Well...what do you think of Obamacare now?

All kidding aside - Republicans are just fine with ObamaCare. Surely you know that?

 

I would like to know why in the 80's and 90's most health plans had a low deductible so people could afford to see their doctor.

 

It would be nice if you could post legitimate sites to support your conclusions. America has the most expensive healthcare in the developed world and not much by way of results to justify the cost. And this is not new since Obamacare.

 

No I didn't. Actually the only thing I know for sure is the Republican Party has no ideas about how to improve healthcare in America.

 

The Republican Party is the Democrat Party. It is not very subtle now.

 

Sorry, I've been more active on another forum and have listed all my sources. This topic is more or less a ground hog day experience both here and there. I'll try to provide sources from now on. And I do have sources to back all this up.

 

Actually both parties are a sham. America is an Oligarchy and anyone who believes otherwise is living in a dream world.

 

You probably can't. America has a great healthcare system for the rich and a terrible system for the other 80% or so of it's citizens. If you actually look at American Healthcare as two systems instead of one system it all becomes clear.

 

I have. 80% of US citizens were happy with the pre ObamaCare system. There was no reason to blow up this system to gain ~ 10 million additional people on Medicaid which is the net effect of ObamaCare. Of the 46 million without insurance which was used to sell ObamaCare ~ 14 million were eligible for gov sponsored health care. It would have been much easier and less costly to identify those and sign them up.

From a post I did on another forum:

http://www.wsj.com/articles/the-slow-motion-implosion-of-obamacare-1446417104

http://www.heritage.org/research/re...ase-due-almost-entirely-to-medicaid-expansion

http://spectator.org/articles/41931/myth-46-million

 

Gee if the ten million additional people who got healthcare though Obamacare were so easy to add to Medicaid I wonder why the Republicans never did it. Probably because they were to busy trying to figure out how to cut spending on Medicaid.

And your use of the 80% figure from the Gallup poll is at best deliberately misleading. The actuall poll says 80% were happy with the quality of their medical care. A much lower percentage were happy with the cost of that healthcare.

 

What R's are trying to cut Medicaid spending? The reform that governors want with regard to Medicaid is for the federal government to block grant funds to each state and let the individual states determine how best to provide health care to their low income citizens. Scott Walker in WI refused to accept the Medicaid expansion from the ACA which was estimated would result in ~ 85K not being eligible for Medicaid. Instead he was able to pass reforms which resulted in ~ 250K being added to the insured totals by working with private health insurance companies. Tens of thousands were moved off gov healthcare and for the first time in WI everyone living in poverty had health insurance.

Source - "Unintimidated" - Scott Walker - 2014 - page 228.

Walker figured out how to ensure more people in WI without taking the Medicaid money. More states should follow his lead with appropriate modifications for their state's particulars. Block granting federal funds to the states would make this process much easier.


Nobody likes to pay bills. But Obama sold ObamaCare on these statements: Families would save ~ $2500 per year on health insurance premiums and if you like your health insurance and doctor you can keep them. Remember those 4 Pinnochio moments ?? In fact families are paying ~ $2500 more for premiums and the additions to the ObamaCare exchanges were balance by those who like their insurance but lost it due to ObamaCare.

 

In what reality did the system "blow up"? Most working age people are still insured through an employer, the elderly are still in Medicare. The ACA filled in the eligibility gaps in Medicaid and put in place an actual market for the small minority of people who get private coverage independent of their employer. Structurally, on the insurance side at least, this was a filling in of gaps in the existing system. And one long overdue.

What do you think the ACA did? It modernized and streamlined eligibility and enrollment systems in Medicaid programs around the country, eliminating the barriers that kept the eligible out and actively reached out to them.

 

ObamaCare blew up the system by requiring that insurance sold have a very extensive number of mandated coverages resulting in a very expensive insurance product. The net result has been many people losing existing coverage which did not meet those requirements and having to pay higher premiums with higher deductibles. That process created a net zero sum. The additions to the number of insured have all been in the Medicaid system. There were no barriers to people getting on Medicaid - in fact if uninsured went to the emergency room they would be signed up. Again, why did we need ObamaCare to accomplish that ??

ObamaCare cuts Medicare spending by $500B over 10 years. ObamaCare fines/taxes those who do not purchase health insurance thus removing the option for some to self insure. ObamaCare fines employers for not providing health insurance compliant to ObamaCare mandates (this has not been applied yet). ObamaCare taxes medical device manufacturers sales revenues (not profits). ObamaCare relies on the young and healthy to purchase expensive health insurance policies that they do not need and reduces the max ratio between old and young from 5:1 to 3:1 - the young are paying for health care for the older.

ObamaCare is a mess. It is a drag on the economy and employment. It must be repealed and replace with reforms to the old system.

 

Again, a huge exaggeration. Most privately insured people in are in self-insured employer plans which are not and have never been subject to benefit mandates. Beyond that, the essential health benefits are deliberately and explicitly pegged to those benefits that were already offered in the most popular plans in the fully insured small group market. So they're a step up primarily for those buying insurance in the individual market. Which, again, is a tiny piece of the market. Now individual plans are as generous as group plans (which most people have anyway) have always been.

Describing that as "blowing up" the system is absurd hyperbole.

Premium increases in the individual market tend to be due to (in descending order of magnitude): (1) the elimination of pre-existing condition exclusions, (2) the minimum actuarial value (plan generosity) standards, and (3) new benefit mandates. If the sick are finally getting a chance to enroll (they are) that will impact costs; if they didn't gain coverage that it wouldn't have impacted anyone's premiums. As for plan generosity, let me guess: you're going to argue the bronze plans are too skimpy and leave too much exposure (deductibles!) for enrollees who buy them, while simultaneously arguing that they're too generous a minimum standard?

And of course there were barriers to Medicaid enrollment (not least the categorical eligibility criteria and various hurdles like asset testing). Bringing enrollment systems into the 21st century was one of the points of the ACA. Again, it's done well on that front.

It was supposed to save Medicare about $500 billion or so. In actuality it's saving over a trillion. Not to mention spurring a bit of a revolution in care delivery improvement.

Yes, this has been applied to most people's employers. And it doesn't change much of anything. Its intent is to prevent the erosion of employer-based coverage (virtually every employer subject to the mandate already offered coverage prior to the ACA). It's job is to maintain the status quo that you're so bizarrely convinced has been upended. And it seems to be succeeding.

"The old system" is very much in place.

 

I notice you ignore my catching your deliberate misrepresentation of the Gallup poll statistics. Why bother talking to someone who is willing to fabricate data.

 

I ignored nothing. People were happy with their health care under the old system. And now they get to pay more for less.

 

ObamaCare mandated coverages are now applied to employer supplied health insurance. That means that premium costs go up and the share that employees pay goes up as well. Employees have no choice on what insurance product they want based on mandated coverages. If plans exceed the Obama mandates a Cadillac tax will be collected. In both ways employees pay more under ObamaCare. I call that blowing up the old system.

.

http://www.cbsnews.com/news/how-obamacare-will-change-employer-provided-insurance/

Those with pre existing conditions (~ 1.5 million) which prevented them from obtaining insurance could have been added to the federal employee plan which covers ~ 10 million people. That plan is based on premium support. The premium support would be paid out of general tax revenues instead of health insuree premiums. And yes the bronze plans are really no insurance for daily health issues. The premiums are low but the deductibles are high all as a result of the mandated coverages. A superior plan would be to allow a national health insurance market with plans of various coverages, premiums, and deductibles combined with health savings accounts. This would allow low income families to purchase the health insurance product that best suits their needs and budgets.

The superior way to handle Medicaid is to block grant fed funds to the individual states. Even without out this provision Scott Walker implemented a plan which resulted in many more low income people receiving health insurance than would have gained Medicaid access if he had taken the ObamaCare Medicaid expansion funds.

What's the source for ObamaCare saving $1T ?? Estimates using rationing from the IPAB ?? The doc fix will be passed every year. That will eliminate any ObamaCare savings. The superior way to handle Medicare is premium support system, again similar to the system available to federal employees. We came close to implementing this reform in the late 90's but Clinton pulled his support after his liberal friends defended him in the Monica case.

ObamaCare must go. The Obama economy is limping along at ~ 1% per capita growth rate. ObamaCare is an anchor on economic growth mostly due to it's stifling effects on small businesses.

 

Again, most people in group plans are in self-insured employer plans which are not subject to benefit mandates; those in fully insured group plans are, but the benefit mandates are generally set to match the set of benefits they already have.

The individual market is where benefit mandates actually matter. No, the system didn't blow up, individual market plans are just better than they used to be. Nothing has changed structurally.

It was obvious from your initial statement that you don't know how things worked before and you're not very familiar with how they work now. Which is about the only way one could ever conclude the existing system was "blown up."

Why would we do that instead of building functioning markets? We would've been left with the same opaque, broken, uncompetitive market that existed for individual insurance before.

In other words, exchanges. Yes, that's happened.

You'e like a slogan machine. The sole purpose of block granting Medicaid is to limit the federal responsibility for financing the program, it doesn't have anything to do with the coverage expansions or delivery system reforms in the ACA. These are not substitute concepts.

And no, Wisconsin is not covering more low income people than it would be if it had made Medicaid eligibility universal for those under 133% FPL. That's an absurd statement, not to mention mathematically incoherent.

Comparison of the pre-ACA Medicare budget with actual spending (and the current projection for the next several years).

Medicare Spending, in Billions of Dollars (blue numbers are actual)
[table="width: 900, class: grid"]
[tr]
[td][/td]
[td]2010[/td]
[td]2011[/td]
[td]2012[/td]
[td]2013[/td]
[td]2014[/td]
[td]2015[/td]
[td]2016[/td]
[td]2017[/td]
[td]2018[/td]
[td]2019[/td]
[td]2020[/td]
[td]Total, 2010-20[/td]
[/tr]
[tr]
[td]Pre-ACA (Jan. 2010)[/td]
[td]528[/td]
[td]574[/td]
[td]581[/td]
[td]638[/td]
[td]710[/td]
[td]735[/td]
[td]794[/td]
[td]830[/td]
[td]867[/td]
[td]962[/td]
[td]1,038[/td]
[td]8,257[/td]

[/tr]
[tr]
[td]Post-ACA (Aug. 2015)[/td]
[td]524[/td]
[td]554[/td]
[td]551[/td]
[td]585[/td]
[td]600[/td]
[td]639[/td]
[td]695[/td]
[td]704[/td]
[td]715[/td]
[td]793[/td]
[td]852[/td]
[td]7,212[/td]
[/tr]
[tr]
[td]Savings[/td]
[td]4[/td]
[td]20[/td]
[td]30[/td]
[td]53[/td]
[td]110[/td]
[td]96[/td]
[td]99[/td]
[td]126[/td]
[td]152[/td]
[td]169[/td]
[td]186[/td]
[td]1,045[/td]
[/tr]
[/table]

Medicare is saving about a trillion dollars relative to pre-ACA policy and trends. That's far more than was required and expected under the ACA.

The doc fix is priced into all of these numbers (in 2010-2014 since those are actual Medicare spending numbers for the year, and from 2015 on because the permanent doc fix was passed last spring and thus is priced into the budget for all future years).

You mean an exchange. Yes, that concept is being tested all over the country right now. If it works well with the private market, sure we can consider whether it makes sense to extend to Medicare. But we're only in the third year for the private market. Let's give it some time to work out the kinks.

 

Employer supplied insurance policies are absolutely subject to ObamaCare coverage mandates. Is Obama's spokesperson lying ?? It is the specification of these coverage mandates by which the gov has taken control of the US health insurance industry. Insurance carriers are nothing more than utilities. The prior system has been blown up.

The market that ObamaCare creates only has one coverage option. That isn't a market. Allowing purchase of health insurance policies across state lines does indeed create functioning markets. Policies are available with differing coverages, dedcutibles, and out of pocket maximums with or without health savings account. Whole foods and the state of Indiana offer their employees high deductible policies with health savings accounts. The employees are very happy with that product.

Block granting allows each state the discretion to implement programs to insure it's low income population. Scott Walker did this in WI but without the block grants:

http://www.jsonline.com/news/opinio...medicaid-expansion-b99376397z1-280373632.html

Your table lists actuals vs. projections. What is the source of the table ?? And what is the source of the projections ??

The market I'm talking about has various coverage options. It does not mandate coverages to only one choice. ObamaCare basically says that a consumer must buy a green Chevy Impala with various finance options and down payments.

 

Self-insured employers don't purchase insurance products from insurance carriers. If you're in a self-insured employer plan (as ~97 million Americans are), your employer is your insurer. They set aside funds to finance medical claims directly. They contract with health insurers only for administrative functions (e.g., the mechanics of paying the claims and access to the insurer's provide network).

Most people "in private insurance" in the United States are not actually insured by a health insurance company. They're insured by whoever their employer happens to be. And those plans are not subject to all of the rules that fully insured plans sold by insurers are (including benefit mandates).

How can you say the "prior system" was blown up if you don't even know what it was (or what it still is)?

That's exactly what exists now. You've got plans with everything from 60 to 90 percent actuarial values; that's a large variation in cost-sharing. And plenty of HSA-compatible plans. See the conservative Manhattan Institute's Health Savings Accounts Under the Affordable Care Act ("The report finds that, far from becoming obsolete under the ACA, high-deductible plans are widely available—98 percent of uninsured Americans have access to at least one HSA-eligible plan. Moreover, these plans also make up about 25 percent of total offerings on Obamacare exchanges. ")

...discretion that states aren't lacking. Sounds like you've got a solution in search of a problem.

The same as the source of your $500 billion estimate: the CBO. Those are the projections from the January 2010 budget outlook (the one published just before the ACA passed) and from the August 2015 outlook.

The ACA was supposed to drop those Jan. 2010 projections by about $500 billion, as you've already pointed out. In reality, given what's already happened and the spending trajectory on which Medicare now finds itself, the real numbers will be closer to $1 trillion below the pre-ACA budget. Huge, huge, savings.

 

That's not what Mr. Carney said when describing the 80% is insured or covered through an employer plan. Those plans are subject to the ObamaCare mandated coverage. And if the actual coverage exceeds the mandates the policies/coverage will be subject to a Cadillac tax.

The ObamaCare policies all have the same mandated coverages. The only differences are the premiums, deductibles, and out of pocket maximums. Sure, HSA's are also available but coupled with the excessive mandated coverages. Stripped down catastrophic coverage policies are not available. And subsidies are given to those who cannot afford these high premiums. The young and healthy are opting to pay the fines instead of the premiums until they get sick and then apply for coverage which they don't believe will happen.

States are stuck with Medicaid. They are not able to craft policy like premium support for catastrophic coverage coupled with HSA's for all low income earners which is what is really needed.

The ACA proposes to cut hospital payments for Medicare but hospitals will then make up the difference by increasing charges to those on private insurance plans. Cutting hospital payments is really just a form of rationing. The added $500B in projections comes from slower spending growth having nothing to do with the ACA.

http://blogs.wsj.com/washwire/2014/02/04/cbo-medicare-growth-to-remain-slower-than-usual/

 

Employers with more than 50 employees have to offer insurance (almost all already do). That's not what I'm talking about. What I'm saying is that self-insured plans are not subject to benefit mandates. They weren't before and they aren't now. The essential health benefits have to be offered by fully insured plans, not self-insured plans.

Odd that Medicaid programs in Arkansas, Indiana, and Michigan are all experimenting with that approach as we speak then (including the savings accounts). Not to mention Iowa, Montana, and others that have adopted a premium assistance model.

And yet commercial hospital price growth has slowed right along with public sector prices. From earlier this year: Hospital prices drop for the first time.

Falling rates from Medicare and Medicaid was accompanied by all time lows in price growth for private payers. The exact opposite of what you're claiming.

It comes from the unprecedented slowdown spending growth our system has experience over the past few years. As your article notes:

The health care system has been getting more efficient, transitioning to value-based payment models under the ACA. That's leading providers to redesign they delivery and re-think their role in promoting health (not just churning out health widgets). That, coupled with greater price competition thanks to the market reforms in the ACA, is helping to hold down cost growth system-wide.

As I said, the savings to Medicare have turned to be way, way more than anticipated by the ACA's framers.

 

You are right about the self insurance. Apparently Mr. Carney was not aware as well. But this "loop hole" is not good news for small businesses. Large self insured companies can afford to implement this plan but small companies cannot because a few cases of cancer could bankrupt them. Small businesses are very important to economic growth. This is another way in which ObamaCare limits the growth of the economy and increases unemployment.


Then what is the contribution of the ObamaCare Medicaid expansion. Block granting federal funds to the states allows the states to develop their own methods for providing health care for the low income families. Medicaid is not a good example of how to best deliver health care to people.

****

Yes, the cuts in Medicare reimbursement have resulted in less care. That's called rationing. Reduce the reimbursement and you have less total spending. Also the major contributor to these cost reductions is Part D.

http://healthaffairs.org/blog/2014/10/21/the-500-billion-medicare-slowdown-a-story-about-part-d/


ObamaCare has increased the rate increase of health care spending and has resulted in fewer insured. Which is exactly what I'm claiming.

http://www.forbes.com/sites/theapot...ending-up-while-covering-fewer-than-expected/

http://www.forbes.com/sites/theapot...tient-centered-consumer-driven-health-reform/

I've learned some new things about ObamaCare from you but I'm more than ever convinced that the legislation should be repealed and reforms made to the old system to address Medicaid, tort reform, buying across state lines, and Medicaid block grants as the best way to reform US health insurance and health care systems.

 

First of all, large self-insured companies generally offer the most generous plans available anyway. It's not as if they need benefit mandates to meet a minimum standard--they generally already far exceed anything you could come up with. Think of the concept of a Cadillac plan (overgenerous plans that tend to drive up health spending)--you can't even buy those from an insurer, they're too expensive and generous to be sold in the actual open market. They're creatures of the self-insured employer space.

The point of bringing up the self-insured market is that most privately insured people (nearly 100 million) are in such plans. I'm not saying that's a good thing, I'm saying that's how it's been and that's how it is. Nothing is blown up.

As for the small group market, those plans were already subject to state benefit mandates. The essential health benefits floor put in place by the ACA thus affects them minimally because the EHB package in a state is defined to be that which they were already offering under their state's existing benefit mandates. Literally: the most popular product that small employers were already buying before the ACA is the default benefit package.

That's not much of a change at all (indeed, the ACA actually limits states from introducing new mandated benefits, something states used to do all the time). Where there was a change would be the individual market, which historically had much skimpier benefits than what small employers offer their employees. That is not some massive upheaval of the system, that's a slow and deliberate filling in of gaps for a very small segment of the market.

The contribution of the Medicaid expansion is that for the first time it makes all poor people eligible for Medicaid (in that respect it's the opposite of block granting, which is designed to make it easier to kick people out of the program). The states I mentioned are all using the Medicaid expansion--not to mention the new exchanges--to test these HSA and premium assistance approaches. Without the ACA, they wouldn't be doing this.

As for whether Medicaid is the best way to pay for care, it's not all that different than anything else. It's mostly in the hands of private health insurers at this point, meaning it functions a lot like commercial insurance. It just has less money attached to it.

If they've resulted in more efficient care delivery and quality ratings have gone up (which in many of the new accountable care organizations serving Medicare beneficiaries, they have) then that's a good thing. It's a big step toward sustainability and better care.

It's absurd to claim it resulted in "fewer insured." The uninsurance rate is now the lowest ever recorded (and still falling). More people are insured now than ever before.

As for the bump in spending in 2014, that was always expected. Millions and millions of people just got insurance coverage for the first time. There will be an enrollment effect until the coverage expansions top out (probably in 2017 or so) and then the spending of the newly insured will be baked into the baseline and growth will fall again.

What's significant here isn't the temporary enrollment-fueled bump in the health spending growth numbers, it's how that growth numbers, like those preceding it, has come in way below expectations.

The CMS actuaries, the ones who compile those national health spending numbers, also do forecasts of national health spending. Their projections from back when the ACA passed in 2010 showed the 2014 bump but they expected health spending growth last year would be 9.2%. This is what they (and thus all of us) expected (from "National Health Spending Projections: The Estimated Impact Of Reform Through 2019"):



The red bump is due to the coverage expansions under the ACA (relative to the blue ACA-less alternate reality). Now in green I've added what's actually happened since the ACA passed:



Health spending growth below even what would've been expected if we hadn't covered 12 million additional people last year. Given that the historical average for annual health spending growth is around 7%, a temporary bump to ~5% as tens of millions gain insurance isn't quite the disaster you seem to think it is. It's actually pretty amazing.

State-level tort reform was in the ACA, the GOP Congress just hasn't funded it.

Medicaid block grants are designed only to restrict coverage. The codeword for booting people out of the program at the governor's discretion is "flexibility"--you know this because the examples of flexibility needed by the states you cited are all things that states are already doing under the current program.

And buying across state lines is a red herring. It's just a euphemism for deregulating so we can make it harder for those with riskier medical histories to buy coverage. That's where the "savings" comes from--no longer paying for the sick to access care. Hardly a miracle cure for the health system's problems.

 

Those self-insured employer plans under ERISA is the main reason why premiums went up for everyone else. Employers that are self-insured do not pay the insurance company of their choice full premium rates, they only pay 5% of that amount. The rest of that premium is put into the employer's bank account for the purpose of paying claims for their employees who use their benefits. They pay the insurance company the allowable amount and then the insurance company pays the provider.

The benefit to the employer is that he or she earns interest on those premiums saved year after year. Also employers obviously employ the healthiest people in the population since obviously someone that is sick a lot is not going to be able to keep their job very long. The ACA gave them the excuse to raise deductibles so their employees end up spending their own money to meet their yearly deductible. Most healthy people never reach that amount so all money put aside in that employers bank account gains more interest.

If you happen to work for a self-insured employer and they make you pay a small amount out of your paycheck to help pay your premiums is a bonus for the self insured employer too since they get to keep that if you seldom use your benefits. The employee unknowingly has taken a pay cut without even realizing this latest scam.

Since most employers have gone this route, the insurance companies were left with small businesses that are fully insured, individual policies, the government's Medicare Advantage, Veteran's insurance and Medicaid population for each state. These are most expensive of the population for obvious reasons.

At one time almost everyone was under one pool except people that were on government insurance. That is why for years premiums, low deductibles, small co-pays was the norm during the 80's and 90's for people employed.