Healthcare reform

[glunn]

I just sent the following message to Al Franken's website:

 

"I am glad that the Republicans failed to pass their health care legislation. But I am unhappy with the Democrats celebrating this when they should be governing.

 

Obamacare was flawed from the start.  Even Obama acknowledged that it could be improved, but the "party of no" blocked him.

 

Next week, the Democrats could show some real leadership by proposing some compromises that would include many of the changes that Obama wanted to make.

 

Please consider working on both sides of the aisle, and in the media, to find common ground that will help the American people. You will likely fail, but please try. The American people deserve your best effort, not a celebration of the train wreck that happened last week."

 

Anyone who wants to join in might send a similar message to Senator Franken at the following link:  https://www.franken.senate.gov/?p=email_al

 

I will be sending similar messages to Senator Warren and to my own Senators.

 

Am I being naive?  Or is this a meaningful opportunity to find common ground on an issue where failure costs lives?

[DaveW]

IMO Reform needs to come to the insurance companies and pharma companies before we can see a ton of change for the better in terms of pricing and fairness and a massive improvement overall.

 

Too many politicians on BOTH sides in the pockets of big pharma and insurance.

[Squirrel]

I just sent the following message to Al Franken's website:

 

"I am glad that the Republicans failed to pass their health care legislation. But I am unhappy with the Democrats celebrating this when they should be governing.

 

Obamacare was flawed from the start. Even Obama acknowledged that it could be improved, but the "party of no" blocked him.

 

Next week, the Democrats could show some real leadership by proposing some compromises that would include many of the changes that Obama wanted to make.

 

Please consider working on both sides of the aisle, and in the media, to find common ground that will help the American people. You will likely fail, but please try. The American people deserve your best effort, not a celebration of the train wreck that happened last week."

 

Anyone who wants to join in might send a similar message to Senator Franken at the following link: https://www.franken.senate.gov/?p=email_al

 

I will be sending similar messages to Senator Warren and to my own Senators.

 

Am I being naive? Or is this a meaningful opportunity to find common ground on an issue where failure costs lives?

I think you also need to send letters to Republican leadership on why this failed, and encourage them to govern, and put together legislation that actually helps people. And frankly, I was celebrating, too; not because Trump and the House Republcians failed and that this debacle showed just how fractured they are, but because this piece of horrible, horrible legislation did not go forward as a result. While I think your letter to encourage Democrats to work on is good, I think your scolding telling them to govern was a bit one-sided and quite a bit off base. The Democrats do not have the majority. They aren't the governing party. And you sound a bit like trump pointing your finger only at them. I will be writing letters to my representatives THANKING them for whatever part they had in this bill's failure (although they really had no part in the failure) and reminding them there is more to be done.

 

And Dave's right, healthcare reform in this country won't work until you get big pharma and the insurance ciompanies in line. And both Dems and Reps are in their pockets. The ACA might have functioned better if they made it mandatory for everyone to get coverage. Too many young and healthy people just paid the fine and went on their merry way so the insurance companies were over burdened with the costs with the disproportionate number of sick people signing up for coverage. They had no choice but to raise rates as they did. But a mandatory clause wouldn't have passed last time. The ACA that was passed was watered down quite a bit from its original proposal, as the more progressive parts did not get enough support.

 

Perhaps what needs to happen first is to get rid of Citizens United and take away the power and money of PACS and lobbies, then maybe representatives will start behaving as if they are for the people and of the people.

[TheLeviathan]

 

I think you also need to send letters to Republican leadership on why this failed, and encourage them to govern, and put together legislation that actually helps people. And frankly, I was celebrating, too; not because Trump and the House Republcians failed and that this debacle showed just how fractured they are, but because this piece of horrible, horrible legislation did not go forward as a result. While I think your letter to encourage Democrats to work on is good, I think your scolding telling them to govern was a bit one-sided and quite a bit off base. The Democrats do not have the majority. They aren't the governing party. And you sound a bit like trump pointing your finger only at them. I will be writing letters to my representatives THANKING them for whatever part they had in this bill's failure (although they really had no part in the failure) and reminding them there is more to be done.


Perhaps what needs to happen first is to get rid of Citizens United and take away the power and money of PACS and lobbies, then maybe representatives will start behaving as if they are for the people and of the people.

 

Governance should not be one party or the other.  That mentality you express in the first paragraph is part of the problem IMO.  We need to get back to expecting our politicians to work with people of all political persuasions.  Some of our best legislation is when one party's central idea is bolstered by ideas to make it better from the other side.  So I'm with glunn - we don't need the Dems to dance on the ashes of this defeat, we need them to inject some of their ideas in the ultimate solution.  

 

Otherwise, what's the alternative?  They just hang around, waiting for Republican failures to bask in, waiting for "their chance" to govern?  And we repeat that brutal cycle over and over again?

 

One of the things that bothers me most about Ryan's rhetoric is how he talks about "the governing party" vs. "the resistance party".  That is an enormously problematic way to frame this and I feel like your criticism buys into that.

 

Also, on your last paragraph, we had money in politics long before Citizens United.  That decision was a bad one, but let's be real.  Those problems have existed for a long time.

 

Personally, I think some brave politician should stand up and talk about single payer with a well worked-out, sustainable way to pay for it.  I think there is an appetite for that in America.  Especially if it's sold well.

[Squirrel]

Governance should not be one party or the other. That mentality you express in the first paragraph is part of the problem IMO. We need to get back to expecting our politicians to work with people of all political persuasions. Some of our best legislation is when one party's central idea is bolstered by ideas to make it better from the other side. So I'm with glunn - we don't need the Dems to dance on the ashes of this defeat, we need them to inject some of their ideas in the ultimate solution.

 

Otherwise, what's the alternative? They just hang around, waiting for Republican failures to bask in, waiting for "their chance" to govern? And we repeat that brutal cycle over and over again?

 

One of the things that bothers me most about Ryan's rhetoric is how he talks about "the governing party" vs. "the resistance party". That is an enormously problematic way to frame this and I feel like your criticism buys into that.

 

Also, on your last paragraph, we had money in politics long before Citizens United. That decision was a bad one, but let's be real. Those problems have existed for a long time.

 

Personally, I think some brave politician should stand up and talk about single payer with a well worked-out, sustainable way to pay for it. I think there is an appetite for that in America. Especially if it's sold well.

I agree whole heartedly on single payer. At the time the ACA was passed that would not have passed. Most people thought that getting at least the ACA would be a stepping stone.

 

As for the other my point was it is BOTH parties. My response to Gerald is that he shouldn't be singling out Dems in this. What he stated does nothing if it's not inclusive to both parties. What he stated is no different, imo, that Trump blaming Dems for the failure. If you are going to write to one party to govern, you need to write to both. And I'm sorry, but I do celebrate this bill's failure. It was legislation to move us backwards not forward. I don't celebrate it as a republican failure, as I said, because that is pointless. But that bill would have been horrible. And maybe celebrate is the wrong word. I am joyful with relief!

[TheLeviathan]

 

I agree whole heartedly on single payer. At the time the ACA was passed that would not have passed. Most people thought that getting at least the ACA would be a stepping stone.

As for the other my point was it is BOTH parties. My response to Gerald is that he shouldn't be singling out Dems in this. What he stated does nothing if it's not inclusive to both parties. What he stated is no different, imo, that Trump blaming Dems for the failure. If you are going to write to one party to govern, you need to write to both. And I'm sorry, but I do celebrate this bill's failure. It was legislation to move us backwards not forward. I don't celebrate it as a republican failure, as I said, because that is pointless. But that bill would have been horrible. And maybe celebrate is the wrong word. I am joyful with relief!

 

Why wouldn't he single out the role of the Democrats in emailing a Democratic Senator?

[Squirrel]

Why wouldn't he single out the role of the Democrats in emailing a Democratic Senator?

He was suggesting we write only to the Democrats not to all our representatives. This debacle isn't just about one party's glee. And I didn't say don't write them, I said also, not only, but also write to the republican leadership as well. I think the one-sidedness with his intent is flawed and no better.

[TheLeviathan]

He was suggesting we write only to the Democrats not to all our representatives. This debacle isn't just about one party's glee. And I didn't say don't write them, I said also, not only, but also write to the republican leadership as well. I think the one-sidedness with his intent is flawed and no better.

Where was that suggestion? The last paragraph suggests otherwise in fact.

[Squirrel]

Where was that suggestion? The last paragraph suggests otherwise in fact.

His suggestion to write to Franken and Warren is implying that we write to only the Democratic leadership, but not the Republican leadership. If you are going to write to representatives that are not your own, it should be to leadership of both parties. Yes, write to your own reps, but I don't know why only Democrats (Franken and Warren) were singled out. That is no better than Trump saying this was the a Dems fault, imo, when both parties have created this.

[USAFChief]

I'm with glunn.

 

I want action from Democrats. Govern, or at least try. Let's get some ideas before the American public, and maybe we can elect more Democrats.

 

Don't just celebrate R failure...give us alternatives.

[TheLeviathan]

 

I'm with glunn.

I want action from Democrats. Govern, or at least try. Let's get some ideas before the American public, and maybe we can elect more Democrats.

Don't just celebrate R failure...give us alternatives.

 

One of my biggest worries is that the Trump win turns the Democrats into the post-2008 Republicans.  

This is a key time to resist that.

[kab21]

 

I'm with glunn.

I want action from Democrats. Govern, or at least try. Let's get some ideas before the American public, and maybe we can elect more Democrats.

Don't just celebrate R failure...give us alternatives.

Since Trump won the election the GOP has basically given democrats the middle finger in all proposed legislation and executive orders. Democrats shouldn't be gloating about the GOP's failure in this and I don't really like the blatant obstructionism strategy that the democrats are employing (copied from the GOP during Obama who copied it from democrats and so on) but I find it very difficult to place any blame on the democrats for the failure of AHCA. It was drawn up quickly behind closed doors and kept a complete secret until they wanted to hold a vote.

 

The blame lies squarely at the top. Trump repeatedly campaigned on having a plan that included everyone for cheaper costs. These were blatant lies then and that is obvious now.

 

I also think the OP's argument is conveniently deflecting the attention/blame from the GOP. They have made it clear that they have no interest in any input from the democrats. They intend to ram everything that they can through with the House/Senate/POTUS advantage that they hold. The AHCA was too much for even the moderates (and the far right) in the GOP to handle though.

 

It will be interesting to see how tax reform goes. This actually has potential (getting rid of the many ridiculous deductions and loopholes) to be a positive. Yes, there will be tax cuts and I disagree with that but there is a slight chance that some good could come from this. Unfortunately, at the end of the day I think too many politicians (both sides) are invested too deeply in special interests that they block the good and the tax reform bill becomes a travesty also.

 

The democrats should up their game though and stop simply obstructing the process. Whether they like it or not Gorsuch will be confirmed. If not him then someone similar. Whether they like it or not the ACA will be repealed and replaced. The GOP will find a common ground to make it happen at some point. They need to selectively pick their battles and focus their attention.

[Willihammer]

http://www.cnn.com/2017/02/03/politics/donald-trump-approval-rating/

 

This is going to be the most ineffectual administration of the last 50+ years. No president has come into office with less political capital, and its only going to go down, barring (god-forbid) another 9/11 type event.

[Brock Beauchamp]

 

http://www.cnn.com/2017/02/03/politics/donald-trump-approval-rating/

This is going to be the most ineffectual administration of the last 50+ years. No president has come into office with less political capital, and its only going to go down, barring (god-forbid) another 9/11 type event.

That article is from early February. Trump's approval rating is actually lower than that now... by 6-8 points, IIRC.

[Bark's Lounge]

 

Am I being naive?  Or is this a meaningful opportunity to find common ground on an issue where failure costs lives?

It can't hurt, but I can see where it won't help, but if one takes that point of view, their passions, wants and desires, and needs will be lost in the void. 

 

Things seems so screwed up right now, that I believe only the citizens of this nation can get us back on track... and I am not talking about voting, it has to be a lot more than that - a lot more. What that is, I am not quite sure.

 

The deck seems stacked against us, but usually you have to suck it up and go against the odds, and bet on yourself no matter the outcome.

 

You did a good thing Glunn. I should probably do the same. If anything, at least I did something.

[glunn]

On reflection, I agree that similar messages should be sent to Republican leadership. The reason that I initially focused on Franken and Warren is that I have been a significant contributor to their campaigns and to Franken's PAC. I see them as potential leaders in this effort.

 

I am glad that I posted this on TD. As I hoped, good ideas have been presented that have changed my thinking.

[glunn]

 

IMO Reform needs to come to the insurance companies and pharma companies before we can see a ton of change for the better in terms of pricing and fairness and a massive improvement overall.

Too many politicians on BOTH sides in the pockets of big pharma and insurance.

I agree with you Dave, and I would add big hospitals to that list. Too often, the big hospitals are acting with monopolistic pricing power. Also, because it may take 60 votes in the Senate to address those issues, bipartisanship may be necessary to get anywhere.

[TheLeviathan]

 

I agree with you Dave, and I would add big hospitals to that list. Too often, the big hospitals are acting with monopolistic pricing power. Also, because it may take 60 votes in the Senate to address those issues, bipartisanship may be necessary to get anywhere.

 

Yeah...but for how long?  Already Republicans are talking about having McConnell bypass that rule so they can push legislation through.  

[drjim]

I'm in favor of a week or two of celebrating upholding a good law and mocking the dumpster fire.

 

The time for new plans will come soon enough. In fact, Clinton had some ideas ready to go on day one. Dems can start with them. There is still space for a bipartisan maternity leave for example.

[drjim]

Also looks like Bernie Sanders will introduce "Medicare for all" which probably isn't a great idea overall, but is at least a start.

[glunn]

What about Trump's idea of allowing insurance companies to compete across state lines in order to foster more competition? Is this a good idea or merely a Trojan horse to allow further consolidation?

[drjim]

 

What about Trump's idea of allowing insurance companies to compete across state lines in order to foster more competition? Is this a good idea or merely a Trojan horse to allow further consolidation?

 

I don't think it's a Trojan Horse, it's just basically meaningless.

 

Insurance is still local, so each insurance company (of significant size) has a state "brand" of the larger umbrella organization. So for all practical purposes interstate competition already happening, just under different local names.

[PseudoSABR]

 

Also looks like Bernie Sanders will introduce "Medicare for all" which probably isn't a great idea overall, but is at least a start.

I just don't see any viable alternative to single-payer.  Get rid of the insurance companies, the for-profit hospitals, and disconnect healthcare from employment.  What's your beef with single-payer?

[drjim]

 

I just don't see any viable alternative to single-payer.  Get rid of the insurance companies, the for-profit hospitals, and disconnect healthcare from employment.  What's your beef with single-payer?

 

I mostly endorse single payer, just don't think Medicare for all is the best iteration - though I concede it might be the most realistic political option at the moment.

 

I personally would have extensive coverage for those under 18 and would drop Medicare to 55. In between (18-55) I would have state supplied catastrophic coverage, along with coverage for routine physical examinations and screenings. I would also have sate supplied maternity care from conception to 3 months after birth. For those that develop chronic diseases/conditions, I would have a public option for continuing care (to also cover disabled, mental illness, etc) that would probably be similar to Medicaid. I would anticipate the majority of these services would be provided via a single payer scheme (speciality clinics for check ups/screenings, maternity, etc).

 

Beyond that, I would have the option for private plus up, in order to either receive higher level of care for basic items covered above, or for providing true cost insurance for unexpected costs that would otherwise come out of pocket. There could be a public option for this coverage as well.

[DaveW]

Get rid of the insurance companies, the for-profit hospitals.

a noble thought, but too many powerful people make too much money of those things (including a high amount of our politicians)

 

Radical reform like this wont happen in a country that is so driven by capitalism. I think realistic options need to be discussed in the meantime. Sanders heart is in the right place, but his proposed bill is only going to further the divide.

[kab21]

 

I mostly endorse single payer, just don't think Medicare for all is the best iteration - though I concede it might be the most realistic political option at the moment.

 

I personally would have extensive coverage for those under 18 and would drop Medicare to 55. In between (18-55) I would have state supplied catastrophic coverage, along with coverage for routine physical examinations and screenings. I would also have sate supplied maternity care from conception to 3 months after birth. For those that develop chronic diseases/conditions, I would have a public option for continuing care (to also cover disabled, mental illness, etc) that would probably be similar to Medicaid. I would anticipate the majority of these services would be provided via a single payer scheme (speciality clinics for check ups/screenings, maternity, etc).

 

Beyond that, I would have the option for private plus up, in order to either receive higher level of care for basic items covered above, or for providing true cost insurance for unexpected costs that would otherwise come out of pocket. There could be a public option for this coverage as well.

This is the one area that the ACA failed and one reason that health care is so expensive. The ACA raised the minimum coverage and no longer allowed insurance companies to offer the catastrophic type insurance that you mention. I was off health insurance for about 2 years a decade ago and was able to purchase a plan that included some basic preventative checkups, the first $500 of expenses covered but nothing else covered until $5000 of expenses. This isn't great coverage but I had the piece of mind that my entire life savings (or complete bankruptcy) would be wiped out if I needed a major (or even a minor) operation. For example, I have heard of appendectomies costing 25,000-35,000. This happens to young and healthy people and you don't have time wait or shop around (if you could shop around).

 

things that need to be addressed for health care costs that neither side really focus on:

*transparent pricing so patients can shop around for different operations - almost impossible to find out costs at a certain clinic
*Less regulatory paperwork - clinics have far more staff doing paperwork than they have doctors/nurses - Trump is actually going after this

*Crack down somehow on trumped up malpractice suits

*Reduce the hoops needed to get a generic drug (or all drugs) approved - I can understand something that is new needing to be tightly regulated but it is very expensive (and lengthy) to get generics approved and many generics don't have pricing competition due to this (see martin Skumreli)

*more people that are price sensitive (cheaper insurance but with larger copays and less every day coverage) for medical care. This creates a price sensitive market instead of the current 80% that have decent insurance and don't give a ^%$#^$% how much the care they receive costs. They have good insurance and they want to get their money's worth out of it. The ACA and potentially a single payer system made this worse.

Of note I live in Taiwan and we have a single payer system here. It is great that everyone has decent coverage and it is one of the better systems in the world from everything that I have read but there are some drawbacks. I wouldn't trade it for the US system though. Even if I didn't have insurance I could still see a doctor without risking 100's of dollars just for a consultation.
 

 

[Mike Sixel]

I am going to start by saying I work for the largest insurance company in the US, and these thoughts are mine, and in no way endorsed by them.

 

1. Ya, well, prices aren't going up because of insurance companies. We take the costs, mark them up, and pass them on. costs are going up because people are living longer, drug costs are going up, and providers (docs and hospitals) have no interest in controlling costs at all as they consolidate and drive up the cost of care (they also have to pay for all that fancy equipment they buy). Seriously, yes, we make a bleep ton of money, but we make it by marking up escalating costs, not by escalating the costs.

 

2. Yes, if you cut insurance companies out, you'd cut some profit out. But, hey, MN only allows non-profit insurers (irony, given who is HQ there and supplies yuge numbers of jobs there), are the costs there any lower than neighboring states? I think not. Why? Because all insurance companies do is mark up the rising cost of care for a profit. While that might seem wrong/bad/evil, we do offer some important services (especially to those that don't get much healthcare, and done come from a background where it was important), and while I don't love all of what we do, I think we do add value.

 

3. Selling across state lines is nonsense. There are huge barriers to entry in insurance, there just aren't that many (any?) companies out there that don't sell where they want to sell. Also, since the states regulate the benefits in plans, how would that work? Can insurers that cross ignore those? If not, then it is just, um, nothing. States will let anyone that is solvent sell in their state, as long as they provide legal benefits (nearly anyone, I used to be in regulation).

 

I would endorse the following, until we can get single payer:

a. Universal catastrophic insurance, pick a threshold, the government sponsored insurance pays it all.

b: An account is created the day you are born (if already alive, it phases in for all of us over time) where the government puts 2-5K a year. That money is invested in the markets, and you can use it to cover education and medical expenses only (until some later time, when you can take out some profit but not principle). This is funded by cutting out various subsidies (including medicaid and medicare over time, but mostly for companies). I ran the numbers on this 30 or so year ago, and it worked then. Given our love of corporate welfare, it probably works even better now.

c: Even under this or single payer, there will be private insurance. People will want more. Also, a company like ours will probably run parts of the system. This stuff is infinitely more complex than most anyone can imagine.

[DaveW]

This is the one area that the ACA failed and one reason that health care is so expensive. The ACA raised the minimum coverage and no longer allowed insurance companies to offer the catastrophic type insurance that you mention. I was off health insurance for about 2 years a decade ago and was able to purchase a plan that included some basic preventative checkups, the first $500 of expenses covered but nothing else covered until $5000 of expenses. This isn't great coverage but I had the piece of mind that my entire life savings (or complete bankruptcy) would be wiped out if I needed a major (or even a minor) operation. For example, I have heard of appendectomies costing 25,000-35,000. This happens to young and healthy people and you don't have time wait or shop around (if you could shop around).

 

things that need to be addressed for health care costs that neither side really focus on:

*transparent pricing so patients can shop around for different operations - almost impossible to find out costs at a certain clinic

*Less regulatory paperwork - clinics have far more staff doing paperwork than they have doctors/nurses - Trump is actually going after this

*Crack down somehow on trumped up malpractice suits

*Reduce the hoops needed to get a generic drug (or all drugs) approved - I can understand something that is new needing to be tightly regulated but it is very expensive (and lengthy) to get generics approved and many generics don't have pricing competition due to this (see martin Skumreli)

*more people that are price sensitive (cheaper insurance but with larger copays and less every day coverage) for medical care. This creates a price sensitive market instead of the current 80% that have decent insurance and don't give a ^%$#^$% how much the care they receive costs. They have good insurance and they want to get their money's worth out of it. The ACA and potentially a single payer system made this worse.

Of note I live in Taiwan and we have a single payer system here. It is great that everyone has decent coverage and it is one of the better systems in the world from everything that I have read but there are some drawbacks. I wouldn't trade it for the US system though. Even if I didn't have insurance I could still see a doctor without risking 100's of dollars just for a consultation.

 

Kurt, your plan mentioned earlier is basically the same thing I have now (except the first $500 isn't paid) and the preventive measures it includes are weak. Deductible is 10k so I basically pay anything up to that amount.

 

My monthly premium is $430

 

Which seems outreagous for such ****ty coverage. At the end of the day though, I can afford it, even if I have a major issue and have to pay $10k, I feel a lot worse for people that can't afford the $430 a month or 10k more in a year.

 

**** like that for healthy under 35 year olds needs to change. I end up going to the doctor maybe once every 18 months anyways.

[Mike Sixel]

I'm sorry, but the market won't be price sensitive (something I've argued with our product and network strategists about, to little avail).

 

1. Less than 30% of US adults have a college education. You want them to argue with docs about procedures? You want them to shop around for the best deal, or the best healthcare?

 

2. This isn't an elastic product. It also is just the opposite, as the need/cost escalates, we need the product more. When we actually need the product, it is most expensive, and you can't just decide to not take drugs and be healthy if you need them.

 

3. This isn't some optional thing, like cheetos or twinkies. We can't just decide not to do it.

 

4. Because it effects everyone, because it is so expensive, and because it is unpredictable, we need to share the costs. That means healthy people will be annoyed they aren't getting their money's worth, and sick people will constantly be fighting to get everything they need (because the healthy people don't want their money wasted). This creates HORRIBLE incentives for every single party in the transaction.

[drjim]

Yup, "transparent pricing" is the ultimate red herring in health care reform, for all the reasons mentioned above.

 

"Cutting down on malpractice suits" is a close second. Any kind of meaningful reform on this would be such a small portion of the overall pie and would do nothing to change any of the structures.

 

I think an underrated aspect of the cost, as hinted at above, is the high cost of medical professionals. They have to be paid so much because their schooling is so expensive, but a not insignificant portion of health care costs is spent subsidizing our education system.