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As Republicans put repeal-and-replace on hold, what would actually fix the Affordable Care Act?

REUTERS/Aaron Bernstein
Senate Majority Leader Mitch McConnell announced a delay in the vote on the Senate GOP’s bill to alter the Affordable Care Act after support for the bill faltered.

The news for Republicans’ plans to repeal and replace the Affordable Care Act have not been great: the past few months have seen stories detailing GOP infighting over policy, reports of bills negotiated and written behind closed doors, budget analysis projecting that these plans would leave millions and millions of people without insurance coverage.

The news got so bad, in fact, that on Tuesday, Senate Republicans delayed their health care bill from an expected floor vote this week.

Democrats, naturally, have pounced on all this: unanimously against the GOP’s designs on health care, the opposition party has described them in the harshest, starkest terms available. Rep. Keith Ellison said that some people will pay for the GOP’s bill with their lives; Sen. Elizabeth Warren tweeted that the bill’s tax cuts were “blood money” that pays for tax cuts “with American lives.”

Instead of scrapping Obamacare altogether, Democrats have long called on Republicans to work with them to improve the law. But Republicans have scoffed at that, arguing that Obamacare is broken, in an irreversible “death spiral,” and the only cure is to repeal it and start over. In recent years, insurers have fled the ACA’s marketplaces for insurance, leaving those in some states with few options to obtain coverage. Other states have seen significant increases in insurance premiums.

Though Democrats reject Republicans’ apocalyptic vocabulary — collapse, death spiral, crumbling — they acknowledge that there are significant problems with Obamacare; members of both parties say that the cost to obtain coverage is far too high, and that the economics of the insurance marketplaces aren’t working.

So, setting political realities aside, what could be done to fix the law?

The ‘death spiral’

The causes of the so-called death spiral are debated, but there’s agreement that a problematic sequence of events have happened: because insurers can’t charge sick people more for coverage under the ACA and have to provide more benefits, they have lost money in the first years of the law, as expected.

Government measures to offset insurers’ losses have been inadequate and been blocked: in 2015, Florida Sen. Marco Rubio led a group of Senate Republicans in denying funding for measures designed to offset the losses insurers were expected to sustain in the first decade of Obamacare. These were called “risk corridor payments,” meant to be made to insurance companies annually. Rubio in the GOP compared them to a slush fund or bailout for insurance companies. With insurers on the hook for a much more significant chunk of money than expected, however, costs for consumers went up.

Rising premiums drove away the healthier, younger people who reasoned paying the fine for not having insurance was less costly than paying for insurance, which increased even further the cost of insuring the remaining sicker patients.

This bad economic proposition has forced insurers to exit state markets where they were losing money. For example, this year, three insurance companies announced or suggested that they would opt out of providing coverage in Iowa, leaving over 50,000 enrollees with no insurance option next year, and all residents with no avenue to purchase individual coverage in the Obamacare marketplace. People in 49 U.S. counties have no insurance options on the individual marketplace; about a quarter of all counties have just one insurer on the market.

In Minnesota, the insurance marketplace experienced the fourth-highest increase in average premium last year; the legislature approved in January a $330 million package to support people coping with soaring health care costs.

The GOP’s plans

When it comes to the matter of actually agreeing on a fix to halt Obamacare’s “death spiral,” the two parties have found little common ground.

The plans that congressional Republicans put forth have sought to provide relief for people getting hit with serious premium increases. When lawmakers who supported the House’s bill, the American Health Care Act, defend it, they often bring up constituents suffering from skyrocketing premiums under the ACA.

The Senate’s plan extends for two years subsidies to reduce peoples’ out-of-pocket costs for insurance, but both chambers’ bills aim to operate fully on tax credits, replacing the ACA’s mix of tax credits and subsidies to help people purchase insurance. The ACA’s measures to reduce out-of-pocket costs took into account a person’s age, income, and cost of insurance in their area, while the AHCA’s tax credits only take into account age, and the Senate’s bill considers age and income. (Important to note: the Senate plan, which was withdrawn as proposed, may change in the coming days.)

Beyond that, both House and Senate bills loosen up regulations that would allow people to purchase cheaper plans, though some analysis suggests that these subsidies may fall short, while out-of-pocket costs and deductibles would simply increase as a result. Premium prices vary widely by age and location, but broadly, older Americans are projected to see higher payments than younger people.

Importantly, the Republican plans would do away with Obamacare’s individual mandate; the House replaces it with a one-year 30 percent tax on premiums if people let their coverage lapse, while the Senate would make people wait six months to obtain coverage if their coverage lapses.

Insurers are concerned that the GOP’s plans do not have strong enough incentives to spur healthy people to get and keep coverage, and that the plans do not have enough resources to keep insurers in high-risk, high-cost state markets.

But Republicans maintain that their proposals will make the markets healthier. Second District GOP Rep. Jason Lewis maintained Republicans are, in fact, fixing the ACA.

“We’re going back even further than the ACA, since there were problems in the markets that predate the ACA,” Lewis said in a statement. “But the real issue here is the death spiral in the insurance markets, which the ACA created, and the Democrats have offered no real solutions for.”

Democrats: get more people in the market

Democrats don’t dispute that people are paying more for health insurance and that the exchanges are growing increasingly unworkable. Most admit that if no changes are made, the system could fail. But they maintain that those changes should happen within the framework the ACA established, and with most planks of the law intact.

As Senate Minority Leader Chuck Schumer said this week, Democrats never argued Obamacare was perfect. But a common refrain you hear from Democrats these days — one that has endured for the past few years — is that the ACA was not intended as a complete legislative product: the law’s architects fully anticipated that Congress would move to amend and improve the law over time.

Rep. Keith Ellison told MinnPost “there’s never been a piece of legislation, not one ever, that has not needed to be reformed and improved. That goes without saying.”

Republicans were not interested: when they took control of the House of Representatives in 2011, they made clear their only goal was killing the health care law. Democrats point to the example of Rubio and the risk corridors as a sign of their intent to undermine the law’s implementation if it couldn’t be repealed outright.

Sen. Al Franken told MinnPost that effort sabotaged Obamacare. “Getting rid of the risk corridors, that drove out people like Blue Cross Blue Shield out of the main market in the exchanges. Because we have less competition, you have less choice and higher prices,” he said.

To most Democrats, changes to the insurance exchanges could make the ACA much more successful and end the death spiral. “There are a lot of things that are going right with the ACA,” Ellison said. “I don’t want to get into a negative thing… the bill is working. But we do need to work on the individual exchange market.”

Some argue that the government should take stronger action to shore up the insurance marketplaces, largely by mitigating insurers’ financial risks — keeping them happy enough to remain in the marketplace, preventing situations like Iowa’s from occurring.

Options include increasing subsidies for individuals to buy plans, or granting insurance companies additional, direct subsidies or increasing existing subsidies — potentially through re-establishing risk corridors — to deal with the costs of insuring high-risk patients. (The House’s AHCA did include $8 billion for states to fund coverage for high-risk patients, which Democrats said was inadequate.)

First District Rep. Tim Walz said he doesn’t want to place the failings of the individual marketplaces on the risk corridors, but said it’s an important part of the puzzle. “I’d like to see what that would look like if [the risk corridor] was fully functioning,” he said.

Besides pumping more money into the insurance markets for both insurers and consumers, those on the left also favor incentivizing younger, healthier people to participate in the exchanges, which would bring down costs. Some experts have suggested adjusting the penalties people pay if they don’t have coverage — the goal being to ensure that as many healthy people as possible participate in the exchanges. (Under the ACA, adults without insurance have to pay a $695 annual fine.)

Wisconsin health care executive John S. Toussaint, writing in Harvard Business Review, suggests making the penalty equal to the cost of the cheapest insurance plan on the market, and making it mandatory for people to stay in the pool for at least one year.

John Cassidy, in the New Yorker, suggests another approach: “drastically” raising the fine for not having insurance, enough so that remaining covered even with premium payments would be less expensive than opting out and paying the fine.

Those on the right are skeptical of these measures. “Both sides seem concerned that people are waiting until they’re sick to buy insurance,” said Lewis in a statement. “While Democrats prefer a federal mandate, Republicans prefer market incentives resulting from lower premiums.”

The big goal for many Democrats, particularly progressives, is the establishment of a public option — a government-operated health insurance plan that would compete with private ones. (After much debate, a public option was excluded from Obamacare when the law was being considered.)

Proponents say a public option would be modeled on Medicare, and provide those in some areas who are now without insurance options, or left with few, with a viable alternative. Cheaper costs on the public option, the argument goes, would spur insurers to lower their prices to become more competitive.

Franken said a public option would be a boost to the entire system. “A lot of us in the Democratic party want to create a public option, which gives everyone in the country the ability, especially in those countries that have very little competition, to have someplace to go.”

Room for compromise?

Few of these Democratic ideas for shoring up the Affordable Care Act have much chance of going anywhere in the current Republican-controlled Congress. But there are a few areas where Democrats and Republicans could plausibly work together to make improvements to the health care system — some of which could occur regardless of what happens to Obamacare.

One area is the rising cost of prescription drugs. According to a Johns Hopkins University estimate, Americans spent $425 billion on prescription drugs last year, a full 10 percent of all health care spending. It is now the fastest-growing share of medical costs.

But the ACA largely left pharmaceuticals alone, even as they eat up more of patients’ cash. In the Senate, both Franken and Sen. Amy Klobuchar have advanced measures to lower the cost of pharmaceuticals. Klobuchar has sponsored legislation with Arizona Sen. John McCain to allow the importation of cheaper prescription drugs from Canada, for example.

There is also broad Democratic support to allow the government’s Center for Medicare and Medicaid to negotiate prescription drug prices for all Medicare patients. (Klobuchar introduced a bill on this; it has 11 co-sponsors, including Franken, but no Republicans.)

But Democrats expressed disappointment that the GOP’s legislation as constructed contains few of their ideas on how to improve health care. The House and Senate’s bills were crafted by a small group of Republicans, and contain no Democratic input.

Those on the right say that the GOP’s bill has more in common with Democratic proposals than most might realize. In a buzzed-about op-ed for the New York Times, conservative analyst Avik Roy argues that the Senate GOP plan borrows several Democratic policy ideas, such as linking per-person Medicaid spending to medical inflation costs, which Roy says is identical to a proposal pushed by former president Bill Clinton.

But Democrats aren’t buying the notion that there’s anything for them to cheer in the GOP plan. Walz — who caught some fire from the right for criticizing Obamacare harshly last week — says “I wish they’d come up with a bill that’d work, and I’d support it… . They’re going to have to fail miserably on this and then come back.”

Democrats say they stand ready to help Republicans improve the system if or when the GOP does come back. If the Senate falls short of the 51 votes it needs to pass its bill, they might be forced to go to the table with Democrats: Majority Leader Mitch McConnell is warning his senators that this will happen if they do not pass a bill.

Franken was not surprised that McConnell moved to pull the bill, which he said was deeply unpopular. “I would take Mitch’s word there,” he said. “If they fail, I think they’ll come to the table.”

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US Health Care

Why have our government leaders failed to understand why many other countries have been able to deliver better heakthcare to more people and lesser ciost. Is it our habit to elect incompetents to office the main reason?

We have a swamp in D.C. that does not controll costs

The D.C. swamp is rewarded by increasing spending and has no interest in controlling costs. Medicare is a sad example. Look at the geographic disparities in Medicare. The cost per average Medicare recipient in the Twin Cities was $6700 while it was over $14,000 in Miami. The extremely low Medicare administrative cost does not allow for standard cost control.

Not disagreeing, but . . .

I'd say you're 100% right when it comes to the Swamp Masters, and you may mean something different than I'm thinking when you say "standard price controls," but once a person starts taking a look at what it is that makes those other industrialized country's systems work so much cheaper (and better, in terms of "health care outcomes" -- longer lives and less chronic disease), their "standard price controls" are a key factor . . .

As I understand it, the governments in those countries take a thorough look at the real costs of providing medical services and say to industry participants, "We will pay you $50 to perform a blood test and that's it. Take it or leave it."

And, wonder of wonders, plenty of (private sector) companies in Europe and other countries around the world say, "Okay," and provide a blood test for $50, or $48, or $47.95, and wind up making enough money to survive and generate enough profit to allow everyone who works with them a decent living.

https://www.washingtonpost.com/news/wonk/wp/2014/01/13/what-liberals-get...

The ironic thing is, even though a lot of people don't realize it, that's what Medicare and Medicaid are already doing here in America . . . That's why we hear all these scare stories about doctors, dentists, etc., not accepting Medicaid patients because Medicaid (and Medicare) "doesn't pay enough."

I don't mean to get down on doctors and dentists (they're paying obscenely inflated prices to THEIR "parts suppliers" too) but what "doesn't pay enough" really means is Medcaid and Medicare are already doing a quiet version of what countries like Canada, the UK, Australia, etc., are doing when it comes to "standard price controls":

"We have 70 million clients, we know the real cost of a blood test is $45 to $46, so we will not pay more than $50. Take it or leave it."

Right now, some number of medical professionals are opting to not take it because, as things stand, they can charge and get $200 or $250 for that $45 test.

In a strange way, Medicare's and Medicaid's refusal to be extorted COULD turn out to be the silver lining in this mess . . .

On the one hand we have those who bow to the Swamp Masters (Republicans especially, but Democrats too) and the result is a health care system that is SO far overpriced that, IF Republicans are able to pass their health care bill, it is almost a certainty that it will crash the health care industry (and the American economy) within three to five years (if not sooner).

The reason for that is the Swamp Masters have pushed things about as far as they can be pushed (see: "Bubbles"). They've pushed them so far that an overwhelming majority of Americans are closing-in on the point where they simply CANNOT AFFORD TO PAY the prices the Swamp Masters are demanding.

A basic, huge, potentially catastrophic miscalulation on the Swamper's part. A person would think they'd realize that. A person would think Republicans, who so proudly claim to be the people who understand "market forces," would understand that economics 101 law of supply and demand. But, I guess, "Such is the blinding power of hubris and greed."

But while that's what we have that going on (royally) on the "supply-side" side of the equation (with Republicans doing all they can to throw even MORE gas on the fire despite the fact that more than 80% of THEIR CONSTITUENTS are telling them not to do it), on the other side of the equation we have Medicare and Medicare quietly and patiently saying, "No. We will not pay $254.83 for a $45 blood test. Sorry."

So if Republicans succeed in passing their "Better Health Care" idiotacy it will most likely "hasten the fiscally catastrophic train wreck": Some market-crashing number of Americans would finally be pushed over the invisible line where they simply cannot afford to pay. Not in the abstract; not in theory; not in "political debate" terms; but in Real Life terms.

And then we would most likely see a genuine moaning and gnashing of teeth and all kinds of health care industry participants: A) short of customers; B) short of cash to pay the next installment on all those billions or trillions they've borrowed from the financial services industry and shareholders (to expand their "market share"); and C) filing for bankruptcy and heading for the hills with whatever severance packages they were able to collect before things got REALLY bad.

And, if that happened (and why wouldn't it?), there would be Medicare and Medicaid with their 70 million (soon to be 150 to 200 to, who knows, 320 million?) customers, still offering $50 for those blood tests which, all of a sudden, COULD look pretty attractive to a lot of health care providers.

And all that (or something like it) COULD turn out to be the reason Paul Udstrand (who, don't forget, called the election) is right when he says, "In many ways, this Republican fiasco might be pushing us closer to single payers than we would have gotten with Clinton," and "The only plan that can possibly bring costs under control and provide universal and state of the art health care, is a single payer Medicare for All system."

Soooooooo . . . The good news MAY turn out to be that Medicare and Medicaid are in place and ready to go, like some kind of super-FEMA "rapid response team" long-staged and training in someplace like Arkansas, tuned and ready for situations like another hurricane Katrina, should it hit anywhere on the Gulf Coast.

And, if that happened and Medicare or Medicaid suddenly turned into Medicare or Medicaid For All (by default and because of "market forces" Republicans failed to read -- again), the bonus good news would turn out to be those "standard price controls" already in-place would, all of a sudden, start saving the American taxpayers somewhere around $1.5 trillion per year which, magically, would bring the per capita cost of health care in the United States ALMOST in-line with the rest of the (global) market.

Don't you just love a happy ending?

Repubs do not care if we have affordable healthcare

Two big difference between repubs and Dems regarding healthcare:
1. Dems want to make it better
2. Repubs don't care if we have affordable healthcare

Three things to know about the repub bill:
1. It's a $700 Billion tax cut for the wealthy
2. It will remove 22 million from the insurance rolls and premiums will rapidly increase for those approaching middle age...and...if you have a preexisting condition such as a knee surgery in your 20s...well...that's a preexisting condition. I know that from personal experience.
3. 28,000 to 100,000 people yearly will die before their time (from LA Times and Chicago Tribune). Remember, in MN, half of those in our nursing homes are covered by Medicaid, not Medicare. Medicare does not cover extended stays. Not only will they die earlier because they lack care, many families will be destroyed fiscally or damaged trying to care for their parents...which only the wealthy will be able to afford.

The ACA was designed to fail

How can you fix the ACA when it was designed to fail? 60 Democratic Senators passed the ACA and made promises that were flat out lies: if you like your plan you can keep your plan, if you like your doctor you can keep your doctor, it will save your family $2500...

The Senate cannot get 60 votes with this obstruction of the Democrats.

Let the Democratic ACA implode; it is a failure that is 100% due to the Democrats.

Not exactly...

While very popular with the right, the actual facts on:

"If you like your private health insurance plan, you can keep your plan"

are a little different. At the time of the statement in 2009 it was rated "half true". Four years later it earned its' lasting infamy as "Lie of the year". We do not have to wait four years to get a conclusive decision on Trump lies: They hardly escape his lips when every rational, thinking mind can evaluate the evidence and see another blatant Trump lie. Yesterday's whopper of the day:

"The Senate healthcare plan does not cut Medicaid"

Does this mean the ACHA is based on lies?

Horror of horrors...

Any doubt that Mitch McConnell is an immoral political hack caring far more about party than country is erased when his idea of a threat is:

"pass this or I will resort to reasonable compromise"

Scrapping the ACA is stupid, but fixing it is impossible.

If we mean by "fixing" Obamacare, that we're going to bring down costs or even contain costs, and provide universal coverage, it simply can't be done. Obamacare is a neoliberal non-solution derived from the false premise that a health care "market" is better than a health care system. At the very least neoliberalism assumes that health care markets, i.e. private insurance, for profit providers, deregulated equipment and medication suppliers and manufactures etc, will, under the umbrella of some kind of competition, yield an affordable and universal health care system. This hasn't happened anywhere else in the world, there's no reason beyond delusions of American exceptionalism to expect that it will work in the US.

Sure, Obamacare addressed some long standing outrages that should have been settled in the 1970s, like coverage limits, and denial for pre-existing conditions etc. But this was low hanging fruit that almost every other country on the planet dealt with decades ago. In that respect it is simply to our shame that such practices were allowed in this country as recently as 2010. These aspects of the ACA are really nothing to brag about.

Democratic offers to work with Republicans on this are actually alarming because it may signal a common delusion among both parties that health care markets rather than a functioning health care system are a rational objective. Neither the economics of health care, nor the basic nature of medicine and actually providing health care, can be satisfactorily addressed with convoluted neoliberal market schemes.

The only plan can possibly bring costs under control and provide universal and state of the art of the health care, is a single payer Medicare for All system. This is what Democrats should be preparing to offer the American people (the majority of whom want it by the way), not tweaks to Obamacare.

I can see in a way why the Democrats make these offers from a political perspective, but it's bad policy and poor politics. The Democrats should just stay out of it and let the Republicans stew in their own incompetence, there's no good reason to throw Republicans any kind of lifeline on this because any compromise that might be reached would be a betrayal for the American people that would prolong suffering and get people killed.

Here's are some excellent suggestions from Jeffrey Sachs

A national healthcare plan in the USA is absolutely doable, once political partisanship and drama and obstructionism are removed:

Jeffrey Sachs: America can save $1 trillion and get better health care

http://www.cnn.com/2017/06/27/opinions/fixing-americas-health-care-sachs...

~

Thanks

for sharing that article, he really gets at the core issue. Our health care system (not health insurers) have bought and paid for both political parties, thus they get a pass. They are where the problem lies and the biggest obstacle to a single payer system. They have too much wealth to lose. They would never tolerate a Medicare fee schedule for every patient. They want to keep us blind to their costs until the bill comes in the mail.

In a nutshell…

“…This bad economic proposition has forced insurers to exit state markets where they were losing money.” In a nutshell, this is the most egregious, basic flaw in the American health care system.

It’s about profit, not health or health care.

Whether Republican or Democrat, the major parties’ proposals to “fix” the ACA are essentially nibbling around the edges of a far larger issue, one that Republicans, especially, are loath to acknowledge. That issue is that, in health care, there is no such thing as a “market” in the sense that economists (and Republicans, most of whom are far removed from economic literacy) use the term. That’s also true for those of us (i.e., virtually all) who will, at some point, be health care consumers, not just observers. The bedrock of any true market is, supposedly, supply and demand, with a strong nod given to informed purchasing decisions. Consumers have no influence whatsoever over any of those “bedrock” aspects of a health care market that’s essentially mythical.

Sure, cigarette smokers have higher risks of serious illness, as do people who drink alcohol or use other psychotropic substances, but so do those who drive or ride in an automobile, or whose genetic makeup (over which they have zero control) inclines them toward a lengthy list of diseases, some of them chronic, some of them fatal. “Living a clean life” may slightly increase your odds of living a long and/or active life, but it’s not at all a guarantee.

Like every other kind of insurance, health insurance, whether public or private, national or local, provides a means by which insurance companies, sometimes formed specifically for that purpose, can make money. Health insurance, as it works in this country, has little or nothing to do with actual health, and everything to do with an insurance company’s profitability.

In our current version of a capitalist society, companies have no social, moral or ethical obligation to the people who send them money every month except what is provided by the law and regulations which most companies (and most Republicans) work very hard to eliminate. Their obligation is to shareholders, and when costs (meaning actual health care) cut into the profits that those shareholders expect, neither company executives nor shareholders are happy. The company often then leaves the market (i.e., rural Minnesota) where its operations are unprofitable.

If it’s the only health insurance provider in the area, you’re out of luck. The choices are: through some form of magic, stay perfectly healthy for an indefinite period that might last decades; or suffer a serious injury or illness and die. A third, sad, relatively common choice is to try to pay all your medical expenses out of your own pocket. Billionaires can afford to do this. The other 99% will go bankrupt. An ordinary, uncomplicated vaginal childbirth in a hospital can cost anywhere from $10,000 to $20,000. Think about that. Even if we ignore the staggering cost of what is, after all, a normal human function, the price for a fairly routine medical service can •double*, depending upon which hospital you use—and the prices are never, ever listed. Treatment of multiple injuries from a serious auto crash can easily run into six figures. I can’t afford that, and most of the people reading this can’t afford it, either, but there are many thousands of automobile crashes every year, with thousands of associated injuries.

How many people, mangled in a car crash, have the inclination or time to shop around for the best combination of cost and medical services while they’re in the ambulance on their way to a medical facility they may never have used previously, or even heard of? It’s the antithesis of a “market” in any real sense.

It won’t be adopted in my lifetime, or perhaps ever, but I’ll continue to favor government-run, non-profit, single-payer health care and health insurance, covering every citizen, paid for at progressive rates by taxes on all incomes, with health care providers whose educations were provided at little or no cost by the government, and who are, practically if not literally, rather well-paid government employees. I’d rather see that system adopted nation-wide, but if Minnesota wants to get ahead of the curve and adopt a state-wide system that operates in essentially the same fashion, I’m for it.

You might be surprised..

In many ways, this Republican fiasco might be pushing us closer to single payers than we would have gotten with Clinton.

Exactly

"It’s about profit, not health or health care."
Capitalism has made healthcare and prescriptions unaffordable.
You're exactly correct that these are about profit

Not a fan . . . but . . .

Both parties and all individuals think there is one single answer. In my opinion there isn't. Even counties with single payer programs have inequities. The rich can get supplemental insurance in many programs, while the poor still wait in line. The only way for the poor to get equal healthcare is for those with the means (and I don't just mean the rich) to pay for it. I am not saying I don't believe in the single payer approach, it's just it will not solve all of the problems we are facing no matter which party is in control. Once we accept this fact and all stop arguing about it maybe we can start chipping away at developing the best program possible.

Here's the thing...

No one with the except of the super wealthy pays for their own health care, NO ONE has the means to do that. If you have health insurance of any kind be it private or Medicaid, you're only paying for a fraction of your health care. The "poor" are no different in this regard than anyone else.

The issue isn't actually who "pays" for health care, there's only one possible source of funding in any modern economy. The issue is who has "access" to health care, and what kind of health care we have "access" to. In the US, even with Obamacare, 28 million have no access or insurance, and 50% of the people who do have insurance still face unaffordable deductibles and onerous premiums. The actual cost of health care in the US is 2-3 times higher than our peers in the developed world, and the over-all quality of that health care is worse.

No system is perfect, all systems will have problems, but Medicare for All would be a vast improvement that would eliminate the biggest problems we currently face in the most simple and economic way. Any remaining problems we'd face with single payer would be much more manageable than those we have without it.

So long as the Republicans, who are currently in power, continue to believe that Obamacare IS the only problem with have with health care in America, we have to fight them. They're on the verge of unleashing real suffering, harm, and death upon hundreds of thousands of our fellow Americans and we have a civic and moral responsibility to oppose that and fight for a better system. Solutions don't emerge or manifest themselves unless someone is working the problem, whether we're arguing about it or not.

The American people have to

The American people have to speak up about what they want, and that seems to be: universal access to quality affordable health care. Not just insurance. Health care. For everybody.

We can't let Congressional Republicans be blind to the fact that most people who know what Obamacare does, like it fine! So fix the holes in the ACA. That can be done, and all that will happen is that a bunch of temporarily healthy people will complain about having to pay insurance premiums (everybody will need health care eventually), but they'll have decent health care coverage when they need it.

After all these years of Republicans attacking anything Obama, and ignorantly screaming against the Affordable Care Act that actually tries to address a health care crisis in our country, wouldn't it be wonderful to have open hearings on how to improve Obamacare and help our fellow citizens get care when they need it? To do something constructive!

I ask you: Wouldn't it be fun to try to solve a real problem for once?

Warren Buffett speaks about his own taxes

...and the GOP healthcare law.

Warren Buffett was interviewed on NewsHour by Judy Woodruff.

He brought along his 2016 tax return and showed the amount he would save if the GOP Healthcare law was passed. He would save $600,000 just in 2016. A 17% tax cut. SEVENTEEN PERCENT TAX CUT.

He also pointed out that he paid 20% of his net income for income taxes, while his housekeeper, a 1099 worker, paid 15% just for SS and Medicare withholding, not counting her income tax.

The law is an attempt to pay back the ones who gave them their campaign money, their organization and their jobs.

http://www.pbs.org/newshour/bb/america-stand-just-wealth-says-warren-buf...

btw Warren Buffett observes that the estate tax (affecting a mere 5,000 Americans a year) would yield 3 Trillion dollars a year- about the amount free-for-all healthcare would cost.

Indeed

Yes, I saw that interview. Logically, we shouldn't be surprised that Republicans are repaying the (very) wealthy people who “…gave them their campaign money, their organization and their jobs."

That doesn't mean what they're proposing is good national policy, just that it shouldn't surprise us that sycophants would want to preserve the incomes of their patrons. Unfortunately, Democrats are not immune to this sort of thing, though (hopefully) on a smaller scale, and doing much less harm to the society.

The estate tax business ought to be broadcast from every TV station every night, with pointed references to the Minnesota GOP's efforts to roll it back in this state, as well. Pandering to the wealthy is usually ugly and demeaning, and the estate tax is no exception.

Fixing Obamacare

We could add more layers of complexity on the fringes but the idea that we can have some kind of bipartisan progress is kind of delusional.

The neoliberal platform that Obamacare is built on has pretty much been pushed to its limits. The biggest problems Obamacare has failed to address are universal coverage, uniform quality of care, and cost. There are no "small" or "easy" bipartisan tweaks that can applied to Obamacare that will resolve these issues.

The only way to address the remaining problems in any significant way within the context of Obamacare would be to build in a public option and make every State participate. We'd also have to implement pharmaceutical price controls and restore AND increase government research funding across the board. Anything short of these measure is just moving the deck chairs around. Republicans will NEVER agree to any of these expansions of Obamacare.

Politically, no matter which party fails to fix this, or if they both fail to fix it together, American's aren't going to be fooled into thinking it's been fixed. Obamacare didn't fool them, and tweaking Obamacare won't fool them. The majority of American's aren't satisfied with Obamacare, and they want a single payer system. The dissatisfaction the Republicans tapped into is REAL. Their "solution" is delusional but the notion that American's are "happy" with Obamacare is one of the factors that cost the Democrats the election.

No Big Ideas in GOP Health Insurance Fix

No “big ideas” to fix the individual and small group health insurance market? So far it has been just GOP patches on four ACA flat tires amid Democrat demands to keep the ACA “as is”. These insurance markets have long suffered from habitual market failure.

One lone GOP House Member had the beginnings of a “big idea” but it was significantly diluted when adopted in the House Rules Committee. Congressman Palmer’s (R-Alabama) intelligent and courageous March 23, 2017, proposal entitled a “Federal Invisible High Risk Pool” would have significantly reduced health insurance premiums for this market and would have reduced the need for any insurer “anti-selection” mechanisms without a forced march back to the ACA mandate. Affordable health insurance works better than forced purchase.

In her rigorous 2006 examination of why more middle-class people are uninsured entitled Reinsuring Health; economist Katherine Swartz outlined a government reinsurance plan for the individual and small group markets. While the large employer group market is operating fairly efficiently she observes that employment is shifting to small firms and self-employed independent contractors who rely on the individual market for health insurance.

It’s “claims” that really drive up the premium increases. Regulations and benefit mandates are contributors. It is estimated that 5% of those insured account for 50% of the claims costs. Reinsurance would take a portion of those high claims out of the insured pool and separately pay for them, leaving less expense to be shared by the remaining 95% of insureds. Health costs for hospital and physician care that account for 85% of each dollar of rising insurance premiums run unabated, however, under both the ACA and the GOP proposals.

A federal reinsurance program for the individual and small group market would bring affordability back to this insurance market. Voters relying on this market would forever remember who it was that made health insurance an attractive financial protection without the punishment of a mandate or IRS penalty. This is an opportunity reminiscent of “only Nixon could go to China”.

You just end up chasing you're tail.

High risk pools aren't cheap, and they don't control costs. What happens is insurance companies just start classifying people they don't want to cover as "high risk" so they can shove them out and retain low risk (i.e. more profitable) patients. The ranks of "high risk" swell and the cost of treating them (i.e. "claims") balloons creating a crises market.

High risk pools are neither a big or new idea, we've had them before and they didn't work. The Republican idea is to subsidize them but that's not going contain cost, Republicans will contain cost by capping the subsidy, which brings us back to where started. Sure, some Republican's have promised to put more money into the subsidy in the future, but Republican's don't put more money into social programs, it's just not what they do. Why would a bunch of guy who want to cut Medicare because it's too expensive turn around and dump more money into high risk pool subsidies? It's not going to happen. And even if subsidies were sufficient, it's not a good idea because all it really does is create a mechanism for insurance companies to shed less profitable patients, that doesn't contain costs in the long run although it might boost revenue for investors for a short while.

In other words....

Socializing the losses and privatizing the profits. Where have we heard THAT before?

any

evidence, facts, documentation to back up your first paragraph?

Yes

Information about the history and nature of high risk insurance pools is easily obtainable, you can find it if you look.

Affordable health insurance

As things stand (and have stood for a long time) there is no such thing as "affordable health insurance" for an increasing number of people.

And, no offense, but the idea that, "It's 'claims' that really drive up the premium increases," isn't accurate . . . What drives up the already off the charts cost of insurance is the PRICES of the products and services insurance pays for (pharmaceuticals, "medical devices," $4.00 aspirins and everything else on the anti-competitive and invisible "ChargeMaster" list).

I'm not defending the insurance industry (they're culpable as can be), but as long as the focus -- as long as the spotlighted center ring issue -- is locked on the price of insurance (the smoke screen) nothing will change, or they'll just get worse, at the rate of somewhere around 5% to 6% per year.

Insurance prices are just a reflection of the cost of the things it's paying for and THAT's where the focus needs to be.

And I'd say you're right when you say, "Health costs for hospital and physician care that account for 85% of each dollar of rising insurance premiums run unabated, however, under both the ACA and the GOP proposals."

The question is, what is it that's pushing those costs up? It's not insurance and it's not (really) hospitals, physicians, front-line health care providers. It's the "product and service" providers BEHIND those entitities.

For example, if you look it up you'll see the cost of a pacemaker procedure runs somewhere between $19,000 and $110,000 or so (depending on geographic location, of all things) and roughly half of that is the cost of the pacemaker mechanism (the overall cost of the procedure is right around $45,000 in MN, by the way).

If you do a quick search on the RasberryPi computer, you'll see that those people have developed what amounts to the core of a PC system and are selling it for -- get this -- $35.

That $35 computer has more power than the computers that ran the mechanisms that put a man on the moon (almost 50 years ago).

The heart of that computer (which is smaller than a fingernail) has 100 or 1,000 times more than enough power to do whatever a pacemaker does, in terms of "firmware-driven monitoring and impulse electronic control" (which hasn't been rocket science for a long long time).

Yet a pacemaker (minus physician and hospital or clinic fees) costs $9,000, all the way up to $50,000 or $60,000.

Ask yourself "Why?" and investigate it a little.

And then take a look at and think about how much an MRI machine costs (a hospital or clinic) and ask yourself if you think somebody like Elan Musk (and his SpaceX company) could MAYBE figure out a way to build a less expensive model of comparable or superior quality and why that kind of thing isn't happening.

Neither the ACA, the AHCA, or whatever the Senate bill is called, or reinsurance is "the sollution."

As far as that goes, anytime you read or hear anyone saying, "What we need to do to get the cost of insurance under control," you can bet they're barking up the wrong tree if the discussion doesn't include the lowering the obscenely inflated prices being charged by those supplying the products and services the health care industry runs on (and insurance is paying for).

Its' weird isn't it?

"Claims" drive up the cost of health care? It's so bizarre when someone shows up the "latest" research that reveals that... the cost of health care... is responsible for the cost of health care; as if that's some kind brilliant discovery? Yeah, we can only imagine how cheap health care would be if nobody needed it. I could have saved thousands if I never went to the Dr. Of course I'd be dead by now, but think of the money I'da saved if I never made a "claim"!

I don't think you understand the cost drivers

The electronics technology is not as simple as you make it out to be. The secret to designing a pacemaker is to make sure it uses as only as much power as necessary so it lasts up to 10 years. Your mobile phone uses similar underlying electronics technology but I doubt you get 10 years on a charge.

You can see from the linked estimates of power consumption that a Raspberry Pi drains a battery pretty quickly.

https://raspberrypi.stackexchange.com/questions/56455/raspberry-pi-zero-...

I don't think you want your pacemaker to last just 20 hours before you need a new one.

However, I don't think the underlying technology is the real cost driver. The technology costs for medical electronics keep gradually dropping just like technology costs for other electronics. The price paid for pacemakers is also going down year on year. That is not the reason why medical costs are going up at greater than inflation every year. Look for the costs that are increasing to explain that phenomenon, not the costs that are decreasing.

There are three models for universal health care and

real world examples.

If you are going to absolutely insist on having private insurance, Germany's system would be the one to emulate. Their system is all private, BUT the companies are on a choke chain. They have to be non-profit (REALLY non-profit) with limits on executive compensation and requirements for prompt payment, with the burden on the company to prove fraud. Since all companies are required to provide the same benefits and charge the same premiums, they compete by offering extra goodies.

Britain and a few other countries follow the national health service model. The government owns and operates the medical facilities, and the medical providers are government employees. There is also a parallel private system for affluent people who want to jump the queue. When I was in England about ten years ago, the people I talked to were very satisfied with their health care, including a woman whose G.P. suspected cancer and got her an appointment with an oncologist in two days. She had surgery two weeks later with follow-up chemo. Lately, the Conservative government has been trying to destroy the NHS by underfunding it and freezing pay for the employees, so that it can claim that the NHS has "failed."

The most common model is the single-payer model. The providers are mostly in private practice, but instead of dealing with dozens of insurance companies (and thus needing a staff or a contract with an outside company to file claims), they deal with one payer, which sets the prices for everything. Doctors make less money than they do here, but U.S. doctors are the international outliers when it comes to annual incomes.

In Japan, the foreign country I am most familiar with, many people receive health insurance through their jobs, but there is a parallel public option that offers exactly the same benefits and is used mostly by the self-employed and students. It has no deductibles, although the co-pays are high. Still, if the co-pays exceed a certain figure, they are refunded, and certain chronic and catastrophic conditions are covered in full.

None of these are "free health care," because residents of the country pay for them, either through their taxes or through income-based premiums.

Most of these countries don't know what a deductible is, nor do their citizens experience medical bankruptcy. Must be nice!

Of these options MFA is the most workable for the US

We're not going to rebuild the private insurance industry from the ground up, and we simply don't do "regulation" well enough to make the German model work here.

The Japanese model only works because they've contained costs, they implemented their system before costs got out of control, we missed that opportunity and trying cram costs down so private and public insurance plans could be comparable just isn't an option.

Likewise, government ownership of all provider services at this point would be sheer folly and politically unfeasible. The government could neither legally take over existing health care providers, nor build a parallel system of it's own.

The most reasonable and workable solution is simply expanding Medicare and Medicaid to cover everyone. We don't have to build a new system because these systems already exist. We don't have to find a new financing mechanism because that already exists as well. And having a single payer would substantially reduce administrative costs for everyone, and eventually bring down actual costs, which would in turn reduce cost of the program itself. We could roll this out in one year, any other scheme will take at least a decade, and likely fail anyways.

Another advantage to MFA is it would put an effective quality of care system in place. A single universal payer can far more easily drill down into best care practices simply because of the leverage. You can create universal evidence based best care practice guidelines (like having a pre-op checklist or sufficient nursing staff) and make those practices requirements for reimbursement.

The only people who don't like MFA are the providers, who know that ability to hike prices would actually be checked, suppliers who likewise know that their ability to set prices would be subject to control, and private insurers, or rather private investors in private insurance who would see their ROI's pretty much collapse. Note however that the negative effects in these sectors are actually positive effects for the nation, the American, people, and the economy in general.

Trillions of dollars that are currently tied up in a small segment of the economy would be available elsewhere and would likely spur over-all economic growth. From individuals who would be free to explore new jobs or business opportunities without fear of losing health care, to trillions of dollars that companies large and small currently spend on providing, or trying not to provide insurance, this is all capital that would flow into the general economy rather than get trapped in an encapsulated health care industry. Trillions of dollars currently dedicated to moving paper around would actually become productive capital.

I agree with that analysis

and the advantage of MFA is that the insurance companies could still get their fingers into selling supplements.

At the time the ACA was implemented, I was in that awful age range in which even the ACA allows insurance companies to price-gouge (three times the normal premiums).

If Obama had said, "We are going to lower the age of eligibility for Medicare five years every year till everyone is covered," that would have been immensely popular. Millions of 60-64-year-olds would have been freed from burdensome insurance premiums, and since they tend to be healthier than the older crowd, having them pay the same premiums as the 65+ group would have helped stabilize Medicare's finances. Every year, a new group of younger, healthier people would have been added, adding further premium payments but using the system less than the older people.

The insurance companies don't want to cover anyone over the age of 50 anyway. In fact, Medicare began because the insurance companies did not want to cover people over 65 at all or at least not at any price that the non-wealthy could afford.

The Republicans' suggestion of raising the age for Medicare is precisely the kind of counterproductive violation of basic arithmetic that they are notorious for.

This morning's tweet

" If Republican Senators are unable to pass what they are working on now, they should immediately REPEAL, and then REPLACE at a later date!' Trump wrote on Twitter Friday morning."

www.politico.com/story/2017/06/30/trump-obamacare-repeal-replace-tweet-2...

Apparently, the far right health care geniuses in Congress are excited.

Repeal and don't replace.

I would like someone to explain exactly how a country with over 330 million residents is going to come up with a health plan to cover everyone, or even to cover those that don't have group insurance. We tend to look at other countries and compare, but most countries that have universal health have a much smaller population. Example: Norway has a population just a little more than 5 million citizens, they have a wonderful universal health plan that insures every citizen in the country. But that is just about a million more than the region known as the Minneapolis–St. Paul MN-WI Combined Statistical Area, which is nearly 4 million people. Coming up with a health plan for 5 million people is like writing a group plan for the top ten Fortune 500 companies and it pales in comparison to 38 million that congress is trying to write a health plan for and involve dozens of insurance companies. The ACA is failing with only 11.5 enrolled as of June 2017. I think we should let it fail or repeal it and let the insurance companies handle it. Maybe pass a law that requires insurance ocmpanies to insure pre-existing conditions with out a higher premium, it is done with group insurance, why not individual?

Japan does it with 127 million people,

and they have a much larger population of seniors than we do.