You had such a good point, until you scuttled it all by going pointlessly political and partisan. There is a problem here, but it's utterly without a political identity. The bottom line is that we need price controls, and something like an NHS; the current model is just utterly broken. Nothing the R's or D's are saying will change it either, and laying it at one person's feet is pathetic and wrongheaded.
Except that I despise Hillary, it's just that despising her doesn't make me lose my rationality. It's something I wish I could say for many others here and elsewhere.
Free market + insurance version of healthcare. How much of my money(my premiums) are you willing to spend to control your diabetes, risk of heart-attack, or cure your cancer? I'll give you a hint, all of it.
Price controls? We already have doctors willing to pull out of medicaid because it doesn't cover their costs. Price controls just reduce supply and give you situations like in China where medical scalpers sell places in line for doctor visits at up to $500 a pop.
I'm in the same boat. To cover my wife and child on top of my employee portion of insurance, I'm at ~$1200 a month. It's more than my car and rent. Going through a long drawn out process of lowering my spending income down ~$15k a year only to move to ~20k with 2017 increases.
I'm with m_gray though. Either party doesn't matter to me. Not a fan of Hillary or Trump. Just want someone to actually make a difference that doesn't include a higher cost to my wallet every time they enact something.
Normalized pricing based on income with transparency on procedures and tests. Deductible + premiums + out of pocket should add up to no more than 8-10% of my income.
And out of pocket should be some fraction of real price based on income. It should always cost 3x to go to a hospital than a doctors office its just the amount should vary based on income.
Let private insurance compete in the supplemental market. And offer public option on exchange.
It would be interesting to know how many of these people are from states that didn't expand Medicaid. Of the two mentioned in the article, one is from Georgia (didn't expand Medicaid) and the other is a customer of someone in DC (could be from DC, Maryland or Virginia; the first two expanded Medicaid, but Virginia didn't).
Why? If you would have qualified for Medicaid, had it expanded, you don't have to pay the penalty anyway - the government doesn't punish you because your state didn't expand Medicaid.
Only if you qualify for the subsidized private coverage (which poor people do not) do you have to pay a penalty for not getting health insurance. Frankly that part of the law is a little insane, even if it is because it wasn't implemented as intended; if you don't have any income, then you have to pay the full price for coverage on the exchange, no subsidies. Your income has to meet a certain minimum level to qualify for subsidies - the intent was that below that level, you'd get Medicaid.
I just heard a former Clinton lawyer on t.v talking about all Wikileaks emails, and trying to say something nice about the Clinton's and Bill's 501c3 corporation.
I perked up when he talked about how his son just got insurance. His son is 26, and his yearly premium is $4000.00
His deductible is $3500.00
He pays $7500 before insurance helps out. wow?
I was a former supporter of the Health Care Act. There's a lot in the bill that's good. That said, Insurance companies ruined it. They should be lynched.
I don't know how to fix it. It's an embarrassing mess.
The public exchanges are a slap in the face. Companies like walmart expect the government to pay for healthcare. The poor wanted socialized healthcare to make WalMart et al pay for it. The poor desire the destruction of the insurance industry, and what they got was what they already had only with IRS penalties.
The irony is that we're all, WalMart included, going down the same chute into the same incinerator. Between costly wars and wasted money on Insurance and healthcare, we're just killing ourselves as a country.
Those expensive wars are fought with expensive weapons, which are mostly still made here by American companies. Those soldiers fighting those wars are citizens with full time jobs for many years.
Healthcare is another thing that's made here and someone is getting paid when we pay an efficient amount or simply overpay.
So killing ourselves is all a matter of perspective, some people are doing quite well.
The broken window fallacy simply demonstrates that there is an opportunity cost to going to war, not that it's unsustainable. Depressingly it actually is pretty sustainable for the American economy.
There's also an enormous opportunity cost to not spending money on young men in the military too - and just dumping them on the street, with a job market that cannot absorb all of them.
The US actually already did that once. In 2003. A large group of young, heavily armed men who have really only been trained how to kill were suddenly without income or purpose.
That story demonstrated the opportunity cost of suddenly packing up the military and sending them all home without a job.
poor? I work for a small company that offers horrible insurance because almost everyone 50-60+. We have 4 people in our family and we're about 20k over the median income line. Insurance companies want 15K a year plus 2.5k deductible before they pay dime 1. Exchange, insurance at work doesn't matter both are completely un-affordable.
Blaming the elderly for our problems is a bad move. Simply because the laws of the universe say we will become old too.
Now I agree with you on your other points that the insurance companies took this law and said fuck it we will just raise prices. That is what happens with corporations they want to make money. The fact that the government thought they could just force these folks to do the right thing and cover people with pre-existing conditions and all this other stuff without a single consequence was a really bad oversight.
All the more reason for a single-payer/public option system. Spread the costs across the entire system instead of making individual small businesses take the hit on their own.
How does that mesh with Health Care Co-operatives which are also raising premiums?
Actually, the co-ops are dying in dramatic rates because they don't have enough capital to become self sufficient. How do they get there if they don't have investors? How do they incentivize investors without showing a plan to profitability?
I believe what parent means is that because the workforce is old, they would be expensive for the company to properly insure, so the company has opted to get poor health care coverage. It's more the company's fault.
Most poor people are worried about making ends meet the very last thing they are thinking about is their taxes and possible IRS penalties. They are expecting a refund and not to get hit with a fine. This is really just another burden on the middle class, it was for sure an unintended side effect by the folks who came up with his law.
An example of said burden on the middle class. I make a senior software engineers salary and my wife has Lupus. I'm beginning to have signs of having Lupus and RA myself. Her prescriptions alone barely have any coverage until we meet our out of pocket max, and by then, 10-15% of our income is gone paying just for drugs. This is on top of 25-30% taxes, plus the rising cost of food, and now they are telling me I may need the same drugs as her? So in this new found world, I could potentially lose up to 55% of my income in taxes and health coverage. Oh and for a laugh, Medicare won't cover her because I make too much. This is insane.
Despite this, I'm of the mind that we can't return to the way things were before ACA, and ACA isn't the answer either. Something has to change or we may have to move to another country with better options. People huff about waiting lists, but neglect to realize that waiting lists are often for non-life threatening surgeries. They also forget to tell the part about how routine office visits don't have the same types of waits, and how prescription coverage is still free.
All of my crying aside, I'm left with one thought. How in the actual fuck do poor people afford this shit? I grew up poor and I know what we did--we didn't have insurance and thankfully we were lucky enough not to have any chronic illnesses in my immediate family when I was growing up.
On a lighter note, a small joke: I downloaded the GoodRx and it physically started emitting laughter from the speakers once I typed in the drug names.
>All of my crying aside, I'm left with one thought. How in the actual fuck do poor people afford this shit?
A unpopular thing to say is that there exists two types of poor in this country. The poor and the working poor. The poor are fine, they get Medicaid, Medicare and discounts at the exchange. The working poor are fucked they get to pay higher taxes because insurance is too expensive and when they lift themselves up to a point where they can afford it, it doesn't cover anything anyway.
This sort of bullshit has chilling effects. Rig the game so obviously against low income Americans and they might just decide to stop playing. That is why you see the lowest labor participation rates since the 70's. It's better to be poor than working poor anymore.
It's also really difficult to say what premiums would have been without the changes the ACA made. Medical inflation has slowed since the law was passed, but again, I think it is difficult to figure out how much of that to attribute to the ACA.
> It's also really difficult to say what premiums would have been without the changes the ACA made.
No it's not. Forcing insurers to take people with pre-existing conditions completely screws up risk pools. Anyone could've told you that doing so would make premiums rise much faster than if those customers could be denied.
It's without a doubt the provision with the biggest impact. The whole point of an insurance pool is to pay out less than you bring in, and if you suddenly introduce a lot of people that cost more than they bring in, premiums have to go up. A lot.
> Obamacare was expressly designed to fail, it seems.
Of course it was. Anyone with half a brain understands how risk pools work and understands that allowing people to join said pools after developing an expensive, crippling illness will completely wreck everything.
I think we're just experiencing the ultimate end game of the system. The ACA was nothing more than ointment on an infected wound. It worked for a time but it is becoming more and more obvious that this leg our economy needs to be amputated.
We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon.
The pharmaceutical industry would practically go to war to prevent a single payer or a price-fixed system but they would lose if they're opponent was the insurance industry (and the American people; who have very low esteem for "big pharma").
A most interesting change resulting from an American single payer system would be the increase of drug prices for everyone else (other countries). As it stands right now the only reason drug companies can get away with some of their lower prices in single-payer countries is because the US can and will make up the cost. Lowering the cost of drugs in some countries really does result in higher costs for Americans.
We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon.
What role do insurance companies have if there is a national body fixing prices?
Looks like not much of a role at all. After all of my experiences with insurance companies I'm quite okay with that.
A NHS-style system would still need staff in order to function and I expect many rank-and-file insurance people would end up there. The executives can go to hell as far as I'm concerned.
Providers also have a lot of staff dedicated to working with the insurance companies. I'm pretty sure billing complexity is one of the things driving consolidation of physicians into large practices and health systems.
Which is America's end game: to end that apparent scam.
This is why I actually had hope for the original draft of Obamacare: he straight up cloned the Netherlands system where insurance companies must insure x% of various classifications of sick people (cancer, AIDS, asthma, heart disease, overweight, etc), where x% approximates the national average...
... and they must spend ridiculous high levels of what they make on actual health care, AND the prices of health care are nationalized.
In the end, they fight over sick people (have a rare sickness? insurance companies will give you a discount to get you, instead of trying to figure out how to lifetime ban you from insurance instead). And what happens if an insurance company can't get enough people to meet the strict guidelines? They're banned from selling insurance in the Netherlands until they do.
This is essentially the original Obamacare, filtered through the American way of doing shit. What we got instead? Half of that, and maybe not even the good half.
The ACA was pretty much a terrible proposal from the start.
The logic that lead people from "insurance companies are the problem!" to "force everybody to buy insurance!" required a mind blowing level of cognitive dissonance.
You assume that this current broken state was unintentional. I believe this situation is intentional and was predicted and expected.
Back when Obamacare was being debated I and many others argued that the best it could do would be to slow the meteoric rise of health care costs because it was painfully obvious (to me at least) that it didn't actually solve the problem. I have no doubt that the politicians knew this as well which was why Republicans fought so hard against it and why Democrats wanted it so bad.
I believe they wanted it to come to this. They wanted to demonstrate that even if you force people to get insurance it still wouldn't be enough. It is a real-world application of how, "the compromise" (forcing people to get insurance) doesn't actually impact the price much because health care costs are not controlled by traditional market forces.
What is the price, "the market will bear" when someone will die or suffer immensely without treatment?
Wouldn't surprise me, but among numerous other issues all it's doing is amplifying how everything gets worse when the federal government gets involved.
I'm also seeing something else here too, with the "screw you, raise price by *1000" executives, schrekli (sic) being one of many.
What many of these comes down to, is they own a right of patent on something that allows them to set the price at will. Or, if they choose, to not license or sell it at all.
Stated differently, why should someone or government tell me how much I should set my price on a patent I own?
An answer, which I am not aware of being used, is eminent domain. We do as such for public good when it comes to roads, buildings, and similar. I know the Supreme Court had to rule back with Wilbur and Orville Wright because they kept avionics back for a decade whilst Europe was booming... because someone wouldn't sell the rights to do aircraft.
Of course, the underlying problem is public institutions pay for the research, and drug companies get access to this and extract. The drug co's aren't researching; the public institutions do; and we do.
Except the drug "schrekli" priced gouged was out of patent. It should have been a commodity, so why weren't any competitors allowed on the marketplace? Take a look at Washington for your answer.
There are lots of amazing companies trying to invent cures that don't otherwise exist, and need compensation for their work. Then you have Epipen and "schrekli" jacking up prices on 30 year old drugs.
Indeed. Whatever his name is, used the fact that the FDA has to "authorize" a drug, which is more akin to an indefinite patent.
Then again, the deeper we dig, the more idiocy we see. How can we expect anyone to fix: insurance, pharmaceutical, device companies, FDA, AMA, government interference, medical schools - everyone has a part in the current system. And it is the combination of the worst that capitalism and socialism have to offer.
And yes, I misspelled his name, because a google search was too much work to get his name correct (marque of disregard). But admittedly, probably was not the best case to explain.
> We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon.
Insurance companies are legally obligated to pay out 80-90% of their receipts for treatment. Since they can't become more profitable on a percentage basis, they have every economic incentive to drive the cost of medicine up. What's better than making $500/year/customer? Making $1000/year/customer because medicine costs twice as much. You don't even need to get more customers!
There's definitely a whole slew of market failures piled up on top of one another in the healthcare system here in the US.
There are people who are afraid of single payer for silly reasons, but there are also people who are scared of rationing. That's a legitimate fear! And it's not one that can really be assuaged because we've seen that while it's very difficult to get laws passed today, that's nothing compared to rolling them back. So everyone could go into single payer with the best of intentions but it only takes a few changes of administration for things to start to go off the rails, and then it'll be nearly impossible to get the mess sorted out.
I mean, look at the ACA! The whole thing was done with the best of intentions but even before it made it to being a law it got all messed up. And now that it is a law, it's maybe not necessarily having the intended effect.
Couple that with the idea that everyone in the US is about to "make it" or that everyone thinks they're middle class or upper middle class and fears about rationing can seem entirely well founded.
Anecdotally I had a prof who was from Vancouver who had a knee problem and needed an MRI to make sure it wasn't cancerous before they operated. 9 month wait list fo r the MRI or a half day excursion to Seattle and about a grand and he had his imaging. It doesn't prove that everyone in Canada experiences rationing the same way, but it does mean that fears aren't completely unfounded.
" but even before it made it to being a law it got all messed up"
Requiring legislators to read legislation (and maybe even take a test on bills that are larger than 10 pages?) before they vote on it might help. Being told "we have to pass it before we can look inside of it" is... I can't think of anything less sane.
Re: Canada and other countries. I know in the UK you can get private insurance and "go private" for most services, or you can take the public option, which may involve waiting. Why we think here it's going to be 100% one thing... I don't understand. Your canada story already demosntrates that - someone with more money paid for faster service. I have a strong suspicion he could have had that done privately someone in canada for $x, but seattle was closer/easier (?)
Technically, a senator can require that a bill be read aloud by the clerk. However from what I understand that pretty much never actually happens because even if a senator makes the relevant objection, the schedule can just be reworked so that the bill is no longer considered at that time.
> Being told "we have to pass it before we can look inside of it" is... I can't think of anything less sane.
There's the republican influence for you.
That quote Pelosi said was about the disparate bills in House and Senate. In order to see the final bill, each side had to pass it so a merge committee would be made to combine the bill.
Then the merge-bill would be re-forwarded back to Senate/House for a final vote.
Or what she should have said: "We have to pass the House Bill before we can see the Merged bill."
But a 10 second republican talking point snippet makes her look bad. But if you know how Congress works, it makes a heck of a lot of sense.
Healthcare is always rationed, though. It can be rationed by need, ability to pay, or some other way, but there's no system for infinite healthcare yet developed.
Yup! Everything is rationed so far, except maybe for air.
But the point is, you're going from implicit rationing (you can have whatever you can afford) to explicit rationing (we can only do X MRIs per week and it'll take 37 weeks until it's your turn). There are a lot of folks who don't like that idea, and I can see why.
A lot of proponents of single-payer completely play this down and pooh-pooh folks who bring up that point by saying "oh it'll never be like soviet medicine where only well connected people get better" but don't explain at all how our government will be 100% guaranteed not to do that. And if you can't lay out how that'll happen in blindingly obvious detail and personally promise them that we'll start executing people if it goes badly, well, there are a lot of folks who aren't terribly trusting. And they're not necessarily wrong.
Having a single entity negotiating prices would obviously lower them--it'd establish a monosopny. But would that be a good thing? I mean, we could lower prices for everything that way. Have a single entity negotiate prices for cars, or construction services, for example. That'd lower prices too. Why don't we do that for everything?
arguably not everyone needs everything - many people can get by just fine without a car, or construction services, or other things you might list. Not too many people get by (for long) with poor/ailing health.
Some aspects of health care - basic stuff like getting people insulin they need and whatnot - does that not potentially get justified under "general welfare" clause? Many other countries seem to get by just fine with a baseline "health service" provided to everyone, with "premium" service paid for out of pocket or via private insurance. People should not have to face bankruptcy (or just extreme debt) because they happened to be born with the wrong genes.
That's an argument for the government paying for healthcare. But why is it a good idea to achieve lower consumer prices via centralized price negotiation for health care but not for other things?
There are other things that people need by: food, housing, clothing. We don't use the government as a single entity for purchasing those goods. What makes them different from drugs?
The big successful aspects of the law remain in my mind:
Elimination of lifetime caps, pre-existing conditions. Allowing children to remain on plans until 26.
Insuring millions more via expansion of Medicaid or subsidies of premiums with initially more competitive plans.
By and large I think it was a success, albeit a completely temporary bandaid to a system that requires massive re-thinking
I agree - a lot of the issue in the US is that there isn´t any effective competition (or control of) the drug companies and price gouging. A single payer will help tackle that. But the key question is, why is American healthcare so expensive, and for such poor outcomes - measured by life expectancy at least? You can lop off a few percent as the cost of running the insurance company infrastructure, but it still doesn´t explain all of it. Nor is it the case that US patients are subsidising other patients drug costs - not all drugs are researched or manufactured by US drug companies.
There is a supply element to all this as well, and it´s not just drugs. Let me give you one example from the UK, since I don´t know the US figures.
One of the problems in the UK is that doctors are very expensive, and there aren´t enough of them - this isn´t because of their student loans, it´s because there´s a shortage of doctors. The NHS imports a lot of doctors from abroad to cover this (causing issues in their home countries), the US does the same. (If you´re a doctor from a country with low cost medical training the markup for working in the US is insane. I digress.)
Dig into the statistics for medical training in the UK, and it becomes clear that the number of places has been held more or less constant, while the base population has increased significantly, and you can put whatever fudge factor you like on the population needs more healthcare because of obesity/ageing/excessive tea drinking, etc.
Which unfortunately won´t have any real impact for at least 6 years or so.
To solve the american health care problem requires essentially a large scale attack on the cost of the health provisions, and that has to be across the board, and it´s going to take years just because of the lag times involved. Personally I would start with simply doubling the number of medical school places - maintain standards on admission - and work on dropping the salary levels. Provide scholarships so students don´t need big loans. Attack the anti-competitive practices of the drug companies directly, etc.
In other words, remove artificial supply bottlenecks, let the market sort it out... and have some kind of bailout ready for the existing medical professionals, and medical providers, who then can´t repay their loans.
Making the rest of the world pay US prices...isn´t going to happen. Sir Alexander Fleming was Scottish.
The market for widely used generic drugs in the US is incredibly competitive. It's niche and patented drugs that see crazy prices.
As far as doctors, the US currently has a surplus of medical school graduates and not enough residency slots to train them. I imagine the most immediate thing the US could do would be to train even more physicians assistants and nurse practitioners and then do a better job of billing less for lower levels of service.
That's a workable idea. The residency slot shortage could be addressed by building more hospitals.
In most US states, that's a problem thanks to certificates of need.
https://en.m.wikipedia.org/wiki/Certificate_of_need
Insurance companies have to meet their quarterly earnings goals or investors will punish them. If their lobbying can't get the tax penalty raised, then it will continue to be a better deal for the young and healthy to take the penalty.
- Mandatory price transparency. Health care is procedures and medicines, not a used car. Also all procedures signed off beforehand (with the exception of emergency ones, naturally). If Procedure A costs $100 for Health Insurance A, why should they charge a BS price for someone without Health Insurance?
- Zero drug advertisement (maybe for no-prescription drugs, still)
I'm kind of on board with zero drug advertisements. But what rationale for banning drug advertisements doesn't also apply to banning other kinds of advertisements? I mean, I'd be on board with that too but I'm wondering if you see some distinction.
We do ban other kinds of advertisements already when we deem them against the greater public good.
So I can see how banning drug advertisements falls into the same category as banning cigarette ads, in that it makes for a more healthy public. The same thing can of course be said about just about anything, but sometimes you just have to stand on that slippery slope.
The rationale behind banning cigarette ads is that those are products that actively harm consumers. What's the equivalent rationale for banning drug ads? Presumably, it's that drug advertisements cause people to, e.g., demand expensive brand names when cheap generic alternatives are available, or to demand drugs they don't really need. But isn't that true for almost all consumer advertising? Everything from toothpaste to cars to razor blades to jeans to handbags?
Sure. And if we decided that rampant razor blade advertising was causing systematic pricing imbalances that dramatically impacted the greater public good, we could ban those too.
That begs the question. Consumers pay huge premiums for brand-name products when cheap generic alternatives would serve the same function. Is that not a "systematic pricing imbalance?"
Hospitals don't even know how much somethings costs. They just start billing for this that and the other until their bottom line looks decent. This is likely an artifact of our current insurance system where the customer is the insurance company, not the actual patient, and the insurance company can profit at a fixed percentage of costs. So they're fine with spending as much as possible.
The fine is structured such that only people that can pay for health insurance are hit with it. The various income tests and whatever might not be perfect though.
Here's some numbers.
~8 million people chose the fine[1].
More than 9 million people receive subsidies on the ACA exchanges[2].
About 58 million people receive Medicaid (heavily subsidized insurance)[3].
>The fine is structured such that only people that can pay for health insurance are hit with it.The various income tests and whatever might not be perfect though.
That is to say the least. It is all based on the poverty line and that is extremely flawed.
"The current federal poverty level is $23,550 a year for a family of four and $19,530 for a family of three. But this measure is based on a methodology developed in the 1960s and now widely recognized as outdated. One major criticism is that the official poverty level is too low. Current research suggests that, on average, families need an income of about twice the federal poverty level just to afford basic expenses. Moreover, although the cost of living varies significantly within and across states, the federal poverty level is the same across the continental U.S."
What money are you talking about? The fines are coming out of the pockets of the people that are not insured and they are choosing the fines because they are lower than the cost of the premiums. So it isn't possible to insure them with the money they pay in fines.
We know that they don't qualify for Medicaid (those people aren't fined). I guess you could further expand Medicaid, but that probably wouldn't be real popular, and there would probably still be fine payers that had too much income to qualify for it.
I see a lot of value in a single payer system as health care system as I fundamentally believe healthcare spending does not conform to the same rules as other parts of the economy and thus might make all of our (basic) understanding about economics moot.
That said, single payer does not solve the single biggest classic problem with the current healthcare system in the US and that is the agency issue. Right now I cannot make informed choices as a consumer in this market. Prices are not transparent and the people negotiating the prices are not the people receiving the care.
Further, we've coupled insurance to employment which is just insane.
Oddly McCain's health plan from a few elections back would have at least dealt with the last point. I wonder if the exchanges would be more successful if the entire population was buying insurance through them.
Yeah, I do wish we'd figure out a way to decouple insurance from employment. Right now, I have two choices... one from my employer, and one from my wife's employer. One is terrible ($12k/year OOP max), the other is better (but still worse on cost and benefits than the typical PPO from 15-20 years ago).
It should have been done as part of the ACA. Remove the tax incentive and encourage all those people to go to the exchanges. It would probably have to have been done in a staged manner.
After that, eliminate Medicaid in favor of fully priced exchange subsidies (I say "fully priced" because as far as I can tell, much of the funding for Medicaid comes from jacking up prices that other people pay for care, creating a tax that gets hidden in insurance premiums and deductibles).
Instead the ACA placed more requirements on employers and expanded Medicaid.
I see no value in turning a whole industry into defacto civil servants. Doctors and nurses are people too who need to be able to choose themselves. I don't give a rip about insurance. Getting access to health care is what matters. Doctor/patient relationship is what matters. I see no need for government to get involved other than stopping ethical type (illegal) abuses.
And how do you provide access to extremely expensive health care without insurance or government? Risk sharing is the issue and in this case it seems fraught with moral hazards regardless of how it is done.
If you don't give a rip about insurance, you should be especially irritated at ACA and the ACA status quo ante, because the insurance companies and hospital chains quietly negotiate the prices for health care services, collude to establish favorable prices for the insurers, and lock individual consumers out of those prices.
A fun experiment I've had the pleasure of running: try to get an MRI done outside of your insurance policy --- that is, try to pay the rack rate for an MRI, out of pocket.
> It has not worked all that well, and that is at least partly to blame for soaring premiums next year on some of the health law’s insurance exchanges.
People love to blame any post-2010 health insurance problem on Obamacare, but what's the evidence that rate hikes are actually significantly influenced by PPACA?
> but what's the evidence that rate hikes are actually significantly influenced by PPACA?
For 4 years before "mandatory purchase" was in effect, I saw annual 3-5% increases in premiums. In 4 years since, I've seen ~20% increases each year (last year was 'only' 11% increase - I'm bracing for much more).
The 'evidence' is insurance companies bringing in more people who previously didn't have insurance - generally, they either needed or used more services than whatever the premiums (+ subsidies) they were paying covered, and insurance companies lose money because of this. In NC, BCBS lost ~$400million last year (or so the claim goes). They can't sustain those losses indefinitely.
Twenty to fifty years from now historians are going to reference the ACA as a case study of early 21st century American government:
1) hyper partisan political process
2) special interest control of the content of laws
3) release of information by the government used as a method to manage the electorate rather than inform
4) front loaded benefits with back-ended payments
5) political class taking credit for the good stuff and leaving if for others to clean up the mess
Generally speaking, all aspects of American government in this place and time are reflected in the ACA. All aspects share the same sustainability issues.
I will always support the ACA, for one big reason: friends and coworkers of mine who were denied insurance before can now get insurance.
I am more than willing to pay higher premiums (or tax penalties) if it means that people who need treatments can now have access to those treatments without going bankrupt.
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[ 3.4 ms ] story [ 190 ms ] threadHillaryCare isn't working.
https://twitter.com/HillaryClinton/status/697967580770869248
The article is about Obamacare, aka Hillarycare. Seems on-topic to me.
https://news.ycombinator.com/item?id=12789100 (2 days ago) https://news.ycombinator.com/item?id=12784217 (3 days ago) https://news.ycombinator.com/item?id=12774938 (4 days ago) https://news.ycombinator.com/item?id=12770303 (5 days ago)
"How much is this procedure/appointment?"
And all I get are sneers of derision or confusion. Then I'm told, "The bill will be in the mail." Yeah, well fuck you too.
You want price controls; I want an estimate, and a list of procedures and their costs.
Then again, I'm waiting to sue someone over the lack of informed consent based on financial availability. I'd do it, but I'm not a lawyer.
I'm with m_gray though. Either party doesn't matter to me. Not a fan of Hillary or Trump. Just want someone to actually make a difference that doesn't include a higher cost to my wallet every time they enact something.
Normalized pricing based on income with transparency on procedures and tests. Deductible + premiums + out of pocket should add up to no more than 8-10% of my income.
And out of pocket should be some fraction of real price based on income. It should always cost 3x to go to a hospital than a doctors office its just the amount should vary based on income.
Let private insurance compete in the supplemental market. And offer public option on exchange.
Only if you qualify for the subsidized private coverage (which poor people do not) do you have to pay a penalty for not getting health insurance. Frankly that part of the law is a little insane, even if it is because it wasn't implemented as intended; if you don't have any income, then you have to pay the full price for coverage on the exchange, no subsidies. Your income has to meet a certain minimum level to qualify for subsidies - the intent was that below that level, you'd get Medicaid.
I perked up when he talked about how his son just got insurance. His son is 26, and his yearly premium is $4000.00
His deductible is $3500.00
He pays $7500 before insurance helps out. wow?
I was a former supporter of the Health Care Act. There's a lot in the bill that's good. That said, Insurance companies ruined it. They should be lynched.
I don't know how to fix it. It's an embarrassing mess.
Those expensive wars are fought with expensive weapons, which are mostly still made here by American companies. Those soldiers fighting those wars are citizens with full time jobs for many years.
Healthcare is another thing that's made here and someone is getting paid when we pay an efficient amount or simply overpay.
So killing ourselves is all a matter of perspective, some people are doing quite well.
There's also an enormous opportunity cost to not spending money on young men in the military too - and just dumping them on the street, with a job market that cannot absorb all of them.
The US actually already did that once. In 2003. A large group of young, heavily armed men who have really only been trained how to kill were suddenly without income or purpose.
That story demonstrated the opportunity cost of suddenly packing up the military and sending them all home without a job.
Part of the issue is that Americans seem peculiarly unwilling to point their pitchforks in the right direction.
Now I agree with you on your other points that the insurance companies took this law and said fuck it we will just raise prices. That is what happens with corporations they want to make money. The fact that the government thought they could just force these folks to do the right thing and cover people with pre-existing conditions and all this other stuff without a single consequence was a really bad oversight.
There's no argument to be made, it's just a fact: Old(er) people have higher health care costs.
Everyone here should know by now that older systems are more expensive to maintain!
Same with smokers. My old company didn't hire smokers and I'm sure it had to do with healthcare costs.
I'm not blaming them any more than I'm blaming the actuarial tables the rates are based on.
Also, I'm not making any comment towards them as far as their work. They all are very good at their jobs and I like working with them.
It is about investors, not consumers. Always.
Actually, the co-ops are dying in dramatic rates because they don't have enough capital to become self sufficient. How do they get there if they don't have investors? How do they incentivize investors without showing a plan to profitability?
Most poor people are worried about making ends meet the very last thing they are thinking about is their taxes and possible IRS penalties. They are expecting a refund and not to get hit with a fine. This is really just another burden on the middle class, it was for sure an unintended side effect by the folks who came up with his law.
Despite this, I'm of the mind that we can't return to the way things were before ACA, and ACA isn't the answer either. Something has to change or we may have to move to another country with better options. People huff about waiting lists, but neglect to realize that waiting lists are often for non-life threatening surgeries. They also forget to tell the part about how routine office visits don't have the same types of waits, and how prescription coverage is still free.
All of my crying aside, I'm left with one thought. How in the actual fuck do poor people afford this shit? I grew up poor and I know what we did--we didn't have insurance and thankfully we were lucky enough not to have any chronic illnesses in my immediate family when I was growing up.
On a lighter note, a small joke: I downloaded the GoodRx and it physically started emitting laughter from the speakers once I typed in the drug names.
A unpopular thing to say is that there exists two types of poor in this country. The poor and the working poor. The poor are fine, they get Medicaid, Medicare and discounts at the exchange. The working poor are fucked they get to pay higher taxes because insurance is too expensive and when they lift themselves up to a point where they can afford it, it doesn't cover anything anyway.
This sort of bullshit has chilling effects. Rig the game so obviously against low income Americans and they might just decide to stop playing. That is why you see the lowest labor participation rates since the 70's. It's better to be poor than working poor anymore.
ACA? Not hardly.
Take an issue and make it worse, wait for the backlash, then come back to the public and offer a new solution: single payer.
http://www.cnbc.com/2016/05/18/health-insurer-highmark-sues-...
It's also really difficult to say what premiums would have been without the changes the ACA made. Medical inflation has slowed since the law was passed, but again, I think it is difficult to figure out how much of that to attribute to the ACA.
No it's not. Forcing insurers to take people with pre-existing conditions completely screws up risk pools. Anyone could've told you that doing so would make premiums rise much faster than if those customers could be denied.
Of course it was. Anyone with half a brain understands how risk pools work and understands that allowing people to join said pools after developing an expensive, crippling illness will completely wreck everything.
We need a single payer system or at the very least a single body that negotiates the price of all drugs and health care services on behalf of all Americans. Frankly I'm surprised that the insurance companies aren't lobbying for such a thing as it could be their only hope for continued existence very soon.
The pharmaceutical industry would practically go to war to prevent a single payer or a price-fixed system but they would lose if they're opponent was the insurance industry (and the American people; who have very low esteem for "big pharma").
A most interesting change resulting from an American single payer system would be the increase of drug prices for everyone else (other countries). As it stands right now the only reason drug companies can get away with some of their lower prices in single-payer countries is because the US can and will make up the cost. Lowering the cost of drugs in some countries really does result in higher costs for Americans.
What role do insurance companies have if there is a national body fixing prices?
A NHS-style system would still need staff in order to function and I expect many rank-and-file insurance people would end up there. The executives can go to hell as far as I'm concerned.
Which is America's end game: to end that apparent scam.
This is why I actually had hope for the original draft of Obamacare: he straight up cloned the Netherlands system where insurance companies must insure x% of various classifications of sick people (cancer, AIDS, asthma, heart disease, overweight, etc), where x% approximates the national average...
... and they must spend ridiculous high levels of what they make on actual health care, AND the prices of health care are nationalized.
In the end, they fight over sick people (have a rare sickness? insurance companies will give you a discount to get you, instead of trying to figure out how to lifetime ban you from insurance instead). And what happens if an insurance company can't get enough people to meet the strict guidelines? They're banned from selling insurance in the Netherlands until they do.
This is essentially the original Obamacare, filtered through the American way of doing shit. What we got instead? Half of that, and maybe not even the good half.
We got fucked.
The logic that lead people from "insurance companies are the problem!" to "force everybody to buy insurance!" required a mind blowing level of cognitive dissonance.
Back when Obamacare was being debated I and many others argued that the best it could do would be to slow the meteoric rise of health care costs because it was painfully obvious (to me at least) that it didn't actually solve the problem. I have no doubt that the politicians knew this as well which was why Republicans fought so hard against it and why Democrats wanted it so bad.
I believe they wanted it to come to this. They wanted to demonstrate that even if you force people to get insurance it still wouldn't be enough. It is a real-world application of how, "the compromise" (forcing people to get insurance) doesn't actually impact the price much because health care costs are not controlled by traditional market forces.
What is the price, "the market will bear" when someone will die or suffer immensely without treatment?
What many of these comes down to, is they own a right of patent on something that allows them to set the price at will. Or, if they choose, to not license or sell it at all.
Stated differently, why should someone or government tell me how much I should set my price on a patent I own?
An answer, which I am not aware of being used, is eminent domain. We do as such for public good when it comes to roads, buildings, and similar. I know the Supreme Court had to rule back with Wilbur and Orville Wright because they kept avionics back for a decade whilst Europe was booming... because someone wouldn't sell the rights to do aircraft.
Of course, the underlying problem is public institutions pay for the research, and drug companies get access to this and extract. The drug co's aren't researching; the public institutions do; and we do.
There are lots of amazing companies trying to invent cures that don't otherwise exist, and need compensation for their work. Then you have Epipen and "schrekli" jacking up prices on 30 year old drugs.
Then again, the deeper we dig, the more idiocy we see. How can we expect anyone to fix: insurance, pharmaceutical, device companies, FDA, AMA, government interference, medical schools - everyone has a part in the current system. And it is the combination of the worst that capitalism and socialism have to offer.
And yes, I misspelled his name, because a google search was too much work to get his name correct (marque of disregard). But admittedly, probably was not the best case to explain.
Insurance companies are legally obligated to pay out 80-90% of their receipts for treatment. Since they can't become more profitable on a percentage basis, they have every economic incentive to drive the cost of medicine up. What's better than making $500/year/customer? Making $1000/year/customer because medicine costs twice as much. You don't even need to get more customers!
There's definitely a whole slew of market failures piled up on top of one another in the healthcare system here in the US.
There are people who are afraid of single payer for silly reasons, but there are also people who are scared of rationing. That's a legitimate fear! And it's not one that can really be assuaged because we've seen that while it's very difficult to get laws passed today, that's nothing compared to rolling them back. So everyone could go into single payer with the best of intentions but it only takes a few changes of administration for things to start to go off the rails, and then it'll be nearly impossible to get the mess sorted out.
I mean, look at the ACA! The whole thing was done with the best of intentions but even before it made it to being a law it got all messed up. And now that it is a law, it's maybe not necessarily having the intended effect.
Couple that with the idea that everyone in the US is about to "make it" or that everyone thinks they're middle class or upper middle class and fears about rationing can seem entirely well founded.
Anecdotally I had a prof who was from Vancouver who had a knee problem and needed an MRI to make sure it wasn't cancerous before they operated. 9 month wait list fo r the MRI or a half day excursion to Seattle and about a grand and he had his imaging. It doesn't prove that everyone in Canada experiences rationing the same way, but it does mean that fears aren't completely unfounded.
Requiring legislators to read legislation (and maybe even take a test on bills that are larger than 10 pages?) before they vote on it might help. Being told "we have to pass it before we can look inside of it" is... I can't think of anything less sane.
Re: Canada and other countries. I know in the UK you can get private insurance and "go private" for most services, or you can take the public option, which may involve waiting. Why we think here it's going to be 100% one thing... I don't understand. Your canada story already demosntrates that - someone with more money paid for faster service. I have a strong suspicion he could have had that done privately someone in canada for $x, but seattle was closer/easier (?)
There's the republican influence for you.
That quote Pelosi said was about the disparate bills in House and Senate. In order to see the final bill, each side had to pass it so a merge committee would be made to combine the bill.
Then the merge-bill would be re-forwarded back to Senate/House for a final vote.
Or what she should have said: "We have to pass the House Bill before we can see the Merged bill."
But a 10 second republican talking point snippet makes her look bad. But if you know how Congress works, it makes a heck of a lot of sense.
But the point is, you're going from implicit rationing (you can have whatever you can afford) to explicit rationing (we can only do X MRIs per week and it'll take 37 weeks until it's your turn). There are a lot of folks who don't like that idea, and I can see why.
A lot of proponents of single-payer completely play this down and pooh-pooh folks who bring up that point by saying "oh it'll never be like soviet medicine where only well connected people get better" but don't explain at all how our government will be 100% guaranteed not to do that. And if you can't lay out how that'll happen in blindingly obvious detail and personally promise them that we'll start executing people if it goes badly, well, there are a lot of folks who aren't terribly trusting. And they're not necessarily wrong.
Some aspects of health care - basic stuff like getting people insulin they need and whatnot - does that not potentially get justified under "general welfare" clause? Many other countries seem to get by just fine with a baseline "health service" provided to everyone, with "premium" service paid for out of pocket or via private insurance. People should not have to face bankruptcy (or just extreme debt) because they happened to be born with the wrong genes.
https://en.m.wikipedia.org/wiki/Right_to_health
It's only been in effect for a few years - what "time" did it "work"?
By and large I think it was a success, albeit a completely temporary bandaid to a system that requires massive re-thinking
There is a supply element to all this as well, and it´s not just drugs. Let me give you one example from the UK, since I don´t know the US figures.
One of the problems in the UK is that doctors are very expensive, and there aren´t enough of them - this isn´t because of their student loans, it´s because there´s a shortage of doctors. The NHS imports a lot of doctors from abroad to cover this (causing issues in their home countries), the US does the same. (If you´re a doctor from a country with low cost medical training the markup for working in the US is insane. I digress.)
Dig into the statistics for medical training in the UK, and it becomes clear that the number of places has been held more or less constant, while the base population has increased significantly, and you can put whatever fudge factor you like on the population needs more healthcare because of obesity/ageing/excessive tea drinking, etc.
http://dera.ioe.ac.uk/16155/1/medical-and-dental-school-inta... (p11)
Finally - this year:
https://www.gov.uk/government/news/up-to-1500-extra-medical-...
Which unfortunately won´t have any real impact for at least 6 years or so.
To solve the american health care problem requires essentially a large scale attack on the cost of the health provisions, and that has to be across the board, and it´s going to take years just because of the lag times involved. Personally I would start with simply doubling the number of medical school places - maintain standards on admission - and work on dropping the salary levels. Provide scholarships so students don´t need big loans. Attack the anti-competitive practices of the drug companies directly, etc.
In other words, remove artificial supply bottlenecks, let the market sort it out... and have some kind of bailout ready for the existing medical professionals, and medical providers, who then can´t repay their loans.
Making the rest of the world pay US prices...isn´t going to happen. Sir Alexander Fleming was Scottish.
As far as doctors, the US currently has a surplus of medical school graduates and not enough residency slots to train them. I imagine the most immediate thing the US could do would be to train even more physicians assistants and nurse practitioners and then do a better job of billing less for lower levels of service.
- Mandatory price transparency. Health care is procedures and medicines, not a used car. Also all procedures signed off beforehand (with the exception of emergency ones, naturally). If Procedure A costs $100 for Health Insurance A, why should they charge a BS price for someone without Health Insurance?
- Zero drug advertisement (maybe for no-prescription drugs, still)
- Cut on incentives (briberies) by drug-companies
So I can see how banning drug advertisements falls into the same category as banning cigarette ads, in that it makes for a more healthy public. The same thing can of course be said about just about anything, but sometimes you just have to stand on that slippery slope.
-have individuals/families pay for healthcare, not employers.
Only then people will start caring how much things cost.
In the US: You can't pay for health insurance? Here is a fine of 700$
:s
Here's some numbers.
~8 million people chose the fine[1].
More than 9 million people receive subsidies on the ACA exchanges[2].
About 58 million people receive Medicaid (heavily subsidized insurance)[3].
[1] http://www.cnbc.com/2015/07/20/irs-more-paid-obamacare-fine-...
[2] https://www.healthinsurance.org/obamacare/will-you-receive-a...
[3] https://www.medicaid.gov/medicaid/program-information/downlo...
That is to say the least. It is all based on the poverty line and that is extremely flawed.
"The current federal poverty level is $23,550 a year for a family of four and $19,530 for a family of three. But this measure is based on a methodology developed in the 1960s and now widely recognized as outdated. One major criticism is that the official poverty level is too low. Current research suggests that, on average, families need an income of about twice the federal poverty level just to afford basic expenses. Moreover, although the cost of living varies significantly within and across states, the federal poverty level is the same across the continental U.S."
http://www.nccp.org/topics/measuringpoverty.html
That way they have insurance, which was the goal of this program, no?
We know that they don't qualify for Medicaid (those people aren't fined). I guess you could further expand Medicaid, but that probably wouldn't be real popular, and there would probably still be fine payers that had too much income to qualify for it.
That said, single payer does not solve the single biggest classic problem with the current healthcare system in the US and that is the agency issue. Right now I cannot make informed choices as a consumer in this market. Prices are not transparent and the people negotiating the prices are not the people receiving the care.
Further, we've coupled insurance to employment which is just insane.
Oddly McCain's health plan from a few elections back would have at least dealt with the last point. I wonder if the exchanges would be more successful if the entire population was buying insurance through them.
After that, eliminate Medicaid in favor of fully priced exchange subsidies (I say "fully priced" because as far as I can tell, much of the funding for Medicaid comes from jacking up prices that other people pay for care, creating a tax that gets hidden in insurance premiums and deductibles).
Instead the ACA placed more requirements on employers and expanded Medicaid.
And how do you provide access to extremely expensive health care without insurance or government? Risk sharing is the issue and in this case it seems fraught with moral hazards regardless of how it is done.
A fun experiment I've had the pleasure of running: try to get an MRI done outside of your insurance policy --- that is, try to pay the rack rate for an MRI, out of pocket.
People love to blame any post-2010 health insurance problem on Obamacare, but what's the evidence that rate hikes are actually significantly influenced by PPACA?
For 4 years before "mandatory purchase" was in effect, I saw annual 3-5% increases in premiums. In 4 years since, I've seen ~20% increases each year (last year was 'only' 11% increase - I'm bracing for much more).
The 'evidence' is insurance companies bringing in more people who previously didn't have insurance - generally, they either needed or used more services than whatever the premiums (+ subsidies) they were paying covered, and insurance companies lose money because of this. In NC, BCBS lost ~$400million last year (or so the claim goes). They can't sustain those losses indefinitely.
1) hyper partisan political process
2) special interest control of the content of laws
3) release of information by the government used as a method to manage the electorate rather than inform
4) front loaded benefits with back-ended payments
5) political class taking credit for the good stuff and leaving if for others to clean up the mess
Generally speaking, all aspects of American government in this place and time are reflected in the ACA. All aspects share the same sustainability issues.
I am more than willing to pay higher premiums (or tax penalties) if it means that people who need treatments can now have access to those treatments without going bankrupt.