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rated:
We have had several threads concerning all the changes that are happening or could happen with ACA. 

Instead of letting them through only to remove every other post and eventually lock the thread, we are going to allow this thread to have more shades of gray when it comes to our no politics rule. 

We have an official political thread here.

This will follow the same rules as that thread. 
Keep all discussion civil. If there are personal attacks or insults, you will be banned from the thread, and possibly the forum.
If the thread gets out of hand, it will be locked, and this experiment will come to an end.

All that being said, enjoy the discussion and have fun, just not at others expense.



 

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rated:
I'm not sure about what changes we're talking about for ACA. IIRC the deadline for insurers to decide whether to be part of exchanges for 2018 was mid September so with Senate in recess and then talk about having a bipartisan discussion (that would likely take a long while), I'm pretty sure nothing will change until Jan 2019 even IF legislation gets passed for it in 2018. Especially since I'm not sure the Democrats in the Senate have a clear idea or consensus on what they'd like to see done to improve ACA.

And that's a big IF considering 2018 will be a mid-term election year with lots more pressure on people in Congress to listen to their constituents and/or potentially get bashed by rivals for promoting changes negatively affecting large parts of the electorate.

Another big reason for inaction in Congress on ACA will simply be the need to work on tax reform and others. So I'm very confused about what if anything will change regarding ACA in the near future.

But my bet is on this administration letting the situation get worse (maybe scaling down subsidies) while attempting to minimize/deflect the blame they could take from inaction or refusal to fund subsidies. Then after Nov 2018, assuming still in control of both House and Senate, try to pass a new healthcare proposal depending on public support for it.

rated:
Green for FWF staff coming up with this solution.

rated:
Some of you have affordable and better coverage due to the ACA and I am happy for you and don't want any of you to lose coverage that works for you and your family. Where I live, the only options available are HMOs with no out-of-network coverage. Although there are some excellent doctor's in my limited network, there are some large gaps in availability of those providers that I would choose for some very complicated and expensive procedures.

One of the reasons that even very healthy people should have health insurance is to protect against accidents and high cost illnesses. Although these types of procedures are rare, they are the main reason that I want health insurance. There are no in-network plastic surgeons in any of the available plans that I am aware of, which means that there is no coverage for reconstructive plastic surgery. The cancer hospital that I would choose, even if paying out-of-pocket, is not in an available ACA plan. If I seriously injured my back skiing, I would be comfortable being evaluated by an in-network orthopedist but would pick the same out-of-network surgeon that their peers might pick if they were injured.

To be clear, it is unlikely that I will get cancer, injure my spine, or have an accident that requires plastic surgery; but that doesn't mean I am unconcerned about that risk. I am considering participating in a health share ministry offered by Liberty HealthShare as a supplement to my ACA policy in order to cover some of the gaps in coverage. Assuming it works as explained, any procedure would be covered at a similar percentage to the one used by insurance companies that offer out-of-network coverage or between 150 and 170% of Medicare rates. Although the plan appears to cover even those providers who won't accept their rates once, I am not expecting them to actually pay for the full amount charged by a top surgeon who doesn't take any insurance. Still, having some payment for a doctor or hospital that wouldn't be otherwise be covered at all under our ACA plans is better than nothing. 

Liberty will offer plans to those with pre-existing conditions; but will pay nothing for those conditions in the 1st year, up to $50K in years 2 and 3, and provide normal coverage afterwards. Liberty will cover certain lifestyle conditions, like hypertension, high cholesterol, type 2 diabetes and obesity if the insured pays $80 for a health coach to modify controllable health issues. For those who follow through, it might dramatically improve their health and reduce medical costs. 

The plan I am considering would cost $299 per month for a couple and has an annual fee of $125 the first year and $75 in later years. That plan covers $1MM per incident without a lifetime maximum and has a $1K deductible. For less than $4K per year, I could drop my current out-of-pocket maximum for covered care by about $13K and get some out-of-network coverage. This plan offers discounts for prescriptions, dental, vision, hearing and chiropractic care but limited or no coverage for those items. At this point, I am only considering this as an addition to our ACA plans and not as a substitute. While this may be a waste of money for those who have a great insurance plan, it could be a reasonable option for some people as long as they understand that health sharing ministries are not insurance companies and that many of the rules and protections for ACA customers don't apply to them. 




 

rated:
Healthcare should have never become politicized, and people just need to calm the f down.

rated:
Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?

rated:
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
Option A: Become healthier as a society? That would mean getting rid of a lot of the foods and drinks that we all enjoy so it will never happen.

Option B: Reduce end of life spending. Why spend $200k keeping someone alive for 6 more months when their quality of life will suck. This will never happen either because just one more day with my dad/grandma/cousin/child is worth every penny spent (as long as "insurance" is paying for it).

rated:
bbr said:   
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
Option A: Become healthier as a society? That would mean getting rid of a lot of the foods and drinks that we all enjoy so it will never happen.

 

  You can always tax those foods and drinks and put that into health care pot

rated:
Thank you FWF Mods for this excellent solution.  There are lots of financial details and complications for individual medical insurance and with the numerous changes we're seen over the past couple years and quite possibly more to come in the future, it will be good to put the dedicated efforts of FWF to work on finding good financial solutions for our effected members.   In any event, here's a kickoff for some resources here at FWF and BH threads, many of which are now locked or archived, but often had fairly long and useful discussions.

Loss of choice / coverage
My Obamacare plan is being closed; most ins cos have pulled out of my state for '18; I may have to move states
https://www.fatwallet.com/forums/finance/1575667/

Another insurance co. likely to pull out in 2018 hope you are not in Colorado, Kentucky, Missouri and Ohio  
https://www.fatwallet.com/forums/finance/1562150/

Aetna will withdraw from several states (ACA)
https://www.fatwallet.com/forums/finance/1520563/

Received a letter that health insurance company is closing (IL)
https://www.fatwallet.com/forums/finance/1517129/

discussing new ACA plans
Preview of 2017 ACA plans now active
https://www.fatwallet.com/forums/finance/1535330/

What are your health insurance stats (cost, coverage, etc)
https://www.bogleheads.org/forum/viewtopic.php?f=2&t=222422

2017 ACA plan reviews
https://www.bogleheads.org/forum/viewtopic.php?t=201899

Limitations of ACA coverage, small networks / out of network woes
Out of network issues
https://www.bogleheads.org/forum/viewtopic.php?t=151672

New health insurance rules cap surprise billing (out of network charges at in network places)
https://www.fatwallet.com/forums/finance/1548922/

general speculation on ACA and effects
What realistically is going to happen to ACA in Q1'17
https://www.fatwallet.com/forums/finance/1538314/

Individual health premiums tripled.  Why?
https://www.fatwallet.com/forums/finance/1537507/

Future of ACA / health insurance 
https://www.bogleheads.org/forum/viewtopic.php?t=196736

personal costs / strategies
Is ACA making your wallet slim?
https://www.fatwallet.com/forums/finance/1472555/

Should young healthy people buy insurance?
https://www.fatwallet.com/forums/finance/1561370/

Importance of high deductible insurance 
https://www.bogleheads.org/forum/viewtopic.php?t=208304

healthcare costs and self funding 
https://www.bogleheads.org/forum/viewtopic.php?f=2&t=201714

ACA renewals, shop around
https://www.bogleheads.org/forum/viewtopic.php?t=200920

Individual ACA-related decisions
Various ACA vs COBRA decisions
https://www.bogleheads.org/forum/viewtopic.php?t=221782
https://www.bogleheads.org/forum/viewtopic.php?t=161600
https://www.bogleheads.org/forum/viewtopic.php?t=152545
https://www.bogleheads.org/forum/viewtopic.php?t=170687

PPO/EPO/HMO choices
https://www.bogleheads.org/forum/viewtopic.php?t=210968
https://www.bogleheads.org/forum/viewtopic.php?t=151675

rated:
Its the combined effort of hopital industry, pharmaceutical companies, insurance companies, and misc industries surrounding healthcare that they are making so much profit and an average person cannot afford going to the doctor.
Solution -
Have competition in insurance plans, negotiate prices with pharmaceutical companies and hospital industries should be checked for frauds and overbilling.
If you can customize your car insurance quote there should be more customization available for health insurance.


How can you get it done?
Try making an effort today.
Call your representative, go to town meeting and be active on social site.
Inaction is not an option.

rated:
Any details about how to form a small "group" and get a group plan?

For certain lines of work, it is an option to form a small corporation and work on a corp-to-corp basis (1099?).

Usually, everyone who does it gets the insurance via some other means - either via spouse's work, or individual market etc.

I've never really got a satisfactory answer why they don't form a small group and get insurance that way - since that will give them a lot more control of taxes.

Any ideas?

rated:
utsavdesai said:   Its the combined effort of hopital industry, pharmaceutical companies, insurance companies, and misc industries surrounding healthcare that they are making so much profit and an average person cannot afford going to the doctor.
Solution -
Have competition in insurance plans, negotiate prices with pharmaceutical companies and hospital industries should be checked for frauds and overbilling.
If you can customize your car insurance quote there should be more customization available for health insurance.


How can you get it done?
Try making an effort today.
Call your representative, go to town meeting and be active on social site.
Inaction is not an option.


I think you have some misguided prescriptions for the problem.

You want the patient to "negotiate" with the anesthesiologist on the operating table??!!

Luxury items like "customization"s are expensive, and already available to the billionaires - for a price!!

Profit is a problem, but even eliminating 100% of profits won't nearly save as much as you think!!

Stealing from what someone else said - there are three parties here - patients, providers and insurers. All three have to learn to make do with less for the costs to come down.

rated:
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
  
Telemedicine. Most doctor visits can be done over webcam. 

rated:
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
Potential cost-control measures would be education and financial incentives for people to use healthcare more responsibly. Cut people's premium if they take steps to improve preventive care or reduce risk factors. Someone who alters their diet, increases exercize and manages to reduce blood pressure or cholesterol levels, keeps doing their annual physical exams, etc... could get a break on their premiums. Vice versa increase premiums when people do not perform bare minimum preventive care regularly. Most plans have cheap or free annual physical exams. There's really little excuse not to go for them. People who do not take care of controllable risks should face higher premiums. In turn, that should incentize better control of health risks and thus reduce overall costs.

Also curbing medical lawsuits would save costs in the long run. Effectively it currently diverts medical money into lawyer fees for no overall benefit for society. You don't need an MRI every time you have a minor event. But due to lawsuit risks, a lot of doctors will defensively request unnecessary procedures.  They also pay high amounts in malpractice lawsuit insurance. None of those translate into better healthcare, just inflates costs. And from the patient's standpoint, often you're not in a position to evaluate whether a procedure truly needed or not so you go with the doctor recommendation - just in case/to be sure - especially if it comes at no cost (or low copay) to you.

Another thing would be to greatly simplify all the in-network/out-of-network nonsense. There should be no possibility to have out of network doctors working at an in-network facility. If an out-of-network doctor somehow ends up working at an in-network hospital, he should be paid the in-network rate or not work there at all. And prohibit completely drive-by doctoring.

rated:
avalon6 said:   BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
  
Telemedicine. Most doctor visits can be done over webcam. 


I never understood telemedicine. How does a doctor properly check your breathing, ear or throat over a webcam?

rated:
bbr said:   ...
Option B: Reduce end of life spending. Why spend $200k keeping someone alive for 6 more months when their quality of life will suck. This will never happen either because just one more day with my dad/grandma/cousin/child is worth every penny spent (as long as "insurance" is paying for it).
 

  There was a great Freakonomics podcast about this a few years back - http://freakonomics.com/2015/08/27/are-you-ready-for-a-glorious-...

Here's the general idea of it:
“Why don’t health insurance companies offer bonuses to patients who are willing to forego standard end-of-life medical care? When a patient receives a terminal diagnosis, I have to believe that the health care companies have actuaries and data sets that would give them guidance on what the next 6-24 months of medical care would cost. For patients willing to skip this type of care, my idea is for a bonus according the following formula: an immediate bonus of approximately 50% of the difference between the actuarial underwriting of standard medical care and hospice or palliative. The patient maintains control over the optionality, but an immediate benefit opens up to them (one last grand vacation, a lasting legacy for the next generation, etc). The health insurer gets an actuarial gain and makes progress towards disincentivizing excessive consumption of health care in the final months of life. Seems like a no brainer to the economist in me (though my sociologist wife thinks I’m completely cold-blooded).

...We kept coming back to the idea that, depending on the study you look at, 40, 60, 80% of lifetime medical care is expended in the final twelve months, or the end of life, generally.
 

rated:
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
  
Have the consumers of healthcare pay for the healthcare they consume. Billing anything through insurance costs a fortune because 1) The consumer doesn't care about the cost as the bill gets sent to a third party and 2) there's a lot of overhead required for insurance claims. 3) Overconsumption

The goal of insurance is to protect someone from a risk that cannot be easily absorbed. You need insurance to protect you from a $50,000 heart attack incident. You don't need insurance to protect you from the risk of minor illness, annual checkups, the cost of birth control, etc. These are routine expenses that should be paid out of pocket.

What we have today is not really insurance. It is prepaid medical and it insulates the consumers of healthcare from the costs of healthcare. The best plan for most individuals would be a high deductible health plan where the vast majority of expenses are paid for out of pocket. In a real health insurance market consumers would be a lot more price sensitive, would shop around, minimize their consumption, make better decisions, and would naturally control prices like they do for any other good or service in the free market. 

rated:
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?

On the provider side:
1. Negotiate with all providers - not just drug companies. Everybody pays medicare rates - or provider and/or anyone working in there can't get any $$ from medicare. This will automatically create a two-tier system - one for us, and another for the rich people - those who can pay the asking price for providers who don't take medicare.
This will create a situation where "world leading" specialists in a certain field will not need to take medicare in order to survive. That can cause issues for people which really complicated health situations if they wanted to consult with such doctors. Not sure a good solution exists there. May be a downside for the "socialized" healthcare solution.

2. Somehow (not sure what is the best approach here) make it very difficult/expensive for an "individual practice" to survive - so that we have 1X big overhead cost for coding+billing+shiny-new-XYZ-machine instead of 10X - one for each individual doctor's office. We have examples of both in our area. A medicare-for-all may even force this automatically due to the sheer economy forced by medicare reimbursement rates.

I am not convinced any kind of banning etc. will work. Solutions arrived at by economic incentives tend to be more durable than "banning" stuff.

On the consumer side:
Make sure everyone has skin in the game.
Easiest way? Tie premium and co-pay to a formula depending on his last year's healthcare spend subject to a ceiling based on his AGI and Assets. 
e.g. XYZ cost medicare $1000 last year. His premium is (actuarial rate) X $1000 X (some constant factor) for the next year, and his co-pay/deductible is also dependent on a similar formula.
All of these are subject to a max out of pocket of, say, X% of his yearly income or Y% of his assets - whichever is higher. To simplify the administration of such - form 1040 needs to have you declare both assets and AGI each year.

Funding
------------
There will be sizable gap between the insurance cost and premiums. This has to be funded by a fairly sizeable tax. We can get a bunch of this money from corporations - in lieu of group insurance plans. But that would still fall short. Tax increase has to happen.
Question is how much! I don't quite know the answer to this right away - but the question needs to be answered by math, not politicians.

Insurance
--------------
Insurance companies will have to work with medicare rates. They can offer additional "coverages"/"services" on top for extra money, or you should be able to buy directly from medicare/ssa.
This will mean a lot of people - thousands - will lose jobs in my state (CT) as insurance company profits will go down. But I don't see any way around it. 

rated:
brettdoyle said:   
BostonOne said:   Besides allowing the federal government/medicare/medicaid to negotiate with drug companies, what are some reasonable cost-control measures folks are aware of?
  
Have the consumers of healthcare pay for the healthcare they consume. Billing anything through insurance costs a fortune because 1) The consumer doesn't care about the cost as the bill gets sent to a third party and 2) there's a lot of overhead required for insurance claims. 3) Overconsumption

The goal of insurance is to protect someone from a risk that cannot be easily absorbed. You need insurance to protect you from a $50,000 heart attack incident. You don't need insurance to protect you from the risk of minor illness, annual checkups, the cost of birth control, etc. These are routine expenses that should be paid out of pocket.

What we have today is not really insurance. It is prepaid medical and it insulates the consumers of healthcare from the costs of healthcare. The best plan for most individuals would be a high deductible health plan where the vast majority of expenses are paid for out of pocket. In a real health insurance market consumers would be a lot more price sensitive, would shop around, minimize their consumption, make better decisions, and would naturally control prices like they do for any other good or service in the free market. 


>> The best plan for most individuals would be a high deductible health plan where the vast majority of expenses are paid for out of pocket.
Who keeps track of the deductible? Based on which prices? Real market price? or some "reasonable and customary price"? If market price - do you realize the scope of abuse?
See - you can't eat your cake and have it too! Market does not usually work with halfway measures. Either you let people die on the doorsteps of ER's because they can't pay - or you have socialized medicine. 

Are you really saving any money once you create mechanisms to account for all these "nuances" in your Halfway House market?

>> The goal of insurance is to protect someone from a risk that cannot be easily absorbed. You need insurance to protect you from a $50,000 heart attack incident.
The problem is distinguishing between the "$50,000 heart attack incident" that is urgent and expensive, and a "$60,000 hep-C drug" that is expensive but not quite urgent.

Try coming up with any set of rules - and I can bet I can show you a scenario where it would simply mean a large portion of the population would simply not get a life-saving treatment they need! That is the ultimate, conservative, "personal responsibility" vision.
I would even argue that this catastrophic personal consequence is necessary for the market to work. I grew up in a place where this is how the healthcare "market" operates - you simply die without treatment if you can't pay! That causes deep seated cultural changes in the society over generations! Till that generations-spanning adjustment happens though - be ready for armed revolution much worse than the Orange One being elevated to the highest office!!

The fallacy is treating healthcare as a market where normal rules of demand and supply can make the market work! Try modeling a supply-demand curve where demand is inflexible and see if you economic model stays stable.

rated:
Beanholio said:   
bbr said:   ...
Option B: Reduce end of life spending. Why spend $200k keeping someone alive for 6 more months when their quality of life will suck. This will never happen either because just one more day with my dad/grandma/cousin/child is worth every penny spent (as long as "insurance" is paying for it).

  There was a great Freakonomics podcast about this a few years back - http://freakonomics.com/2015/08/27/are-you-ready-for-a-glorious-... 

Here's the general idea of it:
“Why don’t health insurance companies offer bonuses to patients who are willing to forego standard end-of-life medical care? When a patient receives a terminal diagnosis, I have to believe that the health care companies have actuaries and data sets that would give them guidance on what the next 6-24 months of medical care would cost. For patients willing to skip this type of care, my idea is for a bonus according the following formula: an immediate bonus of approximately 50% of the difference between the actuarial underwriting of standard medical care and hospice or palliative. The patient maintains control over the optionality, but an immediate benefit opens up to them (one last grand vacation, a lasting legacy for the next generation, etc). The health insurer gets an actuarial gain and makes progress towards disincentivizing excessive consumption of health care in the final months of life. Seems like a no brainer to the economist in me (though my sociologist wife thinks I’m completely cold-blooded).

...We kept coming back to the idea that, depending on the study you look at, 40, 60, 80% of lifetime medical care is expended in the final twelve months, or the end of life, generally.

  
The problem is Reagan, and his EMTALA act!!

Any ER is bound to treat all medical emergencies in all patients that show up. End of life complications, I bet, is a pretty big emergency - strictly going by medical rules.

What do you think happens when a "end of life" patient takes the bonus, then has a problem and shows up at ER? Do you want ER to have the option of deciding to treat or not treat based on paperwork??

This is what I call "Halfway House" market in action!! 
 

rated:
puddonhead said:   
Any ER is bound to treat all medical emergencies in all patients that show up. End of life complications, I bet, is a pretty big emergency - strictly going by medical rules.

 

  

I don't believe thats how it works.     

I don't think the ER is obligated to do anything more than stabilize your condition and move you on out.    That would not benefit someone in an end of life situation.    You're not going to get a permanent bed or any kind of ongoing care via an ER.   
 

rated:
For the year 2017 I decided to enroll my child in the state health exchange in NY as it would cover a certain condition related services that employer sponsored health insurance doesn't. 
I chose Fidelis Care .
it was a disaster. I was able to obtain preapproval for 2 kinds of services . 
I got a phone call as well as letter by mail saying I was approved . 
The providers also verified with insurance, got the letter saying they were preapproved. 
Service bills have been denied unnecessarily stating one thing after the other , after the other 
we lost hope and discontinued the insurance after paying 6 months , we gave the required one month notIce via state exchange 
we are still calling them every 2 weeks and listening to their dumb excuses and trying our best to get the bills paid 

moral of story 
Educate yourself about the different insurances , maybe get word of Mouth referral before choosing one 

i regret my decision very much 


 

rated:
It seems like a lot of the options considered here, have some sort of provider-side cost management, and patient/consumer-side cost management incentives.

But one aspect of ACA that is not discussed here much as far as cost-management goes is the individual mandate. I know it's been heavily politicized but stepping away from the partisanship, what are the options on that and effect on costs?

Doing away with the individual mandate would increase premiums. Those who'd go without insurance clearly estimate they do not benefit from having health insurance and pay more for insurance than they would consume in healthcare. If they are basically net contributors, allowing them to drop out, increases costs for the remaining insured members. But to me that decision is also made easier by the fact that ERs will still stabilize and minimally treat you even if you don't have insurance or means to pay the bill. That is a cost too for the healthcare system which is paid by insured people.

So would ER turning down people declining insurance be a cost-saving measure to balance the increase in premium for insured people for allowing others to decline insurance coverage?

What about the treatment of on-demand healthcare? Basically, the scenario of people waiting to get sick with illness requiring expensive treatment before signing up for insurance. We already see plans with reduced benefits for a few years after joining in. Is it sufficient protection from on-demand health insurance behavior?

What other methods are out there? Could a system of premium credits work? Basically, if you sign up and are healthy, contribute more than you cost to the system, get future credits for lower premium for use when you're older and sicker? That could be seen as some kind of healthcare savings account to encourage people to sign up for insurance now. Maybe have your premiums go into an account where if at the end of the year you have money leftover in it, some fraction of it could end up in a HSA-like account for paying future premiums?

rated:
jerosen said:   
puddonhead said:   
Any ER is bound to treat all medical emergencies in all patients that show up. End of life complications, I bet, is a pretty big emergency - strictly going by medical rules.

  

I don't believe thats how it works.     

I don't think the ER is obligated to do anything more than stabilize your condition and move you on out.    That would not benefit someone in an end of life situation.    You're not going to get a permanent bed or any kind of ongoing care via an ER.   


How do you suggest it will work in practice?
In our neighborhood hospital - the patient will simply be moved into the hospital for EOL care. The billing will not even communicate back and forth with the doctors.
Will the hospital check insurance paperwork before extending end of life care services? Put a feedback loop with billing in place?

I am sure that could be made to work! But the administrative costs of doing so will probably eat up much of the savings.

Why not simply use more "market-based" incentives? Simply exclude EOL care from ALL insurances - if that is what we as a society choose to do. Anyone who needs/wants all such care can pay out of pocket for it!

Much cheaper!! Any kind of "customization" or "option" you want adds extra cost - even for those who don't want it.

rated:
>> But one aspect of ACA that is not discussed here much as far as cost-management goes is the individual mandate. I know it's been heavily politicized but stepping away from the partisanship, what are the options on that and effect on costs?

That is where a tax increase to fund the single payer comes into play.
"There will be sizable gap between the insurance cost and premiums. This has to be funded by a fairly sizeable tax. We can get a bunch of this money from corporations - in lieu of group insurance plans. But that would still fall short. Tax increase has to happen.
Question is how much! I don't quite know the answer to this right away - but the question needs to be answered by math, not politicians."

No to mandate! But you need taxes!

rated:
Shandril said:   
So would ER turning down people declining insurance be a cost-saving measure to balance the increase in premium for insured people for allowing others to decline insurance coverage?


 

  

Yes it might save us all some money.   But then people die.

Thats not exaggeration or politicizing anything.    We have the ER law so people don't die simply for lack of insurance.

I suppose they could filter any non life threatening issues and turn away people with trivial stuff.   That at least seems reasonable.   But even there it might be hard to know for sure in a lot of cases so they run the risk of accidentally turning away people who then die on the hospital sidewalks.   (ok so that bits over dramatized)

Also I've seen studies saying that the uninsured don't use the ER more than anyone else.    So its not like they're using it for their free primary care physician as has been implied by some.     Theres also a lot of insured people using the ER unnecessarily.    I've done that unintentionally myself.

 

rated:
puddonhead said:   
In our neighborhood hospital - the patient will simply be moved into the hospital for EOL care. The billing will not even communicate back and forth with the doctors.

  

You know for a fact this is what happens in your hospital?   

Someone goes to the ER with stage 4 cancer and no insurance or means to pay and then gets checked into the hospital for free for the rest of their days?    And the people running the place don't even know/ notice / check on the insurance or payment ??

 

rated:
jerosen said:   
puddonhead said:   
In our neighborhood hospital - the patient will simply be moved into the hospital for EOL care. The billing will not even communicate back and forth with the doctors.

  

You know for a fact this is what happens in your hospital?   

Someone goes to the ER with stage 4 cancer and no insurance or means to pay and then gets checked into the hospital for free for the rest of their days?    And the people running the place don't even know/ notice / check on the insurance or payment ??

 

  
No - I don't know this for sure.

I know this though: https://www.ynhh.org/patients-visitors/billing-insurance/financial-assistance.aspx
Please note the "Free Care" section.

AND, I have seen patients in front of me in ER (my daughter bumped her head on a saturday night when she was 1.5 years old), without any insurance, be admitted!!

AFAIK, all hospitals must provide some level of free care to retain their "not for profit" status and certain other incentives.

<Edited link to go to main hospital page, instead of psychiatric care page>

rated:
puddonhead said:   
jerosen said:   
puddonhead said:   
In our neighborhood hospital - the patient will simply be moved into the hospital for EOL care. The billing will not even communicate back and forth with the doctors.

  

You know for a fact this is what happens in your hospital?   

Someone goes to the ER with stage 4 cancer and no insurance or means to pay and then gets checked into the hospital for free for the rest of their days?    And the people running the place don't even know/ notice / check on the insurance or payment ??

 

  
No - I don't know this for sure.

I know this though: https://www.ynhh.org/psychiatric/patients-visitors/billing-information/financial-assistance.aspx
Please note the "Free Care" section.

AND, I have seen patients in front of me in ER (my daughter bumped her head on a saturday night when she was 1.5 years old), without any insurance, be admitted!!

AFAIK, all hospitals must provide some level of free care to retain their "not for profit" status and certain other incentives.

  

Yes they give free care in the ER.    But it generally ends there or ends as soon as they can stabilize the person and get them out of the hospital bed.

This doesn't generally mean free end of life care.

I'm sure some hospitals are more charitable than others but there isn't any mandate to give unlimited care for any illness.    If you're stable enough not to need hospitalization then you don't just stay for free.   My impression of end of life care is that they would be discharged generally.
 

rated:
jerosen said:   
 
Yes they give free care in the ER.    But it generally ends there or ends as soon as they can stabilize the person and get them out of the hospital bed.

This doesn't generally mean free end of life care.

I'm sure some hospitals are more charitable than others but there isn't any mandate to give unlimited care for any illness.    If you're stable enough not to need hospitalization then you don't just stay for free.   My impression of end of life care is that they would be discharged generally.


Even so - won't you agree that the original point I was making still stands?
1. You can't have a midway solution - healthcare should either be completely market driven, or socialized. Anything in between is a recipe for financial disaster.
2. We should generally NOT have too many "option"s - as they increase costs. Anyone who needs more options than the "socialized version" should pay out of pocket for it without the benefit of collective bargaining or regulations - I'm sure a market for that will Spring up for the billionaires. This applies to EOL care as with anything else.

rated:
>> Thats not exaggeration or politicizing anything. We have the ER law so people don't die simply for lack of insurance.

I contend (without any "proof" or studies to back it up, but simply appealing to your common sense) that this catastrophic personal consequence is required for the market to function financially.

Remove the consequence - and you mess with the "free market".

My "common sense" in this regard is backed by experience seeing such a marketplace up, close and personal - as well as experiencing how the society changes it's culture and behavior to adopt to such a market.

In certain situations - I much rather prefer the completely "market driven" approach and the consequent cultural adjustments. I saw my grandpa die at 99+ - completely refusing any medication/doctor for last few years. When I compare that with the painful end of life situations I have read about in some newspaper articles here (you tend to start having multiple organ failures etc simply due to old age and it becomes very painful) - I know which one I will choose, bonus or not!!


 

rated:
puddonhead said:   >> But one aspect of ACA that is not discussed here much as far as cost-management goes is the individual mandate. I know it's been heavily politicized but stepping away from the partisanship, what are the options on that and effect on costs?

That is where a tax increase to fund the single payer comes into play.
"There will be sizable gap between the insurance cost and premiums. This has to be funded by a fairly sizeable tax. We can get a bunch of this money from corporations - in lieu of group insurance plans. But that would still fall short. Tax increase has to happen.
Question is how much! I don't quite know the answer to this right away - but the question needs to be answered by math, not politicians."

No to mandate! But you need taxes!

  I'm not following maybe but are you suggesting single payer universal system? And the proposed payment for that healthcare would be based on employer tax in place of the group insurance they pay for this employees currently AND via another general tax? What tax would that be?

Either way, single payer is not terribly different from mandate to me. Both force people into fixed insurance plans. Both force healthy individuals into subsidizing higher risk pools. Single payer would only make it so it guarantees that there is an insurance provider in your county. But as far as overall healthcare cost-control, I'm not sure how different the two options would be.

rated:
Shandril said:   
puddonhead said:   >> But one aspect of ACA that is not discussed here much as far as cost-management goes is the individual mandate. I know it's been heavily politicized but stepping away from the partisanship, what are the options on that and effect on costs?

That is where a tax increase to fund the single payer comes into play.
"There will be sizable gap between the insurance cost and premiums. This has to be funded by a fairly sizeable tax. We can get a bunch of this money from corporations - in lieu of group insurance plans. But that would still fall short. Tax increase has to happen.
Question is how much! I don't quite know the answer to this right away - but the question needs to be answered by math, not politicians."

No to mandate! But you need taxes!

  I'm not following maybe but are you suggesting single payer universal system? And the proposed payment for that healthcare would be based on employer tax in place of the group insurance they pay for this employees currently AND via another general tax? What tax would that be?

Either way, single payer is not terribly different from mandate to me. Both force people into fixed insurance plans. Both force healthy individuals into subsidizing higher risk pools. Single payer would only make it so it guarantees that there is an insurance provider in your county. But as far as overall healthcare cost-control, I'm not sure how different the two options would be.


Qualified yes!
When you say "single payer universal system" - that tends to mean everything is government run. That may not be necessary.

The critical part you need is a single entity that does ALL negotiations, and sets ALL rules regarding who gets paid what, who gets subsidized by how much, and who pays for that subsidy. Once the rules are set, and negotiations are done, and subsidies are decided, and taxes are calculated - we can have many market driven solutions to handle the actual cash flow. We can even leave our trusted, old IRS to handle the tax/subsidy side of things.

This is the lowest hanging cost control mechanism!! This can be used either with mandate, or with a more socialized, government run system. 

>> Either way, single payer is not terribly different from mandate to me

Mandate is simply to make sure the pool is big. It is not a direct cost control mechanism - but it is a pre-requisite to make things work.
Mandate is not going anywhere - because it is required by math - which is more powerful than any political party, and even the Orange One.
In a completely socialized system - by definition - everyone participates since everyone is eligible!

I have detailed the cost control mechanisms a few posts above. Many of them, I think, would not be possible without a "single payer" seating in between all patients and providers. I also think that no such cost control measures exist in a market driven system. Hence my conclusion - single payer is required to control costs. I will correct my opinion once another fact and number driven proposal is presented on the contrary. So far, I've seen none!

rated:
puddonhead said:   
jerosen said:   
 
Yes they give free care in the ER.    But it generally ends there or ends as soon as they can stabilize the person and get them out of the hospital bed.

This doesn't generally mean free end of life care.

I'm sure some hospitals are more charitable than others but there isn't any mandate to give unlimited care for any illness.    If you're stable enough not to need hospitalization then you don't just stay for free.   My impression of end of life care is that they would be discharged generally.


Even so - won't you agree that the original point I was making still stands?
1. You can't have a midway solution - healthcare should either be completely market driven, or socialized. Anything in between is a recipe for financial disaster.
2. We should generally NOT have too many "option"s - as they increase costs. Anyone who needs more options than the "socialized version" should pay out of pocket for it without the benefit of collective bargaining or regulations - I'm sure a market for that will Spring up for the billionaires. This applies to EOL care as with anything else.

  
1.   No.     Its not a 100% one wy or the other choice.    There are a number of nations that don't have the financial disaster we do yet have a hybrid between market driven private care and socialized programs.

2.  I'm not sure what options you want to eliminate and how too many options matters.
 

rated:
puddonhead said:   >> Thats not exaggeration or politicizing anything. We have the ER law so people don't die simply for lack of insurance.

I contend (without any "proof" or studies to back it up, but simply appealing to your common sense) that this catastrophic personal consequence is required for the market to function financially.
...

 

  
No people don't have to die due to lack of insurance in ER rooms.   Free ER care for the uninsured or poor is just charity for the poor.  Charity can and does exist along / within perfectly functional markets.

e.g. food stamps have not ruined the grocery business.

 

rated:
>> No. Its not a 100% one wy or the other choice. There are a number of nations that don't have the financial disaster we do yet have a hybrid between market driven private care and socialized programs.

Example please?

<rant on>
I am using the term "socialized medicine" too loosely - as a re-appropriation of a term maligned by ideologues. This is my favorite rhetorical tool when dealing with ideologues.

I love the song Yankee Doodle Dandy!!

What I am suggesting by that re-appropriated term is centralized rate and rule setting and some other paraphernalia. In most of the world - this would probably qualify as a centrist, maybe even slightly center-right solution to healthcare.
In the US context, however, where politics is owned by far right (establishment democrats) or ultra right (republicans) - this proposal will come across as "socialist". Hence the misappropriation.
</rant off>

I would be surprised if you can show any country with a stable healthcare system that does not have a centralized rate setting and provides healthcare coverage to every citizen.

The two important parts are "healthcare coverage to every citizen" and "does not have a centralized rate setting". Show this combination in practice and I will agree to your point.

>> I'm not sure what options you want to eliminate and how too many options matters.
Should be driven by how much we want to cut the cost.
One size fits all is the cheapest! 
From there we can go all the way up to personalized medicine. I once even spoke with a post-doc whose cancer research position was funded by a billionaire with a family history of that kind of cancer!! That is the ultimate in personalized medicine.
Okay - that bit is hyper-dramatized!!

Basically the approach should be to check which choices cost us the most and then attack them from there one. EOL care, from what I hear, is very expensive. Should be the first one the study and see if we can simplify/eliminate etc!!

rated:
puddonhead said:   
When you say "single payer universal system" - that tends to mean everything is government run. That may not be necessary.

The critical part you need is a single entity that does ALL negotiations, and sets ALL rules regarding who gets paid what, who gets subsidized by how much, and who pays for that subsidy. Once the rules are set, and negotiations are done, and subsidies are decided, and taxes are calculated - we can have many market driven solutions to handle the actual cash flow. We can even leave our trusted, old IRS to handle the tax/subsidy side of things.

 

I'm assuming that if one entity did all the price/premium negotiations, it'd be a governmental agency. In that case, isn't it a technicality if someone else runs healthcare?  Think about some regions of the world where gas prices are uniform and fixed by the local government. Does it matter if you go to Shell, Exxon, or B.P. gas stations then? Yes you could still have small differentiation on performance and customer service but that's minor. Which is why, in a healthcare system where everything cost and premiums are negotiated by the government, it might as well be called a universal healthcare single payer system. Otherwise insurers are simply third party intermediates with little differentiation between them if they are not allowed to compete on costs and premiums.

To be clear, that's not a point against your argument. More of calling it like it is if every aspect of healthcare is tightly regulated by the government. Speaking of that, would it be federally-negotiated or something left to the states? Would it make a difference?

rated:
>> To be clear, that's not a point against your argument. More of calling it like it is if every aspect of healthcare is tightly regulated by the government. Speaking of that, would it be federally-negotiated or something left to the states? Would it make a difference?

You (almost) made my point!!

Federally negotiated is better than leaving it to states! Simply because that increases the pool size. Leaving it to the states would mean states like Idaho will not really get a good deal from providers - while TX, NY or CA will!! States like mine (CT) will be somewhere in between.
Federal rate (and rule) setting would be better economically.

Besides rate setting, we also need this single entity taking decisions on how to fund and subsidize - simply because it will otherwise be logistically difficult, and there are a lot of positives of doing so.

So, at the end of the day, this becomes your "Single payer", even if the actual cash-flow can go through multiple players. Any participant who does not want to play by this "single payer"s rules - is simply left out in the cold!!

rated:
puddonhead said:   I am using the term "socialized medicine" too loosely ...
  
OK, I took you to mean owned / operated by the government.

Setting prices isn't the kind of socialism generally associated with health care.     

I don't know what countries do and do not set prices.    I would not be surprised if theres a nation out there that has universal care and doesn't fix prices.


Singapore or Australia maybe ? 
 

Skipping 117 Messages...
rated:
samko said:   

 
  I would change Medicaid to a PPO.  There would be monthly premiums and co-pays.  If you couldn't afford either, you'd need to apply for credit; get a sponsor; put up a gofund me, or find some other means of payment.  Otherwise, you'd get waitlisted, referred to charity doctors or put in a raffle (I'd allow a small percentage of poor people to get free treatment through dumb luck).

  There's always grumbling about everything, even free stuff. But, I don't think anyone would prefer to not have it at all. 

I sincerely don't think your system would work. You expect poor people to:
"apply for credit" - If they're poor, they will be denied
"get a sponsor", "put up a gofundme", "or find some other means of payment" - I think this is idealistic and I can't imagine it working. 
"get waitlisted", "charity doctors", "put in a raffle" - this sounds like what many underdeveloped countries do and I do not want to see that here. 

I respectfully and wholeheartedly disagree with your suggestions. 

  "not to have it at all" is the lowest possible standard. that's not too different than saying that most students would rather have a D minus than an F.  That's what Medicaid/Tricare are: D minus.  That's fine for other people.  But my worry is that gov't would get involved in my insurance and bring it down from a B minus to a D minus.  No thanks.  D minus is ok for freeloaders, but not for me.

haven't heard of sub-prime lenders?

Gofundme seems to work quite well for some emotional pleas for help ( i didn't say it would work 100% of the time, or even most of the time.  But that would be one of several avenues that poors could explore).

I have seen some type of sponsorship for free medical care..  For example, the UFC paid for some kid's heart surgery, after some UFC fans took to the social medias.  Similarly, Kylie Kardashian (of Kylie Cosmetics) has already promoted her brand by spending six figures on cleft-lip surgeries for poors.  These things could be extended by major corporations who wanted to look caring on the Twitter or the Instagram. 

These other things are already done here.  haven't you heard of people being waitlisted for organ transplants? There are also charity doctors who routinely go into poor parts of the US and give medical care free. the same is true of dentists. there was a whole segment on 60 mins. about some guy who rents a warehouse for altruistic dentists.  Over a weekend, they serve hundreds if not thousands of poors for free. I'm not sure whether anybody uses a raffle system for medical/dental.  But I don't see how that's any worse than making people wait in long lines for hours on end to get free stuff (like the ones at that dental warehouse).

Lastly, consider more openness to ideas and not shutting something down because "you can't imagine it working" or because it's "low class."  Lots of things don't seem as if they would work.  And, in their initial form, they would bomb.  But experimentation provides a way of tweaking things, until a version of the prototype is found that DOES work.  Also, it very likely necessary to use a mix of "high class," mid-class" and "low class," when you've got limited resources, and a populace where about 47% freeloads/quasi-freeloads.   If anything, we're most likely using too few "low class" ideas, since health-care costs keep spiraling.

For some reason, I keep getting caught in a "SPAM" filter, even when my posts contain ZERO links. 

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