Views on Obamacare

[ridethecliche]

As I said before, it makes more sense to tune the program designed for the issue that has been in place for a half century than to add more redundant bureaucracy. We're affecting all policy holders with the ACA when it makes more sense to just expand medicaid. (Assuming the notion that the main concern of the ACA is insuring poor Americans)

Except that it was poor and also 'otherwise healthy' individuals that were uninsured. Also, while that was part of it, the legislation also took aim at curbing growing costs. I'm not sure how well it handled the last bit, but all the data about access to care that I've seen coming out of data for medicaid (which you support expanding) is relatively positive.

Also, the exchanges allow for direct comparison of plans that wasn't previously possible. Isn't that what increased competition in the private sector looks like? The private insurance sector is also mind bogglingly bureaucratic. How do you navigate a system where the paying party has a huge incentive to eff over their customer base?

The current system isn't a libertarian one.

You made an appeal to the masses in your previous post, a logical fallacy. I said the correct answer may be used by no country currently. I didn't say the answer did not exist. Just because most countries use a system doesn't mean it is best. That's my point which I think you missed there.

No actually, I do think it's pretty hilarious when people talk about taking government out of the industry altogether. I never said the current system is libertarian. Where are you even seeing that?

Your point falls flat on its face when you compare health equality and care access between our pre-ACA system and other systems used by other countries. I never said that other countries have the best system instead saying that it was better. My appeal was to a data based conclusion (i.e. healthcare access, usage, and equality for the masses), if you think that's a logical fallacy then I'm going to go pray at the church of the flying spaghetti monster some more.

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[moop]

Outside of some good posts on reddit and that Kaiser video, do you have a good link for a coherent write up? I want to read a chunk of info from the same source instead of piecemeal if possible regarding the law, what states have the option to implement/not implement etc.

Furrow et al., Health Law (the green hornbook, not the black casebook). It's a good buy (>1000 pgs) and has literally everything you'll ever need to know for health care law.

Or you could try reading the actual SCOTUS opinion from 2012. NFIB v. Sibelius. It summarizes the research and legal arguments nicely.

 

[WingedOx]

Are you saying I don't know the difference between medicare and medicaid?

That may be a stretch, but given that your alternative (to what exactly?) proposal is a larger medicaid expansion, which will somehow result in lower levels of bureaucracy I have doubts about your knowledge level of how Medicaid actually works.

 

[Aloft085]

The Democrats reneged on their promise to not cut physician compensation. It seriously made me doubt my political affiliation.

Just wait till you get your first real paycheck and see your tax bill!

 

[Aloft085]

Also, the exchanges allow for direct comparison of plans that wasn't previously possible. Isn't that what increased competition in the private sector looks like? The private insurance sector is also mind bogglingly bureaucratic. How do you navigate a system where the paying party has a huge incentive to eff over their customer base?

Ah, now this is getting to the crux of the argument. Who is the customer base of large health insurance companies? Is it you, the end recipient of healthcare? Nope, it is your employer, who actually purchased the plan on your behalf. It's that employer-based insurance system that needs to die. If individuals are actually purchasing policies, they'll avoid businesses known to dick over their customers, just like they do in every other sector of the economy.

Another issue: So why do the young and healthy tend to not have health insurance? Previously, this was due to the individual insurance market being the exception rather than the rule, which was largely filled with high-risk individuals. Now it is largely due to the fact that young and healthy individuals pay far more than their actual risk premium. This is by design of the ACA. The young and healthy must subsidize the old and obese. Males also subsidize females. You only break even if you have a low enough income to qualify for taxpayer subsidies.

This is not meant to address the entire debate here. I don't have time for that; just addressing those two subtopics.

 

[fancymylotus]

Just wait till you get your first real paycheck and see your tax bill!

Taxes. Sigh ><

 

[ridethecliche]

Just wait till you get your first real paycheck and see your tax bill!

I work for a really large health system that is relatively good to employees, ie low salaries and good benefits. Even we are starting to shift more costs to employees. They resisted for quite a while too.

Then again, I could turn down employer coverage, take a contribution from my employer and buy insurance via the exchange. I have a feeling that companies are going to move in this direction unless the go dickish and drop everything altogether.

 

[WingedOx]

Working for the Feds has its advantages....
... and disadvantages...

...but a net gain of advantages.

 

[The_Sunny_Doc]

Ah, now this is getting to the crux of the argument. Who is the customer base of large health insurance companies? Is it you, the end recipient of healthcare? Nope, it is your employer, who actually purchased the plan on your behalf. It's that employer-based insurance system that needs to die. If individuals are actually purchasing policies, they'll avoid businesses known to dick over their customers, just like they do in every other sector of the economy.

Another issue: So why do the young and healthy tend to not have health insurance? Previously, this was due to the individual insurance market being the exception rather than the rule, which was largely filled with high-risk individuals. Now it is largely due to the fact that young and healthy individuals pay far more than their actual risk premium. This is by design of the ACA. The young and healthy must subsidize the old and obese. Males also subsidize females. You only break even if you have a low enough income to qualify for taxpayer subsidies.

This is not meant to address the entire debate here. I don't have time for that; just addressing those two subtopics.

So true. That's why my and my 20-something friends don't have health insurance. The premiums are ridiculous.

 

[The_Sunny_Doc]

If individuals are actually purchasing policies, they'll avoid businesses known to dick over their customers, just like they do in every other sector of the economy.

2 words: Direct pay.

 

[ajj70]

Perhaps they really mean expand Medicare? Medicare is the most cost-efficient medical insurance out there, whereas Medicaid is a trainwreck that hardly even counts as insurance since its reimbursements are so low no one will even treat people on it.

Medicare is highly inefficient and no where near close to cost effective. It works because it is highly subsidized by the federal coffers. Reimbursements under Medicare are woefully low. True Medicare has very limited coverage and no cap on out of pocket expenses. When it was first introduced it did not even cover prescription medications. With proper supplements, the coverage is pretty good for the end-user, but when you get your $12.39 reimbursement for your first medical procedure, you will see that the provider end pretty much stinks. Medicaid, however, operates at the state level and depending on the state, the reimbursements are generally similar to what a traditional insurance plan pays.

And you know the ACA expands Medicaid, right? Expands the eligibility, that is. What's your point on Medicaid again?

It only expands Medicaid in states that have adopted that expansion, 27 and DC.

Premium increases in 2015 are the lowest the US has seen in 15 years, average of 2-3%. Many group plans that have moved to Consumer Driven plans (the High Deductible plans with health savings accounts) have seen premiums level off or decrease. Along with these health savings accounts come fewer billing issues for providers since there is a funded account, usually, to pay out of pocket costs. If you look past the Fox News rhetoric and see the plans in real life action, on the whole, they are excellent. Yes, there are going to be some growing pains and the individual marketplace needs to move away from the HMO model, but Medicare had the same issues when first introduced as well.

 

[pithy84]

I will make a ton less money over my career because of the ACA.

If your profile is accurate and you are still a resident, then you cannot accurately make that prediction. Your career will stretch about 30 years into the future, hopefully. Do you think the status quo before the ACA could possibly survive 30 more years? Here's a hint: no way in hell. Health care costs in the US far outstrip any other country on the planet, full stop. And health care outcomes are not very good in the US compared to Western Europe. Not only is our health care expensive, but our economy cannot support it.

If pre-ACA trends had continued for 30 years without legislative reform or industry restructuring, then the US economy would be devastated. The number of patients able to pay for care would continue declining, and your earnings would eventually drop.

That's the best case scenario. Worst case scenario, you would get murdered by one of the terrorist groups that targets doctors because they see the US healthcare system as killing helpless poor people. We already have terrorist groups that kill abortion doctors, I can certainly imagine a future with terrorist groups that kill all doctors who only treat people with the means to pay for care.

More realistically, legislative reform was absolutely inevitable. If not the ACA, then it would have been something else a few years later. It might have been better, it might have been worse, we just can't know.

All that said, the ACA is not effective at lowering costs in the grand scheme. The ACA contains relatively few cost-lowering measures. It has some limited experiments with lump sum prepayment and accountable care organizations (ACOs), but not really much for the economists to be happy about.

Rather than directly lowering costs, I think the ACA will serve as the foundation and the catalyst for further laws and industry reforms that will effectively lower costs. A good start would be repealing the Medicare Modernization Act of 2003. The ACA has not fully kicked in yet, so give it a few years. The other shoe will drop.

When the US does cut costs, it is my hope that we will cut the profits of drug companies, medical device companies, insurance companies, and secretaries. This is actually a realistic hope, if you look at the breakdown of healthcare spending in the US versus, say, France. The profits of doctors can be kept relatively high. Look at a hospital bill from the US and a hospital bill from France, and you will see that only a tiny portion of the US hospital bill is going into doctors' pockets.

There is a problem - if we significantly cut drug company profits, they may cut back on research and development. The US leads the world in drug development by a wide margin. However, I think we need to raise taxes and then use government funds for more drug research. In my utopia, government-funded drug research will lead to public domain drugs (not patented drugs), and that will reduce drug costs considerably.

Drug companies already hate to do research and development, they prefer to spend money on advertising. Advertising helps your profits next quarter. R&D is a long-term investment, and a very risky one.

That's my rant, and I'm sticking to it.

 

[moop]

It only expands Medicaid in states that have adopted that expansion, 27 and DC.

Wrong. The ACA expands Medicaid in all states. It was SCOTUS that limited the applicability of the law and allowed states the choice to expand or not.

It might take a while, but eventually, all states will expand Medicaid. Governors are not going to be able to withstand the political pressure and criticism for not accepting free federal money. There's gonna be a lot of political theater before that happens, but just like with the original implementation of Medicaid, every state will eventually expand, especially as the reimbursement rates finally approach Medicare levels (part of the ACA that's hardly ever mentioned).

 

[ajj70]

If your profile is accurate and you are still a resident, then you cannot accurately make that prediction. Your career will stretch about 30 years into the future, hopefully. Do you think the status quo before the ACA could possibly survive 30 more years? Here's a hint: no way in hell. Health care costs in the US far outstrip any other country on the planet, full stop. And health care outcomes are not very good in the US compared to Western Europe. Not only is our health care expensive, but our economy cannot support it.

If pre-ACA trends had continued for 30 years without legislative reform or industry restructuring, then the US economy would be devastated. The number of patients able to pay for care would continue declining, and your earnings would eventually drop.

That's the best case scenario. Worst case scenario, you would get murdered by one of the terrorist groups that targets doctors because they see the US healthcare system as killing helpless poor people. We already have terrorist groups that kill abortion doctors, I can certainly imagine a future with terrorist groups that kill all doctors who only treat people with the means to pay for care.

More realistically, legislative reform was absolutely inevitable. If not the ACA, then it would have been something else a few years later. It might have been better, it might have been worse, we just can't know.

All that said, the ACA is not effective at lowering costs in the grand scheme. The ACA contains relatively few cost-lowering measures. It has some limited experiments with lump sum prepayment and accountable care organizations (ACOs), but not really much for the economists to be happy about.

Rather than directly lowering costs, I think the ACA will serve as the foundation and the catalyst for further laws and industry reforms that will effectively lower costs. A good start would be repealing the Medicare Modernization Act of 2003. The ACA has not fully kicked in yet, so give it a few years. The other shoe will drop.

When the US does cut costs, it is my hope that we will cut the profits of drug companies, medical device companies, insurance companies, and secretaries. This is actually a realistic hope, if you look at the breakdown of healthcare spending in the US versus, say, France. The profits of doctors can be kept relatively high. Look at a hospital bill from the US and a hospital bill from France, and you will see that only a tiny portion of the US hospital bill is going into doctors' pockets.

There is a problem - if we significantly cut drug company profits, they may cut back on research and development. The US leads the world in drug development by a wide margin. However, I think we need to raise taxes and then use government funds for more drug research. In my utopia, government-funded drug research will lead to public domain drugs (not patented drugs), and that will reduce drug costs considerably.

Drug companies already hate to do research and development, they prefer to spend money on advertising. Advertising helps your profits next quarter. R&D is a long-term investment, and a very risky one.

That's my rant, and I'm sticking to it.

Actually, shifting some of the costs to the patient via higher out of pocket costs will keep prices in check. When a patient knows they only have to pay $10-20 to see the dr, they tend to go more often than is needed--only to be told they have a virus and sent home. If they have to pay $150-200 for an office visit, they might wait it out a day or two and more often than not, really didn't need to go in. They will do research for cost savings on elective procedures or prescribed procedures that are not immediate-a CT scan, PT, etc. In states like MA and MN that have had similar provisions for years, their premium costs are the lowest in the nation and overall expenditures for medical care have leveled off (keeping pace with normal inflation). What the ACA missed, however, was requiring that insurance companies and hospitals be not-for-profit, keeping in mind that doesn't mean they can't make money, they make loads of money, but those profits have to be returned to policy holders/patients in the form of lower costs.

 

[Aloft085]

Premium increases in 2015 are the lowest the US has seen in 15 years, average of 2-3%.

It's important to add the context that those smaller-increases in premiums followed years of exceptionally-high increases in premiums after the passage of the ACA. Insurance companies were essentially trying to establish a higher baseline rate prior to the implementation of Obamacare, due to the stricter regulations on cost increases.

To know how effective the ACA is at controlling healthcare costs, it's really going to take a 10+ year data sample. Fortunately or unfortunately for us, healthcare will likely be reformed again before then.

 

[ajj70]

It's important to add the context that those smaller-increases in premiums followed years of exceptionally-high increases in premiums after the passage of the ACA. Insurance companies were essentially trying to establish a higher baseline rate prior to the implementation of Obamacare, due to the stricter regulations on cost increases.

To know how effective the ACA is at controlling healthcare costs, it's really going to take a 10+ year data sample. Fortunately or unfortunately for us, healthcare will likely be reformed again before then.

Actually, that is not true. Double digit rate increases have been happening since the 1990's, well before the ACA. There are a lot of reasons for these increases, but in my opinion the escalation began with the popularity of HMO's and the access to "cheep" medical care and costs started skyrocketing after that. The plans on the market today are very similar to major medical plans, although with higher out of pocket maximums, users saw before HMO's took off. The data is rolling in and costs are being contained. Keep in mind, the ACA has been in effect for several years, rolling out in stages and last year was just the first year all people were required to have insurance. While that is a large change for enrollment, the nuts and bolts of the policy changes have been rolled out for the past several years.

 

[RC4L]

It is certainly affecting people in many different ways so I wont say it is just bad or just good. I like the concept of universal healthcare but at the end of the day, we are trying to squeeze an idealistic idea into a much less than ideal healthcare system. The best plan is going to be one that effectively covers the most people with the most fair and manageable burden and I understand not everyone will be happy with it regardless of efficiency. I am a healthy, 24 year old male medical school applicant who is making enough to pay the bills every month. I don't have coverage for the time being because it just not worth the money right now. I am not happy about the penalty fee stuck to my taxes around the corner. The doctors I know and have been around have been largely negative about it for a variety of reasons including less treatment jurisdiction, un reasonable amounts of paper work, less compensation, and more time at the office. I wont say the profession as a whole is declining because I have not yet practiced as a physician and I do understand that doctors who have been practicing for over ten years are going to complain about any change, period. However, I have yet to meet one person who has benefitted from the ACA but I have met people who are paying more money, myself included. Thus far, I am not fond of it at all but I am not going to say it is a bad policy just because it is not doing me any good at this point in life. Because you said Obamacare rather than AFA, I will say that I am not fond of how it is being implemented. I am not fond of hardly anything the current POTUS has put into play for that matter but that's another story. I honestly don't believe the policy was created with the greatest good of American citizens in mind but for those it is helping, I am happy for them. I love the idea of everyone having health care and if that is possible without totally screwing over hard working people, I am all in.

 

[plumazul]

It is certainly affecting people in many different ways so I wont say it is just bad or just good. I like the concept of universal healthcare but at the end of the day, we are trying to squeeze an idealistic idea into a much less than ideal healthcare system. The best plan is going to be one that effectively covers the most people with the most fair and manageable burden and I understand not everyone will be happy with it regardless of efficiency. I am a healthy, 24 year old male medical school applicant who is making enough to pay the bills every month. I don't have coverage for the time being because it just not worth the money right now. I am not happy about the penalty fee stuck to my taxes around the corner. The doctors I know and have been around have been largely negative about it for a variety of reasons including less treatment jurisdiction, un reasonable amounts of paper work, less compensation, and more time at the office. I wont say the profession as a whole is declining because I have not yet practiced as a physician and I do understand that doctors who have been practicing for over ten years are going to complain about any change, period. However, I have yet to meet one person who has benefitted from the ACA but I have met people who are paying more money, myself included. Thus far, I am not fond of it at all but I am not going to say it is a bad policy just because it is not doing me any good at this point in life. Because you said Obamacare rather than AFA, I will say that I am not fond of how it is being implemented. I am not fond of hardly anything the current POTUS has put into play for that matter but that's another story. I honestly don't believe the policy was created with the greatest good of American citizens in mind but for those it is helping, I am happy for them. I love the idea of everyone having health care and if that is possible without totally screwing over hard working people, I am all in.

Actually, you do have coverage. Catastrophic coverage, paid for and provided by the taxpayers in your local community, free of charge (except in areas where they will take a lien on your property when you don't pay). I think it would be an improvement to the ACA if those paying the "penalty" actually received some type of formal "rights" for their payments. For example, if you paid the penalty, then you should have the right to pay providers Medicare rates for their services and that you would have actual catastrophic coverage in case you have a serious accident or sudden serious illness.

 

[RC4L]

Actually, you do have coverage. Catastrophic coverage, paid for and provided by the taxpayers in your local community, free of charge (except in areas where they will take a lien on your property when you don't pay). I think it would be an improvement to the ACA if those paying the "penalty" actually received some type of formal "rights" for their payments. For example, if you paid the penalty, then you should have the right to pay providers Medicare rates for their services and that you would have actual catastrophic coverage in case you have a serious accident or sudden serious illness.

Haha so basically if the gov can't force us to buy a lot of insurance, they could force us to buy a little insurance. I would prefer to have the freedom to choose whether or not to buy insurance, a lot or a little. Maybe that wouldn't have to be such a dramatic choice if our tax dollars were used wisely.