ACA REPEAL: HERE WE GO AGAIN

According to one report, VP Pence has offered three changes to the repeal bill to win Freedom Caucus support for the Trumpcare bill:

  • Elimination of requirements for what insurers must cover
  • Eliminating coverage for pre-existing medical conditions
  • Eliminating limits on what insurers can charge people with medical conditions

 

Whether the bill can retain any support among moderates in the GOP with these changes is questionable. These provisions will cause problems for hospitals and healthcare providers, and result in more people having no health insurance coverage, and may allow a sharp increase in insurance prices for consumers, as the Congressional Budget Office has predicted.

 

This simply makes a terrible bill worse.

 

Sources:

  1. Marlene Satter, “Freedom Caucus would support health care bill that kills 3 ACA provisions,” BenefitsPro, 10 April, 2017. http://www.benefitspro.com/2017/04/10/freedom-caucus-would-support-health-care-bill-that?kw=Freedom%20Caucus%20would%20support%20health%20care%20bill%20that%20kills%203%20ACA%20provisions&et=editorial&bu=BenefitsPRO&cn=20170413&src=EMC-Email_editorial&pt=Consumer%20Driven%20PRO

Comments

Victor Crain Added Apr 14, 2017 - 6:37pm
New rules announced on 14 April make the situation worse for many consumers. For instance, insurers now can refuse to cover consumers who have failed to make payments on health insurance.
Thomas Sutrina Added Apr 14, 2017 - 6:59pm
Victor, when did miss the response that has occurred since the election of 2010.  900 democrat seats in state and federal legislatures flipped to the GOP.  More States now have GOP legislatures then ever before and first the House 2010 and then the Senate in 2014 flipped to the GOP.  Victor this occurred even thou John Boehner and then Paul Ryan and Mitch McConnell in effect supported all of Obama's Programs.  The said one thing as candidates then what they did as legislators.  
 
The citizens felt more lied to by the Democrats then the GOP. Obama, Pelosi, and Reed lead the campaign to deceive us.   That is the starting point that Democrats want to forget.  "GRUBER:  This bill was written in a tortured way to make sure CBO did not score the mandate as taxes.  If CBO scored the mandate as taxes, the bill dies, okay? ... If you made it explicit the healthy people pay in and sick people get money, it would not have passed, okay?  Lack of transparency is a huge political advantage.  And basically, you know, call it the stupidity of American voter or whatever. But basically that was really, really critical to getting the thing to pass. ... The media carried the lie forward, and it was all based on their belief that you are too stupid to figure out what they're doing. ... Supreme Court chief justice decided to write the law himself in order avoid declaring it unconstitutional.  ... essentially a bunch of people have gotten subsidies that do not deserve them, that do not qualify for them.  The only people who get subsidies are from the states, state exchanges, and most states did not set up an exchange.   Which means the federal government came in and, essentially, in violation of Obamacare, set up their own exchange and provided their own subsidies, which is not legal." 
http://www.rushlimbaugh.com/daily/2014/11/10/obamacare_architect_jonathan_gruber_we_lied_and_counted_on_the_stupidity_of_the_american_voter  also  http://abcnews.go.com/Politics/obamacare-architect-jonathan-gruber-fire/... and http://abcnews.go.com/Politics/obamacarearchitectjonathangruberfire/
print?id=26919286
 
Victor, the point is Trump and the GOP promised for years to repeal Obama Care and in fact Mitch McConnell said every root and branch will be repealed.  The RINOCARE  bill from Paul Ryan was rejected by 65% of citizens and only approved by 17%.   What the people want is very clear Victor a return to a free market that we have not experience in decades.  That everyone knows will be the only way cost go down.  That is the only way we stop filling the pockets of lobbyist and they fill the coffers of Paul Ryan and Mitch McConnell. 
 
John G Added Apr 14, 2017 - 7:09pm
What the people want is very clear Victor a return to a free market that we have not experience in decades.
 
In reality the public overwhelmingly wants single payer/Medicare for all.
But neither faction of the corporatist war party will offer it because it goes against the interests of their Wall St benefactors.
 
Jeff Michka Added Apr 14, 2017 - 7:27pm
Tommy the subatomic Sutrino writes:What the people want is very clear Victor a return to a free market that we have not experience in decades.  That everyone knows will be the only way cost go down. - Really, and despite those links
what do people want?  The hardcore Trumpist long term unemployed realized is they got something through that would hurt "Those people", like they wanted, it would further gut the Trumpists.  Trying to claim this was some sort of will of the people stuff is bogus.  Jogn G'S PREVIOUS COMMENT IS CORRECT, rightist.
Thomas Sutrina Added Apr 14, 2017 - 9:28pm
Jeffry boy, it is obvious that a free market is the opposite of Obamacare and the next step that will happen when it collapses if the authors of Obamacare were in power.  Single payer.    And Jeffry boy I have presented the evidence that Obamacare is a failure so the next step one would expect fails before it begins.
John G Added Apr 14, 2017 - 10:19pm
Sutrina. You're avoiding and evading the point. Your assertion as to the public's wishes on health care reform is false.
Obamacare was written by Republicans at the Brookings Institute and the private insurers. It is a world away from single payer or Medicare for all.
Bill H. Added Apr 14, 2017 - 10:38pm
 
John G, you are absolutely correct on both points, "In reality the public overwhelmingly wants single payer/Medicare for all" and "Obamacare was written by Republicans at the Brookings Institute and the private insurers".
Not to label people, but the uninformed diehard Right gets it's "facts" from sources like Fox News and the many Breitbart clones out there. When they actually try to do some research to obtain real facts, their Google algorithm (that understands them better than they understand themselves) just sends them off to yet another Right Wing "fact" source. 
John G Added Apr 14, 2017 - 10:41pm
I don't understand how half of them can tie there own shoelaces in the mornings.
Bill H. Added Apr 14, 2017 - 10:42pm
Also, elimination of coverage for pre-existing conditions in my opinion would be the saddest, most evil thing that the GOP could ever do to American citizens. But then again, we know who the insurance lobby is in bed with!
Victor Crain Added Apr 14, 2017 - 11:24pm
Let's be clear. Most Americans have no clue what single payer is. Nor is there anything "free market" in anything anyone is proposing in either party.  Read the bills; its not there. Nor is there even consensus on whether the ACA (I refuse to call in Obamacare; that's not factual) is failing. The Blue Cross consortium is very loyal to the program.  No, the issue is division of the spoils. The bill that failed called for a 30% increase in premiums on anyone who let insurance lapse and then wanted to get it back. The current proposal allows insurers to refuse coverage.   Even without the penalty, the bill that failed was forecast to cause insurance rates to increase by 20% per year through 2020 (the CBO forecast, and the head of the CBO is a Republican).  Personally, I'd really like to see people retire the partisan labels and ideological gibberish and focus on facts and figures. That's the only way something useful is going to happen.
John Minehan Added Apr 14, 2017 - 11:44pm
"According to one report, VP Pence has offered three changes to the repeal bill to win Freedom Caucus support for the Trumpcare bill:

Elimination of requirements for what insurers must cover
Eliminating coverage for pre-existing medical conditions
Eliminating limits on what insurers can charge people with medical conditions"

It would make a lot of sense to tailor coverage to what particular groups of people need, rather than to craft "one size fits all" policy at the national level.  Of course, this would work best in the context of group plans.
 
Here's the thing: you can cover people pretty efficiently with pre-existing conditions within the context of group plans.  We have been doing it (with a provision for a waiting period) since HIPAA passed in 1996.
 
Insurers HAVE to charge more for people with pre-existing medical conditions, otherwise there is no way for it to work economically.  Of course, they could charge less in the context of group plan. 
 
Medicare, is a circa-1966 BC/BS 80-20 Indemnity Plan. Absent a good Medi-Gap Plan (or Medicaid dual eligibility), it is unaffordable.
 
The intelligent thing to do would be to figure out how to do group benefits in what is increasingly a 1099 world.  Some people in the GOP seem to be seeing this. 
 
"The world presents enough problems if you believe it to be a world of law and order; do not add to them by believing it to be a world of miracles." Louis D. Brandeis
 
John G Added Apr 15, 2017 - 12:47am
Why is Medicare for all "unaffordable"? Private insurance is far more expensive.
John G Added Apr 15, 2017 - 2:48am
Let's be clear. Most Americans have no clue what single payer is.
 
Here's your chance to redress this issue buddy.
 
Let's hear you.
John Minehan Added Apr 15, 2017 - 7:05am
"Why is Medicare for all "unaffordable"? Private insurance is far more expensive."
 
Straight Medicare (parts A and B) pays like indemnity insurance, it pays 80%.  The remaining 20% can be quite large.  More affluent seniors generally either opt for Medicare Advantage (a Medicare PPO) or have Medi-Gap Policies that help them deal with the  20%.
 
Seniors in poverty or people on Total Disability, in most states, have Medicaid to help deal with the 20%.
 
People without those things have a fairly large problem. 
Thomas Sutrina Added Apr 15, 2017 - 7:41am
John G.  True, "Obamacare was written by Republicans at the Brookings Institute and the private insurers." BUT THE GOP DID NOT PUT IT IS PRACTICE THE DEMOCRATS DID.  Ryan wanted to also but the GOP rebuffed RINOCARE.  (Repeal in name only)
 
John  G. VELCRO works great for shoes.
 
Victor 63% of those poled do, "Let's be clear. Most Americans have no clue what single payer is."
 
John G.  free market in healthcare died during WWII when companies provided insurance and the government wanting that gave them a tax break but no tax break for individuals.  SPECIAL INTEREST. 
Dino Manalis Added Apr 15, 2017 - 8:40am
The Freedom Caucus doesn't want to replace ObamaCare.  Trump has to realize health care is complex and a long-term problem, not just a matter of repealing and replacing the ACA, even more importantly, we have to reduce expenses, like import foreign prescription drugs and cap medical malpractice compensation, but that will also take time and varous pieces of legislation.  Ideally, the mandates and taxes should be repealed, Medicaid ought to stay as is, but recipients should pay something for it, because nothing's free!  Business tax cuts should come first to improve economic conditions as quickly as possible, that's the priority, health care takes time and has to be delivered in pieces.  Don't rush it!
John Minehan Added Apr 15, 2017 - 9:54am
Bill H. Added Apr 15, 2017 - 11:11am
The Trumpcare bill is nothing more than bowing to the insurance companies to allow them even more profits than they are making now.
The strange thing is that medical insurance companies have reaped record profits for the last three years. The top five health insurers - UnitedHealth, Anthem, Aetna, Humana and Cigna  have doled out nearly $30 billion in stock buybacks and dividends from 2013 to 2015. The increase in customers that these health insurers received under ACA helped raise the stock prices of the top five insurers - some 80 percent for Anthem and 165 percent for Aetna since the court ruled on June 28, 2012 that Obamacare was constitutional. The insurance companies that bowed out of Obamacare were not losing money; they just might not have been making as much money as they like.
Obamacare is not responsible for the ongoing rising costs for insurance, it is the greed of the insurance companies, who's only priority is profits with no thought whatsoever of their customer's well being.
My wife has made it thru 3 bouts with cancer, and with all of the hassles and battles I have had with insurance companies, I know where there priorities are and how they are constantly working on ways to avoid paying for even what they state they will cover.
Capitalism is great, but it’s wrong to allow profits to drive our health care system. Congress doesn't care because they receive taxpayer-subsidized health coverage.
Thomas Sutrina Added Apr 15, 2017 - 11:34am
Dino, where did you get this piece of wisdom, "Freedom Caucus doesn't want to replace ObamaCare," they said that RINOCARE was not what they promised their citizens.  Mitch McConnell described what they promised, "repeal Obama Care Root and Branch."  He did not mean in, but the Freedom Caucus did.  They said they wanted to return to a free market system where you choose your doctor your insurance and the care you get without government interference.  That was what was promised Dino.
 
RINOCARE that Ryan put forth is DEAD.  And we have not seen another bill yet so all the comments of what is in RINOCARE or the comments of the VP is just speculation, wild ass guess. 
 
Victor Crain Added Apr 15, 2017 - 11:43am
Pew early this year reported that 60% of Americans view healthcare as a government responsibility. Further, they noted that support for that view has risen by 20 points among low and middle income Republicans.  The only group holding the line against it are affluent Republicans.  http://www.pewresearch.org/fact-tank/2017/01/13/more-americans-say-government-should-ensure-health-care-coverage/  (Pew is the gold standard for surveys these days in terms of sound methodology and reliable analysis.)
 
That said, just because people may have heard the single payer term doesn't mean they understand it.  Usually, in surveys, when you ask people awareness and then follow with more detailed questions on a topic, they may claim awareness but fail the detail.  I think that's the case with single payer.
 
John, Medicare Advantage and Supplements don't have to be horrifically expensive and some aren't.  Yet there are poor seniors who can't afford them.
 
The national average cost for in-home care is $3,600 per month, and for nursing home, $9,200 per month. Medicare covers the first 100 days, period. People require an average of 2.4 years of this care.
A single premium Long Term Care policy for a 66 year old can cost $128,000. The average American has $35,000 in savings at retirement.  Those numbers just don't add up for most people.
 
The Trump administration has been talking about removing the option for people to spend down assets and use Medicaid to pay LTC expenses. What then?
 
A person can live a good upstanding life, work hard, and still have a humiliating experience at end of life. What does that say about this country?
 
 
John Minehan Added Apr 15, 2017 - 12:26pm
"John, Medicare Advantage and Supplements don't have to be horrifically expensive and some aren't.  Yet there are poor seniors who can't afford them."
 
Which is my point. 
 
Even more on point, there are a lot of people who can't afford Advantage or a Medi-Gap policy and don't qualify for Medicaid (which helps the categorically needy).
 
So . . . .
 
How does "universal Medicare" actually help?  How will giving everyone insurance most can't afford . . . and which could be ruinous in many cases where the 20% of "patient responsibility" is astronomical . . . be feasible, when it comes at a huge cost to the public fisc?
 
And . . . if more of the general public understood these facts, would "60% of Americans view healthcare as a government responsibility?"
 
There are better ways . . . .   
Thomas Sutrina Added Apr 15, 2017 - 12:36pm
I said that free market heath care died during WWII. This was not an accident. FDR's second Bill of Rights, 1944 State of the Union address: • The right to adequate medical care and the opportunity to achieve and enjoy good health. He earlier started to achieve this goal by giving a tax advantage to businesses that provided health insurance for their employees.

The following is from a study of Medicare and since Medicaid was started at the same time the comments apply to both since the same proceedures are used. https://www.mercatus.org/publication/medicare-role-determing-prices-throughout-health-care-system https://www.mercatus,org/sites/default/files/Feldman-Medicare-Role-Prices-oct.pdf
"• By reducing comsumers' out-of-pocke price for heath care, insurance tends to increase the use of health care services and weaken consumer's incentive to protect their health. These effects increase with the generosity of coverage, which is fueled by policies that subsidize the price of insurance, including the tax deductibility of employer-based insurance and the government's implicit subsidy of Medigap premiums.
• Many health care markets are concentrated, giving providers market power to raise prices above their marginal costs."
When Medicare and Medicaid were introduced government became the largest payer in the health care industry. "Payments by the government substantially influenced the prices paid, and many private insurers, those companies purchased, simply adopted the government levesl of reimbursement. ... Since 1992 Medicare has set prices using the Resource-Based Relative Value Scale (RBRVS), ... [RBRVS] relies on a special committe of the AMA to propose data on which to base the prices. • The committee has no incentive to reduce the value calculation for services. • There have been few reductions in the estimates of values even for porcedureal services in which physicians' productivity increased and volumes expanded. • The expert panels cherry-pick results, often developing more favorable (higher-cost) estimates if they deem the survey data to be "flawed or incomplete."
Fees should be based on "contingent-claim insurance" that is, lump-sum payments tied to illness so that consumers use the efficient levels of services, including those that prevent illness and protect their health.
John Minehan Added Apr 15, 2017 - 12:51pm
. "'Payments by the government substantially influenced the prices paid, and many private insurers, those companies purchased, simply adopted the government levesl of reimbursement. ... Since 1992 Medicare has set prices using the Resource-Based Relative Value Scale (RBRVS), ... [RBRVS] relies on a special committe of the AMA to propose data on which to base the prices. • The committee has no incentive to reduce the value calculation for services. • There have been few reductions in the estimates of values even for porcedureal services in which physicians' productivity increased and volumes expanded. • The expert panels cherry-pick results, often developing more favorable (higher-cost) estimates if they deem the survey data to be "flawed or incomplete.'"
 
Medicare reimbursement is quite low, in some places, approaching a physician or other provider's cost.
 
Despite that, Physicians often 'pared" with Medicare because it paid net 45 days on a clean claim, giving a practice cash flow, even at a low rate.
 
Until recently, the need for the "Doc Fix" each year slowed Medicare's payments, which means that many docs stopped paring.  That trend continues even after the "Doc Fix" issue was largely figured out a few years ago.
 
Medicaid uses a different fee schedule than Medicare, the last time I checked . . . and it reimbursed at an even lower rate.
 
One problem with Medicaid Expansion is that a lot of the care is still through the ED, although now there is reimbursement for the House.      
Thomas Sutrina Added Apr 15, 2017 - 1:13pm
John M. I am retired so have Medicare.  It is an national program not a state program.  Where Medicaid is a state program and the problems you mentioned occur in these programs.   The two programs use similar method of setting prices, however; since states can not print money, Medicaid follows that solution that all government health care programs choose.   That is balancing the budget becomes more important then providing services.  The AMA may suggest prices but the bureaucrats are in charge and adjust them to balance the budget.  States Medicaid bureaucrats know they are one of the top 5 payers for health care in their state so they have power to effect the price.   The public outcry will shame service providers, and the bureaucrats also know the law clearly states that critical health care can not be denied.   So service providers like hospitals will in the end treat the patent on medicaid.  They will get a mixed bag of people that died quickly and those that are very expensive because early prevention measures were not done.   
 
As a foot not on a free market Adam Smith described the effect of a free market and when government or someone else makes decisions for a group of people.  insurance companies, AMA, employers, etc.: 

Ref: "Free to Choose" Milton & Rose Friedman 1979 Introduction: Adam
Smith key insight was that both parties to an exchange can benefit and that,
so long as cooperation is strictly voluntary, no exchange will take place
unless both parties do benefit. ... Adam Smith put it, an individual who
"intends only his own gain" is led by an invisible hand to promote an end
which was no part of his intention. Nor is it always the worse for the society
that it was no part of it. By pursuing his own interest he frequently
promotes that of the society more effectually than when he really intends to
promote it. I have never known much good done by those who affected to
trade for the public good." ... "an individual who intends only to serve the
public interest by fostering government intervention is "led by an invisible
hand to promote" private interest, "which was no part of his intention."
 
John Minehan Added Apr 15, 2017 - 1:53pm
"The public outcry will shame service providers, and the bureaucrats also know the law clearly states that critical health care can not be denied.   So service providers like hospitals will in the end treat the patent on medicaid.  They will get a mixed bag of people that died quickly and those that are very expensive because early prevention measures were not done."
 
But . . . a private Physician's office is bound by the Emergency Treatment & Active Labor Act ("EMTALA"), so much of the treatment for Medicaid patients comes from EDs.   
Victor Crain Added Apr 15, 2017 - 2:04pm
Medicare has experimented with several approaches in the last year to reduce costs and improve quality of care, including "bundled payments." What they've learned is that some hospitals and physicians are perfectly happy to game the system for their own profit. (There's no fiduciary rule, apparently, for medical institutions or professionals.) At the same time, Congress has limited the ability for Medicare to negotiate rates with drug companies. A very expensive phama lobbying campaign that included $6 million in campaign contributions to leaders in the GOP helped to kill a bill just this past January. Paul Ryan reportedly received $293,000 from that effort. 
 
There's been no public outcry over this because most people don't care enough to be informed.
John Minehan Added Apr 15, 2017 - 2:22pm
Mr. Crain,
 
So, given what you say, how do you understand:
 
1) what people mean by "reported that 60% of Americans view healthcare as a government responsibility;" and
 
2) what do you think that should mean?
 
I'm not trying to be harsh, I just don't see your point.
 
To me, the most workable course of actions are:
 
1) to expand the use of HSAs, in order to get insurance out of Primary Care;
and
 
2) to make it easier to let small businesses and the self employed have access to group plans, probably by making it easier to form MEWAs under ERISA law and regulation.
 
I think a "Bismarck System for the Gig Economy" would help a real market develop for common specialty services, as opposed to the current system, which everybody (not just providers) game.
 
The ultimate goal would be a system, like that of India with little use of private insurance and little government intervention.  However, as Thomas Sutrina points out, there is not a true market now.
 
I think the road to India (a pure-market system) lies through France (a Bismarck system).   
  
Mike Haluska Added Apr 15, 2017 - 3:18pm
Looking at this list:
 

Elimination of requirements for what insurers must cover
Eliminating coverage for pre-existing medical conditions
Eliminating limits on what insurers can charge people with medical conditions

I see NOTHING that the Federal Government should be involved in.  The Federal Government should do ONE thing and that is break any artificial barriers to competition (e.g. can't cross state lines bullshit)!
 
Get rid of the phony "Insurance Market Websites" and let people buy health insurance the same way they buy car insurance!!!
 
And if people don't want to purchase health insurance that's their business, and the government shouldn't be subsidizing people who are fully capable of purchasing health insurance and choose NOT to. 
Micahel Dolan Added Apr 15, 2017 - 3:25pm
SINGLE PAYER----------
The final step for the socialist leftist government to now own you for your life. Is Hussein Obama in one of his Obamacare-plans-NO. Are our useless politicians enrolled in a Obamacare plan-NO. Read the Obamacare plan- death panels for the elderly.
Mike Haluska Added Apr 15, 2017 - 4:30pm
Micahel - excellent post!  The best "Litmus Test" for any piece of legislation is whether or not the politicians exempt themselves from it!  The Obama Administration knew the ACA was a "House of Cards" and certain to collapse.  It's real purpose was to further "condition" the Entitlement Class into wanting Single Payer as a "solution".
John G Added Apr 15, 2017 - 5:09pm
How does "universal Medicare" actually help?  How will giving everyone insurance most can't afford
 
You make it affordable. Hell, I'd make it free. There is no better cause for government than the health and well being of the people.
Thomas Sutrina Added Apr 15, 2017 - 5:21pm
People do thing government has a responsibility for health care.  Emergency Treatment & Active Labor Act ("EMTALA") is an example of the government's response.  So we will never have a totally free market system.  At least catastrophic health care will be regulated since you do not shop for the service when you need it.  And life or death being the options price is not an issue.  
 
People can vote with their feet for the day to day health care and most elective operations.  With health saving accounts the accumulation of money or purchasing an insurance at the start  before a cushion is built up the amount of care that catastrophic insurance will cover will be small.  And if a person does not have insurance then they will take out a lone and pay for it in future earnings.  
 
Today health care is taxed by the hospitals to pay for the free care given.  So the price we pay is likely half the cost charged.  The health saving accounts and the insurance I listed above will reduce the free care given.  
 
Catastrophic health care insurance will be cheep and maybe required or a minimum policy be required by government.  In effect that is what medicaid and EMTALA is already.  This would achieve the people expecting government to be involved in health care.  Society to exist has always provided for the misfortunate.  The local and state governments in colonial times already did this.  You can read what the founders thought of welfare.   It did exist as an emergency stop gap.  And they knew that some people maybe covered for the rest of their lives but very few.  Health care if better in those times would have receive a similar response.    
John G Added Apr 15, 2017 - 5:29pm
health saving accounts
LOLz.
Thomas Sutrina Added Apr 15, 2017 - 5:30pm
Welfare has moved to a card with a fixed amount given and few restriction on what can be purchase.   Medicaid could provide an amount that would go into a health savings account so even the poor could vote with their feet and build up a cushion.  The majority of the poor do know how to live within the amount provided or game the system to get more.  So I believe a health saving account management would be within their capacity.  Catastrophic and chronic health maybe done in a different way.  Drug treatment would be a chronic health care issue.  The overall cost of health care will be reduced because even the poor want to get the best value for their money.
John G Added Apr 15, 2017 - 5:52pm
The private market is the problem, not the solution.
Bill H. Added Apr 15, 2017 - 6:16pm
Haluska-
If we left it up to the insurance companies to control the industry, it would turn out like the pharmaceutical industry. Massive profiteering and only the top 10% would be able to afford it.
Is that Capitalism at it's best?
 
Thomas Sutrina Added Apr 16, 2017 - 10:20am
John G. so tell me how successful is the Canadian or the British health care systems?  Why do the Canadians come to the US to get elective procedures.  Why is the teeth of the British average citizen so poor and why do ambulance sit outside the hospital emergency entrance until they have a spot?  
John G. those health care systems are not failures in so far as they to meet the goals of a service provider and a customer.  The problem John G. is that the customer is not the patient but the bureaucrat  that  that defines the metrics of success and the amount of money available.   Adam smith's invisible hand does work:  "Smith key insight was that both parties to an exchange can benefit and that, so long as cooperation is strictly voluntary, no exchange will take place unless both parties do benefit. ... Adam Smith put it, an individual who  "intends only his own gain" is led by an invisible hand to promote an end which was no part of his intention. Nor is it always the worse for the society that it was no part of it. By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it."  As I pointed out the two parts do are the service provider and a government bureaucrat so the instead of society being citizens it is the overall government.  
Now John G., when you want to consider citizens Adam Smith also has an insight:  I have never known much good done by those who affected to trade for the public good." ... "an individual who intends only to serve the public interest by fostering government intervention is "led by an invisible hand to promote" private interest, "which was no part of his intention."
Thomas Sutrina Added Apr 16, 2017 - 11:10am
John G. do you get it?  The free market has its problems and they usually are that when the number of players are low it starts to serve special interest.  Multinational corporations, governments, etc. are the players that create a market with few players.   Also a watch dog and a representative for the weak is needed.  That is the job of government.  But government can not be a player and a watch dog at the same time in a market segment.  The reason for the congress with two houses of one voted by citizens and the second which should be voted by the state via legislatures is to have laws that are less likely to server special interests.  Regulation from bureaucrat that came form the special interests and receive favors from the special interests or representative and their parties that receive favors also serve the interest of special interest.  Adam Smith clearly state that NOTHING GOOD COMES FROM THIS.  
 
So the issue is how to make a free market contain sufficient providers and customers so the non can have undue influence?  And how can government become the representative define a value for of those with no voice in the market (clean water, air, natural resources in the ground, the poor, etc) without favoring special interests including the governments itself.  And finally how can the government be a rule make and then enforce the law uniformly , blind of influence.   That John G. was what the Constitution sent out to do.  It is ranked among the best in achieving this results but not close to success.
Victor Crain Added Apr 16, 2017 - 12:52pm
John M (and everyone else),
The government did make it easier for small companies to offer group insurance, to a point. The HRA made it possible under the ACA for companies to reimburse employees with pretax dollars for part or all of their spending on Marketplace health plans. That basically cuts the cost of offering healthcare to employees by up to 60%.  Then there's the SHOP program. I'm both a research professional and a licensed independent agent, found out about the HRA option from Zane Benefits, independently checked the laws and regulations to verify it, and have discovered that most people (including some very good CPAs) don't have a clue about what I've learned.
 
I've made it a point to be certified on everything in the health insurance space so I could give people sound advice. Most insurance people sell, I educate. Less profitable but more satisfying.
 
The ACA was/is a very complex law. A lot of the people who are complaining about it never knew about how to use it to their best advantage.
 
Vic
 
John G Added Apr 16, 2017 - 4:33pm
Sutrina John G. so tell me how successful is the Canadian or the British health care systems?
 
Both countries have much better health outcomes than the US at roughly half the cost.
The problems that they are experiencing are largely down to interference by right wing ideologues who wish to privatise services into the hands of their rent seeking capitalist buddies.
You have to be a special kind of stupid to believe that deregulation will rid any system of corruption. Truly blind and stupid.
John G Added Apr 16, 2017 - 4:35pm
And finally how can the government be a rule make and then enforce the law uniformly , blind of influence.  
Ever heard of the separation of powers?
Ari Silverstein Added Apr 17, 2017 - 12:26am
The ACA requires companies of greater than 50 employees to provide Obamacare compliant healthcare insurance and it allows employees who work only 30 hours a week to qualify for Obamacare compliant healthcare insurance.  Both of those regulations serve to depress the desire of employers to expand and makes it more likely that part-time workers don’t get as much work as they’d like.  Not to mention it provides yet another benefit for people not to work.  It’s the equivalent of throwing a wet blanket on the economy and it needs to be repealed…QED.
Victor Crain Added Apr 17, 2017 - 12:47am
Hi Ari, I've yet to find a company making growth decisions based on the ACA. Do note that the ACA calculates employees on an FTE basis, so you could have 80 part time employees and still not be required to offer healthcare. What I don't understand is how an employee benefit is an incentive not to work.  What I see as the wet blanket on the economy is the proportion of consumer income that is pre-empted for health insurance. What gets spent on overpriced healthcare can't be spent on other goods and services.
Bill H. Added Apr 17, 2017 - 1:04am
 
John - I think we have seen the results of deregulation many times over. For those who have been around for a while, remember what portion of your income went to your telephone bill say back in the late '80s and how well the service performed. Compare this to the present time.
Only one example. 
John G Added Apr 17, 2017 - 2:09am
Is that deregulation or technology?
We saw the results of the deregulation of Wall St in 2008.
One very large example.
Mike Haluska Added Apr 17, 2017 - 9:02am
John G - with your latest suggestion regarding government health care:
 
" Hell, I'd make it free."
 
you have displayed your true economic credentials and lost any credibility with anyone who takes this subject seriously.
 
Mike Haluska Added Apr 17, 2017 - 9:09am
Bill H - I will address your statement:
 
"I think we have seen the results of deregulation many times over."
 
1) Trucking Industry - deregulation got rid of useless "permits" and made the industry open to competition
2) Airlines - went from a handful of carriers to many carriers, introducing low fare airlines, regional airlines, all sorts of choice we never had
3) Insurance (non-health care) - dereg opened door for many more firms to compete, internet made getting multiple quotes easy
4) Telecom - you can now get voice, data, video using many different carriers at cheap prices.  If you're still using a Ma Bell land line that's your choice and you're paying thru the nose voluntarily
 
Show me ONE example where deregulation gave us better pricing, quality and choice in the market - come one, ONE!!!
 
Mike Haluska Added Apr 17, 2017 - 9:11am
Bill H - the government adding on more and more taxes has NOTHING to do with deregulation.  That is simply taxation without representation - something the liberal courts can't get enough of!!!
Thomas Sutrina Added Apr 17, 2017 - 9:18am
John G.  You want to ignore the facts.  Canadians are coming to USA hospitals to get procedures due to timing and capacity.  There medicals system has failed these people.
This is the result of a simple search John G.  Open you eyes
http://www.investors.com/politics/commentary/u-s-shouldnt-copy-u-k-s-collapsing-single-payer-health-care-system/
 
http://www.dailywire.com/news/14470/7-things-you-need-know-about-britains-failing-aaron-bandler
 
http://www.bbc.com/news/health-32057948
I could continue providing many more articles about the failure of the single payer British health care system.  the problem for both Canada and Britain and all national health care systems is that cost and services are disconnected so more services are desired then capable of being paid for.   The government then sets up rules that are not medically driven to limit services.
Bill H. Added Apr 17, 2017 - 11:43am
Mike- How about the price of electricity for another.
Victor Crain Added Apr 17, 2017 - 12:16pm
Thomas,
 
"Failure" is in the eye of the beholder, and I know people in Maine who travel to Canada for medical service.  I think the term failure is a polemic that doesn't describe the reality.  They have issues with their system as we do with ours, however, for most people it works. We have Americans who travel to Costa Rica, Brazil or Thailand for surgery. Would you use that as an indictment of the US system?
 
On an objective measure, Canadians have a life expectancy that is two years longer than in the US, and life expectancy is not as strongly correlated with personal wealth as it is in the US. To me, both of those are positives.
 
Vic
Thomas Sutrina Added Apr 17, 2017 - 12:44pm
Victor C. you are correct we have problems before ObamaCare and with ObamaCare.  The Canadians that come to America for medical services shop around and I was told by a person that grew up in the Buffalo area that the prices they paid were much lower then charge Americans with or without insurance.  Now why is that.  Maybe Victor C. we do not have a free market system either.
 
We have not had free market health care since 1942 or 43 when FDR fixed wages and the companies introduced health care insurance as a benefit.  Government showed its approval (a point on the Second Bill of Rights)  by giving the company a tax break.  Note Victor individuals do not and have never gotten this tax break.  
 
That Victor skewed the health care market. Insurance companies bargain with providers not the patents.   When someone else bargaining for a group Adam Smith points out always helps a special interest (my guess is the profits of the insurance companies and hospitals)  and the special interest of a very low requirements to provide expensive services.  
 
Victor it is not an accident we have world leading health care and very expensive health care.  That results in high profits for those special interests.  And that is why we gone RINOCARE from speaker Ryan.  Congress is also a special interest.  
 
Adam Smith also said that nothing good comes out of someone else bargaining for a group.  Society is worse off.  So yes Victor Canada, America, Britain, and all countries are worse off when someone else bargains for an individual's health.
wsucram15 Added Apr 17, 2017 - 1:17pm
The PPACA was the Republican/Democratic compromise, no matter what you are told.  It is based on a Republican healthcare bill and added to from there.  The have been several amendments since that time.  However, Republicans decided not to amend any further for gaps which is why the healthcare bill is where it is...
Now put a free market plan in place and moderates nor dems will vote for it.  I dont think it will pass the Senate either.  Too many will lose seats in 2018.  This is a number 1 priority with the people.  Only 10-15% of the people ( per numbers I have ) are a problem with the PPACA.  Everyone else gets a subsidy thats 85-90% of the country who (if you go to town halls or protests) are extremely angry with Congress right now.  
The Freedom Caucus doesn't care, because of Koch money, and gerrymandering. But they will.  Im watching this in states I dont even live in..people are angry about this.  This is a for profit system..which is WRONG for healthcare.
The bottom line is this..we have the most expensive health care in the world and out of 55 countries ranked by W.H.O. we are #50 for quality and efficiency of care.  Thats just pathetic..
In other countries that have tried this system it has failed..and it will here also...period.  But people will die in the interim.
Healthcare is something that all Americans should have, like any other country we compete or are allied with. Its the humane thing to do for each other.
 
 
Victor Crain Added Apr 17, 2017 - 1:29pm
Thomas, I don't think there's a basis for arguing that the US has world leading healthcare. We used to, not now. The leading country in terms of life expectancy is Monaco -- 12 years longer than in the US. Out statistic is virtually identical to that of Bosnia.  We are however number 1 in spending.
 
I did a study on technical advertising for the aesthetic surgery industry in Brazil a few years back. Did you know that many of their docs are cross-licensed to practice in the US? That you would be hard pressed to see a difference between Beth Israel Deaconess in Boston and Beth Israel Sao Paulo? Language, yes. Not much else.
 
On another point, insurers largely dictate to providers rather than bargain with them. They bargain with pharma companies, and pharma companies used Congress to limit the ability of Medicare to do similar bargains.  Pharma also used Congress to limit the ability of Americans to buy drugs from other countries -- even when the same drug from the same company is 75% cheaper.  My Advair inhaler is $400 off insurance in the US and $75 in Canada. Same product from GSK in both countries.
 
An age-old definition of politics is "deciding whose ox is getting gored." What actually happens has nothing to do with "free markets" or "socialism." It has everything to do with profits. Companies want regulation to limit competition and boost profits, and deregulation when that will boost profits. That's all it is. 
 
Germany has private insurers like we do. The difference -- health insurers are required to be non-profit, and Germany regulates CEO pay. Other than that, it's a market system, and costs a lot less.
 
Brazil offers universal care to 200 million people at a fraction of our cost.  Pro bono time in a public health clinic is a requirement for having a medical license.
 
There are things we could do to actually fix the healthcare mess in the US, but there's no political will to do them.
Thomas Sutrina Added Apr 17, 2017 - 2:20pm
Victor.  The insurance companies obviously do not dictate to providers.  If that was the case the costs in the big cities would be as low as they are in the rural areas.  Bargaining is going on.  The big cities provide more speciality services and they use this to bargain up the prices of the other services they provide and the larger higher salary staff.   Also the price variations between hospitals in a city varies.  The only conclusion that makes sense is bargaining occurs.   Your argument Victor is just wrong that insurance companies set prices.  
 
Canadians get even better prices because they can vote with their feet and they represent such a small fraction of the business that American market ignores them.  And individual Americans can not get the same prices by voting with their feet because the hospitals do not want word of mouth advertizing of a lower actual price.  Then they would complain to the insurance companies or employer and force them to bargain down to a lower price.
 
Drug prices are set by the large share single payer in the market Medicare and Medicaid that by law can not bargain for price.  Guess who lobbied for that law?  The insurance companies have not reason to lower their profits, a fraction of the cost charged, by demanding lower prices.  They do get some relief to please the patents, but we know it is no where near the cost saving possible.
 
Wsucam15,  please explain why the Democrats in state and federal legislature have lost more then 900 seats to the GOP?  Why states and the house, senate, and now White House have flipped to GOP majorities?  The political commentators  blame ObamaCare.   The GOP candidates including McConnell all campaign on repealing "root and branch" said McConnell and have been doing so since Obama took office.  So I do not understand how you came to the conclusion that voters will reject representative that repeal "root and branch", ObamaCare?  Ryan tried exactly what you suggest and 63% of voters polled rejected RINOCARE and only 17% wanted it.  That agrees with the seat losses.  
 
 
John G Added Apr 17, 2017 - 2:29pm
When did Adam Smith become god? And I'd bet money that Sutrina never read WoN anyway. Just quotes on his wacky right wing web sites.
Victor Crain Added Apr 17, 2017 - 2:57pm
Thomas, you're trying to argue from logic while I'm arguing based on documented events. For awhile, Aetna was reimbursing physicians $5 for an office visit. The only "negotiation" was physicians dropping Aetna as an insurer they would accept.
 
Of course, the desire to be able to negotiate may be one of several factors in the closing or consolidation of a lot of smaller physician offices.
 
The difference in pricing between urban and rural areas isn't based on negotiation. It's closer to classic supply and demand, plus physicians can't charge  more than their patients can afford to pay. That's why there's such a shortage of physicians in rural areas.
 
Drug companies do negotiate tiers (reimbursement levels) and prices in with insurers. That's why services like Humana Pharmacy exist. Insurers are able to undercut traditional pharmacies with the discounts they get.
 
Whether its logical or not, that's what is happening.
wsucram15 Added Apr 17, 2017 - 3:00pm
Thomas...I think thats because people didnt understand insurance or the PPACA and more importantly hated Obama.
Overall, though, you will see more changes again unless something significant changes.  Even the middle class is fighting this one, so I am sorry but I have been out and traveled on this doing research in even deep red states at the town halls.  Its a battle.
I wasnt at McConnell's two town halls, but I did see a good bit of video from them. He was booed off stage at one point.  Even Lindsey Graham had a hard time (I was at that one). 
Paul Ryan did not do what I suggested...nor did Trump. In any way, shape or form. Although there is a consensus to that by the far right. You need to read BOTH bills.  I have.. he took some things that mirrored the PPACA, but it would fail and thats why it didnt pass, the things needed to make those perks work are in the PPACA.
There is a small slice that still wants repeal..I think its at 1 in 4 voters still back a repeal of the PPACA.  I think thats high..but ok, Im not polling just observing.  Im talking to Republicans more so than Democrats because I already know how they feel.
When you start taking benefits away from people and it causes death, which it will..you are risking A LOT.  Only the very stupid or very greedy will do this and it will cost them...I assure you.  Dont take my word for it..go out to some town halls outside your area.  Better yet, go to a Democratic Town hall, they arent having it any better right now.  Congress is catching hell...their jobs, all of them are on the line.  People are angry.  Many of the people you see voting for repeal STILL are hoping the vote will die in Senate or are avoiding those town meetings.
In fact, one of my Senators I bitched at and got a call from his aide who was on vacation (my Senator was doing foreign work on a commission). Also my other Senator and Congressional members. They are having a town hall this Thursday collectively. Im sure they have had lots of complaints since they have not been meeting with people. They are all Democrats but it doesnt matter, people are upset..and they want to know what the hell is going on.  I  dont think anyone liked the Dems using the filibuster over Gorsuch, at least no one with a brain.  I didnt like what happened to Merrick Garland but it was to take Scalia's seat and only for associate.
But the dems were given orders much like your Republican representatives, obstruct..so they are as are the people. 
Thomas with healthcare and immigration..I afraid you are going to see major battles. Major ones.  Republicans know they need that money for the budget and people arent having it and will fight it.
 
Victor Crain Added Apr 17, 2017 - 3:16pm
 

wsucram15, that's a fair representation of the mess, and pretty much mirrors the WSJ analysis on why Trump is trying to deal with healthcare before tax reform.
wsucram15 Added Apr 17, 2017 - 3:35pm
Dino..I disagree on the free market system entirely.  The costs are high because the medical trade (in every form) owns Congress.  The costs need to be regulated like medicare, period.   People can pay based on income, it covers 80%.  But this regulates costs..which is why providers hate the plan. If you want more insurance you can pay more for it and the deductibles are low. Its one large pool of people as opposed to smaller groups throughout US by state, the rates are therefore regulated although they do vary.
Did you know medicare has a scale for low income individuals so there is no cost, not even for part B or D?  Its interesting. So effectually its like the PPACA, in theory...just much more effective. Because the costs are controlled and wellness care is essential and in some areas at reduced or at no cost.
John Minehan Added Apr 17, 2017 - 3:46pm
"The government did make it easier for small companies to offer group insurance, to a point."
 
Not much of "a point." 
 
What you can find in the  SHOP marketplace is generally not as good coverage and more expensive than what a good broker (or a Chamber of Commerce program using a good broker) might have found prior to the ACA. 
 
Grandfathered plans are still doing pretty well, but ACA seems to have a bias towards smaller employers either dropping  coverage or exclusively using SHOP plans. 
 
Believe me, I'm not knocking brokers and within the exchanges and SHOP, they tend to be able to "Sherpa" people towards better plans.
 
HOWEVER, the Bronze Plans in the Exchanges are narrow-network Medicaid managed Care plans with a high deductible slapped on (in 2017, a deductible that can be as high as $7,500 for an individual and $15,00 for a family).  And it remains a High Deductible insurance program with no provision for HSAs, in fact the ACA made it harder to have an HSA.
 
Further, outside states like NYS that have addressed the issue legislatively, the narrow network plans make it easy for someone to incur an "out-of-network" charge in the not-too-uncommon eventuality where a participating Hospital has a Radiology Service or Emergency Department run by a non-participating group practice. 
 
In addition, I agree with Ari's comment.
 
Yes the PPACA is a "complex law," but it is also a poorly thought out one. 
John Minehan Added Apr 17, 2017 - 3:51pm
"I've yet to find a company making growth decisions based on the ACA."
 
That has not been my experience.
 
You are correct that " the ACA calculates employees on an FTE basis, so you could have 80 part time employees and still not be required to offer healthcare" and that drives some of the movement towards more part-time employees, which I also observe.
 
The PPACA is perceived as being another administrative burden on a small business where the "HR Department" may be the owner's wife or child doing it part-time. 
John Minehan Added Apr 17, 2017 - 4:01pm
"We have Americans who travel to Costa Rica, Brazil or Thailand for surgery."
 
Additionally, the US and India are also destinations for "Medical tourism."
 
That is a function of cost and quality.  I note that neither Canada nor the UK tend to be destinations.  (In fact, the British NHS systems tend to actively "outsource" to India.
 
Brazil and Costa Rica have parallel systems of "public" and "private" health care.  Thailand and India have an almost entirely market-based system.    
Victor Crain Added Apr 17, 2017 - 4:02pm
You raise an interesting point. It's possible for companies to outsource HR, legal, receptionist, scheduling, bookkeeping and other functions for pretty much nominal amounts. For a lot of companies, the burden is a function of lack of knowledge about available resources. For the cost of one employee, you could have skilled professionals doing all of these tasks.  Why wouldn't you?
John Minehan Added Apr 17, 2017 - 4:16pm
"The PPACA was the Republican/Democratic compromise, no matter what you are told."
 
Nonsense.
 
The PPACA is based on a plan proposed by Heritage when it appeared almost certain that The Health Security Act of 1993 was going to pass.
 
That proposal was something of the basis for Gov. Romney's Health reform plan in Massachusetts, but Romney had two Houses of the State Legislature controlled by Democrats.
 
To the degree that the Massachusetts plan is a model for the PPACA, it is a Democratic product in practice: a Heritage Foundation concept, proposed to provide an alternative to a Democrat Plan that was expected to pass, that was then modified to pass two houses in a Democrat controlled state.
 
The PPACA passed with out ONE GOP VOTE.
 
The nearest argument for it being a "compromise" is that one GOP Rep, who was concerned about re-election, voted for it after it narrowly passed the House.   
John Minehan Added Apr 17, 2017 - 4:18pm
"Now put a free market plan in place and moderates nor dems will vote for it.  I dont think it will pass the Senate either."
 
Which is an absurd, straw man argument, since that is not the alternative proposed.  
John Minehan Added Apr 17, 2017 - 4:25pm
"Germany has private insurers like we do. The difference -- health insurers are required to be non-profit, and Germany regulates CEO pay. Other than that, it's a market system, and costs a lot less."
 
The Germans (like the French and the Japanese) have a Bismarck system, a system of mandatory private insurance that covers everyone.  These systems are generally rated as being the cheapest and most clinically effective in the world.
 
The Germans (particularly, due to their robust union and almost universal union system) have a system where the buyers have about the same influence that the providers and the patients do.
 
You could do something similar here through non-employer-based ERISA Plans . . . but we don't.
  
Thomas Sutrina Added Apr 17, 2017 - 8:45pm
Victor C., the price variation within a city for the same procedure where experts suggest checking price at different hospitals. That LOGICALLY suggest that hospitals and insurance companies bargain.
Wsucam15 the flipping of 900 seats in legislature to the GOP LOGICALLY suggest that people do understand the bottom line effect of PPACA and do not like it. That is why the GOP has run on repealing PPACA and why even Mitch McConnell made a campaign add saying "repeal ObamaCare root and branch" without any intention to actually do it. That is why since 2010 the house have passed 70 repeal bills and the since the Senate control flipped to the GOP a bill was put on Obama's desk repealing ObamaCare.
Wsucam 15 the Democrats flood town hall meeting so I ignore them as just theater. Same thing to the riots that have occurred after Trump's election. It is theater and since the liberal media (funded Democrats 95% to 5% for GOP) make in major news. where Tea Party protest of taxes when Obama was elected of the prolife march the week after the women's march was not covered similarly. Even the media recongnizes the bias.
Wsucram you a liberal so I expect no willingness to consider a free market. I suggest you move to Venezuela so you can experience fully implemented liberal economic system.
John G Added Apr 18, 2017 - 2:55am
Wsucram you a liberal so I expect no willingness to consider a free market. I suggest you move to Venezuela
This is the intellectual standard of  Sutrina. Truly pathetic and childlike.
 
Thomas Sutrina Added Apr 18, 2017 - 8:44am
John G.  I agree that the loosing 900 seats by the Democrats because of ObamaCare is pathetic.   I agree that Mitch McConnell campaigning as a Conservative to get his way as many other RINO Republicans has done is childlike.  
John G. you want to throw around smears with nothing to back them up.  Now that is childlike and pathetic. 
Mike Haluska Added Apr 18, 2017 - 9:39am
Bill H - you prove my point more often than I do.  Your question:
 
Mike- How about the target="_blank">price of electricity for another.
 
Last time I checked there wasn't much of a choice about where I buy electricity.  Just another example of a GOVERNMENT SUPPORTED MONOPOLY.
Mike Haluska Added Apr 18, 2017 - 9:43am
John - here's the Litmus Test for the quality of care a nation's health care system:
 
Where do people who can afford to get their health care anywhere in the world go to most often???
 
Hint:  It isn't a Caribbean Island where health care is "free"
Mike Haluska Added Apr 18, 2017 - 9:47am
John - here's a Litmus Test for the quality of a nation's health care professional (doctors, nurses, tech's):
 
Where do the top health care professionals around desire to practice more than any other nation?
 
Hint:  Which nation has Mayo Clinic, Johns Hopkins, University of Chicago, etc.???
John Minehan Added Apr 18, 2017 - 10:02am
"For the cost of one employee, you could have skilled professionals doing all of these tasks.  Why wouldn't you?"
 
Why would any business waste money on non-core functions? All the examples you raise ("HR, legal, receptionist, scheduling, bookkeeping")are cost-centers, rather than profit centers.  This was the point made by Peter Drucker in his seminal 1989 article Sell the Mailroom
 
Additionally, law and accounting services are traditionally separate to allow those professionals to keep a level of independence in the advice they give.  
John Minehan Added Apr 18, 2017 - 10:15am
"There is a small slice that still wants repeal..I think its at 1 in 4 voters still back a repeal of the PPACA."
 
No.  A majority want repeal.
 
The issue is what to replace it with.
 
The original GOP plan was to allow for expanded use of ACAs and for Association Health Plans (essentially MEWAs).  Strangely, these  workable ideas were dropped from the final plan. 
John Minehan Added Apr 18, 2017 - 10:26am
This is an interesting article on Association Health Plans.
 
In my opinion, there are risks but that draconian regulations adopted in the 1980s under ERISA are NOT a workable way of managing those risks.
 
Fully self-insured plans, that can pre-empt state insurance laws, but which are subject to regulation by the Charities Bureaus of State AG's offices are probably a better answer.  Guild plans (for example, the Writers' Guild of America and Screen Actors' Guild Plans and non-health insurance group plans, like USAA in auto insurance) provide useful insights into expanding these programs.    
Thomas Sutrina Added Apr 18, 2017 - 1:09pm
John M., seem that you have missed the pole for RINOCARE (repeal in name only)  63% of the citizens opposed the bill and only 17% approved.    Are you crazy only one in four want repeal stated in percent 80% want ObamaCare and 20% do not.  If you do not believe in poles then since ObamaCare passed first the Democrats lost the house and started loosing state legislatures in 2010. Deepened in 2012 even with Obama being re-elected.  ObamaCare was not on the menu for the presidential election since the Republican was tagged with RomneyCare for his state.  And who make him the candidate.  You got it the same people that pushed through RINOCARE.   So the deepening continued in 2014 with the loss of the Senate and finally even more deepening in 2016 with the loss of the trifecta, House, Senate, and White House.   Total of 900 legislative seats in legislatures in the nation.   Now that John M. backs up the 63% opposition to ObamaCare.
John Minehan Added Apr 18, 2017 - 2:10pm
Thomas, "white space" (paragraph breaks) is your friend.  Also, it's "polls" unless you mean sticks.
 
The American Health Care Act ("AHCA") was basically nothing.
 
Two fairly good ideas were included: 1) refundable, individual tax credits; and 2) expansion of HSAs.  (Lack of meaningful HSA provisions in the ACA, given it was built around High Deductible Insurance is a fair sign the ACA was either VERY poorly thought out or intended to fail).
 
However, it did not promise enough change to be beneficial while potentially "upsetting the apple cart."  (Also, something less than a triumph of bill drafting.)
 
I attended a "Town Hall" in Ulster County, NY and my general sense is that people do not, by and large, favor the PPACA, so much as they really fear something even worse . . . .          
 
 
Thomas Sutrina Added Apr 18, 2017 - 2:30pm
PPACA is RINOCARE (repeal in name only)  that is the nick name tagged to it by libertarians and conservatives.  The funding taxes have been removed from ACA and the requirements to purchase in effect still present by a trick.  The regulations the key to ACA were not effected at all.  That is why PPACA is repeal in name only.  63% of the citizens understood these facts.
John Minehan Added Apr 18, 2017 - 2:34pm
"The costs need to be regulated like medicare, period.   People can pay based on income, it covers 80%.  But this regulates costs..which is why providers hate the plan. If you want more insurance you can pay more for it and the deductibles are low. Its one large pool of people as opposed to smaller groups throughout US by state, the rates are therefore regulated although they do vary.   Did you know medicare has a scale for low income individuals so there is no cost, not even for part B or D?"
 
Actually, in discounted fee for service plans, the rates per CPT are set as a multiple of the Medicare Reimbursement for that CPT in that Catchment Area.  So it is "regulated like Medicare" or, at least as a function of HOW Medicare is regulated.  (Also, these Catchment Areas are HOW they "do vary," too.)  Additionally, Medicare has a "most favored nations clause" in its Conditions of Participation, meaning if you par, you have to give CMS your lowest rate.  
 
Actually, Medicare has nothing to do with income per se, you pay in and you are eligible for Part A, B and D (you have to elect Part C-Medicare Advantage). 
 
To my knowledge, Medicare has no such sliding scale, however, low income seniors may qualify for dual Medicaid eligibility.  For people who do not qualify for this (and can't afford a Medi-gap Plan) Medicare can be a major financial hardship--20% of unaffordable is still usually unaffordable.
 
In addition, you have to be careful, as a provider in giving a Medicare patient a break on your fee unless you have established bona fide financial hardship, as such a waiver can be seen as a kickback under the Anti-kickback Statute.   
John Minehan Added Apr 18, 2017 - 2:45pm
Another agency (National Health Service Corps or "NHSC") has a "sliding fee schedule policy" that MAY apply to Medicare Beneficiaries:
 
"Although the NHSC doesn’t require extending the discount policy to Medicare beneficiaries or those participating in Medicaid and the Children’s Health Insurance Program (CHIP), many clinics have indicated an interest in doing so. The Medicare law requires clinicians to charge Medicare beneficiaries the same as they charge other patients. Waiving or discounting the Medicare co-pay on an ad-hoc or case-by-case basis is not allowed. Medicare will, however, accept a discounted fee schedule if appropriately designed and implemented. The key is to establish a discount policy that is uniformly applied to all patients based upon ability to pay. So long as the discount policy is uniformly applied to all patients, all the time, it is acceptable to discount deductibles and co-payments for Medicare beneficiaries if they qualify under the discount policy established by the clinic."
 
So something like this MAY exist under limited conditions BUT do it carefully!
 
 
wsucram15 Added Apr 18, 2017 - 3:01pm
FIRST- I NEVER SAID THAT IT WAS NOT PASSED ON A PARTY LINE VOTE...HOWEVER the PPACA was written in part by Republicans damn it..38.5% was written by Republicans via changes or original framework.  Thats what I said.  It was based on the target="_blank">Health Equity and Access Reform Today Act of 1993,  which is based on... target="_blank">Heritage Foundation’s paper Assuring Affordable Health Care For All Americans.  A REPUBLICAN FAR RIGHT IDEALISTIC PAPER.
THATS WHAT I SAID....
75% of the country wants the repeal gone and healthcare fixed and thats on the low end. It is my thinking that most dont even understand the PPACA, but just want the type of healthcare they have now or something comparable.  The "fear" is coverage being taken away in its present form.  Like for example did you know that the PPACA covers miners benefits once on disability and will be paid to widows?  This will disappear when the PPACA does. Those people deserve those payments. This bill is very comprehensive...it covers more than just healthcare, for millions of people. 
My opinion has nothing to do with being a "liberal".  I guess I am more a liberal than most of you, but far less so than what I would consider progressive.  BECAUSE I LISTEN TO OBJECTIVE PEOPLE FROM BOTH SIDES.  I DON'T LIKE UNINFORMED DEMOCRATS EITHER. 
John..good at least you went to one...I agree to a point.  I think people (Republicans especially) hated Obama and Obamacare. But they had no idea that the benefits encompassed as much as they do.  Much like Ryan when he wrote his very rushed Healthcare bill, which if he had taken some time on it, might have been possibly acceptable. Problem was it has to be comprehensive for the benefits he proposed or it will not work.
Workers 10-15% are the most affected by this..and this needs to be fixed, but it is a simple fix by legislation which has been sitting in Congress forever.. .. I wrote a 31 page thesis on the bill after reading the entire bill, months of research and working in HR and legal consulting on the legalities of forms and compliance for the PPACA.   See framework for bill above.  It is such a simple fix, correct legislation, take off Obama's name and control costs.
Often people see a problem and the best way to overcome it is to avoid or bypass it.  This is a mistake here.
John..it does, this I know for a fact.  Depends on income..ask them at social security, you can get your benefits for free.  Perhaps it depends on state, not sure.  Medicaid pays the 20%, but the federal cost to you on your 80% is nothing based on income.  I promise.  
Why do you guys even bother to question me..do you not know by now that when I put stuff in writing I have either researched the hell out of it or have personal knowledge of it myself? Seriously?  Come on..
John Minehan Added Apr 18, 2017 - 3:30pm
wsucram15,
 
Paragraph breaks are your friends.
 
I deal with these issues for a living.  The PPACA is a bad bill and most people want it gone.
 
Where people have issues is with what replaces it.  PPACA slashed and burned the individual health insurance market in the US.  People are a bit leery of more change.  We are what we used to call in the Army, "Good idea cut off time."
 
"Like for example did you know that the PPACA covers miners benefits once on disability and will be paid to widows?  This will disappear when the PPACA does. Those people deserve those payments."
 
But, why is it there and not under the SSA, as it covers disability?  PPACA has a lot of these odds and ends thrown in that should exist but ought to be more transparent.
 
I could care less if people are Liberal or Conservative.  For my part, I'm neither: I am a Libertarian with strong Communitarian impulses (that don't go away even if I take an aspirin and get enough rest.)
 
My bias is against big centralized programs as against legal frame works that allow people to work together to solve their own problems in ways that fit the local conditions.   
 
 
Thomas Sutrina Added Apr 18, 2017 - 4:28pm
John M. ACA slashed and burned the individual insurance market, and PPACA only remove the funding mean form ACA.  My opinion. Now some would say that the individual health insurance market still existed.   But the policy is written into law as is it in Medicare supplemental insurance policies.  At least with Medicare there are about a dozen choices.  ACA you have three choices and you must purchase a policy.  Company policies do not escape.  So the competition is on price and service. 
 
It depends on what you consider destroying the market?
wsucram15 Added Apr 18, 2017 - 7:23pm
John,
We are having our first disagreement!
I cant disagree with some and if I listened to the tv..I would say the same but I dont.  I went out, actually to write an article on thisplace and time  (the town halls just got caught up in it). I found in speaking with Trump supporters while they really support Trump, they are having problems with the healthcare portion.  I went to West Virginia (where my boyfriends mothers family is located), South Carolina, North Carolina, PA , VA and was invited to Georgia but didnt get that far. Up North, I did get to Delaware and New York.  I did have some invitations for other areas but have seen video on those instead, like Washington State, Oregon and California.  Now these are places I have family or close friends. 
There are other places I have seen video from people I volunteer with on protests but I wont even count those.  So when I say I can take this as not opinion but firsthand..I mean it.  Most people are upset about healthcare...many more than not, do not want the PPACA repealed, currently or just dont understand what OBAMACARE really is.
However, there are some still hollering and even physically fighting for repeal.
 
I used to deal with PPACA for a living as I said the laws.  I have a friend that owns his own company and we went through 4 years of college and began our masters together..he deals in insurance on the daily.  I learned a lot from him as to intricacies that I didnt know from research.   Although I did teach him one or two things about the law itself aside from the general practice of it.
 
The SSA does PAY miners benefits and if you knew the PPACA you would know why. There is no specification in Social Security for that illness apparently so its written into healthcare. There are many things wrapped up in this law like that...its just one example.  But please dont take my word for it..look it up.  Do some research, its how I learned.  You are going to have to take my word when I tell you that Im pretty knowledgeable on this law by research, trial and error.  Specifically the law itself, its foundation and benefits, how it was adjusted, when and why.
Let me give you another example...on pre-existing conditions. Even with the ADA laws that protect me in a job or educational situation, they do allow for discrimination in rates on ALL insurance. I have had epilepsy ALL of my life.  Its been under control (no seizures) for more years than I can count.  But they ask so I have to report it.  It the past, insurance (even through employers for this condition) was denied or withheld for long periods of time.  Even just for the medicine to maintain my health.  Having healthcare that does not cost so much you cannot afford it (like Cobra which does hold your health into account)..for example, I hear people bitching now about FAMILY premiums of 800-1200  month.  My premiums BEFORE The PPACA were 1200-1500 just for me @ a 2K deductible. Now that was circa 2008-2009.  So I dont want to hear it..its much worse to throw a cancer patient into a pool with me and expect a payment even that low now and give a 4,000 subsidy.  Really? lets add the rate up that on the low end 18,000-4,000...hmmm who with a severe disability can afford healthcare?  They will die.  Come on John.  On this basis alone it will be a court battle, just like the PPACA except there are laws  something like this violates in two disadvantaged groups, age and disability. The court is not corrupted enough yet that those laws would be overturned. 
 
The payments need to be spread out NATIONWIDE. Not state to state..since you know insurance you also know ALL PLANS will be cheaper this way.  
 
I get why the far right is against it.  I CAN ALMOST go with that ideal of non-centralized healthcare...but then I cant. You cant take away something that creates issues for 10-15% of the population without a huge backlash.  You can fix it for them or make a better plan for everyone.  But again dont take my word for it..just watch.   I can tell you the Dems are getting slammed just as hard if it helps, Ive seen crowds grow and get much more aggressive on several issues.  Healthcare just seems to be the worst.
 
John..Im telling you on a couple of issues, I have spoken at the congressional level, while this is not one of them from the past couple of years, on Thursday it will become one.  It needs to be fixed but there has to be some adjustment that the 10-15% can accept to work with the majority.  Look up the statistics.
wsucram15 Added Apr 18, 2017 - 8:23pm
I forgot NJ and Florida..although I did Not attend the Florida meeting, my Friend Don did and sent video. I started writing a piece on the conflict (not healthcare) of "liberals" and "Trump supporters" at the core belief system.  It just gets more complex everyday.
But even hardcore supporters like my cousins in East Texas, who are middle class and work for a living dont support all of what Donald Trump wants. So it is what it is...
But to be fair, they watched their mother die in 2009, before The PPACA, from cancer which exhausted the funds from her reverse mortgage, the cancer society and donations from the family. The insurance she had as an RN was cancelled...yes they could do that then.  We appealed to the Governor, it was denied.  Yeah...
My Mother was the same way except in Maryland she got more financial help.  She died 2 weeks after my Aunt although she lived 10 years longer..my Aunt was young. 
John G Added Apr 19, 2017 - 1:59am
Thomas Sutrina Added Apr 18, 2017 - 8:44am
 
Sutrina, a reasonably intelligent 12 year old could make a better case than you do. You sound like you are mentally retarded.
Thomas Sutrina Added Apr 19, 2017 - 8:18am
John G. the first indication that your loosing is when the only argument left is to smear the opposition.  
Thomas Sutrina Added Apr 19, 2017 - 9:01am
I keep pointing out that the American citizens have rejected ACA by votes at the ballot box that replaced democrats with republicans.  ACA was just one of many other actions of Obama so ACA many not be alone in the reason for the change in votes.  Trump realized this better then most candidates to achieve the White House.  But in his campaign he promised to retain pre existing conditions and to insure everyone.   How you as then Minority Leader in the Senate campaigned for his seat said, "Repeal ACA root and branch," and retain pre existing condition coverage and insure everyone is beyond my understanding.
 
I do know that the only way to reduce cost is to stop using the laws of the states and federal government to serve the interest of special interests.  Obviously this cost us patents money because why else would those interest, Crony capitalist, lobby and fill the coffers of the politicians?  How can this be done?  We must demand it and I would say that rejecting ACA or PPACA and now Speaker Ryan, a manager of one of those coffers, AHCA or Rinocare and showing our discuss with the VA health care system corruption.  
 
History has shown us that only one system has a natural tendency to reduce cost.  Capitalism.  Adam Smith observed centuries ago and no one has disputed it, ignored his invisible hand yes but not disputed it.  Ref: "Free to Choose" Milton & Rose Friedman 1979 Introduction: "Adam Smith key insight was that both parties to an exchange can benefit and that, so long as cooperation is strictly voluntary, no exchange will take place unless both parties do benefit. ... Adam Smith put it, an individual who "intends only his own gain" is led by an invisible hand to promote an end which was no part of his intention. Nor is it always the worse for the society that it was no part of it. By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it. I have never known much good done by those who affected to trade for the public good." ... "an individual who intends only to serve the public interest by fostering government intervention is "led by an invisible hand to promote" private interest, "which was no part of his intention.""
 
Government does have a part to play.  Make a level playing field by clipping the wings of corporations so they can not take over the market, thus skewing the trades.  And Government needs to be the voice, set the value of traders that can not speak for themselves.  Pre-existing Conditions is one of these areas.  
 
Government already by law does provide last resort medical care to everyone.  Emergency rooms can not reject people for lack of the ability to pay.   This is in effect universal health care.  We can do it better and cheaper.  part of welfare needs to be health care.  Welfare is not without bounds so the health care also needs bounds.  I am talking about average medical needs not catastrophic medical events. 
 
Mike Haluska Added Apr 19, 2017 - 3:07pm
Thomas - are you saying that "Pre-existing Conditions is one of these areas" is something the government can/should fix?  I don't see how a system designed to spread risk over a large population can take on existing problems.  That's like forcing an insurer to give fire insurance coverage to a landlord with a building going up in flames! 
John G Added Apr 20, 2017 - 3:35am


Thomas Sutrina 



I keep pointing out that the American citizens have rejected ACA by votes at the ballot box
You can say this until you're blue in the face. It doesn't change the fact that Americans overwhelmingly support single payer/Medicare for all.
A long history of legitimate polling proves it.
So shut the fuck up, will you?
 
Thomas Sutrina Added Apr 20, 2017 - 8:42am
Mike I agree about pre existing conditions, "retain pre existing condition coverage and insure everyone is beyond my understanding."  But Trump made that promise.  
 
John G. you can ignore the vote and poles until you blue in the face but it doesn't change them.  It doesn't reverse the 900 seats lost, it doesn't put Pelosi back a speaker, it doesn't make Shummer Majority leader.   It does not put Hillary in the White House.
John Minehan Added Apr 20, 2017 - 9:22am
"Thomas - are you saying that "Pre-existing Conditions is one of these areas" is something the government can/should fix?  I don't see how a system designed to spread risk over a large population can take on existing problems.  That's like forcing an insurer to give fire insurance coverage to a landlord with a building going up in flames!"
 
Except that something of that time (if more limited, with a waiting period, usually waived if there is continuous coverage) has existed in group plans since 1996 with the passage of HIPAA.
 
I think this is a "show-stopper" in the context of the individual market . . . that largely becomes irrelevant in a group plan context.
 
I think health insurance should be a group market.  Even in auto insurance, the usual example of a successful individual insurance market, you get a better product with a group plan like USAA.   
Thomas Sutrina Added Apr 20, 2017 - 11:50am
John M., what I think does not matter.  Trump made the promise.  I think these is a difficult problem to solve because it is against the way insurance companies make money.  ACA approach is clearly stated by Prof. J. Gruber, "If you have a law that makes explicit that healthy people pay in an sick people get money, it wouldn't have passed. ... Lack of transparency is a huge political advantage and, basically, call it the stupidity of the American voter or whatever.  But basically that was really critical to getting the thing to pass."  The Democrats have loosed 900 legislative seats, the house in 2010, the senate in 2014, and the white house in 2016.  If it was not for RomneyCare Obama many not have had a second term. 
 
John M., the solution is to put the cost of present pre-existing conditions on the head of tax payers and make a system where everyone chooses to buy catastrophic health insurance and welfare and unemployment pays for catastrophic insurance.  Then pre-existing conditions will disappear.  
John Minehan Added Apr 20, 2017 - 12:48pm
This may be of interest.
John Minehan Added Apr 20, 2017 - 12:51pm
target="_blank">http://content.healthaffairs.org/content/25/6/1591.full



 
My experience with representing a Chamber of Commerce that had to convince the US DoL they were NOT a MEWA in the early 2000s, convinced me that they should have been.
 
I think the mid-1980s changes to ERISA and its implementing regulations that made it harder to operate MEWAs has crippled this potentially useful form at a point where the emergence of the "Gig Economy" makes it potentially necessary.
 
HSAs can handle Primary Care needs, High Deductible insurance can handle "Black Swan" medical events.  MEWAs  can provide a mechanism for providing both at group rates AND provide a mechanism for discounted-fee-for-service coverage for specialty care for things that are common maladies (heart disease, cancer).
 
This model could prove far more effective, affordable and sustainable than the ACA . . . if someone would get behind it.    





John Minehan Added Apr 20, 2017 - 12:54pm
William Hill Added Apr 20, 2017 - 1:00pm
Thomas, you asked, "Why do the Canadians come to the US to get elective procedures?" The answer is in your question - because it is "elective", not medically necessary. Medical necessaries are treated timely and without cost; non-life threatening procedures are dealt with, but the patient may have to wait while those with more serious problems are dealt with first.
And, "Why is the teeth of the British average citizen so poor?" If by "poor" you mean not perfectly aligned, perhaps they understand that the function of teeth is to chew food and not just to make a pretty smile. If by poor you mean unhealthy, then so are those of many Americans, and that is hardly the fault of either the British or American health systems.
Thomas Sutrina Added Apr 20, 2017 - 2:04pm
William, by elective I mean not life threatening but could significantly effect quality of life.  Knee and hip replacement are examples given.  I do think that heart and kidney and other transplants also would be considered elective. 
 
A chef on a Chicago talk and variety show in the early afternoon was from England.  He said he love Chicago and has a book and "teeth" from America.  William we are talking about general dental care.  From what I understand the coverage is so low that few people are going into the profession and no dentist works overtime.  Thus it is very hard to actually get service.   Medicaid has the same problem of many doctors not serving these patents.  So it is hard to get medical care.  
 
John Minehan Added Apr 20, 2017 - 2:48pm
"Medicaid has the same problem of many doctors not serving these patents.  So it is hard to get medical care."
 
Very true and a lot of the services are rendered through EDs.  Thus Medicaid Expansion is a NOT untrammeled good.  
  
John Minehan Added Apr 20, 2017 - 3:04pm
"Thomas, you're trying to argue from logic while I'm arguing based on documented events. For awhile, Aetna was reimbursing physicians $5 for an office visit. The only "negotiation" was physicians dropping Aetna as an insurer they would accept"
 
I recall one negotiation I was involved with where an IPA presented a lot of useful data on the modalities their members represented and their very favorable medical loss ratio and having the rep from a big payer entering the area say, "We're winning.  Why would we want to win less?"
 
Well, that is one answer to why there is so much consolidation in medical practice today, as you say.
 
That insurance company, while it has grown more profitable since the early part of this century, has also gotten a LOT smaller and less influential.
John Minehan Added Apr 20, 2017 - 3:22pm
"If that was the case the costs in the big cities would be as low as they are in the rural areas.  Bargaining is going on.  The big cities provide more speciality services and they use this to bargain up the prices of the other services they provide and the larger higher salary staff."
 
A lot of bargaining goes on and it is a black art. 
 
Big groups get better reimbursement and that drives consolidation, which so far, is dominated by Hospitals, despite the fact that "pHos" (big Hospital, little physician and no organization) didn't work back in the 1990s. 
 
ACOs (in my opinion, the new IDS) won't change the fact that Hospital management usually don't understand office practices and docs are MUCH more productive when they work for themselves (hence, the adoption of a law firm model in larger groups with "Associates" working towards becoming "Partners/Members").
 
Almost all private third party payer fee schedules are a function of the Medicare Fee Schedule for that CPT in a given catchment area.
 
Sometimes that screws things up. 
 
For example, you might want (if you are a payer) to pay more to a very competent specialist in a smaller MSA rather than sending a plan member to a participating specialist in a neighboring Catchment area (say, the NYC or Chicago MSAs), where the reimbursement is generally  higher as a function of the Medicare Fee Schedule.
 
We have the data to have price points (which you really need for an effective market) but we have not really had them to date because the payers (at least seemingly) benefit from their absence.    
John Minehan Added Apr 20, 2017 - 3:25pm
By the way, Very nice article, Mr. Crain.
John G Added Apr 22, 2017 - 1:58am
John G. you can ignore the vote and poles (sic) until you (sic) blue in the face
I'm not ignoring the polls. You are. Polling consistently shows that a sizable majority of Americans want single payer/medicare for all.
Part of why Dems are losing is that they won't deliver a progressive agenda.
Jeff Michka Added May 1, 2017 - 4:47pm
Tommy "subatomic Sutrino sez: What the people want is very clear Victor a return to a free market that we have not experience in decades.  That everyone knows will be the only way cost go down.- Yeah, all those people out there not wanting healthcare, but a return to a "free market" where they can be overcharged, under-served, and profited off with no return.  You "free marketeers" all need Mickey Mouse hats and get together where you  sing a theme song.  Where o where are all these Trumpeters, tears streaming down their faces, in sorrow over the lack of a "free market" solution to anything?  The same crowd are being sold a Trickle-down "tax plan," and they're buying into it, so maybe they are crying in the gutters.