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

[PeterMP]

I reject the idea that something much more resembling a free market in healthcare cannot work simply because it hasn't been tried. If you think about the nature of free markets, you recognize that they generate more efficiency but also necessarily push the marketplace to the point that access is limited for a sector (in this case poor and sick). However, this is where I become less conservative and support help for the sick and poor to participate in the marketplace in the form of subsidies.

What do you think about the food stamp program?

Generally, it seems to have produced a system of obesity and still pretty large undernourishment in this country yet it has mantained the semblence of a free market system (i.e. people on food stamps are free to choose what goods and brands they buy)?

Do you think that the food industry (and giving them access to it in a pretty unregulated manner via food stamps) has been good for the poor in this country?

Does that affect how you consider how to deal with people in the context of healthcare?

Now, consider where patients will go if they need care and cannot get an appointment...the very costly emergency room.

Where are they going NOW?

---------- Post added July-22nd-2012 at 09:59 PM ----------

Your taxes and mine will be increased significantly...... Therefore I am now paying for these people more than ever before.

How?

Assuming your taxes go up (I'm not going to ask you to actually back that up w/ some evidence), does it matter if you pay through the federal government or via increased hospitials costs, which means increased insurance costs?

The fact of the matter is you are paying, does it really matter how or to whom you pay?

Edited July 23, 2012 by PeterMP

[skins2victory]

Supposedly the taxes will be increased at an estimated of 18% for 10 years before this plan even takes effect. So in this 10 year stretch, not only will we be paying an extra 18% in taxes, the people going to the emergency room without healthcare will still have to be seen, and we will be paying for them too. By the sounds of it, at least in this 10 year stretch we will be paying basically double. We will be paying much more than ever before, until this takes effect we will not be able to know the actual numbers. And the 18% is again an estimate; it could be much, much more. Time will tell….. unfortunately

[PeterMP]

Supposedly the taxes will be increased at an estimated of 18% for 10 years before this plan even takes effect. So in this 10 year stretch, not only will we be paying an extra 18% in taxes, the people going to the emergency room without healthcare will still have to be seen, and we will be paying for them too. By the sounds of it, at least in this 10 year stretch we will be paying basically double. We will be paying much more than ever before, until this takes effect we will not be able to know the actual numbers. And the 18% is again an estimate; it could be much, much more. Time will tell….. unfortunately

But the number of uninsured will drop, OR they will be paying the penalty.

Fewer uninsured mean fewer people going to the ER w/o insurance, or if they are paying the penalty, then that means more income for the federal government, which should offset increases in taxes to us.

There's no way under this plan that the number of uninsured can't drop w/o a substantial increase in federal revenue with respect to health care costs.

Edited July 23, 2012 by PeterMP

[skins2victory]

But the number of uninsured will drop, OR they will be paying the penalty.

Fewer uninsured mean fewer people going to the ER w/o insurance, or if they are paying the penalty, then that means more income for the federal government, which should offset increases in taxes to us.

There's no way under this plan that the number of uninsured can't drop w/o a substantial increase in federal revenue with respect to health care costs.

That may be the case after the 10 years is gone, and the plan is actually underway. But what about in this 10 year stretch, when we are paying increased taxes for the plan before it gets underway, and then the uninsured person seeking health care is going to the ER. These uninsured people are still going to have to be payed for, so we will be paying much more at least till the plan takes effect.

---------- Post added July-22nd-2012 at 09:32 PM ----------

Then even when the plan does take effect, again an estimated 40% of Americans do not pay income tax. So essentially these people will be getting free health care. And if I have to pay my taxes, and do not get free health care, I don’t see how that would be fair.

[PeterMP]

That may be the case after the 10 years is gone, and the plan is actually underway. But what about in this 10 year stretch, when we are paying increased taxes for the plan before it gets underway, and then the uninsured person seeking health care is going to the ER. These uninsured people are still going to have to be payed for, so we will be paying much more at least till the plan takes effect.

The majority of the things aren't going to take 10 years to take effect.

In fact, I don't know of anything that is going to take effect:

http://www.healthcare.gov/law/timeline/

Now, with the court issues, there will be delays on things, but that still isn't going to give you 10 years.

Origianally, specifically the mandate would start to go in place in 2014 and will essentially be fully in place by 2016.

**EDIT**http://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspx**

That was going to be my original point, but I thought MAYBE you were saying that was what the predicted taxes were going to be over 10 years.

I don't know where you've been getting your information, but you might want to consider getting it from some new sources. You seem to have been lied to.

---------- Post added July-22nd-2012 at 10:38 PM ----------

Then even when the plan does take effect, again an estimated 40% of Americans do not pay income tax. So essentially these people will be getting free health care. And if I have to pay my taxes, and do not get free health care, I don’t see how that would be fair.

It doesn't matter.

If they have low enough incomes to get subsidies, they will get health insurance, or they will pay a penalty.

If they are low enough that they will go into a program like Medicaid, they will still have insurance (i.e. Medicaid).

They will not be showing up to an ER uninsured.

Again, either way you are paying.

Edited July 23, 2012 by PeterMP

[twa]

Fewer uninsured mean fewer people going to the ER w/o insurance, or if they are paying the penalty, then that means more income for the federal government, which should offset increases in taxes to us.

There's no way under this plan that the number of uninsured can't drop w/o a substantial increase in federal revenue with respect to health care costs.

What I see will be even more use of emergency rooms and services that will simply increase healthcare costs

You are making more care available,but simply increasing the cost to others....you cannot deliver more care cheaper simply because they are now insured

the notion of savings is a fallacy and one demonstrated in Medicare/Caid today(which they hope to cut)

[PeterMP]

What I see will be even more use of emergency rooms and services that will simply increase healthcare costs

You are making more care available,but simply increasing the cost to others....you cannot deliver more care cheaper simply because they are now insured

the notion of savings is a fallacy and one demonstrated in Medicare/Caid today(which they hope to cut)

1. I never said that healthcare costs will be lowered.

2. Why do you think there will be more ER use?

[twa]

The same reason it increases with Medicare...opportunity and access

n/m, I don't feel like pursuing it.

[PeterMP]

The same reason it increases with Medicare...opportunity and access

n/m, I don't feel like pursuing it.

Again, the medicaid population is different than the population that is non-insured.

The uninsured population is mostly young and healthy. They don't go to the ER because they don't need to.

[twa]

The uninsured population is mostly young and healthy. They don't go to the ER because they don't need to.

I see a great number of young people there....young and dumb judging from many

drugs,accidents,fights ect

[Larry]

Some thoughts on the subject of this claim that Obamacare will increase use of the ER.

Let's look at a few demographics, and compare how things are now, and how they supposedly will be, under Obamacare.

1) The wealthy and most of the middle class will see no change. They're carrying insurance now, (and paying their various deductibles and copays), and they still will. It's possible that their coverage will change a small amount. Some things that they weren't covered for, before, but Obamacare mandates that they must be covered now. And their cost may rise a slight amount, to reflect the increased coverage.

2) People who are covered by Medicaid right now, also shouldn't see much change. In effect, they will keep their present insurance.

3) Now, let's consider a hypothetical person who isn't quite poor, but who chooses not to carry insurance. Let's divide that demographic into two groups, depending on whether Obamacare successfully persuades them to get insurance.

3a) The people who don't have insurance, and who will choose to remain uninsured under Obamacare: These people's health care situation really doesn't change. Their access to health care is the same as it was before. They still have the option of going to the ER, and sticking someone else with the bill. Only difference is that now, because of The Tax, part of that bill is actually being paid for, by their demographic.

Net result: The expense is the same, but the expense has been partially shifted onto the people receiving the service.

3b) People who can afford insurance, have been choosing not to, but Obamacare's Tax persuades them to get insurance.

These people's access to the ER hasn't increased. They can go to the ER, and if they do, the bill will be the same. Part of the bill will have been shifted to other people in their demographic (via the insurance company.) Their personal bill will likely be the same, though. Before, going to the ER cost them everything they had, till they were bankrupt. And it likely still will.

Net result: No change in access. No change in their personal bill. But instead of the rest being paid by society, part of it gets paid by the other "formerly uninsured, but I decided to get insurance" demographic. (Society as a whole likely still gets stuck with a part of the bill, it's just a smaller part.)

Obamacare really doesn't change their access to the ER. they have access now, and they still will.

What it will do, however, is to give them access to places besides the ER.

Right now, the people in this demographic have full access to the ER, but they don;t have access to the Urgent Care clinic down the street. Under Obamacare, those people will now have access to Urgent Care. The guy who used to take his "my arm might be broken" to the ER, can now take it to the Urgent Care center. If he goes there, then his total bill will (IMO, I have no actual idea of the relative costs) likely be half what it was in the ER. And his bill will likely be paid entirely by members of his demographic (via the insurance company), and by him (his deductible and copay.)

In short, yes, Obamacare increases access to health care. But it doesn't increase access to the ER. It increases access to urgent care. (Thus, greatly lowering costs.) And it shifts part of the costs to the "currently uninsured" demographic.

Just my opinion, but that is going to be the big "cost savings" of Obamacare: The shifting of health care for the lower class, to places where it's cheaper to care for them.

[LadySkinsFan]

I don't have insurance and I use urgent care centers when necessary, about once every 2 or 3 or more years. I used the ER when I had appendicitis. Bill was about $15K for hospital, doc, and other sundries. I paid it off over a year's time on a payment plan that didn't have interest attached. I haven't had insurance for more than 10 years. I have pre-existing conditions, so my premiums would have been about $400 a month or more. So, $4,800 per year for 10 years is $48K, and I have used only at most $17K in services. Big savings for me.

I'll pay the "tax" and not buy any insurance and I have 4 years to Medicare. And I'll continue to pay for my healthcare when I receive services, just like the old days before the Great Health Insurance Industry Scam started when Nixon signed the HMO law that opened up the for profit insurance industry. I'm old enough to remember when health insurance was not part of an employee's compensation and people paid as they received service. Introducing that profit generating third party has been the biggest reason why US healthcare costs have soared over the past 4 decades.

Edited July 23, 2012 by LadySkinsFan

[Larry]

Why would you chose not to be insured, when pre-existing conditions are covered?

[Son of Gadsden]

The law doesn't say it isn't a tax, and in fact, I believe the lawyers that were supporting it in fact argued that they didn't think it was a tax, but if it should be considered a tax it should be Constitutional.

So the Supreme Court didn't change it from a mandate to tax. The law is vague, and they exercised judicial power with respect to it.

They decieded it was tax and given the Constitutional power of the government to tax, therefore constitutional.

But healthcare is inter-state commerce.

And Congress has the power to tax.

We have a Republic, which isn't a democracy.

I'm making the point that a free market health care system will fail because people don't even have the necessary basic information to know if they are making good decisions.

1. I never said that government can make better decisions than people. In fact, I expect them to make bad decisions.

2. That centerally managed healthcare systems have lower overhead, and therefore reduced costs, is not a matter of my opinion. It is a based on several different studies that look at over head costs in different medical systems.

3. That people make poor decisions in complex situations, especially with respect to things like healthcare, again, is not my opinion. It is backed up by multiple studies. If you want some reading you can start with this:

http://www.rwjf.org/files/research/71844.pdf

Why do you expect that a free market health care will do fine?

Why do you expect that centerally controlled systems will fail?

The NHS in Britain is over 50 years old and while it is undergone modifications, I don't see any reason to think it is going to fail any time soon.

1) The law might not say it isn't a tax, I'm not a lawyer, therefore I can't confirm that or not, and I don't see any citations from you citing that it says anything about being a tax. I know that our dear president has stated repeatedly that it is not a tax...yet it turns out that it was only held up by the feds power to tax.

But the government isn't requiring me to buy health care, they're requiring me to buy health INSURANCE. I can get sick and not go see a doctor if I choose not to, but I don't have a choice of buying health insurance or not. Health insurance is not sold across state lines.

1) republic: A state in which supreme power is held by the people and their elected representatives, and which has an elected or nominated president

indirect democracy: A form of democracy in which the citizens elect government officials but following this election have little or no input as to governmental decisions made by those officials

Spared from being politically correct, there is no difference.

3) And I am arguing that the government doesn't either.

4) a) That's exactly what you are saying, you are saying the people can't make good enough decisions, so the government should make them for them. So, if that's the case and the government can't make good decisions either, what the heck are we doing giving them more stuff to decide?

but who's paying for all the overhead that's going away? It's going somewhere. Nothing is free.

c) liberty means people are free to make bad decisions, and I'm all for it...because from what I've seen, the government does NOTHING but make bad decisions...and, as stated, we are suggesting the government should take this over. So, I'll stop arguing with you that people make bad decisions if that is what you are set on and I can't convince you otherwise. So, who's going to make better? Rex sucked last year, but our question was...who can make better decisions? We tried Beck and he didn't make better ones. Oh yes, I just compared Rex to the people and Beck to the government, so?

Because it hasn't been tried, and it deserves a chance.

Because government takeover never ends well. Europe has it, yeah...and if you haven't noticed, it's not doing so well economically. Plus, I've been to Europe, and though I can't say anything about their health care...let's just say I'm glad I live here...so you won't see me lobbying to be more like Europe. Like I said, there will never be an issue in the world that I side with government on. I believe the people can handle themselves in every aspect other than protection. You're right in whatever statement you made above, to tell you the truth. We don't have a free market. We say we do, but we don't. A free market has to have minimal government intervention. We certainly do not have that. To have that we would need contracted police forces, volunteer or contracted fire departments, privatized education, etc. And in my belief, this country would be better were that the case.

Edited July 23, 2012 by Son of Gadsden

[skinsmarydu]

The last time I had to go to an ER was because I cut my finger while at work. (pretty bad, but not life-threatening). I was one of maybe 5 people in the very crowded waiting room that did not require an interpreter. (I'll let that sink in for a second.)

I have to believe that ERs caring for non-citizens, a greater portion of whom work for cash and send it to their families in their home countries, has contributed to the rising costs. How do we address that? Citizens also wait (sometimes in great pain) while non-citizens are cared for. Not to bash anyone, just something I think of, especially since non-citizens outnumber citizens in my neighborhood.

[JMS]

I reject the idea that something much more resembling a free market in healthcare cannot work simply because it hasn't been tried. If you think about the nature of free markets, you recognize that they generate more efficiency but also necessarily push the marketplace to the point that access is limited for a sector (in this case poor and sick). However, this is where I become less conservative and support help for the sick and poor to participate in the marketplace in the form of subsidies. In terms of high-level philosophy, my position (and that of Romney and most R's) doesn't differ significantly from Obama's. We all want to give assistance to the sick and poor so they aren't excluded from the system. The difference isn't whether to help them, the difference is how. Obama is taking a lot of financial risk out of the hands of consumers, particularly the millions of poor and sick, and I absolutely believe that will result in higher prices over the long run than a system that adds the consumer to the financial equation.

We don't have a free market in healthcare costs, and never have(modern history of the country), because no intellectual argument can be created that would support using a free market to provide healthcare. Healthcare is so specialized today it's long ago eclipsed most peoples abililty to pay as you go with regard to treatement.

I reject the premise where no logical model can be described which would be deemed acceptable. . Do you know why it costs $100 for an aspirin at the ER? Why doctors nor anybody else in the hospital can tell you what it's going to cost before you recieve treatment? Because healthcare is freaking expensive, from top to bottom it doesn't work as a free market. Aspirin's cost so much because the profit they make on selling you asprin at 10000% mark-up goes to pay for your neighbor's CAT-scan where they loose money charging him $2000. Nobody can tell you what your fee is going to be becasue they don't caculate fee's based upon services. They charge you on a rolling basis depending upon (1) what your insurance company negotiated, (2) What machines are proximal to you when you recieve treatment whether they use them or not. (3) If you have no insurance; what they think you can afford based on any information they can gleen from you at the time of your admittence... ( shoes, credit card if you are foolish enough to give them one, if you own a home etc.. )...

Bottom line, you can not describe a model, where modern healthcare services, could be provided under a "free market system" and would be affordable to 90% of the people in this country. Example...How many people in this country are sick and injured at any given moment as a percentage of our population? I'm a relatively healthy middle aged guy, I've probable had 1 hospital visit a year. or (1/365)*100 = 00.3% of my time has been spent in a hospital, averaged out over my lifetime. But let's say 10 x my personal experience is a reasonable number for the entire population.... that's still only 3% of the population.. We spend about 18% of our GDP on healthcare. how can 3% of the population pay 18% of the GDP? Can't.. Given those folks still have to pay for taxes, food, housing etc... 3% of the population likely couldn't afford to pay even 1% of the GDP for healthcare costs.

Building on that let's imagine what happens to healthcare costs when 90% of the population drops out of the system? Cost go up by 100, 1000%. It's not at all unrealistic to imagine a resulting system where not even top 1% earners can afford healthcare services as they exist today, in such a system...

This is an over-statement on a couple of levels. First, the fines don't take away the financial incentive not to buy insurance. They somewhat diminish it, but the supreme court even said (Roberts) that it's a tax fine and not a penalty because the amount is small relative to the cost of insurance. The fine does not, therefore, ensure that not buying insurance is "not a viable savings plan."

Obama and Romney said it wasn't a tax but a fine. Congress said it wasn't a tax. The supreme court said it was a tax, and said because it was a tax it was constitutional. Roberts did not say the "tax" was relatively small based upon the cost of insurance. The fact is the "fine" is based upon the envisioned cost of insurance and the entire motivation for the "fine" is to take away the financial incentive for young healthy people to opt out of the system because the revenue they pay into the system is going to allow us to include 30 million new folks into the system and do away with pre-existing conditions and do a bunch of other stuff which will mean ideally healthcare cost will no longer be the #1 reason cited for bankrupcies in this country.

You should check out the Washington Post's fact check on the second 10 years. First, the 1.2 trillion savings number was extrapolated by either Rahm or Weiner (forget) and based on very rough guesstimates by the CBO as it relates to GDP in the second 10 years of the bill. Even years 5-10 become very hard to score. Years 10-20 are basically a total shot in the dark given all of the assumptions and uncertainties.

I definitely understand that. Yet still one must use the CBO numbers as the best available number. The CBO's guestimates are more credible than any cherry picked numbers.

Folks in favor of the ACA would say the CBO significantly underestimated the revenue saved based upon the current growth model of healthcare over the last 40 years.

So Republican mistakes or bad politics of the past automatically invalidate current arguments?

Republicans ongoing willingness to fund programs which are 2 to 7 times more expensive than programs they deem "unsustainable" cast in doubt their credibility in calling something unsustainable. Frankly cast in doubt their credibility on economic issues in general.

Bottom line: if this country does nothing but implement ObamaCare, we still have budget busting cost issues that will cause massive cuts to all kinds of federal programs, including healthcare, and higher taxes. We need to do better.

Agreed, but the perfect should not be the enemy of the good.

Edited July 23, 2012 by JMS

[twa]

Why would you chose not to be insured, when pre-existing conditions are covered?

That sounds good...till you see the premium

are pre-existing conditions covered for adults yet?...I thought that came into force in 14?

Edited July 23, 2012 by twa

[JMS]

Why would you chose not to be insured, when pre-existing conditions are covered?

Because the cost ( fine/ tax) associated with not having insurance is designed to take away your financial incentive to go without.

So the question becomes why would you not pay $4k for some minimal insurance when it will cost you $4k in additional fines/taxes to obstain from purchasing insurance?

[Wrong Direction]

What do you think about the food stamp program?

Generally, it seems to have produced a system of obesity and still pretty large undernourishment in this country yet it has mantained the semblence of a free market system (i.e. people on food stamps are free to choose what goods and brands they buy)?

Do you think that the food industry (and giving them access to it in a pretty unregulated manner via food stamps) has been good for the poor in this country?

Does that affect how you consider how to deal with people in the context of healthcare?

I'm happy to be corrected if I'm wrong here, but I think the food stamp program (under Obama and the last couple of congresses) is financed exactly the way welfare generally used to be. It is an open-ended program which is inviting states to over-enroll and providing nearly no incentive for states to limit duration of enrollment. In that regard, I think it is incredibly wasteful. States are able to shower their population with benefits while only paying a relatively small portion of the costs.

I'm generally for a food stamp program, but one that is limited in duration for non-disabled and one that is block granted to states so they can target those benefits to the most needy without the incentive to create more of a dependent class. Since it's my money going to these people to eat, I'd absolutely be in favor of removing fast food from the program, but that point would be minor in a program that contains the duration of enrollment, so it's not really an issue worth fighting.

Where are they going NOW?

To the ER. My point is that many are assuming the ACA will fix this problem, but I think it does not. I'm not saying it'll make it worse.

One lesser-discussed issue, but very costly, is the fact that the feds and states have both guaranteed just about any care to be covered as emergency care. The feds and insurance companies should dramatically limit the definition of emergency care so the hospital's uncompensated care pool diminishes and the costs of insurance (private or public) is diminished. If both did this, I'm sure you'd see urgent care clinics popping up around every hospital. People - regardless of whether they're insured - would be directed to those clinics where they would get fine care for less cost.

Last point: the issue with the number of doctors/NPs in the marketplace is one that Obama addresses in the ACA. Once again, I just think he addresses it poorly. In a nutshell, he threw more money at the problem by adding more subsidies for graduate medical education. This will likely increase the number of doctors over the previous baseline, but it doesn't fundamentally change 1) the number of medical students being admitted to med school or 2) the cost of med school. Obama could have taken acute steps to dramatically increase the number of med-school spots open to students. As far as I'm aware, despite his other efforts on GME, he did not. That makes his response inadequate, but certainly not non-existent.

One huge issue most of us have faced (or will face in the next 10-20 years) is the cost of college tuition. This is a massive bubble created by mostly state politicians who are unable to think creatively to address surging demand (indeed, they just subsidized it to actually increase the problem) in an era when information is cheaper and more available than at any point in world history. I'd love to hear a major politician take this issue head on. It would garner massive bi-partisan support.

---------- Post added July-23rd-2012 at 11:27 AM ----------

But the number of uninsured will drop, OR they will be paying the penalty.

Fewer uninsured mean fewer people going to the ER w/o insurance, or if they are paying the penalty, then that means more income for the federal government, which should offset increases in taxes to us.

There's no way under this plan that the number of uninsured can't drop w/o a substantial increase in federal revenue with respect to health care costs.

Keep in mind that Medicare hospital reimbursement was lowered as part of the ACA in anticipation of lower amounts of uncompensated care. That was a major pay-for in the bill, but hospitals basically come out whole because of increased insurance coverage. What we will see is more people with insurance going to the ER, which means that that price gets factored into the price of insurance, as opposed to our tax money paying for Medicare. So, for the taxpayer this is a slight gain because at least our insurance premiums won't be paid with interest for the next X decades.

[PeterMP]

4) a) That's exactly what you are saying, you are saying the people can't make good enough decisions, so the government should make them for them. So, if that's the case and the government can't make good decisions either, what the heck are we doing giving them more stuff to decide?

but who's paying for all the overhead that's going away? It's going somewhere. Nothing is free.

If party A is going to make bad decisions and party B is going to make bad decisions, then I need to consider other factors in making my deicion than the quality of the decision made.

If party A can make bad decisions AND cost less money, then that gives party A an advantage over paty B.

If you don't have insurance companies, then you no longer have to keep track of who has what insurance.

All those records and details are extra over head. The associated costs simply go away.

Not to mention duplication of the efforts by individual insurance companies can be eliminated.

As well as things like advertisement and recruiting customers.

The associated costs are eliminated not transferred (or at least transferred to non-medical related costs. You might see them show up in things like the price you pay for cable tv).

---------- Post added July-23rd-2012 at 11:37 AM ----------

Last point: the issue with the number of doctors/NPs in the marketplace is one that Obama addresses in the ACA. Once again, I just think he addresses it poorly. In a nutshell, he threw more money at the problem by adding more subsidies for graduate medical education. This will likely increase the number of doctors over the previous baseline, but it doesn't fundamentally change 1) the number of medical students being admitted to med school or 2) the cost of med school. Obama could have taken acute steps to dramatically increase the number of med-school spots open to students. As far as I'm aware, despite his other efforts on GME, he did not. That makes his response inadequate, but certainly not non-existent.

Actually, over the last decade or so there has been an effort to increase the number of med schools and therefore med students. Med school spots are going up, but the real problem is actually residencies.

https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html

One of the thoughts is to try and focus resident slots into primary care (and therefore force more people into primary care).

http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20101201hcreform-gmeredistrib.html

I'll also point out that the healthcare law's changes in loans and such is focused on those in primary care so again an effort to shif the population of doctors.

---------- Post added July-23rd-2012 at 11:45 AM ----------

Just my opinion, but that is going to be the big "cost savings" of Obamacare: The shifting of health care for the lower class, to places where it's cheaper to care for them.

I don't think this is likely, and there certainly is no evidence for it as far as I know.

The uninsured don't currently use the ER more than the privatly insured and use it less than people on Medicaid.

Might their behavior shift to using it even less if they have insurance, maybe, but I doubt it.

In addition, there are real limits on access to non-ER healthcare for the poor. There is a reason that many of the poor end up in the ER and that is because they can't find "normal" healthcare that will take their insurance and see them in a timley manner (i.e. medicaid). People aren't rushing to start primary care offices or other for profit healthcare businesses in poor areas based on what Medicaid and the non-insured are paying.

By putting more people on Medicaid, you are only going to stress that system more.

I have heard people argue that the best way to really lower costs (especially with respect to the federal government) would have been to give block grants to the states and non-profits to open "no fee"/"no insurance" clinics in the poor areas. These clinics would operate without worrying about billing and therefore have reduced over head.

You'd give people places to go rather than the ER. And since we are already paying anyway and these clinics would be less expensive and operate with less overhead (as they wouldn't bill and worry about insurance records), you'd actually save money.

Of course, you still have a lot of people out there w/ no insurance and if they get really sick and are beyond the point these clinics can help, they'd still have issues.

---------- Post added July-23rd-2012 at 12:05 PM ----------

I'm happy to be corrected if I'm wrong here, but I think the food stamp program (under Obama and the last couple of congresses) is financed exactly the way welfare generally used to be. It is an open-ended program which is inviting states to over-enroll and providing nearly no incentive for states to limit duration of enrollment. In that regard, I think it is incredibly wasteful. States are able to shower their population with benefits while only paying a relatively small portion of the costs.

I'm generally for a food stamp program, but one that is limited in duration for non-disabled and one that is block granted to states so they can target those benefits to the most needy without the incentive to create more of a dependent class.

I don't think Obama has changed the food stamp program laws. That seems like it would have made the news.

And certainly since issues related to obesity and malnutrition amongst the poor pre-date him, it is irrelevant to my point.

Do you think that healthcare support for the poor should be given with duration limits on it?

Edited July 23, 2012 by PeterMP

[Larry]

I have heard people argue that the best way to really lower costs (especially with respect to the federal government) would have been to give block grants to the states and non-profits to open "no fee"/"no insurance" clinics in the poor areas. These clinics would operate without worrying about billing and therefore have reduced over head.

You'd give people places to go rather than the ER. And since we are already paying anyway and these clinics would be less expensive and operate with less overhead (as they wouldn't bill and worry about insurance records), you'd actually save money.

That sounds a lot like an idea I've had for years. (So it must be a great idea.)

I'd been looking at the problem of feeding the poor, and I'd observed that it would be vastly cheaper to set up soup kitchens and hand out free food to anybody who shows up, than it is to hand people cash (or things easily convertible to cash), and tell then to go to the grocery store and pay retail.

Now, in the health care soup kitchen situation, we all know that there will still be rationing. You can't give away anything for free and not have demand exceed supply. I would assume that the rationing mechanism would be time based. Demand would rise until people weren't willing to wait in line for (however long it is.)

But yeah, that does sound, to me, like an idea that would be a whole lot cheaper.

[Wrong Direction]

We don't have a free market in healthcare costs, and never have(modern history of the country), because no intellectual argument can be created that would support using a free market to provide healthcare. Healthcare is so specialized today it's long ago eclipsed most peoples abililty to pay as you go with regard to treatement.

This is just false. There have been studies showing HSAs save money.

http://www.banyan-llc.com/bc/bc.nsf/archivedarticles/Aetna-Study-Shows-CDHPs-Can-Save-Money

A recent study released by Aetna has demonstrated that people participating in a health savings account (HSA) visit their primary care physicians 15 percent less than average for non-routine visits. They were also shown to have medical costs that were a total of 10 percent less than that of traditional plans.

...

Individuals with HSAs were also shown to focus more on preventive care. Screenings by HSA users for diabetes and cancers, such as breast cancer and cervical cancer, were much higher. HSA users also saved money by visiting the emergency room far less and using generic drugs more often than name brand medications.

There's much more on the subject. Frankly, I think the savings would be even larger if our whole system was introduced to cost sharing. Yes, we'd lower waste through overutilization of the system, but the real benefit would be in the outlandish prices for very simple services. A market is definitely the solution to part of the problem, IMO.

I reject the premise where no logical model can be described which would be deemed acceptable. . Do you know why it costs $100 for an aspirin at the ER?...

Hospitals are businesses that are heavily dependent on Medicare. They charge the way they charge because of Medicare and because they need to cover uncompensated care that they're required to provide. The ridiculous payment schemes in hospitals are the result of government, not any rational market.

Bottom line, you can not describe a model, where modern healthcare services, could be provided under a "free market system" and would be affordable to 90% of the people in this country.

JMS, you cannot describe a model where healthcare can be paid for under a government system without massive arbitrary cost cuts. What a rational market (e.g., some cost sharing for everyone, with subsidies for poor/sick) is move us to a need-based system and away from a wasteful fee for service type of system that encourages overuse. The beauty of any rational market is it directs resources to where they're most needed and away from where their most wasteful. A government directed system only attempts to do that, is ridiculously slow and reactionary to politics and thus fails miserably.

I just want to re-iterate...I WANT to subsidize the poor and sick. I WANT to provide better access. I also WANT customers to have some skin in the game in the form of cost sharing, rather than in the form of premiums. I also WANT insurance for where it is needed most, which is catostrophic costs.

Obama and Romney said it wasn't a tax but a fine. Congress said it wasn't a tax. The supreme court said it was a tax, and said because it was a tax it was constitutional. Roberts did not say the "tax" was relatively small based upon the cost of insurance. The fact is the "fine" is based upon the envisioned cost of insurance and the entire motivation for the "fine" is to take away the financial incentive for young healthy people to opt out of the system because the revenue they pay into the system is going to allow us to include 30 million new folks into the system and do away with pre-existing conditions and do a bunch of other stuff which will mean ideally healthcare cost will no longer be the #1 reason cited for bankrupcies in this country.

Go look at the fines and then look at the cost of insurance and now tell me they're comparable. They're not, and Roberts did say that.

I definitely understand that. Yet still one must use the CBO numbers as the best available number. The CBO's guestimates are more credible than any cherry picked numbers.

The CBO never said $1.2 trillion. Never.

Folks in favor of the ACA would say the CBO significantly underestimated the revenue saved based upon the current growth model of healthcare over the last 40 years.

Look enough and you'll find people who say the ACA will cost an extra trillion and others who say it will save an extra trillion. There are many well-paid advocates out there.

Republicans ongoing willingness to fund programs which are 2 to 7 times more expensive than programs they deem "unsustainable" cast in doubt their credibility in calling something unsustainable. Frankly cast in doubt their credibility on economic issues in general.

Lol. So the R's are the only party doing this, right? I'm trying to look past the politics of all of this. D's have their political issues. R's have their's. Neither is relevant to a discussion about what the best model to pay for care would be.

---------- Post added July-23rd-2012 at 01:10 PM ----------

Actually, over the last decade or so there has been an effort to increase the number of med schools and therefore med students. Med school spots are going up, but the real problem is actually residencies.

https://www.aamc.org/advocacy/gme/71178/gme_gme0012.html

One of the thoughts is to try and focus resident slots into primary care (and therefore force more people into primary care).

http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20101201hcreform-gmeredistrib.html

I'll also point out that the healthcare law's changes in loans and such is focused on those in primary care so again an effort to shif the population of doctors.

I get the focus on residencies and primary care, but this is all woefully inadequate, which is my point. I know a guy on the faculty at Stanford who is beside himself because of the number of high quality applicants they turn away from their med school. Listening to him, there are many more wanna be doctors than the system will allow for.

I don't want to be misconstrued here. A general increase in the number of med schools (or nursing/pharmacy schools) is a good thing. However, it's not nearly enough to address our medium-term shortages AND it fails to substantively address the high costs of med school/training in any way other than subsidy (e.g., not market-based).

I don't think Obama has changed the food stamp program laws. That seems like it would have made the news.

And certainly since issues related to obesity and malnutrition amongst the poor pre-date him, it is irrelevant to my point.

He extended eligibility and increased the benefit. This likely increased the roles, but it's not a fundamental change. The point stands though about incentives for states when there's no limitation to the federal benefit:

USDA: States have increased outreach to low-income households, implemented program simplifications, and streamlined application processes to make it easier for eligible individuals to apply for and receive SNAP [food stamp] benefits. Most States also have reduced the amount of information that recipients must report during their certification period to maintain their eligibility and benefit levels, making it easier for low-income households to participate.

The incentive to manage the program strichtly isn't there, and it calls for reform.

Do you think that healthcare support for the poor should be given with duration limits on it?

Yes.

Able-bodied adults should only qualify for "maximum" benefits for a time-limited period. I wouldn't reduce their eventual benefit to zero necessarily, but they should be reduced over time. My position for people with serious chronic illnesses would be different.

Edited July 23, 2012 by Wrong Direction

[JMS]

This is just false. There have been studies showing HSAs save money.

http://www.banyan-llc.com/bc/bc.nsf/archivedarticles/Aetna-Study-Shows-CDHPs-Can-Save-Money

Sorry, No "creditable" evidence exists that show that Free Markets would work for healthcare delivery... A study done by an insurance company which makes billions on the healthcare services provided is hardly creditable....

Besides, It's commical really... I could see healthcare savings accounts being used in conjunction with insurance; but the idea that if you need brain surgury or cancer treatment or heart surgury most americans would be able to pay for it with the money squirled away in some account is idiotic. On can easily spend a million dollars on any one of these events it would not be possible for most people to save enough money as there sole solution to high healthcare costs.

...

---------- Post added July-23rd-2012 at 01:45 PM ----------

Hospitals are businesses that are heavily dependent on Medicare. They charge the way they charge because of Medicare and because they need to cover uncompensated care that they're required to provide. The ridiculous payment schemes in hospitals are the result of government, not any rational market.

Hospitals are businesses which are allowed to charge different rates for the same services as a strategy to alleviate very high operating costs....

Medicare and uncompensated patients aren't the only culprits.... If you walk in and pay cash you will pay twice the expense of what some insurance companies will allow. There is no market because you are not aware of a price when you walk in.. Ask and they won't tell you a price, if they tell you a price you can't hold them to a price. They'll charge you whatever, because they can. It's not a market where you can shop and compare. Not generally when you need imminant attention, and not even when you have time to plan in my personal experience.

Edited July 23, 2012 by JMS

[Wrong Direction]

Sorry, No creditable evidence exists that show that Free Markets would work for healthcare delivery... A study done by an insurance company which makes billions on the healthcare services provided is hardly creditable....

Besides, It's commical really... I could see healthcare savings accounts being used in conjunction with insurance; but the idea that if you need brain surgury or cancer treatment or heart surgury most americans would be able to pay for it with the money squirled away in some account is idiotic. On can easily spend a million dollars on any one of these events it would not be possible for most people to save enough money as there sole solution to high healthcare costs.

...

High deductible health plans achieve cost savings through the cheaper care. They still cover brain surgery, etc. That stuff is not paid for with "money squirled away in some account."

The next key is for the market (government, insurance companies, hospitals, surgeons) to capitate payment for the most expensive care. This is a debatable point actually for several reasons, but health economists are generally dividing savings targets up by cost and setting, and most of what I've talked about so far here is directed toward the low/medium cost healthcare. The high cost stuff is very complicated to actually fix, but easier to achieve savings because even small changes in use and price care (e.g., $100,000 drugs) achieve greater cost savings.

[JMS]

JMS, you cannot describe a model where healthcare can be paid for under a government system without massive arbitrary cost cuts..

I can do better than describe such a model. I can point to more than 30 such models working in the world today which the World Health Organization ranks above ours...

Will there be cuts, absolutely as the most expensive system in the world is 40-50% more effiecent ( less expensive) than our system. Are these cuts "arbitrary", no; because these systems outperform our system for delivering services.

---------- Post added July-23rd-2012 at 01:52 PM ----------

High deductible health plans achieve cost savings through the cheaper care. They still cover brain surgery, etc. That stuff is not paid for with "money squirled away in some account."

Yes they do, and they aren't examples of a free market system, and they are also options in the ACA.

"capitate payment" ?