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Old 01-09-2010, 09:51 AM   #21
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So if you were to pass Noonan's "simple bill that mandated insurance coverage without respect to previous medical conditions." You'd also have to mandate that individuals buy insurance to avoid adverse selection problems. And if you have an individual mandate then you have to either exempt people who can't afford insurance from the mandate or give them subsidies.

Which kind of sounds like the bill we got.
To me the funding mechanisms are the worst problem because of its disproportionate impact on "effective" middle class tax brackets. The phaseout of the subsidy occurs entirely within the solidly middle class brackets and then goes away. So people needing to buy their own health insurance on a middle class income take the brunt of reform.

As a result, every extra dollar a $60K household earns can effectively have its take-home equivalent pay reduced a lot more than someone earning $200K because the former is losing somewhere in the neighborhood of 15-18 cents on the dollar in the form of reduced subsidy to buy health insurance.

Remember the old income tax "bubble" right after the 1986 Tax Reform Act when the tax brackets went 15-28-31-28, with the 31% bracket being a phaseout of the 15% bracket until it was all gone? That's similar to the middle class "tax rate bubble" here, only this one is gargantuan compared to the upper-middle class tax bracket bubble that occurred after '86 -- and hits at considerably lower inflation-adjusted income levels.
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Old 01-09-2010, 10:00 AM   #22
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Insurance that can't be denied if you're sick?

Insurance that can't be dropped if you become sick?

Am I close?


You might reconsider the value of "low cost" insurance in other states against the risk of having that insurance "rescinded" once you file a large claim. Often times you get what you pay for.
Some plans in New Jersey are upwards of $14,000 per month. That's not a typo. The absolute least expensive plan with the lowest coverage for someone under 25 years old is about $300 per month. How many people do you know that are 23 years old who can afford $3600/year for health insurance? Two of my friends just moved from Virginia to New York - they're both 24-25 years old and were paying $140 per month for a high deductible plan here in VA. In NY, the least expensive plan they could get was over $800 per month, and most were $1100-1400 per month. The average plan for a husband/wife in many of these states exceeds $1000 per month already - where will that be in 5 years?

Do you know what the percentage of rescinded policies is for states that underwriter coverage? Slim to none, and 98% of the time there is a good, valid reason for it. Many people have selective memory when filling out insurance applications, whether it be for health, life, disability, etc.
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Old 01-09-2010, 10:05 AM   #23
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Because I think it's unsustainable . . . and I think it could be economically ruinous.
As is the status quo.

Although it doesn't get any press, this is the first bill that ever tries to do something about the cost of health care. According to David Brooks . . .

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The third reason to support the bill is that the authors have thrown in a million little ideas in an effort to reduce health care inflation. . . . If you’ve ever heard about it, it’s in there — improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research. There’s at least a pilot program for every promising idea.
He ultimately comes down against the bill. But it seems his complaint is that the current bill doesn't completely blow up the existing system and start over, which, although perhaps desireable, isn't exactly realistic.

My view is that this is the start of a process and a step in the right direction. It solves one problem (that our existing system attempts to control costs by kicking out sick people) and highlights another (how to pay for health care over the long-term). But this second problem isn't new. We currently have a system of massively subsidized and cost shifted insurance. It is really not much more so under the new bill. Only under the existing system the cost is mostly invisible (lower wages). Now it will be a budget item, and one that will need to be addressed directly.

Probably the best of a bad situation.
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Old 01-09-2010, 10:09 AM   #24
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My view is that this is the start of a process and a step in the right direction. It solves one problem (that our existing system attempts to control costs by kicking out sick people) and highlights another (how to pay for health care over the long-term).
That's fair. But it seems to ignore one thing: as I see it, the biggest problem with the health insurance mess, bar none, is the runaway rate of health care inflation. This bill attempts to deal with the universal access issue -- which is important -- and how to pay for it -- also important (even if I have strong feelings that it's a terrible funding mechanism).

But it does next to nothing to make changes to the system that will stop double-digit inflation in health care. THAT, to me, is the 800-pound gorilla in the room; solve it and ALL the other problems become much more solvable. Ignore it and no matter what you do, in another couple of years you have another crisis. Health care reform is an intractable (if not impossible) problem to solve without getting costs under control.

We should address the health care inflation problem first, or at least concurrently. That is the problem which has made all the others so much worse.
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Old 01-09-2010, 10:17 AM   #25
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To me the funding mechanisms are the worst problem because of its disproportionate impact on "effective" middle class tax brackets.
The options to fix this are:

1) No subsidies
2) Subsides that phase out above the middle class
3) Single payer insurance

Of the three, the third option is actually the best but the one you probably like least.
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Old 01-09-2010, 10:18 AM   #26
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Do you know what the percentage of rescinded policies is for states that underwriter coverage? Slim to none, and 98% of the time there is a good, valid reason for it. Many people have selective memory when filling out insurance applications, whether it be for health, life, disability, etc.
Please provide a reliable source to back up this claim.

Here's what insurance industry execs told Congress this summer . . .

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Late in the hearing, Stupak, the committee chairman, put the executives on the spot. Stupak asked each of them [insurance company CEOs] whether he would at least commit his company to immediately stop rescissions except where they could show "intentional fraud."


The answer from all three executives:


"No."
And rescissions aren't the only way to get at this. Martha summed it up nicely here:

Quote:
They also can raise rates for everyone on a particular plan, driving out the healthy who can get underwritten so they buy a cheaper plan and leaving the unhealthy behind with a very expensive plan.

They can offer a new deal to those who can get underwritten, leaving behind the unhealthy and then raising their rates because of the bad group experience.

HIPAA doesn't bar rate increases. Some states do not bar raising rates because of claims by an insured.
But of course you know that because you were part of that thread and agreed at the time . . .

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I very much agree that something needs to be done about the ability to rescind a policy. I don't care whether you are Republican, Democrat, for health reform or against it, it's pretty much universally agreed upon that hte practice of rescission needs to be eliminated, or at least limited to obviously intentional fraud (like a smoker claiming they are a non-smoker and then getting lung cancer). Unfortunately, arguing about the technicalities is what lawyers are for.
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That's what I wrote above about the practice of "blocking" [in response to Martha's comment quoted above]. Scummy, but that's what they do and you have to play the game the way the rules are set as of now.

So again, I ask, what is the value premium on a policy where these things are prohibited versus where they are not? If we're going to compare costs across states, lets at least compare apples to apples.
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Old 01-09-2010, 10:25 AM   #27
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But it does next to nothing to make changes to the system that will stop double-digit inflation in health care. THAT, to me, is the 800-pound gorilla in the room; solve it and ALL the other problems become much more solvable. Ignore it and no matter what you do, in another couple of years you have another crisis. Health care reform is an intractable (if not impossible) problem to solve without getting costs under control.

We should address the health care inflation problem first, or at least concurrently. That is the problem which has made all the others so much worse.
I agree with all of this and am disappointed that the bill mostly deals with things that are politically "easy" to do - like extending coverage.

But a large part of the blame for that has to be borne by those who demagogued any attempts at controlling costs as instituting death panels and the like. If we actually had a grown up political process, and electorate, we could have had a better bill. But we don't. So it isn't.
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Old 01-09-2010, 10:35 AM   #28
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Please provide a reliable source to back up this claim.

Here's what insurance industry execs told Congress this summer . . .
I don't have a source, I just know that people applying for health insurance tend to suffer from bouts of selective memory when filling out applications. I am 100% in favor of changing the law to only allow rescission in the case of fraud, so I am not disagreeing with you on that.

The question is - who can afford the insurance when it costs $1,000 per month, or $2k per month, or $4k per month? At some point, you just take your chances. Like I said, if you can't write the check, you can't write the check. That has nothing to do with rescission.
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Old 01-09-2010, 10:36 AM   #29
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The options to fix this are:

1) No subsidies
2) Subsides that phase out above the middle class
3) Single payer insurance

Of the three, the third option is actually the best but the one you probably like least.
Another option--straight (no tiered rate) income-based caps on medical expenditures. Subsidies after you've spent the determined percentage.

Rationale: If medical care is such a basic necessity (like food and shelter), then it is entirely reasonable that everyone be willing to pay a percentage of their income for their own care. There's no free lunch, and this is a got-to-have service. The present tax code implies that the gummint believes 7% is a starting point--I'd say 15% is probably a lot closer to the mark . No "standard deduction," no "personal exemption" etc: from the first dollar of income, people would be expected to have available 15% for their medical needs. "Medical needs" = the insurance premiums for the govt-sanctioned high-deductible private policy and any co-pays or cash payments made by the patient for medical services. When a taxpayer exceeds the 15%, then the government subsidies kick in for essential services. No tummy-tucks or IVF, but cancer treatment.

With this system, it might be feasible to not have a personal mandate. We'd still need community rating.

This is a great deal for the poor, it asks them only to contribute to their care the same % as everyone else. And, yes, I do think it would fair to deny any publicly-funded care (or to mandate privately-funded care) to those who won't participate.
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Old 01-09-2010, 10:49 AM   #30
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The options to fix this are:

1) No subsidies
2) Subsides that phase out above the middle class
3) Single payer insurance

Of the three, the third option is actually the best but the one you probably like least.
Methinks you are making assumptions about my ideology that probably not entirely correct. I have some reservations about single payer (especially when looking at what Medicare is facing) but I would reserve judgment until I saw the details.

I'm not too ideological about health care reform. The devil is in the details, and my thought processes tend to look for unintended consequences.
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Old 01-09-2010, 10:51 AM   #31
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I don't have a source, I just know that people applying for health insurance tend to suffer from bouts of selective memory when filling out applications.
This is harder than you think. We're in the process of doing it now, and trying to do it honestly. When asked the question "please list all of the medical conditions you've been treated for over the past five years" it is surprisingly hard to remember and be 100% certain you've listed everything. Do you even know what's in the medical file of every doctor you've visited in the last five years? If he writes down "high blood pressure" but doesn't think it serious enough to mention to you you're screwed. In our personal situation we have an instance where a strange symptom was treated but never diagnosed as something specific, what do we put down for that?

Combine those challenges with the fact that the application is written by lawyers for a company that actually wants you to make mistakes and you don't have a chance.

Now add in all of the other ways the insurance company can drop you or raise your rates over time once you get sick and it makes "low cost" individual health insurance basically worthless in my view.

So you can get a basically worthless policy from a "low cost, low regulation" state or a high cost policy that does what it says it will do but may be unaffordable. Those are your choices now. Seems like reform is a far better option.
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Old 01-09-2010, 10:56 AM   #32
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Methinks you are making assumptions about my ideology that probably not entirely correct.
I did use the word "probably".
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Old 01-09-2010, 11:00 AM   #33
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Another option--straight (no tiered rate) income-based caps on medical expenditures. Subsidies after you've spent the determined percentage.
I like this approach and have argued for something similar in the past.

But you still have to pay for it, and it was the funding mechanism that we were talking about. To avoid the impact on marginal rates you're still left with the three options I identified, no?

Plus, if you determine out of pocket expenses as a percentage of income you are still creating an incentive to reduce income (which was the basic problem Ziggy had with the way the subsidies are structured under the existing bill).

This is a hard nut to crack. All things considered I think they did a good job within the confines of what is politically possible.
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Old 01-09-2010, 02:03 PM   #34
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Here is what I see.... we wanted them to 'fix' the cost of health care.... but I see three big categories....


1> Fix the cost of health care

2> Fix access to insurance (insurance reform)

3> Provide coverage to the uninsured (universal coverage)


The problem is most of the people I know want them fixed in that order... and a number do not want #3... because THAT is what is costing so much money....

But they are trying to get #3 first with a few items thrown in for #2 to make it worthwhile for a good number of people... with very very little (or no) items for #1....

The problem is if you do NOT fix #1 (as others have said), it really does not much matter if we have #2 or #3... and if you do NOT fix #1, then #3 WILL bankrupt the country (well, not really since by then we will really start to ration and not have a good system)....
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Old 01-09-2010, 02:25 PM   #35
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The problem is if you do NOT fix #1 (as others have said), it really does not much matter if we have #2 or #3... and if you do NOT fix #1, then #3 WILL bankrupt the country (well, not really since by then we will really start to ration and not have a good system)....
Agreed! I would be MUCH more open to considering #3 (universal single-payer) if we first got #1 (cost and inflation pressures) under control.
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Old 01-09-2010, 03:09 PM   #36
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How do you control cost? The best bet is to try to emulate low cost areas that have good outcomes and probably weaning away from pay per service. There are a number of people who are working on this issue, it isn't like it isn't being talked about. This is a good article that discusses efforts to get a handle on the cost issue: Health Affairs Blog A good place to read about the cost issues is National* Institute of* Health Policy.
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Old 01-10-2010, 11:31 AM   #37
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Considering the legislation at hand--I do hope that it can be unwound in an elegant way if required. As our discussions here illustrate, the proposed package addresses a lot of symptoms without getting at the underlying causes. Whatever fragile political consensus used to exist is evidently fast on the wane. The astounding shakeup in the Massachusetts senatorial special election race has got to waking a lot of people up right now. If a race in very-liberal MA is within single-digits, it's time for everyone (on both sides of the aisle) to acknowledge that there has been a major sea change among the electorate.
Given that, I hope that whatever package might get passed in the coming weeks is something that can be undone at minimal cost and disruption to the health care of Americans when the time comes. Good plans of any type usually feature "what if" branches and sequels that allow for flexibility in the event of unanticipated changes in the situation. That would be good here, too. If, instead, the plan deliberately incorporates lots of devices to shackle the American people to this construct even if the political consensus changes, it will validate the growing cynicism of the voters.
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Old 01-11-2010, 03:11 AM   #38
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I agree that people are frustrated with the health care bill process. Most of the time people dont pay much attention to legislation being made and this one put it all out there for people to see. My frustrations as a liberal are very different from the frustrations of a conservative. The frustrations do not mean that the public has suddenly turned conservative. (Though mid term elections always seem to lose seas for the incumbent party) It is hard to see how starting over is going to help at all. I also agree with Yrs to go, politically has been next to impossible to address many of the cost issues--too many scare tactics and not enough careful thought. It has been very disappointing to watch. Just getting provisions in the bill allowing Medicare to experiment with reimbursement mechanisms has been extremely difficult.

If a pollster asked if I liked the senate bill I would say no. But I also would say we need to pass a bill. My feeling is we need to pass it and work on it after it is in effect. It just is the first step of many. But I sure would like to see some changes made in the bill before it passes.
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Old 01-11-2010, 08:22 AM   #39
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If a pollster asked if I liked the senate bill I would say no. But I also would say we need to pass a bill. My feeling is we need to pass it and work on it after it is in effect. It just is the first step of many. But I sure would like to see some changes made in the bill before it passes.
The big problem is that cost containment is Issue #1, but that requires buy in from a lot of representatives and senators who are in the pocket of special interests (of all sides of the dabate). Doesn't matter whether it's Big Pharma, the insurers, unions, trial lawyers, seniors or any other powerful lobby -- the bottom line is that cost containment requires leaving NO sacred cows and no stones unturned. But as soon as you threaten one of these fiefdoms, it's time to scream bloody murder and watch nothing get done in the sausage-making process.

The net result is a half-baked reform package that avoids seriously infringing on any of these overly-powerful lobbying groups, thus getting the support needed on Capitol Hill to pass something.
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Old 01-11-2010, 09:29 AM   #40
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The net result is a half-baked reform package that avoids seriously infringing on any of these overly-powerful lobbying groups, thus getting the support needed on Capitol Hill to pass something.
And so this time the proponents made an effort to buy off everyone up front. The AMA got a special deal to exempt doctors from cuts for a couple of years and (more importantly perhaps) were assured that the new arrangement would preserve the AMA's very lucrative federally-enforced monopoly on their "medical coding" business. The insurers were bought off with promises of govt-enforced individual mandates and a continuation of the practice of restricting interstate sales of insurance (thus reducing competion and preserving the protected territories of inefficient, high-cost insurers). The proponents of the new health care promised the drug companies that reimportation of drugs would continue to be banned and that they'd get other concessions/protections on prices. All of this was worked out in private away from the inconvenient glare of public scrutiny.

And then a great thing happened: the lawmakers broke their word and some of the sweatheart deals were abrogated. A cry went up among the other plotters and the whole stinking, corpulent compact of special favors and secret deals collapsed in front of everyone. Hooray! There truly is no honor among thieves.
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