The unofficial Obamacare thread...

buzzdog said:

I think something along these lines could work, with one caveat. In the name of true competition, and to turn this concept into something that could be bi-partisan, I would do what Paul says but add an option for people to buy into Medicare as one of the competing groups to choose from. If this were done in a way that the Medicare option premiums reflected the true cost with no subsidies (while benefiting from the efficiencies and buying power that come with something as big as Medicare), then I think both sides of the aisle could support such a system.

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The problem with that is that Medicare has a very difficult time attracting enough physicians because the reimbursement rates are so low. Most doctors who accept it subsidize their income with people who pay more than Medicare rates. This is a reality that continually gets ignored by those who offer opening Medicare to all as an option.

So, Medicare already is pretty much stretched about as thin as it can get. If you made "Medicare" another option for everyone under 65, especially with no government subsidies, you'd have a flood of new Medicare patients but very few additional providers willing to work for those rates.

I'm a conservative, but as long as it happens exactly as you say, with the premiums reflecting the true costs without any government subsidies, I'd be willing to accept that as a necessary compromise. Not because I think it would work, but because I'd want to get the rest of what Paul wants through.

buzzdog said:

To add to the above... I see over-reliance on employer based health care insurance as a problem because it creates a financial and administrative burden on employers. What I describe above would allow employers to have more options to either continue with the status quo, or to join larger buying groups, or to just pay out a stipend for employees to buy into thier own choice, or they could still just choose to pay nothing towards this if they are able to find employees without providing such benefits. Again, no mandates, just people and companies making their own choices on a more level playing field.

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I'd agree with that -- you just need to change the tax code to treat such payments as excludable income. But I think you'd still need some kind of system to ensure that the excludable income is actually being used to pay for health care.

The Human Q-Tip said:

I'm a conservative, but as long as it happens exactly as you say, with the premiums reflecting the true costs without any government subsidies, I'd be willing to accept that as a necessary compromise. Not because I think it would work, but because I'd want to get the rest of what Paul wants through.

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That's kind of my point. Both sides truly think their system is the better way to go. The way I see it is let them all compete with a Medicare option being available as just one more choice with everything else being a level playing field.

I've never dealt with Medicare so I don't know much about your points about provider reimbursement rates. But if those are inadequate it would be reflected in limited choices for those who opt in to Medicare and if it's bad enough would push people to other options that give better choice of providers.

Whether or not there are subsidies for certain lower income or otherwise disadvantaged groups would be a completely separate issue and it would need to be funded with a separate tax that would be equally available for any available plan, public or private.

If Medicare or any government run non-profit system is truly better, cheaper, more efficient, I assume that would come out in the wash as long as neither side is aided nor hamstrung. The Medicare option would exist as simply one more group plan that is available, and it would require premiums as set by whatever actuarial tables they use without adding debt to that system.

Then let the chips fall where they may.

Seems to me this could get support from all sides if it were set up properly. I wonder if Rand Paul and other conservatives could get behind this to get the free market buying groups and some of their other ideas through.

I also wonder if progressives would get behind it because it would open up a Medicare option.

It would be a tough thing to hammer out and it would require a hell of a transition but as an independent I really like the idea of putting opposing systems out there and letting them compete. If a fiscally solvent Medicare option were truly more efficient it would grow, and at the very least force private group insurance options to compete.

I assume the Medicare option would be more expensive because it would be more comprehensive, where there would probably be some private groups out there offering less comprehensive a-la-carte types of coverage for less money.

The Human Q-Tip said:

I'd agree with that -- you just need to change the tax code to treat such payments as excludable income. But I think you'd still need some kind of system to ensure that the excludable income is actually being used to pay for health care.

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I agree, just as a Medicare option or private group insurance would receive the same treatment tax-wise.

buzzdog said:

Seems to me this could get support from all sides if it were set up properly. I wonder if Rand Paul and other conservatives could get behind this to get the free market buying groups and some of their other ideas through.

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Well, Democrats have pushed for it, but it has always foundered on the subsidy issue. What Democrats want is to simply open up Medicare/Medicaid to everyone, because those systems include the government picking up the tab. And Republicans don't want to do that.

The other big issue of concern is that if you opened up Medicare for everyone, and it resulted in far too many patients chasing far too few doctors, then you'd essentially be dramatically reducing the quality/availability of care for current Medicare patient. That's a big point of debate, with Republicans suspecting that Democrats want to have Medicare blow up so as to create greater public pressure for a new national single-payer system.

Anyway, one partial solution to the shortage of doctors willing to take Medicare/Medicaid is to increase the number of doctors, and one way to do that is to reduce the training requirements for doctors. Right now, they need to go undergrad, then med school, then residency, before being able to practice on their own and take patients. If you shortened that, you'd have more doctors with less student loans to pay off.

But the AMA opposes that, in part because of pure self-interest, and in part because of a concern that lessening the training would lead to some new doctors being not as good at their jobs, and thus a threat to patient safety.

The Human Q-Tip said:

Anyway, one partial solution to the shortage of doctors willing to take Medicare/Medicaid is to increase the number of doctors, and one way to do that is to reduce the training requirements for doctors. Right now, they need to go undergrad, then med school, then residency, before being able to practice on their own and take patients. If you shortened that, you'd have more doctors with less student loans to pay off.

But the AMA opposes that, in part because of pure self-interest, and in part because of a concern that lessening the training would lead to some new doctors being not as good at their jobs, and thus a threat to patient safety.

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I already see some form of this in the use of Physician's Assistants. I could see loosening this up as long as there is proper oversight of the PA's and given information technology and communication there is no reason having more PA's who are well supported with the best available information couldn't be possible.

I think the AMA would still oppose this because it means more competition for medical service providers, which puts downward pressure on their compensation. The smart ones would figure out a way to leverage it to their benefit though.

The Human Q-Tip said:

Well, Democrats have pushed for it, but it has always foundered on the subsidy issue. What Democrats want is to simply open up Medicare/Medicaid to everyone, because those systems include the government picking up the tab. And Republicans don't want to do that.

The other big issue of concern is that if you opened up Medicare for everyone, and it resulted in far too many patients chasing far too few doctors, then you'd essentially be dramatically reducing the quality/availability of care for current Medicare patient. That's a big point of debate, with Republicans suspecting that Democrats want to have Medicare blow up so as to create greater public pressure for a new national single-payer system.

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Any Medicare option would need to be set up to ensure the protection and viability of the existing system. I wonder if opening it up to paying customers could actually strengthen Medicare by providing greater cash flow, larger group with more leverage and buying power?

It would be up to those administering the plan to set rates accordingly, and some kind of solvency protections would need to be written into the statutes.

For this to work this would be need to be run by proponents who wanted to see it succeed and who would give it their best shot. At the same time it would be essential for there to be a level playing field for this option versus whatever private, for-profit group plans there might be.

The Human Q-Tip said:

The problem with that is that Medicare has a very difficult time attracting enough physicians because the reimbursement rates are so low. Most doctors who accept it subsidize their income with people who pay more than Medicare rates. This is a reality that continually gets ignored by those who offer opening Medicare to all as an option.

So, Medicare already is pretty much stretched about as thin as it can get. If you made "Medicare" another option for everyone under 65, especially with no government subsidies, you'd have a flood of new Medicare patients but very few additional providers willing to work for those rates.

I'm a conservative, but as long as it happens exactly as you say, with the premiums reflecting the true costs without any government subsidies, I'd be willing to accept that as a necessary compromise. Not because I think it would work, but because I'd want to get the rest of what Paul wants through.

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I think you're correct on that. Maybe you guys get a little sick of me posting about my dealings with medicaid, but it's all I know. Lets take my dealings with the healthcare system pre-18. I was on my step dads private insurance and there was nothing that could not get done for spina bifida. After 18 with the switch to medicaid I could no longer see the doctors I had because they only saw children with the condition. I talked with many of my doctors over the years and they sited funds as the reason they could not see me anymore.

Also some of the doctors that would see me freely admitted to billing for tests that were not performed on me to make up for the costs. So you're exactly right.

Now with the ACA clinics have opened up for me for spina bifida, but my doctor told me it's them donating their time for the cause, and doctors do drop out of the clinic every year because the pay is really trash for the time they commit to take care of me.

When ever I hear a medicare for all, I'll admit it does make me moist but I do see it's not as easy as it sounds.

So, since Jan 1, I have seen four doctors. Not one is from the US. They are from Bangladesh, Kenya, Nigeria and Pakistan respectively.. at the same time my son has a friend who went to case and graduated with a 4.0.. could not get into med school in the states. After a year he finally landed a spot in Grenada.. WTF..

CleveRocks said:

So, since Jan 1, I have seen four doctors. Not one is from the US. They are from Bangladesh, Kenya, Nigeria and Pakistan respectively.. at the same time my son has a friend who went to case and graduated with a 4.0.. could not get into med school in the states. After a year he finally landed a spot in Grenada.. WTF..

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Why does country of origin matter? It isnt about GPA with graduate school specifically. He also probably didn't apply to every med school in the country.

Plus, if he went to Case, why wouldn't case take him? More to the story.

The Human Q-Tip said:

Anyway, one partial solution to the shortage of doctors willing to take Medicare/Medicaid is to increase the number of doctors, and one way to do that is to reduce the training requirements for doctors. Right now, they need to go undergrad, then med school, then residency, before being able to practice on their own and take patients. If you shortened that, you'd have more doctors with less student loans to pay off.

But the AMA opposes that, in part because of pure self-interest, and in part because of a concern that lessening the training would lead to some new doctors being not as good at their jobs, and thus a threat to patient safety.

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This is the key to all of this. Like any profession or skilled job, most of the time you get what you pay for. I know the doctors I go to, no longer accepts new Medicare patients because what Medicare pays is drastically lower then what private insurance or paying on your own does. How we pay for medicare is only one issue we face. If you look at the entire supply chain of what goes into everything there are a lot of other areas that need to be tackled as well.

DJTJ said:

Why does country of origin matter? It isnt about GPA with graduate school specifically. He also probably didn't apply to every med school in the country.

Plus, if he went to Case, why wouldn't case take him? More to the story.

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With the tremendous amount of federal money med schools receive, I can see how people would think the citizens who paid those taxes should be favored to get the benefits.

Strange I see american students from case every time I go to the Cleveland clinic. There was also a shit ton at the spina bifida conference downtown.

buzzdog said:

Why not open up Medicare so individuals can buy in at a price that reflects the true cost of the insurance, which would be roughly equivalent to whatever the tax increase would be under a single payer system?

Then allow people to opt in or out, and give them the other option to buy into private insurance collectives as Rand Paul suggests?

Let the government run insurance compete honestly against private companies either with no subsidies, or if subsidies are given they're equally available for either the public or private insurance options?

Then, whichever system is truly better, cheaper, more efficient would provide fair competition for the other. And, people would have the choice of either the private, for-profit collective buying groups that Paul suggests, or they could buy into the Medicare option without being mandated or forced one way or the other?

I'm not seeing anyone respond, I assume because people are generally locked in to either one side (all public option only) or the other (free private market only).

I've always said that Obamacare was nothing other than a huge blow job given by the government to the insurance companies and the AHCA does look like Obamacare light, and to me it looks destined to be a train wreck.

What I propose is radically different, and could conceivably be bi-partisan, giving both systems and ideologies a chance to compete without cramming anything down anyone's throat.

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What are the true costs of Healthcare? IMO this is a huge problem. If you talk to someone who knows, you can't get a price before a procedure is done, because it is calculated after they treat a bunch of uninsured people in the ER and they put a little on top. Transparency is real problem. In other countries they have rates and you can go to Mexico for an operation and they will tell you how much they need. That's why there is medical tourism.

It isn't the worst idea to expand the size of medical schools. DO schools are gaining more traction these days too.

The upside is that more and more people are going to PA school. We could use a lot more PAs for primary care stuff and non-specialized treatment so that MDs and DOs are burdened with having to deal with minor, garden-variety ailments.