The real life impact of reversing the ACA

[Smallsteps]

And if not for the ACA, he and his family would be on Medicaid and taxpayers would be paying for it anyway. What's the difference? What really changed in this scenario with the introduction of the ACA?

This is the difference...…... in comparing picking up all or most costs (Using ACA ) vs we will have to pay for it anyway...………..Is resolving yourself that no matter what you do someone will steal your car so why not leave it unlocked and with the keys in it.

There is a different attitude between the two (same family was according to wife) "they were careful and tried being healthy before coverage now they have Insurance the kids can juggle knives".
I am DEMONSTRATING an attitude and the reality of what I have seen first hand.

IN going back to a post on another thread the big issue is so many are simply awful healthcare consumers .
Some view the ACA coverage as a credit card they never has to face the bill on.

We are not instilling a sense of responsibility.Which by the way in most single payer countries have.
I had a long debate with friends two of whom were from countries that have had single payer and they agreed people in their home countries had a sense of responsibility to be savvy consumers of their healthcare out of an grateful attitude that many Americans simply do not have.

Life is a RISK.
Yes people need to weigh many items when staying or changing jobs like will I be ok for the 90 days or whatever until next insurance kicks in ? Many pros and CONS in changing but that is the risk for the reward of maybe better opportunities / pay etc.
Comparing plans through even enrollment paperwork is not clear and some may find what they thought was covered was not or company is a pain to deal with.
Sometimes people simply do not know how GOOD or BAD a plan they have until they use it.

The IDEA that in healthcare and now being talked about retirement is not about making better choices but instead making sure there are no consequences for bad choices is not just a bad idea it is INSANE.
Livingalmost large … Where was the outrage and complaints when we were sold on the notion that portable retirement in the control of the owner was the best thing for us?
Instead we are on the verge of many retiring with little or no savings we are glorifying the good old days when people put in 20/ 30 years to secure their pension.

The whole selling points were hat YOU controlled level of risk an mount saved etc ..............because many pension plans were not managed well were raided or simply lost on crazy get rich quick investments.
What these salesmen ( lol I mean lawmakers ) seemed to overlook is not everyone is serious and committed about saving …...often because if investments went bad it would be on them no faceless bad guy to blame

[disneysteve]

We are not instilling a sense of responsibility.Which by the way in most single payer countries have.

Very true, but that has nothing to do with the ACA. That existed long before the ACA came along. If you want people to be savvy consumers of healthcare resources and take personal responsibility for their actions and their own well being, they need to have skin in the game which they don't with most health insurance. In recent years, this has actually gotten a little better with the introduction of HDHP. Give someone a $5,000 deductible and suddenly they actually care about what things cost. "Doc, is there a cheaper option? Do I really need this test? Is there something I can do on my own to get better?" That is in stark contrast to the no/low deductible plans where the conversation is more typically "It's covered so do everything. What do you mean I don't need an MRI? I want the medicine that I saw on TV. Don't give me any generic drugs." Any time you divorce the consumer from the cost, you remove any incentive to be responsible. Heck, if I knew my auto insurance rate would stay the same and I wouldn't get any fines no matter what, you can be damn sure I'd be barrelling down the highway going 90 any chance I got.

Sometimes people simply do not know how GOOD or BAD a plan they have until they use it.

This is unfortunately true. They make it extremely difficult to compare plans. Not only that, but what they do and don't cover is a moving target. This month they may cover your blood pressure medicine but come January 1, their 2019 formulary may have that drug removed forcing you to get your doctor to change your treatment for no actual medical reason. I always hated January in my practice because all of the time I had to waste changing people's medicines due to formulary alterations.

The IDEA that in healthcare and now being talked about retirement is not about making better choices but instead making sure there are no consequences for bad choices is not just a bad idea it is INSANE.

This is America today. Everybody is a victim. Nobody is ever at fault for anything that happens to them. And this mindset is reinforced on a daily basis by those in leadership. Point fingers and blame "them" whoever "them" happens to be in any given situation. Take credit when things go well and assign blame when they don't.

It will be interesting to watch what happens when more and more people reach retirement age only to discover that they haven't saved nearly enough to actually stop working. Unfortunately, it will likely be like watching a car wreck.

[LivingAlmostLarge]

Retirement without pensions will be a car wreck. And healthcare already is smallsteps. You have to decouple healthcare from employment and make it truly painfully free market in order for the market to work. I'm definitely more single payer but my next choice would be completely free market. That means decoupling employer provided coverage, medicare, medicaid, tricare, etc. Everyone goes on a be responsible and shop around. That's the only way to make the free market work. We can't keep subsidizing healthcare for more than half the population.

Smallsteps if you are so against single payer are you on medicare? Do you plan on buying your own or using medicare? That's the biggest single payer in the US. And one which people won't give up. It's political kryptonite. So until we discuss why single payer won't work when elderly won't give up their single payer, then the argument that single payer is bad doesn't fly.

Second I don't think pensions are the answer. But I am pointing out that we haven't truly seen the repercussions of retiring without pensions yet. I think it started in the 80s and people are starting to understand. But there hasn't been en masse the same number as they used to retire with pensions retiring without yet. When the majority of private sector workers who had to "depend" on saving into a 401k retire and their $100k balances don't = zero income it'll hit home hard.

I mean it's a compound effect. These same people likely haven't paid off their homes. They probably still have mortgages and they probably haven't saved for retirement.

[Thrif-t]

I absolutely agree with you Living on having to divorce people from employer benefits if the free market is going to work. And this coming from someone who's DH works for a government and has great/cheap benefits!! But it truly is the only way.

And as far as the pensions, in my area, around 1995 companies stopped giving new hirer's pensions, and then somewhere in the 2000's they froze them for all current workers. I only know that because I switched jobs in 2001 and had a hard time deciding if I should leave because I would be giving up my pension. Once I found out my x employer froze everyone's pensions soon after I left, I felt better that I had made the switch.

[Smallsteps]

"Smallsteps if you are so against single payer are you on medicare? Do you plan on buying your own or using medicare?

That's the biggest single payer in the US. And one which people won't give up. It's political kryptonite. So until we discuss why single payer won't work when elderly won't give up their single payer, then the argument that single payer is bad doesn't fly."

FAR from the age to be on MEDICARE
I find the comparison between single payer and Medicare filled with half truths and assumptions.
For example I had a discussion with some co-workers/ friends some on in their 20s- 30s. Most had NO idea that Medicare did not pay 100% of things and like their insurance now there are co-pays and premiums.
When they found they would still be paying out of pocket it was NOT the single payer they had envisioned. They want something like their Parents that just paid and they never even had to think about it.

I did enjoy the huge laugh with your line " everyone goes on to be responsible" that as I have been discussing is ONE of the factors of why we have a mess in healthcare and retirement.

Honestly I am often simply amazed at the complete insanity of some.

Every time the subject comes up I remember what a newly elected congress person said about the huge cost of single payer …."the taxpayers will have to pay some then the government will pick up the rest"

Seriously that is the clueless mentality believed by TOO many people it is embarrassing and I often wonder how they manage the basics of life. Those PAYING are already upset that they are subsidizing so many on ACA how do you think picking up EVEN more will put a smile on their face.

As for the claim " seniors love it and will never give it up"
You do not need to like something in order to want to keep it many are SIMPLY afraid the next thing will be worse. Part of why so many send back the same dinosaurs to congress and the senate.
Better the idiot you know then taking a chance on a new one.

Tests and treatments are often limited,finding providers can be difficult as many limit that part of practice because the low reimbursement rate.
If you feel that you have already invested for decades into something you would not be willing to give it up. Like ending up with a giftcard to somewhere out of business,Or elaine on Seinfeld eating one more crappy sub cause her punchcard was almost filled and she got a FREE one.

I REALLY think many people believe the actual amount invested is more then it really is / this is the same with SS.
If Many people especially the working poor did the math they might be shocked.
I did a basic calculation on a friend based on her payments ( I used her best year for the as the amount x years working) based on what her check is ……..if the checks stopped when her contributions were used she will be out of money in a very short time.

This is happening many people did not invest in IRA or 401k for many reasons. Each person has their own some I have heard.
1, afraid to make investment choices
2. did not see that even a little bit added up over time. or thought when they got their next job or started their career they would have plenty of time/ money to fund
3 cashed out if they changed jobs because they did not understand where they could start a rollover IRA. many who have no experience are (cautiously) afraid of being taken by an advisor / plan.

Anyone who plans these things out and ASSUMES 100% participation is kidding themselves and when it becomes clear that some thing is NOT working like it did on paper it must be some other issue … ( fill in excuse here).

[LivingAlmostLarge]

Small steps if you hate socialized/single payer what do you suggest for healthcare? What is your idea that would be better/? Through this all I have heard you poking holes on why single payer is bad. But how would you suggest we fix the system? Unless you think it's already great?

[TexasHusker]

Pre- ACA, most states had "high risk" pools that took anyone and everyone, with most providing benefits far richer and less expensive than Obummer Care. I'm down for doing away with ACA, but states should be required to offer a high risk pool as they did before - all states. I have several friends who "lost" this coverage when Obummer Care took effect and they are paying twice as much for half the benefit.

[Smallsteps]

Small steps if you hate socialized/single payer what do you suggest for healthcare? What is your idea that would be better/? Through this all I have heard you poking holes on why single payer is bad. But how would you suggest we fix the system? Unless you think it's already great?

There are many items that could help people but MOST require personal responsibility which is not an item you can legislate.
The reality is we NEED a bit of reality in the mix,,,,, TORT reform is a huge item almost never mentioned (but used in most single payer systems).

The best item is to create better health care educated consumers and that entails a lot of work and questioning of follow the money and question the outcomes. Second opinions etc.
The biggest help was a med group in my area was a published a menu board of fees and that aggravated many other groups because they were using different fees on all plans or out of pocket payers.

With a idea of what items should cost makes it easier to shop around. EVERYONE needs skin in the game and realize what kind of care are they purchasing and ASK questions.
This is work and takes backbone in some cases as in ANY profession there are good and bad medical providers and systems quite frankly many are not weeded out of the profession.
Some med groups want frequent return trips like a restaurant or store wants repeat customers regardless of patient outcome.

maybe a doctor /patient contract where both parties set out guidelines (for example if patient does not follow through on treatment the doctor can severe the contract and walk away instead of just waiting for a patient of their family to blame doctor for NO progress in a condition.

The HSA idea could be adjusted as well from my perspective it is MOST enjoyed by those who are basically using it as another tax savings not because of saving for medical items.

Look at the tax situation the people who basically pay 0 tax are not trying to maximize an HSA, yet the low income people are the ones most often uninsured.

Look at where any ACA money went. Over 40% went to 4 states..... the rest shared by the other 46 states…..

[disneysteve]

Pre- ACA, most states had "high risk" pools that took anyone and everyone, with most providing benefits far richer and less expensive than Obummer Care.

You've mentioned this before and I can honestly say that having been in practice for 25 years, I was not aware of this and don't think I ever saw a single patient who had that coverage. If, as you say, there was cheaper and better coverage available before the ACA, why were there tens of millions of uninsured people who got insurance under the ACA? Why didn't all of those people take advantage of those state programs? And I'm not being sarcastic here. I'm genuinely curious as I had never heard of that option until you mentioned it in another thread. Maybe people just didn't know it existed. I didn't. They sure didn't publicize it, to patients or to doctors.

[TexasHusker]

You've mentioned this before and I can honestly say that having been in practice for 25 years, I was not aware of this and don't think I ever saw a single patient who had that coverage. If, as you say, there was cheaper and better coverage available before the ACA, why were there tens of millions of uninsured people who got insurance under the ACA? Why didn't all of those people take advantage of those state programs? And I'm not being sarcastic here. I'm genuinely curious as I had never heard of that option until you mentioned it in another thread. Maybe people just didn't know it existed. I didn't. They sure didn't publicize it, to patients or to doctors.

Your post underscores some significant things:

1. Your practice should never see any "coverage", any more than my plumber should see my homeowner coverage, or my oil change place should see my car warranty. Back when it was medical insurance, that is, insurance against an actual LOSS, it was affordable and workable. Now, it is "health insurance", and so every nickel and dime thing is a copay. You scratch your elbow and it's off to the doctor for a $20 copay. That's fine, but "lifestyle maintenance" plans come with a price. Trips to the doctor should be for cash, just like having an appliance repairman is paid to come fix your dishwasher. What do you think you'd be paying for homeowners insurance if you had a $20 copay for every torn window screen, leaky faucet, or A/C recharge? I can tell you this, it would be a multiple of what you pay now.

2. Tens of millions got insurance under ACA because 1) they were subsidized (it was free), and 2) it was the law.

3. Of course states didn't go out there advertising their high risk pools - they weren't intended to be in competition with Aetna and Blue Cross.

4. For people that actually have to pay the premiums, Obummercare is a financial disaster. When I dropped it, it was around $2500 a month for a family of four, and I figured I'd have to spend around $40K annually in premiums and deductibles to get a dollar of insurance. Obviously that isn't "Affordable", and it certainly isn't "Healthcare."
It's a ripoff.

[disneysteve]

Pre- ACA, most states had "high risk" pools that took anyone and everyone, with most providing benefits far richer and less expensive than Obummer Care.

2. Tens of millions got insurance under ACA because 1) they were subsidized (it was free),

You seem to be contradicting yourself here. First you say the high risk coverage was cheaper, but then you point out that one reason why so many took coverage under the ACA was because it was cheaper, or even free.

As I said, I'm unfamiliar with those high risk pools but I can't imagine they were actually cheaper. If they had been, I think a lot more people would have taken advantage of them.

[TexasHusker]

You seem to be contradicting yourself here. First you say the high risk coverage was cheaper, but then you point out that one reason why so many took coverage under the ACA was because it was cheaper, or even free.

As I said, I'm unfamiliar with those high risk pools but I can't imagine they were actually cheaper. If they had been, I think a lot more people would have taken advantage of them.

The High Risk Pools generally speaking were cheaper. Many of the "new" insureds under ACA that are subsidized merely moved off of Medicaid rolls - they weren't "new" insureds - they just moved from one public dole to the another.

[disneysteve]

1. Your practice should never see any "coverage", any more than my plumber should see my homeowner coverage, or my oil change place should see my car warranty. Back when it was medical insurance, that is, insurance against an actual LOSS, it was affordable and workable. Now, it is "health insurance", and so every nickel and dime thing is a copay. You scratch your elbow and it's off to the doctor for a $20 copay. That's fine, but "lifestyle maintenance" plans come with a price. Trips to the doctor should be for cash, just like having an appliance repairman is paid to come fix your dishwasher. What do you think you'd be paying for homeowners insurance if you had a $20 copay for every torn window screen, leaky faucet, or A/C recharge? I can tell you this, it would be a multiple of what you pay now.

There are some flaws with the health insurance/auto insurance analogy that we often use. Same for home insurance.

You wouldn't give your mechanic your auto insurance or warranty because an oil change isn't a covered service. But if you were going in for a transmission issue, you would present your warranty because that is a covered service.

The same goes at home. You can't use your home insurance for a torn screen, but you might have a home warranty that covers your dishwasher breaking. Or perhaps you have a service contract for your HVAC system.

Health insurance is similar. There are things it covers and things it doesn't cover. If you're coming because you sprained your ankle, that's covered. If you're coming for Botox injections for the wrinkles on your face, that's not covered. So when a patient walks into the office, we have to see their insurance information. First, we have to verify that it is in effect and second, we have to verify that it covers the treatment they are coming for.

All of that said, I totally agree that the system is broken. Health insurance covers things that it probably shouldn't. There are (or at least used to be) "Major Medical" policies that only covered serious stuff, hospital care, etc. They didn't cover routine office visits. Of course, then the problem becomes that you introduce an incentive for people to delay care, just as high deductible plans do. When people have to pay out of pocket, they are less likely to seek care until their condition worsens. That leads to them not getting treated until they have a more serious problem. So, for example, if you have to pay to see the doctor for the splinter in your foot that you couldn't get out, you might just wait to see if it works its way out on its own. But a week later when it has gotten infected and your foot is red and swollen, you then go to the doctor for antibiotics and a more involved procedure to remove the splinter that is now overgrown with new skin. Or somebody keeps self-treating their cough and chest tightness with over the counter stuff until they eventually end up in the ER diagnosed with pneumonia.

There's no easy solution no matter how you look at it.

[disneysteve]

Many of the "new" insureds under ACA that are subsidized merely moved off of Medicaid rolls - they weren't "new" insureds - they just moved from one public dole to the another.

Do you have a source for this?

I can certainly tell you that in my practice, the folks who got ACA coverage had no coverage before that. That's why we had such an influx of patients once the ACA went into effect. They were all people who weren't getting care before that. They definitely didn't have Medicaid.

[msomnipotent]

You've mentioned this before and I can honestly say that having been in practice for 25 years, I was not aware of this and don't think I ever saw a single patient who had that coverage. If, as you say, there was cheaper and better coverage available before the ACA, why were there tens of millions of uninsured people who got insurance under the ACA? Why didn't all of those people take advantage of those state programs? And I'm not being sarcastic here. I'm genuinely curious as I had never heard of that option until you mentioned it in another thread. Maybe people just didn't know it existed. I didn't. They sure didn't publicize it, to patients or to doctors.

I have been in the high risk pool before. It was extremely expensive and had high deductibles. It has been years since we have been on it, but I think the numbers were $2,000 per month for the 3 of us with $5,800 individual deductibles plus something like $8,000 out of pocket. The premiums went down the longer we were on it, but I think the cheapest was about $1,500 a month after a year. I'm pretty sure Blue Cross administered it, so I had a BC card and not something that said, "IL high risk pool insurance" on it. I forgot how I found out about it, but it wasn't publicized and out of all the employees and their wives at the start up my husband worked at, I was the only one that knew about it.