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Old 03-09-2017, 04:41 PM   #41
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The Ex-CEO of Aetna on CNBC said selling across state line is not a silver bulletin, but he seemed to imply it might help, but not 100%.
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Old 03-09-2017, 05:38 PM   #42
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I'm just not smart enough to know the answer to that part of the problem.
Me either.

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I avoided subsidy the whole post! Oops.
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Old 03-09-2017, 05:43 PM   #43
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I don't understand how competition between insurance companies can affect premiums much, either. The ACA requires 80% of premiums to be paid out as benefits. That leaves 20% that can be affected by insurance company competition. That 20% includes operating costs and profits. Taken to a ridiculous extreme, assume the insurance companies don't have operating costs or make any profit, the premiums drop 20%. That isn't enough to make premiums affordable for a lot of people.
I understand what you're saying re: insurance costs. As you know, it's the underlying costs of procedures, and the staggering variation in those costs that are the root of the issue. By restricting competition between insurance providers, you help medical providers keep prices high.

Add the trend with hospitals being bought out as the industry consolidates. That removes competitive pricing between hospitals, even across state lines.

Now imagine the extreme cost variance below. If you need a hip replacement in a state/hospital system where it costs $125,000, even if your insurance providers knows it costs $11,000 a state or two away - they can't do anything about it. And we all pay.

Competition across state lines may not be a silver bullet, but it could only help in time. The underlying costs of health care in the US are much higher than all other developed countries, and we don't have better outcomes to show for it. If we don't get at underlying costs, the rest won't make it more affordable.

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Here's an experiment. Call up dozens of hospitals all over the country. Tell them your grandmother needs a hip replacement and ask: How much will it cost? The answers are stunning. If you can manage to get an answer, it might range anywhere from $11,000 to 125,000. This very experiment was described in an article published online yesterday by the Journal of the American Medical Association, the Internal Medicine edition.
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Old 03-09-2017, 06:48 PM   #44
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I understand what you're saying re: insurance costs. As you know, it's the underlying costs of procedures, and the staggering variation in those costs that are the root of the issue. By restricting competition between insurance providers, you help medical providers keep prices high.

Add the trend with hospitals being bought out as the industry consolidates. That removes competitive pricing between hospitals, even across state lines.

Now imagine the extreme cost variance below. If you need a hip replacement in a state/hospital system where it costs $125,000, even if your insurance providers knows it costs $11,000 a state or two away - they can't do anything about it. And we all pay.

Competition across state lines may not be a silver bullet, but it could only help in time. The underlying costs of health care in the US are much higher than all other developed countries, and we don't have better outcomes to show for it. If we don't get at underlying costs, the rest won't make it more affordable.
Well, I did mention cost of services is one of the big problems, in the paragraph you snipped.

I don't see how allowing insurance companies to offer policies across state lines (which has been allowed in a limited fashion by the ACA since January 2016) can induce competition between medical providers in different states.
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Old 03-09-2017, 06:57 PM   #45
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Which provision is this? Do you have a link?
They have to do it in mulitiple parts and the first is the "easy" one. In the others they need 60 votes.

http://www.msn.com/en-us/news/politi...zlr?li=BBnb4R7

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Sure, Republicans would like to do it all at once — peeling off this section of the Band-Aid has been painful enough. But they can't. That's because of a special budget rule called reconciliation, which forces them to make a decision: undo some of Obamacare with a simple majority vote in both chambers, or undo all of it and face a 60-vote majority threshold — a majority Republicans don't have and won't get — in the Senate.
<snip>
The ability to buy insurance across state lines, an attempt to lower drug prices and malpractice liability protections for health-care providers, “can't be done through this current bill,” Trump press secretary Sean Spicer acknowledged this week.
<snip>
Ryan outlined three phases in which health-care reform would be achieved: first, via the special budget procedure known as reconciliation, of which the current measures are a part; then, through regulations at the Department of Health and Human Services; and finally, the passage of other bills that will need bigger backing and could include the ability to buy insurance across state lines.
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Old 03-09-2017, 08:04 PM   #46
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............ By restricting competition between insurance providers, you help medical providers keep prices high.................
Is this true? I was under the impression that bigger insurance companies could bargain harder for lower prices. It would seem that many small insurers each would have little leverage against a big medical system.
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Old 03-09-2017, 08:06 PM   #47
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I'm trying to run the numbers for DW and I

Current ACA plan is 1103 a month or 13236 a year. We are over the cutoff by about $19k - pesky LTCG at end of year gets us.

If I divide the current premium by 3 and then multiply by 5 it becomes 1838 a month.

Multiply that by 12 and then subtract the new tax credit - the result is 14560

So the yearly cost goes up 1326

I guess this is the worst case scenario.

Has anyone else ran their numbers?

Frankly if they kept the current ACA plan and did the HSA enhancements that would work out pretty well.
I think you've actually identified one of the best case scenarios here, because your numbers are predicated on the young person's premiums remaining the same as what they pay now. A worse case is that rates go up substantially due to decreased regulation or fewer healthy people buying insurance. For every $1 that the young person's premium increases, yours can go up $5. A $100/mo increase at the lower end of the scale could add up to $500/mo or $6K/yr on top of that $1326.
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Old 03-09-2017, 10:05 PM   #48
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I don't understand how competition between insurance companies can affect premiums much, either. The ACA requires 80% of premiums to be paid out as benefits.
I 100% agree that the big driver of HI cost is the underlying cost of care. But insurers can affect the cost of care, and increasing competition among insurers can induce them to help reduce care costs.
Imagine there's one insurer in a market, and lots of medical care providers. The insurer has very little incentive to drive down the underlying cost of care--the insurer effectively gets a 20% "commission" on top of whatever the medical costs are. They can charge higher premiums if MRIs cost $500 than if they cost $100. And they can pass it all on to policyholders, who have no choice but to pay it. But if there's competition between insurers, the insurers have a reason to get a good deal on the MRI, knee replacements etc because customers will be shopping among many insurers in a competitive marketplace for the best value. So the insurers will seek to get the best value, too.
The market can work, but I have big concerns that enough info will be available to consumers, in a readily digestible manner, to allow competition to work.
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Older Americans may have to postpone retirement under New health bill
Old 03-09-2017, 10:47 PM   #49
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Older Americans may have to postpone retirement under New health bill

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The three elements of health care are
Universal
Accessible
Affordable
No country has gotten more that 2 of the three. Why do Canadians come across the border? because they do nt want to wait to get treated


I have spent time in Canada. That's way overblown. The vast majority of Canadian's love their healthcare system and in fact have greater satisfaction with their care. Also the Canadian med system is proven to have less mis- diagnoses and lab errors. Emergency care and routine care wait times are only slightly longer (days) while appointments for specialists for elective procedures can take 4 weeks or longer. Very few Canadians travel south in actuality for care in the US. They truly laugh at our health care system in comparison to theirs. They like the Netherlands have 3 out of 3 of the above criteria pretty close. I am pretty sure there are more, but those more well traveled will weigh in is my guess.
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Old 03-09-2017, 10:52 PM   #50
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From the article: "Given that possible change, experts say pre-Medicare workers are likely to stay in their jobs longer to keep their employer-sponsored health insurance, even though they may be ready to retire in other ways financially and emotionally, for instance to retire."

This is the first time I have ever heard/read that someone might need to be emotionally ready to retire. I think I was emotionally ready to retire at 18. I just didn't have the money.


I don't read that as either financially or emotionally, but literally as written: "financially AND emotionally", which I believe you have to be both, or your not qualified.
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Old 03-09-2017, 11:21 PM   #51
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I've said multiple times, the ACA was not in existence a few "short" years ago, yet people figured out how to ER.

I'll be more blunt. If you can't make a plan to ER without counting on other peoples money in the form of "subsidy", then you need to go back to FIRECALC, and build another plan.


Yes they did, but with healthcare costs projected to be 10%-50% of your annual expenses to worry about via either COBRA ( appropriate name : snake that will slowly kill you) or previous open market insurance ( no online state sponsored comparison shopping) most had to wait til 65 even if all other finances were in line. Then with the onset of the ACA came more affordable healthcare for those not yet Medicare eligible. This created a notable spike in early retirees from 2012 until the present. There were entire groups on this board that all ER'd solely after having that piece of the equation resolved.
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Old 03-09-2017, 11:35 PM   #52
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I have spent time in Canada. That's way overblown. The vast majority of Canadian's love their healthcare system and in fact have greater satisfaction with their care. Also the Canadian med system is proven to have less mis- diagnoses and lab errors. Emergency care and routine care wait times are only slightly longer (days) while appointments for specialists for elective procedures can take 4 weeks or longer. Very few Canadians travel south in actuality for care in the US. They truly laugh at our health care system in comparison to theirs. They like the Netherlands have 3 out of 3 of the above criteria pretty close. I am pretty sure there are more, but those more well traveled will weigh in is my guess.
They are also 10% the size of the USA. Add another 300 million people to their system and see how they do.
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Old 03-09-2017, 11:49 PM   #53
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They are also 10% the size of the USA. Add another 300 million people to their system and see how they do.


Not sure. I was in Toronto at the time. You know, the 3rd largest city in North America with almost 3 million in city limits and 8.7 million in greater Toronto. Yeah that little berg.
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Old 03-09-2017, 11:51 PM   #54
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They are also 10% the size of the USA. Add another 300 million people to their system and see how they do.
You mean adding economies of scale won't help make it even cheaper?
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Old 03-10-2017, 07:01 AM   #55
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I 100% agree that the big driver of HI cost is the underlying cost of care. But insurers can affect the cost of care, and increasing competition among insurers can induce them to help reduce care costs.
Imagine there's one insurer in a market, and lots of medical care providers. The insurer has very little incentive to drive down the underlying cost of care--the insurer effectively gets a 20% "commission" on top of whatever the medical costs are. They can charge higher premiums if MRIs cost $500 than if they cost $100. And they can pass it all on to policyholders, who have no choice but to pay it. But if there's competition between insurers, the insurers have a reason to get a good deal on the MRI, knee replacements etc because customers will be shopping among many insurers in a competitive marketplace for the best value. So the insurers will seek to get the best value, too.
The market can work, but I have big concerns that enough info will be available to consumers, in a readily digestible manner, to allow competition to work.
Ok, I can see the insurers possibly affecting the 80% portion if they can negotiate lower prices from medical providers.

I agree with your last point, price transparency is a big problem. Whenever my doctor recommends a test or procedure, I ask for a price quote, and it can take a few weeks to get it.
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Old 03-10-2017, 07:26 AM   #56
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Ok, I can see the insurers possibly affecting the 80% portion if they can negotiate lower prices from medical providers.
.............
But the negotiated price between the insurer and the medical provider depends on agreement on both sides. What is the incentive for a very big hospital system to give much of a break to a tiny insurer, who may even be out of state? It seems to me that some insurer competition is good, but there needs to be a match in bargaining power between the insurer and medical provider to drive down prices.
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Old 03-10-2017, 07:32 AM   #57
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I 100% agree that the big driver of HI cost is the underlying cost of care. But insurers can affect the cost of care, and increasing competition among insurers can induce them to help reduce care costs.
./.
The market can work, but I have big concerns that enough info will be available to consumers, in a readily digestible manner, to allow competition to work.
"Free market" economics do not apply to health care. We know this, Kenneth Arrow was awarded the Nobel Prize for economics when he demonstrated it.

The more extensive coverage and lower cost of health care among other developed OECD countries (Euro Area, Japan, Australia, Canada) is not the result of a "free market" approach, it is the outcome of a heavily regulated approach where all the constituents share common objectives. In the US this is not likely to happen, as the participants have defined objectives that are not compatible with each other. There is no example in the world of a large diverse free market in health care that is extensive and cost effective.

Back to our health care proposals, insurers are not required to offer insurance everywhere to everyone. They are free to pick and choose where to sell. Insurers and providers have put in place a multi-tiered pricing system that discriminates against the individual consumer and forces the consumer to use the insurer as a price intermediary. This is (continues to be) a major disadvantage for the consumer, who is forced to use an insurer, while the insurer has no reciprocal obligation.

It looks as if the problem of insurers leaving some markets around the country will continue, and health care providers will continue to price as aggressively as they can, uninterrupted and undeterred.
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Old 03-10-2017, 07:36 AM   #58
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Many years ago, we overheard a conversation between several high school aged girls.

"I work with an older woman at <clothing store>. She is sorta different, but I guess she is OK."

"How old is she? She sounds nice."

"Oh, she's old, probably something like 28."
Yep, it's all relative, isn't it? Compared to Methuselah, we are all rookie greenhorns...
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Old 03-10-2017, 08:07 AM   #59
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What is the incentive for a very big hospital system to give much of a break to a tiny insurer, who may even be out of state?
Not much. I just said I could see it possibly affecting the cost, I didn't say it would drive costs to affordable levels. I agree that the impact is likely to be low.
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Old 03-10-2017, 09:21 AM   #60
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I also agree that both the ACA, and the new proposal are WAY too focused on paying for premiums through "breaks" of some kind, rather than cost control.
I agree. Focusing just on premiums is not getting to the root of the issue.

There are things that can be done. What are the Canadians doing that allows them to get Rx drugs so much cheaper? I think we know that answer to that, so let's implement it.

A friend was in India a few years ago. Her traveling companion had broken an arm so they went to the hospital. They spoke to a Harvard Med School trained doctor. He worked on her friend's arm then asked if either of them had any other problems. My friend mentioned a shoulder issue that had plagued her for years. They did an MRI and he diagnosed some small problem in the shoulder - total cost for for the MRI and consultation was $65!!

Ok, India is a far less expensive third world country. But, Belgium isn't.

I think most of us know about the guy in the NY Times article who had a hip replacement done in Belgium. He was looking at a $78,000 bill in the NY.

Quote:
he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.
http://www.nytimes.com/2013/08/04/he...pagewanted=all

Or this:

http://www.nytimes.com/2013/08/07/us...-overseas.html

Quote:
Services like MediBid allow patients to shop online for lower-priced medical care, whether local or in another state. Ralph Weber, the chief executive of MediBid, said the service recently sent a patient to Glendale, Calif., for a hip replacement for $14,450 and another to San Antonio for $19,000 — comparable to European rates.
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