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Author Topic: ACA  (Read 8905 times)

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Offline Valthazar

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Re: ACA
« Reply #125 on: November 08, 2013, 11:43:02 PM »
Sorry had some weird posting issues, but I think got it fixed now.

On the death spiral, what happened in Massachusetts? From what I can recall the uptake from young people (and men in particular) was very low right up to the last minute, at which point a rush occurred. Does anyone more familiar with the situation know what that did to premium costs?

Glad you brought this up, because I think Romneycare was far more successful in its rollout, as compared to ACA. 

Before getting into the death spiral, it's important to look at some preliminary differences.  In 1996, Massachusetts passed an isolated law that banned insurers from refusing coverage because of pre-existing conditions, and selling premiums at similar rates.  This is completely separate from Romneycare.  This law is often known as “guaranteed issue” and "community rating."  In theory, this is a great clause, but what ends up happening is, people will wait until they get really sick, and only when they get sick will they get insurance.  In other words, people will just wait until they get diagnosed with cancer, then get health insurance.  Very cost ineffective, and there was a huge problem with premium rate increases for many years.  This led Massachusetts to have the #1 cost of healthcare, and premium rates in the country.

So, in 2006, Romneycare 'added on' to this existing law, by mandating everyone to buy insurance, along with providing subsidies to make it affordable.  In other words, the timing of these various provisions were staggered.  So basically, this created a sudden, across the board, premium decrease, as a result of the mandates and subsidies.  With the ACA, what is happening is that the "guaranteed issue" clause is being passed into law at the same time as the individual mandate and subsidies - creating a perfect storm, which is what is causing certain plans to be dropped, and thus, rate increases for people with sub-standard insurance - like for example, phaia's situation.

http://www.bostonglobe.com/opinion/2013/11/06/why-was-romneycare-rollout-smooth-and-obamacare-buggy/eLqidsI56zFW1gI0QP2taK/story.html

Now, with regard to the death spiral, it is very important to realize that under ACA and Romneycare, people can stay on their parent's health insurance plan until age 26 and 25, respectively.  This means that if their parents are enrolling for health plans through ACA, many young adults ages 18-25 will thus be getting insured as a result as well.  Because of this, the real death spiral effect will be focusing on the enrollment of young adults from age 25 to 34, or so - because these are the real young adults who are having a choice as to whether to enroll, or pay a penalty fee.

Here's the official Massachusetts Health Insurance Survey data from 2011.  Go to page 15 of the PDF (or page 11 of the document itself), and look at that graph at the bottom:
http://www.mass.gov/chia/docs/r/pubs/13/mhischartpack-1-29-13.pdf

You'll see how there's actually a decrease in the number of uninsured ages 19-25 in Massachusetts from 8% in 2008 to 6% in 2011.  This is largely because many of these individuals were now automatically getting coverage through their older parents' newly minted Romneycare plans.  However, look at the number of uninsured from ages 26-35 - there is an increase from 3% to 6%.  This is the evidence suggesting decreasing enrollment among young people - and arguably representative of the death spiral effect (albeit, to a lesser degree than with ACA, due to the reason above).

As far as the premium rates themselves, you're really going to find opinions going both ways.  The reality is that in comparison to other states, Massachusetts has consistently had a higher than average growth in premium rates after the passage of Romneycare, but granted, this higher than average growth has slowly been declining.  Some attribute this decline to Romneycare itself, as a tribute to its success, while others say that this decline was inevitable considering the drastic initial hike in premiums immediately after the passage of Romneycare. 

In other words, because this was a state-based health reform, and there are essentially only a few health insurance companies in MA, there's a school of thought that these insurance companies colluded with one another and artificially spiked premium costs, fully aware that a healthcare mandate was in the works.  It's really a very complex issue, since a very significant portion (nearly half) of Romneycare is funded through federal subsidies.  As a result, its cost efficiency, as compared to ACA is difficult to measure.

http://www.washingtonpost.com/blogs/wonkblog/wp/2012/09/21/how-romney-paid-for-romneycare/

Maybe someone who lives in Massachusetts can speak more directly about premium rates.  In a nutshell, yes, premium rates have increased.  Whether or not the blame can be attributed to Romneycare is questionable - and you'll get a different answer depending on if you read a Republican or Democrat columnist.

Ironically, most Democrats will defend Romneycare and attribute the gradual decline in premium growth (despite still being above US averages) to Romney's plan, while most Republicans will criticize continued rising costs as a failure of Romneycare.
« Last Edit: November 09, 2013, 12:15:36 AM by ValthazarElite »

Offline kylie

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Re: ACA
« Reply #126 on: November 09, 2013, 03:00:02 AM »
With regard to healthcare, I was speaking about how premiums are determined today (either pre-ACA or post-ACA).  Certainly, under ACA, no one can be denied health insurance due to pre-existing conditions, but premium rates are still variable based on age, health, and status of the individual. 
          Well thanks for bopping back.  I think we may just have a fundamental philosophical disagreement somewhere.  But if you were really only concerned about ACA, that makes it somewhat more understandable I suppose.  Some other people have popped in saying more or less that the government simply can't handle health care at all -- in ways that seem quite reminiscent of the Tea Party to me (not saying they are necessarily people who support the Tea Party, but some things do end up pushing in the same direction with many of the same claims).  And as I have tried to make abundantly clear, at least on the surface of it, there are some commonalities between some of your points of emphasis and some of theirs / those of some other radical withdrawal supporters I have seen on the web.   

         It seems to me that the question of pre-existing conditions being covered or not is a rather big deal.  And further...  Though you may not have been on about this, if one accepts your logic in principle that the nature of the healthcare industry must be to focus on differential risk and assign people very different fees based on likelihood of so many specific conditions (in addition to more general groupings such as age etc.), then I think we would still end up (when all is added together) with a situation that may not be so healthy for women (and other classes of people) generally, and will have some heavy social costs somewhere else.  Though it's arguable enough they're costs that people have started to accept as inevitable, and in that case women and various other groups are just doomed...  And that, well, call me crazy -- but I'm just not willing to accept that as the best we can do.

Quote
I already posted about my views earlier in this thread as to what I consider the optimal solution.  That would be focusing heavily and incentivizing the creation of full-time job opportunities (through tax subsidies for businesses creating entry level jobs, full-time positions, etc.), and naturally creating avenues of opportunity for people to purchase private insurance on their own.  While I did not vote for Obama in 2008, nor do I agree with many of his perspectives, I at least found his original healthcare proposal to be sensible, and fundamentally sound.  It made sense, and whether or not I agreed with it, it would at least provide one solution to expanding coverage and reducing healthcare costs.
          If I'm not mistaken, Cyrano had several rejoinders to your suggestions (I believe I'm still thinking of the same thread, it's been a few days).  I think I share a lot of his concerns, and I didn't feel like they'd really been answered quite to my satisfaction.  I didn't bother posting just to repeat/ cheerlead what I feel he'd said in more succinct and poignant words. 

           However, I must grant you that I'm not reading every single line carefully.  There are some more technical arguments and hypothetical cases people have tossed, where if I think we probably have some difference in principle, then I just may not be so interested.  This is perhaps lazy on my part, but there has been a lot of discussion here never mind anything/anywhere else I might prefer to read, and I'm looking for things that I feel I understand -- and honestly, have some good feeling about -- in shorter form first, as I go along.  If it feels problematic to me on the face even "somehow," then I sometimes skim on or let it go.  Short of serious debt relief, even a substantial change in future arrangements isn't going to serve me personally in the next couple years probably anyway...  So I'm a little low on enthusiasm when it starts to feel like picking over mechanics. 

Quote
I am not disagreeing with the ideology of what you are saying,
         Trying to be fair...  But I honestly kind of wonder if you aren't.  I have become more inclined to agree that ACA itself has serious problems (and this isn't entirely surprising after all the wrangling and modification the original ideas faced -- but it is quite disappointing).  That said, some of the broad claims you make about the role of business, the potential for enterprise finance to elevate people who seem to be politically locked into really oppressive environments, the apparently 'unchangeable' nature of insurance...  I'm not sure where you think the limits are on the influence and benefits of business as we know it. 

Quite often, I somehow get the impression that at the end of the day, you'd end up feeding many of the same cycles by relying on an overall economic model that's already pretty well defeated the people.  Maybe you just think that's the farthest we can safely go, and you might prefer more...  But where does cynicism turn into surrender, and where does "optimism" slide into simply being a servant of gross inequality (optimism for the managerial handful, and profession of their philosophy that everyone will "someday" do better if they just keep imitating wealthier people)?  I don't know.  That's sort of my gut feeling. 

         I suppose if you prefer, you might say well this is all well beyond discussing ACA, but if these are also issues that caused the dilution of the original concept, then I think it's kind of relevant.  Of course anyone could say let's not talk about anything elsewhere in society here -- you can just go on repeating, oh I don't disagree, oh but I'm only here to recite the problems with the ACA (are you?); see elsewhere for other matters.  And then it kind of seems to me, politics remains neatly compartmentalized into "narrower topics."  Such that no one can suggest anything innovative or radical about whatever say, gross economic inequality has to do with campaign finance, lobbying, the intense focus on corporations as supposedly irreplaceable 'partners' in change (really?!), etc. which make up the health care crisis.
« Last Edit: November 09, 2013, 03:05:16 AM by kylie »

Offline Valthazar

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Re: ACA
« Reply #127 on: November 09, 2013, 08:55:23 AM »
kylie, I do appreciate your views on issues, and I am more than open to discussing them.  But it's difficult to debate ideologies without having any sources to know what you are basing your criticism and views on.  From what I understand, you are saying that on a purely ethical level, individuals should be able to get health insurance despite pre-existing conditions, and that premium rates should be the same for all individuals - regardless of age or sickness.

I acknowledged this point of view in my last post, and I actually went into depth explaining how in 1996, Massachusetts passed its guaranteed issue and community rating law, doing exactly what you say.  I then cited sources explaining some of the impacts of this law, and the fact how Massachusetts has received considerable federal funding for Romneycare in 2006.  Part of the reason Massachusetts received immense federal funding for Romneycare is because its cost of healthcare was sky-high, and number one in the nation due to the 1996 legislation.  If you feel that this type of stand-alone legislation is feasible regardless of its costs, I would be interested in seeing sources demonstrating that.

"The new federal bill [guaranteed issue in 1996] would expand those rules to the entire nation. Under guaranteed issue, insurers must accept all enrollees regardless of their medical condition; under community rating, they must charge all customers similar premiums, even if their costs are far different. The result is that prices rise steeply for young, healthy customers, who must pay far more than their actual costs. It also give them a strong incentive to drop insurance; then they can "game the system" by signing up any time they need surgery or get diabetes."
http://money.cnn.com/2010/06/15/news/economy/massachusetts_healthcare_reform.fortune/

"Hence the pool of insured people gets older and sicker as the healthy drop out. That's what happened in Massachusetts, and it contributed to soaring premiums. The 2006 reform plan (Romneycare) was supposed to solve the problem by requiring that everyone buy coverage or pay a fine of around $1,000. It worked, but only in part: Of the 600,000 uninsured in 2005, around 450,000 are now covered. But a large share of 150,000 who still lack coverage are young residents who choose to pay the fine instead of high premiums. Insurers are also getting socked by people who sign up for insurance to get expensive care mandated under state law, including hospitalization for childbirth or hip replacements, and then depart once the procedure is completed."
http://money.cnn.com/2010/06/15/news/economy/massachusetts_healthcare_reform.fortune/

I am interested in a healthy discussion, and I am sure there is merit to many of your views.  But without having sources for me to read about the arguments in support of your views, it is difficult for me to engage them.  I looked back through this thread, and Cyrano has not posted in this thread, so I couldn't find any sources there either.  So far, all I have done is report some of the differences between the ACA and Romneycare, and given some current figures on how insurance companies are responding to the ACA, and provided extrapolations on what might potentially happen, based on what happened in Massachusetts.

If you feel there are more innovative, and outside-the-box solutions, we can certainly discuss that.  As I told Kythia though, I am not really very strong when it comes to defining "ideal" policy for health insurance companies, and can only provide opinions of their response.  Most of what I have been saying so far, has basically just been what I have read and researched regarding the current initial response to ACA.
« Last Edit: November 09, 2013, 09:27:11 AM by ValthazarElite »

Offline vivaciousvixen

Re: ACA
« Reply #128 on: November 11, 2013, 10:58:27 AM »
I think the ACA has noble intentions, but it was very poorly crafted legislatively and economically.  As I have said previously, it will artificially cause premiums for non-ACA insurees to rise, and as a result, due to declining enrollments, may cause private insurers to drop coverage in certain target demographics and markets.

Obama had marketed the ACA with the promise in 2009, “if you like your health plan, you will be able to keep your health plan,” and even in 2012 was saying, “If [you] already have health insurance, you will keep your health insurance.”

http://www.cbsnews.com/8301-505263_162-57609737/obamacare-more-than-2-million-people-getting-booted-from-existing-health-insurance-plans/
http://investigations.nbcnews.com/_news/2013/10/28/21213547-obama-admin-knew-millions-could-not-keep-their-health-insurance?lite

Basically, as the law was originally written, all health insurance plans as of March 23, 2010 would be 'grandfathered' in, and the ACA would not cause their insurers to modify their plans in any manner.  However, since then, the Department of Health and Human Services wrote changes that said if any part of a policy was changed since that date, for example, the deductible, co-pay, or benefits (which is pretty normal, considering how frequently slight modifications occur in most insurance plans), that the policy would not be grandfathered.  So that's the situation we are in now.

Many individuals in their 20s are choosing to not purchase health insurance under ACA, and would rather pay the tax penalty, which is another financial uncertainty for insurance companies.  If you've just graduated from college, healthy, and tight on cash, would you rather pay extra for insurance you'll probably never use, or just pay a lower penalty fee to the government?  When the ACA was written, the young, uninsured demographic was supposed to the prime source of premiums to help pay for the medical care for the unemployed and uninsured older population - but the strength of this plan is increasingly under question now.  Many insurance companies are approaching the ACA from a risk management perspective, (since it is an external pressure on their industry) and trying to do financial damage control at this point.

I can't really say much about the technical glitches/issues with the website.  I guess those will be sorted out in due time.  It's a blessing that most small to midsize businesses will have until Jan 1 2015 to comply, because many of them are seriously unsure about all the uncertainties surrounding ACA.  I've tried to explain the ACA to my friend, who is working on a business plan, and it's frustrating when I can't provide him all the answers because the law is so vague with regard to business requirements.

Well said ValthazarElite. You and I share many of the same views on this issue. A class in economics can explain why the ACA is a terrible plan for the U.S. as it stands.

Offline Kythia

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Re: ACA
« Reply #129 on: November 12, 2013, 12:25:33 PM »
Well said ValthazarElite. You and I share many of the same views on this issue. A class in economics can explain why the ACA is a terrible plan for the U.S. as it stands.

Odd, I would have expected at least one of the democratic party to have taken a class in economics.  What a weird statistical fluke.

Unless, maybe, the lessons learnt from such a class aren't as unambiguous as you claim?  Nah, no democrats ever took an economics class, that's far more likely.

Offline Valthazar

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Re: ACA
« Reply #130 on: November 12, 2013, 01:05:10 PM »
Odd, I would have expected at least one of the democratic party to have taken a class in economics.  What a weird statistical fluke.

Unless, maybe, the lessons learnt from such a class aren't as unambiguous as you claim?  Nah, no democrats ever took an economics class, that's far more likely.

It has nothing to do with Democrat or Republican.  Many Democrats are expressing concern over ACA as well.

"A rising tide of Democrats has begun voicing support for easing the deadlines and penalties of the Affordable Care Act, showing the first cracks in party unity against GOP opposition to the health care law.  A prominent 2014 Senate Democratic candidate, Michelle Nunn in Georgia, on Thursday endorsed delaying the requirement for individuals to buy insurance.  A House Democrat, Rep. John Barrow of Georgia, also called for delaying the individual mandate in a floor speech this week, citing the administration's prior decision to delay for one year a separate requirement for employers."

http://www.usatoday.com/story/news/politics/2013/10/24/democrats-waver-obamacare-delay-hagan/3181655/

Interestingly, the Obama administration's 'prior decision to delay' was pushed by Congressional Republicans.

Offline Kythia

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Re: ACA
« Reply #131 on: November 12, 2013, 01:07:32 PM »
It has nothing to do with Democrat or Republican.  Many Democrats are expressing concern over ACA as well.

"A rising tide of Democrats has begun voicing support for easing the deadlines and penalties of the Affordable Care Act, showing the first cracks in party unity against GOP opposition to the health care law.  A prominent 2014 Senate Democratic candidate, Michelle Nunn in Georgia, on Thursday endorsed delaying the requirement for individuals to buy insurance.  A House Democrat, Rep. John Barrow of Georgia, also called for delaying the individual mandate in a floor speech this week, citing the administration's prior decision to delay for one year a separate requirement for employers."

http://www.usatoday.com/story/news/politics/2013/10/24/democrats-waver-obamacare-delay-hagan/3181655/

Interestingly, the Obama administration's 'prior decision to delay' was pushed by Congressional Republicans.

That wasn't the point I was making, and I suspect you're aware of that.

Offline vivaciousvixen

Re: ACA
« Reply #132 on: November 12, 2013, 02:09:49 PM »
@Kythia That was not to say they never took a class in economics....perhaps they are just forgetting their lessons. As was explained earlier in this thread by other posters, all the ACA is doing is inflating the cost of insurance and causing many people who already had established health insurance to lose their plans, when they were told by the President that they could retain their plans.

Offline Kythia

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Re: ACA
« Reply #133 on: November 12, 2013, 02:28:12 PM »
@Kythia That was not to say they never took a class in economics....perhaps they are just forgetting their lessons. As was explained earlier in this thread by other posters, all the ACA is doing is inflating the cost of insurance and causing many people who already had established health insurance to lose their plans, when they were told by the President that they could retain their plans.

Mmmm.  This is my concern:  Your point seems to be that the negative effects of ACA are basic common sense.  And yet a number of people in the US without noticeable mental defects appear to think the act is a good idea.  So either you're saying that a number of people in the US can't see a simple, basic, common sense problem with something despite not being institutionalised or wards of the state or you're saying...what?

It doesn't bother me in the slightest, I'm in the UK.  But it seems you simply must be overstating your case as otherwise - if the objection really is so simple - you have a heavy burden to lift in explaining why ACA isn't universally disliked and, in fact, how it ever became law in the first place.  Having problems/issues/concerns with it is fine and dandy.  Stating that those problems are so basic that failure to understand them indicates a basic lack of understanding of the world flies in the face of both reason and Nobel Prize in Economics Winner Paul Krugman who, you know, presumably hasn't forgotten his economics.

As I say.  Object to it by all means, but try not to overstate your case so radically.

Offline Valthazar

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Re: ACA
« Reply #134 on: November 12, 2013, 03:52:00 PM »
Stating that those problems are so basic that failure to understand them indicates a basic lack of understanding of the world flies in the face of both reason and Nobel Prize in Economics Winner Paul Krugman who, you know, presumably hasn't forgotten his economics.

The reputable pro-ACA sources that I did find, such as the one above, were basing their analysis on the assumption that all individuals with employer-based healthcare plans currently would retain them.  Krugman's article is no different.

"How would ObamaRomneycare change American health care?  For most people the answer is, not at all. In particular, those receiving good health benefits from employers would keep them. The act is aimed, instead, at Americans who fall through the cracks, either going without coverage or relying on the miserably malfunctioning individual, “non-group” insurance market."
http://www.nytimes.com/2012/03/19/opinion/krugman-hurray-for-health-reform.html?_r=0Paul%20Krugman

We already know this isn't the case.  Many of the people who voted for Obama in 2012 truly believed these types of articles (especially considering that this article was written in March 2012).  Part of the reason there is a backlash now, is because the ACA was marketed on a premise that was largely economically unfeasible - which is, the idea that rates would remain the same, and current private insurance holders would not be affected.  Honestly, if I was uninformed about this issue, and had read that article in March of last  year, I would be struggling to understand why people are so opposed to ACA.

Krugman is an incredibly smart man, and has some excellent articles, but his lack of clarification on economic matters, such as assuming coverage will not be dropped, largely detaches his views from the reality of how the response already is.  The assumptions themselves are not backed up, at least in the articles I've come across.
« Last Edit: November 12, 2013, 06:04:34 PM by ValthazarElite »

Offline Phaia

Re: ACA
« Reply #135 on: November 12, 2013, 04:05:10 PM »
Mmmm.  This is my concern:  Your point seems to be that the negative effects of ACA are basic common sense.  And yet a number of people in the US without noticeable mental defects appear to think the act is a good idea.  So either you're saying that a number of people in the US can't see a simple, basic, common sense problem with something despite not being institutionalised or wards of the state or you're saying...what?

It doesn't bother me in the slightest, I'm in the UK.  But it seems you simply must be overstating your case as otherwise - if the objection really is so simple - you have a heavy burden to lift in explaining why ACA isn't universally disliked and, in fact, how it ever became law in the first place.  Having problems/issues/concerns with it is fine and dandy.  Stating that those problems are so basic that failure to understand them indicates a basic lack of understanding of the world flies in the face of both reason and Nobel Prize in Economics Winner Paul Krugman who, you know, presumably hasn't forgotten his economics.

As I say.  Object to it by all means, but try not to overstate your case so radically.


So Kythia I have to ask, with you being in the UK and not bothered in the slightest...why all the fuss from you about ACA Anyway? it is not like it effects you?

Phaia

Offline consortium11

Re: ACA
« Reply #136 on: November 12, 2013, 07:28:54 PM »
Stating that those problems are so basic that failure to understand them indicates a basic lack of understanding of the world flies in the face of both reason and Nobel Prize in Economics Winner Paul Krugman who, you know, presumably hasn't forgotten his economics.

No, but Krugman's Nobel Prize and the respected portions of his work relate to international economics and trade, specifically international geography and what became known as the "new trade theory". That's what he's specialized in and what he's spent the serious academic portion of his life writing about on and working on. Using his Nobel prize as evidence for his understanding of a topic which isn't related to international economics (and ACA isn't) is pretty close to an appeal to authority. This seems to happen a lot in certain fields... science is one and economics is another... where people look at an individual, see they are experts and almost universally respected in one area of a field and then assume they are experts on all areas related to it. We don't present a pulmonologist... however eminent... as an expert on cardiology because of their work on the lungs and that they're a medical expert; they're a medical expert on pulmonary issues, not cardiology.

That's not to say that Krugman is necessarily wrong on ACA but he's not an expert on the economics on health care and isn't considered a particularly respected figure in that field; you'd look to the likes of Michael Grossman and Sherm Folland for that, just as one would turn to Krugman for works on international trade. That shines through when you read his pieces on the economics of healthcare; they're low level op-eds, not serious academic discussion. It also has to be said that over recent years Krugman has had a tendency to bend his economic theories and analysis to fit his political positions rather than his political positions to fit his economic theories and analysis... I suspect at least partially due to the monetary value he gets by being the "go-to" man for economic discussion on the left of the political spectrum... in the same way that say Robert P. Murphy bends the facts to fit his Austrian theories rather than his theories to match the facts.
« Last Edit: November 13, 2013, 05:40:51 PM by consortium11 »

Offline Kythia

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Re: ACA
« Reply #137 on: November 13, 2013, 04:22:27 PM »
In order:

Valthazar - yes.  My comment was more aimed at Vivaciousvixen than at you.  My objection was to her blanket statement that the subject was cut and dried with a clear right and wrong.

Phaia - It doesn't affect me personally, no.  It does actually affect a few friends of mine but that's not why I'm saying anything.  I'm vaguely surprised at what I see as the implication behind your question though, that only things that affect one personally are worthy of consideration. 

Consortium - Yes, excellent points and I was perhaps lazy in appealing to Krugman.  It was tied in to my comment above to Valthazar, that I was trying to show that there wasn't a simple, universally accepted, "right" answer to the conversation.  But its a fair criticism.

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Re: ACA
« Reply #138 on: November 14, 2013, 03:44:57 PM »
A few people in this thread have asked what sort of healthcare policy I believe would be ideal, so I figured I would outline my views.

One of main misconceptions is that the American healthcare system prior to the ACA was a purely privatized, free-market paradise.  This is the not case, as over 73 million people are on Medicaid (not even including Medicare), which exceeds the population of the UK, or even France.  As a result, ideologically, the ACA really isn't a threat to American principles, considering we have already accepted Medicaid and Medicare.  In contrast, the primary issues at hand are the high cost of healthcare, and as a result, an inability to purchase insurance.

Currently, most Americans that do have health insurance obtain it through their employers, and receive healthcare at quite affordable rates.  There is a law in place which provides tax exclusion for employer-provided health coverage.  This means that employers receive tax breaks for whatever percentage they subsidize healthcare costs, and the employees (recipients), do not have to pay taxes on this subsidy.  This is a seemingly excellent and ideal situation, however, the fact that there are no caps on this tax exclusion, is what many feel is the primary reason for rising healthcare costs. 

In other words, because there is no cap, employers are increasingly covering an increasing percentage of insurance costs (routinely 75-80%) these days, since the more they cover, the greater tax reduction they get.  Again, this seems ideal.  However, the counter effect is that because of these large employer subsidies, many employees are increasingly choosing expensive and extensive plans, since their portion of payment will remain the same, even though the empirical cost of insurance as a whole is higher, as priced by the insurance company.

Although at first glance, it might seem like it is a great thing that employers are continuing to pay a large portion of these high premiums, look at the math for a second.  The reason employers are so willing to pay these increasingly high percentages of rising premiums, is because they are getting more tax breaks from the government for doing this.  In other words, it is actually the government itself that is fronting the majority of rising healthcare premium increases.  As insurance costs rise, and employers continue to subsidize a large portion of the premium costs for their employees (due to the tax break incentives), the amount the US government is giving back in tax breaks continues to rise.  It took me a second or two to understand this reasoning.

As a result, I suggest putting a cap on these tax breaks.  It is a fantastic program and one that we truly need - but without a limit, we are actually contributing to the rising cost of healthcare.  By setting a cap on these tax breaks, it will naturally make employees more cost-conscious with regard to which plans they opt into through their employers, and increase competition among insurance companies themselves to appeal to employers for hosting. 

In addition, by adding a cap on tax exclusion for employer-provided heathcare, the government will actually have much, much, more revenue (since they are giving out far less tax breaks).  This additional revenue would be used to subsidize catastrophic coverage for individuals that do not have health insurance.  In other words, this will directly reduce healthcare costs in hospitals for people involved in car accidents and who have heart attacks.  The best part is, there would be no premium at all for this - and purely subsidized through the government.  The idea of people with pre-existing conditions being denied  would also be resolved, since they would have their own coverage pool (in line with a similar program to ACA), however with the increased tax revenue directly subsidizing the high premiums for this at-risk group.

Based on the research I have done, this sort of model is a far more fiscally sensible plan, and unilaterally targets the foundational problem - high costs of healthcare. 

It is not a humanitarian plan, however, like the ACA was marketed as, and does not make any promises for increasing healthcare coverage for elective procedures or care.  However, as a cost reductive program, it would be a blessing for the US, and reduce all of our premiums.

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Re: ACA
« Reply #139 on: November 14, 2013, 03:48:05 PM »
So what do you think of pure government funded healthcare, without the insurance companies at all.  I'm thinking, obviously, of our NHS but its not the only example.

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Re: ACA
« Reply #140 on: November 14, 2013, 04:02:29 PM »
The NHS is a functional system and it works for the UK, that's for sure, but I would not consider it to be an ideal model. 

I say this because I like having choices.  I certainly realize that a minority of people in the UK have private insurance, but it is arguably out of reach for many.  The employer-subsidized model in the US is not at all a bad way of doing things, and for those who have employer-provided healthcare, it is very affordable, and we get plenty of choices.  People with full-time jobs with benefits get many options, choices, plans, doctors, deductibles, etc - at arguably the same premium contribution (taking into account what the employer is playing) as you in the UK are paying through through your cumulative NHS funding.  Basically, for people with stable jobs, the American healthcare system is actually superior to the UK one - at least from their perspective.

The problem is, not enough people have access to these full-time jobs with benefits.  As a result, the solution lies in expanding these opportunities, and in reducing costs.  I believe that if you can restore the fundamentals of the economy, most of the battle will be won.  That's why the solution I outlined above addresses the economics of the matter, which moves us in the right direction.

They key is to get more full-time jobs.  But that's another discussion entirely.
« Last Edit: November 14, 2013, 04:06:49 PM by ValthazarElite »

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Re: ACA
« Reply #141 on: November 14, 2013, 04:28:23 PM »
Hmmm.  Healthcare in the US costs twice what it does in the UK as a percentage of GDP, and the individual spends around 150% of the UK total - stats from here but there are multiple sources.  We also have a higher life expectancy and more doctors and nurses per capita.  I'm not certain that "People with full-time jobs with benefits get many options, choices, plans, doctors, deductibles, etc - at arguably the same premium contribution (taking into account what the employer is playing) as you in the UK are paying through through your cumulative NHS funding." holds.  But that's very much a side issue and I'm not sure its productive to dwell on it.

The main issue is what precisely do you mean by "choices"? I'm a little confused by your word usage there.  Choices on what?  I'm not entirely sure what you're getting at there.  Do you mean choice of location for medical procedures?  Choice of doctor?  Choice of which procedure to have?  We have all those things.  I'm really not certain what "choices" refers to in this context.

Offline Ebb

Re: ACA
« Reply #142 on: November 14, 2013, 07:36:49 PM »
In other words, because there is no cap, employers are increasingly covering an increasing percentage of insurance costs (routinely 75-80%) these days, since the more they cover, the greater tax reduction they get.  Again, this seems ideal.  However, the counter effect is that because of these large employer subsidies, many employees are increasingly choosing expensive and extensive plans, since their portion of payment will remain the same, even though the empirical cost of insurance as a whole is higher, as priced by the insurance company.

The employer-subsidized model in the US is not at all a bad way of doing things, and for those who have employer-provided healthcare, it is very affordable, and we get plenty of choices.  People with full-time jobs with benefits get many options, choices, plans, doctors, deductibles, etc - at arguably the same premium contribution (taking into account what the employer is playing) as you in the UK are paying through through your cumulative NHS funding. 

Do you have cites for either of these facts? They run directly contrary to my experience, and what I've read. In general the trend seems to have been employers putting a higher percentage of insurance costs on their employees. After all, even if there is a tax reduction for increased insurance subsidies by the employee, that reduction is far short of 100%. It still costs the company more to provide better benefits. To the extent that this is useful as a recruiting and retention tool it is worth the company's money. But it's hardly free for them.

I'd also dispute that having employer-supplied benefits results in more choice for the employee. On the contrary, the vast majority of companies offer only a very few options. Perhaps you're focusing mostly on very large corporations? I have worked at companies ranging from six employees to about thirty thousand, and it was only at the very largest that there was any substantive choice in plans available (beyond 'family' vs. 'single')

My opinion is that the marriage of full-time employment and availability of health insurance is an historical accident that does far more harm than good. Before the ACA, for instance, it was not uncommon for someone with a chronic medical condition to be essentially bound to their current job for fear that switching companies would result in a failure for the new insurance provider to cover their treatment. This results in a suppression of the free market in terms of peoples' ability to choose their own jobs.

I'd be very interested to hear the other side of the argument, though.
 

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Re: ACA
« Reply #143 on: November 14, 2013, 08:50:30 PM »
Hmmm.  Healthcare in the US costs twice what it does in the UK as a percentage of GDP, and the individual spends around 150% of the UK total - stats from here but there are multiple sources.  We also have a higher life expectancy and more doctors and nurses per capita.  I'm not certain that "People with full-time jobs with benefits get many options, choices, plans, doctors, deductibles, etc - at arguably the same premium contribution (taking into account what the employer is playing) as you in the UK are paying through through your cumulative NHS funding." holds.  But that's very much a side issue and I'm not sure its productive to dwell on it.

I completely agree with you regarding the cost efficiency of the NHS system on healthcare spending per capita.  As I said in my post, the UK has a functionally sound, efficient system in comparison to the current state of private insurance in the United States due to a variety of economic factors (rising unemployment, reduction in full time jobs, etc.).  However, per capita healthcare spending is an aggregate individual average for expenditure based on all individuals taken together (whether or not they have insurance).  My statement in my last post, regarding the private insurance industry being superior for some Americans, was purely with regard to those Americans who are receiving employer-subsidized healthcare, and their particular net expenditure, on their own healthcare.  In other words, to do a proper analysis, we would need to compare an American woman's individual contribution to her health premiums for a year, versus a British woman's empirical $/£ amount of their taxes, that goes to fund NHS.  Both individuals would need to be identical as far as their incomes and attributes, but I agree with you, that this type of analysis is largely a moot point when discussing the overall efficiency of the system at large.  Your point certainly still stands, that %GDP spending is considerably higher in the US vs. UK, and one that I never refuted.

As far as choice, I was actually referring to monetary freedom, as well as healthcare choice freedom (and obviously these views here reflect the pre-ACA landscape).  Private insurance is quite affordable to the average full-time employed individual, while in the UK, private insurance is largely out of reach for the average full-time worker.  I'll address Ebb's point regarding the number of private insurance choices below, but in an ideal economic climate, the average American full-time worker will have more flexibility in obtaining a plan that fits his/her desires and needs.  For example, in the UK, the National Institute for Health and Clinical Excellence (NICE) determines which drugs and treatments will be covered under NHS.  I like knowing that if I choose to purchase the highest-tier private insurance through my employer, which is affordable, albeit a little pricey in comparison to other plans the employer offers, that I can receive superior coverage, far beyond what the NHS would offer.  If a similar person of similar income were living in the UK, the likelihood that they could even afford a similar private plan is unlikely.  There's both pros and cons to both healthcare models, and we can both form opinions on what we feel is logistically better in our perspective.

The unfortunate reality with such a situation though - and one can hold differing ethical views on this - is that part of the reason I have the ability to opt into a little pricey yet affordable private insurance is because there is a significant population in the US that is not receiving healthcare access.  This goes back to my original point, that the real factor here is bleak economic prospects, and lack of good jobs that offer employer-subsidized private insurance.  I believe that emphasizing premium cost reduction in American healthcare will naturally allow our healthcare model to function with more efficiency and access - in addition to necessary legislation.

Do you have cites for either of these facts? They run directly contrary to my experience, and what I've read. In general the trend seems to have been employers putting a higher percentage of insurance costs on their employees. After all, even if there is a tax reduction for increased insurance subsidies by the employee, that reduction is far short of 100%. It still costs the company more to provide better benefits. To the extent that this is useful as a recruiting and retention tool it is worth the company's money. But it's hardly free for them.

I'd also dispute that having employer-supplied benefits results in more choice for the employee. On the contrary, the vast majority of companies offer only a very few options. Perhaps you're focusing mostly on very large corporations? I have worked at companies ranging from six employees to about thirty thousand, and it was only at the very largest that there was any substantive choice in plans available (beyond 'family' vs. 'single')

My opinion is that the marriage of full-time employment and availability of health insurance is an historical accident that does far more harm than good. Before the ACA, for instance, it was not uncommon for someone with a chronic medical condition to be essentially bound to their current job for fear that switching companies would result in a failure for the new insurance provider to cover their treatment. This results in a suppression of the free market in terms of peoples' ability to choose their own jobs.

I'd be very interested to hear the other side of the argument, though.

Here are the "Share of premiums paid by employer and employee for family coverage" for 2013 from the Bureau of Labor Statistics

http://www.bls.gov/news.release/ebs2.t04.htm

Based on that data, employers seem to be covering premium costs in the high 60s to mid 70s percentages.  I would agree with you that it is by no means a free endeavor for companies, and the tax breaks the government is offering for greater percentage coverage by employers is by no means fully eliminating the cost involved.  However, like you said, its use as a recruitment and retention tool, in addition to its strong tax break incentives have made this a generally accepted, and growing, practice among American employers.

Again, I fully agree with you that there are many negatives to our current model of healthcare.  The reality is that our current economic climate just isn't compatible with the way our private insurance industry is set up.  Historically, there used to be a time in the US when it was "normal" for the average person to stay with one company their entire life.  That isn't the reality anymore.  In addition, there used to be a time when insurance companies really did compete with one another (before these mega-insurance conglomerates).  When you have truly efficient competition, without today's insurance lobbying, you'll actually have multiple smaller insurance companies competing with one another to get "contracts" for small business employers.  Basically, the insurance company which offered the most plan varieties would win the contract.  But you're right, those days are slowly dying away, and in some cases, are gone.  Several states have only 2 insurance providers now, and as you can imagine, they illegal collude with one another to prevent true competition.  So far, we've done our best with Medicaid and Medicare, to prevent people from slipping through the cracks, but it really isn't enough. 

The real question then becomes, do we unilaterally find fault with the infrastructure and system itself of American healthcare, or do we find fault with the illegal practices?  Personally, I believe it is the latter.  I'll be the first one to say that modifications are absolutely necessary, but I think an attempt to massively overhaul the system will ultimately do more harm than good.

In this discussion, I'm really trying to analyze viable solutions that can realistically be achieved.  Whether we love it or hate it, the federal government can't just get rid of private insurers from dominating the healthcare industry, so suggesting a complete switch to an NHS-style system just isn't realistic (at least over the next couple of decades).  Some were saying the ACA was the first step in that direction, but as I have tried to convey in this thread, from what I can see, it seems to be causing more problems so far than improvements.

What I proposed above, involving "premium-free" emergency coverage to those without insurance, and highly subsidized premiums for at-risk individuals, and those with pre-existing conditions, seems to be the most sensible step in the right direction.  With a such system, no one will be "dropped" from their existing insurance plan (the only difference will be, employers may cover a lesser percentage of their premiums).  So in other words, the empirical cost of premiums won't change, but the amount most employees have to pay, might be higher.

It's not really a win-win situation, nor really a desirable one (who wants to pay more?).  But just seems to be the right way forward.
« Last Edit: November 14, 2013, 10:57:45 PM by ValthazarElite »

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Re: ACA
« Reply #144 on: November 15, 2013, 09:48:41 AM »
NICE actually stands for National Institute for Health and Care Excellence.  They have a few roles, one is analogous to the one served by the FDA in the US - making sure the next Thalidomide is taken off the market (leprosy aside).

One of the others, and the one you focus on, is making cost/benefit analyses for NHS clinical standards.  They examine every treatment and say yey or nay.

If I want a treatment NICE have said no to, though, I can still get that through the NHS.  I simply have to pay the difference between the "standard" NHS treatment and the one I want.  This is exactly the same as your proposed system - people who want a pricier option have to be able/willing to pay for it.

This payment - the difference between my desired product and the NHS one - can be paid either as out of pocket expenses or through a private medical insurance.  About 8% of people have private medical insurance - I'm actually one of them for reasons I don't plan on delving in to.  AXA - one of our biggest medical insurance companies though not actually the one I use - call their highest level of cover "Gold Cover".  It costs £17.75 per month.  The national average monthly wage for a female is about £2000 per month.  Private medical insurance is not at all out of the reach of most people, and I'd be intrigued to see your source for your claim that it is. 

Take up rates are so low for the same reason premiums are so low - the NHS provides an excellent level of care and so not only do people not need private coverage but the policies cover far less as the majority is covered by the NHS.

In essence, if people want to pay more to exercise a choice they are able to.  This seems essentially identical in outcome to the system you propose, except considerably cheaper and with considerably better medical outcomes for the basic case.

I think part of your argument is based on a misunderstanding of how the NHS, and the UK health market in general, works.

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Re: ACA
« Reply #145 on: November 15, 2013, 10:01:50 AM »
Kythia, clearly you are more familiar with the British healthcare system than I am, and I was never trying to suggest that the NHS is a bad way of doing things.

The NHS was never central to my argument though, and I only even brought the NHS into this conversation since you had asked for my views on it - and clearly I know very little.  The original argument I put forth was a proposition for how the American healthcare system can be reformed.  As I said in my last post, it's not realistically possible for us to transform ourselves overnight into a single-payer system, which certainly seems to have many positives, as you indicate. 

Perhaps Obama's original plan was a shift in that direction, but the current form of the ACA is far from accomplishing that goal.  The reality is, you're not going to see single payer in the United States anytime soon, because you can't just get rid of the private insurances.  All we can do is make modifications, and hope that over time, changes will occur - or as some say, we shift more towards single-payer.

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Re: ACA
« Reply #146 on: November 15, 2013, 10:28:02 AM »
It seems to me, though, that ACA is a viable move towards a, I can't think of the word, a version of a single payer system.

Everyone pays an amount for a basic level of coverage - in the US that's the ACA compliant minimum over here it's funded through taxes.  People have the ability to pay more on top of that.  In that sense - state differences in cost of minimum level of coverage aside the two are the same.

Your argument has been that in the (short?) term companies will raise premiums.  Mine is that, if we accept the two as analogous in this way, the evidence is that what will actually happen is that higher level packages will drop to a pittance (relative to basic level ones).  I accept the comparison is far from perfect but don't forget the UK didn't always have an NHS - we put it in within living memory.  Our landscape before that was essentially the same as the current US one. 

Returning to your white bread analogy.  I own a bakery.  I sell brown bread, white bread, granary loaves, etc.  The government steps in and says "all bread must be at least as delicious as this loaf right here".  Fine, some of my shittier bread is no longer legal, and I'm forced to stop selling it.  Those who didn't mind the less delicious bread will see their product disappear from my shelves.  However, people now have a guaranteed level of tastiness for their morning toast which has been assessed as suitable, so several will stop buying more expensive loaves because they now know that the basic one is a taste sensation.  Further, as this applies to all bakeries, I now have a strong incentive to make my basic loaf, the minimum allowable by law, as cheap as possible to lure in customers from my competitors.

Offline consortium11

Re: ACA
« Reply #147 on: November 15, 2013, 10:45:26 AM »
AXA - one of our biggest medical insurance companies though not actually the one I use - call their highest level of cover "Gold Cover".  It costs £17.75 per month.  The national average monthly wage for a female is about £2000 per month.

I'm possibly being pedantic here, but the various Gold, Silver and Bronze plans from AXA aren't actually insurance. They're cashback plans, that's to say as you as long as you pay the monthly fee AXA will give you back a set amount of money for any of the covered medical issues. In some ways it's the reverse of insurance; an insurance policy mandates that you pay the set excess while the insurer picks up the other costs, in a cashback plan the insurer pays you a set amount and you cover the other costs.

Running figures through their system for a male in his mid-20's, the best level of standard coverage (that is to say without negotiating specific inclusions/exclusions) and with the lowest excess costs £92.24 per month... which is a pretty hefty chunk of change for most people. And that's for general cover (albeit with the add-ons) as opposed to specialist cover which can increase the price significantly.

I'd also note that NICE doesn't deal with the regulatory side of things with regards to approving/removing products. That's the Medicines and Healthcare Products Regulatory Agency (MRHA). NICE's remit is to which products should be used on the NHS and how they should be used and in recent years offering guidelines to the public sector on how to avoid ill-health and guidance for social care users and practitioners.

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Re: ACA
« Reply #148 on: November 15, 2013, 10:53:46 AM »
Returning to your white bread analogy.  I own a bakery.  I sell brown bread, white bread, granary loaves, etc.  The government steps in and says "all bread must be at least as delicious as this loaf right here".  Fine, some of my shittier bread is no longer legal, and I'm forced to stop selling it.  Those who didn't mind the less delicious bread will see their product disappear from my shelves.  However, people now have a guaranteed level of tastiness for their morning toast which has been assessed as suitable, so several will stop buying more expensive loaves because they now know that the basic one is a taste sensation.  Further, as this applies to all bakeries, I now have a strong incentive to make my basic loaf, the minimum allowable by law, as cheap as possible to lure in customers from my competitors.

I don't want to rehash what has already been discussed, so I'll just raise a few relevant points.

What about people who just get fed up and say they don't want healthcare anymore?

Also, how can you assume that people with top-tier healthcare plans are now going to stop using these superior plans simply because the government now mandates (albeit inefficiently) that everyone purchases a minimum coverage?  I definitely have no intention of doing that.  There is no evidence to suggest such a trend, unless of course, their superior plans were altered or dropped for whatever reason.

How can you say that most Americans actually view the minimum private coverage requirements mandated by the government as in any way being desirable?  The government has already made the rollout of the ACA a debacle.  It is only reinforcing many Americans' skepticism of the American government's ability to do things efficiently, including my own.

Finally, because the private insurance companies are detached from the government, and are free to set their own prices, there is not a strong incentive to make the basic coverage as cheap as possible.  The government has "mandated" that people get these plans, so insurance companies are free to set their prices at whatever they wish, knowing they will have an extremely high demand for the product.  The government will certainly provide subsidies based on need, but they can't control the empirical price of the insurance itself.  Certainly, after a while, more people will be "opting-out" through the penalty fee, rather than paying these progressively more expensive premiums.  However, at that point, the onus will fall on the government for failing with their ACA pledge.  In that scenario, the government response will be to raise the penalty fee, to encourage more people to purchase heath insurance instead.  You can see how this does very little to help the consumer.
« Last Edit: November 15, 2013, 10:57:04 AM by ValthazarElite »

Offline Phaia

Re: ACA
« Reply #149 on: November 16, 2013, 12:15:17 AM »
In order:
Phaia - It doesn't affect me personally, no.  It does actually affect a few friends of mine but that's not why I'm saying anything.  I'm vaguely surprised at what I see as the implication behind your question though, that only things that affect one personally are worthy of consideration. 

first off Kythia I was not trying to imply that if it did not effect you then it was not worthy for consideration. When you mentioned you are from the UK ..well it helped me understand your frame of reference...

As an example [and I am sure you did not mean offense] at least twice [I think] you have use the reference 'the south' as if to imply all those of us that live in the south are backwards, red neck hillbillies that do not know how the real world works. It is not just you but I often see in these political forums the term 'the south' used and nothing more. I grew up in Virginia on a dairy farm went to the Uof Virginia and work in central Florida [married to a Bostonian but I dont hold that against him...much] so with you being from outside the US it explains why you used that term.

Now the past week I did a bit of survey at work...I work for a major theme park here in central Florida [a very world wide major one] I am a member of the actors guild and handle a troop of performers numbering 32. They range in age from 17-41; here is the break down for ACA...14 of us are staying with the 'new ACA mandated' company insurance plan even though in every case its at least a 50% increase per month mainly because we have families or other medical needs. of the other 18...7 are on there parents plans until 21... of the other 11..only 4 are getting insurance the rest just cannot afford the big increase when before they did not pay anything now the minimum would be about 140 a month... that means that out of 42 ...7 have 'opted out'
and 7 more are being covered by someone else. So almost half of the group are not paying for insurance

That is what is concerning me since almost all in my group are very liberal and supported the president and his health care program...in fact many here are upset enough that they are talking about more moderate senators [which could mean indenpents or even republicans]

Anyway I hope this helps explain  the local view points and why I am questionings the worth of ACA when nearly half in my small group wont even be part of it [which of course raises the cost for those of us that do]

phaia

edit: I really should not try making a post at 1:30 in the morning...after a long day at work and then running around chasing the 4 year old...I make to many mistakes and misspells ...*yawns*
« Last Edit: November 16, 2013, 12:25:17 AM by Phaia »