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Affordable Care Act in US


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#41 swansont

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Posted 21 May 2017 - 10:07 PM

Insurance also covers some percentage of the bill, exclusive of the deductible. You have to account for that as well.

AFAIK medicaid has limited out-of-pocket expenses
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#42 Delta1212

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Posted 21 May 2017 - 10:16 PM

Insurance also covers some percentage of the bill, exclusive of the deductible. You have to account for that as well.


Not if you're comparing the end user costs of the system. Any money paid out by the insurance company has to be paid in by customers unless the company is in the red, so you're already accounting for that amount in the monthly payment figure.

What you need to compare to see relative expenses of private insurance healthcare vs government insurance is how much people spend on their insurance payments + how much they spend themselves on healthcare, and then compare that to the total tax figure used to cover all of the people on government health insurance + anything they spend on healthcare.
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#43 iNow

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Posted 21 May 2017 - 11:04 PM

that implies that not only are we trying to help people of limited means, we are also prohibiting people from exercising in free choice. (...)  Maintenance of freedom is worth paying for, at least to me.

The concept of freedom in healthcare is an interesting one. This piece aligns with my thinking on the matter. A short snippet below, but the larger article is worth a quick read.

https://www.nytimes....ealth-care.html

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one’s life. It’s also not like buying some other service tailored to individual demands, because for the most part we can’t predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom.
(...)
As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom. So is the freedom of knowing that none of it will bankrupt us.
(...)
If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America’s corporations and businesses to streamline their operations, releasing them from bureaucratic obligations


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#44 KipIngram

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Posted 21 May 2017 - 11:07 PM

I think what swansont meant (swansont, please correct me if I'm wrong) is that even after you've paid your deductible insurance only pays X% of the remainder for some services, so the (100-X)% also has to come out of the customer's pocket and would add to the total.  He's right about that, but that varies all over the place and I'm not sure how to calculate it without getting the details of some plan in front of me and crank numbers.  In addition to that the plans usually have a maximum out of pocket, so there's an upper limit to that effect that would have to be factored in as well.

 

Summing up some things, I think we've identified three different approaches to providing health care for those who can't afford it on their own: 1) give them money (or vouchers, or whatever) and let them buy insurance on the open (private) market, 2) operate a plan like Medicaid in parallel with the private healthcare system, and 3) mandate that something like Medicaid is the only system allowed, and everyone relies on it.  I would love to think that option 1 could work for a reasonable cost (even if it's some percentage (10-40, say) more expensive than option 2.  Option 3 seems much, much more invasive to me - it goes beyond simply taxing me (a cost I am more than willing to bear) in that it tells me, someone who has managed to not need government assistance, that I'm not free to handle my healthcare in any way I choose.  The big reason I like option 1, even at a higher cost, is that it makes all of the people it helps "just as free as me" - they are equipped with funds with which to shop the same market I shop, and that market will view them no differently from the way it views me.  It makes them my equal within the healthcare market.


iNow: Those are nice words, but if in fact options that are available to me now are not available to me under some other plan, some of my freedom has in fact been taken away, whether that was "the point" or not.  I'd much prefer to focus on giving those freedoms to everyone.


Edited by KipIngram, 21 May 2017 - 11:07 PM.

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#45 iNow

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Posted 21 May 2017 - 11:09 PM

Yes, everyone should be equally free to be unable to afford their healthcare. I'm well familiar with the GOP stance.
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#46 KipIngram

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Posted 21 May 2017 - 11:13 PM

Except that's not what I'm saying.  I'm not trying to defend the status quo; I've been trying very hard to talk about new things we could actually do to make healthcare available to everyone.  It's how I feel about poverty-related issues in general; I truly believe that a nation as rich as ours could lift everyone above some meaningful poverty line if we implemented the right sort of approach.

 

I just believe it's at least possible that we could do so with a minimum of government intervention outside of the tax code.


Edited by KipIngram, 21 May 2017 - 11:13 PM.

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#47 swansont

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Posted 22 May 2017 - 12:03 AM

Not if you're comparing the end user costs of the system. Any money paid out by the insurance company has to be paid in by customers unless the company is in the red, so you're already accounting for that amount in the monthly payment figure.
What you need to compare to see relative expenses of private insurance healthcare vs government insurance is how much people spend on their insurance payments + how much they spend themselves on healthcare, and then compare that to the total tax figure used to cover all of the people on government health insurance + anything they spend on healthcare.



That was my point. If my premium covers 80% of my costs, it's not correct to compare it with a plan that covers 90%. All else being the same (deductible, co-pay), my plan will be cheaper, and for good reason.
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#48 Delta1212

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Posted 22 May 2017 - 12:24 AM

Except that's not what I'm saying.  I'm not trying to defend the status quo; I've been trying very hard to talk about new things we could actually do to make healthcare available to everyone.  It's how I feel about poverty-related issues in general; I truly believe that a nation as rich as ours could lift everyone above some meaningful poverty line if we implemented the right sort of approach.
 
I just believe it's at least possible that we could do so with a minimum of government intervention outside of the tax code.


The major problem is that the only way that 1 works from a cost efficiency stand point is if everyone who chooses not to buy health insurance at all is simply refused service in an emergency unless they can cover the expense in full or qualify for a loan ahead of service being performed.

Requiring hospitals to provide expensive services to non-paying customers drives up costs considerably and prevents efficient allocation of resources.

The point of insurance is to pool risk. If there's a 1/100 chance of me needing $100,000 care, I can get together with a group of 100 people and we each pitch in $1,000 and now I know exactly how much I have spent on health care and can plan around that much less burdensome amount. I probably won't end up needing it, but all of us get the peace of mind of knowing that we're on steady financial ground no matter what.

If, however, someone who didn't join our pool gets sick and the hospital has to perform the procedure and can't recoup the expense, then suddenly the $100,000 procedure for one of us becomes a $200,000 procedure and now we each need to kick in $2,000 to cover our own costs and the cost of the other person.

But now the risk pool has failed, because we're paying higher rates than our level of risk would dictate, and the risk itself is much reduced because not being in the pool still allows me to have my costs covered by those remaining in it in the event that it ever becomes an issue.

And then even if hospitals simply straight up deny care to those who can't afford to pay through insurance or otherwise to keep costs down for those who can, you have the issue of pre-existing conditions. Because if my pool allows someone to buy in who is already sick, it comes out to being the same as the above example. Statistically, one of us is still likely to need the $100,000 from our pooled resources, and now there is an additional person who is guaranteed to need it, so we need to increase the buy in to $2000 to cover that cost.


So if you want to control overall costs, you need to figure out what to do with people who are already sick and are therefore a losing bet for private insurance to cover, and people who choose not to get insurance and therefore aren't paying into cover everyone's costs.

Those are two of the primary obstacles to the distribution of healthcare through private insurance.
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#49 KipIngram

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Posted 22 May 2017 - 02:11 AM

The major problem is that the only way that 1 works from a cost efficiency stand point is if everyone who chooses not to buy health insurance at all is simply refused service in an emergency unless they can cover the expense in full or qualify for a loan ahead of service being performed.

 

Yes, that's the line of reasoning that leads to a mandate.  I think my option 1 is neutral on that point - you've given people the financial means to afford health insurance on the open market - whether you also require them to is a separate issue.  I think you have a valid point; if there is not a mandate then some people will opt out and take a vacation or something instead (or just fall prey to poor budgeting).  I don't think we can have that one both ways - I think we either have to have a mandate or do just what you said: turn people who opted out and can't pay away.  I feel fairly sure we'd go with the mandate.  It sounds harsh, but on the other hand we all have a mandate to buy food - it's just a biological mandate instead of a government mandate.  I'm required by my state to carry car insurance in order to legally operate a car on the public streets.  So as much as people moan and groan about it, there is precedent.

 

Pre-existing conditions are a problem no matter what.  I think that ties in with a mandate too - if you are going to force the insurance companies to accept anyone, then you probably also have to force people to own insurance.

 

So, yeah - I'm not going to claim that we can "have it all" - fully private industry, no mandate, guaranteed acceptance regardless of pre-existing conditions.  That just won't work.  And I do want to say again that my support for a minimal government intervention approach does not mean I admire the way insurance companies operate today.  I think most of them are pretty despicable, when you get right down to it, and will happily screw people over for profits.  I don't think that can be fixed without government regulation and oversight.


iNow: Just so you know, I am actively thinking about this from as many different angles as I can, trying to give every perspective a fair shake.  For example, just now I was thinking about how emergency room service is really "different" from when I go in to see my doctor for a regular checkup.  ER service is rather like having your house catch on fire, and I don't sit around thinking about how we should have privatized fire departments.  Is it possible that there's more than one situation in play here, and that the different "types" of service might be addressed in different ways?

 

Like, what about discretionary surgery, for example?  Totally superficial things, like cosmetic surgery?  Cosmetic surgery is "required" in very few cases - it's usually a vanity thing that doesn't really need to be done at all.  So I certainly don't think the government should be footing the bill for things like that.  That's one extreme, whereas life-and-death trauma such as that faced in emergency rooms is the other extreme.


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#50 iNow

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Posted 22 May 2017 - 03:01 AM

The fire department example is a good one. My position is that the fire department should be in place for everyone. No matter where you live, what job you have how wealthy or how poor... there's a minimum level of security we afford you due merely to your existence within an advanced civilization.

Now, should you want to supplement that minimum fire department coverage with smoke detectors, hoses, sprinkler systems, escape hatches, and fireproof bunkers, then great! Nobody should stop you. That's your preogative and you are free to move forward in any way you desire with all that awesome Batman style supplemental swag... but before that we should ALL have access to AT LEAST the fire department.

Health insurance is the same. There are some lowest common denominators we should guarantee to all. We should treat healthcare no differently than fire departments, and if folks wish to supplement that minimum level of health coverage and protection from the government with private insurance on top (maybe for nose jobs and liposuctions or whatever else), then good on ya! Alternatively, just pay out of pocket.

We then merely need to agree on the thresholds of what us and is not included... what maximizes outcomes and minimizes waste... and it's hardly like we're the first people on the planet ever to explore this. We can borrow the best ideas from the countless other nations who have already struggled with and addressed these hard questions.

Edited by iNow, 22 May 2017 - 03:08 AM.

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#51 KipIngram

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Posted 22 May 2017 - 03:17 AM

Ok, so from that I infer that you would not be in favor of banning private medical arrangements, then?  I think that's the most frightening aspect of all of this to me - that someone will propose that the only way for things to be "fair" is for the government to completely control all access to healthcare services.  As long as you're willing to leave the freedom to make other arrangements in place, then I'm open-minded to almost any arrangement.  It was swansont's comment earlier that doctors would stop turning away Medicaid patients lickety split if Medicaid was all there was that caused me to engage that worry.

 

I would assume that the only reason doctors would turn away Medicaid patients would be because they worried they wouldn't get paid (although I suppose it could also be related to difficulty of dealing with a bureaucracy).  Either way, I'd say let's fix Medicaid so that they don't want to turn those patients away, rather than either impose some coercion on the doctors or attempt to make Medicaid the only game in town.


To tie this back to ACA, I think anything like ACA, if implemented in a freedom-respecting sort of way, would have no impact whatsoever on people who already had health insurance / didn't need the ACA benefits.  Short term you might see an increase in demand for medical services, as the new beneficiaries flowed into the situation, but supply and demand should cause that to take care of itself in a small number of years.  So by "no effect" I meant no direct effect, not second order effects arising from increased demand.


In other words, the attitude should be, "Hey, here is a new benefit for those of you who need it," not "Here is a new way and now all of you have to use it."


Edited by KipIngram, 22 May 2017 - 03:19 AM.

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#52 Delta1212

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Posted 22 May 2017 - 12:52 PM

Private supplemental insurance is pretty common in countries that have national healthcare. I think that is something that gets glossed over frequently in these discussions.

The desire for single-payer isn't driven by a desire to ban insurance as a practice. It is driven by the primary concern that healthcare is not an ordinary commodity. It is quite literally a "your money or your life" situation.


You can't choose to budget around future healthcare expenses the way you can around a big purchase like a car or a house because you don't know what those expenses will be. And while you can go to an open house, decide the asking price is too high and go check out another one the next town over, that option isn't really available when you show up at the hospital while having a heart attack. Sometimes it's literally unavailable even if you were so inclined to risk your life wasting time trying to find a good deal on emergency surgery because you get carted to the hospital while unconscious and then get billed for services you didn't consent under the presumption that you would have because the alternative is dying.

The only way to mitigate these problems is with insurance, which does provide a cost that can be planned around, but unfortunately, there are tons of people who it is simply not profitable to insure, either because they don't have the money to pay for their calculated share of the risk or because their calculated share of the risk is so high that almost no one would reasonably have that much money. Ironically, leaving these people uninsured winds up driving costs up for everyone anyway because it means they can't afford to do basic maintenance lik check-ups that catch things when they can be treated early and cheaply instead of when they are an emergency, thus landing those people in emergency rooms where they are guaranteed service but at a much higher cost to the healthcare system and placing greater strain on our emergency resources.


An optimal solution provides a base level of healthcare to everyone regardless of income or health that includes emergency room visits, hospital stays for anything that is threatening to life or long-term health and basic health maintenance that keeps people healthy and overal costs down like an annual check up, recommended exams as people get older, vaccinations, that sort of thing.

If you then want private insurance to cover extra things like braces, or a nutritionist, or extended private care for additional recovery time after you leave the hospital or cosmetic surgery or what have you, then yeah, have at it.

We're talking about making sure that the system keeps people alive without bankrupting them and driving up overall medical costs, not advocating free nose jobs for everyone or the abolition of insurance as a business sector if people feel they would like to supplement a basic level of care provided to everyone.
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#53 KipIngram

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Posted 22 May 2017 - 01:21 PM

Yes, re: showing up at the hospital with a heart attack I do see the difference - emergency services do seem more akin to the "house on fire" example I mentioned above.  I'm beginning to think that it's important in these discussions to differentiate amongst the various sorts of medical service.  You've got your emergency services, you've got your routine "health maintenance" type stuff, where feeling comfortable with your doctor really does highlight the importance of getting to exercise some choice, and you've got your discretionary services that likely shouldn't even be included in the debate about assisted funding at all.  It's a spectrum for sure.

 

I am a huge, huge fan of consistency of reasoning in things like this - as soon as I had the thought last night about the similarity between emergency medical services and stuff like firefighting, police protection, and so on I felt that we should bring similar reasoning to all of those things.  With police protection, for example, we expect that to be funded by our general tax payments.  The same with firefighting, though I did see last night that some places have controversially started to try to charge for the service.  After having those thoughts I'm quite open to the idea of emergency medical service being "free" (i.e., covered from general revenues) just as police protection and other such services are.  But I do think that would mean "free for everyone."

 

I like iNow's way of describing it - your fire department protection is free, but you are also still allowed to get smoke alarms etc. to enhance your situation if you choose to.  I've suggested that a privately funded system might do the job better, but I don't KNOW that - it's just an attitude that's rooted in my general political / economic philosophy.  What I really want is "the best system we can put in place," with best defined by the quality and effectiveness of the services rendered.  If it turns out that a single-payer style system is the best solution in those terms, then that's what I want.  If a privatized system is best, then that's what I want.  I want people to have access to quality healthcare services as much as anyone else in this debate.

 

I think all of the possible solutions here have their weaknesses and would need very, very careful oversight.  Private businesses succumb to greed.  Government organizations often succumb to bureaucratic inefficiencies.  I don't think any solution is just going to "automatically work" without us being vigilant.  I also understand that an effective system will have a cost, and I'm totally down for the "more fortunate" bearing most of that cost, simply because the less fortunate can't.

 

This all particularly comes home for me when we talk about children.  I can't even put into words how wonderful I think children are (all children), and the idea of a child suffering or (worse) dying because his parents didn't have access to medical care that could have made a difference absolutely breaks my heart.  And even though I try to be rational and fair minded, the place I am most likely not to be is when my own children are involved.  I have five daughters, and one of them had a struggle with anxiety and depression that would up requiring a therapeutic boarding school stay to address.  The facility we chose was out of our insurance network, so we had to cover it totally.  During that selection process we heard horror stories about the state-provided alternatives.  I don't know how true those stories are, but if they are true then it absolutely was a situation where our financial good fortune made it possible for us to "get something better."  It more or less cleaned us out, but we were able to do it.  Trust me - I have thought about that a great deal, and I do not consider it right that others wouldn't have had that opportunity just because they hadn't been as lucky. And the availability of those funds really was luck - in 2012 I was working for a small company that got bought by IBM, and I got a windfall from that, even though I'd only been with the company for five months.  In no way can I say I "earned" that largesse in any tangible way.  It was a case of being in the right place at the right time.

 

BTW, my daughter is in college now and is doing great - I don't know what those people did, but it worked and I cannot thank them enough.  So I really do support solving these problems - no parent should have to watch their child suffer, physically or mentally, when something could be done about it, if only it could be afforded.


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#54 swansont

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Posted 22 May 2017 - 01:35 PM

Ok, so from that I infer that you would not be in favor of banning private medical arrangements, then?  I think that's the most frightening aspect of all of this to me - that someone will propose that the only way for things to be "fair" is for the government to completely control all access to healthcare services.  As long as you're willing to leave the freedom to make other arrangements in place, then I'm open-minded to almost any arrangement.  It was swansont's comment earlier that doctors would stop turning away Medicaid patients lickety split if Medicaid was all there was that caused me to engage that worry.

 

 

 

There are going to be procedures not covered by basic care. Universal healthcare is probably not going to cover elective surgery, for example.

 

There is a monetary incentive to only accept private insurance when they pay more, so naturally some doctors will decide to limit the number of medicaid patients they accept. That's only a negative if basic healthcare has the two options, because it goes away when everyone is covered for the basics.

 

In the long-term, one might choose not to go into the kind of medicine covered by universal care if it doesn't pay well enough. I don't know if this is an issue in the developed (health-care-wise) world.


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