I am trying to understand the pros/cons of each, here.
Pre-ACA (Whatever the system is called before “Obamacare”)
ACA/Obamacare
Universal Health Care
I worry that I am horrifically ignorant on these matters and even looking at Wiki, it is overwhelming. I’m asking for very simple explanations – who pays for what? Are there significant tradeoffs here?
I understand the concept of risk pooling but past that I don’t know the main differences in each system and how they are financed.
Simple explanations are hard for this one - even your simple list of 3 items have hidden complexities, such as ‘pre-ACA for whom? Employed? Unemployed? Retired? Child? Adult? Military?’.
With ACA, some of these change, others not at all. If you want to get an idea of how ACA might work, read up on the Massachusetts system in the Wiki. Objections to the ACA range from ‘it is socialism’ to ‘it won’t do enough’.
The last item ‘Universal Care’ is also complex - is it single payer (like the UK) or insurance based (like in Germany)?
To get a feel for various worldwide approaches to health care, I suggest this book review. The book would be even better, but then a book is not simple.
One quote stayed with me:
“Unlike any other country, the U.S. combines all four models (of health care). The employer-based coverage most workers get follows the Bismarck Model. Veterans and soldiers are treated under the Beveridge Model (which conservatives often call socialized medicine). Medicare is so similar to Canada’s system that they share the name. And the 47 million uninsured do as Cambodians do.”
Wow. Don’t ask for much, huh? 
I’m sure I’ll get ninja’d before this is done, but anyhow.
The original situation (which is currently largely still the case) was that insurance was a private market. In many cases, it’s an employee benefit – a person’s company provides part of their compensation in the form of subsidized health insurance as part of the company risk pool. (Some companies don’t subsidize it at all, but there’s still a benefit to being allowed in to their risk pool.) Employers do this because insurance benefits are given beneficial tax treatment, so it’s cheaper to provide an employee with $80k salary and $5k worth of insurance than it is to pay them the $85k straight out.
Employer-sponsored care, whether subsidized or not, is reasonably stable, and there’s a lot of competition to sign up this or that company among insurers. But the individuals don’t have any opportunity to make the insurers compete – it’s either take what’s on offer or don’t.
The major problem is for people who do not have employer-sponsored care (or some similar group purchaser). Individuals without insurance are in an extremely precarious position. First, if they have a pre-existing condition (even ones that are largely manageable with medication), it’s difficult or (in most cases) impossible to find a private insurer to take them on, and even if they do, costs can be extreme. That applies for most people who have a history of serious illness too, even if they’ve been healthy for years. Also, if you get sick, your insurance carrier can drop you from future coverage. Moreover, many plans have annual or lifetime caps on total benefits, so if you get something really serious, you’ll run out of money even though you paid your premiums. (The little girl with the heart condition featured at the Democratic National Convention had this issue – she’s already something like halfway to her lifetime cap, and she has at least one more necessary surgery on her program. Under the current regime, she’d have no chance of finding private health insurance her whole life.) And finally, women pay higher premiums than men with the same medical history.
Moreover, there are of course millions of poor (including substantial amounts of the working poor) who couldn’t afford insurance even if they could qualify for it. Medicaid covers poor children and the disabled, but prior to the ACA it didn’t cover every person that was poor.
Under this regime, something between 12-50 thousand people die in America annualy due to lack of insurance.
So what changed with Obamacare? A ton, which I’ll get to. But first a word on timing – the ACA will be fully effective on Jan. 1, 2014, so for now the basic pattern is the same as described above. But many of the individual provisions of the Act have already taken effect; they were staggered over the nearly three years between passage and full implementation.
The most substantial change is that insurance companies are no longer allowed to refuse a paying customer. They must offer one plan to all comers, at the same price, no matter the person’s medical history, gender, etc. There are no more annual or lifetime caps, and children are permitted to stay on their parents’ plans until the age of 26. Insurers must dedicate a minimum of 80-85% of premium revenues to the actual provision of medical care (which has already resulted in millions of refunds being disbursed), and regular physicals and preventive care (including IIRC mammograms and gynecological check-ups) must be provided with no out of pocket costs (co-pay or co-insurance).
The flipside of these protections is the mandate. Obviously, the above makes the provision of insurance a lot more expensive for the insurers – when they can’t cull out the people who are likely to use the benefit in favor of only the profitable customers, of course the cost will go up. However, when costs go up, healthy people stop buying insurance because they believe it’s a luxury they can’t afford. This leads to the risk pool getting even sicker and less profitable, which leads to further price increases, etc., until the insurance companies just pull up stakes. It’s called the insurance death spiral, and it’s quite probably what would happen with the protections of the ACA were the mandate, or some other process, not there to address the issue. (I know this is GQ, but I think I’m safe noting, here, that this is why the GOP position of keeping the pre-existing coverage requirements but getting rid of the mandate, is not feasible.)
The ACA’s response to this is the indivdual mandate. Each individual will soon have a legal responsibility to secure health insurance for themselves, either through an employer or other group, or on the open market (which will now be feasible even for the less than perfectly healthy). If the person can’t afford to buy individual insurance, the government will buy it for them, or at least defray the costs. But the real impact will be to people who actually can afford insurance but would rather spend the money on something else because they figure they’re healthy and are willing to take the risk. (These are called the “Young and Invincibles”.) Under the current regime they can do this. Then, of course, some minority of them end up developing cancer or getting hit by a bus and they’re now unable to find insurance to cover their long-term care. Under the ACA, starting in 2014, they won’t be permitted to take this risk. Because the majority of these folks are healthy, and therefore don’t require a lot of medical services, these are the profitable customers for the insurers, which then subsidize the cost of services to the sick people in the risk pool.
Side note – it’s not just that these folks are being used to subsidize everyone else’s costs, although certainly that’s true. But for the minority of them that do end up needing non-trivial medical help, they are actually hurting the rest of us as well. Sick and injured people without insurance get treatment at the emergency room, which is legally obligated to treat even the uninsured to the extent necessary to ameliorate emergent conditions. The hospital will bill them for these costs (which is what drives over 2/3ds of personal bankruptcies in this country, last I researched it). When they’re no able to pay, the hospital has to recoup them on the backs of paying patients, like those of us who have insurance. Also, catch as catch can emergency room treatment for serious conditions tends to be more expensive than adherence to a stable treatment plan, because you only go to the ER when you’re in extremis, and they’re not legally obligated to treat indigent patients who aren’t.
For someone who can afford insurance who fails to secure it, there is a financial penalty. I don’t remember what it is. It’s modest, but non-trivial.
There are a ton of other provisions in the ACA as well. For instance, it penalizes large employers (500+ employees, IIRC) who fail to offer insurance to their workers, thereby establishing additional options for employees. OTOH, it offers tax incentives to small businesses to make insurance cheaper for them to provide to their employees. It establishes a Commission to do the first-ever systemic reserach into the effectiveness of treatments. Some huge percentage of medical services provided to patients have no impact on quality of care, and this is one of the ACA’s efforts to reduce that waste. There are also student-loan provisions that saved the fisc several billion annually, IIRC something like half of which is used for additional Pell grants and student loan forgiveness. And then there’s the changes to Medicare…
Oh, but before I get there – Medicaid. Medicaid, as I said above, has always covered the poor and disabled, but only if they fall in certain categories. Now (or rather, in 2014), it will cover everyone who makes less than 133% of the federal poverty line (currently about $15,000) who does not have insurance through other means. The Medicaid expansion is expected to cover about half of the new insureds under Obamacare, IIRC. One wrinkle is that the Supreme Court decision upholding the ACA said that this Medicaid expansion can’t be imposed on the states, which partially fund Medicaid. (Note that under the ACA, the federal fisc is going to fund 95% – going up to 100% over time – of the cost of the new enrollees. The costs to the states will be small, and will likely be offset by savings in other areas like subsidizing hospitals, but it is a cost.) So the Supreme Court has said that states will have the opion to opt out of the Medicaid increase. I’m sure some will do that for political reasons, but recall that the citizens of that state are still going to be paying the federal taxes that fund Medicaid, so you have to imagine that the political pressure for states to opt-in will be high.
OK, Medicare. Two big changes to Medicare in the ACA. First, it is closing the “donut hole.” Under the Bush-passed Medicare prescription plan (Medicare Part D), seniors get their prescriptions subsidized. After a deductable, Medicare pays 75% of prescription costs up to $2,700 (this is 2006 numbers, because that’s what Wikipedia had, they change from year to year but it’s the same system). After that, there’s no prescription coverage until the senior gets to over six grand (nearly $4500 out of pocket), at which point it kicks back in at 95% coverage. Also according to Wikipedia, a quarter of Medicare beneficiaries stop taking their meds when they first hit the donut hole.
The ACA is closing the donut hole by issuing rebates to seniors who had to buy meds out of pocket. The rebates started at $250 in 2010 but grow every year until 2020, at which point the gap will have been eliminated. In the meantime the Act also created discount plans for generics for seniors in the gap.
The other major change is the $700 billion in Medicare cuts you’ve heard about. About a third of that is savings related to scaling back Medicare Advantage, a program begun under Clinton and expanded under Bush to allow private insurers to provide insurance to Medicare beneficiaries, paid for by the government, instead of the government doing it directly. There are wrinkles, but the private companies said they could administer the plans more cheaply; as it turns out, they were actually considerably more expensive, with no change in quality of care. Another large part is the cuts to “Dish” payments, which were extra Medicare payments the fisc made to hospitals and providers in rural areas to keep them afloat, compensating them for the poor people who didn’t pay their bills. These are going away because all the new insureds under Obamacare are expected to make up the loss. (This is what I mentioned above about pressuring states to agree to the Medicaid expansion – the DSH payments are going away whether you get the new insureds or not.) There’s other stuff I’m forgetting. Again, none of this is expected to impact quality of care provided to Medicare patients (except I guess if hospitals go out of business because they lose their DSH payments but don’t get new business from the expanded Medicaid population).
Holy shit this is long. Simple, you said, huh?
Finally – “universal” care. That’s a catch-all for any system in which the state provides or ensures that every individual can get care. Obamacare is a big step in the direction of universal care for the reasons discussed above. But it’s by no means universal. First, it doesn’t cover nondocumented workers, aka illegals, of which there are some 12 million in the U.S. Some (maybe a lot) of them will have insurance through their parents or employers, esp. once big companies have to start providing insurance, but many will remain uninsured. Moreover, there’s still going to be some, probably very small, percentage of people who are going to pay the penalty to avoid buying insurance. Finally, as mentioned above, the Supreme Court’s restrictive reading of the Medicaid expansion might lead to some states to opting out of that program despite the quite monumental costs for political reasons. Moreover, the system reamins, fundamentally, private in character. UHC is often used as a shorthand for some type of state-provided insurance, like Britain’s National Health Service, although you could have a privately managed regime that is still universal. Nothing like that is contemplated in the ACA.
Could this post possibly be any longer? Actually, yeah, there’s some stuff I left out, but this covers the bases pretty thoroughly.
–Cliffy
Oh, what the hell, jasg! You had to bring up veterans, huh? The one thing I cut for space?
Anyway, yeah, veterans are theoretically provided government-provided care in a model very similar to UK’s National Health Service – the VA owns the hospital, the VA employs the docs and pays them a salary, the vet shows up and gets treated, then goes home. But the VA is always underfunded by design, so it prioritizes care for those who are poor, injured in service, otherwise unable to access benefits, and so forth. I honestly don’t know much about that side of it.
–Cliffy
Back when this round of the health care debate was starting, PBS’ Frontline did a show that compared and contrasted different systems around the world. You can watch it online (for free!) here. I highly recommend it if you’re at all interested in this sort of thing. It explained everything pretty simply, though it is an entire hour program.
It is difficult to be concise for this. Here is my general take on your question (dopers please feel free to disagree and correct):
Pre-ACA - Health insurance is provided by private, for- and non-profit companies. Individuals can purchace health insurance on their own, but pay a steep penalty by not being part of a risk pool. Most employers will offer to subsidize health insurance for their employees - each year employees are paying a larger part of the equation than before, because costs of insurance keep climbing in response to climbing medical costs. The only way for many to access health insurance is thru their employer, and with a lot of people out of work, there are a lot of uninsured people. When people without insurance get sick, they go to the emergency room for treatment that would have otherwise been dealt with by their doctor when they were insured, and this is a very expensive proposition for those that are already insured (someone has to pay for this - usually thru higher insurance premiums that are paid-for by employees and their employers).
Also, you may be hearing about “pre-existing conditions”. This is where someone has a chronic health issue that could be treated, but under many insurance policies this person is a bad risk, so they may be denied insurance if they are seeking it on their own. If they are part of an employer group, then the insurer must insure them. Again, you need to have a job with benefits to access the system (and not all jobs offer health benefits, due to climbing insurance costs). If you have a pre-existing condition in the US and somehow become uninsured and unemployed, typically you will need to drain your assets (financial doom) before you become eligible for state aid like Medi-cal.
Pro: As long as you are employed with benefits, you are probably doing all right.
Con: If you lose your job, you and your family may be hosed if someone gets sick, and the system is very expensive.
ACA intends to get more people covered by insurance and accessing regular care without fear of rejection by insurance companies. People will generally not wait until an acute health problem becomes a serious illness if they have access to a doctor on a regular basis. ACA eliminates the pre-existing condition issue by requiring health insurers to accept all comers - but this increases risk to the insurer so they have baked into the plan the “mandate” you may have heard about. The Mandate is that everyone must buy into the system (buy health insurance) so the risk is offset by more customers. The Mandate really only affects those who, today, could get insurance, but choose not to. For those insured under your employer, the mandate does not really affect you. For those that cannot afford to purchase health insurance, the state will help them afford it (under the theory that healthy peopel are less expensive and more productive). There are a lot of other provisions in the ACA that deal with allowing children to stay on their parent’s insurance policy until they are 26, etc. The goals of the ACA are to get more (if not everyone) insured, and control the cost of health care by enlarging the risk pool, by using the same system of health insurers and hopsitals that are being used today.
Pro: More people covered under health insurance, healthier workforce, less instances of people losing everything if a family member gets sick, less passing the costs of the uninsured onto the insured.
Con: Costs are not well understood as well as how to pay for the program before savings begin to arrive, and uses the current expensive health insurance infrastructure.
Universal Health Care (UHC) is generally referring to the health systems used in other countries where the state manages the health care system. In UHC, there may only be one insurer - the state, who decides how it will pay doctors and hospitals for each procedure, supplies, etc. When someone gets sick, as a citizen of that country, they are eligible for health care, whether or not they are employed or have a health condition. Doctors do not need to have contracts with all the insurance companies because they are only dealing with the state. I do not know if employers pay taxes for this privilege, or if it us all financed thru higher taxes on the populace (a British, Canadian, or Australian doper can tell you). There are no pre-existing conditions, and getting sick while you are out of work will not necessarily mean financial doom (as it may in the US). Citizens who can afford it can purchase additional insurance policies that perhaps prvide more coverage. Under UHC, there is some debate about long waits to recieve treatments, but I will let other dopers comment on that. UHC means everyone is paying to be in the risk pool, and everyone is covered.
Pro: Everyone is covered. No need to worry about insurance if you lose your job, or want to take time off, or start a business, etc.
Con: Costs are better understood, but are considered high by US standards relative to taxes.
Have you been following this thread in GD?
La la la. I’m bumping this, ostensibly to find out if the OP found any of it helpful, but mostly because I spent an afternoon writing it and I don’t want it fading into obscurity so quickly.
–Cliffy