RyanCare/TrumpCare

[Pointedstick]

Thoughts? My first impressions are that it's an embarrassing trainwreck. After (accurately) crowing for 7 years about how horrible Obamacare is, the GOP leadership puts together a bill that keeps the same basic structure but just tweaks where the money goes to and comes from. Still got the marketplace, still got subsidies for coverage, still got penalties for going uninsured, no improvements at all to the basic problems of high costs, cost shifting, price transparency, or the gaping maw of the medical regulatory bureaucracy. It's still a cronyistic nightmare that picks winners and losers.

It seems like most of the congressional Republicans are revealing that what they hated most about Obamacare was that it was passed by the Democrats, not themselves.

[Tyler]

A few things:

1) The bill is written in such a way that it can pass via reconciliation. So all the things the right really wants (sales across state lines, totally overhauling regulations, etc) aren't possible in the bill. Demanding them as a litmus test for passing any bill means demanding that they negotiate with Dems. Good luck with that.

2) Straight repeal is not politically possible because it would strip coverage from millions. Also, the individual market before the ACA totally sucked and was downright exploitative in many cases. It's a non-starter, and is why Republicans have always talked about repeal and replace.

3) What exactly did hard-liners think "replace" actually meant?

Now whether the doable via reconciliation details of the bill make sense is certainly up for debate. Some sort of guaranteed coverage for preexisting conditions (provided people maintain continuous coverage) is virtually guaranteed to be in any future plan, so that shouldn't surprise anyone. I personally think the 30% premium penalty for one year for those who sign up for insurance only when they get sick is laughably low to incentivize young people to maintain coverage. I also have mixed feelings about the subsidies, as I understand many people need them to afford insurance and much prefer the age-based rate for overall fairness but also believe they only serve to drive up prices. But those types of issues seem fixable without throwing the whole thing out.

Overall, I see the proposal as a concession that changing the healthcare system simply can't be done all at once. I understand why people would dislike the bill in the surface, but I'm not sure doing nothing until Republicans hope to have a super-majority in the senate after 2018 is a tenable plan. "Watch the world burn" is a pretty terrible strategy when you hold the house, senate, and White House. All voters see is complacency. I personally hope that Republicans get their act together and negotiate something reasonable to get us moving in the right direction asap.

[flyingpylon]

2) Straight repeal is not politically possible because it would strip coverage from millions. Also, the individual market before the ACA totally sucked and was downright exploitative in many cases. It's a non-starter, and is why Republicans have always talked about repeal and replace.

If I'm not mistaken, repeal is also not possible because the Republicans don't have 60 votes. So there's really no option but to try to do things in phases and the reconciliation process limits what kinds of things can be done.

[dualstow]

Side question: who gets the website creation contract this time?

[Pointedstick]

Now whether the doable via reconciliation details of the bill make sense is certainly up for debate. Some sort of guaranteed coverage for preexisting conditions (provided people maintain continuous coverage) is virtually guaranteed to be in any future plan, so that shouldn't surprise anyone. I personally think the 30% premium penalty for one year for those who sign up for insurance only when they get sick is laughably low to incentivize young people to maintain coverage. I also have mixed feelings about the subsidies, as I understand many people need them to afford insurance and much prefer the age-based rate for overall fairness but also believe they only serve to drive up prices. But those types of issues seem fixable without throwing the whole thing out.

So suddenly Obamacare isn't so bad, huh?

That's what's so weird to me. For years conservatives have been voicing cogent criticisms of the law: it's full of perverse incentives; increases the bureaucratic burden on doctors; forces people to buy a product provided by the private market; acts as a permanent subsidy to the insurance industry; etc. Suddenly most of those critics have gone silent, with the exception of perennially-ignored tricksters like Rand Paul.

I don't even see a fig leaf to fixing the actual underlying problem: that retail health care is too expensive in the first place. Instead it's yet another big government program to attempt to mitigate the consequences of this very basic problem with very little hope of succeeding--just like its predecessor.

I get that there are political realities in play, but that's exactly what the Democrats said in 2010 when they passed the original. It strikes me that this kind of sweeping lawmaking it just fundamentally a bad idea.

[Pointedstick]

As for the fact that they can only do certain things with Reconciliation, I see this as a dirty trick, abusing the process to push through something they know would get filibustered. If they're willing to play dirty, why don't they just get rid of the filibuster? Serious question.

Heck, I remember a time when it was possible to pass bills with a majority vote because the minority party side didn't filibuster every single thing their opponents supported. IMHO, either the filibuster should be gotten rid of, or else you should need 60 votes to pass anything in the Senate. The status quo is just ridiculous.

[farjean2]

After (accurately) crowing for 7 years about how horrible Obamacare is, the GOP leadership puts together a bill that keeps the same basic structure but just tweaks where the money goes to and comes from.

I think the average GOP voter didn't need the 7 years of the Obamacare fiasco to realize how full of shit the Republicans were when in it came to what they say as opposed to what they actually do. And that's basically the reason Trump is president today, having vanquished the likes of Bush, Rubio and other "establishment" figures. With Trump I think the voters might have thought there was actually a slight chance that the actions would live up to the rhetoric for a change. I guess time will tell.

[Pointedstick]

Yeah, but Trump is putting his weight behind this turd.

pass the turd polish it later

doesn't seem any better than passing it to find out whats in it...

[Pointedstick]

Personally it will hurt since we're on Medicaid and don't pay a penny for anything right now. But I don't care about that. I think it's ridiculous that we're on Medicaid. I don't mind getting kicked off Medicaid; what I mind is the lack of any sanity in what they're planning to implement instead.

It looks like my family would get $9,000 a year in tax credits to buy insurance. I don't know how much that would defray the cost of a family insurance plan, but I do know that $9,000 is almost twice as big as the biggest tax refund I've ever gotten. The maximum family credit total is $14,000 (!!!). I strongly suspect that the cost of insurance is going to somehow magically rise to exactly capture 100% of the tax credit in cases where it would currently or otherwise be lower. The amount of money that will flow straight to the insurance companies is unbelievable.

[Pointedstick]

Yeah, I understand. It's a bad system. When healthcare is in essence socialized, the insurance companies no longer serve any useful purpose, it appears to me. They simply skim tons of money out of the system and return little value. We should go ahead with single payer and stop paying the insurance companies if we want socialized healthcare.

Exactly. Let's have single-payer with no insurance, or a real free market that lets insurance be insurance again. This crappy cronyistic combination is the worst of both worlds.

[Tyler]

So suddenly Obamacare isn't so bad, huh?

Well, as a user of Obamacare the last few years, I can say it has worked for me. Is it sustainable? Clearly no. But I also know that the individual market prior to the ACA wasn't so hot for patient's rights and I'd prefer not to completely turn back the clock. There are certainly much easier ways to address those things without the full ACA, though.

For the early retirees (Tyler, PS and others), do you see this bill materially changing your healthcare costs, if it passes?

I don't use Medicaid, preferring to game my MAGI using investments to stay over the threshhold for purchasing insurance normally while maximizing subsidies. We get about $6k now, which covers most of our costs. Based on the Ryancare proposal we'll be eligible for $6k, so that's a wash. The deductibles will go way up, but that doesn't really worry me. Now whether prices will keep rising overall is anyone's guess (I assume they will).

Honestly, I'm confident I can handle almost anything they roll out. My budget is very conservative with room to grow if necessary. The only thing that worries me is the prospect of eliminating the coverage for preexisting conditions in a way that restricts portability even for those who maintain continuous coverage. But as long as that's part of the package, I'll be fine.

BTW, Rand Paul just released his own plan. https://www.paul.senate.gov/imo/media/d ... ctions.pdf It also seems pretty reasonable and would meet my needs, especially if it results in more affordable options becoming available.

[dualstow]

That must be pretty recent that you're on Medicaid, PS. You earned too much to qualify, I would think.

[ochotona]

If the GOP doesn't manage blowback properly they could get trimmed in 2018.

[Pointedstick]

That must be pretty recent that you're on Medicaid, PS. You earned too much to qualify, I would think.

Yes, my post-ERE budget puts us in the range in New Mexico where you're not eligible to buy into the marketplace and you need to go on Medicaid instead.

[WiseOne]

Yeah, I understand. It's a bad system. When healthcare is in essence socialized, the insurance companies no longer serve any useful purpose, it appears to me. They simply skim tons of money out of the system and return little value. We should go ahead with single payer and stop paying the insurance companies if we want socialized healthcare.

Bingo.

I just don't see any realistic alternative to Obamacare that doesn't follow one of two paths: 1) single payer national health insurance, or 2) wean us off insurance for all but expensive catastrophic or chronic conditions and hospitalizations. I was really hoping that the talk about price transparency and competition would translate.

Option 2 btw is more realistic than you might think. Paying for routine office visits in cash would drop prices drastically, at least 50% if not more. Gone would be the arcane documentation requirements, the 30% off the top that goes to billing/collecting services, need for insurance pre-approval and PMD referral, etc. Price competition would drive down costs still further. Similar good things would happen to costs of pharmaceuticals especially generics, if the government put some effort into dealing with monopoly pricing, and allowed US citizens to import drugs from overseas.

Some of the problem of increasing medical cost is the re-definition of illness to mean "anyone still alive". We've gone way overboard on the extensive cancer screening programs and preventive medications. Life expectancy in the US has decreased despite all this, so clearly much of it is useless. It's well past time to evaluate which of these actually provides worthwhile benefits. That was vaguely part of the Obamacare goals, but it was implemented so badly it just became more money thrown out the window.

[Tyler]

As much as I wish Mark Cuban would shut up about politics (and I'm a Mavs fan), I really like his proposal for health insurance.

http://blogmaverick.com/2017/03/08/some ... is-please/

Basically, he proposes single payer for chronic physical or mental illness and for any life threatening injury, and let truly free-market insurance cover everything else for people who are interested.

[Maddy]

I just don't see any realistic alternative to Obamacare that doesn't follow one of two paths: 1) single payer national health insurance, or 2) wean us off insurance for all but expensive catastrophic or chronic conditions and hospitalizations. I was really hoping that the talk about price transparency and competition would translate.

Option 2 btw is more realistic than you might think. Paying for routine office visits in cash would drop prices drastically, at least 50% if not more. Gone would be the arcane documentation requirements, the 30% off the top that goes to billing/collecting services, need for insurance pre-approval and PMD referral, etc. Price competition would drive down costs still further. Similar good things would happen to costs of pharmaceuticals especially generics, if the government put some effort into dealing with monopoly pricing, and allowed US citizens to import drugs from overseas.

Some of the problem of increasing medical cost is the re-definition of illness to mean "anyone still alive". We've gone way overboard on the extensive cancer screening programs and preventive medications. Life expectancy in the US has decreased despite all this, so clearly much of it is useless. It's well past time to evaluate which of these actually provides worthwhile benefits. That was vaguely part of the Obamacare goals, but it was implemented so badly it just became more money thrown out the window.

WiseOne, I like the way you're thinking on this. Regarding the useless screenings and expensive end-of-life care: I'm betting that with a return to the "self-pay" model, these concerns would take care of themselves. If people had to pay out of pocket, we'd start seeing very rational utilization patterns and perhaps even healthier lifestyles.

[WiseOne]

I just don't see any realistic alternative to Obamacare that doesn't follow one of two paths: 1) single payer national health insurance, or 2) wean us off insurance for all but expensive catastrophic or chronic conditions and hospitalizations. I was really hoping that the talk about price transparency and competition would translate.

Option 2 btw is more realistic than you might think. Paying for routine office visits in cash would drop prices drastically, at least 50% if not more. Gone would be the arcane documentation requirements, the 30% off the top that goes to billing/collecting services, need for insurance pre-approval and PMD referral, etc. Price competition would drive down costs still further. Similar good things would happen to costs of pharmaceuticals especially generics, if the government put some effort into dealing with monopoly pricing, and allowed US citizens to import drugs from overseas.

Some of the problem of increasing medical cost is the re-definition of illness to mean "anyone still alive". We've gone way overboard on the extensive cancer screening programs and preventive medications. Life expectancy in the US has decreased despite all this, so clearly much of it is useless. It's well past time to evaluate which of these actually provides worthwhile benefits. That was vaguely part of the Obamacare goals, but it was implemented so badly it just became more money thrown out the window.

WiseOne, I like the way you're thinking on this. Regarding the useless screenings and expensive end-of-life care: I'm betting that with a return to the "self-pay" model, these concerns would take care of themselves. If people had to pay out of pocket, we'd start seeing very rational utilization patterns and perhaps even healthier lifestyles.

Yes - if government and/or physicians can't convince people that a particular preventive test or treatment is worth their hard-earned money, precious time & missed work, and the associated pain & suffering, then it shouldn't happen - period! End of life care is a separate issue, because it usually happens in the setting of a condition that should be covered by a government insurance plan. It is an obvious target for reducing costs, but the truly egregious things like the massive expenditures for administrative overhead and inflated pharmaceutical costs should be higher priority.

[Libertarian666]

Yeah, I understand. It's a bad system. When healthcare is in essence socialized, the insurance companies no longer serve any useful purpose, it appears to me. They simply skim tons of money out of the system and return little value. We should go ahead with single payer and stop paying the insurance companies if we want socialized healthcare.

Bingo.

I just don't see any realistic alternative to Obamacare that doesn't follow one of two paths: 1) single payer national health insurance, or 2) wean us off insurance for all but expensive catastrophic or chronic conditions and hospitalizations. I was really hoping that the talk about price transparency and competition would translate.

Option 2 btw is more realistic than you might think. Paying for routine office visits in cash would drop prices drastically, at least 50% if not more. Gone would be the arcane documentation requirements, the 30% off the top that goes to billing/collecting services, need for insurance pre-approval and PMD referral, etc. Price competition would drive down costs still further. Similar good things would happen to costs of pharmaceuticals especially generics, if the government put some effort into dealing with monopoly pricing, and allowed US citizens to import drugs from overseas.

Some of the problem of increasing medical cost is the re-definition of illness to mean "anyone still alive". We've gone way overboard on the extensive cancer screening programs and preventive medications. Life expectancy in the US has decreased despite all this, so clearly much of it is useless. It's well past time to evaluate which of these actually provides worthwhile benefits. That was vaguely part of the Obamacare goals, but it was implemented so badly it just became more money thrown out the window.

Of course this plan is garbage, but it doesn't look likely even to pass the House, because the Freedom Caucus is against it. In the Senate it is DOA due to several Rs saying they will not vote for it.

Hopefully this means something like your option 2 would be the next step.

[Maddy]

The term RINOcare is catching on. I like it.

[dualstow]

The term RINOcare is catching on. I like it.

Repeal In Name Only, but it sounds like nasal maintenance. I guess that would be Rhinocare.

[Libertarian666]

One thing that I'm trying to wrap my mind around in the desire to reduce health care costs (which I'm certainly in favor of)...

Since everyone's spending is someone else's income, who exactly will end up losing income when health care costs are reduced? Will the loss in income be spread around proportionally? What I'm afraid of is that the cuts end up hitting those who are actually delivering the care. That is, there will still be multiple layers of administration, but fewer doctors, nurses, and technicians.

If health insurance other than for catastrophic events were to disappear (which it should), then prices would go WAY down and administration costs would almost disappear.

[Pointedstick]

The problem is that in the USA, administration costs can't disappear, or else American households go bankrupt.

Most of these admin jobs are worked by women. If you find a way to cut that fat, those women lose their jobs and their households lose their second incomes. Then the McMansion gets foreclosed on and the 3rd vehicle (a crew cab truck, naturally) gets repossessed. Upset that Apple cart and political careers get destroyed. Politicians know this, even if only intuitively.

You cannot cut the fat anymore. People's fragile livelihoods depend on that fat.

[Pointedstick]

Sometimes pain is necessary. Death paves the way for new growth, and all that. But there ain't never been a politician who won on that platform.

[Libertarian666]

The problem is that in the USA, administration costs can't disappear, or else American households go bankrupt.

Most of these admin jobs are worked by women. If you find a way to cut that fat, those women lose their jobs and their households lose their second incomes. Then the McMansion gets foreclosed on and the 3rd vehicle (a crew cab truck, naturally) gets repossessed. Upset that Apple cart and political careers get destroyed. Politicians know this, even if only intuitively.

You cannot cut the fat anymore. People's fragile livelihoods depend on that fat.

This is Keynesianism, which has been proven beyond doubt to be completely foolish. Paying people to dig holes and fill them in cannot make the country wealthier, and this is of the same level of valuelessness.

So if you don't have a better argument against getting rid of waste, you don't have an argument at all.