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The core complaint here, as far as I can tell, seems to be that bare bones insurance plans were banned.

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.

The reason the bare bones plans were banned were because many of them had rules that really screwed consumers. No one wants to think they'll be the one that gets cancer, but people do, and when you have plans that practice rescission, or lifetime maxes (after which they don't pay for anything), or annual maxes, then you've got the case where all of a sudden you are going bankrupt and losing your house due to treatment costs.

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.)

No the issue is that ALL the plans are now 'bare bones'.

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.

Not all plans. I've been on a PPO pretty much forever, before and after ACA. The deductibles have always gone up, as have the costs; but it's always been an option at every company I've worked for.

Well, you're still an employee right?

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.

The full bill for insurance (minus savings for being part of a larger group) is coming out of my paycheck and profit shares, one way or the other.

> 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.

So your argument is that the ACA should provide healthcare that's both very cheap and very comprehensive. Because it isn't doing so, we should repeal it and go back to 2008, and healthcare will be made cheap and comprehensive?

I think the core argument is that it wasn't working and isn't working any better now but costs everyone a BUNCH MORE.

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.

"isn't working any better now"?

I know people who are literally alive today because of the ACA. Do their lives have no value?

OF COURSE their lives have value. This isn't a moral argument. I'm not arguing that we should NOT provide universal coverage to everyone.

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.

But repealing the ACA, which is by all appearances what you want (correct me if I'm wrong), would leave these people without health insurance. You make fair complaints about the high costs for care in this country, but you're acting like they're the fault of the ACA. The ACA bent the cost curve downward, if anything.

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.

Noooooo. The cost curve was NOT bent downward and if you can show me any evidence it was I'll certainly change my opinion.

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.

And FYI: I campaigned for BHO in 2008 primarily on his platform promise to reform healthcare.

I helped get him elected. I wanted reform. I wanted better outcomes. I wanted people to participate.

Consider me disillusioned.

In my opinion, this idea that someone may only need "catastrophic" insurance because they "work hard to stay healthy" seldom works out without costing everyone a lot of money. Often these plans don't cover enough, and people end up with no real insurance at all. Perhaps a stroke or heart attack would be covered in the immediate sense (ambulance and initial hospital stay) but does it cover physical and occupational therapy?

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.

The ACA isn't supposed to help healthy and financially secure people like your lawyer friend. It is supposed to help sick and financially insecure people, by forcing healthy people (who are in the majority) to subsidize the cost of their care (which is very expensive).

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.

I think you've answered a question you'd like to answer instead of one you don't: WHY is healthcare in this country SO EXPENSIVE?

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.

Your second paragraph is not even close to true - if you do more research on the ACA you'll find that it does all kinds of things to try and improve the affordability of care, a lot of which has made real improvements. Incentives against fee-for-service, quality-of-care rules, medicare/medicaid rules, there's just a ton of that stuff in the ACA. The stuff in your last paragraph is directly addressed by many parts of the ACA. And, more can definitely be done, including price transparency etc. These things tend to be supported by Democrats and opposed by Republicans.

I think you should post some links to relevant sections of the ACA and show me where they take specific actions to drive down costs.

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.

I work for a company which operates in the Medicare Advantage space.

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.

In that scenario, are your interests served more by spending via medicare increasing or going down?

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 don't profit from paying out to providers; we're an insurer.

We profit when people are healthy.

I think you misunderstand my question.

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.

I don't see how that point has any value. It's kind of like calling Social Security a ponzi/pyramid scheme. It's only true if children cease to exist. Similarly here, your point only has value if sickness and accidents cease to exist. But that won't happen. The market for health insurance naturally exists already. And the incentives for increasing health care costs are very much what the ACA is about - those incentives are being affected by things like the ACA rewarding quality-of-care instead of fee-for-service, etc.

I'm for aligning incentives.

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.

Interestingly, Medicare is a slight counterexample to your comments, because you can -- given motivation to sit down and collate the necessary public data sources and understand the rules -- calculate what rate Medicare allows for a given procedure. And since providers who accept Medicare have agreed to those rates, it means that for Medicare, at least, you can find out the price (or the ceiling of the price, which is what people often want to know anyway).

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.

Interesting that you should bring up Medicare.

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-...

Unless medical care is cheap enough for everyone to always afford all the care they might require with the cash in their pockets or the money in their checking accounts, I believe my fundamental question is relevant. Since some medical care currently, and for the forseeable future, requires the time of extremely smart, talented, and highly-trained individuals, I don't believe it's possible to make it that cheap.

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.

Well said. Can we also work on the supply of medical care? We keep giving more and more people insurance which increases demand without doing anything to increase supply and then wonder why prices go up.

You see the lack of honesty on both sides of the aisle. You're right in that Republicans don't just come out and admit that they believe that healthcare is not a right and that people should have to deal with their own health issues.

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.

> 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.

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.

You might want a redistribution program, just like I don't want healthcare to be a right, but none of that changes that no politician will speak about their support for some healthcare policy in those terms. It would be electoral suicide if they're from a competitive district.

Personally, I thought the ACA was a very honest plan. The individual mandate is a very clear statement of: healthy people must get insurance so that we can offset the cost of requiring that sick people can get insurance. I never had any illusions that, as a healthy young person, this would do anything besides increase medical costs (including insurance premiums) for me, as a trade-off against the possibility that I may one day be one of the older and/or sick people that it would benefit. I hoped it would decrease costs because we would no longer need to subsidize the uninsured by making up for care providers' lost revenue, but I didn't think that would (especially in the short term) be anything besides shifting that subsidy from being included in the cost of care to being included in premiums and federal taxes.

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!

I want a wealth redistribution program as redress for past injustices. Current concentrations of wealth and property are the result of force and fraud, and I do not see how anyone should support preserving those distributions, let alone enshrining their preservation as a moral imperative.

You're friend's story does not make any sense. New York screwed up its individual health insurance market a long time ago, via 'community rating'.

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.

At what point does your friend not say "f-it" forgo ACA individual mandate, pay the $2085 fine and not put the difference from paying 450x12 premium into a Health Savings Account?

Edit: It looks like you need to be enrolled in a plan to be eligible for a HSA

> So, if your good coverage went from $175/month to $450/month and covered less and less with each passing year

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.

I'd offer you the opportunity to do your own research into the subject if you'd like to investigate the implementation of ACA in NY state:

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.

> [link to NY Exchange, 50k cap for subsidies]

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.

Guess what, you can't just "form a C corp" and go from there. The rules specifically exclude that kind of structure.

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.

Regarding C corps, that's why I noted diversifying the ownership of the company and "he's a lawyer, he'd know better than I."

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...