Who'd a thunk it? Obamacare not repealed

[Tyler9000]

From my understanding, that tweet is extremely misleading. Note the fine print "at the time of application". People with those conditions will not have their rates on existing insurance hiked one penny. But people who only sign up for insurance after learning they have those conditions will have to pay that much more (or get help through a high risk pool). Big difference.

I have no problem with continuous coverage requirements to maintain the normal rates. IMHO, the real issue is whether the normal rates are portable when you switch insurance as long as you maintain continuous coverage. Previous proposals accounted for this, but I have yet to see how it's handled in the new bill.

[bryan]

why would they be portable? I would strongly assume NO.

[Tyler9000]

In the original Ryan plan, people could get the normal pooled rate in any new plan as long as they maintained continuous coverage from the old one. But if they allowed their insurance to lapse, all bets are off and insurance companies could charge them more. It's the free-market alternative to the insurance mandate -- carrot vs stick. But like I said, we'll see if that changed.

[Tyler9000]

Here's Ryan's explanation:

http://www.speaker.gov/general/verified ... conditions

"Even if a state asks for and is granted a waiver, no person may be priced based on health status if they have maintained continuous coverage."

And here's a good opposing opinion:

https://www.brookings.edu/blog/up-front ... -premiums/

They claim that even though continuous coverage protections will remain for all health insurance customers, healthy people will be incentivized to opt out of the community rated pools and apply in the new personally-rated pools to get cheaper coverage. So even though people who maintain continuous coverage will still keep the same rating, prices will go up.

That said, even the negative article admits at the end that there are simple ways for states who opt out to prevent this from happening. I'm not happy about the added uncertainty, but we won't know the final impact until they pass the bill. Where have I heard that before?

[BRUTE]

any change is progress at this point

[Dragline]

Um,no. That's never been true about anything with a modicum of complexity.

But I agree they should go big or go home. If they really believe what they have been saying the past 8 years, they should just repeal it and not replace it with another government-regulated insurance system such as they have proposed. Why waste everybody's time when repeal will supposedly restore all of what was right and good in healthcare circa 2007 and put us all in the land of milk and honey?

Or maybe that stuff was all just lies -- err, rhetoric, I mean. Yeah, that's the ticket.

[IlliniDave]

I hate to break it to you but Paul Ryan, like many politicians before him, lies a lot. If he wanted to have an idea about impact, he could wait until the draft is scored by the CBO.

I think they know what the impact is going to be--at best a return to the good old days pre-ACA after a glorious flame out. They keep getting kicked for not having repealed ACA. One half kicks them because they expect them to honor campaign "promises", the other half in an attempt to humiliate them. They appear not to have the wherewithal to repeal it; so they are set to slash the tires and pour sand into the oil pan, then stand back and laugh.

Looking solely at the insurance aspect of it and holding everything else constant, there's no way to lower premiums for a portion of the population without forcing people in the aggregate to pay even more for medical care than we are today. I don't see any way around this plan leaving some of the most vulnerable people hung out to dry--the "plan" being to look at people with real medical issues and tell them, "Good luck, you're pretty much on your own until you're dead broke or you reach the magic age of 65, whichever comes first."

[BRUTE]

Um,no. That's never been true about anything with a modicum of complexity.

sounds like status quo bias to brute. brute has some hopes for AHCA. not because Trump's administration is full of geniuses, but because ACA was just a fucked up band aid on a fucked up system to begin with.

circa 2007, healthcare was not a free market. health care has been ruined by the government since what, the 30s?

[Dragline]

Well, you seem to be assuming that something magical would happen if health care was a "free market" (cough, never really existed fantasy land of rational computer-brain patients who are all-knowing about exactly what they need and can never be fooled), and that cost is the only issue that means anything. There are reasons that no developed country relies on a "free market" system for healthcare -- see state of health care industry in U.S. circa 1865 - 1905. We've been there before. It wasn't good. In fact, it really sucked balls. Why go there again? So we can suck more balls?

Which gets to the point: How does government "ruin" something that was just crappy to begin with? Other than via the magic of "Golden Era" fallacies that only point to non-existent Golden Eras? Make America Drink Poison Fools Gold Elixirs again, I suppose.

But what's on the table offers nothing "free market" and nothing even useful -- its just a poorly constructed Frankenstein version of Obamacare with some of its pieces missing and others glued on (or a rearrangment of the deck chairs if you prefer), which only purpose at this point is to show that "something's happening" in the kabuki theater.

[Spartan_Warrior]

"which only purpose at this point is to show that "something's happening" in the kabuki theater."

Well, not quite the only purpose. It also serves, of course, as a further consolidation of wealth.

https://reportingsandiego.com/2017/03/0 ... of-wealth/

(Actually, I'd agree with your statement to the extent that the entire kabuki theater has the purpose of concealing the ongoing consolidation of wealth.)

[jennypenny]

It's not going to pass the Senate in its current form, so I'm not getting too worked up over specific changes yet.

[ThisDinosaur]

There are reasons that no developed country relies on a "free market" system for healthcare -- see state of health care industry in U.S. circa 1865 - 1905. We've been there before. It wasn't good.

What was the state of healthcare industry at that time? Some things I know: no standardized medical training (you could either go to Harvard Med or apprentice a physician; equal standing), low tech, and unregulated snake oil.

This is why I'm agnostic on the Libertarian vs. Socialist solutions. A free market for MRIs, open heart surgery, or anything else expensive would either mean no market for those things or only the uber-wealthy could afford them. It just seems more efficient to pool the entire country under a single payer given that a)shit's expensive, b)none of us knows if we will need these services or c)which services we'll need, if any. Flip side is that that removes skin in the game. Which leads to over-utilization because, if its "free", why not abuse it?

[IlliniDave]

Flip side is that that removes skin in the game. Which leads to over-utilization because, if its "free", why not abuse it?

Most of us would have skin in the game because the government spends our money! It would take a pretty noticeable tax hike to pull that off. The total bill would be north of $3T/year. Even the doofuses in DC can't throw that sort of money around casually.

[Spartan_Warrior]

Seems to me a personal deductible locked at something like 2% of one's reported income, and perhaps some similarly nominal copay for office visits, would be a perfectly fair way of solving the skin in the game/overusage problem in a single payer system. Incidentally, Medicare already uses many of the same mechanisms used by private insurers to prevent overutilization, including co-payments, deductibles, premiums, coverage requirements, etc. Skin in the game is not a real issue in single payer care, it's just another talking point.

[jennypenny]

Considering the changing needs of healthcare (hello big pharma) and the looming health crises related to lifestyle, doesn't it seem like they are fighting the last war by focusing on insurance? Neither ACA nor AHCA addressed lowering costs. I find it almost absurd to talk about potential insurance costs of $50K/yr without first talking about *why* healthcare costs that much in the first place. Even a single-payer system wouldn't directly address that. We need to have some uncomfortable discussions about whether healthcare should be a for-profit enterprise.

[bryan]

I agree with you, but careful with wording like:
> whether healthcare should be a for-profit enterprise

Capitalism is not best for some circumstances and it needs to have some checks lest it turn into dystopia.. but I like the innovation, dynamic/complex world it brings about. Of course I am open to alternatives that don't kill creativity, innovation, etc. Hard to tell if medical research would be better/worse without profit-motive. Obviously we've already put some limits on medical research (human trials, etc) that we think are for the common good..

[Campitor]

This is going to be a bit long winded so bear with me.

A single payer system with co-pays to stop abuses will not make healthcare affordable or more widely available. There are a finite number of hospitals with a finite number of staff which throttles the number of visits/surgeries that can be processed per day. The cost of training hospital staff is expensive and time consuming; many years of education needed with nurses and doctors paying the greatest sacrifices in time and money.

The lack of some free market principles in the healthcare industry creates a culture that does little to reduce the cost of educating medical professionals, building new healthcare facilities, or reducing the cost of bringing new technologies or drugs to market. All of this produces artificial scarcity which increases cost.

Medical institutions also have no visible accountability in regards to how they calculate expenses or if they are using their dollars efficiently or wisely. The culture is “patient care comes first” with secondary regard to fiscal analysis which must be done to help manage scarce resources. The "patient care" mantra is often used to distract from inefficient and costly behavior.

Washington in the meanwhile believes it can manage an enterprise as complicated as healthcare without any negative impacts or incentives. They gladly take lobbyist money and pad the bureaucracies to pander for votes which drive up the cost of healthcare even more. They ignorantly stumble about like bulls in a china shop.

What would I do? First I would allow cross state insurance coverage so patients can get high cost outpatient one-time procedures done in any state of their choosing in order to contain cost - take advantage of interstate arbitrage. I would make hospitals publish the costs of their procedures. I would consult as many physicians, economist, and educators as possible to determine how the cost of a medical education can be reduced. And their has to be liability reform to drive down the cost of malpractice insurance which erodes the desire to enter medicine or removes incentives to perform high risk but needed procedures whose outcome is unsure. There should be a single payer system for those with no insurance. And yes - the system should be paid in by all - young and old. Today’s 18yr old fatty, chain smoking teen, or adventure seeking young adult will be tomorrow’s triple bypass patient, lung cancer victim, or torn meniscus/shoulder arthritis outpatient visitor.

[BRUTE]

Well, you seem to be assuming that something magical would happen if health care was a "free market"

it would be more moral not to steal money. that's a start.

[IlliniDave]

Considering the changing needs of healthcare (hello big pharma) and the looming health crises related to lifestyle, doesn't it seem like they are fighting the last war by focusing on insurance? Neither ACA nor AHCA addressed lowering costs. I find it almost absurd to talk about potential insurance costs of $50K/yr without first talking about *why* healthcare costs that much in the first place. Even a single-payer system wouldn't directly address that. We need to have some uncomfortable discussions about whether healthcare should be a for-profit enterprise.

Ah yes, the elephant in the room ...

Actually one of the contributors to the high cost is the high rate of people defaulting on their medical bills. An anecdote: I have a colleague at work (who is basically a "freedom caucus" guy--will be relevant below). His son/DIL wound up temporarily without insurance during a move/job transition. His grandson was born premature during that time. By the time the kid was discharged from NICU the bill was $625,000 (an aside to illustrate the crazy ballooning of healthcare costs, my youngest daughter was a premie and actually spent a couple days longer in NICU than the aforementioned kid and the total bill for her was $34,000, 1992 versus 2006). The young couple couldn't pay. The hospital opted to just walk away because they didn't want to lose even more money in pointless collections/lawsuits. The hospital (for-profit) would have to recoup those costs by jacking up the prices they charged to every other person that was admitted. That scenario plays itself out over and over. Setting aside money to pay for medical care at the time of service should largely put a stop to that.

The other discussion that needs to be had is reminding everyone of the distinction between medical insurance an pre-paid healthcare plans. I was talking with the same guy at work and he was arguing along the lines of: "why should my son who's young and healthy pay $6,000 a year in premiums on a plan that's not going to pay anything until after they eat $13,000 in bills?! That's like not having insurance at all." So I asked him, "What if your next grandchild is a preemie too?" People buy health insurance and look at it in terms of, "What's it going to pay me right away?" The same people don't ask that about their homeowners/renters/auto/term life insurance. You don't carry the insurance to make a profit. You carry it because you never know when Murphy is going to take a dump on you.

I saw some statistics yesterday from 2013. At the time healthcare costs in the US were more than $10,000 per person, with a total of about $3.3T I'd guess by now it is pushing $4T. Half of that is incurred by 5% of the population (the average in that 5% is something like $185,000 each). I don't know what percentage of us become part of that 5% at some point in our lives. I'd guess it is pretty high. If we strip those people from the the insurance pool, yeah, our premiums will go down, but we'll just wind up paying even more for the bills of that 5% in some other way.

My same friend was arguing that healthcare isn't a right because it isn't in the Bill of Rights or anywhere else in the constitution. My counter was that life, liberty, and the pursuit of happiness, aren't in the Bill of Rights; do you think they are rights? He said of course they are, they are in the Declaration of Independence. So I asked him how do you separate the right to life from medical care?

It's certainly not an easy problem, and is a multi-faceted one. I think we should have tried to tackle the cost side of it first before the R&R of ACA. People in the US love to tell lurid anecdotal stories about how utterly awful healthcare is in places like Canada and northern/western Europe (other relatively wealthy nations), but to me they never come armed with any sort of evidence. Seems like many of those other countries have figured out how to achieve substantially equal or sometimes superior overall results for less money with less economy of scale. I think the only thing I saw the US was somewhat better at was cancer treatment. Everywhere else we were mid pack except cost. We weren't leading the pack in hospital beds or doctors per capita, but we do conduct considerably more MRIs and CT-scans, at a much higher unit cost. So I think part of the problem is the persistence of some myth that partially taxpayer-funded healthcare leads to practitioners dressed like wizards treating everything with a bowl of leeches. We need to scour the world for ideas and implement the ones we can. Unless we want to unwind all of the regulations (federal, state and local) surrounding the medical services industry, the idea that the free market will produce a panacea system is almost silly. It will only produce the most profitable one it can given the regulations.

I guess it all comes down to relative morality. It may be immoral for the gov't to take my money from me (push-comes-to-shove, at the point of a gun) and give it to someone else, but it's also seems immoral to me to let sick people languish because they are only of median or somewhat below median wealth in the wealthiest society on the planet, or for hospitals to charge me for services provided to someone else, or for people to say, "Hey, I'll save a buck today and skip insurance--even if I win the crap lottery, I can just go to the hospital and they'll take care of me and if I can't pay the bill I'll declare bankruptcy and let 'em add it to the bill of the next sucker who comes in with insurance."

[Chad]

@IlliniDave
One thing your long explanation points out is the complexity of this issue. Even your long post, through no fault of your own, doesn't even scratch the surface of the moving parts. Thus, there is no easily definable solution.

I have come around to creating a single payer system. The costs vs results are all in favor of it.

Concerning Jenny's point. I do think we really need to examine the idea that some portion of medical services shouldn't be for profit. My macro argument would be that most healthcare services can not function as a free market no matter what we do. There are numerous reasons for this, such as most people don't have enough transactions to make judgments, most people don't have the ability/knowledge to make these judgments given the complexity of healthcare, many healthcare services happen without planning, no way to judge cost, etc. The typical forces that make a free market efficient don't exist.