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Something Not So Terrific

The brand new President Barack Obama, whether wittingly or not, invested his entire political capital in reforming health care in America. He gambled and he lost, not because he had nefarious intentions, but because he left the gory details to a corrupt Congress and a shady cadre of lying and conniving technocrats, ending up with something vastly different from what he campaigned on. From everything I’m reading now, Mr. Trump is about to walk in Mr. Obama’s footsteps, and if he does, the results will be unsurprisingly identical.

On the campaign trail, Mr. Trump repeatedly stated that Bernie Sanders forfeited his place in history when he “made a deal with the devil” and embraced the corrupt Democratic Party establishment that fought his candidacy in most abject fashion. Guess what? Mr. Trump seems to be making the same deal with the red version of the same devil. Mr. Trump’s cabinet choices indicate that he is now embracing the ultra-conservative factions of the Republican Party, the same people who actively or passive-aggressively opposed his candidacy. Nowhere is this peculiar and completely unnecessary capitulation more evident than in the beleaguered health care sector.

Mr. Trump campaigned on repealing and replacing Obamacare with something “terrific”, because Obamacare premiums are “going through the roof”, and because deductibles are so high that you can’t actually use your Obamacare plan “unless you get hit by a truck”, and because people can’t keep doctors and plans they like. Mr. Trump also recognized that some Obamacare provisions are good and should be retained. One would therefore assume that whatever Mr. Trump proposes to replace Obamacare with, will lower premiums, lower deductibles and increase choice of plans and doctors. Although the details were rather fuzzy, two things were consistently mentioned during the campaign: selling insurance across state lines and utilization of health savings accounts (HSA). Both “ideas” can be summed up as essentially deregulation of the health insurance industry and the unleashing of free-markets. We’ve seen this movie before.

Déjà Vu

As late as 1978, interest rates on loans were governed by local state usury laws. Based on biblical moral and ethical considerations, these local regulations placed modest limits on interest rates charged by banks in a particular state. Just like our own advocates for selling health insurance across state lines, the national banks lobbied back then for the ability to lend across state lines, which means that the bank home state governs the interest rates in all other states. In 1978 the Supreme Court ruled in favor of the banks, and in 1980 Congress passed formal legislation to that effect. The result, as surprising as that may be, was not fierce competition between banks offering the lowest possible interest rates in all states. Instead, some states immediately removed all caps on usury in order to attract big banks, and high interest rates spread like wildfire, rendering state protections against usury irrelevant.

With a little more help from the Court, the same deregulation was applied to credit card late fees in 1996, with the same typical free-market results for citizens who watched their late fees quadruple. To create the appearance of efforts to counteract the disastrous effects of deregulation on interest rates, the Federal government created the Consumer Financial Protection Bureau, an agency with no power to do anything of consequence, and which is currently busy spending taxpayer money on a mega database containing “more information than most people can remember about themselves”, financial, personal and social. The parallels to health care should be self-evident.

And then of course there is the saga of the Glass-Steagall Act of 1933, which enforced the separation between banking, insurance and dealing in securities, because mixing these activities was seen as a conflict of interest and an increased risk to bank failures. Glass-Steagall was repealed in pieces, with the death blow delivered by the Financial Modernization Act of 1999. Financial institutions merged and integrated vertically and horizontally into gigantic experiment labs for innovative financial instruments with no oversight and no accountability. The results came home to roost in 2008, with millions of people kicked out of their homes while their taxes were diverted to feed the gargantuan players of free financial markets. We never had a Glass-Steagall in health care, but watching hospitals merging, gobbling physician practices and morphing into underwriters, while insurers are expanding in the opposite direction, is more than enough to trigger that spooky déjà vu feeling.

Savings

Health Savings Accounts (HSA) are another financial instrument beloved by free-market advocacy groups. The idea is to allow people to spend their own money as they see fit, instead of forcing them to buy government defined insurance benefits. To sweeten the deal, HSA moneys are not taxable. HSAs are usually paired with so called catastrophic health insurance to cover life’s major disasters. The theoretical logic favoring HSAs is impeccable. Why should you buy insurance for things you don’t need? Why should you buy insurance for routine services you know you will need and are able to budget for, just like you budget for oil changes on your car, haircuts, gutter cleaning and such? Just imagine how expensive all these things would become and how little choice you would have, if you paid for them with insurance. Fair enough.

There is one small problem though. According to a recent Fed report, “forty-six percent of adults say they either could not cover an emergency expense costing $400, or would cover it by selling something or borrowing money”. Another survey from GoBankingRates found that “nearly seven in 10 Americans (69%) had less than $1,000 in their savings account”. These are not “just” the traditionally poor people in inner cities, rural boonies, Appalachian trailer parks, or however your pampered mind imagines poverty in America. This is the middle class.  These are the “nice” people you see every day all around you. So how much funding do you think will be going into those spiffy HSA accounts? Not much.

Catastrophic Care

This week, President-elect Trump picked Rep. Tom Price, a former orthopedic surgeon, to be the next Secretary of Health and Human Services, and Dr. Price is a man with a plan. The plan is to replace Obamacare with age adjusted, tax credits and HSAs, while making the same model available to employers, Medicare and Medicaid too. People would use the tax credits to buy a catastrophic health plans across state lines, and deposit the difference in their HSAs to cover routine health care. Sounds good until you realize that the tax credits proposed by Dr. Price are ridiculously low and would cover less than half the cost of a catastrophic insurance plan. Now, it is possible, that once all Obamacare protections are removed, trashy little health plans, priced exactly the same as the tax credits, will return to the marketplace, but I seriously doubt that anything will be left over for HSA deposits. I’m willing to bet that the majority of employers will jump at the chance to extend the same parsimonious offer to their employees.

Once the Medicare modernization features of Dr. Price’s plan are also implemented and Medicaid gets cut and tossed into the lap of perpetually bankrupt states, America will finally achieve universal catastrophic health care. Let me dispel the bleakness for a brief moment though. Dr. Price’s plan has all sorts of great features for doctors. Malpractice insurance reform, freedom to provide cash services to Medicare beneficiaries, freedom to balance bill, some relief from regulatory burdens and a seat at the table for medical associations, are all included in the plan. It is also quite possible that physicians in non-catastrophic specialties will get to enjoy some well-deserved leisure time. I can’t imagine too many non-catastrophic customers, flush with non-existent HSA cash, banging on their doors. 

Augment and Replace

Mr. Trump has a mandate to replace Obamacare with something “terrific”. He has a mandate to defend Medicare, Medicaid and Social Security. Those are the things he campaigned on and this is the mandate that comes with his election, nothing more and nothing less either. The conservative apparatus that rode into power on his surprisingly long coattails has no independent mandate. Donald Trump was elected President of the United States by the people of these United States in spite of the Republican Party not because of it. We did not send Mr. Trump to the White House to help Speaker Ryan and his conservative posse of faux intellectuals to dismantle the big bad “welfare state”. I can only hope that the President-elect understands that the manufactured urgency of repealing Obamacare, while blowing up Medicare, is nothing but a shrewdly laid trap for him personally, for his presidency, and for the American people.

It may be helpful to remember that for each Obamacare frustrated person, there is at least one fairly content person, and many if not most of those content people are less affluent, mostly white, working families who either receive large subsidies or have become eligible for Medicaid. These are the forgotten workers Mr. Trump promised to speak for, fight for and win for. Yes, Obamacare needs to be replaced, and the best and safest way to replace it is not to repeal it, but to augment it. Try selling insurance across state lines if you must. Add options to pair catastrophic plans with HSAs. Heck, while you’re at it, might as well try an experimental public option. And sure, get all your anti-abortion stuff in there to keep the faux intellectuals happy. Let people choose what works best for them, because free people trump free-markets every single time, and that is truly terrific.

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PerryRichard LippinpjnelsonAllanNiran Al-Agba Recent comment authors
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Richard Lippin
Member

How quickly most of you forgot what was posted just a week ago by Dr. Nortin Hadler https://thehealthcareblog.com/blog/2016/11/25/american-healthcare-rackets-monopolies-oligopolies-cartels-and-kindred-plunderbunds/ American Medicine is morally bankrupt and it costs so much in large part because of unnecessary excessive- often dangerous- overuse for many leaving little or none for others.Trump’s election will just hasten the inevitable march toward American Medicine finally retaking the moral high ground. Count me as a proud “Charter Hadlerian”.

pjnelson
Member
pjnelson

It’s likely that the cost of our nation’s health care will continue to increase faster than the growth of our nation’s economy: a la Parkinson’s Law. It is also likely that the economic mandate for Complex Healthcare Needs will continue to neglect the social mandate for Basic Healthcare Needs. In the same mold, it is likely that we will continue to fund post-graduate medical education based on the size of the medical research activity from state to state. And, finally, we will continue to ignore the problems caused by the lack of uniformly available and accessible Primary Healthcare, community by… Read more »

Niran Al-Agba
Member

Any chance you are interested in a locums job once a year for a week? We need someone like you when my dad and I take our annual family location. You would LOVE it!

pjnelson
Member
pjnelson

What a kind gesture! The only way I would consider would be if your practice is close to 137th and Lexington.

Allan
Member
Allan

We know two things about healthcare. Government intervention has increased on a continuous basis. We also know that the cost of healthcare has increased as a percentage of GDP almost every year.

We know the economics of socialism and capitalism.

Capitalism has increased the standard of living for the entire world.

Margalit Gur-Arie
Member

Sure, but we know two more things 🙂
There can be good and bad government intervention.
Everywhere in the world where capitalism has increased standards of living, health care is delivered by non-capitalist means…

Allan
Member
Allan

Overall, the best healthcare is probably in the US. It is true that many of our western friends use non capitalist means, but whose economy is the strongest? Whose economy generates wealth all over the world? How many of those nations are as pleuralistic as the US? It’s a hard thing to say, but the cost of healthcare goes up unless there is some type of rationing. The most efficient type so happens to be market based. However, you and I cannot stand to see poor people unable to afford care so we intervene. Intervention causes dollars to be lost… Read more »

Margalit Gur-Arie
Member

The problem I see here is that prices of medical services far far exceeds what most people can afford. So we are not talking about a few less fortunate folks that can be helped by a church or something. We are talking about at least half the country and growing. I think two things need to happen. First, income inequality needs to be addressed because as health care costs take larger and larger portions of GDP, all but the top 20% or so are taking home a smaller and smaller part of that GDP. Second, the science of medicine has… Read more »

Niran Al-Agba
Member

Margalit, Allan is right about the rationing. I agree with you both that I cannot stand to see poor people go without care, so we must find another way. The reason the cost is so high is because we have to pay numerous staff to help us keep up with requirements that are unnecessary. I can do my work with one medical assistant if I am paid cash for visits or procedures or whatever. I could drop prices considerably. For instance, a few days ago a teenager needed a procedure to remove a bad piercing gone wrong. Total cost (they… Read more »

Perry
Member
Perry

Comparing what physicians can do here in a highly technologically advanced country to what we can do in a third-world nation is interesting. You can see scads of patients in a third world clinic with minimal tools and paperwork, however, your ability to treat may be limited due to availability of certain meds or technological tools.
In this country, we have all the bells and whistles, but our interaction with the patient is stifled by computer and coding mandates.

Allan
Member
Allan

“The problem I see here is that prices of medical services far far exceeds what most people can afford.” Margalit, I am sorry, but I believe that is not true. Removing Medicare (just for convenience) leaves us with a population where the vast majority have very low medical costs, a small fraction of the premiums they are paying today. Even the bulk of the Medicare population can afford their costs. I’m retired, but I actively treated many on Medicare and a large portion of my patient population had low level incomes and were among the sickest in the area. As… Read more »

Margalit Gur-Arie
Member

I agree with all your points, Allan. I mostly agree that we have more than enough money in the system, which translates to not having to ration, at least in my opinion. I find it somewhat amusing that the biggest advocates for rationing (or “financial stewardship”, or “choosing wisely”, or “parsimonious care”) are precisely those people who add costs to the system and produce nothing in the way of patient care. I also estimate around 30% or so loses to administrative waste, and 50% is also possible if you add the billing circus. As I said in a previous post… Read more »

Allan
Member
Allan

“translates to not having to ration” We ration all the time. Margalite, I agree with your contention that there is a lot of waste caused by those feeding off of healthcare. We agree society has been robbed by a few bad actors, but what can one expect when the federal government has trillions of dollars to spend (more than it needs)? That is why the lobbyists spend so much money. They want a chunk of all that money and they get a large portion of every dollar the government collects from the taxpayer. It appears that people are better able… Read more »

Allan
Member
Allan

“Its really not the best ” PJ, when one subsegments the groups in such comparisons we really don’t have much evidence one way or the other. Care is better for the affluent, but that is true in other countries as well. The best I can do is compare Canada with the US, the insured and uninsured. All Canadians are insured but compare the care provided to a person from Quebec or elsewhere in Canada to the care provided to the Inuits of Canada. The Inuits don’t have the same care and die much earlier etc. Compare the US to Canada… Read more »

Paul @ Pivot ConsultingLLC
Member

Alan, Excellent points. Scott Atlas’s book In Excellent Health does a thorough analysis of international health system outcomes. Bottom line in category after category is that the US health system performs exceptionally well in terms of quality of care…..better than the developed European countries. Unfortunately facts and sound analysis don’t matter to those who want to centralize power in a single payor system….so they peddle the theme that our health system is terrible. We can do better, but it can only be done by reducing the control of bureaucrats (who gave us EHR mandates/Macra/driving out private practice etc etc) and… Read more »

Allan
Member
Allan

Thank you Paul. I never read Scott Atlas’s book and have relied upon the raw data, Eberstadt’s book, the few studies that exist etc., but I just bought the book on your suggestion. Too many people are making statements based upon ideology or op ed pieces that are ideologically based.

pjnelson
Member
pjnelson

Its really not the best since it is so “unevenly” available and “unpredictably” accessible. It could “easily” be the best if we could solve the problem of equity and justice. 1500 years ago, someone said “In the absence of justice, what is sovereignty but organized robbery?” Hmmmmm! I wonder if there is anyone, tuned in, who recalls the person known to have written that observation. The last WHO/UN report listed the USA as 38th among the 45 world-wide developed nations for its maternal mortality ratio. More importantly, we would need to reduce it by 75% to rank in the best… Read more »

Steve2
Member
Steve2

Finally got an HSA plan started for our group as an option. Corporation made a big contribution to the HSA and we (the corporation) still saved money. What we saw, much as one would predict, is that the young, healthy people w/o kids took the HSA option. Older people, those with pre-existing illnesses and those with kids chose conventional insurance. When you look at how health care money is spent, it makes sense. 5% of people account for about half of our spending. About half of the population account for 3% of spending. I think HSAs are largely aimed at… Read more »

Margalit Gur-Arie
Member

Precisely!!!

Steve2
Member
Steve2

Thanks. Was so tempting to be a smart-as# and say I told you so. But, it is too early. Maybe they will come up with something good, but so far it looks bad. Brings back an old saying from internship. They can always hurt you worse. Trump was the change candidate, so I understand people voting for him, but the odds favored change for the worse.

2healthguru
Member

Margalit you nail it (as you often do)! Obama’s 8 principles while substantively different from that outlined at ‘Great Again’ aka ‘TrumpCare’ is a remarkably similar style to Obama’s ‘bottoms up’ vs. ‘top down’ approach to health reform.

My thoughts on @ACOwatch: https://acowatch.me/2016/11/30/trumpcare-as-the-puzzle-emerges/

Margalit Gur-Arie
Member

Good read, Gregg. Thanks.

BobbyGvegas
Member

“This week, President-elect Trump picked Rep. Tom Price, a former orthopedic surgeon, to be the next Secretary of Health and Human Services, and Dr. Price is a man with a plan. The plan is to replace Obamacare with age adjusted, tax credits and HSAs, while making the same model available to employers, Medicare and Medicaid too.” __ From my current post: “Why anyone — particularly Medicare benes — would want to do that escapes me. Unless the forthcoming legislative provisions will be so onerous as to eviscerate Medicare to the point where it’s really just one more penurious, care-obstructive “welfare”… Read more »

anish_koka
Editor

Margalit, What about Seema Verma’s approach to this in indiana? Seems interesting and seems like an approach to subsidizing the deductibles so they are affordable for the poor? This is an interesting video from Meg Edison. Its not an either/or approach right? We can still provide for the very destitute and disabled, but have different options for the working poor, right? http://rebel.md/who-is-seema-verma/ And peter, even now negotiations take place. I sometimes see patients for free who don’t have health insurance and simply don’t have money but need to be seen – that conversation is a negotiation right? If a patient… Read more »

Barry Carol
Member
Barry Carol

Anish — I’m curious what percentage of your patients are seen either for free or at a deeply discounted rate and is this typical for most of your colleagues as well? I know there are plenty of low income and working class people in Philadelphia who can’t afford full fees and may either lack insurance or have a high deductible exchange or employer plan.

anish_koka
Editor

I don’t have that wonderful of a heart. If I was really good, I would seek out the underserved and the poor. But as peter likes to highlight, Mother Theresa I am not. It makes up a small percentage of my practice. There are folks who don’t have insurance who I’m asked through a friend of a friend to see. More commonly it’s folks in hospitals who had an acute problem who then need follow up. Somebody who has acute heart failure for instance who needs follow up to try to see if they can be kept out of the… Read more »

Niran Al-Agba
Member

Barry, I can answer this. About 5%, although I rarely see them completely for free. I have charged as little as $10 for an office visit. We do deep discounts and to be honest, people often reciprocate (unsolicited) in their own way by fixing a broken plug here or there, changing out a fluorescent lightbulb we can’t reach, or bringing pies (my favorite), cakes, homemade jams and jellies. Sometimes fresh eggs from their farm, fruits and vegetables, or even elk meat during a lucky year (another favorite of mine.) Oh, people bring me lots and lots of clothes in great… Read more »

Allan
Member
Allan

Niran, when I gave charity care, sometimes costing me a lot of money in expenses, I would always charge even if it were $5. I feel every patient deserves the same respect and that $5 says they pay their bills. I have had people come in and pay several hundred dollars only to return it to them and keep only $10 because I knew that was money necessary for the kids and family. As government became more intrusive and costly I had to curtail many of those activities. On occasion I would let the senior keep the Medicare payment and… Read more »

Niran Al-Agba
Member

Thanks Allan, but I am no more a hero than the people who help me out when I need it too. Patients pick me up and fix my car when it breaks down, they keep my kids supplied with clothes, and they offer to babysit when I am in a bind. It truly takes a village, but my point is the village does not have to involve so many regulations and oversight. Let me run my office so it suits me and my patients, let someone else do it their way if that works for them as long as patients… Read more »

Margalit Gur-Arie
Member

Read this, Niran…. https://thehealthcareblog.com/blog/2010/11/02/dismantling-the-cottage-industry/ …six years ago… you are him 🙂

Niran Al-Agba
Member

OMG! I am so him. Wow. What happened when he got the EHR system? Is he still independent today or did he have to sell out to the large hospital? Dr. Green and those of us like him, will always be the best system available no matter what the government comes up with.

Margalit Gur-Arie
Member

Oops. typed in the wrong box. Ignore.

Margalit Gur-Arie
Member

I warned you that I’m a bit left of socialism… 🙂 I’ll watch the video tonight, but I don’t believe in “skin-in-the-game” stuff exclusively for people with widespread 3rd degree burns caused by greedy arsonist psychopaths, and I don’t believe in voluntary private charity as a substitute for social fairness. This is not to minimize your wonderful heart Anish, but on the other side of the phone there is a person robbed of dignity. I think the 1%, the big corporations, and the global money cartels need to understand that adding insult to injury will not be an acceptable strategy.… Read more »

2healthguru
Member

On Verma’s work in Indiana: ‘the design burdens patients with more paperwork and more out-of-pocket expenses compared to similar programs in other states.’

Source: https://www.washingtonpost.com/news/wonk/wp/2016/12/01/what-trumps-pick-to-run-medicaid-did-for-the-white-working-class-in-indiana/?tid=sm_fb&utm_term=.3abac031ed4c

Niran Al-Agba
Member

Why is it that few are concerned burdening 1 physician with paperwork for 2000 patients but is so worried about the paperwork burden of one patient?

Niran Al-Agba
Member

Anish, I like you, think Seema Verma’s ideas are intriguing and am interested to see what she comes up with.

realdoctor
Member
realdoctor

what if we took the money saved in monthly premiums by moving most people to high deductible plans and put it instead into HSAs? It seems we could find good ways to divert money into these accounts without spending more, then let the “impeccable logic” of HSAs help us move in a more rational direction re: spending and incentives.

Peter
Member
Peter

Scenario: “Doc, your prices are too high, if you don’t lower them I’ll have to go to someone else.”

Tell me what the doc’s response would be?

realdoctor
Member
realdoctor

I don’t know. It depends.

maybe a clinic would have a plan for financial hardships, discounted rates, etc.
maybe there would be a certain percentage of free care given
maybe there would be vouchers or public assistance of some sort to help with fees for those under certain income levels
maybe there would be a conversation with the patient about how the fees are set, and that they are felt to be reasonable

And maybe some patients would decide that they want to look for lower cost options elsewhere, which could be a reasonable response for some people.

Peter
Member
Peter

No, we’re not talking about hardship, just that free market negotiation you believe in and want to lower costs. What would be your response be realdoctor?

realdoctor
Member
realdoctor

as I said,

“maybe there would be a conversation with the patient about how the fees are set, and that they are felt to be reasonable

And maybe some patients would decide that they want to look for lower cost options elsewhere, which could be a reasonable response for some people.”

Peter
Member
Peter

I see, so you yourself would not negotiate your fees. Do you know of any doc that would – except maybe a hardship case?

See in all this, “let the marketplace decide” fantasy, no provider will actually participate in a marketplace (it’s beneath them), but they promote it as a distraction for real price reform trying to hoodwink patients into thinking this could actually work.

realdoctor
Member
realdoctor

I’m not sure who you’re arguing with.
It’s perfectly consistent with “the marketplace” for someone to set a fee for their services and let those participating in “the marketplace” decide if that fee is worth it to them or not. If someone wanted to negotiate regularly as a part of that, I suppose they could, but that’s not a necessary component of having “the marketplace” work well.

Steve2
Member
Steve2

In our practice we have worked with our hospital (we are the one on the wrong side of the tracks) to set income levels at which we either charge people nothing or reduced fees. Of course, we just don’t take their word for it. The guy who said our fees were too high and he wanted to negotiate so he could better afford his country club fees (true story) did not get a lot of sympathy and backed off when we wanted proof of low income.

Steve

Peter
Member
Peter

Well the health care “marketplace” is certainly working well for providers drug companies and device makers.

Care to publish your fees in the front office?

Niran Al-Agba
Member

I am in primary care, my fees are not only published on a sheet in the front office, they are on my website and every patient signs the fee schedule which is updated annually. This is for covered fees as well as non-covered fees, such as no-shows, records, and others.

Peter
Member
Peter

You’re probably in the minority Niran, but I don’t know what choses your patients have for alternate care. But this discussion arouse because docs here were saying that if the patient has skin in the game they will make better health decisions – i.e. lower cost in a “marketplace”. But it seems that marketplace does not extend to lower cost docs – of which there are almost nil, unless the patient has a hardship case, which means they’d have to belittle their pride (if there’s any left) and ask for help. Further PCPs employed through the local hospital don’t get… Read more »

Niran Al-Agba
Member

Peter, patients in my area have the local FQHC as a choice but as you can imagine, that is the one of last resort. There are family practice physicians (who come and go) at the large hospital group as a second option too. Like where you are, the one hospital has purchased almost every independent group except for three peds practices (we are all hanging on by a thread) that remain. Patients who pay cash do get a discount because it is less paperwork, overhead, and headaches. Someone like me has always been concerned about patient cost. When we used… Read more »

Allan
Member
Allan

Peter, it seems you do not understand what a free marketplace is. A seller doesn’t negotiate with himself. His competitor undercuts the price to gain market share. That makes the first seller improve his product or lower it so that he doesn’t lose customers. Sometimes to gain market share the entity will have special rates for certain people or at certain times (like a sale). The only reason healthcare isn’t more competitive is that physicians aren’t generally setting the prices. Look up north at the Canadian border where Canadians get healthcare in the US. Prices are competitive and very transparent… Read more »

Niran Al-Agba
Member

Peter, I am going to jump in again, but do not want to fight. I will answer your question. Sometimes people call and say “I don’t want to pay for you removing earwax from my child’s ear even if its necessary to diagnose an infection.” My answer is that if I do it, I am obligated to code and charge for it. Most patients say “in the future, I would like to know if there will be an extra charge ahead of time, so I can decide .” I invariable say, “no problem, thanks for communicating about this. I am… Read more »

Margalit Gur-Arie
Member

Sure, except there will be no “savings”. Dr. Price suggests $3,000 tax credit for the oldest individuals. Do this: log into healthcare.gov and see how much a Bronze plan with over $6,000 deductible (totally catastrophic) would cost for a 64 years old male. Maybe 3 months of coverage. Let’s further assume that we can pare down more stuff from the Bronze plan, and let’s even assume that competition will actually have an effect (it won’t with 3 national carriers), the final price is not going to come anywhere close to $250 per month. There will be nothing left to put… Read more »

BobbyGvegas
Member

Where’s the dad-gumbed “like” button?

realdoctor
Member
realdoctor

I don’t doubt your numbers example above (although I don’t know if the same analysis holds for 30-59 year olds, or whatever other group that isn’t 64 and male). This is just anecdotal for me, but I would think many have this experience: Every time I sign up for my employer health plan for our family, they give at least 3 options. the highest monthly premium is always the lowest deductible. The monthly premium is usually substantially less if we choose the high deductible plan. (we’re talking 3 figure differences). If this is the case for many, then put that… Read more »

BobbyGvegas
Member

My 46 year old daughter sat on our couch last night in the family room huffing and cursing as she tried (without success) to enroll in coverage via the “Covered California” website. She called out one to me that had premiums of about $500 a month with a $6,300 deductible. She’s the ED of the non-profit Stepping Stones Project based in Richmond, with a gross salary in the low $60k’s (which puts her out of the ACA tax subsidy range, and is not exactly big dough here in the Bay Area). Single woman, no covered dependents (her 22 yr old… Read more »

chasedave
Member

The bill that looks like a more plausible path that may get some Dem support does what you suggest…builds on top of the ACA yet has things conservatives like. Senator (and doctor) Bill Cassidy has proposed it. It will be interesting to see if it’s gets any traction. Read http://healthaffairs.org/blog/2016/06/16/the-worlds-greatest-health-care-plan/ for more.

Peter
Member
Peter

“Senator (and doctor) Bill Cassidy has proposed it.”

Another in a stream of doctors telling us what our health care should look like.

Margalit Gur-Arie
Member

I’m pretty sure there will be bi-partisan support from the DC millionaire club, a.k.a. Congress, particularly for the notion that Medicaid for all is good enough for the bottom 4 quintiles.

Peter
Member
Peter

Buyer’s remorse Margalit?

Also given the stream of “insiders” (from the swamp), not “populists “, and including the Wall Street barons he accused Hillary of conspiring with, which includes, from that bastion of “ethical banking”, Goldman Sacks, the foxes are guarding the hen house.

Rep.Tom Price, the “peoples” HHS Secretary.

Margalit Gur-Arie
Member

Not at all. I was perfectly aware of who I was voting for. I also voted for President Obama twice and spent 8 lovely years criticizing his health care reforms. I fully expect to do the same for President Trump. I will continue to complain until we have traditional Medicare for all, or I drop dead, whichever comes first… 🙂

2healthguru
Member

Stick around…. FWIW, you are a valued member and contributor to this community!

Paul @ Pivot ConsultingLLC
Member

Margalit, So you are not completely against expanded access to Health Savings Accounts paired with catastrophic care?……you just want more options than that? HSA’s paired with catastrophic plans are the best studied option that actually work (Rand 2011…a large sample multi state study). Fyi, the 12/1/2016 Wall Street Journal has an excellent op ed by Capretta and Gottlieb of AEI. Four principles: 1. Provide a path to Catastrophic plans for all. 2. Accommodate pre-existing conditions. 3. Allow broad access to Health Savings Accounts. 4. Deregulate the market for health services. The link is here, but I believe it requires a… Read more »

Margalit Gur-Arie
Member

HSAs are irrelevant unless they are progressively funded by someone else and ALL utilization of HSAs counts towards deductibles.Since this is not the case, and since nobody except the wealthy has money to “save” nowadays, I have no idea why we are even taking about this stuff. I have no objections to letting rich people enjoy a tax cut, if they have no objection to funding decent medical care for the masses who make their wealth possible.

Paul @ Pivot ConsultingLLC
Member

In my past corporate sponsored HSA plan spending paid by my H.S.A. DID count toward meeting the deductible. In my wife’s current plan spending paid by her HSA account DOES count towards meeting the deductible. A couple posts in this thread suggest payment out of HSA’s do not count toward meeting the deductible. I think they are wrong. Am I missing something? It is likely the reform plan will incorporate catastrophic plans linked to HSA accounts funded by government taxpayer funds for the poor….a better way than paying subsidies to insurance companies as in the ACA. Let the people control… Read more »

2healthguru
Member
Paul @ Pivot ConsultingLLC
Member

From the United Healthcare website: ” As you pay for out-of-pocket medical expenses, these expenses may apply to the deductible. This can include payments using your HSA”. I have had HSA high deductible plans linked to catastrophic health care for years and I have always had HSA paid medical expenses count towards my deductible. Yes, there are few things that don’t count as qualified medical expenses toward the deductible like eye glasses and over the counter meds…..but these are minor items.

Margalit Gur-Arie
Member

Only things that are “covered” by the plan count towards the deductible and only the contracted amount counts. If you have a crappy plan that covers few things, and if you use your HSA to get stuff the plan doesn’t cover, it will not count.

Paul @ Pivot ConsultingLLC
Member

Margalit,
As it stands today, due to state and federal mandates there are no crappy plans….only Mercedes plans. Hopefully in the future people will be able to choose a plan that meets their needs….as they see them…..not as some bureaucrat sees them. I’d take a Ford plan.

Margalit Gur-Arie
Member

Oh there will be lots of crappy plans…. really, really soon…. 🙂

Niran Al-Agba
Member

Then, let’s change this. 🙂 Do you know any activist types?

Paul @ Pivot ConsultingLLC
Member

Almost every medical tx paid with funds from an HSA DO count towards your deductible. There are a few things you can use your HSA to pay for that don’t: eye glasses, dental tx, over the counter meds….. Minor.