Will “repeal and delay” work for Obamacare?

by on December 2, 2016 at 3:32 am in Current Affairs, Economics, Law, Medicine | Permalink

Probably not:

But here’s the problem: There would be huge real-world impact of a repeal vote, regardless of when it actually takes effect. A repeal vote would tell the insurers that sell on Obamacare’s marketplaces to get out of the marketplace as soon as possible.

“Insurers have got to put their products together this spring, and we’re right in the middle of killing Obamacare,” says Robert Laszewski, a longtime health insurance consultant. “Are they going to submit proposals to sell in 2018? Why would they stay in the pool?”

The experts I’ve talked to over the past few days argue that a repeal vote would give health insurers good reason to quit the marketplaces — and that could leave 10.4 million Obamacare marketplace enrollees in the lurch.

That is from Sarah Kliff at Vox.

1 Alan December 2, 2016 at 3:51 am

I’ll confess to something rarely admitted on MR: I’m confused. I thought that leaving enrollees in the lurch was the point of repealing ACA.

2 anon December 2, 2016 at 5:44 am

The rock and the hard place.

Back when Republicans were (or pretended to be) free marketeers, they said that a free market would provide health insurance for everyone. (Well, except sick people, but that’s another story.)

In the short term they have to explain why less Obamacare means less insurance.

Now, the obvious answer (scam) is to let companies sell “insurance.” That is policies that give some level of comfort until you discover that your maximum out of pocket for a heart attack is “unlimited.”

Can “insurance” come online fast enough?

3 Brian Dixon MD December 2, 2016 at 7:11 am

Insurance IS the problem as it disrupts direct accountability between patient and provider. We need to create a system where insurance is an option but isn’t necessary. http://www.changehealth.today explains how.

4 Rowe December 2, 2016 at 9:30 am

[[ “Insurance IS the problem…” ]]

No. False application of the actuarial-insurance concept by the government is the problem.

The entire modern concept and discussion of “health insurance” is phony and deceptive, but most everyone accepts it automatically as valid.

Massive government intervention in the health care markets was/is guaranteed to be highly disruptive, erratic, wasteful, and counter-productive. No one should now be surprised that private health insurers are very worried and confused on what the government will do next. Mainstream economists are of no help.

They never learn. Once you are riding the wild government tiger — there are no options for a safe dismount, nor pleasant continued ride.

5 mulp December 2, 2016 at 12:30 pm

So, intervention in Africa’s health care system by outside money is harmful and the West should have let the free market deal with ebola and HIV/AIDS, including doing zero screening or restrictions of economic migration?

And malaria, dengue, etc, are best addressed by the free market and left to spread constantly in Africa and other tropical regions as the best free market solution, along with high birth rates and high death rates before age 5, also the free market optimum?

6 Sam The Sham December 2, 2016 at 9:45 am

Wait… are you suggesting there’s a difference between health, medicine, and insurance? Die heretic!

I’m getting a general checkup today plus vaccines. Paying cash, it’ll be about 300$. Have a dental cleaning thing next week, 100$. It’s not cheap, but easily budgetable without insurance.

I eat right and exercise, although have 15 pounds to get rid of. I don’t smoke, and I laugh plenty. Not only do I feel all right, I suspect this lifestyle will save money when i’m 50. Saving money and taking care of your health is not rocket surgery for the vast majority of Americans. I want something for whom that is not enough, but it would be a fringe benefit.

7 msgkings December 2, 2016 at 11:48 am

Do you have any kind of coverage for catastrophes like cancer or accidents that put you in the hospital?

8 The Free Market Is Not God December 2, 2016 at 11:55 am

Many people don’t think they need coverage for catastrophes. They just eat right and live right and think positively– until catastrophes happen, which greatly interfere with their positive thinking program and their belief that they can control 100% of what happens to their bodies.

9 Mark Brophy December 2, 2016 at 12:15 pm

If you exercise and are 15 pounds overweight then you’re not eating right.

10 mulp December 2, 2016 at 12:42 pm

He’s doing free market “eating right”. The deal is you cut the wages of food workers in half because that are better off because cheaper food means eating right now means eating four times the quantity of food to double the income of food Workers!

The problem is clearly that personal trainers need to have their pay cut in half so he will increase his exercise by four times and thus make trainers better off with double the income.

I do note he talks of living only to age 50, based on the life of Jim Fixx, the man credited with restoring health by exercise that everyone can do: long distance running.

11 Sam The Sham December 2, 2016 at 2:40 pm

Nah, I’m just not exercising enough. I could easily melt the 15 pounds by going for an extra run a week and doing away with my shandies. I do have catastrophic coverage.

Actual health care is that extra run and mindfulness of what you eat. It ain’t expensive, and it’s damned cheap to the alternative.

12 Brian Dixon MD December 2, 2016 at 10:56 pm

Catastrophic care won’t be “catastrophic” in my plan.

Firstly, any conditions unrelated to lifestyle choices will be paid by the general health fund. For example, cystic fibrosis, type 1 diabetes, sickle cell, intellectual disabilities…these are all caused by no fault of our own. The medical community has a pretty good “risk” assessment for most other things so in framing your risk, it frames how much you’re liable to pay for your care in the event of catastrophic illness.

But heart attacks won’t cost 100,000. Why? Because in a transparent system where providers compete, where hospitals compete, and where you can see the cost, you’ll be able to shop around for the best deal. Since you’ll have more money in your pocket from eliminating Medicare contributions, employee insurance contributions, and getting paid more from your employer (who won’t have to pay ridiculous employer premiums) you can now save so that when that event happens, you’ll be able to afford it.

I remind people constantly that the burgeoning home health field teaches us of price hyperinflation. You can be on telemetry at your house and have it feed through wifi to your doctor and a nurse can come around 2-3 times a day to check on you, thereby saving thousands of dollars. So yeah, we can make healthcare cheaper.

13 Fred December 3, 2016 at 12:22 pm

Shop around for heart attack treatment? Who does the shopping, your ambulance driver? Or maybe you mean shop ahead of time by paying some amount to cover a heart attack, should it happen. You might call that “premium”.

14 anon December 2, 2016 at 6:22 am

“According to an article from the National Business Group on Health, the average total cost of a severe heart attack–including direct and indirect costs–is about $1 million.”

There is simply no fancy math that lets people have both cheap insurance and million dollar payouts. Choose one, or the other, but not both.

15 The Free Market Is Not God December 2, 2016 at 11:53 am

No, leaving enrollees in the lurch is not the point of repealing ACA. It’s just “collateral damage” that doesn’t matter. Repealing ObamaCare is done so that insurance companies can make more money. There is no intent to hurt sick people. It’s just that sick people do not matter, one way or another to the GOP dominated Congress and the president elect. The only parties that matter are the mega-corporation crony capitalist welfare queen donors to political campaigns.

16 Brian December 2, 2016 at 3:58 am

Nope. The plan as I understood it was always:

1) Repeal ACA
2) ???
3) Something terrific

17 dan1111 December 2, 2016 at 4:56 am

Wow, that’s almost as bad as not repealing the ACA.

18 The Free Market Is Not God December 2, 2016 at 11:58 am

Yes, that would be the absolute worst thing– to not repeal ObamaCare. That would deprive us of things like pre-existing conditions, that could send our health care costs skyrocketing into the stratosphere. Why did we ever enact ObamaCare and deprive ourselves of the pre-existing condition thrill?

19 mulp December 2, 2016 at 1:03 pm

The history of the US health care system in the 21st century are just like the Republican version of history around how tax cuts boost sustained gdp and job growth and thus generate more tax revenue eliminating all deficits and debt.

In this version of history, income taxes on individuals and corporations have been much higher than during the 60s for the entire 21st century.

Not to mention banking being totally controlled by government since 2001 unlike the 60s when there was zero government regulation of any banking or financing or investing,….

And unlike the 60s, when there was no government spending on infrastructure,….

What I find so interesting is how much conservative ideology has gained in terms of political power since the 60s, yet conservatives keep claiming total control by 60s liberals destroying America, while crowing about how conservatives have beat liberals almost totally in flyover country, with only the coasts oppressed by liberal hold outs who ignore the decay of flyover country.

Oddly, the conservative elites live in the liberal bastions, not in flyover conservative territory.

Will McConnell ever return to live in Kentucky, especially eastern Kentucky, where a third of the population will lose health care coverage if Republicans get their way? Or will he remain in leftist DC area where big government health care policy forces health care on everyone and wastes money funding new medical interventions?

20 Massimo Heitor December 2, 2016 at 7:08 pm

You are being sarcastic, but in seriousness, the ACA idea that people should have to pay the same prices whether they’ve been buying insurance in the past and paying into the system or not is terrible. People should have to pay more more health care if they don’t buy health insurance, pay zero, wait until they get sick, and then decide to buy health insurance. People with “pre-existing” conditions, sick people who are expected to consume large dollar quantities of health services, should have to pay more for those services.

21 Brian Dixon MD December 2, 2016 at 7:14 am

Hahaha. Word.

I’ve been surprised that politicians dont want to divest themselves of private healthcare decisions. Now’s a great time for us to shift the paradigm and get government completely out of healthcare. Note, I didnt say healthcare will be unregulated (each state has health boards for licensure and safety.) instead, we let the market help define quality and cost. http://www.changehealth.today explains how.

22 zbicyclist December 2, 2016 at 8:03 am

To quote a famous Sidney Harris cartoon, “I think you need to be a bit more explicit here in step 2”.


23 rabidwombat December 2, 2016 at 9:27 am

I must be young (but not that young), since I immediately took it as a reference to underpants gnomes.

24 zbicyclist December 2, 2016 at 3:54 pm

I must be old (and, yes, that old) since I’d never heard of underpants gnomes (until I googled it).

25 Steve Sailer December 2, 2016 at 3:59 am

So Paul Walker was elected President after all?

26 msgkings December 2, 2016 at 11:49 am

No he died in a car crash, I think you mean Scott Walker

27 Jeb Kinnison December 2, 2016 at 4:02 am

I’ve been following Sarah Kiliff’s writing on the ACA since it began, when she was at WaPo. Party line thinking, accepting the Administration’s spin on everything. Even now denying the underlying plan to heavily tax middle-class and younger people to give client citizens a gift of cheap insurance. Like most Vox people, she “explains” by leaving out contrary thought.

Not that it’s an easy problem, but freeing the insurers to sell low-cost, catastrophic insurance to individuals again without the many routine care requirements would be a good start, plus a subsidized high-risk pool and those continuous insurance safeguards. I lost my good, cheap plan the first year when the small insurer realized they could not survive under the new rules.

28 anon December 2, 2016 at 5:46 am

Just curious, what was your maximum out of pocket on the cheap plan? Capped, or an open ended percentage?

29 Jeb Kinnison December 2, 2016 at 1:04 pm

That was 7 (?) years ago, so I don’t remember the details of the plan — run by a small company out of Minnesota, and it took a lot of research and shopping to find it. Excellent coverage with no fixed out-of-pocket limit but a really high (many millions) cutoff, so good protection against dire need. And cheap, like $250 a month (I was 55.) As soon as the ACA passed they announced they were leaving the individual market in CA. The three companies that offer insurance now cost about 3x as much and are no better in coverage — in fact, deductible at $6K is much, much worse than I had. This was, of course, to force the healthy and young to pay many times the true actuarial cost of insurance for them so that the unhealthy and old could pay less, no matter how high Theron income might be. The biggest middle-class tax increase in history for small business and independents, disguised as an insurance scheme.

Wrote a lot about cutting costs and modernizing to get rid of the layers of gatekeepers here: https://jebkinnison.com/2016/11/14/sekrit-reform-agenda-untangling-government-medical-deregulation/

30 anon December 2, 2016 at 1:47 pm

It has been a while for me too, but I think my HMO offered some plans that were a co-pay on hospitalization, and I chose to pay more to limit out of pocket (probably why my plan was Obamacare legal).

If your co-pay is 30% and your bill is $100k, you owe $30k. That is more than median family savings.

Obamacare limited out-of-pocket spending to “$5,950 for individuals and $11,900 for families, excluding premiums.”

As I say I think we are heading back to big bills for bad luck, and most people won’t see it coming. I think most people do less diligence than you, and just think “I make payments, I have insurance.”

31 Jon December 2, 2016 at 5:46 am

That doesn’t work. The routine care requirements for healthy people aren’t the big driver; it is the care requirements for unhealthy people that drive up the costs. For most families, the current ACA plans amount to catastrophic care plus their preventative care anyhow. If you look at Bronze plans you can easily see deductibles >$10,000. And note that is “per year” not per illness!

How many people elect $10,000 deductibles on their home and car insurance?

32 TMC December 2, 2016 at 8:07 am

So just like what they had before, but triple the price and one-forth the healthcare provider options. Obamacare is sweet.

33 PD Shaw December 2, 2016 at 9:15 am

How many people are forced to have oil-change coverage as a part of their car insurance? Or annual furnace inspections as part of their home-owners insurance? The reason that these are objectionable is that regular anticipated needs are not something insurance pooling provides any useful solution. It’s just misusing insurance for forced savings, imposing additional administration costs at the provider, insurer and government levels. And since there are no cost controls on preventive services, costs are increasing rapidly, particularly vaccines.

34 Jon December 2, 2016 at 9:49 am

While I tend to be uncomfortable with anything being entirely free, there are some reasonable reasons in the case of preventive care.

First this is not the big driver in the ACA premium costs; it is the population of unhealthy people getting insurance. Secondly, vaccines in particular have clear positive externalities. Other preventive care has quite clear benefits and more subtle positive externalities—healthier people are more productive and we avoid paying for their care later when it is more expensive

35 jon December 2, 2016 at 5:51 am

Yes, ‘freeing the insurers’ to fill the gaps by providing products people need is the right course.

The “probably not” political here that claims repeal “could leave 10.4 million Obamacare marketplace enrollees in the lurch” assumes that repeal stands alone, without offering an alternative. A very progressive framing of the issue: ACA is the only workable thing and tis opponents have literally nothing in mind for a replacement because nothing can replace it. Odd that MR prefers ACA to a freer market….

36 Thomas Taylor December 2, 2016 at 9:24 am

” ACA is the only workable thing and tis opponents have literally nothing in mind for a replacement because nothing can replace it.”
If they had, we would have been told after almost ten years of this argument.

37 derek December 2, 2016 at 9:47 am

Told by whom? Vox?

38 Thomas Taylor December 2, 2016 at 9:56 am

People who oppose Obamacare. After ten years campaigning on the issue, if they were serious, there would be an alternative plan in place. There is none, except accepting Trump as your Lord and Savior, who will make “great deals” on your behalf.

39 Bob from Ohio December 2, 2016 at 10:06 am

“there would be an alternative plan in place”

Congessman Dr. Price, nominee for HHS secretary, has a detailed proposal called Empowering Patients First Act. Without Obama to veto, it will be the basis for the replacement.

Try reading beyond Vox once in awhile.

40 JWatts December 2, 2016 at 10:28 am

“..if they were serious, there would be an alternative plan in place. There is none”

That does seem to be an amazingly in the bubble claim, since there have been links to the Empowering Patients First proposal on this very site, this very week.

41 Thiago Ribeiro December 2, 2016 at 10:28 am

Can I quote you on this, that ‘we” finally have a plan (I admit “Bob” doesn’t sound a more trustworthy-sounding source than Vox or even Fox, but thanks to Republicans — particularly Donald Trump — refusal of settling on specific policies, I am grasping at straws here), this plan? Becuse it doesn’t sound like this guy’s plan (https://www.donaldjtrump.com/positions/healthcare-reform)

42 eccdogg December 2, 2016 at 10:55 am

Actually you could even just read Vox and see what the republican plans looked like.


43 Thomas Taylor December 2, 2016 at 11:03 am

“I read 7 Republican Obamacare replacement plans.”
FAIL I am asking for THE plan, how difficult is it to understant? Democrats don’t the luxury of having seven plans, only the one they actually managed to get through Congress.

44 Eccdogg December 2, 2016 at 11:57 am

There is never a single plan at this stage. There certainly wasn’t when Obama got elected. Legislation is always a negotiation between Senate House and President. But most of the Republican plans share similarities and at least one has been drafted a a bill.

45 Thomas Taylor December 2, 2016 at 12:14 pm

“Legislation is always a negotiation between Senate House and President”
So, after 10 years of whinning, he where we are: it is the plan we have versus a ghost, that may be awesome or not, but we can’t know just yet and shouldn’t have to discuss it during the campaign. Virtually everything the president tries to do must be negociated with Congress, this is why the USA are not dear Saudi Arabia. Why even have platforms then? “Eventually, we wil have a surprise plan you will love” is not haealthcare policy.

46 Hazel Meade December 2, 2016 at 10:22 am

Lots of people have proposed lots of alternative solutions. Your side doesn’t want to hear about anything that doesn’t involve more regulation.

47 Thomas Taylor December 2, 2016 at 10:32 am

I don’t want “lots” of plans. Democrats don’t have the luxury of having lots of plans, just the one they could get through Congress. There can be only one plan at a time. I want ONE Republican/Trump plan (even if the plan is hving no plan and letting the market take care of the issue — if this is the plan, say so). After ten years of this circus, we are entitled to know the Republican plan. As Mr. Bush once pointed out, a bunch of complaints is not a plan.

48 eccdogg December 2, 2016 at 10:50 am

Well one plan will ultimately be voted for. Remember Obamacare was not the plan that Obama ran on.

49 Hazel Meade December 2, 2016 at 10:59 am

Translation — “Lalalalalalalalalaala! I don’t hear you! You have no plan! Lalalalalalalalala! “

50 Thomas Taylor December 2, 2016 at 11:40 am

I see, one plan will be voted one day maybe. Which one? It will be a surprise (after ten years of Republicans whinning about poor people getting coverge, we still don’t know what Republicans want). Does it matter? Just put your trust in our Lord and Savior Trump. Who cares if he never mentioned ANY plan before? At lest, we know he has huge hands, the rest will work out somehow.
“Remember Obamacare was not the plan that Obama ran on.”
It wasn’t the pIan he wanted either, but it was the plan he could actually get approved. It was also the plan Romney could have run on if it hadn’t to disallow Romneycare and all his works.

51 The Free Market Is Not God December 2, 2016 at 12:08 pm

All hail the Lord and Savior of the Middle Class and working class, riding in on his VERY white horse, LOL.

52 Brian Dixon MD December 2, 2016 at 7:16 am

I agree with low cost catastrophic plans. In fact, I think that’s the only type of plan health insurers will have available to sell once we get rid of our current concept of health insurance and embrace the philosophy behind http://www.changehealth.today

53 Ricardo December 2, 2016 at 8:54 am

As Jon pointed out, Bronze plans are already “catastrophic plans” for many people of modest means and the preventive care thing is a red herring. Spending on preventive care is not a major driver of health spending in the U.S.

Since you admit that expanding access to basic health insurance while keeping costs down is not an easy problem to solve, you should hold off on the insinuations of bad faith against those with whom you disagree. Removing the mandate and shunting the least healthy citizens off into subsidized high-risk pools would almost certainly cost taxpayers more money. Whose taxes do you think should go up to pay for this?

54 eccdogg December 2, 2016 at 10:02 am

“Removing the mandate and shunting the least healthy citizens off into subsidized high-risk pools would almost certainly cost taxpayers more money. Whose taxes do you think should go up to pay for this?”

Yes it may cost taxpayers more money, but it is also fairer. Obamacare forces a small subset of people to bear a large portion of those cost. People who buy now expensive insurance in individual market.

If we have a societal goal of caring for those folks why should only a small subset of society bear those cost?

And remember tax payers are currently on the hook for a lot of the Obamacare premiums today through the subsidies, It is not totally clear to me what the net affect of getting rid of many of the subsidies + high risk pools would be as far as net cost.

55 Ricardo December 2, 2016 at 10:16 am

“If we have a societal goal of caring for those folks why should only a small subset of society bear those cost? And remember tax payers are currently on the hook for a lot of the Obamacare premiums today through the subsidies, It is not totally clear to me what the net affect of getting rid of many of the subsidies + high risk pools would be as far as net cost.”

This is pretty much an argument for national health insurance with income-contingent premiums. E.g. Medicare for all, possibly with higher deductibles and co-pays for younger people. I am not objecting to that but my impression is that this is something the original poster I was responding to would oppose.

56 eccdogg December 2, 2016 at 10:30 am

I don’t think it is an argument for that. It is an argument for a safety net program for the truly hard cases, those who are abnormally sick and/or poor.

I could get behind a heavily cost controlled medicaid/medicare (or high risk pool) that allowed anyone to join with premiums capped at a certain % of income.

Then let everyone else use a lightly regulated market.

57 JWatts December 2, 2016 at 9:15 am

“Like most Vox people, she “explains” by leaving out contrary thought.”

That’s Voxsplaining. Though generally they don’t leave out contrary thought, they just provide a weak argument and then give a quick dismissal.

Back when Vox was new, they had a few articles that ran with two opposing editorials. One pro and one con. I thought they were going to bring Crossfire to the web with graphics and was interested in the concept. Either it was a fluke or they dropped any pretense of being objective within a few months.

58 FE December 2, 2016 at 9:25 am

Here is Ezra Klein two years ago Voxsplaining that Obamacare is working even better than expected: “On the whole, though, costs are lower than expected, enrollment is higher than expected, the number of insurers participating in the exchanges is increasing, and more states are joining the Medicaid expansion.”

59 Jon December 2, 2016 at 10:06 am

They were lower than expected through this year and the recent cost increases likely bring premiums within a reasonable error margin of original projections.

The premiums are so much higher than what people quote for president ACA plans because the previous ACA numbers cited usually are for healthy people and the “expectations” took into account that people who would have been charged far higher premiums would be in the new pool.

60 JWatts December 2, 2016 at 10:36 am

The premiums are so much higher, because the Administration fed a lot of unrealistic expectations to the media and gamed the CBO budgetary guidelines. Obamacare was always going to cost more than advertised.

61 Zach December 2, 2016 at 6:14 pm

I went through a six month jobless period recently, and I really missed the pre-Obamacare catastrophic plan I had purchased the last time I was faced with a similar situation.

I didn’t need a plan to cover everything. I needed a plan to cover the possibility I got hit by a bus or something equally terrible, but otherwise had no medical expenses.

When you’re actually in that situation, a few hundred extra bucks a month for a larded up policy just doesn’t make any sense at all.

62 dan1111 December 2, 2016 at 4:48 am

Item one on the agenda after Republicans control government: find a way to take all the blame for the already-impending failure of a liberal policy while accomplishing nothing of substance on the issue!

Way to go, Republicans. You have really found a winner.

63 Brian Dixon MD December 2, 2016 at 7:18 am

Republicans and Democrats have fallen victim to the same bug: listening to monied interests.

There is ZERO reason for a health insurance company to come between me and my patient. Instead, we should focus on creating an environment where people have money to buy their healthcare and an environment where providers are numerous enough to compete for those dollars. http://www.changehealth.today explains how

64 Hazel Meade December 2, 2016 at 10:23 am

Price signals would help.

65 JWatts December 2, 2016 at 9:23 am

“Item one on the agenda after Republicans control government: find a way to take all the blame for the already-impending failure of a liberal policy while accomplishing nothing of substance on the issue!”

The only way to have prevented that was a Clinton win. Obamacare is in an obvious death spiral. With Trump as President, the Republicans are going to be blamed for Obamacare’s death regardless of whether they repeal it or not.

Even had Clinton won, the narrative would have been, that Evil Republicans blocked her from saving Obamacare. That would of course ignore the significant fact that the reasons Obamacare is circling the drain is that the design was poor.

Obamacare would only work with either a lot more carrot (expensive subsidies) or a lot more stick (high mandates with strict enforcement).

66 dan1111 December 2, 2016 at 9:37 am

I’m sure you are right that some will attempt to blame Republicans no matter what. But it does not follow that what they do makes no difference. Some narratives are more plausible and stick better than others.

The repeal and delay strategy would result in a very plausible story that Republicans now “own” the failure.

On the other hand, if the Republicans try to repeal and are thwarted by filibuster, the natural narrative is that the Democrats created a broken system and are now blocking attempts to fix it. Attempts to spin it otherwise will happen but are unlikely to be credible. I would prefer the Republicans to push for this; as the status quo becomes increasingly untenable, there will be pressure on Democrats to compromise.

67 Bob from Ohio December 2, 2016 at 9:53 am

“if the Republicans try to repeal and are thwarted by filibuster”

Obamacare was passed under a Congressional budget procedure known as “reconciliation” which is not subject to filibuster. A repeal to be done under “reconciliation” is likewise limited to 20 hours of debate per Senate rules.

Live by “reconciliation”, die by “reconciliation”.

68 JWatts December 2, 2016 at 9:58 am

“On the other hand, if the Republicans try to repeal and are thwarted by filibuster, the natural narrative is that the Democrats created a broken system and are now blocking attempts to fix it. ”

Obamacare was passed using reconciliation and didn’t require 60 votes. Ending it wouldn’t require 60 votes. If Republicans were to arrange things so that it was “normal” vote and the Democrats filibustered it, the Republican base would be outraged that the Republicans in Congress were once again all talk and no walk. It would take about 30 seconds for various people to point out that you don’t need a super majority to kill the funding.

69 JWatts December 2, 2016 at 9:58 am

Beaten to the post by Bob!

70 dan1111 December 2, 2016 at 11:14 am

The main ACA wasn’t passed primarily by reconciliation, though (and couldn’t have been, since it can only be used for budgetary stuff). Reconciliation was just used for some tweaks to make the Senate bill palatable to the House.

The Republicans could defund Obamacare by reconciliation, but that mechanism couldn’t be used for an adequate replacement bill. Hence their harebrained scheme.

71 JWatts December 2, 2016 at 12:17 pm

The original PPACA legislation did require 60 votes.


So, while Republicans could stop funding Obamacare with a reconciliation vote, I think you may be correct that a replacement would require 60 votes. That will be interesting. The Republicans will need to bring in 6 votes, revoke the filibuster rule or fail to pass a replacement plan.

72 Ricardo December 2, 2016 at 1:45 pm

“So, while Republicans could stop funding Obamacare with a reconciliation vote, I think you may be correct that a replacement would require 60 votes.”

As much as you mock Vox, they actually did a good job of explaining all this in a series of articles. Google it, we won’t tell anyone. Promise.

Republicans can remove funding for subsidies for health insurance purchased on exchanges and for Medicaid and can also get rid of the penalty for not having insurance. What they cannot repeal through reconciliation is the ban on pre-existing condition exclusions, the requirement that people under 26 can stay on their parents’ insurance, and the ban on annual or lifetime limits.

73 JWatts December 2, 2016 at 2:11 pm

“As much as you mock Vox, they actually did a good job of explaining all this in a series of articles.”

I’ve read several of the Vox articles. As is the case with most of their articles, they don’t explain, they Voxsplain.

74 JWatts December 2, 2016 at 2:28 pm

Oh to be fair, Vox does often show useful information. It’s just that they assume their way is the only reasonable way, and they do a very poor job of showing both sides of the issue. It’s better than Slate, but not by a lot.

75 Jon December 2, 2016 at 5:52 am

Note this is not just that 10.4 million people who end up in the lurch, but anyone who loses employer coverage and is not eligible for Medicaid or Medicare would be screwed. Also I don’t know what the implications are for the Small business plans.

Basically if the Republicans do repeal and delay we end up with exactly the system they don’t want—-employer provided and government provided health care will be the only games in town.

76 anon December 2, 2016 at 5:59 am

Maybe I am too cynical, but I think the plan is for everyone to have a cheap plan, and for them to never (in theory) know the limits of cheap plans.

Individual tragedies as a backdrop.

77 Brian Dixon MD December 2, 2016 at 7:23 am

My plan eliminates Medicare, Medicaid, and the VA system along with employer based health insurance. This will put money directly into people’s pockets.

The structure of my idea creates citizen-shareholders in a state based health company so that we reconnect our actions to own healthcare. Physicians and other healthcare providers (including hospitals) are restored to full autonomy and compete for citizen-shareholder dollars.

78 Slocum December 2, 2016 at 10:58 am

But they weren’t all screwed before the ACA — the individual market was an actual thing — so why would they necessarily be screwed after repeal? Or do you think the ACA is so bad that it has poisoned the well for individual insurance forever? And keep in mind that insurers have already been exiting the exchanges for some time, pushing the exchanges into a slow-motion collapse. If Clinton had won, that process would surely have continued as the Republican congress and the new Democratic president engaged in the same repeal-veto stalemate as before.

79 msgkings December 2, 2016 at 12:14 pm

The individual market was pretty much nonexistent (at any reasonable cost) if you had pre-existing conditions. Insurers can’t afford to cover those without a mandate for healthy people to buy in. This is the essence of the problem. Get rid of the ACA and we are back to millions of sick people who go bankrupt due to health care costs, and people staying in jobs they hate to maintain their coverage or their kids’. I’m happy to see if the Reps can improve the ACA with a better idea but if it doesn’t cover people with pre-existing conditions it’s a total fail.

80 eccdogg December 2, 2016 at 2:54 pm

Most of the Republican plans actually do handle this.

Most do not let insurers charge higher rates for pre-existing condition as long as you have had continuous insurance. So as long as you kept paying while you were healthy you can’t get charged differently once you get sick. The Republicans substitute the stick of penalties in Obamacare for the apple of guaranteed issue and community rating as long as you paid when you were healthy and the stick of potentially higher rates if you get sick and did not keep insurance.

But for folks who still choose no insurance and then get preexisting condition some still have high risk pools which folks can enroll in and others only allow temporarily higher rates for pre-existing conditions and those are capped. The Price bill allows someone who did not have insurance to by at at most 150% of standard rate for two years before reverting to normal rate. The Senate even goes so far as to default folks into an insurance plan with premiums equal to the tax credit so you would have to go out of your way to not have continuous coverage.

81 msgkings December 2, 2016 at 3:30 pm

That’s good, I hope the whole things works better than ACA.

82 Lee A. Arnold December 2, 2016 at 5:57 am

These are people who think that healthcare can be a free market item, and so if you die unless you can afford it, it’s your moral fault. Trump’s achievements largely consist of building gilded towers to mammon. Two proofs that the U.S. is not a Christian nation.

83 dan1111 December 2, 2016 at 6:32 am

Reasonable people can disagree on what kind of system will lead to the best health outcomes. Mandating that the government provide something doesn’t magically make the resources to do so spring into existence, and there are limitations and shortages in government health systems, with people dying in some cases because care is not available. No matter which side we take, we should all be willing to admit that this is a very messy issue, and people with good intentions are on the other side.

I was disappointed by Christian leaders’ embrace of Trump, though.

84 Lee A. Arnold December 2, 2016 at 6:53 am

Reasonable people will NOT agree that resources cannot be made available, that people need to die due to lack of care in any system, nor that this needs to be a “messy” issue. That is shameful. This is all about the emotions surrounding the use of money. It is buttressed by a bunch of phony assertions from modern economics.

85 Brian Dixon MD December 2, 2016 at 7:28 am

That’s why we should return healthcare to a private, two-way conversation and eliminate government involvement completely.

We must get rid of this notion of health insurance “saving” us. It isn’t. In fact, it poisons us into thinking we can get away with poor health choices (poor diet, sedentary lifestyle, poor choices, etc) yet never fully covers those fateful things (genetic cancers, intellectual disabilities.)

We need a system that emphasizes preventative care, eliminates mental health stigma, and let’s you decide where to spend your money. http://www.changehealth.today does that and more

86 Lee A. Arnold December 2, 2016 at 7:55 am

Getting rid of the insurance companies in basic healthcare is necessary because they are still allowed to take 20% of the dollar (they took 25-40% before Obamacare restricted their “MLR”) yet they provide no value-added for it. None.

But “letting you decide where to spend your money” for basic (non-elective) care is a nonsensical distraction.

The idea of “market forces” in health care is false. Talk of “market forces” among providers is usually an economically-uneducated cover for, “so I can make enough money to pay off my creditors and have a reasonable standard of living.”

A full education in economics concludes that the “market” will not work in basic healthcare. This is because of problems on both the supply-side and demand-side of the transactions.

On the demand side, consumers (“patients”) cannot shop around much, particularly when they are in dire need, and/or when the decision has n-branched decision-making that becomes too complex to calculate.

On the supply side, producers (doctors, hospitals) are not numerous enough to allow proper entry and exit from the market place: doctors are not like bubblegum in a convenience store, and more than a few hospitals in any locale is too costly and wasteful. Therefore neither supply nor demand will ever work correctly.

In addition, healthcare is NOT like other goods, insofar as moral people believe that the poorest of the poor should also have complete access to it (unlike, say, flat-screen TVs or fancy autos) — and giving them complete access to it does NOT increase the DEMAND for healthcare to infinity, because nobody sane wants more healthcare than they need.

The solution is paying taxes into a gov’t monopsony like Medicare: socialized single-payer with private doctors and hospitals. If you don’t like the payment schedule, then don’t get into medicine.

I think we could also have a secondary tier of add-on insurance for people who can afford concierge service and think that “freedom” equals the massaging of their rhinestone encrusted lifestyles. If private doctors want to cater to this market and drive around in hot cars, then let them do so.

87 TMC December 2, 2016 at 8:12 am

Until recently I worked at a healthcare insurance company. We always cost around 15%. Obamacare has added to that a little, not decreased. And only added a little because of the subsidies that are going away. Soon they’ll need to absorb the $100 million losses or adjust coverage/price.

88 Lee A. Arnold December 2, 2016 at 8:25 am

What was the value-added, which was worth that 15%?

89 Ricardo December 2, 2016 at 9:13 am

“Getting rid of the insurance companies in basic healthcare is necessary because they are still allowed to take 20% of the dollar (they took 25-40% before Obamacare restricted their “MLR”) yet they provide no value-added for it. None.”

The Netherlands has a PPACA-like system where insurance is provided by non-profit co-ops. A system like that might lower costs a bit. Any insurance company needs to earn an acceptable return on capital, purchase reinsurance along with maintaining adequate reserves to keep the business above water in bad years, and pay all necessary administrative and legal costs. Maybe 20% is too high a number — I don’t know — but it is impossible to run any kind of insurance on zero overhead.

90 JWatts December 2, 2016 at 9:37 am

“Maybe 20% is too high a number — I don’t know — but it is impossible to run any kind of insurance on zero overhead.”

Thank you Ricardo, for being the voice of reason.

91 dan1111 December 2, 2016 at 9:40 am

If all of the insurance companies are making obscene profits, than why doesn’t one of them lower prices a little bit and steal all the others’ business?

92 A Definite Beta Guy December 2, 2016 at 9:51 am

“Getting rid of the insurance companies in basic healthcare is necessary because they are still allowed to take 20% of the dollar (they took 25-40% before Obamacare restricted their “MLR”) yet they provide no value-added for it”

Your entire post is garden-variety socialism and applicable to practically every single industry that ever existed.

93 Lee A. Arnold December 2, 2016 at 10:45 am

Ricardo: “impossible to run any kind of insurance on zero overhead”

It is NOT insurance, it’s more like a transfer system, because almost everybody is going to need it sooner or later, and so it is not like efficiently-insurable things like fire and auto.

A transfer system like Medicare can run it on 2% overhead, or even less.

Don’t bother us with details of Medicare inefficiency, which amount to roadblocks legislated by Congress to force privatization.

“Definite Beta Guy’s” implication that healthcare is like “every single industry that ever existed” is false.

94 andreasj@gmail.com December 2, 2016 at 10:58 am

“nobody sane wants more healthcare than they need”

There’s no shortage of insane people, particularly if that’s the standard.

95 Art Deco December 2, 2016 at 12:02 pm

because nobody sane wants more healthcare than they need.

People’s capacity to consume the wares of physicians and pharmacists is pretty elastic.

96 Lee A. Arnold December 2, 2016 at 12:51 pm

“pretty elastic”

For non-elective healthcare it is almost inelastic. Total demand for non-elective healthcare is predictable.

97 Art Deco December 2, 2016 at 1:15 pm

For non-elective healthcare it is almost inelastic.

First, you have to define ‘non-elective’.

98 Lee A. Arnold December 2, 2016 at 1:54 pm

“First, you have to define ‘non-elective’.”

Everybody knows what elective/non-elective means. They may not know that you are hiding a limited definition of “demand” inside your use of “elasticity”.

99 Art Deco December 2, 2016 at 2:43 pm

Everybody knows what elective/non-elective means.

No, they do not. There are various approaches to problems, contingent judgments made, actuarial calculations made, and so forth. There are procedures which look passable antecedently which you can tell later were unnecessary.

100 Lee A. Arnold December 2, 2016 at 3:38 pm

Hindsight is always 20/20. The rest of this is between the patient, the doctor, and God. Prices and incomes do not really solve this “elasticity” problem, except when buttressed by a bunch of phony assertions from modern economics.

101 Art Deco December 2, 2016 at 3:52 pm

Oh, yes they do, because whether or not to spend on a medication which induces incremental improvement (over and above it’s iatrogenic effects) or to submit to a diagnostic procedure which may or may not find anything, there is an implicit cost-benefit calculation being made.

102 Lee A. Arnold December 2, 2016 at 4:05 pm

A cost-benefit calculation which has few prior indicators except the knowledge and feelings of the patient, the doctor, and God. Healthcare is not an economic good, it is a moral good. You think should be treated as an economic good, because you have emotional priors of your own. So go worship money, and leave everybody else alone.

103 Art Deco December 2, 2016 at 6:33 pm

Healthcare is not an economic good, it is a moral good.

I’m afraid it’s a moral good subject to considerations of scarcity and cost, like anything else which requires resources to produce.

104 Lee A. Arnold December 2, 2016 at 6:56 pm

Healthcare is “subject to considerations of scarcity and cost” as a false outcome. There is nothing in healthcare that is permanently scarce. The idea that production of healthcare items requires less production of other goods and services is false. It is an artifact of the hypothesis that money, which is kept artificially scarce, is a complete measure of value across all goods and services. This hypothesis about money is false, but we keep it as true, in order to 1. maintain the fiction that people must work for a living to prove their moral worth, and more important, 2. to prevent rampant inflation in the price of one of the few things that is genuinely scarce, i.e. desirable real estate. Other than that, we have enough resources and means to give everyone on earth a good standard of living without fear of deprivation, and in fact, we already had enough, starting about 50 years ago.

105 Art Deco December 3, 2016 at 11:31 am

There is nothing in healthcare that is permanently scarce.

If fantasy helps you feel better, fine. Just don’t bother the adults with it.

106 Lee A. Arnold December 3, 2016 at 4:28 pm

What is permanently scarce in healthcare?

107 Lee A. Arnold December 15, 2016 at 6:26 am

Two weeks later, still waiting for an answer…

108 Amigo December 2, 2016 at 6:27 am

Even if that insurance pays nothing , access to negotiated rates is likely as valuable as any catastrophic plan for many. What’s scary is your bill can be 3X-5X or more for the same procedure than if you have insurance.

I’m just not knowledgeable enough to know what these procedures are or how much they should cost. I just know they cost a whole lot more if I don’t have insurance. For instance, some recent blood tests were billed at $350. Negotiated rate was $23. The entire system is that way top to bottom.

Before a doctor visit a few weeks ago I asked the “check-in” staff how much the visit would cost. I said I don’t want it to cost as much as the last visit which was a “new patient” visit and was billed ridiculously high imho ($230 billed, $140 out-of- pocket for a visit to get a prescription renewed). She couldn’t tell me how much it’d cost. Said they’d just have to run it through the insurance. I cancelled the appointment and walked out. The problem is I have one prescription (levothyroxin for hypothryroidism) that I’ll be taking the rest of my life, so I really should get a prescription. It’s a cheap medicine, but the doctor visits are expensive. And this new doctor only gave me a 3 month supply vs. 12mo supply w/ previous doctor. This is a problem and of course I don’t trust him. I cynically think he’s milking me. Unless I order from Canada, which I heard might work. I’d hate to get in trouble with the law over thyroid medicine though.

Yes, I ramble, but I see a way to cut a lot of cost out of this process. Yes, I take some risk, but that’s OK.

109 anon December 2, 2016 at 6:37 am

Good point that cheap plans at least get you the insurance rate from providers.

110 Troll me December 2, 2016 at 7:31 am

You always need the prescription though, so if the issue is the cost of doctor visits to get the prescription it’s not going to help you to order from Canada.

Also, while it’s allowed to bring personal amounts across borders, I’m pretty sure the mail order stuff it’s always possible that it will get legally taken away enroute. Probably the risk is very low, but the sure thing if med expenses are high and you have to order internationally, you might actually be best off to take a short holiday so there is zero doubt that you can bring it back with you.

111 Brian Dixon MD December 2, 2016 at 7:32 am

I’m sorry that you’re experiencing this. That’s why I post my prices on my website and more physicians are opting out of insurance and going to direct pay.

What most people dont realize is that insurance contracts underpay doctors and then contractually binds us from divulging the details. Who wins from this purposeful sleight of hand? The insurance company.

Go read my plan http://www.changehealth.today then share with friends and family. We must fix our system from the ground up and the government cant do it for us.

112 JWatts December 2, 2016 at 9:43 am

“She couldn’t tell me how much it’d cost. Said they’d just have to run it through the insurance. I cancelled the appointment and walked out. ”

That’s an inherent problem with the system and you did the right thing. I’ve also encountered a situation where absolutely no one on staff could tell me how much a non-required but “recommeneded” procedure would cost. Not even to an order of magnitude. I asked them whether it would cost around $100 or more than $1,000. No one knew. I told them no.

The next week someone from the Clinic called and told me they had a response back and the procedure would be $2,300. I wonder how many people (who are used to having co-pays and who’s insurance would cover it) would have just said sure. My guess is that most would.

113 Bob from Ohio December 2, 2016 at 10:00 am

“access to negotiated rates is likely as valuable as any catastrophic plan ”

Like in international trade, I have always favored requiring “most favored nation” treatment of individuals. There would one rate for any procedure. No setting of the rate by government but whatever is allowed to one must be given to all.

114 Hazel Meade December 2, 2016 at 10:38 am

Well, that conflicts with the use of health insurance as pre-paid health care. You’re paying $$$ every month for access to the reduced price, like a discount club.

115 Ricardo December 2, 2016 at 12:39 pm

Under this idea, Medicare and Medicaid would almost certainly wind up paying higher prices than they do currently. If you are one of those people who advocates “small government” and decries increases in entitlement spending, your only option to reign in entitlement spending after losing control on prices is cutting back on what these programs will cover, e.g. “death panels.”

116 Hazel Meade December 2, 2016 at 10:37 am

Even if that insurance pays nothing , access to negotiated rates is likely as valuable as any catastrophic plan for many.

Yes. I had one of those “junk” catestrophic plans, that cost $60/month, with a $10,000 deductible – pre-Obamacare.
I had an emergency appendectomy, and the insurer negotiated prices brought the cost down from ~$30,000 to ~$6,000. I didn’t even meet my deductible!

117 Amigo December 2, 2016 at 3:16 pm

I had similar experience when my wife broke her wrist. @$7k, not meeting catastrophic deductible. I have savings for those type of things and that’s the way it should work. But without the negotiated rate it would’ve cost far more. I don’t remember the billed amount with surety, but if I recall it was in ballpark of $30k when all said and done.

These are not the type of things I can negotiate a rate on the spot, and I’ve fortunately not had to do it after the fact.

One of the key outcomes of these billing practices is it makes me not trust anything associated w/ the healthcare system. I can’t help it, but even as a doctor is talking to me, I’m wondering is this necessary, or is there some other incentive going on. Do I really need to come back in in 3 months and do this again? Why won’t he give me a 12 month prescription like I’d convinced my other doctor to do? Are all of these tests necessary, seems more than my last doctor ordered? Why is he wanting me to come back in to go over the results? Is there something I should be concerned with, or is he just needing some revenue? I hate to think that way, but I can’t help it.

118 Hazel Meade December 2, 2016 at 3:55 pm

So, a thought that I had is that the insurance company should have a representative that works with the patient in an advisory capacity. Not to say “we’re not going to pay for X, Y, and Z”, (because if it’s under the deductible, they won’t pay for it anyway), but to get the doctor to the tell the patient why he’s spending what he’s spending, to help the patient make informed decisions. Like a doula for financial planning. (A doula is a person who assists a woman in labor by dealing with the doctors and communicating the woman’s desires, so she doesn’t have to stress out about it or get in an argument with the doctors in mid-labor.) You could be laid up in a hospital bed and barfing your guts out from chemo, and the advisor would do the work of gathering cost estimates and laying out which costs are fixed and which ones are negotiable, and then present you with a summary and let you decide what, if anything, to cut.

119 msgkings December 2, 2016 at 4:09 pm

Nice idea but wouldn’t a patient advocate be another cost?

120 Hazel Meade December 5, 2016 at 10:02 am

Clearly, the question is whether the patient advocate would be cheaper than paying for all the unnecessary defensive testing the doctor is going to order.

121 rayward December 2, 2016 at 6:28 am

Lest readers forget, the point of Obamacare repeal isn’t to free insurers, but to free the wealthy from the taxes that fund Obamacare. To see what is in front of one’s nose needs a constant struggle.

122 Bill December 2, 2016 at 7:06 am

Hey, don’t tell them about the Net Investment Income Tax of 3.8% for those earning above $250.000 that helps fund Obamacare..

123 Alain December 2, 2016 at 11:08 am

Hey, let’s enslave those other people so I can get what I want.

You are reprehensible.

124 Brian Dixon MD December 2, 2016 at 7:08 am

I found the solution.

Healthcare interactions are actually very straightforward: a patient and a provider. Nothing else needs to come between them.

My idea is a bipartisan approach creates market forces that empower patients and restores physician autonomy. My website explains how in a 3 minute video.

I work with patients on a daily basis and see needless suffering because of our greedy system. I would love to chat with anyone about my idea as I need your help to take it viral and into the general public discourse.

A health revolution is indeed coming and will change our country for the better. http://www.changehealth.today

125 Bravin Neff December 2, 2016 at 8:18 am

@Brian Dixon MD: Are you an automated troll bot? Because your posts, all of which end in a clickbait commercial, seem like it.

126 AlanG December 2, 2016 at 9:19 am

and the click bait is pretty useless when you read his proposal. Basically a troll for the medical profession.

127 MOFO December 2, 2016 at 10:11 am

Thats fine, but if you provide the same link over and over it looks like spam. Trust me, weve seen the link by now.

128 Brian Dixon MD December 2, 2016 at 11:05 pm

Y’all are funny. Take a step back and think about it. What is a healthcare interaction?

A person with a question and a person with an answer. Period. Why do you need to involve the government or anyone else in that interaction?

Call me a troll bot or whatever you wish but everyday I go to work, I see my plan working. I have set price schedule. If you want to see me, you pay a set price and I provide a service. More and more physicians are going to this model. Why? Is it because we’re mindless trollbots?

Nope, it’s because it makes sense. Just like buying a pizza. Or a car. Or anything else.

I built the rest of the plan around that premise and it makes sense. I’m sorry that the system has tricked you into thinking you need to buy a commercial product in order to survive. But I can say with 100% certainty that the trend of doctors and other health professionals leaving insurance behind will only be increasing. So if Americans are hellbent on paying premiums to an insurance company and not getting any actual healthcare, who am I to say otherwise?

129 carlospln December 3, 2016 at 12:05 am

You’re not a physician.

You’re a shrink!

130 C December 2, 2016 at 7:53 am

In some weird way the ACA reminds be of US involvement in Iraq at the start of the Obama administration. All the Bush supporters said “We’ve got things more or less under control you’ve just got to keep following our lead” The Obama folks replied with “We thought it was a bad idea to start with. It’s not working as well as you say and we’re not going to keep anything moving forward.” End result was arguably (though not conclusively) the worse of all possible worlds.

131 TMC December 2, 2016 at 8:19 am

I’m pretty sure it was Obamacare that has told insurers to get out of the marketplace as soon as possible.

132 The Original Other Jim December 2, 2016 at 8:54 am

>”A repeal vote would tell the insurers that sell on Obamacare’s marketplaces to get out of the marketplace as soon as possible.”

Which is exactly what they’ve been doing for years. 80% of them are already gone.

But please, keep up the fearmongering.

And keep wondering why you lost the election.

133 Art Deco December 2, 2016 at 9:09 am

They need to craft a replacement, not a repeal. Problem: a sustainable replacement cannot incorporate first-dollar coverage unless you have administrative rationing a la the British National Health Service. It’s doubtful the Republican caucus has the stones to enact a plan which incorporates large deductibles and promotes price transparency, and if they did, the Democratic Party’s media wing would locate everyone in America likely to be injured by such a solution and put them on the nightly news day after day for a year.

134 Ricardo December 2, 2016 at 9:41 am

A paper from 2007 estimated that half of health spending in the U.S. was for chronic conditions: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3064915/ .

Moreover, we know that the distribution of health spending per person is very lopsided and approximately follows the 80/20 rule. This suggests first dollar coverage is mostly a red herring. If you want to keep costs down, you are going to have to go after big ticket items in the U.S. health care system such as treatment for cancer, diabetes, and chronic kidney disease and the difference between a $0 and $1,000 deductible is almost certainly not going to play a crucial role in keeping the costs of treating these diseases down.

135 Art Deco December 2, 2016 at 10:11 am

This suggests first dollar coverage is mostly a red herring.

It suggests nothing of the kind, and your point about skew distribution is irrelevant. The insistence on first-dollar coverage with it’s opaque prices and cross-subsidies prevents any efficiencies which might be had from price signals. Slap people with a bill for $150 for visiting the emergency room and they’ll be sensible and stay home.

As we speak, out of pocket spending is over $330 bn a year and spending on household insurance is roughly $200 bn. A comprehensive program of public insurance conjoined to private plans insuring employee pools (offered, say, by trade unions, credit unions, or stand-alone associations set up by particular employers) would require deductibles of roughly $9000 for an ordinary size household if the current distribution between public spending, insurers’ spending on employee pools, and household expenditure were to be maintained (presuming every household in the country were insured).

136 Hazel Meade December 2, 2016 at 10:28 am

The insistence on first-dollar coverage with it’s opaque prices and cross-subsidies prevents any efficiencies which might be had from price signals.

What price signals? I’ve yet to see any doctor tell me in advance what anything is going to cost. Certainly not if it is “free” preventative care.

137 Art Deco December 2, 2016 at 11:38 am

Well, you need state-level guild law which requires hospitals to publish their chargemaster and commit to those prices. Ditto clinics. A controlled vocabulary for medical services might help in this regard.

I go to the veterinarian and they give you an estimate up front. I’ve received one for oddball services from my doctor as well.

138 Hazel Meade December 2, 2016 at 1:59 pm

Well, you need state-level guild law which requires hospitals to publish their chargemaster and commit to those prices.

So, the federal government withholds medicaid funding unless states pass such laws. Not a new concept. We could require price transparency without controlling prices. It’s regulation, but it’s sort of correcting for the way in which third-party payment fucks up the price mechanism. If we’re going to get out of the conundrum this moves things along.

139 Ricardo December 2, 2016 at 10:40 am

Average household size is 2.54 so that gets us to an average deductible of $3,500 and change per person. I just checked a Bronze plan offered by Blue Cross in California for a single person and the annual deductible is $4,800. High deductibles are already a feature of the system you are claiming needs to be replaced.

As to your first point about ER visits, again, serious acute and chronic conditions make up a much larger proportion of health spending than frivolous ER visits. And as I already pointed out, a trip to the ER under a Bronze plan will be subject to a yearly deductible of $4,800, at least in California. Even after you reach the deductible, you are still on the hook for 60% of the bill (which will almost always be higher than $150) until you reach the out-of-pocket maximum. Even many employer-sponsored insurance plans already to include co-payments of $100 or more for ER visits.

You are presenting solutions that have already been implemented.

140 Hazel Meade December 2, 2016 at 10:49 am

I would make the deductibles even higher than that personally.

However, if high deductibles are still not creating price transparency, then perhaps we need to do something additional to make prices transparent. The point of the high deductibles is to incentivize people to shop around. If you have a chronic condition, you can shop around, provided you can actually tell what things cost. I see no reason why we can’t get some competition in markets for diabetics and other chronic conditions. Most people with chronic conditions are not confined to a hospital bed. They can search the internet.

141 Art Deco December 2, 2016 at 11:57 am

Large deductibles would have to be made universal. They are not at this time.

142 Ricardo December 2, 2016 at 12:10 pm

“Large deductibles would have to be made universal. They are not at this time.”

That is an expansion of PPACA, not a “replacement.” Push more and more people out of employer-sponsored coverage and into Bronze plans — perhaps by abolishing the tax deduction for employer-sponsored coverage.

143 JWatts December 2, 2016 at 12:21 pm

“Large deductibles would have to be made universal. They are not at this time.”

They are a minority.

144 Hazel Meade December 2, 2016 at 12:27 pm

Push more and more people out of employer-sponsored coverage and into Bronze plans — perhaps by abolishing the tax deduction for employer-sponsored coverage.

Yes, no, yes. Two out of three.
Push more people out of employer sponsored coverage onto high deductible policies by abolishing the tax deduction for employer sponsored coverage.
The difference between a “Bronze” and a standard high deductible policy is that the standard high deductible doesn’t have to cover the “essential benefits” like maternity, mental health, substance abuse treatment and pediatric dental care. Basically, let people buy high deductible policies that cover unplanned core medical expenses, not peripherals. It also doesn’t have to cover “free” preventative treatment. It also doesn’t have to be community rated or include pre-existing conditions. You can charge risk-based pricing. A “bronze” plan by definition presumably means that all of the
ObamaCare regulations apply to it, which is what drives up the price.

145 Art Deco December 2, 2016 at 12:51 pm

There is a distinction between medical care and services offered by people with medical training. Psychotherapy and counseling are not properly considered medical care, nor are such things as cosmetic surgery, contraception, abortion, eyeglass frames, cosmetic dentistry, and most uses of psychotropic medication. And it’s doubtful there really is such a thing as preventive care, except for some cancer screenings.

146 Hazel Meade December 2, 2016 at 10:26 am

Throw drug deregulation into the mix.
High-deductibles for cost pressure, less regulation on delivery of home treatments. More competition for things like epipens.
Transparent pricing + competition is usually a very good formulat for keeping costs down.

147 AlanG December 2, 2016 at 11:36 am

Epipens are generic and there has been competition but marketing by Mylan made it a brand name. Hard to get around that one. High deductibles for cost pressure, give me a break. Do you know the monthly cost of some of the new biologicals? If someone needs one of these drugs to manage a chronic disease how are they supposed to do it. Eventually there is a biogeneric but that’s 10-15 years after the initial market entry. I guess you just want people to suffer. At least be honest about it.

148 Hazel Meade December 2, 2016 at 12:07 pm

You know, we don’t have to make brand new pharmaceuticals available to absolutely everyone right away. They can live with some of the older drugs that they used before the new drugs were invented, for a while.

I know, I’m a heartless monster.

149 JWatts December 2, 2016 at 2:50 pm

“I know, I’m a heartless monster.”

You want people to live off pharmaceuticals from the 1990’s! Why that’s absolutely barbaric.

150 Rich Berger December 2, 2016 at 9:16 am

I’m absolutely shocked that vox cannot identify a way out. Especially considering all the brainpower in residence, like Ezra and Matt.

151 AlanG December 2, 2016 at 9:18 am

And what is your solution? It’s easy to throw stones, more difficult to solve a problem.

152 derek December 2, 2016 at 9:58 am

1. Remove the federal government from the equation except as a provider of cash with some very basic conditions.

This should not be a Washington debate. Let the states do their very own insurance death spirals if they want. Let the well run rational states manage their systems as well. Let them be accountable to the voters so that your health care isn’t dependent on voting for some other issue.

What you are saying is ‘we can’t change the VA because where would those veterans get their health care’! ‘We can’t change the school system because where would those poor kids in the inner city get their education!’.

153 Thomas Taylor December 2, 2016 at 10:45 am

State elections don’t have other issues? Who said that?

154 Art Deco December 2, 2016 at 11:33 am

1. Cut the country up into catchments. Each catchment will have a minimum population of about 1.1 million and a metropolitan settlement of at least 550,000 people therein.

2. Incorporate two insurance authorities in each catchment, one to provide medical insurance, and another to provide long-term care insurance. The governing body of each would be the state legislators whose constituencies touch on the catchment. Each would have a weighted vote.

3. Incorporate four nationwide authorities. Two replicate the catchments but enroll a specialty clientele poorly integrated into geographic regions (e.g. Americans living abroad, military families, refugees and other temporary residents, reservation Indians, people in itinerant occupations, residents of various insular dependencies, residents of Alaska). The other two provide binders. Congress would be the governing body of these.

4. Define by statute an outer boundary of what constitutes ‘medical care’ and ‘long term care’. The governing body of the authorities could adopt the outer boundary or could constrict per their discretion.

5. Enfranchise the governing bodies of each authority to assess premiums on everyone resident in the catchment for at least a year. The franchise would allow the authority to assess up to x% of discoverable personal income up to a maximum of $Y per year. The value of Y would be adjusted each year in accordance with the annual change in nominal personal income per household. The governing bodies could assess the full amounts or a lesser amount per their discretion. The IRS would collect the premiums through withholding.

6. Sort the population of your catchment into cohorts through random assignment. First assign the individuals in the quondam Medicare clientele, then sort the remaining fragment of such persons’ households, then sort all other households. Random assignment will render the composition of each cohort pretty similar. The number of cohorts would be determined by the population of households but would be perhaps 15 for a typical catchment. The authorities will be letting out contracts to insure these cohorts.

6. Sort your cohorts into three piles. Each year, you let out a three-year contract to insure the cohorts in one of the piles. The authority writes the contract, which incorporates the substantive coverage and delineates procedures regarding the interaction between providers, underwriters, utilization review specialists, arbitrators &c. The contract would also set performance metrics, defining the % of providers in each specialty who must accept the insurers posted and negotiated rates for the contract to be fulfilled.

7. Open the bidding on medical insurance this year’s cohorts, allowing participating insurers to bid on one or two cohorts. The bid would be in the form of stating the deductibles you as a company will require, presupposing that deductibles for various client segments will have a fixed ratio to each other and a bid on one commits the insurer to a given deductible on the others (say $x for an individual in the former Medicare clientele, $nx for a single person outside that clientele, $2nx for a 2 person household, and $3nx for a larger household). The benefit to the company will be the premiums collected from the cohorts each year.

8. Open the bidding on this year’s cohorts for l/t care insurance. Here, in lieu of a deductible, the bid might be for the maximum lifetime spend-down for the individual in question (say, 100% of assets up to $x).

9. Conjoin the forgoing to efforts to promote controlled vocabulary for medical billing via a federal commission. Each state could then compel it’s providers to make use of the controlled vocabulary so stakeholders could compare prices. Such a commission might also produce a model statute governing the commercial aspect of providing medical services (e.g. provisions requiring due notice of fee changes and due notice that the re-imbursements of a given insurer will no longer be accepted).

10. Provide through federal law a legal conduit for the formation of actuarial pools, enfranchising trade unions, credit unions, and stand-alone associations of a company’s workforce to offer insurance to those who meet their bond of association. Participating employers would withhold a standard clip off their employees wages and salaries (say, 8.5%, with a maximum assessment of $13,000) while individual households would face a $ value charge derived from a formula which combined the size of their household, their longevity with the program, and the deductible they would accept in a given year. This would be an expensive guaranteed-issue product, covering all charges over the stated deductible up to a maximum determined by the deductible you face for your public insurance. Stated deductibles would have to exceed a standard value (say, $4,000 per household, adjustable each year). Such insurance would be old-school, requiring the client to apply for re-imbursements.

11. Restructure federal income taxes. Make the tax base comprehensive. Calculate liability as a flat assessment on a person’s income less a general credit for each taxpayer and each depended and less a geezer credit for each person on the form who qualifies as elderly or disabled. Many will be due a net rebate to be paid out in installments. Cap the rebate at a particular % of earned income, but relax the cap for the elderly and disabled. This will allow you to sluice cash to people to pay for services below the deductibles which will be incorporated within the public insurance. (You can also replace programs like LIHEAP, Section 8, SNAP, and TANF with this scheme).

12. Provide a legal facility for mandatory savings for medical care and l/t care. These would be assessed by the IRS at a% of your income for the one and b% for the other.. These accounts would have a fill-line, so if you had cash in the account over a certain sum, you could remove the excess and use it for other purposes. Out of pocket charges from a medical provider could be satisfied with the presentation of a debit card for the account. Accessing the l/t care account would require a hearing in front of an administrative tribunal. Philanthropic benefits could make checks payable to these accounts, and relatives helping you out could do so as well.

13. Add some ancillaries for certain clients, e.g. institutional infirmaries at military bases and federal prisons, supplementary insurance for veterans, travel vouchers for those residing outside the continental U.S. &c.

14. Mandate travel insurance for anyone wishing to enter the U.S. who would not qualify for the foregoing.

Of course, getting from here to there is a problem, as is the number of moving parts. We’re the foregoing successful, you’d get some real prices appearing, you’d have some sort of coverage (if lousy high-deductible coverage) for everyone bar illegal aliens, you’d remove the uncertainty employers are faced with re medical costs for their employees as well as making employee compensation more granular, you’d institute a strict limit on the share of personal income to be devoted to public insurance, and you’d devolve to state legislators the finicky questions about what constitutes medical care.

155 AlanG December 2, 2016 at 9:17 am

I’ve been studying healthcare reform from back in the days of the Jackson Hole Group meetings. I have also had first hand experience helping my younger daughter out with the Obamacare policy she had for three years before moving to CA and enrolling in a major HMO out there (which she really likes). Obamacare worked for her as she was an independent contractor and did not have a full time employer which offered health insurance. Many of her peers also fall into this category and it’s becoming more prevalent as firms don’t want to pay benefits and hire people at half-time to work. Without employee provided insurance, something like Obamacare is needed. the hiigh deductible policies work only for the very wealthy or the very healthy. Someone with a $40-50K/year salary isn’t going to be enjoying having to come up with $10K to meet a deductible if they have some type of health problem that involves hospitalization or other costly tests/interventions. Tax credits, as in the Price plan, also don’t work very well for this group of people who pay very low taxes anyway. The tax credit number that I’ve seen is only enough for one of the high deductible policies.

IMO, the only ‘rational’ solutions are a single payer NHS model or a private insurance model with vouchers. Both of these are being used in various EU countries successfully. I’m agnostic as to which one would work in the US as they both have pros and cons. Either system will involve a fair amount of government regulation. The NHS works well in the UK and no government has seen fit to dismantle it. The insurance model is used in both Switzerland and The Netherlands and works well. All three of these countries have better health outcomes overall than the US.

The current hodgepodge system is clearly not working at a variety of levels.

156 JWatts December 2, 2016 at 9:51 am

“Someone with a $40-50K/year salary isn’t going to be enjoying having to come up with $10K to meet a deductible if they have some type of health problem that involves hospitalization or other costly tests/interventions.”

Insurance isn’t going to change the fundamental issue. Which is the high cost of health care in the US.

157 AlanG December 2, 2016 at 9:57 am

Yes, health care is expensive, but what is your solution?

158 Hazel Meade December 2, 2016 at 10:10 am

If people are paying more of the cost out of pocket, there will be more effective price signals and cost control. The insurance should protect you from bankruptcy in an emergency. The deductible gives you a reason to care about price when it isn’t. The market right now is dysfunctional because there are no price signals visible to the patient, so there is really no price equilibrium. Nobody pays the official price, they pay prices negotiated with the insurer, which are generally confidential. If people are paying out of pocket the medical profession will be forced to disclose prices in advance, so people will be able to choose and put downward pressure on cost. Once real prices are established, that will bring down costs for emergency treatments as well.

159 Lord Action December 2, 2016 at 10:10 am

Clearly we have to, at some point, buy less of it. The evidence suggests we’re not getting good value for money anyway.

Perhaps we should start by doing less to subsidize demand?

160 JWatts December 2, 2016 at 10:16 am

High deductible plans that encourage the patient to avoid expensive procedures and shop for low cost care.

The medical system is expensive, because for decades the medical industry has been able to charge very high rates with poor feed back. When an insurance company tries to push back, the patient gets upset because the insurance company is interfering. When the insurance company raises rates, people blame them instead of the medical industry.

161 hoonose December 2, 2016 at 11:17 am

Not so easy. Not at all when it comes to docs and Medicare, as Medicare sets the rates. Hospital Medicare DRG’s have set the inpatient rates since the early ’80s. Even with the private carriers there is heavy pressure and negotiation on reimbursements. Bigger carriers have more price control strength.

Some big money is in the hospital outpatient setting. There the hospital lobbies still get great deals. My local hospital gets about 3X what I would get for the same outpatient testing.

162 Art Deco December 2, 2016 at 11:43 am

There is no solution. There are trade-offs between different sorts of dissatisfaction. A sustainable system requires rationing mechanisms and fixed limits on the share of personal income devoted to publicly financed medical expenditure.

163 Hazel Meade December 2, 2016 at 10:00 am

Someone with a $40-50K/year salary isn’t going to be enjoying having to come up with $10K to meet a deductible if they have some type of health problem that involves hospitalization or other costly tests/interventions.

Um, yeah, you’re not supposed to enjoy it. It’s just supposed to protect you from bankruptcy. That’s all. Where is it written that you should sail through a $50,000 emergency hospitalization with no significant impact on your budget? Can a person on a $40-$50K salary afford to pay back $10,000 in debt? Yes, they can, over a few years. That’s all that is relevant. That’s what insurance is for. It’s to protect you financially, not to make it like health problems never happened.

164 AlanG December 2, 2016 at 10:08 am

But you are overlooking the blunt fact that chronic health problems can result in $10K of costs every single year. Now maybe you are a callous person and think well that’s just tough, you drew a short straw in the genetic pool but I don’t think this is the basis of a moral country.

165 Hazel Meade December 2, 2016 at 10:11 am

So, basically you are saying that it’s moral that someone else should pay for your chronic condition? Everyone who has a chronic condition – someone else should pay for it?

166 Hazel Meade December 2, 2016 at 10:15 am

I mean, they ARE only paying $10K already, evne if their condition costs $50K, or $100K.
You’re basically saying “They shouldn’t pay anything! it should be free! Life shouldn’t be unfair!”

Or what would you set the bar at?
$1000 a year? $50?

167 anon December 2, 2016 at 11:14 am

I do not have a chronic nor expensive condition (I got a flu shot this year, I think that was it), but I think that yes, the insurance pool for expensive events should be as wide as possible.

If everyone has some odds of being told they have cancer, it makes sense to me for it to be funded by everyone.

We are a natural insurance pool.

168 anon December 2, 2016 at 11:36 am

As an aside, pushing everyone who is a little sick to a state level high risk pool, and then underfunding it, is not a way to share costs.

It is a way to enrich insurance companies that will then cherry pick the young and healthy until the cows come home.

(Once when looking for a policy I was told that 2 visits to investigate back pain meant that the majors would not cover me and I should go to the high risk pool.

And here I thought the pain had gone away.

That is not what I thought “high risk” really meant. But it is a great thing for the insurance company when you can reject the hint of a claim as “high risk.”)

169 Alain December 2, 2016 at 11:12 am

If you don’t think it is moral then YOU should contribute to a chairity which covers those expense. Putting a gun in some else’s face and saying : “you shouldn’t think it is moral, and if you do I will kill you. Pay up!”

170 Art Deco December 2, 2016 at 11:47 am

But you are overlooking the blunt fact that chronic health problems can result in $10K of costs every single year.

Well, resources devoted to addressing those problems are resources not devoted to other problems. You can try dog-chasing-its-tail subsidies (not sustainable, see the first 20 years of Medicare), a command economy in medical services (sucks for certain clients), or charging people for consuming medical services up to a certain limit (sucks for a different array of clients). There is way to run this which is not infested with suckitude.

171 Brian Dixon MD December 2, 2016 at 11:10 pm

Single payer won’t work. Why? Because you won’t have physicians. We’re slowly waking up to the fact that we don’t need health insurance to help patients feel better. We can just work directly with patients. The entire “direct” care model speaks to this.

As a child psychiatrist (one of maybe 8500 across the country now), I can say with 100% certainty that if I’m forced to participate in a single payer/insurance model, I’ll quit. Why? Because that’s the antithesis of the American business model. I’ve worked and trained for 13 years and I have the right to charge what I think my time and expertise is worth. We respect that model in our phones, our lawyers, our mechanics…why not our physicians?

I think my system works better because it builds full transparency on all sides. Patients are accountable for their own care, society provides preventative care, and providers are accountable to the patients they serve. It’s a win-win-win proposition.

172 Hazel Meade December 2, 2016 at 9:51 am

Repeal, but with a clause that the policies have to be renewable provided the customers keep paying their premiums. Like COBRA, but indefinite.

173 Issao Natsumoto December 2, 2016 at 10:04 am

Isn’t COBRA the enemies of G.I. Joes and America?

174 Lord Action December 2, 2016 at 10:13 am

I believe that Cobra is not all-caps.

175 Issao Natsumoto December 2, 2016 at 10:21 am

But the way they pronounce it seems to demand all-caps


Maybe it is spelled “Cobra!” instead? I don’t speak English very well.

176 AlanG December 2, 2016 at 10:05 am

Do you get subsidized employer insurance? Do you know what a full price policy costs? It’s not an issue of just having renewable policies which might not be all that good if the preferred provider pool shrinks from year to year. If there is not some kind of mandate that requires everyone to purchase insurance you won’t have a decent risk pool on which to base premium pricing. I don’t see any of the Republican plans addressing this matter. Even Obamacare tax penalty was worthless in terms of encouraging signups.

I’m on Medicare and get my Medigap and drug benefit from my former employer. My premium is 25% of the full premium which has gone up to $1160/month. Of course that employer provides a generous policy with excellent coverage and modest deductibles. My wife is also on this policy but as a non-employee she pays 50% of the premium. I can tell you that with our Medicare premium (news flash – Medicare is not free!!), we will be paying about $1200/month in 2017. The Medicare Part B premium went up about 10% for next year and Medicare has good negotiated pricing. Prices keep going up!

177 Hazel Meade December 2, 2016 at 10:13 am

I do and yes. I’m not looking for a “solution” that means “everyone gets to keep their free shit”, or “nobody should have to pay the actual cost of the health care they consume”.

I’m looking for a political solution that eases people out of the ACA merketplaces.

178 AlanG December 2, 2016 at 11:47 am

What kind of free stuff are you talking about? My daughter had a Silver Obamacare policy for three years with no subsidy. There was nothing free about it other than the gynecological exam, but you had to go to an MD in the plan for that. Birth control pills were free only if they were generic which hers were not. You are just like the rest of the folks that are talking out of the side of their mouth. Do some home work and you will see that Obamacare was horribly imperfect but not for the reasons you state.

179 Hazel Meade December 2, 2016 at 12:13 pm

Well, if she had no subsidy then she wouldn’t be harmed by my proposed solution above, which you objected to, on the grounds that COBRA premiums are more expensive than the employer-subsidized premiums. If she’s not benefiting from a subsidy then her premiums will stay the same. And if the people sicker than her are driving up the premiums, then guess what? She can stop buying it and buy something cheaper in the newly deregulated market in which she’s not forced to subsidize sicker people. Either way, your daughter is not worse off with an ObamaCare repeal.

180 Art Deco December 2, 2016 at 10:17 am

Currently, employer pools purchase about $800 bn in health services. An 8.5% assessment on employee compensation (topping out at about $13,000) could finance that.

181 JWatts December 2, 2016 at 10:23 am

“Do you get subsidized employer insurance?”

You realize it’s only subsidized up to the tax rate? So, your talking about 20% on average.

The reason, that insurance for non-working people tends to be higher is mostly because non-working people tend to have more expensive medical conditions.

182 hoonose December 2, 2016 at 11:08 am

I think what you are seeing is that your employer is paying very dearly to cover you in any way on the office plan. If you go Medicare/supplement on your own, your premiums will be much lower and help reduce costs for the other employees. Medicare shouldn’t cost you each $600/mo. I pay about $250 and another $125 for the supplement. Drug plan is smaller potatoes.

183 AlanG December 2, 2016 at 11:42 am

Our Medigap policy include Rx coverage and it’s better than any Part D program around which is why the cost is higher. We have access to any drug no questions asked and the copay per prescription is modest. That is why we are sticking with this program. I’ve priced it out and it’s overall cheaper than any alternative.

184 Thiago Ribeiro December 2, 2016 at 10:05 am

“Em casa que falta pão, todos ralham e ninguém tem razão”. Sad.

185 The Free Market Is Not God December 2, 2016 at 12:43 pm

I put that in Google Translate.

“In the house that lacks bread, everyone scolds and no one is right”

186 Thiago Ribeiro December 2, 2016 at 2:21 pm

Yep (Google Translate is surprisingly sharp, isn’t it?).

187 GoneWithTheWind December 2, 2016 at 10:55 am

This is why I say don’t repeal it, instead make it voluntary and not mandatory AND end all federal subsidies. Let those who love Obamacare keep it and keep their doctors if they want.

188 hoonose December 2, 2016 at 11:09 am

I would like to see a public option, and let the private carriers do as they free market may. With sensible state or federal regulations of course.

189 Alain December 2, 2016 at 11:17 am

I would like the democrats to say “we lied. We sold the ACA under free pretenses. It was entirely about ‘access’, and by that we mean giving away services to people we like, it was not at all about cost control. We did this because we knew that access would not pass, and that the electorate did not want it, but we are dishonest sanctimonious shits and we wanted to pass something that made us feel good no matter how much it costed”.

Dammit. And they were not called out on this once, not once. The lying bastards.

190 AlanG December 2, 2016 at 11:44 am

Is this even a serious post? You imply that the insurance companies that offering these policies are not controling costs. Have you even read one of Bronze or Silver policies. Maybe you don’t know anyone who has had one of them as I do. There are significant cost control features in the policy with regard to the MDs that are in the plan, Rx tiered pricing and co-pay, etc. If this is the best you have you need to do some homework.

191 Hazel Meade December 2, 2016 at 12:20 pm

If the cost control is so great why are premiums rising?

192 The Free Market Is Not God December 2, 2016 at 12:42 pm

Mostly because the wonderful “free market” will bear it. Sick people are very vulnerable. Even with ObamaCare, we’re still in a capitalist economy, which tends to prey on its most vulnerable citizens like sick people, school children, and prisoners– in order to enrich more “deserving” people like highly paid bankers or insurance executives, or people like Martin Shkreli.

193 Hazel Meade December 2, 2016 at 2:07 pm

Mostly because the wonderful “free market” will bear it. Sick people are very vulnerable.

We’re not talking about a free market. We’re talking about one in which people are FORCED to pay for insurance. So yeah, under the individual mandate, insurance companies can keep on jacking up premiums and people have to bear it, because it’s the law.

Funny how that works. When people are forced to buy your product they have less negotiating power. Who could have guessed?

194 anon December 2, 2016 at 12:45 pm

There is a natural explanation for this. New treatments are higher tech, require more facilities, equipment, and highly trained personal.

“Let’s try radiation and chemo” is more expensive than “here is a bottle of laudanum.”

Similarly in vitro is more expensive than sleeping with his brother.

195 Hazel Meade December 2, 2016 at 2:10 pm

Yes indeed, giving people all the latest treatments is more expensive. Tell me again about the fabulous cost control.

196 anon December 2, 2016 at 3:44 pm

You might have an interesting time selling low cost insurance that promises “not the latest healthcare!”

197 Hazel Meade December 2, 2016 at 4:01 pm

It’s actually not a bad idea.
What if you could market a plan that only covers <1990s technology and pharmaceuticals?
You don't have to sell it as "not the latest", you sell it as "affordable, reliable, tried-and-true".
It you want the latest and greatest, you have to pay out of pocket.

198 The Free Market Is Not God December 2, 2016 at 12:35 pm

AlanG, you don’t understand. For a Republican, the whole point of discussing health care– or anything– is to find a way to bash Democrats– to “prove” that Democrats are evil, corrupt, stupid, liars etc. Facts don’t matter. We are in a post-truth political system now. See wikipedia page on post-truth politics.

That’s why the Republicans have no plan to replace ObamaCare– or have tons of different plans, if they want to phrase it that way. Because doing something constructive is not an area of focus for Republicans. And they now control all branches of government. The reason why they do is because voters have decided that they would rather bash people, and have their elected officials bash people– rather than to get anything constructive done.

Voters, in their infinite wisdom, rewarded the politicians who simply bashed their opponents incessantly, and didn’t try to get anything constructive done.

We are in for some rocky years.

199 AlanG December 2, 2016 at 1:17 pm

I completely understand this Republican approach to health care. However, though I’m a total libertarian on a bunch of stuff (decriminalize drugs, eliminate all tax preferences, etc) I do believe that it’s a national obligation to protect the health and welfare of its citizens and that means figuring out a way to deliver a basic healthcare package to everyone. Ultimately this is what will happen I just don’t know the time span. If the Republicans want some kind of free market system they better do so soon before the realization that the nation has been conned. I have never had anyone tell me why the healthcare voucher system using current insurance providers as advocated by Fuchs and Emanuel back in 2005 cannot work. I would be happy for one of the experts who is posting to this particular topic will do so and don’t give the answer that it is politically infeasible. I want to know why the nuts and bolts of it won’t work. I’ll treat anyone who has a rational answer to a hamburger at the fast food restaurant of their choice.

200 AlanG December 2, 2016 at 1:18 pm
201 Anon39 December 2, 2016 at 11:14 pm

Hilarious. A plan without a cost. Great, thanks for the insight.

This would require a what, maybe $1 trillion in taxes raised a year? Jesus Christ dude, get a grip.

Never believe a cost savings that assumes government spending decreases due to a redundancy.

I would support a universal catastrophic insurance plan paid by Medicare, so that no more than 15% of income can be spent on healthcare. That should be the goal, for insuring citizens.

202 jorgensen December 2, 2016 at 6:13 pm

There is no mystery here.

The Republican plan is simple:
1) repeal ObamaCare now with a deferral
2) ObamaCare collapses because insurance companies withdraw before the deferral runs out
3) Republicans announce that the failure of ObamaCare proves no such program can work and they will not replace it.

Republican voters as a group are too stupid to understand the plan (and the Republican Party is counting on that). Trump himself is on the record saying that Republican voters are stupid.

203 Massimo Heitor December 2, 2016 at 7:21 pm

People with lots of savings in their bank account can enter a car dealership and buy the car that they want or need and get a happy experience. Other people have a pre-existing condition called NINJA: No-Income, No Job, no Assets. They are denied the car of their dreams.

Students with the highest GPAs and academic records get flattering offer letters and scholarships to attend the top most prestigious universities in the nation. Other students have a pre-existing condition
of low GPA and terrible academic records and they don’t get the same opportunities.

Is this type of pre-existing condition fair? Will Democrats ameliorate these civil rights injustices?

204 Troll me December 2, 2016 at 8:35 pm

I wonder if people try harder in school when 3 of dad’s friends have offered them internships in major companies since the age of 12 …

as compared to children whose most “successful” role model is their teacher, perhaps followed by some number of folks whose humility is sufficient to have lots of self respect while just holding down any job that feeds the kids, etc?

Compare “if you get over an 80 average, Dan’s dad already promised you a kick at the can” as compared to “if you get over an 80 average, you’ll have the right to take out lots of loans and then go compete for jobs in markets where you don’t know anyone”.

Which student tries harder?

Some people face steeper mountains to climb that others. Some start with a lifetime lift pass and a pair of skis.

205 Massimo Heitor December 2, 2016 at 10:19 pm

@Troll Me, you make valid points but for a completely different discussion thread.

206 Anon39 December 2, 2016 at 11:28 pm

Interesting perspective. We should analyze the percentage of students admitted to Ivy League schools I suppose. As percentage of student body, which percentage had rich parents and a 3.0 GPA. And which percentage had over a 3.0 average.

Of course Nathan knows, no poor or minority student takes out loans at Ivy League schools. They are given a full ride, and are readily hired at the best consulting and banking firms. Because who cares about trivial nonsense when a good hire can land your firm hundreds of thousands of dollars in profits. Greed always wins against discrimination in the end.

Protip Nathan, smart people don’t try in school. They don’t have to. Not until the Ivy League masters engineering or conceptual mathematics courses (topology fucking Christ) Then we have to actually start looking at the material on a weekly basis. If you have to study or work at school, congratulations, you were meant for repairing HVACs.

Degree inflation has wasted more money than anything else.

207 Troll me December 3, 2016 at 5:01 am

Life is so unfair. The poor and minorities get such an easy ride. And anyone who was ever challenged by anything they did prior to grad school should never have even bothered with education.

Hard to say whether a degree is worth more or less than it used to be. Less security anyways … but I’m not sure you can blame the degree or education system for the facts of that different economic structure and more job turnover.

If you could get every employer to commit to a dedicated month or two of tailored training for career entrants in many areas of work, probably you could knock back the fact that a master’s is basically worth what a bachelor’s used to be worth in terms of what it does for you to get a job, to only needing a bachelor’s again (sort of on average, because they’re really just not the same thing in some fields too…).

Employers are too risk averse and demand an incredible suboptimal level of EASY signalling instead of digging deeper to see where they can get value and good fits in a company.

Say … you want someone with a master’s because you’re sure they can do the maths and data modelling stuff. But then you decide to look past the first line after seeing they have a BA and not MA, to find that in fact they have all the relevant skills and can be had at a savings of 10k a year relative to the master’s graduate.

I think the question of how many employers are willing to take a few more seconds and be less focused on the specific level of formal qualification is highly related to the extent of “degree inflation”, as you put it. But then I think that points more to a matter of highly suboptimal cost reduction (lower costs for the employer) and risk reduction which forces that.

But hey, school’s not the worst thing ever and there aren’t hungry people roaming everywhere or anything ..

208 Anon39 December 3, 2016 at 6:24 pm

You missed the point entirely. It’s a great thing that poor and minority students don’t pay a dime to attend Ivy League schools. It’s a function of a meritocratic system. Business want these kids because they’re smart and capable. Harvard wants them for the same reason. Like I said, the 99.9th percentile of intelligence is valuable to Bain and Goldman Sachs. They could care less who your father is, outside of China where they actually hired sons of government officials. They want your grey matter and your work ethic.

Most people, by definition, literally do not have what it takes. Just like I can’t make it in the NBA. It’s not a moral failing, it’s just genetic reality.

209 Brian Dixon MD December 2, 2016 at 11:36 pm

How do I know http://www.changehealth.today works? Let me give you an example.

About half of my patients have insurance. And they were miserable. They would see their psychiatrist for 10-15 minutes, get a script and be out the door. And they got worse. This includes kids and adults, rich and poor, of all backgrounds.

My patients tell me that they appreciate how much I listen and how I de-emphasize medications. That I have a system where they can email me and I can address problems without them coming in (thus saving them money.) That they always know they’ll get their 30 minutes to an hour and that I give them my undivided attention. How’s this possible? Because I don’t take insurance. What most people don’t recognize is that insurances skew healthcare. For example, when I do therapy with my patients, it’s not reimbursed by insurance unless I denote to the minute how much time I spent and what exactly we talked about. And click no less than 15 boxes on a computer screen. How is that quality healthcare?

I tell each person I see that my goal is simple: to work myself out of a job. When you’re feeling better, I hope to never see you again. But in the event they need to come back, they’ll know exactly what it costs and exactly how to find me and exactly what’s expected of themselves to be in my care. To me, that’s ideal responsible medicine. Patients and physicians are directly accountable to one another. I grew up on food stamps so every dollar I charge someone for my services I take very seriously as I know many of them have to save to see me. And I’m appreciative of their trust in me and the therapeutic process.

We can complain on this thread all we want but until we put effort into an idea that works: direct accountability between patient and provider, then you’re not contributing to the solution. You are the problem.

Instead, take a step back and really look deeply into my plan without bias with healthy inquisitiveness. There’s a phase-in schedule that I think is sorta cool and having a true universal medical record means you can go anywhere in the nation and your information follows you. We stand at a unique opportunity. Share the idea, talk about it, and let’s get healthcare out of the hands of Trump, Pelosi, Obama, McConnell, Schumer, Greg Abbott, and every other politician.

210 zztop December 4, 2016 at 6:03 pm

The most insane and evil thing in ALL human history is the US Healthcare nonsystem. It’s worse than Nazi deathcamps. That’s right. All the rest of the world says not a peep about their healthcare systems because they work, marvelously, at 1/2 the portion of their GNP’s than that of the USA. The USA is more wrong than wrong and more abysmal than abysmal. It should be a capital crime to even say any more about the US System since it’s all pointless, but goes on and on.

211 zztop December 4, 2016 at 6:10 pm

And, if you hear anything suggesting choice, and empowering patients and their doctors, you should run from it. Any use of those words, empowering patients, is meaningless, at best, and pure evil, in reality.

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