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A big part of the problem is that younger, healthy people like myself are simply opting out of the ACA policies and, frankly, any sort of medical insurance programs altogether if it's not provided by their employers - and paying the penalties and playing Russian roulette with their financial futures.
Working people in professional level jobs are almost always going to be covered (at least as it stands now with the 50+ employee mandate) by employer provided medical insurance. The affluent are likely paying less for coverage because their employers chip in for the bulk of it, and also have better coverage, compared to those stuck on the exchanges. Unless their employer yanks their coverage, and many will with the mandate being removed, these people probably have things as good as it can get under the current system. My coverage is so-so - it is affordable on my portion of the monthly premium, but would be an inconvenience to meet the deductible. Still, it won't financially ruin me if something serious did occur.
The ACA silver plan I was on back in 2013 was the worst coverage I recall having before or since, and that was before things really hit the fan. Many of the people on the exchanges are low income earners, but make too much to qualify for Medicaid, especially in states that didn't expand Medicaid coverage. When you're making under $21,000/year like I did in 2013, you can barely afford to make ends meet in the most basic of ways - layering on another several hundred a month in health care premiums plus thousands in deductibles just to get to your first dollar of coverage is not viable. That's why people forewent coverage and just paid the penalty. Yes, technically they had access to insurance, but it was unaffordable for most of the folks on the exchanges.
What you're left with on the exchanges are those making too much for Medicaid (the very poor are taken care of that way), but not enough to afford the premiums and deductibles comfortably. They're likely in crappy jobs with little to nothing in the way of benefits or stability. The people wanting coverage are those who are sick, can't do without, and have no other options, causing premiums to skyrocket and insurers to face heavy losses from this high risk, high cost candidate pool. Fewer people will have any insurance at all as insurers pull back due to unsustainable losses, this cost is then going to be shifted back onto the hospital systems, medical care providers, and patients, resulting in all of them ending up in a bath of red ink.
This is a good microcosm of what's happening in my area, which is chock full of the uninsured and unhealthy.
Health insurance performs best when you have a huge pool of healthy young people to offset the costs of the sick. Think about your homeowners insurance. Most homeowners make no claims every year; it keeps the costs low.
The big employers are already cherry picking from the pool. They select healthy, productive employees who have demonstrated that they can successfully hold the job. They tend to skew young if the organization is growing. That keeps their costs down.
I think we should follow the rest of the developed world and have everyone in one pool; yes single payer.
I'm in a single payer plan now. It's called Medicare. It works.
Health insurance performs best when you have a huge pool of healthy young people to offset the costs of the sick. Think about your homeowners insurance. Most homeowners make no claims every year; it keeps the costs low.
The big employers are already cherry picking from the pool. They select healthy, productive employees who have demonstrated that they can successfully hold the job. They tend to skew young if the organization is growing. That keeps their costs down.
I think we should follow the rest of the developed world and have everyone in one pool; yes single payer.
I'm in a single payer plan now. It's called Medicare. It works.
Either the subsidies needed to be greater (keeps costs down for younger, healthy, but poorer workers), the plans cost less to begin with, or the penalties raised to the level it's advantageous to stay in the program.
I think we should follow the rest of the developed world and have everyone in one pool; yes single payer.
What should the taxpayers do about the tens of millions of noncitizens in the US -- they still won't be eligible for Medicaid nor Medicare, but some kind of medical care may be needed. Do we send the bill to Mexico?
I like a low-tier solution, like Medicaid for all citizens, but there is also the asset problem -- currently Medicaid requires close to zero assets. So if you need health care, you have to sign over your house and retirement savings to the government.
What should the taxpayers do about the tens of millions of noncitizens in the US -- they still won't be eligible for Medicaid nor Medicare, but some kind of medical care may be needed. Do we send the bill to Mexico?
If the non-citizen is here legally, require the person to sign up and pay for insurance. If the person is here illegally or has not signed up, tell him/her that they will be treated but must either pay or be deported.
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I like a low-tier solution, like Medicaid for all citizens, but there is also the asset problem -- currently Medicaid requires close to zero assets. So if you need health care, you have to sign over your house and retirement savings to the government.
It should be Medicare for all, not Medicaid for all. If you cannot afford Medicare, then it is Medicaid. That is pretty much the situation today except Medicare is only for >= 65.
If the non-citizen is here legally, require the person to sign up and pay for insurance. If the person is here illegally or has not signed up, tell him/her that they will be treated but must either pay or be deported.
It should be Medicare for all, not Medicaid for all. If you cannot afford Medicare, then it is Medicaid. That is pretty much the situation today except Medicare is only for >= 65.
Agreed -- I am curious what the pricing would be for full-fare Medicare Part A plus Part B. That is, how much would the monthly premium cost for someone who is buying the coverage from the government (not yet age-eligible).
The current eligible-retiree monthly premiums at the highest cost levels are Medicare Part A, $413 and Medicare Part B, $429. I am assuming that the otherwise non-eligible citizens who would buy Medicare as part of a Medicare-for-all scheme would be expected to pay at least as much as the maximum rate for eligible participants, so $842 per month.
Equitable distribution is absolutely the topic before Congress, and the topic of this thread. This thread was prompted by the fact that older people are going to be faced with a huge jump in their premiums, and hence the OP posted that fact as a warning to potential early retirees (before Medicare eligible), which is inequitable (older pays more than younger person).
"Equitable" is one of those words that carries a lot of baggage and is arbitrary.
For example, you say it is inequitable for an older person to pay more than a younger person. Why? Someone else might say the only "equitable" way is that the insurance premium must reflect the actuarial costs of the customer's demographics (where old people consume more medical care and hence should pay more for health insurance) (insert my view on "insurance vs. financing.")
Health insurance is not "distributed" -- it is "purchased." Because it is not distributed, the adjective "equitable" really doesn't apply.
Insurance is "purchased," not "distributed." The thread was prompted by the uncertainty of the price of the product being purchased, not by its distribution.
I think all we can really say is it costs to damn much and nothing being considered right now will make it less expensive.
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Originally Posted by TwoByFour
ACA was founded on the notion that there are two big problems in health insurance: Access and cost. Both ACA and AHCA are trying to solve the access problem but both have done it in an inequitable way - some segment of the population is getting screwed.
The driver of the cost of health insurance is the cost of health care. Neither Obamaare nor Trump/RyanCare really address the drivers of the cost of health care. If we found a way to drive down the cost of health care, then the cost of health insurance could come down.
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Originally Posted by TwoByFour
Prior to ACA another segment getting screwed were people with pre-existing conditions.
By your logic, it would OK to have no automobile insurance, get in an accident, then buy insurance and expect the insurance company to pay for the "pre-existing condition" of the mangled fender.
Insurance of course is for the unknown & unexpected -- by definition, you cannot insure something that has already occurred.
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Originally Posted by TwoByFour
All of these things constitute the equitable access problem - how to make sure all income levels, all ages, and all levels of health have the same (i,e, equitable) access to health care.
The real issue is the cost of healthcare, not the "distribution" of health insurance. Drive down the cost of healthcare and the price of health insurance will follow.
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Originally Posted by TwoByFour
The above is a distinct problem from one of cost. We can lower the cost of healthcare by 40% so it matches the average across OECD countries but that doesn't help the equitable access problem. If you are poor and have near 0 income, 40% cheaper is not going to do anything for you. And if you are denied access due to a pre-existing condition, 40% cheaper won't do anything either. Hence the need to solve both problems.
Your hypothetical of "poor with near 0 income" is a corner case that should not be the driver in designing a replacement for the failing Obamacare. How do the poor with near 0 income buy food? Buy housing services (rent)? Buy transportation services (bus fare)? Buy clothing? Buy anything at all? It sux to be dirt poor (ask me how I know!) but that is a different problem altogether.
I don't think anyone on this thread contemplating retirement and concerned about the price of Obamacare or its replacement for the next few years fit into the hypothetical category of "poor with near 0 income".
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Originally Posted by TwoByFour
As I said, single payer is necessary but not sufficient for a rational national health care strategy. We have a hodge-podge of insurance companies that each negotiate rates with providers. That creates lists of "preferred" providers which takes choice away from the individual. People need choices or it is not a free market.
I agree completely with your characterization of the marketplace now -- the hodge-podge of insurance companies with negotiated rates divorces the purchaser (consumer) from the price and the payment. If I don't know the price of something, clearly I cannot make informed rational purchase decisions.
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Originally Posted by TwoByFour
You are confusing single payer with the totally out-of-whack regulations and laws we have in the US for health care.
I was just illustrating yet another thing that we both agree is out-of-whack in the context of the cost of health care (I'm including prescription medicine in healthcare).
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Originally Posted by TwoByFour
Personally I think that any provider (pharmacy, doctor, hospital, etc.) can choose the price they want to charge, but once they choose it, that is the price everybody pays, regardless of whether you have insurance or not. So no more behind your back bargaining of prices. And all prices must be published so you can make a choice whether to go to Costco or Walmart.
I agree completely with you there. I agree for 2 separate reasons:
1) Transparency so we each can make rational purchase decisions (I think that's your point)
2) Cutting costs out of the system (which, I think, isn't your point).
Today (pre-Obamacare, Obamacare, post-Obamacare) we have armies of administrators (costs!) at hospitals and physicians offices who have learned how to code forms so as to maximize reimbursement from insurance providers. Insurance providers have armies of administrators (costs!) who scour bills looking for ways to cut the reimbursements.
All of those administrators are non-value-add. If we had the scenario you describe and for which I completely agree (published prices with no negotiated rates with behind-your-back kickbacks etc), we could eliminate those jobs, pulling costs out of the system. That would drive down the cost of healthcare, which in turn will drive down the cost of insurance.
Everyone wins -- except for the formerly employed health administrators who would have to go find new careers, perhaps in the fast-food preparation or housekeeping industries.
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You & I are just not going to agree on the single-payer. You see it as part of the solution. I see it as part of the problem because it divorces the purchaser from the price.
Agreed -- I am curious what the pricing would be for full-fare Medicare Part A plus Part B. That is, how much would the monthly premium cost for someone who is buying the coverage from the government (not yet age-eligible).
The current eligible-retiree monthly premiums at the highest cost levels are Medicare Part A, $413 and Medicare Part B, $429. I am assuming that the otherwise non-eligible citizens who would buy Medicare as part of a Medicare-for-all scheme would be expected to pay at least as much as the maximum rate for eligible participants, so $842 per month.
Medicare is complicated because it is pulling in money from people who are not yet receiving it and it is also getting unfunded money (i.e., it is an entitlement). So Medicare-for-all would have to change that model a bit. The thing I like about using mostly taxes to pay for Medicare is that we have a progressive tax system already so you don't have to create complex rebate schemes.
Bernie Sanders went through all of this during his campaign and had some numbers for premiums and taxes. His plan was that most of Medicare-for-all would be funded with taxes and part with premiums. It made sense to me but probably needed more scrutiny. But you can look up his numbers to see what those were.
Interesting that your Fortune 50 corps did their due diligence. I suspect that was because of the whole sale slaughter of the Reduction in Force made by the Fortune 1000 corp I worked for where you got a pick slip on Friday, given to you as you left the compound by security, never allowed to return for their belongings, through a plate glass window. Workers were going home and committing suicide over the weekend so they started handing out the slips on Monday.
This, mind you, was 20 years ago. I would think companies learned how to cover their asses a lot better since then. One can only hope.
Some times the companies hit it by accident and it misses review. A fortune 100 I worked for once laid off a group of people, they looked for people who had held the same position for more then 10 years (not management) with no moves (lateral or vertical) and raises at or above inflation during that time period. This for what ever reason resulted in almost all of the 100 people who were laid off being over 50 and most of them not white and female. I heard there were several lawsuits filed shortly after which resulted in everyone laid off in that round receiving a settlement equal to twice their normal severance.
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You & I are just not going to agree on the single-payer. You see it as part of the solution. I see it as part of the problem because it divorces the purchaser from the price.
You can look at all the systems around the world and there really does not appear to be a good answer other then single payer. The problem is the emergency services and serious condition costs. You don't have much choice but to get care when your dying, and these are the services that drive cost. Which is at a point when reviewing a menu board of prices is irrelevant you get driven to the hospital and you get charged no choice about it.
Singapore uses a semi free market system, every day stuff you pay for yourself out of an account the government forces you to add to. Major items are paid thru state controlled medicare type programs and the government directs how much those items should cost. I think that's about as close to a free market as you will find that will work in healthcare. Other then that make the Gov control everything, when there is only one payer costs will come down.
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