Two valued community members raised good points yesterday in comments:
the blue states can build their own plans. Romneycare might be the model, and some states might try something else; perhaps some sort of single payer system. I suppose they will pretty much have to.
And Martin:
There’s an opportunity now in California, however. The 6th largest economy on earth and 1/6 of the US economy. Dems have supermajorities in both chambers and have the governorship. We’ve twice passed single-payer and Brown has indicated he’d support it if the finances work out. If there is going to be a widespread national privatization effort, CA now has renewed incentive to make it go. Yes, its hella complicated as Richard has noted, but CA also has the most actively managed exchange in the country, one of the most competitive health care marketplaces in the country, and some of the best health policy folks around Kaiser Family Foundation.
The big problem with both of these cases is that state healthcare policy will interact with federal healthcare policy. That means some type of waiver will be needed. That could be a major blockage.
However, the core point is very strong and very valid. Blue states if they want to take care of their own citizens while allowing the Red States to race to the bottom can do so. If there are massive high income tax cuts, there will be fiscal space from high income Blue state taxpayers to fund local social insurance programs. California has the size and the expertise to make a go at something that could work. My bet is that they would go multi-payer in a tightly regulated market and build from the fairly successful Covered California exchanges with higher subsidies and tweaked eligibility but that is a guess purely informed by speculation before my first cup of coffee.
The next big challenge is getting traditional Blue States with super majorities in the Legislature back to Trifectas by retaking governorships so experimentation can move forward with motivated stakeholders. But that is a discussion for a different day.
Major Major Major Major
Richard,
What’s the situation here with regards to abortion, Hyde, Stupak (assuming that part of the ACA is intact) etc.?
Diana
What about the Rethug promise to force states to allow insurers to “cross state lines” so that “competition” can drive down health care costs? Isn’t that designed to prevent states from doing exactly this?
The Moar You Know
As a CA resident, I think this is a great idea with one huge caveat: it will have to cover only CA residents, and we’re probably going to have to make a residency length proviso (5 years), otherwise the red-staters will gleefully come here just to saddle us with their expenses.
Mnemosyne
@The Moar You Know:
I wonder if CA can build a consortium with OR and WA. It looks like Kaiser is in all three states? Maybe include NV as well?
gene108
@The Moar You Know:
I don’t think the residency requirement needs to be 5 years*, because most of the red-states aren’t that close to CA.
The people, who could afford to go to CA for medical care, can afford to go pretty much anywhere in the world. And there are cheaper options than anything offered in the USA.
The poor slobs, who will be dying because of Republicanism, couldn’t afford to make the trip.
* You’ll need some kind of residency requirement, which would closer to 6 months to 1 year.
Mnemosyne
Also, too, can I hijack @Richard for a moment?
So it’s looking like my mom in IL is going to need open heart surgery fairly soon. I want her to get it done before Inauguration Day, but would there be any need to push it faster than that?
md S Oregon
Richard: I live in Congressman Walden’s district 2 in OR. I have been calling his office since the Monday before Thanksgiving. I have an ex-relative that relies on Medicaid to keep her child alive, and most likely voted for him I want to be accurate when I voice my complaints re: voucherizing Medicare/Medicaid. On his website he outright lies about Obamacare. He is all in for Ryan’s “Better Way”. Can you give me some concise/accurate tips that I can leave in his voice mail? The Monday before Thanksgiving I got a live person, and this week all I get is his voice mail. Thanks!
SW
Colorado Care lost in the last election by a 2-1 margin. Still, if Medicare is destroyed, and a more well thought out proposal were put together, my guess is that it would pass handily.
LeftMass
I am a CA resident and I sincerely hope that the Legislature undertakes this. Especially as I had been thinking of retiring at 63.
I see timing problems. The impetus to act will not kick in until ACA repeal. By the time this occurs, there will be a new Governor and a 2018 Legislature, which will likely have more Republicans (off-year election). So, when the need is actually pressing, the votes might not be available.
Mnemosyne
@Mnemosyne:
Couldn’t edit, but obviously I mean insurance reason, not medical reason.
Barbara
@Major Major Major Major: Right now, California funds abortion via Medicaid with its own dollars. There is no issue with this in California, unlike in many other states. As I understand it, the Colorado initiative tried to finesse this and they did not do a good job of satisfying NARAL and PP that abortion and contraception would not be blackballed under a unified Colorado plan. That may not have been why it lost, but the issue was definitely given a fair amount of visibility.
O. Felix Culpa
Would this approach be feasible for small (population-wise), poor, blue states like New Mexico?
jacy
It seems like a promising road to at least start down. Blue states are going to have to find a way to protect themselves from what’s going down nationally. I would think this would only empower the blue states and make them more successful. If I could move to a blue state, I would do so immediately, but I’m stuck here for 6.5 more years barring a miracle.
Richard Mayhew
@The Moar You Know: There is little evidence that low income individuals move towards states with better benefits (https://t.co/0tI11l3LLU looks at Medicaid expansion)
Richard Mayhew
@Mnemosyne: No… 1/20/17 should be safe…
Barbara
@Mnemosyne: What is her coverage? Does it include any kind of high deductible?
The Truffle
@SW: What was the reason for Colorado Care’s failure? As I understand it, they weren’t sure how to pay for it.
Cheap Jim, formerly Cheap Jim
What happens when they allow insurance companies to just set up in Kansas (or whatever regulation-free state emerges) and sell across state lines?
Mnemosyne
@Barbara:
She has Medicare and supplemental coverage. I don’t think her deductible is particularly high except that she’s on a fixed income, but the family can help her with that. I just don’t think we can pay for open heart surgery out of pocket since we’re not frickin’ billionaires over here. ?
MomSense
What needs to happen for RomneyCare to be back in effect in Mass? Is it still in effect?
Barbara
@Richard Mayhew: There is some evidence that people with such extraordinary needs that they essentially define their lives move based on benefits, but that’s a really small number, although seriously high cost. The same is true for special needs education programs. Cities that have a good reputation sometimes see an influx of people moving there to take advantage of good special needs programs. In any event, right now, California is more generous than most other states and no one has reported an influx based on that difference yet.
Barbara
@Mnemosyne: Medicare isn’t going away any time soon. Even if they engineer some kind of phase out, I infer a trigger date for the kind of two-tiered program they seem to want that is at least 7-10 years away. I have tried to explain why in prior comments. Your mom is good to go.
Pogonip
@Barbara: When I retire I’ll pack my kid up and move to wherever has the best services for autism–right now that looks like Cleveland, Ohio, of all places, although I have not finished researching all 50 states.
Florida’s out, thank God. I would tolerate giant flying roaches to help my kid but I wouldn’t be happy about it!
Brachiator
Love their meal:
Real down to earth, working class stuff.
And yeah, I actually kinda like and respect the menu choice, depending on what sauces were available for the frog legs.
No dessert?
bemused
Richard,
Pre Trump getting the presidency, what options were being considered to do something about the spike in insurance premiums? I know Marco Rubio managed cut a bailout for insurance companies in a budget bill. Were there viable solutions to the problem that might have gotten done if Hillary had won? The increase in premiums very high in Minnesota and hitting the self-insured hard. They’re very discouraged and can’t get up much enthusiasm for ACA at this point when their savings are being drained.
Pogonip
@Mnemosyne: No, such a big change will take at least 2-5 years, and that’s assuming they even get that far. Medicare is a gold mine for doctors and hospitals, they are not going to want their gold mine replaced with piddly little vouchers. Trust in God, tie up your camel, and don’t be afraid.
Comrade Carter
What if you’re in a blue state, like Wisconsin, that has a GOP Governor, a GOP Senate and a GOP House despite not getting anything like the votes the Democrats got? What then? No healthcare.
Pogonip
@Comrade Carter: No, but if you establish a consultancy to detect voting fraud you might make a lot of money.
Britlaw
Richard,
If you were estimating the private cost of a Medicare equivalent, would simply multiplying the current cost of supplemental insurance by four be a reasonable proxy? I realise it’s hard to speculate without policy specifics, but as a talking point against vouchers, would this be feasible. In my experience this would put the theoretical replacement cost at or above $12k annually per individual.
Omnes Omnibus
@Comrade Carter: As much as I hate to say it, Wisconsin is no longer a blue state. We are purple – with some vote suppression tossed in for good measure.
rikyrah
Is this true?
the 6th largest economy – in the world?
Roger Moore
@Cheap Jim, formerly Cheap Jim:
One of the points of single payer is that it short circuits that whole argument. Essentially, the state becomes the insurance company for all its residents and pays their premiums out of tax revenues. Other insurance companies can try to compete in that market, but I think they’ll have a hard time!
Yutsano
@Mnemosyne:
Kaiser only covers one county in Washington (I know, I’ve looked into joining it here) and doesn’t seem to be expanding any time soon. There are several big players including an HMO that could probably merge with Kaiser and establish a dual payer system of some sort. (BC/BS is big up here and Regence pretty much rules the west side insurance market.) The real big issue is implementing an income tax since there would be no way we could finance it the way the current funding streams are. But if it gets sold right plus the direct benefits of near universal coverage come around it should be doable.
Regnad Kcin
@gene108: in-state/out-of-state tuition model, maybe with a clawback for anything egregious?
Cheap Jim, formerly Cheap Jim
@Roger Moore: But only single-payer, right? Forgive my parochialism, but it’s gonna be a hard road getting that out of Larry Hogan.
Ohio Mom
@Pogonip: I also have a son on the spectrum and I live in Ohio. What kind of services are you looking for?
If you are looking for a Medicaid Waiver, they are in short supply in Ohio. My kid has been on the waiting list for a dozen or so years, and there are 900+ in front of him in my county — admittedly I live at the other end of the state but I don’t know why Cleveland would be much different.
In short, unless he is able to hold down a job, he won’t have money to live on his own (group home, supervised, supported living or any other variation) until both my husband and I die, then he’ll be an emergency case and move to the start of the waiting list.
You are right, states are wildly different. In Massachusetts, a person with autism also has to have ID to get services (ID=intellectual disability, the condition formerly known as mental retardation). No matter how much your autism gets in the way of your functioning, if you have an average IQ or above, you are out of luck.
I hear good things about California but don’t know any specifics.
Darkrose
@rikyrah: Yup!
Miss Bianca
@SW: you have more faith in our “Taxorado!” fellow residents than I do.
Miss Bianca
@The Truffle: As far as I can tell, it came down to several factors, including the confusion of the structure – it was governmental but non-governmental. They were billing it as a non-governmental statewide coop, but it was definitely supposed to be collecting and using tax money. Basically, it wasn’t supposed to be accountable to anyone but a board, and there didn’t appear to be any clear-cut qualifications for who sat on that board.
Oh, well, and it was going to raise taxes. That in and of itself was virually guaranteed to doom it – Coloradans love to bitch about how over-taxed they are.
Pogonip
@Ohio Mom: We’re looking for a place where he can live on his own with soneone checking on him a few times a week. Somehow or other his special needs trust allows him to have the magic waiver. One of the things we have to worry about is does the waiver travel from state to state: so far the answer appears to be No. It’s all incredibly complicated and supports my theory that TPTB deliberately complicate everything so the peasantry will have neither the time nor the energy to demand substantive change.
The Moar You Know
@rikyrah: If we were our own nation: yes. Bigger than France, now.
This is why I have wanted #calexit for decades now. We are paying a substantial portion of the bills of the United States, and get shit on and made fun of in return.
Jay S
@Yutsano: Kaiser is in the process of acquiring Group Health Cooperative of Washington and will have a significant footprint here assuming the acquisition completes. And it seems likely to complete soon.
Ohio Mom
@md S Oregon: Medicaid, which is for poor people and the disabled, wouldn’t be voucherized (Medicare for the elderly, is threatened with that).
The way Medicaid currently works, a state puts up x dollars, then the Feds match that amount (usually one to one, but I think some poorer/red states get a higher match). Then the state distributes the combined funds according to whatever system they’ve set up, different states have different systems.
The threat is that the Federal money would be changed to a set amount in the form of a block-grant, which would remove any incentive a state would have to increase their contribution, or even keep it constant. We know from other block-granted programs that this is a recipe for severely weaken and reduced programs.
Lurking Canadian
There will not be “massive income tax cuts”. There will be massive cuts to (and possibly elimination of) capital gains taxes, massive cuts to (and possibly elimination of) the estate tax, and massive cuts to (and possibly elimination of) the corporate income tax. Personal income taxes might be affected by a reduction in the marginal tax rate, or perhaps an elimination of the top bracket.
>95% of the population will not see any direct benefit from any of this stuff. However, they will be able to benefit by paying increased payroll taxes for reduced social services.
Darkrose
@The Moar You Know: Apparently the shitgibbon wants people coming to his Ohio victory rally to sign someone demanding that federal funding be withheld from sanctuary cities like LA and SF. If he does, I hope there’s a legal way CA can keep some of the money we give to the feds.
https://twitter.com/mattmfm/status/803986024242286592
EBT
@Pogonip: Real Talk: Cleaveland isn’t great for queers and non whites right now. I have several friends from cuyahoga county that have said it’s been worse every time they have visited.
Ohio Mom
@Pogonip: I once asked Peter Gerhardt, who is one of those people who speak at autism conferences and who bills himself as an expert in transition to adulthood issues, where the best place to be an adult on the spectrum would be. He said, “A good-sized city.” His logic was there would be public transportation and a variety of types of jobs and recreational opportunities. So Cleveland would meet that requirement.
I am also under the impression that waivers do not transfer between states, though some states may not have waiting lists, which means you could give up the current one. If you can get it, SSI does transfer anywhere. As it sounds like you already know, both Medicaid and SSI have strict resource limits (no more than $2,000 for SSI) so sheltering resources in a trust and/or ABLE account is essential.
To be disabled and to require public assistance is to commit yourself to poverty. And yes I agree, it is all way too complicated, difficult and ultimately, punitive.
I’ll be interested in what you finally come up with. Who knows, maybe one day, after my kid’s 22nd birthday, we’ll look to move, too.
Ohio Mom
@Darkrose: Someone should be giving the people in line for that Cincinnati Trump rally handouts to sign saying something along the lines of, “Keep your campaign promises re: no changes to Medicare and Social Security, Also, no changes to Medicaid, and increased funding for ACA.”
(Wish it could be me but tomorrow is cataract #1 removal day.)
Pogonip
@EBT: That’s a shame. I hope things improve for them.
Pogonip
@Ohio Mom: Let’s keep each other posted here. If Cole ever gives up the site we can always correspond. Good luck with the eye!
What Have the Romans Ever Done for Us?
@O. Felix Culpa: Possibly if blue States form multi-State consortiums you could glom on to one of those. i have no idea if that is feasible but Vermont is probably in the same boat and could maybe join Massachusetts as a partner. I live in Maryland which I presume would also be interested in a State based solution if Obamacare and/or Medicare get destroyed or plundered. Maryland is wealthy and has a pretty sizable population but it would probably be beneficial to partner with other progressive States if possible because we have no where near California’s clout.
altofront
This is a question for Richard, although I would welcome answers from anyone. My 4-year-old son is on the spectrum, and he currently receives about 30 hours of one-on-one therapy a week. This is covered by my insurance, as I understand it, because of a California law that was passed at around the same time as Obamscare. I’m guessing it costs the insurer upwards of $100K a year, so thanks, community rating, as well as everyone on the plan who doesn’t have a kid with special needs.
So what happens now? Is community rating going to disappear? Will a flood of cheaper out-of-state plans force my employer to switch? What should be keeping me up at night?
Pogonip
@altofront: In your position I would watch the therapy and learn how to do it myself as well as I could. If you can’t be there because your son would be distracted ask for videos of the sessions.
Mnemosyne
@Darkrose:
California grows the vast majority of the nation’s fruits and vegetables.
Enjoy trying to re-tool the entire nation’s agriculture so you can have tomatoes and lettuce, motherfuckers!
Это курам на смех
When the new maniacs in charge succeed in destroying all of the nation’s future prospects, and secession talk starts, hey California please take us with you (Oregon and Washington).
Ohio Mom
@altofront: I remember how fraught it is to be at the start of parenting a child on the spectrum. Every minute of intervention feels crucial, not being able to see ahead is maddening, and all the nagging questions: Are we doing enough? Is this good progress? Should we also try x or y?
You have a robust, working program and now it looks like it may be in jeopardy; on top of all the uncertainty you feel about about your kid, nobody can begin to guess what will happen to any aspect of insurance coverage, private or public (Medicaid, Medicare).
We can be pretty sure awful things will be proposed and then we will have to fight back. Hopefully we will be as successful as we were in derailing GW’s push to privatize Social Security. It will probably be several months in the making so your kid still has many hours of touching his nose, clapping, pointing, doing puzzles, and all the rest before the ground starts shifting. You might as well enjoy that.
Not the answer you were looking for. Sorry. I don’t know anything about California and the autism advocacy community there but on a national level, the Autistic Self Advocacy Network has really stepped up. You can check their website for the latest news on how the fight(s) is shaping up.
And who knows, maybe one day the Autism Society and The ARC will also wake up and realize it’s time to rally.
Ohio Mom
@Pogonip: Thanks for the good wishes. I’m told it is an easy surgery and I am looking forward to much improved vision.
Darkrose
@Ohio Mom: Good luck–hope everything goes smoothly!
Gemina13
@Mnemosyne: I think a lot of people here in WA would be happy to build a consortium with OR and CA. For one thing, more people involved = more revenue to cover costs. And for another, we Left Coasters have to stick together.
Now if we could also get the East Coast to join in . . .
Darkrose
@Mnemosyne: We need to get the legal weed infrastructure in place ASAP.
Gemina13
@The Moar You Know:
Which is why the Left Coast needs to become its own country. Not Cascadia per se, although that name just jumped to mind.
Darkrose
@Gemina13: I’m not in favor of #calexit except as a literal last resort. It would be incredibly ugly and people would die. I also think too many liberal-left Californians get way too smug about how awesome we are, especially up here in Northern CA. I do think that we should use whatever legal means are available to ensure the protections we have in place for our citizens and for our environment remain, even in the face of pressure from the federal government.
Mayur
@Lurking Canadian: Not quite correct. There will be massive income tax cuts to the top 1 percent.
https://www.theguardian.com/us-news/2016/nov/23/trump-tax-plan-cuts-wealthy-low-income-inequality
altofront
@Ohio Mom: Thank you for your thoughts and suggestions; I really appreciate it.
altofront
@Pogonip: Thank you, that makes a lot of sense–we’re already pretty involved, but there’s certainly more we have to learn.
LeftMass
@Darkrose: I am completely in favor of #Calexit. The society I want, where the government guarantees health care and spends less on the military is not achievable in the United States. Perhaps a generalization after CA shows the way, the remaining states can be convinced to follow the example.
It won’t happen any other way.
SWMBO
@altofront: Sweet fucking Jeezus, this brings back a lot of memories. W was diagnosed with autism when he was 4 years old. The pediatric neurologist told us to put him in an institution and forget he was ever born. I cried myself sick and then started putting together a program for him that worked for him. My husband’s work insurance paid for most of it. The insurance policy changed every 2-4 years as the company would change coverage. God it was a fucking nightmare some times because what was covered one year wouldn’t be covered the next. On the plus side, there (finally) was a law in Florida that said that children with disabilities were covered under all aspects of the policy. The insurance companies tried to capitate services and costs so that if he needed hospitalization, he could run out of money under that policy until the company switched. Richard posted about his friend calling the insurance company to see if the anesthesiologist was covered under that policy. We had to hospitalize W after a psychotic break and we had the emergency room call the insurance to tell them which psychiatric hospital to send him to. We took him there and it was billed at some godawful amount ($2500/day for 22 days). The insurance denied the bill because the hospital assigned a doctor to the case without checking to see if he was covered under the insurance plan. It took a visit to the Insurance Commissioner’s office and the threat of a $10,000 a day fine for every day they didn’t pay before the insurance company paid. Not sure where you live but in general the insurance should transfer and cover most of what your child needs. And if you need to make a well placed call to the Insurance Commissioner’s office, DOCUMENT EVERYTHING!!! When you make a call about anything, open a file and tell who you talked with (doctor’s office, therapist, insurance lackey, whoever), give the date and time, a summary of the conversation and what the end result of the call was (refusing to pay a bill, paying only part, etc.) When dealing with the insurance company, you will find that they usually have some disclaimer that the call may be monitored or recorded. Ask for a transcript of the call. That usually gets you bumped up the food chain to someone with more latitude to make things go away.
altofront
@SWMBO: God, your experiences sound horrible–we haven’t had to deal with anything at that level (yet, I guess). Thank you for sharing that, and for your excellent advice.