Insurance companies and Pharmaceutical companies can more or less dictate the prices they'll charge because if you're chronically ill, you can't just choose not to be treated (unless you're ok with dying.)
This behavior should not be surprising. Until the American people get pissed off enough, we'll continue to have these shenanigans.
The ACA was deliberately modelled on Republican/Industry plans with the hope it would have been a bipartisan solution. This was, of course, a vain hope as we now know, but it was fundamental to why it had the shape it did.
The ACA was already the workable compromise.
I have no idea what Trump's plan is, but I hope whatever it is the Republicans don't play games with the GAO accounting and they also bring Democrats on board so both parties have a political stake in success.
Republicans and Democrats in government (not necessarily in the electorate) now (this was not as obviously the case before the ACA was proposed) have fundamentally opposed goals on healthcare. So a bipartisan compromise is improbable.
- Restoring Patient Control and Preserving Quality in Healthcare
- Protecting Individual Conscience in Healthcare
- Better Care and Lower Costs: Tort Reform
- Advancing Research and Development in Healthcare
- Putting Patients First: Reforming the FDA
Freedom of choice, high quality, affordability, and limited regulations are the goals. I don't think they're against universal coverage, but as a party it is not a main focus.
The Democratic platform healthcare section begins with "Securing Universal Health Care: Democrats believe that health care is a right, not a privilege". Their priorities are:
- Securing Universal Health Care
- Supporting Community Health Centers
- Reducing Prescription Drug Costs
- Enabling Cutting-Edge Medical Research
- Combating Drug and Alcohol Addiction
- Treating Mental Health
- Supporting Those Living with Autism and their Families
- Securing Reproductive Health, Rights, and Justice
- Ensuring Long-Term Care, Services, and Supports
- Protecting and Promoting Public Health
- Ending Violence Against Women
- Preventing Gun Violence
The main goals are universal coverage, public funding, affordability, opposing discrimination, and a couple specific areas of focus. Some of this overlaps with the Republican platform, but this is clearly a very different set of goals, and I think universal care is the most significant difference.
From wikipedia:
"House Democrats had expected to be able to negotiate changes in a House-Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[165] They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.[166][169][170]
As per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations.[171][172] Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."[169]"
Despite the gloss the wiki authors put on it, this is highly irregular. It's within the letter of Senate rules, but if you're expecting to ever get cooperation from the opposition party this is not the sort of stunt you want to pull.
I saw a headline that said something along the lines that the Republicans plan to repeal the ACA using reconciliation, which would be poetic if true.
So they avoided filibuster by suddenly being more cooperative than expected and not having more rounds of edits? I might be deeply misunderstanding, but that trick seems okay. Don't pass a bill if you don't want the bill becoming a law...
What happened in this case, as I understand it, was the Democrats in the Senate took a bill that had already passed, a bill addressing some other matter entirely, and rewrote it completely while maintaining it was the "negotiated third version" above, i.e. it was a reconciliation of the bill that had been discarded.
I'm a bit fuzzy on the details, TBH, but that's the essence.
Then, the Democrat leadership argued that it wasn't actually a tax, so Clause 1 didn't apply.
Then, in the infamous Supreme Court case, they argued that it was a tax and therefore couldn't be challenged before collections actually begin due to the Pre-emption clause.
The process of taking a bill in progress and completely rewriting it (while retaining "credit" for those procedural steps the original bill completed) is commonly known as "gut-and-amend".
That's not what the text around your quote says. In fact reading it in full context implies that nobody got tricked. First the senate broke the filibuster and passed the act. Then the house, realizing that breaking another filibuster was unlikely, decided to pass a version that was compatible with the senate version and only needed budget reconciliation. Then it passed without the ability to filibuster and became a law.
I don't see where a bill addressing something different comes into the picture. I don't see any deception. Am I missing something?
And I used the word "trick", not deception. I'm not aware of any deception, just the abuse of a process.
They shouldn't have done that, ideally, but the rule of which house a bill starts in is pretty unimportant.
I don't see how reconciliation could be used to help repeal the act, because the reconciliation was not key to getting it passed, and neither was the trickery used to say the bill 'started' in the House.
Then you just sit back and let it collapse on itself.
The bills were negotiated for over a year, and liberal features like the public option and coverage for abortion were removed due to Republican and independent opposition. The bill ultimately received a Supermajority in the Senate and a majority in the house in regular voting, and not through reconciliation. The Republicans are unlikely to pass the repeal through the senate with anything close to the same numbers.
You allude to the origination clause below, but that argument was rejected by the courts, and the Supreme Court declined to hear it. The first version of the bill was also introduced in the House, as was the original revenue bill that the senate bill was built onto.
At the time of Republican minority. Power has shifted to the Republicans and there can be a new "compromise"
While there is funding for experiments aimed at reducing costs, none of the bill's major facets deal with this issue.
Here's an article where one of the bill's intellectual architects talks about the topic: http://www.nejm.org/doi/full/10.1056/NEJMp1006571
Unfortunately I don't see high deductible plans working for anyone unless healthcare providers and pharmacies are required to list all prices up-front. As it is there's no way for consumers to "shop around" because they can't get prices for most tests, procedures, or even medications until they bill through insurance (which can take weeks).
Never mind the fact that you can't exactly shop around for places to deliver when your OB/GYN only has admitting privileges at one hospital. I'm about as free market as they come but when the providers flat refuse to tell you what they are going to charge you. Try going to one of those corner ERs, you'll have to sign a form saying you are solely responsible for all charges but they sure won't tell you what those charges are until you sign it.
High deductible plans definitely don't make anyone smarter consumers. The market is opaque and your options are limited to in-network in the best case.
To complicate things further, some of these things will happen while people have passed out and taken to the emergency room. This might be the only sort of debt you can incur while both unconscious and without prior specific authorization. Many other medical decisions are made under duress - sickness and pain, with an occasional risk of death.
Dentists, optometrists, physical therapists, etc. all have straightforward pricing for each procedure, and you can call and ask them what it is and it's not too hard to shop around. Only medicine has mystery prices hidden behind third party payers.
Not IME. I've gotten different prices from what I was quoted, and some places have refused to quote me a price.
As long as we view this as a "not my problem, I'm not sick" issue, this will never be fixed.
HDHPs quote their deductible as a maximum out of pocket per year. Paying $10k a year to manage a chronic illness doesn't sound ridiculous.
I'm lucky to be able to afford it, but it's highway robbery.
Most people I know don't have 10k a year sitting around, just those lucky enough to have relatively well-paying jobs - and having a chronic illness will only make finding such a job harder.
$10k max out of pocket is not that bad. $10k deductible is bad if you're single over 30.
Single payer would be ideal for most Americans, but (opponents) seem to prefer the high deductible health plans
I can imagine how Britain's NHS could be created in a time of great national unity, scarce resources, and complete Labor control, but I can't picture the mechanism by which health care could be nationalized in the present-day USA, even if a popular mandate existed.
Not for Americans who care more about economic ideology than health. This is how many Americans appear to vote.
The truth is that many don't even know that Obamacare and the Affordable Care Act are the same thing.
I live in flyover country, and people legit believe that letting the market make choices is best, and single payer is a quick step to full on communism. I'm looking for positive arguments to counter that nonsense.
I would bet a truckload of money that it's between zero and one.
What kind of choice is that?
(for the record I am pro single payer)
Oh yeah... the Government Option is a real winner.
Wait... I know... lets go to the VA model where people aren't dying... while on waiting lists... and the administration spends millions on Bonuses, Art Work and Vacations.
Lack of choice? That's from lack of ACTUAL 'free market competition'.
Taking away more choice and removing more competition isn't the way to solve the problem caused by removing choice and competition.
The worst thing you can hear? I'm from the Government and I'm here to help.
"Free" might sound affordable... until you have to pay the taxes that drive "free".
And government run anything? Yeah... how about a big ole glass of no. With a double dose of hell no. Look at all the cost overruns, crappy care and red tape surrounding the VA, Medicare, Medicaid...
However I fear that any attempt to will result in companies suing the state for unfair competition or the like.
Of course, conservative states can do the same to advance conservative agenda to bypass gridlock in DC. But nothing wrong with that either. We will have some sort of real world A/B testing between the two groups and see which policies work better for a given problem.
The advantage of a compact of states is that it enables significant weight behind a proposal, which would be hard to ignore for the companies (eg. fuel efficiency standards might be ignored for MA alone, but will be hard to ignore for market controlling 30-40% of the population).
For those curious:
https://en.wikipedia.org/wiki/Healthcare_in_Canada#The_begin...
Not universally of course, but enough to have a big impact on availability of services.
California might be able to try it.
This. California democrats recently achieved a supermajority[1] making such an experiment possible. If California cannot push state legislators hard enough to give it a shot, the idea that a fractured national Congress will is fatally flawed. Voters rejected the idea in Vermont[2] (Bernie country[3]) -- so, can California be different? Granted, a California experiment must balance the fact the CMS money originates from federal sources, but that should not completely inhibit an experiment.
[1] http://www.latimes.com/politics/essential/la-pol-ca-essentia... [2] http://www.politico.com/story/2014/12/single-payer-vermont-1... [3] https://en.wikipedia.org/wiki/Vermont_Democratic_primary,_20...
There is a large segment of the population that worships the free market. They believe it will fix anything. Any flaws are because it's not a truly free market, but we can fix that and make it free and then it will work properly.
I am from Denmark originally where we have it and it's not without issues because suddenly you turn a profit center into a cost center which means you need to budget and you need to restrict who can get what, how much you can afford etc.
What about illegal immigration, do people who are here illegally get access too?
These are all questions that are very hard to answer IMO because the US after all is such an open society.
Are the same decisions not still made when health care is for-profit? Except it becomes the insurance companies that get to decide who gets treatment and who is too expensive to treat so we'll just drop their coverage instead?
So yes the individual insurances are limited to various degrees but there are for some access to he best of the best.
In my world the major problem in the US is that you can "go bankrupt" by being too sick too long.
It should be so that everyone pay to go to the doctor for minor things but no one go broke if they happen to be sick.
Why this balance can't be found baffles my mind.
> Why this balance can't be found baffles my mind.
Because paying for a doctor visit for a minor infection is the cheap part of healthcare. "Being sick too long" is extremely expensive. Getting a shot of penicillin costs a couple hundred dollars. Treating cancer can cost tens of thousands.
I don't strictly disagree with your assessment that people should cover their own basic healthcare needs. I just don't think that this actually does much to make coverage more affordable in general, because it's catastrophic coverage that costs so much.
In Denmark it's both free to go to the doctor and to go to the hospital.
This model is obviously great but it has it's limits with things like treatment opportunity.
What I am proposing is a model that mixes the US and the Danish system. We pay for our non-serious things but don't get bankrupted on serious illness.
The price of US hospitals are inflated, they aren't the real cost which any visit to a hospital anywhere else in the world will tell you.
I don't see how this is at all related to the inflated costs of American hospitals.
There is a reason why the us healthcare system can have inflated costs and thats because of the nature of the the way it gets funded. And because it gets funded differently it allows for a different kind of dynamics in the offering.
Go to Denmark the hospitals mostly look the same with a few notable differences and you have to wait til it's your turn.
Oh, not at all. The dialog goes like this:
A: I'd like a treatment, but I can't pay for it.
Hospital: Go away.
Most people in the U.S. have no access to care costing more than a few hundred dollars, because that's how much money they have.
This may not hold for other forms of immigrant/refugee, but the agricultural laborers are a net boon to the state.
Here in California, for example, ~45% of ag workers are estimated to be here illegally. Similar percentages are in construction, and other manual labor jobs.
Also keep in mind that the job descriptions of this migrant population are fluid- who is counted as agricultural vs. construction, etc. changes by season and state.
http://www.wsj.com/articles/immigration-does-more-good-than-...
For a good start on reading material.
The private insurers already do that.
A cost center literally puts a stop to how much you can spend, it doesn't have the flexibility of a profit center.
It's a very different world where it's possible (for some) to get the latest treatment because it exist vs. a world were it doesn't because there isn't money for it.
I am no fan of private insurers but it's very different.
Edit: Not sure why this comment warrant a downvote. Anyone care to elaborate?
I'd also like to propose a thought exercise for you. Imagine a private insurer. They have, say, 50K clients. They make a couple million dollars a year in profit and make many millions of dollars in medical payments. Next year they double in size, which reduces their risk of failure and improves profit margin slightly. The better profit margin allows them to reduce costs a bit to attract more new clients. The next year they do the same, and the year after. Then they start merging with other insurers while continuing to grow. All along, as their client base grows, they improve profitability (and/or reduce costs) and their business becomes less risky.
Suppose eventually all Americans use this one enormous insurance company. They have the power to negotiate the best rates with doctors, drug companies, hospitals, etc. They have such a large client base that there is no risk, just extremely predictable income and expense. They can get costs as low as the medical industry will allow because they have such a large base.
Now suppose that this one enormous company is simply a part of the federal government. What changes to make single payer not work when it was working just fine before the words "federal government" were introduced?
its uncommon to say an entire organization is a cost/profit center; instead you would say x department is a cost/profit center.
FWIW, i believe most insurance companies make their money from investing the insurance premiums - i would say within an insurance company the finance department is likely the profit center, and whichever department handles payouts to healthcare providers would be seen as a cost center for the org.
oh it may be worth adding- most major US insurance companies are run as non-profit organizations.
Another way to put it is that companies have both cost and profit centers, public healthcare systems like the one in Denmark only have a cost center.
I am not sure what this seems so controversial.
This IS the big difference between a system which is purely run by tax money and don't take any revenue and then one which do.
Every dollar a private insurer makes (or invests) is a dollar they didn't spend on care for their clients. If you assume that insurers have, say, a 5 percent margin, the fastest way to cut the cost of care by 5% is to eliminate the profit.
You are getting way to hung up on the internal details of how it works.
Insurance companies are one part of the healthcare package. There is a reason it's a business which can do well or not so well.
Thats very different than a public healthcare system where EVERYTHING is budgeted.
I also don't know why you think private corporations are excluded from having budgets. I assure you that Aetna and Kaiser and all the other insurers have budgets for the medical care that they pay for. They cannot print money to pay the bills. All they can do is raise rates or provide less coverage. On the other hand, the government can print money if they need to.
We are talking about a healthcare system like the US version and comparing it to the Danish version.
The funding of those two systems are very different. The US healthcare system is run as a business with profits.
There is no such thing as profits in a public healthcare system like the danish and so everything is a cost.
In the US system thats not the case.
I frankly don't know why this is such a controversial discussion.
What about illegal immigration, do people who are here illegally get access too?
This is a problem with overreaching intellectual property law, not with having a choice in health providers.
How is this consistent with the pre-ACA availability of high deductible, low premium PPO plans in low-regulation states?
As an example, in 2008, a middle aged man could buy such a plan in Arizona for $70/month with a $10K deductible and $2 million lifetime coverage. This included free annual wellness visits, women's wellness checkups, etc. Keep $10K in the bank for emergencies, and you're good to go.
Millions of self-employed people and people working jobs that provided no group insurance benefits were able to take advantage of these products. I was able to insure my family of three for $330 a month at that time, and the coverage was quite good.
I don't fully understand the single payer concept, except that it essentially is a form of national health insurance similar to the British NHS. For a country as big and diverse as the U.S., it sounds expensive and unworkable.
I would propose as an alternative a hybrid of low-regulation plans such as we had prior to ACA, plus support for those who can't even afford one of these low price plans. Free or low fee clinics for the needy, less regulatory load on hospitals and small practices, e.g. remove or delay the electronic medical record requirement, attack the causes of high malpractice insurance, stop incentivizing physicians to "turf" challenging patients off to specialists and overprescription of tests to cover their liability.
There has to be a way that works, short of a national Medicare for all that I fear would lead to great mediocrity.
1. Only if you were already in good health and had no pre-existing conditions. Otherwise you would be rejected.
2. $2 million lifetime limit is not great for certain illnesses that can become very expensive to treat (e.g. cancer).
3. The practice of recission meant that you had no idea whether or not that $70/month plan would actually pay out in the event that you needed it.
Insurance plans were great for insurance companies pre-ACA, you could reject everyone except those least likely to need health care, and then drop their coverage if it turned out they actually needed it, or if they got too expensive to treat. It was a win-win-win situation for the insurance companies.
It's true that a catastrophic case could blow through the lifetime cap, but then there was something else called catastrophic coverage for not that much more. I chose not to get it, but maybe should have.
I suspect it's not so much that the coverage was prohibitive but that people simply didn't, and don't, understand the economics. A lot of people were knowingly going "bare", i.e. foregoing coverage altogether. Even today, people are consciously choosing to pay the personal penalty.
Your claim that "you could reject everyone" pre-ACA is completely false. In fact, insurance companies were required to carry a certain percentage of high liability customers. It varied from state to state, though.
Finally it's also worth mentioning that even for people with no coverage whatsoever, hospitals were (and are) required to care for them. If you stumble into the ER with any condition, they are required to provide care, or at least transport you quickly to a place that can. The poorest among us will get excellent care albeit they may not have the wherewithal and knowledge to actually go seek out that care.
The ACA sought to rationalize this fragmented and confused system and deploy a universal system throughout the country. It will be a subject of debate for decades to come whether this law would have worked.
Besides, what good is a plan that will pay $ to treat a broken bone but refuses to pay $$$$$$ to treat leukemia?
> Your claim that "you could reject everyone" pre-ACA is completely false. In fact, insurance companies were required to carry a certain percentage of high liability customers. It varied from state to state, though.
What? Tell that to the millions of people that couldn't get coverage pre-ACA due to pre-existing conditions.
> Finally it's also worth mentioning that even for people with no coverage whatsoever, hospitals were (and are) required to care for them. If you stumble into the ER with any condition, they are required to provide care, or at least transport you quickly to a place that can.
Are you suggesting you can go into a emergency room with a non-emergency condition and they're legally obligated to treat you? Can you cite a source for this?
Here's why single payer works to keep costs in check everywhere it's implemented:
Providers and pharmaceutical companies have only 1 organization to negotiate with.
Another alternative that won't see the light of day is cost regulation for the entire industry. My sons type 1 diabetes supplies for a quarter bill my insurance plan $6000. There's not more than a couple of hundred dollars worth of materials there (and I'm being generous.)
A friend of mine takes Gleevec, a leukemia drug, costing his insurer $14,000 per month. Generics are now coming on the market for a much "cheaper" $38,000/year. That same generic in Canada is $8,800/year.
We're being systematically ripped off.
Through higher domestic prices you are subsidizing the lower prices in most other countries for American-developed drugs.
You are also subsidizing the R&D. A single drug can cost billions (with a "B") of dollars to develop, test, and manufacture. It takes years of experimentation and careful trials, and even after the chemical is approved by the FDA, there are hundreds of millions of dollars in liability insurance baked into the price against the almost inevitable class action suit should there be an unforeseen side effect.
For example, Roche has developed an MS drug, ocrelizumab, which attacks B cells exclusively and appears to slow the progression of the disease. It's in stage 3 tests and has cost well over $1 billion so far. There is a large market for this treatment, should it ever make it out of the lab. The problem is, a side effect may cause the FDA to deny approval, and there is no particular compensation. Maybe they can use the knowledge to develop a better drug, or maybe it will help some other research organization. Either way, it's a very expensive and risky gambit.
The way they recoup their costs is by charging a lot up front. Since Canada and other countries cap the prices they can charge, they can only do so in the domestic market.
I'm not saying I approve of this approach. Frankly if I had MS I'd not want to wait 5 years for the FDA to declare it perfectly safe. I used to volunteer in an MS clinic and I can tell you, people were often willing to take the risk. Tysabri was another one that was amazingly successful against MS, but it also activated a rare and fatal virus in the brain in a very small number of patients, so it was pulled off the market. I've read that it's being allowed in limited cases.
The key word you're looking for here is "high deductible."
$10k is a very high deductible; it essentially renders the medical plan useless for anything short of emergency or life-threatening care. Most people don't just have $10k lying around.
Today, people resent even paying the co-pay, and the notion of coming up with a few thousand dollars that might be a small fraction of the bills would be considered outrageous and unfair.
Whenever I see a like claim tossed around I always ask (and never get a straight answer): What was your deductible and out of pocket maximum for your family of 3 at $300/mo?
For some conditions, the high deductible was waived. I don't remember now what they were.