Distance equation
September 26, 2013 12:16 AM   Subscribe

  1. It is strange, in my opinion, that the insurance market has evolved so, that so few individuals understand the fundamentals of the medical insurance plans they are insured under."
  2. Among the 19% polled who are uninsured, nearly four in 10 don't realize the law requires them to get health insurance next year. Among young people, whose participation is seen as crucial for the exchanges to work, just 56% realize there's a mandate to be insured or face a fine.
  3. Health policy is an extremely personal and complicated topic... Observing historical patterns of attempted healthcare reform and backlash towards these reforms, we may begin to understand what is keeping such a prominent and promising nation from enlisting a social contract of health.

posted by four panels (172 comments total) 23 users marked this as a favorite
 
If we had just done a public option we wouldn't be facing any of this. Of course, the Republicans would really be opposed to that.
posted by JHarris at 1:20 AM on September 26, 2013 [41 favorites]


Oh also, a few days ago the owner of the local Dominos franchise had a meeting of his Georgia stores and practically exhorted us to "opt out" of the insurance he'd be providing his employees, claiming it'd be worse for us overall, and threatening (although trying not to make it sound threatening) reduced hours for those who didn't. I've considered posting on Ask about it, to get unbiased information -- what is really the deal with this law concerning employers?
posted by JHarris at 1:23 AM on September 26, 2013 [14 favorites]


I'm sure the answer is out there and available, but in order to weed through the inevitable bullshit, what is a single person age 30-40 expecting to pay (per month) for the "minimum required health insurance"?

Not really asking for myself, as I have insurance through my spouse's employer, but more if a "what if" scenario.
posted by ShutterBun at 1:36 AM on September 26, 2013 [1 favorite]


(And yeah, count me among those who likely would have had no clue the new laws were going into effect soon)
posted by ShutterBun at 1:37 AM on September 26, 2013 [2 favorites]




You know, it's funny, when the ACA (fuck everyone, including Obama now, that calls it that stupid name) was first proposed, I looked at it and thought "man, we're really gonna need to move someday." Then the abortion that they passed instead of the actual ACA went through, and I thought "good grief, seriously, can this possibly be the train wreck it seems to be?" Now, we're starting to stare down some of this stuff actually going into effect, and still, almost nobody has any clue how messed up it is (or how messed up the degree of misinformation among the public is going to make it, for years).

All I keep thinking is, "man, we're really gonna have to move, what other country do I wanna raise my kids in...because this situation will not be stabilized in my lifetime and it's just getting worse right now?"
posted by trackofalljades at 1:50 AM on September 26, 2013 [6 favorites]


From what I know so far the ACA plan is to provide pretty much what we've had in the Netherlands for some years now:

1) Obligatory insurance for everybody, provided by a multitude of insurers
2) Insurance cannot be refused (as long as you pay the premium)
3) Medicial history/pre existing conditions do not affect coverage or cost of insurance

The following is the case in the Netherlands but not sure if it's also done this way in the US:

4) Coverage included in the insurance is determined by the government, through negotiation with health care providers and insurers
5) Customers can switch annually between insurers

The Dutch system has its drawbacks (biggest being that if you don't have the money, you can't get insured, though there are various schemes to help those who can't), but for most people it does succeed in providing insurance for a reasonable-ish price.

Is the American system very different, or are there other problems with the ACA I don't know about?
posted by MartinWisse at 2:03 AM on September 26, 2013 [6 favorites]


nearly four in 10 don't realize the law requires them to get health insurance next year

Almost perfect, first we put the poor in jail if they HAVE drugs, and now we put them in jail if they CAN'T GET drugs (legally through insurance).
posted by sammyo at 2:05 AM on September 26, 2013 [8 favorites]


Well one of the big differences would be that nothing in the ACA repeals anything that was shoehorned into HIPPA to "protect our privacy" by creating a complex system of secret prices that nobody ever gets to see or know or compare. So there's that whole fundamental problem of none of this actually responding to normal "market" capitalist forces like supply, demand, competition, etc.
posted by trackofalljades at 2:06 AM on September 26, 2013 [2 favorites]


> what is a single person age 30-40 expecting to pay (per month) for the "minimum required health insurance"?

I provide fairly high-end insurance to a pool of people in that age range and the spend is about $2.5k/person/year. A high-deductible catastrophic-only plan would shave a nice chunk of that cost.

For those with low wages and no employer-provided coverage, there's a premium assistance tax credit that covers up to the entire cost of a typical "bronze" policy.

The Republicans are ramping up the fight against Obamacare for one reason: once people are using it, they'll realize it is not horrible. Until then, they will work as hard as they possibly can to FUD it and pretend that it is much, much more complicated than it really is.
posted by grudgebgon at 2:08 AM on September 26, 2013 [31 favorites]


@trackofalljades: what are you referring to?

There are a number of companies working to create some level of price transparency in the market, and to my knowledge HIPAA has absolutely no detrimental effect.

These firms are seeing a lot of support from payers, especially as a benefit for individuals with high-deductible plans who care quite a lot what they're paying for. The prices tend to be valid only for a specific insurance plan not because of HIPAA, but because providers have a habit of charging uninsured an inflated retail price while each insurance network negotiates their own set of discounts.
posted by grudgebgon at 2:10 AM on September 26, 2013 [3 favorites]


Almost perfect, first we put the poor in jail if they HAVE drugs, and now we put them in jail if they CAN'T GET drugs

If you're poor you get the insurance subsidized to the point of it being essentially free. But snark on you crazy diamond.
posted by Justinian at 2:39 AM on September 26, 2013 [47 favorites]


the insurance market has evolved so, that so few individuals understand the fundamentals of the medical insurance plans they are insured under

I can't help but wonder whether that's the system working as intended. IANAEconomist, but everything I've ever seen on the subject says that efficient markets drive prices down (...or quality up), and that for a market to be efficient all the customers need to have good information, the ability to make rational decisions based on that information, and the ability to switch suppliers based on those decisions.

People in general are bad at assessing risk and healthcare is a very complex and very emotive field, so making rational decisions is always going to be hard. My understanding is that most Americans get their healthcare through their employers, so switching providers based on those decisions is hard. Ensuring that most people don't really understand the details of their coverage -- truthful but slightly misleading ads, dry legalese, details buried in appendices -- seems like it'd be a good move for insurers, to cover the last angle in that "efficient market driving profits down" problem.

More cheerily, 64% of poll respondents in the second link think that they understand the new law "somewhat" or "very" well, and for the questions they show, 69%, 51% and 51% have the correct answers. They leave us to guess how those intersect, but you could read it as evidence that most people have a pretty accurate idea of how well they understand the law, rather than having loads of people firmly convinced of batshit crazy ideas. It's not a fantastic result, but it's a start.
posted by metaBugs at 2:41 AM on September 26, 2013 [3 favorites]


The real problem isn't the poor, the real problem is the not-quite-poor wiith kids who are actually in worse shape. They are generally living paycheck to paycheck and don't get nearly the subsidy which means they are going to be paying more than they can afford for insurance even with partial subsidy.

Of course the joke of the law is that the penalty for not getting insurance is significantly lower than the cost of insurance even if it is enforced which it probably won't be.
posted by Justinian at 2:47 AM on September 26, 2013 [15 favorites]


"Distance equation"

Well, we only have negative distance at the moment. The markets don't even open 'til next week. The big reason why Repubs are fighting for a 1yr deferral of the mandate is that -- golly gosh!! -- by then, it will be midterms again and they want/hope/expect the general population to still be as ignorant as they are now. Yay! More fauxrage and misdirection and lying.

We can't judge this thing for at least 6 to 9 months. Once the lefty states have had time to generate enough good health stories and the those states whose repub governors took the medicaid bait have generated their own persuasive and influential outcomes........then there will be ample contrast and facts and, also, by that stage, the huge roll out advertising and booster effort by the gov and the supporter people/firms/assocations will have dragged a lot of the ignorance numbers upwards I reckon.

It's not going to get hugely popular in a year of course, but some of the main elements will start to be baked in as perpetual necessities. It will be hard to go back to hospitals being the safety net for 1/4 of the pop'n. But anyway, there's gonna be glitches and some states will go better than others and it's gonna be a process to get this airship above the treelines.


[Justinian, that's a very generalised piece of negativity you're throwing out there. It'll depend on a bunch of factors. Why not wait a bit and see what really happens before damning it.]
posted by peacay at 2:52 AM on September 26, 2013 [2 favorites]


Uh, which part? That the penalty for not getting insurance is less than the cost of insurance? That's established fact since the penalty is $95 or 1% of your income and the cost of insurance is higher than 1% of your income unless you make a lot of money.

I'm not arguing against Obamacare, I'm arguing the penalties for not getting insurance aren't high enough which is kind of the opposite. If you want young and healthy people to buy insurance you need to make the cost of not getting insurance more than the cost of getting insurance.
posted by Justinian at 2:55 AM on September 26, 2013 [7 favorites]


Oh sorry J. I read it as a concrete dismissal of family rates. Oops.
They did a LOT of work on setting the penalties right. The first year is very lenient but afterwards it gets much more onerous and eventually it will be a painful fine AND you won't have health insurance. Some people say it could have been done in other coercive ways (as it is with medicare after age 65 so someone said on Ezra's health debate last night). But everyone's gotta be in the pool so I personally - from my cosy antipodean position - thinks it doesn't matter.
posted by peacay at 3:02 AM on September 26, 2013


You're right, the penalty does increase over time. We'll see if having it so low the first year bites them in the ass or not since you know dang well the Republicans will trumpet the news until your ears bleed if not enough healthy people sign up in 2014. I hope you are right that it isn't a problem.

My paperwork for my new California plan should be arriving next week. My old plan with Blue Shield is going away and I have to switch to one of the new plans. I need to look over the details, obviously, but the top line summary I've seen appears to show I can either pay a bit less money for the equivalent to what I have now or roughly the same money for a moderately lower maximum out of pocket cost per year. Which is probably what I'll go for.
posted by Justinian at 3:12 AM on September 26, 2013


We'll see if having it so low the first year bites them in the ass or not since you know dang well the Republicans will trumpet the news until your ears bleed if not enough healthy people sign up in 2014.

But there will be all the new revenue from fees if they don't....
posted by empath at 3:20 AM on September 26, 2013


If we had just done a public option we wouldn't be facing any of this. Of course, the Republicans would really be opposed to that.

And this is what really infuriates me about the Democrats. Republicans were already going to flip out and cry 'socialism' no matter what form healthcare reform took, so why not go all out and actually adopt a plan that would be worthy of their insults? All this compromise to keep single-payer off the table, do away with the public option, nix the medicare buy-in, and completely enact what groups like the Heritage Foundation were proposing as recently as a decade ago, and we've still got a GOP voting to defund it at every turn and morons like Ted Cruz theatrically giving an hours-long speech on the Senate floor calling for its repeal.

We could've had so much more for probably the same amount of aggravation.
posted by RonButNotStupid at 3:23 AM on September 26, 2013 [36 favorites]


But everyone's gotta be in the pool

And that's the rub. Millions of healthy young people already burdened by student loans and underemployed in the Obama economy who are not actually in need of health insurance are going to be forced to buy it. I wonder how this will go down. The effect for most people will be to have a car payment without the car. Because that's how insurance works. You cannot expand insurance coverage to people with pre-existing conditions at "affordable rates" without massively increasing the pool of people who pay for something they don't need or use.

The young voter might not be so enthusiastic about this, but at my age I am glad to see those kids being forced to pay so that everyone can have free healthcare.
posted by three blind mice at 3:25 AM on September 26, 2013 [1 favorite]


The real problem isn't the poor, the real problem is the not-quite-poor wiith kids who are actually in worse shape. They are generally living paycheck to paycheck and don't get nearly the subsidy which means they are going to be paying more than they can afford for insurance even with partial subsidy.

Yup. My husband's employer sent around a letter informing everybody about the law, probably in anticipation of dumping everybody off the plan that they offer their employees.

So I went to see what it's going to cost us to pay for insurance on the exchange on the Kaiser calculator. (This calculator was suggested by the ACA website.)

11,589 dollars a year (after subsidies.) Or about a thousand dollars a month. Right now at the end of the month, we're super lucky to have 200 bucks in the bank. We have no savings.

Unless my husband's boss gives him a raise to cover the difference, we're screwed. Or, more accurately, we'll buy insurance for our daughter, we'll get catastrophic for rest of us, my asthma will not be treated, and fingers crossed that nothing short of catastrophic happens forever and ever amen.

I'm actually for this law, I think ultimately this law or some version of it, will improve healthcare in America. But I'm sick with anxiety over what's going to happen next June-- when my husband's employer-provided healthcare plan probably disappears.
posted by headspace at 3:26 AM on September 26, 2013 [13 favorites]


so why not go all out and actually adopt a plan that would be worthy of their insults?

There was no going all out, the public option was not going to pass the Senate.
posted by Brandon Blatcher at 3:30 AM on September 26, 2013 [7 favorites]


He should probably be looking for another job if they decide to dump their insurance plan. It's the same as if they cut his wages.
posted by empath at 3:30 AM on September 26, 2013 [12 favorites]


If people earn up to 135% of poverty level : they get sliding scale subsidies 3bm. You talk about insurance like it's a commodity. It's INSURANCE. A broken arm snowboarding and 3 months loss of wages or a car crash or meningitis ..........you know, the list is LONG of what might go wrong. It doesn't just have to be catastrophic to destroy yours and your family's savings and life. (I expect most adverts will target mothers and wives).

headspace, do you think your hub's employer pays the insurance now IN ADDITION to his salary? You don't see how much it costs. And if there are >50 employees they will be fined if they don't supply insurance (**I'm pretty sure** but not 100pc sure on this).
Take a little solace from the fact that the vast majority of plans are coming in well under the estimates given by the non-partisan budget office.
posted by peacay at 3:36 AM on September 26, 2013 [1 favorite]


> ...at my age I am glad to see those kids being forced to pay so that everyone can have free healthcare.

Nobody is getting jack shit for free.
posted by ardgedee at 3:38 AM on September 26, 2013 [20 favorites]


headspace, do you think your hub's employer pays the insurance now IN ADDITION to his salary?

Oh, indeed, I do because up until ACA passed, they sent around a letter every year with a Wage Summary. Here's how much we pay you in money. Here's how much your benefits cost. So look, here's how much you REALLY make.

As soon as ACA passed, they stopped sending those letters around. But I'm in a unique position to know exactly how much they pay for insurance for their employees.

I also have the letter they sent out warning us that if Obamacare passed, they might not be able to provide insurance... and the brand new letter letting us know that we would have insurance until next June, and then all bets were off.
posted by headspace at 3:40 AM on September 26, 2013 [2 favorites]


I also have the letter they sent out warning us that if Obamacare passed, they might not be able to provide insurance... and the brand new letter letting us know that we would have insurance until next June, and then all bets were off.


I think a lot of employers are using Obamacare as an excuse to get out of the insurance business. Some of them may just drop their employees' insurance, but I would guess that most of them will simply give them a per-month payment to cover insurance costs.

I know that if the company that i worked for dropped insurance without making it up in wages, the company would not exist in 6 months because everyone would get new jobs.
posted by empath at 3:45 AM on September 26, 2013 [7 favorites]


morons like Ted Cruz theatrically giving an hours-long speech

At least he stood there and had to do something to be an obstruction. VS the way obstruction has been happening. The general public should be offered the same coverage that Congresspeople get, where were the morons giving an hours long speech about that idea?

Given I've never heard of actual healthcare being given by insurance companies this whole rig-a-ma-roll seems to be a bailout to the insurance companies. Government protected markets mean profit.

What'll be interesting is how the courts will handle the contract law issues. If one doesn't like the terms of the insurance companies and you go from firm to firm looking at the terms, modifying the contracts and getting rejected by each firm because you do not like the terms what are you to do if there is no one to buy from? How do the insurance firms handle a suit over something that a medical billing coder screws up?
posted by rough ashlar at 3:53 AM on September 26, 2013 [2 favorites]


Good luck with the "get new jobs" part at the moment.
posted by Holy Zarquon's Singing Fish at 3:54 AM on September 26, 2013 [15 favorites]


I am glad to see those kids being forced to pay so that everyone can have free healthcare.

Perhaps the schools these kids are coming from are getting a better education about free VS forced to pay.

Because if one is forced to pay it is not free. And if one is forced to pay, shouldn't the terms of the contract allow you to be able to go to a public court and have the matter decided by a jury of your peers?
posted by rough ashlar at 4:02 AM on September 26, 2013 [2 favorites]


Vermont was exploring a single-payer system, right? Has anything come of that?
posted by edeezy at 4:03 AM on September 26, 2013


Wow, I'm really kind of surprised at how low my annual premium would be for unsubsidized insurance on the silver plan from the exchange. Like, two grand a year. I won't be needing it, of course, but I expected it to be more.
posted by TrialByMedia at 4:10 AM on September 26, 2013 [2 favorites]


A quick Google search reveals Vermont passed the bill and are working on implementation. Kickin' rad.
posted by edeezy at 4:11 AM on September 26, 2013 [1 favorite]


I'm pretty hopeful and excited about the ACA, myself. My son is 24 and first of all can stay on our insurance for two more years because of the new laws and then after that he'll most likely be able to buy his own. I understand that some people wanted a better system than we're getting but it's still so much better than what we've had before.
posted by octothorpe at 4:13 AM on September 26, 2013 [2 favorites]


Is the American system very different, or are there other problems with the ACA I don't know about?
The Patient Protection and Affordable Care Act is an attempt to shoe-horn full health coverage into a system overwhelmingly controlled by private interests. Only 81% of Americans have health insurance coverage, usually provided through an employer, which means 19% of the lowest income earners don't have access to preventive medicine. But because ER rooms will never turn away a patient, they do end up getting health care – they just get it when the situation has become very serious (i.e. expensive) and they have no choice but to go to the hospital. And if you are uninsured (and possibly unemployed), with few savings, and you need a $200,000 operation to save your life, you will probably end up filing for bankruptcy, eventually. But bankruptcy is expensive for the state and for the private sector (not to mention damaging the credit of the person filing), and because this individual didn't have access to preventive care, it's likely that the cost of their treatment over the span of their lifetime is much higher than it needed to be. That person needing a $200,000 operation at age 54 might have had a cheaper series of treatments at age 41 if the cancer had been caught. It would actually be cheaper for our corporate overlords if poor people had regular checkups. Of course, the cost of this "full coverage" must be paid for by the poor (exempting those for whom the cost of coverage would be 8% or greater of their annual household income, who are allowed to opt out... or those paying 9.5% of annual household income, who will be subsidized). So we shall pass a law mandating that every person must purchase insurance coverage or face a fine. Hence, the Affordable Care Act.

There are some obvious holes. First, the 8 million undocumented workers living in the United States will still have zero coverage; they are exempt from the mandate, but still have access to the ER (see previous paragraph for why this is bad.. someone will have to eat this cost). It's also unclear whether some of the provisions, like mandating that a parent's health insurance plan cover a dependent until age 26, will increase the coverage for young people or decrease it. Furthermore, the "mandate" is hardly a mandate.. if it's cheaper to pay the fee to opt out of the system entirely (and there is some speculation that it will be, for many) then the system won't expand the "pool" as it is designed to. Instead, it will be regarded as yet another wasteful "tax" to be cut at some point by a future Republican administration.

On the plus side, forcing insurance companies to cover everyone nudges the United States ever so slightly closer to a public option, if only because now the rest of us who are already covered will see our premiums go up in order to cover the risk. The down side is, the system is still designed to allow corporate giants to profit enormously on providing health care. There is no such thing as "free" health care in the United States, even with "Obamacare" in place.

But there are some pleasant effects in the ACA as well, such banning the use of "preexisting condition" clauses.*


*Fun story: I got rejected from the insurance plan for my first "real job" out of college because I had taken a prescription medication on my parents' plan a year earlier while still in school. This was regarded by the insurance company as a "preexisting condition". Um, yeah, it was a health condition that I had? Because that's a thing that happens to people? The U.S. system is seriously fucked, even for we privileged members of the educated class.

posted by deathpanels at 4:14 AM on September 26, 2013 [13 favorites]


Government protected markets mean profit.

Not necessarily. Used effectively, government protected markets can also mean 'gilded cage' as in, "follow the rules, play nice, and you will be guaranteed a tidy profit; break them or get greedy and you're completely shut out".
posted by RonButNotStupid at 4:18 AM on September 26, 2013


JHarris: I've considered posting on Ask about it, to get unbiased information -- what is really the deal with this law concerning employers?

Since he has multiple stores, I imagine he is over the 50+ FTE line, so he is considered a "large employer." From now on, any employee who averages over 30 hours a week is considered full-time, which means probably far more employees he is responsible for insuring than he was before. The idea would then be to severely limit hours on part-timers to make sure nobody gets too close to that 30 hour mark. So if he had some folks who were really part-time but always willing to kick in extra hours when needed, these folks would now be strongly encouraged not to help out.

Something I haven't been able to figure out yet is the effect on overall employment. For companies that rely on part-timers with some flexibility to get over 30 hours when needed, will they then hire more part-timers to keep everyone's average hours closer to 20? Or will they then require more flexibility/overtime on the part of full-timers?
posted by mittens at 4:24 AM on September 26, 2013 [1 favorite]


So this article about Pennsylvania, where I am, says that my son will be able to get the lowest priced plan for about $109 a month after subsidies.
posted by octothorpe at 4:26 AM on September 26, 2013


Does anyone know how useful Healthcare.gov actually is?

It looks like basically a "healthcare wizard" sort of thing, but I can't imagine it'd be that easy.
posted by Ray Walston, Luck Dragon at 4:27 AM on September 26, 2013


Can someone explain whether the subsidies are paid to you right away, or whether you have to shell out the money first and then get a rebate at some eventual point?
posted by EmpressCallipygos at 4:28 AM on September 26, 2013 [3 favorites]


There was no going all out, the public option was not going to pass the Senate.

Putting aside Leiberman's petty tantrum over the public option, how much of that was conservative Democrats protecting their reelection prospects? How much of that was them hiding behind the cover of wanting a bipartisen bill that could pass with Republican votes?
posted by RonButNotStupid at 4:28 AM on September 26, 2013


Empath: I know that if the company that i worked for dropped insurance without making it up in wages, the company would not exist in 6 months because everyone would get new jobs.

I picture a lot of companies not making it up in wages...am I wrong about that? I just assumed they would pocket the savings.
posted by mittens at 4:32 AM on September 26, 2013 [2 favorites]




The low income subsidies are going to be pretty expensive for the working, older poor, who aren't yet Medicare eligible. As in, income tax credits in the upper four figure range for older workers, per person, making minimum wage or thereabouts, who may well be among those working 2 or 3 hours restricted part time jobs (and thus ineligible for employer sponsored plans), to keep body and soul together. That would be in addition to subsidies that may include as many as 14 million disabled people under 65, getting some combination of Social Security or SSI assistance.

And if something isn't done, beyond annual Congressional relief bills, to align Medicare payments and the formulas that are used to calculate them, with real world costs of doctors and service providers, the whole house of cards, including ACA, will come down, from a financial perspective.

The Chinese have long since stopped being massive financiers of American Federal public debt, and if Uncle Ben closes up shop as a buyer of low interest Treasury notes, as he's been promising he's going to, there's going to have to be a major fast re-think of entitlement programs and the ACA. And ACA without significant subsidy arrangements made good by the Federal treasury, is a game of 3 card monte in a hurricane.
posted by paulsc at 5:05 AM on September 26, 2013 [1 favorite]


The Chinese have long since stopped being massive financiers of American Federal public debt, and if Uncle Ben closes up shop as a buyer of low interest Treasury notes, as he's been promising he's going to, there's going to have to be a major fast re-think of entitlement programs and the ACA. And ACA without significant subsidy arrangements made good by the Federal treasury, is a game of 3 card monte in a hurricane.
Unless the Fed extends bond buying. Like they just did.
posted by deathpanels at 5:20 AM on September 26, 2013 [4 favorites]


All of this is really scary to me: I can't afford an extra $100-200 a month. I'm making under $15k a year. I think twice about spending $3 on lunch. (Even as I sell $15 lunches to people).

Thank god(s), I don't have to worry about it, because I'm covered by the Ontario Health Insurance Plan (link), which - until recently - had no premiums and was funded purely by geared-to-income taxes. (The premiums introduced range start at $60/year, but only if you make more than about $30k). For this, I have receive the same quality of preventative care as someone making $500k per year. (Except for eyes, teeth and drugs - those are problems we need to fix.)

Health is not a fire or a car accident. Illness does not strike like lightening out of the sky. It is a predicable cost, higher for some people than others, and a cost high enough that the only reasonable way to fund it is by progressive taxes. The private insurance model is inherently broken.
posted by jb at 5:21 AM on September 26, 2013 [9 favorites]


The Chinese have long since stopped being massive financiers of American Federal public debt, and if Uncle Ben closes up shop as a buyer of low interest Treasury notes, as he's been promising he's going to, there's going to have to be a major fast re-think of entitlement programs and the ACA. And ACA without significant subsidy arrangements made good by the Federal treasury, is a game of 3 card monte in a hurricane.

Um, what? First of all that's not true, and it's even gone up since last year. Second of all, the Fed just continued their QE and low interest rates. And third of all, what's up with the weirdly racist "Uncle Ben" nonsense?
posted by zombieflanders at 5:25 AM on September 26, 2013 [27 favorites]


I've been severely underemployed for years, and I'm not eligible for unemployment insurance payouts. I can just scrape by as it is, and adding even cheap insurance premiums will drive me into an inescapable hole of debt.

I don't go to the doctor. If I had insurance I would probably go for a checkup once but I'm not a healthcare user. If there's anything chronically wrong with me it isn't worth treating. I don't want to survive a bad accident. I don't expect to live forever.

I understand that I am not in the average situation, and that this is truly the best option for the largest number of people, and I guess that's the price I pay to be an individual member of a civil society.

I would give up every so-called advantage of being American in return for something simpler that doesn't just look like a federally enforced handout from my wallet to big insurance companies. I don't care about guarantees and I don't mind taxes. I wish I paid more taxes, in fact, because that would mean employment, and healthcare, and self-worth.

I've done a shitty job managing my life and I put myself in a position to get screwed. Having health insurance wouldn't have prevented this. Being forced into the US healthcare system causes me great anxiety, and I wish there was a better option.
posted by Ice Cream Socialist at 5:37 AM on September 26, 2013 [2 favorites]


24/F, company's dropping the healthcare plan through some bullshit trickery because we're definitely more than 50 people. I'm not on it, anyway, because I can't afford it. I currently spend about $10/m on a generic medication prescribed by a doctor I see once every six months for $100/OOP. So my healthcare costs hover around $220/year.

Bronze plan's going to cost me about $200/m, give or take $30. The subsidy's a whopping 7% of my total premiums. $2,400 over a year (or $1,900 on the catastrophic plan) or the low-three-figure penalty? Yeah, I know which one I'm doing. I'll risk it.

Most of my other mid-20s "healthy young people" friends are going the same "screw it" route, from our conversations on the topic. If it goes like this everywhere, some re-evaluating about placing the lower costs of older people's healthcare on the backs of under-employed, debt-burdened, underpaid young people is going to have to be done.

(Anyway, they all get SSI checks with money I pay into the system that I'll never, ever see the benefit of, because I'm willing to bet that in 40 years when it's my turn to retire, the social security system as we know it will long since have disappeared. I'm happy to fund the social safety net but knowing that the net will be long gone by the time I need it just really bothers me.)
posted by none of these will bring disaster at 5:44 AM on September 26, 2013 [1 favorite]


" it's even gone up since last year"

Your second chart shows that in the period July 2012 to July 2013, total Chinese holdings of Treasury debt increased from $1160 billion to $1277.3 billion, so it is true that China bought $117 billion of new Federal debt. Which is a pittance compared to how much our own Federal Reserve had to buy to fund our Federal deficit, and less than China has bought in some previous years, even though the Obama administration has been allowing the Chinese to buy Treasury notes directly in that same period. That's because, since our own Federal Reserve is buying for QE, the interest return to the Chinese debt holders has been going down sharply, especially on new debt issues, as your first chart demonstrates. Moreover, China has to do some recycling of hard currency earnings, as long as they run a trade surplus with us, if they don't want exposure to large foreign currency holdings, and keep to their foreign reserve targets.
posted by paulsc at 5:48 AM on September 26, 2013 [1 favorite]


And third of all, what's up with the weirdly racist "Uncle Ben" nonsense?

I imagine he's talking about this guy, not this guy or this guy.
posted by Ham Snadwich at 5:52 AM on September 26, 2013 [5 favorites]


From Jeb Lund's blog: Why Universal Healthcare is Unambiguously Necessary for America. Depressingly, the post dates from 2009, and the piece itself from earlier still.
posted by Rustic Etruscan at 5:53 AM on September 26, 2013


Ice Cream Socialist, you sound like you don't earn a lot of money. I don't know the specifics of the cutoff points for subsidies etc but somewhere along the line, if you are poor (and you are lucky enough to live in a state that thumbed their nose at Justice Roberts nullification attempt), you will qualify for medicaid. A big part of the ACA is embiggening the medicaid base. Now, more than half the states have opted in. So there's a good chance - I see you live in NY - you won't have to pay anything.
posted by peacay at 5:55 AM on September 26, 2013 [4 favorites]


Based on the kaiser calculator, if I was still at my old job, which had about 10 employees and no health coverage, I would have to pay $207 a month AFTER the subsidy.

Which if I was still at the old job would mean I'd be in a pretty tight spot after student loan payments and car insurance. I like having health insurance, don't get me wrong, I just think the people on the fringe are going to hit hard and that's what the republicans are hoping for.

So i'd probably have to get rid of my car, which would limit my job options.

Luckily I found a new job this year which gives me free healthcare that's awesome.

But I will continue to hope that a better version of this bill gets passed.
posted by sio42 at 5:57 AM on September 26, 2013


I don't go to the doctor. If I had insurance I would probably go for a checkup once but I'm not a healthcare user. If there's anything chronically wrong with me it isn't worth treating. I don't want to survive a bad accident. I don't expect to live forever.
I have insurance, and I pretty much use it the same way you're describing. I get a yearly checkup, just to be safe, and if I get a nasty cough I'll go in to the doctor to make sure it's not infected, but otherwise I don't take any medications. Hell, I don't even take Tylenol. I'm not sure what you mean by "healthcare user", but I think this is the problem with U.S. health care culturally, the fact that we think of doctors as candy stores that hand out pills to anyone who wants them because, hey, you're rich and you can afford to. This is a sign to me that a lot of people have too much health care. How many Americans are on prescription meds for ADD who don't really need them? Everyone should have yearly checkups and access to preventive care. Women should have access to prenatal care and maternity care. This is basic stuff that any modern nation with a GNP the size of the U.S. should be able to provide. The fact that we don't always and forever boils down to politics. Whiny rich assholes don't want to pay an extra $100 a month to make sure the people on the other side of town are able to get that bad cough checked out. I hate that the best solution our idiot "representatives" came up with is to charge the poor (or a segment of the uninsured population, anyway) for their own coverage, but it might be the only way to get a public option on the table, or to raise the minimum wage or increase unemployment benefits, since the ACA mandate at least makes the cost of basic health coverage visible. (For, you know, a rather small portion of the population who are a) legally recognized citizens and b) not exempt from the so-called "mandate".)
posted by deathpanels at 5:57 AM on September 26, 2013


And this is what really infuriates me about the Democrats. Republicans were already going to flip out and cry 'socialism' no matter what form healthcare reform took, so why not go all out and actually adopt a plan that would be worthy of their insults?

Because the goal was never really to get a perfect, or even good or workable policy solution to the healthcare debacle, it was for the President to mark a check box on his "Hope and Change Magic Unicorns Will Make All The Republicans Sit Down and Have a Beer With Obama the PostPartisan Uniter" Agenda.

To get the political result, Obama was willing to pass the Heritage/Mitt Romney solution of throwing money at private insurance companies and call it a day. It was supposed to be a relatively quick solution that Republicans could get behind, with more pro-business giveaways, Republican-lite-ish solutions to immigration, climate change, "entitlement reform", balanced-budget, etc. to follow on the march to Hopey Changey happytime funland. Single payer or a public option was never really on the table because Obama figured Republicans would just say yes without a huge fuss if he offered to pass everything they wanted to pass in the 90s.

Then the teaparty happened and even the formerly Republican solutions pushed by Obama became Socialism.
posted by T.D. Strange at 6:07 AM on September 26, 2013 [4 favorites]


I think this is the problem with U.S. health care culturally, the fact that we think of doctors as candy stores that hand out pills to anyone who wants them

This is a common assumption, but the data indicates the US actually underutilizes healthcare compared to other developed countries. We have fewer physicians per capita, fewer hospital beds, fewer doctor consultations, and shorter lengths of hospital stay than most of the developed world. The problem with US healthcare isn't how much of it we use, it's that it's all overpriced--drugs, doctors, and medical equipment.
posted by mittens at 6:12 AM on September 26, 2013 [16 favorites]


Observing historical patterns of attempted healthcare reform and backlash towards these reforms, we may begin to understand what is keeping such a prominent and promising nation from enlisting a social contract of health.

On the other hand, observing every other first-world nation on the planet, one wonders what the hell is wrong with the US.
posted by Foosnark at 6:16 AM on September 26, 2013 [4 favorites]


Because the goal was never really to get a perfect, or even good or workable policy solution to the healthcare debacle, it was for the President to mark a check box on his "Hope and Change Magic Unicorns Will Make All The Republicans Sit Down and Have a Beer With Obama the PostPartisan Uniter" Agenda.

In addition to that, it had to get past the Joe Liebermans and Ben Nelsons in the Senate at the time.
posted by gimonca at 6:18 AM on September 26, 2013


-But I will continue to hope that a better version of this bill gets passed.-

Yeah, well, if everyone's gonna simply judge this thing by their own biased personal situation it will fail and you'll never get anything other than expensive policies that only RICH people can afford. Because a small number of people may have to pay a bit more, but the country as a whole and a huge number of people will be eons ahead of where they/youall were last year. Again, I suggest that you wait before you jump to judgement and criticism. The ultimate equilibrium will take a decade to emerge for many reasons.

I say this with empathy I assure you, buy you guys (USA) have to have a bit of a stereoscopic view of this thing and not simply look at it from a selfish point of view. Most people don't know what healthcare costs: it's paid by employers and so there's no view of why the costs are high. The health cost inflation has already declined in the last few years, well beyond what a good estimate might be of the great recession's effects (YAY ACA!). Right now all you employed people with healthcare pay MORE because the insurance companies fund the hospitals that treat the uninsured. Now, the way the money is being spread around is changing to hopefully provide incentives for better outcomes rather than on a per-treatment rate basis. There are some great innovations in cost controls built into this thing.

But that's not to say there aren't some big tweaks worth doing. But how do fix bits when the fuckers on the other side are just rabidly comparing you to nazis and the like?

TD Strange, "...relatively quick solution.." is complete bs. I've followed this thing every single day since before Hillary dropped out. You're just plain wrong. This was AlWayS gonna be a REALLY REALLY HEAVY lift and especially in the middle of a cratering recession. Of course Obama had to go to the Repubs with the idea of personal responsiblity to get buy-in, but your cynical view of it is just unbelievable.
The repubs were on board with heaps of the ACA for a LONG time in so many of the committees ---- that's politics: you express interest ask questions have discussions and hold meetings then meet with your henchmen down the track and try to kill it and get $$ from the faithful and hurt the dems politically at the same time. Repubs have been arseholes THE WHOLE WAY. Nothing would have passed by the blue dogs in the senate if it was even 0.1 of an inch further to the left.
posted by peacay at 6:18 AM on September 26, 2013 [6 favorites]


Because the goal was never really to get a perfect, or even good or workable policy solution to the healthcare debacle, it was for the President to mark a check box on his "Hope and Change Magic Unicorns Will Make All The Republicans Sit Down and Have a Beer With Obama the PostPartisan Uniter" Agenda.

Wow, that Obama is truly a naive clown. Why didn't he simply follow the example of all the other Presidents who passed healthcare reform? Probably because he was too busy living in fantasy land.
posted by leopard at 6:19 AM on September 26, 2013 [13 favorites]


Bronze plan's going to cost me about $200/m, give or take $30. The subsidy's a whopping 7% of my total premiums. $2,400 over a year (or $1,900 on the catastrophic plan) or the low-three-figure penalty? Yeah, I know which one I'm doing. I'll risk it.

You can do that if you promise not to AskMetafilter what to do when you get hospitalized with pneumonia for four days and end up with $20k in bills you have no idea how to pay. That's the real risk for you, not the tax penalty. A sudden illness/injury that doesn't kill or disable you. It can happen to anyone, even the relatively young and healthy like yourself. You'll be paying for those bills, plus the insurance you should have just buckled down and gotten in the first place.

This is one of the downsides of letting people under the age of 26 stay on their parents' plan- Mom and Dad took care of everything, and now they're all freaked out at having to OMG PAY FOR HEALTH INSURANCE! My 26-yo sister is having the same tantrum, because she doesn't realize that paying a portion of health insurance premiums is something a lot of grownups already do. My company picks up most of my health insurance premium and I pick up the balance, for me, my husband and my child. It's about $450 a month, which, sure, I could think of more fun things to do with. It used to be people couldn't get that kind of deal independent of a group employer plan. Now they can. THAT'S AWESOME! Why would anyone turn that down?
posted by ThePinkSuperhero at 6:20 AM on September 26, 2013 [11 favorites]


wow peacay - sorry for the mistatement i apparently made.

my idea of a better version would be single payer.
posted by sio42 at 6:20 AM on September 26, 2013


Interesting (and sad) article about The Heritage Foundation who wrote the basis of the ACA but is now fighting full force to get it repealed.
posted by octothorpe at 6:23 AM on September 26, 2013


Aw c'mon sio42. I wasn't attacking YOU. But 3/4 of your comment was bemoaning your situation had you kept that job. I was using that as a point of reference; not as a personal attack and sorry if it seemed otherwise.
You could have got Sen. Cruz licking Obama's boots before you could have got single payer. Maybe in a decade or 4, sure. But it's ALWAYS been fantasy talk in this last decade.
posted by peacay at 6:25 AM on September 26, 2013


All I keep thinking is, "man, we're really gonna have to move, what other country do I wanna raise my kids in...because this situation will not be stabilized in my lifetime and it's just getting worse right now?"

Many, many countries will not give you access to their tax-subsidised healthcare for at least the first few years of living in their country leaving you to rely entirely on private health insurance. I'm currently living in a country where I am not a citizen, although am a tax payer, and am currently not insured for various reasons so the only health care I have access to is what I can pay for out of my own pocket. So none really given how eye-wateringly expensive even a basic doctors visit is. Something to take into account for anyone actually serious about moving countries.
posted by shelleycat at 6:30 AM on September 26, 2013 [1 favorite]




A friend of mine broke her arm a few months ago, and the cost of surgically correcting the injury before insurance coverage was just over $20,000.00.

If I can break my arm uninsured and owe more than my student loans in medical bills to fix my arm, it's going to be a problem. Just because I have health insurance now doesn't mean I'm going to break my arm for fun, either.
posted by oceanjesse at 6:34 AM on September 26, 2013


It seems to me that if someone's income is low enough to qualify for the tax credit subsidy, it's low enough that they may not have to pay any taxes, in which case the subsidy isn't going to do them any good.

Clearly I'm reading it wrong, because that doesn't make any sense.
posted by still_wears_a_hat at 6:35 AM on September 26, 2013 [4 favorites]


i haven't had enough coffee so maybe i wasn't clear enough and also maybe that's why it did come across as a personal attack.

my situation if i had that kept that job is similar to many other people with a reasonable amount of student loan debt. thank god i have a decent car and no car payments and extra thank sky dude for no chronic health problems or kids or kids with health problems. (and that former job was the only fulltime job i could get after being laid off despite LOTS of trying, so i was lucky to have a job at all, even without health insurance.)


i was trying to use my (former) situation to show that there will be many many people who get screwed by this and it's what the naysayers want, so they can point and say "see? it didn't work!". but if they had just done something BETTER there wouldn't be so many people in that situation. because those people won't qualify for medical assistance programs either.

i'm glad the'yll have health insurance but it's all very fucked up.
posted by sio42 at 6:35 AM on September 26, 2013


"The problem with US healthcare isn't how much of it we use, it's that it's all overpriced--drugs, doctors, and medical equipment."

And by requiring everyone to go through insurance you further separate the end user from the product which will do nothing to lower prices, right?

LASIK surgery plummeted in price becaus it's not covered by insurance, and the demand by people paying out of their own pockets helped regulate a normal market value.

With the upcoming rules, the insurance companies will set the price, not the consumer.
posted by BlerpityBloop at 6:36 AM on September 26, 2013 [1 favorite]


look like a federally enforced handout from my wallet to big insurance companies.

It looks like that because that is what it is. The commercial real estate market went bust and that hurt the insurance companies investments. This way they know they have a cash flow by government mandate.
posted by rough ashlar at 6:36 AM on September 26, 2013


If your company is dropping coverage and is more than 50 people, you should drop a dime on them.
posted by gauche at 6:38 AM on September 26, 2013 [10 favorites]


The numbers for the federal exchanges are out and just as an example, a family of four with an income of $50,000 pa AFTER the tax credit, is looking at premiums of less than $300 per month for a Silver plan. For a bronze plan it goes as low as $28 a month in MS.

For a 27-year old on a bronze plan earning $25,000 a year, after the tax credit, it's as low as $48 per month in AK.

I'm looking at weighted averages in both cases, since there's some variety based location, etc.

The law requires employers to send a letter to all employees about the ACA, so that's why people are seeing them.

FWIW A colleague went into the hospital recently for one night and some heart work. The billed cost was over $80,000. There are a lot of good things in the ACA to do with transparency, billing for health outcomes, evidence-based medicine and other things. The exchanges provide a structured marketplace where plans are competing on a level playing field on the basis of cost and NOT how much they can obscure the realities of their plan.
posted by idb at 6:39 AM on September 26, 2013 [4 favorites]




"There are a lot of good things in the ACA to do with transparency, billing for health outcomes, evidence-based medicine and other things. The exchanges provide a structured marketplace where plans are competing on a level playing field on the basis of cost and NOT how much they can obscure the realities of their plan."

But it's not really 'transparent', is it when you are dealing with these private companies.

The rates seem arbitrary. WHY is a bronze plan that amount? Why can't it be less? And what recourse does the consumer have when rates rise because of "it's complicated"? What, exactly, am I paying for and why is it that amount?

Let's say you banned liquor stores and forced everyone to buy bottles of wine through a restaurant. You once knew the same bottle of wine they charged $60 cost $15 retail. That level of knowledge is disappearing. The restaurant can now say its $70 because it just is.
posted by BlerpityBloop at 6:49 AM on September 26, 2013 [2 favorites]


Blerpityboop: "And by requiring everyone to go through insurance you further separate the end user from the product which will do nothing to lower prices, right?

LASIK surgery plummeted in price because it's not covered by insurance, and the demand by people paying out of their own pockets helped regulate a normal market value. "


I don't think your first statement is necessarily true, and I think the LASIK example can't be applied to most of medicine.

First: Lower prices come from negotiations between the payer and the supplier. If the end-user is not the payer, then yes, you've got to put pressure on the insurer to negotiate for lower prices. This is why it is crucial to give Medicare the power to negotiate drug prices, for example.

I can see the point in allowing a more end-user-as-payer approach as a way to lower costs--certainly the pharmacies that offer $4 generics are seeing some good business by creating competitive choices for consumers--but that breaks down rapidly in medicine, because even though a lot of treatment is way, way overpriced right now, even at a reasonable price, it would still be out of reach of most people. You're not going to get an open heart surgery for 20 bucks, you know? And since you have no idea if you're going to need a bone marrow transplant or gamma knife or something, you can't save for it the way you would a car or a house. Most people are not going to be able to save enough to stash away some cardiac cath money. And we want people to have healthcare. It's a moral good. And so a health savings account is an awful way of paying for healthcare, because the costs are going to be unknown, and millions will be left to sicken and die. What you're left with is some form of insurance, and so yeah, you and I will not be determining prices, but the people you're voting for could, and should, have a say in cost control.
posted by mittens at 6:51 AM on September 26, 2013


Mittens, I totally absolutely agree. I just have less faith in putting the onus of negotiation on profit driven private insurance companies that have a federally mandated customer base.
posted by BlerpityBloop at 6:55 AM on September 26, 2013 [3 favorites]


My fiancee is graduating in December and she will not have health insurance.

She won't be eligible for medicaid, despite the fact that her income is 0, because she is not pregnant, elderly, or disabled. WTF?
posted by MisantropicPainforest at 7:02 AM on September 26, 2013


If she was in PA she'd receive no subsidy and would need to pay $175/month for the bronze plan.

Ugh. This is gonna be a long road to healthcare for all.
posted by sio42 at 7:08 AM on September 26, 2013


She won't be eligible for medicaid.... but she'll be eligible to buy some, possibly heavily subsidized since she's out of work? Unless she gets a job that provides her with some? Either way she'll have insurance? Not sure I see the problem.
posted by ThePinkSuperhero at 7:15 AM on September 26, 2013


If she was in PA she'd receive no subsidy and would need to pay $175/month for the bronze plan.


Which is A LOT cheaper than what she was paying when she was unemployed.
posted by MisantropicPainforest at 7:17 AM on September 26, 2013


A friend of mine broke her arm a few months ago, and the cost of surgically correcting the injury before insurance coverage was just over $20,000.00.

Single-person making $25K: the total yearly out-of-pocket is $5200 for "silver" and higher for "bronze", according to the kaiser calculator, and who knows what gets counted against deductible. Yearly cost: $1700 with subsidy.

It sounds like even with silver, this person might be bankrupt or scraping money from friends and family after breaking their arm but who knows, and that's the real problem. It's not insurance if you still don't know whether you are fucked after you buy into it.

Single-payer wasn't going to solve shit, by the way. The economics of "general practitioner" medicine in this country is collapsing. If every patient was billed at Medicare/aid levels, there wouldn't be any GPs. What we needed was federal subsidies for basic medical services: subsidized clinics, medschool loan forgiveness and cash. And then, we needed to reduce the Medicare age to 55 and let the Republicans and blue dogs field the millions of calls by out-of-work people in their fifties about why they shouldn't get their medicare.

There were plenty of incremental steps that were possible... not that it really matters. But the "single-payer now" crowd is completely myopic about the practical problems of the system, which allows the people in bed with big business, like Obama, to push in "pragmatic" solutions that fuck things even more.
posted by ennui.bz at 7:18 AM on September 26, 2013 [2 favorites]


I don't think your first statement is necessarily true, and I think the LASIK example can't be applied to most of medicine.

LASIK is also a terrible example because it's something people can do without or put off indefinitely (or until it becomes affordable) with absolutely no adverse effects. I've never studied business or economics, but I assume having X number of people who are ready to jump on something once the price drops to Y is a significant effect on pricing.
posted by RonButNotStupid at 7:19 AM on September 26, 2013 [3 favorites]


Single-payer wasn't going to solve shit, by the way.

Well it would make most of the 40 million or so uninsured people insured. That counts.
posted by MisantropicPainforest at 7:19 AM on September 26, 2013 [8 favorites]


She won't be eligible for medicaid.... but she'll be eligible to buy some, possibly heavily subsidized since she's out of work? Unless she gets a job that provides her with some? Either way she'll have insurance? Not sure I see the problem.

No, because she didn't make any money and thus is too far below what the ACA would subsidize. The ACA basically says, "you're too poor, for us, so you'll have to go on medicaid". Then medicaid says, "you're not eligible because your not old, pregnant, or disabled."
posted by MisantropicPainforest at 7:24 AM on September 26, 2013


Or have children.
posted by MisantropicPainforest at 7:24 AM on September 26, 2013


And this is what really infuriates me about the Democrats. Republicans were already going to flip out and cry 'socialism' no matter what form healthcare reform took, so why not go all out and actually adopt a plan that would be worthy of their insults?

In another world, we could have gotten closer -- what had been shaping up was some sort of compromise between the conservative Senate plan (more or less what we got) and a more liberal House plan.

But then Ted Kennedy died, and Massachusetts went completely dipshit and voted to hand power to Mitch McFuckingConnell, and at that point the conservative Senate plan became approximately the best that could be achieved.
posted by ROU_Xenophobe at 7:26 AM on September 26, 2013 [2 favorites]


Ooops, I'm sorry, I missed something: in 2014 my state will expand Medicaid to include poor people. She's not eligible now, but will be.
posted by MisantropicPainforest at 7:26 AM on September 26, 2013 [2 favorites]


Part of what makes this process so painful is that the main way most Americans get health insurance is through their employer, and employer-provided health insurance is a TERRIBLE IDEA. It makes the cost of hiring people much higher. It detaches people from their health insurance, so they can't suit their policy to their needs. It means people stay at jobs they hate because they need the insurance. It discourages hiring by employers, it discourages entrepreneurship by workers, and it encourages all sorts of 29.5-hours-a-week system-gaming. It imposes tremendous drag on companies that they're not really equipped to handle, not to mention forcing widget-manufacturers to be insurance brokers, a task far outside their mission or competency.

The US needs to move to a system where employers are simply out of the business of providing insurance, and to a system where either individuals or state governments provide. But getting their is going to entail throwing a lot of people out of the employer-provided insurance they're known all their lives, and that is a very scary prospect.
posted by ThatFuzzyBastard at 7:30 AM on September 26, 2013 [14 favorites]


The general public should be offered the same coverage that Congresspeople get

They are. As of 1/1/2014, here is Congressional health coverage: "Nothing. Look for insurance on your exchange."

Even before then, the general public has been sort of offered Congressional health care benefits: get a federal job, and you get the same benefits (minus a couple of ways to get outpatient care), since Congressional health care had been the same health care plans offered to all federal employees.
posted by ROU_Xenophobe at 7:31 AM on September 26, 2013


medschool loan forgiveness

This is such a huge one I was surprised not to see it featured prominently in debates. It solves two problems at once, the shortage of GPs, and the "Well I have to charge you a lot of money because I paid a trillion dollars to get my degree."
posted by mittens at 7:35 AM on September 26, 2013 [1 favorite]


If every patient was billed at Medicare/aid levels, there wouldn't be any GPs.

How do Medicare/Medicaid levels compare to how much GPs are paid in countries with national health programs?
posted by jeather at 7:41 AM on September 26, 2013 [3 favorites]


The US needs to move to a system where employers are simply out of the business of providing insurance, and to a system where either individuals or state governments provide. But getting their is going to entail throwing a lot of people out of the employer-provided insurance they're known all their lives, and that is a very scary prospect.

People say the current system of health insurance is illogical and doesn't work. That's not true. It works just fine at what it was designed to do. It's just not designed to deliver healthcare. It's designed to be a tool that employers can use to pressure their workers into accepting lower wages and progressively worse working conditions. It's designed to DENY healthcare to the working man and woman, not DELIVER it. It's not a carrot, it's a stick. There is no carrot. But it is a tool that has turned on its wielder and, before the ACA, was threatening to eat the entire economy if it didn't get its way. That's why the reactionaires are screaming and crying so hard. They're afraid they're going to lose the boot they have on the neck of their workers.
posted by vibrotronica at 7:41 AM on September 26, 2013 [14 favorites]


Bronze plan's going to cost me about $200/m, give or take $30. The subsidy's a whopping 7% of my total premiums. $2,400 over a year (or $1,900 on the catastrophic plan) or the low-three-figure penalty? Yeah, I know which one I'm doing. I'll risk it.

I paid almost $200 for a catastrophic plan in my 20s which didn't cover ANYTHING that these new plans are covering. $200/month is a really, really good deal for real insurance.

Seriously, I pay more than that for our family health insurance AFTER really good employer contributions from my large employer who can negotiate premiums. It's a full coverage plan, but my employer is paying a significant amount of the cost as well so I imagine it costs over $1K a month in reality.
posted by rainydayfilms at 7:44 AM on September 26, 2013 [2 favorites]


Single-payer wasn't going to solve shit, by the way.

Well it would make most of the 40 million or so uninsured people insured. That counts.


insurance is useless if you can't get medical services with it. the idea that you could reform the whole mess which is the medical care industry in the US by putting everyone on medicare and manipulating payments is actually a recipe for the sort of disasters right-wing people blame on socialism.

the point of reform isn't to give people magic insurance, but to give everyone a humane standard of medical care. there are huge structural problems with the health care industry in the US that need to be solved piece by piece.

The problem is that people like Obama are the only ones who actually believe in "free market" economics. They really believe that everything has to be solved by building a marketplace. The Republicans were going to oppose anything he did. So, I don't blame Obama for what is happening. It's not possible to do anything constructive given the politics we have, but we definitely need new possibilities.

The one way I was suckered by Obama was in his comments about Reagan. I thought he understood that Reagan managed to completely change the politics of what was possible in this country and that was what he admired. Instead, I think he actually admired some of Reagan's politics.
posted by ennui.bz at 7:46 AM on September 26, 2013 [2 favorites]


It's designed to be a tool that employers can use to pressure their workers into accepting lower wages and progressively worse working conditions. It's designed to DENY healthcare to the working man and woman, not DELIVER it

Can you point to some scholarly literature that advances this argument? Thanks.
posted by MisantropicPainforest at 7:49 AM on September 26, 2013 [1 favorite]


Then medicaid says, "you're not eligible because your not old, pregnant, or disabled."

This isn't true under the ACA anymore. Poor is another category now eligible.
posted by rainydayfilms at 7:49 AM on September 26, 2013 [1 favorite]


Can you point to some scholarly literature that advances this argument? Thanks.

Dude, he used caps, you CAN'T argue with CAPS, man.
posted by entropicamericana at 7:50 AM on September 26, 2013 [3 favorites]


insurance is useless if you can't get medical services with it.

Yeah, true, but irrelevant, because you can get medical services with insurance.
posted by MisantropicPainforest at 7:51 AM on September 26, 2013


"... Clearly I'm reading it wrong, because that doesn't make any sense."
posted by still_wears_a_hat at 9:35 AM on September 26

You may be confusing tax credits with deductions. Let's say a person has low earnings, an appropriate level of withholding, and enough deductions to avoid paying any additional income tax at the end of the tax year. Then, when they fill out their tax return, they apply the new ACA tax credit appropriate for their income level and insurance expense, and voila! the Federal government owes them a refund equal to the tax credit! They get a check from the government for that, which should reimburse them for much of their health insurance premium cost, on a sliding scale where the credit reduces to zero as their income grows.

However one problem for many poor people is, they have to wait a year to get that money back, and be able to afford monthly ACA health insurance premiums through that period, in order to qualify for the credit, insofar as I understand.
posted by paulsc at 7:51 AM on September 26, 2013 [3 favorites]


This isn't true under the ACA anymore. Poor is another category now eligible.

Its my understanding that this is a state-by-state basis, some have refused to expand medicaid eligibility.
posted by MisantropicPainforest at 7:51 AM on September 26, 2013 [1 favorite]


Sure, i have no problem with the idea that she is better paying $175 a month for health insurance because it's better than NOT having health insurance.

My question is where is that money coming from and what happens when she can't afford it?

She gets fines heaped and her pay garnished?

I want everyone to have health care. I don't want people still going bankrupt because of it when we have this law that is supposed to be helping.

I'm not really arguing so much as trying to find out what will really happen when you can't pay because that is not something I've heard discussed anywhere.

Everyone talks about it's affordable (which it really is for the most part,$200/ mon was what I was paying when I had a job w healthcare before I got laid off). But what if you don't have $125? Or $175?
posted by sio42 at 7:53 AM on September 26, 2013


Obviously she doesn't have a job so pay garnishment was referring to when she DOES get a job.
posted by sio42 at 7:53 AM on September 26, 2013


mittens: From now on, any employee who averages over 30 hours a week is considered full-time, which means probably far more employees he is responsible for insuring than he was before. The idea would then be to severely limit hours on part-timers to make sure nobody gets too close to that 30 hour mark.

We are all Wal-Mart now.
posted by wenestvedt at 7:54 AM on September 26, 2013 [3 favorites]


Yeah, true, but irrelevant, because you can get medical services with insurance.

Umm... what? I live in Massachusetts and am on a heavily subsidized state-sponsored plan. I'm not sure if it is "bronze" or "silver" or what now. There are maybe 3 general practioners/clinics in my county that take this insurance and that number has decreased over time.

Have you never had insurance in the US: what providers will take what insurance is a total nightmare. It's one of the stronger arguments for single payer.
posted by ennui.bz at 7:56 AM on September 26, 2013


My question is where is that money coming from and what happens when she can't afford it?

Me.

But for most people, medicaid, or if she lives in a state with a right-wing asshole governor who would rather fuck over their constituents, nothing.

The tax penalty is $95 bucks a year, so its not large at all.
posted by MisantropicPainforest at 7:57 AM on September 26, 2013


So if she can't afford the $175/month and Medicaid is not an option, she pays the penalty of $95/year?

Just making sure i understand this.
posted by sio42 at 7:58 AM on September 26, 2013


However one problem for many poor people is, they have to wait a year to get that money back, and be able to afford monthly ACA health insurance premiums through that period, in order to qualify for the credit, insofar as I understand.

Yeah, who the fuck knows. I would be SOL if I had to pay my subsidized insurance upfront and take a credit on my taxes.

The problem is that the wizards who are figuring this all out have no idea what it is like to live at the poverty level in this country and no political incentive to find out.
posted by ennui.bz at 7:59 AM on September 26, 2013 [2 favorites]


Yes, if I'm understanding everything correctly.
posted by MisantropicPainforest at 8:00 AM on September 26, 2013


"... But what if you don't have $125? Or $175?"
posted by sio42 at 10:53 AM on September 26

If you live in a state which has agreed to expand Medicaid eligibility, you'd be expected to qualify for Medicaid, and your state would get, for a while, big Federal subsidies to its (expanded) Medicaid program. Two problems with this approach, as follows. First is, the Federal guarantees for Medicaid aren't a forever thing; eventually, states that expand Medicaid are going to have to figure out how to finance all that extra medical care themselves, most probably through higher taxes, as states don't typically do long term deficit financing. Second, because Medicaid payments to doctors and service providers are so low, you, as a healthcare consumer, may have trouble finding doctors and hospitals that take Medicaid payments for services.

If you don't live in a state which has agreed to expand Medicaid under ACA, you'll have to hope for charity, or file bankruptcy after running up unpayable medical bills.
posted by paulsc at 8:00 AM on September 26, 2013 [1 favorite]


It's only a $95 penalty the first year; after that it will increase.

On the other hand I do know they're not allowed to garnish wages to collect that penalty.
posted by mstokes650 at 8:02 AM on September 26, 2013


It's important to note that the penalty is nearly toothless; one of the many ways the law was cut back in the name of sweet sweet bipartisanship was to bar the IRS from using any enforcement mechanism to collect the uninsured penalty. The only way they can collect it, unless you volunteer to pay, is to take it out of your refund. viz.
posted by Holy Zarquon's Singing Fish at 8:06 AM on September 26, 2013 [1 favorite]


Also, there's this:

"23. If my income is so low that I am not required to file a federal income tax return, do I need to do anything special to claim an exemption from the individual shared responsibility provision?

No. Individuals who are not required to file a tax return for a year are automatically exempt from owing a shared responsibility payment for that year and do not need to take any further action to secure an exemption. Individuals who are not required to file a tax return for a year, but file anyway, will be able to claim the exemption on their tax return."

So if someone doesn't make any money, they won't have to pay the penalty.
posted by MisantropicPainforest at 8:13 AM on September 26, 2013 [4 favorites]


Millions of healthy young people already burdened by student loans and underemployed in the Obama economy who are not actually in need of health insurance are going to be forced to buy it.

There's no such thing as a person who doesn't need health insurance. A perfectly healthy young person can develop cancer, can get in an accident and need surgery and ongoing therapy, and can very quickly go bankrupt from having these things happen to them. A person can lead a relatively healthy and safe lifestyle and still have things like these happen to them.

This is why health insurance at all is not the answer. What we need is comprehensive health care that covers everybody and that everybody pays into according to their ability. People get angry about those who take shitty care of themselves and end up with smoking-related or poor-diet-related diseases, but by spiting those people we are making millions of healthy people suffer and live in fear of going bankrupt because they might get a disease or injury they couldn't have prevented.
posted by wondermouse at 8:19 AM on September 26, 2013 [14 favorites]


Adorable Care Act
posted by peacay at 8:21 AM on September 26, 2013 [10 favorites]


I'm in love with that site!
posted by ThePinkSuperhero at 8:27 AM on September 26, 2013


There's no such thing as a person who doesn't need health insurance.

Wait, scratch that - the very rich don't need health insurance because they can afford any health care they want as they need it. In general, the rest of us can't.
posted by wondermouse at 8:34 AM on September 26, 2013


LASIK surgery plummeted in price becaus it's not covered by insurance, and the demand by people paying out of their own pockets helped regulate a normal market value.

LASIK is cosmetic surgery. How much are you willing to pay for that bypass surgery? How much do you have?

It's telling how thorough the conservative victory has been in the US when liberals champion a plan by the fucking Heritage Foundation. As usual we fuck over the working poor to subsidize the rich perpetuators of human misery who run the health insurance industry. We are so fucked.
posted by dirigibleman at 8:44 AM on September 26, 2013 [4 favorites]


There's no such thing as a person who doesn't need health insurance.

This. Just because you're healthy today doesn't mean that you can't get ill or injured tomorrow.
posted by octothorpe at 8:48 AM on September 26, 2013 [3 favorites]


headspace: "So I went to see what it's going to cost us to pay for insurance on the exchange on the Kaiser calculator. (This calculator was suggested by the ACA website.)

11,589 dollars a year (after subsidies.) Or about a thousand dollars a month. Right now at the end of the month, we're super lucky to have 200 bucks in the bank. We have no savings.
"

This is going to be a dumb question, but I'm assuming you have made adjustments to put back the money you're paying in now, so that it's not the full amount you'd be paying (that is, you won't be paying into your employer's health plan, so you would get that money back). Have you done that?

I think as paulsc points out a lot of this is really dependent on the state governments, and that's one huge flaw with this. People in Red States have to suffer for their political leaders' intransigence. Look at that WSJ post above showing the costs of those on the "federal plan"... But if you look at the costs on states that are implementing it themselves, the costs are lower.

For all the talk of a free market, the Republicans will do anything in their power to remove transparency and an open exchange of competition. They want the monopolies and the locked in systems so there can't really be a strong sense of competition.

There are a lot of things I hate about "Obamacare". But I also recognize that it's better than nothing and I think down the line it could work. Unfortunately, whenever we do this "mixed economy" thing, it gives too much room to the corporations to engage in political capture and ruin it for the rest of us.

The sooner we break the stranglehold on employer based health insurance, the better. The ruling class, overall, doesn't want that, because they know that with a subjected populace they can easily use their power to punish those not fortunate enough to have a job. And that's what it comes down to: fucking the poor ever more.
posted by symbioid at 8:55 AM on September 26, 2013 [2 favorites]


The Premium Tax Credit is the method of subsidizing premiums for low-income folks. As the IRS link notes, you can get it paid to your insurance company so your monthly bill for subsidized insurance is, in fact, the subsidized rate:

If you are eligible for the credit, you can choose to:
Claim It Now: have all or some of the credit paid in advance directly to your insurance company to lower what you pay out-of-pocket for your monthly premiums during 2014; or
Claim It Later: wait to get all of the credit when you file your 2014 tax return in 2015.

posted by akgerber at 9:01 AM on September 26, 2013 [5 favorites]


The Premium Tax Credit is the method of subsidizing premiums for low-income folks. As the IRS link notes, you can get it paid to your insurance company so your monthly bill for subsidized insurance is, in fact, the subsidized rate rate...

oh jesus is that a clusterfuck in the making:
During enrollment through the Marketplace, using information you provide about your projected income and family composition for 2014, the Marketplace will estimate the amount of the Premium Tax Credit you will be able to claim for the 2014 tax year that you will file in 2015.

You will then decide whether you want to have all, some or none of your estimated credit paid in advance directly to your insurance company.

Change in Circumstances


Report income and family size changes to the Marketplace throughout the year. Reporting changes, increases or decreases, will help you get the proper type and amount of financial assistance and will help you avoid getting too much or too little in advance.

For example, if you do not report income or family size changes to the Marketplace when they happen in 2014, the advance payments may not match your actual qualified credit amount on your federal tax return that you will file in 2015. This might result in a smaller refund or balance due.

Claiming the Credit on Your Federal Tax Return


Whether you choose to claim the Premium Tax Credit now at the Marketplace or claim it later, you must file a federal income tax return.
If you choose to claim it now: When you file your 2014 tax return in 2015, you will subtract the total advance payments you received during the year from the amount of the Premium Tax Credit calculated on your tax return. If the Premium Tax Credit computed on the return is more than the advance credit paid on your behalf during the year, the difference will increase your refund or lower the amount of tax you owe. If the advance credit payments are more than the Premium Tax Credit, the difference will increase the amount you owe and result in either a smaller refund or a balance due.
posted by ennui.bz at 9:08 AM on September 26, 2013


... most Americans get health insurance is through their employer, and employer-provided health insurance is a TERRIBLE IDEA. It works just fine at what it was designed to do. It's just not designed to deliver healthcare. It's designed to be a tool that employers can use to pressure their workers into accepting lower wages and progressively worse working conditions.

Actually, one of the reasons we have employer-sponsored coverage in the US is because the government imposed wage controls after WWII (wikipedia link) and giving people healthcare was a way to attract new workers. I get to hear my father talk about this when I wonder why we purchase health insurance from our employers.

Aside (further down in the wikipedia link)- President Truman proposed an optional public health insurance plan in 1945 which was popular with the public but was denounced as "socialism" by the AMA and businesses. Guess times haven't changed too much!
posted by bCat at 9:09 AM on September 26, 2013 [4 favorites]


EC: Not sure you're still following the thread, but the answer to your question:

Can someone explain whether the subsidies are paid to you right away, or whether you have to shell out the money first and then get a rebate at some eventual point?

is that the subsidies are paid right away. Technically they're called "advanced premium tax credits," which means that the final level of your health insurance subsidy for 2014 will be based on the income you report on your federal taxes in April 2015. However, my understanding is that when you apply for coverage through the exchange in your state, they'll look up what your income was on your 2013 tax return and estimate your subsidy based on that, and it will seamlessly be added to the premiums you pay monthly through the exchange website. (So you'd pay your $100 per month, the exchange adds in $150 or whatever, and sends it along to the insurance company.) The reconciliation happens when you file your federal taxes in the next year; if your subsidy should have been bigger (because you made less than expected in 2014), you'd get a tax refund, if it should have smaller (because you made more than expected), your federal taxes would go up to cover the difference.

CAVEAT: I am fairly well-versed in how the mechanics of this will work but I am not actually involved in any of the implementation, so what I wrote above is my best understanding but could be slightly off.
posted by iminurmefi at 9:12 AM on September 26, 2013


There's a ton of talk about the costs of existing plans or new plans equivalent to existing plans going up under this, mostly the higher-end plans, which I don't quite get - with a wider base of healthy people paying in to the system and not using it, and a set limit on how much of the money an insurance company makes has to be spent on healthcare instead of being pocketed as profit, how can any plan's cost go up? And we've already seen a lot of insurance companies issuing rebates because of the new laws. Either I'm missing something or I smell a price-jacking rat at the insurance company or employer level, leaning towards the latter - a lot of rebates have been straight-up pocketed by employers without being passed down as savings to the employees, because reflecting the savings in your benefits is done at their discretion.
posted by jason_steakums at 9:14 AM on September 26, 2013


However, my understanding is that when you apply for coverage through the exchange in your state, they'll look up what your income was on your 2013 tax return and estimate your subsidy based on that, and it will seamlessly be added to the premiums you pay monthly through the exchange website. (So you'd pay your $100 per month, the exchange adds in $150 or whatever, and sends it along to the insurance company.) The reconciliation happens when you file your federal taxes in the next year; if your subsidy should have been bigger (because you made less than expected in 2014), you'd get a tax refund, if it should have smaller (because you made more than expected), your federal taxes would go up to cover the difference.

And what if your income (or family composition) is highly variable? Using the IRS and the unknown "marketplace" bureaucracy to do this sort of adjustment seems like total madness:

either you get screwed every month because your income last year was too high or you get screwed at tax time because your income for the year was too high.

It's insane. You have to be able to both estimate your income and your health insurance rate and save enough money to buffer the difference.
posted by ennui.bz at 9:16 AM on September 26, 2013 [1 favorite]


Also, to everyone looking at that Kaiser premium subsidy calculator:

You should note that while the subsidies it is estimating are correct, the premiums are based on estimates that the Congressional Budget Office (CBO) put together a while ago. In fact, the prices for plans in the marketplaces are pretty much set at this point (and will go live in 5 days), and it looks like the actual premiums that insurance companies are bidding in order to be included in the ACA marketplaces is lower than what the CBO projected. So that calculator is probably overestimating what you'd actually pay. Of course, premiums vary quite a bit from state to state; where you live will probably have the biggest influence on what you're going to face.
posted by iminurmefi at 9:20 AM on September 26, 2013 [4 favorites]


EC: Not sure you're still following the thread.....

Ironically, it was probably only just minutes before you answered that I remembered "hey, wait, yeah, I had that question" and came back in to check on that.

I'm actually quite lucky in that my temp agency does offer a health plan, which I signed up for. But I know a couple who have erratic employment (theater folks) and was wondering what the deal was with that. I tried playing with the Kaiser calculator to see what I'd have to spend on health care - the by-month premium wasn't bad for me. But for them....well, there are months when it would be easy for them to come up with the premium, because those are months when one of them IS working for a couple weeks on the big corporate gig in Witchita where he's running the lights for a corporate event and getting paid hand over fist....and there are months when it would be hard.
posted by EmpressCallipygos at 9:26 AM on September 26, 2013


I'm a contractor. But the employees where i work just got a notice their premiums increasing. The family plan now costs $70 more a month.
posted by sio42 at 9:27 AM on September 26, 2013


And what if your income (or family composition) is highly variable?

Under the ACA, family composition is defined by the tax-filing unit--in other words, if you have a lot of housing instability and move several times over the course of the year (living alone with your kids, then everybody moving in with grandma when you can't pay rent, then moving your family in with your new boyfriend at the end of the year), it won't have any effect from the perspective of the subsidy you qualify for. So long as grandma doesn't claim you as a tax dependent on her taxes, and you don't marry your boyfriend, the federal government will consider your household to consist of you and your kids only, regardless of who else actually lives with you.

The above is only true for people who file federal taxes, but it's worth noting that this is a MUCH more generous way of calculating insurance subsidies and determining Medicaid eligibility than what the vast majority of states did before, which was to assume that every adult living in the household could and was contributing to household income for the purposes of calculating benefits. Since many human service aid programs take Medicaid eligibility as automatic "proof" of eligibility and don't require additional income verification--for example, the Women Infants and Children (WIC) food assistance program--this change could end up benefiting low-income households quite a bit for more than just accessing health insurance.

And changes in income can be reported to adjust your subsidy and/or Medicaid eligibility every month; it then creates a burden on the applicant to provide pay stubs for the past month (which they were trying to avoid by doing this seamlessly on the back end by linking to IRS data). Also, I think it's probably the case that the families with the highest levels of income instability--e.g., income changing a lot every month, versus single-time events like losing a job or getting a higher-paid job--are most likely to qualify for Medicaid. One of the other changes under the ACA is that states can now automatically extend 12 months of Medicaid eligibility to anyone who qualifies at a given point in time, which is explicitly intended to help this group of people avoid bouncing back and forth between Medicaid and private insurance with constantly-changing subsidy levels. Once you qualify for Medicaid or your kids qualify for CHIP, in many states you'll stay there for a full 12 months regardless of whether you suddenly score a better-paying job and no longer have income low enough to qualify. It's not perfect, but it is certainly something that was and is on the radar of the people who wrote the law and are implementing it now.
posted by iminurmefi at 9:31 AM on September 26, 2013 [2 favorites]


I'm honestly baffled at the hate for the ACA from individual people. I get it from the corporate perspective and of course the healthcare industry hates it, but for the average person how is this not a HUGE net positive for most actual people in the US?

- expansion of medicare to cover the poor
- requirement that insurance plans actually provide core services (catastrophic plans are total BS, from personal experience)
- can't refuse insurance based in pre-existing conditions (HUGE)
- ability to stay on parents insurance until age 26 (used to be tied to college attendance I believe)

And yes, it's not the perfect European style plan we would all likely prefer, but again, it seems like a massive improvement over the current system which is held together with rubber bands leaving so many people to fall through the cracks.

I'm starting to think the right wing propaganda machine has done an amazing job making this all seem like a net negative.

*Btw, I'm pretty sure the WSJ chart is comparing an insurance plan with actual benefits to a catastrophic plan to make it look like premiums will go up. Again, catastrophic plans don't cover what regular insurance covers.
posted by rainydayfilms at 9:37 AM on September 26, 2013 [3 favorites]


I want the libertarian health care plan. Sell your kidney to pay for your broken arm.
posted by Ghost Mode at 9:37 AM on September 26, 2013 [2 favorites]


Just wait for the state and class warfare. Border towns and Senators writing exceptions to the existing law to keep costs from skyrocketing. This "afforadable" care only works if you force someone to pay more in order to allow subsuides for those that can't. How many can have an additonal $358 increase per month? This law does not encourage upword mobility. By getting a single pay raise, the cost for health care will increase. I'm glad they tried to stop it from being implemented because this is not good legislation. It only looks worse by extending the employers and not the employees coverage.
posted by brent at 9:40 AM on September 26, 2013


I'm a contractor. But the employees where i work just got a notice their premiums increasing. The family plan now costs $70 more a month.

Premiums tend to go up almost every year, I doubt this is caused by the ACA even if your employer wants to claim that is so.
posted by rainydayfilms at 9:41 AM on September 26, 2013 [2 favorites]


rainydayfilms: the people i know who hate health care for all do not and will not understand the way that healthcare works in this country. They think that if you if you have a job, you have health care that pays for everything. They have never experienced or known someone who has experienced meeting a lifetime limit or who has to deal with a catastrophic or chronic injury.

They truly believe that if you can't afford healthcare it's because you are drain on a society and a bum.

I am not kidding.
posted by sio42 at 9:43 AM on September 26, 2013 [2 favorites]


They think that Obama is taking their money and giving it to people who don't work and sit around drinking beer and watching tv all day.

Again, not kidding. I have heard people say these things.
posted by sio42 at 9:44 AM on September 26, 2013 [1 favorite]


So long as grandma doesn't claim you as a tax dependent on her taxes, and you don't marry your boyfriend, the federal government will consider your household to consist of you and you kids only, regardless of who else actually lives with you.

The tax dependent thing is a bit flexible on the healthcare end, though. I was able to claim my girlfriend as a dependent when I was supporting her financially during a long recovery from brain surgery, and her Medicaid didn't change one iota after notifying all parties involved about that.

Premiums tend to go up almost every year, I doubt this is caused by the ACA even if your employer wants to claim that is so.

Anecdotally, it seems there's a LOT of this going on right now, employers latching on to Obamacare as an opportunity to cut benefits on the sly for their employees. I think this will cease to fly after next year, but who knows.
posted by jason_steakums at 9:46 AM on September 26, 2013


This "afforadable" care only works if you force someone to pay more in order to allow subsuides for those that can't.

Not true. You can also reduce costs, which the ACA does. You can also get more revenue by having people buy insurance that were not previously buying insurance.
posted by MisantropicPainforest at 9:46 AM on September 26, 2013 [2 favorites]


Okay, last post for while, but I don't think anyone has posted this link and it's really interesting to look at the actual numbers that are starting to come in:

Actual subsidized & unsubsidized premium prices in 18 markets

Figures 3 and 5 show the premiums before subsidy for a 40- and 60-year old in the new marketplaces. (If you're younger than 40, you'd face lower premiums than in Figure 3.) My parents are both in their 60s, not yet eligible for Medicare, and buy their insurance in the individual market. According to Figure 5, they could each potentially be facing premiums of between $400 and $531, depending on how generous a policy they choose. I know that's cheaper than what they pay now. Also, my dad will almost certainly qualify for subsidies, so his costs will come down even further.

They've been asking me for the past year what is going to happen to their health insurance costs and it's been frustrating to have to say, "Uh, it depends, there are countervailing factors, blah blah blah." I'm exceedingly pleased that at least in Colorado it looks like they'll be facing premiums that are a lot more reasonable than what they can buy now, and they'll get better coverage to boot.
posted by iminurmefi at 9:46 AM on September 26, 2013 [1 favorite]


> Republicans were already going to flip out and cry 'socialism' no matter what form healthcare reform took, so why not go all out and actually adopt a plan that would be worthy of their insults?

This baffled me since the start. The Republicans were very clear that they'd never, ever agree to any health care plan proposed by Mr. Obama - they said it every day before the election, and then said it again every day after the election. And yet Mr. Obama pissed away a year or so attempting to get their buy-in, watered down the plans to almost nothing, and completely suppressed any discussion of single payer - the system that almost all other countries with successful health care systems use.

My first thought was simply that Mr. Obama must be a truly incompetent negotiator - and indeed, the subsequent negotiations involving extending the Bush tax breaks and the debt ceiling seemed to corroborate that. But he seems to be pretty smart overall. These days, I believe he actually got what he wanted - something that looked like real change and took off some of the pressure on the poorer consumers of medical treatment, without actually disturbing the status quo at all. (And as for the budget, it looks as if Mr. Obama considers "deficits" to be of comparable importance to "jobs", a decision that I predict will make him go down in history beside Hoover.
posted by lupus_yonderboy at 9:59 AM on September 26, 2013 [1 favorite]


paulsc:
"6. How will the Medicaid expansion be financed?

The federal government will finance the great majority of the costs associated with the Medicaid expansion. For the "newly eligible population" (anyone not previously eligible in their state), the federal government will cover 100 percent of costs in 2014-16, and it will always cover at least 90 percent of the costs of this population. States will continue to receive their standard federal contributions for "traditionally eligible" populations. This amount is different from state to state, and averages less than 60 percent." [SOURCE]
I think there's a tendency for people to diminish the ongoing cost saving / curve bending measures that will be in place, including the (hated) board that will have an easy time implementing quick changes without too much congressional undermining. I don't remember them all, but hospitals are switching from being paid for services rendered to an outcomes basis model. These things (of which there are quite a few significant, but, yes, untried strategies) are thought to already be impacting the whole of the health industry costs, a la, reduction in rate of health cost increases over last few years. I'm not saying that there is a path of absolute certainty forward in relation to states meeting ongoing medicaid needs, there are well worked out parts of the law that will - it is hoped - help drive down the costs pressures so it won't be as much of a burden on states as you intimate.
posted by peacay at 10:11 AM on September 26, 2013


peacay: thought to already be impacting the whole of the health industry costs

For example, capital expenditures going down.
posted by mittens at 10:18 AM on September 26, 2013


Have you never had insurance in the US: what providers will take what insurance is a total nightmare

It's not only what providers will take what insurance, insurance companies limit the number of providers in their plan. For instance, my therapist is in a group practice and under ACA I should have 0 copay for therapy. However, BCBS doesn't have her on their plan as a provider, if I want to have the 0 copay, I would have to switch providers to the ONE person in their practice that BCBS has on their plan. From what I've been able to find out, BCBS hasn't added a single person to their covered mental health providers list in well over 10 years. Providers apply and are rejected by the health insurance company for unknown reasons.
posted by hollygoheavy at 10:36 AM on September 26, 2013


mittens, that article's headline isn't very well supported by its content. It vacillates, seems to me and I got the conclusion that not much has really changed in the last couple of years on capital exp. front. But I don't think that's where the bulk of non-recession savings in health care costs of which I speak have come from in any event (and which I fully admit I don't properly know/recall). Besides, that speculative article was written at the beginning of this year so we don't know what's happened since. And again, I think the cost saving potential from a lot of these large interconnected pieces (payment arrangement changes; capital investments; narrowing of acceptable treatment regimens & more) of the health care industry puzzle, can't be judged quickly or easily in terms of causation and outcomes. Anyway...enough(!!) from me.
Sarah Kliff / Ezra Klein / Wonkblog (WaPo) are my mainstay informants.
posted by peacay at 10:51 AM on September 26, 2013 [1 favorite]


The above is only true for people who file federal taxes, but it's worth noting that this is a MUCH more generous way of calculating insurance subsidies and determining Medicaid eligibility than what the vast majority of states did before, which was to assume that every adult living in the household could and was contributing to household income for the purposes of calculating benefits. Since many human service aid programs take Medicaid eligibility as automatic "proof" of eligibility and don't require additional income verification--for example, the Women Infants and Children (WIC) food assistance program--this change could end up benefiting low-income households quite a bit for more than just accessing health insurance.

And changes in income can be reported to adjust your subsidy and/or Medicaid eligibility every month; it then creates a burden on the applicant to provide pay stubs for the past month (which they were trying to avoid by doing this seamlessly on the back end by linking to IRS data). Also, I think it's probably the case that the families with the highest levels of income instability--e.g., income changing a lot every month, versus single-time events like losing a job or getting a higher-paid job--are most likely to qualify for Medicaid.


Having gone through all of this, I wish you and the people you work for/with could actually "dogfood" your policies. It creates a total meat-grinder of forms and offices and evaluations. It's easy to say that it will all work out, but what goes into that sausage is really disastrous and I think is only tolerated because everyone involves breathes a sigh of relief when people are discouraged from actually obtaining benefits. It took me 8 months of back and forth to obtain state-subsidized insurance, during which time I was injured (again) and without coverage... the effects of which I still live with.

I'm exceedingly pleased that at least in Colorado it looks like they'll be facing premiums that are a lot more reasonable than what they can buy now, and they'll get better coverage to boot.

You had better be right, or this sort of political "happy talk" will be far more toxic than Obama's "recovery summer." But the thing is, you guys just don't get how terrifying the uncertainty is, for people whose health insurance coverage is marginal. It's like everything else, health care is in total crisis if you don't have insurance or have bad insurance. But no one making policy really seems to understand: the house is on fire, saying maybe things will be ok... isn't ok.
posted by ennui.bz at 11:57 AM on September 26, 2013 [2 favorites]


And yet Mr. Obama pissed away a year or so attempting to get their buy-in, watered down the plans to almost nothing, and completely suppressed any discussion of single payer - the system that almost all other countries with successful health care systems use.

this is the self-serving tale liberal advocates of single-payer have been telling themselves the whole time. Obama and his neo-liberal friends needed you guys as an unrealistic 'foil' to play against.

the truth about the "new Democrats" like Clinton and Obama is their whole political raison d'etre is promoting policies which are painful... to prove the point that the "great society" programs of the old democrats are foolish pipe dreams. A policy which was of actual straight-forward benefit to a group of people is clearly a "free lunch" and suspect to the conservative blue-collar voter they pretend to be wooing.

look at how quickly Obama backed away from high speed rail infrastructure spending. he literally had those red state governors by the balls: rejecting billions of federal money was going to drive the state construction interests nuts. that was always the sort of politics which was actually going to improve things: forcing republicans to choose between money and ideology and driving a wedge between the national and state parties. but that would have involved giving people money for nothing... or trains or doctors, or whatever.
posted by ennui.bz at 12:07 PM on September 26, 2013 [2 favorites]


And that's the rub. Millions of healthy young people already burdened by student loans and underemployed in the Obama economy who are not actually in need of health insurance are going to be forced to buy it

Just wanted to re-emphasize that this is bullshit. Everyone is in need of healthcare. The attitude that "I don't need it 'cause I'm young / healthy / have healthy genes" is ridiculous and wrong-headed.

Healthcare is not some durable good. It's not like "I don't need another TV because I already have a TV derp!"

You never KNOW when you will suddenly need healthcare. Marathon runners suddenly develop cancer. Nonsmokers suddenly get hit with heart problems. Gym-rats suddenly get hit by a bus while crossing the street. Perfectly healthy young people develop brain tumors and die within 6 months. This is reality. This is how it works.

I am young, go to the gym regularly, ride my bike to work and eat clean - none of that mattered earlier this year when a knife slipped and sliced the tendon in my pinky requiring two surgeries and rendering my pinky unable to fully bend. LOLS.

Everyone of every age needs healthcare because even though you're so smart...you never know.
posted by jnnla at 12:56 PM on September 26, 2013 [15 favorites]


I haven't read through everyone's comments yet, but I thought it might be useful to point out that the Kaiser Family Foundation calculator shouldn't be relied upon as the best estimate of cost. My husband and I purchase insurance independently in WA State and we've already received letters from our insurers detailing the new premiums under ACA. The KFF calculator has underestimated by about $1500/year.

And my husband's premiums are going up by about 90%. We support the ACA and we want everyone to have access to healthcare, and I understand the math about risk pools enough to accept the hike, but that doesn't make it any less substantial.
posted by stowaway at 1:44 PM on September 26, 2013


I'm honestly baffled at the hate for the ACA from individual people. I get it from the corporate perspective and of course the healthcare industry hates it, but for the average person how is this not a HUGE net positive for most actual people in the US?

Wooooord.

I'm a 29-year-old freelancer (who also works from home part time to close the gap between gigs), married to a guy who works from home. And pregnant. And right now, we pay 26% of our income to health insurance, which, hi, I actually use (it's talked about, here and elsewhere, like it's some moral positive if you don't, but fuck it, I had an ear infection a month ago and a UTI two months before that and you can bet I went to my doctor, what else am I paying for health insurance for?) There have been many times when we thought we couldn't do this anymore, that I should just get a full time job or something and stop paying for our own but that's hard because this is what I want to do with my life and it lets me create art and maybe it's supposed to be a huge privilege to do that but I think it's better for society overall.

Once the ACA goes into effect, our insurance rates will go down to 8% of our income. Our kid will be covered for free (if I get a big book contract at some point, we'll have to pay more. That's okay--we'll be making more. This is how it should work.) This will let me pay off student loans, will let things not be desperate, will let me have the life for my family that I want without feeling like I'm drowning. Socialization of health care supports the arts and the low income and all of us who were told that we shouldn't be able to do this because we grew up working class and had to take out student loans or whatever and I just, I don't know. There are all these ask metafilter questions about academics and freelancers in similar situations and they're always like "but the ACA is going to be terrible and not work, amirite?" and I can't help but think that somehow, propaganda has worked on them or something because I am so flippin' excited for January.
posted by PhoBWanKenobi at 1:49 PM on September 26, 2013 [21 favorites]


iminurmefi: We've made the same point about not relying on the KFF calculator - it underestimated for my family.
posted by stowaway at 1:52 PM on September 26, 2013


Just wait for the state and class warfare. Border towns and Senators writing exceptions to the existing law to keep costs from skyrocketing. This "afforadable" care only works if you force someone to pay more in order to allow subsuides for those that can't. How many can have an additonal $358 increase per month? This law does not encourage upword mobility. By getting a single pay raise, the cost for health care will increase. I'm glad they tried to stop it from being implemented because this is not good legislation. It only looks worse by extending the employers and not the employees coverage.

Upward Mobility had already stagnated in the US about 20 years ago thanks in large part to Reagans libertarianesque policies. The ACA has nothing to do with it. If you want social mobility, move to Europe. Also, healthcare costs are skyroocketing because there is no real market in the existing system and no real bargaining power in the US to effectively bargain down prices with pharmaceutical companies and medical product manufacturers...which unfortunately the ACA does little to fix. Want to see an actual market in healthcare? See medicare, where a single entity representing buyers is able to effectively bargain with manufacturers who give bulk discounts...driving prices down to reasonable levels.

This "afforadable" care only works if you force someone to pay more in order to allow subsuides for those that can't.

Waaaaah! You still pay for people that can't afford care in the form of higher premiums because poor people use the ER as their doctor. Only now you are paying less, depending on your situation, because more people are putting into the pot to pay for people who are on the margins and need care. If you think that people on the margins should be denied healthcare because they can't pay for it, and you cry about paying a marginal amount for their care in a first world democracy than you are effectively subhuman yourself. A healthier population is good for everyone.
posted by jnnla at 2:13 PM on September 26, 2013 [8 favorites]


stowaway, that's a total bummer. Do you know if the plan that you are currently insured with is the same as the plan that your insurer will be offering through the Washington Health Benefit Exchange? It looks like they've released the actual rates that insurers have been approved to charge inside the exchange (annoying PDF interface), and if other states are any indication, insurers can be REALLY far apart on premiums for the exact same benefit package. Keep in mind, the rates at that link are before any subsidies you'd qualify for, which the KFF calculator takes into account. Looks like Washington state has its own subsidy calculator here, although I'm not sure if they're feeding actual premiums for 2014 into that or just estimates of what they thought premiums would be from earlier in the year.

Anyway, just a thought--seems worth a shot to check whether you can get a cheaper policy with the same coverage level by switching into the Exchange or to a different insurer.
posted by iminurmefi at 2:21 PM on September 26, 2013


Yup, I've seen all those PDFs. The prices don't vary a whole lot by insurer in WA. (Due to my profession, I am more educated than the average bear on health insurance costs in WA.) Also, we don't qualify for subsidies.

Another thing that's sort of messed up about this is that, according to the fact sheet the insurance company sent, we'll actually be paying more to have a higher deductible. Double ouch. I mean, it sucks, but we've been paying directly for health insurance for a while now so we will simply absorb the increased cost as best we can. Right now what we're looking at, to balance cost/benefit/deductible, is to get us all on the same plan with the same amount of coverage.
posted by stowaway at 2:40 PM on September 26, 2013


That sucks, I'm sorry. I didn't realize you had all that info already, hope you don't mind I posted it--just figured it was worth checking since I wouldn't put it past insurers to tell their current nongroup members that prices were going up "because Obamacare!" just like some employers are evidently doing, when that's not so much the actual case.
posted by iminurmefi at 2:46 PM on September 26, 2013


No worries, it's alright. It is certainly useful information to put out there.

Washington State is an interesting case because many of the state's health insurance regulations were already pretty close to many parts of the ACA. It's my understanding that it's somewhat of a surprise that rates in WA are changing as much as they are for men under 40. It was thought that WA could be a model for what rates would like nationwide.
posted by stowaway at 3:01 PM on September 26, 2013


My husband's employer sent around a letter informing everybody about the law, probably in anticipation of dumping everybody off the plan that they offer their employees.

Your husband's employer sent the letter because they were required to by law, just like every other business subject to the FLSA.
posted by zakur at 3:11 PM on September 26, 2013 [1 favorite]


Consumer Reports has just launched a new site to help consumers wade through the ACA:

HealthLawHelper.org

Give it a try if you're not finding what you need at Healthcare.gov or KFF.org.
posted by zakur at 3:17 PM on September 26, 2013 [3 favorites]




ennui.bz: But the thing is, you guys just don't get how terrifying the uncertainty is, for people whose health insurance coverage is marginal.

Instead of sitting in ignorant terror and whining, you could at least make a minimal effort to find out the facts about the ACA. It isn't that hard.

I'll try to answer some of the questions from this thread below. If this is too long and annoying, feel free to use the scroll bar.


Almost perfect, first we put the poor in jail if they HAVE drugs, and now we put them in jail if they CAN'T GET drugs (legally through insurance).

Totally false. Nice Republican fear mongering. Nobody is going to jail. Poor people, 21 million of them, for the first time, will get health insurance for free through Medicaid (at least in the Blue states.) This includes everyone up to 138% of the federal poverty level. Middle income people, up to 400% of the poverty rate will get subsidies.

There are two big pieces of the ACA. The one most people are familiar with are the insurance exchanges for individuals who don't have employer insurance and the infamous mandates. This was approved by the Supreme Court.

The second piece of the ACA is the expansion of Medicaid for poor people. In its bizarre split decision, the Supreme Court disallowed this provision, making it optional for the states. Even though the federal government pays 100% of the cost for this expansion, gradually declining to 90% by 2020, many red states are refusing to participate out of spite, even though it costs them little or nothing, just so they can say no to a piece of Obamacare.


The general public should be offered the same coverage that Congresspeople get.

They will. Starting in 2014, Congress and their aides will get their insurance through the same exchanges that other individuals do. The government will pay their premiums, just as they do for their current insurance as part of their compensation package, but it will be the same insurance plans you can get.


Can someone explain whether the subsidies are paid to you right away, or whether you have to shell out the money first and then get a rebate at some eventual point?

You will estimate you income for the year and the subsidy will be pre-paid directly to the insurance company. When you file your tax return, you will reconcile the difference on your tax return. If you underestimated your income, you may owe more taxes. If you overestimated your income, you will get a credit on your taxes.

If you have a volatile income stream, you have the opportunity to modify your income estimates, and thereby pre-paid subsidies, throughout the year to minimize any surprises at tax time.


The Chinese have long since stopped being massive financiers of American Federal public debt, and if Uncle Ben closes up shop as a buyer of low interest Treasury notes, as he's been promising he's going to, there's going to have to be a major fast re-think of entitlement programs and the ACA. And ACA without significant subsidy arrangements made good by the Federal treasury, is a game of 3 card monte in a hurricane.

According to CBO calcualtions, the ACA reduces the federal deficit by $143 billion over 10 years. Without the ACA, the deficit would be higher.


All of this is really scary to me: I can't afford an extra $100-200 a month. I'm making under $15k a year.

You would fall under the 138% of poverty threshold and be eligible for free or nearly free health insurance under Medicaid (in the Blue states). Medicaid thresholds below:
1 person household = $15,900
2 person household = $21,400
3 person household = $27,000

For people above these thresholds, there are subsidies to buy insurance up to the 400% of federal poverty level. Subsidy limits below:
1 person household = $46,000
2 person household = $62,000
3 person household = $78,000



Bronze plan's going to cost me about $200/m, give or take $30. The subsidy's a whopping 7% of my total premiums.

Note that the subsidies are not based on your gross income but your Modified Adjusted Gross Income (MAGI). For most people this is line 37 on your Form 1040 from last year. This is your gross income minus 401(k), IRA, and student loan interest.

Many have mentioned student loan burden. You can subtract your loan interest from your income to determine your subsidy eligibility. You can also lower you MAGI by contributing more to your 401(k) or IRA and thereby increasing your subsidy.


I've been severely underemployed for years, and I'm not eligible for unemployment insurance payouts. I can just scrape by as it is, and adding even cheap insurance premiums will drive me into an inescapable hole of debt.

See above. You probably will be eligible for free health insurance under Medicaid expansion (if you are in a Blue state).


And this is what really infuriates me about the Democrats. Republicans were already going to flip out and cry 'socialism' no matter what form healthcare reform took, so why not go all out and actually adopt a plan that would be worthy of their insults?

You have no idea just how close we came to having no ACA at all, let alone a single-payer one. Not one single Republican in the House or Senate voted for the bill. At the time of initial passage, they needed every single Democrat to overcome the Republican filibuster in the Senate. Democrat Joe Lieberman refused to pass anything having single-payer. Pelosi in the House barely passed a better version by four votes, but by the time it come to reconciliation with the Senate version, Teddy Kennedy was dead and Scott Brown replaced him. So they were stuck with the inferior Senate version previously passed. You are very lucky to have any ACA at all. One single vote and you would have nothing.


It seems to me that if someone's income is low enough to qualify for the tax credit subsidy, it's low enough that they may not have to pay any taxes, in which case the subsidy isn't going to do them any good.

No. The ACA subsidy is what is known as a refundable credit. That means you get the subsidy even if you have zero taxes. The easiest way to get the subsidy is to have it pre-paid to your insurer. Otherwise you get the full amount as a refund when you file your tax return.


And by requiring everyone to go through insurance you further separate the end user from the product which will do nothing to lower prices, right?

Actually the insurer has a better chance of negotiating lower prices on medical services than you do as an individual. Studies have shown that locations with fewer insurers actually have lower medical prices because they have more leverage over doctors and hospitals. Of course the ultimate leverage over medical providers occurs with a single payer.


Looks like a federally enforced handout from my wallet to big insurance companies.
The rates seem arbitrary. WHY is a bronze plan that amount? Why can't it be less? And what recourse does the consumer have when rates rise because of "it's complicated"?


The ACA actually mandates that the insurance companies pay out 80% to 85% of the premiums they collect to their customers for medical services. This limits the amount that companies can spend on operating expenses and profit. Any excess they collect in premiums must be refunded to customers at the end of the year. In fact, last year millions of people already received insurance refunds due to this provision.

So the rates aren't arbitrary. They must pay out the required amounts. They can't just arbitrarily raise premiums because they would just have to refund them at the end of the year. That is the consumer recourse. Since basic benefits are the same for all insurers, the cost differences depend on how well each insurer can negotiate lower prices for medical services and how wide of a network they allow.


My fiancee is graduating in December and she will not have health insurance. She won't be eligible for medicaid, despite the fact that her income is 0, because she is not pregnant, elderly, or disabled.

This changes in 2014 with the expansion of Medicaid to cover all low-income people. However, if you live in a Red state that is not expanding Medicaid, you will be the same as you were before, going to the emergency room for healthcare.


The economics of "general practitioner" medicine in this country is collapsing. If every patient was billed at Medicare/aid levels, there wouldn't be any GPs.

This is false. GPs in the U.S. are paid at rates that are 150% to 200% higher than other developed countries like Canada, UK, Germany, France. There are plenty of people waiting in line to enter medical schools. There are plenty of doctors in other countries that would be happy to come to the U.S. and earn Medicaid rates.


My question is where is that money coming from and what happens when she can't afford it? She gets fines heaped and her pay garnished?
I want everyone to have health care. I don't want people still going bankrupt because of it when we have this law that is supposed to be helping.
I'm not really arguing so much as trying to find out what will really happen when you can't pay because that is not something I've heard discussed anywhere.

You simply aren't paying attention. These questions have been answered. No one is having their pay garnished nor going to jail. Low-income people will get free health insurance (in Blue states). Middle income people will get subsidies.


So if she can't afford the $175/month and Medicaid [in a Red state] is not an option, she pays the penalty of $95/year?

No. There is a specific hardship exemption from the insurance mandate and penalty for Red states that do not implement Medicaid expansion. She will not pay a penalty for not having insurance.


I would be SOL if I had to pay my subsidized insurance upfront and take a credit on my taxes. The problem is that the wizards who are figuring this all out have no idea what it is like to live at the poverty level in this country and no political incentive to find out.

Actually the wizards have figured it out. You can have your subsidies pre-paid to your insurer.


First is, the Federal guarantees for Medicaid aren't a forever thing; eventually, states that expand Medicaid are going to have to figure out how to finance all that extra medical care themselves.

No, this isn't true. 100% of the cost of the Medicaid expansion is paid by the federal government for the first two years. Then it gradually declines to 90% in 2020 and remains at 90% from then on. The Feds will be paying almost all of the expansion forever, not the states.


Second, because Medicaid payments to doctors and service providers are so low, you, as a healthcare consumer, may have trouble finding doctors and hospitals that take Medicaid payments for services.

This is another fallacy, often promoted by anecdote. Studies have shown that 90% of all providers accept Medicare and 70% Medicaid. This is another scare tactic put out by whining doctors begging for more physician welfare.
posted by JackFlash at 4:29 PM on September 26, 2013 [22 favorites]


Studies have shown that 90% of all providers accept Medicare and 70% Medicaid.

The link you gave didn't mention Medicaid, so I poked around and found this...the numbers vary by state, but for the most part are far higher than I would've thought. I remember having a lot of trouble finding a doc while I was on Medicaid, and ending up at a teaching clinic as they would take it; but then, that was twenty years ago.
posted by mittens at 5:06 PM on September 26, 2013


Yay, the too much personal information post. After reading through this thread, I don't know if I should apologize or say thanks.

(On preview, thanks JackFlash!)

The last time I discussed this issue (here - and apologies for quoting myself) this was the insurance scenario I was looking at:

"To further depress myself, I went to the United Healthcare site mentioned upthread and pulled the following numbers based on what was asked - my zip code, my age and whether or not I smoke. There were no questions about any pre-existing conditions (of which I have several), so I shudder to think what my premiums would actually be.

[... etcetera]

[...]You might [notice] though that the $169/month policy doesn't actually cover a visit to the doctor."


I'm one of the people the ACA is going to help.

Forgive me if this is too much life-on-the-edge-of-poverty information, but it is a Real World Example: me, a 35-40 hours/week government employee at $10/hour, no benefits. According to my most recent W-2, I made roughly $16,400 last year, 143% of poverty level. As an official Full-Time Working Adult with No Kids, there are damned few safety net programs I qualify for in this state (um...none) - I make too much money.

Plugging my info into the Kaiser calculator for my state and region, I get this:

Based on a Silver plan:

Unsubsidized annual health insurance premium in 2014: $4,503

Maximum % of income you have to pay for the non-tobacco premium, if eligible for a subsidy: 3.57%

Amount you pay for the premium: $586 per year
(which equals 3.57% of your household income and covers 13% of the overall premium)

You could receive a government tax credit subsidy of up to: $3,917
(which covers 87% of the overall premium)

I qualify for the Bronze plan at 100% subsidized. Assuming those numbers are somewhat close to accurate, I could actually pay for a silver plan - it would be roughly $50 a month out of pocket. It would come out of my grocery budget, but I could pay for it and paying for it would be totally worth it.

I'm 50 years old. I haven't seen a doctor in over four years (not even at the ER!). I have previously diagnosed chronic health problems which are necessarily currently medically un-managed. I live in terror of my salaried, fully-benefited fellow-employees who come to work dripping with cold and/or flu germs because they can turn their unused sick days in at the end of the year for a bit of cash. I don't blame them, I just don't want them to stand next to me.

"Be grateful you have a job" is not a platitude in this region. There are thousands in my city and millions of Americans in my position; a still-depressed (but slowly improving) economic region with individuals and families who exist on just-above the poverty level income from their full-time employment.

There is no question that if the hourly requirement stands, my employer will cut my hours to 29 a week or less. If I have not found a "real" job by then (hell yes, I've been looking, and the finally improving economy gives me more hope than I've had for a couple of years now), I will get a second job to make up the hours - because having insurance means I can fucking go to the doctor when I get sick and that I will actually be able to participate in preventive care/management for and of my already-existing conditions.

I don't want to be any more of a worthless money-sucking drain on society than I already am as a government employee, so I apologize to those this is going to sting with higher premiums. But holy-shit-batman, prescription medication. Thank you.
posted by faineant at 6:02 PM on September 26, 2013 [9 favorites]


BlerpityBloop: "LASIK surgery plummeted in price becaus it's not covered by insurance, and the demand by people paying out of their own pockets helped regulate a normal market value. "

This is elective surgery; being able to negotiate isn't going to help you when you have a sucking chest wound or something.

JackFlash: "The second piece of the ACA is the expansion of Medicaid for poor people. In its bizarre split decision, the Supreme Court disallowed this provision, making it optional for the states. Even though the federal government pays 100% of the cost for this expansion, gradually declining to 90% by 2020, many red states are refusing to participate out of spite, even though it costs them little or nothing, just so they can say no to a piece of Obamacare."

$Deity Fornication what the $infernalLocation is wrong with these people. It's going to cost them practically nothing and it's going to reduce the costs treating the uninsured with emergency medicine. But because they don't like the guy in charge they are all "No Thanks, we'd prefer to piss all over poor people again".
posted by Mitheral at 6:09 PM on September 26, 2013 [2 favorites]


"... No, this isn't true. 100% of the cost of the Medicaid expansion is paid by the federal government for the first two years. Then it gradually declines to 90% in 2020 and remains at 90% from then on. The Feds will be paying almost all of the expansion forever, not the states. ..."
posted by JackFlash at 7:29 PM on September 26

So the states that opt in for Medicaid expansion will only have to indefinitely find new funding sources for 10% of an expanded pool of beneficiaries, many of whom are or will be (in my state, at least) low income elderly, and chronically ill persons with low income, at least under current, untested plan provisions, which Congress can change as time goes on, even before 2020. Good to know, I guess, but that additional state liability is causing my state legislators to talk of new taxes in a state which heretofore hasn't had a personal income tax, and which has had a fairly generous (by middle class standards) homestead property tax exemption for seniors for a long time.

"... This is another scare tactic put out by whining doctors begging for more physician welfare."
posted by JackFlash at 7:29 PM on September 26

In a state where more than 40% of current Medicaid service providers already don't accept new patients (which are only a fraction of all physicians and service providers, anyway), according to the link mittens posted in the comment directly below yours, due to insufficient reimbursement rates and billing/payment issues, I'd hardly characterize concerns about provider availability to an expanded Medicaid pool the way you have.
posted by paulsc at 9:21 PM on September 26, 2013


$Deity Fornication what the $infernalLocation is wrong with these people. It's going to cost them practically nothing and it's going to reduce the costs treating the uninsured with emergency medicine. But because they don't like the guy in charge they are all "No Thanks, we'd prefer to piss all over poor people again".


Yes, it's disturbing and just comes down to mean-spirited spite and is no skin off the nose of the wealthy politicians making the decision. Plus they get some cred for sticking it in the eye of Obama.

The story of Medicaid is convoluted. Medicare is quite different. Medicare is 100% funded by the Feds and 100% regulated by the Feds. They make all the rules about eligibility and benefits. It is a federally adminstered program.

Medicaid, by contrast, is a federal and state joint venture. The Feds currently put up about 60% of the money but each state administers it, decides how it will be spent, who is eligible and what level of benefits are provided. The amount of money each state contributes is up to the whims of local politicians. So throughout the country there is no consistency to the program and who is eligible for it and at what poverty level. But in all states benefits were limited to poor children and their parents, pregnant women and the disabled. No single adults without children have ever been eligible for Medicaid no matter how poor or destitute. This is why there are 20 million people who have no regular healthcare other than going to the emergency room with critical conditions.

The intent of the ACA was to standardize Medicaid in all states equally, providing free healthcare for all poor people and filling the gap between existing Medicaid and the insurance exchanges for the middle class. Everyone below 138% of the federal poverty level would be covered. The Feds provide 100% of funding for the first two years which declines to 90% in 2020 and thereafter.

Unfortunately the Supreme Court's bizarre split decision allowed the mandate to require individuals to have health insurance but disallowed the mandate to require states to expand Medicare. Apparently Justice Roberts is okay with coercion of individuals but coercion of states is a bridge too far. Sounds like some sort of states rights argument right out the 19th century.

The unexpected side effect of this split decision is that the ACA will be eliminating extra payments from Medicare and Medicaid that went to hospitals to compensate them for services they provided to the uninsured for which they were not compensated. These bonuses are being eliminated because, as planned by the insurance mandate and expanded Medicaid, there will no longer be uninsured people. Except that in the Red states that don't participate in Medicaid expansion, there will still be uninsured people and millions of dollars of uncompensated care at the hospitals. So while Federal law still requires the hospitals to serve anyone regardless of ability to pay, they will not longer be compensated for it by the Feds. The hospitals are worried about bankruptcy and perhaps they will put enough pressure on the recalcitrant politicians to change their minds about participation.
posted by JackFlash at 9:39 PM on September 26, 2013


"... Unfortunately the Supreme Court's bizarre split decision allowed the mandate to require individuals to have health insurance but disallowed the mandate to require states to expand Medicare. ..."
posted by JackFlash at 12:39 AM on September 27

I'm pretty sure you meant Medicaid there, didn't you, JackFlash? Because ACA's effects on Medicare are a whole 'nother bag o' snakes...
posted by paulsc at 9:47 PM on September 26, 2013


"... According to CBO calcualtions, the ACA reduces the federal deficit by $143 billion over 10 years. Without the ACA, the deficit would be higher. ..."
posted by JackFlash at 7:29 PM on September 26

Eh, in May 2013, CBO revised its February estimates of revenue, because of impacts of ACA, downward, by $68 billion ($58 billion in excise tax revenue from generous private insurance plans, and $10 billion from employer penalties), according to this article. And perhaps tellingly, according to that same article, CBO in those estimates, also lowered its 10 year spending estimates for both Medicaid and Medicare, in a country whose population is getting older, and whose researchers, drug companies, and health care providers are constantly coming up with new technology and treatments which said population is bound to want, once they see the TV ads. Who is kidding who here, with their estimates?

The plain fact is, nobody, but nobody, yet knows what this thing is going to cost, or whether it will be a net positive or negative for society as a whole. Personally, I'm trying hard to remain optimistic. No American with an honest heart wants the President or the Congress, or both, to fail in such a big national endeavor, purely on politics. We fail personally, in some measure, when we all don't succeed as a nation.
posted by paulsc at 10:28 PM on September 26, 2013 [1 favorite]


that additional state liability is causing my state legislators to talk of new taxes in a state which heretofore hasn't had a personal income tax

They'll probably just increase the sales tax, since income and estate taxes would require a constitutional amendment.
posted by one more dead town's last parade at 3:55 AM on September 27, 2013


And perhaps tellingly, according to that same article, CBO in those estimates, also lowered its 10 year spending estimates for both Medicaid and Medicare, in a country whose population is getting older, and whose researchers, drug companies, and health care providers are constantly coming up with new technology and treatments which said population is bound to want, once they see the TV ads. Who is kidding who here, with their estimates?

I've been reading JackFlash's and your conversation here.

Honestly, JackFlash is offering an argument, you are not. Do you have any evidence, at all, that the CBO, which is staffed by many many non-partisan, top of their field PhDs, are wildly off the mark with their estimates?
posted by MisantropicPainforest at 6:42 AM on September 27, 2013 [6 favorites]


paulsc: The plain fact is, nobody, but nobody, yet knows what this thing is going to cost

What's patently clear is that you certainly don't, as you've illustrated multiple times in this discussion by making statements about the ACA and surrounding topics that are outright false. You've thoroughly discredited yourself as a reliable source of information on the topic at hand.

I suggest you spend some time reading some of the helpful links that have been shared in this discussion, asking questions, learning and refraining from speaking with an unearned voice of authority on a topic about which you are obviously poorly informed.
posted by syzygy at 6:59 AM on September 29, 2013 [2 favorites]




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