual mandate.
Cut the open enrollment period in half.
Spread lies and FUD.

[EscapeVelocity2020]

Seriously, for a moment, let's just indulge in the idea that Hillary was President (you know, the spouse of the former President that floated universal healthcare).  Do you really think that Hillary would let the ACA either fall apart due to neglect (insurers pulling out, double digit increases in premiums, healthy folks paying the penalty and going uninsured, and pharma and insurers both profiteering like drunken sailors during reforms to rationalize their profits)?  Yet here we are now, Republicans HAVE TO repeal ACA or else their careers are over.  Admitting that ACA is better than anything they propose, especially after having opposed it...  well, I wouldn't hire that person to represent me ever again.

This is the setback we have to live with for the time being.  ER's will be the least of their worries, so good luck.  There is a good chance that Trump (or someone Trump-like) will be re-elected for the second term, based on the tactics that succeeded in the last election.

[sol]

Seriously, for a moment, let's just indulge in the idea that Hillary was President (you know, the spouse of the former President that floated universal healthcare).  Do you really think that Hillary would let the ACA either fall apart due to neglect

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

But I can wager that she would be trying desperately to fix some of the identified flaws with the ACA, and Republicans would be stonewalling her all the way.  They would be wailing about death panels and the end of America at the top of their lungs, and simultaneously refusing to do anything about it.  Remember the Party of No?  Republicans would force the US to live with the ACA exactly as it currently exists, warts and all, for as long as possible.

But what's the end game in that?  I mean EVENTUALLY they were going to get a Republican majority, so holding the ACA in current form would just delay their current problem until that later time, and it's not like they haven't had six years to figure this shit out.  Why would they want that problem later instead of now? 

No, I think I agree with EV2020 and that they are absolutely committed to repeal at this point, consequences be damned.  They'd rather throw 20 million Americans off of their current insurance, and try to spin it as "it's for your own good" than conceded that the Democrats actually helped people.  They'll throw in some tax breaks for their wealthiest constituents to try to save face for fucking with the poor, like they always do.  Maybe their replacement plan will actually be better for some folks, probably rich self-employed business owners or other high-income folks without employer insurance, but I don't see how it could possibly be anything but worse for everyone else.

Well scratch that, I do see one way.   They can always just deficit spend the bejeezus out of it.  They could wholly repeal the ACA and then give every American family a $15,000 refundable tax credit for health insurance.  It would crash the federal budget, but it would technically deliver on their promises of potentially better coverage, with more choices, at lower cost to Americans.

[brooklynguy]

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

The main difference is that, under Hillary, there would have been a presumption in the marketplace of a presidential veto to override any ACA-dismantling legislation that managed to make its way through Congress (just like there was under Obama).  This would have precluded the deleterious effects that uncertainty itself (fueled by the absence of not only any such presumption, but also any clarity into what form the ACA's replacement will take or fail to take) is currently inflicting on the individual health insurance markets.  So even without having yet taken any actual steps to change the status quo, the Trump administration and Congressional Republicans are, wittingly or unwittingly, enabling (or at least facilitating) their own predictions of the ACA's failure in becoming a self-fulfilling prophecy.

[EscapeVelocity2020]

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

The main difference is that, under Hillary, there would have been a presumption in the marketplace of a presidential veto to override any ACA-dismantling legislation that managed to make its way through Congress (just like there was under Obama).  This would have precluded the deleterious effects that uncertainty itself (fueled by the absence of not only any such presumption, but also any clarity into what form the ACA's replacement will take or fail to take) is currently inflicting on the individual health insurance markets.  So even without having yet taken any actual steps to change the status quo, the Trump administration and Congressional Republicans are, wittingly or unwittingly, enabling (or at least facilitating) their own predictions of the ACA's failure in becoming a self-fulfilling prophecy.

Well... that's a pretty big difference.  Even, maybe one could say, yuge.

[thenextguy]

Ugh!  I feel so sorry for people that need the ACA.

Everyone? There are numerous benefits the ACA provides to everyone, no matter how you get your insurance. No more lifetime caps are a big one that is gone now.

[stoaX]

Ugh!  I feel so sorry for people that need the ACA.

Everyone? There are numerous benefits the ACA provides to everyone, no matter how you get your insurance. No more lifetime caps are a big one that is gone now.

Shouldn't your post have said "No more lifetime caps are a big one that is at risk now"?  I haven't seen anything saying that provision has been eliminated. 

[thenextguy]

Ugh!  I feel so sorry for people that need the ACA.

Everyone? There are numerous benefits the ACA provides to everyone, no matter how you get your insurance. No more lifetime caps are a big one that is gone now.

Shouldn't your post have said "No more lifetime caps are a big one that is at risk now"?  I haven't seen anything saying that provision has been eliminated.

I was saying that lifetime caps are gone as a result of the ACA.

[stoaX]

Ugh!  I feel so sorry for people that need the ACA.

Everyone? There are numerous benefits the ACA provides to everyone, no matter how you get your insurance. No more lifetime caps are a big one that is gone now.

Shouldn't your post have said "No more lifetime caps are a big one that is at risk now"?  I haven't seen anything saying that provision has been eliminated.

I was saying that lifetime caps are gone as a result of the ACA.

I get it now... you can add dependents to age 26, $0 copay preventive care, no pre-existing condition limitations and maximum 90 day waiting period on group plans. There's probably a few more that effect most everyone.   

[thenextguy]

Ugh!  I feel so sorry for people that need the ACA.

Everyone? There are numerous benefits the ACA provides to everyone, no matter how you get your insurance. No more lifetime caps are a big one that is gone now.

Shouldn't your post have said "No more lifetime caps are a big one that is at risk now"?  I haven't seen anything saying that provision has been eliminated.

I was saying that lifetime caps are gone as a result of the ACA.

I get it now... you can add dependents to age 26, $0 copay preventive care, no pre-existing condition limitations and maximum 90 day waiting period on group plans. There's probably a few more that effect most everyone.

Exactly. I believe the debate focuses too heavily on those who purchase insurance on the exchanges. The exchanges are important, of course, but the fact is that the ACA benefits everyone that has an insurance plan.

[Metric Mouse]

Seriously, for a moment, let's just indulge in the idea that Hillary was President (you know, the spouse of the former President that floated universal healthcare).  Do you really think that Hillary would let the ACA either fall apart due to neglect

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

But I can wager that she would be trying desperately to fix some of the identified flaws with the ACA, and Republicans would be stonewalling her all the way.  They would be wailing about death panels and the end of America at the top of their lungs, and simultaneously refusing to do anything about it.  Remember the Party of No?  Republicans would force the US to live with the ACA exactly as it currently exists, warts and all, for as long as possible.

But what's the end game in that?  I mean EVENTUALLY they were going to get a Republican majority, so holding the ACA in current form would just delay their current problem until that later time, and it's not like they haven't had six years to figure this shit out.  Why would they want that problem later instead of now? 

No, I think I agree with EV2020 and that they are absolutely committed to repeal at this point, consequences be damned.  They'd rather throw 20 million Americans off of their current insurance, and try to spin it as "it's for your own good" than conceded that the Democrats actually helped people.  They'll throw in some tax breaks for their wealthiest constituents to try to save face for fucking with the poor, like they always do.  Maybe their replacement plan will actually be better for some folks, probably rich self-employed business owners or other high-income folks without employer insurance, but I don't see how it could possibly be anything but worse for everyone else.

Well scratch that, I do see one way.   They can always just deficit spend the bejeezus out of it.  They could wholly repeal the ACA and then give every American family a $15,000 refundable tax credit for health insurance.  It would crash the federal budget, but it would technically deliver on their promises of potentially better coverage, with more choices, at lower cost to Americans.

I can't see Hillary trying to fix any of the problems. The dems can't admit there is any problems with the ACA they've fought so hard to keep unchanged for 6 years. Just like the republicans can't admit there is any good parts (though they sort of have, with saying they won't repeal the popular provisons). Hillary would be hamstrung by a congress that wouldn't put forth any bills to improve it, insurers would still be hiking premiums and withdrawing from market places just like they are doing now.

Would such a tax credit be a bad thing? Sure it would crash  the budget, but once the republicans are voted out Dems could raise taxes or at least repeal some of their recent tax cuts and fund it. Would be a win win.

[rpr]

Can someone tell me more about this $15000 refundable tax credit per family for buying health insurance. Is it only applicable to only those who do not have employer provided health insurance? Or for all Americans. If the latter, then it will be a Trillion dollar budget buster. If this goes through, then it could conceivably have significant effects on all health insurance markets (even employer provided).

[jim555]

Ryan's super secret repeal bill was supposed to be in a hidden location.  Rand Paul was seen dragging a copy machine behind him to make a copy of it.  After a search of hidden rooms the bill was nowhere to be found. 

I am not making this up!

[brooklynguy]

Can someone tell me more about this $15000 refundable tax credit per family for buying health insurance. . . If this goes through. . .

It is highly unlikely to become law, given that it was not proposed by any legislator or other government official but merely floated by forum denizen Sol as an example of an outlandish, hypothetical method for Republicans to make good on their promise to improve the health insurance coverage landscape for most Americans.

Separately and unrelatedly, Trump's general income tax proposal had proposed increasing the individual standard tax deduction to $15k (as discussed in this Kitces article), which is why you might have heard the $15k number come up as part of an actual proposal outside the four corners of this forum.

[rpr]

Separately and unrelatedly, Trump's general income tax proposal had proposed increasing the individual standard tax deduction to $15k (as discussed in this Kitces article), which is why you might have heard the $15k number come up as part of an actual proposal outside the four corners of this forum.

Thanks for clarifying. I would definitely be in support of increasing the individual standard deduction to $15000. At the same time we can get rid of deductions such as for mortgage interest, health insurance premiums (both employee/employer), HSAs, 529s etc. Plus if they also increase IRA contribution limits to $15-20K, I'd also be in favor of getting rid of deductions for retirement accounts like 401ks, 403bs, SEP-IRAs. 

[Iplawyer]

Seriously, for a moment, let's just indulge in the idea that Hillary was President (you know, the spouse of the former President that floated universal healthcare).  Do you really think that Hillary would let the ACA either fall apart due to neglect

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

But I can wager that she would be trying desperately to fix some of the identified flaws with the ACA, and Republicans would be stonewalling her all the way.  They would be wailing about death panels and the end of America at the top of their lungs, and simultaneously refusing to do anything about it.  Remember the Party of No?  Republicans would force the US to live with the ACA exactly as it currently exists, warts and all, for as long as possible.

But what's the end game in that?  I mean EVENTUALLY they were going to get a Republican majority, so holding the ACA in current form would just delay their current problem until that later time, and it's not like they haven't had six years to figure this shit out.  Why would they want that problem later instead of now? 

No, I think I agree with EV2020 and that they are absolutely committed to repeal at this point, consequences be damned.  They'd rather throw 20 million Americans off of their current insurance, and try to spin it as "it's for your own good" than conceded that the Democrats actually helped people.  They'll throw in some tax breaks for their wealthiest constituents to try to save face for fucking with the poor, like they always do.  Maybe their replacement plan will actually be better for some folks, probably rich self-employed business owners or other high-income folks without employer insurance, but I don't see how it could possibly be anything but worse for everyone else.

Well scratch that, I do see one way.   They can always just deficit spend the bejeezus out of it.  They could wholly repeal the ACA and then give every American family a $15,000 refundable tax credit for health insurance.  It would crash the federal budget, but it would technically deliver on their promises of potentially better coverage, with more choices, at lower cost to Americans.

I can't see Hillary trying to fix any of the problems. The dems can't admit there is any problems with the ACA they've fought so hard to keep unchanged for 6 years. Just like the republicans can't admit there is any good parts (though they sort of have, with saying they won't repeal the popular provisons). Hillary would be hamstrung by a congress that wouldn't put forth any bills to improve it, insurers would still be hiking premiums and withdrawing from market places just like they are doing now.

Would such a tax credit be a bad thing? Sure it would crash  the budget, but once the republicans are voted out Dems could raise taxes or at least repeal some of their recent tax cuts and fund it. Would be a win win.

But tax credits don't help with lifetime maximum caps or pre-existing conditions.  And they don't help if the insurance cost many times more than the credit.

[snapperdude]

Seriously, for a moment, let's just indulge in the idea that Hillary was President (you know, the spouse of the former President that floated universal healthcare).  Do you really think that Hillary would let the ACA either fall apart due to neglect

If Hillary Clinton was the US President right now, the health insurance market would not look materially different because the Republicans haven't changed much yet, and what changes they have promised haven't gone into effect.

But I can wager that she would be trying desperately to fix some of the identified flaws with the ACA, and Republicans would be stonewalling her all the way.  They would be wailing about death panels and the end of America at the top of their lungs, and simultaneously refusing to do anything about it.  Remember the Party of No?  Republicans would force the US to live with the ACA exactly as it currently exists, warts and all, for as long as possible.

But what's the end game in that?  I mean EVENTUALLY they were going to get a Republican majority, so holding the ACA in current form would just delay their current problem until that later time, and it's not like they haven't had six years to figure this shit out.  Why would they want that problem later instead of now? 

No, I think I agree with EV2020 and that they are absolutely committed to repeal at this point, consequences be damned.  They'd rather throw 20 million Americans off of their current insurance, and try to spin it as "it's for your own good" than conceded that the Democrats actually helped people.  They'll throw in some tax breaks for their wealthiest constituents to try to save face for fucking with the poor, like they always do.  Maybe their replacement plan will actually be better for some folks, probably rich self-employed business owners or other high-income folks without employer insurance, but I don't see how it could possibly be anything but worse for everyone else.

Well scratch that, I do see one way.   They can always just deficit spend the bejeezus out of it.  They could wholly repeal the ACA and then give every American family a $15,000 refundable tax credit for health insurance.  It would crash the federal budget, but it would technically deliver on their promises of potentially better coverage, with more choices, at lower cost to Americans.

I can't see Hillary trying to fix any of the problems. The dems can't admit there is any problems with the ACA they've fought so hard to keep unchanged for 6 years. Just like the republicans can't admit there is any good parts (though they sort of have, with saying they won't repeal the popular provisons). Hillary would be hamstrung by a congress that wouldn't put forth any bills to improve it, insurers would still be hiking premiums and withdrawing from market places just like they are doing now.

Would such a tax credit be a bad thing? Sure it would crash  the budget, but once the republicans are voted out Dems could raise taxes or at least repeal some of their recent tax cuts and fund it. Would be a win win.

But tax credits don't help with lifetime maximum caps or pre-existing conditions.  And they don't help if the insurance cost many times more than the credit.

It is total bullshit to say that Democrats don't want to fix ACA. Obama and other Democrats have been saying for years that there are things about ACA that need to be improved.

[Roland of Gilead]

Separately and unrelatedly, Trump's general income tax proposal had proposed increasing the individual standard tax deduction to $15k (as discussed in this Kitces article), which is why you might have heard the $15k number come up as part of an actual proposal outside the four corners of this forum.

Thanks for clarifying. I would definitely be in support of increasing the individual standard deduction to $15000. At the same time we can get rid of deductions such as for mortgage interest, health insurance premiums (both employee/employer), HSAs, 529s etc. Plus if they also increase IRA contribution limits to $15-20K, I'd also be in favor of getting rid of deductions for retirement accounts like 401ks, 403bs, SEP-IRAs.

Plus public and private pensions should be taxed on accrual as income, especially if the pensioner is also eligible to contribute to a IRA.

[sol]

Plus public and private pensions should be taxed on accrual as income, especially if the pensioner is also eligible to contribute to a IRA.

They already are.  Do you know of any exceptions?

Some portion of social security isn't taxable.  Everyone gets a standard deduction that makes the first part of their income nontaxable.  But in general, pensions are taxable income and are treated as such.

Or did you mean they should be taxed as you contribute to them each month while working, before being taxed as income when they pay out?

[rpr]

Separately and unrelatedly, Trump's general income tax proposal had proposed increasing the individual standard tax deduction to $15k (as discussed in this Kitces article), which is why you might have heard the $15k number come up as part of an actual proposal outside the four corners of this forum.

Thanks for clarifying. I would definitely be in support of increasing the individual standard deduction to $15000. At the same time we can get rid of deductions such as for mortgage interest, health insurance premiums (both employee/employer), HSAs, 529s etc. Plus if they also increase IRA contribution limits to $15-20K, I'd also be in favor of getting rid of deductions for retirement accounts like 401ks, 403bs, SEP-IRAs.

Plus public and private pensions should be taxed on accrual as income, especially if the pensioner is also eligible to contribute to a IRA.

Agreed.

[brooklynguy]

Ryan's super secret repeal bill was supposed to be in a hidden location.  Rand Paul was seen dragging a copy machine behind him to make a copy of it.  After a search of hidden rooms the bill was nowhere to be found. 

I am not making this up!

One could be easily forgiven for assuming these news reports were coming from the pages of The Onion.

http://www.vox.com/2017/3/2/14792196/gop-obamacare-bill-search

[Roland of Gilead]

Or did you mean they should be taxed as you contribute to them each month while working, before being taxed as income when they pay out?

Yes, this.  Right now a person contributes somewhere between 0% and what, 30%? toward their pension while the employer contributes the other half (or fails to fund it as some entities seem to do).   I do not believe the employer contribution is taxed as income at the time it is made but I may be wrong?

If we are going to just have everyone get a IRA contribution deduction and remove 401K deductions then I think you have to examine pensions also, to be fair.