The Sad Case of the Patient Protection and Affordable Care Act

[FreshFish]

This thread title is NOT about how health care “should be” organized and delivered. My initial comments are limited ONLY to the actual language and administration of PPACA itself.

My thesis is that, no matter what you believe about the way health care should be organized and delivered, PPACA will fail to meet your criteria.

Do you believe that, whether you are self-employed, a partner in a partnership, employed by someone else, retired, or in transition, the tax treatment of your health insurance premiums should be the same?
-- nope, you don’t have it

Do you believe that the delivery of healthcare is so important to each person’s well-being, that the government should pay for it for everyone?
-- nope, you don’t have it

Do you believe we should have universal health insurance coverage?
-- nope, you don’t have it

Do you believe we should use market forces to contain or reduce costs?
-- nope, you don’t have it

Do you believe we should educate patients and provide them with full upfront disclosure of costs and provide them financial incentives to utilize healthcare resources wisely?
-- nope, you don’t have it

Do you believe we should provide incentives for technological innovation, scientific advancement, and more efficient administration?
-- nope, you don’t have it

Do you believe we should provide people with flexibility to choose the healthcare plan design that best suits their needs, goals, financial situation and station in life?
-- nope, you don’t have it *

Do you believe that people should be able to keep the health insurance plan they have now if they are happy with it?
-- nope, you probably won’t**

Do you believe that doctors and patients should have primary responsibility for healthcare decisions?
-- nope, you don’t have it

Do you believe in equal protection under the law?
-- nope, you don’t have it ***

Do you believe in rational insurance pricing (i.e., people are classified into risk pools, and then charged a premium commensurate with the morbidity experience of their risk pool)?
-- nope, you don't have it

Do you believe a healthcare plan should be actuarially sound?
-- nope, you don't have it. ****



As I said at the outset, I'm not debating what is the "best" way; I'm merely saying that no matter what you believe the best way to be, PPACA fails.



* The law allows only specified deductibles and co-insurance levels. For many people, a $5,000 deductible might make sense; they can't get one.

** If you look at health insurance premiums relative to the penalty for not paying them, there are substantial incentives for employers to drop coverage. They can do so in clear conscience because their employees will automatically be enrolled in state insurance exchanges and many will be eligible for subsidies. "Hmm.. pay $20,000 in premium for family coverage? or pay a $2,000 fine and have my employee receive a $10,000 subsidy under PPACA? Is this a hard choice?"


*** over 800 waivers granted in 2011. What kind of a law is it that requires so many waivers in its first year of operation?


**** The plan's own actuaries have certified that the CLASS benefit is actuarially unsound (technically, they refused to certify that the CLASS benefit is actuarially sound).

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

One thing I typically bring up with this act, and I'm sure many of the small townies will understand this one: What is the accreditation process going to be for these doctors to allow for reimbursement? As an example, where I grew up, there were two dentists in town. However, under the state's dental care plan, I was not allowed to utilize the services of either dentist and receive reimbursement. Instead, I would have had to travel 35 miles to a clear other side of the county in order to receive the services and have it reimbursed by the state.

With this plan, I can almost guarantee that family doctors and small practices will not receive accreditation, they'll likely then be forced to go out of business, and people will be forced to travel up to 100 miles just to receive health care.

[Kepler]

Re: The Sad Case of the Patient Protection and Affordable Care Act

From the title I assumed this was more mookie spam.

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

From the title I assumed this was more mookie spam.

Sadly, no. Quite serious instead. There were even more bullet points in my original article that I omitted from the thread starter, and a companion piece (tongue-in-cheek) that actually would have read just like some of his recent threads, describing why someone would still support PPACA despite its failure to deliver on any of its promises.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

From the title I assumed this was more mookie spam.

You're not the only one.

[ScoobyDoo]

Re: The Sad Case of the Patient Protection and Affordable Care Act

The country is going to go bankrupt. It doesn't matter what the Health Care Act is. Ryan plan, Obamacare, Obamneycare, Romneycare, Single Payer.

Don't make any difference.

Thank God we had so much money that we didn't have to tax for the wars though. Just think if we had to tax folks for that?

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

An interesting alliance regarding point # 1 of the thread starter:

Could gay conservatives have the answer to ObamaCare?

Gay Americans understandably chafe at the way the tax code discriminates against them with regard to health insurance. If you are heterosexual, the insurance provided your spouse by your company is treated as a benefit—which means it is untaxed. If, by contrast, you are gay, the insurance provided your spouse or partner by your company can be treated as income—which means taxed.

Most gay-rights groups understand that. Most also know that to get President Obama's health-care bill through Congress, a provision that would have included gays in this tax break was stripped out. Yet with one notable exception, most gay organizations nevertheless continue to argue for solutions that expand the federal government's role in health care and leave the employer privilege intact.

The exception is GOProud, a pro-free market, pro-individual liberty, pro-limited government coalition of gay conservatives and their allies. This group argues that the problem with our tax code isn't just that it discriminates against gays. It's that it discriminates against every American who doesn't have his or her health insurance through an employer.

The folks at GOProud aren't asking for special treatment. To the contrary, they want a system in which all health-care consumers are treated equally. They argue that this requires a thriving national marketplace for individual insurance—which is why GOProud also favors removing restrictions that prevent health-insurance plans from competing across state lines.

From my perspective, this also is the "best" way to reform the health insurance market: break the relationship between employment and coverage. Everyone buys their own policy. You can still have group rates, but now the rates are based on the morbidity profile of the group, you are not forcing the young to overpay so that middle-aged and elderly don't howl so much (I cannot believe any young person would favor Obamacare given how drastically over-priced their rates will be! talk about a perverse incentive).

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

An interesting alliance regarding point # 1 of the thread starter:




From my perspective, this also is the "best" way to reform the health insurance market: break the relationship between employment and coverage. Everyone buys their own policy. You can still have group rates, but now the rates are based on the morbidity profile of the group, you are not forcing the young to overpay so that middle-aged and elderly don't howl so much (I cannot believe any young person would favor Obamacare given how drastically over-priced their rates will be! talk about a perverse incentive).

Good points....

Should all policies be issued to one person only (with the provision that a newborn has 1 yr to get his/her own coverage) and bag the family plan? Then your "group" would be like term life insurance? Riskier behavior would result in a higher premium? This would make an interesting debate topic.

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Good points....

Should all policies be issued to one person only (with the provision that a newborn has 1 yr to get his/her own coverage) and bag the family plan? Then your "group" would be like term life insurance? Riskier behavior would result in a higher premium? This would make an interesting debate topic.

No reason not to maintain insurance as we pretty well know it know, in a certain sense....family coverage is an option, and is individual coverage, people would pick and choose (some years the same married couple might have a family policy with no dependents; other years they each might have an individual policy). There probably would be open enrollment periodically, and a special risk pool set aside for people with certain severe conditions.

It may not necessarily be like "term life insurance" either; no reason not to have policies that build cash reserves when you are younger and can afford it, so that those same reserves become available later in life as a resource to help defray cost of coverage in senior years so that it's not always all out of pocket.

I'd certainly expect smokers generally to pay a higher premium than non-smokers, though it would not be "required." Market forces probably would lead to distinct smoker rates, just like market forces would encourage people to develop healthier living habits.

These are necessary and obviously no where near sufficient improvements.....letting those just out of college buy $5,000 deductible catastrophe only policies and save the difference indefinitely in a tax-sheltered account would really help them buy into the system. There's no reason each state couldn't require every resident to purchase a high-deducticle policy as a condition of being eligible for treatment in a state facility. The states do have that right (in theory, it depends upon the actual state constitution), it's the Federal government that (i hope!) does not have that right.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

No reason not to maintain insurance as we pretty well know it know, in a certain sense....family coverage is an option, and is individual coverage, people would pick and choose (some years the same married couple might have a family policy with no dependents; other years they each might have an individual policy). There probably would be open enrollment periodically, and a special risk pool set aside for people with certain severe conditions.

It may not necessarily be like "term life insurance" either; no reason not to have policies that build cash reserves when you are younger and can afford it, so that those same reserves become available later in life as a resource to help defray cost of coverage in senior years so that it's not always all out of pocket.

I'd certainly expect smokers generally to pay a higher premium than non-smokers, though it would not be "required." Market forces probably would lead to distinct smoker rates, just like market forces would encourage people to develop healthier living habits.

These are necessary and obviously no where near sufficient improvements.....letting those just out of college buy $5,000 deductible catastrophe only policies and save the difference indefinitely in a tax-sheltered account would really help them buy into the system. There's no reason each state couldn't require every resident to purchase a high-deducticle policy as a condition of being eligible for treatment in a state facility. The states do have that right (in theory, it depends upon the actual state constitution), it's the Federal government that (i hope!) does not have that right.

Not term where you get a flat benefit but the premiums rise as you get older, but an annuity like policy. Say somebody offers a health policy with a maximum of $1 million in lifetime benefits. If, as a whippersnapper in my first job, I buy such a policy I would pay a slightly higher premium than somebody who has a annual contract, but the insurance company would invest my premiums in an interest bearing account that my premiums would be stable over most of my life and then at some point, they would go to zero as the interest earned would pay for the premiums (Conversely, if I was 90 and wanted such a policy, my premiums would be through the roof).

The only trouble would be if the whipppersnapper dies suddenly (train wreck) without receiving a large amounts of benefits. What happens to the premiums paid?

[Plante26]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Not term where you get a flat benefit but the premiums rise as you get older, but an annuity like policy. Say somebody offers a health policy with a maximum of $1 million in lifetime benefits. If, as a whippersnapper in my first job, I buy such a policy I would pay a slightly higher premium than somebody who has a annual contract, but the insurance company would invest my premiums in an interest bearing account that my premiums would be stable over most of my life and then at some point, they would go to zero as the interest earned would pay for the premiums (Conversely, if I was 90 and wanted such a policy, my premiums would be through the roof).

The only trouble would be if the whipppersnapper dies suddenly (train wreck) without receiving a large amounts of benefits. What happens to the premiums paid?

I like the idea. You'd have to specify whether this arrangement is an annuity or standard health insurance policy (that would be surrendered to the insurance company upon death in the case of the former, or simply cease to exist in the case of the latter), or a life insurance policy that is of the whole/universal/variable life variety (which would be part of a decedent's estate).

If it functions like a life insurance policy, you can bet the Feds will try to get theirs via the estate tax. Though it might be beneficial to dictate that the funds be must transferred to the corresponding health/life insurance policies of the decedent's heirs......especially if the spotlight remains solely on insurance coverage and ability to pay rather than on the reining in of medical costs, the expansion of health care availability and the improvement of the health of Americans as a whole--all three of which are more pressing issues.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

One thing I typically bring up with this act, and I'm sure many of the small townies will understand this one: What is the accreditation process going to be for these doctors to allow for reimbursement? As an example, where I grew up, there were two dentists in town. However, under the state's dental care plan, I was not allowed to utilize the services of either dentist and receive reimbursement. Instead, I would have had to travel 35 miles to a clear other side of the county in order to receive the services and have it reimbursed by the state.

With this plan, I can almost guarantee that family doctors and small practices will not receive accreditation, they'll likely then be forced to go out of business, and people will be forced to travel up to 100 miles just to receive health care.

I wonder where you would get that opinion. I work in a small practice like this. We would anticipate no problem. It may be the dentists around you made the decision not to participate becasue the reimbursment wasn't worth the effort. In my area most dentists made a conscious effort not to deal with the state for that reason and all of them opted out.

The current law isn't great by any means. I don't know the legality. It doesn't handle a lot of the issues. It does begin to handle some like covering preventitive exams. Anecdotally my practice is slammed by people who haven't been able to get a physical for financial reasons and now can get one. This is esp true for the elderly who have Medicare. They only got one PE before the current law. That PE had to be within the first 6 months after becoming eligible or they missed out. After that one they were never covered again. We now have a wait for physicals out 3 months. This is the first time in the 8 yrs the practice has been open. Compliance for many of the screening tests is way up because they are now covered. I don't hear "I can't do that, I can't afford it"

Listening to the news this AM and the 'analysis' on the SC case. I am curious to hear what the people who do not think this law is OK would propose. The argument I heard for- people who aren't covered by insurance still must be treated which costs everyone. The argument against was requiring us to purchase something was not legal. If this was legal they could at some point require us all go to the market and buy broccoli if this law continued. My immediate thought, which frustratingly no one said, was no one in the market is required to give you the broccoli for free if you go in and say you are hungry.

I resent the fact that it is OK for medical facilities to be required to treat people for free (not the ones who qualify for free care) which no one seems to have a problem with unless it is an illegal immigrant. It is a problem to require people to be prepared for what they will eventually need.

They interviewed on ER Dr. who said approx 25% of the patients have no insurance in his ER. This was in a medium sized ER. Well the minimum they are going to be charged to walk through the door is probably more than 250$. So assume that 25 people a day have no $. 10 are easy- somewhere around 2500$ (sig underestimate). 8 are more complex (1000$ a pop, not unreasonable) 8000$. The next 2 you might have a trauma, a heart attack, (Care around 50-100K by the end. Once they are in the door you can't refuse them) This costs resources, supplies, a room, staff, medical provider to manage care and then the aftercare. Do the math. It is bad and this is one day. All that will not be paid in a timely manner and probably not at all. No regular business is required to take a hit like that on a daily basis and then chastised for increasing costs but not allowed to stop the bleeding. I am not talking about the crooks that are insurance company CEOs. THis is actual $ that hospitals need to build in to their budgets.

On the patient side they get hit with a bill for even 3-5K and they are in trouble. If they are doing this urgently they probably don't have that cash to just hand over. If they are on a fixed income they have no way to catch up. If they are out of work they aren't making the $ to catch up. This affects the entire extended family.

This is not to say the law is OK or not. I haven't a clue. I know what I would do if I had total control but I am pragmatic and realize a reasonable answer will most likely not be entertained.

I am very curious what the people who are so vehemently opposed to the law would answer to the dilemma of not requiring one set of people to take action yet requiring another set of people provide service and goods for free in response to that lack of action. What are the chances of having a nice little room in the corner of the ED where people can die peacefully because they are not able to afford care. (it comes to mind that many of the stalwart supporters of this need for civil freedom are also the ones who feel it should be illegal to pull the plug as life is sacrosanct)

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

The idea is good. The law is bad (ly flawed).

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

The idea is good. The law is bad (ly flawed).

Agree but the law as first floated was a regurgitaion of what was proposed by the GOP/Reagan and also failed. How this is labled Obamacare I will never know. I don't think much of what he originally proposed made it thru. Anything that would have been a sweeping change (read the real fixes) were nixed.

[WeWantMore]

Agree but the law as first floated was a regurgitaion of what was proposed by the GOP/Reagan and also failed. How this is labled Obamacare I will never know. I don't think much of what he originally proposed made it thru. Anything that would have been a sweeping change (read the real fixes) were nixed.

I mean, other than the fact that he signed it, praised it, tried to start a twitter hashtag with #Ilikeobamacare, and is currently defending it in court, it's a mystery to me too.