Second installment on ACA for those that like to read tea leaves...

[pb4uski]

.... According to the chart in the article below Alaska is on the high end for health insurance costs so if you can live anywhere maybe that isn't your best choice of states?

10 Best and Worst States for Health Insurance Costs | The Huffington Post

I'm not sure that this Huffington Post article is useful. Who buys silver plans? I can see it if you have health issues but if you're healthy then bronze plans are much more affordable and you can upgrade to a silver plan if you later need to.

 

[samclem]

Who buys silver plans?

I think they are popular among households with low incomes. IIRC, the only way to get the govt subsidies for medical care expenses/OOP is with a silver plan. These subsidies are in addition to the subsidies to help cover the insurance premiums.

 

[Senator]

A bit off topic but this idea of letting people buy health insurance across state lines gets tossed around a lot, really annoys me.

Offering insurance in a state requires the hard work of negotiating with hospitals and doctors to set up a network of providers. An insurer can negotiate good rates if it has a big base of customers, but it needs good rates to build up a big base of customers. Insurers leave a state altogether if it can't overcome this catch-22. That's why you can't just buy health insurance from an out-of-state insurer who doesn't have a network in your state.

Letting people buy insurance across state lines will only cause all the insurers already in your state to elect to be regulated by a different state, likely one with the most anti-consumer insurance commission.

All they have to do is mandate that federal regulators regulate the healthcare insurers, not the state. Similar to the way the ACA does now.

And then, offer the big carrot. Anyone can buy the insurance no matter what state they are from, or the company cannot sell insurance at all. Different states may have different premium costs, or not. With a USA market, they could have flat rate pricing across all states.

 

[explanade]

Will never happen.

They can't even have one market in CA, because Southern CA generally have more hospitals per capita so the rates there are lower than they are in Northern CA.

Now try to work out these difference across the nation.

Hospitals don't have incentives to be on every network either, it seems. Especially the newer hospitals that everyone ones to use -- the management of those hospitals will demand higher rates, which means only certain insurers which will charge higher premiums.

Anyways, states regulate all other forms of insurance, like auto, home, etc. It may not be that easy to take away their power for just health insurance.

Not to mention, a lot of state legislators depend on contributions from insurance industry. So they probably won't give up their power easily to the feds.

 

[Texas Proud]

I was inferring that if you pay less than the 20% of your income on Health Care, you are getting a bargain.

Not really... the cost are very skewed to the old and sick...


End of life costs are pretty high here.... with little to prevent spending that is not cost effective.... IOW, should 'society' pay $1 million to keep you alive another 6 months? If so, what about 3.... or 1.... some will say sure, others would say it is a waste....

 

[NW-Bound]

Not really... the cost are very skewed to the old and sick...

End of life costs are pretty high here.... with little to prevent spending that is not cost effective.... IOW, should 'society' pay $1 million to keep you alive another 6 months? If so, what about 3.... or 1.... some will say sure, others would say it is a waste....

There are many factors, but I suspect the above is a major one. We can spend a lot of money there, without much to show in the statistics of expenses vs. longevity, what people always like to quote.

I am really curious to know how other developed countries deal with this.

 

[Senator]

Not really... the cost are very skewed to the old and sick...


End of life costs are pretty high here.... with little to prevent spending that is not cost effective.... IOW, should 'society' pay $1 million to keep you alive another 6 months? If so, what about 3.... or 1.... some will say sure, others would say it is a waste....

True, but overall, if a person paid 17.2% (or 20%) of all their earnings, from day one that would be what it costs for a revenue neutral healthcare system with today's systems and pricing. I am not trying to say what is 'fair', just trying to get a perspective.

Is that what it means when we say the USA spends 17.2% of it's GDP on healthcare. Or maybe it is a 17.2% of what is spent, not earned?

It would seem that if half the people only spend 8.6%, the other half need to spend 25.8%.

 

[Senator]

Will never happen.

They can't even have one market in CA, because Southern CA generally have more hospitals per capita so the rates there are lower than they are in Northern CA.

Now try to work out these difference across the nation.

Hospitals don't have incentives to be on every network either, it seems. Especially the newer hospitals that everyone ones to use -- the management of those hospitals will demand higher rates, which means only certain insurers which will charge higher premiums.

Anyways, states regulate all other forms of insurance, like auto, home, etc. It may not be that easy to take away their power for just health insurance.

Not to mention, a lot of state legislators depend on contributions from insurance industry. So they probably won't give up their power easily to the feds.

You just have to have a different way of looking at things. One price for all states, anyone can use any hospital, as they are all in the same network. A primary care Dr would make decisions. Go to the earliest available appointment at the nearest hospital.

All costs are reimbursed to each hospital the same. Eventually, it would even out. Hospitals would leave high expense areas or become more efficient. Places that hospitals leave would become lower COL areas as they are further from medical facilities.

We have one price for income taxes no matter what the COL is. Healthcare premiums could be the same. And they could be taken right out of a person's paycheck, like medicare.

 

[sengsational]

I think there are 2 main problems with the language you quoted. First, simply not paying for the insane ER prices doesn't solve the problem. Hospitals can and do sue for balances due particularly if someone may have money to pay it. That can lead to a medical bankruptcy and is not something I want to expose myself too either.

The other thing that I think many no insurance people miss is that many things that require expensive care are not the type of thing that get treated in the ER. The ER is not going to pay for your expensive chemotherapy for example.

It was intended to be a bit tongue in cheek (not paying ER), but it still retains some reality. The hospital sells the debit to a collection agency. When they realize you won't pay, they get a judgement against you. But retirement assets are all some folks have, and home equity (which could be siphoned off if needed). They'd have a heck of a time getting any money out of some determined people.

Yes, if you got kicked out of the ER, it would be a pain to fly down to Panama, but it might be an interesting adventure too. As to chemo, you probably would feel like crap and want to be in your own bed, but if it meant bankruptcy, one may wish to define ones own bed as one in a place wherer you could live like a king, fly family down for visists, have multiple servants including a personal chef, plus world class healthcare, for a fraction of the cost of slogging along in your current abode.

 

[Katsmeow]

As to chemo, you probably would feel like crap and want to be in your own bed, but if it meant bankruptcy, one may wish to define ones own bed as one in a place wherer you could live like a king, fly family down for visists, have multiple servants including a personal chef, plus world class healthcare, for a fraction of the cost of slogging along in your current abode.

And sometimes time makes a difference. Getting diagnosed with cancer and deciding to move to a foreign country is a major undertaking. Even if fully willing to do it, there are things like figuring out which country, finding a good provider in that country, getting the money to pay for it and having it available in that country, finding a place to live, etc. All of that takes time and in the meantime the cancer is marching on. And all of that is assuming you still feel well and are chipper and able to manage all of this. For many illnesses that simply isn't the case.

Basically, yes, I would do that if I had to do it. But, I would rather find a solution in advance that wouldn't involve upturning my life in the middle of a health situation (and even the cancer situation doesn't deal with a situation where there is something that needs way beyond ER available care, but needs immediate treatment and can't wait for you to relocate).

I do know that if I had insurance through ACA and I found out I wouldn't be able to get insurance in my state in the event of repeal, I would most likely move to a state where I could get insurance (assuming availability).

 

[NW-Bound]

You just have to have a different way of looking at things. One price for all states, anyone can use any hospital, as they are all in the same network. A primary care Dr would make decisions. Go to the earliest available appointment at the nearest hospital...

I wonder how we can motivate a surgeon to do better than his peers, if he gets paid the same no matter what he does. And if he is better, but does not cost more, he will be all booked up, and who would want to go to a less skilled surgeon for the same price?

I don't think decamillionaires and centimillionaires, let alone billionaires, want to go to the same hospitals as everyone else. They will have their own private healthcare, while the rest of us share the same semi-public facilities.

I wonder how it all works in other countries. The devil is always in the details.

 

[samclem]

If healthcare is 20% of the economy, would that imply that in a perfect world everyone would pay 20% of their income on healthcare?

Or is my analysis incorrect?

Not quite correct. GDP is higher than the sum of all personal income. GDP is the sum of the value of all goods and services produced in the country. Obviously, if we think of the simple case of a business, the value of the goods sold at a McDonalds in one day is going to be less than the money paid to the workers there (otherwise, nobody would run a business). It's the same for the raw materials used by the McDonalds--the frozen meat, shake mix, etc--everything they bought had a value higher than the total labor cost that went into making it.

More here. It's pretty complicated, and the more I look into it, the more tangled the ball becomes. For instance, one big cause of "loss" between GDP and total national personal income is corporate profits (thinking back to our McD example). Yet, to the degree corporations take these profits and pay dividends, the money goes back to individuals and becomes personal income.

 

[AllDone]

A bit off topic but this idea of letting people buy health insurance across state lines gets tossed around a lot, really annoys me.

Offering insurance in a state requires the hard work of negotiating with hospitals and doctors to set up a network of providers. An insurer can negotiate good rates if it has a big base of customers, but it needs good rates to build up a big base of customers. Insurers leave a state altogether if it can't overcome this catch-22. That's why you can't just buy health insurance from an out-of-state insurer who doesn't have a network in your state.

Letting people buy insurance across state lines will only cause all the insurers already in your state to elect to be regulated by a different state, likely one with the most anti-consumer insurance commission.

If allowing people to buy insurance across state lines, then you would think that health insurance in a state that is bigger than the entire country of Canada should cost less than Canada. Ask any Californian the answer to that. Note that Canadian insurance is actually administered at the province level.

We can also skip a step in this argument that Canada monitors its wait times for medical care while the US does not so comparing Canadian wait times to fake US wait times is meaningless.

 

[sengsational]

For sure, I'm all-in for a plan that lets me stay put! But if they make it stupid expensive or simply impossible to get insured, there may be some otherwise 'logical' people that will roll the dice (go without coverage) and use medical tourism as a plan B.

 

[Katsmeow]

End of life costs are pretty high here.... with little to prevent spending that is not cost effective.... IOW, should 'society' pay $1 million to keep you alive another 6 months? If so, what about 3.... or 1.... some will say sure, others would say it is a waste....

Well, often, the issue is that you don't really know in advance what is end of life costs and what isn't. When my father many years ago had surgery for cancer, he had a complication that resulted in a wound that didn't heal and prevented him from eating food. He had been released from the hospital but had to go back and had to be fed through an IV. This went on for months, hospitalized the entire time. He kept deteriorating (he was 75 at the time) and eventually they decided on a last ditch surgery to try tor repair the area that wouldn't heal so he could eat. In the meantime, he couldn't have the radiation that would ordinarily have occurred after his cancer surgery. Before they took him in for the surgery so he could perhaps be able to eat, they did a scan and found that his cancer had metasized to his liver. So, doing the surgery was no longer indicated and he died 48 hours later.

But, here's the thing. Until the last little bit of it, it wasn't really known this was end of life care. Until then there was the hope that eventually this place would heal and he could eat and then he could have the radiation. Yes, of course, the cancer might come back but on the other hand it might not have.
So, in retrospect, it is easy to think it was all a waste of money (and it certainly wasn't pleasant for my dad), but at the time it wasn't clear early on that he was destined to die.


I remember my husband's mother had a stroke and ended up in a nursing home. She deteriorated and was literally put into hospice. But, she rallied and lived several more years. So, what is end of life and what isn't is not always clear at the time.

 

[Senator]

I wonder how we can motivate a surgeon to do better than his peers, if he gets paid the same no matter what he does. And if he is better, but does not cost more, he will be all booked up, and who would want to go to a less skilled surgeon for the same price?

I don't think decamillionaires and centimillionaires, let alone billionaires, want to go to the same hospitals as everyone else. They will have their own private healthcare, while the rest of us share the same semi-public facilities.

I wonder how it all works in other countries. The devil is always in the details.

A price would be quoted for each procedure. They can do it for that price, and keep their medical license, or get out of medicine. Or they can never take any patients that were on the 'single price' system, for anything. Just like a painters union.

Better doctors would fill up first, and they would have less downtime. It's that way now.

 

[sengsational]

I wonder how we can motivate a surgeon to do better than his peers, if he gets paid the same no matter what he does. And if he is better, but does not cost more, he will be all booked up, and who would want to go to a less skilled surgeon for the same price

We need published outcomes data. Then it's simply a matter of bribery. Hey, you asked how it worked in other countries, lol!

 

[AllDone]

Different countries have different systems. Germany and Switzerland were the models for the ACA. France has a single payer plan that covers 80% of costs and employer provided or privately purchased Medigap type coverage. Canada also has a single payer type plan, but each province controls their own system. The UK has parallel public and private systems. It varies widely from country to country.

 

[NW-Bound]

We need published outcomes data. Then it's simply a matter of bribery. Hey, you asked how it worked in other countries, lol!

I was told by a European visitor that her young son needed a knee surgery, but it was not critical and he had to wait. However, if she wanted to pay for it out of pocket, they could come to the surgeon private clinic and had it done the following week.

 

[gerntz]

With as much criticism as ACA has received don't know how a lesser and possibly more expensive replacement will be accepted. To me version 2 of anything should be better than V1, if not it's a failure.

Now there's a lot of folks who will be happy they don't have to have insurance anymore so maybe a percentage of people will be happier, till they're sick.

Except this isn't V2. It's different all together.

 

[explanade]

You just have to have a different way of looking at things. One price for all states, anyone can use any hospital, as they are all in the same network. A primary care Dr would make decisions. Go to the earliest available appointment at the nearest hospital.

All costs are reimbursed to each hospital the same. Eventually, it would even out. Hospitals would leave high expense areas or become more efficient. Places that hospitals leave would become lower COL areas as they are further from medical facilities.

We have one price for income taxes no matter what the COL is. Healthcare premiums could be the same. And they could be taken right out of a person's paycheck, like medicare.

How are you going to make each doctor or each hospital take the same rates?

That would be like having single payer big enough to dictate all the rates.

I don't think we're going to get that any time soon.

The politicians won't even agree if there should be volume pricing negotiated for drugs.

One price for income tax is one govt. entity, vs. thousands or millions of doctors, clinics, hospitals, etc. which make up the provider network.

 

[samclem]

Germany and Switzerland were the models for the ACA.

Maybe that was the drafters' intent (I'm not sure, things are still fairly opaque on that), but it's clear that what we have now is nothing like what is done in Switzerland or Germany. The Swiss system was >talked< about as something we should consider, but that wasn't implemented.

 

[NW-Bound]

The hard part is how to provide universal healthcare, but still allows for individualism, which is more valued here in the US than anywhere else.

Consider Mr. A and Mrs. B who both need hip replacement. Mrs. B does not mind to pay extra to be pampered in a nice hospital, and with no wait list. Mr. A would rather use his money to buy a Tesla car with the "ludicrous acceleration" mode, and so does not mind the county hospital and the longer wait list.

People have different priorities, and want to spend their money differently. We do not want to leave anyone dying out in the street, but must also recognize that there are people who want to spend more to get more healthcare.

 

[explanade]

Or Mr. A buys the Tesla but demands he gets care in the nice hospital anyways.

BTW, it seems a number of doctors are offering concierge subscriptions.

 

[NW-Bound]

Well, he can ask, but he's not going to get it.

Perhaps other countries can be more generous, but we are broke. Need to make the nice hospitals cheaper, then we will talk.