ACA, Subsidies and Better off Americans (which means many FIRE)

[Montecfo]

When I first read the details of the ACA I was shocked that the subsidies went to people with that high of an income. I think it would be reasonable to go down to 300% or even 250% to match the cost sharing cap. I know some people on here would not be happy about that but I think it would be a fair way to cut costs if needed.

I doubt the structure of ACA will be preserved, as many appear to be assuming. There are still 28-30m uninsured, though all now have "access". If you analyze the uninsured the largest category is people who choose not to afford it, including a number of folks who qualify for subsidies.

I think what we will see is tiers of coverage and prices for same and fewer subsidies. Pre-existing conditions covered as long as you remain insured. High risk pools for people that used to be "uninsurable". And better pricing for the rest.

I expect folks like us will buy what we are willing to pay for, same as housing and cars.

YMMV and mine may also. Just a guess.

 

[Texas Proud]

I doubt the structure of ACA will be preserved, as many appear to be assuming. There are still 28-30m uninsured, though all now have "access". If you analyze the uninsured the largest category is people who choose not to afford it, including a number of folks who qualify for subsidies.

I think what we will see is tiers of coverage and prices for same and fewer subsidies. Pre-existing conditions covered as long as you remain insured. High risk pools for people that used to be "uninsurable". And better pricing for the rest.

I expect folks like us will buy what we are willing to pay for, same as housing and cars.

YMMV and mine may also. Just a guess.

From what I read, not all have access.... at least on the article I read... they said 21% and not legal, so would not be eligible for ACA plan...


But, I do wonder how much they can actually change... if they want to 'require' access and keep some of the other benefits, somebody has to pay the costs... so it might not be revenue neutral....


I will say that I was surprised to learn of some people who do not have insurance... I take a class at the gym... one lady got sick and was in the hospital for a week (she is in her 40s).... talking to another lady there I found out she did not have insurance.... that she had just paid off a big bill from some other problem in her family when they also did not have insurance... I do not know what she or her husband does, but it did surprise me...

So I mentioned that I was on Obamacare and was surprised sick lady did not have a plan... then the lady talking to me said her family did not have a plan!!! Said her husband was self employed and they could not afford it... I said she could probably get a cheap plan if they income was so low... maybe $200 a month cost to them.... her comment "We cannot afford $200 per month".... Sooooo.... at least a family of 3 (she brings her daughter in as she is home schooled) and maybe more and you do not think health insurance is important enough to pay $200 per month

 

[ivinsfan]

And yet, she can take classes at the gym....money is sometimes just the excuse, though for the life on me, I can't understand this attitude.

 

[Texas Proud]

And yet, she can take classes at the gym....money is sometimes just the excuse, though for the life on me, I can't understand this attitude.

Do not a make judgements on this since you do not know... the cost of the class is ZERO and the gym membership is $10 plus tax per month...

 

[travelover]

Do not a make judgements on this since you do not know... the cost of the class is ZERO and the gym membership is $10 plus tax per month...

Can't speak to this particular case, but I think that the general sentiment is valid that many don't think that having health care is a spending priority. When the uninsured get free care, it is off the backs of those that have already stepped up to pay for their own care.

 

[ChiliPepr]

That's why many of us prefer to see the health care costs reduced, instead of let stay artificially high and then subsidized by the government. Even the government can and will run out of money, so that would not be long lasting.

Want to see medical costs go down? Mandate that all insurance covers wellness visits, but also requires the person to pick up the 50% of all other medical procedure up to $5k/year. Allow people to get some of the $5k back when filing taxes depending on income.

Why is the average cost of a facelift about $6k and the average cost of an partial knee replacement about $50k? Because people shop around for a facelift and insurance picks up the bill for the knee. If people had some skin in the game they would care what it costs.

Try this, next time you go to the doctor for a procedure, ask them what it would cost if you did not have insurance, bet you they do not know. If I needed to get a MRI on my knee and I was going to have to pay 50%, would I look for the place that was closer to $500 than to $3,000. I may also be willing to wait a week if the doctor thinks that it is a sprain than to demand I get one right away.

When things are subsidized, the prices tend to rise fast like college or medical costs. The more of a subsidy a person gets, the more likely the provider will raise the price. If the price of some was completely covered by someone else, why would I care about cost or even looking for something cheaper? It is the same principle with people on a business trip, if your company is picking up the tab you don't look at the price, if you are picking up the tab you look at the price and that goes into your decision.

 

[travelover]

Want to see medical costs go down? Mandate that all insurance covers wellness visits, but also requires the person to pick up the 50% of all other medical procedure up to $5k/year. Allow people to get some of the $5k back when filing taxes depending on income.
..........

Great idea except....

Two-thirds of Americans would have difficulty coming up with the money to cover a $1,000 emergency, according to an exclusive poll released Thursday, a signal that despite years after the Great Recession, Americans' finances remain precarious as ever.

Poll: Two-thirds of US would struggle to cover $1,000 crisis | APNORC.org

 

[MrPotatoChip]

Want to see medical costs go down? Mandate that all insurance covers wellness visits, but also requires the person to pick up the 50% of all other medical procedure up to $5k/year.

I might actually sign up for that. If I was to get Obamacare, I would have a $6850 deductible. No copay for me.

And guess what, medical costs are not going down.

 

[samclem]

Want to see medical costs go down? Mandate that all insurance covers wellness visits, but also requires the person to pick up the 50% of all other medical procedure up to $5k/year. Allow people to get some of the $5k back when filing taxes depending on income.

Great idea except....

Two-thirds of Americans would have difficulty coming up with the money to cover a $1,000 emergency, according to an exclusive poll released Thursday, a signal that despite years after the Great Recession, Americans' finances remain precarious as ever.

Poll: Two-thirds of US would struggle to cover $1,000 crisis | APNORC.org

Maybe have every taxpayer/household establish an HSA, and the government deposits $5K in it immediately. That is recouped by the government over the next 5 years. Failure of the taxpayer to keep the HSA topped off every year results in a fine/penalty/tax (since we've already crossed this bridge . . .). Sure, the $5K would take a big chunk of govt spending at first, but it's a great long-term investment if it helps reign in medical care costs.

But:
-- People won't be able to shop for medical services unless there is price transparency. They also need good information on the quality of the services provided. Even a survey of patients would be better than nothing.
-- We still need to give an incentive for people to choose insurance that keeps costs under control for the big ticket items, else nobody will care about costs once they hit their out-of-pocket max.

 

[Texas Proud]

Maybe have every taxpayer/household establish an HSA, and the government deposits $5K in it immediately. That is recouped by the government over the next 5 years. Failure of the taxpayer to keep the HSA topped off every year results in a fine/penalty/tax (since we've already crossed this bridge . . .). Sure, the $5K would take a big chunk of govt spending at first, but it's a great long-term investment if it helps reign in medical care costs.

But:
-- People won't be able to shop for medical services unless there is price transparency. They also need good information on the quality of the services provided. Even a survey of patients would be better than nothing.
-- We still need to give an incentive for people to choose insurance that keeps costs under control for the big ticket items, else nobody will care about costs once they hit their out-of-pocket max.

Not to get us sidetracked....


But, I would bet that a good percent (maybe even a majority) of people would have zero clue on what to do when confronted with what you propose.. first off, most have nothing in medical training... if a doc says you 'need' something then you 'need' it.... second, usually the doc sends you to a place to get it done... or you get it done right at the docs... who wants to spend a lot of time trying to figure out what an MRI costs when they will wheel you in right now and let you know.... third, I do not think people price shop as much as you or I do.... I am amazed that the cost of gas can be 15 cents difference in stations that are very near each other.... and I see many people getting gas at the expensive place... even though I am pretty good most of the time, I will buy stuff and the grocery store or even Home Depot without looking up prices... why? because the cost of everyday items are not that far off from another place... IOW, someone does not try and sell you something for 3X or even 10X that another place charges.... but in the medical field, that is more common than it should be...

 

[Texas Proud]

Can't speak to this particular case, but I think that the general sentiment is valid that many don't think that having health care is a spending priority. When the uninsured get free care, it is off the backs of those that have already stepped up to pay for their own care.

OH, I agree with this.... I have always thought it was even when the price of medical care was not so far out of line.... but I knew people who never thought of what would happen if they had a bad illness or cancer...


I also think that this lady is spending on something that probably has more impact than insurance... going to the gym 3 to 5 times a week for $10 a month has a better return than spending $1000 or more a month on health insurance, or even $200 with subsidies.... that is until you need it...

 

[ChiliPepr]

if a doc says you 'need' something then you 'need' it....

The thing I would like to stop is the person coming in and saying "I need an MRI/X-Ray/test/specialist" and the doctor saying, I do not think so, but since I do not want to get sued if I am wrong I will prescribe and MRI.

 

[NW-Bound]

Can't speak to this particular case, but I think that the general sentiment is valid that many don't think that having health care is a spending priority. When the uninsured get free care, it is off the backs of those that have already stepped up to pay for their own care.

... and gets on the back of every taxpayer.

That is OK with me, because it spreads the pain among more people, and beyond the group that buy their own insurance such as the ERs here.

 

[ShokWaveRider]

What makes me choke is the fictional thinking that being able to purchase insurance across state lines will make it cheaper. That is not the issue, the cost of service is the issue and what providers charge the insurance companies and individuals. OK Insurance companies can negotiate a little better if they have a lot of clients. But the cost will still be high. The ONLY way to get control of costs is to MANDATE (I know you do not like that word) EVERYONE has to pay into it and get insurance.

without subsidies 20m odd could not afford the premiums. Me included.

 

[samclem]

The ONLY way to get control of costs is to MANDATE (I know you do not like that word) EVERYONE has to pay into it and get insurance.

I don't understand your reasoning. The cost of insurance is not the root problem--the problem is the cost of the medical services we are paying for >through< insurance. The crazy-high cost of medical services is (by far) the primary factor underlying the price of medical insurance. Driving more people into the malfunctioning/distorted health care market will not decrease the cost of services, in fact it may increase them. Driving more people into the insurance market might lower premiums for those already paying for health insurance, by spreading the unreasonable and irrational cost of the health care services among more health insurance customers, but it will drive >up< the share of our GDP we spend on health care.
We need to build a system that provides incentives for improving the value of health care services (or, better yet, decreases the cost of staying healthy). Spreading unreasonable and escalating costs among more people isn't the answer.

 

[ShokWaveRider]

The cost of insurance is not the root problem--the problem is the cost of the medical services we are paying for >through< insurance. The crazy-high cost of medical services is (by far) the primary factor underlying the price of medical insurance.

I do not disagree with you here. BUT Insurance is the way we do it. The Insurance model is to spread the load. Whether is it ACA or any other form of whatever is to come, costs are still high and you need more people paying to spread the load.

If it is too expensive then people cannot afford it. They still get healthcare at the expense of others. At least with ACA style system there are more people paying into it.

It is not an easy subject to discuss, but not having anything at all is a recipe for increased costs and more people going to get services at the last minute that costs a lot more than preventive and early diagnosis.

 

[travelover]

I do not disagree with you here. BUT Insurance is the way we do it. The Insurance model is to spread the load. Whether is it ACA or any other form of whatever is to come, costs are still high and you need more people paying to spread the load.
..........

I have to agree with samclem on this. Spreading the cost through insurance has simply not worked. We need to reduce the cost of medical services and prescription drugs. Someone's ox is going to be gored.

 

[Texas Proud]

In this discussion I am conflicted.... the free market person in me says that the gvmt should stay out of it....

But, the practical side of me says that is not working... there is little to no incentive to becoming a low cost provider of services... there are a lot of incentives to become a high cost provider and spread the pain...

As an example... insurance would cover a shared room unless nothing was available... so guess what the hospitals started doing?? Yep, make new hospitals with no shared rooms at all... if you ain't got em you can't put people in them...

The other is to keep up with the newest and best equipment... so your MRI is a few years old, but there is another one that is newer and better... so, get rid of the old one even though it might be great for many minor MRIs and cost less....



Yes, I think that the gvmt should have a say in the cost of procedures... IOW, find out the true cost of something and publish that info... maybe allow facilities to charge 150% of that price.... but, if you want to charge more then you cannot get any money from the gvmt for any reason...

 

[ivinsfan]

Do not a make judgements on this since you do not know... the cost of the class is ZERO and the gym membership is $10 plus tax per month...

ten bucks here 10 bucks there it adds up, the fact the family hasn't even looked into ACA says something too. You took her word for it that they couldn't afford it.

In my family the first dollar would go towards health insurance. But I realize the choice lies with each family, but there again. The insured help pay for the uninsured....

I also noticed the family homeschool so Mom does not work outside the home, again a personal choice, but with no health insurance that seems likes an indulgence.

 

[gerntz]

What do others think is the likelihood that ACA could be modified after election to eliminate subsidies for those with low income, but high assets? In other words many on this Forum...

Who is going to count assets? How? What asset value do I put on my Picasso? Sounds like a nightmare to enforce.

Then there's two folks who both made $5M over their lifetime & one has zilch today & the other $4M. Should they pay anything different?

 

[travelover]

In this discussion I am conflicted.... the free market person in me says that the gvmt should stay out of it....
............

I think that, in general, Canadians are pretty happy with their system, as are Western Europeans. People on Medicare seem happy. There has gotta be a compromise / solution in there somewhere.

 

[Texas Proud]

ten bucks here 10 bucks there it adds up, the fact the family hasn't even looked into ACA says something too. You took her word for it that they couldn't afford it.

In my family the first dollar would go towards health insurance. But I realize the choice lies with each family, but there again. The insured help pay for the uninsured....

I also noticed the family homeschool so Mom does not work outside the home, again a personal choice, but with no health insurance that seems likes an indulgence.

Ahhhhh, no.... I did not 'take her word'... that is what she told me and I could care less if she has it or not.... I was not going to try and dig into her finances.... I am more like you.... if you want it you will find a way to get it... and if they are really poor then they might qualify for Medicaid... at least CHIPS for her kid....

I agree about her not working... but as you say that is a lifestyle choice...


I have no idea about the lady who went into the hospital... she does not talk to me and that is OK with me... I would have thought she would have been more interested since someone told me she had just finished paying off a $20K plus bill... now has another $20K plus bill to pay....

Some of the ladies now talk to me since my DW also started to come to the classes ... I am the only man there...

 

[MRG]

The cost of Healthcare does seems out of control. Doesn't it double every ~10 years at the current growth rate?

How could insurance costs do anything but follow the same growth?

I remember my old PCP sending me out for tests when I knew he really thought he'd like to try another treatment first. His judgment was as good as the tests.

His office was part of a fairly large public healthcare company. They were supposed to use the company's internal offerings for testing and referrals. I had quite a few CT and MRI, never once went to their facilities. The public company had negotiated twice the rate for those services with insurance companies. The practice I was with tried to send patients to less expensive alternatives.

I remember a neurologist sending me outside their own internal treatment to an outside group. Her comments were along the lines of "I'm going to get questions about sending you outside, but you're far too ill for them to practice on you". She knew the quickest path to success, benefiting me and keeping the costs lower.

I belive some providers do try to help keeping costs down but it's increasing difficult for the individuals who do that.

 

[AllDone]

I doubt the structure of ACA will be preserved, as many appear to be assuming. There are still 28-30m uninsured, though all now have "access". If you analyze the uninsured the largest category is people who choose not to afford it, including a number of folks who qualify for subsidies.

While there are certainly uninsured who could sign up for insurance, a lot of the uninsured are the poor living in states that did not accept the Medicaid expansion. That's the fault of the state, not the individual. They would take the insurance, if they could get it.

 

[EastWest Gal]

We in the U.S. are paying way more for medications, surgery, and tests than the rest of the world. The lack of transparency in medicine makes it very, very easy to commit fraud. I have seen fraudulent charges on my family's medical bills 3 times between 2006 and 2009, but was only able to combat one of them, because the others were just not accessible. I have no doubt that costs could be contained if we could combat fraud and also if drug prices were not so astronomical. The claim that it takes $1 billion to bring a drug to market is just ridiculous. Most of that cost is born by the NIH and university researchers, not the drug companies, but they reap all the profits.