Barack Obama Publishes Defense of the ACA in the New England Journal of Medicine
nejm.org
nejm.org
because its compulsory. this shouldn't an argument for the ACAs effectiveness. I have to buy car insurance if i choose to drive a car on public roads. i have to pay income tax if i have income. now, by birth, i automatically owe the state. i'd like my freedom and right to choose back please.
the fact this isn't the main argument from GOP shows their incompetence.
It's quite possible that your health insurance could be limited at first, and grows to cover more things and higher dollar amounts.
And before anyone says you can't do this, go look at your dental insurance. Odds are that your coverage increases each year so long as you have two checkups annually and don't let a lapse of insurance occur.
Note that as the ACA is __currently__ written, the situation the OP states probably exists.
Insurance is a useful product for mitigating risk, so accident insurance could be a very constructive concept (protecting against accidental injuries, broken arms, falls, car crashes, etc.). However, health problems are not a risk; they are a guarantee with probability approaching one as you age. The whole point of insurance is that you mitigate risk by paying more than you take out on average, but that doesn't make sense for healthcare, where almost everyone ends up going over their limit near the end of their lives.
If we didn't have all of these subsidies everywhere and inflated demand from Medicare/Medicaid/restrictive occupational licensing/FDA-granted monopolies/ACA, then perhaps we could pay everything out of pocket, which would make a lot more sense.
There are big problems with running the whole system using insurance, of course. It's fairly easy to predict future costs for a lot of people. Given free reign, insurers will charge completely unaffordable premiums to those people, effectively excluding them from the system. You see the same thing with other types of insurance: if you have a horrible driving record, or if your house is in an area that gets a devastating hurricane every ten years, your premiums will be huge. The difference is that those are optional activities, and if you can't afford the premiums then you can walk, bike, hitch a ride, buy a different house, etc. A sick person can't switch to a healthy body.
That's why the ACA has the mandate. If you require everyone to pay in, then you can also require insurers to ignore certain predictors of future risk when determining premiums.
Fundamentally, there are only two choices. One choice is to have lots of people dying of easily treated conditions because they can't afford the treatment, and the other choice is to have government step in and socialize the system to some extent. The system was already socialized before the ACA with the Emergency Medical Treatment and Labor Act, which requires hospital emergency rooms to treat all patients regardless of ability to pay. This was horribly inefficient, of course, but that's how it was.
So: choose your poison. If you think the advantages of going full free market in health care outweigh having poor people die of easily treatable diseases, then that's a valid opinion, but you should acknowledge the negative consequences. If you want poor people to be able to obtain treatment, then you'll need to accept some interference, the only question is how you'd like to have it be structured.
Edit: rather than "poor people," I really should say "people whom the hospital thinks are poor." If you get beaten up and mugged and left for dead, the ER won't know if you have money, and might decide not to take the risk. There are good reasons for even a selfish wealthy person to want some form of universal treatment.
How does one lead to the other? Social safety nets are not mutually exclusive with removing a lot of other market barriers. See my prior comment on this thread -- our healthcare market is the most distorted in the world (even when compared to 'universal healthcare' countries). Freer market means 'easily treatable' conditions are cheap, as opposed to our current system where they are expensed behind oppressively occupationally licensed practitioners selling monopolized medical products, where a 10 minute checkup with a dermatologist out-of-pocket is nearly $500. But regardless, it is certainly an interesting, quantifiable argument (albeit hypothetical) that a 20% speed increase medical innovation in a free market could be measured against lives saved with today's medicine in a socialized system, assuming that system makes services as affordable/accessible as intended.
Here's the reason health insurance as an industry can be considered fraudulent, especially when it's generally the gateway to all healthcare access -- and why ACA fails to fix it. Pre-existing conditions and re-adjusted contract rates.
If there was one company and one client, they could certainly craft a perfectly sound insurance contract to pay a set rate with steady increases over X years in exchange for coverage in the event of future, currently unascertainable medical services. But if you are responsible and get insurance BEFORE you get sick (by the way, not much sympathy for those who do not and demand that insurers take them, since that's the whole point of insurance), you are effectively tied to this contract and can never again negotiate another of equal value after you have been diagnosed with a condition, even though your initial/current contract already priced in the risk of getting those conditions. In fact, the rates to cover your risk, which need to be higher on average than the amount of healthcare you actually use, become ridiculous quite quickly. This problem is amplified by the fact that the government thought it was a good idea to tie healthcare to employers, so people switch very frequently and therefore are forced to renegotiate contracts frequently, robbing them of lost value that would be acquired if they were able to ride out the original contract.
So to say health insurance is inherently fraudulent is hyperbole, but in the current setup, it functionally is, because it is non-transferrable. ACA attempts to address this problem by subsidizing those who do not make much money and forces insurers to take everyone, but this just adds artificial demand (due to the subsidies especially) up to the amount of the maximum subsidy and raises everyone's rates (although those who are subsidized will see somewhat lower rates), and does nothing to address risk renegotiation, especially since it includes people who never had a contract. Similar economic effect as student loans/student aid. Each dollar increase in student aid raises tuition by over 40 cents... the rest is probably distributed across student housing, amenities, textbook prices, concert prices in college towns, etc.
A better way to eliminate the fraud, while still limiting ourselves to an insurance-dominated system, would be to legally codify standards for contract negotiations, which would allow contracts to be traded/transferred between companies, effectively locking in your risk at the time you first get uninterrupted insurance (and perhaps some protections for temporary uninsured periods).
So, screw people who are born with a chronic condition, or people who lose coverage due to poverty and then want to get back on later?
I don't think insurance is necessary in the system I propose, but to the first point, nature already screwed you, life isn't fair, etc. To the second, I actually addressed that in my comment as something that could be eligible for protection for some period.
But let me know if you take issue with the main points -- not trying to get into a battle of details.
I consider these questions to be among the main points. If you don't, that would explain our difference of opinion. I really can't understand shrugging off screwing over people born with chronic conditions on the basis that life is unfair anyway. I mean, you can use that argument to justify nearly anything. Why outlaw murder? Sure, it sucks to get murdered, but life is unfair.
Our current system of infinity is clearly problematic. But I really don't want to get into an argument of defending any implementation of health insurance (even one which I think would be better than the current) because I don't think there's a good way to do it period, as per my first comment.
> Why outlaw murder? Sure, it sucks to get murdered, but life is unfair.
Two completely separate things, not even on the same spectrum. Outlawing murder is preventing a violation of a person's rights, i.e. aggression. You maximize society's net freedom by outlawing it. Forcing society to try to make life "equal" for someone who was born with some terrible condition inherently violates freedoms through mandates, taxes, etc. And of course there's the whole thing about it not being practical. Everyone dies, and almost everyone would benefit from an extremely expensive heart transplant/frequent blood transfusions late in their life. But unfortunately, we can't give it to them (yet). However, there will always be some new and great medicine that is too scarce for everyone to have. Fortunately, private individuals are very charitable without the government and create institutions to treat and study chronic diseases.
I get that you probably don't think health care is a human right, but "not even on the same spectrum" is not a simple statement of fact.
If your preferred outcome involves screwing these people and various others because you think overall it's a worthwhile tradeoff, then so be it, but I want to make sure we're clear on that consequence.
Correct, I consider human rights to be more fundamental than a new product/service -- health care didn't even exist a century ago. It is expensive, scarce, and difficult to define, as it is constantly changing. The only thing that is guaranteed is that there will be a point where a patient cannot be given any more healthcare, because of the diminishing returns (measured in hours of added lifespan per dollar).
> If your preferred outcome involves screwing these people and various others because you think overall it's a worthwhile tradeoff, then so be it, but I want to make sure we're clear on that consequence.
Yes you've mentioned that point before and I addressed it. To recapitulate: there is definitely an interesting argument to be made for the tradeoffs involved, and I think it would be worthwhile if measured in terms of average lifespan. However, as I said, I am not as convinced as you are that people with pre-existing conditions are going to be "screwed" in a more free-market, insurance-free system. Their costs of treatment goes down, and by the nature of insurance, they would typically be paying more than the cost of their treatment anyway (over time) to the insurance company, so....
As for paying more in insurance premiums than you'd pay for treatment, that's only if insurance companies are allowed to account for your chronic condition when determining premiums. If you forbid insurance companies from charging more for existing conditions (as the ACA does) then that doesn't apply, and healthy people subsidize the costs.
That said, while in some sense "health problems" are guaranteed, the range of costs involved is huge.
Young people, and especially young, healthy people are the ones subsidizing the elderly and the unhealthy, including most of those who are unhealthy by choice through poor decisions.
> The point of insurance is to distribute risk
Perverse incentives. Insurance needs to be structured in such a way as to incentivize people to take part in preventive care, which costs a fraction of treatment and palliative care.
And before you reject that notion, try asking someone from one of those other industrialized countries if they'd like to swap their system for ours.
And of course, it's not by birth, you owe nothing if you're dependent on someone else.
Your logic makes no sense in the current environment. If I'm unemployed and can't afford it, I'm free riding.
So yes, you should be able to choose. If for no other reason than you already can (by not working).
In this situation the person in the accident can later claim that they didn't want to be saved and thus owe nothing. We, that is the rest of us who participate, are then forced to carry this cost and they free ride.
If you want to go off the grid, you need to go ALL the way off the grid. Otherwise you're just another moocher.
Not to mention that the majority of people who do have Obamacare are getting subsidized by the government (i.e., they're "moochers", in your terminology).
How does making this public subsidy pass through more sets of pockets before it gets to the doctor make it any less "mooching"? Please be specific.
Also, what about the people with expensive preexisting conditions? Virtually all of those people are consuming far more resources than they will ever pay in. Are they also "moochers"?
Note that I'm not saying that those people shouldn't have health care. I'm just objecting to calling it "insurance", because it isn't. Insurance is a bet.
No it isn't, the parent poster made no judgement about the system available, just that one must participate. What that system looks like is an entirely different debate to the "I should be able to not have insurance" debate.
> Also, what about the people with expensive preexisting conditions? Virtually all of those people are consuming far more resources than they will ever pay in. Are they also "moochers"?
That is the entire point of insurance. Some will pay more than they take and others will take more than they pay, but in the end, both sides of the ledger for the collective is balanced and both individuals had the same* access. *for some loose definition of same.
If you are allowed to buy "health insurance" after you are already sick, it's not "insurance" at all. Sorry, it just isn't.
Do you also think that you should be able to buy fire insurance after your house is already on fire, or car insurance after you've already had the accident?
Note again, and note well, that I'm not saying that people who are already sick should be abandoned. That is a real problem and one which should be addressed. I'm saying that bundling them into an "insurance" program makes no sense whatsoever.
It makes even less sense when you bundle them into Obamacare, the other users of which tend to be poor. I mean, they weren't able to afford insurance before... and now they're expected to not only cover their own costs, but the costs of all those with preexisting conditions? How did anyone expect that to work?
If you insist on funding the preexisting folks by charges on another risk pool, it probably should be done across the board (i.e., by charging the costs of the preexisting folks to all recipients of health insurance, not just the ones unfortunate enough to be stuck with Obamacare). That, at least, would have spread those costs over a much larger pool.
In western countries where we have deemed that immoral, you will be treated, and we would like not to pay for you.
Which option do you think is more likely to happen?
Furthermore all of us are consumers of health care at one time or another. I admit I am resentful against the many people that take terrible care of themselves but the fact is 40% of americans will get cancer. http://www.upi.com/Health_News/2010/05/06/41-percent-of-Amer...
Due to laws like this: https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an... and of course for ethical reasons hospitals can't turn you away when you can't pay.
I do feel it all needs urgent reform but I do feel the ACA was an attempt to expand competition and fairness while not leaving it completely unfunded like so many government plans seem to.
Is it still proper to refer to him that way?
This article was published on January 6, 2017, at NEJM.org.
Admittedly it's a bit confusing, given the online article is dated January 26, and includes "SOURCE INFORMATION: Mr. Obama is the former President of the United States." Likely inconsistency when repurposing content.
It is but these days it can hard to know going by past reputation alone.
There seems to be a push by some sleazy publishers to buy prestigious medical journals and then take money to publish questionable studies.
Even the watchdogs who have tried to warn everyone have given up (or were forced to shut up).
http://www.ctvnews.ca/health/website-tracking-so-called-pred...
That's good to know NEJM is run by a stable group.
Well, unless the change brings them more money. In this case I guess it didn't.
http://www.chicagobusiness.com/article/20170124/OPINION/1701...
1. http://www.slate.com/blogs/moneybox/2017/01/12/obamacare_rep...
Edit: 2. If this is bullshit I sincerely want to know so I can understand all sides.
If you're talking about virtually every major country besides the U.S., though, they do have something close to free healthcare for all, and it does work, and it's actually a lot cheaper for their societies than the system we have in U.S.
Our crap healthcare is one of the biggest drains on the economy. What the US government spends on healthcare disregarding spending by individuals is still more per capita than any other universal health service.
And if the costs go up - it's because perhaps healthcare is better as a not-for-profit system rather than a for-profit system. Pretty hard to negotiate which hospital gives you the better deal when you're having a heart attack.
And I say this from a position of love in New Zealand - I wish you had normal government healthcare, like most other countries in the world. America spends 3x the amount on healthcare per capita compared to NZ (https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...).
Many people think that without ACA, the US healthcare market is free, which is why it has so many problems. 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, and which will apparently be replaced with something similar).
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 New Zealand/other countries with long wait times, not as much access to specialists, slow innovation, and a system where the government gets to decide who gets the last liver transplant and who dies. That would be a less distorted market than we have today, but ONLY if accompanied by fixing the aforementioned problems.
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. And maybe even declare health insurance fraudulent and pay everything out of pocket (accident insurance makes more sense as a hedge against risk, which is what insurance is supposed to be, whereas all people are expected to develop health problems at some point, with a probability approaching one).
http://kff.org/medicaid/state-indicator/medicaid-spending-by...
(When people have no money left, Medicaid pays for nursing home care)
Serious claims require serious proof.
http://www.latimes.com/business/hiltzik/la-fi-hiltzik-aetna-...
I reject the claim that 'we just can't afford it', and claim instead that the economic loss of not doing it is far greater, just not properly accounted for.
Here is republican senator Rand Paul on the huge budgetary expense of ACA repeal