Author Topic: Obamacare Repeal and Replacement  (Read 14091 times)

Wayward Son

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Obamacare Repeal and Replacement
« on: January 19, 2017, 03:50:14 PM »
It's about time we started a thread on this one.

Congress is biting at the bit to repeal the Affordable Care Act.  PEOTUS (POTUS tomorrow) Trump declares that Obamacare and its replacement will be passes at the same time.  Which annoys Congress, because they haven't been able to agree on a replacement yet (having had only 6 years or so to work on it).

Meanwhile, 20 to 30 million people who rely on Obamacare wonder if they'll have insurance next year, or even next month.  Fortunately, Trump has promised that they'll lose nothing that they love, and the replacement will be fantastic.  Not that anyone believes him... :)

So, anyone got any opinions on the subject. :D

Personally, I think Congress will go with the "Let the States Figure it Out" program.  I forget which Congressman talked about it.  Basically, they would tell the States to cover people, and probably give them a check to help cover it.  When the programs fail, they can then blame the States for not making it work. A masterfully weaselly way of avoiding blame, even if millions of people may end up uninsured. :)

But, the possibilities are still wide open.  I hear Ryan has a plan that is basically Obamacare, but with the name crossed out in crayon... ;)

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #1 on: January 19, 2017, 03:52:46 PM »
Oh, does anyone have a good source that details how many people are on Obamacare, the total number of people insured today, how much insurance costs (with or without Obamacare), and other such statistics?  Preferably one that will be around in four years or so.

When the fantastic replacement comes out, it would be good to have something to compare it to, just to check the Donald's work.

I've looked for one, but so far haven't had any luck.  :-[

Pete at Home

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Re: Obamacare Repeal and Replacement
« Reply #2 on: January 19, 2017, 05:48:13 PM »
I just barely found out that I'm covered by Medicare come february, which is pretty magical luck considering the dates.  Obamacare's been a godsend for me over the last year.  Back on basic meds, I've even been able to start a small online tutoring business.  In the last 2 weeks, I've even been able to buy internet, so you may notice I no longer sound like I'm, well, typing everything with my arthritic thumb.

But to the real conservative out there, here are some numbers that I think you should consider.  The number of abortions in the United States has been going down slowly since Reagan left office, but since Obamacare has totally plummeted.  There are fewer abortions, not just per population, but fewer TOTAL abortions in the USA today than at any time they have ever been measured, i.e. since Roe v. Wade.  Inexpensive access to birth control and adequate health coverage, even some mental health coverage for the poor and desperate, has helped to accomplish this.  If actual fetal lives matter to pro-lifers any more than actual black lives matter to Black Lives Matter, I'd hope that you'd take note of this as an accomplishment, and try to keep those abortion numbers going down.

Kasandra

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Re: Obamacare Repeal and Replacement
« Reply #3 on: January 22, 2017, 05:42:44 PM »
Trump got to work immediately after the inauguration, probably because he had said he would be taking the weekend off (other than to insult the CIA).  This is one of his first two Executive actions he carried out before he took off:

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By the authority vested in me as President by the Constitution and the laws of the United States of America, it is hereby ordered as follows:

Section 1. It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act (Public Law 111-148), as amended (the “Act”). In the meantime, pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.

Sec. 2. To the maximum extent permitted by law, the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall exercise all authority and discretion available to them to waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.

Sec. 3. To the maximum extent permitted by law, the Secretary and the heads of all other executive departments and agencies with authorities and responsibilities under the Act, shall exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.

Sec. 4. To the maximum extent permitted by law, the head of each department or agency with responsibilities relating to healthcare or health insurance shall encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.

Sec. 5. To the extent that carrying out the directives in this order would require revision of regulations issued through notice-and-comment rulemaking, the heads of agencies shall comply with the Administrative Procedure Act and other applicable statutes in considering or promulgating such regulatory revisions.

Every day will be a further descent into the rabbit hole.  For instance, when KellyAnne Conway was confronted with Sean Spicer's lies in his WH briefing yesterday she defended him by saying he was using alternative facts.  If the stupidity and mendacity of this bunch of losers and bullies isn't enough to unite both Liberals and Conservatives to work together to get them all out of office, nothing is.

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #4 on: January 22, 2017, 09:28:53 PM »
https://www.yahoo.com/news/trump-may-not-enforce-individual-health-insurance-mandate-175653215.html

"WASHINGTON (Reuters) - The Trump administration may no longer enforce a rule requiring individual Americans to carry health insurance or pay a penalty if they do not, a senior White House official said on Sunday"

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That's a very splendid start because forcing people against their will to pay for an overpriced substandard product to support the multi-million dollar salaries of fat cat insurance executives is not who we are as a people or what we stand for as Americans. That never should have been held to be Constitutional in the first place.

Whatever replaces Obamacare will be fine by me even if nothing replaces it. I know it's not all about me but... Obamacare has been entirely worthless to me, worse than useless even because of the penalty for not buying it. It's too expensive with both premiums and deductibles just being outrageous.

If the good parts can be kept like allowing people with pre-existing conditions to get insurance that would be great and accomplishing such a feat while also getting rid of the mandate would be incredible though I'm not sure how it would be done. I'd be fine if straight tax dollars were used to do it somehow. Being forced to pay taxes to help our fellow Americans is something we're all used to by now, but being forced to pay multi-million dollar salaries for CEOs is not acceptable.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #5 on: January 23, 2017, 01:00:20 AM »
OK, let's get some numbers here.

According to Henry J. Kaiser site, in 2015 (the most recent year they list), in the U.S.:
49% get health insurance through their employer (155.9 million)
7% non-group health insurance (21.8 million)
20% Medicaid (62.4 million)
14% Medicare (43.3 million)
2% Other Public (6.4 million)
9% Uninsured (30.0 million)

Let's see if Trump can beat these numbers (mainly in the Uninsured row).

Kasandra

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Re: Obamacare Repeal and Replacement
« Reply #6 on: January 23, 2017, 07:23:28 AM »
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Whatever replaces Obamacare will be fine by me even if nothing replaces it.
Cherry, what will people who lose their health insurance do when they get sick?

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #7 on: January 23, 2017, 07:52:10 AM »
What good is having insurance when it's so expensive to use it?

If your insurance has a six thousand dollar deductible then what good is that?

Most people need health insurance for broken bones, hernia surgery, childbirth, getting the flu or other viruses, and so on, all of which come in at thousands of dollars under the deductible but thousands of dollars over what people have available to pay.

I even read a story that said that fewer people with insurance are actually using it because it's so expensive. How is that any improvement?

Sure it's going to be good if you get cancer, a snake bite, or have a heart attack, and that's fine. But that's not all it should be good for. And what about dental? That should be wrapped into health insurance and not something separate because dental health is directly connected to overall health.


cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #8 on: January 23, 2017, 07:53:29 AM »

Kasandra

"Cherry, what will people who lose their health insurance do when they get sick?"

What kind of sickness are we talking about?

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #9 on: January 23, 2017, 07:59:34 AM »
For everyone who has Obamacare right now they should be allowed to keep it if they are happy with it.

I heard that the mandate penalties weren't even nearly enough to cover the costs of the seriously sick anyway. The highest penalty I ever paid for not having health insurance was $185. And paying that saved me tens of thousands of dollars in health insurance premiums. That was a no brainer. Obamacare was already in its death spiral. Whether Trump won or not something was going to have to give. Now I have tens of thousands of dollars extra to pay for actual healthcare instead of almost certainly useless health insurance. Health savings accounts might be an option for many people, or an insurance bond like you can buy for car insurance.

Kasandra

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Re: Obamacare Repeal and Replacement
« Reply #10 on: January 23, 2017, 08:08:45 AM »
Chronic illnesses that require repeated care like diabetes, kidney disease, arthritis, congenital or hereditary disabilities, mental illness (schizophrenia, depression,...), Alzheimer's, cancer..., or long-term care after an accident or expensive drugs....

Bear in mind that 50% of the population account for 97% of health care costs (other than premiums), and it's often too expensive for people who are insured to get the care they need.  If you divide people into high/low risk pools the actual costs for medical care will skyrocket.  In other words, insurance is a shared risk pool, so healthy people are underwriting the costs for those who are sick.  If you let them opt out they will be the ones who have no one to help them when they get sick as they get older.  It's not only foolish, but deadly to think that it's wrong that everyone should have insurance and everyone who can afford to pay should do so.  That highlights how absurdly high health care costs are in the US, especially when compared with every other modern nation that has nationalized health services.
« Last Edit: January 23, 2017, 08:12:10 AM by Kasandra »

Kasandra

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Re: Obamacare Repeal and Replacement
« Reply #11 on: January 23, 2017, 08:10:24 AM »
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Now I have tens of thousands of dollars extra to pay for actual healthcare instead of almost certainly useless health insurance.
Do you actually have those "tens of thousands of dollars" or are you just talking about how much you think you saved that you spent on other things?  Don't forget that about 50% of people over the age of 50 have almost no money saved up for any catastrophic or chronic illness.

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #12 on: January 23, 2017, 08:38:22 AM »
I actually have it, and more than that because I bought stock in a company a few years ago and it's almost tripled now. If I had invested in Obamacare instead I'd have so much less money right now it's just crazy to think about it. What if I got really sick? Yeah, life is a gamble, so I bet and I won. I should have paid for everyone else's healthcare instead of saving up for the future? That would have been very generous of me. I just don't believe me paying to the insurance companies and having them take a 15% cut off the top is the way to go about this. If really sick people need care then just have "the government" do it directly with tax dollars instead of paying through an insurance company. I'm not sure how medicare and medicaid work but I keep hearing that is the way to go. After people are bankrupt from using all their assets to pay for their healthcare then they should be able to qualify for government assistance with their healthcare costs. I don't mind paying for it through taxes; I just don't think I should be forced to pay for it through an insurance company. I've never complained about having to pay for medicare and medicaid or healthcare for indigent Americans who come into an emergency room. If people like me need such healthcare because we have a million dollar healthcare bill and we pay the hundreds of thousands of dollars we've saved up by not buying insurance so that we're now bankrupt and qualify for government assistance that still seems to work out well for the healthcare industry and doesn't seem that different from if we'd been paying six to eight thousand a year in premiums. In fact it may work out even better because if we've invested wisely we'll have even more money to pay into the system before we are bankrupt than we would have paid in premiums.

Now having said all that, if health insurance was reasonably priced and there was a good chance I could get my money's worth out of it, I would consider buying it. That was what Obama promised, to bring health insurance prices down. He failed. If it was about 3,000 bucks for a family of four per year and the deductible was around $2000 that would seem like a reasonable thing to buy. Over $6000 premiums with another $6000 deductible is just absurd.

Kasandra

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Re: Obamacare Repeal and Replacement
« Reply #13 on: January 23, 2017, 10:49:37 AM »
For once I agree with you, as you are making a very strong argument for single payer health care.  I am now on Medicare and receiving as good care as I ever got from private health insurance.  The premiums and out of pocket are far lower, too.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #14 on: January 23, 2017, 11:16:06 AM »
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What if I got really sick? Yeah, life is a gamble, so I bet and I won.

Lucky you.  Just remember that there are many others who aren't so lucky.  (After all, if no one loses, it ain't a gamble. :))

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If really sick people need care then just have "the government" do it directly with tax dollars instead of paying through an insurance company.

That sounds like a Single-Payer system, cherry. 

I certainly hope you voted for the political party that is amenable to implementing a single-payer healthcare system in our government.  Because the one that's in power now has been campaigning against such a system for as long as I can remember, and the chances of one being implemented now is practically nil.  As anyone could have told you before the election.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #15 on: March 15, 2017, 03:23:26 PM »
Now that the CBO has weighed in on the Republican Healthcare Plan, it's time to resurrect this thread!  :D

It's not a pretty picture.

Estimated 24 million will lose their health insurance over the next 10 years, including 14 million by next year.  (Quotes and numbers from FiveThirtyEight discussion.)

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perry: Well, 14 million of the 24 million are in Medicaid. People are choosing to get Medicaid in record numbers right now. The GOP is trying to limit that choice.

anna: Yeah, we’re talking about people earning about $16,000 a year or less. That’s not enough for food and housing in many areas.

(So don't say those people losing Medicaid "chose" to be uninsured, Seriati. ;) )

On the plus side, these 14 million are the main reason the program will save $337 billion over the next 10 years.  And it is still lower than the 26 million people who would lose insurance that the White House estimated.

Next, premiums are likely to go down on average, but they will cover less.  For comparable insurance they will likely go up 15 to 20 percent on average.  And they will go up even higher for older adults (since Obamacare limited the costs to only 3 times the amount for younger people, and this will allow the premiums to go to 5 times) and those in rural areas.  And the tax credit is a straight across-the-board $4000, regardless of how much it costs in your area (like in the more expensive rural areas).

But no one will be required to buy insurance anymore.  And the tax premium on the wealthy will go away, so a lot of that savings will go to those who need it least!  ???

Finally, Planned Parenthood would be cut for a year, increasing the number of births.  (I heard somewhere that they only want to cut it for a year to minimize the number of births, since Medicaid covers births and thus would cost more in the long run.)  But, then again, since the plan is also to change Medicaid to a block-grant instead of paying per procedure, it doesn't matter to the Feds, does it?  They won't have to pay the increased cost.

So, decreased number of insured, especially among the poor, elderly and rural populations, increased premiums, and increased births.  And Republicans will own this.  Assuming, of course, they can pass it.

This is what you get with 7 years of planning.  ::)

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #16 on: March 15, 2017, 03:46:42 PM »
Just out of curiosity, was the CBO accurate about their predictions for Obamacare?

D.W.

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Re: Obamacare Repeal and Replacement
« Reply #17 on: March 15, 2017, 04:20:31 PM »
I like the Republican Insurance Plan.  Saw that and got a chuckle.  Anyhow...  Does the 24 million really mean people who will lose insurance, or does that also include the young healthy gamblers who choose not to get insurance?  While I think they SHOULD have health care, it's a little misleading to say they will "lose" it.  (If they are just opting out.)

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #18 on: March 15, 2017, 04:47:02 PM »
Just out of curiosity, was the CBO accurate about their predictions for Obamacare?

Ah, yes, the Republican talking point. :)

According to this analysis, reasonably close.

Coverage: 30 million predicted, 27.9 million actual.

Exchange use: 23 million predicted, 10.4 million actual.

Medicaid increase: 10 million predicted, 14.4 million actual.

They were apparently closer than any other major estimate, and a whole lot closer than most (especially partisan) estimates. :)

(Make sure any analysis you look at uses the 2012 CBO estimates, NOT the 2010, since the law effectively changed because of the Supreme Court ruling allowing states to opt out of Medicaid, which changed the assumptions the CBO were working from.)

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #19 on: March 15, 2017, 04:52:31 PM »
I like the Republican Insurance Plan.  Saw that and got a chuckle.  Anyhow...  Does the 24 million really mean people who will lose insurance, or does that also include the young healthy gamblers who choose not to get insurance?  While I think they SHOULD have health care, it's a little misleading to say they will "lose" it.  (If they are just opting out.)

Per the FiveThirtyEight discussion, 14 million will lose it because of Medicaid changes/cutbacks, which (at less than $16,000/year cutoff) means that practically all of them won't be able to afford it.  Since they have it now, I think we can safely say that those 58 percent "lose it."

The discussion also says that the CBO says a number of older people currently insured will not have it after their premiums increase (from 3x to 5x the youngster's premiums), so those people would also count.

I don't have any more precise estimates right now.  But well over half from what I've read.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #20 on: March 15, 2017, 05:12:31 PM »
Now that the CBO has weighed in on the Republican Healthcare Plan, it's time to resurrect this thread!  :D

It's not a pretty picture.

Estimated 24 million will lose their health insurance over the next 10 years, including 14 million by next year.  (Quotes and numbers from FiveThirtyEight discussion.)

It seems to me if you want to start a report about the CBO's numbers you should repeat what they said, rather than spin on it.  The primary source of the 14 million less year is from the free choice of those who will not be forced to buy plans they don't want.  A different group 10 years from now, who the CBO otherwise beliefs would be eligible under Obama's expanded Medicare will not be eligible by then.

Meanwhile, that expansion, and Obamacare itself, remains an another unfunded promise by a Democratic politician that he expects everyone else to make good on.

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(So don't say those people losing Medicaid "chose" to be uninsured, Seriati. ;) )

Don't really have to, already pointed out that their Medicaid was never paid for, and you're referring to people you expect to become eligible in the future.  Meanwhile, this bill will lower everyone's premiums (and maybe costs) and free the industry to produce lower cost insurance options for those who want them. 

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Next, premiums are likely to go down on average, but they will cover less.  For comparable insurance they will likely go up 15 to 20 percent on average.

Yes, people will be able not to pay for services they don't need or want and save money.  Ohhh.... the horror!

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And they will go up even higher for older adults (since Obamacare limited the costs to only 3 times the amount for younger people, and this will allow the premiums to go to 5 times) and those in rural areas.

So apply logic to this problem.  What multiple is the average cost of providing medical care to older adults versus younger?  Greater or lesser than 3 or 5?

Young people often have the least ability to pay bills and the most calls on their resources, yet you favor a system that deliberately transfers wealth from them to older adults who on average have substantially more wealth than they do? 

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And the tax credit is a straight across-the-board $4000, regardless of how much it costs in your area (like in the more expensive rural areas).

My understanding of the tax credit is that its per person, and can range from $2-$4k depending on your income.  Which could be a large amount for a family.  Most of the critiques use a cherry picked scenario of a single man in a high cost area.  Did you look at the CBO's actual report?

Not sure your point on planned parenthood, birth control is widely available free or at a low cost to everyone even without planned parenthood.  And as we've repeatedly been assured no federal money is used for abortions so elimination of the grants by logical necessity has a zero impact on the ability to continue to provide abortions.  Or is it just a lie that this money is not currently used for abortions?

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But, then again, since the plan is also to change Medicaid to a block-grant instead of paying per procedure, it doesn't matter to the Feds, does it?  They won't have to pay the increased cost.

Medicaid should never have been expanded in the first place.   This correction has hardly any real current impact.  The idea that because Obama lied and made a promise to pay for care that no one can afford its a "change" to put it back on a more reasonable path is absurd.  The care was unfunded and therefore imaginary.

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So, decreased number of insured, especially among the poor, elderly and rural populations, increased premiums, and increased births.  And Republicans will own this.  Assuming, of course, they can pass it.

So better care, less expensive plans, if we're lucky increased consumer awareness of health costs which will force more reductions, lower premiums, and I seriously doubt any real impact on births (talk about pushing granny over the cliff style scare tactics).

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This is what you get with 7 years of planning.  ::)

No this is what you get without 7 years of planning.  You are right to criticize them for lying about having a plan.

This debate is going to be garbage.  Maybe rather than repeating memes about a laundry list of everything without explaining the logic behind it, we could focus on the realities of a couple issues at a time. 

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #21 on: March 15, 2017, 05:43:03 PM »
Thank you for looking up those figures for me, Wayward Son. That's good information to take into account when thinking about their new predictions for Trumpcare.

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #22 on: March 15, 2017, 06:00:26 PM »
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The primary source of the 14 million less year is from the free choice of those who will not be forced to buy plans they don't want.  A different group 10 years from now, who the CBO otherwise beliefs would be eligible under Obama's expanded Medicare will not be eligible by then.

Could you show me a source for that statement?  That seems to contradict what was discussed on FiveThirtyEight.

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Yes, people will be able not to pay for services they don't need or want and save money.  Ohhh.... the horror!

People don't need or want insurance until they need it. ;)

And if they need it and don't have it--well, then they pay more than they want to for it, and when they're broke, we pick up the rest of the tab in higher insurance rates.  So while inadequate insurance may sound good for the individual, for society it's not a good idea.

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Young people often have the least ability to pay bills and the most calls on their resources, yet you favor a system that deliberately transfers wealth from them to older adults who on average have substantially more wealth than they do?

Except that most of those older adults aren't making much more than the youngsters.  Those who have "substantially more wealth" would either have insurance through their employer or are substantially wealthy.  What about older adults who don't make much money?

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My understanding of the tax credit is that its per person, and can range from $2-$4k depending on your income.  Which could be a large amount for a family.  Most of the critiques use a cherry picked scenario of a single man in a high cost area.  Did you look at the CBO's actual report?

My understanding is that the maximum credit is $4000/year, regardless of how expensive the insurance may be in an area, and that insurance can easily surpass this cost (and is expected to do so).

Perhaps you could quote the relevant portion of the CBO report?

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Not sure your point on planned parenthood, birth control is widely available free or at a low cost to everyone even without planned parenthood.  And as we've repeatedly been assured no federal money is used for abortions so elimination of the grants by logical necessity has a zero impact on the ability to continue to provide abortions.  Or is it just a lie that this money is not currently used for abortions?

The money is not used for abortions, but Congress wants to cut off all funds to Planned Parenthood for everything.  So they cannot be paid for birth control, mammograms, etc.

And while birth control is available, much like the AHCA, it may not be obtainable.  Many low-cost community clinics are already overwhelmed, and, as was reported on NPR, some refer patients to Planned Parenthood as a matter of course for specific procedures and needs, such as birth control.  So it will take awhile for them to take up the slack, if they are ever able to, especially in rural areas.

It's going to cause problems, no matter what certain Republicans say.

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Maybe rather than repeating memes about a laundry list of everything without explaining the logic behind it, we could focus on the realities of a couple issues at a time.

I wanted to mention all items on the list.  Is there any particular item you feel needs more of a reality check?

Wayward Son

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Re: Obamacare Repeal and Replacement
« Reply #23 on: March 15, 2017, 06:10:40 PM »
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What about older adults who don't make much money?

According to this site (from a quick Google search), about 1/4 of people aged 55 and older make less than about $25,000/year.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #24 on: March 15, 2017, 06:29:03 PM »
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The primary source of the 14 million less year is from the free choice of those who will not be forced to buy plans they don't want.  A different group 10 years from now, who the CBO otherwise beliefs would be eligible under Obama's expanded Medicare will not be eligible by then.

Could you show me a source for that statement?  That seems to contradict what was discussed on FiveThirtyEight.

I took it from the New York Times article I was reading at the time, but we should be looking at the CBO report directly:

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The number of uninsured would shoot up next year by 14 million, the budget office said. Most of the increase in 2018 would result from people choosing not to buy insurance after tax penalties for those without coverage are repealed, but in later years, the office said, the number of uninsured would rise further because of changes in Medicaid, the health program for low-income people.
https://www.nytimes.com/2017/03/13/us/politics/affordable-care-act-health-congressional-budget-office.html?_r=0

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Yes, people will be able not to pay for services they don't need or want and save money.  Ohhh.... the horror!

People don't need or want insurance until they need it. ;)

That's a corruption of what I said.  Do gay men need maternity coverage?  Or free IUDs?  What about post menopausal couples?  Those are expensive add-ons that give them no benefit.  Does a healthy young single person really need much than catastrophic coverage?

Honestly, you're trying to lay at my feet a problem you caused.  I don't believe that health insurance should cover pre-existing conditions, if you want coverage for that risk sign up ahead of time.  That said, our health plan needs to address how to deal with people who don't have coverage.

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And if they need it and don't have it--well, then they pay more than they want to for it, and when they're broke, we pick up the rest of the tab in higher insurance rates.  So while inadequate insurance may sound good for the individual, for society it's not a good idea.[/quiote]

So your solution to the risk we might pick up higher insurance rates is to...   wait for it... bake in mandatory higher insurance rates?  Obamacare is an unfunded liability that has increased insurance prices (as well as premiums), increased tax burdens and payments and resulting in a minor coverage bump in doing so, made up with a large group of people who can't afford to use their insurance.

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Young people often have the least ability to pay bills and the most calls on their resources, yet you favor a system that deliberately transfers wealth from them to older adults who on average have substantially more wealth than they do?

Except that most of those older adults aren't making much more than the youngsters.  Those who have "substantially more wealth" would either have insurance through their employer or are substantially wealthy.  What about older adults who don't make much money?

Isn't it cute how you forget the difference between income and wealth when its convenient!

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My understanding of the tax credit is that its per person, and can range from $2-$4k depending on your income.  Which could be a large amount for a family.  Most of the critiques use a cherry picked scenario of a single man in a high cost area.  Did you look at the CBO's actual report?

My understanding is that the maximum credit is $4000/year, regardless of how expensive the insurance may be in an area, and that insurance can easily surpass this cost (and is expected to do so).

$4k per person right? So a family of four could get quite a bit more, right.

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Perhaps you could quote the relevant portion of the CBO report?

Lol, or the law, or actual accounts.  Sure could.

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The money is not used for abortions, but Congress wants to cut off all funds to Planned Parenthood for everything.  So they cannot be paid for birth control, mammograms, etc.

Saw a report on that, may be fake news, may be not, this is a hot area that something like less than 1 in 20 PP locations provide mammograms, yet 100% of the comments seem to include that service.  I don't see any legitimate reason to fund PP, when those some funds could be given to any other organization that is willing to provide such services and is not tainted by the abortion issue.

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And while birth control is available, much like the AHCA, it may not be obtainable.  Many low-cost community clinics are already overwhelmed, and, as was reported on NPR, some refer patients to Planned Parenthood as a matter of course for specific procedures and needs, such as birth control.  So it will take awhile for them to take up the slack, if they are ever able to, especially in rural areas.

Or they could go to Walmart and get a $4 a month or less prescription for pills. 

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It's going to cause problems, no matter what certain Republicans say.

That's true.  It will cause problems.  Lots of them.  It will also solve problems.  Lots of them.  In my view way more than it causes.  But we don't decide issues anymore on logic and a weighing of the relative gains and losses, we decide them on who can drag the most emotional one liner out to hammer the other side on.

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Maybe rather than repeating memes about a laundry list of everything without explaining the logic behind it, we could focus on the realities of a couple issues at a time.

I wanted to mention all items on the list.  Is there any particular item you feel needs more of a reality check?

Lets start with explaining how one is "losing" insurance when the mandate to grant it was never really funded or supportable.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #25 on: March 15, 2017, 06:31:43 PM »
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What about older adults who don't make much money?

According to this site (from a quick Google search), about 1/4 of people aged 55 and older make less than about $25,000/year.

Wealth v. income, there's at least 250,000 write ups on the difference.  Try looking at average wealth by age, and lest you think its grossly broken by the rich take a look at the medians or even the percentiles.

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #26 on: March 15, 2017, 07:00:41 PM »
Is there a certain amount of wealth that you could have to consider yourself reasonably self-insured?

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #27 on: March 15, 2017, 08:15:30 PM »
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What about older adults who don't make much money?

According to this site (from a quick Google search), about 1/4 of people aged 55 and older make less than about $25,000/year.

Just as another follow up, what's interesting about your link is that while it shows the bottom quartile for 55+ as under $25k (with some very caveats), you kind of ignored that the 55+ age group actually has the highest income of any age group at each quartile.  So they not only have more wealth, they also have more income on average, with less non-health related expenses.

Greg Davidson

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Re: Obamacare Repeal and Replacement
« Reply #28 on: March 24, 2017, 06:46:41 PM »
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Is there a certain amount of wealth that you could have to consider yourself reasonably self-insured?

Self-insurance must work not only to provide payment for services, it must also duplicate the price benefits due to the buying power of insurance companies.  Real example: the uninsured price for something like a single MRI can be $13,000 while the billable cost on insurance is around $1000 and the cost to the patient is $120. It's easier to self-insure against needed a $1000 MRI (or even a series of them), but when they cost 13 times as much, that is a much steeper threshold.

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #29 on: March 24, 2017, 07:06:48 PM »
That's a good point about how the individual is often overcharged versus what an insurance company would be able to negotiate. Sometimes it can work the other way around though if you shop around. An insurance company might be overcharged but an individual paying cash could pay only a fraction of the cost that's billed to an insurance company. I'm also wondering after hearing something on the radio about possible super high deductible plans like a 20 or 30 thousand dollar deductible to bring the price of the premiums way, way down. Apparently the Obamacare repeal has failed so it's going to be interesting to see what happens next. It doesn't look good, but so far all of the options put on the table seem to have major problems.

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #30 on: March 24, 2017, 07:14:31 PM »
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Is there a certain amount of wealth that you could have to consider yourself reasonably self-insured?

Self-insurance must work not only to provide payment for services, it must also duplicate the price benefits due to the buying power of insurance companies.  Real example: the uninsured price for something like a single MRI can be $13,000 while the billable cost on insurance is around $1000 and the cost to the patient is $120. It's easier to self-insure against needed a $1000 MRI (or even a series of them), but when they cost 13 times as much, that is a much steeper threshold.

Isn't the claim that these price discrepancies are largely a result of hospitals having to jack up the price for some to make up for inability to pay of others? If so it strikes me as ironic that the inability of some to pay egregious costs may be due to the inability of others to pay lesser costs. It also strikes me as amazing that it's actual legal to devise multiple market prices for the exact same product depending on who's asking. If that was done at McDonald's there would be discrimination charges tearing the place  down.

Gaoics79

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Re: Obamacare Repeal and Replacement
« Reply #31 on: March 24, 2017, 07:14:55 PM »
Greg, do your insurers realize such significant bargains? Or more to the point, if most people were self-insured, would the prices be so high?

Not speaking rhetorically - just seems to me like healthcare costs in the USA are ludicrous (at least compared with what our Provincial health plans pay in Canada) and I often wonder if they'd be that high if average citizens were paying for their plans rather than insurers. The situation smells a bit like first class airfares and retail costs for smart phones - almost like the price is being distorted somehow by a disconnect between the consumer and the real cost of the service (either because the end user isn't actually paying the cost out of pocket i.e. first class airfare where you know most people are not paying out of their own pocket, or the end user is paying, but is doing so through byzantine contract plans that obscure the true cost a la smartphones)

Of course, it raises the question why Provincial insurers in Canada get such a great deal (relatively speaking). My suspicion is that there could be issues of fewer costs on the suppliers (maybe since 100% of the population is covered, the hospitals and end-point providers don't eat so many costs from indigent and poor people they would in the USA - see Fenring's point) or maybe due to lower insurance premiums in Canada for healthcare providers (better liability insurer for doctors and a tougher tort system).

Anyway just throwing some stuff around there. Not disagreeing with any point anyone made. Just questioning whether the purchasing power of insurers actually gets you a real "deal" in this case - because it doesn't seem to me like US. healthcare is anything of the sort!!

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #32 on: March 25, 2017, 01:06:30 AM »
Isn't the claim that these price discrepancies are largely a result of hospitals having to jack up the price for some to make up for inability to pay of others? If so it strikes me as ironic that the inability of some to pay egregious costs may be due to the inability of others to pay lesser costs. It also strikes me as amazing that it's actual legal to devise multiple market prices for the exact same product depending on who's asking. If that was done at McDonald's there would be discrimination charges tearing the place  down.

It should be pointed out the comparison is Apples to Oranges in that specific case. McDonald's has the right to refuse service on the basis of inability to pay. In fact, they often don't start making it until you've already paid for it.

Meanwhile healthcare providers are legally required to render services in "life or death" scenarios(at least so long as their services are relevant to the issue at hand), where cost isn't really allowed to be much of an object. This was so even before Obama Care.

Now if you wanted to compare it to Applebee's or Texas Roadhouse for example, you'd have more of a case. Except the cost differential is much smaller, and the time frame for finding a "payment problem" is typically much faster, usually before the customer leaves the building.

cherrypoptart

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Re: Obamacare Repeal and Replacement
« Reply #33 on: March 25, 2017, 01:30:32 AM »
I like the point about discrimination based on customer though. Why should an individual be charged more than an insurance company? Okay, looking at my own question I can see an obvious answer would be because organizations that purchase in bulk are entitled to bulk rate discounts, but since healthcare is an exception to so many other rules, perhaps it's worth looking at making it an exception to that rule too. I like all these little pop-up medi-clinics though, where you can find out what the price will be in advance, and often have to pay in advance as well but that's fine. You can go to the emergency room for e-coli stomach pain, be assured that before they do anything that will cost a lot of money they will let you know, have the doctor examine you for five minutes before telling you it's best to just wait it out and have him end up being correct about that as the problem goes away on its own, but then be charged over a thousand dollars for five minutes of his time. If that's the case, then when you go in and you tell them you are paying cash and want to know how much it's going to cost, they need to tell you up front that the minimum charge is going to be over a thousand dollars for five minutes of the doctor's time even if he (correctly) prescribes no medication or treatment. You might decide to go to a little 24 hour emergency medi-clinic and get the same thing for just fifty bucks.

In other words, I'm thinking there should be something of a menu for services with the prices listed. Instead they make a big production about how they don't know. Well, they may not know what they're going to find but they should have some idea what the prices will be based on the different possibilities, and they should be required to tell you in advance. Otherwise it's like if you go into a restaurant where the menu has no prices and you order a meal that might cost, at most, a couple hundred dollars and they charge you several thousand dollars instead. How is that possibly legal?

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #34 on: March 25, 2017, 01:40:57 AM »
Now if you wanted to compare it to Applebee's or Texas Roadhouse for example, you'd have more of a case. Except the cost differential is much smaller, and the time frame for finding a "payment problem" is typically much faster, usually before the customer leaves the building.

The fact of pre-payment at McDonald's versus paying after you finish eating elsewhere isn't really the point. The point is that even if Applebee's wanted to incorporate into its prices a price hike to offset non-paying delinquents, all they would do is increase the price on the menu to an appropriate level to make up the difference. Retail stores that experience significant theft no doubt have to take such things into account when setting their prices. In the case of hospitals this isn't what happens. Instead, they observe who is coming through the door, how much money they have, whether they have insurance and with what company, and then basically make up a price as they see fit. That is not equivalent to the Applebee's scenario where the higher price offsets their losses but is the same price for all customers. If you want to make an apples to apples comparison you would have to look at an Applebee's where they ask each customer personal questions and then make up a price on the spot based on the answers. How much do you want to bet that if a restaurant tried to pull that they would literally have the police on the scene demanding answers? A court order would shortly follow obliging them to stop, possibly on the grounds of unconstitutional discrimination. It's not rocket science; this wouldn't fly in any sector not supported by a powerful lobby guiding the legislation.

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #35 on: March 25, 2017, 09:26:15 AM »
Now if you wanted to compare it to Applebee's or Texas Roadhouse for example, you'd have more of a case. Except the cost differential is much smaller, and the time frame for finding a "payment problem" is typically much faster, usually before the customer leaves the building.

The fact of pre-payment at McDonald's versus paying after you finish eating elsewhere isn't really the point. The point is that even if Applebee's wanted to incorporate into its prices a price hike to offset non-paying delinquents, all they would do is increase the price on the menu to an appropriate level to make up the difference. Retail stores that experience significant theft no doubt have to take such things into account when setting their prices. In the case of hospitals this isn't what happens. Instead, they observe who is coming through the door, how much money they have, whether they have insurance and with what company, and then basically make up a price as they see fit. That is not equivalent to the Applebee's scenario where the higher price offsets their losses but is the same price for all customers. If you want to make an apples to apples comparison you would have to look at an Applebee's where they ask each customer personal questions and then make up a price on the spot based on the answers. How much do you want to bet that if a restaurant tried to pull that they would literally have the police on the scene demanding answers? A court order would shortly follow obliging them to stop, possibly on the grounds of unconstitutional discrimination. It's not rocket science; this wouldn't fly in any sector not supported by a powerful lobby guiding the legislation.

Not going to argue the charge side of things. But you did further expand on how the scenarios are not similar, so direct comparison doesn't work. It just happened that at the most basic level, Medical Care is usually paid for after the fact at this point, in particular "emergency care," which is a category which doesn't exist in any other service sector in such a form.

If you want "Emergency Services" rendered from any other service sector. You better either have one hell of a good SLA where they're "the responsible party" for resolution. Or you will need to otherwise be prepared pay through the nose, and be able to demonstrate the ability to pay for services even if the payment isn't required upfront.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #36 on: March 25, 2017, 12:37:47 PM »
Self-insurance must work not only to provide payment for services, it must also duplicate the price benefits due to the buying power of insurance companies.  Real example: the uninsured price for something like a single MRI can be $13,000 while the billable cost on insurance is around $1000 and the cost to the patient is $120. It's easier to self-insure against needed a $1000 MRI (or even a series of them), but when they cost 13 times as much, that is a much steeper threshold.

We talked about this before.  This discrepancy exists because of governmental interference and manipulation, not in spite of it.  The fact is there a reasonable price that a hospital is willing to take for an MRI that is much less than $13,000, just like my knee surgeon billed $20,000 and took payment of $1200.  We don't see that price because of the way that medicare/Medicaid reimbursement works.  The government pays a percentage of the going rate, which is set by complicated formulas, that are not subject to adjustment based on inconvenient facts like (what people would actually pay) but rather by the complex web of what that initial market price and other adjustments.  Many of those services end up being below cost after the formula works its way out.   

Medical service providers have learned that the only way they can get those prices up is by establishing absurd prices for their products up front.  What the insurance companies end up getting is not materially off from what the market price would be if people were asked to pay their own expenses and got a benefit from keeping their costs down.  You can expect that such prices would drop dramatically thereafter the exact same way they do for any for non-insured medical product you can buy.  Fear of the "free market" and life or death situations keeps us in the manipulation game and keeps all those prices artificially high.

Imagine how efficient a medical world could be if each doctor wasn't required to maintain staffs of multiple "insurance adjusters" (which is what their assistants really are) and spend a substantial chunk of their time on insurance and governmental issues.  Resolving the inefficiency of the true life or death situation or abusive medical costs situation would be far easier and more efficient than running the entire system in such a manipulated and parasitic way as we currently do.

In other news, the House's failure to pass reform legislation is laughable.  Dems made the correct call that they had everything to gain by staying out of the process.  There are not enough moderate Republicans to put in place a solution that can pass, which meant the resulting bill would either fail or be too conservative to be favored.  Of course, that means they missed any chance to sit down at the table and come up with a moderate reform.  I'm interested to see if Trump will carry out on his threat to keep Obamacare around and let it fail (as it was destined to do).  It's funny that while, anything Obama did to undermine Bush in Iraq (and he did a lot) didn't change the characterization that the mess was Bushes, that no matter how quickly Obamacare fails the media is going to claim its all Trump.  Blatant double standard coming, and you can watch it real time.

JoshCrow

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Re: Obamacare Repeal and Replacement
« Reply #37 on: March 25, 2017, 06:58:50 PM »
We don't see that price because of the way that medicare/Medicaid reimbursement works.  The government pays a percentage of the going rate, which is set by complicated formulas, that are not subject to adjustment based on inconvenient facts like (what people would actually pay) but rather by the complex web of what that initial market price and other adjustments.  Many of those services end up being below cost after the formula works its way out.   

Medical service providers have learned that the only way they can get those prices up is by establishing absurd prices for their products up front.  What the insurance companies end up getting is not materially off from what the market price would be if people were asked to pay their own expenses and got a benefit from keeping their costs down.  You can expect that such prices would drop dramatically thereafter the exact same way they do for any for non-insured medical product you can buy.  Fear of the "free market" and life or death situations keeps us in the manipulation game and keeps all those prices artificially high.

It's an interesting explanation, but why does this not occur in other countries with more intrusive government (single-payer scenarios)? Do they not use their own "complicated formulas"? I really think this is insurance company shenanigans, and that they are really the ones with the formulas that drive price discrepancies between chargemaster prices and billed amounts. I was just looking at a bill for a urine drug test where the charge was $7500 and I just stood there laughing at it for a minute (insurance paid $247 and I got billed for $125... incidentally it was supposed to be covered but the lab my physician used subcontracted out to this other lab and... well, it's a damned mess but I'm making phone calls).

My wife just underwent a C-section and I'll also state for the record how absurdly overcosted that is on paper compared to other countries that do the procedure just as well. In the end I'm bracing for $4k or so out of pocket after my insurance does its part, whereas that would be the uninsured total in some countries.
« Last Edit: March 25, 2017, 07:01:50 PM by JoshCrow »

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #38 on: March 25, 2017, 08:05:41 PM »
In other news, the House's failure to pass reform legislation is laughable.  Dems made the correct call that they had everything to gain by staying out of the process.  There are not enough moderate Republicans to put in place a solution that can pass, which meant the resulting bill would either fail or be too conservative to be favored.  Of course, that means they missed any chance to sit down at the table and come up with a moderate reform.  I'm interested to see if Trump will carry out on his threat to keep Obamacare around and let it fail (as it was destined to do).  It's funny that while, anything Obama did to undermine Bush in Iraq (and he did a lot) didn't change the characterization that the mess was Bushes, that no matter how quickly Obamacare fails the media is going to claim its all Trump.  Blatant double standard coming, and you can watch it real time.

This times a thousand.

Of course, this could be "sneaky, liberal Trump" in play as well. The Arch-Conservatives have had their moment in the sun on this issue, and they've failed utterly.

Now Trump can come in and "make a deal" with a more moderate/liberal slant to a final solution if he's so inclined. I wouldn't declare efforts to amend ObamaCare as being dead at this time.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #39 on: March 25, 2017, 08:56:50 PM »
The overcharging is two things

1) Collusion with the insurance companies - the high sticker price makes the insurance companies look like they are saving the consumers lots of money, when in reality almost the full value is paid by the insured individual as their deductible.  So the hospital claims 10x, insurance pays .5x but looks like it is paying 9x and then the insured pays 1x as their deductible.  So the insurance company looks needed; the hospital makes more with insurance than without; and insured feel like they are getting value.

2) Tax deduction of loses from uninsured.  The insurance company claims a loss of 10x when the uninsured can't pay, this is then deducted against taxes.  A large 'loss' deduction is more valuable than charging and being paid a reasonable amount.

Regarding medicaid and medicare - the elderly insurance pays a reasonable amount - and it is generally about the same amount that gets paid from insurance + deductible after transfers.  The coverage of the poor the government underpays in general.  The elderly prescription coverage the government drastically overpays.

Fenring

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Re: Obamacare Repeal and Replacement
« Reply #40 on: March 26, 2017, 12:07:29 AM »
The overcharging is two things

1) Collusion with the insurance companies - the high sticker price makes the insurance companies look like they are saving the consumers lots of money, when in reality almost the full value is paid by the insured individual as their deductible.  So the hospital claims 10x, insurance pays .5x but looks like it is paying 9x and then the insured pays 1x as their deductible.  So the insurance company looks needed; the hospital makes more with insurance than without; and insured feel like they are getting value.

I don't know that much in-depth about these matters. My first inclination in branding this activity would simply be "unconstitutional". But if your description is correct than it should in fact be a slam dunk under RICO as a criminal racket and conspiracy to commit fraud.

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2) Tax deduction of loses from uninsured.  The insurance company claims a loss of 10x when the uninsured can't pay, this is then deducted against taxes.  A large 'loss' deduction is more valuable than charging and being paid a reasonable amount.

Similarly, if this is correct it should be an easy case for tax fraud.

Why have no class action suits taken down this system yet?

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #41 on: March 26, 2017, 01:36:31 AM »
Fenring,

see this article on 'repricing fees', similar but not exactly what I'm describing.

http://wolfstreet.com/2014/09/16/how-hospitals-and-health-insurers-collude-to-keep-prices-high/

and see this paper that describes other ways that hospitals and insurers collude

https://www.law.uh.edu/hjhlp/volumes/Vol_14/Brown.pdf


Gaoics79

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Re: Obamacare Repeal and Replacement
« Reply #42 on: March 26, 2017, 08:29:42 AM »
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I really think this is insurance company shenanigans, and that they are really the ones with the formulas that drive price discrepancies between chargemaster prices and billed amounts. I was just looking at a bill for a urine drug test where the charge was $7500 and I just stood there laughing at it for a minute (insurance paid $247 and I got billed for $125...

Josh, that's why I always think about smart phones and first class airfare regarding this topic. Would Apple really charge $1,200 or whatever for a smart phone if their customers were actually paying up front? (as opposed to under multiyear contracts) Would an airline really charge $8,000 for a business class ticket (versus $1,200 for coach) if the majority of the people flying weren't charging it to someone else? Would they actually have enough customers to make such prices viable? Paying with someone else's money (or even one's own money, when the true cost is obscured by complicated cost defraying multiyear schemes) seems to have weird effects on retail "prices".

By the way, regarding your $7,500 urine drug test, while I don't have a bill for such a test in Canada, I do have a recent case where the cost of care for an elderly lady, including the cost of open reduction internal fixation surgery for a fractured knee, (with hardware insertion) inclusive of diagnostics (MRI, X-ray, etc...) came to around $10,000 CAD, physio and meds not included. That was the amount actually paid by the Provincial government. And FYI, orthopedic surgeons in Ontario make well north of $600,000 CAD.

When I see bills from the USA for medical care like the one you described all I can think is BS BS BS BS BS.
« Last Edit: March 26, 2017, 08:40:16 AM by jasonr »

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #43 on: March 26, 2017, 11:38:55 AM »
It's an interesting explanation, but why does this not occur in other countries with more intrusive government (single-payer scenarios)? Do they not use their own "complicated formulas"?

Why would it cause the same effect in a single payer scenario?  In a single payer scenario you don't have the multiple and independent lines of bill payers (ie government, collective an individual).  You have a single-payer and they pick the price they will pay (again, often without regard to the actual costs of the service). 

Our formula is related to the prevailing price of a service (what is supposed to be the market price).  The government finds it convenient to lower the rate of reimbursement when it needs to control costs, without regard to whether this results in fair compensation.  That's what causes an incentive to force the prevailing price ever higher (so that this declining reimbursement percentage results in a similar sized payment).  Keep in mind this is a problem with central government, they can not effectively monitor whether a fair price is being paid for every service at every location in the country so they have to pass one size fits all prescriptive rules to try and limit the ability of locals to manipulate them.  A problem that is completely fixed by having the consumer make the pricing decisions.

There isn't a market price in single payer system to manipulate.  Nor would their be a reason to manipulate it in a similar manner.

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I really think this is insurance company shenanigans, and that they are really the ones with the formulas that drive price discrepancies between chargemaster prices and billed amounts. I was just looking at a bill for a urine drug test where the charge was $7500 and I just stood there laughing at it for a minute (insurance paid $247 and I got billed for $125... incidentally it was supposed to be covered but the lab my physician used subcontracted out to this other lab and... well, it's a damned mess but I'm making phone calls).

Those bills directly reflect the fact that you as the customer only care about the $125 out of pocket.  You literally don't care what the starting number is do you? $3k, $7k, $20k if you always pay $125 what do you care?

The overcharging is two things

Overcharging is dozens of things, but its root is government manipulation of the pricing market.  You're misidentifying symptoms as causes in the below:

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1) Collusion with the insurance companies - the high sticker price makes the insurance companies look like they are saving the consumers lots of money, when in reality almost the full value is paid by the insured individual as their deductible.  So the hospital claims 10x, insurance pays .5x but looks like it is paying 9x and then the insured pays 1x as their deductible.  So the insurance company looks needed; the hospital makes more with insurance than without; and insured feel like they are getting value.

And why are they set up to do that?  The insurance company that is paying the bill makes more money if they pay less, why would they pay a third party a fee just to get to a higher price themselves (before you even consider the fee)?  Does that sound like a rational decision?  Do you really believe that some of the best predictors of financial results in the world (ie insurance companies) voluntarily create a system when they have higher expenses than they have to?

The system you're complaining about is the direct result of dozens of "micro-manipulations" from the government (and some big ones too). 

Your opinion piece cited to ERISA - ERISA is a bear of a compliance burden, with massive penalties that can apply for even technical breaches where there is no intent to harm.  Anyone that deals with ERISA makes inefficient decisions when they think they are technically required as the consequences of non-compliance are too great (e.g. even an innocent mistake (without any harm to someone) can require you disgorge the gross revenue and eat the costs, and if there is harm associate with a non-compliant decision (even one that looks like it was the best you could have done) you could be hit with triple damages as well).

Insurers would love to use non-hospital medical providers.  You know what they get labeled by the government regulators when they do?  Cut-rate services, dangerous "for profit" providers that are cutting corners with your health.  They get inspected and regulated if they use these less "safe" or non-traditional providers (and who can argue that a provider giving the "same" service for $500 that a hospital needs $5000 to do is not cutting corners?  It's almost a prima facie case).  So what do they do?  They find ways that are "approved" and then repeat them endlessly.

They get sued for "cutting corners" with your health care on any negative result, notwithstanding that some results will always be negative, and health insurance litigation is a major cost driver with the need for defensive medicine and ordering of tests that are not medically necessary.

Keep in mind the opinion piece you cited to is a doctor running a non-hospital practice complaining about what he thinks is unfair.  Hardly unbiased.  Follow the link in his opinion piece.  It looks to me like he has a bee in his bonnet about negotiation fees but that doesn't make him correct that they are the major cause of his problems.  I will point out though, that the medical industry is replete with "governmental work-arounds" and this certainly could be another one that some people do.  Another is the way, that medical groups have acquired testing groups in line with the expansion of the over testing regime to generate profits they used to get from their medical appointments but that have been squeezed.

I do agree that the whole system is being manipulated to make consumers believe that insurance is "vital" to protect from health care costs, when the truth is that they'd be better off if we chucked the whole parasitic insurance operation into the ocean (every dollar spent on administration is wasted health spending and our current model spends big on governmental, insurance company and doctor office administration).  Who is it that forces you to buy insurance at law again?  The government. 

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2) Tax deduction of loses from uninsured.  The insurance company claims a loss of 10x when the uninsured can't pay, this is then deducted against taxes.  A large 'loss' deduction is more valuable than charging and being paid a reasonable amount.

Tax deductions are deliberate governmental manipulation - trying to attribute them to private actors is beyond the pale.

The biggest problem in the industry is that employers get a tax deduction for providing insurance that employees don't get for purchasing it themselves.  Make the tax deduction personal, and let employers get a separate tax deduction equal to 20% of the value of any plans their employees obtain as result of the employer's negotiations.  Then you still incentivize employers to act but stop treating the self employed unfairly.

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Regarding medicaid and medicare - the elderly insurance pays a reasonable amount - and it is generally about the same amount that gets paid from insurance + deductible after transfers.  The coverage of the poor the government underpays in general.  The elderly prescription coverage the government drastically overpays.

Who cares what the elderly pay out of pocket?  I'd dispute its "reasonable" to have payments that are less than your costs, but I get you're looking at the absolute amount they are paying and not what they are getting in return.

But the issue with Medicaid and medicare is not what the consumers are paying, its what the government is paying.  The reimbursement formulas used are just about the single largest factor pushing medical price manipulation out there.  It's a known fact that reimbursement rates are so low that its becoming ever more difficult to find doctors willing to take such patients, particularly in big cities, so I don't where you think the rates work out to be about the same as what insurance pays generally?

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #44 on: March 26, 2017, 11:41:15 AM »
Josh, that's why I always think about smart phones and first class airfare regarding this topic. Would Apple really charge $1,200 or whatever for a smart phone if their customers were actually paying up front? (as opposed to under multiyear contracts) Would an airline really charge $8,000 for a business class ticket (versus $1,200 for coach) if the majority of the people flying weren't charging it to someone else?

I can answer that with one question.  If the law required employers to reimburse for a business class ticket, but allowed the employee to keep the change, would anyone ever fly in business again?

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #45 on: March 26, 2017, 11:48:08 AM »
Josh, that's why I always think about smart phones and first class airfare regarding this topic. Would Apple really charge $1,200 or whatever for a smart phone if their customers were actually paying up front? (as opposed to under multiyear contracts) Would an airline really charge $8,000 for a business class ticket (versus $1,200 for coach) if the majority of the people flying weren't charging it to someone else?

I can answer that with one question.  If the law required employers to reimburse for a business class ticket, but allowed the employee to keep the change, would anyone ever fly in business again?

Yes. More space, and better amenities are factors for a number of travelers. But you're also correct that fewer people would be using it all the same, as they'd be willing to endure the comparative discomforts of Coach, particularly on short flights, so they could pocket the difference.

Gaoics79

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Re: Obamacare Repeal and Replacement
« Reply #46 on: March 26, 2017, 01:59:00 PM »
I would be shocked if even half the people regularly flying business or first class pay for their ticket out of pocket.

Seriati

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Re: Obamacare Repeal and Replacement
« Reply #47 on: March 26, 2017, 02:03:56 PM »
TheDeamon, I'm a tall person with a decent income and for Jason's posited $6,800 I get to keep, there's no chance I'd take the business flight.  Would you really give up almost $7000 dollars to avoid sitting in a smaller uncomfortable seat?

TheDeamon

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Re: Obamacare Repeal and Replacement
« Reply #48 on: March 26, 2017, 02:43:39 PM »
TheDeamon, I'm a tall person with a decent income and for Jason's posited $6,800 I get to keep, there's no chance I'd take the business flight.  Would you really give up almost $7000 dollars to avoid sitting in a smaller uncomfortable seat?

If it's "no cost" to me on a trans-oceanic flight(particularly over the Pacific)? Yes I would. Now if we're talking a flight that lasts only a few hours, I'd be there in coach right beside you with all 6 feet of me.

LetterRip

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Re: Obamacare Repeal and Replacement
« Reply #49 on: March 26, 2017, 02:44:16 PM »
Seriati,

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You have a single-payer and they pick the price they will pay (again, often without regard to the actual costs of the service).

Actually it is generally negotiatied, and the negotiated prices reflect actual time and material estimates based on research.

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Overcharging is dozens of things, but its root is government manipulation of the pricing market.  You're misidentifying symptoms as causes in the below:

No, it is predominantly those two things I listed.  It is unbridled greed and gaming of the system.

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And why are they set up to do that?  The insurance company that is paying the bill makes more money if they pay less, why would they pay a third party a fee just to get to a higher price themselves (before you even consider the fee)?  Does that sound like a rational decision?  Do you really believe that some of the best predictors of financial results in the world (ie insurance companies) voluntarily create a system when they have higher expenses than they have to?

I think you misread or misunderstood.  Insurance companies make the most money when prices to uninsured are artificially high and when prices to the insured look high and they appear to be providing major value.  Do you want insurance that pays 33% of a bill or that appears to save you 90% of the bill?  So an artificially high price that they don't actually pay gives the consumer the 'wow my insurance saved me so much' and a disincentive to not be insured 'wow if I'm not insured it will cost me far too much'.

Under the current system - the insurance company appears to be paying 90% of your bill and you pay 10%, but actually only pays 33% of the bill and you are paying 66%.

So example

Hospital claimed price 10,000$
If insured - insurance company pays a net of 500$ (there might be 9000$ but 8500$ returns to the insurance company), insured pays deductible of 10% of 10,000$ = 1,000$.  So the hospital is making 1500$.

If uninsured - the hospital charges you 10,000$
you can't afford to pay - they deduct 10,000$ loss from taxes, giving a tax benefit equal to about 3,000$, 1,500$ better off than if you were insured (this is only true though as long as they have adequate number of insured that the claimed losses offset significant income)
you manage to pay full amount - they make 10,000$, 8,500$ more than if you were insured
you pay partial amount - they make whatever partial amount and deduct the rest, again dramatically better off than if you were insured.

So from the hospitals and insurance industry this is a win win.

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Tax deductions are deliberate governmental manipulation - trying to attribute them to private actors is beyond the pale.

I wasn't complaining about tax deductions.  I was talking about deliberately inflating costs to create a large deduction well beyond the cost of providing the care.  The tax deduction was created so that the 'must treat all that need care' wouldn't be burdensome and could be completely offset via tax deduction - what I find unreasonable is massive over inflation.

Your thesis appears to be that these manipulations are somehow the fault of the government - rather than the obvious deliberate abuses that they are.  Apparently in your reality businessmen never engage in shady practices to maximize profit and everything bad is due to wrong action of the government.  It truly impresses me the idealogical gymnastics you go through to blame the government and excuse the inexcusible behaviour of businesses.