Speaking of ACA

[samclem]

We talked earlier about how Germany would not pay more for new drugs that had no better efficacy than old drugs.

This question of drug (or even overall treatment) efficacy is a very complicated one. There are a >lot< of things that can determine whether a particular treatment is valuable for a particular case, it's seldom true that X is never better than Y. The age and sex of the patient, other complicating factors that might rule out the use of a particular drug/procedure, etc. We're now getting to the point that both the genetic profile of the patient and the pathogen/cancer can be used (and work well) in evaluating the treatment options.

Then we have the cost issue: Say we have 2 options:
1) New Treatment X can be expected to give a particular patient a 5 year survival rate of 80%, has minimal side effects, and costs $200K
2) Existing Treatment Y is expected to give a 5 year survival rate of 70%, costs $20K, and has a good chance of serious long-term side effects.

Which one will the committee choose/allow? Which one would I choose for my wife? What if we were paying the whole thing? If we then determine that the government will use the "saved" $180K to provide vaccines and preventative care for 500 children, or save two lives through liver transplants, which option is then the best one?

It ain't simple or easy. Still, that doesn't mean we shouldn't try. I'll be happier when the choices are explicit, clearly explained to everyone, and we can make our decisions based on facts/responsible assessments rather than fear or opaque guidance. People deserve to know where they stand and the basis for decisions that affect them.

 

[NW-Bound]

Yes. Of course the whole thing about how to value healthcare is very complicated.

I cited this example before. Suppose we can spend a) $1M to extend a terminal patient life by 6 months, or b) we can spend $10K to improve the life of 100 people by 1 month.

In case b) we will see a much better improvement in overall lifespan statistics.

I suspect that other countries choose b), while in the US we take a). But again, I have no data, just a suspicion.

PS. One data point I cited earlier: a study showed that cancer patients have a better survival rate in the US than in other Western countries, and it was suggested that it was due to more aggressive treatments in the US.

 

[candrew]

Regarding the extending of life for a terminal patient - and this is not necessarily ACA related, however, I do believe that part of Medicare enrollment should *require* that enrollees have advanced directives in place. According to a Kaiser Family Foundation study, about 4 in 10 Americans ages 65 and older do not have advanced directives or have not written down their own wishes for end-of-life medical treatment.

https://www.kff.org/medicare/fact-s...-role-in-end-of-life-care/#footnote-153315-12

 

[Alan]

I know other countries have at least some element of private insurance. What I don't know is how consumer experience is over there with getting claims paid, getting procedures approved, or dealing with in-network and out-of-network stuff when you use a network facility with a non-network provider in it. (Or, for that matter, if they even have the concept of "networks".)

That is a large part of the frustration with insurance in the USA, I think.

Still, I do think it would be educational to make people realize that yes, not all insurance models are like the NHS, which is truly "socialized medicine" since even the facilities and providers are public (the closest we have here to that would be the VA and the Indian Health Service, I think).

Around 10.5% of the population are covered by private insurance in the UK. Even without insurance many folks can afford to pay out of pocket. Our local private hospital advertises total knee and total hip replacements for an all in price of £8,500 including follow up physiotherapy. Last year our retired friend in Scotland with retiree insurance had the 2nd of his hips replaced. (He had the first one done in 2016 right after he retired)

We have health insurance ourselves which we can use if the NHS waiting list is greater than 6 weeks. It costs each of us £40/month with an annual deductible of £500.

I had outpatient surgery to remove a mole and 2 lesions that could have been cancerous, on the NHS. I also have had multiple visits and a bunch of tests at our NHS cardiac unit followed by Ablation surgery last year. All very timely, and excellent treatment and facilities. With my Ablation surgery my recovery was in a single room with en-suite bathroom.

My wife needed cataract surgery in both eyes, complicated by having had RK surgery in 1988/9. Since the waiting list was over 6 weeks we went private. The costs were as followed for the first surgery;

£380 Surgeon including 2 follow-up appointments, £2,163 Hospital facilities + biometry. Our deductible and total oop was £500. EOBs from the Insurance company were extremely clear and simple to understand.

The second eye was more complicated and required a customized torric lens. The surgeon told her that since she was on his list that he would prefer to do that eye in the NHS hospital since the insurance wouldn’t cover the specialized lens. 10 weeks later she had the 2nd eye done on the NHS.


https://www.internations.org/go/moving-to-the-uk/healthcare/private-health-insurance-in-the-uk

 

[youbet]

. just add people to a system that's working.

But Medicare isn't working all that well financially. It's in a horrible financial state destined to go broke before SS if I recall correctly. Before we add more folks to the rolls, shouldn't we figure out how to sustainably pay for the current scheme?

 

[NW-Bound]

Medicare Part A (hospital coverage) will be solvent until 2026, then will need additional funding of 11%, increasing to 22% in 2043.

Medicare Parts B and D are financed 25% by premium, and 75% by general revenue. By definition, they cannot get insolvent, and just eat up more of the tax revenue.

See: https://www.cbpp.org/research/health/medicare-is-not-bankrupt

 

[MichaelB]

But Medicare isn't working all that well financially. It's in a horrible financial state destined to go broke before SS if I recall correctly. Before we add more folks to the rolls, shouldn't we figure out how to sustainably pay for the current scheme?

If we do choose to expand Medicare I would hope the new entrants fully fund their health care. Of course, I feel the same about current users, but that's another discussion entirely.

 

[GenXguy]

But Medicare isn't working all that well financially. It's in a horrible financial state destined to go broke before SS if I recall correctly. Before we add more folks to the rolls, shouldn't we figure out how to sustainably pay for the current scheme?

And sadly, the premiums are outrageous to get reasonably sufficient coverage with Medicare A, B, D, and supplemental. I think I posted recently to this thread or another that I know couples that are paying over $10,000/yr on premiums. If they're paying less, it's typically because they have some major gaps in coverage. In my FIRE budget, a decade off, I have even more than that allocated to my health care budget because I figure those premiums will go up faster than inflation.

I would like to see some of this financial burden lessened for our most vulnerable citizens - our senior citizens, who have contributed to Medicare and other taxes along with many other contributions to society over a lifetime. They deserve that, and just as we would hope for the same when our generations reach Medicare age.

 

[REWahoo]

And sadly, the premiums are outrageous to get reasonably sufficient coverage with Medicare A, B, D, and supplemental. I think I posted recently to this thread or another that I know couples that are paying over $10,000/yr on premiums. If they're paying less, it's typically because they have some major gaps in coverage.

Interesting. We (early 70's) are paying about half that amount for A, B, D and supplement (Plan N), with no major coverage gaps. Do the couples you reference pay more than most in Medicare premiums due to having a high income?

 

[aiken]

This is another of those no-win threads that sometimes pop up on ER.org and is especially emotional because many here are beneficiaries of ACA subsidies (while at the same time having large retirement portfolios).

Nothing in life is free. There is a cost to having preexisting condition coverage. There is a cost to having community ratings (or a lowest to highest age scale that doesn't reflect cost differentials), and there is a cost to having plans with tons of coverage items beyond catastrophic coverage.
http://www.early-retirement.org/sk/forums/images/editor/separator.gif
All one has to do is to look at one of the states (for example NY) which even pre-ACA had some/most of these features (e.g. community rated).

Way back in 2009 when I retired I looked at health plans in NY State which was community rated, guaranteed issue, no-preexisting condition checks. For a family of three (two adults, one child), I was looking at $25K or more annually for coverage.

Here's the net: Those of you who are getting discounted ACA coverage are doing so on the backs of young healthy individuals and the US taxpayer. Your subsidized costs do not come close to reflecting the actuarial costs (age adjusted) for your plan.

Many here want to blame the insurance companies. While I am not a fan of them, I seriously doubt that is the magical fix to the problem. We have a country of overweight and in general unhealthy people and a system that encourages bad health decisions, along with highly paid doctors and other hospital administrators (and insurance companies). That is why it is possible to go to other countries (e.g. Poland or wherever) and pay "full boat" and yet pay less for medical treatment.

I was going to reply to this thread, but your post summed it up perfectly.

 

[NW-Bound]

People often think of "universal healthcare" as "single payer", and also as "free". But universal healthcare is usually funded by a tax. How else the government gets the money?

In Germany, it's 15.5% of your income, but that includes 7.3% from your employer. In addition you also pay 2.55% for long-term disability care.

If you make above a certain threshold, or fit certain criteria such as being a freelancer, you can buy private insurance. Private insurance premium varies, and may be higher for pre-existing conditions.

I have not been able to find info on healthcare for retirees. Logically, it is the same as that for workers, but I don't know what happens to the employer matching portion.

 

[joeea]

But Medicare isn't working all that well financially. It's in a horrible financial state destined to go broke before SS if I recall correctly.

It doesn't work that way.

Medicare is funded by Congress. It could only go "broke" if Congress chooses not to fund it any given year.

Social Security cannot go broke. At minimum, it will run on the SS taxes collected each year. It could only go "broke" if no SS taxes were collected.

 

[Rianne]

Hot Topic Simplified, IMHO, OP Here

Is Healthcare a privilege, a right or business? Who is healthcare serving? Who profits (by dollars or by services)?

-Shareholders
-Patients
-Providers
-Pharma research
-Medical staff
-Medical equipment
-Medical research


How are we defining The Healthcare Industry? What is the Mission Statement? I consider this the end of this discussion for obvious reasons. We have to get the Mission Statement right. That's all.

 

[NW-Bound]

Healthcare is more and more regarded as a right.

Even so, most (all?) countries still implement some restrictions, as it is a limited resource.

And people with money can usually get more. It's the same as people with money have better housing than Section 8, and eat caviar and lobster that people on SNAP (foodstamp) cannot afford.

 

[Montecfo]

Here's the net: Those of you who are getting discounted ACA coverage are doing so on the backs of young healthy individuals and the US taxpayer. Your subsidized costs do not come close to reflecting the actuarial costs (age adjusted) for your plan.
.

I agree with most of your post but this stood out. All insurance is healthy subsidizing sick. That is how it works.

Our tax system is all about high earners subsidizing low. That is how it works.

We have an income tax, not a net worth tax.

I do understand your point, but it actually is quite complicated and cuts several ways, as I see it.

 

[MichaelB]

Healthcare is more and more regarded as a right.

More like a need that every person has for their entire life.

 

[NW-Bound]

Healthcare is a bit more than a need.

We all need love, recreation, and entertainment, but nobody has suggested that these be provided universally.

 

[ziggy29]

Healthcare is a bit more than a need.

We all need love, recreation, and entertainment, but nobody has suggested that these be provided universally.

Maslow would say it's a "safety need" -- more basic than love, recreation or entertainment, but not as basic as, say, food, water or oxygen.

 

[NW-Bound]

And whether we call it a right or a need, how much should be shared?

Do we force RobbieB to share his caviar and wagyu beef with SNAP recipients?

Hey, I want to share his wagyu beef too. Not the caviar because I do not care for it. I will take double the beef portion to make up for it, thank you.

 

[flintnational]

We also have the ability to build Ferraris. But, we cannot afford to provide them to everyone. I am fairly certain our ability to provide unlimited top shelf healthcare to everyone also exceeds our ability to pay for it. We will need to work out a gatekeeper, someone that says "no". The government, an insurance company or the consumer are all candidates. I don't know that anyone currently has this role.

 

[MichaelB]

We also have the ability to build Ferraris. But, we cannot afford to provide them to everyone. I am fairly certain our ability to provide unlimited top shelf healthcare to everyone also exceeds our ability to pay for it. We will need to work out a gatekeeper, someone that says "no". The government, an insurance company or the consumer are all candidates. I don't know that anyone currently has this role.

Of course, no one suggested ferraris or unlimited top shelf healthcare.

And whether we call it a right or a need, how much should be shared?

Do we force RobbieB to share his caviar and wagyu beef with SNAP recipients?

Hey, I want to share his wagyu beef too. Not the caviar because I do not care for it. I will take double the beef portion to make up for it, thank you.

Are you going to an extreme to make a point or avoid one? Do you disagree that health care is something each of us needs for our entire life, and also the life of the mother before birth?

 

[flintnational]

Of course, no one suggested ferraris or unlimited top shelf healthcare. ...........

But, I think that is what we currently have in many cases. I have not seen a lot of evidence that cost benefit analysis is being conducted. And in some situations, total cost is not even an issue. I agree these are tough decisions.

 

[ShokWaveRider]

Some form of basic affordable healthcare should be available to all. Suppliments should be avialable for those who want more. The basic care should not be so basic, as it allows anyone to go bankrupt.

I believe Australia works on that principle, maybe other countries also.

 

[NW-Bound]

Of course, no one suggested ferraris or unlimited top shelf healthcare.
Are you going to an extreme to make a point or avoid one? Do you disagree that health care is something each of us needs for our entire life, and also the life of the mother before birth?

I made a joke to point out that defining the basic level of need is not simple. I don't think we have been able to do that with healthcare.

For example, can we really afford to spend an unlimited amount of money to extend a human life? But that's what ACA no lifetime coverage limit means.

If we say that, yes, a human life is so precious that there should be no limit in health care for a single person, then why are we letting homeless people die in the street? Why are wrongful death awards not even higher?

It is never that simple. I do not have an answer, and just tried to raise the point.

 

[Aerides]

A lot of the problem with lifetime caps is not because of the craziness that can happen with end of life care, but the start.

Imagine having a child who is born with a defect, that's fixed in surgeries and premie care, who finally leaves hospital at say 3 months old... and they've already burned off their lifetime cap?

I was the recipient of a surgical error decades ago that left my insurance covering above $300k. So, before 30, having burned off a quarter of my cap, wasn't a fun prospect. I always looked for employer plans with providers that didn't have a cap. I'm personally glad they all have to, now.

Obviously anecdotes shouldn't drive policy, but there is something to envy in the idea that, in some countries, no one has to ever worry that a catastrophic illness could result in financial devastation.