Health Care Mandate - To Supreme Court to Decide

[easysurfer]

2-2. Looks like Supreme Court might have to be the tiebreaker...

Circuit Court strikes down part of health care law | The Ticket - Yahoo! News

 

[obgyn65]

I think we already know the answer - tens of millions of people in this country will be denied healthcare. I bet this thread will end up being closed.

 

[donheff]

I haven't read the latest decision but I heard it reported that it is fairly restrictive, invalidating the individual mandate but not the rest of the law. Other courts have upheld the mandate. So the Supremes could go either way. If they support the latest decision they may strike down the mandate and leave the rest standing. A lot of people will cheer such a result but that seems short sighted. The Affordable HC Act eliminates preexisting conditions so that provision would be remain in place with the individual mandate gone. It also sets up state exchanges so those would continue as well. Unfortunately, without mandatory coverage, the health insurance industry would have to charge exorbitant rates for coverage without pre-existing condition exceptions. So we would end up with half a loaf of an already challenged system. That is the definition of a Pyrrhic victory. And if people assume Congress would simply vote down the rest of the system, think again. It is easy to filibuster any move like that. We can have more fun with brinksmanship as far as the eye can see.

My prayers (if I was a praying guy) would be on the Supremes leaving the Act intact.

 

[rescueme]

I bet this thread will end up being closed.

It should be, IMHO.

Once a decision is made by the (highest) courts, we can discuss the impact upon ours, and others lives.

Today, we can talk about it, but none of us (unless we have a Supreme Court Justice on this board ), will not affect the outcome.

Give us the result, and we can see how it will apply to us, and those around us.

 

[Gumby]

Actually, it is a fascinating constitutional issue that could be discussed at length by those interested in such things. Last fall, I was a moot court judge for UCONN law school and the individual mandate was the issue up for argument. In light of that experience, I have really enjoyed reading the circuit court opinions, and I look forward to seeing the Supremes grapple with the case.

But you are right that, aside from a pure academic interest in the legal issues that someone like me may have, it is best in this forum to await the outcome and then discuss the ramifications.

 

[donheff]

Actually, it is a fascinating constitutional issue that could be discussed at length by those interested in such things. Last fall, I was a moot court judge for UCONN law school and the individual mandate was the issue up for argument. In light of that experience, I have really enjoyed reading the circuit court opinions, and I look forward to seeing the Supremes grapple with the case.

But you are right that, aside from a pure academic interest in the legal issues that someone like me may have, it is best in this forum to await the outcome and then discuss the ramifications.

+1 I felt the same way about the 2nd amendment DC gun law case. The Supreme Court discussions are a fascinating review of history. This one will be also. And there isn't a topic much more important to us (or at least the US members) given all the worries we see expressed about health insurance in ER.

 

[Stella_Barbone]

The future of the ACA is a big part of my retirement calculation. My sister retired last year and my self-employed BIL was unable to get insurance except through the high-risk pools set up under the ACA. Should my sister have to go back to her corporate j*b so that he can be insured? We hear a lot of praise for entrepreneurs, but we make it difficult to pursue that path when health insurance is unavailable. My BIL has a fairly minor condition and can't get insurance, but what about cancer survivors? My perfectly healthy mom was unable to get insurance that covered her right leg when my older father retired because of a history of a fracture and a subsequent hardware removal operation. My coworker's mom couldn't get insurance that covered her colon when her husband retired because of diverticulosis. Twenty years later neither of these women have had a minute of trouble from either of the relevant areas, but they were unreasonably excluded. I have patients who are working well past retirement age for no reason other to supply insurance to s younger spouse. I could even tell you the story of a patient who died because of this stupid system even though she did everything right. The current system stinks. The ACA isn't great (not surprising given it's Heritage Foundation origins), but it's substantially better than the status quo.

I think that I should stop reading the politics forum, because this is another subject that lights me up, so forgive me. I work in a deeply red area of an otherwise blue state and I hear a lot of the scary disinformation that my senior patients are getting from their favorite news channel and it builds up inside me. Soon, I will retire and move to Portland, right?

 

[ERD50]

I think we already know the answer - tens of millions of people in this country will be denied healthcare.

That assumes that something else isn't passed to replace it.

That might be a very good assumption, but it is an assumption. Speaking of assumptions, one thing that bothers me is the assumption that anyone who doesn't like this bill is against any HC bill. It's been discussed before, so I wont repeat the details.

But, specific to your statement, it is true even after the HC bill takes effect:

Obama signs health care bill: Who won't be covered? - CSMonitor.com

Signs indicate that some 23 million Americans will lack insurance in 2019, after key provisions of the law have been in effect for as long as five or six years, according to a Congressional Budget Office (CBO) estimate.

-ERD50

 

[Hamlet]

I think an individual mandate is required to make our private insurance model work in the future.

We are quickly reaching the point where insurance companies have so much information about our health that they can tailor individual rates to a point that prices anyone of moderate risk out of the market.

Private individual insurance had already started to collapse, even pre-ACA.

Unless insurance companies are forced to take all comers, it isn't going to work, and you can't force insurance companies to take all comers without the individual mandate.

Insurance is a bad method for paying for health care costs, and is steadily becoming worse.

That assumes that something else isn't passed to replace it.

That might be a very good assumption, but it is an assumption. Speaking of assumptions, one thing that bothers me is the assumption that anyone who doesn't like this bill is against any HC bill. It's been discussed before, so I wont repeat the details.

But, specific to your statement, it is true even after the HC bill takes effect:

Obama signs health care bill: Who won't be covered? - CSMonitor.com

-ERD50

 

[ziggy29]

I haven't read the latest decision but I heard it reported that it is fairly restrictive, invalidating the individual mandate but not the rest of the law.

Without the universal mandate, other provisions (primarily the elimination of medical underwriting) become impossible to implement.

And if this is shot down by the Supremes, about the only way around it is the "Medicare for All" approach (combined with significant reforms to the Medicare system to make it more sustainable), since Medicare has presumably already passed Constitutional muster with the courts.

 

[ziggy29]

Should my sister have to go back to her corporate j*b so that he can be insured? We hear a lot of praise for entrepreneurs, but we make it difficult to pursue that path when health insurance is unavailable.

This is a big problem as far as I'm concerned. Basically the large employers are the only ones who can afford to provide health insurance, making it really hard for small business to compete for the best employees (who will understandably hold out for medical benefits). And I believe many people who would normally make great entrepreneurs do not give it a go because they can't afford to lose their corporate employer health insurance.

And finally, how many people are still working *only* because they need the health insurance? And if the link between health insurance and corporate employment were severed, how many folks could retire tomorrow and make that many more jobs available?

These are some of the indirect and incalculable "costs" our current system imposes on us.

The two most important aspects of health care reform, to me, are:

(1) Cost containments to make the program sustainable for the longer term;

(2) Breaking the link between employer and health insurance.

The law as passed (and now in legal limbo) failed on both of those counts.

 

[ERD50]

The two most important aspects of health care reform, to me, are:

(1) Cost containments to make the program sustainable for the longer term;

(2) Breaking the link between employer and health insurance.

The law as passed (and now in legal limbo) failed on both of those counts.

We whole-heartily agree on those two points. And they are important indeed.

It's why I get frustrated when some people characterize the bill opponents as being against everything. To me, it is a real shame that Congress spent (I started to say 'invested') so much time on this, and ended up with such a poor bill. We do need something. We don't deserve what we got.

Copy the Swiss system (vouchers for all, individual choice on how to use them), and start from there. Adjust as needed.

-ERD50

 

[MichaelB]

Copy the Swiss system (vouchers for all, individual choice on how to use them), and start from there. Adjust as needed.

-ERD50

From Wikipedia

Swiss are required to purchase basic health insurance, which covers a range of treatments detailed in the Federal Act. It is therefore the same throughout the country and avoids double standards in healthcare. Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans

The insured pays the insurance premium for the basic plan up to 8% of their personal income. If a premium is higher than this, then the government gives the insured a cash subsidy to pay for any additional premium

The compulsory insurance can be supplemented by private "complementary" insurance policies that allow for coverage of some of the treatment categories not covered by the basic insurance or to improve the standard of room and service in case of hospitalisation. This can include dental treatment and private ward hospitalisation which are not covered by the compulsory insurance.
As far as the compulsory health insurance is concerned, the insurance companies cannot set any conditions relating to age, sex or state of health for coverage. Although the level of premium can vary from one company to another, they must be identical within the same company for all insured persons of the same age group and region, regardless of sex or state of health. This does not apply to complementary insurance, where premiums are risk-based.

This is an option I could live with.

 

[donheff]

Without the universal mandate, other provisions (primarily the elimination of medical underwriting) become impossible to implement.

And if this is shot down by the Supremes, about the only way around it is the "Medicare for All" approach (combined with significant reforms to the Medicare system to make it more sustainable), since Medicare has presumably already passed Constitutional muster with the courts.

Copy the Swiss system (vouchers for all, individual choice on how to use them), and start from there. Adjust as needed.

-ERD50

The Swiss system would make sense to me as long as the vouchers were big enough to cover a basic insurance policy and could only be used for insurance. That with provisions that insurers must take all comers would work better than the AHCA. I was going to say to the top quote that there are a lot of alternatives to single payer (although I would prefer single payer). One would be to recast the mandate as an option but tax everyone with a credit for buying insurance instead - thus the mandate disappears and the penalty is just a tax (if you don't buy insurance no credit). But that proposal sounds like a different way of describing Swiss vouchers. The biggest obstacle to a Swiss type system is the Norquest pledge -- can't have vouchers without taxes.

ERD -- I don't think many of us have said or implied that opposition to the AHCA is opposition to universal health care. We had that argument on a thread attached to the poll about whether to repeal AHCA and start over or keep it and fix it. IIRC, the poll results were strongly in the keep it and fix it categories. The fear most of us AHCA supporters have is that outright repeal will leave us back where we started with no likelihood of an alternative for decades. I hope that if the Supreme Court goes with selective invalidation of the mandate that will lead to us fixing it rather than simply repealing it.

 

[Stella_Barbone]

This is a big problem as far as I'm concerned. Basically the large employers are the only ones who can afford to provide health insurance, making it really hard for small business to compete for the best employees (who will understandably hold out for medical benefits). And I believe many people who would normally make great entrepreneurs do not give it a go because they can't afford to lose their corporate employer health insurance.

And finally, how many people are still working *only* because they need the health insurance? And if the link between health insurance and corporate employment were severed, how many folks could retire tomorrow and make that many more jobs available?

The CBO estimates that 1.6M will leave their jobs when the ACA goes into effect. The GOP has been presenting this number as an estimate of the number that will "lose" their jobs rather than as the estimate of the number that will chose to leave their jobs. Some of those people will chose retirement, I'm sure, but some will be starting their own businesses. Many of the western European countries, especially France and Scandinavia have much higher levels of entrepreneurship than the US as a result of their "socialist" social safety net. That doesn't fit in well with our mythology about ourselves, does it?

And yes, of course a social safety net can be too generous, but in the US we are a long way from that state.

I'd post a link, but then I get moderated, besides the CBO is easy to google.

 

[Hamlet]

It's not clear to me that the Swiss system is vastly different from the system that we just passed.

It has the individual mandate, and subsidizes the purchase of private insurance based on income.

It actually requires the insurance companies to provide the basic plan without making a profit.

It mandates that the insurance companies must charge completely flat rates to all comers, which amounts to a giant subsidy of the old by the young.

The system we just passed limits the difference that insurance can charge based on age, but it allows a fair amount of variation.

What exactly is the reason you would prefer the Swiss model?

We whole-heartily agree on those two points. And they are important indeed.

It's why I get frustrated when some people characterize the bill opponents as being against everything. To me, it is a real shame that Congress spent (I started to say 'invested') so much time on this, and ended up with such a poor bill. We do need something. We don't deserve what we got.

Copy the Swiss system (vouchers for all, individual choice on how to use them), and start from there. Adjust as needed.

-ERD50

 

[Stella_Barbone]

We whole-heartily agree on those two points. And they are important indeed.

It's why I get frustrated when some people characterize the bill opponents as being against everything. To me, it is a real shame that Congress spent (I started to say 'invested') so much time on this, and ended up with such a poor bill. We do need something. We don't deserve what we got.

Copy the Swiss system (vouchers for all, individual choice on how to use them), and start from there. Adjust as needed.

-ERD50

The Swiss system is a relatively minor tweak to the ACA as it is currently configured. Additionally states have the right under the Wyden exemption to experiment with other configurations as long as they meet minimum standards. Vermont is already developing a single payer plan, Hawaii wants to maintain theirs, and Oregon is working on a plan too.

 

[ziggy29]

It mandates that the insurance companies must charge completely flat rates to all comers, which amounts to a giant subsidy of the old by the young.

Which also helps these older folks retire and maybe get some younger folks off the unemployment line. So there is *some* give-back here, I think.

Few policy decisions exist in a vacuum.

(By the way, this is also true about where to set the age to receive SS and Medicare. On one hand these are intergenerational transfer programs, but they also help the older folks retire which, in an era of unacceptably high unemployment for younger folks, has some offset to it as more retirements mean more help wanted signs go up.)

 

[MichaelB]

It's been weeks since we had a good health care thread. I guess that means the panic over debt ceiling, S&P ratings, double dip recession, and stock market crash must all be receding.

Much as I enjoy this subject, DW and I are off for a family visit this afternoon. I'm taking the chance that it won't be resolved and everything agreed on until I have a new opportunity to post again tomorrow.

 

[donheff]

It mandates that the insurance companies must charge completely flat rates to all comers, which amounts to a giant subsidy of the old by the young.

That is a very good thing. Employer provided insurance generally does the same. And family plans involve a giant subsidy of large families by couples and those who have smaller families. No problem there either.

 

[MichaelB]

term;

(2) Breaking the link between employer and health insurance.

I agree with both, but this in particular was a real disappointment for me as well. Breaking this link would have many positive ramifications for the economy, business and employment.

 

[ziggy29]

I agree with both, but this in particular was a real disappointment for me as well. Breaking this link would have many positive ramifications for the economy, business and employment.

Agreed, as I alluded to before, I can't count the number of times I've heard people say they could retire except for the health insurance conundrum, or bright and innovative people who say they'd love to leave their jobs and start up their own businesses except for the health insurance conundrum.

This is an economic drag that's hard to calculate, but it is very real. In the former case you reduce unemployment and turn someone from a net tax consumer into a net tax payer, and in the latter case you unlock a lot of growth potential that's stagnating in a corporate cubicle.

 

[samclem]

What exactly is the reason you would prefer the Swiss model?

IMO, the biggest advantage of the Swiss system over what we might get under the ACA is the ACA's continued linkage between employers and health care. Luckily, the ACA will destroy employer provided health care in the US (it is much cheaper for employers to simply drop coverage,pay the fine, and let the employees buy their own insurance with a big government subsidy. The much larger need for subsidies as this process continues is a reason the estimates for the cost of the ACA are far too low). If we still have private insurers competing for business in the exchanges when the employer coverage ends, and if the government can restrain the urge to mandate all kinds of "free" care in the obligatory packages, then things might work out. It could also be a good model for Medicare--just open the exchanges to the Medicare age group and let oldsters use their government Medicare entitlement as a voucher to buy from whichever provider they'd like. That shouldn't be controversial.

I still think it's possible the vast majority of people could be induced to buy health insurance even without an individual mandate. Once the US puts in place a system that goes the extra mile to make individually-purchased health insurance more affordable, then folks without insurance will feel some increased pressure to get aboard.
-- Isn't a person with health insurance more creditworthy than someone without? Medical costs are a big reason for bankruptcies. So, those without insurance might have lower credit scores, pay more for loans, etc.
-- Isn't a prospective employee with health insurance more desirable than one without? Isn't it a sign of a responsible individual? No reason employers shouldn't look at this factor, and laws should specifically permit it. Because high health costs definitley make an individual more prone to have an acute need for money, failure to have insurance could be a factor in granting security clearances, in bonding, in obtaining and maintaining licenses and certificates issues by accrediting agencies for those who handle funds or valuable property, etc.
-- Child support arrangements should make it clear that divorced parents must cover their kids.
-- There should be big costs to individuals who lean on public payments to health care providers when they get sick. It's gotta be painful--garnishment of wages, seizure of assets by the government, etc. If the system is set up so people can get affordable insurance and they don't do it, then they really have no right to expect free care.

 

[Hamlet]

If insurance companies are forced to take all applicants, without an individual mandate you will have a strong incentive to simply wait until you are sick to buy insurance.

I still think it's possible the vast majority of people could be induced to buy health insurance even without an individual mandate. Once the US puts in place a system that goes the extra mile to make individually-purchased health insurance more affordable, then folks without insurance will feel some increased pressure to get aboard.

 

[samclem]

If insurance companies are forced to take all applicants, without an individual mandate you will have a strong incentive to simply wait until you are sick to buy insurance.

I understand that. I'm providing some positive and negative inducements to get people to sign up for this insurance when the individual mandate is found to be unconstitutional. Let's say, after the government subsidy, health insurance were to cost you $2000 per year out of pocket. Would you buy it? Would you buy it if it would help your credit rating so it lowered your mortgage by $2000 per year? Would you buy it if having insurance made it more likely you could get and keep a job? Would you buy it if "free" treatment at an ER meant the government would take serious steps to get their money back for the care you received?