20th January, 2017

[Rob C]

No, it was right in front of your face if you had chosen to see it.

Do you have a handy little arrow or Shakespearean pointy-glove to attach to it, so I can find it? I don't think I choose not to see things; I tend to think it's smarter to notice them where one can.

But as you wrote, let's agree to disagree. It saves a whole heap of sore fingers.

;-)

Rob C

[N80]

I just saw a patient who will start on Obamacare in February. He is unemployed but still has enough money to get on it. He has multiple medical problems. For he and his wife (she is a smoker) their monthly Obamacare payment is $700. Their deductible is $14,000. There is only one provider of ACA exchanges in this state, BC/BS. The others dropped out.

If either of them requires hospitalization they will be immediately bankrupt and unable to pay their premium. This is the real story of the ACA.

[Alan Goldhammer]

I just saw a patient who will start on Obamacare in February. He is unemployed but still has enough money to get on it. He has multiple medical problems. For he and his wife (she is a smoker) their monthly Obamacare payment is $700. Their deductible is $14,000. There is only one provider of ACA exchanges in this state, BC/BS. The others dropped out.

If either of them requires hospitalization they will be immediately bankrupt and unable to pay their premium. This is the real story of the ACA.

but they would be bankrupt under the old system as well!  Why is ACA any different?  Let's not try to pretend that everything is the fault of the ACA!  If someone goes into a hospital and is uninsured they are on the hook for the whole bill and not some insurance company negotiated bill.  What you don't know is what hospitalization would be covered as part of the policy. Yes, their premium might be $700 but at least they were not subject to medical underwriting which might have made it much higher than that.  the deductible seems to be a little on the high side.  My younger daughter (now in CA and at Kaiser Permanente) had a $6K deductible but lots of stuff was covered before the deductible kicked in.  A bunch of hospitalization stuff was covered by the policy.

[Alan Goldhammer]

Regarding any private companies she or Trump offspring may have, they are not in office as President; why would they be held to the same rules and be obliged to surrender something that may have been grown on the back of their own expertise?

It's just that there is a sense of hypocrisy for them to not have made an attempt to "make things in America" when the husband/father is preaching this. 

As for throwing out entire administrations-worth of civil servants just to replace them with chosen true believers, what an unimaginable waste of broader experiences gained under varying party colours, mistakes and successes. I'd have expected that people who have spent their lives working under the leash of a variety of different parties would not need to reinvent any wheels each time.

But then that's the olde worlde.

;-)

Rob

I don't think the President has advocated this.  they are just implementing a hiring freeze.

[JoeKitchen]

but they would be bankrupt under the old system as well!  Why is ACA any different?  Let's not try to pretend that everything is the fault of the ACA!  If someone goes into a hospital and is uninsured they are on the hook for the whole bill and not some insurance company negotiated bill.  What you don't know is what hospitalization would be covered as part of the policy. Yes, their premium might be $700 but at least they were not subject to medical underwriting which might have made it much higher than that.  the deductible seems to be a little on the high side.  My younger daughter (now in CA and at Kaiser Permanente) had a $6K deductible but lots of stuff was covered before the deductible kicked in.  A bunch of hospitalization stuff was covered by the policy.

Prior to the ACA, catastrophic plans were less money and had lower deductibles.  I know, I use to have one. 

However today, with the ACA, it appears, for all intents and purposes, all we have is catastrophic plans, because really what normal procedure is more then $14K?  The only difference is we need to pay more for it. 

[Alan Goldhammer]

Prior to the ACA, catastrophic plans were less money and had lower deductibles.  I know, I use to have one. 

However today, with the ACA, it appears, for all intents and purposes, all we have is catastrophic plans, because really what normal procedure is more then $14K?  The only difference is we need to pay more for it.

Did you read my post?  Do you know someone who has an Obamacare policy as I do?  ACA policies were not catastropic plans.  they covered lots of things including hospitalization.  Also look around at corporate plans.  they are increasing co=pays, hiking premiums, and increasing deductibles (I know this for a fact as the premium payment for my Medigap plan is from my former employer that I get as a retiree.  In the past three years my premium has doubled and my co-pays have gone up for both Rx coverage and doctor visits.  My Medicate Part B premiums have gone up as well.  I sick of all the sycophants blaming Obamacare for everything that is wrong with healthcare in the US when all parties are equal culpable.  Everyone wants to turn the clock back to the Norman Rockwell 1950s.  Ain't going to happen.

[JoeKitchen]

Did you read my post?  Do you know someone who has an Obamacare policy as I do?  ACA policies were not catastropic plans.  they covered lots of things including hospitalization.  Also look around at corporate plans.  they are increasing co=pays, hiking premiums, and increasing deductibles (I know this for a fact as the premium payment for my Medigap plan is from my former employer that I get as a retiree.  In the past three years my premium has doubled and my co-pays have gone up for both Rx coverage and doctor visits.  My Medicate Part B premiums have gone up as well.  I sick of all the sycophants blaming Obamacare for everything that is wrong with healthcare in the US when all parties are equal culpable.  Everyone wants to turn the clock back to the Norman Rockwell 1950s.  Ain't going to happen.

Yes, I read your point and I do know people with ACA plans. 

However, did you get my point? 

The deductibles on the plans are so high that they might as well be catastrophic plans of the past.  Yes, they cover hospitalizations and such, but only after some extreme deductible. 

I had a hernia removed a few years ago and some of the plans on the ACA exchanges have deductibles higher then the cost of that surgery.

At least with my last plan, I would need to pay for 20% of the surgery, but now I would have had to pay nearly 100% of the cost. 

We essentially created a near worthless plan that cost an extreme amount of money and is only going up both in price and overall cost (deductibles). 

And the reason the prices are going up is because we absolutely need young people to offset the cost and their not buying.  Young people are unreliable and not signing up in the mass numbers we need. 

And to add insult to injury, the hopes of young people signing up were further destroyed by allowing 26 year old children to stay on their parents' plans.  Either they (the writers) designed it to fail, or they are completely inept of determining the consequences of their decision. 

It baffles me that law makers actually thought that all of a sudden young people would start buying health insurance just because it is now the law.  And the fines for not buying are a joke, since they are so much lower then the actual cost of the insurance. 

Not to mention, how are you going to enforce it?  What if they don't get a tax return and owe money, or simply do not need to file a return, and refuse to pay the fine?  Are we going to start locking people up for non-compliance? 

The exchanges are already in a death spiral. 

But keep on signing that song and completely ignore all of the logic that I have listed a few times already about why the law is failing. 

[JoeKitchen]

Essentially, the ACA is a law that absolutely relies on the most unreliable group of people in the country for it to work, 20 year olds.  Then, if 20 year olds decide not to buy, which was predicted before it was even signed into law, there is no real way to enforce the law or the fines.  Last, even if we could collect the fines, they are not nearly high enough to make up for the lack of 20 year olds buying plans, not to mention the fines are probably not even allocated to the exchanges anyway. 

[JNB_Rare]

I'm getting an interesting perspective on US Health Care reading posts from both sides of the ObamaCare debates.

Here in Canada, our health care is administered provincially, and the Federal government assists provinces with some transfer payments from the general tax pool. For all my working life, I paid into the provincial health care plan through payroll deductions. Those earning less than $20,000 per annum don't pay anything. Others pay on an indexed system from $60 to a $900 per year ($900 per year cap for those earning more than about $200,000 per year). Self-employed individuals contribute separately, in the same order of cost.

I had a heart attack (lots of family history) and spent a few days in the hospital with appropriate tests, etc., etc. Later, I had quadruple bypass surgery, and a few days in the hospital. Then I had 3 months of cardiac rehab therapy (twice a week). Regular visits with the GP and cardiologist, gradually diminishing over time. The cost? Zero. The treatment? First rate. And everyone is entitled to the same treatment.

Is our health care system perfect? Of course not. I pay for my ongoing generic statin and blood pressure medication. And generics in Canada are very costly compared to other countries in the world. Higher even than the US. Brand-name drugs are on a par with the US, but still much higher than countries like New Zealand (there's pressure on the government to see how we can reduce costs here). And waiting lists, yes, we certainly have them. My brother was put on an 18-month waiting list for knee surgery. Fortunately for him, he changed his diet, lost a few pounds and declined to have the surgery when it came due, because the pain was mostly gone.

There is always wrangling between the Feds and Provinces regarding the amount of health-care funding transfers. And, more recently, wrangling about the Feds wanting to provide targeted monies toward mental health and elder-care at home, rather than letting the provinces decide on their own priorities for all funding.

During the US election campaigning, Mr. Trump said that our Canadian health care system was so broken that patients were pouring across the border into the US to be treated. Perhaps I like in a bubble, but I don't personally know anyone who has gone to the US for surgery or any other treatment. I do know many friends and relatives who have had excellent care for everything from premature deliveries and months of subsequent hospital care, to transplants, to cancer treatment, etc.. etc. All covered by their provincial health care plan. People here complain about our system (and things could always be better), but I think most of us are very glad we have it.

[Alan Goldhammer]

Yes, I read your point and I do know people with ACA plans. 

However, did you get my point? 

The deductibles on the plans are so high that they might as well be catastrophic plans of the past.  Yes, they cover hospitalizations and such, but only after some extreme deductible. 

Umm, not quite.  One can get a gold or platinum plan with much lower deductibles.  Don't assume that everyone just gets a Bronze plan.

I had a hernia removed a few years ago and some of the plans on the ACA exchanges have deductibles higher then the cost of that surgery.

Yes, but what is the cost of hernia surgery today?  Greater or lower than when you had yours?  I could have bought a lot of things several years ago for less than I would have to pay today.

At least with my last plan, I would need to pay for 20% of the surgery, but now I would have had to pay nearly 100% of the cost. 

Not necessarily

We essentially created a near worthless plan that cost an extreme amount of money and is only going up both in price and overall cost (deductibles). 

What is the alternative that you would have done?  Would you have accepted the status quo?  It's easy to throw bricks, much more difficult to formulate a plan.

The exchanges are already in a death spiral. 

  If so, why are so many people still signing up?  Maybe they haven't received the message that their polices are worthless.

But keep on signing that song and completely ignore all of the logic that I have listed a few times already about why the law is failing.

It's the way it is because the Republicans never wanted to do any heavy lifting during the Congressional discussion and the small number in the Senate were cowed into submission by Minority Leader McConnell.

[Alan Goldhammer]

I'm getting an interesting perspective on US Health Care reading posts from both sides of the ObamaCare debates.

Here in Canada, our health care is administered provincially, and the Federal government assists provinces with some transfer payments from the general tax pool. For all my working life, I paid into the provincial health care plan through payroll deductions. Those earning less than $20,000 per annum don't pay anything. Others pay on an indexed system from $60 to a $900 per year ($900 per year cap for those earning more than about $200,000 per year). Self-employed individuals contribute separately, in the same order of cost.

We have good friends in Montreal who also have great healthcare for a fraction of what we in the US pay for.  I have friends in The Netherlands who were astonished by how much my wife and I pay for insurance.  they have an insurance based system the provides healthcare for everyone and those at the low end of the economic spectrum pay little or nothing.

[JoeKitchen]

Umm, not quite.  One can get a gold or platinum plan with much lower deductibles.  Don't assume that everyone just gets a Bronze plan.
Yes, but what is the cost of hernia surgery today?  Greater or lower than when you had yours?  I could have bought a lot of things several years ago for less than I would have to pay today.
Not necessarily
What is the alternative that you would have done?  Would you have accepted the status quo?  It's easy to throw bricks, much more difficult to formulate a plan.
  If so, why are so many people still signing up?  Maybe they haven't received the message that their polices are worthless.
It's the way it is because the Republicans never wanted to do any heavy lifting during the Congressional discussion and the small number in the Senate were cowed into submission by Minority Leader McConnell.

Thank you for providing an ample amount of Red Herrings!  I may be a photographer, buy my degrees are in mathematics and logic, so lets stick with logical arguments that do not contain fallacies. 

Any comments on my point that the fiscal architecture does not work?  Any comments on the fact that 20 year olds are not buying in the droves we need and that their is no real way to force them, leading to an utter collapse of the system? 

In all of your comments, you are completely ignoring the heart of the matter, that the bill is not working financially due to design on the law of the reliance on young people, whom are inherently unreliable, signing up. 

They are not, and study after study is finding this to be the case.

I am a realist and a numbers guy.  I really don't care how much good the ACA is doing for some, or how much pain it is causing others.  I want the plan to be budget neutral and cost controlling.  The ACA is far from that. 

Not to mention, it has stifled competition and decrease , even contracted, growth in the market, which history has shown repeatably is the end result whenever you introduce more regulations into a market. 



Now since you keep on mentioning the amount of people singing up, lets remember that only 20M additional people are covered by the ACA.  However, the majority of that 20M are covered by medicare expansion, so less then 10M are covered in the exchanges.  Of that remaining <10M, most are sick and old, I think around 80%.  When the plan was first signed into law, it was proposed that over 40M would have signed up on the exchanges by now, and that at least 60% of those would be young and/or healthy. 

Actually, 60% or more being young/healthy is what the financial architecture of he law is based on for it to work properly. 

[jeremyrh]

Not to mention, it has stifled competition and decrease , even contracted, growth in the market, which history has shown repeatably is the end result whenever you introduce more regulations into a market. 

What is the role of competition in health care? To reduce costs? Have you compared the cost of health care in the US with that in any other country?

[Alan Goldhammer]

Now since you keep on mentioning the amount of people singing up, lets remember that only 20M additional people are covered by the ACA.  However, the majority of that 20M are covered by medicare expansion, so less then 10M are covered in the exchanges.  Of that remaining <10M, most are sick and old, I think around 80%.  When the plan was first signed into law, it was proposed that over 40M would have signed up on the exchanges by now, and that at least 60% of those would be young and/or healthy. 

Actually, 60% or more being young/healthy is what the financial architecture of he law is based on for it to work properly.

I'm sure you meant Medicaid expansion and not Medicare.  They are getting Medicaid funding to purchase private insurance policies.  One thing that has not been counted in the numbers are people such my two daughters and their friends who bought their insurance polices outside of the exchanges as they knew which provider they wanted and also that they would not qualify for any subsidy.  This number is of course not knowable except to the insurance industry.  The tax penalty part of the mandate was poorly designed and useless.  A far better approach would have been to allow medical underwriting for anyone who didn't sign up.  the healthy might have had a different take on things if they realized that their premiums would be sky high if they got sick and tried to sign up. Maybe it would have made a difference but probably not.

Don't get me wrong I was not a fan of what it turned out to be and my employer was heavily involved in the discussions and ultimately endorsed the legislation (I'm retired now).  It was a kludge from the get go and they are reaping the problems right now.  the problem is that it was the only game in town and has provided benefits to a lot of people.  You might thing those benefits were bad, I have a different personal experience as I'm sure that my daughters would have had to pay more for health insurance in its absence.  I was fortunate to have a good corporate plan while I was working and that I could keep upon retirement.  However, my premiums have gone up much more than any of the Obamacare stories that I have read about (65% over three years) and that's on top of Medicare premiums that I have to pay for as well.

The whole thing is a train wreck and I'm looking forward to seeing what the Republican proposal is.  I'm not at all counting on allowing insurance companies to sell across statelines will move the dial at all.  the major insurers already do that today and the only other players are the BlueCross/BlueShield franchises and I'm not sure that they are prepared to do so.  I think Health Savings Accounts only work for those who are healthy and can bank the full amount every year.  Look at your own example of the hernia surgery. With an HSA you would have been on the hook for the full amount until the deductible was met.  You might not have been able to bank a single dollar that year.  If you are on any Rx meds you would be on the hook for those until the deductible was met.  I just don't understand how it works.  Tax credits might be good 'if' they are enough to buy insurance.  I've only seen $3K mentioned.  that doesn't buy one a lot of insurance.  We'll have to see what happens but I doubt it is going to be "terrific" and "cost less" to quote our President.  I hope to be proven wrong.

[Alan Goldhammer]

What is the role of competition in health care? To reduce costs? Have you compared the cost of health care in the US with that in any other country?

US pays the most for healthcare per capita than any other western country.  https://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf

[JoeKitchen]

What is the role of competition in health care? To reduce costs? Have you compared the cost of health care in the US with that in any other country?

Competition lowers cost and increases quality.  Once again, shown repeatably throughout history. 

N80 replied to your other question in a much better way that I could. 

"That is a far more complicated problem. The biggest problem is not that we're big spenders. The problem is primarily four-fold. Number one, we are, as a nation, fat, rich and sedentary. Lifestyle is the biggest killer. It takes a lot of money to fix people who are, as a nation, trying to kill themselves. That has absolutely nothing to do with the capability of the healthcare system. Second, we expect the best, the quickest and no limits. An American with a tummy ache expects a full body MRI and now. We have an insatiable appetite for healthcare. Again, this has nothing to do with the delivery of good care. Third, the US pretty much foots the bill for medical research and innovation. The rest of the world follows. That costs. Big. Fourth, medical malpractice. It is a lottery that costs this nation billions. It shapes the way physicians treat their patients and if you think we practice CYA medicine all day every day, then you are right. We order way too many tests and procedures but you only get sued for the test you didn't order. So yes, we're a fat, lazy, spoiled rotten and litigious nation that pretty much pays for the bulk of cutting edge medical innovation. But NONE of that impugns our ability to deliver good care.

The other issue is that our healthcare system is constantly compared to those of tiny socialist western European nations who have the money to fund universal healthcare primarily because the US spend billions keeping them from killing each other or at the very least keeping the Russians out of their backyards. Let Sweden build a military capable of keeping the Russians (or the Germans) at bay and see what their healthcare system looks like. And the truth is, the majority of European nations are crumbling fiscally under their socialized systems the most costly of which is likely healthcare. So at least compare apples to apples." 

[JoeKitchen]

I'm sure you meant Medicaid expansion and not Medicare.  They are getting Medicaid funding to purchase private insurance policies. 

Yes, I meant Medicaid. 

One thing that has not been counted in the numbers are people such my two daughters and their friends who bought their insurance polices outside of the exchanges as they knew which provider they wanted and also that they would not qualify for any subsidy.  This number is of course not knowable except to the insurance industry. 

This is meaningless since prior to the ACA you could do this as well, which is exactly the route I went. 

The tax penalty part of the mandate was poorly designed and useless.  A far better approach would have been to allow medical underwriting for anyone who didn't sign up.  the healthy might have had a different take on things if they realized that their premiums would be sky high if they got sick and tried to sign up. Maybe it would have made a difference but probably not.

Better to enforce, however it probably would not have made a difference.  The young and healthy would have still ignored the need for insurance until it was too late and they needed it. 

Don't get me wrong I was not a fan of what it turned out to be and my employer was heavily involved in the discussions and ultimately endorsed the legislation (I'm retired now).  It was a kludge from the get go and they are reaping the problems right now.  the problem is that it was the only game in town and has provided benefits to a lot of people.  You might thing those benefits were bad, I have a different personal experience as I'm sure that my daughters would have had to pay more for health insurance in its absence.  I was fortunate to have a good corporate plan while I was working and that I could keep upon retirement.  However, my premiums have gone up much more than any of the Obamacare stories that I have read about (65% over three years) and that's on top of Medicare premiums that I have to pay for as well.

The whole thing is a train wreck and I'm looking forward to seeing what the Republican proposal is.  I'm not at all counting on allowing insurance companies to sell across statelines will move the dial at all.  the major insurers already do that today and the only other players are the BlueCross/BlueShield franchises and I'm not sure that they are prepared to do so.  I think Health Savings Accounts only work for those who are healthy and can bank the full amount every year.  Look at your own example of the hernia surgery. With an HSA you would have been on the hook for the full amount until the deductible was met.  You might not have been able to bank a single dollar that year.  If you are on any Rx meds you would be on the hook for those until the deductible was met.  I just don't understand how it works.  Tax credits might be good 'if' they are enough to buy insurance.  I've only seen $3K mentioned.  that doesn't buy one a lot of insurance.  We'll have to see what happens but I doubt it is going to be "terrific" and "cost less" to quote our President.  I hope to be proven wrong.

Agree here. 

Get ride of all the necessities of coverage with the exception of no life time coverage limits. 

[Alan Goldhammer]

Competition lowers cost and increases quality.  Once again, shown repeatably throughout history. 

Nobel Laureate Kenneth Arrow argued that healthcare doesn't fit into traditional market based thinking and I agree.  http://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

What you say is correct only if you have transparency in pricing and some type of quality measurement.  ONe of the things Obamacare did do was to improve hospital practices such that there are far fewer infections in surgical wards and as well as fewer mistakes in Rx dosing.  There is no transparency in pricing at all.  I tried to get the prices of a lumbar spine MRI and no provider would tell me how much they charge.  the only control on pricing right now is through insurance negotiations and if you go to an in plan facility or have Medicare you can get a preferred price.  What if you are on your own and you can't get pricing information.  this is exactly what will happen if you have an HSA or some other high deductible policy.

As to quality, how do you define it?  How do you know the hernia surgeon was the best one?  How do you know about surgical infections in the hospital? etc.  To make this argument that market forces will take care of this is specious at best and certainly not a recipe for good healthcare.

[Rob C]

What is the role of competition in health care? To reduce costs? Have you compared the cost of health care in the US with that in any other country?

Any time I had to get insurance for foreign shoots, the travel agent would hope I wasn't going to the States. It's a problem that is perhaps just visible to others outside (foreigners) who do not live within the US system. Unless you experience something else, you can't know if you get value for your buck or not, and especially do you not know if the buck you're paying is way too large in the first place.

I think many systems are in trouble because of money; the Brit one, certainly, is facing problems with recruitment, and one factor is doctors not wanting to opt for general practice work - too much stress with too little funding to make it work, as well as patients who expect the Earth and waste surgery time with friggin' colds! Or simply don't turn up for appointments. Spain is without doubt having serious problems on the financial side. And they grow, as I know having waited zonks for a test I need. I recently saw figures (on tv news) showing that France spends a far higher percentage of GDP on medicine than does Britain, and it seems to have a pretty workable sytem in place. If France can do it...

As I've mentioned before, I think that most people (apart from the USA) cherish their national health services, if they are fortunate enough to have them, and would gladly pay more direct taxation if they were convinced that such money would indeed go into the health sytem, and that it would be spent according to the wishes of the professionals working there, medical professionals, not bean-counters recruited at inflated rates to push paper. Or mice. Those doing that seem to have wasted millions getting IT systems that don't work... I haven't heard if the health system gets its money back when computer system failures occur. Probably not.

Apart from US health services being or not being accessible to all Americans, I think an even greater calamity is waiting in the wings. Mexico is now estranged via Twitter. Dear God, what have you guys unleashed both on yourselves and the world at large?  It took centuries for a working diplomatic system to be created; now we are playing at Caesar again. I don't think it will last; even the Romans had to sort out their messes at home.

Rob C

[kers]

A few days later...

Waterboarding is permitted;
Oil pipelines cross the US unhindered
Climate scientists reports will be screened by the White House
The Embassy in Israel will move to Jerusalem.

The US president said meeting Enrique Pena Nieto would be "fruitless" if Mexico didn't treat the US "with respect" and pay for a new border wall.
and now the US will raise import taxes for the Mexican goods to fund this Wall

and still uses his unsafe Samsung S3, an easy to hack device.

It always takes less time to destroy a reputation than to built one.

Trump is a specialist in destroying the US reputation within days.