Let us make the following assumptions about a potential Obamacare Improvement Act of 2017:
- The exchange and Medicaid coverage expansion both go live on 1/1/14
- There are known and unknown glitches with both programs
- On Jan. 21, 2017, Democrats control at least one veto point (The Senate is the easiest veto point. The 2016 terrain is very favorable for Democrats to add a significant number of seats in blue and purple states from the Tea Bagger wave of 2010)
- We’re living in a more rational political universe where trade-offs can occur.
The strongest assumption leading to an Obamacare Improvement Act of 2017 is that by then “fuck you, I’ve got mine” will work in our favor. The weakest assumption is the “rational” political universe.
People will be used to buying insurance on the Exchange/Marketplace. People will be used to getting tax subsidies. People will be used to not having a panic attack when a round of lay-offs are announced for the one member of the family who has employer sponsored group insurance coverage. Obamacare will be status quo. Inertia and tweaking works in favor of improvement.
So what would such an act look like?
I think we can divide the changes into four major categories. Bug fixes, cost sharing, pilot projects being brought to scale and coverage expansion.
The first and I think the easiest set of changes to incorporate will be bug fixes. There are four notable bugs at the moment. The first is Congressional staffers have to go on Exchange for their insurance, but there was ambiguity as to whether or not their employer contribution followed them to the Exchange. OPM made a rule saying the premium subsidy from the employers followed the employees. A simple fix could clarify this. Another example is clergy can’t apply subsidies to some church sponsored plans that don’t qualify as adequate coverage for Obamacare regulations. Sen. Coons and Sen. Pryor have a bill to tweak the regulation. The bug that will get the most headlines over the next three years is the family coverage glitch. Right now, if an employer offers “affordable” insurance to the employee but not the family, the family is unable to get subsidies on the Exchange. That needs to change. The final issue is PPACA was passed with the assumption that all states would quickly expand Medicaid and therefore individuals who made less than 100% FPL would never see the Exchange and thus should not receive subsidy. Tweaking that language so that anyone who qualifies for the Exchange can get subsidy is a straightforward fix. There are other small known issues. There will be a laundry list of other issues that pop up during the next three years that can be fixed.
Currently subsidies are on a sliding scale up to 400% FPL. The maximum the second lowest silver policy can cost is 9.5% of modified adjusted gross income (MAGI). In most cases this works out very nicely. However there are a few corner cases where the second lowest silver for an individual who makes just more than 400% FPL is significantly above 9.5% of FPL. Good social welfare policy making should not have explicit or implicit marginal tax rates of several thousand percent. That messes up work incentives a bit. The policy change should be subsidies apply to any and all situations regardless of income to bring the cost of the second lowest silver down to 9.5% of MAGI. If that means someone with an income of 512% FPL gets a $1,200 subsidy, oh well, they need it.
Conservatives could campaign on a marriage penalty correction as currently two unmarried adults who have lived together for a decade, share a mortgage and two cats (and no I’m not thinking of my friend who is an irrational Jaguars fan and her girlfriend) can qualify for significantly more subsidies than a married couple with the same income level.
The next three change drivers are inter-related. The PPACA/ACA negoatiations left a lot of money on the table from a variety of rentier interests because those players were able to be involved veto actors if they were threatened. However, there is still a lot of money on the table that can be used to finance coverage expansion and benefit enrichment.
My first major change as a liberal would be to tweak the federal funding share of both legacy Medicaid and Expansion Medicaid. The Feds would offer to pay 95% instead of 90% of the costs of Expansion Medicaid and 75% of the costs of Legacy Medicaid for any state that operates Expansion. Yes, this is a massive bribe to get Texas, Georgia, Alabama and Missississippi et al to expand Medicaid but I think it has policy relevance on a few areas. First, as counter-cyclical economic policy, the federal government can and should run very large deficits during bad times. States are pro-cyclical spenders so they slash Medicaid spending just as demand soars. Secondly, if a couple extra billion dollars per year is needed to get Texas buy-in, that is worth it. Significant cost savings can be anticipated as subsidy and premium levels will decrease as the Exchange risk pool gets healthier.
My next major change would be to start offering incentives to Qualifying Health Plans to adapt Accountable Care Organizations and bundled payments and reference pricing and any other system that has demonstrated cost saving and health enhancing impacts on the Medicare population. Enhanced subsidies of $10 or $20 per month for plans that adapt pay for performance and pay to avoid hospitalization schemas should drive significant business to higher quality systems of care. I would also encourage Medicare/Medicaid to take any pilot project that is working to at least regional if not national scale.
This set of projects should be close to self-financing. If it not, there are a couple big pools of money to pay for them. The easiest pools are durable medical equipment and Medicare drugs. Currently Medicare only puts some DME contracts out for bid in some locations. Expanding DME bidding to cover more products and the entire country should generate $100 billion over a decade. Medicare gets a significant discount on Medicare Part D drugs in the donut hole, but otherwise Medicare has to buy drugs at average wholesale price plus six percent. Medicare can’t be like the VA legally and tell suppliers that Medicare is the biggest buyer in the world for drug X so a good deal is necessary. Both of these steps leverage sheer buying power to get good prices for the American people. Reforming Medicare Part D and allowing a Veterans Administration like formulary would free up a couple hundred billion dollars as well.
The next round of coverage expansion would be to embrace the exchanges for all companies. Right now the Exchanges will be open to large companies (over 100 FTE) in 2017 if the state approves. I would remove the state approval and open the federal exchange to all large companies. Additionally, I would allow states to offer Medicaid buy-in at the same metallic bands as other qualifying health plans. Finally, I would lower Medicare eligibility age from 65 to 62. The three years of expanded Medicare eligibility would be offered as Gold Plus coverage at cost on the Exchanges with the normal subsidies available. Conservatives could get Bronze and Silver HSAs with favorable tax treatment as a policy accomplishment
These are primarily structural changes. Subsidy and eligibility levels would be an area of argument but they are effectively a secondary area of dispute. If the structural changes go through, a few more people are under a single payer(ish) system, the government’s ability to act as a massive buyer with amazing market power is confirmed and the success stories of the first seven years of implementation are brought to scale. This sets the ground for the Health Financing Improvement Act of 2029 for another Medicare eligibility enhancement and a further sliding up the income scale of Medicaid.
CarolDuhart2
Which is why the Tea Party is so determined to somehow overthrow the ACA. A government program that just about everybody benefits some in some way is an antidote to their “anti-government rhetoric” and their sick Calvinism.
And thanks to their calling it “Obamacare” whatever dim hope they had to relegate Obama to the status of a not-very-beloved President is done. Permanently.
Baud
No public option?
And I thought you were one of the good guys.
Paul Papanek, MD
Brilliant. Bravo. Thank you, sir.
Yes, we can surely anticipate ongoing tweaks to the Affordable Care Act. Every other nation with a national health plan has learned to tweak its plan every year or two. And paradoxically, the more a country loves its national plan (like France), the more the plan gets tweaked. Things cannot be otherwise, since pricing and other incentives for health care utilization are dynamic.
I would add a few other planks to your terrific list above. For example, some of the promising policy doo-dads in the ACA’s handling of employer-sponsored plans (such as variable incentives for wellness behaviors in the Section 1201 plans) could be extended to the small business (SHOP) plans, and perhaps ultimately to the individual Exchanges. The role of Navigators could be expanded to include personal health coaching or ombudsman services. This could be a great role for private-sector innovation. Yes, agree strongly that successful elements of ACOs (if we can identify some clear ones) should be made available for private sector plans as well. And of course we’ll surely learn that some best practices from Medicaid expansion, including pricing or UR strategies, could be adopted by private sector plans. This has already happened all over the EU.
Maybe we’ll also learn from some state Exchanges (like Vermont’s) that Single Payer or Public Option variants can co-exist with other avenues for delivering coverage. We’ll also learn about the effects of global budgeting for integrated delivery systems (like Mayo or Kaiser Permanente or Geisinger), and become smarter about pricing for capitated plans.
But the grand lesson will surely be this: If the ACA survives current Republican attempts to derail it, then the nation might develop a rhythm of continuous improvement. I hope that Americans, slow learners that we are, will eventually develop the political maturity to regard identified “bugs” in the ACA, not as fatal flaws, but as opportunities for helpful tweaks. Nearly every other advanced nation in the world has already learned that lesson about their health care plans.
kindness
Richard you are too rational.
CarolDuhart2
@Baud: With 95% of the American public under something (Medicaid, inexpensive private insurance, expanded VA, concierge plans for the simply loaded) there won’t be much appetite for a public option, especially if we also add a buy in to Medicaid for folks over 55.
Remember, the real goal is affordable universal coverage. The public option is just a mechanism.
Besides the ebil Health Care Insurance companies provide a nice share of middle class jobs, and Dems are not going to interfere that much in that for the sake of a “public option”.
Add the expected and the better than expected increased employment in the health care delivery area, and Dems will only remodel Obamacare around the edges.
Baud
In all seriousness, Obamacare is important because it provides a platform for future improvements for health care delivery. Maybe if things go well, we can start to see improvements in 2015.
Baud
@CarolDuhart2:
No argument. It was a dumb hill for bloggers to die on.
CarolDuhart2
@Baud: That’s true. The goal is what matters most. If the solution is fair, affordable and under enough public scrutiny and management to avoid real problems in care and coverage. that is what counts most.
Alexandra
@CarolDuhart2:
How about free at point of delivery, a long-term goal already met by a large number of western nations and implemented, as I understand it, by Veterans Affairs?
In the long-term, looking 30-40 years down the line, why settle for less?
CarolDuhart2
I would include as another data point the Presidency. I don’t see anyone on the horizon that can get 270 on the Republican side. And these days, folks who want to have a reasonable chance of getting the nomination have to come out pretty early. I would wager that the only way we lose the Presidency is to nominate a clunker candidate or have folks stay home because they don’t like the Democrat running.
CarolDuhart2
@Alexandra: That is not incompatible with a private delivery system. If things are prepaid, or the co-pay gets subsidized in some other way, then we get “free on delivery” in practice.
Botsplainer
In 2017, you’ll have to fight through a road gang while pushing your child in a wheelbarrow to see the nearest doctor, who operates 15 miles away by foot. It is a perfect free market, however, as he’ll accept chickens, carrots, canned goods, ammo, etc. He’s cheap because there are no electronic gadgets, limited surgical tools and no anesthesia outside corn liquor that is distilled through car hydraulics and radiator cores.
Freedom, bitchez!
Higgs Boson's Mate
Doesn’t the enactment of these improvements depend on having a Congress with solid Democratic majorities in both Houses? That’s certainly to be hoped for but I wouldn’t bet the ranch on it happening. I’ve lost count of the number of times the House has attempted to repeal the ACA. Rather than learn from the failure of those bills to pass the Republicans have upped the ante until having the nation go into default is a non-zero possibility. Absent the Dems retaking the House we’ll be lucky if the ACA isn’t nibbled to death in a series of hostage negotiations.
CarolDuhart2
The nibbling won’t even happen before 2017 if it ever happens. It’s too late. Folks are already signed up for plans, and the Insurance Companies are nobody to renege on. Besides the ACA is law….only repeal will change things.
Kay
@CarolDuhart2:
There are co-ops right now, non-profits that were started with federal grants to compete with for-profit insurers.
The grant money was cut when the GOP took the House, but some survived. There’s one in Ohio.
They are running on a shoe-string, but if I were them I would pool resources and advertise as “the public option” online. Just go crazy with that angle: “we don’t have over-paid executives!” (they don’t).
They say they have created competition in the states where they are available and rates (overall) are 8% cheaper in those states, but the study was commissioned by the co-op org, so I don’t know how valid it is.
Botsplainer
I’m no longer sanguine about all this. I was thrilled about the rates and deductibles, but now am gunshy, in fear of some kind of bullied repeal after I make a commitment to ditch my current shit plan.
Kay
@Botsplainer:
Right, but every person who signs up makes it harder to repeal. Can you imagine the people in Kentucky who signed up listening to asshole Rand Paul? Must be terrifying.
Higgs Boson's Mate
@CarolDuhart2:
I believe that depends on the result of the upcoming midterms. If Republicans are punished at the ballot box for their intransigence then maybe they’ll pull back. If the crazies are returned to the House then all bets are off.
Richard Mayhew
@Baud:
That is at least a kissing cousin of a public option without introducing a new name to the public debate — these are minor technocratic fixes to exisiting law — how can you object to those :)
Richard Mayhew
@Higgs Boson’s Mate: I’m not worried about 2015 or 2016 as the Democrats are guaranteed to hold one veto point with one extremely invested veto actor. I could see tweaks (the clergy problem is probably the easiest one for Republicans to accept in 2015), but I don’t see weakening.
Botsplainer
@Kay:
Toying with registering GOP and offering myself up as a sacrificial lamb to primary my “worst of the worst” freshman Teatard Congressman where I live (as opposed to where I work, where the awesome John Yarmuth has his district).
I’ll lose, but I can get in my shots. Problem is, a high school classmate who I used to count among my inner circle of friends was his campaign chairman in 2012, and can be counted on to take it personally.
Tripod
I’d couch Medicaid expansion as that rather than Obamawhatever. Even in the yahoo states that polls 60%+ and would be a useful cudgel.
Davis X. Machina
Thousands of brave bloggers fought and died for this and you call it ‘just a mechanism’?
For shame, sir, for shame.
Unless by ‘mechanism’ you mean ‘shibboleth’. Because then you’re spot-on.
Kay
@Botsplainer:
I admire people who do it, even run on the Dem side, so less strategic than your plan.
It’s hard to run for office as the minority Party in a lopsided district. It’s a pain in the ass. Every time I read “we have to go back to the 50 state strategy” I think about how difficult it is to find statehouse candidates here. I’m pretty sure we almost wrecked the marriage of our last statehouse candidate. He wasn’t home for a year. He had “events” every night.
I wrote about the race here. He of course lost, but we wanted a candidate in every race and he wanted to run. It’s basically a full-time, unpaid job and at least 50% of it is fundraising.
Chyron HR
The only true progressive course of action is to just give up on healthcare reform entirely and start again from scratch in 15-20 years. That’s what Ted Kennedy did in the 70s and Bill Clinton did in the 90s, and it worked out great in the long run.
CarolDuhart2
Is it just me, or has it occurred to anyone that this may well be the template for other sorts of entitlement reform?
Richard Mayhew
@CarolDuhart2: Carol — can you expand on that? I’m modeling PPACA reform on both Social Security and Medicare reforms — build off of an established base and take a whack at changing one or two more things every couple of years so that the coverage gets more comprehensive.
Lurking Canadian
@Botsplainer: luxury!
CarolDuhart2
@Richard Mayhew: I’m thinking of the idea of some sort of public/private partnerships, buy in for insurance for those who make too much to currently qualify.
For example, housing. Right now the housing model is one of vouchers/and in an increasingly stingy environment, public housing. This is for those who make too little on the private market to buy outright. Could there be some transitional plans, working with some private real estate that would allow eventual buy-in?
nastybrutishntall
A question for Richard Mayhew:
Here in CO, I went on the exchange, and the same plan I already have, if I were to re-enroll via the exchange, is 100% more expensive, with the same high deductible. Since, on paper, I make too much for assistance, I am therefore stuck w/ the same “bronze” plan (i.e. don’t get sick, or your life is ruined for 10 years instead of forever, but thanks for the premium payments sucker!)
1) Is this because of community pricing?
2) Where are the savings form Anthem now not being allowed to use less than 85% of premiums towards healthcare?
3) If I am healthy, have good genes, and am a very careful person who doesn’t engage in risky behaviors / sports, does it really make sense to pay Anthem $2500 / year for something (or $5000 / year on the exchange) that will bankrupt me anyway if I get sick (since I will likely not be able to work, and my business will fold)? How high are the IRS penalties going to be?
I am a big proponent of universal healthcare – my wife is German, and I see what a deal she got for $150 / month (Gold plan, essentially). But I just don’t see how someone in my situation is doing anything except paying money I could be saving for whatever catastrophe might happen.
amk
40,000 New Yorkers have signed up for quality, low-cost health insurance in just a little over one week, more than any other state reporting thus far.
Seabe
I think all of your suggestions are rational, simple, and would greatly expand coverage. I especially like the removal (or fixing of) the means-testing aspect. Means-testing is obviously one of the ACA’s biggest flaws. Aside from not being single payer obviously.
Richard Mayhew
@nastybrutishntall:
1) I don’t know enough about Colorado to be sure, but most likely. If you already qualified for medically underwritten individual market insurance from Anthem AND are relatively young AND have no pre-exisiting conditions AND are male, you are probably one of the losers of the community rating mechanism.
2) Not sure
3) This is an individual decision on your part. 1st year mandate penalties is 1% of income or $95 with a sub $300 family cap. IF you have reserves and the ability to pay $20,000 for a blown ACL that you got because you slipped on the floor as you’re walking to the bathroom at 3:00 in the morning and the cat decides to take you out, then it might be a worthwhile risk. Or 100,000 to cover a nasty one car accident caused by a deer leaping into the road and you swerved too hard to avoid. However if you can’t afford that, then insurance (the guarantee of a small loss to avoid a much larger loss) is a good option. I would see if you could renew your individual policy by Dec. 1 from Anthem as they could medically underwrite you for one more year (to Dec. 14) and that buys you time to see how the Exchanges shake out.
Richard Mayhew
@Seabe: There is still some means testing in my proposal. Right now someone at 138% FPL has a much lower percentage of their MAGI expected to to premiums than someone at 399% of FPL, and my plan would keep that in place.
Seabe
@Richard Mayhew: right but there wouldn’t be such a steep cliff from “I get help” to not, which is the biggest problem with the means testing of any program. I’d remove all of the means testing obviously but moving the bar so middle income people don’t get fucked is good policy.
MomSense
The thing that I tried to stress to the progressives who wanted to kill the bill or who were disappointed in the PPACA was that the history of progressive legislation, Social Security is probably the best example, is that you get what you can in the first pass and then expand and improve it over time.
In order to get social security through Congress, FDR had to “cave” to the conservative Southern Dems on the Senate Finance Committee who restricted eligibility such that many people were left out. My grandmother was one of those people and only became eligible to participate in social security in the last year she worked.
In addition to the fixes Richard outlined, I have a hunch that we will see a lowering of the Medicare eligibility age to 62 and then 55 in the not so distant future.
Belafon
@Botsplainer: If, for some reason, by 2017 the Republicans are able to take enough offices to change things, the bill they pass will amount to “Rename Obamacare to Republicancare.” Which won’t mean anything since the law is called the Affordable Care Act.
MomSense
@Botsplainer:
What’s going on on the Dem side of things? Any good candidates?
Matt McIrvin
@Richard Mayhew:
Never say “guaranteed”.
Lots of things could happen. Whenever I see Obama and Biden in a picture together, I worry that somebody’s going to try to eliminate both of them at the same time to put Boehner in the White House. I think Biden should stay as far away from Obama as possible, if not hunkering down in Dick Cheney’s Undisclosed Location.
some guy
Yay, the validation of skimmers and parasites in the Insurance Industry is a great and glorious project. Onward and upward to the most expensive/least effective healthcare industry in the industrialized world. Yes We Can! Hip Hip Hooray, the shareholders approve!
Belafon
@some guy: Yay, a system that only protects white businessmen, not farmers, women, or blacks. It’ll never do us any good.
-some guy’s grandfather, 1935.
Ash Can
I have nothing to add to the discussion here — I just want to say that Richard Mayhew is a treasure, and giving him a set of keys to the blog was one of the best things John Cole has done for this joint since drop-kicking his GOP affiliation.
RaflW
I am curious why single payer isn’t in the mix here? Are we relying on Vermont to be the test case? Seems like the fastest way to wring a lot of overhead out of the system and close the coverage gaps.
There is starting to be a ripple of folks wanting to work towards a 2017 waiver for Minnesota to go single payer. MN state Sen. John Marty, a long time leader in MN Democratic politics, is working towards a bill to get the MN waiver.
Ash Can
@Matt McIrvin: Heh! Seriously, though, I have noticed Biden’s absence from the spotlight during this whole funding-default kerfluffle. Maybe it’s because he and everyone else know darned well there’s no way he’d get through a speech or statement or Q&A without dropping multiple F-bombs.
some guy
“Of course we should let everyone’s cattle graze as much as they want on the public common. it’s public, people.”
-Belafon’s great greatgrandfather
some guy
“We are all equal before the law. Everyone is entitled to sleep under a bridge, no matter who they are.”
-Belfaon’s grandfather
some guy
“I got mine, so fuck you!”
-Belafon’s father
some guy
“what’s good for the shareholders of Aetna and State Farm is good for America.”
Belafon
Belafon
@RaflW: Or California. As for why, this is the United States. Over half of our population doesn’t consider some things to be important until it happens to them. Remember, a large number of states, including Texas, have opted out of taking Medicaid expansion money, even though it will actually lower the cost of insurance for everyone.
We are not going to jump into single payer for a while. And it will probably end up being one of those things where we find out we’re on single payer even though it never gets called that.
Richard Mayhew
@RaflW:
I would prefer comprehensive single payer instead of old people single payer, poor people single payer, veteran single payer and working age adult middle class multi-payer system. However, I don’t see any plausible path that does not rely on peyote to get 218 votes in the House, 51 much less 60 in the Senate, a presidential signature AND 5 votes on the Supreme Court for single payer in 2017.
Look at Canada’s experience to national healthcare; Saskatchewan experimented with it, and slowly that model was adapted by the rest of the country. I think that will be the case here too, just not in 2017.
Belafon
@some guy: I see that stung.
Please, in your awesome knowledge, tell me how you are ever going to get a one shot, remove all of the insurance companies, law passed in this country?
catclub
I am deeply involved in a church, and think that the insurance for clergy that does not meet the qualifications should be scrapped, instead find a way to put them on the exchanges.
Fixing that glitch is just a boon to those particular insurance companies, not the clergy.
Betty Cracker
@some guy:
That must be why the insurance companies and assorted fatcats are squarely on the Obamacare train. Oh wait…
Look, I get the anger at the skimmers and parasites: I’d like to see them kicked to the curb and universal Medicare enacted yesterday. But this ain’t the Gumdrop Kingdom. It’s not perfect by any means, but Obamacare is a massive transfer of wealth DOWNWARD, which is why the GOP is going full apocalypse over it.
Ash Can
@some guy:
When you sober up, you’ll realize that we’re already there, and have been for a while, and that the ACA is a step in the direction of fixing that. A big one, in fact. Or you could just take another hit of purity dust and keep digging in the manure looking for that unicorn.
catclub
@Richard Mayhew: Expand medicare one year per year,
so the eligibility age falls every year. Also, newborns and their families automatically enrolled.
Votes for it? Ha ha.
Chyron HR
“Obama will abolish Social Security in his SOTU address, I swear!”
– @some guy, January 2009, 2010, 2011, 2012, 2013, 2014, 2015 and 2016
Botsplainer
@MomSense:
Not really – the bench is mighty thin in the biggest demographic lump in the district, the Southern suburbs of Cincinnati. That area has experienced a sprawling influx of scared white folks over the past 10 years, and their voting patterns show it. They had a conservadem until 2002, and the only guy to really have a chance was George Clooney’s dad, who been a beloved newscaster/sportscaster in Cincy for years. Problem is that the newcomers went reflexively R and didn’t know him, and he got destroyed.
There are probably 400,000 residents of the district directly in the Cincy suburbs. Due to the loss of a congressional district, that district now stretches from a slice of the far Northeast Louisville exurbs 80 miles west (50,000+ where I live) to Cincinnati, then another 150 miles from Cincinnati east to the coal/steel areas just outside Ashland. On that mix, if you don’t get the Cincinnati suburbs and exurbs, you’re screwed even if you pick up heavy majorities of every other county.
I haven’t looked lately, but I’d estimate that the district is running at something close to R+15 in a shitload of Northern Kentucky precincts. Of course, the big Delta hub at CVG had a shit ton to do with the reason why a lot of people were drawn to the healthy economy in that area, and that hub came together due to a significant bipartisan effort of Democrats and Republicans in county, state and federal government.
Felonius Monk
And what if this lawsuit is successful?:
or any of the others:
Source
nastybrutishntall
@Richard Mayhew: Thank you, Richard. Pretty much what I thought.
MomSense
@Botsplainer:
Interesting. Here in Maine about 1/3 of the voters are registered Undeclared and refer to themselves as Independents. Is it a possibility to run as an Independent and get the support of both the Democrats and disaffected Republicans?
Fair Economist
@nastybrutishntall:
The IRS penalties are trivial. Medical extortion, however, is a huge danger. If you need medical care and don’t have insurance, the hospital will charge you three times as much as if you have insurance. I see it on every bill – something like hospital charge $2000, $1200 disallowed by insurance, insurance pays $650, patient pays $150. If you don’t have insurance, you’re liable for the entire $2000.
Over the next few years, the IRS penalties start become substantial, but they’re still nothing compared to the threat of medical extortion.
El Caganer
I’d like to see ACA up and running successfully for a bit before worrying about how it needs tweaked. There are a whole lot of people filled with bad intent out there who would be delighted to tank it – if the Republicans in Washington are having such a fit over Obamacare, what about their even-nuttier brethren at the state level?
Lee
Honestly I’d drop the Medicare age to the 55 just to get healthier people enrolled.
I would think it would also help out with the cost of private insurance as that would be the most expensive demographic for them (55-65).
Just a thought.
PhoenixRising
@nastybrutishntall: You need the pricing for services that the Anthem card will get you, in the event that anything at all goes wrong.
My financial/employment facts are similar to yours. What I learned when I came down with an invasive malignancy for which I had no risk factors just before my 40th birthday is that the true purpose of insurance isn’t to cover all my expenses when things go sideways. It’s to get the adjusted provider price for the PET scan instead of paying the retail (rack) rate.
What’s going to happen to that form of cost shifting (no one ends up paying those prices, in practice, so they allow the health plans to write down the care while bankrupting the uninsured) is an interesting hypothetical I’d like to hear about from an expert.
Meanwhile your smart play is to renew whatever you have now for 2014, if you can, or buy the HDHP in the exchange. Get your whole family on one deductible and OOP and it starts looking less onerous in the event that you need to use it.
Botsplainer
@MomSense:
Not really. Independent runs are not part of the local culture, and there would also be a ballot access issue, I believe.
Those southern Cincinnati suburbs are so weird. Tons of mini-McMansions, a bunch of them opting out of the local schools because public schools are “too liberal”, and they tend to go to either sprawling mega campus evangelical-churches or the sorts of Catholic Churches where the greatest expressions of Catholicity come from manning a fence at a Planned Parenthood clinic, fetus doll in hand, while screaming “fucking WHORES” at any woman who walks in.
MomSense
@Botsplainer:
It would be worth finding out what the ballot access issues are because I can see that you could probably pick of some Repubs with DC is broken message while appealing to moderate Republicans and pragmatic Dems who would vote for an Independent if they saw a coalition forming. Also, if you want to do this to get some digs in you might get a lot of initial attention just by doing something new.
ETA My Mom is in Akron, btw.
piratedan
@MomSense: all politics are local…. Maine has a pretty fierce Independent streak, Kentucky? Georgia? not so much… not to say that such movements can’t start or couldn’t start… just where do they begin and behind whom do they coalesce?
Belafon
@Felonius Monk: Those were pretty much already challenged in the case that the supreme court handled.
Amir Khalid
@Matt McIrvin:
I can all too easily imagine one of your right-wing nutjobs hating Obama and Biden enough to want to kill them both. But the Tea Party tendency despises John Böhner; would that RWNJ like him, Böhner, enough to want to make him president?
CarolDuhart2
@Amir Khalid: The answer is probably no for Boehner.
Robert Sneddon
@nastybrutishntall: I read a blog posting recently from a young man who basically said “If you have an appendix, get medical insurance.” He didn’t have medical insurance because he was young, healthy, good genes, didn’t smoke etc. but he did have an appendix. He now has 20,000 bucks of medical debt and no appendix. His credit is trashed (no cheap car loans, no mortgage etc.), he’s facing paying off this debt over the next ten or twenty years along with his student loans and he’s used up hundreds of hours of his spare time negotiating with the hospital and their debt collection agencies to get some kind of payment schedule that means he doesn’t have to declare bankruptcy.
MomSense
@piratedan:
We didn’t always have an Independent streak here, either. This might be the right time to test it in his district especially if the goal is just to get some digs in at the tea party Rep.
Felonius Monk
@Belafon:
Not according to the article:
Matt McIrvin
@Amir Khalid: Evidently they can operate him like a puppet on a string, so sure.
Stella B
@Kay: California is putting together a co-op. If it works for 10% of the country, I would say that the fat lady has finished singing.
Mnemosyne (iPhone)
@nastybrutishntall:
Here’s a random idea that may or may not work since it sounds like your kids may live in another state — is there any way you can put them on your insurance rather than your ex-wife’s? Weirdly, that might help reduce your premium a bit and/or make you eligible for a subsidy. But your ex would have to agree to it and it might not work across state lines.
Also, too, you Coloradans need to demand answers about why you’re getting screwed harder than everyone else in the country. Start getting your friends and neighbors mad, because the problem seems to be how your state implemented things, not with ACA itself. We in California are getting really good rates while you guys are getting hosed — make your governor and legislature fix that.
? Martin
I think the employer mandate will be one of the first fixes. The negative incentives, while overblown by the GOP are still real. Some businesses will draw their employees down under 30 hours – particularly those in the service sector where <8 hour shifts are the norm. And the penalties for low-wage workers need to not be eliminated, but at least tweaked because there will be another set of employers that outsource workers to get around that.
The mandate overall isn't the problem, but those two rules need to be fixed. The first is fairly easy – coverage mandate should be based on FTE, so that 30 hr/wk employee still needs 75% employer contribution. The second is ultimately a stealth minimum wage law – you get penalized if your employees are under the poverty line. The goal is a working wage. So, that problem and all of the complexities that come with it needs to be addressed.
fuckwit
If I could hug this post, I would. This seems like a fine legislative plan. This is governing.
Commenting at Balloon Juice since 1937
It would be nice to add some type of dental coverage.
Marc in MD
@Commenting at Balloon Juice since 1937: Absolutely – I always wonder why this huge subject is never addressed. It’s becoming clearer and clearer that dental health is closely related to overall health. I’m far more likely to forgo dentistry for financial reasons – past time to fix this, too.
? Martin
@Commenting at Balloon Juice since 1937:
It has dental coverage! At least, it has pediatric dental.
Costs should be quite low, and it’ll be covered by subsidies if households do buy it. It won’t entirely save Appalachia which suffers from massive adult tooth loss due to poor adult dental, but it’s quite a good start.
TooManyJens
@Ash Can: Agreed.
mazareth
@Robert Sneddon: This.
I had my appendectomy 6 months before I aged out of my parents’ insurance coverage. I was in the hospital for 11 nights. Apparently, it’s not good when your appendix is 9″ long.
Had the above happened 6 months later, I’d probably still be paying on that.
Aaron
Employer Mandate: Each 1750 of hourly labor worked counts as one full time employee. -pro rated by hours worked divided by 1750 hours for part time. Same for full time, less then a full year employment. For non hourly workers- prorated by portion of 260 days worked.
mai naem
I would like a break between employer and healthcare period. Nothing that can be done legally but Americans just need to be weaned off that. Maybe if the employers offer you supplemental insurance maybe for copays or something but not for the real insurance.
I would like dental added(i don’t know but I am thinking under the Obamacare policies the insurance cos. may offer it as a sweetener if they make enough money off them.)
Also, I would like to see assisted living added in some form. I have some ideas on this but assisted living can bankrupt somebody pretty damn quickly. I have no idea if it would work, but I wonder if assisted living could be done cheaper in depressed areas in the country. Instead of prisons, create cheap assisted living options.
pseudonymous in nc
Reference pricing and bundling seems like a no-brainer: carrot and stick. Create a bureaucratic fast-track for within-range billing, and a slow-track for out-of-range billing. And for those who want price transparency, “reference plus $X” is a far better way to do it than “$random”.
The blue-sky incremental wish would be for a Dutch-style carve-out of long-term and “extraordinary” care, funded by a payroll tax. Tighten the sandbox in which standard insurance gets to play.
mere mortal
“So what would such an act look like?”
Reduce the eligibility age for Medicare by one year, every year, going forward until everyone is covered.
That would give insurance companies enough time to figure out something useful to do with their companies, while each year removing the least attractive insurance group from their responsibility, and offering the most popular and most efficient insurance provider in the country to more and more people.
Next question.
Will Twiner
or .. you know .. Medicare for all …