Omamacare is Romneycare.

Neomalthusian · Jun 20, 2019

Checkerboard Strangler said:
They were, ad nauseum.
Didn't matter...Republicans seized on the fact that a Democratic administration was pushing the idea, so man the battle stations. And they did. And several turncoat "Democrats" (who have proven all along that they're really just Republicans) helped them.

Joe Lieberman is the single reason the Public Option never even made it to the floor of the Senate.

True, President Obama could have fought tooth and nail, but he didn't. I don't know if he was simply trying to placate the Republicans, or if he simply threw in the towel due to weakness.
But former CIGNA executive Wendell Potter tells the story.

ELIMINATION OF ‘PUBLIC OPTION’ THREW CONSUMERS TO THE INSURANCE WOLVES
Wendell Potter, February 2015

Democratic party candidates are already sending signals that they're ready to pivot back to a public option, either because they're nervous about hanging their hat on MFA during election season, or because they know it's dead-on-arrival regardless of election politics.

Either way, I don't see why people are drawn to this public option idea. It just doesn't make sense to me. The crux of it is if the public option is significantly more generous than the private markets can afford to be, it will kill the private markets straight away, which would make proponents' claims that people can keep their private insurance if they like it extremely disingenuous. But if the public option is not significantly more generous than the private markets can afford to be, what the hell would be the point?

Technically I see three ways the public option could go.

1) It's priced lower across the board than the private sector can charge. Voters are initially happy, but, because private enterprise can't deficit spend to cover a difference between what they charge and what they spend, this would cause runaway migration to the public option. This is what insurers were protesting back then. Politicians pitching it act like it would preserve the private sector when, if you read between the lines, people would demand the public option be priced better than the private sector (because otherwise, why even have it?), but doing this would ensure the private market's demise.

2) The public option is priced roughly equal to private plans to avoid destroying the private sector. But as I said, what then would be the point of it in the first place?

3) The public option is priced better for certain types of people, but not other types of people, than the private sector.

If it's priced better than the private sector for the young and healthy, but not the old and sick, it concentrates the old and sick in employer group plans, causing employer group plan prices to spike insanely, resulting in employers ceasing to offer health insurance at all, at which point eventually the private sector plans implode altogether, and older/sicker people grow increasingly pissed off that the public option ended up killing the good deal they once had.

If it's priced better for the old and sick, but not the young, than the private market plans are, the old and sick all flock to the public option (dumping ground scenario, which could be a huge favor to insurance companies), while the relatively young and healthy continue fending for themselves in the private markets.

I think the last scenario is the most likely if any sort of public option were passed. It would intentionally incentivize the oldest and sickest to self-select out of employer group and private market plans (even though overall this cohort already gets the best deal on health care in terms of what they pay relative to what they cost). This would probably be warmly received by health insurers who could then offload the biggest drains on their pools, and large employers may be pleased if it reduces their overall employee benefit costs, and the older and sicker would be pleased because it opens up an even better deal for them. So who gets the shaft? It depends on who pays the excess cost of this new option. Either the wealthy, somehow, via some new tax on only them, or it'll be the younger and healthier overall (once again). Which is more likely, if we're being honest with ourselves?

ataraxia · Jun 20, 2019

I'm Supposn said:
Ataraxia, since Theodore Roosevelt's administrations, the concept of the population's medical conditions being of government's concern has been advocated by some Republican and Democratic presidents. The Patient Protection Affordable Care Act, (the first federal act upholding that concept), was passed and enacted during Bock Obama's administration, it will increasingly improve his reputed historical status.

Similarly to federal Social Security retirement, and the federal minimum wage rate, it would be futile for a political party to attempt eliminating, or undermining, or otherwise reducing federal laws or regulations regarding individual's entitlements of medical insurance; It would be politically detrimental to do so.

Respectfully, Supposn

Yes, agreed. Actually, in 1948 the US spearheaded the Universal Declaration of Human Rights, which most countries of the world have now passed. The document says that governments shoudl have the responsibility to protect the basic human rights of their citizens, which includes the right to food, clean water, shelter, a basic education, and access to healthcare. This helps people in civilized countries in the modern world avoid desperate situations and indignities which no human being should ever have to face.

I find it ironic that most countries of the world have embraced this idea, but that it is so under siege in the country of its birthplace.

I'm Supposn · Jun 20, 2019

Refer to:

I'm Supposn said:
Preventive medical and catastrophic medical costs.
Regarding preventive medicine; (i.e. “an ounce of prevention”): I’m a proponent of medical insurance plans by federal law not charging any effective charge for what’s a reasonably conventional preventive or diagnostic service or procedure applicable to the patient’s condition.

I’m also a proponent of federal catastrophic medical expenses insurance as a federal entitlement of USA legal insured or uninsured residents. Regardless of whatever is or will be our nation’s medical policies, this policy would improve our nation’s economic and social condition. ...

Respectfully, Supposn

Greenbeard · Jun 20, 2019

I'm Supposn said:
Green beard, my interpretation of larger employers medical insurance responsibilities as described within
Employer Responsibility Under the Affordable Care Act | The Henry J. Kaiser Family Foundation , is:
If an employer of 50 or more full time employees
and
offers affordable medical insurance to 95% of those employees,
and
the insurance pays for no less than 60% of the covered health care for “a standard population (called minimum value)”,
then that employer is in compliance with the federal Patient Protection Affordable-Care-Act.

I'm confused upon that mouthful of “a standard population (called minimum value)”. Is this a concept that replaced the concept of the 8% of an employees income that you referred to? If you have some insight to this, please help me understand it.

Respectfully, Supposn

The "minimum value" (60%) refers to actuarial value. Every plan covers some set of benefits and over the course of a year its enrollees will incur some total cost from using those benefits. Some people have a hospitalization, some visit the ER, some see a doctor, some don't interact with the health care system at all. A plan with a 60% actuarial value--i.e., bronze-level--will in the aggregate, across all those enrollees, see the insurer pay for 60% of those total costs incurred and enrollees pay the remaining 40% (through deductibles, copays, or coinsurance).

It doesn't mean that's how it shakes out for any individual person--a given enrollee could see the insurer cover a much lower percentage of the cost of covered benefits they use, another could see it cover a much higher percentage--it's in the aggregate across the entire enrolled population.

"Standard population" just means that when you're calculating out how much of those aggregate costs an insurer is likely to shoulder under a given benefit design you're not projecting it using the actual population that will be enrolled--since this is calculated in advance--you're using some reference population that reflects characteristics of the whole market.

Actuarial value is way of characterizing how generous a health plan is when you go to use it. That is, it tells you how much cost-sharing at the point of care people experience (again, in the aggregate).

The 8% of income I was referring to is about the premium, which doesn't vary based on how much (or whether) you actually use your insurance the way cost-sharing does. In an employer-sponsored plan, the employer contributes most of the premium and the enrollees covers the rest. If the part of the premium the employer asks the employee to pay was greater than 8% of that employee's income, that's when the Free Choice Voucher would have come into play.

I'm Supposn said:
Green beard, the Republicans voted to repeal permitting employees' some determination of their own individual medical insurance at little or no additional cost to their employer?

The employer premium contribution I just mentioned would have become portable if employees were being asked to contribute more than 8% of their income toward the employer-based plan's premium. The GOP repealed that.

I'm Supposn said:
Greenbeard, isn't the tax credits for medical insurance premiums and a federal subsidy of insurance for individuals with incomes that do not exceed 400% of the federal poverty line both sufficiently generous?

Wouldn't increasing those individuals' tax credits or caps upon those subsidies be net detrimental to our annual federal budgets?
Why do you believe increasing the annual federal budget deficits in those particular cases would be justified?

Respectfully, Supposn

Increasing the subsidy would raise federal spending on the subsidies, yes. Spending under the ACA has turned out to be much lower and savings have turned out to be much higher than what was projected to calculate the price tag of the law a decade ago. We have room to be generous. The ACA turns 9. So how'd the CBO do?

Checkerboard Strangler · Jun 20, 2019

I'm Supposn said:
Checkerboard Strangler, those more to the left want to “stick it” to employers; too many employers believe they'll benefit more if the money all flows first through employers and/or conservatives believe it will some how cost taxpayers more if the money doesn't flow through employers first.

I absolutely agree, “employers should not be in the health insurance business” and federal basic single payer medical insurance is the best way to go. Respectfully, Supposn

One of the main reasons Canada is building so many American cars is because the car makers don't have to add in three thousand extra dollars in health care overhead PER vehicle like they have to in the USA.

Greenbeard · Jun 20, 2019

Checkerboard Strangler said:
They were, ad nauseum.
Didn't matter...Republicans seized on the fact that a Democratic administration was pushing the idea, so man the battle stations. And they did. And several turncoat "Democrats" (who have proven all along that they're really just Republicans) helped them.

Joe Lieberman is the single reason the Public Option never even made it to the floor of the Senate.

True, President Obama could have fought tooth and nail, but he didn't. I don't know if he was simply trying to placate the Republicans, or if he simply threw in the towel due to weakness.
But former CIGNA executive Wendell Potter tells the story.

ELIMINATION OF ‘PUBLIC OPTION’ THREW CONSUMERS TO THE INSURANCE WOLVES
Wendell Potter, February 2015

There was a compelling case in 2009 for having a public option when the exchanges opened, and there's a compelling case today to create one going forward.

But given what we know now, it probably doesn't matter that there was not one at the beginning. The case for a public option was heavily based on cost (i.e., it would help keep premiums down). But when the exchanges opened, insurers underpriced big time. Their premiums were ~15% below what the CBO had expected and lots of them took losses for the first 2-3 years. That means those insurers were subsidizing patients' costs, since those costs exceeded the premiums the insurers were collecting from those patients and the taxpayers.

More importantly, the fate of the public option's replacement, the CO-OP plans, probably would have befallen the public option if it had existed. Because they had no existing market footprint and no existing lines of business to fall back on when times got tough, they weren't able to survive the combination of 1) the tumultuous first enrollment in the wake of the botched healthcare.gov rollout, 2) the underpricing more established competitors were able to survive (e.g., by relying on revenue from their employer plans, or Medicaid, or Medicare, etc), 3) the GOP cutting off their access to new capital, and 4) the GOP's sabotage of the risk corridors. The public option would've been susceptible to all of those things since it, like a CO-OP or any payer, was required to be self-sustaining on premium revenue, it relied on initial start-up capital that was subject to Congressional whim, and it had no safety net in the form of alternate lines of business if the marketplaces got rocky for a few years.

Potter focuses in on the rise of narrow networks, but those are a cost containment mechanism. Insurers brought them to market because they offer a lower premium competitor to broader network plans (which also exist but have proven less popular among buyers), which suggests they are--or at least were--under the sort of pressure to contain premiums that the public option was supposed to encourage.

Checkerboard Strangler said:
It's long past time we forget the idea of fighting to get insurance companies to take their foot off our throat, and just implement single payer.

It's hard to believe that under any system we'll have a situation where people can get anything paid for with no oversight or questions asked.

I'm Supposn · Jun 20, 2019

Neomalthusian said:
Democratic party candidates are already sending signals that they're ready to pivot back to a public option, either because they're nervous about hanging their hat on MFA during election season, or because they know it's dead-on-arrival regardless of election politics.

Either way, I don't see why people are drawn to this public option idea. It just doesn't make sense to me. The crux of it is if the public option is significantly more generous than the private markets can afford to be, it will kill the private markets straight away, which would make proponents' claims that people can keep their private insurance if they like it extremely disingenuous. But if the public option is not significantly more generous than the private markets can afford to be, what the hell would be the point? ...

I waste a lot of time because I'm not precisely certain and must confirm, or don't remember, or never knew of the acronyms I encounter within posts. I wish posters would actually spell them out at their first use in each posted response. What's MFA?

Due to the economic or social, or simply the preservation of our nation, there are some things that should be the case without regard to the cost to the insurer, or the purchaser, or the taxpayers. Politics should not be onnly the determination of validity, but also resolution of differences between valid but contradictory concepts, conditions, and goals.

I'm among the proponents of basic government medical insurance in some form. I don't believe yours or my opinions are particularly invalid, but they should be resolved and the middle “compromising” points of such resolutions are very often not the best and sometimes the least advantageous to one or all parties involved. That's why King Solomon suggested cutting the baby in half.

Respectfully, Supposn

Greenbeard · Jun 20, 2019

Neomalthusian said:
Democratic party candidates are already sending signals that they're ready to pivot back to a public option, either because they're nervous about hanging their hat on MFA during election season, or because they know it's dead-on-arrival regardless of election politics.

Either way, I don't see why people are drawn to this public option idea. It just doesn't make sense to me. The crux of it is if the public option is significantly more generous than the private markets can afford to be, it will kill the private markets straight away, which would make proponents' claims that people can keep their private insurance if they like it extremely disingenuous. But if the public option is not significantly more generous than the private markets can afford to be, what the hell would be the point?

Technically I see three ways the public option could go.

This is a two-parter.

The basic argument is simply that more insurer participation has been associated with lower premiums, or at least slower premium growth, in the marketplaces (e.g., "ACA Marketplace Premiums Grew More Rapidly In Areas With Monopoly Insurers Than In Areas With More Competition"; "The effects of competition on premiums: using United Healthcare’s 2015 entry into Affordable Care Act’s marketplaces as an instrumental variable"). The CO-OPs were intended to inject more competition into every state's insurance market, but start-up funding was eliminated by the GOP House before they all got up and running so fewer than half of states ended up with one. But they seem to have been working, before their untimely deaths, anyway: "Lower premiums in CO-OP states."

If we could lure more insurers into the marketplaces, particularly those with little competition today, one could argue that a public option isn't entirely necessary.

But beyond that, there were two flavors of the public option floating around in 2009/10: a "strong" public option and a "weak" public option.

The weak public option was just another insurer, but one that happened to be publicly sponsored. By that I mean it has to build a provider network (the weak public option gets to start with the Medicare network, but providers can opt out of participation without penalty) and it has to negotiate reimbursement rates. Just like any insurer. So in this incarnation it's pretty much just like any other insurer, it just adds another option in the market. Which is good, for the reasons already outlined above. This is the version of the public option that ultimately passed out of the House in 2009.

The strong public option, which was the original version, had a little more muscle. Its reimbursement rates were to be set administratively, initially at Medicare rates or Medicare + 5% for physicians and then subsequently at levels to be determined by HHS. It also had the Medicare network at the outset, with an unspecified opt-out potential that was significantly less clear than the weak version as to whether that option would be painful for providers exercising it.

In either case, the actual operations would be contracted out to a private entity and the whole thing has to be entirely financed by premium revenue (other than some initial start-up funding provided by the government).

The current flavor of the public option being offered in the Medicare-X bill is a strong one.

Greenbeard · Jun 20, 2019

Regardless, other than the network development and reimbursement setting pieces I mentioned above, the public option plays by the same rules as any other plan. It doesn't offer more generous coverage because it offers the essential health benefits, like everybody, and it offers metal tier plans that are sold in the marketplace. A bronze plan sold by the public option still has a 60% actuarial value (and thus a high deductible) just like any other payer's. It also can't differentiate between the young and old differently than other insurers do, because the age rating bands are set in regulation. Everybody uses the same ones.

How its premiums stack up against the competition depends. Really there's not all that much that determines premiums: it's the prices you pay for services, it's who you enroll, it's how well you manage your enrollees' care and utilization, and it's whether you are doing anything interesting in terms of benefit designs or provider payment methodologies that moves the needle on how people or providers behave.

The public option--whether weak or strong--gets pulled in different directions.

If it's strong, it initially has a pricing advance on its competitors because it's paying Medicare prices and its competitors are not. The potential benefit of that market-wide is that it could force providers to offer greater pricing discounts to private insurers to mitigate enrollee defections to the public option. This is why I personally supported a strong public option back in 2009. The goal wasn't to drive private insurers out of business, it was to reshape the market such that payers had greater leverage to negotiate lower prices with providers. There's a little evidence of something like that happening in the early years of the marketplaces--"Hospital prices drop for the first time"--but provider market concentration remains a significant issue, and the higher prices providers in concentrated markets can command directly impacts premiums (e.g., "ACA Marketplace Premiums and Competition Among Hospitals and Physician Practices"; "Provider Market Concentration Outweighs Payer Concentration"; "The Association Between Hospital Concentration And Insurance Premiums In ACA Marketplaces").

That said, a public option might have a harder time engaging in utilization management for political/optics reasons, which would drive its spending up relative to unencumbered competitors.

And if it maintains a wider provider network than many of its competitors, it risks adverse selection (this is something that happens in Medicare vs. Medicare Advantage, where people who get very sick disproportionately move off their Medicare Advantage plans and back into traditional Medicare, potentially due to network differences). This is one I struggle with generally, independent of the public option discussion: if network breadth, or at least the inclusion of certain providers in-network, correlates with the risk of the enrolled population, then network design could conceivably become a way of steering higher risks away by simply leaving out certain providers that are particularly desirable for very sick people. There are two countervailing forces there: (1) state network adequacy rules, but those are under state control and enforcement, and (2) the risk adjustment in the marketplaces, which theoretically should level the playing field so that insurers drawing disproportionately sick enrollees don't suffer. But established payers seem to be better at accurately capturing the risk of their enrollees, so how well the public option achieves that may well depend on who the government contracts with to administer it.

That's a long-winded way of saying it's not clear how the public option's premiums will stack up against competitors when it all shakes out, precisely because its presence has the potential to reshape the dynamics of those markets. If it offered premiums on par with everyone else's but at a premium level re-set below today's premiums, that would be good!

Neomalthusian · Jun 20, 2019

I'm Supposn said:
I waste a lot of time because I'm not precisely certain and must confirm, or don't remember, or never knew of the acronyms I encounter within posts. I wish posters would actually spell them out at their first use in each posted response. What's MFA?

Due to the economic or social, or simply the preservation of our nation, there are some things that should be the case without regard to the cost to the insurer, or the purchaser, or the taxpayers. Politics should not be onnly the determination of validity, but also resolution of differences between valid but contradictory concepts, conditions, and goals.

I'm among the proponents of basic government medical insurance in some form. I don't believe yours or my opinions are particularly invalid, but they should be resolved and the middle “compromising” points of such resolutions are very often not the best and sometimes the least advantageous to one or all parties involved. That's why King Solomon suggested cutting the baby in half.

Respectfully, Supposn

MFA is the acronym I use for Medicare for All.

nekrodev · Jun 21, 2019

Greenbeard said:
It's hard to believe that under any system we'll have a situation where people can get anything paid for with no oversight or questions asked.

I know what you mean. It's hard to imagine that we could ever implement a system that looks remotely like the systems already in place in Canada or the UK or Germany or Japan or Finland or Greenland. Clearly, it's never been done before. No one has had the vision or the testicular fortitude to create such a bold and utopian landscape.

Greenbeard · Jun 22, 2019

nekrodev said:
I know what you mean. It's hard to imagine that we could ever implement a system that looks remotely like the systems already in place in Canada or the UK or Germany or Japan or Finland or Greenland. Clearly, it's never been done before. No one has had the vision or the testicular fortitude to create such a bold and utopian landscape.

Which of those nations are you saying has zero utilization management and zero oversight or stewardship of its health care dollars?

nekrodev · Jun 22, 2019

Greenbeard said:
Which of those nations are you saying has zero utilization management and zero oversight or stewardship of its health care dollars?

That's not what you said, you said "no oversight or questions asked". Obviously, there is likely going to be an organization that makes sure that the wheels keep turning, but you don't need people pecking through everything to make sure there's no abuse or going "do you really need that kidney transplant?".

Greenbeard · Jun 23, 2019

nekrodev said:
That's not what you said, you said "no oversight or questions asked". Obviously, there is likely going to be an organization that makes sure that the wheels keep turning, but you don't need people pecking through everything to make sure there's no abuse or going "do you really need that kidney transplant?".

I don't know what "makes sure that the wheels keep turning" means. I'm talking about scrutiny of the medical necessary or clinical appropriateness of a service, and oversight of the stewardship of health dollars more generally. That will exist in any system simply because health care is a finite resource.

The fact that you're suggesting there's any place on earth where organ transplants or of all things are given out willy nilly without so much as asking whether the patient actually needs one is absurd. Every country has waiting lists for organs because there aren't enough to go around so yes nations tend to be somewhat thoughtful about their allocation.

nekrodev · Jun 23, 2019

Greenbeard said:
I don't know what "makes sure that the wheels keep turning" means. I'm talking about scrutiny of the medical necessary or clinical appropriateness of a service, and oversight of the stewardship of health dollars more generally. That will exist in any system simply because health care is a finite resource.

The fact that you're suggesting there's any place on earth where organ transplants or of all things are given out willy nilly without so much as asking whether the patient actually needs one is absurd. Every country has waiting lists for organs because there aren't enough to go around so yes nations tend to be somewhat thoughtful about their allocation.

The ****ing doctors know what they're doing and if they say a person needs something, that person gets it. You don't need some independent body of accountants to meddle in this ****. That's what the private insurance companies we already have are.

Greenbeard · Jun 23, 2019

nekrodev said:
The ****ing doctors know what they're doing and if they say a person needs something, that person gets it. You don't need some independent body of accountants to meddle in this ****. That's what the private insurance companies we already have are.

What could go wrong what that attitude?

Two months ago:

Federal prosecutors on Tuesday said they dismantled one of the largest health care fraud schemes ever investigated by the FBI, charging 24 people in a $1.2 billion alleged scam involving telemedicine and durable medical equipment companies.

As part of the complex operation, doctors got kickbacks for prescribing unneeded back, shoulder, wrist and knee braces to elderly and disabled patients and charging the government's Medicare program, the Department of Justice said.

The accused "concocted an elaborate scheme to exploit the U.S. health care system by targeting Medicare beneficiaries, paying doctors for prescriptions, paying kickbacks and bribes, and in turn selling these prescriptions to DME companies to ensure that they could line their pockets," IRS special agent Matthew Line said, according to Tut Underwood of South Carolina Public Radio.

2018:

Attorney General Jeff Sessions and Department of Health and Human Services (HHS) Secretary Alex M. Azar III, announced today the largest ever health care fraud enforcement action involving 601 charged defendants across 58 federal districts, including 165 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving more than $2 billion in false billings.

2017:

Attorney General Jeff Sessions and Department of Health and Human Services (HHS) Secretary Tom Price, M.D., announced today the largest ever health care fraud enforcement action by the Medicare Fraud Strike Force, involving 412 charged defendants across 41 federal districts, including 115 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $1.3 billion in false billings.

2016:

Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced today an unprecedented nationwide sweep led by the Medicare Fraud Strike Force in 36 federal districts, resulting in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings.

2015:

Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced today a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulting in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings.

2014:

Attorney General Eric Holder and Department of Health and Human Services (HHS) Secretary Kathleen Sebelius announced today that a nationwide takedown by Medicare Fraud Strike Force operations in six cities has resulted in charges against 90 individuals, including 27 doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $260 million in false billings.

nekrodev · Jun 23, 2019

Greenbeard said:
What could go wrong what that attitude?

*snip*

A lot of this will be fixed by fixing issues w/ prescription drug costs and kickbacks and stuff anyway, but even those levels of fraud are literally negligible - even smaller percentage-wise than welfare fraud.

Greenbeard · Jun 23, 2019

nekrodev said:
A lot of this will be fixed by fixing issues w/ prescription drug costs and kickbacks and stuff anyway, but even those levels of fraud are literally negligible - even smaller percentage-wise than welfare fraud.

The GAO estimates that in 2017 Medicare made $52 billion in improper payments out of $702 billion in total spending. That's 7.4% of its spending.

For comparison, the net cost of health insurance in 2017 was 6.6% of the cost of the health system.

Perotista · Jun 23, 2019

I'm Supposn said:
The Patient Protection Affordable Care Act, (“Omamacare”) is conceptually “Romneycare”.

The federal Patient Protection Affordable Care Act was modeled after the existing medical policy that was signed by the then Massachusetts Republican governor Mitt Romney.

Romneycare's individuals' mandated requirement for individuals to purchase or otherwise acquire acceptable medical insurance was a concept advocated by “right-wingers” such as the Heritage Foundation think-tank. They proposed it to enable non-government medical insurance continuous existence. Without sufficient proportions of the population's participation within a medical insurance plan, any (government or non-government) medical insurance provisions for not considering applicants' previous medical conditions are much less financially sustainable.

Respectfully, Supposn

I technically agree. The one huge difference was Romneycare was confined to Massachusetts. Every other state was free to either adopt Romneycare or something akin or not. Nothing was forced on the other states or on the nation as a whole. I'm sure if Romneycare was great, many other states would have followed suit. Since none did, I can only conclude Romneycare wasn't so hot. That was left to the people of Massachusetts to decide.

nekrodev · Jun 23, 2019

Greenbeard said:
The GAO estimates that in 2017 Medicare made $52 billion in improper payments out of $702 billion in total spending. That's 7.4% of its spending.

For comparison, the net cost of health insurance in 2017 was 6.6% of the cost of the health system.

Yes, it's a larger percentage of the "Medicare" payments, but it's a negligible percentage of our total healthcare costs. We spend roughly $3.2 TRILLION per year on healthcare, with nearly half of that being private insurance payments, so that leaves like $1.5 TRILLION as what gets spent through the government. A Medicare for all system would essentially consolidate all of this, including the private insurance portion to a single government system.

And, you're still not taking into account how the fraud actually works. It's the for-profit health systems and pharma companies that are giving the money to the doctors. Medicare payments don't go to the doctors.

Greenbeard · Jun 23, 2019

nekrodev said:
Yes, it's a larger percentage of the "Medicare" payments, but it's a negligible percentage of our total healthcare costs. We spend roughly $3.2 TRILLION per year on healthcare, with nearly half of that being private insurance payments, so that leaves like $1.5 TRILLION as what gets spent through the government. A Medicare for all system would essentially consolidate all of this, including the private insurance portion to a single government system.

That's precisely because not all spending is Medicare spending at present. If you propose to make all payments Medicare payments, then the rate for Medicare payments matters greatly.

As I said, it's hard to believe that under any system we'll have a situation where people can get anything paid for with no oversight or questions asked.

And, you're still not taking into account how the fraud actually works. It's the for-profit health systems and pharma companies that are giving the money to the doctors. Medicare payments don't go to the doctors.

I don't know what point you're trying to make. Lots of corrupt providers, including doctors, fraudulently bill Medicare for services they shouldn't. That's why "just trust the doctors, what they say goes" is not a substitute for thoughtful stewardship of how money is being spent.

nekrodev · Jun 23, 2019

Greenbeard said:
That's precisely because not all spending is Medicare spending at present. If you propose to make all payments Medicare payments, then the rate for Medicare payments matters greatly.

As I said, it's hard to believe that under any system we'll have a situation where people can get anything paid for with no oversight or questions asked.

I don't know what point you're trying to make. Lots of corrupt providers, including doctors, fraudulently bill Medicare for services they shouldn't. That's why "just trust the doctors, what they say goes" is not a substitute for thoughtful stewardship of how money is being spent.

The point that I'm trying to make is that you need to cut off the root cause of the problem, then you don't have to have a bunch of people constantly looking for corruption, because the corruption no longer exists.

Neomalthusian · Jun 24, 2019

Greenbeard said:
Regardless, other than the network development and reimbursement setting pieces I mentioned above, the public option plays by the same rules as any other plan. It doesn't offer more generous coverage because it offers the essential health benefits, like everybody, and it offers metal tier plans that are sold in the marketplace. A bronze plan sold by the public option still has a 60% actuarial value (and thus a high deductible) just like any other payer's. It also can't differentiate between the young and old differently than other insurers do, because the age rating bands are set in regulation. Everybody uses the same ones.

How its premiums stack up against the competition depends. Really there's not all that much that determines premiums: it's the prices you pay for services, it's who you enroll, it's how well you manage your enrollees' care and utilization, and it's whether you are doing anything interesting in terms of benefit designs or provider payment methodologies that moves the needle on how people or providers behave.

The public option--whether weak or strong--gets pulled in different directions.

If it's strong, it initially has a pricing advance on its competitors because it's paying Medicare prices and its competitors are not. The potential benefit of that market-wide is that it could force providers to offer greater pricing discounts to private insurers to mitigate enrollee defections to the public option. This is why I personally supported a strong public option back in 2009. The goal wasn't to drive private insurers out of business, it was to reshape the market such that payers had greater leverage to negotiate lower prices with providers. There's a little evidence of something like that happening in the early years of the marketplaces--"Hospital prices drop for the first time"--but provider market concentration remains a significant issue, and the higher prices providers in concentrated markets can command directly impacts premiums (e.g., "ACA Marketplace Premiums and Competition Among Hospitals and Physician Practices"; "Provider Market Concentration Outweighs Payer Concentration"; "The Association Between Hospital Concentration And Insurance Premiums In ACA Marketplaces").

That said, a public option might have a harder time engaging in utilization management for political/optics reasons, which would drive its spending up relative to unencumbered competitors.

And if it maintains a wider provider network than many of its competitors, it risks adverse selection (this is something that happens in Medicare vs. Medicare Advantage, where people who get very sick disproportionately move off their Medicare Advantage plans and back into traditional Medicare, potentially due to network differences). This is one I struggle with generally, independent of the public option discussion: if network breadth, or at least the inclusion of certain providers in-network, correlates with the risk of the enrolled population, then network design could conceivably become a way of steering higher risks away by simply leaving out certain providers that are particularly desirable for very sick people. There are two countervailing forces there: (1) state network adequacy rules, but those are under state control and enforcement, and (2) the risk adjustment in the marketplaces, which theoretically should level the playing field so that insurers drawing disproportionately sick enrollees don't suffer. But established payers seem to be better at accurately capturing the risk of their enrollees, so how well the public option achieves that may well depend on who the government contracts with to administer it.

That's a long-winded way of saying it's not clear how the public option's premiums will stack up against competitors when it all shakes out, precisely because its presence has the potential to reshape the dynamics of those markets. If it offered premiums on par with everyone else's but at a premium level re-set below today's premiums, that would be good!

Thanks for the thorough explanation. If as you described a public option offered something comparable enough to what's already out there that it wouldn't risk serious adverse selection, then I guess my initially stated concerns, but on the other hand I could imagine the public being disappointed with its costs relative to benefits, feeling like it didn't solve many of their individual problems or complaints.

American · Jul 6, 2019

nekrodev said:
I know what you mean. It's hard to imagine that we could ever implement a system that looks remotely like the systems already in place in Canada or the UK or Germany or Japan or Finland or Greenland. Clearly, it's never been done before. No one has had the vision or the testicular fortitude to create such a bold and utopian landscape.

Finnish Government Collapses Due to Rising Cost of Universal Health Care

Finland? Yeah [emoji38]

Sent from Hillary's private email server.

I'm Supposn · Jul 17, 2019

Jay59 said:
You have presented nothing which contradicts anything I stated, but it appears you think you have. The OP first sentence is still in error.
It would be more accurate to say that there is wide bipartisan opposition. Specific elements have support but the entire law is a trainwreck.

I'm Supposn said:
The Patient Protection Affordable Care Act, (“Omamacare”) is conceptually “Romneycare”.
The federal Patient Protection Affordable Care Act was modeled after the existing medical policy that was signed by the then Massachusetts Republican governor Mitt Romney. ...

Excerpted from
Massachusetts health care reform - Wikipedia .
“The Commonwealth of Massachusetts passed a health care reform law in 2006 with the aim of providing health insurance to nearly all of its residents. The law mandated that nearly every resident of Massachusetts obtain a minimum level of insurance coverage, provided free and subsidized health care insurance for residents earning less than 150% and 300%, respectively, of the federal poverty level (FPL)[1] and mandated employers with more than 10 full-time employees provide healthcare insurance”.

Excerpted from
'RomneyCare' Facts and Falsehoods - FactCheck.org .
“Summary
BOSTON — It has been nearly five years since Massachusetts Gov. Mitt Romney signed the state’s landmark health care law amid the political flourish of a fife and drum corps and 300 guests in Boston’s Faneuil Hall. The overhaul is largely seen as a blueprint for the sweeping federal legislation that followed, making the state a political target for critics of President Obama’s efforts”.

Excerpted from
Lessons from the Fall of RomneyCare | Cato Institute .
“Perhaps the most publicized aspect of the Massachusetts reform is its mandate that every resident have health insurance, whether provided by an employer or the government or purchased individually”.

Omamacare is Romneycare.

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