“Collapse and Replace”


"President Trump has said himself on numerous occasions that Republicans could simply let Obamacare die on its own, allowing Democrats to continue to pay the political price for it. But then he always clarifies that the GOP won't do that.

"I actually talked with [House Speaker] Paul [Ryan] and the group about just doing nothing for two years, and the Dems would come begging to do something because ’17 is going to be catastrophic price increases … and they will come to us,” Trump said in January at a Republican retreat, adding: "If we waited two years, it will explode like you’ve never seen an explosion."

That idea was also pushed Wednesday by a sometime Trump foe, Sen. Lindsey Graham (R-S.C.). On Hugh Hewitt's radio show, Graham suggested letting Obamacare "collapse" on its own. "Here’s what I would prefer he do," Graham said of Trump. "If he can’t get us in a good spot where we all feel comfortable, we’ve improved Obamacare dramatically, which we told people we would: Let it collapse."

When Hewitt pushed back on the idea, Graham added: "Democrats are not going to lift a finger to help President Trump. I would do collapse-and-replace if you can't get a good, solid fix to Obamacare using reconciliation.""   Washpost


Graham supporting Trump?  Cats and dogs sleeping together?  How can this be?

Do the Republicans really have a choice?  They are in complete disarray internally with regard to the terms of  a replacement law.  There are various bits of tax law embedded in the present Affordable Care Act (Obamacare).  This supposedly blocks Trump proceeding to a proposal to revise the federal tax code, a measure IMO essential to Trump's hope for an economic boom.

If I were Trump, I would let Obamacare die a seemingly inevitable death and move on to tax reform.  pl 


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114 Responses to “Collapse and Replace”

  1. r whitman says:

    Obamacare wont die on its own. That’s just Republican propaganda. While its not flourishing it still has plenty of users. Most of the premium increases are negated by subsidies. Those users in counties where there is only one insurance company have the best of all possible worlds–a single payer system like Medicare or Tricare or the VA with the premiums subsidized.
    Do not believe the Republican mantra that that that the ACA will die on its own.

  2. Edward Amame says:

    Except that Lindsey G is full of sh*t. The latest CBO report disagrees that the ACA’s imploding (they say it’s stabilizing). It’s covering more than 20 million people at a lower cost than originally projected. The problems it faces could be addressed pretty inexpensively but won’t because this is all politics all the time here in the USA in 2017. Col Lang’s prescription for GOP butt-saving certainly would have made sense politically — it’s what the GOP basically did as the oppo party to try to make it fail — except that the GOP spent 7 years demonizing it and now they’re stuck between a rock and a hard place. “Who knew governing could be so difficult!?” Couldn’t have happened to a more deserving crew.
    As for what Pres Trump will do: not lead. My prediction is that he will do what he thinks is good for Pres Trump and leave Ryan or whoever out to dry if that’s what it takes. There will be no attempt to work with Dems.

  3. Dante Alighieri says:

    I agree with Mr whitman that Obamacare isn’t gonna die. That is a typical Trumpian delusion, which has many more delusions in its tow. It is striking how much those delusions resemble the Obama delusions with reverted signs. Why is it so hard to tell you Americans you didn’t elected The Savior? Is it really so hard to see?

  4. asx says:

    Obamacare will not implode quick enough to give Trump a clean sheet for tax code reform. And RyanCare is a clear rollback of the entitlement levels with even the CBO projecting a $300B+ reduction in federal deficit over 10 years. It is a hard sell politically. We need a fix ASAP or we will see an alaming increase in mortality for the under-65 crowd which will get culled before reaching the promised Medicare land.
    I am disappointed that there is no attack on predatory pricing of medical services in the works. Any Obamacare variant will need some/all of the following to be viable.
    1) Separation of Basic Preventive and Wellness based health services from chronic/palliative/end-of-life health care. Allow young and healthy people access to a health system that will keep them healthy without forcing them to subsidise high risk customers. This should cover regular medical check ups and broken bones. Full disclosure: I am neither young nor without health issues.
    2) Pricing protection for uninsured a la carte customers. The practice of billing $500 for a regular check up and getting paid $90 by the insurers hurts walk in customers. If someone uninsured can pay at the point of service, they should not have to pay more than the insurance company average for the same service.
    3) Allow importation of drugs and medical professionals from Canada and other countries which have a well regulated system for healthcare. The U.S. customer and government being the largest, should not meekly pay retail prices for any drug/provider as a subsidy for the industry.
    For the Trumpists, apply the same logic we are using for our NATO partners. Why should we pay more to the manufacturer for a drug than Canadians or Germans? Aren’t we subsidizing their healthcare costs, in addition to their defense?
    Team up with Bernie crowd and identify which medical service/device/drug has seen astronomical price inflation without significant new R&D effort in that area. Our costs are what has made medical tourism a fast growing industry.
    4) Recognize that a weed epidemic is better than the current opiod epidemic. Get off the high horse and end the war on weed. And start a war on prescription opiods and its peddlers.
    5) Sessions and team need to drop the hammer on medical malpractices in billing and bogus unneeded services. And FTC should require all advertisements about public health to clearly list the sponsors. Mammograms do not exist to provide livelihood to the lab techs.
    6) No mention of Taut reform in RyanCare as a way to trim costs.

  5. turcopolier says:

    So, if the GOP (temporarily) abandoned the effort to repeal the ACA, the Democrats would accept that? pl

  6. Karl Kolchak says:

    …Graham said of Trump. “If he can’t get us in a good spot where we all feel comfortable…”
    Ironically, getting powerful men in a good spot where they feel comfortable is how political whore Graham got his Senate seat in the first place.

  7. Lars says:

    I agree with all the wishful and wrong thinking. For better or worse, healthcare policy is now owned by Mr. Trump and the GOP, even if they do nothing. Should they decide to create a bi-partisan solution with wide support in both parties, they could get this issue settled for a long time. But the chances that will happen is slim to none.

  8. Eric Newhill says:

    I agree. I don’t understand what the Republicans are trying to do. The ACA will be dead at the end of 2018 if things are left to the current course.
    As always, I qualify my comments on healthcare by stating that I have worked almost 20 years as an actuary/healthcare economist for both not-for-profit Blue Cross/Blue Shield companies and for profits. The last 6 years for one of the major nationwide carriers and currently, and in 2016, on that company’s ACA/Obamacare products. My team is in the cost driver and financial data. We analyze that stuff and report to the executives.
    The ACA is absolutely dying on its own. Our CEO has been meeting with Trump and the result is that talking about not carrying ACA products in 2018. Read into that what you wish. There is more I could say about this, but am not at the liberty to do so. The other big players have already pulled out or are prepared to do. We are losing way too much money on the ACA and if we increase premiums anymore – which we’d have to – then we will be stuck with even more adverse selection and moral hazard with healthier people priced out of the market and deciding to forego coverage.
    Most of our members are not subsidized (premiums) or are subsidized at insignificant levels.
    The only viable replacement is a combination of the following: 1. Federal aid to expand Medicaid 2. Put people with serious, chronic, expensive conditions (e.g. end stage renal disease, hemophilia, aids) on Medicare, regardless of age. 3. Remove ACA benefit requirements so that individuals and small groups can purchase affordable high deductible catastrophic policies. These should be combined with pre-tax/tax free health savings accounts (HSAs).
    Maybe….just maybe the ACA could continue more or less as is **if** the feds reinstated the reinsurance program at set the reinsurance back to $45k (was $45k, then $90K in 2016 and ceases to exist in 2017) and they tweaked the risk adjustment program (reimburses carriers for taking on higher risk) to give back more to carriers. However, doing so will hit the federal budget hard and I don’t see that happening (apparently neither does our CEO).
    Everything else discussed is bunk and hot air.

  9. Edward Amame says:

    Col Lang
    I think the Dems would be happiest if efforts to sabotage it stopped post haste and instead efforts were made in good faith to try to make improvements where needed, but that will never happen. If the ACA were allowed to proceed as is, even temporarily, they’d probably breathe sighs of relief. But I’m not sure that can happen either.
    Essentially the CBO’s saying that the current Ryan bill that would become Trumpcare will benefit young urban Hillary voters and harm older rust belt Trump voters. Trump’s in a bad position. He needs to say the hell with ideology and stand up to the GOP. Maybe he should listen to the advice of his friend/editor at NewsMax who suggests he go bi-partisan and push for an upgraded Medicaid system that would become the country’s blanket insurer for the uninsured.

  10. r whitman says:

    The Dems are as screwed up and poorly led as the Repubs.

  11. Robert C says:

    It won’t die. In 5-10 years data may be available indicting decreased morbidly and mortality in those who chose to sign up compared to those who didn’t .

  12. Eric Newhill says:

    I think it is more like 12.5 million that are enrolled in the ACA in 2017 – not 20 million.
    The problems it faces could be addressed inexpensively? I am curious as to what you think the problems are and how they would be addressed and how you have assigned a cost to your solutions.
    I don’t know exactly what the CBO says and don’t much care. The problem from where I’m sitting is that the private insurance companies that carry the product are losing money hand over fist on the ACA. As in paying out much more to cover the members’ medical expenses than they have coming in from premiums + federal govt cost offsetting programs like reinsurance (sunsetted in 2017) and risk adjustment. Therefore, the private companies will cease to carry the ACA products. This cessation has already begun and will hit big time in 2018.
    Premium increases occur to try to make up for the above mentioned loss. However, that is a double edge sword. If premiums increase too much, then the only people willing to pay them are those that know they will be incurring cost in excess of the premiums. That is an actuarial death spiral and we in the industry are aware that we have already entered into it. Hence, simply decline to carry the ACA.
    It was the no pre-existing conditions exclusions law and wide enrollment periods that really did the harm combined with minimal penalty for not having insurance. The healthy are far better off simply paying the little penalty. Those with pre-existing conditions could sign up, get the care they needed and then drop coverage. Repeat as needed. That is not insurance; anathema to it actually.
    I don’t recall stepping over dead bodies on the way to the store all the way back in 2012 before the ACA. People with pre-existing conditions could always get insurance, they just had to wait a period of time being receiving insurance paid for care on those conditions. I don’t know why there’s going to be a massive die-off of Americans now if the ACA is repealed or fails. That’s another one you can explain to me.

  13. turcopolier says:

    Eric Newhill
    I have said before that I personally favor a single payer system like that of Canada or France. What is the French system like? pl

  14. Eric Newhill says:

    I know little to nothing about the French system. Personally, I think the Australian system does a pretty good job. I know a lot about it. Sound economic principles applied there.
    I too think that a single payer system would be best *if Americans would come to understand and agree, before implementation, that they are going to be getting a Ford Taurus and not the Cadillac that many are used to*.
    In fact, I think it is permitted for me to say that, at least in the company I work for, it is recognized at the top level, that the current US system, such that it is, is not sustainable. Furthermore, we would like to work with the govt to bring about the inevitable change in a rational manner. I believe that the future will be a socialized system with all citizens covered administered by private companies. This would look like Medicare Advantage for all. The US, as you know, is a big, populous and regionally diverse country – unlike France – and the private companies’ expertise in contracting acceptable rates with providers is needed. This makes sense to me. When will it happen? No idea, maybe within ten years to fifteen years.

  15. turcopolier says:

    Eric Newhill
    Perhaps our Australians could explain their system. pl

  16. Nancy K says:

    I agree completely, single payer is the way to go. Members of congress should also have the same insurance as the rest of us. We could all pay according to how much we make or don’t make or it could be taxpayer supported much like Medicare is now.
    It is just wrong that in a nation as rich as we are and as so called advanced that people can die due to lack of or inadequate medical care.

  17. Edward Amame says:

    Eric Newhill
    Yup, UnitedHealthcare got clobbered but 2016 was the first year where policies got priced based on real info, since exchanges didn’t exist prior to 2014. Bad strategic decisions got worked out via course changes or getting the hell out of the market. So 2017 looks like it could be (have been?) better and some insurers are even making $$$ on Obamacare.
    How could problems get take addressed inexpensively? Adding the public option would be a good start.

  18. Edward Amame says:

    Eric Newhill
    If what you wish for came to pass I’d be thrilled, but I don’t see that happening in this country until pragmatism trumps ideology.(pun intended) No new “entitlements” and all.

  19. petrous says:

    R Whitman,
    you are correct. The implosion & death are at best exaggerations or maybe a bit of wishful thinking. The main aim is to scare participants away (both providers & users). Ads were pulled before the inscription period ended exactly to ensure that. It has problems and needs some tweaks to be sure. Yet it is not on its death bed.

  20. petrous says:

    Here is an excellent article, non partisan, with data and excellent charts about what ails our healthcare system and where we stand and which way we might head if we want to improve it.

  21. Fool says:

    Counterpoint: one could argue that the ACA, being a pretty bad bill all things considered, cost the Democrats. (Something that’s been lost amidst the post-election hysteria is that during the same week of Comey’s infamous October surprise ACA premiums jumped an avg of 25%.) Maybe, then, the Dem’s sigh of relief is that now the ball is in the Republicans hands; the latter made their bed — campaigning against ACA across the board — and now they have to sleep in it.
    Second, I notice here and above you cite the CBO’s findings. In fairness, though, the CBO as an agency is pretty ideological (neoliberalism), which tends to reflect in its prescriptive forecasting (generally: austerity). This is particularly so in their analysis of healthcare, which they view as essentially a consumer good (“choice”) as opposed to a natural right that a country owes its citizens (among other ideological assumptions about the fed budget).
    In any case, i think we agree: to hell with ideology. An expansion of medicare/medicaid would be practical.

  22. doug says:

    This is really what needs to be done. The current state of American healthcare is a prime example of socialism meets capitalism with many actors at the trough. All with big financial interests and lobbying money to toss around.
    The socialism aspect is from government induced insurance tax benefits for employers and employees so the cost is both not visible and subsidized by the tax structure. Also, the poor are covered by Medicaid and the young, lower, middle class just opts out knowing that they will not be turned away from emergency care which is government mandated regardless of insurance or whether you can pay. Sure you can be billed at ridiculous markups for walk in or emergency care. Far above what insurance pays. OTOH, few people without insurance wind up paying their bills and even when they show up as a collection on credit reports medical collections are not considered the same as other collections and don’t as negatively affect people’s ability to obtain credit. So overall is there any cost decisioning that goes into it? No. You can see this if you are ever getting treatment in a hospital. No one has any idea what any cost is. They just offer treatment options. You can choose to do this or that and later someone will send you a bill but good luck trying to get that at the time.
    And on the capitalist side insurance companies may want to hold down some individual cost, but collectively, they benefit from rising overall costs since their net profit is generally capped at a percentage of the total billings made.
    The incentives of big pharma are obvious and basically the rule is that any treatment that shows even the smallest “benefit” is brought into the system of insured (and uninsured) provided treatments.
    Small deductible, single payer base line medical care with overall fiscal limits to limit treatments to those that have a proven benefit. AKA outcome based medicine. Roll it into medicare and let the private sector insurance handle whatever added medical/dental/eye/birth control, etc. a citizen wishes to be covered for.

  23. Eric Newhill says:

    I should add, in fairness, that although I think Trump is the best thing that’s happened in US politics in a long time, his statements about “phase 2” erasing “state lines” and promoting “competition” is pure misguided BS.
    Competition for what? All major insurance carriers are already competing for market share across state lines.
    Additionally, insurance costs what it does because that’s what healthcare services cost. It’s not that insurance companies are gouging profits out of members. In fact, the activities of insurance companies lower the cost, typically reimbursing providers at 50% to 60% of what they bill (and what is paid by the uninsured). Care management and utilization management activities further reduce cost and improve quality. The insurance companies keep some of that savings as profits.
    Surely he can’t mean that providers are going to compete across state lines with sick people in Ohio traveling to Idaho to get a better deal on their knee replacement.
    So what does it mean? I think it’s just empty free market ideology air talk.

  24. Richard says:

    Yes, the problem with all the health care proposals that are being discussed is that they fail to address the issues of collusion, anticompetitive practices and predatory pricing. The health care, insurance and pharmaceutical lobbies have been very effective so far in preventing any fundamental changes.
    As long as you do not start to work on these problems, US health care costs will continue growing at the rate that you have observed in the previous years (I think the average cost increase is around 6 percent every year) until you reach the point where people cannot afford it anymore and have to choose between paying for healthcare or other essentials. It doesn’t matter if you have Obamacare, Trumpcare/Ryancare or a single payer system, eventually the system will implode. You can play around with the system so that richer or healthier people subsidize poorer and less healthy people more and that can buy you a few more years of time, but that does not change the eventual outcome.

  25. bob g says:

    — Obamacare was self-destructing the day before Donald Trump was elected, and the Republican victory, with their talk of “repeal and replace,” has only accelerated things.
    Aetna’s CEO recently said that the Obamacare insurance exchanges are in a “death spiral.”–

  26. VietnamVet says:

    Either the USA adopts a single payer system or healthcare will collapse due to high costs. Right now, it costs each American $9,990 a year. In other developed countries like our northern neighbor it costs around $5,000. In the USA despite the exorbitant costs, public health is collapsing and life expectancy is decreasing for poor whites. Together with higher education, hospitals and pharmaceuticals are profit centers that burden Americans with unpayable debt that breeds despair and illness.

  27. Swami says:

    If Trump wants to leave a positive and enduring legacy, he would push for single payer (or the public option). He could get it done if he makes it a priority.
    Coming out for single payer will catch both parties off balance, something he could exploit to push through legislation.
    Any other changes to the ACA are not currently politically viable.

  28. Eric Newhill says:

    Not just United. I don’t work for United.
    You are going to see other big companies pulling out in 2018, Anthem and Cigna amongst them. It is no secret that they are also losing money on the ACA. Having experience in the market is no help if it makes you realize that you have to increase premiums to the point where only the very sick sign up. I am unaware that any major companies are making a profit on the ACA line up.
    How would adding the public option make a difference?

  29. Eric Newhill,
    Thank you for pointing out that “his statements about “phase 2” erasing “state lines” and promoting “competition” is pure misguided BS.”.
    I’d also like to suggest that taking the regulation of the insurance industry out of the hands of the States sure seems to go against the grain of the 10th Amendment.

  30. SR Wood says:

    T.R. Reid has a new book out about health care around the world. I have yet to read it but I did hear him speak about health care on NPR. He presents a lot of common sense. Here is his book:The Healing of America: A Global Quest for Better, Cheaper, and …

  31. Dr. Puck says:

    “People with pre-existing conditions could always get insurance, they just had to wait a period of time being receiving insurance paid for care on those conditions.”
    This is not in anyway true. Are you a betting man? What evidence would you accept that falsifies this? One turn downed coverage, 1,000,000?

  32. Sylvia D says:

    The odd thing about the Affordable Care Act i.e. Obamacare, is that it’s basically “the Republican Plan”. It’s patterned on a model developed by the Heritage Foundation in the 1990’s that became the basis for Romney Care in Mass. This kind of “system” can never work because it is based on health insurance companies (who take about 30% of every health care dollar and increase provider costs), it does nothing to control costs, if fails to deal with health care monopolies, does not address price fixing, nor does it demand transparency in the system.
    I was pleased to read that Colonel favors a single payer system. So do I. There’s a bill in Congress HR 676 which calls for expanding Medicare to cover all creating a single payer system. The delivery of health care would remain in private hands. The sale of insurance would be prohibited for any covered item, corporate medicine would be ended, and all for profit hospitals et al would have to convert to public or non-profit. The bill is 30 pages long and easy to read and understand.
    The problems in the bill are 1) it covers all “residents” which makes sense but will be controversial, 2) it does not recognize that we currently do not have enough providers to service our population, 3) it doesn’t make clear how this universal coverage will be paid for. We will have to provide assistance to the institutions and to people we will need to train to provide these services.
    I know it sounds expensive to cover everyone–but the US already spends 20% of our GDP on health care, we pay the highest costs in the world, and the health of our population continues to decline. Improving the health of the American people is a national security issue.

  33. Eric Newhill says:

    You are correct that the problem is increasing healthcare costs. All of these solutions that people talk about are really just one-offs. You stop, maybe even reverse, the trend for a short period of time, but then the cost increases re-start their inexorable ascent.
    collusion, anticompetitive practices and predatory pricing to the extent that these things exist, are just another one-off.
    This is because new technology keeps getting introduced and it is expensive. It’s not just that the cost of purchase is high. It’s that it means that more people can be treated for more conditions.
    The only solution to keep healthcare costs from growing from 17% of GDP to 20% in a couple of years to 25% estimated in a decade is to ration care – which is what most of the socialized systems seem to do. No one wants to have that discussion. In a rationing system the wealthy will always be able to purchase supplemental insurance (or pay out of pocket) for the latest and greatest care and/or for conditions not covered under the socialized system. Many of the best physicians will cease to accept patients with the socialized coverage only, preferring to work high end boutique practices.
    There will always be inequality. That fact should not obfuscate the need to create something that is adequate for all. The perfect is certainly the enemy of the good. Now, find a US politician that is willing to tell her constituents that they won’t get everything they want.

  34. Dr. Puck says:

    President Trump stated unequivocally that his vision for his healthcare reform included: lower premiums, lower copays, lower out-of-the-pocket expenses, and, much better coverage, all while resecurring the patient-doctor relationship, and, “covering everybody.”
    Was he telling all of us the truth, or, telling a lie?

  35. walrus says:

    The Australian healthcare system comes in Two parts; pharmaceutical benefits and medical benefits.
    The pharmaceutical benefits scheme does two things. It provides access to very high cost medication to all and it caps the annual cost of medication per person to around $1000 per year. Basically a new drug is evaluated not on mere efficacy, but on public health outcome based criteria comparing it to other drugs and surgical treatments. If the drug is shown to be producing better outcomes for Australian patients it get subsidised and makes it onto ‘the list”. Naturally, big Pharma hates this system. If you want to try something not on “the list” you pay for it yourself.
    The medical benefits system runs a two tier system of both public and private hospitals – each counterbalances the other and keeps them honest. If private healthcare costs get too extreme, people gravitate to the public system. If the public system gets to onerous you can always pay for a private hospital.
    Our Medicare system pays a scheduled fee for each medical procedure. It pays this to doctors/providers on a virtually no questions asked basis this goes from a simple ten minute consultation all the way to open heart surgery. If doctors or hospitals want to charge more then the scheduled fee they can do so, but then they have to collect from you.
    We have a private insurance system as well and the premiums are tax deductible because private insurance takes load off the public system. The premiums for the two of us in our sixties are about $500 per month for platinum level private cover.
    All of this is financed by a 1.5% income tax levy. People bitch and moan about the system. Various states play cost shifting games with the Feds, but overall it seems to work pretty well.
    My late partner got world class treatment for her colon cancer, for free via the public system (unfortunately to no avail). My current partner endured breast cancer chemo, mastectomy, radiation and reconstruction through last year with (hopefully) a clean bill of health through the private system. The only thing we really had to put our hand in the pocket for was reconstructive surgery ($15,000) which is still regarded as elective.
    Typical GP medical consultation cost is around $60. Hospital emergency room treatment is free. If you have a heart attack, etc, you will end up in a big public teaching hospital if that is the nearest with a heart unit.
    To put it another way. There is no real “market” for a lot of healthcare. We know this and don’t try to pretend that government interference isn’t needed to keep the system honest.

  36. Eric Newhill says:

    Dr. Puck,
    I am a betting man.
    I know for a fact that pre-existing doesn’t get you turned down at the BCBS or for profits I have worked for. Perhaps there are some smaller shadier companies where it could happen. I don’t know because I have never worked for such an outfit. That said, people can shop around and find a reputable company that would accept them as a member. I am not impressed by one off sob stories. I have seen too many such stories that are pure BS from the likes of Michael Moore and his ilk writing in Mother Jones, Daily Kos, etc. The cancer drug that would have saved the poor single mother of six, but was denied by the evil profit grubbing insurance company – except then I look at the drug mentioned in the story and see in our data that it has saved no one. That sort of thing.

  37. Bobo says:

    If you consider that 74 million humans are on Medicaid, 56 on Medicare, 27 on government payrolls with health insurance that’s 157 million people out of a total population of 325 million on government paid (partial) healthcare that is 48%. Now that leaves 148 million plus the 20 million paying something for ACA. In the private market the cost for a top of the line policy to cover a family with four children is around $40,000 per year. Our system is not working and efforts to cover the 20 million (6%) is not solving the problem.
    We will keep kicking the can down the road till the time comes for a National Healthcare System similar to the rest of the world to save us from ourselves.

  38. Edward Amame says:

    Eric Newhill
    My understanding is that erasing “state lines” would probably result in the young/healthy purchasing plans in states that are cheapest (with fewest regulations), etc, turning states with better plans and more regs (and higher prems) essentially into higher risk pools resulting in higher and higher prems for the old/sick.

  39. Edward Amame says:

    Eric Newhill
    As you suggest, only the older/sicker would sign up. Which is
    the ACA can’t work w/o a mandate.
    You’ve identified the problem of private insurers pulling out of the exchanges. In some states there may be only one insurer participating, which kills competition/raises costs. The public option would increase coverage/create more insurance competition.

  40. different clue says:

    Eric Newhill,
    I am just a layman here, obviously. My understanding of the Canadian system is that the health work and delivery itself is Private and it is the Coverage which is Unitary and Tax-Funded and Government-Administered. Am I entirely wrong about that? Wrong in particular parts?

  41. different clue says:

    Eric Newhill,
    I think part of the “best thing” about electing Trump is that all kinds of people who never used to discuss things like “economics” and “money” and “monetary policy” are beginning to try learning about these things and discuss them deeper and deeper.
    I read somewhere that during the 1810s and 1820s and into the 1830s in this country, that spreading and deepening economic distress lead to spreading and deepening efforts by lay citizens to understand these things and discuss them enough to try affecting them through politics and policy. And I think a growing number of citizens are starting to replicate that process today.
    Even if nothing else has changed at the end of Trump Term One, more people will know more things about more stuff than what people know today.

  42. Eric Newhill says:

    Thanks Walrus.
    I was most impressed when I studied the system with the cost/benefit analysis that is performed to a) decide whether or not a drug or procedure will be covered and b) if covered what the covered cost would be.
    I hope your partner makes a good recovery and receives a clean bill of health.
    The breast reconstruction not being covered – that’s what I’m talking about. A good example. In the US, it would be covered. That’s why I keep trying to tell people that socialized medicine won’t be what they think it will be. Rationing will be a feature and Michael Moore will still have plenty to rabble rouse about.
    Question to you – how do you diggers keep your politicians from stumping on a platform of less rationing? I am certain that would be the case in the US. Are you people just more hard nosed realistic?

  43. LeaNder says:

    All with big financial interests and lobbying money to toss around.
    doug, that’s what it looked like to this outsider. Oh, my friends in the PR/marketing business must have experienced a real bonanza, I thought at one point. It is palpable when the same slogans and arguments appear everywhere. Camp Obama woke up much too late asking for sponsorship support in the field. At that point I unregistered. They should have known better.
    On the other hand our own ministers are visibly using more and more PR to dress up their work. Public media starts to pay attention too, lately. The difference is they use their own budget. And no, I never looked it up if or to what extend it shows, or is otherwise dressed up. … But that is only a part of a larger topic.

  44. fanto says:

    the American College of Surgeons in the 1990´s also favored single payer system, but it was put in place by the AMA, which was against it. I don´t know the real behind the scene maneuvers which led to ACS switching side.

  45. LeaNder says:

    Could you clarify the last paragraph before “However … and “bunk and hot air”, Eric?
    I recall your earlier struggle here now.

  46. TV says:

    Obamacare was designed to fail (not too hard to do either, since it was mostly written by 25 yr. old staffers).
    The Dems thought that once it failed the only solution would be their 50 year long wet dream: state-run rationed “care.”
    Once you have control over a population’s health “care”, then you got ’em by the balls.
    And THAT is really the Democrat wet dream.

  47. Valissa says:

    I agree with Col. Lang that moving on to tax reform is a better strategy. I have long had concerns about whether the Republican leadership in the congress would actually support Trump and his objectives. Some of them of them don’t want him to succeed any more than the Democrats do, which is obvious from the dynamics of the attempt to create a viable “repeal & replace” strategy.
    Trump’s preference for noisy and direct action and actually trying to accomplish things is antithetical to the norms of the political establishment of both parties. Plus, he’s an OUTSIDER. His chief of staff Priebus has no congressional experience, and it doesn’t appear that Pence is trying to help out on this. So who does Trump have in his corner, who has deep knowledge of how congress works, to move his agenda along?
    I recently came across this very entertaining and informative short talk by Tucker Carlson at a Firefighters conference. In it he makes the point a few times that that the Republican Establishment in DC hates Trump and not helping him succeed in congress. I highly recommend watching this!
    The full video is ~35 minutes, but Tucker’s talk is only about 15 minutes or so. The rest of the time is Q&A, which is also very informative and worth watching.
    WOW: Tucker Carlson GOES IN on DC Politicians, Says They Hate Trump @ IAFF Fire Fighters Conference https://www.youtube.com/watch?v=t2dct9ErA_g
    OT Bonus link, to start off ST. Patrick’s Day toasting 🙂
    Congress Demands Investigation Into Obama Admin Meddling in Foreign Elections. Obama admin gave taxpayer money to Soros to spark leftist political revolution http://freebeacon.com/politics/congress-demands-investigation-obama-admin-meddling-foreign-elections/
    A group of leading senators is calling on newly installed Secretary of State Rex Tillerson to immediately launch an investigation into efforts by the Obama administration to sway foreign elections by sending taxpayer funds to “extreme and sometimes violent political activists” that promote leftist causes, according to a copy of the letter. The lawmakers disclosed multiple conversations with foreign diplomats who outlined active political meddling by the Obama administration’s State Department, including the use of taxpayer funds to support leftist causes in Macedonia, Albania, Latin America, and Africa.
    I just bought a bottle of Glendalough Single Malt Irish Whiskey for tomorrow, but decided it’s already after midnight in Ireland so I’m good to go.

  48. Jack says:

    Fascinating reading all your points of view.
    IMO, Richard and Eric get it. VietnamVet notes an important FACT, that we spend DOUBLE per capita on health care than any other OECD country. Walrus alludes to how Australia is able to provide health care for all its citizens while spending half of what we do per capita.
    Obamacare, Ryancare, Medicare and Medicaid WILL collapse financially within at most 2 decades unless the elephant in the room – COST and the growth rate of those costs are not brought down. This is grade school math. Over the past several decades health care expenditures have grown at 8% CAGR. Doubling every 9 years! Medicare and Medicaid consume a THIRD of federal government expenditures, around $1.19 trillion. The ratio of healthcare expenditures to GDP is also twice the other OECD countries.
    Think about this for a moment. If our per capita expenditures were similar to Australia, Canada or Germany, then our expenditures would be half. We’d have no problem covering every citizen. But…who takes the hit when medicare expenditures are CUT in HALF? Clearly, those making out now are gonna fight that tooth and nail. Yes, identical pharmaceutical products cost 10-20x here relative to Canada. Identical procedures using identical equipment cost many times what it costs in Germany.
    Single payer will not fix this cost differential and cost escalation as we’ve seen with medicare. It’s no magic bullet unless it’s payouts are reduced significantly. That means rationing. Just as Walrus described how it works in Australia. Caps on benefit payouts. Caps on treatment options. Waiting periods. Now tell me which politician is gonna cut medicare expenditures in half to make our costs the same as Australia? It is sheer delusion that we can spend twice per capita and double that every 9 years and keep that going for another 50 years.

  49. sillybill says:

    In most other markets and industries in the capitalist world acceptable balances (which we call a ‘good price’) are found between buyers and sellers, makers and users. One of the fundamental conditions that lead to this happy state is the ability for either party to walk away. We can decide not to buy a car, or not move to that bigger house, or go to community college instead of Princeton.
    Medicine doesn’t work like that. We can’t NOT do all we can for our loved ones. We don’t have the freedom to just walk away from the ‘deal’.
    I’ll happily take the ‘Ford Taurus version’ socialized plan. Wealthy folks can have the gold plated Mercedes version.

  50. ISL says:

    Dear Colonel,
    While I was on a big institution plan, I had to get an MRI, and the bill as 2400 with 600 deductible. Instead I paid cash $450. Where did all the extra money go? To arguments between the doctor and insurance company who ended up paying $900. Our system is absolutely assinine.
    I now self-insure a wrapper plan on a bronze plan and cover all my employees COMBINED (we are a small tech shop for the same as what I had to pay from my account for the aforementioned insurance plan (pool size was 15000) with the same features. I repeat, our system is assinine and if obamacare doesn’t die soon, it will kill the US economy. Under what scenario can we have a functioning economy with 20 or 25% going to healthcare while all our competitors are 8% or less?
    All Trump has to announce is the system we have is rationing, and in Trumpcare (aka medicare for all), the same plan you have now will not drive you into bankruptcy. For those (or employers) with the cash, full coverage plans are available at nationwide negotiated prices. Trump has indicated in the past he is okay with single payer. It would consign the Dems to the wilderness for many many years, and be the best thing for US Businesses to grow jobs in the US.

  51. Jack says:

    Here’s some data. Look at the trend. Does it seem sustainable over the next 50 years? Are we getting value for the increased spend?
    Year: Federal govt spend on healthcare as % of total federal govt spend: federal govt healthcare spend as % of GDP
    1970: 6.6%: 1.13%
    1980: 10.3%: 1.93%
    1990: 14.2%: 2.6%
    2000: 24.5%: 3.4%
    2010: 31.1%: 5.5%
    2015: 38.6%: 5.73%
    If we do ONLY one thing. That is bring our healthcare costs in line with other OECD countries. It will dramatically change the finances of federal, state and local governments as well as make our companies so much more competitive.

  52. walrus says:

    @Bobo. The biggest achievement of the American healthcare industry is that it keeps debate focussed on how you pay for healthcare and not on the absurd absolutely outrageous prices they charge for treatment.
    I was told years ago that an anterior cruciate ligament reconstruction that I needed as a result of a skiing accident would have cost $25,000 in the U.S. Mine cost me a total of about $150 in Australia – and the guy that did the operation also used to treat American football players who were sent over to him from the West Coast.

  53. b says:

    If the Republicans were smart they would replace ACA by a Mandatory Universal Minimum Health Service that would cover basics and emergencies at *regulated* service- and medicine prices through private AND state service providers (hospitals, doctors).
    Everyone would also be pointed to the additional products of the private health industry which could cover all the “nice to have” medical service and medicine stuff one could think of. Think of three possible packages, silver, gold, platin. These would always be on top of the mandatory universal basics (iron-care).
    Mandatory basic insurance will NOT give you nice shiny teeth but you also will not die from tooth infections. Basics covers amputation and crutches but not protease (except where medically absolutely needed). The basic hospital rooms would be three or four bed per room with no choice to eat except the standard meal.
    The additional voluntary private insurances (when contracted) could cover shiny teeth, high tech protease, single bed rooms and a la carte meal services.
    With the successful introduction of such a universal BASIC service the Republicans could win elections for the next 30 years.
    Unfortunately the people in Congress only think of the very next election and the very next donation (aka bribe) from the various industries. Would they think of (more profitable) long term rule this would be a no-brainer. Trump could certainly punch this through if he would put his energy to it.

  54. The Virginian says:

    I am not Australian, but just recently moved back to the US from Australia. While I defer to the health care policy analysts in the group, what I can certainly say is that I now pay higher medical bills for consultations, emergency room care, medicine (reduced choice unless I go outside my US plan, but then even higher costs) and pediatric care (two kids). And while in Australia I was, as a permanent resident, able to use the general Australian Medicare system – no private coverage was really needed from my perspective.

  55. Edward Amame says:

    Eric Newhill
    According to the Kaiser Family Foundation:
    “We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C). Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation most people (53%) report that they or someone in their household has a pre-existing condition.”
    “The rates of declinable pre-existing conditions vary from state to state. On the low end, in Colorado and Minnesota, at least 22% of non-elderly adults have conditions that would likely be declinable if they were to seek coverage in the individual market under pre-ACA underwriting practices. Rates are higher in other states – particularly in the South – such as Tennessee (32%), Arkansas (32%), Alabama (33%), Kentucky (33%), Mississippi (34%), and West Virginia (36%), where at least a third of the non-elderly population would have declinable conditions.”
    According to this 2001 Kaiser Family Foundation study:
    “Regulation of individual health insurance coverage is largely under the jurisdiction of states, and most have taken some action in response to these access problems. Many states have enacted high risk pools to make coverage available to residents when carriers turn them down or offer substandard coverage. These programs offer an important health insurance option to people who are otherwise unable to obtain private coverage. However, state high risk pool coverage is always more expensive than comparable private insurance policies. In addition, many states restrict covered benefits or
    cap enrollment in order to hold down pool costs. As a result, only about 100,000 individuals are enrolled in state high risk pools nationwide, raising questions about whether state high risk pools, as currently structured, are equipped to offer a meaningful coverage option to all those who may encounter barriers in the private individual market based on the results of this study.”
    “…Inability to afford coverage is the primary reason why 43 million Americans are uninsured…”

  56. Dr.Puck says:

    “I have seen too many such stories that are pure BS from the likes of Michael Moore and his ilk writing in Mother Jones, Daily Kos, etc.”
    These are BS because you researched and falsified their underlying claims, or, alternately, you respect your hunches so much on such matters that you’re confident all such claims are always in every instance dubious?
    What neutral and social scientific evidence would you accept as proving in the positive or negative that persons with pre-existing conditions would not be able to find any coverage whatsoever under the market conditions prior to the ACA?

  57. Edward Amame says:

    Eric Newhill
    Also, the 20 million + figure comes from here and includes people covered under the ACA’s coverage provisions between Medicaid, the Marketplace, and young people staying on their parents plan.

  58. Eric Newhill says:

    Insurance companies do not take 30% of premium pay-in as profit.
    I wasn’t going to comment any more on this thread, but I feel compelled to correct that statement. That kind of misinformation obscures the true nature of the issues.
    Insurance companies that are for profit are running at around 80% to 85& medical loss ratio. That means that 80% to 85% of what comes in by way of premiums goes right back out the door to pay for claims (medical cost). The remaining 20% to 15% isn’t all profit. Administrative costs are in there too. Even the government has administrative costs. No savings opportunity on that.
    I guess you maybe didn’t read what I said about how insurance companies take profit, but create savings well in excess of what they take. Savings of 40% to 50% on contracting (e.g. the hospital bills $10,000, but the contract reimburses at only $5,000 – that savings is passed along to the member in terms of lower premium). Savings are also realized through utilization management (approving only medically necessary and medically effective treatments), care management (ensuring that clinically at risk members are receiving the care they need – e.g. did the diabetic fill a prescription? If “no” contact member or physician), Fraud detection and other activities.
    What of the Blue Cross/Blue Shields that are not for profit? The run at around 90% MLR and 8% admin cost. Their premiums cost the same as the for profits – though usually the benefit structure is a little richer. It’s always fun for socialist ideologues to target for profit capitalists, but they always close their eyes regarding the not insignificant presence of the not for profits.
    You can tell me that the government could do all these things too. I haven never seen the govt do it nearly as well. It’s not incentivized. The private companies must do it to keep cost down so they can compete. But the larger point is, healthcare coverage doesn’t cost too much b/c of insurance companies gouging members. It is because healthcare services are really expensive. This must be understood first and foremost if there is to be a viable solution.

  59. Eric Newhill says:

    I’d like to hear from you an answer to the same question I ask Walrus. That is, how do Germans and Australians have politicians and a public willing to accept the basic/rationing approach to healthcare whereas in the US, politicians avoid the topic as much as the public. Is it cultural? If so, what do you see as the difference in culture?
    I should ask the question pertaining to doctors. In the US it is the doctors and other providers that fight affordable healthcare (somehow they have been very skilled at hiding their activities and putting the focus on the cost of insurance). How is it that German/Australian doctors are willing to focus more on being healers than seeing their practice as being a path to riches? Cultural?

  60. Matthew says:

    Nancy K: If we wanted an intermediate step, we need to address two profound irrationalities in our system: (1) we spend way too much for end-of-life care; and (2) we need to obtain bulk discounts for prescription drugs.

  61. Eric Newhill says:

    Edward, How would it increase coverage and create insurance competition?
    With respect, you’re in way over head here and you just repeating talking points from google searches. And the talking points you’ve selected are leftist fantasies and magical thinking.
    Are you aware that the ACA set a limit on MLR? Insurance companies, by law, must run at 80% MLR or higher. Within that remaining 20% are admin cost. So competition would be for what? 10%? 10% on a $1000 policy is $100….affordable now? But, in reality, no company is going to enter the market to compete for business where there is no profit opportunity.
    Why would people sign up for the public option. If they can’t afford Obamacare, how would they afford the public option? That whole fantasy is premised on the belief that coverage is so expensive because private companies are gouging profits. How many times do I have to repeat myself to relieve you of that false belief?

  62. Eric Newhill says:

    “While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting…”
    So you’ve snipped some material of unknown context that then hints that’s it’s all hypothetical numbers juggling.
    If you’re so sick that you can’t work and your spouse doesn’t work so you can be on his/her plan as a dependent, then you’d be on public coverage.
    I’m not going to chase down every curve ball you try to toss. Believe what you want. If your beliefs include the idea that I am here lying to you or that you know more about this subject than I do, then pat yourself on the back and smile at yourself in the mirror. You’re a true social justice warrior hero.

  63. Norbert M Salamon says:

    What you describe is similar to Canada’s and from what my daughter says it is similar to Spain [she lives there] in many respects. Other countries in the EU also have similar plans.

  64. Eric Newhill says:

    For the first two years of the ACA there was a reinsurance program wherein the federal government would reimburse the insurance company a % of expenses for any member that incurred more than $45,000 in medical expenses. Last year that amount moved up to $90K with a $250K cap. That program does not exist in 2017. There is also a program that reimburses a company for taking on riskier (or sicker) members. The risk level is calculated by running diagnoses and procedures from members’ claims through an algorithm developed by the government. It a major pain in the neck, but it results in some money back from the feds. I am saying that if the reinsurance program were brought back, and at the $45K level with no cap and the reimbursement for risk were increased, then maybe the ACA could stagger along for a longer time. However, I do not think these things will happen because it is too costly to the feds.

  65. Fred says:

    Erasing state lines increases the power of the Federal government and if it is done here it can be done with any other facet of government. There is no way the states are going to accept that. It would require a constitutional amendment to eliminate the states as sovereign entities.

  66. confusedponderer says:

    “although I think Trump is the best thing that’s happened in US politics in a long time”
    Actually Trump is the perhaps baddest thing that happened to the US recently. Trump not that long ago said that it was the greatest US error in fighting in Iraq TO NOT USE nuclear weapons. He likes nukes.
    Trump tolerates neo nazis like Spicer without having problems or wisdom collating with his grand decisions. And having to watch Trumps demonous hairdressing causes me sickness.
    Worse – Trump has access to US nuclear weapon codes and he thinks they could and should be used, say, at whim. If Trump ever decided to use nukes, he actully could do it rather easily. May the Lord protect the US from Trump going full mad and ever ‘use the nukes’.
    The US would be well advised if they investigate Trump for his brazen and blatant tax evasion, they should confiscate the money he owes the US taxpayer and, alas, kick him out of an office that he cannot (and shouldn’t) have with a criminal record. Sweeny – bonus after bonus.
    When being at it, the US could do another well deed and just cut Trumps abolished hair also. He would remain who and what he is, but at least he’ll be less ugly.

  67. Sylvia D says:

    @ Eric Newell
    The 30% figure includes both the overhead costs of the Health Insurance companies themselves AND the overhead costs to the providers who have to deal with these companies both to file the claims and to fight to get paid. This is above and beyond “profits”. I will readily admit that I see no real viable role for health insurance companies in the provision of basic health care. Maybe I’m wrong. HR 676 would make it illegal to sell insurance on any covered item.

  68. It is clear that President Trump is a lightweight when it comes to governance. As is most of his team. Paul Ryan even lighter. And the DEMS lightest of all IMO!
    Did potential appointees not know that Cabinet government destroyed long ago by operations of the White House Personnel Office?

  69. Tosk59 says:

    Simply trying to reducing the cost of healthcare is not the answer; the $$ spent there need to be redeployed and spent on items that effect the social determinants of health. Yes, the U.S. spends way more on healthcare than most other countries, but it simultaneously ‘shorts’ social spending.

  70. Eric Newhill says:

    Under a federal socialized system the providers would still have to file claim forms, request authorization to render certain treatments. You know there are only two claims forms – one for facility and one for professional – that have to be filled out and both are electronic. All companies and the feds use the same two forms.
    Yes, there are coders that take the diagnoses and procedures ordered by the physician and translate these into ICD-10 and CPT/HCPCS. Guess what, the feds demand this too for Medicare. In fact, the whole coding scheme originated with and is demanded by the feds.
    I always hear physicians gripe about the huge cost of hiring an office staff to code and fill out the forms. Tough! I know what profit margins and levels are for various practices. I have no sympathy. They are making plenty of money, even in small town family practices.
    Main point is that these practices are not doing anything for insurance companies that they are not also doing for the federal and state programs. Most of the arguments over payment are because they did not follow the rules and get pre-auth.s , etc.

  71. different clue says:

    First, if you are the same confusedponderer from before . . . the one who put up all those pictures of leaders and asked us to guess the fake . . . it is good to see you back.
    Second, I wonder if Trump is more likely to generate a big H-bomb exchange than Clinton would have been. Clinton after all supported several policies and policy choices which would have brought American and Russian forces into open shooting conflict with eachother. Such as forcibly establishing a no fly zone over Syria in order to rescue and support her beloved Cannibal Liver Eating Jihadis.
    If we get the big nuclear war which I voted against Clinton to save myself from, then my vote for Trump will have all been for nothing. If we finish the Trump term without a nuclear Temper Tantrump, then I will feel that our survival has vindicated my vote.
    I also wonder if Trump really evaded any taxes. My understanding is that he took full and fully legal advantage of tax laws written for people up at his economic class level to be able to take advantage of.

  72. different clue says:

    Eric Newhill,
    Does the Canadian government do it not nearly as well?

  73. different clue says:

    How much of the cost of health care in America goes to spending on heroic treatment in the last few months or weeks or days of life? On keeping the semi-dead body just semi-dead after the medical futility threshhold has been reached and passed?
    If final death-agony prolongation were replaced with hospice-care for good last days and decent death, would major savings be realized in return for not prolonging final pre-death where nothing but final pre-death remains to be prolonged?

  74. walden says:

    I am not b but, at the risk of sounding starry-eyed, I believe most voters here in Canada accept the necessary trade-off between universal coverage and high-cost but non-essential medical services because they have less tolerance for social inequality (than does the U.S.)This is probably true in Europe also.
    So in that sense I’d say it is cultural. That, of course, may change over time but public support for our health care system is strong. It also helps that the amazing media stories we read and hear about the U.S. health care system serve as Awful Warnings.

  75. MRW says:

    Excellent Tucker Carlson video. Since I happen to agree with his observations, I heartedly suggest everyone watch it.

  76. Croesus says:

    Agree fully with #1, “We spend way too much for end-of-life ‘care.’ Most of my immediate family is dead; I witnessed their last days, even having to decide the date and time that a sibling’s life support was to be terminated — after 35 days in private, intensive care. Combined, my deceased family consumed in medical expense in the last 2 months of their lives about twice as much as they earned in their long lives — 84, 85, and 70 years. We need to come to grips with the reality of our own deaths, that living is finite and technology cannot really extend it but only delay for a very short time the inevitable.
    I would either add, or substitute for #2, that many Americans do not take basic responsibility for their health/wellbeing: how many health care dollars are spent on diseases exacerbated by profoundly bad personal choices, like consuming sugared drinks by the liter?
    Additionally with respect to #2, re prescription drugs — hasn’t the use of prescription drugs gotten way out of balance with other forms of healthy living choices, and is that imbalance market- or capitalist-driven rather than a genuine contribution to healthy living?
    Finally, but actually, at root, the discussion is distorted because the language is distorted: “Affordable Care” is not about “care,” or “health,” or “medicine,” it addressed affordable [sic] insurance. Elana Kagan insisted that means of paying for “health care,” i.e. insurance, was synonymous with “medical care,” but I find the argument bogus.
    Thus, the very first thing the Republicans AND Dems must do is start to speak honestly with the American people and among themselves; fire the PR agencies and speech writers and communicate the basic facts of the situation.

  77. Croesus says:

    Wouldn’t erasing state lines create a nightmare for enforcement and dispute resolution/litigation of health insurance related issues?
    My 101-level understanding of insurance was that such matters were the province of state governments, to define, regulate, resolve and litigate.
    If Aunt Sue in Massachusetts is denied a claim for her emergency appendectomy in a hospital in Florida by her Idaho-based insurance carrier, must she travel to Idaho to protest it? Would insurance companies operating in multiple states be required to establish physical offices in each state? How would that reduce costs and produce competitive advantage?

  78. steve says:

    “I know for a fact that pre-existing doesn’t get you turned down at the BCBS or for profits I have worked for.”
    Absolutely untrue, at least where I live and work. As someone who has been in the field for nearly 50 years, I have had many patients turned down. I have had family turned down who died while waiting to get into a high risk pool. I know parishioners at our church who have been turned down. I have had this conversation with our insurance broker (took care of his wife) and he has acknowledged there are people they won’t insure. Maybe if you are in New Jersey or New York where they have weird rules it doesn’t happen, but it sure does in other places. Link goes to study of pre-ACA declination rates.
    And at the personal level, next link goes to article by Matt Welch who edits the libertarian online mag Reason who describes his rejections.

  79. steve says:

    That may have been his vision, but the plan was written by Ryan and company. They never had any intention of covering everybody, just cutting out the taxes that were in Obamacare and cutting, eventually, Medicaid.

  80. Edward Amame says:

    Eric Newhill
    Tough? You really lost me with that. Dealing with multiple insurers, each with their own forms, and requirements, etc isn’t gonna jack up admin costs?

  81. steve says:

    T R Reid’s book, The Healing of America has the best description I have seen of the French health care system. One of the nice parts is that you can carry your history around with you on smart card. You can present that to your doctor when you see one so they have complete access to your history. All prices for procedures must be publicly displayed where the patient can see them. When done, they bill you directly through that same smart card. Very little overhead for doctors and little paperwork for patients.

  82. Eric Newhill says:

    Why did they not have insurance before they got sick? Why do they or a spouse not have insurance on which the sick person is a dependent? In employer based insurance a pre-existing condition will not get you turned down.

  83. Eric Newhill says:

    Sometimes I question your reading comprehension. I just said, above, that each insurance company does NOT have its own forms. The forms are standard, electronic and are the same as used by the federal government 1 for facility claims and 1 for physician claims.
    But maybe you’d like a situation where doctors and hospitals just do whatever they want and ask to be paid. Would you take your car to a mechanic and just let him tell you that he fixed it and hand you a bill without telling you what he did and how much it costs?
    You want healthcare costs to really sky rocket, then, by all means, remove all responsibility from doctors explaining what they’re doing and why and how much it costs.
    Part of doing business is submitting invoices to customers. If doctors and hospitals can’t handle that, yes,! tough.
    But go ahead and enlighten me as to what all these various forms that you imagine are

  84. Eric Newhill says:

    You hit the nail right on the head.
    The dam is breaking and everyone is stuck on blaming the fish that swim in the reservoir. Maybe if we replace catfish with trout things will be better.
    No one looks at the volume of water.

  85. Eric Newhill says:

    Thank you Walden.
    I would really like to hear more perspectives like that. The US system is great for the employed. It works well for veterans with VA benefits, the poor on Medicaid and seniors on Medicare.
    This whole debate pertains to a minority of people in the US who slip between the gaps in these systems. However, it is seized upon by ideologues who want socialism generally and by the self proclaimed defenders of capitalism.

  86. Eric Newhill says:

    Different Clue,
    A not insignificant amount – maybe 13% in non-Medicare plans.
    However, it depends on how you define end of life. A lot of cost related to the ACA is people with renal disease, especially at end stage, who are on dialysis and related expensive drugs three or four times a week. These people would die without the treatment and they will die in a few years even with treatment if they don’t get a kidney transplant.
    Another big driver of ACA cost is cancer patients on chemo. Many of these will not survive even after long anguishing treatments.
    Chronic cardiac conditions are in there too. These are also usually fatal in time.

  87. Eric Newhill says:

    Why weren’t they then on Medicaid or Medicare (if > 65)?
    Why didn’t you render the care for free? Are you a profiteer?
    What were the diagnoses? Something terminal?
    No group plan would turn down enrollment for pre-existing conditions. I have already said that some carriers would turn down an individual. Others would not – unless the member has a very serious condition chronic condition or near terminal.
    Where is personal responsibility in all of this? People with no savings for emergencies. No job. Somehow not qualifying or enrolling in public health like Medicaid waiting for insurance until they are already sick – your story begins to sound like a sad fish story.

  88. Cold War Zoomie says:

    “I have said before that I personally favor a single payer system like that of Canada or France.”
    I can’t speak to either of those countries, but I can say that the British NHS was OK. But Eric is right, Americans would need to accept basic care through the socialized system. My memory (and it’s been 20 years now!) with the NHS was that everyone got something like 95% of the care they needed. It was the 5% – high end, expensive, cutting edge treatments – that patients either paid out of pocket for in the UK, or travelled overseas to get. And companies offered private health insurance for boutique practices. Believe it or not, back then GPs still made house calls!
    A friend of mine was in the ICU for about a week after a motorcycle accident, and he had a nurse standing next to his bed 24/7 along with every other patient in there. I’ve never seen that level of care here.
    I always viewed the NHS like the care I got in the Air Force. Just the right amount when you needed it.

  89. Edward Amame says:

    Eric Newhill
    OK, so forget the effing forms. Health care staff still have to know the scores of different insurance plans each insurance company offers inside and out. Hence apparently the need for armies of staff to cover all that right? All for intermediaries to take $$ in and then pay it out while taking a cut for admin and in some cases, profit. Thanks to the ACA, as you pointed out earlier, at least now 80% must cover health care costs. What do we get for that other 20%? Help controlling costs? Efficiently delivering healthcare? Quality control? How often do insurance companies screw up claims and deny coverage? Does prior authorization for prescription meds = savings? Sorry, but this is the one of the stupidest systems on the planet and comparisons of health care costs country by country proves it.

  90. Eric Newhill says:

    The Canadian system also requires coding of claims and claim submission just like we do. I hired an IT guy from Canada once and we’d talk about these things as they related to data. Edward has offered up another red herring.

  91. VietnamVet says:

    Astonishing. I agree with everything that Fox’s Tucker Carlson said out loud. He describes what is happening in America but is not broadcast by the rest of corporate media. How could anyone think that destroying the Middle Class in the USA will turn out well? Unless, that is how they are cashing in.
    Hospitals and pharmaceuticals are two of the profit centers extorting money from the little people who have no alternatives.

  92. Farooq says:

    Healthcare insurance industry is not all that bad when it comes to technology standardization. HIPAA standardized a lot of information exchange via EDI standards and formats. It is commonly believed in healthcare insurance industry that it has saved billions of dollars since its inception in 1996. They also have a widely used canonical data model to support information systems in HL7.
    Last time i was doing a gig for healthcare insurance industry, we had to design information model for Accountable Care Organizations (ACOs) which were created as a result of ACA (sec 2706).
    I found it to be a pretty good idea and at least at that time the healthcare industry was all in embracing the idea. The basic idea is that providers part of ACOs sign up to get paid on the basis of medical outcomes instead of frequency of procedures and tests that are part of medical encounter. I am guessing this will most probably be taken to shed and quietly buried with the rest of ACA.
    One more thing to notice is that insurance companies had other reasons besides pulling out. At least in one instance a judge found that one of the biggest insurance company lied about why they were pulling out:
    By the way now that the merger referenced in above news has fallen apart, the same company supposedly cutting loses by pulling out of exchanges will be paying – wait for this – 1 BILLION dollars in breakup fees.
    These guys literally gambled 1 billions dollars on a merger that didn’t go through. I have seen stuff like this when it comes to technology projects throughout this industry. Programs are initiated, projects are launched, products bought, resources are hired, savings are claimed that will accrue as a result of these efforts and nothing really comes out. These programs get shelved, rolled back or keep getting delayed like a slow death march. There is no accountability for such stuff and you can bet that all these costs are passed on the the consumer.
    Fun fact: HIPAA was co-sponsored by an evil democrat Edward Kennedy and centrist republican senator who will most probably be called cuck***ive by the usual suspects today was she alive. It was signed into law by Lucifer, Bill Clinton himself.

  93. Bobo says:

    Your correct on that and I expect in a year or two the politicians will get around to that area and will make some but not enough headway. Just tell an American Hospital or Doctor that single payer is around the corner and they will get their act together. The real problem as mentioned by others is cultural as the American consumer has been spoiled with 24/7 availability of health care, this will be a hard fight.
    On the good side one of my children came home from working overseas and took a six month hiatus without health care and got caught. He had some problems and was diagnosed with an aneurism that fortunately turned out to be something that needs to be monitored. Visits to family doctor, cardioligist(s) and numerous tests got a good answer and each practitioner worked with him financially and his total bill was less than $1,000.00 which we all were thankful for. They do have a heart.

  94. Laura says:

    Edward Amame–You are correct that the Dems would be happiest if efforts to sabotage stopped and efforts were made to improve. That is, if by Dems, you mean all Americans who use the healthcare system. Could we please STOP thinking about the damn parties and think about the American people. The citizens of this country who need access (ie. insurance) to affordable health care in their communities–wherever those communities might be.
    What is wrong with us that we tolerate a Congress that no longer cares about the people (not the corporations) that live in their districts? We all need to talk about the people of the United States and never forget them.

  95. Laura says:

    Dr. Puck — Vision without knowledge is hallucination.

  96. Laura says:

    Eric, I think that the way the NZ system works is that everyone has a good solid Ford but can buy (fairly inexpensively) a rider that gets them to Cadillac status. Price insurers still have a role—sort of like Medicare supplement. Is this how Australia does it as well?

  97. Nancy K says:

    Of course they can find coverage, they just would not be able to pay for it as the cost would be astronomical. Insurance companies do not provide medical insurance out of the goodness of their hearts. There is no goodness involved, it is all about profit.

  98. Nancy K says:

    I agree completely.

  99. Edward Amame says:

    Eric Newhill
    Seriously Eric? The reason we can’t have nice things in this country is because lobbyists and the insurance industry and hospitals have a lot of ’em. As Dick Durbin once blurted out in a frustration to a radio reporter as to why banking reform couldn’t pass after banks nearly blew up the world economy in 2008, “…they frankly own the place.” People blather on about the “deep state,” the real deep state is the “corporations are people too” who are really running the place.

  100. LeaNder says:

    Get it. Once worked for a man heading a unit we call Controlling over here, in pseudo-English. Insurance company. Comparable to your management control. A mathematician. And a lady heading accounting. … Meaning a lot of what you write about sounds vaguely familiar.
    Obviously our statutory health insurers (Social Code, chapter V, SGB V) cannot have your problem. Its a collective system. I probably wrote this before. If you prefer to save money and chose a private insurer, plus miss the chance to get back in time into the public system your rates increase accordingly. Maybe to rates you don’t like?

  101. Eric Newhill says:

    There’s the insurance lobby, there’s the AMA, there’s hardcore capitalist/free market ideologues and there’s leftist/socialist ideologues. These are all competing forces. The USA is a big diverse country. So lots of different ideas about how things should be done and lots of competing interests among the population itself. I thought you liked diversity.
    We do have nice things in this country. If you’re employed either in the private or public sector above the level of hamburger flipper, you’ve got coverage and access to the best healthcare possible. Far better than the socialized systems (remember Walrus’ story above about his partner’s $15K breast reconstruction not being covered – it is covered by all insurance that I am aware of in the US routinely as part of the breast cancer surgery. I’ll save you the google search. Here’s a link to a fairly typical medical policy sheet on that procedure to verify what I said: http://www.aetna.com/cpb/medical/data/100_199/0185.html).
    If you are poor in the US the coverage you get under Medicaid is at least as good as the socialized systems (as far as I can tell).
    If you’re a senior citizen and you paid in even a small amount over the course of your adult life, you get Medicare, which is pretty darn good.
    Retired military have a pretty good VA system to access.
    Getting back to the hamburger flippers and the uninsured generally, these are mostly young people who really do not need insurance. They’re healthy. At most they are going to incur an emergency room visit for a broken leg or something similar. The money they saved by not paying for insurance is far greater than the money they would spend on the broken leg out of pocket. The hospital will put them on a payment plan. Having a 26 year old on his parents’ plan is not a huge accomplishment. That 26 yr old is not likely to incur anything expensive.
    So this whole debate is over 1. some small group of people who do not have insurance and somehow do not qualify for Medicaid or Medicare and who are also very ill. This is probably 5 to 7 million people. 2. People like you that a) generally hate capitalism and are prepared to attack it at every opportunity and who knee jerk to wealth redistribution as a solution to all societal issues b) Have been made to believe a bunch of bunk about public options and other magical pixie dust that going to make healthcare affordable c)Are willing to, for reasons of “social justice”, cause all the people that drive the Cadillac to drive a cheap Ford and pay for the same Ford for, yes, that 5 to 8 million and also for a lot of people that don’t really need it (e.g. the 19 year old burger flipper).
    I already stated that I am all for a socialized system in the US if the people (the Cadillac drivers) were made to understand what they would be giving up and what they would be paying to benefit others. Talking to you makes me think that that condition will never be met. You seem hell bent on finding reasons to convince yourself that removal of the insurance model and nothing more will result in lower costs and the same care. You’re wrong as wrong can be. Unfortunately, when I listen to the Democrats in office, they appear to be pushing the same line of thought. Therefore, at this time, I am opposed to socialized medicine. Socialized medicine **at the level of care and price offered by the providers** would sink this country financially.
    On its current course, Obamacare is going to die at the end of 2018. People won’t pay for the premiums unless they are very sick.
    Companies won’t carry it any longer.
    Trump and the GOP have offered nothing so far that appears reasonable and they should back off and let nature take its course and let Obama take the hit – except that is not what Trump promised. So now he is stuck with making a show of things. We’ll see if he can weasel out of this. It’s doubtful, though.

  102. Edward Amame says:

    Col Lang
    If I were Trump, I would let Obamacare die a seemingly inevitable death and move on to tax reform.
    Aha! ACA repeal first looks like it’s probably Ryan’s game plan, not Trump’s.
    Ryan DOES want to redo the tax code and will need to do it via reconciliation (which just requires a simple majority, not 60 votes), just like how the Bush tax cuts passed. However, the Bush tax cuts expired because the tax cuts created long-term deficits and that’s against congress’ rules. Repealing the ACA repeals the ACA’s tax increases that provide millions of Trump voters and others their insurance. That’s what will offset Ryan’s tax cuts for the wealthy in a way that won’t increase the long term deficit, making them permanent.

  103. steve says:

    Your ignorance about real life is stunning, but first, yes I fully understand that with group insurance people don’t get turned down. I have had several people who work for me have major illnesses and surgeries. They don’t get turned down, our premiums just increase, though we are now big enough that it shouldn’t be such a problem. However, if you don’t have access to group insurance, you can be turned down. In that case if your spouse has a job you might be OK, but there is no guarantee. Surely you realize that many companies no longer offer family plans? You may not be able to get your spouse on the plan, or the cost may be prohibitive. If you are making about 30k a year and they want about 15k to add the spouse (real number) is that really affordable?
    Savings? Ever look up the average savings for an American household? Go look it up. Aint happening. Sure, if you make 6 figures, but again, if you are making in the 30k-40k range, not affordable for anyone except the very young and healthy. Surely you realize that lots of folks lost work in the 2008-2010 period. They went through their savings if they did have them.
    Did you ever look at the income levels needed to qualify for Medicaid pre-ACA? They varied by state, but in some states you basically couldn’t qualify if you were single. That said, for a number of states if you made more than 10k, you didn’t qualify. Personal responsibility? How do you buy health insurance if you are working but just not making enough to afford insurance.
    So get out more. Talk with real people. If there si anything that Trump tapped into it is that people who are really working, but not making lots of money, just don’t have a shot at some things. That includes health care if they cannot get it through work.

  104. steve says:

    Guys, just a reminder that insurance companies are making lots of money. Take the claims that they can’t afford to participate in Obamacare with a big grain of salt.

  105. Eric Newhill says:

    As usual, you are only looking at one side of the equation. A lot of Trump voters had coverage before the ACA. When the ACA came alive, their premiums doubled or tripled. That is why they are mad as hell about the ACA. You’re acting like they had nothing pre-ACA. Another fantasy.
    A friend who lives down the road is a professional horseman. He breaks, trains, breeds and ships (drives a truck hauling race horses to tracks) and races his own horses when he thinks he’s got a good one. This is a high risk occupation and it’s hard on the body. Before the ACA, he had a high deductible individual policy that covered him, his wife and his son. This guy has good years and bad years. In a good year, he’s making into six figures. A bad year maybe 1/5 of that. He saves money from the good years. So he’s not worried about a $10K hospital bill, but anything over $20 starts to hurt. His high deductible pre-ACA insurance cost $500/month. That was worth it to him. Now, with ACA rules, his policy costs $1,300/month. That starts to hit hard, especially on bad years.
    Another friend is in construction, single guy, healthy, a bit younger. Maybe 40. Had a high deductible plan at $350/month. Now it’s almost $800/month. He’s mad as hell too.
    These guys will be very happy to see the ACA repealed so they can go back to a reasonably priced policy that meets their needs.
    Maybe they need some time on the Amame socialist republic of Amerika re-education potato farm until they see the light?

  106. Eric Newhill says:

    Steve, they are making money off other products, not the ACA.
    The ACA is a losing product. Therefore it must be culled from the list of offerings.
    You think they should be punished for making money by having to keep a loser on their list of offerings?

  107. Valissa says:

    Eric, really appreciate all your knowledge and insight into the realities of the health insurance industry. Thanks for sharing it!

  108. Edward Amame says:

    Eric Newhill
    No, this whole debate is not over some small group of people who do not have insurance, that is part of the debate. And that “small” group of people is around 11.5 million, right? And you’re actually suggesting that 20-somethings really don’t need insurance to keep that number down from approx 20 million. Two friends of mine both survived cancer that they got in their 20s, one for testicular, the other stomach, so eff that.
    I too would support a socialized system in this country but know enough about the state of politics here in the US to know that that’s not gonna happen ANY time soon. That’s why I fully support the ACA, which IMO isn’t gonna die a natural death — it will be GOP-assisted suicide at best because it cannot work without an indy mandate and the subsidies to make it work and to that the GOP is ideologically opposed.
    Maybe the whole debate should begin with why health care in the US costs about $9,500/person vs about $4,400 in France. You pooh pooh admin costs but they’re way higher than any other country. The hospital up the street from me probably has more billing clerks than beds. We also apparently pay more for the same things than other countries, including doctors visits and prescription meds, as Walrus pointed out. What else is there? How much of that $9,500 goes towards actual medical outcomes and how much is going who knows where? And our health care outcomes any better than those in France or Canada?

  109. turcopolier says:

    Apparently you think success in business is disqualifying for participation in government. Who do you think should run the government; pro bono lawyers, school teachers and social workers? pl

  110. Eric Newhill says:

    Thank you.
    I worry that I become overbearing or a thread-hijacker when it comes to healthcare. I try not to, but there is so much misunderstanding and misinformation on the topic and I think it is important for people to get the facts right since it is such a salient issue.
    I will take this opportunity to say that I often enjoy and appreciate your comments on various topics as well.

  111. jerseycityjoan says:

    Eric Newhill:
    Since you know so much about insurance, I would be interested in your opinion on this:
    What are we Americans getting for bucking the rest of the First World in not having a national health plan of some kind?
    Would you agree that we spend a lot more for results that overall are no better — and sometimes are worse?
    I certainly will not argue that insurance companies have to make a profit to remain in business.
    On the other hand, look at all the time and money we spend on arguing about our healthcare financing system, without ever really asking ourselves if the system is worth defending or is actually doing us more good than harm.
    I have come around to the thought that spending almost $1 out of every $5 our economy generates on healthcare is unsustainable and actually kind of crazy.
    So what are the reasons we should continue on the same road?

  112. Eric Newhill says:

    There is a slew of reasons why healthcare costs more in the United States. I have summarized at a high level by saying that it is a Cadillac versus a Ford Taurus. I then highlighted an example of Cadillac versus Taurus that Walrus brought up – breast removal for reason of cancer w/ no reconstruction in Australia versus the US standard of including the reconstruction with its extra cost of $15K. I simply cannot go into all the details, procedure by procedure on a forum like this.
    I have read studies that supposedly compare procedure to procedure US versus European cost. I disagree that that these are apples to apples comparisons. Even a knee or hip replacement isn’t the same. For one thing, the US does a lot more of these, so there is a volume difference that leads to higher US cost (I use knee and hips as an example, but there are so many more procedures where this is the case). Then there is staffing. The US will have more and higher paid doctors and nurses involved in most hospital settings. Then there is the room in which the procedure is performed. The US is going to have the latest airflow mattress and super adjustable bed and the latest wireless monitoring gizmos. The European room doesn’t have these. That all costs money and the cost is passed along to the patient/insurance company. The scalpel itself, in the US is going to be some kind of super improved cutting instrument whereas in Europe they will be using an older model. On it goes.
    Back to utilization – in the US you are far more likely to get an MRI, CT scan, etc for the same diagnosis and situation than you are in Europe. You are far more likely to qualify for cataract surgery and at an earlier age in the US, than in Europe…on and on that list goes.
    I have argued that most of this latest and greatest tech isn’t providing much additional benefit for the extra cost. And I have argued that there is much over-utilization. I am defending a lot of this. Some, but not all. I think breast reconstruction is a good thing and should be done, for example.
    Why are these costs accepted in the US? A lot of reasons. One is physician culture. They won’t work in a facility that doesn’t have the latest and greatest. They won’t accept sharing MRI machines, etc.
    Another reason is that there is a fear of lawsuits. A kid bumps his head at football practice. He’s taken to the ER. Doctor thinks the kid is fine, but better do an MRI just in case. God forbid he be released without everything possible being done and develops complications at home that the MRI would have detected.
    Another reason is that the US is a wealthy country and wealthy people want to know that everything possible is being done for them or their loved ones. So tech, treatments, etc that have little marginal benefit are expended in treating them. Not in Europe.
    Another reason is that the presence of insurance caused consumers and providers (i.e. patients) to be divorced from normal economic decision making at the point of purchase. Should I go the ER because my throat is sore? Sure, Why not? Insurance pays for it. Should I purchase a new gizmo for my ER? Sure. Why not? I’ll raise the cost of an ER visit and insurance will pay for it. That mindset started way back when it could be in effect with little major consequences because there wasn’t a lot of tech. The cost consequences weren’t that noticeable. Premiums might have inched up a bit, but not enough to cause concern. However, over the decades that mindset incentivized all kinds of new tech development. Healthcare cost, and therefore premium cost, began to increase to very noticeable levels. By the early 90s we had everyone talking about it. But no one wanted to call it like it was. Instead we had the same kind of stupid that we have today. Back then it was HMOs to the rescue. Now it’s public options and ACA, etc. So a final contributor to US excessive healthcare cost is idiots that make policy without understanding what they’re doing and while being on the dole from various groups interested in keeping business as usual, most importantly the AMA and their friends in the technological development and sales arena.
    That is why healthcare in the US costs about $9,500/person vs about $4,400 in France. I agree with you that that is where the debate should start and I have been saying that throughout this thread. For what you want to happen, you are going to have to tell all the doctors and hospitals and patients as well as the purveyors of all the tech that it is now cut off. The Cadillac experience is over.
    The fact that I keep saying this and you can’t process it is highly concerning. You’re not the only one. I have this conversation with a lot of people and they all get stuck on blaming the insurance companies; certain that they are artificially inflating costs. Michael Moore-itis very catchy stuff in some circles, I guess.
    And yes, most people are better off without the level of insurance coverage they have today, perhaps even no insurance. In a normal commercial population, 3.5% of the people, on any given year, exceed what they pay in premium in medical cost. There is usually around 25% that have no claims at all. However, for the 3.5% it is typically something that happens once. Meanwhile, they’ve been paying for insurance for many years. Say a family pays $12k/annum for coverage (that’s a fairly normal commercial avg – commercial = employer group based). True, the employer is paying part of that, but, presumably, that money would have been given to the employee in terms of salary if not spent on the healthcare benefit. So in ten years this family has paid $120K in premium. Odds are they didn’t incur anything like that in medical cost. Even if they became one of the unfortunate 3.5%, their costs would have been, with extremely high probability, within $50K – and most likely within $35K. Now risk alleviation has a value. There’s always a risk that costs could exceed $120K and the family places a value and being protected against that event. But that value is not $120K. That is why the company I work for is doing well selling a high deductible plan with an HSA component. Take my own employer policy. It covers my wife and I. It costs me $400/month. I am responsible for costs up to $9K. So I pay $4,800/annum in premium (that includes what my employer kicks in. I put $2,500 in my HSA each year. I have purchased a few small items with the HSA account, some glasses, some check-ups, some pharmacy and a minor procedure. After six years I have around $9K in the account. If something major occurred, I am completely covered. So I am way ahead of the game opposed to the old rich benefit model that is $12K/annum. I am happy and our customers are happy. I’m in my 50s as is my wife.
    Think about young people. They might go ten years or 20 years with nothing more than minor expenses. They could probably get by with an even higher deductible and end up with $60K or $70K or more in savings by putting a % of what they would have paid in premiums into an HSA.
    It is only 1% to 1.5% of a commercial population that isn’t better off with what I described because these people are chronically ill with expensive conditions. Everyone in a risk pool is paying for their care and the care of the 3.5%. that have an acute incident once every ten years or so.
    And no, I’m not making these numbers up. I do this for a living. I took the job on the ACA because I was begged to go there and I have plenty of standing offers within the company to return to more or less where I was before in the likely event that the ACA collapses. I am well respected and not a crank.
    This is what I see as the main difference between liberals and conservatives. You are all upset over that 1%- 1.5% and have a total disregard for the needs of the other 98.5%- 99%. I am more concerned with what does the most good for the most people.
    Now, as for your opinion about the ACA not dying. I would take a bet with you on that. The only way it could work is if the young and healthy actually signed up and stayed signed up. The way the ACA was built there is no reason they would. As outlined above, the young and healthy are much better off financially not having insurance and they know it. Second, the penalty for not enrolling is way too small compared to the cost of the premium. You could raise the penalty to exceed the cost of the premium. That would do it. But I strongly suspect Obama didn’t do that because you’d have a youth rebellion on your hands.
    So the money to get everyone enrolled would come from the government. At which point it is socialized medicine for some. This would break the federal budget as it currently exists.
    The small group is not 11.5 million. As I already stated using the examples of my two friends now on ACA, they had affordable coverage they were happy with before the ACA. The ACA looks to me to be increasingly (as premiums rise and adverse selection/moral hazard grow) to be attractive to only a small % of Americans who are very very sick. I see a lot of end stage renal disease (ESRD), out of control diabetes, congestive heart failure and bad cancer with chemo in our ACA population. Take those people out of the mix and suddenly the ACA looks viable and affordable. Here’s the kicker, as far as I can see, these people would not be getting the expensive care that they are if they were in a socialized system.
    Life is tough. Someone is always going to lose. These people drew some bad cards. Some of it is personal responsibility too. You know how you typically end up with ESRD? You’re obese. You have bad dietary habits. You develop diabetes. You don’t take of your diabetes. Or you have unaddressed high blood pressure due to lack of exercise and obesity. Or you have diabetes and uncontrolled high blood pressure. This eventually kills the kidneys. You had plenty of warning signs and generic pharma and proper diet and exercise would have turned it around, but you just kept going down the wrong road. Then you kidneys failed and then failed worse. Now you need dialysis 3 or 4 times a week and expensive drugs. If you don’t get a new kidney (very expensive) you’re going to be dead in a few years. Now a bunch of responsible people need to pay their hard earned money to keep alive. Can you blame people for maybe being a little self-interested at that point and not want to be in the risk pool with the obese wreck? Again, the difference between conservative perspective and liberal.

  113. Dr.Puck says:

    Eric, I’m not able to verify your credibility when you toss numbers our way. Where do your assertions come from? Is this true or bogus: “Getting back to the hamburger flippers and the uninsured generally, these are mostly young people who really do not need insurance.”
    But, there is authoritative research. In fact, healthcare is much studied by social scientists and governments. The Kaiser Foundation is not only credible, it is respected. Doesn’t The American Academy of Actuaries report every year about who makes up the uninsured? HHS reports annually. Every state does so too.
    If I read something, and I say to myself, ‘this is possibly made up,’ I then go out and look up the factual numbers myself.

  114. Stephanie says:

    Sylvia D,
    Medicare for all would certainly seem to be a simple solution, but there aren’t enough votes for it in the foreseeable future and paying for it would be a significant obstacle. The ACA moves us in the direction of a private insurance system under strict governmental regulation, which can work just as well, if not better, if properly administered and with effective government oversight (big ifs in this country). It is true that some elements of Obamacare derive from that old Heritage proposal, but the Medicaid expansion, which has played a crucial role in getting millions more people covered, does not. The Heritage proposal also had no consumer protections, gutted Medicaid, and replaced Medicare with a voucher system.
    Romneycare does bear a closer resemblance to the ACA.
    Among other provisions, the ACA also eliminated lifetime caps on benefits, a boon to adults with chronic conditions and parents whose children have such conditions. Previously such families faced the possibility, and often the reality, of medical bankruptcies.

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