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Obamacare after Obama

Greenbeard

Greenbeard

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The clock is winding down on the Obama administration so it's worth considering what the next iteration of health policy changes will look like.

Below are some key positions outlined so far by two Democrats and two Republicans. To get a sense of where they're diverging from the status quo, I've color coded based on: (1) green for new policies/approaches, (2) blue for ideas that extend/tweak or are a variation of existing law under the ACA, and (3) red for changes that are incompatible with or diverge sharply from current policy under the ACA. (Bush and Rubio both pay lip service to repealing the ACA, of course, but below I've only looked at specific issues where they've staked out a position.)

O'Malley​
Clinton​
Bush​
Rubio​
Out-of-pocket costsMore VBID in plan designs/carve "critical" services out of the deductibleNew tax credit for OOP costs; carve 3 office visits out of cost-sharing; lower cap on OOP max for prescription drugsHigher contribution limits for HSAs"Encourage and expand" HSAs
Prescription drug costsAllow Medicare, Medicaid, VA to negotiate drug prices; ban "price gouging"Allow Medicare to negotiate drug prices; allow drug reimportation; ban "pay-for-delay""Modernize" FDA regulatory approach?
Reforming care deliveryState-based reforms incl. option for states to adopt Maryland hospital global budgeting model; continue shift to new care models, value-based purchasingContinue shift to new care models, value-based purchasingRequire states that receive federal funds to develop action plans?
Price transparencyReform hospital chargemasters, promote transparent hospital billingEnforce/broaden ACA transparency rulesTransparency standards?
Other cost/price measuresAnti-trust enforcementAnti-trust enforcement, stronger rate review authority??
Employer coverageRepeal Cadillac taxRepeal Cadillac taxCap employer tax exclusion; wellness incentives; employer contributions to ind. market coverage"Glide path" to capping employer tax exclusion
MedicaidContinue ACA reformsContinue ACA reformsReverse Medicaid expansion; block grantsReverse Medicaid expansion; block grants
MedicareUnify Medicare benefits under "Medicare Essential" plan; continue ACA reformsContinue ACA payment reformsTBDTransition to premium support
Insurance marketsFix "family glitch" for marketplace tax creditsEliminate "surprise" out-of-network bills from in-network hospitalsTax credit for individual market coverageTax credit for individual market coverage (?); sales across state lines
Pre-existing conditionsRetain ACA protectionsRetain ACA protectionsPre-ACA approach (state-based high-risk pools); extend HIPAA protections for continuous coveragePre-ACA approach (state-based high-risk pools)

In general, O'Malley's vision in the most extensive so far and Rubio's is the least. But, refreshingly, there are actually some good ideas from both sides here.
 
To get a sense of what these candidates are thinking, I've pulled from:


Perhaps there are other sources on them I've missed, and certainly there are other candidates who may have something to say on the subject. But it's a start. So where do things go from here?
 
I notice you didn't include Bernie Sanders. Your thread fails, simply because Medicare for ALL is the logical next step.
 
Shadowless said:
I notice you didn't include Bernie Sanders. Your thread fails, simply because Medicare for ALL is the logical next step.
Click to expand...

I would've but couldn't actually find a health plan on his website. "Single-payer" could mean any number of things and Sanders himself has not been consistent on what it means (he describes it as "Medicare for all" on the stump but introduced single-payer of a very different stripe in the Senate). If there's more policy detail on what he's envisioning somewhere and I've missed it, let me know--I'd be happy to talk about it.
 
Greenbeard said:
I would've but couldn't actually find a health plan on his website. "Single-payer" could mean any number of things and Sanders himself has not been consistent on what it means (he describes it as "Medicare for all" on the stump but introduced single-payer of a very different stripe in the Senate). If there's more policy detail on what he's envisioning somewhere and I've missed it, let me know--I'd be happy to talk about it.
Click to expand...

Well, I honestly think the easiest, least complicated way to go about it is simply eliminate the age limit on Medicare. That's all that needs to be done, and I know that's what Bernie advocates, as well as a number of others. These other fixes seem overly complicated and not solving all that much.
 
Greenbeard said:
I would've but couldn't actually find a health plan on his website. "Single-payer" could mean any number of things and Sanders himself has not been consistent on what it means (he describes it as "Medicare for all" on the stump but introduced single-payer of a very different stripe in the Senate). If there's more policy detail on what he's envisioning somewhere and I've missed it, let me know--I'd be happy to talk about it.
Click to expand...

Bernie Sanders on Healthcare
Try there.
 
Greenbeard said:
The clock is winding down on the Obama administration so it's worth considering what the next iteration of health policy changes will look like.

Below are some key positions outlined so far by two Democrats and two Republicans. To get a sense of where they're diverging from the status quo, I've color coded based on: (1) green for new policies/approaches, (2) blue for ideas that extend/tweak or are a variation of existing law under the ACA, and (3) red for changes that are incompatible with or diverge sharply from current policy under the ACA. (Bush and Rubio both pay lip service to repealing the ACA, of course, but below I've only looked at specific issues where they've staked out a position.)



In general, O'Malley's vision in the most extensive so far and Rubio's is the least. But, refreshingly, there are actually some good ideas from both sides here.
Click to expand...

Why O'Malley and Clinton instead of Sanders and Clinton? Where's Sanders? For that matter where are the two Rep front runners? Good information, even well presented, but you're distinctly missing a few important players.

On edit: OIC re: Sanders but that doesn't explain choosing Bush and Rubio over the front runners on the Rep side.
 
David_N said:
Bernie Sanders on Healthcare
Try there.
Click to expand...

Thanks, but the same confusion still exists. That site points to his Senate legislation and implies it's Medicare for All; yet that bill actually eliminates the federal Medicare program and replaces it with state-based programs designed a bit more like Medicaid programs. Is this what he's running on? If so, then he's certainly provided more policy detail than any other candidate (via that legislation). But I didn't think he was running on that.

Like I said, I'm not sure what exactly he is running on. So I didn't include him.
 
Summerwind said:
Why O'Malley and Clinton instead of Sanders and Clinton? Where's Sanders? For that matter where are the two Rep front runners? Good information, even well presented, but you're distinctly missing a few important players.
Click to expand...

None of the others you mentioned have released concrete policy positions as part of this campaign that I'm aware of (except Carson, but he backtracked after he received criticism and said he'd come back with something else in the future).

But if you've got policy positions from others you want to include for discussion here, do!
 
What the heck is a Cadillac tax?
 
Ancient Herald said:
What the heck is a Cadillac tax?
Click to expand...

It's a tax on expensive employer-based health care plans that's scheduled to begin in 2018. If the cost of an employer's health insurance exceeds $10,200 for an individual or $27,500 for a family, the excess above those thresholds is taxed at 40% (at present those benefits are not taxed at all).
 
Greenbeard said:
Thanks, but the same confusion still exists. That site points to his Senate legislation and implies it's Medicare for All; yet that bill actually eliminates the federal Medicare program and replaces it with state-based programs designed a bit more like Medicaid programs. Is this what he's running on? If so, then he's certainly provided more policy detail than any other candidate (via that legislation). But I didn't think he was running on that.

Like I said, I'm not sure what exactly he is running on. So I didn't include him.
Click to expand...

Bernie Sanders introduces S. 1782, The American Health Security Act of 2013 - PNHP's Official Blog
This should show you what he wants.
The Program amends the tax code to create the American Health Security Trust Fund and appropriates to the Fund specified tax revenues, current health program receipts, and tax credits and subsidies under the Affordable Care Act. While the final structure of the financing component is still under consideration and is subject to change, the tax revenues in the draft include a new health care income tax, an employer payroll tax, a surcharge on high income individuals, and a tax on securities transactions.
The federal government would collect and distribute all funds to the states for the operation of the state programs to pay for the covered services. Budget increases would be limited to the rate of growth of the gross domestic product. Each state’s budget for administrative expenses would be capped at three percent.
Each state would have the choice to administer its own program or have the federal Board administer it. The state program could negotiate with providers and consult with its advisory boards to allocate funds. The state program could also contract with private companies to provide administrative functions, as Medicare currently does through its administrative regions. State programs could negotiate with providers to pay outpatient facilities and individual practitioners on a capitated, salaried, or other prospective basis or on a fee-for service basis according to a rate schedule. Rates would be designed to incentivize primary and preventive care while maintaining a global budget, bringing provider, patients, and all stakeholders to the table to best determine value and reimbursement.
Finally, the Program also relieves businesses from the heavy administrative burdens of providing health care coverage, puts all businesses on an even playing field in terms of healthcare coverage, and increases the competitiveness of American companies in the global marketplace. Every other industrialized nation has been able to use the power of a public authority to provide universal health care. The American Health Security Act of 2013 seeks to do just that for all Americans and their businesses.
Click to expand...

http://www.sanders.senate.gov/download/american-health-security-act-of-2013?inline=file
Very detailed.
 
Greenbeard said:
It's a tax on expensive employer-based health care plans that's scheduled to begin in 2018. If the cost of an employer's health insurance exceeds $10,200 for an individual or $27,500 for a family, the excess above those thresholds is taxed at 40% (at present those benefits are not taxed at all).
Click to expand...

So it's a double jeapardy tax then. A tax them and tax them again tax.

Thanks socialism,
 
Ancient Herald said:
So it's a double jeapardy tax then. A tax them and tax them again tax.

Thanks socialism,
Click to expand...

Where is the first tax? The under the threshold portion is non-taxable income.
 
I like the new name: Trump Care.
 
Hope I do not get sick.. Maybe I can go to Cuba. The American libs always said they have it better down there.
 
Ancient Herald said:
So it's a double jeapardy tax then. A tax them and tax them again tax.

Thanks socialism,
Click to expand...

Not so, it is simply limiting tax free compensation of some employees. Why should any employer be able to have any compensation of its employees be non-taxed? The limits should be dropped to ZERO on what an employer may pay for on behalf of its employees and be excluded from income taxation.

If Joe gets paid $40K and must buy his own insurance, housing and food then why should Joe (and his employer) pay more taxes than Sam whose employer pays him $30K and also pays $10K toward Sam's insurance, housing or food?
 
Last edited:
David_N said:
Bernie Sanders introduces S. 1782, The American Health Security Act of 2013 - PNHP's Official Blog
This should show you what he wants.


http://www.sanders.senate.gov/download/american-health-security-act-of-2013?inline=file
Very detailed.
Click to expand...

It is not "very detailed" because it lacks numbers. How is that new "employer payroll tax" supposed to level the playing field in a global market? Much of Sanders' new taxes are mandated at the federal level but fall on the states to implement. Some states, including Texas, have no state income tax so Sanders does not explain how those added state tax burdens will "target" the rich instead of adding even more hardship for the poor, especially poor retirees on "fixed" incomes. All taxes levied on a business are eventually transferred to the end user (customer) of those goods/services. Sanders tries to keep the CBO score of his "mandates" lower (or impossible to calculate) by shifting costs to the states and employers, but keeping the mandate authority at the federal level.
 
Last edited:
ttwtt78640 said:
Not so, it is simply limiting tax free compensation of some employees. Why should any employer be able to have any compensation of its employees be non-taxed? The limits should be dropped to ZERO on what an employer may pay for on behalf of its employees and be excluded from income taxation.

If Joe gets paid $40K and must buy his own insurance, housing and food then why should Joe (and his employer) pay more taxes than Sam whose employer pays him $30K and also pays $10K toward Sam's insurance, housing or food?
Click to expand...

What is the quality of the healthcare and whom is he buying it from?

You're only looking at the money, and that is what is faulty.

but then again, that's what all socialists do is look at who has more money and constantly try to lie to take it away from people.
 
Ancient Herald said:
What is the quality of the healthcare and whom is he buying it from?

You're only looking at the money, and that is what is faulty.

but then again, that's what all socialists do is look at who has more money and constantly try to lie to take it away from people.
Click to expand...

No it is you that looks at only some employee compensation as income (or money). What, other than money, is Sam's employer giving to Sam's insurance company? In my post's example how is it "socialist" to tax Sam's and Joe's income differently when they are equally compensated by their respective employers?
 
ttwtt78640 said:
It is not "very detailed" because it lacks numbers.
Click to expand...

In fairness, that's a detailed account of his approach (it ought to be, it's actual legislation). I just don't think that particular proposal is what Sanders is running on in his presidential campaign.
 
Greenbeard said:
In fairness, that's a detailed account of his approach (it ought to be, it's actual legislation). I just don't think that particular proposal is what Sanders is running on in his presidential campaign.
Click to expand...

What matters is the actual cost vs. outcome, and who ends up paying for it, not just the "concept". As you have noted, there are various concepts of "single payer" but they all involve income redistribution and separate who pays the cost from who gets the service. The problem with all such "fairness" schemes is that the costs are then "negotiated" without any actual consumer input. The US is near the top for public K-12 education per student spending yet nearer the bottom of K-12 average student performance outcome among the "advanced" nations. To expect a vastly different result from 100% federal government "managed" health care is doubtful.
 
Greenbeard said:
The clock is winding down on the Obama administration so it's worth considering what the next iteration of health policy changes will look like.

Below are some key positions outlined so far by two Democrats and two Republicans. To get a sense of where they're diverging from the status quo, I've color coded based on: (1) green for new policies/approaches, (2) blue for ideas that extend/tweak or are a variation of existing law under the ACA, and (3) red for changes that are incompatible with or diverge sharply from current policy under the ACA. (Bush and Rubio both pay lip service to repealing the ACA, of course, but below I've only looked at specific issues where they've staked out a position.)

(snip)
In general, O'Malley's vision in the most extensive so far and Rubio's is the least. But, refreshingly, there are actually some good ideas from both sides here.
Click to expand...

Very interesting. Thanks for putting that together.

A word about the proposed caps on amounts and cost sharing, etc.: The ins. cos. can apparently opt out of such caps, with the state ins. commissioner's approval, as long as they send a notice to the insured that the plan does not meet those ACA provision requirements.

I got such a notice from BCBS. "Texas Notice of Noncompliance with Certain ACA Provisions." It is still an approved ACA plan (the one that BCBS is trying to get me to buy, but which I haven't bought), but it does not meet the cost provisions. Example: there is a provision requiring all out of pocket and cost sharing of the insured not to exceed, say, 50% of the total costs. The new policy that BCBS is trying to get me to buy does NOT meet those provisions, which means that if I were to buy that policy, I would end up paying more than 50% of the medical costs, although it's not apparent when you look at the stated deductible and OOP and cost sharing add-ons.

Just to let you know....those caps are not written in stone. People should be careful to look at the cost sharing add-ons (30% coinsurance, copays, the size of the network since out of network under HMOs isn't covered at all and there are ALWAYS out of network providers in a medical event).
 
ttwtt78640 said:
What matters is the actual cost vs. outcome, and who ends up paying for it, not just the "concept". As you have noted, there are various concepts of "single payer" but they all involve income redistribution and separate who pays the cost from who gets the service. The problem with all such "fairness" schemes is that the costs are then "negotiated" without any actual consumer input. The US is near the top for public K-12 education per student spending yet nearer the bottom of K-12 average student performance outcome among the "advanced" nations. To expect a vastly different result from 100% federal government "managed" health care is doubtful.
Click to expand...

I agree that the ACA is not working. It's imploding before our eyes. But it wasn't working before, either. As will always be the case, every system works for SOME, both now and before. Before, over 40 Million people didn't have access to healthcare. In the world's leading country, the "exceptional" America, that is unacceptable, IMO.

I don't have the answer. Do you? Does Paul Ryan?

I think single payer or universal health care might be a good answer, even with the high cost....as long as the ins. cos. are out of the picture except for those who elect to buy private insurance (like Canada and Great Britain). Because of the impetus to the economy without the ins. cos profit and admin costs sucking breath out of the economy. I also think that would address health care costs. But the down side, besides high taxes, would be fewer providers. BUT...many in the ACA market already have access to far fewer providers, because of the limited provider and drug lists (one way that ins cos are protecting their profits; if you can't go to the dr., there will be no claim).

As for higher taxes, each of us would end up paying less because of lower health care costs.

Just a thought. The ACA has been a disaster for the economy and for many, though. (Although, as I said, it works for SOME....paid for by others.)
 
Shadowless said:
Well, I honestly think the easiest, least complicated way to go about it is simply eliminate the age limit on Medicare. That's all that needs to be done, and I know that's what Bernie advocates, as well as a number of others. These other fixes seem overly complicated and not solving all that much.
Click to expand...

That would require a significant tax increase. While Social Security if financially solvent, Medicare has financial problems. In order to maintain it as is, something will need to be done. In order to enlarge it, increasing costs substantially, there would have to be a large tax increase to the Medicare tax. I don't see half the country approving that. Do you?
 
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