Key Republicans Pushing To Have Obamacare Replacement In Place Before Voting On Repeal
With repeal of the Affordable Care Act now likely sooner rather than later, key Republicans are urging the party to have a replacement in place before repeal is voted on.
With Republicans taking control of both the White House and Congress for the first time in a decade in just over a week now, it’s now inevitable that there will be sufficient support for Republicans to achieve something that has been a goal of the party since the 2010 mid-term elections, the repeal of the Affordable Care Act. In the immediate aftermath of the election in November, there were some Republicans who talked about repeal of the six year old law as soon as Donald Trump takes office, which would mean House and Senate votes on repeal within the next week so that the bill would be ready for the new President’s signature almost as soon as he takes office. The closer we have gotten to Inauguration Day, though, the less likely such a quick repeal has become. For one thing, the Senate is quite busy at the moment with confirmation hearings for the new Cabinet, the public portion of which kick off today with hearings before the Senate Judiciary Committee on the nomination of Alabama Senator Jeff Sessions to be Attorney General. Additionally, with the actual prospect of repealing the PPACA actually now within the realm of likelihood, at least some Republican Senators are resisting the idea of repealing the Affordable Care Act without having a replacement in place:
After publicly airing some of their grievances with the GOP’s current strategy of repealing Obamacare without a replacement plan, a handful of Republican senators put their concerns in legislative writing. Five senators on Monday evening introduced a measure that would delay the next steps on repealing the Affordable Care Act by more than a month. The senators, in their statements accompanying the provision, said the delay would buy Congress more time to work out of the the details of a replacement.
“This amendment will ensure that we move forward with a smart, responsible plan to replace the law as quickly as possible,” said Sen. Rob Portman (R-OH) in a statement announcing the measure. He was joined by Bob Corker (R-TN), Susan Collins (R-ME), Bill Cassidy (R-LA.) and Lisa Murkowski (R-AK) in introducing the proposal.
The proposal would amend the budget resolution currently being considered by the Senate that is supposed to act as a vehicle for the Republicans’ repeal effort. The budget resolution as it now stands directs the relevant committees in the House and Senate to come up with the actual repeal legislation that will be passed through the process known as reconciliation, which requires only a majority vote in the Senate. The budget resolution, which was introduced last week, gives the committees until Jan. 27 to submit their repeal bills for the next steps in the legislative process.
In contrast, the amendment introduced Monday evening would extend that deadline until March 3, so that the incoming Health and Human Services secretary (likely Georgia GOP Rep. Tom Price) has “adequate time to review what the Trump administration can repeal and replace administratively versus legislatively, and ensure that Congress puts in place a responsible timeline for replacing the law,” according to the amendment’s press release.
Also joining in the ‘repeal and replace’ position is Kentucky Senator Rand Paul, who says he has the support of President-Elect Donald Trump:
After Rand Paul spent the last week urging the GOP not to repeal Obamacare without having a replacement plan ready, his phone rang on Friday night with a call from a new supporter: Donald Trump.
“He called after seeing an interview that I had done [talking about] that we should vote on Obamacare replacement at the same time,” Paul said in an interview on Monday. “He said he was in complete agreement with that.”
With Trump going out of his way to bless the Kentucky senator’s approach, Paul’s week-long campaign to hold a vote on replacing Obamacare alongside a simultaneous repeal measure has seemingly upended the GOP’s long-sought plans for a cathartic and immediate vote to gut the health care law. As news broke that Trump backed Paul’s play, several other Senate Republicans were also beginning calls for a new strategy — threatening the trajectory of the party’s rush to repeal the law.
On Monday in New York City, Trump said he’s “not even a little bit” worried about how Republicans will replace Obamacare. “That’s gonna all work out,” said Trump, whose campaign pledge was to immediately repeal and replace President Barack Obama’s signature health care law.
Paul said he wasn’t trying to slow the process down, but instead said it’s a “matter of speeding up” the replacement efforts. He’s putting together an initial proposal containing the GOP’s best ideas and will ship them this afternoon to Trump’s administration after getting buy-in from the president-elect.
Still, he admitted that there are now enough critics in his conference to put the brakes on any effort to repeal the healthcare law before there’s broad GOP buy-in around an alternative. Influential Republicans including Tom Cotton (R-Ark.) and Bob Corker (R-Tenn.), have also called for simultaneous repeal-and-replace, complicating plans to quickly pass a repeal bill by a majority vote in the narrowly split Senate.
“We need to work through the discussion. I think there are enough voices in the caucus that are saying we should do replacement when we repeal. So it could get to that point,” Paul said, adding that he’d still likely support a standalone repeal bill. “I still would but I’d feel a lot better about it if we voted on replacement on the same day.”
The GOP-controlled Congress is aiming at repealing the law as soon as it can, potentially shortly after Trump is sworn in. But on Sunday, Senate Majority Leader Mitch McConnell and Trump’s top staffers did not present a clear-cut roadmap to a replacement plan, or a timeline for when one might be unveiled that has the support of the leadership.
McConnell said on CBS that he hadn’t “heard Senator Paul’s plan to replace it. But we will be replacing it rapidly after repealing it.” Pressed twice on the timely, McConnell would only say that replacement would happen “quickly.”
McConnell visited Trump Tower on Monday morning, telling reporters afterward that he had talked to Trump about “repealing and replacing Obamacare.”
“It would be ideal if we could do it all in one big action. But look. It may take time to get all the elements of the replace in place,” said Reince Priebus, Trump’s incoming chief of staff, on “Face the Nation.” “The full replacement may take more time than an instantaneous action.”
But that’s not what Paul says Trump conveyed to him on Friday evening.
“I’d hate to characterize his opinion on it other than he agreed with me that we should do it that at the same time,” Paul said. “There is momentum growing for it.”
The current intra-party debate in the GOP is not a new one, of course. From the start when Republicans took control of the House of Representatives in the 2010 mid-terms, and then again after they took control of the Senate in the 2014 mid-terms, there has been a debate between those who said that it was sufficient for the party to support repeal of the PPACA and those who said that the GOP should have some kind of replacement plan in place to accompany votes on repeal. This argument was also made by Democratic critics during each of the many occasions when the House voted to repeal the law in whole or in part, all of which of course proved to be symbolic due to the fact that Democrats controlled the Senate and/or the fact that there was a Democrat in the White House. Given the fact that the party did not have veto-proof majorities in either house of Congress, of course, this was a largely academic debate since it was never likely that a repeal and replace measure would have anything close to the kind of Democratic support it would need to become law. As a result, the dozens of repeal votes that took place in the House beginning in 2011 and the relatively smaller handful of repeal votes in the Senate since Republicans took control in 2015 have not included a replacement provision, and this has left them open to the valid criticism that they were merely symbolic and not to be taken seriously since the GOP was not proposing what would follow repeal of the law. Now, with repeal seemingly inevitable given the fact that Republicans reportedly plan to use the budget reconciliation process to push any repeal bill through the Senate so as to make an end run around Democratic efforts to filibuster a repeal bill, reality has opened up and Republicans are realizing that repeal without a replacement simply isn’t a realistic possibility.
One consequence of this is the fact that the initial plan to repeal the PPACA and delay that replacement until a replacement can be voted on appears to be dead on arrival:
The Republican plan to repeal Obamacare and delay the implementation of the repeal — with a promise to come up with a terrific replacement later — is probably the party’s best way to destroy Obamacare. Unfortunately for Republicans, it’s also the best way to destroy the Republican majority in Congress.
Something big is happening in the Senate right now: The Republican plan, affirmed again today by Senate Majority Leader Mitch McConnell, is facing dire peril from Republican defections. Republicans need a House majority, 50 Senate votes, and soon-to-be President Trump to pass repeal and delay.
If Republicans lose three Senate votes, that drops them to 49, and repeal and delay cannot pass. At least three Republican senators (in addition to all the Democrats) now oppose repeal and delay. Rand Paul, of all people, has demanded that Congress repeal Obamacare at the same time it passes a plan to replace it. Paul has announced that he spoke with Trump and secured his agreement on this. Trump has not said so himself, confining his comments to date to a vague assurance, “That’s all gonna work out.”
These developments also come on the heels of a new Politico/Morning Consult poll that shows that while voters are generally supportive of repealing the PPACA, they are unsure about doing so without a replacement being in place:
Voters want — and expect — President-elect Donald Trump and the GOP-controlled Congress to repeal the 2010 health care law, according to a new POLITICO/Morning Consult poll released Tuesday, but they are skeptical of repeal without a plan to replace Obamacare and some of its most popular elements.
A majority of voters disapprove of the law, which is teetering on life support as Trump prepares for his inauguration next week and Republicans signal that repealing Obamacare is their top priority. Only 41 percent of voters surveyed approve of the law, while a 52-percent majority disapproves. More self-identified Democrats disapprove of the law (23 percent) than Republicans who approve (16 percent), and independents tilt strongly against it (36 percent approve, versus 54 percent disapprove).
On a list of six initiatives for Trump and congressional Republicans, repealing the health-care law ranks as the most important, with 26 percent of all voters, including 41 percent of Republicans, calling it their top priority
And voters are counting on changes to the law. A combined majority wants the law repealed in part (32 percent) or completely (27 percent). Fewer than a quarter of voters want the law expanded (24 percent), and only 11 percent want the law kept as-is.
A combined 73 percent of voters say it’s either “very” or “somewhat” likely Trump and congressional Republicans repeal the law, while only 13 percent say it’s “not too likely” Obamacare is repealed and 4 percent say it isn’t likely at all.
(…)
Only 28 percent of voters say the law should be repealed “even if there is no current plan for replacing” it. Fully 61 percent say the law “should not be repealed until there is a new plan for replacing the law.”
To be fair to Republicans, there have been replacement plans floating out there ever since the PPACA was passed. Senate Rand Paul, for example, has proposed a plan ever since coming to office in January 2011, and Congressman Tom Price, President-Elect Trump’s selection to be the new Secretary of the Department of Health And Human Services, has had his own replacement plan for virtually the same amount of time. Additionally, other members of Congress have proposed their own plans, as have various conservative and right-leaning think tanks and public policy organizations in Washington and elsewhere. While each of the plans differs in significant respects, they are similar in many respects as well, with each of them containing elements of conservative-leaning ideas on the issue of health insurance reform that have been around for quite awhile now, such as tax-free Health Savings Accounts meant to cover routine medical expenses while most insurance is left to cover catastrophic care, tax breaks and subsidies for lower-income people to allow them to afford coverage, an end to the laws that forbid the sale of health insurance across state lines, and other changes in the law that analysts on the right believe will both lower the cost of health care and health insurance and expand coverage for people who cannot afford it.
The poll also makes clear at least one dilemma that Republicans must deal with heading into the upcoming debate about repeal and replacement, namely the fact that some provisions of the PPACA remain popular even though the public generally supports the idea of repealing the law:
One major complication to any replacement: Trump and some Republicans have pledged to consider some of the more-popular elements of the health-care law in a post-Obamacare framework, and the POLITICO/Morning Consult poll shows voters want to keep large parts of the law.
Testing eight separate elements of the law, more voters want to keep each of the eight provisions than want to repeal them, in some cases by overwhelming margins.
Nearly two-thirds of voters, 66 percent, favor keeping a provision that prohibits insurance companies from denying coverage to patients with pre-existing conditions. Sixty-three percent of voters want to keep the requirement that insurance companies allow policyholders to keep their children on their plans until age 26. Fifty-six percent think subsidies for low-income Americans to buy insurance should stay, and the same percentage wants to keep federal funding for states to expand their Medicaid programs.
Pluralities of voters also want to keep two other provisions of the law, though by narrower margins: 46 percent want to keep the elimination of lifetime and annual limits on health reimbursement to individuals, while 32 percent want that repealed. And 33 percent of voters want to repeal the long-derided medical-device tax, compared to 37 percent who want to keep it.
The most-popular elements of the law are also well-regarded by Republicans. Sixty-three percent of Republicans want Trump and Congress to keep the prohibition on denying coverage to those with pre-existing conditions, and 56 percent want to retain requiring insurance companies to allow the children of policyholders to stay on their plans until age 26.
While other provisions of the law are less popular with GOP voters, those voters are not overwhelmingly in favor of repealing them. Only 40 percent of Republicans want to repeal the 50-employee requirement, slightly fewer than the 44 percent who want to keep it. Just 38 percent want to repeal the subsidies for low-income Americans to buy insurance, compared to 43 percent who want to keep the subsidies. Forty-one percent want to repeal Medicaid expansion funds, while 40 percent want to retain those funds as part of the law.
The problem, of course, is that it’s going to be difficult to find a way to keep these popular parts of the PPACA while simultaneously getting rid of the unpopular elements such as they employer and individual coverage mandates and other provisions that proved to be the death knell of the law in the mind of the public. This is because each of the provisions increases the costs of coverage for insurance coverage while making it harder for them to cover their costs by any means other than raising premiums for everyone rather than charging higher premiums for people that fall within certain categories based on documented actuarial reality. In any case, while also vowing to repeal the law, Republicans have said repeatedly that they would keep most if not all of these popular provisions of the PPACA, with provisions such as the coverage requirements for those with pre-existing conditions and continued eligibility for coverage under a parents’ policy until the age of 26 being the most commonly mentioned as being likely to be maintained. So far, there have been minimal details about how these provisions would be reconciled with the repeal strategy, or how they would be integrated into a replacement plan, but it’s clear that the GOP will have to deal with this prior to voting on any replacement plan at all.
So yes, the PPACA is going to be repealed in whole or in significant part, and most likely sooner rather than later, but not before Republicans are going to be required to get behind a coherent replacement plan. How they get there will be interesting to watch.
The dog that chases the car doesn’t think about what will happen if it actually catches it.
Republicans are purportedly human, so they should know better. The only thing that the GOP had to offer was that Obamacare was bad! because it included the word “Obama.”
Then again, Republicans don’t need to worry about thinking things through, since the voters won’t hold them accountable. The shutdown taught them that they can get away with anything that isn’t a tax increase.
The Republican plans have been exercises in fantasy. They are pie in the sky sketches that substitute words and theories for money and policy.
Here’s my prediction: one way or another the Republican Party is going to destroy healthcare of tens of millions. These “principled” Republicans that may vote with Democrats will fade away once they realize they will be primaried out of office next cycle. So there may be some kind of temporary delay, but eventually it will be either repealed without a plan or the replacement plan will be some libertarian fantasy that has no chance of working in the real world.
Republicans can’t come up with a workable replacement plan because they are incapable of actually governing. Anyone who makes a concession to reality will be driven from office.
They have had seven years to come up with a “smart, responsible” plan. They can’t do it.
The dog caught the car…now it has zero idea what to do…outside of leveraging the Presidency for business deals.
This is actually classic Republicanism – promise the fun parts, pay for nothing. You want an arm’s build-up? Sure! Want to pay for it? No! Republicans are irresponsible hypocrites, forever threatening to shut down government even as they explode deficits. Rant rant rant about government spending and then spend spend spend as soon as you’re in power. And the 46 percenters lap it up.
Because 7 years has not been enough time to figure out a replacement plan, but 7 years and 1 month will be.
You know, I keep reading in different places that Trump opponents need to learn to empathize with his supporters and treat them with respect. But it seems to me that it is the Republican Party that believes its own voters are morons.
This would be comical if people weren’t going to die as a result.
No, I would say that Republicans have a variety of marketing brochures. Those are not plans. And we need to keep reminding folks that they have had 6 years to come up with a completely vetted bill (not plan) that provides the details along with costs and benefits. Until then, they have nothing.
Here are some other polling questions I would like to see:
Do you think Americans have a right to some minimal amount of health care?
Do you think that women should be charged more for health insurance?
Do believe that older Americans (45-65) should be charged at a 5-1 ratio over younger folks than the current 3-1 ratio?
Do think that insurance companies should have limits on how much they spend on administrative costs vs healthcare?
Do you support repealing the ACA even if it increases the deficit and national debt?
Etc, Etc
I was hoping the Republicans would sober up and it looks like a small number of them are starting to do so.
I’m not sure if it’s going to be enough though. Now the republicans do have a health care plan that they could implement; it’s was called Romney-Care. The problem of course is Obama rebranded it and made it toxic.
What happens next? Most likely reconciliation will eventually pass and the health care market crashes and burns. None of the Republican plans that could be implemented will work in the real world. (It would be nice if the media started holding them accountable for their pie in the sky promises,)
Too many people don’t bother to vote; too many people with coverage thru the ACA vote for Trump. The end result is going to be ugly.
I don’t have a solution, not when people who’s lives depend on the ACA vote for Trump. I can’t come up with anything that can counter act that level of ignorance and self indulgence.
If the system does collapse the best I can hope for is state and/or regional versions of the ACA being implemented, possibly against the wishes of the Federal government. The last thing the Trump Republicans will want to see is a successful Canadian style medical system being implemented on the West and East coasts.
The non-Trump states, the reality based states, collectively contribute much more to the governance of this country than the Trump-states. The Trump States, almost to a one, take out more than they put in. Can’t we just kick them out and allow anyone that wants to immigrate to the reality based states? Why are we, who pay the bills, obligated to allow the Trump-states to drive us into a Kansas like nightmare?
It’s critically important to note that the Republican led House has prohibited the CBO from scoring any efforts to repeal or replace Obamacare…this is because Republican lawmakers know that Obamacare has reduced the deficit and saved to taxpayers money, thanks mainly to taxes and payment restrictions on Medicare providers …but they do not want their rubes to know that. And they certainly don’t want their rubes to know how much it is going to cost to keep all the good parts and get rid of the bad.
@MarkedMan:
I’ve been saying for some time now that Lincoln made a big mistake back in 1860; he should have let the South go.
I suppose I’ll have to amend that to include other ‘welfare’ Red States that constantly complain and moan about federal taxes yet get back from the federal government far more than they pay in.
Adios mi estados rojos amigos.
@Pete S:
To be fair, many members have had alternate plans for years, but they were non-starters as long as the Democrats had the White House. The question is whether they be able to cohere around a plan now. My guess is that it will take quite awhile (more than a year).
As for the plans, I presume things like HSAs will mostly benefit rich people. Would I be correct in that assumption?
@Franklin: Yes, because they are funded with pre-tax money. The savings will be whatever your marginal income tax rate is. For example, I would get a 25% break. Presumably, Michael Reynolds will get even more.
It also presumes I have money to put away in the HSA. As an upper middle classer, that is a good assumption.
Oh by the way, the big complaint about current health insurance plans is that they have high deductibles. The HSAs are High Deductible HSAs. Somehow, the marketeers of these ideas forget to mention that part.
@Scott:
No. You can’t have a right to things. We can help people get healthcare because we are a wealthy and generous nation. But no one has a “right” to other people’s labor.
This is how insurance works (as opposed to entitlements). You use more, you pay more. The 3-1 ratio is a big reason why Obamacare is failing because young people don’t want to pay such high premiums when they have such low healthcare costs overall.
No. This is a red herring anyway. Admin costs in insurance industry are not significantly different from public sector when you scrape away the garbage.
No. But I’m highly dubious of ACS’s supposed deficit-reducing abilities. And, thus far, skepticism about high-flying Obamacare projections have proven to be justified (e.g., how many people are in the exchanges against how many they said would be).
@Franklin:
There are no alternate plans. None. There are marketing schemes. There are slogans. And there are people silly enough to think those things count as plans.
I will give reluctant credit to Trump for taking the right stand on this. Much as I dislike ACA, you simply can not repeal it without having a replacement in place. Unfortunately, I think that’s where this will founder. The most like thing is that Republicans try and fail to replace it for two years and then pass a series of fixes to it, rebranding it as Trumpcare.
USP; the United States of Pacifica. The West Coast and Hawaii.
It’s got a nice ring to it, doesn’t it?
No more kowtowing to the South; no more Creationism or Supply Side economics or anti abortion nonsense. All the many ways the South and Midwest hinder progress removed.
The end result? I’m convinced it would be similar to Sweden/Switzerland/Norway living next door to Bulgaria/Romania/Greece.
God dang I’d enjoy that.
@Franklin:
That is not fair. There have been a number of good sources for people and organizations that have evaluated these “plans”. Without exception they have been concept level, PowerPoint arm waving exercises that have no serious analysis of how they would actually be implemented, how much they would cost, and how many people would lose health care. The ones that are treated most seriously by the gullible press have a few slides of libertarian claptrap thrown in.
Here is a test: If any plan relies heavily on “reducing regulation and letting insurance plans compete across state lines” you can know it is just BS. It sounds great, but what it means is that, say, Trump Health Insurance Inc (/sarcasm) could craft a plan using the regulations of some idiot Trump state, you know, the ones that don’t protect patients, heavily favor the insurance company, force you to go to an insurance company paid “arbitrator” if you feel they should have paid for Daddy’s brain tumor surgery but they decided not to, and waive your right to sue if they don’t. The ones that don’t require coverage for anything at all but allow the insurance companies to alter and change what is covered on a month by month, thirty page fine print update. They could then sell this plan into say, California or Illinois or New York where the insurance commissions aren’t controlled by a bunch of good old boys stuffing cash into the commissioners pockets.
Think about it: Most insurance companies already sell plans into all 50 states plus territories. Yet the Republican lap dogs make it sound like big bad government is preventing them selling wonderful innovative plans into the state next door. What is actually happening is that absent meaningful federal regulations (insurance, prior to Obamacare, was almost entirely regulated at the state level and still is substantially regulated there), your insurance coverage in every state would be dictated by the most bribable leeches in the most backward state. But of course the magic of libertarianism would allow people whose families have been bankrupted by medical costs to successfully take on $100B corporations.
@J-Dub:
Now we know why Democrats can do nothing but defend what they should be working to improve….
Also, “Repeal and replace” is a euphemism for “reform.” Republicans don’t want to admit it because after spending years selling BS to their base, they can’t be seen “reforming” Obamacare. So they’re going with “repeal and replace” because they know their voters are, well, I won’t call them stupid…..Let’s just say they are intellectually prepared to believe things that are not true.
“People are gonna die if Obamacare is reformed” is in the same category.
@Pch101:
And it only was called that because the GOP branded it that way as a way to demonize it. The Democrats and the Obama Administration called it the Affordable Care Act, the ACA (or PPACA).
@Hal_10000:
Sorry but that’s BS. It is certainly true that there are hidden administrative costs to Medicare, they don’t come anywhere near the hidden administrative costs for private insurance. Here’s a simple test: Go into any doctors office. Look at all the people in the back working at their computers or handling paper. Almost all of them are doing paper work for the private insurers. Sure, some fraction of it is for Medicare but bear in mind that Medicare and the other government sponsored healthcare accounts for more than half of all billable dollars. I would bet dollars to nickels that in most offices the average effort on private vs government insurers are 2 to 1 for dollars billed, or higher.
Also in that article was a long section complaining that sometimes the government agencies don’t approve certain medical procedures, with the implication being that private insurers pay gladly and willingly (because, because, Libertarianism!). This is just hogwash. All you need to know is that major private insurers have whole departments, hundreds of employees, whose bonuses are based on finding ways to refuse paying bills.
When ObamaCare came in, one of the first regulations to kick into effect was that any private insurer spending more than 30% on administrative overhead had to refund the overage directly back to their enrollees. Despite the fact that they knew it was coming more than $1B was refunded that first year. And of course that doesn’t include all those people at the doctors office, or your time when you are fighting with your insurance company.
Finally, the opinion piece you linked to implied that fraud was a significant portion of Medicare spending. But of course, no links to actual numbers. The most recent analysis we have shows that about 4% of Medicare reimbursements had problems, i.e. 96% did not. Unfortunately, the audit did not make it clear how much of that 4% represent suspected fraud as opposed to failure to get a signature or fill correctly fill out a form.
The US health care system provides first world coverage at roughly twice first world prices. It provides tremendous incentives for drug companies to make yet another pill that is 1% more effective in reducing cholesterol at the cost of $2K a year for the rest of your life, while zero incentive to work on curing, well, anything at all. The drug companies aren’t even committing serious resources to new antibiotics or vaccines. Instead we have the Martin Shkreli’s of the world buying up the old ones and jacking the price up by a factor of ten.
@MarkedMan: Yes, this is what I ask my fellow Texans:
Do you want your health insurance to be regulated by Mississippi?
If something goes wrong, I,e., victim of fraud or some other violation of consumer right) do you want your state attorney general or insurance commissioner to be prevented by law from coming to your aid?
Because that is what selling across state lines means.
@MarkedMan:
For me it always comes back to the abdication of the press. (Unless their goal is to be stenographers.)
They fail ask the simplest questions to the Republicans about their so called “‘plans”.
I have also been struck for years by press reports discussing the ACA and replacement plans that never mention any actual people, actual users that need the ACA. Zero thought given to how they real people are impacted. It’s as if they are discussing widgets instead of people.
It’s only just now that I’m seeing actual stories of users/real people are being brought forward. And yes, the Democrats did a piss poor job of promoting the ACA. Actual user experiences should have been a weekly talking point for every Dem politician. Instead they allowed the Republicans to define the program.
That’s why so many people hate Obamacare but actually like the individual features once they are explained.
@MarkedMan:
I have a plan for faster than light travel. See, all you have to do is go really, really fast, and then keep going really faster. And yet no one will fund me.
The 1994 book Beak of the Finch includes the following anecdote by a biologist:
That pretty much sums up the Obamacare debate. I am absolutely convinced that the vast majority of Americans who claim to hate “Obamacare” don’t have the faintest idea what the law actually does, and if they did understand the law, they’d love it. This is not just speculation; according to every poll on the subject, almost all of the law’s individual provisions are popular while the law as a whole remains unpopular.
The other day conservative wonk Philip Klein wondered why Republicans don’t just come out and say, “We don’t believe that it is the job of the federal government to guarantee that everybody has health insurance.” The answer is simple: they don’t want to have that debate because they know it’s one they’ll lose. The entire Republican strategy on Obamacare hasn’t been to make any genuine conservative arguments against the law but to deny the law achieves what it in fact does achieve and then to make the equally false claim that their own proposals will achieve those things. They “won” the debate over the law by convincing the public the law is virtually the opposite of what it is, and now they’ve committed themselves to doing what they falsely accused the law of doing: causing millions to lose their medical coverage. Voters who thought they supported this action won’t have any idea what hit them.
@MarkedMan:
I worked in health insurance claims for 14 years. That included coding claims, appealing claims, writing programs to find CPT and DRG codes. I might know the industry a bit. And you would be wrong on that bet. You would be especially wrong on hospitals, which invest enormous resource in trying to extract every dollar possible from both private and public insurers. And you would miss the point that many of the problems with insurance claims flow down from the practices established by Medicare. For example, specialists are paid enormously more than family practitioners because of the RBRVS system, which Medicare created, insisted was not a price scheme, then made into a price scheme and was adopted by many insurance companies.
The numbers for Medicare fraud were what Obama himself was touting when he came into office. Google is your friend and will find you all kinds of coverage of the $60 billion claim. And the claim that Medicare needs to spend 10 times as much on fraud which mostly came from a Harvard study, as I noted in that article (which is from my personal blog).
@Hal_10000:
First of all, let me say I up checked you because you responded rationally and we need more of that around here. However, that is not a statement of concurrence.
Insurance is all about risk pools and sharing that risk among members of that pool. You can have a pool of 1 or a pool of millions. You can pool by age, by gender, incomes, etc. Some in each pool will “win”, some will “lose”. It is a matter of choice. Not any thing else.
@Hal_10000:
Okay–we won’t call it a right, but there should be some acknowledgement by all parties that it is in society’s best interest to have everyone covered. Almost everyone will need a doctor at some point, and preventative care that keeps people healthy does lower costs (particularly if people are actually willing to listen). So even if there is no *right* to care, everyone should be cared for–even the 27 year old male who decided he didn’t need care and has just had his appendix burst.
Which leads to:
Then they are freeloaders. I don’t know what is going to get through to these folks, but this is irresponsible AF, for the reason I just alluded to above. You never know when your appendix is going to burst, or some drunk idiot is going to smash into your car, or…any number of things. Uncertainty on the roads is why we demand that (most) drivers get auto insurance (I live in the one state where I think that isn’t mandatory). Same holds true for health insurance, except it is far, far more likely you’ll need a doctor at some point than it is that you’ll get into a significant accident. People should absolutely be required to be insured.
Honestly, I’d like to see health insurance decoupled from employment–but the only way that happens is single-payer.
@Pete S:
One of the newer memes making its way around the boards is that people who have been duped aren’t stupid /bad people and thus shouldn’t be looked down on. That smart people can be conned, too ya’know? It feels like the defensive beginning of self-awareness – that voters are reaching the point where they can’t keep the cog dis up anymore and must soften the inevitable blow. Much like the proud racist who doesn’t want to be called racist (slander!), they refuse to accept the negative social connotations that go with their actions.
They’re used to the Republicans treating them like morons – they excuse it. They’re used to Democrats treating them like morons – they rail about it, real or imagined. What’s happening is they’re starting to wake up to the fact that stupid is as stupid does and maybe, juuuuuust mayyyybeeee…… they might have been played for morons willingly. Repealing the ACA is going to hit rural America right where it hurts and they’ve been cheering for the punch.
@Jen:
No one young thinks anything bad is going to happen to them, health-wise. This is an an age old truism. Unless the government steps in to make people be responsible, with real consequences for failure to comply, it’s never going to work.
I’m perfectly OK with young people signing a document that says they waive their right to emergency care if they are more interested in saving for beer money instead of insurance. Being legitimately poor and not being able to afford it is one thing but if you can afford to go out and party every weekend, you can afford to put money into an HSA. Should they need emergency care, provisions would kick in to cover them but they would then need to repay it all, in full with no option to be a deadbeat via civic service. Perhaps they could go help build Trump’s wall??
@KM:
Absolutely correct. Including the woman, interviewed on PBS, who is getting treatment for her opioid addiction through Obamacare, who voted for Trump, and who “despises” the law (the incredible footage of this particular nonsense begins at 5:18 on the linked clip).
I honestly do not know what to make of this. I can’t wrap my mind around it.
Well, ever since Reagan, Republicans have included pixie dust (whether in the form of “dynamic scoring” or some other such BS) in selling their plans for tax cuts on the rich to the not-rich and never-will-be-rich who routinely vote for them. Invoking Health Savings Accounts and selling health insurance across state lines are just more pixie dust.
@KM:
I did–when I graduated from college and my first job didn’t offer health insurance, I got an individual policy–that was horrifically expensive and specifically excluded the one pre-existing condition I had (migraine headaches). I’d had some acquaintances in both high school and college get hit with some health issues out of the blue and knew it could happen, and if I wasn’t covered it could be financially devastating. Clearly I was an outlier, but even though it cost me a huge portion of my take-home pay, I made it happen. Thankfully that situation didn’t last that long and I got a job with insurance (that didn’t cover much of anything, I discovered, but that’s a different story).
@Hal_10000:
What is that ratio for Medicare premiums? How about employer provided policies?
@Franklin:
I agree that coherence will be a problem for the Republican replacement. At least it has been to date.
@KM: What I would do is the following:
Single-payer/NHS providing basic level of support to everyone who wants it. In return, they get to practice triage (no, no heart transplant for 95-year-old, not enough of a benefit) and nag you about eating your veggies and working out. Monthly payment by everyone who goes for this. And you can (of course) buy extra private insurance on the market.
Hospitals don’t have to take anyone who “just walks into the emergency room” unless they claim to be non-profit charities. Then they do.
Anyone who wants to live depending on whatever the private insurance market throws up, go ahead. Or not even having insurance at all. No regulation of private insurance markets to start.
HSA-sort of accounts, pre-tax. Which you can use to pay for your private heath insurance or private health care costs.
Kids are covered until age 16 by the government. Mandatory. And they get to wag their fingers at the kids and tel them to not drink a lot and eatyourveggies.
Nothing sums up the Obamacare repeal and replace charade as well as pointing out that the Republican solution to “my deductible is too high” is even higher deductibles…
@Hal_10000: Admin costs in insurance industry are not significantly different from public sector
Total BS. I worked as an actuary. There are two things that make insurance companies have higher admin costs than public costs:
1. Profit provisions. Public insurance is not designed to make a profit. When you price insurance, there is a specific profit provision, and depending on the line of insurance, size of company, and some other risk factors, it can be fairy substantial.
2. G&A (general and administrative costs, large salaries, but also other costs). Large health care companies have tons of executives, many of whom make huge salaries. Public sector costs simply don’t have that element.
@Jen:
I remember buying a policy in college just to be responsible. It was actually sold by my school. It wasn’t until I read the fine print that I saw injuries from auto accidents were excluded.
I was 19. At least I was covered for heart attacks and strokes. I look forward to those days returning when consumers can once again get scammed like I did.
How about this: simply open Medicare to anyone. Options could be offered as far as deductibles and co-pays. Also, offer extra insurance to purchase such as full dental and vision, along with some other optional coverages, such as gym membership.
People could sign up quickly on the Medicare site, and the government won’t have to shell out a ton of money for a new health insurance website.
And that “mandate” penalty thing ? My tax preparer got to talking about that and said there are thirty ways around it.
@MikeSJ: That sounds a lot like the employer-provided insurance I did get when I went to work for a small business. It covered almost nothing. Employees called it the Potemkin Policy.
@MikeSJ
I am very ready for California based versions of Obamacare and Medicare. At some point, conservatives will have to reap what they have sown. I don’t see why the productive states that govern more or less by reason and facts should have to eat that shit sandwich too.
@Hal_10000:
And there’s the rub.
Hal’s is an honest expression of the conservative view on healthcare. It may not exactly jibe with Jefferson’s view that “life” is an unalienable right, but at least it is a statement of principle and defendable as such.
But, you’ll note that Trump and Conway and Ryan and Price are all out there SAYING no one who has gained insurance under the ACA should lose it. They’re saying people should not be denied insurance coverage if they’ve had pre-existing conditions. That is, they are SAYING health care is a right, while their plans make clear that it’s not so much a right as a rhetorical device, because the mechanisms in their plans align with Hal’s conservative view – a rich and generous nation will benevolently provide some modest, though inadequate, assistance in getting healthcare, but if in the end the cost of keeping people of modest means alive outstrips the support the public is willing to give, well, it’s tough to be you and maybe your death will serve as an example that people should work harder at being rich.
Of course, the reality is we don’t just let people die – we just keep them healthy and alive using the most grossly inefficient practices of Emergency Room care and medical bankruptcy. And I would propose we, as a nation, have EMTALA and don’t have medical debtors prisons is because in our hearts we understand that any rational determination that no one has a “right” to have someone else pay for their good health doesn’t comport well with our collective sense of humanity.
@Tyrell:
Brilliant idea. Now stop voting for the people who will never, ever, let that happen.
@MikeSJ: A lot of schools used to sell a very cheap policy that covered injuries from accidents on school grounds, with an athletics rider that would cover sports injuries. It was like $25 a year.
There was a time when an accident only policy was very cheap. Public conveyance insurance was dirt cheap and paid off a huge sum.
It is possible quickly reform Obamacare without throwing a wrench into the works. The problem is none of them are likely to appeal to the GOP, even if the public would like most of them. Increase the subsidies. Increase the penalty. Expand Medicaid and Medicare. Add a public option. Lower the maximum allowed deductibles and out of pocket maximums. Increase minimum actuarial value requirements.
Enough of those and pretty much all complaints about the ACA go away. You’ll notice those aren’t the types of reforms being considered…
@michael reynolds: Thank you, Miss Ann Elk.
@ Tyrell:
Great! So they never ever get to leave school grounds for their scholastic career (4+ years!) because otherwise that damn thing is *worthless*.
Accident-only is virtually a scam because so many of them contain disclaimers like that to make them toothless and you poor.
@KM:
Why is it that I think Tyrell has sent a bundle of money to someone with an internet connection in Nigeria. At least twice.
@Hal_10000: “We can help people get healthcare because we are a wealthy and generous nation. But no one has a “right” to other people’s labor.”
Really? You mean I don’t have to pay taxes so that we can afford police to protect the property of rich people? I don’t have to pay taxes so that people who drive have roads? I don’t have to pay taxes so that other people’s children can go to school?
Oh, wait. Of course I do. Your pithy little phrase at the end there is just more libertarian nonsense. It sounds really good on a bumper stick and has nothing to do with reality.
@Franklin:
But that is my point. The goal of waiting another month is not for some individual members to come up with a plan, even if it is half-assed and unlikely to be any better than the old status quo. The stated goal of waiting a month is to agree on a plan and an implementation strategy. If 84 months was not enough for this, 85 months won’t be either.
And let’s be honest, even if you gave the full Republican caucus a month they could not agree on what to order for lunch. All they could agree on in that time is to send their bill to the taxpayers and kick some people off food stamps for being freeloaders, their donors aren’t willing to pay enough tax to cover both..
@Hal_10000:
Somewhere there is a guy who paid for the streets in your neighborhood who would appreciate it if you would send him a refund.
Hell, I probably helped to pay for an interstate near you. Will you be wiring my cash or sending me a check?
@Pch101:
With no children of my own…I’m always sure to remind my neighbors that their kids are going to that shiny new middle-school down the street on my dime.
@Hal_10000:
I guess I’m going to have to resort to facts rather than my memory 😉 which was inaccurate in one of my previous posts. My understanding is that the $60B is an estimate made by multiplying the total Medicare/Medicaid outlay by the 3%-10% overpayment estimate used as a rule of thumb by the insurance industry. People who don’t like the governement or Medicare assume the worst, 10%, and multiply that by the $600B or so outlay and get $60B. But again, that’s overpayment. The anti-gov folks then go on to assume that 100% of overpayment is due to fraud and zero is due to simple billing mistakes, or mistakes of the fuzzy kind where an exasperated doctor’s clerk says: “Geez this is complicated, I’m not sure if it’s covered or not. Let’s submit it and see if it goes through.”
But we do have some fairly recent real numbers from an actual audit:
So the total overpayments in $538B worth of payments (which represents about 90% of the expenditures) is $46B or 8.5%. Even if you assume 100% of this is fraud, which is ridiculous, it doesn’t come out to $60B and it doesn’t come out to 10%.
(I have to point out my faulty memory in a previous post. I was remembering some numbers about the Prescription Drug program as being applicable to the whole of Medicare. It turns out that the Drug program is comparatively cleaner, which makes sense, as the rules for that are pretty explicit.)
Is $46B a lot of money? Sure. And whether it is fraud or overpayment we should strive to reduce it by, say, hiring more government employees to audit claims. But if you could cut it in half, or even by two thirds it is not going to significantly reduce the cost of the program in a game changing way. And we should also be aware that the auditors aren’t looking for underpayment. Anything that reduces legitimate errors is going to cut both ways, if for no other reason that if we start rejecting more claims for say, missing a signature, the providers are going to double down on their efforts to bill for every legitimate claim they can make. I’m not saying that’s bad, just that any effort to reduce errors will probably have a downside as well as an upside.
How does this compare to private insurers. I have no idea, but suspect that it is higher. I know the rule of thumb is 3-10%, so some of them should definitely be lower. But also, they have all those people working for them to deny coverage. The forms are much more complicated, and many, many health care plans require a doctor to get pre-approval to get coverage, so in theory, it should be easier to make sure a claim is legitimate. But that cuts both ways. In expensive cases the insurers tend to go down the list and deny anything they can. Kept the patient on a heart monitor for two days instead of one? Bill the patient. Patient developed complications after an outpatient and they were kept overnight but no pre-approval? Bill the patient or absorb the cost.
@Kylopod:
Not really. Health insurance is an expensive complex product that the average voter cannot be expected to understand. (My guess is that you don’t have an ACA plan, either, which is something that you will have in common with many of its opponents.)
The core problem with Obamacare is that it is an insurance subsidy program, not a healthcare delivery and cost management program. It has many flaws, most of which are attributable to the great lengths that were taken to maintain the status quo for the majority of the population that already had employer-based coverage — in other words, it’s too conservative.
@Hal_10000:
I think the reason everyone is piling on this phrase is because it encapsulates *why* so many fell for the Republican BS in the first place. One of these things is not like the other one in terms of personal responsibility. See, streets and cops and schools benefit many if not you personally. There’s a sense of communal use that you are entitled to and thus is acceptable to pay. You also get some say in how these issues are handled via the government and can affect the outcome. It’s the greater good you can feel.
But healthcare? It’s just you. You have no say in how much someone using healthcare you pay for drinks, smokes, binges, doesn’t exercise, sleeps around, does drugs, engages in high risk behaviors or is just generally a hot mess. It feels like you’re being stolen from rather then getting access to shared resources or seeing a tangible good. It feels like you’re paying for someone else’s mistakes. Well… you are! Ignore the fact that you pay for someone else’s mistake when your tax dollars pay a beat cop’s salary or the highway patrol writing out that ticket. Ignore that you’re paying for other’s bad decisions when you drive past highways barriers being fixed from the latest drunk to plow through it. No, the step too far is paying for some fattie’s heart surgery or a junkie’s treatment…. or little Timmy’s diabetes if you’re particularly heartless.
I’m not ripping on you personally Hal but you just happened to be the one to phrase it so eloquently. “No one has a “right” to other people’s labor” except in cases society demeans it so acceptable no one even notices anymore.
@Hal_10000:
This is a “Taxes are Theft” type of argument.
If the product of labor is greatly increased by the fact that it happened using the resources available in a society, I see no reason why the society shouldn’t expect to get a piece of the action. If the society then decides that it wants to spend some of that take on health benefits for the general populace, that also seems pretty reasonable to me.
Just imagine how productive you’d be if you lived alone on a desert island without any of the technological benefits of modern society. To be sure, you’d only create a few tens of dollars worth of product per year, but at least no one would be taxing you to pay for other people’s healthcare!
@Jen:
And hopefully you never had to use it for anything really costly. I know of at least two very small businesses that offered insurance until one of their employees or dependents got expensively ill. In one case it was about 15-20 employees and the ill person was the owners granddaughter. It was NJ and it meant we were kicked into the high risk pool (NJ law, something Trump states wouldn’t have) and we had to get a new provider every single year. In the other case they had 35+ employees covered and one guy got lung cancer. The next time their policy was up for renewal it was going to double the premium cost – for everyone. The owner went to the guy with lung cancer, a long term employee and close friend who had helped found the business, and told him he was going to have to drop him or no one would have insurance. This was the mid 90’s in either North or South Carolina so there were the state regulations were heavily pro insurance company.
@wr:
I suspect that at one point or another we have both done panel with someone like that character.
That bit is something like 45 years old. It’s a hell of a thing to be able to get laughs almost 5 decades later, isn’t it? Then again, Buster Keaton was 90 years ago and still funny as hell.
@KM: There are students who get hurt in school and may require er visit, x-rays, cast, wrap, stitches, etc. It happens a lot. The school system.won’t pay for it and some parents don’t have insurance. And paying a little more for athletic coverage is wise.
“Rights” are what are granted by a society. You don’t think others have a right to the fruits of your labor? See how far that would have gotten you with the King’s tax collector. Or today in Mainland China. Look up the Right of Conquest:
In nature you have the right to keep what you can defend. All other rights are policed by the society you live in.
@anjin-san:
Why do the Blue States have to eat the Red State shit sandwich?
Wyoming population = 586,000
California population = 39,000,000
Senators? 2 each.
It’s intolerable.
One of the biggest mistakes of the ACA was the attempt to nationalize it. (the sensible, humane and well, American thing to do.) I don’t think the politicians and technocrats who created it understood the mentality of people who don’t want health insurance or hospitals.
How could they? They’re sane.
To what extent can ACA or a replacement force an private insurer to create a new network in a region that the insurer knows will lose money?
To what extent can ACA or a replacement force an healthcare provider to stay in a network that does not serve that provider’s needs?
To what extent can the ACA or a replacement force a private insurer to continue to offer policies that lose money?
My point is that I hear very little about what the private insurers reaction to an ACA replacement that would shrink the number of people who have to be insured.
I could be totally off base, but I thought that the Obamacare “agreement” with the Insurers, Hospitals, Doctors was ….. in return for new (mandated) policy holders you (insurers) will agree to sell policies that don’t discriminate or drop policy holders for pre-existing etc.
@Tyrell :
And if that accident wasn’t on school grounds, the student cannot use the $25 per year insurance they thought would cover it and thus got screwed. While a dorm student is more likely to be hurt on grounds since they live there, a 20-something is statically likely to get into a car accident or get hurt off-property since that’s, you know, where they spend a good portion of time. Getting drunk at the local bar and walking home keeps them in the danger zone, as does getting groceries, going home for visits, driving to work, etc.
Universal coverage is a better bet rather then gambling your injuries will occur only in a specific geographic area. That was the point behind 26 years old staying on their parents health insurance. Thanks Obamacare!
This is actually agree with. I pay for extra insurance as part of my club dues and so should any student athlete. Someone more likely to get injured should expect a higher bill.
I forget which lefty blogger realized that Heisenberg’s Uncertainty Principle applied to Republican Health Care plans. They exist, but if actually looked at for implementation they instantaneously cease to exist.
Ohhhh and now Trump wants it repealed in weeks…..
Man, he’s not even going to give them lube before he bends poor Americans over. Good luck getting replacement healthcare in a week, rural folks! And no, you most likely won’t get to keep your doctor (and your old one won’t take you back either)
@KM:
They’ve been working on this for 7 years and haven’t been able to do it…now the Dumb-Don is telling them they have a couple weeks.
Good luck with that.
@KM: On this I was referring to public schools, not the universities or colleges; which may have different plans. The school insurance plan is clear that it is “school time” insurance, and applicable only on school grounds, field trips, or on the school bus. The schools have also offered a 24 hour accident policy which is more, but still very inexpensive. These insurance companies evidently figured out that the odds of a kid being injured in an accident, even a car wreck, are low enough to sell these policies cheap. And I read over the policy: no deductible, covers all treatments, $500,000 limit per incident.
Now that was some time ago, so I don’t know if the schools offer this or not.
@Pch101:
Hmmm. I’ll give you a few minutes to see if you can think of a difference between a public service that benefits everyone and a specific service that benefits an individual. But no one has a right to roads or police either. The Courts have specifically said that you do not have a right to police protection (which is why you can’t sue them for failing to protect you).
The reason you can’t have a right to things is because things are limited. If there’s one doctor and three patients who need his help, who has the “right” to his care?
Again, not saying we shouldn’t help people get health insurance. I’m just pointing out that thinking about it as a “right” is not constructive.
Profit margins in the insurance industry are a few percent. Executive salaries are even smaller (e.g., $15 million for the CEO of Aetna out of $60 billion in revenue). The bulk of Admin costs in Administration go to rank and file (the 50,000 Aetna employees). Civil servants get paid WAY more than private sector employees for doing the same job. And again, most of Medicare/Medicaid’s admin costs are from the private insurance companies that actually run the system.
@Hal_10000:
Unless we’re neighbors, the interstate near your house doesn’t do a damned thing for me.
Since you’re a fan of ME ME ME politics, let’s talk about ME. For ME, your infrastructure desires should not be MY problem. So where’s MY refund?
@KM: While we are talking about accidents, one area that needs to be changed is the er. Too many people use the er as a routine doctor visit, and for things most people do not even go to a doctor for: cold, hang nail, sneezing, and other non-emergency ailments. And many manage to bring the whole family, relatives, in-laws, out-laws, and half the neighborhood. So you have a bunch of people sitting around in the waiting room carrying on, kids running wild, and noisy. Also, they leave a bunch of drink bottles and food bag trash in the floor. This also makes for a perfect germ distribution center. There should be a limit of people per “patient”.
And these huge waiting rooms need to be done away with.
@MarkedMan:
BTW: the GAO stands by their $60 billion estimate.
Breaking…
http://www.cnn.com/2017/01/10/politics/donald-trump-intelligence-report-russia/index.html
@Pch101:
Really, dude?
I refuse to believe someone as smart as you could be so dense. Might this be that point where you find yourself getting outmatched and you get all snarly?
@Hal_10000:
Seems reasonable. The 2012 report had, I assume, 2011 numbers. The article you cite is from 2015. Every year we have more elderly on Medicare and of course we had a big expansion of Medicaid. And medical expenses did rise although not nearly as fast as in previous years. So going from 46 (audited) to 60 (estimated) in that time frame seems reasonable.
They also noted that 60 percent of that estimate comes from legitimate expenses billed with some form of documentation missing and not fraud. So out of a 600B program, an estimated 24B should not have been paid. And some percentage of that (maybe a high percentage) was actual fraud rather than from people who misunderstood the policies and billed for something that was actually not supposed to be covered, AND that Medicare didn’t catch and so paid out.
Don’t get me wrong, I’m firmly in the camp that Congress should be providing more funding for employees dedicated to rooting out fraud, and more criminal prosecutions when found. I think they should also do it in the IRS, and in dozens of other offices. I have zero doubt that they would recover 10 or a 100 times what they would cost. But instead congress cuts that part of the budget. Why is that? (I’m really asking here.)
@Tyrell:
So write up the legislation and forward it to your House member. I am sure it will get the attention it deserves.
@Pch101:
Hmm. Wonder how long our economy would last without interstate trucking…
@Hal_10000:
While he’s thinking, perhaps you could meditate on the phrase “public health”, and why we have a Public Health Service. Personal healthcare only benefits individuals in exactly the same way that public education only benefits individuals. Will it really take a return to pandemic tuberculosis to get this point across to Republicans?
The claim that “young people don’t use healthcare” somehow always ignores the fact that young women in their twenties get pregnant and give birth, a lot. But somehow women, who are half of all young people, and pregnancy itself, somehow don’t count when discussing medical care.
@Hal_10000:
Thinking of the private healthcare industry as a model of efficiency and controlled costs is not constructive, either.
@DrDaveT:
Considering the Republican response to the AIDS epidemic, I’m not hopeful.
@Scott: I remember recently Clark Howard explaining to a listener about how to make a health savings account work:
1. Put in as much as is allowed to maximize your tax credit.
2. Pay for all of your medical costs out of pocket if you can afford it. (If not, try to get health insurance if you can.)
Reason: This allows you to use your HSA as an additional tax-free investment portfolio.
Disclaimer: I do not know whether this plan will work, nor do I know if it is legal to use your HSA as an investment portfolio (nor what the goal would be in doing that if the money can only be spent on health care).
@Just ‘nutha ig’rant cracker:
It’s entirely legal, but there are caveats. Contributions to HSAs are either pre-tax or tax-deductible, and all earnings / investment returns which accrue are also tax-free as long as they remain within the account or are utilized for qualified medical expenses. Up until age 65, withdrawals for non-medical purposes incur taxation AND an additional 20% penalty (similar to a traditional IRA).
Once the holder reaches 65, non-medical withdrawals are taxed at the taxpayer’s current rate without any additional penalty (again just like an IRA).
The caveat is that holding the balances in an investment account removes them from FDIC protection, so any capital losses are yours to bear (like IRA accounts, the deductibility of capital losses in tax deferred accounts is limited in instances where the basis is essentially zero – which is the situation here). You can potentially find yourself in a situation where you’re exposed to large medical expenses concurrent with large portfolio losses, and in that instance you’re basically just screwed. The strategy is also somewhat dependent on the assumption that the taxpayer will shoulder pre-retirement medical expenses out of pocket rather than fund them out of the HSA, so strategies like these are usually of merit only to people with sufficient cash to cover both fully funding the HSA every year and covering medical expenses out of pocket in the interim prior to reaching retirement age, while being able to absorb any losses which occur within the account in the interim.
Exactly. People phrase it in terms of “I don’t owe you any of my money.” But you didn’t dig gold out of the ground with your bare hands. You got that money, and can keep that money safe from roving Hobbesian gangs, by cooperating with society in countless ways. If it weren’t for society you’d have jack divided by shit. So yeah, you kick in a chunk to keep the ball rolling.
Things I didn’t understand when I was a naive teenage libertardian.
@Just ‘nutha ig’rant cracker:
I do this now. I’m single and, at 58, have no health issues. Don’t take any prescription medicine.
My HSA is a pretty significant investment account.
I assume i will need the money for medical expenses at some point as I age.
The funds can also be used to pay insurance premiums, like for those beyond Medicare.
If you are over 65 you can take the funds without penalty but with taxes similar to IRAs.
@anjin-san:
Now that I’ve come around to Hal’s libertarian line of thinking, I’ve moved passed all of that common good stuff. The libertarian version of me doesn’t need to care about “the economy”, but only “my economy”.
Unless Hal can demonstrate how his chunk of interstate specifically benefits me, then why should I pay for it? It’s not as if Hal’s existence is doing me any great favors, so I owe him nothing.
(Being a libertarian is fun, isn’t it? Me, me, me.)
@Franklin:
One needn’t be rich, but it does help to have a high enough income to contribute a decent amount. Otherwise one doesn’t have enough in the account to cover the deductible.
The latest Quinnipiac University polling has Trump’s approval rating at 37%…an historic low for a transition period…and that’s before this latest Russian influence bombshell, and all the talk of a Golden Shower Presidency. Trump is seriously disliked by everyone but the sycophants.
SAD!!!
(full disclosure; our firm does a significant amount of work for Quinnipiac University, and I work exclusively on QU projects)
@Pch101:
The trick to “explain it to me like I’m stupid” is that you’re not actually supposed to be stupid.
Hal’s making a cogent point. You should try it sometime.
@Mikey: Not just a high enough income, but also the personal discipline to set the money aside.
This is where all of these proposals will eventually fall apart. The savings rate in this country is atrocious. Most Americans aren’t saving anywhere near enough for retirement–what the HECK makes us think that they would set aside earnings for health care? This is a huge, huge problem. A study not that long ago showed that most households couldn’t even get their hands on as little as $400 in cash if they needed it. It is absolutely insane to push forward policies like health savings accounts if they are voluntary because generally speaking, people have not shown they have the discipline to save–and if they aren’t voluntary, Republicans come unglued.
How long do we have before all of these forces really hit the fan? Ten years? Twenty?
@James Pearce: “Hal’s making a cogent point. You should try it sometime.”
Hal’s “cogent point” is that things he likes are rights, and things he doesn’t like are theft by force of jackbooted government thugs.
@MarkedMan: OK, now I know I’m really beating a dead horse, but what can I say? It’s what I do 😉
Here’s something I couldn’t find out about that audit: The federal outlay for the Medi’s is on the order of $600B, but the total outlay is right around $1T when you account for the contribution of the various states. Does the $24B estimate for real overpayments reflect the $600B? Or does it reflect the $1T? I couldn’t figure it out from what I could find online. It changes it from 4% to about 2 1/2%. Anyone have a better source?
@MarkedMan:
FWIW … For years the figure I’ve most often come across is 3%.
@wr:
Well, to be fair….that’s not actually Hal’s point. That’s your point about Hal’s comment.
@wr:
This should be pretty obvious. But there a few posters here who are in the habit of denying the obvious.
@James Pearce:
I guess you’re easily enamored by “healthcare is not a RIGHT” arguments.
How convenient that’s the exact viewpoint the AMA, the drug industry, the insurance industry, the nursing industry, and wealthy Americans who don’t want higher taxes that pay for the healthcare of their fellow citizens want you believe. Nice to know Martin Shkreli is your hero.
Cue the scene where you’re clutching your chest having a massive MI, and wheezing to everyone in the emergency room that “Healthcare is not a right, I want to justly recompense this hospital exactly what it charges for its labor!”
@Rafer Janders: I know a person who is paying $600 a month for his insurance. This month it goes up to $1400 ! Yet he can’t sign up for the ObamaCare. And many are going to see the same kind of increases. Most of the companies have pulled out of ObamaCare. In most states only United Health Care is left. As one company spokesman put it – “Give it a few more months and ObamaCare will repeal itself”. Trump needs to get with the CEO’s of the big health insurance companies and tell them to hold the line; no more of these premium increases to pay for their big, fat cat salaries ! And of course is the scandalous prescription drug pricing !
@Pch101:
There are a few posters here that have your face on them, looking up as your opponent dunks on you.
No, I’m just aware of the difference between the fact that healthcare is not actually a right and the argument that it should be.
And this is why it’s important to remember you’re making an argument. So you don’t say stuff like this:
He is?
@Lit3Bolt:
Well, you have few rights beyond free speech, trial by jury, etc.
But an interstate highway is no more or less of a “right” than healthcare. The issue of rights is not relevant here; what matters is the general welfare of society.
And it’s frankly silly to claim that roads are some kind of entitlement while healthcare is theft. The need for highway building and healthcare are both judgment calls; aside from building “post roads” (roads that were intended for moving mail between larger towns), the government has no obligation to build highways.
What the highway network and healthcare have in common is that they are both useful to society, yet difficult to implement effectively without some sort of coordination as well as funding that isn’t strictly user-based.
@James Pearce: “Well, to be fair….that’s not actually Hal’s point. That’s your point about Hal’s comment.”
Wow. Heavy, dude.
@wr:
Donald Trump is president and the best you can do is beat up on straw men and go “Wow, heavy, dude?”
@Tyrell:
You have no relationship with reality.
@DrDaveT: And we might in fact GET pandemic tuberculosis back, given the increasing cases India has been seeing of antibiotic-resistant strains…
@SKI: Have you seen the screen shot floating around Facebook of a FB conversation that begins with a Trump supporter crowing about how the Republicans can now finally repeal Obamacare. When his/her friends argue back that the OP shouldn’t be celebrating since they’re on Obamacare, the OP said that wasn’t true, that they were on the ACA, “which was created to replace Obamacare after O-care crashed and burned.” A number of people then try to help this person realize that the ACA and Obamacare are the same thing.
@Pch101:
Correct. Hal and James are being pedantic by noting there is no RIGHT to healthcare…except there is no RIGHT to roads, postal services, marriage, or even electricity or radio enshrined in the Constitution either.
Except somehow we agree building roads and bridges everywhere works. Postal Services (when they are funded by Congress) work. Utilities have been set up and provide power to everyone who can pay a usage based fee.
But healthcare is different, somehow, unless we have insurance and drug companies sucking profit to the tune of billions of dollars. The health of the populace does not and should not equal general welfare of a society and government.
@Lit3Bolt:
To quote Eliot, that is not what I meant at all. That is not it, at all.
I feel absolutely no obligation to defend Obamacare for the sake of Obama’s legacy, Democrat victories, or Joe Biden’s Big F’ing Deals. This may seem disloyal to some. So be it. I don’t work for politicians. They work for me.
It’s pretty clear that Republicans are not going to “repeal and replace” Obamacare. They’re going to keep some stuff and chuck some other stuff. The result will be neither magical nor catastrophic.
@HarvardLaw92: Thanks for the explanation. I’ve been wondering what the logic that drives the principle I heard. I suspected that the rationales were along those lines and the caveats that you offered are good to know (and left out of many conversations that I had with financial advisors that I decided not to use the services of.)
@Monala: See? You really can’t fix stupid!
I had to correct a friend from high school who reported that, when he took his mother for an appointment with one of her doctors, the doctor blamed Obamacare for rising drug prices. His mother is 87. I reminded him that, under Medicare Part D, the federal government is barred from negotiating drug prices with their suppliers. He still hasn’t responded.
@Jen: I’ve found as my income increased, the discipline to set some aside increased as well. It became a lot easier to not miss another $350/month as it went into the HSA.
Additional “motivation” was provided by my insurance plan having a $4K deductible.
But I’m in the top 10% of U. S. earners. I have no idea how people down in the 50% range are able to deal with this. I’m pretty sure they just delay care and pay out-of-pocket.
@James Pearce:
I hope you are right but suspect that it will very much be catastrophic. The modern Republican Party is essentially an entirely an oppositional one, incapable of crafting complex legislation. The country has survived despite Republican know-nothingism because the Democrats have been able to keep things running. My prediction: Obamacare will be repealed, it will be done so in a way that not only wrecks that market but also trashes the private health care market in general. Once it is apparent what is happening, Republican Party leaders may or may not cut a dal with Dems to restore some of the infrastructure. But I give even odds that in 3-4 years there will be 30M people newly uninsured and the Republican answer will be to repeal the law that requires hospitals to treat all comers.
@Mikey: I am paying close to $600 a month for a plan that is not bad, but not great. I would like to get dental and vision, but that is expensive for a good plan. I look for the cost to go up a lot later this year. I do not qualify for the Obama Health Care plans. I would like a choice of higher deductibles for a lower premium. The hospitals around here are good about working out payment plans if you owe. A while back, I checked out owing around $3,000. The hospital cut it about in half. After a year of paying on it, they called and said they were cancelling it out. The person said that they can write it off and that a lot of hospital charges are way over inflated anyway. I made sure that it would not go against my credit.
One way to help people would be a straight tax deduction instead of that phony % of income that most people will not reach. So, if you have $8,000 of medical expenses, you deduct $8,000. That would help a lot of people right there.
@Mikey: I also think some people are just better at delaying gratification (the kids and the marshmallow test come to mind) and are better at saving.
I have been absolutely shocked to learn how little some of my friends, family, and acquaintances have saved. While most of it is spoken of in general terms, it’s clear that very few of them have emergency savings of any kind (several have mentioned they would use a HELOC for emergencies, without seeming to understand either the length of time it takes to finalize a HELOC or the fact that depending on the emergency, they might not qualify for one–such as a job loss), several have very little put away for retirement despite having access to 401K plans at work, others have cashed out their 401Ks when changing jobs rather than rolling it over…it really does make me wonder how bad things will get, particularly if Medicare is voucher-ized.
I’m Gen X, and what I’ve observed goes both directions: to older Gen Xers and to Gen Y/Millennials. Suggesting that all we need to do is implement health savings accounts is astonishingly short-sighted. Heck, one acquaintance was complaining not long ago that they didn’t have the money to pay their deductible–and this was after they elected to choose the high-deductible plan because it had the lower monthly cost. If people can’t even plan savings on that basic a level after making the choice to go that route, I just don’t have a whole lot of faith they could do so on a larger scale.
@Tyrell: just curious. Based on your previous comments, I assumed you were past retirement age. Not so?
@Tyrell:
Help me understand why you do not qualify for a Obama Health Care Plan. I’m of the understanding that you can not qualify if you are over 65 (qualified for Medicare) or are qualified for an employer-sponsored plan. Since you have not suggested either of these conditions that would disqualify you, are there other conditions that cause you to be disqualified?
Not challenging you just trying to understand why you do not qualify.
@Bob@Youngstown:
I would consider the possibility that Tyrell spews a lot of BS.
He’s a non-stop FUD generator.
@Tyrell:
Please explain why?
@Jen: I likewise am shocked when some of my friends have divulged how little they have in a savings.
I’ve been retired for over ten years now and my employer had a fairly adequate health insurance program with a 600/year family deductible. The also had a flexible spending account and a 401k (that actually was very generous in not only match but also in employee directed investments – any Schwab mutual fund offering as well as company stocks)
Even during the 1990s what astounded me was that the FSA participation rate was less than 20%, and the 401k participation rate was about 22%.
I fear that reliance on voluntary participation on HSAs will lead to dire consequences, not ony for the average Joe, but for the nation.
@MarkedMan: @Bob@Youngstown:
Tyrell is not a real person. I’m not trying to insult him, its just become clear over the years that he’s a created character. To wit: he often discusses remembering the leadership of politicians who haven’t been in office since the 40s or 50s, describes a contemporary version of rural America that, in my experience, has not existed for decades, and yet is too young for medicare.
He’ll also place clues periodically in his writing that lets you in on the joke–like the time he said Obama’s energy plan needed to reimburse drivers for paint damage on their car from gasoline spillages.
Tyrell is a beautifully constructed caricature of “generic cloistered befuddled old white guy.” I’ve often suspected he’s that spoof account that used to comment her a lot–Triumph? I can’t recall the name now.
@Neil Hudelson:
There’s no need to worry about insulting an internet persona. One may as well worry about offending Garfield the cat or Howard Roark.
Tyrell is either a troll/performance artist or else a hapless propagandist. A distinction without a difference.
@Pch101: Hmm. I have to admit that I usually ignore his posts, so haven’t paid as close attention as you. Troll makes sense. And that is the classic definition of “internet troll” – someone who weighs in on a discussion only to provoke the other participants into shouting matches. But if so, I don’t think he’s very good. There are a number of posters here who have that affect (and I don’t know whether or not they are trolling), to the point where if I see a string of their posts and responses to them I just leave the thread and never come back. Tyrell, on the other hand, doesn’t seem to generate much heat.
@Tyrell: Two other things we could do immediately which could help people:
1) insist that a hospital must offer the same price across the board. No more of this “discount of 40% if it’s Blue Cross/Blue Shield, uninsured people pay full price.”
2) costs for an operation must be made transparent, clear, and fixed. If I come in for operation X, I want to know what the cost will be beforehand. If there turn out to be complications during the operation, maybe a certain surcharge, capped at 5%. But hospitals should be incented to make sure that there are as few complications as possible, and no, you can’t cover up for organizational dysfunctionality by charging people an arm and a leg. (Also, because you know that any “charge more in the case of complications” will result in 99% of the operations having “complications” attached.)
@MarkedMan:
I actually don’t pay much attention to Tyrell. But if it looks, acts and quacks like an internet persona, then that’s probably what it is.
@Pch101: @MarkedMan: @Neil Hudelson:
If so, that leaves me being conned with a generous helping of egg upon my face.
Regardless, “his” statement of being disqualified for Obamacare policy is a narrative I have heard repeatedly. Most often the reason people offer for this is because they make too much money. But of course this is incorrect, they may qualify for Obamacare plans, but not the subsidy.
So…Beyond Medicare eligible or employer sponsored plan eligible are there any other conditions why a person might be inelgible to purchase an Obamacare policy?
@Bob@Youngstown:
I wouldn’t worry about. Irrespective of his sincerity or lack thereof, Tyrell is several counties removed from reality and you’re not going to be able to fix that.
Either your question will be ignored or else it will be answered with a pile of BS that will just confuse those who are uninformed. There isn’t much point in engaging it directly, as taking it seriously will only invite more disinformation.
@C. Clavin: “he” is an internet persona of some old white guy who waxes poetically for an era that never really existed. .
@grumpy realist:
You mean, like Obamacare? Ok, it isn’t universal yet but Obamacare has moved steadily into fee for procedure or fee for condition rather than fee for service.
Tyrell are you from Mount Airy?
@slimslowslider: I have never been there. I have heard about it.
@James Pearce: I hope you’re right, but since they repeatedly voted down proposed amendments to make sure people with preexisting conditions could still get coverage, I’m not optimistic.
Of course, maybe that’s not catastrophic for you. For some, however, it’s a virtual death sentence.
Once again, I’m wondering how anyone lets these GOP %$#@* get away with calling themselves ‘pro-life’. I don’t care where you stand on abortion. As far as I’m concerned, if you are actively in favor of letting people die because they can’t afford standard treatment, you are effectively pro-death.
@bookdragon:
I suspect that the Republicans will require insurers to sell to anyone who can afford it, but won’t regulate the pricing or provide subsidies.
Combine the shrinking pools and lack of subsidy with the inability to deny policies, and you will end up with higher premiums that few can afford and/or policies with premiums that are manageable but that don’t cover much of anything.