Who'd a thunk it? Obamacare not repealed

[OTCW]

Brute makes a lot of good points.

A way to go after #2 may be to phase in/out optional insurance for lifestyle diseases.

You want to take care of yourself and have a slim chance of these diseases developing, you don't opt to purchase this supplemental insurance.

You want to eat like a 12 year old in a candy store, sit in the couch all day, smoke, drink, do drugs? That's fine because there is insurance available for you that covers a lot of the consequenses of behaving that way. It's subsidized now, but each year the subsidy goes down, so unless you can afford it, you'd be wise to make some changes in the next 10 to 15 years.

Most of the people that can't adapt by then will be dead of their ailments by then (as they would under any healthcare system), but the next generations would have plenty of incentive (staying alive and being financially solvent) to not go down the path of that lifestyle.

I also like Brute'approach to #1 - pay as you go with subsidies for the poor for day to day care.

#3 everyone gets/universal coverage.

[Lemon]

@brute and @OTCW

People in general are not going to make lifestyle changes for the additional economic reason of potentially expensive healthcare when there is the already very good incentive of not dying young(er) and not being out of breath mobilising between beer fridge and couch. People think it won't happen to them until it does. Bankrupting them won't make the situation any better.

'Respiratory disease' given pneumonia and flu are taken out are also lifestyle COPD or occupational for rather a large chunk.

MRIs are also not day to day things?! Maybe that is a US thing...

Living in a single provider system I must say I prefer it in general. I like the equity that comes from it being really expensive to go private and 'que jump' other than for pretty routine things. Not that it is currently working particularly well and without the British ability to que forever I don't thing it would work at all.

[OTCW]

Doesn't matter anyway. In this country we will always have a broken healthcare system like we have now that was instituted by one party. The other party will come into power with promises to fix it. The fix will be an equally broken system which will give rise to the other party again... rinse and repeat. Too much polarization and posturing to enact a system to actually make people healthier. It's easier to squabble and scrap over who pays for it and call that reform.

[halfmoon]

As long as we're going to pick and choose what parts of health care we want to subsidize, I'd like to choose not to pay for maternity costs because I'll never be pregnant or black lung because I didn't choose to be a coal miner. I'm certainly not paying for any consequences of using recreational drugs or alcohol (though I do love wine; that's a tough one), sports injuries or any of 7wb5's health care because her BMI is too high and she wanders around in dangerous neighborhoods pulling a wagon. For that matter: I'd prefer not to pay property taxes for schools when I never produced a child and believe that overpopulation is the number one world crisis.

Applying a judgment filter to basic human needs is a dicey affair. How about if we take care of each other while applying social/educational pressure in healthy directions? Of course it will be expensive, but I don't mind paying taxes for universal health care. I don't even mind (too much) that my insurance premiums doubled under Obamacare. I do mind tax cuts for the wealthy funded by health care cuts for the poor. Really??

From each according to his abilities, to each according to his needs. I'm not the first person to say that.

[OTCW]

I don't even mind (too much) that my insurance premiums doubled under Obamacare. I do mind tax cuts for the wealthy funded by health care cuts for the poor.

Better to find something in the middle. Doubt we'll ever get there though.

By the way, politics seem to always color things as rich vs poor. I'm neither, so as long as we get to debate the subject on message boards, I'd prefer the solution revolve around something that benefits me instead. Other opinions may vary.

[IlliniDave]

@IlliniDave: Thank you for clarifying. I had thought you meant lifetime limits (where insurance company payments truly are capped) rather than higher deductible insurance. I think by and large we agree on most points. I would still say that universal high-deductible catastrophic insurance ends up costing similar to and therefore either gradually (leading to lots of death) or quickly becoming more comprehensive single-payer due the reasons brute has outlined.

Well, no matter what kind of system we have there will be lots of death. Humans have a 100% mortality rate and all the insurance in the world won't change that.

I guess I don't see the inevitability , maybe you could explain? I don't see a system that pigeon-holes based on BRUTEs dissection of maladies, rather one that just works on dollars without passing judgement on people or categorizing illnesses, e.g., some hypothetical program that won't cover type II diabetes or allow people who consume alcohol to enroll or whatever.

Much of my family is old enough I an getting a good look at Medicare. Medicare is more than catastrophic coverage, so we're talking about a scaled back version of Medicare for people age 0-64. I don't have numbers, but most individuals incur most of their lifetime medical costs in their last couple years of life, and that mostly happens to people on Medicare. So we've already got a system place where a single payer (the taxpayers) picks up the lion's share of the expenses and people participating have the option of buying supplemental coverage to fill in the gap. And it's not that bad, although it projects to need more funding in the future. The "universal catastrophic" I'm talking about, based on dollars not illness type, should cost a fraction per benefit-receiving participant annually of what Medicare does simply because the insured are younger as a group.

In the end the total cost is always going to wind up being similar irrespective of insurance mechanism because the cost is pretty much the cost. It's only a matter of pooling and smoothing it out over people's lifetimes. However, having a system where providers are always paid promptly and don't have to pass on the written-off costs of people that don't pay (and the cost of delayed payment and failed collections) to future customers that do pay should help a little in lowering the price of medical services. I've seen direct evidence where providers bill 4X-5X the actual cost they can perform services at with a reasonable profit.

From there the next job is looking at how to lower per service costs across the whole industry. For the gov't (both federal and state) it would require massive unwinding and retooling of regulations to further lower costs and allow things like cooperatives a fair chance to get a foothold in the marketplace. Cooperatives are interesting because they essentially combine insurance, group discounting, and the more routine end of healthcare service spectrum. You pay a monthly membership fee which covers doctor visits within the coop (24-7 availability), including tests and lab work, get discounted prescriptions directly from them and such. Something like that pairs very well with a catastrophic/high deductible insurance plan. Problem is there are so many regulations put in place assuming the current commercial insurance model that coops can't optimally exit in many states. I think all of that stuff was supposed to be part of second and third phases Trump alluded to, but the phase 1 was so bad the discussion hasn't moved on to that.

[ThisDinosaur]

So, assuming the next version of US health policy is your worst nightmare, what do you plan to do? I don't know how to budget for health insurance post-FI.

[George the original one]

Assume insurance rates will increase 3x annual inflation (partly due to my increasing age and partly due to system inefficiency) and be prepared to reduce coverage as needed. Continue to consider emigration as a viable strategy.

[Dragline]

Medicare is more than catastrophic coverage, so we're talking about a scaled back version of Medicare for people age 0-64. I don't have numbers, but most individuals incur most of their lifetime medical costs in their last couple years of life, and that mostly happens to people on Medicare. So we've already got a system place where a single payer (the taxpayers) picks up the lion's share of the expenses and people participating have the option of buying supplemental coverage to fill in the gap. And it's not that bad, although it projects to need more funding in the future. The "universal catastrophic" I'm talking about, based on dollars not illness type, should cost a fraction per benefit-receiving participant annually of what Medicare does simply because the insured are younger as a group.

In the end the total cost is always going to wind up being similar irrespective of insurance mechanism because the cost is pretty much the cost. It's only a matter of pooling and smoothing it out over people's lifetimes.

Correct -- we have already had single-payer government run healthcare for most of our lifetimes. Called Medicare. It just only covered old people and the destitute/bankrupt (Medicaid). There is no practical reason it could not be expanded to cover everyone -- just complications due to employer-sponsored insurance and other overlapping/duplicative mechanisms like the VA.

The debate should be about whether we keep Medicare or dump it. And that debate is largely over, as a majority of elected officials want to keep Medicare, which almost everyone is going to end up on anyway. The rest is just window dressing and theatrics about alleged free markets that do not exist in this sector due to the nature of the product, which engenders unlimited demand from a small number of changing people.

The cost of delivering healthcare is really largely a separate problem that should be dealt with largely separately, by analyzing and adopting the best practices of what other countries are already doing. Most likely, we need more doctors (make certification requirements cheaper and easier), less hospitalization and a better handle on the costs of drugs and medical devices. (We already have tort reform in many states and it has not done very much, but we can have more of that too just to take the idea off the table.)

And then we'll start making the Soylent Green out of the old people to fund the system.

[BRUTE]

of course all humans want free stuff. there just isn't enough to go around. and that is, as brute suggested above, due to the rate of high-risk, high-cost conditions.

[IlliniDave]

So, assuming the next version of US health policy is your worst nightmare, what do you plan to do? I don't know how to budget for health insurance post-FI.

Not sure if this addressed to someone specific.

The worst nightmare looking just at myself is after a lifetime of participating in risk pools as a largely healthy individual, to then be excluded from them when I am most vulnerable (when it's time for the net flow of dollars to reverse direction).

In my own case it's part of the reason why I'm guilty of financial overkill. You could say my last-ditch backup plan is to self insure until I'm destitute, after which point I'll either live without medical care or someone else will have to pay for it. I've been FI for a while predicated on a spending rate higher than what most ERE-ers aim for. The largest component of my for-planning retirement budget is for medical-related expenses. I also hope to drive financial assets up to 50X expected/planned withdrawals to fund that spending plan. That gives me room to approximately triple annual medical expenses and still stay around a 3-3.5% annual withdrawal rate. If that's not enough, dial back lifestyle spending and start spending down the stash.

In terms of how to plan for it, it's difficult to say what's best for someone else. What I did is look at the ACA exchage for the place I intended to live and priced an HSA-eligible Bronze Plan. I added the unsubsidized cost to my retirement spending plan, as well as the entire annual out of pocket max. Both are conservative assumptions. I'll have 10 years before Medicare, and to keep things simple I just left the same cost figure in my spending plan for Medicare age onward. Then on top of that (as described in the paragraph above) I put a lot of margin into "my number" so I have wiggle room beyond that.

[IlliniDave]

...

The cost of delivering healthcare is really largely a separate problem that should be dealt with largely separately ...

And then we'll start making the Soylent Green out of the old people to fund the system.

I agree there are two separate issues at play (possibly the reason for the red teams initial multi-phased approach). You hit on a couple of good ideas that could be tossed in there with thinking about things like the coop model (maybe there are ex-US examples of these implemented on a wider scale than here in the US). There's probably room for a Vanguard-like entities (perform services at cost) to help. I think there's room for a lot of healthcare to be delivered by people without the rigorous training physicians are currently put through (you don't need to put a tank gunner through SEAL training). And containing costs in the education system would help too. For whatever reason our culture has taken sort of a "cost is no object" approach to medicine and higher education. Very hard to unwind that without appearing harsh and cold-hearted. And people should be expected to take more ownership of their own health. Also something that sounds harsh and cold-hearted. Make real PT a core part of education from grade school to post-doc.

[7Wannabe5]

Another factor to consider is the extent to which services which might have formerly been provided by family or helpful community member are going to increasingly be packaged into expensive products that will qualify for insurance or subsidy coverage. For instance, if an elderly or morbidly obese or otherwise disabled person falls and needs help getting up, it is currently standard operating procedure to call the non-emergency number for the local fire department and request a team for aided lift. If you slip on the sidewalk as you attempt to get into your Uber ride, your driver can't pick you up without risking liability. Currently there are private fee-based providers of services such as transportation/chaperone to outpatient medical procedures such as colonoscopy, but I suspect these may increasingly become covered or subsidized in some manner as Baby Boomers age and their busy family members (or Gen-X girlfriends) do not want to be bothered.

[ThisDinosaur]

So, assuming the next version of US health policy is your worst nightmare, what do you plan to do? I don't know how to budget for health insurance post-FI.

Not sure if this addressed to someone specific.

No, it was a general question to anyone. This thread is mostly a debate about what Society *should* do. I have plenty of opinions on that as well, but elected officials don't listen to me more than they listen to lobbyists. So, I assume whatever changes happen will not be my first choice. So, im interested in any practical, actionable insight into what an early retiree should do to protect against medical bankruptcy.

[Ego]

So, im interested in any practical, actionable insight into what an early retiree should do to protect against medical bankruptcy.

Well, one of the unexpected consequences of Obamacare was the significant decline in the divorce rate among middle-aged couples in the states where Medicaid was expanded. This still remains a defensive strategy for married couples where Medicaid was not expanded.

http://www.npr.org/2017/03/08/519170657 ... nd-divorce

VEDANTAM: Well, we've known for a while that there is a relationship between Medicaid and divorce. That's because Medicaid traditionally has thought of families as a unit when calculating someone's eligibility for the program. Slusky asked me to think about a scenario. Let's say you have a middle-aged couple in their 50s. They've saved a nice amount of money for their retirement. One spouse suddenly gets diagnosed with early-stage dementia. The couple know they're going to have lots of medical costs. If the family spends down their savings on medical care until they get poor enough to qualify for Medicaid, they'd have nothing left over for retirement. So a financial counselor might advise them to follow another course of action. Here's Slusky again.

SLUSKY: You could get divorced. We could split your assets. And then the government would look at each of you individually. And once the sicker spouse had spent through his or her share of the assets, that person would qualify for Medicaid. And the other one will be able to maintain the assets to provide for in retirement.

Also, I know one (and maybe two) healthy spouses who took classes and became a Certified Home Health Aide. They are then paid by Medicaid (and eventually Medicare if divorced) to take care of their ex-spouse.

https://www.payingforseniorcare.com/lon ... ivers.html

[7Wannabe5]

@ThisDinosaur: Figure out a best-case compromise budget between current and 1940s (post antibiotics and vaccines) and 1840s (willow bark and exercise outdoors) health practice, products and services for yourself and then stick with it. Also might consider having legal document refusing extreme treatment tattooed on to butt. Just brainstorming here.

[classical_Liberal]

...

[Laura Ingalls]

So, assuming the next version of US health policy is your worst nightmare, what do you plan to do? I don't know how to budget for health insurance post-FI.

Not sure if this addressed to someone specific.

The worst nightmare looking just at myself is after a lifetime of participating in risk pools as a largely healthy individual, to then be excluded from them when I am most vulnerable (when it's time for the net flow of dollars to reverse direction).

In my own case it's part of the reason why I'm guilty of financial overkill. You could say my last-ditch backup plan is to self insure until I'm destitute, after which point I'll either live without medical care or someone else will have to pay for it. I've been FI for a while predicated on a spending rate higher than what most ERE-ers aim for. The largest component of my for-planning retirement budget is for medical-related expenses. I also hope to drive financial assets up to 50X expected/planned withdrawals to fund that spending plan. That gives me room to approximately triple annual medical expenses and still stay around a 3-3.5% annual withdrawal rate. If that's not enough, dial back lifestyle spending and start spending down the stash.

In terms of how to plan for it, it's difficult to say what's best for someone else. What I did is look at the ACA exchage for the place I intended to live and priced an HSA-eligible Bronze Plan. I added the unsubsidized cost to my retirement spending plan, as well as the entire annual out of pocket max. Both are conservative assumptions. I'll have 10 years before Medicare, and to keep things simple I just left the same cost figure in my spending plan for Medicare age onward. Then on top of that (as described in the paragraph above) I put a lot of margin into "my number" so I have wiggle room beyond that.

You know your biggest risk is that you will be either dead or too ill to enjoy retirement with your very belt and suspenders approach. I totally respect but don't adhere to especially since I lost my dad.

[IlliniDave]

You know your biggest risk is that you will be either dead or too ill to enjoy retirement with your very belt and suspenders approach. I totally respect but don't adhere to especially since I lost my dad.

Very sorry about your dad. I don't know the details of course, but the implication is that he passed while still on the young side.

I appreciate your concern, but have to disagree with your assessment of my risk.

-I'm 52, healthy, and 793 days from ER (~26 months if I did the math right). The odds are overwhelmingly in my favor to make it that long with my health intact. I am an optimist and have made a deliberate choice to bet on life rather than death in every decision I've made except the one to buy life insurance.

-Even if something does happen to me this year or next, my belt and suspenders approach means one child gets the belt and the other gets the suspenders. Everyone's pants stay up! And if it happens that way I'll have no regrets. I will have lived the last years of my life doing what I wanted to do. I don't seek contentment, I make it. Missing a hiking trip to Belize or whatever wonderfulness the people who sell experiences want to scare me into thinking I'll regret on my death bed doesn't move the needle.

Again, sorry about your dad, and I get the YOLO-now approach. Nothing wrong with it in principle, it just doesn't fit with my values.

[ThisDinosaur]

http://obamacarefacts.com/out-of-pocket ... lth-plans/

Even with ACA still in place, max out of pocket rose again this year to $14,300. Which does not include premiums. I haven't been able to find the maximum premium you could be charged with a preexisting condition. My family is healthy at the moment. But if any of us ever get sick, our rates will go up when its time to renew or switch plans. That is why insuring preexisting conditions is an issue, even for healthy payers. Catastrophes aren't necessarily confined to a single calendar year.

@ThisDinosaur: Figure out a best-case compromise budget between current and 1940s (post antibiotics and vaccines) and 1840s (willow bark and exercise outdoors) health practice, products and services for yourself and then stick with it. Also might consider having legal document refusing extreme treatment tattooed on to butt. Just brainstorming here.

That is probably the most ERE answer we're gonna get. Broke your leg? Stay off it for a few. If your thigh is purple, you don't need an X ray. Pissing blood? Wait until you can't pee at all before bicycling to the clinic.

@Ego, those stories are depressing AF.