How's that Obamacare Repeal Working Out For You?

[Calculus Man]

Does anyone here expect this bill to pass?

I can't imagine it getting through the Senate.

My irrational hope right now is that the bill fails, Congress has to move on, and Trump's words about letting the ACA blow up come true.

[TheReal_ND]

Somebody give me a quick rundown on what's going on with the ACA reform. Also, does anyone else think it's strange this is such a big deal? It makes me think we are just going to end up with a retooled and hopefully cheaper version in the end. I don't think this unconstitutional act is going away.

[Speaker to Animals]

Other than your internet habits, what difference would it have made for you?

Well, I wouldn't have to delve into my freeze-dried food, or worry about whether my survey meter is accurate, or have to fend off an army of cannibal progressives marching out of Asheville into the surrounding towns.

[atanamis]

Yeah, I am royally pissed that the Republicans haven't spent the last 8 years publicly putting together a killer health care reform. That would have been a platform which I would gladly support. Instead we get this trash.

My health care plan (for the first time since the forum migration):

Socialize Emergency Rooms
I support markets, but don't see how anyone can argue there can be a market for emergency health care. Nobody wants to or is able to price shop for the lowest cost ambulance ride, or determine in a crisis which hospital will give them the best rates on ER care. Today emergency rooms are already required to treat all legitimate needs regardless of ability to pay, and I think fully socializing emergency care is the obvious next step. Right now, walking into an emergency room, waiting 6 hours, then seeing a doctor for 15 minutes can and does result in a $1k bill. That's insane.

The reason for it is cost of having the ER available plus the cost of patients who don't pay their bills. But the benefit of having an ER available is really to everyone in that area and not just to those who actually end up using it. As such, like the cost of a military or police force, it makes sense to socialize the costs of having an emergency room. I would like to see all fixed costs of ER care to be paid for by tax revenues. The funding of capabilities that the local ER has would be based at the federal and state levels based on population and projected requirements. The funding at the local level would be based on the willingness of the local population to pay for extra capabilities.

I am still fully willing to allow emergency rooms to charge for the differential costs of treating patients, but paying for bandages and stiches (or even medications) are still better than paying $1k to have a doctor tell you that getting kicked in the head by a horse didn't do you any treatable damage (as my wife's workman's comp provider did when she last went to the ER for a work related injury). For $1k, I bet there are plenty of doctors we could have woken up to come take a look at her for 15 minutes with less than 6 hours wait!

Mandate honest pricing
When my wife first made an appointment with her current primary care physician, we were sent a letter in the mail warning that if we were not insured or they did not accept our insurance we might be charged over $1k dollars for her well patient checkup. When the insurance company paid the full bill, they paid only $150 as a negotiated rate. That's ridiculous. You can't call a doctor and ask them what procedures cost anymore because it can vary by an order of magnitude based on your insurance and required copays (in our case, $1k became $0 out of our pocket). If I were able to make a second change to our current healthcare market, it would be to require doctors to have one price for any service. That price would be the cost to any insurer who bought their services or to anyone walking in with cash in hand. Doctors have become the used car dealers of the modern world, making each encounter a haggling session where both parties walk off feeling they got ripped off. That should end.

In a similar vein, I would require insurers to front the cash and do their assessment after. Currently doctors end up waiting for months to get their payment, and are never sure how hard they will need to fight over what they bill the insurer. The "fair pricing" rule above would mean that doctors are required to sell their services to all buyers at the same price which means that an insurer can either agree to work with a doctor or not, but cannot argue about the compensation amount. There also should be clarity between the doctor and insurer regarding what services are covered and in what conditions, and the doctor should inform their patient whether a given procedure is covered before performing it (assuming no emergency exists). Regardless, the insurer should have the obligation to pay the doctor immediately when billed, and have a arbitration process with that doctor to reclaim the costs from the doctor if they can demonstrate that they properly made information available to the doctor to know that a procedure was not covered at the amount billed. In such a scenario, the doctor would have to repay the overage charged and could not charge this amount to the patient. If the insurer suspects abuse by a doctor, their only recourse would be to drop coverage for that doctor.

The reason for this is to ensure that at all stages those with the most power have the most responsibility to make sure that communication is done properly. In no case should a patient be surprised by a non-emergency bill being higher than they were quoted. If I'm under surgery and need drugs or treatment that wasn't foreseen I understand it. If I am getting a well patient exam and it turns out a blood test is more expensive than I was told I do not understand it. As with car repair, all quotes should be provided before service is started and should be signed off on by the patient or their guardian (except in case of emergency).

Insurance cannot be rescinded or premiums altered as long as premiums are paid
Today, people have insurance through their employer that goes away if they lose their job. Insurance can be rescinded or premiums increased due to poor health. That violates the principle use case for insurance as a concept. People buy insurance when they do not expect to need it to protect them from catastrophic loss if they do need it. Like life insurance, health insurance should come with premiums that either remain static or which increase based on age alone. I am also willing to allow penalties for deliberate life decisions such as smoking, and for rebates for desired behaviors (as allowed by health). But all policies should be inherently owned by the beneficiary, and be maintainable regardless of job changes or health needs throughout ones life. You want young people to buy insurance? Guarantee them that as long as they pay for their catastrophic care plan that they can never have that plan taken from them. Mandate that employers make their health care spending on an employee fungible, so that the employee can use that money to pay for a plan they bring with them to the job. I am fine with insurers offering deals to large groups (including employers) to sign up for their plan, but once that plan has been sold to an individual the insurer can't later change the rate structure so long as that individual pays the premium.


The uninsured
I think the above changes would be a massive improvement for health care in the US. Emergency care would be affordable and regulated. Customers would be protected from predatory pricing schemes designed to force them to use insurance for basic expenses. Insurers would be prevented from dropping people who pay their premium. But the biggest hole the above still leaves are those who can't afford insurance or choose not to get it. For these people, I would offer a public option or a transferable benefit. See, I do think we need to ensure a level of medical care to even the poorest Americans. I don't really care whether a person is a deliberate delinquent who doesn't want to work or a person who through no fault of their own can't hold down a job with benefits. At the same time, I don't want to create a cash giveaway to political cronies either.

In order to avoid rampant abuse by providers, I think we do need to have a government managed insurance program. This program would be required to base its operations on valid actuarial data, and have a specified cost per client. That cost would be subsidized or free to those with low income, and the subsidized portion could also be used by the client on a free market plan of their choosing if they prefer. That might mean that private insurers can do a better job than the government baseline for the same cost and almost nobody uses the government plan. Or it might mean that the government plan is more efficient and everyone buys into that causing the private insurers to go out of business. I really don't care. I know that this is the least popular part of my plan, but I do think that we need an option here and while I don't foresee it leading to full socialization of medicine in the US so long as it is done by the choice of the clients I don't really mind if it does.

Severe needs
I think that most severe needs probably need to get permanent government funding. A child with severe autism needs intense and expensive therapy at a young age, and I think the government should help with that. A person with a major disability might need regular nursing care throughout their life. I don't think it makes sense to ask a private insurer to address such cases well, but that they should be handled by government. This doesn't mean Rolls Royce care for everyone, but the care needed for people with massively expensive conditions to live as normal a life as possible is something we should all be willing to subsidize. Figuring out the details for this category is still something I haven't completely fleshed out in my head.

[Calculus Man]

[Massive load]

Nice post. If you socialize emergency rooms, how do you deal with the people who use them for nonemergency care? My deductibles are so high at this point, that I would be very tempted to use some free(ish) emergency room care for a minor issue.

[Fife]

Does anyone here expect this bill to pass?

I can't imagine it getting through the Senate.

My irrational hope right now is that the bill fails, Congress has to move on, and Trump's words about letting the ACA blow up come true.

As should be by now painfully obvious, there will be no repeal. That precludes "replacement."

[TheReal_ND]

[Massive load]

Nice post. If you socialize emergency rooms, how do you deal with the people who use them for nonemergency care? My deductibles are so high at this point, that I would be very tempted to use some free(ish) emergency room care for a minor issue.

The problem is the minority community use thousands of dollars of services like it's free (it is for them.)

[Martin Hash]

There's nothing wrong with using the ER for practical care, there's plenty of bandwidth. In fact, my experience was in that environment: Highland Hospital in E. Oakland & Lincoln Hospital in S. Bronx. It's not much different than using the NHS in England.

[TheReal_ND]

If you use the ER without insurance you are the problem and should kill yourself. Save us the grief over all the nigger taxes every president has to address.

[jbird4049]

If you use the ER without insurance you are the problem and should kill yourself. Save us the grief over all the nigger taxes every president has to address.

Anger much?

Anyways there are still plenty of people who either can't afford a plan, or the deductibles are so high, that they are often forced into an ER.