Author Topic: What comes after the ACA?  (Read 1144326 times)

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5600 on: July 18, 2019, 11:49:06 AM »
Pretty much what the ACA did.. all while keeping the existing HC industry happy.

Unless you are going to use the huge purchasing power of the Government to drive down costs (like almost every other developed nation on Earth does) then there is little point.

As wealthy people we will simply game the system as best we can.. Just like I can gerrymander our income down to maximise ACA subsidies.

But how does the purchasing power of the government in other countries drive the costs down so low?   We already see that just targeting drug prices will not do it (even a 50% cut across the board in average drug prices would only reduce USA healthcare costs 5% or so).

Do they have salary caps for doctors and nurses?  Real estate caps for land and buildings used by care facilities?

Are we as a nation willing to go that far down the path to get lower healthcare costs?

former player

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Re: What comes after the ACA?
« Reply #5601 on: July 18, 2019, 12:20:52 PM »
31% of health care costs in USA are administrative overhead, compared with 16.7% in Canada -

https://www.nejm.org/doi/full/10.1056/NEJMsa022033

So there's an instant 15% reduction in USA health care costs.

NHS from a while ago had admin costs at 7.7%: see Table 90 -
https://publications.parliament.uk/pa/cm200910/cmselect/cmhealth/269/269i.pdf

That would be a reduction of almost 25% in USA health costs.

PathtoFIRE

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Re: What comes after the ACA?
« Reply #5602 on: July 18, 2019, 03:25:43 PM »
Don't forget, the goal also won't be to get "down" to the level of other countries necessarily. We expect as a wealthy nation that, as a general rule, service-based economic sectors will probably cost US citizens a little more than other countries, $ for $. I would argue that there is probably a natural progression, as economies progress in technology and wealth, to end up spending more and more of GDP on industries that cannot significantly rationalize away labor costs. Per capita health care spending tends to rise with time in most countries, and as one of the first and most mature industrial countries for the past 100 years, it shouldn't be surprising that we are ahead of the curve. But nor does that absolve the obviously inefficient and broken parts of our system either, but just realize that the difference is probably more modest than just pure number comparisons would suggest.*

*I am a physician and that will introduce some degree of bias into my views for sure

rantk81

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Re: What comes after the ACA?
« Reply #5603 on: July 18, 2019, 04:30:07 PM »
Don't forget, the goal also won't be to get "down" to the level of other countries necessarily. We expect as a wealthy nation that, as a general rule, service-based economic sectors will probably cost US citizens a little more than other countries, $ for $. I would argue that there is probably a natural progression, as economies progress in technology and wealth, to end up spending more and more of GDP on industries that cannot significantly rationalize away labor costs. Per capita health care spending tends to rise with time in most countries, and as one of the first and most mature industrial countries for the past 100 years, it shouldn't be surprising that we are ahead of the curve. But nor does that absolve the obviously inefficient and broken parts of our system either, but just realize that the difference is probably more modest than just pure number comparisons would suggest.*

*I am a physician and that will introduce some degree of bias into my views for sure

The problem is that the 2x level of spending is coinciding with worse patient outcomes.
The current system needs to be blown up.  Sorry if it impacts the rate of compensation you've become accustomed to -- but what we have now -- it isn't sustainable and isn't working for the populace.

ysette9

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Re: What comes after the ACA?
« Reply #5604 on: July 18, 2019, 04:40:58 PM »
Don't forget, the goal also won't be to get "down" to the level of other countries necessarily. We expect as a wealthy nation that, as a general rule, service-based economic sectors will probably cost US citizens a little more than other countries, $ for $. I would argue that there is probably a natural progression, as economies progress in technology and wealth, to end up spending more and more of GDP on industries that cannot significantly rationalize away labor costs. Per capita health care spending tends to rise with time in most countries, and as one of the first and most mature industrial countries for the past 100 years, it shouldn't be surprising that we are ahead of the curve. But nor does that absolve the obviously inefficient and broken parts of our system either, but just realize that the difference is probably more modest than just pure number comparisons would suggest.*

*I am a physician and that will introduce some degree of bias into my views for sure

The problem is that the 2x level of spending is coinciding with worse patient outcomes.
The current system needs to be blown up.  Sorry if it impacts the rate of compensation you've become accustomed to -- but what we have now -- it isn't sustainable and isn't working for the populace.
When I mentioned how much more expensive we are I wasn’t comparing to Guatemala or Thailand but England, France, Canada, Australia, Switzerland, etc.

freya

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Re: What comes after the ACA?
« Reply #5605 on: July 18, 2019, 05:35:16 PM »
31% of health care costs in USA are administrative overhead, compared with 16.7% in Canada -

https://www.nejm.org/doi/full/10.1056/NEJMsa022033

So there's an instant 15% reduction in USA health care costs.

NHS from a while ago had admin costs at 7.7%: see Table 90 -
https://publications.parliament.uk/pa/cm200910/cmselect/cmhealth/269/269i.pdf

That would be a reduction of almost 25% in USA health costs.

We'd do even better if we went with Medicare for all.  Medicare's overhead cost is 2%.  And, the cost imposed by Medicare documentation on doctors & hospitals is less than it is for private insurance, so that would be even more savings.  It would get even better if CMS put some serious effort into simplifying the paperwork burden on doctors and hospitals.  You may be looking at cost reductions in the range of 40%!

Even more good news:  CMS has been trying to do just that.  Ironically, the AMA and other large MD organizations have been fighting measures like the proposal to simplify office billing & documentation, from the current 5-tier system with a ludicrously complicated set of point-based documentation requirements, to a single office visit code with minimal documentation requirements plus time-based billing, where you just have to explain what you spent time on.  That would have been an almost miraculous improvement, but of course we can't have that..thank you SO much AMA.

Exflyboy

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Re: What comes after the ACA?
« Reply #5606 on: July 18, 2019, 07:01:10 PM »
31% of health care costs in USA are administrative overhead, compared with 16.7% in Canada -

https://www.nejm.org/doi/full/10.1056/NEJMsa022033

So there's an instant 15% reduction in USA health care costs.

NHS from a while ago had admin costs at 7.7%: see Table 90 -
https://publications.parliament.uk/pa/cm200910/cmselect/cmhealth/269/269i.pdf

That would be a reduction of almost 25% in USA health costs.

We'd do even better if we went with Medicare for all.  Medicare's overhead cost is 2%.  And, the cost imposed by Medicare documentation on doctors & hospitals is less than it is for private insurance, so that would be even more savings.  It would get even better if CMS put some serious effort into simplifying the paperwork burden on doctors and hospitals.  You may be looking at cost reductions in the range of 40%!

Even more good news:  CMS has been trying to do just that.  Ironically, the AMA and other large MD organizations have been fighting measures like the proposal to simplify office billing & documentation, from the current 5-tier system with a ludicrously complicated set of point-based documentation requirements, to a single office visit code with minimal documentation requirements plus time-based billing, where you just have to explain what you spent time on.  That would have been an almost miraculous improvement, but of course we can't have that..thank you SO much AMA.

So what you're saying is.. "if the American healthcare system wasn't Fubar'd beyond recognition it would be much cheaper"

Yeah, I'll buy that.

rantk81

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Re: What comes after the ACA?
« Reply #5607 on: July 18, 2019, 07:11:26 PM »
Don't forget, the goal also won't be to get "down" to the level of other countries necessarily. We expect as a wealthy nation that, as a general rule, service-based economic sectors will probably cost US citizens a little more than other countries, $ for $. I would argue that there is probably a natural progression, as economies progress in technology and wealth, to end up spending more and more of GDP on industries that cannot significantly rationalize away labor costs. Per capita health care spending tends to rise with time in most countries, and as one of the first and most mature industrial countries for the past 100 years, it shouldn't be surprising that we are ahead of the curve. But nor does that absolve the obviously inefficient and broken parts of our system either, but just realize that the difference is probably more modest than just pure number comparisons would suggest.*

*I am a physician and that will introduce some degree of bias into my views for sure

The problem is that the 2x level of spending is coinciding with worse patient outcomes.
The current system needs to be blown up.  Sorry if it impacts the rate of compensation you've become accustomed to -- but what we have now -- it isn't sustainable and isn't working for the populace.
When I mentioned how much more expensive we are I wasn’t comparing to Guatemala or Thailand but England, France, Canada, Australia, Switzerland, etc.

https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends-disproportionate-amount-health

ysette9

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Re: What comes after the ACA?
« Reply #5608 on: July 18, 2019, 08:29:08 PM »
Don't forget, the goal also won't be to get "down" to the level of other countries necessarily. We expect as a wealthy nation that, as a general rule, service-based economic sectors will probably cost US citizens a little more than other countries, $ for $. I would argue that there is probably a natural progression, as economies progress in technology and wealth, to end up spending more and more of GDP on industries that cannot significantly rationalize away labor costs. Per capita health care spending tends to rise with time in most countries, and as one of the first and most mature industrial countries for the past 100 years, it shouldn't be surprising that we are ahead of the curve. But nor does that absolve the obviously inefficient and broken parts of our system either, but just realize that the difference is probably more modest than just pure number comparisons would suggest.*

*I am a physician and that will introduce some degree of bias into my views for sure

The problem is that the 2x level of spending is coinciding with worse patient outcomes.
The current system needs to be blown up.  Sorry if it impacts the rate of compensation you've become accustomed to -- but what we have now -- it isn't sustainable and isn't working for the populace.
When I mentioned how much more expensive we are I wasn’t comparing to Guatemala or Thailand but England, France, Canada, Australia, Switzerland, etc.

https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends-disproportionate-amount-health
Nice summary and visuals

pecunia

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Re: What comes after the ACA?
« Reply #5609 on: July 18, 2019, 08:47:53 PM »
It kind of is sort of beginning to sound like the Middle Ages.  There is this entrenched guild system with multiple Byzantine type layers.  Maybe a layer of public  / private would work the best.  Government handles most of it and bids it all out.  That's the way they build roads, buy equipment and even went to the moon 50 years ago.

This one hasn't been used in a while.  If we can go to the moon why can't we have decent affordable health care.

Exflyboy

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Re: What comes after the ACA?
« Reply #5610 on: July 19, 2019, 12:19:24 AM »
It kind of is sort of beginning to sound like the Middle Ages.  There is this entrenched guild system with multiple Byzantine type layers.  Maybe a layer of public  / private would work the best.  Government handles most of it and bids it all out.  That's the way they build roads, buy equipment and even went to the moon 50 years ago.

This one hasn't been used in a while.  If we can go to the moon why can't we have decent affordable health care.

Because we WANTED to go to the Moon. We (as in the Government) has no interest in providing decent affordable HC. What it wants is to maximise profits for our HC industry.. Totally different objective.

pecunia

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Re: What comes after the ACA?
« Reply #5611 on: July 19, 2019, 05:57:55 AM »

- SNIP -

Because we WANTED to go to the Moon. We (as in the Government) has no interest in providing decent affordable HC. What it wants is to maximise profits for our HC industry.. Totally different objective.

I think you are absolutely right.  When people bring up this health care thing with today's politicians (most of them any way), they tiptoe around it or totally ignore the subject.  We get a president who says we will have a "terrific" new health care plan, but almost nothing is done.  I heard one promise that you could keep your insurance company as though the middle man offers some needed extra value.

There's got to be some way to have the government help to efficiently serve the needs of the majority of the people.

(I wish they wanted to go back to the moon too.)

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5612 on: July 19, 2019, 08:50:04 AM »
I was just reading up on some of the newer gene therapy treatments, especially one from Novartis to treat spinal muscular atrophy.  Evidently these are incredibly expensive to develop and manufacture so the treatments reflect that...$2.1 million dollars.

So how in the world do you sell this to a public who believes drug companies are pure evil profiteers?   I don't think you can.  If I were a CEO I would probably not even pursue a drug that would need to sell for that much to generate a profit because of the potential negative press it would get.

No news agency is going to run a story saying how incredible it is that these new high tech gene therapies are curing babies who would otherwise face twice the cost in medical care for their disease plus the suffering.  They are going to run with the general story of "company pushing $2.1 million dollar drug" because it sells to a stupid uneducated general public.

Omy

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Re: What comes after the ACA?
« Reply #5613 on: July 19, 2019, 09:02:07 AM »
Most of us are smart enough to understand the difference between that and hiking up prices of insulin and epipens by several hundred percent.

rantk81

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Re: What comes after the ACA?
« Reply #5614 on: July 19, 2019, 09:05:58 AM »
I was just reading up on some of the newer gene therapy treatments, especially one from Novartis to treat spinal muscular atrophy.  Evidently these are incredibly expensive to develop and manufacture so the treatments reflect that...$2.1 million dollars.

So how in the world do you sell this to a public who believes drug companies are pure evil profiteers?   I don't think you can.  If I were a CEO I would probably not even pursue a drug that would need to sell for that much to generate a profit because of the potential negative press it would get.

No news agency is going to run a story saying how incredible it is that these new high tech gene therapies are curing babies who would otherwise face twice the cost in medical care for their disease plus the suffering.  They are going to run with the general story of "company pushing $2.1 million dollar drug" because it sells to a stupid uneducated general public.

Maybe these companies would be incentivised to develop treatments more economically.  For instance, they may find it is cost-prohibitive for the company to have a $10M base salary plus additional compensation for the CEO.

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5615 on: July 19, 2019, 09:06:42 AM »
I think you are absolutely right.  When people bring up this health care thing with today's politicians (most of them any way), they tiptoe around it or totally ignore the subject.  We get a president who says we will have a "terrific" new health care plan, but almost nothing is done.  I heard one promise that you could keep your insurance company as though the middle man offers some needed extra value.

There's got to be some way to have the government help to efficiently serve the needs of the majority of the people.
The extra value the middle man (i.e. insurance company, or the government in some countries) provides is to cover low-probability, high-cost medical costs that the consumer would not be in a position to pay out of pocket.  The problem is that the concept of insurance doesn't really work when you try to apply it to someone with preexisting conditions.  At that point, the sick person is a high risk (well, certainty) for incurring great medical expenses, and so to properly cover them, the premiums would be astronomical.  If you want to cover that person's health care costs without them paying it out of pocket, you're no longer talking about insurance, you're talking about charity.  The problem is that people tend to conflate health insurance with health care, and try to force the former to be the latter.

Another problem is that politicians are great at mandating things that they think will help, but seldom bother to evaluate whether such measures are effective (or even "not counterproductive"), and almost never try to undo things that are broken.  Electronic health records are a great example here--honorable intentions, but as others have stated in this thread, ultimately they've caused greater costs.

It's also important, when comparing the US to other countries, to consider cultural factors as well.  For example, I've heard that the US spends a far greater percentage on care for the very young and very old than other countries do.  It would be very interesting to study why that's the case--is it because of a cultural bias towards extending/saving life as long as possible, or is it because our lifestyle choices lead to a longer, more expensive decline late in life, or is it something else?

rantk81

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Re: What comes after the ACA?
« Reply #5616 on: July 19, 2019, 09:13:37 AM »
Quote
The extra value the middle man (i.e. insurance company, or the government in some countries) provides is to cover low-probability, high-cost medical costs that the consumer would not be in a position to pay out of pocket. 
That extra value is unnecessary in a single payer system.

EscapeVelocity2020

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Re: What comes after the ACA?
« Reply #5617 on: July 19, 2019, 09:17:26 AM »
I was just reading up on some of the newer gene therapy treatments, especially one from Novartis to treat spinal muscular atrophy.  Evidently these are incredibly expensive to develop and manufacture so the treatments reflect that...$2.1 million dollars.

So how in the world do you sell this to a public who believes drug companies are pure evil profiteers?   I don't think you can.  If I were a CEO I would probably not even pursue a drug that would need to sell for that much to generate a profit because of the potential negative press it would get.

No news agency is going to run a story saying how incredible it is that these new high tech gene therapies are curing babies who would otherwise face twice the cost in medical care for their disease plus the suffering.  They are going to run with the general story of "company pushing $2.1 million dollar drug" because it sells to a stupid uneducated general public.

Like all technology, the costs will sound outrageous at first and will drop significantly as it matures.  Personal computers were the same way.  If the benefits are significant and make economic sense (as in, gene therapy does save money and provide quantifiable benefits over a lifetime) then the science will continue.  It is a pretty dim view that 'the news' creates or destroys progress by publishing articles and really does not line up with history.  Remember all of the 'no one will ever need a home computer' speculation?  And 'the Death of Equities'.  The news (other than Fake News and opinion pieces - and I highlight that your post is just an opinion) generally just reports on what is happening and captures the progress.  So yeah, I don't think you have anything to worry about, even if you want to continue to believe the general public are stupid and uneducated and yet are following high tech gene therapy.

Greenback Reproduction Specialist

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Re: What comes after the ACA?
« Reply #5618 on: July 19, 2019, 09:22:41 AM »
Congrats to everyone that posted in here, this thread is up over 1 million views!

I can already feel my blood pressure rising with the couple posts I couldnt help myself to skim through.... So Im outta here.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5619 on: July 19, 2019, 09:24:05 AM »
So yeah, I don't think you have anything to worry about, even if you want to continue to believe the general public are stupid and uneducated and yet are following high tech gene therapy.

But they are not following high tech gene therapy.  They only get fed the news articles about drugs costing $2.1 million dollars and figure that it must cost that much because the CEO is getting paid $10 million.  If we could cut that CEO pay down to, say $100,000, then the drug price would drop to a couple of dollars.

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5620 on: July 19, 2019, 09:27:27 AM »
Quote
The extra value the middle man (i.e. insurance company, or the government in some countries) provides is to cover low-probability, high-cost medical costs that the consumer would not be in a position to pay out of pocket. 
That extra value is unnecessary in a single payer system.
Don't be fooled, a single payer system is basically one giant insurance company, except with monopoly power.

rantk81

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Re: What comes after the ACA?
« Reply #5621 on: July 19, 2019, 09:31:30 AM »
Quote
The extra value the middle man (i.e. insurance company, or the government in some countries) provides is to cover low-probability, high-cost medical costs that the consumer would not be in a position to pay out of pocket. 
That extra value is unnecessary in a single payer system.
Don't be fooled, a single payer system is basically one giant insurance company, except with monopoly power.

I'm just beside myself that people continue to argue how our horrendous system now is better than the alternatives in other countries.  The data is clear.  We spend double.  Our life expediencies and overall health are worse.  The system is broken.   Having a whole bunch of insurance company employees, coders, PBMs or whatever, acting as middle men -- they're all skimming a piece of the action, and our overall health is suffering.  Sorry to those who work in the field as medical coders or claims processors or whatever... but your jobs never should have existed in the first place.

henramdrea

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Re: What comes after the ACA?
« Reply #5622 on: July 19, 2019, 09:58:40 AM »
Wow!  113 pages!   This is a monster of a thread, but it's dealing with a monster of a problem.

Like some others who have posted here, I work in healthcare (I'm not a Dr. and don't pretend to be one on the internet) as a clinician and can tell you our system is broken.  Costs are spiraling out of control and there doesn't seem to be a rational plan to fix it.  Pointing a finger at greedy drug companies is easy, they wear a big target around their necks for people to shoot at.  There's so much more though.  Look at how much it costs for medical liability insurance...ouch!  No wonder MD's need to make 6 figures!  Look at the huge overhead hospitals have to maintain just to be able to bill insurance companies.  There are entire departments costing millions per year for the sole purpose of being able to bill insurance companies for services.  I'm not even scratching the surface yet.

Throwing money at this stuff without REFORMING it first won't fix the problem.  The whole system needs to find the will to make it happen.  Right now, there isn't a lot of incentive.  Too many are wanting a piece of the tasty pie, and if a big, wasteful government gets a hold of it BEFORE the pie is reformed into a salad, we're not solving anything.

Don't get me wrong, I think a singe-payer option would be a good one....it's just we're not ready for it yet.   Cart before horse, etc. 
Do good emergency medical care on this "patient" first.  Stop the bleeding from the inside before pumping the patient with meds.

DaMa

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Re: What comes after the ACA?
« Reply #5623 on: July 19, 2019, 11:01:05 AM »
Quote
The extra value the middle man (i.e. insurance company, or the government in some countries) provides is to cover low-probability, high-cost medical costs that the consumer would not be in a position to pay out of pocket. 
That extra value is unnecessary in a single payer system.
Don't be fooled, a single payer system is basically one giant insurance company, except with monopoly power.

Health insurance companies are for profit business.  Their goals are to provide the minimum care at the lowest cost while charging the highest price they can get away with.  Medicare is not run as a for profit business.  It's goal is to provide needed care at the lowest cost.  There is no profit motive.  You can look at the admin expense and profit of the top insurance companies to see where the most obvious savings would be with single payer.

Drug companies spend more on marketing than research and development.  Not to mention ridiculous administrator salaries.  Scientists are going to keep doing research on drugs even if they do it from college labs, funded by the government and private contributors.  Maybe the rate of discovery will slow, but it's not going to disappear.

PathtoFIRE

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Re: What comes after the ACA?
« Reply #5624 on: July 19, 2019, 11:10:20 AM »
<snip>
The problem is that the 2x level of spending is coinciding with worse patient outcomes.
The current system needs to be blown up.  Sorry if it impacts the rate of compensation you've become accustomed to -- but what we have now -- it isn't sustainable and isn't working for the populace.
When I mentioned how much more expensive we are I wasn’t comparing to Guatemala or Thailand but England, France, Canada, Australia, Switzerland, etc.

https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-relative-size-wealth-u-s-spends-disproportionate-amount-health
Nice summary and visuals

Oh, I definitely agree that we have a problem, and I also agree that (many) physicians make a ridiculous amount of money. My point, which maybe wasn't made very well, is that the numerical difference might be a little more moderate than the first appearance gives. Meaning, a reduction of 20-30% in healthcare costs would easily bring us out of outlier status, rather than the 50% I've seen mentioned here and elsewhere.

I also reviewed that website linked above before making my post, and think it makes my point. As per capita GDP increases, so do healthcare costs, so you can't say the bulk of those countries spend half, and just leave it at that. A 20% reduction gets us to Switzerland. Nearly every country above the line would be considered absolutely top tier countries by most economic metrics. If you remove Ireland and Luxemborg, the line average would probably run from Mexico to Switzerland, and the US would look like even less of an outlier. Again, we are still an outlier, but the magnitude of the problem is smaller than we realize. Reducing overhead costs by half, as has been suggested above, would virtually eliminate the difference.

Taken to a possibly logical extreme, couldn't we imagine a highly advanced civilization spending nearly all of it's resources on healthcare, research, technological development, etc? 100 years ago, when there was very little to be done, and it took most of the productive capacity of a country just to provide the most basic of basics, healthcare just couldn't account for much of GDP. But as nations become wealthier, and advances in technology, science, and civics progress, we can expect to spend an even greater percentage of GDP on healthcare, education, science, etc., and less and less on food, clothing, shelter, transportation, etc.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5625 on: July 19, 2019, 11:15:19 AM »
That is a reasonable point.   Maybe spending so much on healthcare is actually not as bad as it seems, as long as we have the other bases covered (housing and food).  With the efficient farming and modern housing, plus renewable energy, directing more resources toward healthcare would seem to be normal.   It is very costly to extend life those extra few years or make the quality of life better, but what should we be spending the money on instead?  Wars?


ysette9

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Re: What comes after the ACA?
« Reply #5626 on: July 19, 2019, 11:37:26 AM »
That is a reasonable point.   Maybe spending so much on healthcare is actually not as bad as it seems, as long as we have the other bases covered (housing and food).  With the efficient farming and modern housing, plus renewable energy, directing more resources toward healthcare would seem to be normal.   It is very costly to extend life those extra few years or make the quality of life better, but what should we be spending the money on instead?  Wars?
If you look at healthcare spending as a % of GDP though we still come out at not-quite double of what comparable rich countries spend on healthcare.
https://en.m.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita


pecunia

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Re: What comes after the ACA?
« Reply #5627 on: July 19, 2019, 11:54:35 AM »

- SNIP -

Taken to a possibly logical extreme, couldn't we imagine a highly advanced civilization spending nearly all of it's resources on healthcare, research, technological development, etc? 100 years ago, when there was very little to be done, and it took most of the productive capacity of a country just to provide the most basic of basics, healthcare just couldn't account for much of GDP. But as nations become wealthier, and advances in technology, science, and civics progress, we can expect to spend an even greater percentage of GDP on healthcare, education, science, etc., and less and less on food, clothing, shelter, transportation, etc.

No!  Today is the 50th anniversary of the first trip to the moon.  I certainly would hope that future advanced generations have licked the better part of their health care issues and a smaller portion is spent on health care enabling researchers to devote time to exploring the other things this vast universe gives us.  The only way I could see them spending nearly all the resources on healthcare were if nearly all of them were sick.  I would expect better education on many things would take place including preventive health care to enable better enjoyment of their healthy future lives.

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5628 on: July 19, 2019, 12:33:23 PM »
I'm just beside myself that people continue to argue how our horrendous system now is better than the alternatives in other countries.  The data is clear.  We spend double.  Our life expediencies and overall health are worse.  The system is broken.   Having a whole bunch of insurance company employees, coders, PBMs or whatever, acting as middle men -- they're all skimming a piece of the action, and our overall health is suffering.  Sorry to those who work in the field as medical coders or claims processors or whatever... but your jobs never should have existed in the first place.
I feel like we're arguing different points, and not necessarily disagreeing with each other.

Health insurance companies have a profit margin of 4-5%.  That's actually significantly below the economy as a whole.  So it's not like they're laughing all the way to the bank.  Sure, going full-on NHS would eliminate that cost.  There's also all the work that's duplicated in each company, in terms of setting reimbursement rates, actuarial stuff, etc.

Nobody's arguing that we spend double per capita as other developed countries.  The problem is that a lot of people think that replacing a big group of insurance companies with one giant insurance company will, by itself, somehow magically reduce the per-capita cost or our health care to be in line with that of other countries.  In short, it's an effort to shift how health care is paid for, rather than addressing the actual costs.  It's politically advantageous, i.e. it gets votes, and under a static analysis, it would appear to reduce costs by a noticeable percentage, but it does nothing to fix the real reason why health care is so expensive.

Someone else in this thread has pointed out that administrative overhead is something like 33% of total cost, compared to half that in the UK.  Ok, let's figure out why that is, and how we can fix it.  Health insurance companies' overhead and profits certainly add some percentage to the cost as well.  Malpractice insurance adds to the cost.  High salaries required in order to pay for high educational costs certainly adds to the cost.  The fact that the US pays far more for prescription drugs than other countries not only inflates our costs, but indirectly subsidizes the costs other countries pay.* The byzantine nature of medical billing, and all the overhead that creates, is a problem.

Stumping for single payer without addressing the underlying costs is, IMO, a lot like transferring a maxed-out CC balance without taking a look at your spending habits.

* Assuming the numbers posted earlier in this thread are correct, 10% of US healthcare spending is medication, and we pay 3x as much as the UK for the same medications.  Let's assume that medications are also 10% of the UK's HC spending, and the rest of western Europe pays similar costs as the UK.   If we passed a law saying pharma companies had to sell the same drugs at the same price to the whole developed world, they'd have to raise prices in the UK and drop them in the US.  Let's say they cut the cost in the US by 50% (say, from $10 to $5), and raise it in the UK by 50% (from $3.33 to $5).  Just that one change would mean that the US pays 1.8X per capita, rather than 2X per capita, compared to the UK.

rantk81

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Re: What comes after the ACA?
« Reply #5629 on: July 19, 2019, 12:44:29 PM »
Health insurance companies have a profit margin of 4-5%.  That's actually significantly below the economy as a whole.  So it's not like they're laughing all the way to the bank.  Sure, going full-on NHS would eliminate that cost.  There's also all the work that's duplicated in each company, in terms of setting reimbursement rates, actuarial stuff, etc.

Going full-on-NHS would not only eliminate the 4-5% of "profit" that the insurance companies are skimming, but would also eliminate ALL OF THE OTHER EXPENSES that the insurance company incurs in order to operate too.  Nearly all of it being unnecessary (except for the actual payment of claims.)  If an insurance company skims $500M off the medical-industrial-complex, and ends up spending $450M in operations costs aside from paying claims, with a profit to report to wall street of only $50M... they've still skimmed off $500M, not just $50M.
« Last Edit: July 19, 2019, 01:12:41 PM by rantk81 »

caleb

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Re: What comes after the ACA?
« Reply #5630 on: July 19, 2019, 12:54:08 PM »

- SNIP -

Taken to a possibly logical extreme, couldn't we imagine a highly advanced civilization spending nearly all of it's resources on healthcare, research, technological development, etc? 100 years ago, when there was very little to be done, and it took most of the productive capacity of a country just to provide the most basic of basics, healthcare just couldn't account for much of GDP. But as nations become wealthier, and advances in technology, science, and civics progress, we can expect to spend an even greater percentage of GDP on healthcare, education, science, etc., and less and less on food, clothing, shelter, transportation, etc.

No!  Today is the 50th anniversary of the first trip to the moon.  I certainly would hope that future advanced generations have licked the better part of their health care issues and a smaller portion is spent on health care enabling researchers to devote time to exploring the other things this vast universe gives us.  The only way I could see them spending nearly all the resources on healthcare were if nearly all of them were sick.  I would expect better education on many things would take place including preventive health care to enable better enjoyment of their healthy future lives.

The problem with spending ever-more on health care is that it has a low economic return.  It's not something most of us want to say out loud in polite company because it's offensive, but in the aggregate health care is disproportionately consumed by people with low economic productivity both at present and in the future.  That's not true in every case (pediatrics are a notable exception where we should probably spend vastly more), but in general the economy isn't grown much by all of our health spending.

Twenty or thirty years from now I hope the health care industry has gone through a transition like the airline industry has over the past few decades.  What was once a luxury product with an astronomical price tag was turned into a super efficient industry providing competent service for comparatively cheap prices.  Open up the industry to professionals with foreign training, mandate price transparency, and let Google figure out a Google-Flights-like system for pricing services in real time.  Professionals with foreign training working for companies with intense price pressure manage to safely and cheaply get me to my destination all the time.  I bet we could do the same with medicine.

ysette9

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Re: What comes after the ACA?
« Reply #5631 on: July 19, 2019, 01:36:52 PM »
I believe the thing that isn’t being said about moving to a single payer system (and allowing it to exert cost-benefit analyses and negotiate prices, is that it would be aligning incentives correctly, to think like économists. Right now high prices are incentivized through our system and the gov isn’t allowed to negotiate prices. The complexity and multiple payers masks inefficiency and makes reduced negotiation power. 

By having a single payer complexity is reduced. That single payer can do calculations like the NHS does to look at how much procedures/meds cost, the likely benefit, put a value of that benefit, and decide 1) whether they are willing to pay for it and 2) how much they are willing to pay. That right there will align the incentives right to reduce costs. If you want to sell medical device widget X and a US equivalent of NHS day’s they are only willing to purchase it if it costs $50, then you can bet it will be priced at $50 or less. Not $50 for the VA system and $234 for Medicare and $500-2000 for private insurance depending on the plan and state and and and.

DaMa

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Re: What comes after the ACA?
« Reply #5632 on: July 19, 2019, 01:56:37 PM »
You say 4-5% like that's not a high number, but in dollars that is a HUGE amount of profit.  And it's profit on sick people!  When I started working in 1995, a 1% profit margin was considered normal, and 2% was a great year.  And health insurance had an "underwriting cycle" where companies would lose for a year, break even for a year, and gain for a year, so over time the profit was even closer to 0.  Today, companies are making money every year.  And that is 5% on a number that is  what, 10x, the number that the 1% applied to.

Administrative overhead in insurance companies is pretty easy to explain with just one comparison:  Seema Verma, the head of CMS, make $165,300 and managed a $1 trillion "company."  David Wichtman, head of UnitedHealth, made $18 million, and managed a $226 billion company.

Underlying costs will be reduced in single payer.  Providers have to pay overhead to manage the requirements of all the insurance companies.  I've heard that doctors pay billers as much as 35% of all receipts.  Providers also have to spend a good deal of their time dealing with insurance requirements other than billing.   We sent them reams of reports on members health metrics in order to meet reporting requirements and revenue optimization strategies.  In single payer, doctors can see patients instead of dealing with all the red tape.  Same with hospitals and other providers.

Lastly, we cannot reduce costs today, because we usually don't know what the costs are until well after we get the service.  With single payer, we will have one price sheet, and can know what something costs.  In a single payer environment, there are no proprietary pricing schemes.  I can envision a phone app where you put in a code and a cost comes up.  In no other industry do I have to get service having no idea what the cost is.

I recognize that enlarging a government bureaucracy is not a good thing.  But Medicare has been doing a pretty good job for over 50 years.  And when Medicare is doing something wrong it effects everyone, so it usually gets fixed. 


waltworks

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Re: What comes after the ACA?
« Reply #5633 on: July 19, 2019, 02:15:26 PM »
Health insurance companies have a profit margin of 4-5%.  That's actually significantly below the economy as a whole.  So it's not like they're laughing all the way to the bank.  Sure, going full-on NHS would eliminate that cost.  There's also all the work that's duplicated in each company, in terms of setting reimbursement rates, actuarial stuff, etc.

You aren't understanding the difference between costs to the consumer and profits/corporate overhead, I think.

Let's say I have a hamburger insurance company, and when you want to buy a hamburger, you have to do it through me. I have an army of auditors, claims adjustors, and lawyers working for me. Let's further say it's not a very profitable business - in fact, my hamburger insurance makes no profits at all.

So your cost for the hamburger, after you pay my overhead, is $1000, because you have to pay a dozen people to be involved in purchasing your hamburger.

My profits, if I had any, would make your burger even more expensive, but they're not the main driver of your costs.

Does that make sense?

-W

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5634 on: July 19, 2019, 03:15:05 PM »
@rantk81 - I didn't ignore those costs, but keep in mind that any gov't-run health insurance system has to deal with the same things. It's also important to remember that the ACA basically put a cap on insurance companies' costs+profit at 20%, so that gives us an upper bound for how much insurance directly adds to the cost of health care.

@ysette9 - You're right that single-payer would be simpler.  At the same time, however, it does not allow for the diversity of culture and priorities that exists across the US.  For example, the level of end-of-life care is one where some people are willing to spare no expense for even a slim chance at extending their life by a short amount, while others are content to let nature take its course.  Anywhere in the middle, and you end up with the latter paying for the former.  You've also hit upon one of the major issues that is often ignored:  if providers (hospitals, doctors, pharma, medical device makers) are charging private insurance more than Medicare or Medicaid, then private insurance is already subsidizing gov't-run insurance.  Any projections based on those costs will significantly underestimate the actual costs, because with single-payer, those providers will have to raise their prices in order to recapture the profit lost from private insurance.

@DaMa It's a huge number in raw dollars, yes, but that's irrelevant.

@waltworks Please see my response to rantk81 above.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5635 on: July 19, 2019, 03:35:46 PM »
It's also important to remember that the ACA basically put a cap on insurance companies' costs+profit at 20%, so that gives us an upper bound for how much insurance directly adds to the cost of health care.
This was a good start but it doesn't account for the costs shifted to providers, like a billing department at my local hospital that employs over 1,000 people. This is a very real cost that is accounted in the 80% portion, not the 20% one.

waltworks

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Re: What comes after the ACA?
« Reply #5636 on: July 19, 2019, 04:00:24 PM »
Ok, zolotiyeruki, why then can I ask for a cash price from many medical providers and get a discount (I've done this many times in my life, though I'm now insured thanks to the ACA) of 20-50%?

Really, that's the easiest way to see how much the insurance overhead really is.

Now, you're right that you can't simply wipe that away. There would still be a layer of bureaucracy even if you went Medicare-for-all. But I'd be shocked if you didn't save a ton of money by getting rid of insurance entirely and just providing services (either by having a single payer system, or by simply making everyone pay out of pocket).

-W

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #5637 on: July 19, 2019, 04:33:59 PM »
There's lots of ways to reduce health care spending as a nation and in fact toward the end of the Obama administration the health care cost for the nation was starting to come down and not outpace inflation. The projected outlays for Medicare/Medicaid were changed and lowered. The ACA has such far reaching implications including the motivations of hospitals regarding health care. New efforts were made to pay hospitals based on outcomes and not merely for performing medical procedures.

Ways to reduce spending include:

Allowing the government to negotiate a fair price on drug prices
Improving patience compliance with taking medications for things like diabetes and high blood pressure
Comparing the efficacy of various clinical procedures. Is there proof that patients get better outcomes with certain surgeries, etc.

Something like 5% of patients account for the majority of health care spending. If we could those patients to be better caretakers of themselves it would lower health care needs and spending.

Threshkin

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Re: What comes after the ACA?
« Reply #5638 on: July 19, 2019, 05:31:24 PM »
All this discussion about there not being a single "silver bullet" way to reduce health care costs has me thinking about the parallels to mustachanisim and the FIRE movement in general.  No one will FIRE by just reducing their expenses in a single category.  It takes a holistic approach of identifying obvious or hidden expenses and working on reducing or eliminating as many of them as possible.  The same approach is needed to address health care expenses.

Of course the dedication required to cut personal expenses is difficult and not "easy". Just look at how small our group is and the level of push back we get from the general population who thinks that is isn't possible to control spending like most of us do.

Trying to apply the FIRE mentality to healthcare costs would get the same kind of push back.  It would need politicians who are less worried about public opinion and are more interested in finding and making the many small cuts needed to actually reduce healthcare costs.

I am not holding my breath........

henramdrea

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Re: What comes after the ACA?
« Reply #5639 on: July 19, 2019, 05:51:09 PM »

*snip*

Something like 5% of patients account for the majority of health care spending. If we could those patients to be better caretakers of themselves it would lower health care needs and spending.

End of life spending accounts for a huge chunk of healthcare costs.  People need very clear advanced directives that cannot be over-ridden by agressive family members not wanting to let grandma/grandpa go in peace.  It's those that don't have their end of life wishes in order that cause a majority of the expensive, heroic medical interventions to occur.

freya

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Re: What comes after the ACA?
« Reply #5640 on: July 21, 2019, 08:08:19 AM »
Having one insurance company instead of dozens would actually go a long way to reduce the administrative burden on the physician/hospital side.  Because they each have their own rules, forms, procedures, requirements for reimbursement, and just plain idiosyncrasies, it's an unnecessarily huge and complicated task to cover all those aggregated bases.

That's a big reason why Medicare for all would be such a miraculous win.  Even if you assume Medicare's overhead increased because the system would have to scale up in size & complexity, it would still be worth it.  Estimates run about $700 billion in savings per year, from this alone.  In practical terms, yes physician and hospital reimbursements would go down - but the reduction in overhead costs would more than make up for it.  Especially if an intelligent simplification effort was undertaken by Medicare (assuming the AMA doesn't try to sabatoge it).  This would also be much easier and more productive if you only had one set of rules to deal with.

pecunia

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Re: What comes after the ACA?
« Reply #5641 on: July 21, 2019, 10:11:39 AM »
Having one insurance company instead of dozens would actually go a long way to reduce the administrative burden on the physician/hospital side.  Because they each have their own rules, forms, procedures, requirements for reimbursement, and just plain idiosyncrasies, it's an unnecessarily huge and complicated task to cover all those aggregated bases.

That's a big reason why Medicare for all would be such a miraculous win.  Even if you assume Medicare's overhead increased because the system would have to scale up in size & complexity, it would still be worth it.  Estimates run about $700 billion in savings per year, from this alone.  In practical terms, yes physician and hospital reimbursements would go down - but the reduction in overhead costs would more than make up for it.  Especially if an intelligent simplification effort was undertaken by Medicare (assuming the AMA doesn't try to sabatoge it).  This would also be much easier and more productive if you only had one set of rules to deal with.

I was just thinking the same thing.  There is a duplication of effort that would be eliminated.  Add to that the organization has one boss, you, the taxpayer.  This is in contrast to the existing setup where the employees serve the stockholders and you are the cash cow to be milked to enable that service.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5642 on: July 21, 2019, 10:37:35 AM »
Having one insurance company instead of dozens would actually go a long way to reduce the administrative burden on the physician/hospital side.  Because they each have their own rules, forms, procedures, requirements for reimbursement, and just plain idiosyncrasies, it's an unnecessarily huge and complicated task to cover all those aggregated bases.

That's a big reason why Medicare for all would be such a miraculous win.  Even if you assume Medicare's overhead increased because the system would have to scale up in size & complexity, it would still be worth it.  Estimates run about $700 billion in savings per year, from this alone.  In practical terms, yes physician and hospital reimbursements would go down - but the reduction in overhead costs would more than make up for it.  Especially if an intelligent simplification effort was undertaken by Medicare (assuming the AMA doesn't try to sabatoge it).  This would also be much easier and more productive if you only had one set of rules to deal with.

I was just thinking the same thing.  There is a duplication of effort that would be eliminated.  Add to that the organization has one boss, you, the taxpayer.  This is in contrast to the existing setup where the employees serve the stockholders and you are the cash cow to be milked to enable that service.

This is why I am a little confused at the price of Bristol-Myers Squibb after their purchase of Celgene.   One would hope that the consolidation of two big pharma would yield a more efficient single pharma company eliminating a lot of the overhead cost.   Investors do not think so as Bristol-Myers Squibb hit a 5 year low yesterday during a period where the stock market is at all time highs.  So much for the theory that pharma is just raking in the profits.

radram

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Re: What comes after the ACA?
« Reply #5643 on: July 21, 2019, 12:04:52 PM »
This is why I am a little confused at the price of Bristol-Myers Squibb after their purchase of Celgene.   One would hope that the consolidation of two big pharma would yield a more efficient single pharma company eliminating a lot of the overhead cost.   Investors do not think so as Bristol-Myers Squibb hit a 5 year low yesterday during a period where the stock market is at all time highs.  So much for the theory that pharma is just raking in the profits.

Time will tell, but their recent price might have something to to with the price paid for the acquisition. If you are more efficient, but you overpaid to get there, it will take some time to reflect that in the stock price.

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5644 on: July 21, 2019, 12:20:00 PM »
This is why I am a little confused at the price of Bristol-Myers Squibb after their purchase of Celgene.   One would hope that the consolidation of two big pharma would yield a more efficient single pharma company eliminating a lot of the overhead cost.   Investors do not think so as Bristol-Myers Squibb hit a 5 year low yesterday during a period where the stock market is at all time highs.  So much for the theory that pharma is just raking in the profits.

Time will tell, but their recent price might have something to to with the price paid for the acquisition. If you are more efficient, but you overpaid to get there, it will take some time to reflect that in the stock price.

Maybe.  An argument can be made that they overpaid but also that they got Celgene for a steal.  I guess it depends on how the proposed reforms play out.   A fair way to reduce drug prices would be to extend the patent length on approved drugs while also capping the price of drugs.  This would allow investors to put their money in at a lower risk and thus could settle for a lower but steady return.   In addition, the USA should use their trade powers to negotiate a more fair sharing of the development cost of drugs.   The drug companies then could set a much lower cost in the USA.   This is about the only way I can see the pharma industry remaining viable considering the immense costs of drug trials.   Even if you cut the CEO pay to a buck a year, require that advertising is eliminated, you are not going to be able to cut drug prices significantly and still attract private investment without some sort of carrot.   As it is right now private investors are fleeing the big pharma on just the chance that a price cut is in the works.   Pharma has been one of the worst investments of the past decade, just look at any chart.   If I am a private investor, my money is going into Amazon, not Merck.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #5645 on: July 23, 2019, 09:46:04 AM »
Harry Sit provides a crystal clear explanation for how to think about and calculate the premium subsidies for insurance under the ACA

https://thefinancebuff.com/aca-premium-tax-credit-percentages.html

MDM

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Re: What comes after the ACA?
« Reply #5646 on: July 23, 2019, 06:23:49 PM »
Harry Sit provides a crystal clear explanation for how to think about and calculate the premium subsidies for insurance under the ACA

https://thefinancebuff.com/aca-premium-tax-credit-percentages.html
He also did a great job with a nice screen-shotted "how to" on the ACA premium tax credits using the case study spreadsheet.

ministashy

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Re: What comes after the ACA?
« Reply #5647 on: July 29, 2019, 06:59:30 AM »
Kamala Harris just officially jumped on the bandwagon by releasing her Medicare for All plan, including how she would want to transition to it and how it would get paid for.  It seems pretty sensible to me, tho personally I think it would be a lot more palatable to the voters if she included at least lip service to the option of keeping (and paying) for your own private insurance, assuming it met fed requirements.  But I'm curious what other people think about it as well.

https://kamalaharris.org/healthcare/

Roland of Gilead

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Re: What comes after the ACA?
« Reply #5648 on: July 29, 2019, 07:59:09 AM »
I don't like the 0.2% tax on stock trades.  Maybe if there were some provision eliminating that in retirement accounts or something.


rantk81

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Re: What comes after the ACA?
« Reply #5649 on: July 29, 2019, 08:16:48 AM »
I agree that the transaction taxes are not a good thing.  A big driver of the economy here is the ease of capital flow.  Also, investments are already taxed plenty.  Dividends are taxed on the corporation's earnings, and then taxed again as income when paid to investors.  Capital gains taxes are owed -- even if the portions of the "gains" of assets that are just keeping up with inflation.  And for a lot of Mustachians, these taxes on investments is on top of money that was taxed from payroll/income taxes.