Speaking of ACA

[sengsational]

The idea would be something that would get the ball down field just a bit. Just a short running play to get closer to the first down. Hail Mary plays look less likely to succeed, so keeping it on the ground might be a strategy worth a look.

 

[ziggy29]

I view my annual ACA deductible as more of a cap on my share of a large, catastrophic event, such as my 12-day hospital stay 4 years ago this month. The bill was for $80k but the deductible and cap on OOP expenses from covered services limited me to about $6,400. If that cap were $7k or $8k (as it has risen to now), I'm not terribly troubled.

Personally, we're in a similar boat. Though I am no longer on an ACA policy, as long as it was a one-off in a bad year hitting my OOP max, the high deductible was not something that would have busted us. But as has been said before, the members of this board are not representative of the general public. There are a lot of people who won't go to the doctor when they have a problem because they are afraid of (say) a $200-$500 bill they can't afford, even if they have insurance and those are lower, negotiated rates. And then a small problem turns into a really big one because they couldn't afford to nip it in the bud, so to speak.

There is a huge segment of the population for which a $6,400 bill would be devastating, and a lot wouldn't be able to pay it at all (which the rest of us end up paying for anyway, albeit indirectly).

 

[samclem]

The idea would be something that would get the ball down field just a bit. Just a short running play to get closer to the first down. Hail Mary plays look less likely to succeed, so keeping it on the ground might be a strategy worth a look.

That might be all we can do (just due to the nature of our system/decisionmaking process). Obviously, it presents the problem of "crossing a chasm in two hops"--some very attractive approaches are just off the table if they can't be done all at once.

Another idea is the "50 individual state laboratories" approach. Obviously, it has limitations (especially due to incentivizing population flows of sicker folks to high payout states). But a solution that Texans want might not sit well in California, so making the decisions closer to home lets a smaller group of voters get what they want and experience the results. Maybe a consensus will emerge, or at least a structure that different locations can modify to suit.

 

[NW-Bound]

...
And then there are economic ripple effects as well. There are a lot of factors that need to be considered below the headline of "what it would cost", because there are a lot of costs in the current system that would go away. Whether that would ultimately cost more or less than the current model, I can't say, but opponents of it have done a good job of preventing people from thinking about all the areas in which there would be cost savings to offset the direct cost of universal single payer.

Medicare for all would cause a huge change, no doubt, and affects everybody, from individual consumers to service providers and employers.

Some countries still have a supplemental network of private health insurers, such as Germany and Switzerland. I understand that even some provinces in Canada such as BC have supplemental private insurance.

I am no expert, but don't see that universal healthcare means single-payer. That is not true with many countries. Nor do they eliminate private insurers.

 

[ziggy29]

I am no expert, but don't see that universal healthcare means single-payer. That is not true with many countries. Nor do they eliminate private insurers.

I actually meant to say "universal / single payer", implying one, the other, or both. The German model certainly keeps private insurance in the mix, and I think the French model does as well. Even before the universal mandate was stripped out of it, the ACA was not a true universal model since it required opting in by signing up (i.e. people were not covered if they did nothing to make it so).

 

[NW-Bound]

The impression I have is that many people still equate universal healthcare with single-payer.

I used to have this misconception too.

PS. The distinction is important. American public is leery of single-payer. It would be more open to universal healthcare. And it is important to know that Germany and many other countries do not have a single-payer system.

 

[ShokWaveRider]

The impression I have is that many people still equate universal healthcare with single-payer.

I used to have this misconception too.

PS. The distinction is important. American public is leery of single-payer. It would be more open to universal healthcare. And it is important to know that Germany and many other countries do not have a single-payer system.

I am sad to say you are spot on here, and it reflects poorly on the American populous' understanding of the systems, and the lack of an attempt to do so. It also reflects even more poorly on our leaders (All Sides) portrayal of it. They are solely responsible for using terms like Socialized, Single Payer, Medicare for all etc., instead of using and sticking to Universal Healthcare, and pounding it's meaning and benefits into the populous at every opportunity till they finally get it.

 

[MRG]

+1

There is much ignorance and misinformation just on the names. Sad. I remember a poll of folks who were happy with ACA but hated Obamacare(or the other way around). Our population is sadly under-educated and confused by basic terms.

I am sad to say you are spot on here, and it reflects poorly on the American populous' understanding of the systems, and the lack of an attempt to do so. It also reflects even more poorly on our leaders (All Sides) portrayal of it. They are solely responsible for using terms like Socialized, Single Payer, Medicare for all etc., instead of using and sticking to Universal Healthcare, and pounding it's meaning and benefits into the populous at every opportunity till they finally get it.

 

[ziggy29]

There is much ignorance and misinformation just on the names. Sad. I remember a poll of folks who were happy with ACA but hated Obamacare(or the other way around). Our population is sadly under-educated and confused by basic terms.

Not to mention that I know people who rail against "socialized medicine" and "single payer" who either love Medicare (if they are 65+), or are looking forward to getting on Medicare (if not yet 65). There's some serious cognitive dissonance there.

Still, it is telling about the state of health care in the USA when Medicare has become the platinum standard.

 

[NW-Bound]

Perhaps our "highly esteemed" leaders from both sides do not understand how other countries' systems work, or they do but present their own interpretation to steer towards their own agenda.

Witness how people often blame the insurance companies for our healthcare cost. They obviously do not know European countries still have health insurers.

 

[ziggy29]

Witness how people often blame the insurance companies for our healthcare cost. They obviously do not know European countries still have health insurers.

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).

 

[scrabbler1]

+1

There is much ignorance and misinformation just on the names. Sad. I remember a poll of folks who were happy with ACA but hated Obamacare(or the other way around). Our population is sadly under-educated and confused by basic terms.

Remember this little gem, from Jimmy Kimmel? Yes, we don't know how it was edited, and how many of those interviewed knew they were the same but didn't make into the clip.

 

[copyright1997reloaded]

Thanks, Ziggy. scrabbler, choose any word you want. Approach, strategy, tactics, blueprint, process.

Health insurance is something every single person requires from before conception (needs a healthy mother) to death, without exception. The risk pool is the entire universe. This is unique to health insurance and not the case in any other type of insurance.

Large group insurance does not segment by age, it requires enrollment of the entire universe and applies one single risk assessment. Community rated Medicare does the same. This insurance is pricey but costs the same for everyone and works well.

US individual and small group health insurance is built on a model of exclusion. Prior to the ACA, it simply excluded some individuals. It still does, by selling products to some residents (groups, seniors) and not others (individuals) in the same geography.

Age based segmentation is a practice that allows insurers to define a segment that excludes most people but allows them to offer an artificially low price for one segment where they want to compete. This effectively makes their product unaffordable to the other segments, so demand is low, which is totally acceptable to the insurers. It's a design point.

All this segmentation allows the insurers to pick apart the market to select and sell where they want to, even though the need is universal. It is a destructive force. Employer large group and Medicare, which cover more than 1/2 the coutry, show that age segmentation is not needed.

So it is a scheme in the negative sense, correct?

I know you've posted on several occasions that large group insurance is the way to go. Hopefully, you realize that the biggest example of this, employers, recognize that their employee health care cost rise as their employees age. I know it isn't legal, but certainly no one here would be surprised about employers trying to get rid off (RIF, move out, whatever term you want to use) older employees who have higher costs and also may have increased absences from the work place. Could this also be a factor in terms of how much harder it is for a 50+ person to get a job with healthcare? Nah, I guess it is just my cynical self thinking that.

My point is that there can be unintended and not so much up front factors that result from these kinds of policy decisions.

But me thinking of me? I want (am better off with) community (group) rated policies, that don't vary based on health, pre-existing conditions, age, etc. Why? From the age of 20 to about the age of 45 I used pretty much zero in terms of health care costs, sick time, etc. Now? Not the same - a couple medications, two operations in the past 6 years, etc.

 

[copyright1997reloaded]

Asking for a friend

Asking for a friend: Would those of you who are on Medicare be OK if "Medicare for All" meant that you could no longer be allowed to have a Medigap plan or other secondary insurance (e.g. ex employer as secondary)?

As can be seen by this discussion, the "individual mandate" (i.e. the requirement to participate) is both a factor in whether a program can leverage overpaying by the young/healthy to support underpaying by the old/sick and also a issue to those who want choice.
.

 

[DatumPoint5]

I would like to push for lowering the age of eligibility for Medicare to maybe 60 and then if all goes well, then to immediately lower it to 55. As someone in this thread mentioned, it "already works" and one of the things I like about the idea, is that an awful lot of people would quickly retire and "open the door" for someone else to fill their vacant position.

There are MANY individuals that I know who are just doing OMY because most can't afford the current cost of healthcare. Give these individuals access to healthcare, and they will immediately retire, and then people "waiting in line" will get a job and pay taxes and "buy stuff" and move the economy ever forward..... Doing this would not only solve a very complex and large social healthcare issue, but, it will initiate and perpetuate a "Circle of prosperity" for every US citizen!!!!!

 

[ShokWaveRider]

Overpaying by the young/healthy to support underpaying by the old/sick and also a issue to those who want choice.
.

This is not a valid statement. The young can get sick too, are more likely to have auto, motorcycle and sporting accidents than the old. So a semi serious accident could cost $500k to treat. So they are not over paying at all, just paying their fair share. To allow them not to do so is defeating the insurance model and putting a heavier burden on the Tax Payers to fund the differences.

 

[DatumPoint5]

I forgot to give credit for my "Circle of prosperity" quote to the individual who I first heard it from - "Robert Reich" who is currently the Professor of Public Policy at the Goldman School of Public Policy at UC Berkeley since January 2006. He was formerly a professor at Harvard University's John F. Kennedy School of Government and professor of social and economic policy at the Heller School for Social Policy and Management of Brandeis University.

 

[Dtail]

I would like to push for lowering the age of eligibility for Medicare to maybe 60 and then if all goes well, then to immediately lower it to 55. As someone in this thread mentioned, it "already works" and one of the things I like about the idea, is that an awful lot of people would quickly retire and "open the door" for someone else to fill their vacant position.

There are MANY individuals that I know who are just doing OMY because most can't afford the current cost of healthcare. Give these individuals access to healthcare, and they will immediately retire, and then people "waiting in line" will get a job and pay taxes and "buy stuff" and move the economy ever forward..... Doing this would not only solve a very complex and large social healthcare issue, but, it will initiate and perpetuate a "Circle of prosperity" for every US citizen!!!!!

I like the quote and concept. I wonder if it would work in reality, but it would be interesting to see.

 

[USGrant1962]

I would like to push for lowering the age of eligibility for Medicare to maybe 60 and then if all goes well, then to immediately lower it to 55. As someone in this thread mentioned, it "already works" and one of the things I like about the idea, is that an awful lot of people would quickly retire and "open the door" for someone else to fill their vacant position.

There are MANY individuals that I know who are just doing OMY because most can't afford the current cost of healthcare. Give these individuals access to healthcare, and they will immediately retire, and then people "waiting in line" will get a job and pay taxes and "buy stuff" and move the economy ever forward..... Doing this would not only solve a very complex and large social healthcare issue, but, it will initiate and perpetuate a "Circle of prosperity" for every US citizen!!!!!

But would this expansion be "free" (which really means paid for by someone else)? Or would it be a buy-in for $12,000/person per year? The later is more expensive than even ACA.

 

[ziggy29]

But would this expansion be "free" (which really means paid for by someone else)? Or would it be a buy-in for $12,000/person per year? The later is more expensive than even ACA.

True. Maybe opting into Medicare through the Exchange could have been the “public option”, at whatever the cost is for delivering Medicare to someone of that age minus whatever subsidy they qualify for. The insurers want no part of this, of course.

 

[copyright1997reloaded]

This is not a valid statement. The young can get sick too, are more likely to have auto, motorcycle and sporting accidents than the old. So a semi serious accident could cost $500k to treat. So they are not over paying at all, just paying their fair share. To allow them not to do so is defeating the insurance model and putting a heavier burden on the Tax Payers to fund the differences.

I, and others, have already posted that ACA plans have a limit on age-based premium differences. The law limits the spread from a 21 year old to 64+ to 3:1.

Yes, the young *can* get sick, and *are* more likely to have an accident. That is irrelevant in terms of the overall numbers when you take the population as a whole.

I stand by my statement: The young/healthy subsidize the old/sick in terms of ACA plan costs.

OK, here's more: https://www.healthsystemtracker.org/chart-collection/health-expenditures-vary-across-population/#item-people-age-55-and-over-account-for-over-half-of-total-health-spending_2016

And here is the underlying table of cost by age:
X.1 Share of Population Share of Spending
65 and over 16 36
55 to 64 13 20
45 to 54 13 13
35 to 44 12 10
19 to 34 22 11
Under 19 24 10

So 56% (over half) of ALL health care costs are due to people aged 55+.

Note that this table is just showing share of cost. Here is a table (as of 2017) of the USA population by age:
Location United States
Children 0-18 0.24
Adults 19-25 0.09
Adults 26-34 0.12
Adults 35-54 0.26
Adults 55-64 0.13
65+ 0.16
Total 1

So, 55+ adults make up 29% of the population, but use 56% of all healthcare costs. That would be a 1.93 ratio (HC%/Pop%). Adults 19-34 make up 21% of the population, but use 11% of the healthcare costs. That would be a 0.52 ratio. The comparison of the two is 1.93/0.52 = 3.71.

So, adults 55+ should be paying 3.71X the rate of age 19-34 adults.


I know this is an emotional subject for us here on FIRE as we are in general older. But the data is the data. (Even within the 65+ population, health care spending is concentrated. About 10% of those in that age bracket make up 50% of age 65+ health care costs.)

 

[NW-Bound]

But would this expansion be "free" (which really means paid for by someone else)? Or would it be a buy-in for $12,000/person per year? The later is more expensive than even ACA.

As mentioned earlier, Medicare cost is $12,353 per person in 2018, and the premium paid by retirees only covers 15% of that.

ACA premium is less than the above even when unsubsidized, but then ACA people are younger than 65.

 

[copyright1997reloaded]

True. Maybe opting into Medicare through the Exchange could have been the “public option”, at whatever the cost is for delivering Medicare to someone of that age minus whatever subsidy they qualify for. The insurers want no part of this, of course.

The ability to "opt-in" brings up interesting actuarial issues. Let's say the overall cost per person in the existing pool is $12k/year. (Source: NW's post). One would expect the overall age 60-64 population to have lower costs, but if this was an "opt-in" pool it would not reflect the overall age 60-64 population (it would likely be higher cost).

This is the major issue with opt-in strategies, and is the reason why the individual mandate was necessary on the ACA.

 

[NW-Bound]

... 55+ adults make up 29% of the population, but use 56% of all healthcare costs. That would be a 1.93 ratio (HC%/Pop%). Adults 19-34 make up 21% of the population, but use 11% of the healthcare costs. That would be a 0.52 ratio. The comparison of the two is 1.93/0.52 = 3.71.

So, adults 55+ should be paying 3.71X the rate of age 19-34 adults...

Earlier, I mentioned that when I dropped the coverage for my two children when they finished college, I saw only a bitty reduction of the premium of my pre-ACA policy.

That factor of about 1/4 sounds about right.

Now, for an entire nation, it still makes sense to have the young subsidize the old somewhat, because people will all eventually get old and enjoy the benefit. That's how corporate insurance works. That's how Medicare has always worked.

 

[LRDave]

I forgot to give credit for my "Circle of prosperity" quote to the individual who I first heard it from - "Robert Reich" who is currently the Professor of Public Policy at the Goldman School of Public Policy at UC Berkeley since January 2006. He was formerly a professor at Harvard University's John F. Kennedy School of Government and professor of social and economic policy at the Heller School for Social Policy and Management of Brandeis University.

I like the concept and generally agree with the thinking of Robert Reich.

I don't think the U.S. workforce could fill all those openings in its current configuration. In my former company, one of the top 2 or 3 risks as discussed by the management team was the oldun's making a mass exodus and being unable to effectively fill those positions for many years. I was part of those discussions. I whistled and stared at the ceiling....