Obamacare...(new title): GOP DEATH PLAN: Don-Ryan's Express

[Tulane Skins Fan]

 

 

#SlamDunk

 

So, there was no answer to how, except medical malpractice reform.  Of course, states that have medical malpractice reform, and about 40+ do, have seen their health insurance premiums rise at exponential rates.  

 

There's no evidence that med mal reform would lower any costs or provide access to healthcare for anyone.  The evidence is just the opposite.  Plus, "why have Washington bureaucrats making decisions for the states as to what med mal reform is best for each state?"

[Wrong Direction]

So, there was no answer to how, except medical malpractice reform.  Of course, states that have medical malpractice reform, and about 40+ do, have seen their health insurance premiums rise at exponential rates.  

 

There's no evidence that med mal reform would lower any costs or provide access to healthcare for anyone.  The evidence is just the opposite.  Plus, "why have Washington bureaucrats making decisions for the states as to what med mal reform is best for each state?"

 

If medical malpractice reform were the basis of the right's arguments, it would be more prominent. It's a minor talking point at this point, meant to make docs happy. 

[@DCGoldPants]

it's also awesome when bureaucrats complain about bureaucrats without any sense of irony.

[Larry]

If medical malpractice reform were the basis of the right's arguments, it would be more prominent. It's a minor talking point at this point, meant to make docs happy.

Uh, maybe behind closed doors.

But tell ya what.

You find me cases of Republican politicians making health care proposals OTHER THAN "eliminate state insurance regulations, and make the health care industry immune from punishment for their actions".

And I'll find you a case where it's the ENTIRE proposal.

And well count up the instances, and then we'll decide whether it's "a minor talking point", or their ENTIRE proposal.

[Wrong Direction]

Uh, maybe behind closed doors.

But tell ya what.

You find me cases of Republican politicians making health care proposals OTHER THAN "eliminate state insurance regulations, and make the health care industry immune from punishment for their actions".

And I'll find you a case where it's the ENTIRE proposal.

And well count up the instances, and then we'll decide whether it's "a minor talking point", or their ENTIRE proposal.

 

http://www.hatch.senate.gov/public/index.cfm/releases?ID=e2ba7198-3031-4a62-992c-42caec55f00e

[Larry]

http://www.hatch.senate.gov/public/index.cfm/releases?ID=e2ba7198-3031-4a62-992c-42caec55f00e

Thanks. That's actually a really extensive proposal. Gonna take a while to go through it.

Things I notice that jump out at me:

Gee, it includes "medical malpractice reform".

Oh, and it restores the tax break for "Cadillac" health care coverage. (Which it refers to as a "distortion in the tax code that drives up health care costs".)

OTOH, there are some things in there that, while it doesn;t actually provide specifics, sure sound like good ideas, to me. (Although I think they're good ideas which Obamacare already implemented).

Specifically, I'm looking at "Increase health care price transparency to empower consumers and patients".

I flash back to when I was advising costumers as to whether they should purchase the extended warranty on the computer they're planning on buying at Best Buy. And my standard speech was that one of the problems with insurance, is that it's something you pay for, up front. And you really don;t find out what you've bought, until you need it. And, when you need it, then as far as the insurance company is concerned, you're not a customer any more, you're somebody who's trying to get some of the company's money.)

I absolutely love the idea of trying to make it easier for consumers to comparison shop.

That's why I at least hoped that one of the big cost-saving parts of Obamacare was the notion of creating an exchange where everybody is offering what is supposed to be essentially the same thing, and letting the consumer comparison shop.

(I also recognized that that was, potentially, the most dangerous part of the law: Because it essentially guarantees that all competition will be on the basis of price only. It actually discourages somebody from offering, say, a plan which costs a bit more, but their customer satisfaction is much better. All the consubers are going to see is a web page, sorted by price.)

[Tulane Skins Fan]

If medical malpractice reform were the basis of the right's arguments, it would be more prominent. It's a minor talking point at this point, meant to make docs happy. 

 

That's just the only thing he said that had any concrete value.  And it doesn't decrease costs or improve access to healthcare.

[Wrong Direction]

Medical malpractice reform will be part of a bill, I suspect. That's an old TP that won't be abandoned. It's not a major consideration though, and if it meant passing versus not passing the right bill, they'd drop it in a second. 

 

I'm really curious about the idea of a tax credit to everyone, versus the differential tax treatment everyone gets now. In the short run, it gives R's cover because their bill would allow everyone who might lose coverage at the SC this year to buy coverage in the absence of a federal subsidy. However, in concept, it gives much more freedom over the long run for the very poor to choose coverage. That's important to me because ultimately I'd like a healthcare system that just has health plans people choose, versus employer, Medicaid, VA, TriCare, FEHB, etc. Neither the R's nor D's would go that far, but removing the differentials in the tax code is a major first step toward a less distorted healthcare system.

[Larry]

Oh, I'm a huge believer in replacing lots of things that are currently tax deductions, with tax credits. REFUNDABLE tax credits.

Because tax deductions represent a subsidy in which righ people get a bigger subsidy.

Which is also precisely why no Republican will ever allow it.

"Skin in the game".

[Larry]

Oh, and I think that the best health care plan, BY FAR, would be a universal "Medicare for everybody" system, that paid for BASIC health care. And then let private insurers compete by offering "Medicare supplement" policies.

Among other things, I believe that even a bloated federal government system has got to be more efficient than the "every insurance company has a different billing system" that we have now.

----------

The problem I see with my Ideal Solution is that, once you create such a system, Congress will be under enormous pressure to make said BASIC coverage, cover everything.

Every voter, every provider, every insurance company will want every medical thing to be covered.

And there won't be any lobbyists at all, trying to pull the system in the direction of not covering something.

No way Congress says no to all those lobbyists, pulling in the same direction.

[twa]

control freak 

 

ya need to be paying taxes to have skin in the game.

 

clarity in how much we pay in taxes and for what would increase the pressure to eliminate many

[Wrong Direction]

Oh, and I think that the best health care plan, BY FAR, would be a universal "Medicare for everybody" system, that paid for BASIC health care. And then let private insurers compete by offering "Medicare supplement" policies.

Among other things, I believe that even a bloated federal government system has got to be more efficient than the "every insurance company has a different billing system" that we have now.

 

Medicare is about as bad as it gets in terms of efficiency. There are public reports of double paying hundreds of millions per year just for drugs and just during hospice care. The politics are too messy to fix seemingly anything. It's everything that's wrong with single payer. 

 

In any case, some R's did formally present an ObamaCare alternative in the Senate yesterday. It's the same guys as the plan I posted above, but updated. Here's an article on it. Much more at the link.

 

http://www.forbes.com/sites/theapothecary/2015/02/05/the-impressive-new-obamacare-replace-plan-from-republicans-burr-hatch-and-upton/

 

The Impressive New Obamacare Replace Plan From Republicans Burr, Hatch, And Upton

 

The plan would replace Obamacare with a means-tested tax credit that individuals could use to buy a far broader range of insurance products, or deposit the funds in a health savings account.

 

 

The tax credits would also be available to those who today are on Medicaid, freeing them to purchase private health coverage with superior health outcomes. A critical feature of the Patient CARE Act is that these tax credits are means-tested. This is something that makes Burr-Hatch-Upton different from most Republican plans to replace Obamacare; more on this in a bit.

Under Patient CARE, people with income below 200 percent of the Federal Poverty Level would get a relatively larger subsidy vs. those above that level. Those with incomes between 200 and 300 percent of FPL would get a lesser subsidy on a sliding scale; those with incomes above 300 percent of FPL would be ineligible for subsidies. (In 2015, the Federal Poverty Level for a childless adult is $11,770; hence 200 percent of FPL is $23,540, and 300 percent is $35,310. For a family of four, FPL is about twice that of a childless adult: $24,250.) By comparison, under Obamacare, people with incomes under 400 percent of FPL are eligible for subsidies on a sliding scale.

 

The plan would also repeal Obamacare’s individual mandate, but still guarantee that all Americans could obtain health coverage irrespective of pre-existing conditions. After a one-time transition period, individuals would need to maintain continuous health coverage to preserve that guarantee.

 

 

 

 

As an aside, Ron Wyden really got smacked down for trying to be bi-partisan a couple of years ago. It's a damn shame. He was one of the good ones, but like the rest he wants to keep his job.

[PeterMP]

Medicare is about as bad as it gets in terms of efficiency. There are public reports of double paying hundreds of millions per year just for drugs and just during hospice care. The politics are too messy to fix seemingly anything. It's everything that's wrong with single payer. 

 

In any case, some R's did formally present an ObamaCare alternative in the Senate yesterday. It's the same guys as the plan I posted above, but updated. Here's an article on it. Much more at the link.

 

http://www.forbes.com/sites/theapothecary/2015/02/05/the-impressive-new-obamacare-replace-plan-from-republicans-burr-hatch-and-upton/

 

As an aside, Ron Wyden really got smacked down for trying to be bi-partisan a couple of years ago. It's a damn shame. He was one of the good ones, but like the rest he wants to keep his job.

 

While not doubting that Medicare has its problems, I don't think anybody that has looked at the issue really doubts that Medicare is more efficient.

 

Now, there are reasons for that, and they aren't all good, but the ability to no have to worry about advertising and profit is a huge advantage, and you see it when you compare Medicare to the total US private market.

 

But also the US market to the Canadian single payer system.

 

http://voices.washingtonpost.com/ezra-klein/2009/07/administrative_costs_in_health.html

 

From only a cost efficiency/overhead issue, there really is no doubt about what the best solution is, and I don't think it is a doubt even taking into account fraud.

Edited February 7, 2015 by PeterMP

[Larry]

In any case, some R's did formally present an ObamaCare alternative in the Senate yesterday. It's the same guys as the plan I posted above, but updated. Here's an article on it. Much more at the link.

 

http://www.forbes.com/sites/theapothecary/2015/02/05/the-impressive-new-obamacare-replace-plan-from-republicans-burr-hatch-and-upton/

Reading the article about this proposal.

There's things I like about the thing. (I think the tax credit should be simpler and cleaner than the current Obamacare subsidy model. And better than tax deductions.)

But I'm seeing some claims that really look, to me, like some really funny math.

This plan is supposedly going to have out subsidies (well, tax credits) to whole bunches of people. (For example, it would supposedly be sending me $4,000+, a year.) And to people making up to 300% of the poverty level. (That's what, 25% of the population?)

 

(Now, one of my big questions:  I am noting that I do not see anything in here that says these are refundable tax credits.  Is this one of those tax credits where "we'll give Larry a tax credit of $4,000 a year, but only if he makes enough money so that he pays more than $4,000 in income tax"?  To pay that much tax, I'd have to be making $50K a year.  And if I were making that much, I'd be making too much to qualify for the credit.) 

 

(But then, I get the impression that the GOP considers refundable tax credits to be socialism or some such.) 

 

but then they get to how they're supposedly going to pay for it. 

 

The tax credits would be funded in a deficit-neutral fashion by reforming the tax exclusion for employer-sponsored insurance: the original sin of American health care. By repealing Obamacare, the plan would repeal Obamacare’s $1.2 trillion in tax hikes.

 

 

Later on in the article, it explains that this "reform" they're talking about, is that they're going to start charging you income and payroll taxes, on the amount of money that your employer pays for your health insurance.  But, only of that amount is more than a threshold that is even higher than Obamacare's threshold for "Caddilac" status.

 

Specifically, they're going to treat employer-paid insurance as income, if the amount is more than $12K for individuals, and $30K per families.  (And, one of the "gotchas":  This cap only grows at the inflation rate.  Over time, your insurance has to get less, or the amount of it that gets taxed will go up.) 

 

And they're supposedly going to raise enough money, with this "reform" (have to call it a "reform", you know.  Not a "tax increase".) to cover all of the tax credits in the proposal, and cover the revenues lost by repealing $1B worth of Obamacare taxes? 

 

(And the odds of the Republicans actually passing a proposal that will raise taxes on people who have employer-funded insurance that's over these thresholds, is . . . . ?) 

[PeterMP]

I didn't read the plan just the Forbes story, but are there subsidies and tax credits?

 

I thought they were two different things based on the story.

 

How much is somebody 200% below FPL paying in taxes that they are actually going to be able to afford insurance based on a tax credit?

 

Larry, I think they are going to long term gut Medicair unless the rate at which health care costs go up change dramatically.

 

The block-grants say something like, we'll give peg health care costs increases at some increase over time and simply give that money to the state.

 

The problem is if healthcare costs go up faster than what people want them to pegged to (which is what has happened over the last 30 years or so), then what you are really doing is cutting Medicare.

 

If you separate the insurance part of this plan from the Medicare reform part (which long term essentially results in a cut in Medicare), then I doubt they save money. 

 

**EDIT**

 

From the plan:

"This capped allotment would grow over time at CPI+1 and reflect demographic and population changes."

 

The problem is that health care costs (not insurance costs) have gone up more than CPI+1 over the last 30 years essentially every year.

 

And while that's slowed some now, I don't think anybody wants to bet that it is going to stay slow.

 

The end result will be over time the states will be harder and harder pressed to meet the needs of the poor in terms of providing health care.

 

http://www.hatch.senate.gov/public/_cache/files/bf0c9823-29c7-4078-b8af-aa9a12213eca/The%20Patient%20CARE%20Act%20-%20LEGISLATIVE%20PROPOSAL.pdf

 

**EDIT 2**

In a "good" year for health care increases (2012), the CPI increase was less than 2%.  Health care was about 4%.  Even CPI+1 didn't cover the increase in health care increases and that's a good year.

Edited February 7, 2015 by PeterMP

[Larry]

I didn't read the plan just the Forbes story, but are there subsidies and tax credits?

 

I thought they were two different things based on the story.

 

That's my sloppiness. I'm using the terms interchangeably. Far as I know, they're only talking tax credits.

How much is somebody 200% below FPL paying in taxes that they are actually going to be able to afford insurance based on a tax credit?

And that's why I was asking if they were refundable tax credits. (I think that's the standard term).

Normal tax credit, if your taxes are $250, and you've got a $1,000 tax credit, then your tax becomes zero, and the other $750 of the credit does nothing.

If it's a refundable tax credit, then your taxes go to zero, and the IRS sends you $750.

If these things aren't refundable tax credits, then they really don't help poor people much. (Cause they don't pay much income tax, already).

[Wrong Direction]

From only a cost efficiency/overhead issue, there really is no doubt about what the best solution is, and I don't think it is a doubt even taking into account fraud.

 

I'm familiar with that line of thinking, but I think it takes too much credit for comparability and really doesn't compare apples to apples. The best apples to apples comparison I can think of is Medicare Advantage, though even that is highly fragmented and doesn't benefit nearly as much as it could from competition or economies of scale. With pretty simple reforms to MA (which may or may not ever happen), I think you'd see it actually become cheaper than FFS Medicare. Right now, MA base premiums are based off of FFS utilization and most recent estimates are still that MA is about 1% more expensive, though offering more benefits. 

 

In a vacuum, if you take profit and advertising away, of course you have an opportunity for lower costs. However, you don't have equal management. I really think in the long run that single payer coverage is a net negative over the alternative. 

[Wrong Direction]

Re: the Republican plan.

 

1. Peter refers to Medicare changes. It's actually Medicaid that's being reformed, not Medicare.

 

2. Re: tax credits versus write-offs...this R plan goes for credits because it accepts the argument that a write-off is regressive. Bobby Jindal is arguing for the alternative, signaling a rift within the party. In terms of judging this plan, I prefer credits. However, the rift means the R's would likely have a problem holding their caucus together. That means this plan would likely only pass if D's were heavily pressured to pass something because the ACA wasn't upheld in court. I have no idea how likely that is. I do know that generally D's would definitely support credits over write-offs.
 

3. Re: linking subsidies to CPI, I think that's a fair argument. The R's would point to their other reforms as part of the proposal which the CBO would score as having a further downward effect on healthcare, so I'm guessing they're relying on a CBO score that would show more people having coverage than the ACA. 
 

4. The tax credit option is actually a great option that Ds could probably get behind insofar as it gives very poor people more options for coverage than just Medicaid. I'd personally like to get rid of Medicaid altogether in favor of one health system treating everyone (over time), so this is a bridge effort that appeals to me.

 

5. This is actually a credible Republican alternative. One of the important aspects of the ACA that people don't talk about is the fact that Obama paid for it (good) with funds from Medicare (bad). Many on the right think that Medicare will need a massive shift in reimbursements to remain solvent over time. By diverting that money out of Medicare, Obama's essentially reduced the options for a Medicare bail out over time. By offering a cheaper alternative, an ancillary benefit of this R plan is it puts more options on the table to pay for eventual Medicare reforms. 

[PeterMP]

Re: the Republican plan.

 

1. Peter refers to Medicare changes. It's actually Medicaid that's being reformed, not Medicare.

 

2. Re: tax credits versus write-offs...this R plan goes for credits because it accepts the argument that a write-off is regressive. Bobby Jindal is arguing for the alternative, signaling a rift within the party. In terms of judging this plan, I prefer credits. However, the rift means the R's would likely have a problem holding their caucus together. That means this plan would likely only pass if D's were heavily pressured to pass something because the ACA wasn't upheld in court. I have no idea how likely that is. I do know that generally D's would definitely support credits over write-offs.

 

3. Re: linking subsidies to CPI, I think that's a fair argument. The R's would point to their other reforms as part of the proposal which the CBO would score as having a further downward effect on healthcare, so I'm guessing they're relying on a CBO score that would show more people having coverage than the ACA. 

 

4. The tax credit option is actually a great option that Ds could probably get behind insofar as it gives very poor people more options for coverage than just Medicaid. I'd personally like to get rid of Medicaid altogether in favor of one health system treating everyone (over time), so this is a bridge effort that appeals to me.

 

5. This is actually a credible Republican alternative. One of the important aspects of the ACA that people don't talk about is the fact that Obama paid for it (good) with funds from Medicare (bad). Many on the right think that Medicare will need a massive shift in reimbursements to remain solvent over time. By diverting that money out of Medicare, Obama's essentially reduced the options for a Medicare bail out over time. By offering a cheaper alternative, an ancillary benefit of this R plan is it puts more options on the table to pay for eventual Medicare reforms. 

 

1. Sorry.  Right. Medicaid not Medicare.

 

2.  I'm still not sure how a tax credit help people that don't pay any taxes.

 

3.  Has the CBO scored it?  Scoring very general things like encouraging states to carry out tort reform is going to be hard (How encourage? What type of tort reform?), etc.

 

4.  Isn't the ACA being paid for by increased taxes on the "Cadillac" and the penalties for the uninsured primarily?

[tshile]

2.  I'm still not sure how a tax credit help people that don't pay any taxes.

 

Because you don't have to "pay taxes" to get a credit. It's not a deduction - it's a credit, how much you get back or pay come tax time is irrelevant when it comes to a credit (unless the credit is written to specifically adjust based on that.)

 

It just requires that you file your taxes.

[Larry]

Because you don't have to "pay taxes" to get a credit. It's not a deduction - it's a credit, how much you get back or pay come tax time is irrelevant when it comes to a credit (unless the credit is written to specifically adjust based on that.)

It just requires that you file your taxes.

Uh, no, as I understand it, most tax credits only reduce your income tax, till it gets to zero, and any credit you have beyond that, is just gone.

Now, the Earned Income Tax Credit is an exception. With it, if the credit is more than your tax, you get the difference back. It's like you had a negative income tax.

I believe the "Washington speak" term for that, is "refundable tax credit".

But I don't see anything that says that's what's being proposed, here.

[tshile]

Uh, no, as I understand it, most tax credits only reduce your income tax, till it gets to zero, and any credit you have beyond that, is just gone.

Now, the Earned Income Tax Credit is an exception. With it, if the credit is more than your tax, you get the difference back. It's like you had a negative income tax.

I believe the "Washington speak" term for that, is "refundable tax credit".

But I don't see anything that says that's what's being proposed, here.

 

Ok, you're right, there are nonrefundable tax credits (where your income matters) and nonrefundable tax credits (where it doesn't.)

 

But saying, in general, tax credits cannot help you if you don't pay taxes is incorrect. They can. Just because someone says they want to use a tax credit for something doesn't mean those who don't pay taxes can't get it. Unless they specify non-refundable tax credit, of course.

 

And the Earned Income Tax Credit isn't an exception... it's a refundable tax credit. It's not the only one. It's a type of tax credit that doesn't depend on income. It is not excluded from anything in terms of tax credits.

 

Sorry for my confusion on the matter

Edited February 11, 2015 by tshile

[Kosher Ham]

The idea is good, the execution of it has been a cluster ( you know ) since.  

 

I am happy that I already have insurance and wont ever have to worry about that.

[Hersh]

 

Nope.

 

http://www.irs.com/articles/refundable-tax-credits

 

There are different types of tax credits. I should have specified the refundable tax credits instead of tax credits in general.

 

When you don't make enough to pay taxes and you still get money back, how is that different from a subsidy?

[tshile]

When you don't make enough to pay taxes and you still get money back, how is that different from a subsidy?

 

Well, that would be over my head. I'm not all that well informed on tax law/code.

 

In my mind it's essentially the same thing, though I wouldn't be surprised if there's differences in terms of who gets to write the rules, when, where the money comes form, etc etc. But generally speaking, it seems like the same thing to me.

The idea is good, the execution of it has been a cluster ( you know ) since.  

 

I am happy that I already have insurance and wont ever have to worry about that.

 

the worst part is the amount of money wasted on healthcare.gov by having it go to the people it went to.  i'm sure we're over the $1 billion mark in cost, for a website. there will likely never be an investigation into it either.

 

so as much as I agreed we needed to do something, and that the health insurance industry needed (still needs?) serious reform, we (the tax payer) got completely screwed over by the obama admin on this and there will not be any accountability.

 

it's very disappointing because even though my republican friends are wrong about many, many aspects of ACA - they're not wrong that we got completely screwed in a few ways.

Edited February 11, 2015 by tshile