1994, 2010 and (?) 2018

Right after taking office in 1993, Bill Clinton — a Democrat with a Democratic Congress — decided to take on the issue of health care policy, putting Hillary in charge. She came up with an innovative but highly complex plan that failed politically, resulting in the Democrats losing the midterm elections in 1994.

Right after taking office in 2009, Barack Obama — again, a Democrat with a Democratic Congress — ignored past history and did the same thing, reportedly fulfilling a promise made to the Kennedys in return for their backing him instead of Hillary in the 2008 primaries. Granted, he did succeed, but again at a huge cost, with the Democrats losing the midterm elections in 2010.

If I remember correctly, originally health care was not a major issue with Trump. And he was a strong supporter of preserving Social Security, a very un-Republican view, and one that is arguably close to the goal of Obamacare in spirit. But like Obama, he had to make a deal to get the support of powerful elements of his party, and he eventually made the repeal and replacement of Obamacare a big goal. And now he could end up suffering the same consequences as did Clinton and Obama in the midterm elections.

The people Trump championed during the election campaign, the little guy, the working people — are exactly the types of folks who tend to be enjoying the benefits of Obamacare today. Will he abandon them?

Let me offer three obvious (to me, at least) facts:

  • No one, even the most extreme Republicans, wants to see people dying in the streets. The federal government does have a role, indeed a responsibility. It’s too big for the states, and even if the feds give them block grants, some states, say in the South, would adopt draconian policies.
  • Many people, especially the stereotypical Trump supporters, live paycheck to paycheck. Tax breaks, health savings accounts and the like are useless to this large group of people. It’s an insult to offer them such things, a let-them-eat-cake solution.
  • Obamacare was a bold step that filled a void that desperately needed to be filled. But it was built on various assumptions that apparently were shaky. It is not sustainable in its current form. Already some insurers have withdrawn from certain markets.
  • The Republicans now are making their own shaky assumptions, e.g. that a 30% penalty, for those who forego insurance but then suddenly need it, is the right “price” for not doing their part to support the system. Really? Why shouldn’t it be 5% or 50%, say? No one knows.

So what is my solution, you ask? Don’t be silly; of course I don’t have one. This is nowhere near my area of expertise. It’s possibly the most complex policy problem our nation has ever faced. But doing nothing is not an option.

Nevertheless, I do have one concrete suggestion, for both political parties: Borrow from the software engineering notion of use cases. Set up 5-10 examples, such as a working single mother,a small business owner, a professional in her 50s who simply can’t get a decent job because of her age, a salaried middle manager with a severely autistic child, a new college graduate working at Starbucks while trying to find work, and so on. In every debate on health care policy, both/all sides of the debate would address the question of how each of these use cases would fare under the policy they advocate.

In 2009, the biggest tragedy was the Obama never tried to sell to the American people to need for big reform. And the second-biggest tragedy was that he OVER-sold it, e.g. with the famous “You can keep your present insurance policy and present doctor” line. Both the Democrats and Republicans need to explain to the nation how they view the problem and how to solve it.

But speaking in abstractions — e.g. invoking the glories of the free market — is unacceptable. Tell us, all you guys on the Hill with your free, high-quality health care, exactly what would happen in each of those use cases under your plan? Give us real analysis with real people, no superstition. Then we might actually be able to solve the problem, and for once people might think Congress is concerned with the well-being of the people after all.

 

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54 thoughts on “1994, 2010 and (?) 2018

  1. Good point, but we don’t have to start from a blank white board.

    Having lived in Oz, Singapore, UK, the Netherlands and the USA, I’ve had a good look at these countries’ medical systems.

    When I was living in the UK, the care was so abysmal, I secured a endocrinologist in Amsterdam and flew to Holland for excellent medical care. I had good experiences in all of the other countries as well.

    Take your use cases and apply them to each of these models, and run a cost projection on each. Look at the care efficacy models, THEN make decisions.

    We’re not inventing the wheel, use others’ experiences.

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  2. The “Solution” is pretty simple. Medicare for all. Sometimes called ‘single payer’. Its what most people want, but congress (both parties) has been largely against it due to pressure from the insurance racket. To replicate the Canadian health system would be pretty difficult, but we could start with baby steps such as “Medicare Part A for all” with a deductible commensurate with the amount that person has paid in over the years. A monthly premium according to that person’s age and income would also be acceptable.

    Medicare Part A pays for Hospitalization. Most people can afford routine doctor visits. I don’t have insurance and a lot of times, I pay less than the copay for people who have insurance. If somebody wants to have outpatient coverage, they can go to private insurance companies for that. However, when somebody has to go to the hospital and doesn’t have coverage, it can bankrupt them in short order.

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    • Single-payer is also SINGLE DENIER. If the government or some bureaucrat or “expert” says that care must be rationed, then who gets shafted? Eventually, everyone. With a multi-payer system, there is always a risk that you might go to another payer; therefore, Draconian rationing is greatly reduced.

      Would you really like to see some bureaucrat steeped in Malthusian dogma decide that you’re not “worthy” from a “societal perspective” to see a doctor? That’s what happens in the UK. Hospitals are given a cash incentive to put patients, especially the elderly, on the LCP. The Liverpool Care Pathway literally means sedate them, and let them die of starvation and dehydration. And the Brits PAY A BONUS to hospitals to do this.

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      • RE: Futureuser / With “Medicare Part A for All”, medicare only covers hospitalization and after care. So its not exactly SINGLE PAYER. You would still be responsible for outpatient services like doctor visits or you can buy a separate medigap policy.

        As far as “Medicare Part A for All” promoting health care rationing, where is the proof that Medicare Part A does that now? The US already has a system similar to the “Liverpool Care Pathway” based on your description. Its called “Hospice” here in the US. I don’t think anyone who can make the decision for themselves should be forced into hospice care, but its definitely a good choice for some people.

        In addition to being a software engineer, I am also a registered nurse. I have seen doctors deliberately giving terminal patients false hope by suggesting an expensive operation that may, at best, postpone death a few days to a few weeks. That’s an example of the kind of stuff that DOES need to be rationed. Traditional insurance draws a line in the sand and labels a lot of this kind of stuff “Experimental Procedures” and usually doesn’t pay. So “Rationing” already happens with multi-payer. And for unemployed people like myself who can’t afford insurance, the current system means NO hospitalization if I need it. Talk about rationing….

        One other thing that I hear from “Medicare Part A For ALL” naysayers is that it would turn the country into a socialist government. So socialist agendas like public schools, libraries, roads, and fire protection must be abolished if we want to purge all socialist ideas from the country. Charging a tax and spending it for the good of the people will not make the country socialist.

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    • Spot on. As my father explained to me decades ago, “insurance” generally is really only necessary for the “catastrophic” expenses. I can handle the small stuff out-of-pocket. I don’t need insurance for that. But like most Americans, I have it anyway, which I’m sure makes the insurance companies happy as clams. We (who do have health insurance) are *all* ridiculously over-insured.

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    • I think the government should take over health care. Private health insurance companies get to profit off young people while the old are dumped into government backed Medicare. Young persons with expensive medical needs are dumped into Medicaid. The government takes care of the sickest people while the private insurance companies get the healthiest customers.

      I think “insurance” is the wrong word. Insurance is for something that is not likely to happen such as a meteoroid hitting your home. Health care is not one of these things.

      Health care is not a free-market system. The government says I have to go to a licensed physician instead of someone else such as a nurse for medical care or a prescription.

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    • Why would you want to model a system after Canada’s? That system is expensive, inefficient, and low ranking compared to other systems in the various surveys. Having worked on operations research issues in one of the provincial health care systems in Canada, I can tell you flat out that it has major problems that will not be solved until several political issues are addressed (i.e., never). It also eliminates choice for consumers of health care services.

      I suggest looking at two tier systems of the sort that some european countries use.

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      • I used Canada as an example, there may be better 100% coverage systems out there. On the other hand, I live in Florida and we get a LOT of Canadians down here in the winter. i have asked several of them outright “How do you like your health care system up there?” The answer is a universal “We love it!” One time I met a Canadian guy and asked that and he went on for a good 20 minutes saying how great the Canadian system is and how horrible the US system is, all while citing numerous examples and facts. Knowing the facts myself, I actually felt ashamed that I couldn’t truthfully argue against his points.

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  3. MDs will never vountarilly relinquish salary, but everyone has stories of out of control costs for health care. Personally, I kept a follow-up visit after a procedure, was met by a doctor filling in for mine, shook his hand and told him I’m fine. He said I need not return. His time spent, 5 seconds, charge was $350.

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  4. Oy, Norm, … OK, let’s say what your suggestion is, is to use “use cases” as the PR face of any health care discussion. Sure OK. But you should realize that there is tons of such statistical (!) work already in any and all of these plans, even the bad ones, that’s what actuaries do, that’s what underwriters do, that’s what the big insurance companies do – and they supply most of the smarts to both sides of these issues.

    And please, try not to refer to half of your fellow citizens as if they were some kind of alien life form that you only know about through rumor and whispered innuendo, those guys, those Trump supporters, those stereotypes, those dumb racists who somehow still get to vote. I know this is California and that’s how the talk goes, and anyone who didn’t vote for the venal sociopath has to walk around quietly, but let’s not make it worse OK?

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    • The statistical work is based on assumptions, and the fact is that those assumptions are typically based on how people act under current policy. Change the policy, and their behaviors change. We can’t know what the effect of that 30% penalty would be without actually trying it. And the statistics are overall; we really need to know what happens to the use cases.

      If you think I look down on Trump supporters, you have totally misunderstood my posting here, and all my postings for the last year and a half.

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      • I take it that the 30% is more or less arbitrary, and meant to be more a behavioral guide than an actuarially accurate number. I think it’s too low, mathematically, but this fits with policy and reality, much of this system is going to run at a loss. Of course things need to be tried, but we don’t want to go all Pelosi on it. Maybe somebody could actually publish a paper explaining the reasoning that went into it but I think it’s pretty apparent.

        I’m arguing with the specific language used to refer to Trump supporters. Even the term “Trump supporters” is derogatory, you’re separating them out somehow and saying they see Trump but not the issues and not their country and all the citizens in it. And I think if you do the research you’ll find this works out, the articles that use that term most generally make a lot of other glib (and false) assumptions as well.

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        • Yes, maybe the 30% figure was not meant to cover costs, but simply to be punitive.

          For any politician X other than Trump, the term “X supporters” would not be derogatory. Unfortunately, the press has made it so for Trump.

          But I don’t know why you think I intended it as derogatory. I certainly did not.

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  5. > Nevertheless, I do have one concrete suggestion, for both political parties: Borrow from the software engineering notion of use cases. Set up 5-10 examples, such as a working single mother,a small business owner, a professional in her 50s who simply can’t get a decent job because of her age, a salaried middle manager with a severely autistic child, a new college graduate working at Starbucks while trying to find work, and so on.

    I very much agree. However, those use cases need to be chosen carefully so that they include all major groups and all groups that would be hurt by any proposed policy. It might be best for the cases to be selected by some non-partisan group like the CBO (Congressional Budget Office) and/or include key cases put forth by both parties. Otherwise, the cases are likely to be chosen to highlight the winners and ignore the losers.

    That’s essentially what happened with six example cases released by the Treasury Department to support Bush’s Tax Relief Reconciliation Act of 2003. In fact, I just noticed something interesting looking at the Internet Archive Wayback Machine at https://web.archive.org/web/20170401000000*/https://www.treasury.gov/press/releases/reports/taxreliefin2003.pdf . Those cases disappeared from the treasury website sometime between January 28th and February 12th of this year, shortly after Trump’s inauguration. In any case, I looked at the six cases at http://www.econdataus.com/tax03ex.html . Judging from those examples, everybody in the U.S. is married and all married couples under 65 have children. These cases show tax cuts between 18 and 96 percent and were likely chosen to take advantage of the increase in the child tax credit and the cutting of the so-called marriage penalty. As shown in the analysis, if the six examples are changed to single with no children (with the income and other items remaining the same), the tax cuts drop from between 18 and 96 percent to between 2.5 and 8.7 percent.

    The second graph at http://home.netcom.com/~rdavis2/taxcut03.html shows the tax reductions from just the rate cuts in the 2001 and 2003 tax cuts. Note that the lowest reductions are for single taxpayers making about $27,050 in taxable income. That’s because $27,050 was the top of the old 15 percent tax bracket which was broken into a 10 and 15 percent bracket. Hence, like all taxpayers, those taxpayers got a reduction on their income in the new 10 percent bracket (under $7,000) but got absolutely no reduction in the rest of their income. Still, the new 10 percent bracket allowed Bush to claim that the biggest tax cuts when to those with the lowest incomes! Clever, huh?

    Getting back to heath care, I think it would also be useful to summarize as clearly as possible what the health care plans are in other developed nations. I don’t understand how we can continue to have the hubris to insist that the U.S. has the best plan when it has the highest costs but is now the only developed country not to have universal health care (see https://www.thestreet.com/story/14030439/2/all-the-countries-that-have-universal-healthcare.html ). In fact, I was surprised to read at http://www.who.int/mediacentre/factsheets/fs395/en/ that “[a]ll UN Member States have agreed to try to achieve universal health coverage (UHC) by 2030, as part of the Sustainable Development Goals”. Universal health care would solve the problem of the opposition to the individual mandate. The mandate would move to being on the taxpayers as a whole to pay for whatever system we implement. That may require that universal health care cover just critical services, at least initially, and have co-pays and such to discourage overuse. But it does seem that we should not insist on remaining the only developed country without universal health care.

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  6. “Many people… live paycheck to paycheck…”

    “The Republicans now are making their own shaky assumptions, e.g. that a
    30% penalty, for those who forego insurance but then suddenly need it…”

    Shaky indeed.

    How does one acquire blood from a turnip?

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  7. Rather than a premium penalty, do not cover conditions that occur within the uninsured period until a person has been insured for at least 2 years.

    Any analysis should include past philosophies. In years past, insurance covered catastrophic occurrences and kicked in only after a deductible was met for “”normal” expenses. There was no well baby, vaccinations, and checkups. I remember it being an event when husband’s university employer started paying a fixed amount for an annual physical. However, a trip to the ER to have son’s head sewn up by a plastic surgeon after an accident was covered. Now, my son uses the county health department for immunizations rather than pay an inflated cost at the physician’s office.

    People who are on Medicare while still covered under their employer’s policy have not been hit with the reality of Medicare as their primary insurance. The issue is less medical (doctor and hospital) coverage but drug coverage. Those drugs on the plan formularies do not include many of the newer drugs (think advertised on TV). The cost of these (one suggested for us was nearly $800/month and another was $600) have me carrying the formulary with me to every visit; if a suggested drug is a maintenance drug and not on tier 1 or 2, we look for an alternate . People on other (non-governmental sponsored plans) can get discounts from the drug companies but not those on Medicare.

    They seem to have solved the cost of medical care for the elderly by making it a choice between food and drugs so that either way, one’s life is shortened. It is essential to get prescription costs under control.

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  8. Just curious , do you know a single soul who likes their ACA coverage? Everyone I know hates the high premiums and ridiculous deductibles. The sickest and poorest benefit , working people pay and get a deductible so high they may as well have no insurance. So the solution is magic money from somewhere; more taxes from people who work. Any wonder Trump got elected.

    How about a simpler program more people can get behind? Expand Medicare to cover children – including pregnant women – up to 18 or 21 if they attend college. Employers don’t pay for family coverage and everyone’s coverage is cheaper. Pay for it with a increase in FICA taxes. I think both parties could get behind this.

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    • “high premiums and ridiculous deductibles”
      Their only point of reference is employer based insurance which is usually only half the copay.
      Few of them ever tried to get insurance on the open market.
      I was paying $700 a month as a 30 yo person with no prior conditions back before ACA.
      ACA is only about 30-50% of the “free” market rate.

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    • Isn’t this the same story on employer coverage also these days? Most of the employer based plans are also high deductible before any benefit kicks in. The premium paid by the employee (forget the employer) is much more than the benefits received by most of them.

      I think that is how the insurance works – 80-20 rule. 80% of people get less than what they pay for.

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  9. I think having a single payer system should eliminate one of the causes for age-discrimination as the employer is no longer paying for insurance. Older workers are more expensive to insure and that incentive goes away when everyone is paying into the system through taxes or insurance.

    I don’t understand the opposition to Obamacare from republicans as it is the same as Romney-care. It is a conservative’s solution. While Obamacare provides access to care, they do nothing to control the costs. After repeal of Obamacare, premiums might skyrocket as there will be a lot more uncompensated care for healthcare providers which they need to cover from insured population.

    Please see the article below on how republicans implemented prescription benefits under medicare and how the congressman who led the effort became a lobbyist soon after that. The same lobbyist successfully lobbied Obama administration also to ensure the same non-competitive advantage for big pharma.

    http://billmoyers.com/story/the-man-who-made-you-pay-more-at-the-drugstore/

    I would like to see some of the free-market solutions applied in IT to healthcare also.

    – Outsource US healthcare management to one of the counties that is doing it better and cheaper, as the cost in most of the developed world is less than half of US. People there have comparable or better life spans. 😉

    – Import more MDs on H1-Bs to spur competition and drive down the costs, better yet let the patients use an offshore doctor..:)

    – Import drugs from Canada as the drugs are a lot cheaper there….

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      • That says a lot about Romney, he would have said anything to get elected. I posted an article above on how republicans cut sweet-heart deals with big pharma for medicare part D.

        Now that the CBO report is out, Trumpcare is going to be much worse than Obamacare in terms of access to care. I believe it is going to increase the cost of care also, as the hospitals and doctors that had an income stream through Obamacare will have to make it up from elsewhere (which is why AMA and hospitals came out against Trumpcare). No one wants to take a paycut (except for american tech workers).

        The replacement income won’t come from Medicaid or Medicare which means it needs to come from employer or individual market.

        https://www.forbes.com/sites/brucejapsen/2017/03/08/ama-says-trumpcare-is-critically-flawed/

        I don’t get how republicans who are big on personal responsibility can oppose something like Obama/Romneycare which promotes that responsibility. To reduce the overhead of subsidies for the poor, the cost of care need to come down through innovations, technology etc.

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    • Why would we want to import physicians who have less education than our physicians assistants and advanced practice nurses? There is no shortage of people wanting to go to med school, just slots. There are more US trained doctors wanting residencies than are available yet these are being given to foreign trained medical graduates who manage to remain in the US to work rather than return to their home country to train others.

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      • For all the free market in US, AMA successfully regulates the supply of doctors to keep the MDs income high (it is the best union one can think of). Since doctors in US make a lot more money compared to similarly skilled professionals elsewhere, our healthcare system is expensive.

        I don’t know if physicians in US have significantly better skills/education compared to their counterparts elsewhere. If we base the quality of healthcare on outcomes over longer term, I don’t think so. Most of the developed countries (and even some of the lesser developed countries) have equal or better outcomes at a fraction of the cost.

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  10. Good points Norm.

    Take a look at the Harvard Negotiation Project. What you suggested follows some of the same philosophy, which if followed would have produced a real solution that didn’t have the significant side effects it has today. Obamacare was cited as bad policy by experts who want a solution – including Obama’s own doctor of 20+ years – a doctor who truly believes in the cause of healthcare for the poor (as do I).

    But was Obamacare really about solving the healthcare problems for everyone, or just a voter base? Consider the interview of Obama on a union TV channel before he was elected, when he said the plan would not be single payer but a step in that direction. And don’t forget about what one of Obamacare’s architects (Jonathan Gruber) said about it:

    “You can’t do it political, you just literally cannot do it. Transparent financing and also transparent spending. I mean, 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? So it’s written to do that,” Gruber said. “In terms of risk rated subsidies, if you had a law which said that healthy people are going to pay in, you made explicit healthy people pay in and sick people get money, it would not 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 really critical to get for the thing to pass. Look, I wish Mark was right that we could make it all transparent, but I’d rather have this law than not.”

    Notice how he said, “I’d rather have this law.” Who made his opinion divine? However, he is incorrect when he said healthy people pay in and sick people get paid. What he really meant to say is that middle class and rich pay in and the poor get paid, fulfilling the prophesy as Obama slipped during his original election campaign and referred to redistribution of wealth, by proxy through healthcare subsidies. Why not fix the social problems (like fixing academia everywhere – a long discussion) so poor people can increase their own situation? Why not fix the insurance industry? Why not provide a public option that was written like Tricare?

    Admittedly, Obamacare changed my life, and not for the better. For many years I had the entrepreneurial spirit and was self-employed. But no longer, cannot afford the risk. Though costs have risen significantly since I was self-employed (before the great recession), prices companies are willing to pay haven’t returned to former levels. And companies have become more age averse.

    If I were to try self-employment today I would need to make an additional $20K+ per year just to pay for healthcare. Yes, a real number directly from the Obamacare marketplace. I would be paying for my own healthcare bills – all of them – and others’ healthcare, until something catastrophic happened and then it would kick in to pay 80%. FYI, I am not wealthy.

    You did hint Norm, to the real problem: partisanship and special interest influence. In short, it’s more about power and politics than solving real problems. Some may truly believe in the cause, but whether smoke screen or sincerity, in the end it’s all smoke.

    Such will continue until the system gets so broken that we either end up with a completely new form of government (and not a good one), or the valiant and true intellectuals stand up with real solutions before that happens. Unfortunately, we are prone from the primate within us, to gain or give power, and given the primal origins of such propensity, effective solutions will likely forever elude us.

    The architect of Obamacare called the American people stupid for supporting the people who signed it in to law. He was correct because of the increase in media persuasion and increase in emotional voting. Emotional decision-making is intellectual stupidity. Ironically, the majority of Americans who were polled later reported they were not in support of the legislation.

    We needed healthcare reform (and we now need it more than ever). Was Obamacare the right reform for healthcare, or were ulterior motives involved?

    When the debate over the bill was raging, I downloaded it and read it. Many parts of it matched good policy required by plans in our own state (I studied our law to fight an insurance company who refused to pay a bill – yes, I won).

    As I read the ACA bill I was optimistic until I found that too much of it gave general and unchecked power to an outline of a bureaucracy to consist of non-elected officials – who would determine, like all other socialized medicine systems, who gets what treatment. Whether on the Indian reservation, our own Medicare or other countries with socialized medicine, patients tend to be devalued as they age.

    I’d lke to ask a rhetorical question. I consider myself a true liberal thinker, but I find it hard to find people like me. Where are the true liberal thinkers today? No, they are not the liberals, which are just left. The dogma the left pushes is as one-tracked-minded and profound as the dogman on the right. Conservatism tends to hang onto dogma involving fear while liberalism (not liberal thinking) seems to hinge on the dogma of anger. The right tends to look at the left as criminals of moral turpitude, and the left tends to look at the right as evil objects to hate.

    Politics today thrives on our emotional dog and its rational tail.

    How will we ever get a real solution?

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    • I agree with most of your points, but in terms of who pays and who gets paid, it’s not quite what you say.

      First of all, if everyone had the same income level, it would be true that the young pay and the old get paid.

      Second, that word “old” is key. While it’s true that the poor get paid now, it’s even more true that older people with catastrophic illnesses are getting paid — a LOT.

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  11. Many people, especially the stereotypical Trump supporters, live paycheck to paycheck. Tax breaks, health savings accounts and the like are useless to this large group of people.

    Bull roar. Having lived “paycheck to paycheck” for several years, I can tell you that the HSA we had (tax-favored) was great!! Yes, eventually, the paychecks stopped–which stopped participation in the HSA. But it was great while it lasted.

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      • OK, I’ll define it more sharply: about $100/month free cash after all obligations, which lots of chilluns who might at any time required MORE than $100.00 worth of whatever.

        Better?

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    • HSA’s are a no deal. As doctors have consolidated into “health systems”, their rates have in many cases tripled for standard ambulatory visits.
      If you have watched your bills, your insurer pays only about 25% of their charges.
      Paying out of an HSA account would obligate you to pay full charge as the health systems are not allowed to give individuals special rates.
      So you save $2000 in taxes but you end up paying as much as an ACA plan even with just a few office visits.

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      • If you are in a health plan (high deductible most likely) together with HSA, you get the benefit of contracted “in-network” charges from in-network providers, even if you have not yet met the deductible.

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  12. A couple ideas:

    1. Why not use 5 states as laboratories? Choose different states to enact plans based on various political views:
    – Libertarian
    – Conservative
    – Moderate
    – Liberal
    – Progressive

    Give them complete autonomy to do what they want. After 4-5 years, look at the results. Come up with a compromise based on what was good/bad in each.

    2. Return the system to what it was before Obamacare. Improve where you can. Set up a separate plan for the poor and uninsured. How to fund it? Drinking, smoking, drugs and air pollution can be bad in excess, SO lets throw a 3 cents tax on:
    – Alcohol
    – Cigarettes
    – Marijuana
    – Gasoline

    If need be, add a 1/2 or 1% tax to the income tax. Tell my libertarian/conservative brethren, beside the poor, its an insurance plan in case they need it. Make it two tier – basic for those with no funds, and more features for those that can pay some fees. It would give incentive to the working poor.

    What made us conservatives mad about Obamacare was:
    You can keep your plan – WRONG
    You can keep your doctor – WRONG
    Its affordable – WRONG
    1990 pages long
    Congresswoman Pelosi – “We have to pass the bill so that you can find out what is in it”
    Senator Boxer laughing when asked if its constitutional
    Obamacare architect admitted lying to get bill passed

    Also the American lifestyle plays a part in healthcare:
    – Sedentary lifestyle
    – GMO foods
    – Wi-Fi proliferation
    – American diet
    – Drug, sex and alcohol abuse

    In closing, citizens have to remember that the US has a current debt of $20 Trillion and future debt of $100-$200 Trillion. Obamacare’s replacement and other programs have to contend with those facts. If we didn’t have the world’s reserve currency and the printing press of the Federal Reserve, Obamacare and many other programs wouldn’t even exist.

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    • Re: $100-$200 Trillion
      – constitutional amendment – no business ever is bailed out
      – constitutional amendment – any/all “campaign donations” go back to donors at end of election cycle
      – constitutional amendment – any/all election configuration is by state referendums (districting, polling locations, etc.)
      – close the Import/Export Bank
      – close the patent office
      – direct bill for use of seaport and airport and intermodal facilities
      – invert our corrupt tax structure, lowering “earned” income and spiking all other non-earned income
      – boot to the curb any company who is Irish on tax day
      – unmonopolize pharmaceuticals
      – kill any/all corporate subsidies
      – cap any/all import profits (being the highest priced consumer market, NO justification for the greed occurring)
      etc.
      etc.

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  13. Regarding the suspension of premium processing for H1-b, I was reading this CIS article (http://cis.org/north/uscis-sends-coded-signals-friday-afternoon-about-h-1b-and-eb-5) & (http://www.breitbart.com/big-government/2017/03/05/white-house-tangles-h-1b-program-red-tape/)

    and it says the suspension would buy the Trump administration more time before the next H1-B lottery commences on April first week.

    And one more interesting thing that seems possible is that this year’s H1-b applicants might have to wait 3-6 months for their H1-b visas since premium processing is suspended. Its going to be tricky to see how this 3-6 month wait time is going to impact the recruitment of OPT’s / workers from foreign countries.

    One question I would like to ask you is that would this mean the Trump administration has more time after April 1 to actually amend the rules.

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  14. About your three “obvious facts” Norm – let me offer alternative facts 🙂

    1. What is wrong with having states decide what is the right level of support for the needy? – if some states are more “draconian” then their citizens bear the responsibility. Or do you believe that those in California are more moral than those in Arkansas?
    2. The refundable tax credits according to the plan may be used to immediately pay for premiums on exchanges, so they will be of use to those living paycheck to paycheck.
    3. The 30% surcharge (1 year only) for those who let insurance lapse is indeed intended as a penalty, and not to cover the costs, which are likely to be much higher for those who suddenly buy due to illness. The number is somewhat arbitrary, and is likely not even high enough to be a disincentive for gaming the system – but it always can be adjusted in later years if that becomes clear. It is one of the few ways to try and keep enough well people in the pool to maintain “guaranteed issuance” without the Obamacare mandate/penalty.

    Liked by 1 person

    • 1) It is obvious there are states that are less moral.
      2) What does “tax credit” do for those with no income?
      3) How is 30% penalty any different that ACA mandate/penalty? You say potatoe, …

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      • 1) “Obvious”? Only to those who judge themselves more moral.
        2) “Refundable” means the credit is paid out to those with no income (like EIC).
        3) 30% “surcharge” on reinstatement, means no “penalty” has to be paid as long as (years) you don’t buy insurance – that is the difference from ACA mandate.

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  15. The people overhauling the health insurance system need to think outside the box. Perhaps the answer is as simple as greatly subsidizing hospitals and letting purchased health insurance cover only physicians and rehabilitation services. Have a copay for hospital services that lingers as long as someone is alive with repayment a designated fraction of an individuals income (like student loan repayments) but have the majority covered as a community service.

    The health insurance proposals – current and future – do not address one of the largest expenses: long term custodial care. This frequently falls to Medicaid. Over 10 years ago, my mother’s end of life nursing home care and other services in the relatively affordable Midwest cost $12,000 per month.

    I am sure other citizens (as opposed to politicians) will have other ideas if we could only get the policy makers to listen.

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    • “Policy makers” have sold off public interest for “campaign donations”.

      50% of health insurance premiums are for no good reason: 30% on paperchase, due to variations in paperwork and coverage of variety of insurance, and 20% (at least, for those capped by ACA) going to profit.
      That doesn’t include other costs that’ve blown ACA/insurance out of the water: prescription price gouging.

      China fined Pharma for price gouging there citizens. No such action by our corrupt congress. $50K a month for a cancer drug that “may extend” death of cancer patient by two months. Priced to prey on last asset of the desperate widow, their house. Why so high? Because they can. How does “may extend” by two months get FDA approval…

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  16. The major flaw in ACA was leaving the back door wide open on prescription costs. Had they come under the profit cap, then it would’ve been workable.
    Given insurance premiums are based on projections and profit is capped, the public and insurance companies are getting gouged by big Pharma.
    $600 for an EpiPen prescription in a country where 50% of the population couldn’t put their hands on $500 if they had to.
    Repeal ACA is death sentence for many.

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