Affordable Care
blog.samaltman.com
blog.samaltman.com
Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact.
This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered.
Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand.
Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).
This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time).
This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
How can you possibly think that?
It's stupid to require the poor to pay for plans they don't need/want/afford, and for rich to pay for plans when they can pay their own way.
MANY people opt to pay the fine as substantially cheaper than compliance.
And it's a safe guess that the political "Left" would be screaming outrage if the "Right" were compelling people to buy private-sector products (health insurance) they didn't want or afford.
Poor people don't need health insurance? Doesn't everyone need it? If anyone didn't need it it'd be the rich.
> /want
Too bad. If we let people not have health insurance we might as well legalize suicide by the same argument.
> /afford
So people who can't afford it should just... die?
> and for rich to pay for plans when they can pay their own way.
You have to be pretty rich for health insurance to not make sense. Not just like upper middle class. If you're suddenly diagnosed with some rare disease you could easily see medical costs in the hundred thousands per year.
Likewise the rich. If you're earning millions per year, you don't need ACA-imposed "$50 co-pay" type coverage for common services totaling under $100,000/yr. (Listen to Rush Limbaugh rant about such issues: forcing him to buy ACA-approved health coverage is stupid; he could buy the hospital if need be.)
Comes down to marketplace & choice: it's my life, and my money, who are you to force me (under threat of violence from the state) to buy what you consider sufficient coverage? Let's discuss fixing systemic problems with narrowly targeted solutions, yes, but don't fine me $3000/yr for preferring to pay my own way out-of-pocket completely up to $10,000/yr.
So if you lose your job and your health coverage, insurers would be able to deny you coverage.
But if you never have a gap, then you can't be discriminated against.
Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.
The gap solution, though, is not a great idea. If someone falls under a certain level of economic or other hard times and incurs a gap for even a very brief duration, it is in my opinion a very harsh penalty to use that as an excuse to deny them coverage. This is especially true when many families pay a large amount for existing coverage.
The only tenable solution is to force everyone to have coverage. If that's the answer, I see no better implementation than single-payer.
Insurance with pre-existing condition is just health care. You are not insuring against anything.
My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.
It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children.
There is no need to require everybody to buy an overprized service bundle.
There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance.
Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them.
Then there are the people who prefer paying for things out of their pocket as they go.
The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.
As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.
I believe the only acceptable solution is a single-payer system where the government is able to set pricing limits on services - like medicare/medicaid already work. This is the only way the costs can be reasonable for the consumers of the care.
I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different?
If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.
If you want everyone to pay something, we (as you pointed out) have something for that, it's called taxes. And that's what pays for your other "insurance" examples. (And don't bring up auto insurance. I don't have to have it, I can choose to not own a car.)
But by involving private companies you have creates perverse incentives that I have no sway or visibility into.
If we want to socialize health care then lets do that, but lets not introduce a private party middle man that not only disconnects the payer from the consumer but has a government mandated client base of the whole US.
I am opposed to it because it is a horrible individual rights breaking precedent.
Don't get me wrong, I'm a strong believer in single payer health care (I'm from Sweden), but in the absence of that, whether you pay the money in taxes or directly to a private end party doesn't seem that different to me. (And the US Supreme Court apparently agrees, since the mandate was upheld as constitutional.)
If it is allowed it will not stop at health insurance. Business has too active a hand in the US government as it is. How much worse will it get when they start greasing the palms to make sure they too have a required audience?
Edit: (Forgot) Yes, the supreme court upheld it. That doesn't make it right, just constitutional. If an amendment to the constitution is required, then so be it.
Seriously, it has me considering moving to another country.
The torture, indefinite detention, universal surveillance, and permanent war were insufficient on their own? It took buying healthcare?
One can decide not to buy insurance, and instead pay a penalty. The Court ruled that this penalty is a permissible tax.
How does that differ, really, from an individual insurance mandate?
vs.
Mandating that I purchase a private company's services myself.
In the first case, the government uses its bargaining power (all that money) to negotiate a lower price by requesting bids and selecting a provider. In the second case, I'm a captive customer with little, if any, bargaining power. My bargaining power does indeed depend on how this second arrangement is legislated and how many providers are available to me.
Yeah, this is something I feel very strongly about in Australia. For context, we have a fairly good public healthcare system. I've been to the hospital many times (not for anything much serious) and never paid anything. It's free to have a baby in a hospital (well, apart from taxes). Private health cover, while it exits, is not a necessity.
Then, the 'Medicare Levy Surcharge' was introduced to encourage higher-income earners to take out private health cover (PHC) to supposedly reduce the strain on the public system. So now, unless I take out PHC I get hit with a $3000 fine at tax time. So I took out a $800/year junk policy which gets me basically nothing and is not something that I need.
I'm really annoyed that the government more or less forces (because regardless how I feel on the topic, it's not unreasonable for me to choose a $800 option over a $3000 option) me to hand money over to a private company for a product that I neither need or will use.
Yep, and that's the catch about politics.
The ACA could've been challenged earlier by the Republicans if it introduced a new tax to pay for itself. That would've been the natural thing to do, and the Democrats were well aware of it. Because of that Republican blockage, they had to hide that fee in the "mandate" instead. Of course the Republicans weren't dupes and sued against it, but the courts sided with the Democrats accepting that the mandate wasn't a "tax". I wish I could come up with a source (it was big news back then), but right now my google search is overloaded with another recent ACA-related budget fight :\
There were many better alternatives to the current ACA as it is, including a single-payer option. But we got the ACA (which started as a Heritage Foundation idea[1], they're a nicely conservative think tank) because that's the best the Democrats could get past the Republicans.
[1] http://www.forbes.com/sites/theapothecary/2011/10/20/how-a-c...
I agree. And what bothers me further is that I am vehemently opposed to patents, while I am forced to send a lot of my money to drug patent holders.
Hence: The actor paying for chronic care is the one incentivized to provide great preventative care, separating the two will create incentives with negative patient outcomes and cost for chronic illness.
Another less obvious issue is that by splitting healthcare payment between actors, they are weakened against an increasingly monopolistic healthcare provider market. One key reason US healthcare is expensive today is that insurers are weak vs. healthcare providers - splitting them up would further reduce their ability to negotiate better prices.
While there's some truth to the argument that US healthcare is expensive because it pays for much of the worlds medical research, there is plenty of truth to the argument that the rest of the west gets better prices because their single-payer insurance is a massively strong negotiating party fighting for good prices for patients.
It is really interesting how the American mindset is to never look abroad to see what works and what doesn't. There's something amusingly arrogant about it. Almost as if every other country must be an absolute cesspit that could never have any lessons to offer, although I admit that other countries' universal healthcare systems have been effectively (but unfairly) demonized in U.S. political discourse.
Our system here is far from perfect and comes with it's own unique set of frustrations in terms of timely access to care, but it seems like those frustrations are nothing compared to what millions of Americans put up with.
I have anxiety even travelling to the United States for a couple weeks on occasion when it comes to healthcare. What if something happens to me? Did I buy the right travel insurance? Is there a certain process I need to follow? (Most travel insurance policies I have seen indicate that if you need medical treatment to call them first before you do anything, which seems like an odd thing to do if you're having a heart attack..) Did I fill out the insurance application forms correctly? And if I end up needing care, will the insurance company find some loophole or technicality to deny my coverage?
The difference with regard to healthcare is that Canadians convinced their government to provide it, while U.S. citizens convinced their employers.
This was fine for most of the century in the U.S., but towards the end and more recently leading up to the passing of ACA, all but the most zealous unions were broken up and employers were providing healthcare less and less.
Unlike the industrial, early 20th century where conditions were horrible for almost the entire working class, we now have some people who are gainfully employed with healthcare and some who are not. Consolidating these two groups to agree on how to provide healthcare for everyone is difficult, because those who "got theirs" don't see it as a problem until they lose it.
http://www.npr.org/templates/story/story.php?storyId=1140451...
During WWII the government imposed wage controls.. but fringe benefits did not count as wages. And with a shortage in labor because of the war, employers used health insurance and other fringe benefits to attract workers.
The unions jumped onboard later.
https://en.wikipedia.org/wiki/Health_insurance_in_the_United...
Employer provided healthcare is an artifact of ww2 where employee compensation was practically frozen. Employers looked for other ways to create competitive compensation, and turned to healthcare.
We also have a large contingent of people who take immense pride in voting against their own self-interest. They'll look to Canada's system and say "yeah but they wait for days to get an x-ray for a broken arm" ignoring the fact that they themselves couldn't even afford to get an x-ray. But it's worth it because even though I can't get healthcare, the people I hate can't get it either.
As shown by the most recent election, it's political suicide to imply that America isn't the single greatest nation in the world. It's even worse to suggest that we should be asking some other country for help. Those other countries are communists, and the only communist we like is Russia.
Recent experience - my daughter sprained her ankle, so went to the hospital for x-rays. I live outside the city so the doctor we saw was coincidentally our local GP. The price $0, time waited - about half an hour, this was on a Sunday night.
One thing that may be a factor here is the medical practices are run by doctors - no professional manager people which, from what I understand, seem to be in the US health system. The doctors, in general, really are people who want to make people well and thats what they do. Sure they like to make a buck and they do but not at the expense of everyone else.
If you let non medical people into the system to manage it then, I'd look closely at their motives, I suspect you'll find sometimes their motives aren't pure.
Oh we definitely look abroad. In fact that's one of the major arguments for a single-payer system in the U.S. - such a system exists successfully in every other capitalist democracy. So why can't we make it work here?
And this looking abroad is not a tonic against bad thinking. Conservatives routinely look at health systems in other countries and decry them: long waiting lists for elective procedures, high marginal income tax rates, etc., etc. Any flaw in another system is magnified and considered a non-starter.
Obamacare was based on an older Republican plan which had been implemented by Mitt Romney in Massachusetts. But in the run-up to Obamacare conservatives hyperventilated about "death panels" and how the ACA was going to destroy the economy. None of which came to pass.
Every other OECD country ("capitalist democracy" is a problematic category) except Mexico has some form of universal coverage, but not all are single payer, several are hybrid public/private systems.
A problematic category? What does that even mean?
https://www.hsph.harvard.edu/news/features/mexico-universal-...
By "capitalist democracy" I simply wanted to point out that a country can have a healthy and thriving free market economy and universal coverage at the same time. (e.g., Germany, Japan, UK, and many more). It's a counterfactual to small-government conservative hyperbole, which holds that universal coverage necessarily destroys and disables a nation's economy.
Everyone understands the healthcare systems in Canada and most of Europe. There is no point mentioning it because for most of Republicans it's a non-starter. It's incredibly niece of you to think a bunch of liberals have never thought to look elsewhere, at best. At worst you wanted to just blanket insult the US.
https://mises.org/blog/how-us-states-compare-foreign-countri...
The plan for my family last year cost over $1200 per month, and this year rose to $1400/month.
Previously, with employer-provided plans I paid at most $400/month for my family.
Not only are the costs outlandish, there are no high deductible plans available for people who are generally healthy. All of the plans, gold, silver and bronze, are geared toward heavy users or highly risk-averse users.
A healthy, disease-free family at an income level to afford $1400/month in health care costs surely ought to be able to purchase a plan that covers catastrophic scenarios and costs a lot less than $1400/month.
In the past I'd had a plan via an employer that was a high-deductible plan. It cost $350/month but I had to pay the first $10K of all costs each year. Do the math, this was a better deal even in the worst case scenario than my ACA plan.
The problem with bundling a progressive tax, a flat fee, a subsidy, and a prepayment plan into one "price" is that it is impossible to tell which dollars apply to what.
I'd much rather have my actual taxes go up a small bit than pay an income-based penalty in my healthcare price.
I'd also much rather self-insure the first $15-20K of risk each year in exchange for a much smaller payment.
One other detail. Nearly all the plans by all the providers are essentially identical. The cheapest bronze plan I could have found was over $900/month! That's for a pretty abysmal level of coverage of most things compared to any other employer provided plan I've ever had.
The idea is self-insuring $15-20k is absurd for most people, and most people who buy insurance on the exchanges will have government subsidized coverage.
If you want to argue the government should subsidize more of the cost of this care, I'm all ears. But I don't think we should dismantle the system because it doesn't benefit your precise set of preferences.
Around $200 per month. The risk pool aspect would be true if the risk were the dominant factor in the price, which I think it isn't.
> The idea is self-insuring $15-20k is absurd for most people
People who can afford $1400/month even if no healthcare is used? I'd much rather save the money and if someone in my household has a catastrophic scenario put it on a credit card or spend the next <12 months on a payment plan of $1000/month.
> subsidize more of the cost of this care
The key word in that sentence is this. What care are we talking about? The ACA plans cost a minimum of $900/month even if I use no care at all (and that's for the plan with very high co-pays, etc.).
I've been on an ACA plan for the past two benefit years, and the plans keep getting much more expensive and offering worse coverage. The question is, why is this happening? And why is it that on the so-called "marketplace" there is not a high deductible plan that had been available via non-ACA plans via employers?
I think the answer is that it is far from an actual marketplace. There must be some incentive for providers not to offer high deductible plans or actual risk-based plans.
A risk pool is a way of packaging a lot of people into one financial model, but the larger and more heterogeneous the group, the more the prices should reflect actuarial reality. The exact opposite is the case.
Considering that so much money and research has gone into building the healthcare.gov website, why can't I simply adjust sliders to optimize the plan the same way I book a flight? I'd like to slide the monthly premium slider to the bottom, slide the maximum out-of-pocket to about 15x the mid-high premium price, adjust the "worst case event" slider to about $20K and (hopefully) find a plan for a few hundred dollars a month, which I know exists in the actual market because I had it a few years ago! If anything, a larger risk pool should have allowed insurers to offer plans that strongly discourage adverse selection (such as high deductible plans) and reflect the actual risk of cost incurred to the insurer.
The plans on healthcare.gov not only fail to offer this, but the wording, the pricing examples, and fine print is all out of some sort of bureaucratic nightmare scenario. I actually had a physician and a lawyer sit with me to try to understand the fine print and the likely cost of a few scenarios other than pregnancy and diabetes (which are shown), and we sat there confused for several hours.
I'd like to see our president sit before the nation sharing his desktop screen and watch him navigate through the site and explain the answers to the very simple things we were wondering about, as well as explain some of the more confusing terminology, as well as things like "why are there two separate plans that are so similar being offered by this company?" or "which of the priced items on this list are excluded from the individual deductible?" I'm quite sure that he'd need to do quite a bit of research and rehearsal before he'd be able to give such a demo with confidence.
When we put trust in our officials to handle things for us, there is a tremendous amount of responsibility that they take on in that capacity. Here we were, one highly computer-literate person, one doc, and one lawyer, utterly flummoxed for several hours. Imagine the average person after a long day trying to make this very important choice for his/her family. It's just wrong.
Maybe the idea is to make all the plans more and more similar until there is really just one choice that is priced based on income and nobody feels it's worth the time searching or reading any of the coverage descriptions because we all realize that the plans are all nearly the same by design, and that we're just meant to pay our "share" based on income and be grateful that such great care has been provided for us.
One thing is for certain. It's not a marketplace. There are simply not competitive plans. There is no way to sort the plans according to any differentiating factors. The "wizard" that the site offers tries to partition people into three groups based on expected usage, but does not offer any consideration to low users or users who are comfortable with the idea of getting a large bill and either taking on debt to pay it off or going on a payment plan with the provider.
And, far worse, all any of the plans I reviewed do to create an incentive for low use is subsidize non-emergent primary care visits. There is zero incentive beyond that to reduce one's use of care. Since the spread between the cheapest and most expensive plan is so small, anyone who expects to need any healthcare at all is better off choosing a silver or gold plan. If this incentive is different for people whose coverage is subsidized, I'd consider it discriminatory fwiw.
The ACA instead helps the insurance companies optimize based on their interests.
The preexisting coverage mandate will need to be re-engineered because it's in direct tension with the fundamentals of insurance. Wide open and the system is just cost transfer.
ACA caps the maximum out of pocket for "essential health benefits". For 2017, that means a max deductible of 7150 for an individual, 14300 for a family. It's adjusted for inflation each year.
It's to prevent people who can't pay the high deductible from signing up for these plans to avoid the penalty for not having coverage.
If it were fair it would be based on a percent of income like other tax-related laws.
We already have a progressive tax, but let's add an individual mandate, tax credits that phase out at 400% FPL, and cost sharing subsidies which phase out after 250% of FPL.
The maximum value of the tax credits for your family would be nearly the full cost of the premiums at 133% FPL, let's say $12,000. Then on top of that the cost sharing reductions would reduce your out-of-pocket maximum -- which if you're truly unlucky could run your family another $14,300 -- to a maximum of $4,500, so that's worth potentially another $10k.
What this means is ACA is a $12,000 - $22,000 tax on your family depending on your health care utilization, as income rises from 133% - 400% FPL.
For a family of 4 the 133% FPL = $32,250 and 400% = $97,000. So as you make that extra $64,750, in addition to all the other taxes you are paying, you are also phasing in $12,000 - $22,000 of increased payments for the same exact health care. Now that is one hell of a tax.
So while you and your spouse are working your asses off to earn $150k, you can look back and appreciate how $10k went to the town, $10k to the state, $30k to the Fed and ~$15k to the SSA. So it's really just the cherry you're being charged an extra $15k for insurance, come on, you can afford it!
I won't mention all the other subsidies you lose out on for being a productive member of society. Because when you realize the real tax rate approaches 100% on the first $97,000 it's a bit of a buzz kill.
Why wouldn't they, customers are insulated from the sticker price but can't really complain because high priced health "insurance" is required.
It's just a coincidence that Mylan took any flak for its abuse of the system. Many other pharmaceuticals are increasing in price way out of proportion to inflation, and way out of step with reality since the R&D costs are all borne before product launch.
That's just Not Even Wrong.
Your health insurance premium is not a "tax". You're getting health insurance. Moreover, not getting a subsidy for your health insurance is also not a tax. You can only use that logic when the tax credit is offsetting another tax. Which it isn't. It's offsetting your health insurance bill.
If, instead, you're trying to claim that every bit of increase in health insurance costs since the ACA is a "tax", that's maybe a bit more defensible, but still Wrong. Health insurance costs have been skyrocketing for decades. The ACA has probably slowed down that trend.
Finally, if you're just complaining that you're healthy but you have to pay for health insurance now...take a walk, please. Eventually, we all get sick. Health insurance only works if healthy people foot the bill of the sick people. That's how insurance works.
It's called "Effective Marginal Tax Rate" if you want to Google it.
From the CBO; "The effective marginal tax rate (for brevity, hereafter referred to as the marginal tax rate) is the percentage of an additional dollar of earnings that is unavailable to an individual because it is paid in taxes or offset by reduced benefits from government programs."
I mean, it seems almost ridiculous to say that buying health insurance & health care is a tax, but when the government is paying over a trillion dollars a year to buy health care for everyone except those who are too young or earning too much money, that's exactly what it's become.
And I'm definitely not complaining that healthy people should not have to pay for health insurance. In fact the healthiest 50 percent of people who pay for health insurance use only 3.5 percent of services, it's what allows the entire system to work!
Being required to pay for a service doesn't make that service a tax. The only thing about the ACA that has been characterized as a tax is the penalty you pay if you don't buy insurance.
The difference between your risk-adjusted premiums (based on your lifetime expected payouts + margin and overhead) and the amount that you actually pay in premiums can best be described as a "tax", because if it is positive, that money is directly going towards subsidizing someone else's premiums, and it is mandated by the government.
You can make the argument that it's the right thing to do because it allows people to purchase insurance that they otherwise would be unable to afford, based on their expected risk level (ie, past health) and their current income, but it's important to understand that that's not the way insurance itself works. The insurance is simply being bundled together with that tax, so you only see the one price at the end, instead of having it broken down and itemized.
Would that still be true if you had to pay retail for all your care?
The grandparent's intuition that by being on a high deductible plan I would not be eligible for the "buying club" benefits of negotiated pricing doesn't pan out: The price is negotiated so that there is a captive "in-network" market which guarantees some level of utilization and helps with planning. Insurance companies want to offer a large population to care networks in order to negotiate a volume discount.
Also, if you consider a catastrophic plan that kicks in if something really bad happens and I use over $20K of care. Nearly any serious condition or accident would qualify. If it happened, I'd be able to switch to a lower deductible plan in the next open enrollment. Worst case, I'd end up paying my premium savings (and then some) toward that one event, but overall I would not be much worse off than if I'd just chosen the expensive plan to begin with.
When I had the high deductible plan through an employer I did the math on it compared to the most deluxe plan offered. Worst case, if I maxed out the individual and family deductibles on the high deductible plan, I'd end up paying about the same as the annual premiums of the deluxe plan. But if, as is likely, I didn't have a catastrophic incident, I'd save a lot of money (which I did).
You've got it backwards - Medicare (and Medicaid, to a lesser extent) are the ones who rip off providers, by reimbursing less than COGS[0]. The "retail" price is actually a way that providers make up for these losses by passing on the costs to private insurers (who then pay for those increased costs by accounting for them as claims, improving their MLR, and allowing them to raise premiums for it).
[0] Medicare's own financial statements attest to this; you don't have to take providers' words for it.
Isn't this just because now insurance companies have to cover preexisting conditions and also not charge them exorbitant prices? Naturally, they would be taking a loss in order to do this so that burden is instead shifted onto the healthy people. To prevent healthy people from just not buying insurance, the mandate was made because it's economically unfeasible without them.
If you're the type of person who would normally use a high deductible plan, you're worse off, but that's the way it was supposed to be. Presumably if one day you get very sick though, you will still be able to get insurance.
We shifted the burden of healthcare from lower class and sick to middle class.
But the fundamental problem is high cost of healthcare. Capitalism is usually a ruthlessly effective tool, but it doesn't seem to work with healthcare due to lack of choice.
Maybe it doesn't make sense to invest so much money into health?
Is it a worthy trade-off getting 80% of our current healthcare quality for say 50% of the cost?
It's a tough call to make, but this country is in decline and we need to make tough choices.
I'm a 19-year old developer working my ass off last 4 years for silly startups. Currently I make $30/hour but paying around 30% of my income in taxes.
Baby boomers benefited from generation before them and borrowed money from gen x'ers/millenials and they run this country into ground.
Once my agegroup starts seriously voting I feel like we won't have a lot of pity for older age groups and their retirement plans.
I support raising minimum wage to livable standards, but I hope universal income comes soon.
Over the last year I've been getting burned out working 60 hour weeks trying to use latest languages and libraries, while my company is hiring $3/hour phillipino php/WordPress codemonkeys...While all I wish in life is to Haskell in peace for next 30 years and then die.
I'm still trying to work toeard American dream, but it's dead for all but the software industry.
It's disilousining to see rich stealing the fruits of my labour while I have to pay government to keep the lower class alive.
As kids we were told about wonders of globalization, democracy, and America.
In the real world we now have to deal with fucked up environment, economics and Putin flexing his geopolitical dick.
So you older folks got us into this mess, what the hell do we do now?
Where are you getting this from? I thought we shifted the burden from.. sick people to non sick people
> But the fundamental problem is high cost of healthcare. Capitalism is usually a ruthlessly effective tool, but it doesn't seem to work with healthcare due to lack of choice. Maybe it doesn't make sense to invest so much money into health?
I don't know if I agree on the ruthlessly effective part, but I'm also not sure what you mean by lack of choice. Lack of choice in what? Insurance? After all, there are plenty of hospitals you could go to.
I'm guessing treatments sometimes are expensive because.. well we don't have a good understanding of how to many things so we use the best thing we know how to use, which is often expensive no matter the industry. On the other hand, it seems like a bad choice to use something cheaper because.. well because we don't want people to die.
> It's a tough call to make, but this country is in decline and we need to make tough choices.
By what measure?
> I'm a 19-year old developer working my ass off last 4 years for silly startups. Currently I make $30/hour but paying around 30% of my income in taxes.
> Over the last year I've been getting burned out working 60 hour weeks trying to use latest languages and libraries, while my company is hiring $3/hour phillipino php/WordPress codemonkeys...While all I wish in life is to Haskell in peace for next 30 years and then die.
You certainly sound burned out. Why not try to find a better job? If they can hire that type of employee then perhaps you need to try to find a job where you aren't going to be replaceable? I don't really know that using the latest languages and libraries is a good thing..
> It's disilousining to see rich stealing the fruits of my labour while I have to pay government to keep the lower class alive.
Sorry you're going to have to elaborate. How exactly are the rich "stealing" your work?
> So you older folks got us into this mess, what the hell do we do now?
Sorry I'm completely lost now. If you have things you'd like to improve then you should vote on them and try to get the change you'd like to see enacted.
If it weren't for medicaid, I would be flat broke. my bills start at $5k... that's only the first bill I've seen. My savings would be dissolved, and I would be forced to find work for somebody else.
Instead, because of this coverage, and in spite of limitations on the amount of time I can work at a computer with a busted arm, I am able to continue my entrepreneurial efforts. My partners and I are all hopeful that this will be a very valuable use of our time, and our investor's money. I hope to be able to pay Colorado & the USGov back in spades, through taxes.
* - edited to correct Colorado Cares --> "Health First Colorado"... because I didn't know what I was talking about.
edit 2 - HFC is medicaid for those who qualify... Thanks HN for educating me :P
http://www.denverpost.com/2016/11/08/coloradocare-amendment-...
The correct name is "Health First Colorado". I signed up the day I was hurt, they backdated the signup to the month prior. It took less than 15 minutes to become covered.
I've been working for 20+ years, with spats of insured or not-insured throughout... mostly uninsured. After I left my SF gig, I gave up my insurance & didn't get any more since I'd already had 6 months for the year.
By the end of December, I needed it.
Edit - link: https://www.colorado.gov/hcpf/colorado-medicaid
They didn't care if you signed up when you were injured because you would have qualified for it anyway... you just didn't complete the paperwork. You definitely cannot do this when you exceed the income limit for medicaid and have to get normal health insurance.
The ACA increased the limits to qualify for medicaid. I know there were a few states balking at increased medicaid costs.. but you could have gotten this in most states, including CA.
Yeah... my income === 0. Hopefully, not for too much longer.
Having insurance tied to employment is utterly terrifying. You'll stick it out in a sub-standard job to maintain coverage. You'll be fearful of taking risks on self-employment. It's the exact opposite thing you'd do if you wanted to encourage entrepreneurship.
I have a pre-existing condition that prevented me from getting non-employer sponsored insurance. When the exchanges came online in my state I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company. That lasted all of a single year because of 30% premium hikes and 290% deductible hikes made ramen bootstrapping no longer possible.
I'm still working in startup space because of connections I made, but I'm now tied to employment and could never again be a founder, unless one of my current bets pays off.
Yay for elimination of pre-existing condition restrictions. But what good is insurance if you can't afford it?
Obviously, I don't think you're obligated to offer any details you don't want to.
I guess I assumed you had a point and weren't just firing off scary sounding exaggerated anecdotes.
Married, two kids. Everybody reasonably healthy, have a decent job.
Healthcare costs have become expensive as shit because of the ACA. That's not a partisan talking-point: that's the bottom line in our household budget.
The happy-face anecdotes the ACA's advocates trot out are lovely, but there are far more people in my position.
https://www.washingtonpost.com/news/wonk/wp/2016/09/19/skyro...
> A new analysis from the Urban Institute found that the average unsubsidized premiums in the Affordable Care Act exchanges, commonly known as Obamacare, are actually 10 percent lower than the full premiums in the average employer plan nationally in 2016.
Because I fall well within the middle class, have 2 kids, and am in reasonable health yet am paying far more for poorer health care than I did a decade ago, and beyond the anecdotal evidence that is the same for every family I've spoken to for the last few years it is clear that the ADA is deeply disliked by a vast swath of America for precisely that reason.
The ACA is a shell game that siphoned money from people who had it, dropped it into a big corporate hole, and spat out a bit of it at people who didn't have as much. As a political issue, we are seeing "success stories" trotted out so as to convince the rest of us that gosh, isn't this worth it?
No, it isn't. There has been no net gain with the ACA. It was passed so we could see what was in it, and turns out most of what was in it was a lobbyist Christmas wrapped in a ton of politician incompetence.
It was wealth-destroying political nonsense in the same sense as "cash for clunkers". Feel good, think less.
What I don't believe is that healthcare costs have gotten more expensive FASTER THAN THEY ALREADY WERE because of the ACA, any more than I think that my cat died in 2012 because of the ACA ("Gee, Thanks Obama!") which I'm sure some people would also argue.
So in your comment, I absolutely believe
> Healthcare costs have become expensive as shit
But I think you're trying to assign blame where it's not due with
> because of the ACA.
The ACA introduced no cost controls and just shifted the costs around from 1 demographic to another (mostly to the lower-middle and middle class healthy people, who don't actually use much health care).
So obviously for every sob story of a saved life, there's at least 2-3 stories of relatively young (26-30) healthy people whose deductibles and premiums have gone through the roof.
That's why people on the internet can't ever agree whether the ACA was a good thing, because there's plenty of anecdata from both sides.
I think we, as a population have to accept that Americans, in general, are very unhealthy people. It's quite obvious with ~35% obesity and the #1 killer being heart disease. Naturally, mitigation health care is an order of magnitude more expensive than preventive care. Hence the rising costs of health care (for everyone, even though some people don't feel the pain of costs, whether by being subsidized or being rich)
In a lot of ways that's exactly what insurance is. It's pooling resources to cover expenses for the people who need it. In any given time period most people won't need it, or won't need it to an extent higher than their contributions, but it's there just in case. There's variation in premium amounts to account for the difference in likelihood of need (so those younger generally-healthier people pay lower premiums), but a very important part of making it work is having a large enough pool that only a limited percentage needs to use it each year.
There are also measures that were taken to try to reduce costs, but how effective they were may be up in the air. The only one I can name offhand was the requirement that insurance companies spend at least 80-85% of revenue on medical expenses. At least one person noted that might also lead to higher costs (via overpaying to let that overhead grow), though I think that that's the kind of problem that market factors would actually address - if you're overpaying, that money has to come from somewhere so you're also charging higher premiums and will shed customers as they seek cheaper insurance.
Other cost-cutting measures have been killed off through effective lobbying (e.g. Medicare being barred by law from negotiating drug prices, introduced back with Medicare Part D and the Donut Hole).
And yes, the general fitness level of Americans is pretty poor. Unfortunately, addressing that is more of a public health matter, and since the onset of modern medicine public health has been more and more relegated to a secondary role. Interestingly, some insurance companies seem to be trying to revive non-medical measures to improve the health of their customers through things like discounts for fitness assessments, fitness programs, etc. The assessments and advice resulting from them may make a difference, but even just the embarrassment factor of being unfit and going for one may help change behaviors.
I'll just note that in general, obesity is different from anorexia - fat people realize they're fat, are often concerned or embarrassed about it, and a large percentage of them would like to be be if not thin at least a lot less fat.
1. Rate Review & the 80:20 rule: http://obamacarefacts.com/obamacare-rate-review-80-20-rule/
2. IBAP or "death panels" if you're a halfwit politician from Alaska: https://en.wikipedia.org/wiki/Independent_Payment_Advisory_B...
3. Readmission Reductions Program where hospitals won't be reimbursed if patients come back with the same issues: https://www.cms.gov/medicare/medicare-fee-for-service-paymen...
4. The HCFAC was given an extra $350M to combat fraud and absuse: https://oig.hhs.gov/reports-and-publications/hcfac/index.asp
5. The ACA authorized CMS to run background checks and site visits (which were previously forbidden) on providers to ensure they're legitimate.
6. The ACA authorized CMS to withhold payments if fraud is suspected -- Previously they were required to pay, then try to get the money back.
7. The ACA greatly expanded the Recovery Audit Contractor program to Medicare C and D, mandating post-billing audits of Medicare providers.
8. The ACA gave the OIG the ability to levy large fines ($50,000/false statement) on providers who defraud health programs.
9. The ACA created a centralized databank to share claims information between Medicare/Medicaid/CHIP/VA/DOD/SSDI.
10. There are a litany of provisions about home health care, hospice, nursing homes, and other areas that were formerly high-risk fraud areas. New penalties, restrictions, enforcement mechanisms, etc.
11. The ACA reduces payments to hospitals that have high incidence of hospital-acquired infections in their patients.
12. The ACA greatly expanded competitive bidding for durable medical equipment ensuring that nearly all categories now will have a proper bidding process and regular price updates.
13. The ACA expanded the prescription drug rebate program: https://www.medicaid.gov/medicaid/prescription-drugs/medicai...
14. The ACA established the Center for Medicare/Medicaid Innovation which research and perform trials of new care delivery models with a focus on lower-cost, higher-quality service.
15. The Bundled Payments for Care Improvement changes the focus of hospitals by providing a target cost for an admission instead of paying for each service the patient receives. So if you go to the hospital with a kidney infection, instead of performing every test in the world on you to run up their reimbursement rate, the hospital is now focused on the lowest cost care that will prevent readmission: https://innovation.cms.gov/initiatives/bundled-payments/
I mean.. there are literally hundreds of cost-control provisions..
In addition while this is a contentious subject telling people to "reconsider your certainty [...] if you don't know basic facts" is needlessly confrontational.
You say this is like a bad thing. Shouldn't the healthier members of society be happy to contribute to the health of those less fortunate?
Gross to think otherwise.
It really depends on the people you have in your society and what the sick people are contributing.
Getting sick needs to have some kind of downside to it. Else people have no incentive to stay healthy. They can take as many risks as they want to their personal health because it's going to be paid for by other healthy people.
America in particular has a large obese population which is addicted to popping pills and overmedicating in general. If you give people free license to eat whatever they want or take as many drugs as they want without consequence our healthcare costs are going to be unaffordable very soon (they nearly already are)
Once you are in a system where everyone is forced to contribute, one person's actions affect others. If you don't take care of yourself and get sick, others are forced to pay for you. If you have too many people who don't take care of themselves, the healthy people are the ones who get screwed because it's effectively a wealth transfer: They're paying for sick people to have the license to do whatever they want.
The reality is that sick people are a drain on society's resources. Obviously we need a humane solution to treat them but the answer shouldn't just be a blank check. There are sick people who require hundreds of thousands of care YEARLY. They are not temporarily sick, they are permanently sick. I dont' think it's fair that they pay the same rate as healthy people. If you are permanently sick, that sucks but you should pay more of the burden.
Yeah it would suck if illness affected your ability to be physically active, gain and keep employment, be part of a happy relationship, enjoy hobbies, etc.
It's great that you've found a way to punish people financially so those ill freeriders don't get off Scott free.
If you remove any sense of personal responsibility from people's health, they will have no incentive to take care of of themselves. Everything they suffer will be covered by insurance (ie. other healthy people). That's how it is right now. Healthy people are not signing up for these shitty health insurance plans because they are being forced to pay for sick people who eat up 80% ( or some ridiculous number, i don't know what it is) of the actual costs.
It's not about "punishment". it's about people paying their own way. If other people were paying for your car insurance they why not speed, drive drunk, drive recklessly, etc. You are not personally liable for any of your driving consequences.
The reality is that people who are sick are a drain on resources. We have to decide , rationally, how much other people should be forced to pay for these sick people. If you are fine joining a health insurance plan with these people and paying more then fine, all the power to you. So are you doing that?
What I read, and I did read this online and haven't had the time to look for primary sources so please take with a grain of salt, but worth looking into is this:
pre-existing condition check was a major risk to the insurance industry since nobody knew how much it was going to cost them. So the ACA told insurance companies we'll subsidize some of your costs until things settle down (this is different than subsidizing people's payments). However when it came time for the gov to pay, Republicans blocked most of the subsidy payments to health insurance companies (I think they only received 12% of the expected amount).
And then because insurance companies didn't get that subsidy they obviously passed the cost onto consumers. And I'm sure whatever subsidy was further promised by the Gov they could no longer rely on so they priced that risk in as well.
And despite all of that, health care cost growth still dropped
The GP comment is just another example of how there's a ton of uninformed anger on this issue. People are spitting mad because they're realizing that health care is becoming really expensive, and they think the ACA is to blame because they heard about the ACA last. The amount of actual understanding approaches zero, because few people pay for their own healthcare in the USA.
I kind of want the GOP to just burn everything down and expose everyone to the full pain of this absurd system (in true, "free market" fashion). We'll have a political revolution overnight.
You can argue that cost increases are due to all of those previously uninsured sick people who are now insured and costing the rest of us money, but that's both wrong (costs have been going up faster than inflation for decades), and a pretty awful worldview.
"I decided to leave my job and get an ACA plan for my family, while trying to bootstrap my company."
Before the ACA, because you couldn't have gotten any health care coverage at all. Thus after the ACA, you had an opportunity that would not have been possible (safely) previously.
As a Canadian with full health coverage, without any special requirements except renewing a picture card every 5 years, this looks like a very dangerous situations for millions of poor people. And while the system isn't perfect, and we do have some wait list on special cases, most heavy or light illness get treated quickly.
Even for the richer US citizens, it seems like a waste of time and a big overhead + legal battles looming on possible contract conflicts.
In term of equality of chances for that "American dream", this looks like the biggest imbalance one can imagine, just beside education.
The federal government imposed limitations on the ability of private firms to offer higher wages, so that the government could more easily recruit workers for war industry. Private employers found a loophole. Offering health insurance.
Still, we all know what it's like to have a major design flaw in the legacy codebase.
The counterpoint is course you're able to take more risks when you have fewer life-dependent expenses, so we should just pay for everyone's utilities, food, and housing too. You might even throw expenses for dependents in there too for older folks. What's special about healthcare except that it's expensive?
Great question. Everyone needs food, everyone needs shelter, everyone needs medical care, but this deep passion only exists for the last item.
My opinion is because the system we have today is basically a wealth transfer from the taxpayers to large interest groups (nurses' unions, big pharma, etc).
Programs exist to make food and shelter universally available, as well, and while imperfect, the proportion of the population unable to afford food or shelter is lower than the pre (or even post) ACA rate of people being unable to afford healthcare.
The fact that the problem is less solved for healthcare is probably why there is more visible passion on the issue.
(I'm the first story in the article)
Deaths due to homelessness (2010)[2]: 700
Deaths due to lack of medical care (2009)[3]: 45,000
What's different is the magnitude. Although the United State's patchwork of services for the homeless is ostensibly supposed to give everyone access to food and shelter, people do fall through the cracks. But it is not an endemic problem like lack of health care.
[1] Debatable, and I can't find a solid source. The only malnutrition related deaths I can find are in elderly populations and abused children.
[2] http://www.nationalhomeless.org/publications/winter_weather/...
[3] http://news.harvard.edu/gazette/story/2009/09/new-study-find... this is a higher end estimate from 2009, the lowest estimate I could find was 18,000 from a study done in 2002
The healthcare system is totally a disaster, and it really should be fixed, but giving college-aged kids a free pass for a few more years isn't really a solution.
This list of founders who were able to make the leap thanks to ACA's safety net is a case in point. Under Republican policies, these businesses would not exist.
I would also personally rather have health insurance actually act as insurance, where you are granted the coverage at the time of diagnosis, rather than having the insurer gradually pay for treatment, but this is unlikely to come to pass.
It also provides for those who may never be able to earn enough working to pay for current health insurance, those who are retraining latter in life, and those starting a company.
We should not have to have an insurance policy for a doctor check out that weird lump on our thigh or come in and spend 10 seconds pretending to talk to us before scribbling out a prescription for something that vaguely sounds appropriate and walking out.
Insurance is what distorts these markets. Patients need to pay doctors directly again. Real competition needs to be returned. Right now, the doctor inflates their bill 5x because they know the insurance is going to talk them down, the insurance talks them down because they know they're going to inflate the bill and not worry about it since it's an insurance company paying out, and round and round we go.
There's no reason the market for medical care needs to be different than the market for food, which is cheap and abundant. People often say that you can't can have an efficient medical marketplace because medical care is emergent, but that's usually not true; most medical care, like most meal times, can wait long enough to allow the patient to make a choice between competitors, and providers who charge more than the average demographic in their area can afford will go out of business.
The incentive to overcharge for emergent care is countered by the incentive to compete, which has already lead to many "urgent care centers" arising throughout the U.S. Good government regulations that prevent cartels from organizing and causing the markets to freeze up/fail can help. These regulations should include outlawing medical insurance.
Whatever the solution is, the current situation is an abject failure. ACA band-aids a couple of warts but it gave us new wounds in the process. Whole thing needs to be torn down and rebooted based on sound market principles.
The FDP (Free Democratic Party) claims to go for liberal rules so businesses can strive. Somehow this mostly includes rules for big corps, with the remark that they provide employment.
Funny thing is, the head of FDP is a guy who burned about 3,4M€ of investment money and federal credit.
There are always parties with nice ideas, but when you see who donates money to them, you understand why they can't realize them :\
The total cost of my health insurance premiums is about 20k/year; some of this is subsidized by my employer. I have a $4500 deductible. The insurance does not pay for anything, outside of preventative care, until I've paid $4500. After that, they contribute 80% up to some number, $7500 I think, and then they contribute 100% until the end of the calendar year.
Because I have such a high deductible, and due to the opacity of medical billing, I am not going to the doctor unless I'm pretty sure that not going to the doctor means I'm going to be put out of work or going to die. "Preventative" care is defined very strictly: you get a physical. For example, "preventing" the development of pneumonia by treating your respiratory illness early does not count as preventative care.
The best I can do is squirrel away what I can in my HSA...but that's one health catastrophe from being blown away. God forbid I come down with any kind of chronic illness that lasts longer than the calendar year.
That said, for the poor population, this is definitely true - Medicaid is a dream compared to private insurance. At least in my state, if you're on Medicaid, you don't even see medical bills. It's really lamentable the states were allowed to turn down the Medicaid expansion - the expansion of public health insurance was the best part of the ACA, in my opinion, and the most regrettable part of the bill is that the public option is not available to everyone.
That doesn't sound right - What is your maximum out of pocket?
Also, those numbers include only in-network providers. If I am given out-of-network care - which isn't always under my control - then I could potentially be on the hook for tens of thousands more dollars.
- An out-of-network providers gives you medical attention at an in-provider facility - maybe your ER doctor, surprise, is not in-network, even though the hospital is in-network. [1] [2] [3]
- Maybe you have a medical emergency and the closest facility at the time is out-of-network. (In some states and with some insurers under some circumstances, you can get them to pay the difference for emergency out-of-network care.)
The biggest risk factor is the "normal" <= $7500 medical bill from an in-network provider, but inadvertent out-of-network care is still something you have to be concerned about.
Also, I'm not sure if I'm reading you right, but "in-network" does not necessarily have anything to do with geography - sure, there exist in-network providers for my insurance throughout the country, but the second-closest hospital to me is still out-of-network.
[1] http://justcareusa.org/beware-of-out-of-network-er-bills/ [2] http://www.consumerreports.org/cro/news/2014/10/protect-your... [3] http://www.realclearhealth.com/articles/2017/01/09/in_throug...
EDIT: The HN backoff must be crazy high - 40 minutes later, and I still can't post, and I'll be offline the rest of the day.
Because the ACA didn't fix it. From my perspective, it was largely a giveaway to private insurance companies with some fortunate side effects.
The total cost for my health insurance premiums are 20k a year.
My in-network deductible is $4500.
My in-network out of pocket is $7500.
My out-of-network out of pocket is $20k.
Those are not hypotheticals, and because of those costs, I avoid medical care unless it is absolutely necessary. I'm afraid we're getting into the weeds - my main point is that the ACA's preventative care provisions are really quite weak and don't mean what we might think they'd mean; the preponderance of high deductibles and out-of-pocket maximums mean that people will continue to avoid getting prompt medical care until their condition becomes serious. The preventative benefit, mainly, is that everyone gets a yearly physical and a few other narrow types of preventative care.
You also said that your costs were 20k a year, but now you're talking about hypotheticals?
Well, you can make the argument for preventive care on medical grounds or even moral ones, but you can't say it actually saves money. When people have access to preventive care, they also tend to consume more, which means greater costs (although better overall care)[0].
This has borne out with the ACA[1], as the data shows that preventive costs increased faster than chronic and acute care costs dropped, by a very significant margin.
[0] https://prescriptions.blogs.nytimes.com/2009/09/03/when-prev...
[1] https://www.nytimes.com/2015/08/06/upshot/no-giving-more-peo...
The ACA report last month shows the opposite of what you're saying, that oupatient costs have dropped more than inpatient costs have risen, and that medical prices have not risen more than inflation.
Page 58+ here: https://www.whitehouse.gov/sites/default/files/page/files/20...
That's not actually the opposite of what I said. Outpatient vs. inpatient isn't the same comparison as preventive vs. responsive care. You're comparing apples and oranges.
> You should really read articles before you cite them
From the Hacker News guidelines:
> Avoid gratuitous negativity.... Please don't insinuate that someone hasn't read an article. "Did you even read the article? It mentions that" can be shortened to "The article mentions that."
The majority of inpatient treatments are responsive healthcare, e.g. emergency, major surgeries, ICU/NICU, burn unit, etc.
Also, when you present an article as a source for something that it is not, then it is valid to question if you read it and present why, like I did. The full sentence of what I said is valid by HN rules, even if you attempt to quote it out of context:
>You should really read articles before you cite them, because neither use data after 2014, when the ACA provisions took effect.
This is absolutely not true, and in fact some of the things you list aren't even preventive care.
>Many Medical Investigations and treatments for acute and chronic illnesses and preventive health care can be performed on an ambulatory basis
Moreover, in the case of expensive or catastrophic coverage, society is picking up those costs anyway (or alternately, just letting people die). Your premiums then go to cover the costs of people who wound up declaring bankruptcy. And no insurance (or bad insurance) cuts into preventative care that can detect problems early, when they're much cheaper to treat.
I support the ACA (or better yet, much more socialized models) because I want to optimize for overall economic productivity.
I agree an employer based model does discriminate against startups, but my point is that the ACA also makes it harder for the median entrepreneur to succeed. The fact that the fringe cases can start companies does not to me justify the drain on all other entrepreneurs.
Without ACA, a software engineer with a chronic illness wouldn't be able to start a business. Meanwhile, a healthy software engineer will start a business regardless of ACA because a minor difference in healthcare premiums is not material to that decision.
People pay into a pool and if one day they too become ill they'll need to draw on that. Prior to the ACA it was in the best interest of insurers to simply eject all the "sick" people from the pool. What use is insurance if when you really need it they cut you off?
This hurts everyone. It's not about paying more in premiums. It's about insurance that sticks around when the shit hits the fan.
There is a big distinction between "pro free enterprise" and "pro business". The former supports capitalism, the latter crony capitalism.
> Under Republican policies, these businesses would not exist
I think the GOP has yet to figure out what their health care policy even is. They really need to figure out how to be for something again.
Neither party is really in favor of free markets in any meaningful sense. The GOP happens to use that rhetoric more than the Democrats do in order to gain support for their policies, but knowing how to leverage the rhetoric doesn't mean that's what they actually support, if you look at their actions.
I'm not sure what the policy is, but I know they don't have a plan. I can't find the link, but I heard a spot on NPR (either Fresh Air or Here & Now) talking about the plan to repeal the ACA. The purported goal was to vote immediately to repeal it but delay the effective date. There's no plan. In the mean time, they're supposed to figure it all out.
A few years ago Ted Cruz and company very nearly shut down the government and defaulted on the national debt, insisting that raising it was irresponsible and laying it at the feet of President Obama. They insisted any increase in spending had to be offset by a cut somewhere else. Sounds like a really bold, principled stand. Then this:
http://www.patheos.com/blogs/dispatches/2017/01/11/republica...
Now that Republicans are fully in charge, they just authorized an escalating increase of the debt limit, running from $580B/year (2017) to $946B/year (2026), or a $10T increase over the next 10 years. There was no dissent, it was just quietly passed. I'm not saying it was wrong or irresponsible to do -- I'm just saying the politics are transparent, if they weren't already.
edit: what I said is 100% correct, so I will assume that the downvotes are simply political in nature.
I think it's pretty clear at this point that both parties love getting involved in the private affairs of individuals. Obama continued Bush-era spying policies, and in fact just this week (https://news.ycombinator.com/item?id=13390511) expanded the power of the intelligence community to snoop on Americans.
Blaming just one political party is demonstrable nonsense.
Growing the deficit from $580bn to $950bn over 7 years means it is growing at over 6.2% per year. To be fair, the median nominal GDP growth rate between 1933 and 2015 was 6.4% [1]. That said, forecasted near-term growth is expected to come in between 2.5 and 3.5% [2].
The difference between the 6.2% deficit growth rate and 2.5 to 3.5% nominal GDP growth rate will need to be made up with a mix of tax increases (austerity), inflation (redistribution) or, while unlikely, default.
[1] http://www.multpl.com/us-gdp-growth-rate
[2] http://www.tradingeconomics.com/united-states/gdp-growth
Rand Paul dissented.
https://www.youtube.com/watch?v=SBWJ_LW_hBI
As a liberal-leaning person, I disagree with Rand Paul on many policy issues, but respect the fact that his actions are consistent with his stated ideals, which is becoming increasingly rare.
The ACA also allowed me to pursue founding a company. 6 months before the ACA kicked in, I left my job to start a robotics company. As I was only 29 years old, I did not think it would be a problem getting individual health insurance -- I had done it in the past when attempting my first venture.
What ended up happening was that every health insurance company rejected me for having the pre-existing condition of asthma! It made no sense as I was very healthy and my asthma under control as long as I took a control inhaler everyday. The cost of my medicine would be way less than the premiums I paid -- but some actuary somewhere decided I was too high risk!
For 6 months, I was scared of getting sick or injured -- to the point where I was considering giving up to get a job just for health insurance. That thought to me was just so ridiculous and heartbreaking that I couldn't do it --I just kept telling myself that I had to make it to Jan 1.
I was overjoyed the day I got my insurance card -- it was a huge sense of relief. What brought me even more joy was knowing all my fellow Americans whom also could not get or afford insurance could finally receive it.
Today I no longer need the ACA -- our company is doing great, we're well-capitalized, and provide excellent health insurance to all of our employees. Without the ACA, this dream would not have been possible. We were able to create wealth and jobs because of the ACA -- it makes no sense to repeal it.
Even before I needed the ACA -- I had enough empathy to know that every person has the right to health care and one of the biggest reasons I voted for President Obama. When it affected me personally, it obviously hit even harder. The GOP's lack of empathy as well as a real solution to the problem are just infuriating -- it is absolutely shameful and disgusting how they are attempting to repeal this law.
So perhaps Sam is happy about all the ways in which the ACA has helped much younger entrepreneurs get off the ground with their companies, but a significant portion of the population is being impacted in a very negative way. Maybe he believes that only young people should be starting startups in the first place, but we know that's an absurd proposition. Even if I was under 26 I wouldn't have been able to rely on my parents for health insurance because they were unemployed. The only way I can make this all work is to claim a low enough income to qualify for medical assistance which is going to be hard to work out because of my monthly expenses.
What I really wish I could do is pay for a very low premium "catastrophe" plan with an absurdly high deductible like $50k, because my family is very healthy and I have enough in retirement savings (IRA, HSA, 401K, etc) to cover it should something severe happen. In other words, I wish I could just buy health insurance that was like my car insurance. But I'm being forced to pay for a plan with far more bells and whistles than my family will ever use or frankly even wants to use.
Just take hope! If you can just make it through this year you won't have to worry about the question of purchasing insurance as an individual, because as a family with several preexisting conditions (fertile female, children/disease and injury vectors) without the ACA you'll be effectively uninsurable unless you can grow your startup fast enough to make a group plan feasible.
[1] https://mn.gov/mnsure-stat/assets/2017-MNsure-healthcare-cov...
I've been on hold with MNSure for 2 hours so far today and I can't start an application until I talk to customer support because of some problem in their system. The whole thing has been a giant comedy of errors so far. I'm definitely not a fan of the ACA.
One thing that I discovered when I did that my first year was that the big difference between some of the Gold plans and the Silver plans was pretty much only in the minimum amount I'd be paying per month as premiums - the maximum out of pocket was pretty much the same and there wasn't that much variation in my "expected" out of pocket - I was just paying it as higher copays IF we did go to the doctor or as a higher premium regardless of whether we went to the doctor.
Something to watch out for is "coinsurance after deductible" aka "you get bupkis until you've used a lot of care." With school-age kids and probably a minimum of one checkup/physical per year per child plus vaccinations, etc. you might be better off looking for a plan with copays even if the premium is a bit higher. It's also worth looking at the emergency coverage, there can be some variation in there.
Oh, and check the provider network - BCBSIL at least has different provider network levels, so if you see seemingly-similar plans from the same carrier with a significant price difference it may mean that most providers or hospitals are going to be out-of-network which means you pay more.
Good luck
But here's the thing, pre-ACA and post-ACA plans are not remotely directly comparable. Pre-ACA plans could reject you for pre-existing conditions, drop your coverage if you got sick and became too expensive to insure (recission), or had maximum lifetime limits that would leave you bankrupt if you got a serious chronic illness (think expensive cancer treatments). All of these practices are now banned under the ACA.
Does anyone remember applying for individual health insurance prior to the ACA? It was a nightmare. You had to fill out a 30-page questionnaire regarding your health history, and if you made any mistakes, the insurance company would have cause to deny your claims if you ever got sick. You weren't sure if your insurance would actually pay out when you needed it. And that's assuming they even approved you in the first place.
So yes, health insurance costs more now, but you have to ask yourself, was that $50-100/month plan you were paying for really health insurance if they could drop your coverage just because you were getting too expensive for them? Besides, in exchange for paying more, a lot of people less fortunate than myself can now get coverage, and I know my coverage will actually pay out in the event that I become seriously ill. So overall, despite the additional cost, I think it's a net improvement.
It's not perfect, however. It still leaves too much power in the hands of the insurance companies, who are essentially middlemen squeezing the health care industry from both ends: charging higher premiums to patients and paying less to doctors, so they can extract a profit in the middle. Ultimately we need to transition to a single-payer system where insurance is administered by a government entity instead of profit-seeking corporations.
This is how every other modern country in the world does it, and the result is better health outcomes than the US. It's absurd how behind the times we are on this front.
Yeah, the significance of rescission and the ACA's prohibition is often overlooked. Prior to the ACA, if you got sick enough and expensive enough, insurance companies could -- while you had outstanding claims, and this happened while people were in the hospital -- retroactively cancel your insurance, refund your premiums, and walk away leaving you fully liable not only for any future healthcare, but for anything they hadn't paid for yet from the time when you had coverage. Now, this could generally only be done based on an omission or inaccuracy in initial disclosures, usually related to a preexisting condition, but there was no requirement (federally, some states had controls) that the be intentional or significant, and insurance companies would hunt out errors once care got expensive.
The ACA elimination of exclusion for preexisting conditions itself elominated most of the basis for rescission and the onerous disclosure requirements that it was based on errors in, but the ACA also explicitly prohibited it except for fraud or intentional misrepresentation of material facts.
My job ended in January '16. I got a large severance and left the US for 7 months. I sold some stock in July, but other than that, my income was $0 each month. Looking forward, my income was likely to be just as erratic, with most months being $0. After spending way too much time talking with the folks at CoveredCA trying to figure out just how to fill out the forms for such an uncertain income level, I finally got all the information on my application and got denied. I couldn't even buy an unsubsidized plan. The exchange failed hard for my scenario and I ended up having to buy insurance directly from the health insurance company I was with when I was employed. It was quick and easy and cheaper than it would have been on the exchanges. And now, to add insult to injury, I'm probably going to have to pay a penalty for not having US health insurance for all those months that I wasn't living in the US, since I'm pretty sure I didn't pass the threshold for being a non-resident.
As a programmer, I'm all to familiar with code that handles the 90% case and just assumes those other edge cases don't exist. It's lazy and error prone and a sign of an amateur programmer. The ACA feels like the legislative equivalent of that sort of code. In their hurry to create a system where the majority of those without health coverage could get it, they created a system that's truly terrible for edge cases like me.
The MediCal denial makes sense. I don't see why I should have the state pay the entirety of my medical insurance costs when I'm making that much money. I also would like more choice when it comes to my doctor and treatment than MediCal allows and I'm willing to pay for it. The CoveredCA part is baffling to me. Why I'm not allowed to purchase health insurance with no premium assistance because I don't have a steady income leads me to believe that the ACA is poorly-written legislation.
I think the anti-ACA lobby sees this as a feature not a bug.
Similarly, a lot of people that support the ACA don't support the ideas behind it, as much as they support something being done from the previous, untenable situation. Obama took mostly Republican ideas and ran with them, now the Republicans have disavowed any involvement with them, and Democrats have adopted them as good (or at least better than what was there before, even ACA supporters acknowledge that it's a deep compromise from what anybody wanted.)
I think that the attitude of "it's going to help my side or nobody" is a much stronger driving force than the desire to prevent people from taking entrepreneurial risks.
The normal institutions of the Senate - primarily, the filibuster - were bypassed in the name of the effecting the greater good. But this also leaves the repeal option open today to a simple procedure that in turn will bypass the filibuster.
In light of the recent election, the ACA will be repealed. the initial votes to do this have already been had and the partisan lines drawn.
There was immense political fallout to the party in power back in 2009 when ACA was passed using shortcut techniques. Many walked the plank, whether wittingly or not, when they cast crucial votes in support of a strictly partisan outcome.
I believe the same will happen to those currently in power if they attempt to jam through purely partisan solutions in support of the ACA replacement, whatever that will be.
Those in power know this and I believe this gives the party out of power leverage to attempt to salvage the more important elements of ACA (many of which are noted in the founder anecdotes cited in this piece).
Given who is in power, any replacement will involve a decided swing back toward free market and away from the single-payer direction that the losing candidate had favored. Among other things, I believe any replacement plan will: (1) do away with the mandate requiring everybody to buy health insurance or pay a penalty; (2) do away with the idea that all policies must be comprehensive and outlawing "skinny" coverage of the type most young people desire (in other words, the replacement will allow insurers once again to offer cheaper policies that appeal to young, healthy people who want to cover only catastrophic risks and do not want coverage for a broad range of other things they likely will not need); (3) do away with penalties imposed on employers who fail to provide health care coverage to their full-time workers (thus causing at least some employers to limit the number of hours many of their employees could work so they could stay within the definition of "part-time"). In other words, far more elements of free-market choice will be brought into the mix. Beyond that, who knows.
Whatever else, I believe we can be assured that whatever emerges will hardly be "affordable" care. Our health insurance system is an utter mess and has been for many years predating the ACA. I can hope for the best but, in this area, have come to expect the worst, whoever may be in power.
If I have to go to the ER and have a hospital bill so high that I literally cannot afford it, I will just declare bankruptcy. After all, it's not like I have any money to lose. And bankruptcy will disappear after 7 years.
This is selfish, but I really don't give a shit. The healthcare system is so messed up and overpriced that I feel no social obligation to it.
So, to pursue some things on my own time I had to negotiate a sabbatical with my company (which they generously allowed), so I could stay on employer health insurance.
If I wasn't able to do that, I'd be up shit creek, because there's no way in hell I'd risk my wife getting pregnant without health insurance.
I hope more and more people decide they feel no social obligation to things. Mass peaceful "law breaking" is really the best option, imo.
This is incredibly naive and ignores a lot of the political and theoretical underpinnings of our society and our country. https://en.wikipedia.org/wiki/Social_contract
FWIW, I used to be solidly in the "social contract" camp, and over the last few years have walked out of that camp, na'er to return.
Want to see how that argument feels when reversed?
"Your blind adherence to the maintenance of the state, despite vast evidence that it's a force of oppression shows an incredibly naïve view of the goodness and trustworthiness of man and institutions composed of members of the human race."
See? not much fun. Lets get a little more nuanced, and talk about, perhaps, at which point might a society by improved by ignoring the "social contract". Do you think that point CAN be reached? If so, when? What must we do when it IS reached?
Seven years is a long time, especially if you want to get married or have kids or get credit or not pay a ton in interest. Note also that bad outcomes in this case will compound; you've had a catastrophic injury and now you have higher interest rates and everything else.
However, missing, as far as I can tell, is the critique of health care that startups and the open source movement stand to make - a point which the ACA ignores:
Health care has a gatekeeper problem. And an IP problem. Many people find that medical doctors are only a part - maybe a small part - of their health care regiment. And that being and staying healthy has little in common with the official positions of agencies from HHS (especially FDA) to EPA.
The ACA enshrines insurance, pharma, and hospital companies, including those that are the biggest parts of the problem in health care in the USA.
For my part, I need to hear how we can move away from the credentialist model of care toward an open source model before I can become impassioned about any plan.
Absolutely agree. The ACA (or repealing the ACA) are both "solutions" to the wrong problem. So much potential innovation in the health care space is illegal. If it wasn't illegal, someone might (gasp!) find a way to provide a valuable service for less money than in the current system.
It will not, and cannot, be fixed by regulation, because of what you said - any regulation MUST be approved by the big companies. They'll never approve something that goes against their interests.
"Health Care’s Bipartisan Problem: The Sick Are Expensive and Someone Has to Pay"
http://www.wsj.com/articles/health-cares-bipartisan-problem-...
Improvements definitely need to be made though, I'd rather have Medicare like my grandparents and I have a hard time understanding why people are so against national healthcare or even exploring the idea.
Have you been to a doctor before? Then you might have a pre-existing condition.
If you don't have employer-provided health insurance, you're still basically screwed even under the ACA.
This could not be further from reality. We have more government distortions in our healthcare market than countries with completely socialized healthcare. For example:
Medicare: socialized medicare for the elderly, which alone creates more distortion than a universal program would cause by inflating demand/prices for non-qualifying citizens.
Medicaid: socialized healthcare for specially qualifying poor people, which creates the same distortion as Medicare.
An oppressive FDA: which, coupled with overly-powered IP laws, grants de-facto monopolies in the medical product industry. We have an incredibly expensive and subjective medical equipment pre-approval process (as compared to a less-terrible FDA that would just be in charge of labeling, preventing fraud, and maintaining accountability in the event of incidents). Then there's the length and flexibility of patent protections in our current system (maybe we could cut those protection times in half, and patent trolling would not be a lucrative industry).
Oppressive occupational licensing: It's way too hard to become a doctor of any kind, even the kinds that don't manually put things into your heart. This will be a major battle as AI comes to the point where it can better diagnose conditions and largely replace generic/non-specialized pediatrics. Of course, the government will not make this easy.
Plus a slew of more minor things like malpractice regulation, and now the ACA (which is not so minor).
If we cleaned up/removed all of the problems in the above and replaced it with single payer, it would be OK and we would have something similar to Canada/other countries with long wait times, not much access to specialists, and a system where the government gets to decide who gets the last liver transplant and who dies.
Or we could try going the free-ish market approach and try to find a much freer balance with the FDA/USDA/occupational-licensing/scrap Medicare/Medicaid,etc., which we do not currently have AT ALL.
Is there any country that has implemented this successfully?
So, do you think everything's already been solved? There have been 100 billion people in Earth's history. Wouldn't you think one of them would have proved P vs NP by now?
If you have a legitimate argument against a cleaner, free(r), less corrupt health-care system, feel free to bring it forward.
But no, in modern medicine's one century of existence, the problem of finding the best health-care implementation has almost certainly not been solved. In fact, only a dozen or so countries have had the economic capability to sustain modern medical practice on a large scale for more than a couple decades. The others constitute the "second/third worlds."
Just ask any veterans relying on the VA how satisfied they are. On a tangent, universal health care is not 'great' anywhere, and the bigger the country, the less compelling the evidence (diseconomies of scale -- see Canada/England vs. Switzerland for example). And our country benefits from another order of magnitude of diseconomies of scale/bureaucratic bloat in trying to institute such a program.
So, moral of the story is that if it somehow did not end up making our healthcare system significantly better than universal healthcare countries, then we could still let states that lean a certain direction handle the bureaucracy of a universal healthcare system with slightly more efficiency.
I don't think there is. I think in many cases, what starts out as a "free market" is ultimately overtaken by a few large corporations (as others fold or get acquired) which then proceed to abuse their position of dominance to engage in monopolistic rent-seeking behavior to maximize their profits at the expense of everyone else. Think Microsoft abusing their dominance of Windows, or Intel abusing their position to prevent PC manufacturers from using AMD products. We're starting to get there with iOS and Android being the only two remaining choices for mobile, and Facebook for social.
My concern is even if you could hit a magic reset switch and turn the health care industry into a free market, it would trend the same way. Insurance companies would grow in size and squeeze the health care industry from both ends, charging patients more and more money, while paying doctors less and less, all so they can squeeze out a larger profit. Pharmaceutical companies would jack up the prices of their drugs because they have a captive audience, they know you're going to pay up because your life is at stake, all so they can squeeze out a larger profit.
It's questionable to me if the medical system could ever act like a free market:
1. In emergency situations you often don't have the opportunity to "shop around" for care.
2. If a pharmaceutical company is the sole manufacturer of a life-saving drug, what stops them from jacking up the price of said drug to maximize their profits, at the expense of patient lives?
3. If paying for someone's medical treatment is unprofitable, insurance companies have an incentive to drop that person's coverage instead of paying for treatment. (And often did pre-ACA.) How could a free market possibly address this situation?
Universal health care systems around the world are not perfect, but many countries have implemented them successfully and as a result spend less money on health care (as a percentage of GDP) than the US while simultaneously having better health outcomes. Why not move towards the known quantity which has already been tested and proven by every other modern country in the world, instead of this hypothetical free market system which we've never seen before, and frankly, sounds rather dubious in light of my questions above (especially (3))?
Yes, that's crony capitalism, not a free market. There is no such thing as a natural, malevolent monopoly (except for governments). They require special government privileges to maintain dominance for long, or they will fall to competition in a free market (or have to become benevolent enough so that they still maintain market share with consumers).
Corruption isn't something you just "solve" in any part of government. Except, maybe, in a government made up solely of AI/programs. But anyway, for now it's fair to assume that it's an eternal problem that plagues government, and in fact it is the problem with our current FDA. So do we just give in? No, let's continuously reset it, be vigilant, and avoid giving the government "privilege-granting" powers that allow it to enable rent-seeking in the first place, so that we don't need to do frequent resetting.
> It's questionable to me if the medical system could ever act like a free market:
Whether healthcare can be a free market is a different issue, and I've heard people even say it's inherently an immoral industry. I think healthcare is perhaps the MOST moral industry inherently, but the idea of medical insurance specifically is terrible to me, because for many people, healthcare is something they access frequently throughout their lives. I don't think health insurance is compatible with a free market, and probably constitutes fraud. The whole business plan of insurance is that people are hedging against risk/accidents, and will end up paying in more on average than they take out, but in reality health insurance is intended to cover WAY more than that as it currently stands. "Accident" insurance makes a lot more sense to me, and it's compatible with the idea of insurance (broken arms/trauma/etc.). But even serious illnesses are not really unexpected, because almost everyone gets them -- it's just a question of when. I think all medical expenses should be paid out of pocket. This is completely unreasonable in our current expensive, heavily and unfairly subsidized system, but if we refactor the system and take health insurance out of the equation, it's hard to imagine just how much costs would come down. Looking at the costs of raw materials and labor, there is absolutely no reason this should be so unattainable, and it's far more "fair." Yes, some poor people who got bad genes all around are going to have a more difficult time than a healthy or wealthy person and will have to pick and choose healthcare options that would be in their body's best interest, but such is life. Scarcity exists, and even the entire healthcare industry cannot keep one person alive forever. Side note: the majority of a person's lifelong medical expenses are incurred in the final two years of his or her life. There is finite medical care, and there is diminishing return (measured in hours/$) for how long you can keep a dying person alive another day. This is not a solvable problem with a socialist system -- there is INFINITE demand, so we need to let the market increase the supply as best it can (which is via competition, freedom, and profit motive).
So I think that answers number 3, where I very much agree with you. Number 1 as well, because you had the option to "shop around" for your accident insurance which should have you covered wherever your insurance is valid. Number 2 is solved by the free market and my additional post on reducing patent lengths. But what if the drug was just invented and they are still the only ones allowed to manufacture it?? Here is the real misunderstanding I think you share with many of my liberal friends. THIS COMPANY JUST INVENTED A LIFE SAVING DRUG -- WITHOUT ITS INNOVATION, EVERYONE WITH THE CONDITION WOULD DIE, AND NOW SOME ARE LIVING WHO CAN AFFORD TO HELP THE COMPANY RECOUP THE R&D COSTS + INCENTIVES OF MAKING A LIFE SAVING DRUG. And eventually, when its protections expire, the price will come down as others enter the market. In fact, it would probably not be in the company's long term interests to price gouge because people will remember that when competitors enter (who hasn't heard Shkreli's name?). Basically, well-intentioned people like yourself would benefit people who depend on this drug in the short term, through government intervention, at the expense of innovation in the long term as fewer corporations are attracted by the riches that await them for furthering the medical field and saving people's lives.
I apologize for the length of this post -- this topic is near and dear to my heart.
You're getting close to "no true scotsman" territory here. Microsoft abusing its position in the PC market: crony capitalism, not a free market? Intel bullying AMD in the processor market: crony capitalism, not a free market? Are there any examples anywhere in the world of a truly free market then?
> "Accident" insurance makes a lot more sense to me, and it's compatible with the idea of insurance (broken arms/trauma/etc.). But even serious illnesses are not really unexpected, because almost everyone gets them -- it's just a question of when. I think all medical expenses should be paid out of pocket.
The problem is serious illnesses tend to be the most expensive. Even if health care costs were magically cut in half, cancer treatment would still bankrupt the vast majority of the population. So, tough luck for them?
> Basically, well-intentioned people like yourself would benefit people who depend on this drug in the short term, through government intervention, at the expense of innovation in the long term as fewer corporations are attracted by the riches that await them for furthering the medical field and saving people's lives.
Yeah... I'm not necessarily convinced that medical research should be a for-profit enterprise either, for exactly the reasons you mention. ("Should we research a cure for this disease?" "Our projections indicate it won't be profitable" "Ok, moving on then...")
I get that you believe free markets will solve the problem of expensive health care, I just don't see the mechanism behind it. So far it seems very hand-wavy to me. 1) Free markets. 2) ... 3) Cheap health care. What exactly happens in step 2? How do you prevent it from turning into an abusive "crony capitalism" situation?
The free market is an ideal -- I do see where you're coming from. But the market is never free so long as there are corruptible people in government or the framework does not fairly protect freedoms, but does that mean we shouldn't strive to get as close to the 'ideal' of a free market?
For the Microsoft example in particular, they didn't benefit from government intervention until the government "punished" them, by forcing them to provide a more inclusive platform. Makes you wonder if 90% of the PC market would still belong to Microsoft if the government had not gotten involved... might have pushed us toward open source/Mac OS sooner. In the other case, Intel just plagued AMD with legal bills, which perhaps says something about the way our legal framework is set up (can't countersue to cover legal costs), but Intel always provided a superior product so it's a quite stretch to say it was a "malevolent" monopoly. So you're right, neither of those are really crony capitalist examples, but that doesn't mean they contradict my points on market freedom and ill-willed monopolies.
I challenge you to provide an example of a longstanding, malevolent monopoly that did not rely on government privilege.
As to the points on medical care, I assume you agree?
I think "free markets" will inevitably trend towards "crony capitalism" as long as 1) government exists and consists of, as you say, corruptible people, and 2) money exists, and therefore can be used to influence said corruptible people. Therefore, even if you managed to hit a reset switch and turn health care into a "free market" and ran the experiment over and over again, 100% of the time it will turn back into the same "crony capitalism" mess that we're in now. What can I say, I'm a cynic at heart.
And I've already mentioned this, but it also seems kind of silly to advocate for this theoretical experiment (which may not actually be possible to implement) when there are already many other countries around the world that have successfully implemented universal health care (either single-payer or two-tiered systems) with better health outcomes than the US.
But you've taken this way off topic to be honest, because I am not advocating the ultra-pure free market ideal. I am advocating scaling back and reducing the scope of our excessive USDA/FDA (which would cause the same problems in a universal healthcare system regardless), reducing IP protections (same problems regardless of universal healthcare system), making it easier to become a doctor (also a problem regardless of whether we have universal healthcare) and getting rid of our existing lop-sided "universal" healthcare systems which would be irrelevant in a universal health-care system.
To my original point, we have the most government distorted healthcare market in the world so it really should not be so surprising that our system is the worst per dollar. You can't just add another "universal healthcare program" and expect all of the problems to go away -- there's a lot of cleanup to do. And even after that cleanup, I think it would be silly to resign ourselves to the mediocrity of other systems instead of seeking progress.
I agree that reducing IP protections is a good idea. I'm not sure I would call other systems mediocre. They're not perfect but they're far, far ahead of what we have in the US. I don't think that our country is so different from others that implementing a similar system wouldn't lead to an improved outcome as well. Anyways, thanks for the discussion.
The ACA has flaws but it also has some great features that need to persist: minimum care requirements, pre-existing condition exclusions banned (having a pulse is a pre-existing condition BTW), no lifetime caps on treatment.
What's the alternative? Still haven't heard anything.
But it's untrue to claim ACA provided benefits to any CA startup in terms of coverage, guaranteed issue or pre-existing conditions.
If you wanted to start a company in CA pre-ACA and you had prior credible coverage, you could get a great plan at a competitive price (the so-called "rating adjustment factor" was capped for the guarantee issue plans) with immediate coverage for pre-existing conditions.
But I am all for an alternative to what we have now or what we had.
The most important thing IMO is to make sure that people don't get hit by pre-existing conditions.
https://www.washingtonpost.com/opinions/why-is-the-number-of...
Example. Out of college. Got job. Had insurance and didn't think much of it. $2 all RX
Mid '80s had kid. 5 days in hospital (C section) and it cost $500. Insurance was 59 per month. (I making $36k)
Got thrown out of tech into federal job with federal insurance. Excellent coverage. Got $102k prostetic from New york hospital for< $5000 out of pocket.
My life with health insurance was been charmed. I am so glad I dont have to start like these young people.
Now that thats out of the way.
I hate the ACA. Its overreach by what the government should be doing. No where in the constitution does it say the government is allowed to force law abiding citizens to do something. ACA does exactly that. It forces people to do things against their will. Or they will be forced to pay a fine. Alright, don't down vote me just yet.
Lets repeal the ACA. But I certainly see things that should be quickly made into law.
* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.
* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
* Lastly, I want hospital prices published. I want to shop around.
* I am business friendly, but these are common sense laws.
I think EVERY Republican can get behind these thoughts as every other Democrat, but forcing me to pay for it, when I just want to live off the land in some small town somewhere. Complete overreach and strictly unconstitutional.
The problem with this POV is that young, healthy people end up having no insurance and thus leave the older, unhealthier population to pay all the bills, whereas a full-insured population would distribute the financial load.
Also, it would lead to young, healthy people foregoing insurance in order to save money, and then when catastrophes happen (you're talking about living on the land, so imagine something as harmless as scratching yourself on rusty farm equipment, being bitten by an animal... both can send you to the hospital for weeks!), these people would face financial ruin.
The purpose of mandatory healthcare thus is to protect elderly or otherwise pre-conditioned people from having to pay devastatingly high premiums, and to protect people literally from their own short-sightedness.
Also, if there's only 50k in the account and the bill is 100k, you're still straight screwed.
I think this is something that a lot of small-government conservatives don't want--it's moving responsibilities from the state governments to the federal government.
2) Sam Altman agrees with you that it's okay to repeal it as long as we maintain the best parts of it.
> "If Congress ends up repealing it, I hope they earnestly try to preserve the best parts, and put in place something better."
We have to start somewhere. The provision about preexisting conditions, and by extension the ACA, is literally life-saving.
The government doesn't require me to get vaccines. Nor does it require me to educate my children.
Now, you can homeschool if you choose, or place your children in a private school. But I'm not sure, legally, that you can leave them completely uneducated.
Private schools can also require vaccines.
These are good things. We want people to be vaccinated and literate.
We want everyone to be able to receive medical care. In the US, that means we want everyone to be insured.
Well, correct as far as healthcare goes, even with the ACA "mandate". You can choose not to get insurance, and you get some extra taxes in return.
1: If people choose not to get health insurance and then have to go to the ER, who pays for that? You and me. In most cases, it is cheaper for people to get preventative care and reduce their chances of a very expensive ER visit.
2: Preexisting conditions. Sure, but without a guaranteed customer base supported by subsidies then those people will be effectively denied insurance by having to pay insane premiums and deductibles. I have seen no evidence thus far that effectively counters this argument.
Lastly, you say you want to live off the land in some small town somewhere and you don't want the government to force you to pay for other people. Splendid! Say hello to Thomas Jefferson for me. But who builds the roads that lead to your house? What about utilities, water, internet? If you slip and fall down the stairs and break your leg who do you call, 911? If so, who pays for the 911 service, let alone the ambulance to take you to the hospital?
Again, I do agree with your premise, but since in my experience most libertarian arguments tend to crack under the pressure of public goods (like national security), where do you draw the line between independence and the needs of the populace as a whole?
2. Then prices will increase within each insurance company and as a user, I will pay for the insurance I want, rather than be forced.
3. Oh Stop. I didn't say I wouldn't pay taxes.
When did Healthcare become a government problem, rather than something that can be done through businesses. Its a business! If you can't afford to pay the bills then work a little harder to do something better with your life.
A hospital cannot "publish prices" because prices vary wildly based on many factors. Even if they did, how am I supposed to know what I need for my healthcare? If I go to the doctor and they say "you need a surgery and it will cost 10,000" the posted prices do not tell me if I need that surgery at all, just what they cost. And, of course, the most expensive medical care is emergency, a time when price shopping is not possible.
> Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
I'm not opposed to this, but it does remove state control over insurance regulation, which is an anathama to Republicans. I also have no idea how it will drive down costs? Are some states that much healthier than others?
> Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
I don't even know where to start. If I can opt out of paying for some medically approved procedures, where does it end? Can I say that I want to opt out of ob/gyn care for unmarried women?
Here's a question: Dentists routinely publish prices. If you ask them how much some procedure will cost, they will tell you. If there is uncertainty, they will give you a range (e.g. to account for the possibility that complications will arise during an oral surgery). What is different in the hospital situation, apart from some rather extreme measures taken to obfuscate pricing?
> And, of course, the most expensive medical care is emergency
Is it? Or is it end-of-life? Genuinely curious to see numbers here!
> I also have no idea how it will drive down costs
Prices, not costs. The current situation is that in a lot of states there are somewhere on the order of 1-3 companies offering insurance of certain types at all. For example, for Maryland, I believe there is only one company offering an ACA-compatible PPO (everyone else has HMOs or even EPOs). See https://news.ycombinator.com/item?id=13393287 for where I got that data.
Of course in a monopoly situation there is absolutely no incentive for a monopolist to cut prices. Why would they? So to the extent that prices represent excessive profits (as opposed to the actual costs of health care), allowing cross-state insurance sales should drive them down. People who believe insurance companies are price-gouging should be _very_ in favor of removing restrictions on such sales.
Pharmaceutical and medical equipment companies are raking in double digit profits. And they can sell wherever they want.
And you're right: by no means are insurance companies the only ones in this sector that engage in attempts at regulatory capture and creation of monopoly profits.
Though I should note that pharma companies have a lower return on capital than insurance companies last I checked, because pharma is so capital-intensive in practice. I haven't really looked into medical device manufacturers.
Similarly, when your diagnosis comes in and surgery is required, you can take time off from your three jobs to carefully research the pros and cons of various procedures to determine which is most financially appropriate for you. I mean, it's not exactly heart surgery we're talking about here. Well, technically and literally it is, but it shouldn't be too hard for anyone to understand the pros and cons of different surgical equipment and procedures to evaluate the risks and cross-compare with the clear apples-to-apples data sets to arrive at a medically and economically responsible decision while blood is pouring out of your extremities and your body feels like it's on fire. Take the time and shop carefully. You are a model fiscal actor and will make the right call.
Free market forces will make this system work and work well. The invisible hand has been after all such a huge success in setting health care prices and has proven to be the model every modern industrial country has taken because it's so intuitive and has great proven results.
A lot of hospital care is non-emergency, but they don't explain pricing schedules for _that_ either, now do they? I think everyone understands the impossibility of comparison-shopping on emergency care.
> I mean, it's not exactly heart surgery we're talking about here
No, it's hip replacement surgery. And people _already_ do comparison shopping on things like that as much as they can, including comparing to and shopping in other countries. See medical tourism.
More to the point, people do comparison shop just like that for oral surgery. Yes, they may not have all the data they might like. Yes, they don't always make the right decisions. But by and large, dentistry works OK.
Again, the "stuff that must be done RIGHT NOW" thing is a strawman: there's plenty of hospital care that is not that sort.
> The invisible hand has been after all such a huge success in setting health care prices
The invisible hand has absolutely nothing to do with most health care prices today (at least in the US). There are some exceptions: plastic surgery, laser eye surgery, dentistry, some forms of occupational therapy, and maybe family medicine.
> and has proven to be the model every modern industrial country has taken because it's so intuitive
Various industrial countries have price transparency for their medical care. If want to know how much my hip replacement will cost in the UK not via the NHS, I go to http://www.privatehealth.co.uk/conditions-and-treatments/hip... and I get all the data I could want, including prices and the hospitals charging those prices. Importantly, those hospitals publish their prices. If I did go via the NHS, I suspect there is no real difference in the pricing, but would welcome data on how it really works.
Anyway, knowing how much medical procedures will cost you is not an uncommon situation. Except in the US, of course, where hospitals will never tell you ahead of time how much a procedure will cost.
Note that price transparency is necessary, but not sufficient, for some sort of sanity in the discretionary medical care market.
Does this exception generalize? From the start, I felt it was immoral to go into Iraq, topple the government, get 4000+ US soldiers killed and cause the deaths of hundreds of thousands of Iraqis. The pennies you pay for birth control a nothing compared to what I as compelled to pay for a war I didn't support from the get go. Can I get my money back for that one? I'm sure my objection to it is/was as sincere and deeply felt as your objection to birth control.
Do you not realize how awful that is? How much of a hypocrite it makes you to hide behind freedom of religion as a means to try to force your religious beliefs on others? Especially via their health care.
How would you feel about tying health in to praying to Mecca multiple times a day?
How about if you work on the sabbath you lose your coverage?
Divorced? No health care for you sinner.
STD coverage should probably be banned. I mean sure, there are other ways to get AIDS but if you were having sex in a nice normal marriage then you probably wouldn't get it.
Oh wait, you mean that someone made a personal choice to use it. A choice that has exactly nothing to do with you, but you see an opportunity to oppress their freedom to choose so you are going to take it.
It's on the fuckin' money!
You want to talk about faith being shoved down people's throats, the Christians are the worst at it.
"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof."
Also known as the Separation of Church and State.
You are free to exercise your religious beliefs by not using birth control. But you cannot demand that Congress write the laws to fit your belief system.
edit: By the way, I downvoted you not because I disagree with you, but because of your hypocrisy.
As for being a Christian, fine, but my faith defines how I think. It doesn't mean the church controls my way of thinking. Just influences it. That in no way has anything to do with the separation of church and state. ESP for founders that were all very religious.
> * Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
I don't think you can simply equate having a job to "do[ing] something with yourself". Neither can you equate not having a job to not "do[ing] something with yourself". As always, situations (especially in the macro) are complex and subtle and solutions can't be boiled down to a simple directive.
Adults < 26 are often not the ones responsible for not being able to obtain a job. Yes, they may have chosen a field of study that's not in demand (even though many were probably told to "do what you love"), but they've also likely had very little opportunity to impact things like domestic economic policy, employment trends, or even employers not recognizing shifts in demographically driven skill-sets.
> * Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
In a system where much (most?) health insurance is provided as an employer paid benefit, why should my employer get to decide whether I'm opted in or out of a particular thing based on religion?
Ideally (from my point of view), religion plays zero part in health care. What is wrong with a benefit being available to all and only used by those that want to use it? Is this so different from the "in the privacy of my own bedroom" argument?
Personally, if someone is morally opposed to what they perceive as killing, I don't care if their morals are based on religion, atheism, or just squeamishness. Preserve their moral objection to killing. It's too valuable to society for us to trample on it.
I can't opt-out of supporting the military with my taxes - how is this any different?
And, while you're at it, please answer my original question rather than throwing out strawman arguments.
> why should my employer get to decide whether I'm opted in or out of a particular thing based on religion?
Setting aside arguments that abortion is permissible even if the fetus has a right to life (e.g. Thomson's "A Defense of Abortion"), for many people the crux of the matter is whether or not a fetus is a living human being. The problem is that current science cannot tell us exactly when a clump of cells becomes conscious; we don't fully understand consciousness, so assigning it to a given object can be contentious. We simply have no good way of knowing when there is a person "in there", so to speak.
Since science cannot answer this question, religion has filled the void with beliefs about when someone's life actually begins. If we understood consciousness and could detect when it "starts", I suspect this debate would be much less dramatic.
Not when pro life means human life begins at conception.
Of course. What part of
> but damnit kid, get a job. Do something with yourself
did you not understand.
Our economy is switching from full time employment to a gig based(lyft,postmates,uber). How do contract workers get health insurance?
I graduated just before 25, and my first job didn't have benefits because although I was working 40 hours they called it casual.
> Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
No, you shouldn't have the right to decide what your employees get to do with their health care. You don't have the right to decide who they sleep with and how. This is the theocratic, forcing my bullshit voodoo beliefs onto others crap that makes the republican party so repugnant.
Now, I'll ask again. Are you going to place restrictions on what I (the business owner) buy with my money?
Health care benefits are also part of that compensation. Why should you have any say in how your employee uses that compensation.
Your employees use of their health care plan is none of your damn business. Trying to use health care to regulate their behaviour based on your religious views is a particularly nasty form of oppression.
Pot, meet kettle.
If pre-existing conditions can't be denied, and insurance can't be mandated, how do you prevent people from only picking up insurance when they get sick/hurt?
First, separation of church and state, your faith doesn't get to be part of government decisions.
Second, do Jehovah's Witnesses get to not pay for blood transfusions in other people? And before you cite that blood transfusions are far more necessary, I think you should hold fast to your fiscal conservative tenets and help prevent unwanted burdens on the state from being born.
I think the problem is that healthcare after years of this broken system is now seen as private consumption rather than a public interest (like infrastructure and basic education).
Well, let's put that to the test. I consider myself pretty liberal. Here's what I think about your bullet list.
* Re: individual mandate
I actually agree with you very strongly on this. When the government wants to force me to pay for something, there's already a long-established way to do that: taxes, with services rendered by the government and thus fully accountable to the people. Forcing us to pay for private services sounds awfully similar to forcing us to pay for British tea, which isn't supposed to be how our country works. If the government wants to force us to pay for health insurance, they should tax us and provide universal coverage.
* Preexisting conditions cannot be denied and should be slightly elevated costs compared to the average user.
Agreed on preexisting conditions, disagreed on higher costs for the affected. "Slightly" quickly becomes a loophole that enables "outrageous". And anyone who lives long enough will eventually acquire a condition anyway. Seems kinda redundant to optimize for that. Just distribute the cost evenly with the understanding that everyone will eventually receive the benefit.
* Age 26 under the parents health care plan, fine, but damnit kid, get a job. Do something with yourself.
That's what the original post is about. When kids have health care, it's easier for them to make their own jobs instead of going out and begging someone else for them. Sounds like a win for this audience on HN, no?
* Birth Control, yes and no. We should be able to opt out paying for it, especially if it goes against my religion and frankly it does, but I won't stop others from opting in and paying for it.
The goal of health-related regulation should be to improve health-related access and outcomes. There is no question, based on data, that birth control improves women's health, allows them to finish school or further their careers in greater numbers, and eventually increases their lifetime earnings potential, which of course contributes back. If you make exceptions for people's precious feelings, you're looking at an awfully slippery slope. I envision a bunch of assholes declaring that they will opt out of vaccines for religious reasons, then everyone else starts opting out of paying for vaccines and, well, hello again Mr. Measles. No, terrible idea. You don't have to like the latest military campaign to acknowledge the need to pay for a military, and likewise, you don't need to approve of the way others behave to acknowledge the social benefits of birth control.
* Remove the boundries of the state borders. This is regulation. Not allowing companies to work and provide across state lines is ridiculous and again government overreach that could quickly drive down costs.
Sure.
* Lastly, I want hospital prices published. I want to shop around.
This just doesn't work unless you publish a single price list at the national level and force all health providers to honor that list (Japan). There are two problems. One, sometimes your health needs are too immediate to allow shopping, and you're beholden to whoever happens to pick you up and treat you. If you're bleeding out on the road, you're not gonna stop someone from calling the ambulance just so you can go on yelp and find the best service. Seems like a bad idea to build policy around the assumption that buying health care is like shopping for shampoo. Two, as a person who is likely not a medical professional, you probably wouldn't be able to make sense of any such price list with respect to your needs. Any such list would be detailed beyond the common person's understanding (see Japan), and anyway, you would need to seek diagnosis to know what to pay for in the first place.
Yep, and I hope it's to prevent "lowest common bidder" syndrome on plans. Why does Delaware get all the Corps? Why does a East Texas Court get all the patent cases ?
Frankly, my Texas health care plan sucks. Doesn't cover "anything".
> Lastly, I want hospital prices published. I want to shop around.
Can't shop around in an ambulance.
Healthy people already sign up for it. Go look at the math before the aca.
- Before the ACA we had Blue Cross and I inquired about maternity coverage. My wife was looking at a shoulder surgery so we were locked in. Blue Cross offered us a $1000/month rider that had to be in place for 21 months before birth and then they would cover anything over our high deductible. It worked out to about $25,000 on top of our regular premiums before they would pick up the bill. We jokingly priced getting an apartment in another city instead.
- Then the ACA came out. Maternity was included free and the premiums are about the same. We had a baby and had to cover twice the deductible. The marketplace gave us some trouble due to stupid bureaucracy so we priced out getting a plan directly (non-ACA) but the price was so much higher and it covered less. So, even with the marketplace, the coverage and affordability made it an easy decision.
Anyway, I could live without the subsidies (we haven't qualified for them every year) and I wish the marketplace was a little easier to work with. Though I feel like our coverage is so much better now. Why take it all away?
If that's the case, addressing the cost is the foremost issue, instead of forcing everyone to join a universal plan. That does not help addressing the root problem above.
Good luck trying to get political support for anything that hurts the insurance companies.
The Japanese system is not terribly different from ours - it still depends on private employer-provided health insurance. But per capita costs are less than half the US cost, with higher utilization and far better outcomes. The key difference is that Japan has strict national-level price controls. The price of identical products and procedures is identical in every facility. This eliminates both complexity and negotiation between insurance and providers. A government board carefully tracks costs for profiteering and makes adjustments.
Do that, and you get rid of the whole "in network/out of network" nonsense of the American system.
We spend several times more in hospitals and clinics than what we spend on prescription drugs:
http://www.beckershospitalreview.com/finance/17-fascinating-...
(nearly $1.6 trillion to large providers, $300 billion to drugs)
So the costs are not concentrated in drugs and insurance. There are certainly some drugs that are very lucrative, it's just that they aren't the dominant spending.
But you can't "improve" the ACA into single payer. You can only get single payer by starting over from scratch.
The pathetic thing is that a public option, the original plan, could quite easily be improved into single payer. And despite the largest Democratic majorities in both the house and senate for several decades, with a sparkly new progressive Democratic president that campaigned primarly on health care reform, they couldn't pass it. It seems the Democratic party has something to learn from the Republican party on how to get shit done.
We have single-payer here in my country, and anecdotal evidence is that it works incredibly better than healthcare in the U.S. for 99% of cases (the U.S. is far better at treating complicated health problems, but at staggering costs).
But Bernie Sanders' position on health care was essentially single payer (https://berniesanders.com/medicareforall/). And he did quite well, particularly with the younger voting bloc.
From a perspective of "the left" overall, I think the seeds for single payer might be a little stronger than you think. That's especially since opinion polls seem to indicate single payer systems are fairly popular. (http://www.gallup.com/poll/191504/majority-support-idea-fed-...)
Whether enough political will can be built up to get past the perverse crony capitalism inside the health care industry, that's another question.
The ACA (or similar basic rules: no pre-existing, must cover, supports small business and self proprietors as the market goes more that way) is needed for entrepreneurship and in cases where you can't get it through a job, it is a must for starting business today. Other places have a competitive advantage to starting a company in a country that has healthcare figured out and away from the job.
We should be able to get insurance as a pool of individuals. The current insurance companies are not setup for non employer based healthcare and need to either change or go. They group based on company or individual not pools of people across companies and individuals, which is a broken legacy system. We need consumer facing companies to be in healthcare if private healthcare is the main thing, companies in auto insurance and other insurance are more consumer focused (Geico, Progressive, Nationwide etc). I wish for more competition in this area that is consumer focused not employer focused.
Insurance needs to be remove from employment (probably through legislation or market benefits) to ultimately solve this consumer facing insurance problem for healthcare. We also probably need a separate health insurance plan for catastrophic events and a healthcare plan that handles day to day healthcare needs, bundling them is a bit wrong when compared with other insurance i.e. car maintenance is not covered under auto insurance, home maintenance is not covered under home insurance.
Ultimately, fixing healthcare is needed for business and quality of life reasons. Our system is becoming a competitive disadvantage to businesses in the US.
ding ding we have a winner. This is a no brainer that anyone, Republican or Democrat, should agree on.
"Finally, in a landmark 1954 ruling, the Internal Revenue Service clarified an earlier administrative court ruling regarding the income tax status of ESI by exempting such benefits from income taxation and adding this provision to the tax code."
Sure, it's nice that pre-existing conditions are covered better and 26 and under people can get insurance with their parents, but those kinds of benefits could have been covered by a one or two page bill. What's in the rest of it? Special deals for corporations such as AARP.
The law does nothing about making malpractice insurance more affordable, or making the malpractice lawsuit environment more rational. Why is that?
Why is my employer still involved in my health insurance? Why not move the tax benefits from my employer (it's a company, and cannot get sick) to me? My employer doesn't need the insurance. I do.
Why can't I buy insurance across state lines like other insurances?
Why are there separate 'risk pools'? The US is a single market - there should only be one risk pool. This would put maximal pressure on the insurance companies in terms of cost as they would have to compete for my business instead of negotiating cozy deals with companies (and companies don't get sick).
Why does the gov't get to tell me what's in my plan? If I'm a single male, why do I need to buy a plan that covers ObGyn? Why can't I buy a high deductable plan anymore?
Why does Obamacare think its wrong for doctors to own medical facilities?
If controlling cost is so important, why is it practically impossible to find out the cost of anything ahead of time? This makes making decisions based on cost impossible. Why is the price one person pays radically different than what another person pays? Why does cost have no relationship to quality? I can get an MRI with a brand new machine or with a 15 year old machine that produces crap images, and the crap will cost more. Why not require publication of prices?
Why is it that my dad, a wounded combat veteran, cannot get decent health care at the VA in a major metropolitan area? The VA is completely controlled by the gov't. It is the gov't. And yet, if he goes to a private hospital to get decent care, he gets penalized.
Because then pretty much EVERY insurance company will pick up and move to the one most desperate state that writes laws in their favor, doesn't tax them, allows them to sell substandard insurance, gives them liability protection and forced arbitration and in every way abuse the customer.
And the industry will become abusive, fraudulant, manipulative, and untouchable. Every state will lower its standards and revenue streams to keep insurers from leaving and taking jobs with them. And the customer will have very few if any good choices and no recourse when screwed over. Over time, the industry's power over the state will become even more entrenched. Exhibit one: The credit card industry, and south dakota. Go watch the Frontline episode I refer to in another thread.
I'd like to answer some of your other questions like "why do I have to buy a plan that covers obgyn" but I'm too pissed over having to pay for rear seatbelts I'll never wear, a space program I'll never use, fire hydrants I'll probably never need, and taxes for schools I'll never attend. Living in a society sucks. I mean, I have to pay for roads I'll never drive on. It's bullshit. I mean even my freaking insurance-- I have to pay for all these diseases that it'll cover! I'm NEVER gonna get ALL of them at once. And only one of them can even possibly kill me, maybe two max. Why should I pay for protection from a heart attack AND cancer treatment?!!! Bullshit, man. That's how they get you. I mean, I saw tonsilectimy on the list and I don't even have tonsils any more. Tyranny. I want an a la cart health insurance plan where I can figure out what I'm likely to get and only get insurance against that specific disease!!!
By that same logic, people would also move to the state most beneficial to them or would vote for laws in their state that they think is best for the people.
Competition benefits everyone.
Mandatory enrollment is what makes it possible to have that preexisting condition part - the basic idea of this (or any) insurance is that it spreads the risks over a larger pool of people, with the insurance companies taking a cut of the money for administrative costs and profit.
If you want to require that the insurance companies cover high-risk preexisting conditions without providing an increased customer base to spread those costs over then you'd better be prepared to see insurance companies go under.
> increased costs of forcing insurers into the ACA
Insurers don't have to participate in the ACA exchanges, and in fact many don't do so. Some participated in the beginning but decided there wasn't enough profit to be made or were losing money, so they've pulled out of the exchanges since then or have significantly raised their rates for their exchange plans. As an example of this, I believe United Healthcare (or its exchange-specific subsidiaries) no longer participates in most exchanges as of 2017 (http://money.cnn.com/2016/04/19/investing/unitedhealthcare-o...).
Interstate insurance competition isn't going to make it any cheaper to insure someone with a preexisting condition, or do you think that your local hospital is going to suddenly say "Oh, ccrush has insurance provided by a company in Montana! We can't charge San Francisco rates, we have to charge Montana hospital rates!" If you do think that, go talk to some hospital billing folks and they'll be happy to correct you.
One thing that the ACA did put in is capping the amount that insurance companies could spend on non-medical expenses, including both administration and profit. All the stuff early on about non-compliant plans having to shut down? That was for crap insurance with high premiums, higher deductibles, crappy service, etc. but with EXCELLENT profit margins. After all, if I can sell insurance but drop you when the bills start to come in, then all of those premiums you paid me are profit.
Prior to the ACA, nearly every employer-based coverage plan stopped dependent coverage at 19-years old or upon college graduation. Those that allowed older children would refuse dependent coverage if the children's employer offered health care, which meant that if you got a entry-level job out of high school at a company that offered insurance at any price, you couldn't use your parents' insurance.
After the ACA, every plan, employer-sponsored or exchange-based, must offer dependent care up until 26-years of age.
2.5 million <25-year olds gained health insurance in the first year after the expansion, which was before the mandate was in place.
The ACA gets credit for the expansion since it caused the expansion.
I'm not convinced that's providing productive selection criteria.
From someone too old to be on their parent's insurance, while I'm 100% behind the reform that disallows previous conditions from affecting ability to get coverage, the ACA was effectively a shake-down that made me delay taking the risk to go full time on my startup -- the options for coverage in my state were expensive and very low-quality, and the penalty for opting-out would have been $4000 for my domestic partner and I (on top of the additional taxes we paid to support ACA).
My claim is this: For the median entrepreneur, there is more financial drag due to insurance now than there was before the ACA. For those who are sick or young, there is less financial drag. Your story anecdotally supports that claim.
The reform surrounding pre-existing conditions for people that let their health coverage lapse is the only good thing that came out of the ACA, and it was very expensive for the taxpayers and continues to be. This should have just been a piece of legislature and not a terrible government shakedown of the American public; a simple reform was needed, not another way to subsidize the non-working while compelling the public to give money to private corporations.
Hmm. I've heard many small companies could not afford to provide health insurance for their employees after ACA passed ( I don't know the details of exactly the causal chain there ). So they stop providing it and pushed people to use ACA which had ridiculous price hikes and also in some states companies withdrawing from the exchanges.
In other cases I've heard companies have pushed people part time status in order to avoid having to provide health insurance and other benefits. I think that is mostly lower wage employment.
My own rates working for a small company a few years before the ACA and after went up much high even before ACA was about to pass in anticipation. There the insurance representative who we talk to every year stated clearly why there is an increase -- because of the volatility and unknown effects of ACA they decided to increase prices. After it passed and was being phased in our rates were going up much high.
Some things were nicer, like no pre-existing conditions, no lifetime maximum, some free preventative checks overall it has been worse.
Now, no doubt it has helped many people, but I am not sure if small businesses and their employees (especially in the tech sector) saw a benefit.
This is a really sincere recommendation: if I were you, I would research that and figure out if it's true or not. There is plenty of propaganda going around on this subject from all sides; it's dangerous to rely on things you've heard.
>> if I were you, I would research that and figure out if it's true or not.
> I can't even seem to validate the original claims, so...
I was just asking if you knew the reason already or have looked into it.
Once there's some data, we can have the perhaps more interesting question of whether or not it's worth it. No question but that increasing the number of people with health insurance costs money and that has to have some effect.
This may have impacted some companies, but none of the ACA small-business provisions were phased in until your company has more than 50 full-time employees. If your startup gets to a point where they have 50 employees, you should probably spend the money to get them health care.
I'm sure there's more as well, but this definitely helped several friends of mine. Seems like these kind of things would have been impossible without large swaths of the ACA.
The fact remains - covering pre-existing conditions, kids till 26, and low income households is expensive. You can pay it by increasing the insured pool - which is what ACA tries to do via the individual mandate, or by introducing a single payer system whose buying power would be so big that they will substantial leverage over healthcare provider. As a society we have decided that a single payer system is socialist, so it cannot be adopted here (and it has its own problems - wait times, lack of R&D incentive etc.). So now we have to choose between not providing healthcare to 40-50 million people or pay increased premiums to cover for those.
Some reforms that may somewhat bring down the premiums: - Offer subsidies to even middle income people, not just poor. May be set the income limit by geography - Make the individual mandate more expensive to incentivize healthier people join the pool - Offer a public option
I look at it this way: Right now, I'm with a large company - I have a wife who left corporate life to raise our daughter. It's all riding on me. And on that, I have some ideas, one has become a small side gig, but if they grow enough to become my focus, that essentially opens the basic question of how I'd provide health insurance to my family.
Thankfully, I have a backup plan to some degree, as I happen to be a citizen of a European country as well as the US, but it's an imperfect backup plan as my "other" nationality is a place with notoriously difficult small business bureaucracy, and while I could live in another EU country, I'd need to establish the ability to support myself before anyone's going to let me stay.
Ideally, we'd stay in the US, because let's face it, this is a pretty great country to found a company, warts and all. But we have to not be having to worry about something as basic as healthcare if we're to take the kinds of risks that lead to innovation.
It's interesting to me that we as a society have long accepted that people have to work for food and shelter, leaving a permanent underclass in the dust, while we're uncomfortable to say the same about healthcare.
But of course, it doesn't matter. Those who oppose the ACA or the individual mandate or employer requirements or the notion of healthcare subsidies are dancing around their justifications and are reluctant to come out and say that people with health complications should just be out of luck. Instead, they'll dismantle, maybe introduce an alibi entitlement scheme to save some political face, and leave a status quo with the exact same result.
Mitt Romney had similarly reformed Massachusetts law in 2006 as Governor.
https://en.wikipedia.org/wiki/Massachusetts_health_care_refo...
I see the article briefly touched upon the American notion of health insurance being tied to employment.
Nobody seems to want to really solve this problem, just band-aids and lip-service. Neither mainstream party would consider a single-payer system, nor direct government negotiation with drug companies.
It's as though the drug and insurance companies are better represented (and have more rights) than its citizens.
Heck, even Medicare is divided into at least four regions to "negotaiate" regional prices.
How do other countries perceive this?
The US falls further and further behind in healthcare and affordable and available high-speed internet. Let's see some real progress.
INSURANCE EXPLANATION OF BENEFIT
Adhesive bandage. . . . . . $300 | Covered: $.02 | You Owe: $299.98
If this is how the government wants to do it, don't call it insurance. Just call it socialized medicine, because I am definitely not getting what I paid for.
* Pricing: How about transparent pricing up front for all non-emergency services? That means the price you pay, and that your insurance pays. Not some mystery of "you are responsible for some unknowable amount if the insurance company doesn't pay" or "we might make you pay your entire deductible".
* More effective implementation of high deductible health plans that's simpler for people.
* Medical expenses and insurance tax-deductible, full stop. No messing with HSA, FSA.
* When you are diagnosed with a condition, your current insurance is responsible for the rest of your life for related expenses. No new insurance company would deny you because it wouldn't cost them anything for your preexisting condition.
* Subsidize normal health insurance for poor people.
Need your appendix removed? Better get a loan from the bank. Just because they can.
I am a bit confused by this story. Was Zach not covered under his families' health coverage? He also went to: Westminster School - one of the most expensive private high schools in the US.
Now, one could argue he had a pre-existing condition and thus, was not covered under any health care providers plan, but he states: "I was virtually uninsurable." This tells me there were options, but none that covered the entire cost of the surgery. Honestly, this story alone makes me seriously question the purpose of this post.
It's unfortunate that we're not able to get these conversations going in a way that's ... what? "unbiased"? I don't know what I'm asking for, but I think it's some variant of honesty and openness. And I think that we're missing a lot of the truth, for ourselves and others, by having to couch our statements in ways that aren't entirely forthcoming.
That said... I'm still glad that medicaid covered my uninsured ass when I broke myself trying something I'm not good at (skiing). I remember thinking (as I was bundled up in the medic's sled) that I was not too different from some New Zealander with a busted body part... about to be carted off to free medical care, to get me back on my feet and working as quickly as possible.
Thanks, Obama.
A friend was virtually uninsurable for having once been diagnosed as clinically depressed. Flat out denied coverage.
Source: I know someone for whom this was the case pre-ACA.
Pre-existing condition. Anthem denied me coverage.
My ortho guy said, I don't understand. It was a good outcome.
I shopped online and bought a sensible plan just like anything else. There were tons of choices and plenty of competition.
This whole notion that we'll all be doomed without it is utter rubbish. The entire Healthcare system is broken, starting from our agricultural subsidies to our ridiculous prescription drug prices (which many pharma-lobbied Democrats just voted to keep high) to the artificially low supply of doctors (you don't need 12 years of school to prescribe penicillin).
ACA is just 2000 pages of nonsense on top of all of that. We can do better at all facets.
It was impossible if you had any pre-existing conditions, no matter how trivial.
1. I shopped online and bought a sensible plan just like anything else.
There are literally more than 50 million Americans with pre-existing conditions that would disqualify them from buying insurance at any price. Many of them were fortunate to have employer-backed insurance, but that doesn't change the fact that they were desperately dependent on it.
2. (which many pharma-lobbied Democrats just voted to keep high)
41 Republicans voted against it, 13 Democrats did. Singling out the Democrats calls into question your intentions..
3. you don't need 12 years of school to prescribe penicillin
The ACA and other changes have greatly expanded the responsibilities of PAs and NPs. They can treat and prescribe in nearly every setting. CRNAs and DNPs are working more independently than ever. In addition; over 25 new medical schools have been established in the past 8 years, along with over 6,000 additional residency positions (which are paid for via CMS funds.)
At the time, I had sleep apnea and had to pay almost $500 a month for health insurance. That was more then I spent on food, almost as much as I paid for rent. (It was more than my car payment, which I paid off two years prior.)
18 months is a very short time period when you're trying different things to see what sticks.
If the ACA was an option, I'd probably had another 4-6 months to go. Would I have found something that "stuck?" I'll never know.
So what's the answer? How can health insurance providers help people with pre-existing conditions, and also not gouge young healthy customers?
Is the healthcare industry just charging too much money?
Certainly there is some waste, fraud, and abuse in the healthcare system which could be cut. But ultimately the only way to significantly cut costs would be to ration care. It's a hard issue and no one likes to talk about it.
In terms of insurance, it's perfectly possible to write healthy young people a significantly cheaper policy that has limits and is no longer available as they age. It's probably pretty stupid for the young people to opt for that policy, but whatever.
As far as I know, Western European countries spend about half (per capita) on health care as what USA spends. I don't know if US health care is that much better. And if it's not, then in theory there is a way to get the same results cheaper.
Parts of the ACA are necessary but I can't help but feeling, based on the price increases, the Act itself is horribly inefficient. We didn't increase the supply, we just increased the demand for a product which is very inelastic, resulting in skyrocketing premiums. A reform must involve increasing the supply of care.
* Taxes go up, but they go up less than health insurance premiums would. Remove insurance companies as an industry. [1]
* Price controls on providers (inelastic demand of healthcare means "the market" sets the price to "you pay whatever it costs so you don't die") [2]
* Allow Medicare to negotiate with drug manufacturers, otherwise buy from other countries [3]
That's about it. If Sam and YC want to see this fixed, start advocating for politicians who support single payer.
Startups will not fix this problem. Blog posts will not fix this problem. Political activism will fix this problem.
[1] https://www.youtube.com/watch?v=LtplKTHa4TA
[2] https://www.cms.gov/Research-Statistics-Data-and-Systems/Res...
[3] https://www.nytimes.com/2016/02/02/upshot/the-real-reason-me...
From the international perspective, I get the impression that Americans are against this because then you are "paying for other people" (as though insurance doesn't count, but through a private company is somehow 'better').
The financial incentive helps preserve that property: If a company can identify the cheaper customers, then they can offer lower premiums than the companies that can't. The customers left behind are more expensive, forcing those premiums to rise in order to remain solvent.
Yes. Twice as much as the rest of the world in fact. Mostly due to lack of competition (25 year monopolies for simply adding a antacid to an existing drug) and zero negotiation on pricing.
The President Elect said as much yesterday.
https://www.washingtonpost.com/amphtml/news/wonk/wp/2017/01/...
One of his proposed solutions is to outlaw these monopolies and let the providers compete between themselves to lower costs.
The reality is that the policies that companies will be willing to sell across state lines are likely to be truly awfully shitty, by doing things like not having a coverage agreement with most hospitals (which will at least drive up out of pocket costs and complicate claims, if not enabling the companies to outright deny claims).
I believe that single payer systems can bring prices lower with more efficiency, but there are plenty of things that can be done that are less controversial (combating waste, increasing administrative efficiencies, etc).
One personal example from my life that put health care costs into perspective was surrounding the issue of Midwives vs. OB/GYNs when we were having our first child. We were approved by our insurance to have an OB/GYN deliver our child, which would cost the insurance company about $5,000 if everything went well (more if there were complications). But they wouldn't cover us at all if we delivered the child with a midwife, which cost about $1,500 and has been shown in study after study to reduce the likelihood of more costly intervention.
In our case, we paid the midwife out of pocket, but there are so many people that don't have the economic freedom to make that choice and the result is that their insurance companies pay far more money for child births than they would have otherwise had to.
Again, just one example, but I'm sure there are thousands more.
PS health cost is US are not just stupid expensive, it is broad day light extortion. the victims for some reason prefer not to see it as robbery, but rather to argue about qualities of their robbers. charging $600 to empty the urine bag is possible only because the whole hospital system is rigged (i.e. excessively regulated and monopolized).
> Precision CNC milled from aircraft grade aluminum to 1/1000ths of an inch tolerance
What you need aicraft-grade aluminum for? And a 1-mil tolerance? Are you building a really tiny aircraft?
"Premium design" stops when the design choices are the best you could ever need. Beyond that, it's no longer a matter of engineering, it's about far less respectable traits.
I mean, we pay taxes for streets, so people can get everywhere. We pay taxes for schools, so people learn everything. Why not pay taxes, so people are kept healthy?
The whole public healthcare stuff doesn't even work like a real insurance, so why not throw this stuff away, make a health tax everyone pays, call it exactly that, and be done with it?
Even if you have a rep that favors the ACA it gives them an idea how much effort in to saving it.
Why is there little or no start up innovation in the insurance space? Why aren't YC17 companies able to attack this?
Is the tradeoff worth it? That's the question.
1) Healthcare costs are out of control.
In the US, healthcare spending is 17% of GDP, the highest of any country in the world; the next highest is France, at 11% GDP. [0] The reasons for this are very complex and intertwined, but there are a few major issues:
(1a) Intellectual Property protections: When only one company can sell a drug for the first 10 years of its existence, they effectively have a monopoly and can set the price to whatever they want.
(1b) R&D costs: If it costs $10mm to develop a new drug to treat a deadly disease that affects less than 1% of the population, then naturally the company must set a high price for the drug to cover costs of R&D; this is related to (1a).
(1c) Primary care providers and pharmaceutical companies are accountable to nobody when setting their prices. Because the majority of people pay for healthcare via insurance, they are price insensitive. After all, if insurance is paying for your healthcare, what do you care if the cost is $100k or $1k? (As an example: A family friend of mine ran a "compounding pharmacy," where he compounded multiple drugs into a single pill, so people who are prescribed 15+ pills to only need to take one. The insurance companies considered the resulting compound to be a "new drug" and therefore he was able to set its price to literally whatever he wanted.)
2) Health insurance costs are out of control.
This is a complex issue but it comes down to a few major factors:
(2a) Risk pools cannot cross state lines. As far as I can see there is literally no reason for this.
(2b) The requirement to cover pre-existing conditions increases insurance costs for everyone. As many have mentioned in this thread, it makes no sense to call coverage for pre-existing conditions "insurance." If you already have a disease, you aren't insuring against it; you're just paying for it. I do think that people have a right to healthcare, and even as a republican I think that taxpayers have a duty to subsidize those with pre-existing conditions. But I don't think we should be including this obligation in the cost of insurance from private companies. It should be a separate budget item, like social security or medicare or medicaid (or better yet, take it out of the defense budget...). If private companies need to insure (read: pay for) pre-existing conditions, then they effectively become the gatekeepers for this tax, and they have every incentive to make it as high as possible.
[0] http://www.commonwealthfund.org/publications/issue-briefs/20...
That way analysis becomes easier and all perceived sample biases can be alieviated.
All I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now.
What happens if you don't have insurance? To me any system where you make sick people pay more than rich people seems bonkers no? If most people's employers already pay it on their behalf, isn't it a business tax already?
None.
> I see from threads like this is a lot of Americans bickering over their own healthcare, and as an outsider I don't really know how how it works, and why everyone is so invested in how it works now.
Because actual change is near impossible these days. (Ultimately this is largely a result of flaws in our electoral system. Most notably, gerrymandering gives Republicans a near permanent lock on the House.)
> What happens if you don't have insurance?
You die.
> To me any system where you make sick people pay more than rich people seems bonkers no?
Republican congressmen are bonkers and/or evil.
> If most people's employers already pay it on their behalf, isn't it a business tax already?
That's a large part of the problem. It got tied to employment in during WWII when the government mandated salary caps for some industries so firms competed on benefits. I think almost everyone agrees this is bad but it's impossible to change because of gridlock.
- It cost me money
- It's not perfect
Arguments in favor of ACA:
- It literally saved my life
Regarding increasing premiums, the complaints tend to be anecdotal. According to the National Conference of State Legislatures, in 2016, the average monthly net premium increased just $4 -- or 4% -- from 2015 to 2016 among the insured that take advantage of subsidies.[1]
Furthermore, premiums have gone up year-over-year every year almost every year since I've been paying for my own insurance -- and that's well before ACA.
There's an interesting chart on the Kaiser Foundation website, where it shows the average plan prices and percent increase year-over-year broken down by state. It also shows that, after tax credits and with very few exceptions, plan prices have remained stable (0% change) between 2015 and 2016.
I understand and sympathize with the high premium prices, but I have serious reservations about the assertion that the high premiums are due to the ACA and not external factors.
[1] http://www.ncsl.org/research/health/health-insurance-premium...
[2] http://kff.org/health-reform/issue-brief/2017-premium-change...
Not only that, but they were increasing at a much faster rate before the ACA. Of course, most people didn't notice, because those who were employed were covered by their employer, and the unemployed were uninsured.
Could you expand on this?
The caveat is that it only works if you're collecting a paycheck, but not if you're bootstrapping from savings.
There are thousands of people whose lives were saved by this. Nitpicking over on example seems rather unproductive.
If Obamacare is repelled at the Federal level, could a state just implement its local ACA? what prevents California for instance of giving health coverage for its residents? California is a good example since it "the world's sixth-largest economy" (If California was a country) I'm sure healthcare companies wouldn't want to cut themselves out of this market?
This would give California and SV an even bigger advantage regarding what is described in Sam's post.
Btw, San Francisco has essentially had universal health care since 2007 (via Healthy San Francisco), though it doesn't cover non-residents on I-94.
It would be interesting to see if citizens and permanent residents represented a high proportion of founders in SF than, say, Silicon Valley.
Ah the classic "if you are middle class F U" program
Some parts of the ACA could be implemented in state law, some would be either illegal or impractical at the state level. It's also likely that a repeal would be accompanied or followed by federal policies which would make state-specified versions of the ACA less practical than they are now.
> what prevents California for instance of giving health coverage for its residents?
California already provides state-run send healthcare beyond the requirements of the federal programs it participates in.
That's my poor understanding of U.S. Federal vs State government that fails me here: what exactly would be illegal, what would be impractical? If a state ACA is challenged in court, couldn't they use the supreme courts rulings of Obamacare as a strong defense?
Other comments here mentions that Massachusetts already had it (and I assume would likely keep it even after Obamacare is repealed), Couldn't California copy the Massachusetts implementation?
> California already provides state-run send healthcare beyond the requirements of the federal programs it participates in.
But I assume those state-run programs aren't providing as strong of a coverage as Obamacare was? Now would seem a good time to update it to match Obamacare?
Mandating coverage, which is basically a requirement of affordable universal healthcare.
"What happens if I don't pay the fee?
The IRS will hold back the amount of the fee from any future tax refunds. There are no liens, levies, or criminal penalties for failing to pay the fee."
The fee structure is different (just a missed deduction on the state taxes, not a separate monthly charge), but it still works.
You wouldn't just copy and paste "IRS" into the state law that a state might decide to create. You would use the state's taxing authority.
Yes, state sanctions don't generally sting as much.
But each state would have to independently decide, with its own constituents, if it could economically offer subsidized health care for all of its residents.
Many states already have some form of parallel subsidized/free health care system for certain segments of the population. Like their school teachers and their children as an example.
Anyway, hope that helps.
Massachusetts had Obamacare (RomneyCare) years before the federal law existed (it acted as a model for the federal plan).
And we (in Massachusetts) are still trying to figure out how to pay for it.
Massachusetts already had an incredibly low uninsured rate to begin with, which helped, but even then, the costs have been unsustainable. In each of the last three governor's races, the major issue on both candidate's platforms were their respective promises to find a way to pay for it all.
Most recently, MA elected Charlie Baker, a former health insurance executive who has promised to find a way to make the program sustainable.
There are a lot of details, though, that make this complicated and not necessarily viable for all states (MA is both relatively wealthy, has relatively wealthy neighboring states, and has a somewhat unusual healthcare market).
No, because the Constitution mandates that states engage in a "race to the bottom." California could create their own healthcare program, but they couldn't preclude neighboring states from free-riding on their system by not having their own healthcare and enjoying lower taxes, and simply driving across the border when they needed care.
Finally, in Saenz, the Court breathed new life into the Citizenship Clause of the Fourteenth Amendment in finding that clause to be violated by a California law that set lower welfare benefits for newer residents than for long-term residents. The Court says the clause "does not allow for degrees of citizenship based on length of residence."
(http://law2.umkc.edu/faculty/projects/ftrials/conlaw/newresi...)
1 in 3 Californians now receives free health care under Medi-Cal
Does this strike people as a long-term sustainable model?
Smaller states may have not big enough to have a healthy market.
Assuming that it requires residency, that requires that the sick person quit their job, find a place in the new state to live and work for say a year or two while staying alive with a dire sickness. It's not just a bus ticket that you need to relocate, there are many more significant costs associated with a move.
And even in that case, unless the state is already overcrowded, this is essentially a way to grow the state's residency and thus it's tax base.
First off, keep in mind the following:
1. Populous states like California pay far more in Federal Taxes than they get in return in return. [1]
2. California must have a supermajority in the legislature to approve taxes. [2]
So it's a complex issue, but simply put, there's not a lot of wiggle room for California to add billions of dollars of health subsidies to it's state budget.
Medicaid is basically one big government subsidy for the poor. When the Obamacare medicaid expansion goes away, millions will fall out of health insurance instantly. [3]
As for the managed plans, subsidies were used to make the plans more affordable to the taxpayers which made it easier for people to afford coverage. [4]
It's possible that some things may stay in tact like the pre-existing condition clause, but unfortunately the health insurance companies won't be able to cover everyone without the individual mandate. [5] Also, before the pre-existing clause, health care companies were rejecting people for health insurance with pre-existing conditions. [6]
The options besides subsidies for California are:
1. Government mandate of costs at doctors offices and hospitals, which may become illegal if the US Congress votes against it.
2. Government mandates on the behavior of insurance companies. This might drive many insurance companies out of California.
Neither appear to be a viable option.
1: https://goo.gl/paMrzG 2: https://en.wikipedia.org/wiki/California_Proposition_13_(197... 3: https://www.healthinsurance.org/california-medicaid/ 4: https://goo.gl/JVkaN0 5: https://goo.gl/STciup 6: https://goo.gl/Uoljhx
California must have a supermajority in the legislature to approve taxes. [2]
That said, the Democrats have full supermajorities now.
Quote:
"In addition to decreasing property taxes and changing the role of the state, the initiative also contained language requiring a two-thirds (2/3) majority in both legislative houses for future increases of any state tax rates or amounts of revenue collected, including income tax rates and sales tax rates."
* Preserve some form of protection for people with pre-existing conditions (this covers the "save my life" part)
* Lower costs of health insurance for both individuals and the public (perhaps dramatically)
* Actually address the underlying healthcare issues directly, i.e. implement policies that will reduce the cost of healthcare itself, not just the cost of insurance
In particular, the risk of losing some important things (like coverage of preexisting conditions) seems extraordinarily low.
Likewise, the ACA repeal efforts are disingenuously framed as "enhancing access to insurance".
If insurance companies have to take all comers, that makes the system easy to game: don't get insurance until you're sick, and then jump onto the system. This would essentially destroy insurance markets.
What's the obvious solution? Mandate everyone sign up for insurance, at risk of facing penalty fees. Then you're always paying into the insurance industry, and insurance companies can survive and provide value to the healthy and the sick.
But this is tough: not everyone can afford health insurance. So, you provide subsidies to those who can't.
So, if you start from the 2008 status quo and want to add protections for pre-existing conditions, that game plan is pretty much set in stone. But the issue is that that essentially is the ACA. There are other aspects, but that's the core mechanic.
It's pretty much impossible to build a system from 2008 to cover pre-existing conditions without re-implementing the ACA. You can play with how high fees should be and how high subsidies should be, but that's pretty much it. And most of the Republican "alternatives" (insofar as they exist at all) work by putting a ton of loopholes in the pre-existing conditions protections, a strategy widely regarded as revolting and that only works because people are being bamboozled about what protections they would actually receive.
For example, one of my good friends is a lawyer with a very simple single-member law practice. He has no employees and is self-employed.
As I understand it, BY LAW, he cannot apply for coverage or subsidies for himself or his family (wife and single child) and the only way they can provide for their health care is to purchase it via the New York exchange.
Every year, their chosen coverage provider has closed up shop to be replaced by a new provider with worse insurance terms involving premium increases and higher deductibles.
The plan they had before ACA (essentially catastrophic coverage) was deemed illegal by NY state and is no longer offered as it didn't meet the guidelines for suitable coverage for a family.
SO...by his words:
"I had a hospitalization plan I liked that was $175/month. Covered only catastrophic shit. I loved that since I do a lot to be healthy and no deductible. ACA banned that. First ACA plan was 300 a month or so - w 2500 deductible. Then that company went out of business. New company HealthConnect - price 350 a month - but 6500 deductible for bronze plan. They went bankrupt. Now i have CareConnect - 450 a month - 10,000 deductible $80 co-pay"
So, if your good coverage went from $175/month to $450/month and covered less and less with each passing year and you had no choice to go elsewhere because as a "business owner" you were deemed ineligible for any subsidies or other assistance from the government that was pushing these changes down your throat, you'd probably think it was a shitty deal.
The part that people don't seem to get is that these deductibles are HUGE for the kinds of people that ACA is supposed to help.
If you're paying $450/month and don't even get a single dollar of benefit until your family needs more than $10K of healthcare, would you feel like the government made your situation better or worse?
The reasoning is that, if you allow bare bone plans, then someone could offer plans that let you pay a nominal fee but cover nothing. That, of course, is pretty much nixing the mandate, and you run into the same issues with pre-existing condition protections destroying the insurance market.
Neither of us really know enough about your attorney friend's exact situation to know what went on, but that $450/month plan certainly covers a lot more than the $175/month one. Before, he was essentially self-insuring for the less costly situations, and now that insurance is required to be externalized.
Not perfect, and I'd like if Republicans came up with a solution to ease your friend's situation. But if it comes to a tradeoff between people dying and an attorney being forced to purchase a more comprehensive health insurance plan, it's really not a hard decision.
Big Fortune 500 companies that used to offer 'PPO' plans (i.e. you paid your rate and then had $10-$20 copays) now only offer catastrophic plans.
So we are paying the same (and higher) for the plans as we used to, but now we don't actually get anything for them until we reach the deductible, which is higher and higher every year.
I pay the same as a few years ago every month, but get absolutely nothing until I hit $2K or so.
Regulatory capture and conflict of interest made it impossible for government (itself the largest payer for healthcare) to find ways to drive down costs. All the incentives are lined up to deliver worse or less care for more money. That's a recipe for disaster.
I know people who are literally alive today because of the ACA. Do their lives have no value?
What I'm arguing is that the ACA, as written, has established a non-sustainable model for healthcare in this country. It's done so at a huge risk to future populations and seems to try and legislate an outcome instead of working with stakeholders to solve the ACTUAL problem: rampantly rising costs for healthcare.
HOW do you explain the crazy high costs for care in this country relative to almost every single industrialized neighbor? What are the factors for that high cost? Overconsumption? Regulatory capture? Lifestyle factors? Perverse incentives? Administrative overhead? PROFIT?
We've done very very little with the ACA to tackle these problems head on because every problem seems to be owned by an interest group that is incentivized to keep that problem alive.
That's the point I'm trying to make here.
Going back to 2008 would make things worse, not better. And sure, improve the ACA, but build on it or in parallel to it, don't tear it down and cost lives in the process.
What did happen was that a whole lot of people suddenly became the beneficiaries of a brand new government welfare program that wasn't paid for in any way by cost savings anywhere. I've got CBO studies to back that up.
Yes, we raised taxes on some rich people. Big deal. A pittance on what the spending required.
What we DID do was shift a whole lot of insurance costs onto people who were already paying a bunch: the middle-class.
If you want to know who really carries the weight of the ACA, look no further than a family of 4 with two incomes making about $125K between them. They saw their premiums rise, their deductibles grow, and their choices shrink.
There were winners: primarily, under or unemployed adults and those with pre-existing conditions that couldn't get coverage anywhere. Single mothers in some cases who couldn't otherwise get coverage under Medicare.
Everyone else who already had coverage they were paying for got screwed.
I helped get him elected. I wanted reform. I wanted better outcomes. I wanted people to participate.
Consider me disillusioned.
You're not the guy actually footing the majority of the bill, so it doesn't really matter as much to you, right?
BUT, if you own a small tire shop and some guy just tripled your healthcare costs, well....he might have a different opinion.
> if you own a small tire shop and some guy just tripled your healthcare costs, well....he might have a different opinion.
I have a few friends and family who can get insurance due to ACA, so no, I wouldn't. I don't fall in that group (thankfully), but I'm more than happy to pay the costs so they can not go bankrupt or have to play the emergency room shuffle.
Hell, we'll all be there someday. It's the unicorn individual who is never sick throughout their life until they simply drop dead.
The main political/democratic value codified into the law is that no one should have to go bankrupt from treatment costs. That means outlawing those practices, which meant a lot of plans no longer qualified. That was the moral argument part that Republicans generally disagreed with. We're all paying a little more so that a family we don't know doesn't go bankrupt from a family member getting cancer. (And we're all also paying a little less due to other parts of the ACA.)
There's a moral question at the heart of this, the answer to which defines the solution space: do we, as a society, think it is important that all sick people receive care? If yes, there are a bunch of potential solutions, but they all involve healthy people subsidizing care for sick people. If no, there are, of course, a lot more options.
The thing that frustrates me about the current Republican approach is that they seem to want to answer "yes" to this question, while telling voters they will not have to subsidize care for the sick in any way.
Depending on your point of view, either the best feature, or the biggest failure, of the ACA was that it made this subsidy for the sick visible to anybody buying their own insurance, rather than hiding it behind taxes or complicated dynamics between governments, insurers, employers, and hospitals.
A little more succinctly: either we decide to let emergency rooms turn sick people away, or somebody will be paying for their care. There's no magical solution.
The way to make care available is to drive down costs. We haven't done a single thing with the ACA to improve the affordability of care, we've just made the un-affordability a problem borne by the people who were already doing a good job of taking care of themselves. That's not a scalable solution.
The ACA got us a lot of short-term benefit for a small group of people but set in motion a chain of events that will only drive UP costs while driving affordability down.
And I'd like to argue that until we do something to improve the market dynamics of healthcare we are very likely to see this sort of thing continue to get worse until it's so unsustainable that it's like trying to legislate away the force of gravity.
One thing I'd like to see in any future version of ACA reform is RIGOROUS price transparency by healthcare providers. It should be absolutely illegal for any healthcare provider to conceal, obfuscate, or otherwise obstruct the price discovery mechanism of the market.
Even if you argue that consumers aren't the best people to decide what services are necessary or needed, they can rely on the advice of trusted advisors and popular understanding to shop for healthcare at providers known for offering good value.
SO MUCH of health care isn't of the "emergent" kind but the kind that is for chronic issues that are the result of unhealthy living or plain bad genetic luck. We need to redouble our efforts to drive those costs of care down and start paying for results and not treatment. Paying for treatment encourages overconsumption. Paying for outcomes encourages optimizing for cures.
I will tell you that I've seen scant evidence that it's working.
A wishlist of initiatives isn't a plan for action that drives down costs. Allowing Medicare to NEGOTIATE prices for drugs is a plan to drive down costs.
The insurance companies wanted to GROW the per-capita spend on healthcare. That benefited them. It's really really unclear if it benefited the public right now.
Forcing people into a market they don't want to be in isn't reform. The way to solve this problem is to make being a part of the market ATTRACTIVE.
IMHO we really missed an opportunity to affect behaviors. For one thing, Romneycare incentivized people to skip insurance until they needed it. That was a recipe for adverse selection.
The way to help this is to provide incentives for people to get in WAY EARLY and pay for their OWN care long before they may need it while also providing a measurable benefit to those who get in early right away.
People are capable of responding to incentives and I'm convinced that there exists a Nash equilibrium in healthcare that helps everybody win.
Remember, the same people who gave you "the Internet is not a truck" are the same people you're expecting to solve healthcare affordability. Think about that.
A provision of the ACA sets a minimum medical loss ratio for us. In simpler terms: it puts a legal cap on our profit margin, by requiring a minimum percentage of the money we take in to be spent on benefits to our members (such as paying their claims).
That is almost certainly going to get repealed.
If your incentive is to maximize the absolute amount of actual profit you earn and the ONLY way you can do that is to push more money towards healthcare providers, then what do you think will actually occur?
Because once you have achieved that spend level on provider care, you're in the clear. The ONLY way for you to increase profit is to ensure that more procedures happen.
We profit when people are healthy.
In a perfect world, you'd keep 100% of the premiums and never pay a cent to a healthcare provider because everyone is healthy, right?
In a terrible world, every single one of your insured has a chronic, long-term expensive to treat condition that requires you to pay tons of money to providers.
In the first/perfect case, premiums are zero, right? In the second/terrible/worst case, you're not making zero money because your (collected premiums - minimum payout) > 0.
See where I'm going with this? In a world with healthy people, there is little need for health insurance and spending trends towards zero. There isn't a need for an insurer. Your company can only exist in a world with sick people.
Quality of care is a good direction but doesn't go far enough. We need to get real price transparency into the market so people understand what it costs to treat lung cancer and what the probabilities are that they'll actually get better.
Do you think the average person on the street really knows what it costs to undergo a round of chemotherapy? Does the EXACT SAME procedure performed in different hospitals across town cost the same? These are important questions and there doesn't seem to be any political will to actually answer them.
And my suspicion for this state of affairs is that the interests of the players in this game is for nobody to really know what things cost because if they did the game would change.
And we can't have that, now, can we.
Note that this doesn't mean the same procedure costs the same at every provider, though; Medicare rates include a geographic adjustment, among quite a few other factors, but it does mean you can work it all out for yourself.
I'd encourage you to read pages 23-28 of the following paper from the Mercatus Center. You'll find that prices for Medicare reimbursement are set by a committee largely stacked by the AMA, a de-facto lobbying group for doctors. They aren't likely to support any schema that cuts reimbursement rates for their members.
https://www.mercatus.org/system/files/Feldman-Medicare-Role-...
I agree with everything else you said though. Costs are too high and are a major reason this is so hard to solve and price transparency is a big part of the problem. A related (because it distorts the market in a similar way) problem is that most people don't see the true cost of their insurance, because they get it as a benefit from their employer. I would be highly in favor of any credible attempts to fix these issues. But that's not what I've been hearing from the party that's about to be completely in power.
Democrats don't just come out and admit that they want a wealth redistribution program that they can use to show voters how compassionate they are with other people's money.
They're politicians. They just aren't honest and voters aren't perceptive or concerned enough to call them on it.
I want a wealth distribution program that means that thanks to a genetic condition I had no role in acquiring (if you're "doing a good job taking care of yourself" and never get cancer or some other nasty expensive disease, why don't you count your fucking blessings that you're healthy instead of bitching about having to subsidize others) means that I don't get a death sentence if I ever am sick enough to lose my job for long enough to lose coverage and get fucked over in the future on preexisting condition exclusions. Or fucked over due to lifetime benefit caps.
And I want one that protects other people in similar situations too.
So maybe not everyone's motivations are as cynical as you make them out to be.
I was pretty sure it was going to make things more expensive for me, and I don't think it was sold any differently than that. I was not in favor of it, largely because I didn't think it would survive politically long enough for me to switch from the "loses" to the "benefits" category. We're sort of seeing that now, except that I'm actually sort of optimistic that its 6-year (or so) survival has enshrined it or something like it.
I believe a repeal-without-replace plan will be completely disastrous for the incoming government and that whatever government is next will have popular support to backtrack, and that a repeal-and-replace plan will end up settling on something very similar, maybe even with some free-market-based improvements!
Edit: It looks like you need to be enrolled in a plan to be eligible for a HSA
These are the situations the ACA is trying to avoid and it was clear from the beginning that these types of plans (a nominal fee for virtually no care) would not be allowed.
Even if plans like this were allowed, we'd be in a situation where the healthy essential chose the equivalent of no insurance for the smallest amount possible. That's nearly the same as not having insurance at all.
But that's not the case, because that $175/month insurance didn't meet current standards of "good." While the ACA made it happen a lot faster for health insurance, this is kind of like me bitching about how high my car payments are because they keep adding on stupid useless things like bumpers, seatbelts, airbags and antilock brakes and I don't need ANY of those because "I don't get into accidents and if I do I have enough savings to cover it."
As for the question of him not being able to get subsidies for himself as a matter of law, I'm 99% positive that the way you become ineligible for subsidies is by making too much money to qualify. It has nothing to do with owning your own business, and if he's telling you it does then he's blowing smoke up somewhere.
As for the amount you're paying before you get benefits, yeah, there are plans in there like that, and they tend to be cheaper. You might almost consider them catastrophic care plans, except they cost more than $175/month and cover things beyond hospitalization. They're the ones with "20% coinsurance after deductible" for regular doctor's office visits, while what you're probably looking for are the ones with a "$40/75 copay" for primary care/specialist visits. That coinsurance/copay bit is one of the things insurance companies can still do to game the system.
The thing that those plans all have in common though is a maximum out of pocket number. That means if your friend the lawyer has a heart attack, is hospitalized, needs a couple of stents put in immediately or god forbid a bypass and doesn't have the time to shop around for other hospitals that might be cheaper, he's not going to be leaving the hospital with $250,000+ in medical bills that he's personally responsible for. Sure, $10-15k is a lot of money to take on as unexpected debt, but for an awful lot of people that's not bankruptcy money it's "payment plans for a few years that are going to kind of suck" money.
https://nystateofhealth.ny.gov/
Let's start with how much money you need to make to see your subsidies completely extinguished: $50,000. That's the limit no matter if you live in Buffalo or Westchester.
Let's then get into the regulations associated with ownership of a company. Did you know that as the owner of a company no matter the size or organization, you're NOT considered an employee of your own company? Nor is your wife?
From the NY state website:
"Under 29 CFR 2510.3-3, an employee would not include a sole proprietor or the sole proprietor's spouse. The definition for Common Law employee can be found here.
The structure of the business does not matter. For example, the business could be a corporation, LLC or d/b/a.
Employees (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership.
Specifically, 29 CFR 2510.3�3 states the following: (c) Employees. For purposes of this section: (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership."
So it does matter that the self-employed seem to get screwed a bit harder than the popular opinion acknowledges.
So, tell me again, which part of shifting costs from people who didn't go to law school and dropped out to work at McDonalds to those who finished school and did sounds like a fair deal to you?
Does shifting costs to those more conscientious sound like a great plan for national unity? How do you feel when your co-workers play hookey, sleep in, and write bad code? Do you think those folks deserve the same promotion opportunities you do? Do you think that any society that punishes achievers is one that is set up for success?
Let's discuss facts and not opinions. Show me the costs for insurance and where the subsidies end and tell me if you think it sounds like a good deal to you in a county where the property taxes for a small condo run about $25K per year.
Great, so he's making more than $50k/year, I'd hope that to be the case if he was able to make it through college and get a J.D.
> [ownership of a company & employee status]
I'm not disputing that, though I suppose if he really wanted to he could form a C Corporation and give or sell a small percentage of the shares to someone else to make it possible for him to become an employee. He's an attorney, he'd have a far better idea of the legal issues surrounding that kind of thing than I would. It seems logical to me (though possibly not in NY law) that if by law he's not an employee that it then follows that he is also not an employer since there are no employees.
I don't see how any of the above is actually relevant. All it really means to me is that he'd be purchasing coverage in the "Individuals & Families" portion of the exchange. I've never lived in NY, but in my experience with the Illinois/Federal exchange I don't think I've never been asked whether I was an employer, only whether I was an employee of a company that provided health insurance (or was required to provide health insurance by virtue of being >50 people).
And quite frankly if he's paying more than twice my annual mortgage amount just in property taxes, my sympathy over his premium increasing from $175 to $450 is very limited.
Admittedly, I'd be perfectly happy to see a return to Kennedy-era tax rates for incomes over $4 million/year and I'd be ecstatic to have those rates apply to me (because it'd mean I was making at least that much in annual income, but my needs and wants are simple and easily met with less than $100,000/month of income), so maybe I'm not the kind of person likely to be incredibly sympathetic here.
Look, it all looks great but when you REALLY DIG down into the rules, what you see is a recipe for disaster. The plans in NY that had to shut down were staffed by a roster of amateurs because the laws SPECIFICALLY EXCLUDED people who had worked in the healthcare insurance industry from splitting off and starting their own companies.
They quite literally expected a bunch of community activists to run an insurance company and it failed MISERABLY.
Facts are sometimes inconvenient things.
Exchange-created co-ops bit the dust elsewhere as well. In Illinois it was Land of Lincoln Health, which was closed by the state because it was going to be unable to make a required payment into the program designed to help keep the newly-created companies stable. I believe whatever remains of LLH may actually still be suing the Federal government, because part of what drove them under was not getting ~$70m that they should have received through those same cost-sharing systems. (caveat: Not an insurance industry person and I didn't watch it that closely). Still, I'm sure that there were a lot of amateurs who got involved. I'm also sure there were a lot of professionals and investors who got involved and in many cases lost money because even minor fixes became impossible after the law was passed. NOTHING that was going to make the ACA's implementation better was going to make it through Congress, particularly the Senate.
The problem is that when you dig down into the rules you may find a recipe for disaster, but you also found the only way it could possibly work. There are minor nuances, but when you really dig down you find that the "liberal dream of Obamacare" is really "Romneycare" is really at its core a design created by the Heritage Foundation[1]. That's not to say that it's great or terrible or doomed because it was championed by Democrats or doomed because it was written by Republicans, it's just the only viable structure that doesn't have single-payer as its core. If the Republicans in Congress actually do come up with a replacement it's going to look almost identical to the ACA except for cosmetic differences and name changes, and if Democrats stick with "You broke it, YOU fix it" then it'll also never pass and we'll be right back where we were in 2008.
[1] http://americablog.com/2013/10/original-1989-document-herita... And a countervailing argument that "[The ACA is from the Heritage Foundation is bunk]" http://www.forbes.com/sites/johngoodman/2016/02/15/where-did...
Here is a nice summary: http://www.newsmax.com/Newsfront/wsj-nyc-insurance-market/20...
There is no way he had any kind of health plan for $175/month, not in New York pre-ACA.
Yes this is what both sides of the aisles won't admit. You can't have 20% of the people use 80% of the services and make things fair without forcing the users to eat the costs.
Same things with:
1. The US (like most Western countries) has a huge post WWII baby boom now approaching old age. The younger generations will have to pay for this.
2. The US refuses to allow chronically sick and dying patients to let death takes it course, managed only with pain killers. Instead, vast amounts of money (some say 80% - there's that number again) are spent on the last year of a person's life carrying out procedures that only prolong a few more painful months, with no chance for recovery.
The costs could be reduced by taking away some of the huge profits of the medical and pharmaceutical industries. But in the end, there will need to be societal changes.
Then they're not insurance companies any more.
The top two Democratic presidential contenders as well as many of the Democrats in Congress campaigned on specific reforms to healthcare. The thing is, Democrats and Republicans have nearly diametrixally opposed goals in reform.
The positive PR of... 20 million people losing health insurance?
Before ACA, as a full-time worker at decent companies I paid maybe $50 a month for my insurance, my employer picked up the rest. When I went to the doctor, filled a prescription, or anything else routine, it was $10-$20 max. In the one year where I had a lot of care (broken wrist), I think I paid my out-of-pocket max of about $750 and that was it.
After ACA:
Catastrophic plan at pretty much every company I work for now (same for many of my friends in non government jobs). Minimum deductible of $1500-$2000 as a single guy. Probably 5x that for someone with a child and wife. When I go to the doctor, I pay for everything out of pocket at full price: $300 for a prescription (in the US they push up the drug prices to astronomical levels - we cannot buy from foreign sources), $200 for a simple doctor's visit. I have never hit my deductible which would then pay 80% of my costs.
Oh and I can't actually just go and get things like a hearing test or sleep study - I first need a referral from my primary physician at $200 / visit. In exchange, I get to put $100 away each month tax-free into a 'FSA' account. It is mostly use-it-or-lost-it by the end of the year, and will go back to my employer (i.e. a perk for them, not for me). At the end of this year, it basically turned into a $200 gift from me to my employer.
Edit: sometimes it's a good idea to call ahead and ask for "uninsured quote", you would be surprised your $200/visit physician might only charge $50 to someone without insurance.
Hospital billing is also pretty awful. I've seen them place every possible reimbursable item on every bill, full well knowing that some insurance companies would cover some items and others different things. This resulted in inflated bills that were never paid in full regardless of a person's insurance coverage.
Many hospitals will negotiate with the uninsured but it's rare for them to make this easy to do.
This article is pretty weak, but the best I could find on this relatively arcane subject:
Most hospitals can't even quote you a price. We were researching a procedure our insurance doesn't cover. One non hospital place quoted $750 cash price within 20 minutes on the phone. We called a nearby hospital and after over 10 hours on the phone spread over a week, and claiming that we don't have insurance (because their policy is you MUST use insurance even if they don't cover it), they quoted us $350 cash price.
We chose the hospital, and when we got there they said that price didn't actually include everything. WTF? It's a frigging mess.
I am a software developer, I worked for a mid-sized community hospital. "It's a frigging mess" is a reasonable summary and also heart-breakingly accurate.
This is one area in which the ACA is making progress: providing an incentive to the hospital to know what a particular procedure actually costs. Your example, while disappointing and frustrating, was extremely rare in the 90's. High deductible insurance has given every customer a reason to shop for the hospital with the most reasonable rates. I can't say if that incentive is strong enough, but I believe it is progress.
The real nadir for coverage was in the end of the Bush years: I worked at Home Depot as a developer. That means that the plan covers a lot of badly paid people, and a lot of old people. I was paying hundreds a month, my doctor visits were $75, 20% coinsurance in hospital visits up to 10K, and a maximum lifetime benefit of 1 million: So if something really bad happened, like a stroke, they'd stop covering before it was all said and done!
Since, my payments kept going up at similar rates, but at least things like maximum lifetime coverage has gone away.
The one and only time things have dropped in price was last year, now that I work at a place where the average employee's age is 26. The company still pays $1600/mo for their side of the coverage, but since it's mostly developers, they can afford it. No company in their right mind will pay that when the employees are making $15/hr
Healthcare has been less and less affordable since the Clinton years, it's just that it started very affordable. the ACA didn't make things noticeably different for the good plans overall: It's all still very expensive, and picking an employer that either has a young, healthy workforce, or has so much money they can pay for expensive plans, is the big difference between having good health coverage or not.
So I guess that what I am trying to say is that if you had the insurance you claim to have had in the bush years, you were incredibly fortunate, and your situation was not common.
I had childhood cancer and at the time it'd have costs millions without insurance.
While the healthcare market is hopeless opaque and corrupt and no doubt that does drive costs somewhat (or a lot), and probably there are things to do about it, but I think fundamentally the success of complex and expensive treatments is also driving costs - things that you'd have gotten painkillers and left to die even in '50s and '60s now can be cured/improved/fixed, it's just ridiculously expensive compared to popping some pills and expiring. Or look at prosthetics. There was a time you might have made do with crutches or a peg leg and now there are specially designed, fitted, and crafted prosthetics for various activities... that don't come cheap. Not to mention improvements to the standard of care or the sheer man-power requirements of health-care. A normal doctor's visit requires interaction with 3+ employees, across ~45 minutes, all of whom are presumably being payed more than $10 an hour, and possibly a lot more. It may actually be reasonable that budgeting $5k/person/year for healthcare is sane in terms of both risk and what you get, but just far more than people are used to thinking about or seems intuitively reasonable.
This is the entire theoretical reason for insurance: to spread costs out across a large group, so that by having everyone pay a little nobody has to pay a lot.
It's also why the logic of modern healthcare makes single-payer systems the ones that work the best; they spread the costs across the widest possible "risk pool." And why the ACA had to include a (deeply unpopular) mandate that everybody buy some form of health insurance -- as long as your system is based on private insurance, such a mandate is the only way to get the young and healthy into that pool.
> It may actually be reasonable that budgeting $5k/person/year for healthcare is sane in terms of both risk and what you get, but just far more than people are used to thinking about or seems intuitively reasonable.
Remember that most Americans' income has been stagnant in real terms for nearly 40 years now, while health care costs have done nothing but increase and seem set to keep on doing so. So, barring some major change in how the economy works, whatever figure you set for "a reasonable amount to save for health care" is only going to seem less and less reasonable as it grows to consume a greater and greater share of those stagnant incomes.
In other words, if peoples' wages increased by $5K a year at the same time as they were expected to bear $5K a year of health care costs, it'd feel a lot less painful than just expecting them to pull that $5K out of the couch cushions.
The reason they are becoming popular is that they are intended to incentivize the consumer to pick and choose their providers since they have to bear the brunt of the initial cost. (And cheaper for employers to fund over non high deductible plans).
I recommend reading up on the history here: https://en.wikipedia.org/wiki/Health_savings_account
For profit corporations will always find a way to game the system? Just like the whackamole with tax cheats?
That trying to regulate a broken marketplace doesn't work very well?
Perverse incentives lead to perverse behavior?
I, for one, am very much looking forward to purchasing insurance from the best provider in any of the 50 states, not just the few available to me in CA.
When this was done with credit card companies, they all moved to the state with the least regulation and started instituting consumer-hostile stuff like mandatory arbitration.
I'd really rather not have this happen with my health insurance.
The reason premiums are high is that costs are high, and our population is obese, disease prone and litigious.
If we want to contain costs we have some options:
1) Public option/Medicare for all could save us 10-20% in parasitical insurance company costs/administrative overhead.
2) We find solutions for obesity. Obesity is the #1 driver of increased health costs in America.
3) We stop holding doctors/pharma financially responsible for bad outcomes outside of their control through the legal system.
Part of the initial law were "high risk corridors" to limit the losses for insurers that initially mispriced their ACA plans. The insurance companies had to make a ton of assumptions about the age, health, and wealth of the populations who would sign up for their plans. To make sure they didn't accidentally bankrupt themselves, the law provided funds to limit their losses for the first three years of the exchanges (2014-2016). In the first year, they had a shortfall as the population was older and sicker than expected, so CMS was going to cover the $2.5 billion gap but congress refused to let them pay these user fees.
The GOP knew that the premium changes would come during the election season, so they denied funding for the high risk corridors last year. To give themselves room against mispricing, the insurance companies predictably raised premiums beyond where they would otherwise have been. Other insurance companies decided they didn't want the risk, so they pulled out of the marketplaces.
The election season was rife with announcements about "20% premium increases" and "xx Insurance company exits the exchange market". Millions of people get to pay more for health insurance but at least their guy won the race.
Aragorn: Ride out with me. Ride out and meet them.
Theoden: For death and glory.
Aragorn: For Rohan. For your people.
Theoden: The Horn of Helm Hammerhand will sound in the deep, one last time!
Somebody is gouging us, but we will never know who, and everybody can point to somebody else, or to "society," but we just don't know.
Chances are, everybody who can make money while covering their tracks through a web of business entities, is gouging us.
One potential advantage of the government owning the whole system, is that it would facilitate figuring out what the costs actually are. This may be why other civilized countries pay half what we pay. It's a saying in business, that you can't manage what you can't measure.
And medical coding to figure out what you're paying for and what a normal price should be is ridiculously hard to understand. Some of this is going to be their response to a litigious society, but you can't use that excuse for all of it.
Also, if someone doesn't have insurance, the fact that the hospital puts you on the hook for the full bill is ridiculous. Insurance isn't paying 100%, they are discounted crazy amounts, even only paying 20% in some cases. But you don't get this discount from the hospital. If you show up without insurance, you will be charged the full amount, less what you can negotiate on the spot. And most people don't know they can even try to negotiate it.
I agree that the insurance companies are a huge problem, but I don't think the hospitals and doctors' offices themselves should be absolved from their share of the blame.
And what happens with the majority of people who don't have insurance, they don't pay it. So the costs get eaten by the hospital and eventually by everyone else that can pay.
In that respect, we have socialized healthcare already. It's just a horrible implementation.
Exactly so. They don't pay it because they can't. And they're ruined. Even people who have insurance -- good insurance -- can be ruined. This system is the ultimate form of price discrimination, perfectly tuned to extract the optimal amount of money from the consumer who has literally no pricing information, and maximize the profits of the business. When insurance companies pay out, it's referred to as "loss".
Markets and the profit motive may be "efficient", but they're not optimizing for health outcomes, and certainly not optimizing for morality. Insurance companies ultimately cannot be part of the equation.
In advanced Western countries, you see many different configurations for functioning health care systems. Some do insurance based models, others do single payer, others are hybrids. The issue is not about choosing which configuration of system, it is about rooting out the disgusting level of corruption that exists currently in the system.
The ACA did nothing to tackle this underlying issue.
"let insurance companies shop for the best state"
Meaning, when customers have the ability to buy across state lines, the true competition becomes not consumers shopping for insurance, but STATES competing for health insurance COMPANIES to set up shop in their state- offering whatever it takes-- handing over amazing liability protections, tax giveaways, dropping regulatory standards-- all to get them to create jobs in the state.
The result is that (A) one or two financially strapped state governments give the industry whatever they ask for, promising them minimum regulation/oversight and low/no taxes, then (B) the entire industry moves there, where they further consolodate power. (C) companies regulated in other states (with safer products and actual responsibility to their customers) can't compete fairly, so they either move to that state or go out of business, resulting in (D) fewer choices for customers, poor quality products, higher prices, and more abuse and negligence from the companies.
I've heard this expressed as a "race to the bottom", which I always thought was a really confusing way to say it without context.
What makes me think this is going to happen? Watch the Secret History of the Credit Card documentary on Frontline about how this exact same thing happened in that industry.
http://www.pbs.org/wgbh/pages/frontline/shows/credit/
The CC industry "state-shopped" to find a state (South Dakota I think it was) that would let them get away with just about anything. At that point, every major player moved there, and suddenly credit cards became super abusive to customers and there was no recourse (until very recently with the consumer financial protection bureau...)
The UK is doing OK with the NHS at half the US cost as a fraction of GDP. Singapore is doing at least as good at about a quarter of the costs.
American combines the worst of government and private healthcare. The UK does a decent job with government healthcare. And Singapore combines the best of government and private healthcare.
http://econlog.econlib.org/archives/2008/01/singapores_heal....
There's a lot of material out there about the likely effects of selling across state lines. To the point it is not even actually seen as a viable option, it's more something that Republicans say because it sounds reasonable at first. But it's not workable.
You say: "It's a race to the bottom in terms of regulation"
Consider your assumption that regulation is good. In point of fact pernicious and arbitrary regulation within states brought us as a nation to this desperate situation.
You say: "To the point it is not even actually seen as a viable option"
Check your prejudice at the door and look at reality. You may need to understand markets and human nature more clearly. You may "see" and understand other, better options.
AND, until we hit our $5K premium, it doesn't really pay anything. So we've got to pay $27K to get a real benefit. And it's not like we're young and healthy (nearly 50). Feels like we're getting shafted.
There are substantial challenges. One is that insurance companies don't actually provide care, of course. Any company wishing to do business with people in a particular state would have to actually obtain a network in that state -- partner with an existing network, or negotiate deals and sign contracts with hospitals, urgent care centers, pharmacies, labs, and doctors. They'd presumably have to be licensed to do business in that state, and adhere to that state's own regulations and requirements for doing so. (Because the US is a federal system, the federal government itself is unlikely to be able to strip away all of each state's specific laws and regulations.) This process would have to be repeated for every state in which they plan to do business. Insurance companies would probably set up state-specific legal entities or subsidiaries to provide financial and legal compartmentalization. So selling insurance "across state lines", as a practical matter, may not differ much from the current system. State-specific legal work and shoe-leather network-building would still be required. There's nothing stopping a national company from setting up a state-specific entity and selling insurance this way right now.
Another issue is that if local regulations were somehow stripped, as some in congress wish, insurance companies, as profit-seeking entities, would all gravitate to the most favorable and least regulated business environment. After the Supreme Court ruling in Marquette v First of Omaha, credit card providers migrated to Delaware, South Dakota, or Arizona because those states have the weakest usury laws and allow them to charge rates of 29% or more to borrowers in any other state. A similarly deregulated and "efficient" market for health insurance would have all the companies set up entities in whichever state would allow them to offer plans that provide the least care reimbursement (known internally as "loss control") and charge the highest premium. This could lead to a situation where a few very large companies offer only high-deductible plans without guaranteed issue, excluding procedures that carry risk of being expensive or are politicized, with lifetime or annual caps, thin networks, and retroactive drops. Lip service would be paid in the form of seemingly cheap policies that actually provide little real coverage, but allow insurance companies and politicians to claim "all Americans now have access to affordable health insurance". As bad as the credit card system may be, lending is at least a business that can be conducted at a distance. Health care is the most local of concerns.
What's needed is not a guarantee of "access to efficient health insurance markets". What's needed is actual health care. In a moral society, everybody should have access to that actual care itself without risk of ruin. The US system forces people to make terrible decisions. People remainining in hated jobs, empowering employers and distorting the employer/employee market. Not taking medicine, or half-dosing, because, even with insurance, the costs are too high. Not visiting the doctor after an injured ankle because of fear of the costs, then suffering forever after due to a poorly healed fracture. Especially pernicious: seeing a doctor but not reporting problems because of fear they'd be labeled as pre-existing conditions for which future coverage would be denied. And employers themselves have higher costs because of the historical accident of employer-based insurance, reducing their competitiveness with foreign companies who have no such obligation.
It's a huge political problem, but this focus on insurance, and access to insurance, begs the question.
No. I don't buy auto insurance on that basis. It is required by my state in order for me to legally operate a motor vehicle. I buy what is "best" for me (and my family).
Only in our closed highly regulated environments that denigrate personal responsibility and individual liberty do we get this extraordinary markets dislocations that come with the bizarre healthcare system that we have today.
Your selection of the best auto insurance policy is qualitatively a different kind of choice. Many millions have no car or need of one. You could live without one. I mean that literally -- it will not end your life if you don't have a car. There are alternatives to owning one, even if one of those is moving somewhere where you don't need one. Likewise, you may never use your auto insurance, and auto insurance doesn't pay for maintenance. But everyone needs health care, including its "maintenance" form. There's nowhere to move that obviates the need for health care.
Insurance is not the right model.
It is being talked about but there is significant opposition from those that don't want to raises taxes to the level that would be required to finance such a proposal.
As an aside, I agree that Medicare expansion would have been a better policy. Good luck getting that through congress, though.
Because you do get fined for not buying health insurance.
We can argue the semantics of the word 'mandate' all day, but your analogy is upside down.
You are being fined for not paying mortgage interest. You are being fined for each kid you don't have. Buy your house and have your kids or you will continue paying more in taxes!
I don't mean this as a rhetorical question, so I apologize if it comes across as snide, but from the point of view of economics, what is the difference? I'm trying to understand why one kind of tax incentive is objectionable and not the other.
If I have $1000 in my pocket right now, I will still have $1000 in my pocket if I choose not to go after an incentive.
But if I have $1000 in my pocket right now, I will not have $1000 in my pocket even if I choose not to buy any health insurance.
In my eyes, being punished for peacefully doing absolutely nothing is as anti-American as it comes. That's another argument, but my point is that the analogy is off the mark.
Person B -- the renter -- will pay more income tax, because Person B does not get to deduct mortgage interest while Person A does.
In much the same way, if Person A carries insurance all year and Person B doesn't, Person B will pay more income tax.
So yes, you do get "fined" for not buying a house. We just spin it as "encouraging the dream of home ownership" instead of as a "fine", a "penalty", as "the government holding a gun to your head and forcing you to buy a house", etc.
How would a renter feel if their rent increased because their landlord was unable to take a mortgage deduction?
I countered that the home mortgage interest deduction doesn't apply to rental properties. Renters and homeowners are thus currently unequal from a tax standpoint, since renters effectively pay a higher tax rate than homeowners. Removing the deduction would thus not create a new inequality; it would remedy an existing one.
If I choose to live rent-free in my parents' basement, I will not get fined for doing so. I keep ALL of my cash. But I'll STILL get fined for having not buying myself insurance.
I'm not sure what logical fallacy you're throwing here, some form of "Denying the antecedent" or something along those lines, but it's not the same situation.
Why people insist the two cases are conceptually different (i.e., that one and only one of them is a "fine" for not doing the thing), I do not know.
There is a tax penalty for not having a home mortgage, so it's mandatory in exactly the same sense that health insurance under the ACA is.
You have to spend money on interest to have a portion of that reduced in taxes. It's not a penalty.
It's not a 'tax penalty'. You're keeping more of your money by not paying interest, and pay normal taxes on those. It's not a penalty.
That's really bizarre (although unfortunately, common) thinking.
There's an incentive for having a home mortgage under certain conditions only, and you do not owe anyone additional money if you have no outstanding mortgages on properties.
The same is not true for the ACA. You are fined for not owning something - e.g. if your net worth was $0, you could go into the negative for not having insurance.
If you don't own a mortgage, you cannot be fined into the negative.
There is no difference between a tax penalty and a tax incentive (more precisely, a tax incentive is exactly identical to a general tax cut plus a tax penalty for everyone who doesn't qualify for the incentive, and a tax penalty is equivalent to a general tax increase plus a tax incentive for everyone not subject to the penalty; so, except as concerns the general level of taxation, penalties are exactly the same as incentives.)
> If you don't own a mortgage, you cannot be fined into the negative
Since having a mortgage or not can make the difference between owing net income taxes or not, if you have $0 net worth before a particular year's taxes are considered, you absolutely can be "fined into the negative" for not paying interest on a mortgage (lenders, not borrowers, own mortgages.)
The healthcare mandate is a tax. What many people object to here is that most taxes tax an activity (making money, buying things, owning things, etc.), such that one does not HAVE to do any of those things, but if one CHOOSES to, they become subject to the tax. Here on the other-hand they are being TAXED for NOT doing something.
Using your analogy, the healthcare mandate is the same as taxing people for not owning a home.
Many doctors don't take Medicare. Over a situation where say there are 3 doctors for a specialty in a town... the two better ones do not take it, and the new less good one will take it. So if that flat answer is let everyone take medicare, I think there are some serious quality of care problems.
(I have no better solution though, every angle seems bad).
But continuing with your theoretical environment: no, they would consider adding new patients until they had a critical mass and then stop accepting new patients.
No we wouldn't, we'd be in a much better position and we'd be paying much less for healthcare. Medicare has far less overhead than private insurance and it'd be the logical move to establish a far more effective and cheaper system of socialized medicine.
Without a mandate for everyone to carry insurance, we have one industry footing the bill for what should really be paid by the government.
Instead, the indigent have insurance (in theory), and they can get healthcare other than at the emergency room, hopefully at lower cost.
The alternative is to end the mandate for hospitals to treat everyone.
> ... "if the bill remains what it is now, I will not be able to support a cloture motion before final passage." In other words, Lieberman will support a filibuster. "I can't see a way in which I could vote for cloture on any bill that contained a creation of a government-operated-run insurance company," Lieberman said.
[0] http://www.slate.com/articles/news_and_politics/prescription...
Prior to 1986, hospitals were not required to treat the uninsured, but most nonprofit hospitals did anyway.[1] For-profit hospitals tried to dump them on nonprofit and charity institutions. The 1986 law makes all hospitals that take any Federal funding treat uninsured people with emergency conditions.
[1] https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
Except that Medicare more like ACA with a public default option than true single payer.
If you're self employed and make over $50,000 a year no matter where in California you live, you'll have to pay full retail premium prices without any discount. My company as a whole makes over 50k a year, but less than 100k a year (still getting off the ground). Thus a monthly premium of $460 a month for a standard decent PPO plan puts a large burden on me. Additionally, if I don't get health coverage I'll have to pay a heavy tax penalty at the end of the year. Essentially as a bootstrapped small business owner, health insurance is a large burden of cost and I was forgotten in the Affordable Care Act. Instead my cost to purchase a plan skyrocketed as I subsidy other people's care. That is not fair, everybody is not paying their fair share. Middle class self employed are the one's who got hurt the most.
Finally go compare CoveredCA.com and then go use https://www.blueshieldca.com. CoveredCA literally is one of the worst designed and functioning apps I've ever seen. It constantly errors and doesn't keep state that I am logged in. The UI/UX is terrible. I'm guessing CoveredCA was outsourced to a non-technically competent contractor overseas. Compare that to BlueOfCalifornia which is a great site, beautifully designed, and functions as it should. This is why government can't have nice things.
Between my employer and myself, we pay $1806 a month for my family of 3. My employer has 3000 employees, so it isn't a weird situation with poor purchasing power.
Insurance is expensive.
That colonoscopy was $6000, btw. This, for preventative care that could save hundreds of thousands of dollars from colon cancer (and quite possibly my life) down the road. In a well designed system, price controls would put preventative care like colonoscopies below actual cost (and make the money up elsewhere), to save money at the macro level.
One of the reasons that the ACA is broken from a financial point of view is that the Democrats didn't want to simply raise general taxes and redistribute to fund the program. Instead they played all sorts of games with the 'individual mandate' to try to force participation without 'raising taxes'. But this is just a way for healthy individuals to avoid participating in the insurance pool -- which is a great way to destroy the actuarial basis of insurance.
It is entirely possible to be for nationalized health care and still think the ACA is structurally unsound and needs to be replaced.
And it's wrong to call this insurance. It's not insurance, it's a health care payment plan.
Before ACA I was paying 1/3 the price, and had 1/4 the deductible. These higher rates are basically a tax to subsidize others, which is fine in principle, I just don't like the idea that this is going largely to a massive for-profit private bureaucracy. My problem with ACA is the private insurance industry is shit, and ACA made the expansion of shit mandatory. It should have been single payer, destroy the perversion that is the private insurance industry who have lobbied for all the anti-competitive behaviors they engage in to ensure near monopoly status in the vast majority of counties in the country. But the political capital just wasn't there to see how treacherous the insurance industry has been.
I don't see how the next round of politicians actually fix this though. Preexisting conditions are made feasible by mandates, mandates are made feasible with subsidies, subsidies are made feasible by some people paying more under mandate. So you can't take away any single one of those without the whole system unraveling entirely. Even the insurance companies have said this. They just don't want to say it loud enough that the blowhard in chief gives them a tweetirade.
The US is the only modern country without cost controls. Providers set prices and insurance companies do little other than pass those costs onto consumers.
When will we get cost controls? Likely never. It's very anti-capitalism to restrain free trade. (Yes, there's some sarcasm there. This issue pisses me off.)
Until we treat healthcare like we treat our regional monopolies (electricity, education, etc.) the the government won't be able to set prices lower.
This is what we need in the US. I should not pay a different price if I have insurance or pay cash. People that pay cash are routinely charged far more than people with insurance.
Secondly, hospitals charge people with insurance more. Typically if a patient is uninsured and paying cash, the hospital will work out ways to charge them less, because they are personally liable for way more than what insured are. Hospitals still want to get paid, and charging a patient into bankruptcy is not a way to achieve that.
Haha fat chance. But there is the subsidy.
On the assumption you're making ... $100K a year, this is 20% of your income.
Hard to imagine how it could be done less efficiently. Of course, the issue is then going to be "Say we reduce costs to even 5% of income", "think of the physicians/hospitals/etc"...
In the USA, income tax is a marginal rate, while Social Security and Medicare taxes are fixed rate (and therefore regressive).
"Medicare gives Australian residents access to health care. It is partly funded by taxpayers who pay a Medicare levy of 2% of their taxable income.
Your Medicare levy is reduced if your taxable income is below a certain threshold. In some cases you may not have to pay the levy at all.
If you don’t have private hospital health insurance, you may have to pay the Medicare levy surcharge (MLS) in addition to the Medicare levy. This depends on your income for MLS purposes."
Of course, choosing to accept work for 80% under market rate in a place where the high market rate for labor drives high cost of living is going to have short-term negative economic consequences.
If anything happened you'd be in the emergency room and would either pay outrageous amounts magnitudes more than $460/mo, or declare bankruptcy making your hospital debt a burden for everyone else.
Rates for 2017 increased significantly, from -3% to 116% depending on the state: http://www.thefiscaltimes.com/2016/11/01/Here-s-How-Much-Oba...
I think the ACA was responsible for temporarily suppressing rates. Now that the costs are better understood, we're back to around where we would have been without it.
Americans, we are all about freedom. Freedom to kill ourselves and eat twinkies. But we expect help when we are sick.
One side or the other has to budge a little. Do we give up being able to get the same insurance despite unhealthy habbits? Do we give up helping the poor and the sick?
Go skiing? Well there's a higher tax for the ticket because you have X% higher risk of breaking a leg. Twinkies right now are a grocery food so in fact it has less tax, where it probably should be taxed like booze or cigarettes (in effect a sin tax). Of course sin taxes get abused, where the money goes to the general fund rather than going to mitigation for the undesirable behavior.
I think for most things we are too stupid to really calculate the extranalaties of products.
I've been paying my own premiums for 9 years. Before ACA, premiums went up ~5% per year - 8% one year, perhaps. Since ACA, I've seen increases of 25%, 20%, 20%, 25%, then 11% then 13%. OK, yes, it's anecdotal. But "it goes up every year regardless" is missing data there - pre-ACA there were inflationary increases - post-ACA there are increases to cover millions of people who weren't included before.
- not able to keep my existing health plan. I had a great low-ish deductible plan with good benefits cancelled due to ACA.
- not able to continue seeing my family doctor (that my folks and sister still see). I'm pretty sure the current doctor I have hates all his patients and staff.
And yes, it costs a lot more in terms of premiums, deductibles and prescription meds. But also in travel time because the other physicians in my town that accept CoveredCA stopped accepting new patients.
We are now on an ACA plan. $270 with subsidies. Think about that. The government doubled the price of the plan or more, and is paying with our tax dollars the difference between my $270 and $780.
The ACA helped many people. It helped people under 26. It helped people with pre-existing conditions. It helped give free or low-cost health care to people that couldn't afford it because now the government is picking up the lion's share of the tab.
As much as people like to rag on the Republicans, and they deserve it, I don't think they will throw out the good parts. I think they will look at the industrial recommendations such as expanding risk pools across states (Commerce Clause allows this regulation), and other rational plans. Will it be perfect? No. Will it be better than the current ACA? Maybe.
It's a second-order effect; there was minimal cost control in the ACA, and plenty of room for companies to raise their prices. In a lot of ways, it was a sweetheart deal to insurance companies: they had essentially a mandate for people to buy their insurance, demand was through the roof, so they could charge more.
My evidence is that the premiums for my insurance went up even before ACA passed just in anticipation. That is exactly what the health insurance representative told us.
It was pretty clear why it happened. After ACA passed it kept going up a higher rate for us than in previous years (I have data for 3 years before).
> What evidence is there that the government itself doubled the price of the plan? The government doesn't collect the money, and it certainly goes somewhere...
Isn't it a bit disingenuous to suggest that the increase in health insurance is unrelated to legislation regulating health insurance. Or to put it another way is there evidence that government regulation didn't affect the prices and something else did?
http://blogs-images.forbes.com/mikepatton/files/2015/06/Heal...
Now, if one were to claim that the government failed to do anything that had the effect of reducing the cost of health care or health insurance, then I would completely agree.
For example, there is nothing to prevent someone from signing up for insurance, having some expensive medical procedures performed, and subsequently dropping the insurance. I have personally heard reports from insurance agencies that some people do in fact do this. And I can't say I'm surprised, either; even after factoring in the tax penalties, it's probably a completely economically rational thing to do in a lot of cases.
Premiums in states which refused federal money to expand Medicaid generally rose much, much more than states (like CA) which did not[1].
Cynically, this was likely a designed play by Republicans to kneecap the effectiveness of the ACA by skewing the risk pool towards the elderly (who require more medical care, in general).
[1] https://www.consumeraffairs.com/news/health-insurance-indust...
In the linked article most of their profit would be coming from the large group market. The individual exchange is a separate segment and where they would be suffering those loses. So the desire to not remain in an unprofitable segment is not really negated by being profitable in a completely different segment.
https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-In...
But there aren't any real cost controls on providers, drug companies, medical device companies, and other suppliers.
That's what I said.
That's not a cost control. That's a price inflater!
If the only way for them to make more money is to have the price of things go up, what do you expect they're going to be in favor of? In a perfect world (from the perspective of the insurance company), everything from premiums to procedures goes up X% so that their profits go up X%.
That's a seriously messed up system and may be the most egregious part of the entire ACA.
It would politically unpopular to "throw out" the parts you spoke of. But the question is can we keep those parts and not keep the insurance mandate?
American's don't follow the actual machinations of the senate much so it's not "politically unpopular" to do this. We think electing a President every 4 years who's a radical departure from what we had before will fix all our problems and prevent us from actually having to pay attention to the details.
They can remove funding for subsidies through budget reconciliation, and let the system collapse on its own, but they don't have the votes to overcome the filibusterer they'd get if they tried to remove those protections directly.
1 of 2 things will likely happen.
1. They will repeal and delay. Meaning they will remove funding through reconciliation, but delay implementation until 2020. Then depending on what happens in 2018 who knows what might happen. This is the bad option because it could cause the collapses of the individual market even before it takes effect.
2. They will repeal and replace. Most likely they will replace it with the new Health and Human Services Secretary's plan to keep the preexisting conditions protection plan, as long as you maintain coverage. If you don't maintain coverage you'll go into a high risk pool with higher rates until you maintain coverage for 18 months.
Plan 2 is very similar to what we currently have, but it replaces the punishment for not maintain coverage with higher premiums instead of a tax penalty.
What they should do is to increase the tax penalty to force more people into the pool and simultaneously add a public option, but that's not going to happen.
That's a repeal of the pre-existing condition protection, because it goes back to how pre-existing conditions worked pre-ACA (HIPAA -- remember the "P" is for "Portability", not "Privacy" -- guarantees you can avoid denial of pre-existing conditions so long as you maintain coverage continuously or with no break longer than 63 days).
You do that by requiring everyone to have insurance when they're well to help cover those that are sick. That's the mandate. If you try to separate them, the system collapses under the weight of even more cost.
You weight until you have cancer to sign up? Well then you have to pay for the cancer treatment, but if you break your leg tomorrow, the insurance company has to pay.
Again previous conditions are not an issue, because they won't cost the next insurance company anything. If you get diagnosed with, say, aids and need treatment for the rest of your life, then it should be the company you were with at the time of your illness that has to paid, even if you are no longer with them.
Couple this with payment in cash for treatment, so that you can shop for the best/cheapest/whatever doctor (just as you would with car work), a mandatory disclosure of prizes and untangle health insurance from your employer and the system should be much more manageable.
Most people develop many pre-existing conditions as they get older. By the time you're 70 you'll have 5 different insurance companies all treating different conditions that you developed at various times in your life.
Not to mention what happens when companies go out of business. This plan isn't workable at all.
Are you even remotely aware of what something like that would typically cost?
Unless you're rich, you either die from lack of treatment, or declare bankruptcy and let the rest of us pay for your treatment. Neither option is particularly good for any of us.
That bankruptcy is not a magic free moment - it simply means someone else pays. Depending on the case, this might be the state through medicare/medicaid, it might be the health care provider, or it might be third party creditors.
Eventually, though, those defaults are all factored into operating costs of hospitals, the government, banks and so on - meaning you and I pay for them.
So, in the old system, we were all forced to pay for health coverage, whether we liked it or not. In the new system, we're all forced to pay for health coverage, whether we like it or not. ACA is explicit and, with extreme certainty, cheaper, since it expands preventative care on a systemic level.
But, of course, since people didn't realize they were paying for it previously, they now throw fits because the cost is made explicit.
But, as with many things, the politics around this issue is all about feels over reals.
Which, of course, is the most expensive way to go. You have people who can't pay visiting the emergency room for an ear infection or the flu. And that cost gets passed on to everyone else, which is why that single Tylenol tablet in your hospital room costs $10.
The state of Washington tried that in the '90s. Passed an ACA-like system. Republicans repealed the mandate, kept the preexisting conditions. Result: within a few years every single insurance company stopped selling individual health insurance in Washington.
Seattle Times article from yesterday about this: http://www.seattletimes.com/seattle-news/politics/dismantlin...
HN submission for discussion: https://news.ycombinator.com/item?id=13393537
The ACA lowered the costs of people with insurance by reducing the pool of people without insurance adn thus the free rider costs. Free markets however continued to raise prices just like they have for the last 30 years. http://www.motherjones.com/files/blog_premium_growth_2014.jp...
HSA require a deductible of at least $1,300 for one person, so people have starting calling that a 'high' deductible from 2003 or so.
Before ACA you could by health insurance with a 15,000$ deductible as an individual. After, ACA the individual out of pocket maximum is $7,150 per year for an individual. So, now legally the maximum is below the old pre HSA threshold for 'high' deductible.
It is certainly insane to expect people who are incapable of paying for their own health care to be capable of paying for their own health care. But the health insurance market is not there for people who are incapable of paying for their own health care.
They need an effective government and socialized medicine. Charity is not a workable solution.
> It is certainly insane to expect people who are incapable of paying for their own health care to be capable of paying for their own health care. But the health insurance market is not there for people who are incapable of paying for their own health care.
Sure it is, that's exactly why it's there, hence the subsidies. It's a shitty system, better than it was, but still crap that needs to be replaced with socialized medicine.
Whether the charity comes through government or private organizations is not relevant to my point. The point is that they need someone else to pay for it, and not via a normal market transaction.
>Sure it is, that's exactly why it's there, hence the subsidies.
Allow me to rephrase: The health insurance market is not there to ensure everyone is able to afford to pay for their own health care needs. It is not broken because some people are not able to afford to participate in it. That is not its purpose. Judging it to be 'broken' or 'insane' because it doesn't do something that it's not intended to do is ridiculous.
The HSA-tied minimum was the old threshold for "high-deductible" since the HSA/HDHP pairing was created, which was several years before Obama was elected.
This also added a lot of confusion as what was considered normal was suddenly called high.
It's not 'people', it's the government, for what that's worth.
https://www.irs.gov/publications/p969/ar02.html#en_US_2015_p...
That depends on how you define "high deductible".
For example, let's start at https://secure.marylandhealthconnection.gov/AHCT/LoadExplore... then click "Get an Estimate". Put in a family of 3, ages 63, 61, 21, no pregnancies, no dental. Income $100k. You get a list of 21 plans. The very first one on the list has a $12,400 deductible and a $13,100 out of pocket max.
In fact, there is not a single option on this list with an annual out of pocket max below $9000.
Granted, these are family plans. Your cited number is for an individual; the number is $14,300 for a family. But note that there are plans on this list that have out of pocket maximums larger than $14,300 (e.g. "BluePreferred PPO HSA Bronze $6,550" has a $26,200 out-of-pocket max). How to reconcile that with your link, I don't know: the theory says they should not exist, but experiment says they do.
Note that I picked on Maryland because they allow you to get this data without creating an account.
In any case, most of the plans on this list would have been considered "high deductible" before the advent of the ACA.
Anyway, what's the definition of "high deductible"? The standard definition used for HSAs is $1300 for an individual or $2600 for a family, which is almost hilariously low in today's marketplace. And the maxium out-of-pocket max for HSAs is actually _lower_ than the overall caps. I have no idea how that $26,200 out-of-pocket plan is "HSA-qualified", as it's claimed to be....
> The ACA lowered the costs of people with insurance by reducing the pool of people without insurance.
That's not true. The ACA raised the costs of people with insurance by pooling them together with people who used to be uninsurable because their estimated care cost so much. This effect completely dominated the effect of adding healthy people to the pool. One reason for that is that for healthy people paying the penalties is way cheaper than actually getting insurance, so a lot of them stayed uninsured, but even that is not the full story. The main upshot is that caring for some people is _really_ expensive and the cost has to come out somewhere.
We can proceed to an argument about whether the tradeoffs were worth it, of course, whether there were other ways of achieving the laudable goal of getting rid of the preexisting condition problem, etc. But let's not pretend that the reason prices went up is just "gouging". Prices went up to a large extent because the risk structure of the insured pool skewed towards more risk.
Now there is certainly _some_ gouging going on, largely abetted by the restrictions on interstate sale of health insurance, which leads many states to have a very small number of companies providing insurance. For the Maryland case above, there are precisely 3 companies represented in the list. And only one of those companies offers PPOs. Which is why the price of the PPOs in Maryland about doubled in the last two years: no competition, why not? This is hardly a "free market" behavior, though; it's a highly regulated, in a dumb way, market, that encourages monopolist behavior. Which is what we get.
So yea, for a tiny slice of the population ACA did make things worse, but frankly the tiny minority that where negatively affected don't really care about the new premiums either. Because, for most families having a 30k deductible is approximately the same thing as not having insurance.
PS: The ACA allowed some people without insurance because of health issues to get insurance. But, it also added a lot of young healthy people that would not have had insurance. The net gains and losses depended significantly on age. https://www.valuepenguin.com/how-age-affects-health-insuranc... So, people looking back on cheap insurance also look back when they where younger. New York and Vermont do not permit any use of age as a factor when determining health insurance rates, so younger workers do significantly subsidize older workers. Masschusetts limits cost increases to 2x so there is a significant subsidy.
For my hypothetical family with the ages I listed, insurance cost about doubled in the last two years in the state of Maryland for an equivalent (PPO) plan. Deductibles also rose significantly. I know a specific family like that, and they are _very_ unhappy about it.
> but frankly the tiny minority that where negatively affected don't really care about the new premiums either
Really? You think people don't care about $25k/year in premiums instead of $12k/year in premiums?
What makes you think this is a tiny minority? What I listed is a basic baby boomer family with one child still in college.
> The net gains and losses depended significantly on age.
Sure. I'm aware of all that. The upshot of the ACA is that people with preexisting conditions are _much_ better off (which is good), but people who are relatively healthy, independent of age, are generally worse off. This is almost a tautology, of course.
I should note that the price cited at your link is way too low for the states I know of, in the "64" age range, assuming you want a PPO. For an HMO, it's perhaps doable.
HSAs are from 2003 and it's overloading a reasonable definition with a new a silly one. You can see people in the mid 90's talking about high deductible and meaning something very different. ACA also capped out of pocket so you need to compare everything about a plan not just it's deductible.
PS: Find me a family plan with a 50k deductible under ACA. They used to exist.
We may be violently agreeing here. ;)
The limits are more sane than they used to be, but a lot of people that are getting subsidies aren't going to have an easy time coming up with $10,000 more in a given year. It's high enough.
The cost to collect and the collection rates themselves are abysmal and the increase in deductibles has amplified the problem to the point that many hospitals are closing due to patients' inability to pay their bills.
Consider the percent of Americans who don't have ready access to $5000 (or even $500) for an unexpected medical event that causes them to hit their deductible. I work in patient payment technology and this is an all too common situation that providers are forced to accommodate.
And the cost is being borne by everyone else.The art of economics consists in looking not merely at the immediate but at the longer effects of any act or policy; it consists in tracing the consequences of that policy not merely for one group but for all groups.
I do not understand why the US can't join most of the western world in instituting single-payer public healthcare. It would be a huge boon for small business and startups, who would no longer have to factor in medical benefits into their compensation structure and whose owners would no longer have to risk being uninsured for an extended period when they start the business.
Moreover, it's the morally right thing to do. It's shameful that the world's premier economic superpower does such a poor job of looking after its most vulnerable citizens.
Until and unless we can get people to examine the facts, this will continue.
http://www.gallup.com/poll/191504/majority-support-idea-fed-...
Opposition comes from the wealthy, whose taxes would go up, and insurance company execs (and employees) since it keeps them in business.
Maybe we could, I dunno, create a government run health care system to show everyone just how super-awesome healthcare can be when DC runs it. We need a demographic... hummm, how about retired military? We'll create a healthcare system for ex-military and their families, show everyone how well these things work, and then the public will be convinced that... oh, wait!
/sarcasm
So, no, you can't just walk into a hospital and get the same care you would if you actually had insurance, and then just stiff them with the bill later.
People without insurance don't go to hospitals. They don't go to doctors for routine checkups. They don't go to doctors to deal with chronic conditions. They go to ERs because they can't afford healthcare, but they know that the hospitals can afford their emergencies.
the hospitals can afford their emergencies
For example, Kaiser's huge new Santa Clara (CA) complex kept its ER from opening until the very day they closed the ER at the prior site on Kiely. There are fewer ERs in the San Jose area than there were 200,000 people ago.
You are mistaken. The good parts, like covering pre-existing conditions is exactly what causes your insurance to go up. It's basic economics. The Republicans do not have a plan to fix that.
If there was a way to fix it, don't you think it would already be implemented? You think they're purposefully keeping your rates high just to fuck with you? Not to mention suffer all the political fallout of it?
Don't forget. Obamacare is the Republican plan. This repeal and objection to Obamacare is all politics, not an attempt to fix a broken system.
Here's one with 8 million members:
The real behind-the-scenes debate in DC this month is about, first, the best mechanism to transfer funds (direct subsidies, state subsidies, Federal reinsurance pool for the sickest cases, etc ... each of which create distinct winners and losers whose lobbyists are currently out in force), and second, how much of an annual budget deficit the fiscal-hawk Republicans (now led by Rand Paul) are willing to tolerate.
The longer-term solutions have much more to do with diet, lifestyle management, and other behavioral health issues than with access to providers and drugs (e.g. look up how much of last year's medicaid/medicare budget was spent on type 2 diabetes treatment alone). Unfortunately it doesn't seem like we can tackle these issues at scale until after the current debate on affordable universal access to care is settled.
Excuse me? What money? The government does not generate net positive economic benefit, and therefore has no [real] money. You might be confused and talking about "taxpayer money" — but then why bother with the gov't at all, why not just say your plan amounts to "we should increase healthcare costs so we're, you know, throwing more money at the problem".
Healthcare is different because consumers often don't know what anything ought to cost, rarely in a position to shop around, and will never be able to afford some big ticket items without insurance regardless.
And the economic consequences are non-obvious. For example, many conditions are much cheaper to treat if caught early; if access to a doctor has an inconvenient cost attached, overall costs go up. The ability to see a doctor for cheap – ideally free – is the most effective way to lower the risk of expensive procedures in the future.
Furthermore, there's an enormous information asymmetry in healthcare, so it's hard for it to function as a market.
Because we already have "free" healthcare in the form of emergency rooms, this is ultimately a conversation about how to best allocate health spending. Emergency care is the absolute most expensive form of non end of life care, so we should focus on minimizing that send. There's a well known path for doing so, regular check ups, vaccinations, preventative care, and chronic disease management. All of which cost money now, but reduce future expenditure. And if we already pay for sick broke people in the emergency room, why not optimize the expenditure of those tax dollars by shifting it to more effective health interventions?
You yourself admit that end of life care is incredibly expensive. Why are we pushing people to live longer, when it incurs a much much greater cost to keep people alive? Why not just let them die young?
In part, this is a huge reason (the other reason is pregnancy cost) why pre-ACA healthcare prices were much much cheaper for <30 men than women - most things that seriously hurt men under 30 just completely off them, and dead boys don't incur major medical cost.
I don't know about your characterization that "Basically all research..."
But if I get pregnant or cancer, I have no choice - I have to get treatment or die.
I've been through chemo and radiation once, if I ever am told I need to do it again, to scrape and cling to another few months of life, I'm going to laugh in their faces, put my affairs in order, go on a hell of a vacation, and Old Yeller myself.
If it happens, it'll be interesting to see how my resolve holds up as I stare into the face of mortality.
If you look at the Federal budget it's clear that the Federal Government, beyond national defense, is simply becoming a giant healthcare and pension fund administrator, re-distributing wealth via social security, medicaid, and medicare. All other expenses are dwarfed by these. I'd expect this trend to continue until the singularity occurs and we enter our long-awaited post-capitalist utopia.
"MLR measures the share of health care premium dollars spent on medical benefits, as opposed to company expenses such as overhead or profits. For example, if an insurer collects $100,000 in premiums and spends $85,000 on medical care, the MLR is 85%. In general, the higher the MLR, the more value a policyholder receives for his or her premium dollar. The ACA requires an annual, minimum 80% MLR for individual and small group insurance plans, and an annual, minimum 85% MLR for large group plans." [1]
Seriously, something is wrong with the whole setup. ACA does address some of it but it has jacked my premiums sky high. Single Payer is the answer in my estimation. The sooner we come to this and stop fiddling around trying to make people we shouldn't happy the better off we will be.
Some business (like insurance) have a fair bit of tail risk they need to take into account.
Some are seasonal (like a ski resort) and need to make sure the profits they make in their high season can carry them in the low season.
Some are cyclical (like furniture stores) where people buy one piece and don't buy anything else for years.
Grocery stores have consistent customers and can generally predict their income and expenses day-to-day for the foreseeable future.
Second, a profit margin will take into account risk. So for the ski resort or the furniture store that includes the overhead of keeping the store open while you have no customers.
Third, if the risk is so insanely high why are these firms so consistently profitable? Shouldn't we expect to see them coming in and out of existence regularly? Restaurants are a truly high risk business venture, the majority fail to exist after the first year. Perhaps they have longer runways but it's rare to hear of an insurance firm shutting its doors. The large and consistent profit seen on their end of year reports belies the risk claim.
I don't think you can deny there are cost risks for insurance companies that a lot of other markets don't have. However, to back you up a bit, their profits are extremely good which probably means they are largely overstating the risk in order to gouge their customers.
The personal auto insurance combined ratio rose by 1.4 percentage points in 2015 to 97.3 percent for a group of 10 publicly traded insurers.
http://www.insurancejournal.com/magazines/features/2016/03/0...
When interest rates are higher car insurance runs > 100% loss ratio. They stay profitable by earning short term interest on premiums before paying out claims.
In a different insurance vertical fixing loss ratios at 80% would be called a cartel, and would put involved executives into prison for a good long time.
In healthcare the government forms the cartel, fixes the prices, gives money to poor to become consumers, and then fines everybody who won't become the consumer.
said Brer Rabbit. "Only please, Brer Fox, please don't throw me into the briar patch."
Sunlight is an amazing disinfectant and it is my hope that our government mandates every doctor and facility publish the total cost of every prescription and procedure they employ. We will collect that data and disinfect the high cost of health care.
[1] https://www.fisherbroyles.com/marketers-for-compounded-pain-...
By comparison, Bush's Medicare Part D prevented the Feds from even negotiating drug prices. Its author, Billy Tauzin, is now a Big Pharma lobbyist.
I mean, this is a constant joke in professional circles. If you are hourly billing and you can use your shitty talent to create something in 8 hours that your good talent would create in 1 - it's usually economically beneficial to have the worse employees do the work as it's more profitable overall. Up until the point where you lose the customer - but in this case that's not a concern.
You may be mishearing the term "excise tax". An excise tax is a tax on any specific good, such as tobacco or gasoline. Those taxes are included in the cost of the good (it just costs more at the pump or on the shelf). Yes, they are typically used to reduce consumption, or to pay for costs associated with consumption (eg roads).
An alternative income source might be luxury taxes. There are a number of luxuries where consumption correlates positively with price - but it would be politically difficult to implement a tax on extravagance.
Why? It seems that if premiums are rising relentlessly for one company that the insured will seek out other companies, and hence that one company will "lose the customer".
Or am I missing something?
They're defence contractors now! :joy:
[1] http://www.factcheck.org/UploadedFiles/2015/02/kff-chart.png [2] http://data.worldbank.org/indicator/SH.XPD.PCAP?end=2014&loc...
http://blogs-images.forbes.com/theapothecary/files/2016/04/S...
It was the recession.
Before ACA, our premiums went up ~5% per year - 8% one year - every year was under 10%. Since ACA, I've seen increases of 25%, 20%, 20%, 25%, then 11% then 13%. This is in NC with Blue Cross - the numbers possibly were different elsewhere (was in Michigan before that but wasn't paying as much attention, unfortunately).
The price increases I was seeing seemed primarily in line with inflationary numbers pre-ACA; post-ACA they seem to have no correlation to inflation, and seem to have more to do with a much larger overall cost for the insurance company covering more people, no lifetime caps, more services covered, etc.
EDIT: On, that factcheck chart - that looks to be showing premium increases for employer-provided health insurance. Employers cutting back their contributions to the premium would account for much/most of those increases. Effectively, it doesn't say anything about the actual insurance premium increases, only what employer-covered workers were having to pay - in my view, that's a big difference.
Unfortunately, I think it's percentage cap, not an absolute cap. So, if you're an insurer and want to increase profits by a dollar, you need to increase costs by a few dollars.
I know that adding infirmed people increases costs. The trouble is that the health insurance system of the US is not focused on individuals managing their own health insurance costs. Most Americans get their health insurance from their employers. This makes the ACA markets problematic because the limited risk pools above are further limited by the people utilizing the markets.
Does this mean that the US should ban company sponsored health insurance? Maybe. I don't know. What I do know is that the Democrats tried to stifle debate and thought on the bill. It went so far as Pelosi saying you can only know what's in the bill once you pass it [2].
Overhauling the risk pool will be huge. That's probably in the realm of repeal and replace. What I doubt we'll see, since it would probably destroy the Republicans in two years, is the total gutting of the ACA and the meaningful, unstable gap. The people wouldn't like it, nor would the business community.
1 - http://www.npr.org/sections/health-shots/2014/05/05/30982695...
I think this is a justifiably correct presumption if you assume that costs are normally distributed. Are healthcare costs and risks normally distributed?
We had this problem where the cost of financial risk was assumed to be normally distributed and we built a lot of policy on that, including pooling financial entities into bigger and bigger codependent pools, but everyone seemed to have forgotten the known-for-centuries-fact that financial risk has infinite variance. Of course it turned out okay after we bailed out a bunch of rich people.
No...
The way to "fix" the exorbitant cost of healthcare is to allow young and/or healthy people to sign up for the bare minimum: a dirt-cheap catastrophic plan that covers the absolute basics and prevents personal bankruptcy. Unfortunately, this hasn't been done.
The first is because the administrative costs are much higher than in other developed countries (about 25 percent). The second is because the U.S. spends much more than other developed countries for the same things (e.g., drugs, doctors, medical equipment, services). The third is because people in the U.S. receive more medical care than people do in other developed countries (for example, they're much more likely to get expensive surgeries).
A cheap, catastrophic insurance coverage plan for young, healthy people addresses all three of these reasons.
No it doesn't. This is insurance, if the young healthy people aren't paying more than a bare minimum, there isn't enough money to cover the sick. You can't mandate care must be given and allow those unlikely to get sick to barely contribute, that's not the purpose of insurance which is to spread the cost and risk across the whole pool. What you propose does nothing to solve the actual problem, providing care for those who actually need it.
No, that's just the way to transfer the costs back to older/sicker people, it doesn't do anything to fix the overall costs (and might drive them up by delaying care.)
It is really as simple as that. Could you imagine a system in which car insurance wasn't mandated but car insurance companies were required to repair your car regardless of its preexisting condition? No smart person would preemptively buy insurance. You just wait until your get into an accident and then bring the already damaged car to the insurance company and demand a policy to repair it. No insurance company can work like that.
Insurance only works when the costs of the most expensive customers are shared among the cheapest customers. You need incentives to encourage the cheap customers to sign up or the whole system falls apart. Rejecting preexisting conditions is the old capitalist way of incentivizing people, but as soon as that is prohibited nearly all incentives disappear for a healthy person to buy into the system.
Our failure to find a non-insurance 'hammer' with which to hit all of the health 'nails' is a larger issue.
You can offer insurance against an event that has already occurred, but the insured price will always be slightly higher than the uninsured price. One could call that insurance, but it'd be a degenerate case, so at that point it's more of a word puzzle than a real question.
> Our failure to find a non-insurance 'hammer' with which to hit all of the health 'nails' is a larger issue.
Exactly - the problem is that people talk about health insurance like it's supposed to solve the problems that a wealth redistribution program would. Except, insurance is not a wealth redistribution mechanism - it has a completely different goal - and trying to turn it into one just results into the worst of all worlds (expensive and ineffective at achieving either goal).
Pretend for a moment that everyone receives their annual physical, as medical guidelines recommend. (They don't, but it makes our example simpler.) And let's say that the fair-market price of providing the physical, accounting for all costs borne by the provider and their practice, is $100. (That is an arbitrary number I have chosen, also to make our lives easier). What will be the co-pay for the annual physical for an insured patient?
The answer is that it will be $100 - there is absolutely no risk involved in this situation, so the expected payouts of the insurance company will be $100, and therefore they will incorporate that into their price. (The consumer will actually pay a bit more than $100 in total, because the insurance company has overhead costs, which are ultimately paid by the consumers as well). But of course, that's not the case, because the expectation is that health insurance will reduce these costs, and that people who can't necessarily afford $100 will still be able to have their physical. That's why health insurance isn't really insurance, except in name - we talk about it as insurance, but in reality, it's a wealth redistribution program tacked onto a risk smoothing product.
By definition, insurance is literally not intended to save the insured person money, in expectation. The expected value of all claims will always be less than the expected value of all money paid to the insurer by the insured entity. (This does not hold for every individual, but it does hold in the aggregate - that's where the risk smoothing comes in). The insured person pays the insurer a premium[0] in order to reduce the uncertainty in how much they would have to pay on any given month without insurance.
[0] Not as in "monthly premium", but as in "a premium on top of the expected value"
It also ignores a number of other selection criteria and behavioral issues, which you are honest enough to note in your pretend for a moment intros.
However, people who proactively care for their health carry "upside risk" as well as downside, which your scenario does not account for.
You fundamentally misunderstand the concept of insurance. Group insurance is, by definition, a way to spread the cost of rare catastrophes around the group so that the affected individuals don't bear the full brunt. There is the full expectation that in the event of a major medical event you will save money.
Try reworking your example around major medical events (e.g. a $500K hospitalization) rather than preventive care (the function of which is to reduce the risk of certain controllable medical events).
> The answer is that it will be $100 - there is absolutely no risk involved in this situation, so the expected payouts of the insurance company will be $100, and therefore they will incorporate that into their price.
No. Even pre-ACA, insurance companies offered low co-pays. How did they do that? Because your monthly fees will over the course of a year add up to far more than the cost of an annual physical. The purpose of insurance is to protect yourself against rare, but catastrophic events: you will probably not experience a wide variety of expensive medical ailments, but if you do they will likely leave you in financial ruin if you're uninsured, so you pay an insurance company money to protect yourself against that risk.
(Or, alternatively, your employer pays a health insurance company money to protect you against that risk, and offers that benefit to you as part of your total compensation package. Which is essentially the same as you paying for it, with some amount of risk differences and thus potentially lower costs due to the pooled employee health insurance policies, but that's outside of the scope of this discussion. TL;DR: it's still regular market economics.)
You might wonder why insurance companies offered low co-pays at all — was it just some marketing gimmick? But no, you can explain that with regular economics too: insurance companies are incentivized to make annual physicals affordable and attractive, because they can catch potentially-expensive medical issues when they're still much less expensive, thus lowering costs for the insurance company.
Yes, this is what I am saying. However, that has nothing to do with the price of co-pays for routine care, which is by definition predictable.
> But no, you can explain that with regular economics too: insurance companies are incentivized to make annual physicals affordable and attractive, because they can catch potentially-expensive medical issues when they're still much less expensive, thus lowering costs for the insurance company.
See, this is another pervasive myth. For healthy individuals, the annual physical is not cost-effective - it is very unlikely to result in long-term benefits to the patient, and it is far more likely to result in unnecessary care (such as follow-up tests and differential diagnoses for false positives): https://sciencebasedmedicine.org/re-thinking-the-annual-phys...
Also, I don't know why you're drawing a dichotomy between what I'm saying and "regular market economics". Everything I have said is standard, textbook economic theory. There's nothing obscure or even controversial about it about economists.
> Everything I have said is standard, textbook economic theory. There's nothing obscure or even controversial about it about economists.
Claiming that "health insurance isn't really insurance, except in name - we talk about it as insurance, but in reality, it's a wealth redistribution program tacked onto a risk smoothing product" is definitely non-mainstream. An insurance company takes in payments to insure you against high-risk events, and that's exactly what a health insurance company does: you pay them a monthly fee regardless of whether you need medical care (or your employer pays them for you as part of your compensation package), and when you do need expensive medical care, they pay for it. In fact, many plans explicitly only pay for expensive medical care: anything under your deductible, aka inexpensive medical care, you're required to pay for. You might be able to make some sort of weaker claim about wealth redistribution post-ACA, but — co-payments existed pre-ACA.
Actually, some of the largest insurance companies and the vast majority of risk-bearing providers (hospitals that act as insurers) are non-profits. Though I never said that their pricing was based on charity; I said it was based on the fact that the product they offer is not really insurance (and that it exists in a marketplace in which prices are incredibly distorted by the existence of other factors, which would have been too long to explain in that simple example).
> Claiming that "health insurance isn't really insurance, except in name"... is definitely non-mainstream
On the contrary, that's the overwhelming consensus among economists. Which isn't surprising, because the economics of insurance are generally covered even at the undergraduate level, and the ways in which health insurance differs from a true insurance program are pretty glaring.
Equating risk-bearing providers and health insurance companies for the purposes of arguing that health insurance isn't insurance might as well be tautological. Sure, blueberry pancakes aren't really pancakes if you include blueberry muffins in the category of blueberry pancakes, but who cares?
That is not insurance. That is a wealth redistribution. Those are not the same thing, although the current discourse around health insurance conflates those two concepts, for obvious political reasons.
> Could you imagine a system in which car insurance wasn't mandated but car insurance companies were required to repair your car regardless of its preexisting condition? No smart person would preemptively buy insurance. You just wait until your get into an accident and then bring the already damaged car to the insurance company and demand a policy to repair it. No insurance company can work like that.
Actually, this would be completely feasible to implement. The insurance company would price you based on your risk. In this case, P(risky event | all available information) = 1), so there wouldn't be much of a point to buying the insurance, but it absolutely would work.
The problem is that the ACA also forbids insurers from underwriting plans based on anything other than age, income, zip code, and whether or not they smoke. That's guaranteed to increase the cost both for healthy and for unhealthy patients, because they have to make overly conservative estimates when evaluating the risk level of their patient pool.
Yes, they are the same thing. Insurance is fundamentally a redistribution of risk with money being shifted from those who have not fallen victim to that risk to those who have. If you have a problem with that aspect of the ACA, you have a problem with the general idea of insurance.
>The insurance company would price you based on your risk (in this case, it would be 100%), so there wouldn't be much of a point to buying the insurance, but it absolutely would work.
You do realize that this is functionally the same as getting rid of the preexisting conditions protection, right? Whether someone pays tens of thousands to a doctor for care or to an insurance company for coverage are in practice exactly the same. The whole point is that many of us think that is a fundamentally unfair system to force someone to face in that situation.
No, they are not the same thing. The fact that a transfer of money happens is not a sufficient criterion for defining insurance.
Take two people with different risk profiles but who are both insured. If you can tell a priori which one is expected to have lifetime claims that exceed their lifetime premiums, then you don't have insurance - you have a wealth redistribution scheme[0].
Note that I didn't specify which person had the greater risk profile, or whether they both purchased the same "tier" of plan, or even whether they purchased their insurance from the same insurer. This property of insurance still holds even if the two people have completely different risk profiles, if one purchases a gold plan and the other a bronze, and if one person purchases from MegaInsurance in New York and the other purchases from AcmeInsurance in California - as long as they are both insured at risk-adjusted rates.
> You do realize that this is functionally the same as getting rid of the preexisting conditions protection, right? Whether someone pays tens of thousands to a doctor for care or to an insurance company for coverage are in practice exactly the same. The whole point is that many of us think that is a fundamentally unfair system to force someone to face in that situation.
First, nobody is paying tens of thousands of dollars to a doctor, because there's an out-of-pocket maximum cap. (And that cap could still exist under a risk-based pricing world.)
Second, it's not, functionally the same, because that doesn't mean that you can't separately provide income- or wealth-based subsidies if you're aiming to redistribute wealth. But that happens at a completely different layer from the risk underwriting - and because the underwriting process is allowed to properly account for a person's risk profile, you end up with lower aggregate premiums (pre-subsidy). Lower unsubsidized premiums means that you don't need to subsidize as much money in order to achieve the same sticker-price premiums that consumers see - in other words, the entire process is significantly cheaper for what appears to be the same result to the patient.
The reason we don't do this, even though it would be significantly cheaper, is because it's politically infeasible.
[0] Which, you may note, is currently the case - and that's because health insurance as it stands is a mishmash of two completely unrelated products ("insurance" and "wealth redistribution") that we happen to try to stuff into the same box.
If they have insurance. Without guaranteed issue they may not. With guaranteed issue they may have "access" to insurance but can't afford it, or the insurance they can afford may exclude the procedure they need. Retroactively. And even with insurance they may pay 25K a year in premiums plus that 10K max. Then 28K and 15K the next year... It's a system designed for optimal profit, not efficient (or moral) distribution of resources that every person will require. Debating whether it's insurance or insurance-like, or how the underwriting works, begs the question. Insurance companies should not be involved.
It sounds like you are trying to respond to a different sort of discussion altogether.
This whole subthread is in reference to the (implied) statement "requiring insurers to cover pre-existing conditions requires a mandate [and it will necessarily increase premiums to the extent that we have seen]"
Your responses is tangential to that, addressing either (a) what would happen if we didn't require insurers to cover pre-existing conditions, or (b) other potential failure modes which could potentially occur, and which already occur under the ACA.
>The reason we don't do this, even though it would be significantly cheaper, is because it's politically infeasible.
I agree with your point here, but it is the whole perfect being the enemy of the good thing. Like the original article states, this system isn't perfect. Even Obama admits this. I do however believe the current system is unquestionably better than the system we had previously. I therefore think it is a bad idea to return to the previous system while we hope to eventually come up with a better one. It is not hyperbolic to say lives literally depend on it.
Probably more than anyone, Obama understands that politics is the art of the possible. The fact that the ACA was passed by a margin of one vote is some evidence that, in the face of raging blind opposition, they didn't leave anything on the table. If congress weren't in thrall to gerrymandered hyperpartisanism and effectively unlimited donor money, the law would have had at least some bipartisan support, been revised numerous times, had bad parts improved, good parts enhanced, and concerns of both parties and various constituencies addressed in light of the empirical evidence gathered over the last seven years. I don't think there will be a return to the previous system. Instead, for several million Americans, they'll try to demolish the first four floors of a building and disingenuously point to the doctor's office on the fifth.
This comment is so profoundly misguided that I have to comment.
Insurance does not work the way you describe. When companies do a fundraiser where someone gets to take a half-court shot with a basketball and win $1M if they make the shot, an insurance policy sells the company doing the fundraiser a policy that reflects the odds that a person chosen at random from the audience will sink the shot. That policy might cost $7K, since the shot will very likely be missed.
The insurance company makes a profit by charging a bit more than the actual odds reflect, so that over time if 200 shots are taken, it pays the $1M once and profits $400K. In a competitive market, the price of insurance will approach the probability.
Similarly, an insurance company might offer insurance that it will not rain on the last weekend in July. Perhaps an outdoor wedding facility wishes to buy that policy, but a farmer wishes to buy the other side of that risk. In such cases, the insurance company can charge less because there is a market for both sides of the uncertain event. Futures markets are also used for this purpose.
Most of our modern health care is not really risk-driven, it's based on markets that are highly regulated and prices that are influenced by lobbyists from various industries etc.
The key problem with your assertion is that at the time insurance is purchased, nobody knows who will be the victim or whether there will be a victim. Purchasers of insurance would rather spend a little bit of money just in case a bad outcome occurs, so they don't bear the full brunt of that bad outcome. Those who don't end up with a bad outcome don't get their money back, which is why the system works.
We all know there is a need for social services to provide healthcare for those who can't afford it or who have really bad luck. That's not insurance, however, it's social services.
You say that my comment was profoundly misguided, but your comment right here is just a rephrasing of mine Someone with risk spends a little bit of money to help absolve themselves of that risk. If a bad outcome occurs and they fall victim to that risk, they don't bear the full brunt of that bad outcome because money is shifted from people who didn't fall victim to that risk.
Regarding you point about probability based pricing of insurance, we have collectively decided that we don't want health insurance to function that way. If it did, it would lead to the preexisting condition problem in which a person cannot afford insurance because they have a condition that requires expensive care. We instead subsidize their policy with a price increase on everyone else's policy.
> we have collectively decided that we don't want health insurance to function that way.
I agree this is the case, the problem is that it's not really insurance any more it's a bundle of insurance, prepayment, etc.
True. And the ACA now levies a tax penalty for those that don't sign up for insurance (2.5% of income, max ~$2K).[1]
[1] https://www.nerdwallet.com/blog/health/how-much-is-the-obama...
And they screwed that part up. As a healthy young person, there is no incentive to buy massively overpriced, shitty high-deductible ACA plans, when one month of coverage costs more than the IRS penalty.
What are you going to do? Not let me die?
Some context for people who don't know about this:
http://www.npr.org/sections/itsallpolitics/2015/10/23/451200...
Now think about who is buying ACA plans off the marketplace. First, it's almost entirely people eligible for subsidies (86%) since the plans are cost prohibitive without them. Second, it's people who didn't previously have or couldn't get insurance, unemployed, or who aren't offered insurance through work.
You can see immediately the problem... ACA subscribers will overwhelmingly be high-cost subscribers. There aren't any healthy subscribers to ACA because healthy Americans are working and get their insurance through their employer and therefore aren't eligible for subsidies and have no reason to look at the high-cost exchanges.
The ACA is effectively cornering the market for super-high risk pool, and premiums on ACA markets will continue to rise to reflect it.
If the subsidies were available regardless of availability of a so-called "affordable" employer sponsored plan, and if they employer's contribution could be taken by an employee and applied to an ACA plan in addition to subsidies, it would fix this all in an instant. Suddenly healthy Americans would be shopping on the exchanges, fundamentally altering the risk pool and drive down premiums for everyone.
It's not nearly enough to counter-balance to huge influx of high risk subscribers. You're being hung out to dry with the high risk pool, which is why your costs have skyrocketed.
"Most people are healthy most of the time, and as a consequence, health care expenditures are heavily concentrated in a small share of the population: about 50 percent of the health care spending in a given year by those below age 65 is attributable to just 5 percent of the nonelderly population. The lowest spending half of the population accounts for only about 3.5 percent of health care spending in a year." [2]
If you want to fix ACA, you have to fix the risk pool. So what's the best way to get healthy people signing up for ACA in droves?
Imagine if you could take your employer contribution, and legally apply it to any plan of your choosing. As-in, sure the employer could arrange a group plan for the office, and you could take it or leave it, but you got to apply the exact same employer-contributed dollars to any plan you chose if you wanted.
Then on top of that, if you could get ACA income-based subsidies, regardless of the amount of the employer cost-share. Because, why on earth should you get less subsidy at the exact same income level, just because you have an employer who is also good enough to contribute?! That's just penalizing employers for contributing. Employer contributions would be an add-back to MAGI for purpose of calculating the subsidy, but nothing more. Currently, today, the meagerest employee contribution will disqualify an employee from all subsidies altogether, almost regardless of income. So-called "affordable" employer-sponsored coverage disqualifies an employee from all subsidies, is defined as an employee share of less than ~10% of household income for an individual plan. WTF?!)
What you would end up with is some extremely cheap plans which a lot of very health workers would flock to. The Fed would pay out significantly more in overall subsidies, but the payment of subsidies would be significantly more fair because it would not penalize an employee for working for an employer who is actually willing to contribute to a share of health costs.
In practice, it would in quick order eviscerate the group market for employer-chosen plans, and see employees taking proper responsibility for choosing their own plans for themselves, while still preserving the ability for employers to share in health care costs with tax-advantaged dollars. It would save millions of small/medium sized businesses the arduous task of trying to negotiate group health plans for their employers evey single year. But most of all, it would fix the risk pool by getting everyone across America actually buying through the marketplace, and not the skewed microcosm we have now.
Early on after ACA passing, I think it was Zenefits was actually trying to sell employers on paying employees to purchased their own plans on ACA marketplaces years ago, until the IRS shut it down. But it was an extremely appealing model at the time.
[1] - http://kff.org/other/state-indicator/total-population/?curre...
[2] - http://healthaffairs.org/blog/2016/03/15/dont-let-the-talkin...
Pre-ACA a non-group plan that wasn't some government mandated high risk pool would typically be much cheaper than group coverage, simply because of the fact that it went through underwriting and you could be denied.
It was priced similar to life insurance where a healthy young subscriber could get a very cheap premium because the expected value was so low.
Back when it was legal to charge 10x more for a 55yr olds plan than a 25yr old, people paid more in line with their expected utilization. Flattening the rate curve shifted massive costs to young middle class families, which IMO is shit policy. When you're 55 you are generally done raising the kids and saving for their college, so it's actually not a bad time for your health care premiums to skyrocket.
(This just to counteract my overly weighty response as sibling to this)
Kinda, sorta, not really [1].
1 - http://www.politifact.com/punditfact/statements/2013/nov/15/...
This was the Republican proposal until Obama took them up on it. Anyone who remembers poor Mitt Romney having to bend himself into logical contortions during the presidential campaign knows that: it was his signature achievement as governor, previously praised by many in his party when advocating against single-payer systems, and suddenly so politically incorrect within his own party that he felt obligated to attack it or invent incredibly fine distinctions to say the ACA was different.
True story:
Pre-ACA, I had never been without insurance. I also have asthma. Never been a problem. No pre-existing condition issues. Then, I became a contractor and had to pay for my own insurance. The insurance refused to pay for anything asthma related. Fine; I was making enough to pay for the hideously expensive inhalers (think an epi-pen ever couple of months), but with those, the asthma was well controlled. Then I left that position and became a regular employee with employer provided insurance. Suddenly, no pre-existing condition limit. Weird.
Which is why it's named after Reagan.
So it works as a totality but not in pieces
Those private plans you researched had crap coverage compared to the standards that the ACA set for all health insurance.
By raising the standard, premiums have gone up on some private plans and overall healthcare costs have been reduced for all Americans.
Costs have gone way up; they've just re-arranged where the money comes from, and punish you for not putting more money into the system.
Ensuring everyone is covered by making it illegal to not be covered is not an acceptable solution.
Maximum out of pocket for a family on an ACA bronze plan is $14,300, including drug costs.
http://obamacarefacts.com/health-insurance/deductible/
> The maximum deductible is equal to the maximum-out-of-pocket limit each year ($7,150 for an individual and $14,300 for a family for 2017).
That's the theory. As I noted in https://news.ycombinator.com/item?id=13393287 experiment suggests otherwise for the out-of-pocket limit, at least....
https://content.carefirst.com/sbc/APHMMN5DRXCMMN5MN012017.pd...
The explanation is "it's a typo".
Medical and Prescription Drug combined: $6,550 individual/$13,100 family for In-Network Providers; $13,100 individual/$26,200 family for Out-of-Network Providers.
Eliminating networks is certainly something the US should do if it wants to do more than pretend that people have good access to healthcare.
But the out-of-network deductible can still apply, as far as I can tell. So can the out-of-network out-of-pocket maximum.
You've also confused deductible with out of pocket in your original post, on top of rounding up by 15%.
Can you provide any proof of that? According to Obama, an average insurance will be as affordable as a cellphone bill. Perhaps your plan had some perks in it, no?
Also there was a lot of fake stories about people getting tripled their insurance cost, all have been pretty much debunked as not real. Even Harry Reed was mentioning that in his speech.
For those that don't know, in an hmo, you have to go see your gp for a referral for everything. In grown tonail, go to gp when you know he will refer you to a podiatrist. With a ppo, you can go directly to the specialist. But ppo under aca are the "premium" plans.
I personally prefer HSA backed plans since I have a real asset. We've saved heavily over the years. Now I can't really do that. I think there is only one such program in Florida. It was a high premium and high deductible.
The Senate has already voted to remove provisions that your praise in your post...
From the NYT: "Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to (gut the health care law) without the threat of a Democratic filibuster."
So take out the editorial "gut the healthcare law" and replace with "repeal and replace" and you have a clear reporting of what actually happened.
Two paragraphs down the actual non-editorialized reporting states the real truth; "The action by the Senate is essentially procedural"
Here's one: http://www.cnn.com/2016/01/08/politics/obama-vetoes-obamacar...
Now that the vote counts just see what actually happens.
The GOP has been talking about repeal for year(s) now and has nothing to show for a replacement plan. Meanwhile, as part of the resolution passed, they took aim at specific provisions that, again, were things praised in the grandparent comment.
In case you're not familiar with the details -- the cost sharing subsidies are payments which reduce co-pays and deductibles for low-income subscribers. These are a step beyond the subsidies, this doesn't reduce the premiums, but rather siginificantly reduces out-of-pocket expenses. The law is written in a way which requires insurers to grant these cost reductions to low income subscribers, regardless of whether the funds to reimburse the insurers are actually appropriated by Congress and paid out to the insurance companies. In other words, every year if the money isn't voted in to fund it, the ACA would immediately collapse because companies would be allowed to flea the marketplaces mid-year, and they certainly would, because they would be facing additional billions of losses due to the now unfunded discounts to low-income subscribers.
To work around this fatal flaw in ACA (one of many) Obama has been using executive orders to "appropriate" the money to pay the subsidies. This is of course an obvious violation of separation of powers (power of the purse is for Congress alone). And the House took the incredible step of suing the Executive branch, and they won. The ruling in the Federal Circuit court would immediately end the $9 billion of cost-sharing payments which Obama has been ordering the DHHS to make to insurance companues... was stayed upon appeal to the Supreme Court. If Trump decides to drop the appeal on January 21st, the payments cease, and ACA self destructs.
So, no, the Senate didn't vote to repeal anything, nor would they have to if anyone wanted to watch the ACA crash and burn. Of course very few elected representatives actually want to see a lot of very needy people lose their health insurance mid-year, as much as they didn't cause this dumpster fire, they will need to try to put it out. So we're likely to see more votes to prop up the failing ACA over the coming months until the replacement can be made ready.
For the most part, the insurance companies are huge, and they operate nationally already. There's really not any economies of scale that are going to produce direct savings. The savings come by slashing everyones coverage.
Going to the doctor for an annual physical is not something that should be insured. It's a known cost. You, as the individual, should pay that out of pocket, or get another extended coverage policy or rider to covert that. It's like my auto insurance paying for oil changes.
As a result, our costs are too high.
A health disaster is several orders of magnitude more expensive than an automotive disaster, and you can't just total out a human being and pick up a new one at the local dealership if it's too expensive.
Preventative maintenance is a money saver long term.
https://sciencebasedmedicine.org/re-thinking-the-annual-phys...
I was born and raised in a single payer country where healthcare is free (or close to it) and we are seriously considering a move back there. If we lose our jobs here in the US we would be screwed due to my wife's ongoing mental health needs.
Like, I don't have mental issues so I don't need the mental health parts. I don't have cancer so I don't need the cancer coverage.
Previous to the ACA people would buy "health insurance" with a deductible so high they realistically couldn't use it anyway. I'm talking working class people with $10k deductibles and $2000 in actual savings. And they were freely sending insurance companies $100-200/month knowing there is no way they could actually use it.
Insurance, as a product, was highly customizable. You could get riders and other policies to cover various risks. You see this all the time with fleet insurance. Health insurance use to be the same.
The ACA set a floor on the offerings. If you don't those features, you can get a non ACA approved plan. You then have to pay the tax penalty. Now the penalty is an oddity. There is no lean. The government removes from your refund $X until you either pay the penalty or have no refund.
I looked at such a plan. Best I found was $438. Assuming an income of > $100,000 (I thought that 2017 insurance rates were set using 2016 actual income, I was wrong), the penalty was north of $3.5k total for my wife and I. This made the ACA plan cheaper since I didn't have to worry about filing quarterly estimates since I always have a refund (I'm giving a price to the time and effort required to file).
So the subsidies make the ACA plan cheaper that the non-ACA plan. I went with that. The question I pose to society is "Should we require government, funded through taxes, handout to make medical costs affordable?"
You are ignorant and heartless.
In the worst and most expensive cases, patients do not even have a choice.
And your subtext is completely clear here.
No, you should not get to pick and choose what conditions are worthy of treatment because you don't have them and don't think they are legitimate, and therefore make coverage more expensive or unobtainable for others.
I don't buy that "I won't ever use" thing. People change their minds, and sometimes you're not capable or competent to decide for yourself.
> People change their minds, and sometimes you're not capable or competent to decide for yourself.
This means one of two things. 1st, I should be able to upgrade my policy or pickup a secondary one. 2nd, my family will have to live with the results of my earlier decision to not include mental health in my coverage. Decisions have consequences. The government shouldn't force me to pickup coverage just because they think it might be a bad decision to forgo it.
So, one of a few things will happen. You may forego treatment and recover, in which case great. You may forego treatment and remain ill, meaning we all lose out due to the loss of a productive member of society. (Or, worse, you hurt a bunch of people.) You may seek treatment and be able to afford it, in which case great. Or you may seek treatment and be unable to afford it, meaning the rest of us get to pay for it for you.
That last one in particular is why we like to force people to have insurance. It's basically the same as forcing you to have liability insurance for your car. You can end up costing others a bunch of money, so we want to make sure you're able to pay it back.
Decisions have consequences. So long as the consequences remain confined to the person making the decision, I don't care much. But once they start impacting others, there's trouble.
You do a disservice by calling everything you don't agree with cadillac coverage. Clearly you've never had it.
You must be wonderful to have as a family member.
Mother: Hey, crazy cousin virmundi is coming to stay with you because he does not have mental health insurance and there is no government social safety net!
Me: Uh, what!?
Mother: Can you clear the guns and knives out of your house?
Me: Uh, what!?
I don't blame you there, it's probably a wise decision. I don't think I would ever want to have that listed in my medical records, for fear that it would be used against me in some circumstance down the road.
I thought brain tumors were for old people and people who didn't take care of themselves. If you asked me at the time I got the tumor my odds of a brain tumor were zero.
It's not a "personal choice" to get sick. You can only prevent illness to an extent.
>Why should I be forced to purchase something I have no intention of using?
I don't intend to ever use the liability coverage I purchase. In fact, I hope I never have to use it. I don't mind I have to purchase it though because it makes society better off as a whole. I would hope if someone caused me injury they would be insured just the same.
I find your attitude extremely disturbing.
And yes mild to moderate depression can often be treated on your own with lifestyle changes. I'm glad that worked for you (honestly) but not all mental health issues are mild depression.
From what I've seen in my volunteer work I doubt you had severe depression,as rarely can severe depression be treated soley with diet and prayer (unless substance abuse was the underlining cause). Let me ask you, were you able to sleep? Eat? Get out of bed? Shower? Dress yourself? Go to work? Leave the house? Brush your teeth? Get through the day? If so your depression was mild to moderate.
Not that dietary change and prayer aren't useful in treating depression, they absolutely are! Depending on the patient we would encourage both as part of recovery. It's just very few severely depressed patients are able to "pull themselves up by their own bootstraps."
I talked to the CEO of a small rural non-profit hospital and asked if ACA had helped since they traditionally wrote off a lot of the care they provided. I figured that everyone being required to have insurance would really help them stay afloat.
She said it actually hurt them because they had an influx of people coming in with subsidized insurance that never paid any portion of the deductible. So the hospital was now struggling even worse than before because they were writing off more than previously.
For me, this was a counter-intuitive result of ACA that I hadn't expected.
If the patient doesn't pay the deductible, does the insurance company not pay anything at all?
My assumption would be that the insurance company has to pay, and then has to work out the deductible payment with the patient. What's the point of asking for an insurance card if the patient can simply not pay anyways?
I fail to see how the amount uncollected could go up from this interaction. Before, uninsured people would have to pay full price (hospitals tend to charge uninsured people more), now they only have to pay a deductible...
Though chances are any time the uninsured rate goes down, the default rates of insured people will go up. Newer insured people are less likely to have their finances intact after all. So anything that lowers the uninsured rate will cause this issue I suppose
Maybe new healthcare revisions should offer FDIC-style insurance for deductibles for hospitals. Wouldn't want people refused from hospitals despite having insurance.
As a sidebar, it's awesome when you have a situation as described, and then never go to the doctor again for the rest of the year, and so get no cost reductions on anything, despite paying out-of-pocket for the services you did use, plus whatever your premiums are.
I understand that this saves people who go way over, but if the deductible is $2500, what's to stop a $25000 operation from becoming a $35000 one?
There's the hospital-insurance relation but given how flexible hospitals end up being on pricing it sure doesn't feel like enough
> Sure it had more bells and whistles, but I didn't want nor need them.
Like FREE preventative care. That's not a bell and whistle. That's worth more than your $20/month right there. Go to the doctor already.
And more importantly, that premium is identical regardless of what condition you were in. Without ACA, if you had cancer, you would die and/or be financially ruined. Worse yet, if you just had something like depression, or high blood pressure, or diabetes, then you'd be screwed out getting affordable insurance even in the event you got cancer or something unrelated but deadly.
My taxes, and everyone else's taxes go to pay this $500 dollar difference. The Federal government didn't some how magically create the gap funds. They have to increase taxes through fines and other sources to pay this.
They've effectively hidden these costs for the subsidized individuals. I'm not paying $780 per month with a large refund at the end of the year. I'm paying a few hundred. Most people don't think about the revenue impact this has on the country. We now have to fund these subsidies. We now remove even more money from people that could have go into stocks, local economies, or services.
The plan should be $280. That's it. Not $280 + subsidies. Just $280.
Maybe, maybe not. Here's a case of a death that cost $250k for want of a $80 tooth extraction: http://www.washingtonpost.com/wp-dyn/content/article/2007/02...
We were already paying for uninsured folks via bankruptcies etc.
It didn't "cost" $250,000. That's the sticker price of what they billed for the services, but that's not what they expected to be paid by insurance. That's a crucial distinction.
Just as you don't pay sticker price for a new car, the insurance company doesn't pay what the provider bills them for; they pay some agreed-upon rate, which is specified as a multiple of what Medicare pays.
> We were already paying for uninsured folks via bankruptcies etc.
Not exactly. Contrary to public misconception, it's well known in the medical world that preventive care is not cheaper in the long-run. (It generally results in better care, but not always, and it always results in greater utilization either way, so the end result is more expensive).
You can make the argument in favor of routine and preventive care on the grounds that it's the right thing to do, medically or morally. But it does result in greater costs overall, and that still has to be paid for.
But it didn't and doesn't provide care. It provides free or low-cost health care insurance to people that couldn't afford the insurance. They still have to pay for their actual health care with high, up front deductibles. Which many probably still can't afford. But the insurance companies are running to the bank with the mandated policy coverage and flow of federal tax dollars (via subsidies).
I don't see how Republicans could not throw out the good parts. When you boil it down, the good parts of the ACA are the requirement to cover pre-existing conditions, and the individual mandate. The former is what's needed to ensure people aren't completely fucked over at the slightest opportunity, and the latter is needed to avoid destroying the insurance industry in the presence of the former. Republicans appear to be fundamentally opposed to both of those. Without them, what's left?
- a cap on profits on insurance companies, enforcing that a certain amount of revenue is going towards client coverage
- Allowing people up to the age of 26 to stay on their parents plan
There's a couple other bits like this as well.
You don't want them now but you might want or need them later.
> The ACA helped many people. It helped people under 26. It helped people with pre-existing conditions. It helped give free or low-cost health care to people that couldn't afford it because now the government is picking up the lion's share of the tab.
There are a few important things it did that you missed. It ended lifetime maximum caps and it capped the difference in what you can charge the based on age to 3x. That last one in particular is greatly under appreciated. Yes, the young are now paying more than before but they will also pay less than otherwise when they get older. Everyone gets older so everyone eventually benefits from it.
> I think they will look at the industrial recommendations such as expanding risk pools across states
Nothing prevented them from passing this since they were in control of Congress. My guess is this is much harder to accomplish than it sounds.
Insurance companies did not know the health, and thereby the cost, of previously uninsured people buying coverage under ACA. To reduce risk of the unknown, the government committed to reimbursing money lost due to underestimating risk (conversely, insurance companies would pay into a pool if they earned above certain thresholds). Over time, prices would meet an equilibrium as policy costs stayed low, allowing more healthy people to join the pool, which lowers coverage costs, which then lowers policy costs. Prices could be raised modestly to account for the difference, and government payments to insurers would ultimately end.
However, Congress rejected payment into the risk pool and ultimately paid out only 12.6% of the promised funds. Many co-op insurance groups had to fold, others needed to dramatically increase premium costs to account for (a) the lost money, (b) the increased cost of the uninsured, and (c) the increased risk that the government wouldn't fulfill its obligations.[1]
The current situation - limited choices, high premium costs, and resultant lower healthy person participation potentially leading to a "death spiral" collapse - is a direct consequence of these actions, not an inherent failure of the ACA.
However, Obamacare gets the blame and Republicans can point to a failing market that they can repeal and, perhaps, replace. Very effective politics indeed. Just ignore the human cost, which certain politicians seem to have no trouble doing.
[1] https://www.nytimes.com/2015/12/10/us/politics/marco-rubio-o...
On the inverse, I see many people on the left pointing to the number of people who have signed up as the primary indication of it's success as well. Which contains it's own notes of ignorance.
Was the government not handing out fines to people who didn't sign-up? So they were basically forcing people onto the program? How could the numbers of sign-ups be meaningful then?
Also, I couldn't imagine going without health care. You have to take what you can get otherwise the risks are significant. So considering it's an essential service, saying "look at the number of people using it" as an success indicator is like saying "plenty of people are calling the firemen, clearly they are doing a good job".
There is a serious human cost here when people have their health plans doubling in cost... while the rest of the world has worked out far more functional systems. So those cost calculations should be relative to this high level reality, not some internal benchmarks between stages of mediocrity.
It seems by not deciding to be free market nor socialized that the US is getting the worst of both worlds. It's easy to blame the republicans for this but the half baked socialized system that the democrats put forward was hardly a good solution.
> Far too few people realize that much of the ACA plans' cost increases is due to Congress reneging on a government promise
Have you considered that maybe the entire Democrat plan of getting to a socialized system via cuts and slivers in one direction, knowing full well that cuts and slivers will be done in the other direction is a terrible idea?
Stop pretending that private companies can function efficiently in an ever more legislated environment, as if only more thousand page bills get passed that it will finally start working well... history has continued to indicate otherwise. Either a) embrace markets or b) go hard on selling the public on the idea of single payer public insurance.
(I should note I'm in favour of public health insurance after living with it in Canada, despite typically being in favour of markets elsewhere)
If you do want my personal opinion, I'll give it here:
1. From an economic standpoint, single-payer healthcare fundamentally makes sense. Put everyone in a single pool to reduce risk, drive efficiency, and maximize negotiating power.
2. From a free market standpoint, the current model of tying healthcare coverage to your employer hurts both employers and employees. As an employer, why am I responsible for paying this "benefit"? If too many of my employees get horribly ill, my premiums go up to the point that I can't provide a competitive benefit; my costs increase, my employees' contribution increases, and my ability to recruit talent suffers. As an employee, why must I forego an entrepreneurial opportunity because I can no longer afford healthcare for my children without an employer footing the majority of the bill?
3. From an efficiency standpoint, the current model wastes tremendous medical resources (bureaucracy, physician time, lack of cost transparency, treatment limits, etc.). I have friends in the medical industry (doctors, executives, med tech providers), all of whom dream of a single-payer system.
4. From a constitutional standpoint, I believe healthcare falls under "promote the general welfare" and "secure the blessings of liberty to ourselves and our posterity." A national, taxpayer-funded health program is no different than any number of other government-funded programs that free us to maximize our potential as citizens. And yes, we pay taxes to fund those services whether we use them or not.
So yes, I'm a believer in a single-payer model. Yes, I believe the ACA is essentially a handout to insurance companies. And yes, I was very disappointed when Obama took single payer "off the table."
However, I also think it's better than pre-ACA, despite its flaws. And at this point, it's certainly better than the chaos that will arise from simply abandoning it. Understanding its compromises, I can't really envision a "replacement ACA" that will pass a Republican congress that can be better.
If Congress delivers a better ACA, I'll happily embrace it. Heck, I'd even give credit to the Republicans if they just tweaked the ACA, renamed it "Winningest Solid Gold Trumpcare" and fully backed the result to make it successful. But I see no positive outcome if they go down the "repeal and delay" path.
Like the U.S. military has maximum negotiating power with its contractors? I mean, who else is going to pay for the F-35?
Monopsonies aren't inherently more efficient than monopolies.
Do you truly feel military procurement is equivalent to healthcare delivery?
Have you ever sold products to the US government?
Do you believe the primary financial gains would come from negotiating power? (Hint, the list I provided is in order of impact.)
Are you familiar with the impact Medicare Part D had on prescription drug prices? (Spoiler alert: it "substantially lowered the average price and increased the total utilization of prescription drugs by Medicare recipients" [1].)
Do you believe the decisions behind funding defense are in any way influenced by non-economic factors? (Hint: defense budgets increase even when the military itself requests lower funding. Does government healthcare funding follow the same pattern? Why not?)
Are you familiar with the many estimates of the cost of a single payer program in the US? [2]
I could go on, but won't. This is not Reddit. Sound-bite caliber anecdotal arguments are a problem, not a solution.
[1] http://faculty.som.yale.edu/FionaScottMorton/documents/TheEf...
"Less efficient" is actually a nonsensical term to economists[0], but monopsonies are inherently inefficient, and it's rather straightforward to demonstrate that economically, the same way it's straightforward to demonstrate that a monopoly is always inefficient, even in cases of so-called "natural monopolies".
> Are you familiar with the impact Medicare Part D had on prescription drug prices? It "substantially lowered the average price and increased the total utilization of prescription drugs by Medicare recipients
You can't use Medicare Part D as an example of the impact that negotiating power would or would not have, because Medicare doesn't "negotiate" (read: unilaterally determine by fiat) the prices it pays for drugs, which it does do for providers.
> Are you familiar with the many estimates of the cost of a single payer program in the US? [2]
Yes, and most of those (including the ones you linked) are based on Medicare's reimbursements as a baseline. But that's totally baseless, because according to Medicare's own financial reports, they pay below-sustainable reimbursement rates to providers[1], which means that they are essentially subsidized by the premiums paid by privately insured patients. If Medicare were expanded to include everyone, they would have to massively increase their reimbursement rates, because the private insurance market wouldn't exist.
[0] Efficiency is best explained to a non-economist as a binary property; there does not exist a total (or even partial) ordering of inefficient states.
[1] They pay below COGS, which means that even if all doctors, nurses, and staff worked for free, they would still make a loss on Medicare patients in the aggregate, if they were not able to charge the difference to private insurers. Incidentally, that's why uninsured patients see such high bills - those are the prices that are used as a starting point when negotiating with insurers, and they're massively inflated to cover the gap.
The flaws of ACA are not inherent to a privatised system, they are the result of this specific implementation.
Second, I can't figure out what your insurance was that was only $250 before the ACA. The only people I know who pay that little were on catastrophic plans. Insurance for me in NY state as a healthy (I was never without insurance so the kidney donation didn't count against me) single male in my 30s on a private insurer was creeping up to nearly $10,000 a year for complete coverage under an HMO like I used to get when I worked for a Fortune 500. Under the ACA, I pay half that for similar coverage.
Do you have evidence that the government is the main cause of the increase of the price of the plan? It could have merely been the companies using the ACA as an excuse to raise prices.
But that plan was only available to healthy people without any pre-existing conditions.
Now, the $780 version of that plan is available to everyone.
You are a healthy person who could get healthcare before and still can for roughly the same price. The ACA wasn't meant to change things much for you: it was meant to increase coverage. Now people who are older or who have a chronic condition or a bad family history can get the same health insurance as you. That's what your tax dollars are paying-for.
> Now, the $780 version of that plan is available to everyone
But you're making a political statement that the government should ensure sick people should have access to health care (which is fine, e.g., I support welfare). It's just odd that you think this program should be paid for primarily by middle class Americans, unlike most other government safety nets which come from taxes which mostly target higher income individuals.
> [...]
>this same plan today is $780 a month without subsidies
The problem with your comment is that your prices are very exact but the consumed goods (insurances) are described only vaguely.
The country I live in, introduced obligatory health insurance 1996. The first proposition by our Democratic Party goes back to 1960. After 30 years of intense political fight we now have a system that is supported by all of the parties. So I think our system is as balanced as it gets. Plus we have a highly competitive system between insurence companies, and you are allowed to switch the insurance company every year, which then is done by lot of people.
The absolute most important thing is a rock-solid legal description of the minimun that every insurance company has to deliver.
Here are the + and - after 10 years of practical experience with obligatory healthcare:
+ High competition, disciplines insurance companies to work efficiently, and allows new, small and innovative companies to enter the market.
+ It's a pretty fair non-discriminatory system, nationwide and across all insurance companies
+ Simple system once it is established
+ Vulnerable persons are well protected.
+ The common health of the people is rising.
- The costs are rising every year because the is no direct interest in keeping the costs down
- The insurance companies get more powerful every year due intense lobbying, this not in our interest.
- There is explosion of special health services, very expensive treatments, rising salaries in the health economy
TLDR: Obligatory healthcare is good and you live longer. But it comes with a price.
Oh yeah? Where do they get their money from?
I ended up taking a job at a start-up when I turned 30 because I figured at 30 I should probably start going to the doctor more often and it was the only way I could afford health insurance.
I was finally able to go back to freelance a little over a year ago because a decent plan only cost about $700 total per month for both me AND my wife, and She has pre-existing conditions, which is to say she had gone even longer without insurance before we'd met. I was merely hedging bets according to my age. She actually needs it.
Of course, BCBS-IL keep cancelling our plans as is their apparent loophole to raise rates. Because even though the non-profit had a surplus of 14B in early 2016, the absolutely perfect plan we were on wasn't making enough money for them, so they killed it. That's twice in a row, so we switched to Cigna this year, which I don't assume will be much better.
It's expensive,. They're all expensive, whether I use the marketplace or not. But they're nowhere near as expensive as they were four years ago. Especially for my wife who literally could not be insured before the ACA.
A healthcare plan where you get dumped the second you have a preexisting condition removes the de-risking benefit of insurance. The only benefit then left is the negotiating leverage of an insurance company able to pay $50k for a surgery that would out of pocket be $100k, lower ambulance bills, etc.
[0] http://www.pbs.org/newshour/rundown/new-peak-us-health-care-...
Similarly, if you want to avoid the problem of expensive drugs that sell for significantly less in Canada, legally require Big Pharma to sell in the US for the lowest 'negotiated' price among all the national healthcare systems.
But he gave up before even trying. Way to move the Overton window.
Never mind that it's the Congress that passes bills, not the President.
Obama's disastrous politics are a result of going into every debate starting at the "compromise" position, and then getting dragged further right. Just go back to his 2004 DNC speech, it lays out exactly how he's going to fail.
It failed, legislators just voted against it and carried on with their day. No noticeable public blowback against them.
I do agree that Obama tended to negotiate badly by compromising before it was even needed, but that "two years of full Democratic control" thing gets repeated so often, and it's annoyingly wrong.
This debate went on like that for a good while, with Democrats negotiating to keep moderates like Ben Nelson (Cornhusker Kickback, if anyone remembers) and Joe Lieberman from defecting. The Democrats were then dealt a blow by the death of Ted Kennedy and subsequent election of Republican Scott Brown to his seat in the Senate. With Brown's swearing in, the Democrats' caucus would have lost the filibuster-proof majority it enjoyed.
I just want to point out that a long debate was expected, and it would have likely gone on for another year had Kennedy's seat not been won by Scott Brown. The Senate's bill, which became the ACA, had to be the one implemented otherwise the Democrats would not have succeeded at any version of healthcare reform. Obama's '"compromise" position' was to encourage a bill that was not single-payer and could keep Blue Dogs on board.
I mean what should he have done? Kneecap Democrats who didn't fall in line?
Lieberman caucused with the Senate Democrats. He had lost his Democratic primary and ran+won as an independent. In fact, he'd endorsed McCain in 2008 (after Obama campaigned for him in 2006).
Lieberman had and used a line item veto over everything that was passed by the Democrats because the Republicans uniformly opposed anything that was proposed. It took a supermajority to pass the ACA and it only barely passed because of Republican opposition.
https://ycharts.com/indicators/us_health_care_inflation_rate
Health care is not becoming more affordable. The rate of inflation in health care is significantly higher than the US inflation rate.
https://fred.stlouisfed.org/series/T5YIFR
How is that affordable? How are $600 epi-pens affordable?[1] How is a 4000% price hike on a 62 year old generic affordable?[2] Google for "snake bite hospital bill." $153,000. That's not affordable. That sounds downright fraudulent.
It seems they should have named it something more appropriate, like the Universal Health Insurance Act. Insurance that is no more affordable than the overpriced health care available in the country. But point this out, and everyone starts their partisan bickering and nothing gets done at all.
[1]https://www.bloomberg.com/news/articles/2016-08-29/mylan-to-...
[2] https://www.washingtonpost.com/news/to-your-health/wp/2015/0...
Mandatory Purchase of Service from Private Industry Act ?
either way it was a redistribution to some at the expense of others. decide yourself which moral side you sit on.
the two sides were 1) it being redistribution to people who cant afford insurace, or 2) it being redistribution to insurance stock holders
I didnt even pick a stance, and youre assuming my position. or they arent mutually exclusive choices.
https://data.bls.gov/pdq/SurveyOutputServlet
It's up to a historic rate of growth that has been typical since the early 90s.
I don't intend any snarkiness, but am I somehow misreading those numbers? I'm reading that statement as "an inflation rate of 2.95% for the last year compared to the long term average of 5.40% could be equated with 'more affordable'".
[1] https://ycharts.com/indicators/us_health_care_inflation_rate
That is the core issue. That was not solved by the ACA. How do we solve it? Ideas? Oh yeah, you know what? Let's argue about Obama and Trump instead. That will surely work. Look at the comments in this thread.
If I asked you how to solve a sorting problem, I'd have a dozen good solutions presented. If I ask how to solve a healthcare cost problem that many other countries don't seem to have, everyone's brain switches off and they go into arguing about politics.
http://ritholtz.com/2012/03/comparing-medical-procedure-cost...
It seems they should have named it something more appropriate, like the Universal Health Insurance Act.
The name of the bill is a lot less important to most people than the substance. If you read Sam's post, there is a man in there with a heart condition who is essentially uninsurable without the ACA. For him, the word "Affordable" definitely applies, but he doesn't care what the bill's title is. In my opinion, you shouldn't either, because the bill's substance is what is important.
>In my opinion, you shouldn't either
It's clear to me, I need to leave and go to a country with a higher average IQ. They, unsurprisingly, have figured out how to deliver actual affordable care. The people here are too ignorant to actually solve this problem. Even "smart" people have been completely brainwashed by propaganda.
Affordable care is more expensive. War is Peace. Ignorance is Strength.
Making healthcare actually affordable -- as in, reining in costs -- is where we should be looking.
Other ways to lower healthcare costs:
* Increase med-school acceptance rates & fund more residency programs/additional slots to increase supply of MD's
* Subsidize med-school tuition so MD's don't graduate drowning in debt
* Allow PA's and NP's more authority in primary care and non-trauma emergent care situations without an attending physician having to sign for every order and discharge - some states are ahead of others here, we have a lot of NP's in GA ER's that work without an attending
Oh, and single payer healthcare would do wonders too. Administrative costs for hospitals and billing companies would drop dramatically not having to manage dozens of different insurance contracts just to get paid, would love to pass that savings onto patients.
The ACA wasn't a bad attempt given the constant efforts of the opposition to sabbotage it.
Actually, it was, given that many of the misfeatures of the ACA were premptive compromises to gain the support of opposition that never accepted it anyway.
But even so, it's better than the status quo ante was, and there's no sign of anything better on the horizon amidst the rush to repeal it.
From the wiki[1]:
By the design of the program, the federal government is not permitted to negotiate prices of drugs with the drug companies, as federal agencies do in other programs
The bill forces the government to pay whatever the pharma manufacturers will charge. If you were selling a product and there were a law preventing your largest customer from negotiating the prices which you set, why wouldn't you heavily inflate your prices?
Oh good, let's see you present to me evidence that the inflation rate of health care in the US is below that of the inflation rate of the country as a whole. Can you do that? Because that's my point.
Health care is not affordable. Hospitals are charging tens of thousands of dollars for treatments that cost a couple hundred dollars 2 hours away across the border.
http://archive.azcentral.com/business/articles/20120831scorp...
That's fraudulent. Put those people in jail.
No, because the cost increases were not due to the affordable care act, they were due to Medicare Part D. The goal of the ACA was to reduce the number of people without insurance. Controlling pharmaceutical costs is outside of the scope and for that you can blame the law that specifically forbids the government from controlling pharmaceutical costs.
You're distracting from the real issue with a different argument. I didn't say the ACA caused the increases. I am saying the Affordable Care Act failed to make health care more affordable.
You can tell because while some premiums have increased, the overall healthcare costs (including premiums) for all Americans has been reduced.
You should only focus on a low-deductible plan if you know you're going to be in and out of the hospital (e.g. elderly, chronic, etc.). I also don't think you know what your out of pocket maximum is now compared to what it was before.
You're correct that I don't know the difference in out of pocket maximums, but I do know it's a great deal higher than it used to be.
As for "what type of plan I should be on", I really don't have a choice. My employer offers what amounts to basically the same plan through two different insurers, and the main difference seems to be which doctors are on which insurer's network, so in practice, it doesn't matter which one I pick-- the out of pockets maximums are broadly similar, and the deductibles are identical.
And that's not counting specialists-- my daughter had a heart defect at birth, so now she has to see a cardiologist every other year, which has the happy(?) benefit of pretty much eating up my entire deductible in one fell swoop right there; before the ACA, I paid $50 for a specialist visit and maybe a few hundred extra depending on which tests that particular specialist ordered.
If only there was some large body that was able to negotiate reasonable rates for health care on behalf of consumers... it's amazing nobody in the world has figured this out before!
I think healthcare has become a jobs project. As manufacturing employment decreased, many found replacement jobs in an ever-expanding health care industry.
There is no incentive for anyone to get medical costs under control. The health care delivery system has every incentive to use the "blank checks" offered by the insurance industry. The insurance industry makes a certain percentage off whatever they pay out in claims, so their incentive is to pay as much as possible.
Patients want to feel better, and aren't in a position to evaluate whether the recommended treatments are actually their best option.
> But point this out, and everyone starts their partisan bickering and nothing gets done at all.
In the early days of medicare the government's costs quickly got out of control. The first reform was to figure out what a procedure should actually cost. It's been "trench warfare" between doctors and payers ever since.
I have some anecdotes from my passengers and friends that would hopefully sidestep the bickering to point out that the status quo is quite harmful to the health industry's customers...
Iatrogenic conditions are exceedingly common. These are conditions caused (or worsened) by the treatment provided.
For example, hospitalists (doctors who manage patients' care in a hospital) are starting to look at old patients' pile of prescriptions to figure out which ones are actually necessary [1].
[1] When less is more: De-prescribing medications - http://www.acphospitalist.org/archives/2016/05/deprescribing...
I'm sick of these stupid names in general.
If you put the starting date at 1970/1980/1990.. it really puts things in perspective.
[0]: Here's one source, although there may be better ones http://www.latimes.com/business/hiltzik/la-fi-hiltzik-obamac...
Without actual PRICE DISCOVERY nothing(in terms of reform) works.
I got a tetanus shot (booster as an adult, Tdap) and called around to different clinics. Prices ranged from $131 to $39. For what is required by law to be exactly the same thing.
That "well your insurance might mean you will pay a different amount" is EXACTLY the problem. No one can easily determine the price of anything.
Is there a base-model Chevy that is sold at one dealership for $35K and at another dealership in the same city, for $65K?
No, because people would very quickly do price discovery...
Also, the medical ratio of youth to elderly is 1:6 and before the ACA, youth would pay about 1/6 of elderly costs. Congress unfairly mandated that ratio to be 1:3 meaning youth pay 75% more than they should. They already have to pay for student loans, save for a house, and now they have additional burdens paying for smokers and those who drink daily sugar Cokes and thus obese.
Tax tobacco like other countries and NYC/NYS and use that money to make premiums for youth and middle class more fair.
Tobacco taxes are incredibly regressive (they very disproportionately tax the poor). So you're essentially proposing taxing the poor in order to pay for the middle class.
They disproportionately tax smokers making smokers at least pay a portion of the additional health care costs they incur by smoking.
Taxing tobacco contributes over half the effect of ensuring teens never start and smokers quit smoking.
Good riddance!
BUT
If they start pulling away Healthcare for millions of Americans ... and Americans start dying because of this - well, there will be a revolution of sorts.
It's inhumane for the wealthiest country in the world to take away basic healthcare for it's most vulnerable citizens.
If you are so 'smart' and so 'great' - then figure out a way to introduce efficiencies, pricing intelligence etc. to get people more and better coverage - instead of just smashing some law because it's not perfect and it was written by 'Obama'.
Which should be a very strong indication that's not going to happen.
Despite the endless propaganda, Republican lawmakers are neither stupid nor evil.
People are not going to be left uncared for, that's just political fearmongering, and we don't have to fall for it.
1) They are voting to repeal ACA in real time.
2) They have not offered even a hint of an alternative.
This is not only going to be potentially damaging those who will lose their coverage - but it's also incredibly difficult for business: there is no roadmap. Insurers, and all other businesses small and large now are left in the dark with respect to their future. Introducing such ambiguity is definitely stupid, and it's 'anti businesses'.
They have at least two years of unlimited power, they should debate solutions, narrow it down to an actionable plan, and then modify ACA in a well thought out process.
As it stands, they're just rolling back laws and haven't discussed anything else, which I think is irresponsible. They don't need to be in such a panic.
People lament that our politics are so divided. Mis-stating the situations we're in and exaggerating for political gain are a root cause of that. Do not be part of the problem. Stop spreading the fear.
1) They are repealing ACA as we speak - the legislative process has been introduced. They are voting today. This is fact.
2) There is no alternative. Neither Republicans nor Trump have offered any plan. There are no white papers, working groups, coordinated policy plans, and certainly no legislation. This is also a fact.
So what you're dismissing as 'fear mongering' is reality.
I don't have a problem with a total re-factor of ACA - but it needs to be done responsibly, thoughtfully, with diligence and transparency.
They're screwing it up on a day one: rolling back legislation that affects 100% of Americans and 100% of business - without a plan. It's totally irresponsible. They are doing it quickly (and recklessly) for political reasons, instead of an underlying impetus of 'good governance'.
Which is too bad, because it's a complex issue and there's work to be done.
The ACA is not being repealed today. This simply is not true. It's not what is happening. Saying that it is is in fact fearmongering.
The ACA will still be in place tomorrow. It will be in place next week. It is not being repealed as we speak.
Yes, it is. The Congressional process was started today:
http://www.businessinsider.com/obamacare-repeal-process-sena...
This is a fact.
And it is also a fact that the GOP has no plans whatsoever in terms of what it will be replaced with.
If you have access to any working groups, white-papers, or legislation otherwise - provide a link.
You can't - because there is nothing.
Obviously it will take some time to clawback all of the legislation, but it is being repealed as we speak.
"The ACA will still be in place tomorrow. It will be in place next week."
Obviously - but what are businesses around American doing now? They have no way to make plans, they have no idea what the future holds.
This is 'anti business' and 'anti responsibility'.
The responsible thing to do would be to craft a plan - and then put the gears in motion so that people know what is going to happen, and individuals and businesses have insight as to what will invariably affect everyone in America.
The Republicans have full control of Congress and they can expedite the repeal at least parts of ACA fairly quickly - once that is done - there is no ACA. Boom, it's gone. Insurers will have to make fluctuating, ambiguous ongoing changes to their polices. With no alternative.
It's laughably irresponsible.
There should be a plan, not a scramble into the void.
So, not being repealed in real time, as you claimed. Not being repealed today, as you claimed. Instead, "the long, winding process" has begun.
From your linked article- "Though the repeal is on the top of the legislative agenda, Trump is unlikely to put his pen into action on it anytime soon."
It will be quite some time before the actual repeal happens. Not anytime soon. No need for panic. No need to sow fear.
From your linked article- GOP leaders' comments that they want to replace the bill at the same time they repeal it suggest that a seamless transition may take time. House Speaker Paul Ryan said replacement and repeal would happen "concurrently," and Trump has pledged it will be "simultaneously."
So by the Republicans own words, there will not be a time when there is no plan in place.
In fact, Republicans are going to vote to continue funding for the present plan. http://www.politico.com/story/2017/01/republicans-obamacare-...
Again, no need to spread fear.