Health Care Reform

[WiseOne]

If it's a straight up switch to Medicare, the care wouldn't look any different from the viewpoint of a patient than it does now. The differences would be in the insurance premiums you pay and the bills you get afterwards. It's sort of like what will happen when you turn 65. You won't suddenly start getting "bad care". In fact, here's two problems you have now that will immediately go away: 1) no more in-network vs out of network headaches, and 2) your doctor says "before we can do this <procedure/test/med>, we have to get prior authorization from your insurance company."

There are a lot of details missing to be sure, like what's going to happen to Medicaid (currently 1/3 of NYS's budget, and a linchpin of the medical education system.) Sounds like the bills's sponsors are severely underestimating the complexity of what they've taken on. Kinda knew that, but I still like the idea and it could work if done right.

[Xan]

Okay... Except I don't have any of those problems now, because I'm paying for everything myself rather than through insurance. So when it's "free", it doesn't do anything except get more expensive, right?

[Kriegsspiel]

I think when a Democrat is starting from the position of "you can't have your own insurance, neener neener comrade!" it would be fun to see someone call their bluff. Really get wild with the Overton Windows.

"Fine. We accept. On one condition...

We release panthers, into every city, to cull the weak. None of those juveniles either. Adult predators. Also gun sales will be frozen from now until 3 weeks after The Releasing."

[Dieter]

Medicare for all seriously needs to happen....

Be careful what you wish for. You should talk to some Canadians before thinking that this is a good idea. Loooong waits to see specialists and have surgery are the norm there.

Long waits to see medical folks here in the US as well.

[WiseOne]

Okay... Except I don't have any of those problems now, because I'm paying for everything myself rather than through insurance. So when it's "free", it doesn't do anything except get more expensive, right?

If you're self-paying I assume you're talking about routine office visits and labs - but realize you're still paying for the insurance-imposed bureaucratic structure that surrounds these visits nows. Definitely agree that putting these outside the purview of insurance would reduce their costs and end up improving services. Having just one insurance agency with a simple billing structure to deal with, though, would be way better than the mess we have now and would also reduce costs - just not by as much.

Interestingly, the rapidly expanding world of telemedicine is pretty close to the self-pay utopia you're thinking of. Visits are in the $40-50 range and you pay for extra time if you're the type who just has to talk for 45 minutes nonstop, no need to deal with waiting rooms and getting to the office, and services are springing up everywhere. Watch for these to replace the phone calls that are the bane of every office practice's existence.

[jacksonM]

Medicare for all seriously needs to happen....

Be careful what you wish for. You should talk to some Canadians before thinking that this is a good idea. Loooong waits to see specialists and have surgery are the norm there.

Long waits to see medical folks here in the US as well.

I have a lot of Canadian friends and have visited there many times. When asked about their health care system, I've yet to hear one person complain about it. Actually, most of them seem to be proud of the fact that their system is so much better than ours.

[InsuranceGuy]

[deleted]

[Kbg]

Totally cool with above recommendations...and while we are taking things out, no limited liability corporations are allowed to engage in providing medical services.

[jacksonM]

If you're self-paying I assume you're talking about routine office visits and labs - but realize you're still paying for the insurance-imposed bureaucratic structure that surrounds these visits nows. Definitely agree that putting these outside the purview of insurance would reduce their costs and end up improving services. Having just one insurance agency with a simple billing structure to deal with, though, would be way better than the mess we have now and would also reduce costs - just not by as much.

Insurance-imposed bureaucratic costs are way lower than government-imposed costs. Please review the billing structure of Medicare/Medicaid if you think somehow they are winning. Better yet compare your benefits to government benefits and then visit your local DMV or Post Office to observe who we are spending these spectacular benefits on. I personally don't understand how we can trust a government to be efficient who has so consistently failed to perform as such.

One of my daughters and one of my grandsons are currently making their living off of the "Insurance-imposed bureaucratic costs" of private health insurance. They both handle pre-authorizations for services on the phone. My daughter has even become a supervisor and is making some decent money for the first time in her life.

So obviously I can't help but wonder what the impact of "Medicare for all" is going to have on their careers and how they handled this economic disruption in Canada when they transitioned to a government run system. Lots of people will be similarly affected, including my wife who is a licensed medical technologist working in a lab. Unlike my daughter and grandson, there will still be a need for people to do her job but there is no guarantee it will be her. Fortunately, I've been trying to talk her into retiring any way.

I tend to think all three of their jobs will eventually be eliminated any way however, if not by the government, then by automation so it's anybody's guess which will come first.

[yankees60]

Anyone here had any problems lately with the healthcare system?

I have not. I'm always amazed at how caring and angelic all the people are who attend to my needs when they arise.

Also, when you are Medicare supplemented by a Medigap plan ... the whole thing is way easier.

[dualstow]

Anyone here had any problems lately with the healthcare system?

I should mention it’s too early to tell if caleb is a bot. Nothing personal Just too early to tell.

But, giving the benefit of the doubt: my wife is currently overseas doing “medical tourism” because we’ve had so much trouble with the U.S. system and are very frustrated. Both getting appointments promptly and the wacky surprise billing.

[Xan]

I'm pretty sure it's a bot. But it's a decent conversation-starter!

[yankees60]

Anyone here had any problems lately with the healthcare system?

I should mention it’s too early to tell if caleb is a bot. Nothing personal Just too early to tell.

But, giving the benefit of the doubt: my wife is currently overseas doing “medical tourism” because we’ve had so much trouble with the U.S. system and are very frustrated. Both getting appointments promptly and the wacky surprise billing.

I live in a rural area where it is supposed to be even more difficult to get medical care.

However, with the medical group that I am with ... if I call in the morning for an appointment, I get one that day. Sometimes only a few hours later.

I was shocked last month when I was calling for an MRI appointment on Thursday and I was asked if I wanted to get one Saturday morning. Less than 2 days away. I think the CT scan was about a week later.

Now physical therapy appointments generally don't get granted until about a month or 1.5 months later.

But, in general, I've been fairly surprised with how not that far out I'm able to get medical appointments.

[dualstow]

I'm pretty sure it's a bot. But it's a decent conversation-starter!

Haha, I was thinking the same. Can we get some more bots trained on the posts of (seemingly) gone members? We could have a technovelist bot and a Machine Ghost bot. It’d be awesome— or is that already the case and I’m alone with a bunch of bots?

[dualstow]

I live in a rural area where it is supposed to be even more difficult to get medical care.
…
I was shocked last month when I was calling for an MRI appointment
… I was asked if I wanted to get one … Less than 2 days away.

The wife will be jealous, Vin. She got an MRI quickly, but I think you have her beat.
I like imagining your life in a rural area, where people tend to be relatively friendly to each other.

[yankees60]

I live in a rural area where it is supposed to be even more difficult to get medical care.
…
I was shocked last month when I was calling for an MRI appointment
… I was asked if I wanted to get one … Less than 2 days away.

The wife will be jealous, Vin. She got an MRI quickly, but I think you have her beat.
I like imagining your life in a rural area, where people tend to be relatively friendly to each other.

I guess that might be the stereotype? But how does that fit with the stereotype of Northerners not being as friendly as Southerners?

[Xan]

I'll take a crack at it. As a traditionally agrarian society, urban southerners retain more rural traditions than urban northerners, whose ancestors were manufacturing in big cities much earlier.

[I Shrugged]

I'll take a crack at it. As a traditionally agrarian society, urban southerners retain more rural traditions than urban northerners, whose ancestors were manufacturing in big cities much earlier.

I think it’s more about ancestry. The Scandinavians, Dutch, Germans were more self-sufficient, introverted, and reserved. They were and are nice, but in keeping with that framework.

[dualstow]

I guess that might be the stereotype? But how does that fit with the stereotype of Northerners not being as friendly as Southerners?

I had a housemate from California who complained that we upstate NY’ers were cold and unfriendly compared to CA. I think he was right, even if he is currently on trial for murder. (yeah, really)

[ochotona]

I'm going to delay retirement a few months until we have more visibility into health policy. "Concepts of a plan"... you can't plan on that, not with pre-existing conditions. I'm going to use COBRA, but if something catastrophic happens to my ex-employer, or they just decide to not offer health benefits anymore (unlikely but who knows?), I need ACA as a backup. I don't do anything without a backup.

But I think by end of 2025 as Congress winds down, I can make the leap, and Medicare starts for my wife April 1 2026, for me May 1 2026.

[barrett]

I'm going to delay retirement a few months until we have more visibility into health policy. "Concepts of a plan"... you can't plan on that, not with pre-existing conditions. I'm going to use COBRA, but if something catastrophic happens to my ex-employer, or they just decide to not offer health benefits anymore (unlikely but who knows?), I need ACA as a backup. I don't do anything without a backup.

But I think by end of 2025 as Congress winds down, I can make the leap, and Medicare starts for my wife April 1 2026, for me May 1 2026.

I am on Medicare but wife will be on ACA for another seven+ years. A huge help at the moment is that through the end of 2025 there is no ACA subsidy cliff. This is a decent summary:

<< For the first several years after the health insurance Marketplaces/exchanges debuted for 2014 coverage, the premium subsidy (premium tax credit) eligibility range was capped at household incomes of 400% of the federal poverty level (FPL). People with incomes above 400% of FPL were on their own when it came to paying for health insurance.

But that temporarily ended as of 2021, thanks to the American Rescue Plan’s provision that eliminates the “subsidy cliff.” And although that provision was scheduled to expire at the end of 2022, the Inflation Reduction Act (IRA) extended it through 2025. So the subsidy cliff has been eliminated for the time being. (Congress would have to act again to prevent the subsidy cliff from returning in 2026.) >>

This has been a huge help for us. Ocho, if you are unfamiliar with the cliff, it means that if your AGI is a dollar more than 400% of the Federal Poverty Level, you get zero subsidy and have to pay full price for your plan.

In our case, if Congress doesn't fix the issue (much less likely to happen under Trump), we will either have to try to limit our AGI or have my wife paying full price for medical insurance from 1/1/26 to 2/1/32. May be doable after SS kicks in for both of us in about four years, but not going to work after I have to start RMDs 1/1/31.

From what you wrote, it looks like the AGI challenge for you and your wife is only from 1/1/26 to 4/30/26, so maybe not a huge worry to pay full price for a few months.

[ochotona]

This has been a huge help for us. Ocho, if you are unfamiliar with the cliff, it means that if your AGI is a dollar more than 400% of the Federal Poverty Level, you get zero subsidy and have to pay full price for your plan.

In our case, if Congress doesn't fix the issue (much less likely to happen under Trump), we will either have to try to limit our AGI or have my wife paying full price for medical insurance from 1/1/26 to 2/1/32. May be doable after SS kicks in for both of us in about four years, but not going to work after I have to start RMDs 1/1/31.

From what you wrote, it looks like the AGI challenge for you and your wife is only from 1/1/26 to 4/30/26, so maybe not a huge worry to pay full price for a few months.

Thanks for pointing this out. I don't think my AGI will ever be low enough in retirement to catch the ACA subsidy, because I really need to pursue my long-term project of Roth conversion once I stop working. Wife's main health provider doesn't accept ACA plans (place into the "this should be illegal" folder), so ACA is really moot for us.

My aim is to have $0 in tax deferred assets by 12/31/2042. It will be Roth and some taxable. That's the plan anyhow.

[barrett]

Yes, agreed that it should be criminal not to accept an ACA plan. So sorry to hear that. On your other point, are you maybe Roth converting too much, or at least planning to do conversions for too many years? From what you wrote a couple of posts up, you are in the RMD at age 75 cohort, correct?

Obviously I don't know your numbers but it would seem likely that you would be paying too much in taxes if you are taking SS and RMDs while also doing additional Roth conversions. The first two (SS & RMDs) are not optional so any additional taxes paid on conversions should be considered to be at your marginal rate in any given year, right?

I frequently see on Bogleheads that a lot of people are planning to have some tIRA funds available later in life to tap for end-of-life care. My impression is that that can be done without paying taxes on the tIRA withdrawals but this is in the category of stuff I haven't researched yet.

[dualstow]

I didn’t know about any of this. My wife and I buy our own health insurance out of pocket. Not on the exchanges, though. We’ve always gotten a better deal from a broker. This month might be the first time I use the exchange, because our guy is missing in action.

Looks like 400% for a famlily of 2 is $81,760
https://www.medicaidplanningassistance. ... uidelines/

[barrett]

I didn’t know about any of this. My wife and I buy our own health insurance out of pocket. Not on the exchanges, though. We’ve always gotten a better deal from a broker. This month might be the first time I use the exchange, because our guy is missing in action.

Looks like 400% for a famliy of 2 is $81,760
https://www.medicaidplanningassistance. ... uidelines/

That is correct. My understanding is that you can't have $81,760 in earning PLUS the standard deduction. How AGI is figured for ACA premiums is very specific.

ETA, Dualstow... Just to reiterate, ACA premiums are capped at 8.5% of income for both 2024 & 2025. This site lays that out quite clearly:

https://www.healthinsurance.org/obamaca ... idy-cliff/

So, what that might mean is creating a cash buffer if you were going to be on the ACA plans into 2026 and beyond. By doing this one could make it easier to stay under the 400% of FPL beyond 2025 because it may not be as necessary to pull from investments if one has money to pay for bills for a few years. Hope that makes sense.

I haven't seen Tyler post on here for ages but I believe he is the Yoda of all things ACA.