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The ACA is hugely beneficial to all people eligible for APTC and Cost Share Reductions up to 250% of the Federal Poverty Level, full stop. It also benefits older people eligible for APTC (about 40-64 years old) making 250-399% FPL. Younger people making decent but not great money, and people over 400% FPL need to somehow be included in the subsidizing of premiums, copays, coinsurances, and deductibles to gain favor for the ACA. That isn't to say it would solve the many other problems of access, drug costs, etc. But to say that few people benefit at all from the ACA is extremely disingenuous.
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Jun 10, 2018 20:16
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The people who've most benefitted from the ACA are those who qualify for expanded Medicaid (in those states that have expanded it) and those with pre-existing health conditions who weren't able to obtain coverage prior to the ACA. It's punitive toward olds because of the 3x multiplier falsely labeled as "community rating" and it's punitive toward those who can't afford the premiums toward a silver-level plan (the only tier that allows cost-sharing reductions). It's also passively punitive toward employed people with stay-at-home spouses (family glitch); toward those who have no control over out-of-network practitioners billing them in in-network facilities; and toward those whose health is reliant on prescription drugs the prices and markets for which private insurers and pharmacy-benefit managers have struck opaque monopolies that result in out-of-pocket prices for drugs sometimes being cheaper than insurance "coverage" for those drugs. The legislation touted as "health insurance reform" was written by the health-insurance industry (among other "stakeholders" like PhRMA) to preclude both meaningful government oversight and meaningful insurance reform.
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Jun 10, 2018 20:36
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Those things are all very true and do not negate the fact that tens of millions of people benefit immensely from the ACA.
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Jun 10, 2018 21:10
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People on Medicaid now outnumber those in the private-insurance ACA marketplace by a factor of three to one--so yes, tens of millions of people have benefitted by the closest the ACA had to a single-payer program. Those of us relegated to overpriced private marketplace insurance with nominal "coverage," those who live in states that didn't expand Medicaid, and those who can't afford to go a doctor because of high out-of-pocket costs (40 percent of those with private insurance), not so much.
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Jun 10, 2018 21:21
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Willa Rogers posted:People on Medicaid now outnumber those in the private-insurance ACA marketplace by a factor of three to one--so yes, tens of millions of people have benefitted by the closest the ACA had to a single-payer program. It's not the closest thing to a single-payer program, it's government-funded health insurance. Why do people want to conflate single-payer with government health insurance or UHC in general so very, very badly all the time? Granted your point is still very valid, but if we're ever going to have a proper debate on healthcare policy, we need to have some sort of common understanding of what words mean.
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Jun 10, 2018 21:27
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PT6A posted:It's not the closest thing to a single-payer program, it's government-funded health insurance. The government pays for Medicaid and Medicare healthcare by paying for the insurance, regulating the insurance rates, and requiring uniform coverage. It also sets rates on providers. I don't care if you want to call it Medicare-for-All or Aunt Bertha; it's essentially single-payer. I think you're confusing the term single-payer with nationalized healthcare a la NHS or the VA.
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Jun 10, 2018 23:38
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Willa Rogers posted:The government pays for Medicaid and Medicare healthcare by paying for the insurance, regulating the insurance rates, and requiring uniform coverage. It also sets rates on providers. By that logic, every insurer is a single-payer system unto itself, at which point the term loses meaning.
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Jun 10, 2018 23:49
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Highbrow Slick posted:Those things are all very true and do not negate the fact that tens of millions of people benefit immensely from the ACA. No one is saying they don't, but this does not somehow make it okay to deliberately bankrupt and kill tens of millions more so politicians' industry buddies can profit.
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Jun 10, 2018 23:51
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Highbrow Slick posted:The ACA is hugely beneficial to all people eligible for APTC and Cost Share Reductions up to 250% of the Federal Poverty Level, full stop. It also benefits older people eligible for APTC (about 40-64 years old) making 250-399% FPL. Younger people making decent but not great money, and people over 400% FPL need to somehow be included in the subsidizing of premiums, copays, coinsurances, and deductibles to gain favor for the ACA. That isn't to say it would solve the many other problems of access, drug costs, etc. But to say that few people benefit at all from the ACA is extremely disingenuous. How many people do you think understand that level of technocratic bowtie spinning and appreciate the genius of a smooth subsidy rampdown???
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Jun 11, 2018 00:24
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PT6A posted:By that logic, every insurer is a single-payer system unto itself, at which point the term loses meaning. This is true; I think Willa may have been focusing on the "the entire country pays into Medicare/whatever" aspect rather than the "only the government (the 'single payer' in question) covers everyone." I agree that it's best to keep to the actual definition in cases like this, though I sympathize with the desire to not just use "UHC," since UHC doesn't really have a strict definition and can be used to describe policy of varying quality. edit: As a vaguely related thing, I dislike the argument some people make of "why focus on single-payer, since other ideas, like a public option, can also end up with a good outcome." The problem with that argument is that, while technically correct, single-payer is particular useful because it's far more difficult to be implemented in a way that isn't good/helpful. The issue with something like a public option is that its efficacy relies entirely upon the quality of the public option, and to be frank I don't really trust the sort of politician who is opposed to single-payer to push a public option that would actually harm private health insurers. Basically, it's a situation where you have one idea that would definitely be able to work, and you have to question why someone would choose to actively oppose that idea (especially when they're only bringing up alternatives in the context of opposing single-payer, which is usually the case). Ytlaya fucked around with this message at 01:20 on Jun 11, 2018 |
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Jun 11, 2018 01:16
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PT6A posted:By that logic, every insurer is a single-payer system unto itself, at which point the term loses meaning. Not at all; private insurers do not have to abide by government controls on premium or provider pricing (beyond the weaksauce regulations within the ACA). But the greatest difference between single-payer insurance and private insurance is that with a plan like Bernie's Medicare-for-All legislation, private for-profit insurance becomes irrelevant--thus saving tens of billions of dollars now spent toward for-profit middlemen that add no value for healthcare "consumers."
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Jun 11, 2018 01:43
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Willa Rogers posted:Not at all; private insurers do not have to abide by government controls on premium or provider pricing (beyond the weaksauce regulations within the ACA). They can set their own limits on premiums and provider pricing through negotiation (and they do). That's what Medicare and Medicaid do, as far as I can tell -- it's the provision of health insurance through the government, instead of through a private company. There are still multiple payers in the overall system, and Medicare/Medicaid is one of the possible payers for those that qualify for it. That's completely different from a single-payer system like Medicare-For-All (Bernie's version) which isn't structurally related to what Medicare currently is, or the single-payer systems that exist in other countries, where only the government can pay for covered services. I think single payer is the best way to go in order to provide universal healthcare, for the reasons Ytlaya outlines, but it's not a synonym for any system in which the government pays for healthcare in some cases.
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Jun 11, 2018 01:51
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Peven Stan posted:How many people do you think understand that level of technocratic bowtie spinning and appreciate the genius of a smooth subsidy rampdown??? I'm certain that you do, and by virtue of that I'm sure you know the answer to your own question is not many other people do. However, what I can tell you is that once it does start working for people, they really don't care about the details. They just become that much more in favor of it. How that is not glaringly obvious to the people for whom it would benefit most politically, I have no idea. Just do it and let public sentiment follow.
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Jun 11, 2018 06:13
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Ytlaya posted:This is true; I think Willa may have been focusing on the "the entire country pays into Medicare/whatever" aspect rather than the "only the government (the 'single payer' in question) covers everyone." It's also extremely important that everyone in the country has skin in the public option. Any system is going to be under immediate and continuous attack from the right, so if it's going to be successful it needs to be set up in a way that makes it very difficult for Republicans to section out select groups of people to screw without directly affecting everyone.
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Jun 11, 2018 07:20
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Willa Rogers posted:I'm not sure how the House bill that included a public option was structured, but I do recall Schumer, in the early days of the legislation being crafted, declaring that any public option had to be priced "on an even playing field" with private insurance. OK yeah, the CBO estimated the public option premiums would be higher because instead of tying the reimbursement rates to Medicare and requiring providers to accept it, the House required the public insurance plan to negotiate rates with providers. The CBO concluded that they would pay about the same for procedures as private insurance but be saddled with a sicker pool of people. They estimated that a robust Medicare-like public option would cut costs but of course the blue dogs opposed that because providers complained that they wouldn't get enough money, revealing that cutting costs was never the goal of health reform after all (because that would mean cutting someone's profits and lol) https://www.cbsnews.com/news/budget-office-public-option-would-cost-more-than-private-plans/
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Jun 11, 2018 15:25
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VitalSigns posted:cutting costs was never the goal of health reform after all (because that would mean cutting someone's profits and lol) VGHCX must be appeased VGHCX demands sacrifice
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Jun 11, 2018 16:45
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Accretionist posted:VGHCX must be appeased Insulin for the insulin throne.
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Jun 11, 2018 16:49
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VitalSigns posted:
Most recent data shows that aggregate Medicare margins for hospitals is negative 8%. Medicare plus five is still negative in that case. Seems a bit like a problem..
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Jun 12, 2018 01:26
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I wonder how that compares to profitability. Time had a giant article on healthcare a few years ago. Non-profits are more profitable than for-profits. They just roll, "profit," into compensation, etc.
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Jun 12, 2018 02:50
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Who gives a poo poo Profit is anathema to provision
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Jun 12, 2018 03:19
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Zauper posted:Most recent data shows that aggregate Medicare margins for hospitals is negative 8%. Medicare plus five is still negative in that case. Seems a bit like a problem.. What's the margin on uninsured people showing up in the ER and never paying their bills
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Jun 12, 2018 03:30
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Zauper posted:Most recent data shows that aggregate Medicare margins for hospitals is negative 8%. Medicare plus five is still negative in that case. Seems a bit like a problem.. Seems like the expectation that hospitals deserve to make a profit is the problem here. There's really only a handful of sectors were incumbents are entitled to make money and they are usually heavily regulated utilities. Do you think your average rape and run nonprofit hospital chain wants to have its prices set by a utility board?
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Jun 12, 2018 03:37
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VitalSigns posted:What's the margin on uninsured people showing up in the ER and never paying their bills Probably directly proportionate to the lack of PCP access for uninsured or Medicaid patients.
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Jun 12, 2018 03:38
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Gunshow Poophole posted:Profit is anathema to provision As "extreme" as most people seem to think that this is, I'm basically with you. Capitalism persists due to humans being innately greedy because of basic survival instinct, which would not be a problem if we didn't live in a society that gleefully encourages that greed to make the rich richer. What's worse than infinite greed and gross overconsumption is that even the idea of an entire planet of 7+ billion people whose day-to-day activities are *not* based on making the most money possible has become inconceivable. Part of me understands it, but mostly it just makes me sad. I don't even use the words "socialism" or "communism" any more because they have become simultaneously incredibly nebulous and mostly despised, especially the latter. Everyone has their own definition of the former and nobody can understand that the latter and totalitarian Stalinism are not the same thing. In any event, people are idiots and both terms are best avoided. I prefer to say "utilitarianism" because it provokes the idea of practicality, marginal utility, maximising the use of resources, conservation and thinking about the long term. It's also a much less socially marked term, by which I mean nobody knows what the bloody hell I'm on about.
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Jun 12, 2018 04:01
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On the other hand, you can have public funding with private providers who are presumably driven by the profit motive, and it's not a huge problem. That's what Canada does, there's nothing terrible about it. The important bit is strictly controlling the amount people are allowed to charge, and making sure access is not constrained based on the ability of the patient to pay.
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Jun 12, 2018 04:07
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Gunshow Poophole posted:Who gives a poo poo What do you do about it? If it can be covered by reduced profit then, "nothing," works outright.
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Jun 12, 2018 04:12
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PT6A posted:On the other hand, you can have public funding with private providers who are presumably driven by the profit motive, and it's not a huge problem. That's what Canada does, there's nothing terrible about it. The important bit is strictly controlling the amount people are allowed to charge, and making sure access is not constrained based on the ability of the patient to pay. This is still intercession based and utterly unnecessary, why doesn't the government just compensate the people providing the care directly? Accretionist posted:What do you do about it? If it can be covered by reduced profit then, "nothing," works outright. I was bein p flippant partly because I thought I was in another thread lol but uh, you can start by nationalizing insurance companies and publicly guillotining their employees above the VP level
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Jun 12, 2018 04:28
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VitalSigns posted:What's the margin on uninsured people showing up in the ER and never paying their bills Medicare's $6.4B in payments to cover uncompensated care is included in the hospital Medicare margins. But also, frankly, that's part of why commercial insurance pays more than Medicare. The average hospital with a higher % of bad debt has a lower loss on Medicare patients (6% vs 15) Peven Stan posted:Seems like the expectation that hospitals deserve to make a profit is the problem here. You mean do I think the average hospital wants all payments to be set by Medicare? Probably not - they don't make money, in aggregate, on Medicare, except for when they can game it. I think the average provider should break even on care in aggregate, I don't care about them making a profit. And frankly, setting prices ala charge master or FFS is a mistake, and Medicare's episodic payment approach (which is how they do hospitals but not docs) is much better...aside from the risk of early discharge. May be worth mention that the average nonprofit loses about 11% on Medicare patients while the average for profit only loses 2%. All payer margins sit at around 6%, which is a sign of just how much they make on commercial relative to Medicare. (iirc Medicare is around 60% of bed days). CAHs generally perform much worse, but are also excluded because their payment status from Medicare is a bit unique. Ultimately the question is how it impacts efficiency and how many hospitals you are willing to put out of business. MedPAC is largely willing to put the bottom quartile of efficiency out of business. That seems fine to me, given the caveat that you'd protect CAHs to guarantee access. But when you get to average efficiency, aggregate Medicare margins are around -1%. I want to say they define efficiency around a combination of cost and outcomes (readmissions), but don't remember offhand.
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Jun 12, 2018 05:33
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Zauper posted:Medicare's $6.4B in payments to cover uncompensated care is included in the hospital Medicare margins. But also, frankly, that's part of why commercial insurance pays more than Medicare. The average hospital with a higher % of bad debt has a lower loss on Medicare patients (6% vs 15) Spin your technocrat bowtie all you want man, you might be aware that hospitals were literally unprofitable before medicare and were considered charities
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Jun 12, 2018 06:27
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Highbrow Slick posted:The ACA is hugely beneficial to all people eligible for APTC and Cost Share Reductions up to 250% of the Federal Poverty Level, full stop. It also benefits older people eligible for APTC (about 40-64 years old) making 250-399% FPL. Younger people making decent but not great money, and people over 400% FPL need to somehow be included in the subsidizing of premiums, copays, coinsurances, and deductibles to gain favor for the ACA. That isn't to say it would solve the many other problems of access, drug costs, etc. But to say that few people benefit at all from the ACA is extremely disingenuous. Peven Stan posted:How many people do you think understand that level of technocratic bowtie spinning and appreciate the genius of a smooth subsidy rampdown??? Highbrow Slick posted:I'm certain that you do, and by virtue of that I'm sure you know the answer to your own question is not many other people do. However, what I can tell you is that once it does start working for people, they really don't care about the details. They just become that much more in favor of it. How that is not glaringly obvious to the people for whom it would benefit most politically, I have no idea. Just do it and let public sentiment follow. I think a major problem among wonks that think about the sliding-scale problem is that they're all economists or public policy people that have never spent a goddamned minute in the trenches of the social work field. A social worker can point to what the problem is at 7AM on a Monday morning before they've even thought about coffee - much less had some. The problem is that people overreport their income when signing up. Think about the Preview page that Healthcare.gov has every single year starting around the beginning of November. It's the simplest kind of shopping you can do and only take a few minutes to get an idea of what your rate will be. You just provide a zip code, number of people, ages, skip the checkboxes, put in your income, and viola...you're at the insurance rates. Because the average person answering that all important question on the sliding scale - income - drastically overestimates it. I doubt the average American knows what Adjusted Gross Income is, and I doubt very few people - even in the accounting field and among self-appointed wonks - know what the ACA's "Modified Adjusted Gross Income" is and how it works - but obviously the Modified's "additional income" bit doesn't really apply to the working poor. Let me give you an example of someone I tried to help out: Person A: She put in her income as $37,800. She didn't even think to subtract all of her business expenses (she didn't even know she could do that on her taxes), she didn't subtract self-employment taxes...she just went to one of those shopping mall tax places and paid to get their taxes done, signed whatever they told her to sign, and walked out. This is the loving problem. When I helped add up Person A's business expenses, other deductible expenses (tuition) and self employment taxes she's realistically looking at closer to $24,000 for her AGI. So for Person A she went from a completely useless "affordable" ($4700/$7350 deductible/OOP) option at $40 a month in a small network OR $305 a month ($200/$7350) if she wanted a plan in a large network and without an insane deductible. Unsurprisingly she went without health insurance because the $40 a month seemed a waste and she'd just gamble at not having a catastrophe. Change Person A to $24,000 and suddenly the small network option is ZERO per month ($25/2450) and the large network is $126 per month ($50/$2450). She had no idea! She was even more flabbergasted because she was worried about what would happen if she made even less money. The prior year had been tough, she'd been sick (so shocked) so often that she had trouble getting into work. So I ran the numbers assuming it happened this year. At $17,000 she'd have either a small network, at zero premium, and zero deductible with an OOP max of $900. Or for $50 a month she'd ahve a large network, no deductible, and OOP max of $850. She just cried. She had no idea about any of this. No one had explained any of it to her. I asked why she didn't just call Healthcare.gov...and she went off on a rant. Her parents were immigrants, she's a natural born citizen, but her entire family is distrustful of everything government related because "you never know what might happen" so she was afraid to call and ask questions or tell them anything because what if they deport her? Telling her she's a natural born American citizen doesn't alleviate any of that fear because her entire family raised her to fear the government and deportations because that's what they saw in their community all the time. That's some built-in fear thats REALLY hard to get past. So did she get insurance? No. I walked her through everything and she just decided to "think about it" before later texting me to say it was nice someone helped, but her family is worried they could use her information to track down other family members (I guess the whole family isn't legally in the US) so she shouldn't get healthcare because she'll cause people to get deported. Poor people live with an entirely different mindset that the economist and policy wonks just seems to completely disregard or outright not understand. Some people - even if you explain the entire system to them - will still want to over report their income just because it's too embarrassing to put in a low number. I've seen people outright lie to a Navigator on their income by over reporting it by $20,000 because it's too embarrassing to say their family with 2 children gets by on $45,000 a year. At $45k a year they can have a ZERO cost policy for a small network, have a $25 deductible / $75 family deductible, and a $2450 individual / $4900 family OOP max. But they lied, said $65k a year, and while that same policy still has no premium they're looking at a $1400 individual / $4200 family deductible, and a $7350 individual / $14,700 family OOP max. Because of loving hubris. $45k a year isn't poor, it's not too far short of the median family income for the US, but that's still "embarrassing" somehow. This is what happens when you get some wonkish sliding-scale system that ignores how people treat a question as simple as "How much did you earn last year?" Because people lie, and not the way those wonks expect them to lie.
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Jun 12, 2018 08:02
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Zauper posted:Most recent data shows that aggregate Medicare margins for hospitals is negative 8%. Medicare plus five is still negative in that case. Seems a bit like a problem.. Do you have a source for this? I'm a little shocked by this--I thought that providers were flush with cash and that the whining about Medicare patients was just greed. I though it was them and the drug & device companies who were making the real money in healthcare. Health insurance companies only have something like a 3% profit margin, so if you were to change nothing about the system but force health insurance companies to run at cost, you wouldn't really change the price of healthcare much.
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Jun 12, 2018 10:39
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silence_kit posted:Do you have a source for this? I'm a little shocked by this--I thought that providers were flush with cash and that the whining about Medicare patients was just greed. I though it was them and the drug & device companies who were making the real money in healthcare. Health insurance companies only have something like a 3% profit margin, so if you were to change nothing about the system but force health insurance companies to run at cost, you wouldn't really change the price of healthcare much. Sure, it's from the March 2018 MedPAC report (they recommended no change from current policy). If you don't know about medPAC, they are an independent congressional agency established by one of the budget acts to advise Congress on cost and other issues in Medicare. http://www.medpac.gov/-research-areas-/hospitals Some of the older reports where they dig into efficiency are really interesting. If you look at the post acute care section, you'll see some crazy margins.
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Jun 12, 2018 12:33
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VitalSigns posted:What's the margin on uninsured people showing up in the ER and never paying their bills When I was in residency my emergency department was reimbursed 14% of what was billed. Since then EMRs have increased both billing and reimbursement, but I don't know whether the ratio of collections to billed amounts has changed. In any case, I suspect that applying even Medicare's historically-terrible reimbursement schedule across all patients would result in a net gain over the current system. (That totally would not be the case for nearby community hospitals with much better payer mixes.) Many hospitals still would require additional subsidies to keep the doors open, however, and unless the Medicare fee schedule was dramatically altered many primary case physicians might not remain solvent.
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Jun 12, 2018 13:03
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silence_kit posted:Do you have a source for this? I'm a little shocked by this--I thought that providers were flush with cash and that the whining about Medicare patients was just greed. I though it was them and the drug & device companies who were making the real money in healthcare. Health insurance companies only have something like a 3% profit margin, so if you were to change nothing about the system but force health insurance companies to run at cost, you wouldn't really change the price of healthcare much. Health insurance companies are mandated to run at cost-plus so they have no interest in reducing costs.
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Jun 12, 2018 13:19
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tetrapyloctomy posted:When I was in residency my emergency department was reimbursed 14% of what was billed. Since then EMRs have increased both billing and reimbursement, but I don't know whether the ratio of collections to billed amounts has changed. In any case, I suspect that applying even Medicare's historically-terrible reimbursement schedule across all patients would result in a net gain over the current system. (That totally would not be the case for nearby community hospitals with much better payer mixes.) Many hospitals still would require additional subsidies to keep the doors open, however, and unless the Medicare fee schedule was dramatically altered many primary case physicians might not remain solvent. Physicians desiring to be to be independent service providers is a) insane b) not something to preserve c) results in very high overheads Unfortunately doctors are arrogant pricks, so..even if you explain the difference between revenue and income, they'll choose revenue every day of the week
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Jun 12, 2018 13:26
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silence_kit posted:Do you have a source for this? I'm a little shocked by this--I thought that providers were flush with cash and that the whining about Medicare patients was just greed. There's a huge variance within the system. The majority of hospitals in the US lose money on patient care. The ones that are making the highest profits have consolidated to the point where they have the luxury of just telling insurers how much they charge (since privately-insured patients are the only revenue generators except for rich self-pay patients who are pretty rare) rather than having to go through the process of negotiating rates. But if you're a CAH then you're probably wondering why the GOP is trying to kill off their voters.
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Jun 12, 2018 13:42
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Crashrat posted:I think a major problem among wonks that think about the sliding-scale problem is that they're all economists or public policy people that have never spent a goddamned minute in the trenches of the social work field. I mean, it's depressing as hell but I appreciate having some understand about those mindsets.
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Jun 12, 2018 13:48
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Malcolm XML posted:Health insurance companies are mandated to run at cost-plus so they have no interest in reducing costs. Volume matters and purchasers are extremely price sensitive so insurance companies do a ton of cost containment. Like negotiated discounts, narrow networks, high deductible plans, care management, claim denials, etc. They have a huge interest in reducing costs and their efforts toward it are obvious.
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Jun 12, 2018 13:50
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Gunshow Poophole posted:This is still intercession based and utterly unnecessary, why doesn't the government just compensate the people providing the care directly? Well, they do in a sense. If I go to the doctor, they take my provincial healthcare card, provide me whatever service I need, and then the government pays them out for that at whatever the rate is for whatever they did for me. If my doctor says, "right, you need to get an ultrasound," they fill out a form, I take it to an ultrasound clinic, and again, somehow that clinic gets paid out by the government in a way that's completely invisible to me. I suppose the government could buy out a whole bunch of practices and compensate everyone involved directly, but provided there are no problems with the current system, what benefit would it provide? The government would all of a sudden be dealing with a massively increased number of direct employees and would be sitting on a whole pile of illiquid assets all over the place for no particular reason. Privatization isn't inherently bad -- the problem is privatization without adequate governmental control. In Canada, we also have privatized air traffic control (for a completely nonmedical example) and it works fine, because it's very strictly regulated by the government even though it's not actually owned by the government. It's not just some for-profit business that's been turned loose to maximize profit, though -- that's a very important distinction when we're talking about privatization.
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Jun 12, 2018 13:58
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esquilax posted:Volume matters and purchasers are extremely price sensitive so insurance companies do a ton of cost containment. They are required to maintain a loss ratio greater than 80% and also required to generate increasing profits for shareholders. Heath insurers have also been merging rapidly. Do the math
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Jun 12, 2018 14:11
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