Republicans essentially are the government - one party rule. Yes I know that a good 30-35 percent of people out there will blame so much as a rainshower that cancels a picnic on Obama but Trump was made possible largely by indifference of centrist voters.
Apparently, per the WP, this is in fact what the Republicans are thinking of doing, if they can’t pass their replacement version.
I’ve been watching conservatives freak out on several levels over this health care plan.
At the top is the notion that conservatives want nothing less than a full repeal of the ACA, which is Act 1 of getting the government out of health care. Once the federal government is out of it, health care emerges as a free market industry and costs go down. (“Capitalism – it works every time it’s tried.”) Also, health care is not a right enumerated in the Constitution, and only liberals think it is.
There is dissatisfaction with Republicans in Congress for promoting Obamacare Lite, also referred to as Ryancare/Trumpcare, over the objections of the party base, which they know is to avoid political fallout and the accusations of letting people die untreated. This is the last straw for many of these conservatives and they intend to leave the GOP and its establishment RINOs, and seek other orgs that better reflect their values. (One recommends the Federalist Party to the rest of the group.)
The plan itself is flawed by retaining many of the ACA provisions and gutting revenue generators that had offset costs, making it more expensive than Obamacare (expressed in the comments of the thinkers in these groups.)
So, all that being said, complete repeal is a non-starter, it’s out of the question and the Tea Party dies on this hill.
A lot of voters strangely don’t understand how legislation works, at all. For like the last 6 years of the Obama Presidency I read two separate things, in mass numbers:
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A vast stream of people who said Obama was a centrist, not a progressive, not an ally of the left because he hadn’t implemented any sweeping reforms. Basically that he had betrayed the progressive who voted for him. This ignores the fact that the Republicans were refusing to pass laws, that if not passed, would cause us to default on our debt and plunge the world into economic chaos. And yet, it’s Obama’s being a traitor that stopped an increase in the minimum wage level? Or more robust response to climate change?
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A vast stream of far righties who said congressional Republicans were liars, since they hadn’t repealed Obamacare like they promised. This line of attack appeared to be oblivious to the fact Obama would simply never sign a law repealing his own healthcare act, and in fact the only way Republicans could’ve repealed it while Obama was President was if they had somehow won 2/3rds of each house.
Considering these two things were so common, and persisted for six years, my conclusion is people have no real idea how the government works so they just believe whatever claim people from “their tribe” make. If someone is a good conservative and you’re a conservative, and you hear them say “Democratic obstructionism” well, that must be true. The alternative would be believing an ally was lying and believing an evil liberal was telling the truth, so that is right out.
I’m not convinced the exchanges will entirely fall apart without the individual mandate. The people who are eligible for the subsidized plans will still have a big incentive to sign up since they will be receiving significant government money for doing so.
I don’t believe there’s a hard upper cap on the government’s liability for subsidy payments. The structure of exchange plans, is if you are within the income limits, the percentage of your gross income that goes to out of pocket expenses on your medical costs is “capped”, the difference between the market premium for your plan and the gross income cap is made up by government subsidies.
The premium that insurers on the exchanges can charge is regulated based on an allowable profit margin and their underlying costs. As they continually raise premiums (within the allowed amounts in the formula, since costs are going up dramatically as exchanges get sicker and older), the government’s bill for the subsidies goes up, but a broad class of people still see no real “hit” to their pay, they’re riding high on ever higher subsidies–at least I think. I spent about twenty minutes trying to find out if there’s a true cap to the government’s liability and couldn’t find anything. I think the legislation was written with the understanding the mandate would be enforced, which was believed to have been enough to keep the risk pools on the exchanges with enough young healthy people on them so that the subsidy costs wouldn’t outright explode as the “exchanges” basically transform into little more than a high risk pool for lower income sick people that is Federally backed.
Now, when that comes to pass I do think you might have most states with no more than one company in there, but if your entire plan is on subsidies, it’s not like you should lose money, especially if you eventually start operating a high risk pool more or less. Part of what makes it so hard for insurers to apply actuarial science to make profits on the exchange plans is it’s been very hard to predict how many young healthy people will be on the plans. If that answer is eventually “none”, then that actually solves that problem–the actuarial science gets easier, but the answer is bad “it’s going to cost a fuck load to keep these plans solvent”, but since the government is bound to provide subsidies and out of pocket % of gross income is capped for subsidy recipients, you would basically just see a big new growing liability on the Federal balance sheet.
I’m not sure the Tea Party could hate anything more than having to pay subsidies for poor sick people, so they do have some incentive to try to not let this situation occur. If full repeal isn’t politically possible, then I do think that if we get to the point I described above the situation will be so unacceptable to conservative principles, that they’ll be willing to find some way to reform i t, even if it means keeping the Medicaid expansion which many hardliners don’t want to keep, if that’s the price of shutting down these expensive subsidy plans and the exchanges, maybe by 2020 the Freedom Caucus is willing to sign on to it.
It’ll be a mess obviously, and incredibly shitty for the millions of non-subsidy exchange participants who will not be able to afford the insanely high costs of the exchange plans because they aren’t within the poverty level limits for subsidies, but because of the guaranteed government subsidies I don’t think the exchanges can truly fail. They can price out everyone not on a subsidy, but I don’t believe there’s a reason they would ever “naturally” shut down otherwise.
So either way the GOP has to eventually be willing to pull the trigger if it wants the exchanges to go away.
Within ACA risk corridors you’ll find that the federal government has an insurance plan for the insurance companies in which losses are capped, a huge and growing liability but not a source of outrage. I wonder if it’s because this arrangement is more acceptable in certain circles, or because people don’t know about it, but the state of things today says that Congress is not friendly to the industry.
A lot depends on what you define as “entirely fall apart”. You’re envisioning the exchanges as being a bunch of subsidized bare-bones plans for lower income people, but that was not the original expectation for them. This devolution might itself be viewed as “entirely fall apart”.
It’s worth noting that the low income subsidies are tied to the premiums for the second lowest silver plan in a given area. The trend on the exchanges has been for “skinny network” plans offered by small-time insurers to occupy the lower the lower rungs cost-wise while major insurers have tended to offer something closer to their standard networks. If trends continue and are exacerbated, then the latter will all pull out, and you’ll be left with something that looks like Medicaid-by-another-name.
You seem to be taking a simplistic view of actuarial science as applied to health insurance underwriting, as if there were 2 categories of people; “healthy people” and “sick people”, and the only question is how many from each category sign up. This is not so, there are healthier people and sicker people in a gradient, and there’s no point at which you’ve completely solved for the “answer” based on the number of healthy vs sick people.
That said, it’s likely that if the exchanges become dominated by subsidized people, that experience will tend to stabilize, and be a better predictor of future experience, which would make underwriting easier.
Does any poster here support the new GOP healthcare plan and wish to defend it? It is simply Obamacare with the names of the different things switched around to claim it is different.
Why does it matter that we no longer have a “subsidy” but instead a “refundable tax credit.” It’s the same thing: a handout from the government. Why does it matter that instead of a “tax penalty” we pay a penalty to an insurance company?
I’m not seeing how this is any better or worse than Obamacare. It’s shuffling deck chairs. If I wanted a massive government program, I would rather the Dems administer it instead of having half-assed GOP efforts.
The tax credit effectively is non-existent at lower income levels. The subsidy was so those in lower income levels could buy insurance.
It is a handout but this time only to the “worthy rich”.
The reason the penalty is paid to the companies is that will increase profits.
I understand that it is based on age rather than income as it was in the ACA
You must be reading a wildly different version of the bill than I am. For the actual poor (the people it’s intended to help), this bill basically removes everything Obamacare gave them, then keeps removing stuff: it all but eliminates Medicaid, women’s health services, and pre-existing condition limitations, mental health services and a whole slate of other stuff, lowers the subsidies to a point where the poor won’t be able to afford health insurance anyway, and combined with the rape of Social Security, basically insures that the lower two thirds of the income ladder in the US will never be able to retire.
And yet we get conservative GOP fuckheads claiming that it’s still way too generous.
It is inconceivable to me that the GOP could, in good conscience, give us a “health care biill” that is actually worse than what we had before the ACA, but I neglected to account for their never-ending fetish for making ALL policy boil down to massive tax reductions for the very wealthy.
It’s also possible on a message board I was doing something called “generalizing”, I’m not an actuary, but I’m also not so stupid as to think actuarial science is as simple as you suggest I thought it was.
Based on the public feedback of industry, they’ve basically said what I have said, that the exchange markets have been volatile and difficult to correctly judge risk on with sufficient accuracy to generate the profits most of the insurers want. Some of the insurers (it seems mostly smaller ones) have said they’ve found it possible to make decent profits on the exchanges. Now, given these are companies that employ some large portion of the entire country’s actuarial corps, I suspect that they aren’t so stupid as to think there are only two categories of persons either, but in conversation it’s simply easier to say it’s hard to estimate how many sick people you’re going to have versus minimal users (i.e. the healthy young guy who pays premiums every month but hasn’t been to a physician in years.)
I could defend parts of the AHCA, but not its intent or its entirety. It’s a net negative versus the status quo, so shouldn’t be passed.
I would argue that it doesn’t completely abandon poor people. The tax credits for example are proposed as “refundable” credits, which means you can get them even if the amount going back to you is larger than your actual Federal income tax liability. This is similar to the EITC, which for many who claim it gives back more money than they’d have owe (i.e. it’s an income transfer payment.)
But the tax credits would be far worse than the subsidies for poor people who actually need health care, perniciously for those who aren’t really sick, but just poor or lower income, they’ll see what I call a “fake” economic benefit versus what they have now. They will probably see lower premiums and more money back on their taxes. But they also will have worse health insurance when they actually need it. I suspect the GOP’s hope is they’ll pay attention to those tax refunds and lower premiums, and they won’t understand the nuances of their insurance plans until/if it bites them in the ass.
I mentioned this awhile back, that part of the issue with the ACA’s acceptance among the people it benefited the most (many of whom became Trump voters) is it proved difficult to sell to them what they were getting, partially I think because the Republicans did good work discrediting it but also because I do think it was “marketed” poorly. Most people in America don’t understand that the biggest thing the ACA did was mandate if you have health insurance it’s genuine health insurance coverage. There were employed people in this country with employer plans, before ACA, which had hilariously low lifetime maximums. I read one article years ago about a man on such a plan that had a $50,000 maximum. Not bad for minor medical incidents, but something like cancer or a serious injury comes up and all of a sudden dude is financially ruined and can’t afford to pay for his continuing care.
He didn’t know, he just knew his job “gave him insurance.” Now, lots of companies had really good, robust plans before ACA, but many had shit plans like I described above. The problem is except for the people like the dude I read about who was ruined by his shit plan, the people who were paying premiums, occasionally using their plan to heartburn or basic preventive care, maybe pre-diabetes or blood pressure management they didn’t fully understand their plans left them exposed to tremendous risk. Cancer isn’t exactly unheard of, and any sort of cancer that is staged bad enough that you’re looking at chemotherapy and radiation, and potentially surgeries, is going to cost hundreds of thousands of dollars. There was a story in the Boston Globe a few weeks ago about a nineteen year old girl, who, covered by her parents plan in part because of ACA, underwent something like $1,000,000 in medical care for an aggressive form of leukemia. Several years later she’s in full remission. That’s the sort of event that ruined family’s financial lives and could even lead to people dying before ACA. But it also raised premiums.
I read a paper by a sociologist some years ago, she basically spent some time “slumming it” to learn “how the other half lived.” One woman she profiled was a waitress who struggled mightily to make ends meet. One thing the waitress mentioned to the sociologist (living basically incognito as a low wage worker), was that she’s hoping to move soon out of her apartment that is $500 (dollar values are from memory) a month to a place that lets you rent a room weekly for $125/week. Now, if you do the math, $500x12 = $6,000 for a year’s housing. The weekly place is $125x52 = $6,500. So $500 more per year, or like basically paying for a whole extra month’s rent a year versus the monthly rent apartment. The sociologist brought it up to her “isn’t that worse than what you’re paying now?” But the waitress disagreed–it was very hard for her to come up for $500 at the end of the month and she often couldn’t, so she ended up facing evictions, late fees etc that she barely avoided. But $125/mo, she could make that happen. The sociologist eventually realized why, for lower income and poor people, they just make too little money to easily save and plan for long term financial matters. For that reason they have to think short term, because they can’t assume they will not have some emergency that requires them to pull $300 out of their sock drawer a day before the month’s rent is due. When your income is just too low, you can’t build the “cushion” that middle and upper class people take for granted, that make it so you can easily take the “smart long term” decision.
This is largely how people looked at the ACA, and I do think it’s something Obama and the Democrats failed to understand. Most of the lower income people who hated ACA hated it because the it fucked with their monthly cash flow and for people in that income bracket nothing is more important. It may have been better for them long term, but they can’t think long term.
Now, the people who were poor enough to be covered by Medicaid expansion, or the lower income who were actually sickly and in need of continuous expensive medical treatment, likely realized more of the benefits of ACA. Particularly the ones who had been unable to get any kind of coverage before. But there’s a lot of people in that $25,000-$45,000 or so income bracket range who either because of employer plan changes or various subsidy situations saw their monthly costs go up under ACA, even though almost everyone in that in come bracket was mostly “better off in aggregate” under ACA. Without a lot of education it’s hard for people who live paycheck to paycheck to see past that.
I’ve tried to tell several people in this situation in my own family, who complained bitter about workplace premiums going up, that the reality is their old workplace employment was terrible. One of my nephews had basically an “indemnity” medical plan before ACA, which is really not coverage at all, but the premiums were low. But because Obama, his premiums went up. That’s what he’s keyed in on, not the fact he has actual health coverage now.
I think you are absolutely right with your analysis. On the other hand, it was drilled into me from a very young age by my parents, “Never, ever go without good health insurance.” I got told stories of people they knew who had gotten sick or hurt who had either gotten well because they had insurance or had died because they hadn’t.
As a result, right now I’m paying a fortune for health insurance for my family, but I’m paying it.
Just popping into say that a sci-fi version of Pitch Perfect would be AWESOME!
It wasn’t your specific language that I objected to but the notion that it’s possible to have no healthy people on the plans and thereby stabilize the pricing. The pricing would be stabilized by arriving at a self-sustaining mix of people, not by arriving at a uniform distribution.
The industry’s issue has been that since the exchanges have been so new, it’s been guesswork in figuring out who would sign up. They don’t think there are two categories of people, but have been comparing the people in various age groups who signed up to the projections they made in pricing these plans. The problem with simply revising these projections for next year is that changes in pricing themselves further impact the mix of people who sign up.
I’ve not seen any industry people discuss the issue in the same terms as you did here.
One thing you left out in your analysis is that the ACA fixed the maximum age ratio at 3:1 although in reality it’s much higher, which means that younger people were subsidizing older people. Looked at another way, younger people were getting a lot less than what they could expect to receive in payments, while older people were in many cases getting a lot more. So for a younger person struggling to make it, it was a big hit.
This is besides for all the various hidden taxes such as on medical devices etc.
It’s at an early stage.
Whether Speaker Ryan will be able to ram a bill through the house I don’t know.
But the senate watchers I’ve heard from saying nothing the house Republicans have suggested so far would clear both houses.
Part of the problem is Republicans have over-promised; much like Obama did when he promised to shut Gitmo his first year in office.
His 8th year is over, and Gitmo is still open.
Perhaps the ultimate irony here is; some say some European “socialized medicine” schemes reportedly deliver health care as good or better health care, for less money for most medical issues.
Wouldn’t it be ironic if the Republicans end up implementing Single Payer?
Never going to happen: that would be a health care plan that improves health care.
You have to understand that improving health care is not a goal of the Republicans – all legislation has to give tax cuts to the upper class and/or businesses. That’s the sole desired result of virtually all GOP legislation. Getting any actual social or governmental benefits out of legislation is done (if at all) just as handwaving to cover up the tax cuts.
TW #39
I know.
It was a musing on (unlikely) irony, not a prediction of how likely it was.
Professor Tim Byrnes of Colgate U. says the Republicans have reverse engineered it.
Their starting point was tax cuts for the rich, and pieced together some Frankenstein legislation they can try to pass off as “health care reform”.
But much like Obama’s “If you like your healthcare plan, you can keep your healthcare plan”,
Trump has seriously over-promised.
If you like, but in the: ACA Future
thread if you please.
Republicans often cite lowering costs.
But one of the most obvious ways to lower per capita cost is to get everyone into the pool.
If the young healthy tax payers don’t have healthcare, and don’t pay into it; then it’s the elderly and infirm that end up carrying the costs, and the per capita costs increase.
The Republicans don’t want to coerce participation (of healthy voters) so if the healthy ones back out of the system, the per patient costs are going to go back up,
which is going to discourage participation,
which will cause more drop-out,
which will drive costs up further.
It’s a vicious cycle.
And they’re trying to work out some complex legislation in an artificially short time.
It’d probably be better if they’d give themselves an extra year or to, and actually make an improvement.
The indication that they’re not interested in that is the fact that they appear to already have the provisions they want:
tax cuts for the rich.