Repealing the ACA under Trump

[NM11046]

 

 

 

 

I grew up hearing horror stories about Canada healthcare and European healthcare. I now hear mostly about how they're model systems compared to the U.S.... I think it really depends on the sources and their motivations. The former were a lot of very conservative bent folks unsurprisingly, and it's become increasingly clear that universal coverage is simply not something they're interested in.

I still hear how bad they are from Republicans.

Living 40 miles from the border and frequently traveling to Canada for buisness, I sometimes talk to the factory workers about things like healthcare. Canadians, I think, generally like what they have for healthcare. Their only gripes are the sometime long waits for evaluations or procedures, and their high tax rates. That is offset by their piece of mind that if they need it, they will recieve adequate healthcare.

Agreed. From the Europeans I hear similar, the wait and the fact that they don't always get the level of expertise that they might get if they could choose their own doctors. Now I think they could probably pay and go to their own doctors if it was that important to them.

If it was that important to them? I mean sniffly noses and ingrown toenails aren't the issue here.

 

Surely you're not saying that untimely and substandard care are acceptable tradeoffs for moving to universal care. That the rich should be able to buy their way to top notch care, while the poor are stuck with something else entirely. This is my biggest concern with the prospect of universal single payer care.

 

People are quick to point out how our system sucks compared to so many others but then you hear about these delays in treatment and lower quality care. It makes me wonder which narrative is actually correct. There's no doubt our costs are too high. I'd like to attempt to fix that before we throw the baby out with the bathwater.

 

To be clear --- none of this is my opinion. Just information that friends and family that live overseas and take part in healthcare in other countries have communicated to me.

 

Sniffles and etc, isn't a big deal at all - they can get into a clinic quickly to be treated. It's when they're looking for a specialist. For instance an orthopedist. Let's say they have a hip injury and need a replacement, there's not a guarantee that they'll get a hip specialist for their surgery, and they may have to wait quite a while to set up the actual surgical visit.

 

I'm all for single payor, with tweaks that would make it more palatable to US citizens. No matter the situation there will be wealthy folks (or needy ones) that pay out of pocket for what we today call concierge doctors. Fine. The doctors that do it don't want to deal w/ins and reimbursement and are old enough to not have to depend on it, and the people interested in it take it on at their own expense 100%. That's a niche that is probably a percentage of a percentage of 1%.

 

And as far as wellness visits and the wait times that jnebs mentions, that's a non issue.

[JJ Husker]

Well, either timely care and quality of care is an issue, or it isn't. And by timely care we're not talking about the length of a visit. We're talking about needing a procedure or test performed and having to wait weeks or months for it. We hear all these anecdotes about people in these supposedly better countries having to wait 6 months or more and that the quality they receive may not be up to the standards we've come to expect. That's basically what you and ZRod were sharing above. IMO, those aren't the types of things we can expect to tweak if we move to universal care. It seems those are the inevitable result of that type of system. Yet we also hear how we are falling behind so many of these other countries. I'm not optimistic enough to think we can move to that system and then outperform the majority of the countries with these issues.

 

IMO, we have one huge problem and that is costs and what providers and insurers are allowed to charge. I want to try fixing that first because I think it can be done.

[Moiraine]

The rich can already pay for better care here. The poor can get whatever their insurance covers.

 

I don't know that that will change regardless of the system.

 

Edit: guess NM already covered that

[NM11046]

Well, either timely care and quality of care is an issue, or it isn't. And by timely care we're not talking about the length of a visit. We're talking about needing a procedure or test performed and having to wait weeks or months for it. We hear all these anecdotes about people in these supposedly better countries having to wait 6 months or more and that the quality they receive may not be up to the standards we've come to expect. That's basically what you and ZRod were sharing above. IMO, those aren't the types of things we can expect to tweak if we move to universal care. It seems those are the inevitable result of that type of system. Yet we also hear how we are falling behind so many of these other countries. I'm not optimistic enough to think we can move to that system and then outperform the majority of the countries with these issues.

 

IMO, we have one huge problem and that is costs and what providers and insurers are allowed to charge. I want to try fixing that first because I think it can be done.

I think much of it is "perceived" quality. If a medical need is emergent nobody is waiting there, for "elective" surgeries they are. Now I might not find hip surgery elective, but the government does if you fit certain criteria (I'm assuming, walking working etc).

 

We are spoiled here - period. We have no patience, and we all want what we consider the best of the best. The doctors I choose to drive 45 mins to see in a major city at a renowned teaching institution cost me the same as my local physicians. But my feeling and research shows that their outcomes are better, their exposure to procedures is higher, their success rates are better so I drive. I'm a total medical snob. Lots of that has to do with what I do for a living and who I know, and some has to do with our system. I would pay extra to visit a specialist at a top tier hospital, but that's me. To your point, the less well off should have the same opportunity to have access to the best doctors. Sadly, few of those folks choose to practice in areas where state plans or medicaid are heavy payor currently.

 

Now, one thing that hasn't been discussed much here is outcomes and success/error ratios. That's something that is very real in the US reviews of hospitals - just like cost analysis' are. I don't know how specialists in single payor countries perform in comparison to US doctors when it comes to outcomes. That would be interesting to me. Or how many specialists there are vs. primary care, mid levels and etc. Much of our view of medicine will likely have to change to accommodate this, and right now we have a hard time even getting medical students to stay in general practice as it is.

 

So in addition to controlling costs, improving outcomes we also need to figure out how the system can motivate doctors to stay in certain areas of focus. Money isn't a draw for anybody to stay in primary care any longer --- it's got to be a "passion" and not many can say they've dreamed their whole life of being an internal medicine doctor.

[JJ Husker]

Yes, I can see how much general and family practice has changed. It doesn't at all resemble what it was 20 or 30 years ago. They used to have sole practices or partnerships or small groups. The docs were pretty much in charge of their practice. Now they seem to be the overworked mules of large faceless corporations. Right before the ACA was implemented I had this discussion with our family doctor. He no longer enjoyed it, did not like the prospects of continuing in the Obamacare system, so he retired at a relatively very young age.

 

It even seems that specialists are maxed out these days. All the regulations and extra testing etc. seems to really be taking a toll on the profession. But having said that, it is still one of the highest paying jobs available to those so inclined. But I agree, I think anymore it takes a real passion for whichever field they choose to specialize in. I don't see any draw to general practice anymore. I think that will only widen and deepen if/when we basically put the government in charge of it. They will basically be higher paid dmv workers. Not a rosy outlook IMO.

[Danny Bateman]

 

TG...I think to a certain extent, you are right. Problem is, we aren't even doing a good job of that.

 

What the Republicans need to flat out admit one way or the other....Is access to healthcare by everyone in society important to them?

 

They need to be flat out asked that and not let off the hook until they actually answer it with a yes or no answer.

 

And....a "yes" with a follow up of....if we free up the world of healthcare, everyone in la la land will somehow instantly have all the healthcare they need and the ability to pay for it....is not acceptable.

 

If their answer is "NO", then we know where the debate really is and we can have that debate.

If the answer is "YES", then they need to, in detail, explain how their program is going to work to accomplish that.

 

Bingo. Perfectly stated, IMO. Know where the debate is and honestly advance your case.

 

 

I wanted to highlight this as well because BRB absolutely nailed something very important in this debate.

 

Republicans DON'T fundamentally believe that the government should have a role in healthcare. At the very least, very very few of them do and they'd have to be extremely centrist.

 

The problem is they know the vast majority of the country doesn't agree with them on that. The public sentiment is shifting rapidly to the belief that we should be guaranteeing healthcare as a right for our citizens because many other successful developed countries do so.

 

So they're trying to have their cake and eat it too. They don't believe healthcare should fall in the purview of the government, but they reliably trot out there to defend this abomination of a bill by saying it will fix what the ACA does wrong, no one will lose Medicaid, no one will have the rug pulled out from underneath them... etc. etc.

 

They have to make these outlandish, bizarre claims that fall apart immediately if you compare them with the facts about their bill. They're forced to because they won't be honest about what their position on healthcare is (because it isn't popular), so they're forced to lie about the real ramifications of their bill.

[BigRedBuster]

 

 

TG...I think to a certain extent, you are right. Problem is, we aren't even doing a good job of that.

 

What the Republicans need to flat out admit one way or the other....Is access to healthcare by everyone in society important to them?

 

They need to be flat out asked that and not let off the hook until they actually answer it with a yes or no answer.

 

And....a "yes" with a follow up of....if we free up the world of healthcare, everyone in la la land will somehow instantly have all the healthcare they need and the ability to pay for it....is not acceptable.

 

If their answer is "NO", then we know where the debate really is and we can have that debate.

If the answer is "YES", then they need to, in detail, explain how their program is going to work to accomplish that.

 

Bingo. Perfectly stated, IMO. Know where the debate is and honestly advance your case.

 

 

I wanted to highlight this as well because BRB absolutely nailed something very important in this debate.

 

Republicans DON'T fundamentally believe that the government should have a role in healthcare. At the very least, very very few of them do and they'd have to be extremely centrist.

 

The problem is they know the vast majority of the country doesn't agree with them on that. The public sentiment is shifting rapidly to the belief that we should be guaranteeing healthcare as a right for our citizens because many other successful developed countries do so.

 

So they're trying to have their cake and eat it too. They don't believe healthcare should fall in the purview of the government, but they reliably trot out there to defend this abomination of a bill by saying it will fix what the ACA does wrong, no one will lose Medicaid, no one will have the rug pulled out from underneath them... etc. etc.

 

They have to make these outlandish, bizarre claims that fall apart immediately if you compare them with the facts about their bill. They're forced to because they won't be honest about what their position on healthcare is (because it isn't popular), so they're forced to lie about the real ramifications of their bill.

 

At this point, I honestly can't figure out what the GOP is trying to accomplish.

 

Many campaigned on repealing and replacing Obamacare because it was so horrible people didn't have health care. They said their plan would expand the number of people who can afford premiums. Trump campaigned on that everyone would have access and nobody would lose coverage.

Then, they get into office and it's baffling how they think their plan works to accomplish any of this. So, one of two things have to be true:

 

1) They flat out lied during campaigns about what they wanted their plan to do.

 

2) They are absolutely too clueless to figure out that their plan sucks.

 

At this point, I actually think its #2. They are just a bunch of blubbering idiots who have been preaching smaller government, less government involvement, liberals are evil, everything Obama did was horrible....that their little brains can't reconcile the fact that their plan can't accomplish what they campaigned on.

 

So, I think very specific questions need to be asked to Republicans so that we know exactly where the debate is.

 

1) Do you believe every American has a right to have access to healthcare?

 

2) Do you believe Americans pay too much for healthcare (NOT talking about premiums....actual health services)?

 

3) If 1 and 2 are "Yes".....do you believe there is any roll government has in making sure those are accomplished?

[zoogs]

https://newrepublic.com/article/143685/bernie-sanders-progressive-lefts-selfless-defense-obamacare

 

Thus, in a perverse way, it is in the left’s long-term political interest for a GOP health care bill to become law—and yet, the most committed single-payer advocates in the country have distinguished themselves as the most vital and effective soldiers in fight against Trumpcare. There is a great deal to learn from this interesting and selfless choice, but I want to focus on what it reveals about the much-discussed schism in Democratic politics, and about the differences between how the progressive left and the conservative right think about and approach politics in America. (...)

The conservative willingness to use human suffering as leverage to advance policy objectives is almost undetectable in the progressive bloodstream.

It is easy enough to divide liberals between those who think Obamacare was an unlovely half-measure that nevertheless improved on the pre-Obamacare status quo and those who think it was a remarkable achievement on its own (though there is considerable overlap between these two factions). It is nearly impossible to find liberals or leftists of any influence who would sit out the fight over Trumpcare, or join the fight to repeal Obamacare, in order to make things worse in the short term (more than 20 million Americans would lose health insurance) for the better in the long run (single payer). In other words, left isn’t making the perfect the enemy of the good.

 

Valuable reading. I don't think it's true of the 'progressive left' in general; just yesterday I scanned a headline from I believe Salon with basically the opposite message. Thus I suspect there's an element of this conclusion that is more aspirational than reality, even if leadership currently behaves this way. I hope this is sustained -- in my view letting the perfect being the enemy of the good will only lead to an unceasing procession of 'bad', justified in increasingly absurd ways.

[zoogs]

^Incidentally, part of the reason I'm less optimistic than this article is I realize there's a good deal of the left that is more interested in eating their own than fighting to protect against blatantly horrendous agendas.

 

At the same time, I appreciate that (political platitudes and infighting aside) the whole of the left is largely aware what's at stake, at least in the case of healthcare. So this is a commendable aspiration.

[Danny Bateman]

Insider trading or nay?

I like how Inhofe's spokesperson calls his $50-100K investment "routine." OK.

 

[TGHusker]

McConnell is showing his metal - or lack thereof. He is a poor excuse of a leader. The Repub party is showing

they don't know how to lead. House, Senate, WH and they still can't get things done.

 

 

http://www.newsmax.com/Newsfront/mitch-mcconnell-republicans-repeal-obamacare/2017/07/06/id/800265/

[Moiraine]

McConnell is showing his metal - or lack thereof. He is a poor excuse of a leader. The Repub party is showing

they don't know how to lead. House, Senate, WH and they still can't get things done.

 

 

http://www.newsmax.com/Newsfront/mitch-mcconnell-republicans-repeal-obamacare/2017/07/06/id/800265/

 

They can't get things done because what they want to do is bad for a lot of people and a tony handful of them want to stop it.

[Danny Bateman]

McConnell is actually someone I consider dangerously competent. It's just that he's sold out to be completely party over country. I'll be surprised if he can't herd his cats on this.

 

The crazy thing is their bill just hammers red states in particular. Lots in the South. I know my part of this state is much better off under the ACA financially than under this bill.

 

As for the state of play, it seems McConnell is trying to work Ted Cruz's amendment into the bill. It would give any insurer that offers an ACA-compliant plan (think covers EHBs) the ability to offer any other plan they want. On it's face that would seem to please both moderates and conservatives. But it's got several problems. The big one is that it would compartmentalize the less healthy folks who really need the EHB coverage (pre-existing conditions) into the first plan while healthy people opt for something less comprehensive. If you know about how risk pools work, you know that's a bad idea. That's exactly what the ACA mandate attempted to prevent - it sought to get the unhealthy people into the same pool with healthy people.

 

If all the unhealthy people wind up in their own coverage pool, their premiums will skyrocket.

 

The other problems were with the existing bill. It still takes a sledgehammer to Medicaid. It still attempts to defund Planned Parenthood. The $45B McConnell added to their opioid fund is still peeing into the wind. And all of this is reflected in the polling for the bill. Seeing stories today it is the least popular piece of legislation in three decades.

[zoogs]

 

McConnell is showing his metal - or lack thereof. He is a poor excuse of a leader. The Repub party is showing

they don't know how to lead. House, Senate, WH and they still can't get things done.

 

 

http://www.newsmax.com/Newsfront/mitch-mcconnell-republicans-repeal-obamacare/2017/07/06/id/800265/

 

They can't get things done because what they want to do is bad for a lot of people and a tony handful of them want to stop it.

 

Public pressure stopped them, I think. Couldn't sneak it through fast enough. It started being a national conversation again -- and Republican Senators who would like to be in favor (*cough* Ben "I want maximum repeal" Sasse) are getting hammered.

[Danny Bateman]

That first paragraph. Woof.