Dismantling Obamacare Brick by Brick.

[Scout26]

First we have the Executive Order:

https://www.newyorker.com/news/amy-davidson-sorkin/donald-trumps-terrible-executive-order-on-health-care

Where the knickers of the New Yorker are such a bunch that they had to break out the thesaurus to get enough synonyms for "Terrible".



Then we have the cut-off of the "illegal" subsidies.

http://www.foxnews.com/politics/2017/10/13/democratic-ags-sue-trump-over-obamacare-subsidy-cutoff.html

From the New Yorker story:

Trump claimed that he had no choice but to defund the subsidies because paying them went against the will of Congress. This is the argument in a lawsuit, instigated by House Republicans, that is making its way through the federal courts. Basically, those Republicans argue that, although the plain language of the A.C.A. describes and authorizes the payment of subsidies, Congress should be allowed to vote on actually releasing the money every year. In effect, Congress promised the money when it passed the A.C.A., but now it wants the right to hold that money hostage on a regular basis. The case relies on a highly technical reading of the legislative fine print; nevertheless, the congressional challengers won a round in the lower courts, though that had been stayed pending an appeal—one that, on Thursday, the Trump Administration apparently decided to drop. (Attorney General Jeff Sessions had earlier said that he agreed with the House Republicans.) More than that, it is, at best, a technical ambiguity that any congressional majority interested in something other than utter chaos in the insurance markets could easily fix. Such a majority does not exist right now.

Sure sucks when the law, as written, doesn't agree with your feelings.  IIRC, authorizations for expenditures have to be approved year-by-year as prior Congresses can't bind the hands of future Congresses via expenditures.  Which is why there is (supposed to be) an annual budget process and budget.

So if Congress won't repeal Obamacare, Trump is bound and determined to keep his promise and push it over a cliff so it can die screaming in a fire.  

While I don't like the dictatorial elements, they do appear to be constitutional means and methods to subvert the ACA via its flaws.  It's not like he's re-writting entire sections to help out his donors and others.  The onus is still on Congress to act to repeal and replace Obamacare.  Since the USSC ruled that Obamacare is a "tax", perhaps when Congress gets to work on Tax reform, they are repeal Obamacare at the same time.  Given what Trump has done, there will not be any insurers left in any of the marketplaces or counties to offer insurance.    

[Ben]

I would love to see the "group insurance" mandate turned into a federal requirement that states can't overrule. I tried to get Costco insurance a few years ago, but it wasn't available in CA. As of now, AFAIK, it's not available to individuals at all in any state. Hopefully the EO will allow big outfits like them, Walmart,  the NRA, etc. to offer affordable individual plans with choices (like not paying for maternity coverage if you're a male).

I always said that if Obamacare was really serious and cared about affordability, they would have allowed for things like people who leave an employer be allowed to remain on that employer's group plan (on their own dime), and allow for organizations to form ubiquitous group plans. Of course that would lower prices too much, keep middle income people out of Obamacare, and not provide money to cover subsidies for the people who get free insurance. Even Bill Clinton said that was an abomination that directly targeted middle income earners.

[Hawkmoon]

I always said that if Obamacare was really serious and cared about affordability, they would have allowed for things like people who leave an employer be allowed to remain on that employer's group plan (on their own dime), ...

You mean like COBRA?

There's nothing even remotely affordable about paying the full price for your former employer's group plan. Been there, done that.

[Ben]

You mean like COBRA?

There's nothing even remotely affordable about paying the full price for your former employer's group plan. Been there, done that.

COBRA includes a surcharge.

[Hawkmoon]

COBRA includes a surcharge.

I didn't know that. [Nobody ever tells me anything.]

[Scout26]

COBRA includes a surcharge.

It's not a "Surcharge".  It's you have to pay you share of the cost AND what share your employer had been paying as part of your benefit package.   So instead of say you paying 50% and your employer paying 50%, you now get to pay 100%. 

[Ben]

It's not a "Surcharge".  It's you have to pay you share of the cost AND what share your employer had been paying as part of your benefit package.   So instead of say you paying 50% and your employer paying 50%, you now get to pay 100%. 

No, I know that - mentioned it in the OP. :)

There is also an additional surcharge since you're no longer a member of the group.

[Kingcreek]

I was able to get on a group plan this year because I'm on the board of directors (not an employee) of a local institution. I pay the full cost for myself and the wife. High deductible HSA qualified plan cost us $1528 per month which is better than the 1730 it was going to cost us.
1 month health insurance premium should not cost more than our mortgage (with no taxes or insurance in escrow btw). And this is no dive joint- 4 BR, 3 full bath, heated garage, all on 40 acres with outbuildings.
We are hearing forecast of 20% premium increases for 2018.
Trump can burn down Obamacare, the insurance companies, drug companies, and the big hospital systems for all I care.
I love where I live but the cost of health insurance is making it increasingly difficult to stay self employed and stay here.

[Ben]

We are hearing forecast of 20% premium increases for 2018.

I'm up 48% for 2018, and it's the absolute cheapest plan available in my area. I'm also HDHP and HSA. If I made $40K or less per year, it would be $1/month on the CA Obamacare. Since I made more last year, I get to pay for all those people getting their health insurance for $1.

It looks like whatever Trump is doing is going to take possibly a year to implement, so it appears I have to suck up that 48%. My once a year visit to the doctor for a physical and blood work is going to cost me $8000 for the one appointment.

[Scout26]

Without the Insurance subsidy payments, it's going to fall apart fairly quickly.  Insurance companies will bail if they are bleeding money. They won't wait until next year.

Also, I'm half tempted to setup my own group (John Browning Aficionados??) work with a Insurance company and offer my members ($5 per year) group plans as outlined in the Trump EO.

There are plenty of entities (Kiwanis, Rotary, Elks, American Legion, VFW, etc) that could be all over this.  Same with Churches/religious groups.

It would not only increase their membership numbers, but it would be full circle (almost) to the "Mutual Aid" societies of the turn of the century. 

[MechAg94]

I was able to get on a group plan this year because I'm on the board of directors (not an employee) of a local institution. I pay the full cost for myself and the wife. High deductible HSA qualified plan cost us $1528 per month which is better than the 1730 it was going to cost us.
1 month health insurance premium should not cost more than our mortgage (with no taxes or insurance in escrow btw). And this is no dive joint- 4 BR, 3 full bath, heated garage, all on 40 acres with outbuildings.
We are hearing forecast of 20% premium increases for 2018.
Trump can burn down Obamacare, the insurance companies, drug companies, and the big hospital systems for all I care.
I love where I live but the cost of health insurance is making it increasingly difficult to stay self employed and stay here.

My problem with that sort of cost is that after a couple years of putting that money in the bank, you would have pretty good medical emergency fund of your own.  Subsidizing other people's medical costs sucks. 

[Ben]

My problem with that sort of cost is that after a couple years of putting that money in the bank, you would have pretty good medical emergency fund of your own.  Subsidizing other people's medical costs sucks. 

For regular stuff, and even moderate medical expenses, yeah, banking money can be fiscally smarter (hence HSAs). You get hit with cancer (or a bus) though, and then not so much.

Hence why I hope they bring some type of catastrophic care insurance back. Hopefully with some different options. While I would take catastrophic care given my current health, at my age, I'd like just a little more than catastrophic, where I'm only out "X" dollars, and the insurance will cover at least up to a couple of million.

Other than it having me covered for pregnancy and other nonsense, I'd be fine with my current HDHP bronze plan for covering major medical (and not covering, as my dad likes to say, "every fart in my belly"). However given what it is, it seems it would be more reasonable in the $200/mo range. Not the $460/mo I'm paying now, and absolutely not the nearly $700/mo they're going to hit me with in 2018.

[Jim147]

I want my plan back that i had before the ACA became law. But the insurance companies are never going to let that happen. So now I am in debt up to my eyes and can't even affairs to go to the doctor.

Yeah it is so much better now.

[Ben]

I want my plan back that i had before the ACA became law. But the insurance companies are never going to let that happen. So now I am in debt up to my eyes and can't even affairs to go to the doctor.

Yeah it is so much better now.

Sorry Jim, but according to the Obamacare fanclub, you are fake news. In the era of Obamacare, it is impossible for anyone to have to pay anything for health care. Anyone who says they're not covered or whose insurance and medical expenses have gone up instead of down is simply a liar.

[KD5NRH]

I want my plan back that i had before the ACA became law. But the insurance companies are never going to let that happen. So now I am in debt up to my eyes and can't even affairs to go to the doctor.

Exactly.  I'm pretty sure I cracked another tooth, and the offer from the ex fiance who's now on disability to "sort of shack up"* so our combined incomes will qualify me for the community dental clinic down the road from her is starting to look really tempting.

*I have about as much interest in living with her more than a few days at a time as I do in paying the neighbor $20 to wipe off some pliers with a vodka soaked rag, yank the tooth and mold a replacement from JB Weld.  On the other hand, every time I do the math, it looks more like the way to go until Trump can get some things done.

[just Warren]

This is one of several good videos from Reason that highlight doctors going insurance-free.

An interesting thing that I learned from this one was that if you subscribe to a direct primary care practice you are disqualified from having a health savings account. Therefore you cannot use an HSA to pay your DPC.

But DPC docs are lobbying Congress to change that. But that seems like something that Trump could just change with an EO. And it certainly the sort of thing he would do. Unless there are downsides to that that I'm not seeing.

[Firethorn]

This is one of several good videos from Reason that highlight doctors going insurance-free.

An interesting thing that I learned from this one was that if you subscribe to a direct primary care practice you are disqualified from having a health savings account. Therefore you cannot use an HSA to pay your DPC.

But DPC docs are lobbying Congress to change that. But that seems like something that Trump could just change with an EO. And it certainly the sort of thing he would do. Unless there are downsides to that that I'm not seeing.

Personally, I'm all for an all-open HSA account.  Annual contribution limit of something like $5k + healthcare costs not already claimed within the last three years.  IE If you spend $15k in healthcare over 3 years, you can deposit a total of $30k into the account, leaving you with $15k + interest.

Add rules that allow you to transfer funds in an HSA to HSAs for your spouse and children, if you chose to.  So somebody's kid might go to college with $60k in their HSA, which should cover medical expenses for darn close to life.  Have some reasonable restrictions.

One that you can even deposit into using post-tax money and deduct later if your employer doesn't want to play.

[slingshot]

Health insurance......  if you are not on an employer's plan, you probably pay a lot more than you're comfortable paying.  The only people who like Obama Care (ACA) are the people that get it for next to nothing.  This has to change, but a law will not all of a sudden make poorer people be able to afford health insurance unless it is subsidized.  The future is single payer unfortunately.  Everything else just chips around the edges.

[Firethorn]

Health insurance......  if you are not on an employer's plan, you probably pay a lot more than you're comfortable paying.  The only people who like Obama Care (ACA) are the people that get it for next to nothing.  This has to change, but a law will not all of a sudden make poorer people be able to afford health insurance unless it is subsidized.  The future is single payer unfortunately.  Everything else just chips around the edges.

Actually, I'd like to alter this just a smidgen - from affording health insurance to affording health coverage.  It doesn't matter if health insurance is $50/year if it doesn't cover anything and people are still going bankrupt from healthcare costs from any illness.

People don't need healthcare insurance.  They need to be able to seek care for an illness or injury without going bankrupt, and insurance should be for evening costs out - like with other insurances.  You spend $600/year on house insurance, for example, to render a possible total loss from a fire down to a predictable $100/year as part of your umbrella home insurance policy.

And, because it is a critical life need, people will see the doctor no matter what.  They'll just declare bankruptcy later, which raises the prices we all pay.  Plus, the bankruptcy procedure is inefficient, so it's better to figure out a different way.

we don''t need single payer.  I say that we raise eligibility for medicare though.  The subsidies are to wean people off of a 100% coverage plan like medicare, to avoid that being a cliff - "We can't earn $1k more, we'd lose $18k in health benefits!"

[Ben]

 The subsidies are to wean people off of a 100% coverage plan like medicare, to avoid that being a cliff - "We can't earn $1k more, we'd lose $18k in health benefits!"

This is one of the major problems with Obamacare, which even Bill Clinton said is "crazy". Someone who makes $50K/yr ends up making less than someone who earns $40K/yr, because they have to pay that full insurance amount while the $40K person who qualifies for the subsidy gets insurance for practically free.

[Jim147]

The disconnect i see on both sides of the ACA argument is that having insurance and being able to afford to go to the doctor are two completely different things.

[Perd Hapley]

The disconnect i see on both sides of the ACA argument is that having insurance and being able to afford to go to the doctor are two completely different things.

Much like having a right to health care, and being able to afford health care are two different things. The right to have arms, and the ability to afford them, and so on...

[Firethorn]

The disconnect i see on both sides of the ACA argument is that having insurance and being able to afford to go to the doctor are two completely different things.

Yep.  Which is my entire point.  If going to the doctor is $40, well, the vast majority of people in the US can scrounge up $40.  

What gets me is that, in many cases, the standard copay for seeing a doctor - turns out to be as high, or higher, than what a doctor who doesn't deal with insurance charges for a standard visit.

That's how much they're screwing us - they've inflated the price of a standard visit something around 100%.  Everything else follows from that, I think.

Another thing that Obama did is make it so there's a maximum percentage insurance companies can use for administration and profit.  Problem with that?  Remember government cost plus contracts?  It places a perverse incentive on insurance companies to pay more for medical care - because then that percentage can be stretched further.

In most areas, there isn't enough competitors to stop this either.

[MillCreek]

Yep.  Which is my entire point.  If going to the doctor is $40, well, the vast majority of people in the US can scrounge up $40.  

What gets me is that, in many cases, the standard copay for seeing a doctor - turns out to be as high, or higher, than what a doctor who doesn't deal with insurance charges for a standard visit.

That's how much they're screwing us - they've inflated the price of a standard visit something around 100%.  Everything else follows from that, I think.

In the systems I have worked at, the typical co-pay (depending on the insurance plan) is $ 15-20.  If you don't have insurance and you are paying cash, you will likely be paying $ 150-225, depending on the specialty and complexity of the visit.  Usually around 70% of that charge goes to overhead, and the provider gets the remainder.

[JN01]

Another thing that Obama did is make it so there's a maximum percentage insurance companies can use for administration and profit.  Problem with that?  Remember government cost plus contracts?  It places a perverse incentive on insurance companies to pay more for medical care - because then that percentage can be stretched further.

If only we could apply that to government.