Just need to vent...

They appear to have incentivized poverty very effectively.

 

Well that's always necessary when the goal is to turn USA to a socialist country. Has there ever been an extreamly well-to-do country that has switched, otherwise? or is it just when country's finances begin to collapse

 

why do they have to be connected?

 

are you saying the current government couldn't do a great job with it?

 

2 out of 3 ain't bad. In reverse order:

• "tax free HSAs coupled with high deductible policies". Implemented. I've got one.
  
  The part about getting "patients to behave more like consumers" is still a bit of gaslighting at this point, given that the patients' ability to get reliable cost information in advance is still really spotty, and it's still not uncommon for the number (even after the original bill has been paid) to change by hundreds or thousands of dollars, or the provider and the insurer both tell the patient they haven't agreed on something, and it becomes the patient's job to either pay the difference or solve their problem and get them to agree, when the one person who never saw and can't get any of the messages exchanged between the provider and insurer is the patient.
  
  Nothing that couldn't be fixed by suitably strict and enforceable regulation, and if that existed, then the "patients to behave more like consumers" idea could become realistic enough to live up to the hype.
  
  
• "decoupling medical insurance from employment so it could be portable from job to job". Partially implemented, thanks to ACA. Larger employers are still expected to offer an employer plan, but as an employee, you no longer have to shape your career plans around whether you'll be able to afford healthcare during a career shift.
  
  
• "opening the insurance market to interstate competition". So far not implemented, which is fine with me, since that slogan is really a dogwhistle for gutting insurance regulation, using the playbook we already saw before when we all lost usury protection on credit-card interest rates. (Some credit-card issuers formed up in states with lousy or nonexistent usury laws, and then argued to be allowed to operate under the same terms in all states.)

The key thing making insurance regulation important is that insurance is an unusual kind of business. In most businesses, you have a product or service that you sell to customers, and you have the price set so as to expect each transaction and each customer account to be profitable.

The whole nature of insurance is that you have a whole 'book of business', a bunch of customer accounts where most of those accounts will make you positive money any given year but some of them won't. You need to price your premiums so that you make your expected profit on the whole book of business, and that's the reason you hire actuaries, and have your book of business include a variety of people you don't expect to have large expenses at the same time. But you never expect each customer to be profitable each year, because if that was happening, what you're selling wouldn't be insurance.

And it becomes something common to see, any time healthcare reform is being debated, where insurance-company flacks say the quiet part out loud and complain how the mean ugly regulations are making them have some customers in their book of business who don't always make them money. They'd probably stop playing for sympathy like that if enough alert people in the audience said "well, right, you're an insurance company." But as long as audiences include enough people who have forgotten (or never knew) what insurance is, they get enough sympathetic "awww"s to be worth continuing the play.

In effect, insurance companies would basically love to forget about the pooling of risk (which is what makes insurance insurance), and instead be installment-financing companies for each person's own health expenses (whether you are or are not a person a tree falls on or cancer strikes). And the one basic, overarching job of insurance regulators is to keep saying "yes, well, you know what, you're an insurance company."

 

• 
  1st yr they were offered - all money not spent by the end of the year got to be kept by carrier. That's legal stealing! If expenses weren't so over scrutinized, it would have been easier to plan to get all the money spent down out of the account Later on they changed it to at least 2 years but who knows how many folks still get short-sheaded by that kind of nonsense.

 

What might not be great is an insurance federalization passed with bipartisan opposition, but then blaming republicans for what passed.

Not everyone has to be thrilled with the McCain proposal, but it would be odd to maintain that it hadn't been proposed.

Pricing regulation can fix bad pricing in theory, but allocating that authority to some part of government has an unhappy history ranging from poor municipal spending to military procurement.

On the other hand, consumers appear to wield considerable authority where they have an array of options offered but not compelled from multiple providers for hamburgers, clothing and appliances as well as procedures typically not made more opaque by the insurance process like laser eye surgery or liposuction.

Some systems have reduced price opacity somewhat with a quote for a procedure that includes the overall price and the net payable by the patient. I agree that many places don't offer the same kind of price competition as you'd have in buying a dishwasher from one of the dozen Home Depots or Lowes in every urban area, but making consumers insensitive to price is unlikely to help them choose like consumers.

Employer paid medical insurance premiums still aren't taxed as compensation to an employee because labor unions were part of the political process that shaped the ACA. I don't believe the ACA has profoundly changed calculations about the affordability of medical insurance. The result seems to be high deductible/high premium insurance for those in the individual market.

We have interstate competition for 529 plans, and that latitude seems satisfactory for people who use them.

Insurance companies are very easy to hate. My doc friends hate that they hire people whose only job is to follow up with ins companies for payment, and those same docs are gullible enough to believe that "out of control malpractice suits" are why they pay high malpractice insurance premiums. Policy holders may hate ins companies for the outrageous premiums they pay and how hard it can be to deal with ins company people whose whole job it is to be a lying PITA.

As long as there are a number of insurance companies from which to choose, no one of them has the power to ruin one's life the way the government does. People frustrated by insurance companies turning to government for less callous deception and waste haven't spent enough time dealing with government.

 

Tell me where in your experience have you seen prices posted at a hospital or doctor's office? And how would you know what procedure you would need when arriving? You can price things like glasses or a tooth extraction. But walk in with a chest pain and it could be heartburn or it could be heart surgery.

Even comparing insurers is hard enough because you don't know what medicines or procedures or tests you'll need that year so seeing a list of items covered and their payment rates? Good luck.

I used to get my $4,000 every two weeks medicine for free, now it costs $120. Why? Did I hit some threshold? I have no idea.

Just like I have little idea day to day how my taxes are affected by legislation. Does TurboTax give you a statement about how your taxes would have been last year under last year's rules and compare it to this year's rules? No. So am I an informed voter when a politician claims hos votes saved me $1000? Ha.

So you can easily compare MacDonald's and Wendy's. But when it comes to medicine ... it gets a bit challenging.

 

In the Cleveland Clinic system, one can email or call about the cost of an upcoming procedure and receive a quote for the total amount and patient balance after insurance is applied. Non-emergency procedures like colonoscopies or periodic check-ups are typically scheduled well in advance.

Pre-ACA, I let people I hired shop for their own plans that would pay for the things they thought most useful. I had one girl who prioritized a plan with excellent prescription benefits so that's what she got, and she was thrilled with it.

I have some things covered sometimes and I'm not sure why, but opacity and complexity are different issues even if the result is the same, patient confusion.

The frustrating thing about contact with a hospital can be specific charges that don't bear on any kind of reasonable price, like a $35 tylenol. A couple of years ago I got the bill for surgery and one of the line items was $14.95 for fentanyl. The streets are awash in this stuff, but it cost me $15?

The complexity of policy terms is another reason insurance companies are easy to hate.

Yes, it's more challenging.

 

Outlets are cheap enough. You can even get them second hand at a Habitat for Humanity ReStore. The lower voltage could have come from any poor connection, anywhere all the way back to the breaker. You probably could have fixed the problem by tightening the screw terminals

 

It certainly is but all of those variable costs Ah-lah heartburn versus heart attack versus ancillary causes of either can all be crafted out even between healthy people & co-morbidly & fat people &/or folks w/ immunocompromisation. Oh wait - can we actually charge more for people who put themselves in many of these bad situations? Or charge them less when they have historically avoided all comorbidities?

 

UPS, Amazon, and FedEx don't have to meet the same pension accounting requirements that Congress has imposed on USPS. The first two don't even offer pensions to the frontline worker bees.

Last I heard, nobody else has to meet the same requirements as USPS.

 

Pricing regulation isn't the only kind of regulation, and isn't the kind I had in mind here. The kind of current abuses I was describing would be most effectively addressed, not by regulating what the prices should be, but by forbidding the shenanigans used to conceal the pricing before service, change it after billing and payment, and stonewall the patient who needs to solve problems between provider and insurer.

For most of my life, that would have been a stunningly naïve thing to say. Whenever you have a health insurance company working at ruining your life, it's safe to say your health condition now presents large expected expenses; they always like you when you are a profit-making customer sending them premium checks, and they treat you very sweetly.

For most of my life, once you found yourself being treated unsweetly by your current insurer, you had the option to leave them, be uninsurable due to preexisting condition, and die. (We may quibble about whether this counts as ruining your life; is there a 'ruined' life where there is no life?)

With the passage of HIPAA in my early thirties, that became sort of half-fixed: there was then a magic 63-day period that could save you from being declared permanently uninsurable for preexisting condition, if you managed to switch from your old to a new insurer with proof that 63 days hadn't passed. The insurers easily learned how to slow-walk your application and/or payment processing past day 63, leaving you, as before, the option to die. An insurer came within two days of winning that play against me, and that was with me having the advantage that a firm that was one of their largest accounts had arranged for my policy, and ultimately got the insurer's VP to apologize to me. If I had been at a smaller firm or had an individual policy, fuhgeddaboudit.

The rest of the fix had to wait for the ACA. It is now, at long last, sensible to talk about having meaningful choice among insurers—as long as you're talking about ACA plans, or non-grandfathered MEC plans that meet ACA's preexisting coverage requirements.

 

I think you must be thinking of FSAs. I didn't think HSAs ever had the use-it-or-lose-it deadline, and Gemini tells me "HSAs were signed into law as part of the Medicare Prescription Drug, Improvement, and Modernization Act. From the beginning, they were intended as a long-term savings vehicle where unused funds would roll over indefinitely."

That's my favorite thing about them. You can't build one very quickly at first, because the annual contribution limits are crazy small compared to, you know, anything healthcare. But if you fund them as aggressively as you can at first, and avoid making withdrawals in those earliest years, you start to see the effects of compound growth, and then it's a different story. I like that mine can now cover the expenses I take each year out of its own growth.

 

I'd agree that what amounts to consumer protection codes applied to medical care networks can help people make smarter choices.

I don't know your age, but medicaid has been around for 60 years. Being privately uninsurable hasn't meant a death sentence for you for most of your life if HIPPAA was enacted in your 30s. There is no medical insurer who can stop you from getting medical treatment. On the other hand, both state and federal government have the power to apply criminal process against you, put you in a cage for the rest of your life or put you in a position in which its agents kill you. It wasn't United Healthcare that showed up a Brian Malinowski's home.

The language to which you responded isn't a declaration that insurers are wonderful, but that governments can be very rough things by which to be mistreated, and the option to enroll with another government will rarely be available.

 

GREAT IDEA. Thank you
kris

 

McCain's complicated health care legacy: He hated the ACA. He also saved it.
McCain's complicated health care legacy: He hated the ACA. He also saved it. | PBS News
​

After you read the article you should see that everything put out by McCain was hated and hammered by his party.

• If implemented in 2009, McCain's proposal is estimated to reduce the number of people who are uninsured by 1.3 million at a cost of $185 billion, though this does not include the effects of high-risk pools. About 20 million people would lose employer coverage under the McCain proposal, and 21 million would gain coverage in the individual market. Obama's plan is estimated to reduce the number of uninsured people by 18.4 million in 2009 at a cost of $86 billion.
• In the first year, McCain's plan is estimated to cost more than twice as much as Obama's while covering 17 million fewer people because most of McCain's tax credits would likely be used by people who already have private health insurance.
• By 2018, McCain's plan is estimated to reduce the number of uninsured by just 2 million out of projected 66.8 million uninsured at a cost of $64 billion. Obama's plan is estimated to reduce the number of uninsured by 33.9 million in that year at a cost of $237 billion.
• Over the 10-year period, the Center estimates that the total federal cost of McCain's plan could reach $1.3 trillion and the cost of Obama's plan could reach $1.6 trillion.
• McCain's proposal is estimated to cover fewer people in future years and cost less over time because the tax credits would grow at the rate of consumer prices, which have historically grown more slowly than medical expenditures. This means that, over time, the value of the tax credits is expected to decline relative to premium costs. This has two implications: 1) fewer people would be able to afford to buy health insurance with their tax credits and 2) people with employer coverage will pay more taxes on employer-provided premium contributions, thus offsetting the federal government's cost of the tax credits over time.
• The Center estimates that McCain's high-risk pool proposal, if adequately financed, could add another $1 trillion to the cost of his plan over 10 years. This feature is likely to be expensive for two reasons: 1) allowing people to buy coverage across state lines would remove existing consumer protections in some states, leading many people who currently have coverage through those markets to the high-risk pools and 2) many people with health problems who lose employer-based coverage under McCain's proposal would seek coverage in high-risk pools.

LOL@ YOU. ... It is really stupid to compare the ACA with Universal Healthcare. But that's OK. Do what you want.

 

I appreciate you cutting and pasting Chusid's 2008 article rather than the 2018 PBS article to which you linked.

You appear to have forgotten what you asked as well as how the ACA was passed.

 

Back to the "is death ruin" question, I guess. What would have had to happen to make me in my thirties into a qualifying Medicaid recipient might, granted, be distinguishable from death, but not so much from ruin.

True enough in a general abstract sense, but multiple things can be simultaneously true, and my experience most of my life has been that the different incidence of mistreatment by corporations or by the government has been stark and unmistakable, and not in the direction you suggest. It has never even been surprising to try to contact a corporation and find some impassable phone tree and anonymous service reps and deceptive fine print and whatever kind of chicanery a government regulator wasn't around to stop them from doing. (The same health insurer that wanted me dead in my thirties had some nifty rule about their phone service reps being named Crystal. If you asked for the name of the rep you'd been talking to for your records, it was Crystal, so then the next time you called, you could be sure to ask for Crystal again, and be told "of course" and connected to some other random rep with no knowledge of your issue.)

For nearly all of my life, I have been met with nothing but professionalism, courtesy, and competence any time I have had any need to contact someone in federal government. They all had real names, you could find them in org charts, they gave straight answers to questions, called back when they said they would. The few times anyone from IRS ever contacted me were mostly to correct mistakes I'd made in their favor and increase my refund. The people at HHS that I contacted during my 61 days of BS from the everyone-is-Crystal insurance company, those people at HHS were great.

Of course, we now get to look forward to learning the real meaning of "run the government like a business."

So far, the main effect I've noticed is being unable to reach anybody at OPM retirement services, There aren't a lot of them left, and the ones still there are handling the "retirements" of a quarter million other federal workers who got DOGEd. Doesn't leave anybody much time to answer my questions about a paltry sum from my few years of federal employment in the '90s....