s/o: Alternatives to the ACA

[aurora]

The other posts have me thinking: what do you think would be a good alternative to the ACA?  Why?

[MrsAxilla]

Medicare for all.

[tres3]

A NHS style system.

[aurora]

I fully support a single-payer system with the government being that payer.

I have about a million reasons. Here are a few.

1. I don't believe that private industry (insurance companies) should be in the business of profiting from health care risk-pooling. I feel differently about actual health care providers, who are actually providing a service that cannot be provided by a management company. I am generally in favor of allowing doctors, clinics, hospitals, etc. to keep on doing what they're doing, just with only having to deal with one payer rather than a multitude, each with different rules.

2. I hate health insurance companies with the fire of a thousand suns. This is even though I have very good insurance now. When I was younger and less experienced at speaking up for myself I was hospitalized for something and my insurance company denied every claim as a matter of course, refusing to pay until I fought. The emergency hospitalization was clearly covered in my benefits. Even the agents admitted that as they told me "oh, our policy is to deny everything until people fight."

3. I am not worried about so-called "death panels." Insurance companies deny coverage of all sorts of things to people every single day in the name of profits. If decisions about how to spend scarce resources must be made, I would rather they be made by impartial third parties (choosing say the lives of 10 6-year-olds than one 95-year-old who may live another 6 months) than by someone looking to line his own pockets.

4. Lack of adequate health insurance propagates all sorts of inequalities in our current system and therefore stifles innovation and economic advancement (of individuals and the nation).

5. Everyone points to wait times in Canada, but that's not the only single-payer system out there (and most of the statistics on wait times aren't even all that bad there). I lived in Denmark for 4 months and people generally loved their single-payer system (I was even covered by it, but didn't need to use it). And quite frankly, I would rather live in a country where I had to wait a little longer for say an elective knee surgery while feeling secure that everyone with a medical emergency could get prompt care.

[josieposy]

Can someone explain to me what happens to insurance companies under a single payor system?

[carowen]

Ditto single payer - I was so angry/disappointed that they dropped the public option from ACA.

Besides the points previously mentioned, I don't think it's right to have businesses bear the brunt of health care coverage. For the life of me, I can't figure out why the business community doesn't lobby the crap out of the government to get out of the business of dealing with and paying for employee's health insurance. Individuals buying their own policies on the market is inherently biased for those who are wealthy and/or not ill.

And I feel like there is just no good reason against it - we have plenty of examples from other nations who do this and have much better patient outcomes. And even with private insurance we have wait times here.

[carowen]

Jul 28, 2014 10:04:41 GMT -5 josieposy said:

Can someone explain to me what happens to insurance companies under a single payor system?

Honestly, I think this problem is the reason why we don't have single payer system. Because those companies are too big to dissolve and no one knows WTF to do about that. And their lobbying $$.

[aurora]

Jul 28, 2014 10:04:41 GMT -5 josieposy said:

Can someone explain to me what happens to insurance companies under a single payor system?

Honestly?  The health-specific ones end.  I could definitely see the employees being hired into the single-payer (probably government), or at least some of them.  But there would be no* further need for for-profit health insurance companies under a single-payer system.

FWIW, I'm totally fine with for-profit insurance companies providing other services, like homeowners, auto, liability, and other types of insurance that are generally optional.  Just not health.  So companies could transition to those services if they wished.


*"no" could be qualified if we went for a system like Spain's, which to my understanding has basic health insurance for everyone under a single-payer system but then people who want to can purchase an additional policy to get additional services.  I don't love the class divide perpetuated by this type of system, but I could possibly consider going this far to the right for the sake of compromise (getting something passed). 

[ringstrue]

I can't help but wonder if the profit insurance companies could start covering more truly elective stuff, like costly beauty treatments or more Wellness activities?

[lya]

I also vote for a single payer system. However, I think that an overhaul of the pharmaceutics system would have to accompany that.

One of the advantages of a single payer system is the ability to negotiate prescription costs, a la European systems. The high prescriptions costs we see here in the States do serve to recoup the research and development investment made by the pharma companies. The ability to negotiate prices would result in great prices for consumers, but would greatly reduce the incentive for companies to develop new therapies. A different avenue for financing the discovery and development of new drugs would be needed.

[aurora]

Jul 28, 2014 10:28:41 GMT -5 lya said:

I also vote for a single payer system. However, I think that an overhaul of the pharmaceutics system would have to accompany that.

One of the advantages of a single payer system is the ability to negotiate prescription costs, a la European systems. The high prescriptions costs we see here in the States do serve to recoup the research and development investment made by the pharma companies. The ability to negotiate prices would result in great prices for consumers, but would greatly reduce the incentive for companies to develop new therapies. A different avenue for financing the discovery and development of new drugs would be needed.

This is a good point.  I know it's not exactly the same thing, but I'd be all in favor of increasing the NIH's research budget, including targeting the early-stage (pre-competitive) research that pharma companies maybe less likely to want to do for specific therapies.  I know this happens to a small extent but not far enough.

[downtoearth]

Jul 28, 2014 10:07:06 GMT -5 carowen said:

Jul 28, 2014 10:04:41 GMT -5 josieposy said:

Can someone explain to me what happens to insurance companies under a single payor system?

Honestly, I think this problem is the reason why we don't have single payer system. Because those companies are too big to dissolve and no one knows WTF to do about that. And their lobbying $$.

There are different ways that a single payer system could work.  I'm not an expert, but if the insurance companies teamed with the providers you could work out a way that the government (single payer) negotiates rates with different private medical systems and you would still need those insurance-type employees to manage that system, but probably far less.  So then jobs would be lost on the insurance/private medical side and gained on the government side (negotiating rates and compliance).  This is similar to Canada, I believe.  I even think you could then leave pharmaceuticals as another private company that would negotiate rates/costs of drugs with the government, so there would be another arm of the government who might absorb some of the health care jobs.  The thing is, with a simplified single-payer (government), you would need less of the medical coders and billing department people on both sides (I would think) and overall jobs would be lost.  However, the technology side of medical records and sharing those records could generate more jobs since that is where a lot of the hospitals/medical offices have to sacrifice costs right now. 

The UK is different in that the government owns the medical centers and pays the nurses/doctors through government funds, but I think Canada and many other European nations have private medical facilities and the government negotiates rates.

Overall, it would be a shock to the medical for-profit system and our economy would need to be strong enough to absorb that big change.  I think that is why a lot of democrats who want a single-payer system, can't pursue it b/c they worry about another hit to the economy (and getting anything passed in Congress b/c taxes would need to increase a TON (basically the same as what you and your employer pays in medical each year).  Can you imagine telling some person who thinks 20% taxes is too much that they now need to be taxed at 28% to cover health insurance for all... actually I think most Americans would see an increase in disposable income except businesses and the wealthiest (according to this link from Health-care Now the top 5% of the nation would see a 12-18% decrease in disposable income, but the rest would see an increase in disposable income.)

However, I'm still an optimist and think we can keep working toward a single payer system by absorbing more groups of users into the medicare program over time... first lower income and elderly and raise taxes a little, then more kids and unemployed young adults and raise taxes a little, then maybe an option for everyone with an additional fee to use it (which the working middle class might embrace if the fee is less than private health insurance) and then maybe an option for anyone until it becomes the norm and the health industry and public are more familiar.  I really do think the ACA is a first step that can get everyone covered, but I just hope it keeps expanding and doesn't stall.

[msmerymac]

Did you see that Vermont is persuing a single-payer system? Some people are complaining that their taxes will double. Well, my in-network OOP max is $9,000/year. I'd be SHOCKED if my state taxes increased by that much... but even if they did, I'd be happy that at least every resident of the state had access to health care.

And to answer the OP, I'd be happy combining the best aspects of Medicare, Medicaid and VA health care and expanding it into a national system. I'd be fine having something similar to the NHS in the UK (which sounds like Spain) - everything is covered in a basic way. Everything. That includes cancer treatment, reproductive health services, preventative care... But if you want a type of cadillac plan - something that covers elective things, like cosmetic surgery, or a private hospital room, etc - that can be an additional insurance cost or something offered through your employer as a benefit.

But before we go down this road, we'd need to appeal the Hyde Amendment.

[lasagnasshole]

So the biggest thing that I've heard is to move away from employer sponsored insurance and to have consumers pay for more things OOP instead of through insurance. One of the advantages about this is supposedly that transparency in pricing (because we can all agree that healthcare pricing is fucked up) will create competition, which will drive down prices. Someone posted a graph the other day showing how people used to pay a larger percentage of their healthcare prices OOP.

I don't think these are terrible ideas in theory. However, I think we'd still wind up with a huge access issue, much like you see in the world of legal services.

As far as the OOP issue, I get the argument that involving a third party (the insurance company) drives up prices. HOWEVER, I don't think you can realistically advocate a return to insurance-as-catastrophe-coverage with people paying for less expensive and more routine matters OOP unless you want to address wage stagnation and concentration of wealth at the top. A huge problem with comparing healthcare spending of today with that of 50 years ago (besides the obvious cost of technology) is that it ignores that the buying power of the median income is far less than it was 50 years ago.

The big problem that I see is that protecting those with pre-existing conditions really can't happen without the mandate. Even if we move away from an employer-based system and everyone buys her own health insurance policy, those with pre-existing conditions would still either be unable to get coverage or would likely be priced out if getting coverage. But if you mandate that insurance companies cover the pre-existing conditions, you really have to mandate that everyone get insurance. I don't see much of a way around that.

[ESF]

Jul 28, 2014 10:56:15 GMT -5 msmerymac said:

Did you see that Vermont is persuing a single-payer system? Some people are complaining that their taxes will double. Well, my in-network OOP max is $9,000/year. I'd be SHOCKED if my state taxes increased by that much... but even if they did, I'd be happy that at least every resident of the state had access to health care.

And to answer the OP, I'd be happy combining the best aspects of Medicare, Medicaid and VA health care and expanding it into a national system. I'd be fine having something similar to the NHS in the UK (which sounds like Spain) - everything is covered in a basic way. Everything. That includes cancer treatment, reproductive health services, preventative care... But if you want a type of cadillac plan - something that covers elective things, like cosmetic surgery, or a private hospital room, etc - that can be an additional insurance cost or something offered through your employer as a benefit.

But before we go down this road, we'd need to appeal the Hyde Amendment.

LOL.

We have more likelihood getting a single payer system than we do having the Hyde Amendment repealed.  If that was a precursor to single payer, single payer will never, ever happen.  That thing ain't going anywhere.

But yes, even under a single payer system, there would still be a role for private insurance companies to cover gaps.  

[racegrrl714]

single payer.

[NewOrleans]

Jul 28, 2014 10:56:15 GMT -5 msmerymac said:

But before we go down this road, we'd need to appeal the Hyde Amendment.

::record scratch::

lofuckinglol!

[debatethis]

Jul 28, 2014 10:28:41 GMT -5 lya said:

I also vote for a single payer system. However, I think that an overhaul of the pharmaceutics system would have to accompany that.

One of the advantages of a single payer system is the ability to negotiate prescription costs, a la European systems. The high prescriptions costs we see here in the States do serve to recoup the research and development investment made by the pharma companies. The ability to negotiate prices would result in great prices for consumers, but would greatly reduce the incentive for companies to develop new therapies. A different avenue for financing the discovery and development of new drugs would be needed.

I know this is a widely accepted theory, but I don't buy it. Europe (and to a lesser extent, South America) is positively exploding with pharma/med devices/biotech R&D. These emerging markets are almost all in more "social medicine" friendly countries but they're still noting very large profits and by 2016 will be a full third of global pharma revenues.

If anything, I feel like that's been an argument trotted out by pharma ("development will be stifled if we don't make as much money!") for so long that people are starting to believe it.

[msmerymac]

Jul 28, 2014 11:04:01 GMT -5 ESF said:

Jul 28, 2014 10:56:15 GMT -5 msmerymac said:

Did you see that Vermont is persuing a single-payer system? Some people are complaining that their taxes will double. Well, my in-network OOP max is $9,000/year. I'd be SHOCKED if my state taxes increased by that much... but even if they did, I'd be happy that at least every resident of the state had access to health care.

And to answer the OP, I'd be happy combining the best aspects of Medicare, Medicaid and VA health care and expanding it into a national system. I'd be fine having something similar to the NHS in the UK (which sounds like Spain) - everything is covered in a basic way. Everything. That includes cancer treatment, reproductive health services, preventative care... But if you want a type of cadillac plan - something that covers elective things, like cosmetic surgery, or a private hospital room, etc - that can be an additional insurance cost or something offered through your employer as a benefit.

But before we go down this road, we'd need to appeal the Hyde Amendment.

LOL.

We have more likelihood getting a single payer system than we do having the Hyde Amendment repealed.  If that was a precursor to single payer, single payer will never, ever happen.  That thing ain't going anywhere.

But yes, even under a single payer system, there would still be a role for private insurance companies to cover gaps.  

Oh sure, it's a pie-in-the-sky kind of wish, but if we had government funded single payer, the Hyde Amendment necessarily means that women would STILL have to pay for abortion out of pocket, or pay for a separate policy that would cover abortion (like the Michigan legislature would prefer), and women who currently have abortion coverage through private insurance would lose it. 

[lya]

Jul 28, 2014 11:13:26 GMT -5 debatethis said:

Jul 28, 2014 10:28:41 GMT -5 lya said:

I also vote for a single payer system. However, I think that an overhaul of the pharmaceutics system would have to accompany that.

One of the advantages of a single payer system is the ability to negotiate prescription costs, a la European systems. The high prescriptions costs we see here in the States do serve to recoup the research and development investment made by the pharma companies. The ability to negotiate prices would result in great prices for consumers, but would greatly reduce the incentive for companies to develop new therapies. A different avenue for financing the discovery and development of new drugs would be needed.

I know this is a widely accepted theory, but I don't buy it. Europe (and to a lesser extent, South America) is positively exploding with pharma/med devices/biotech R&D. These emerging markets are almost all in more "social medicine" friendly countries but they're still noting very large profits and by 2016 will be a full third of global pharma revenues.

If anything, I feel like that's been an argument trotted out by pharma ("development will be stifled if we don't make as much money!") for so long that people are starting to believe it.

I hear you on this.  I am sure it wouldn't be as bad dramatic as the companies would like us to believe.  However, I still think that it is non-negligible. 

In general, I feel like the pharma industry needs a complete overhaul.  Mostly because I am not a fan of a person's health being tied up in a capitalist system.

[lg28]

asdfjkl

Abortion, which is covered under UHC in most of Canada is definitely still contentious from an insurance standpoint. I don't think you could include it in the US.
Even in Canada, not all hospitals will perform them (catholic hospitals won't) and there are private clinics to fill the gap.

Birth control is not free, as with any prescription medicine it isn't covered. Many local health units do offer it at a discount though.

[ESF]

Jul 28, 2014 11:13:26 GMT -5 debatethis said:

Jul 28, 2014 10:28:41 GMT -5 lya said:

I also vote for a single payer system. However, I think that an overhaul of the pharmaceutics system would have to accompany that.

One of the advantages of a single payer system is the ability to negotiate prescription costs, a la European systems. The high prescriptions costs we see here in the States do serve to recoup the research and development investment made by the pharma companies. The ability to negotiate prices would result in great prices for consumers, but would greatly reduce the incentive for companies to develop new therapies. A different avenue for financing the discovery and development of new drugs would be needed.

I know this is a widely accepted theory, but I don't buy it. Europe (and to a lesser extent, South America) is positively exploding with pharma/med devices/biotech R&D. These emerging markets are almost all in more "social medicine" friendly countries but they're still noting very large profits and by 2016 will be a full third of global pharma revenues.

If anything, I feel like that's been an argument trotted out by pharma ("development will be stifled if we don't make as much money!") for so long that people are starting to believe it.

Two inter-related problems with this.  First, there's a global market for health care goods.  The fact that Europe manufacturers pharma/med devices could still happen even if they weren't making enough from a European market for their goods, KWIM?  The bolded still holds true even though there are European manufactures.

Second, my understanding is that because most countries have price controls in place whereas the US does not, the US market gets charged higher prices that effectively subsidizing the lower prices paid by other countries.  So if the US did implement price controls, the bolded would still become true for everyone, because European manufacturers could not up-price the drugs for people in New York, KWIM?

Now, I'm highly skeptical of pharma's marketing budget, and I call into question some of its R&D --- for example, there was that allergy thing were the drug worked perfectly fine, but they just changed the container that dispensed it (ie invested a ton of R&D money into the non-drug component of the product), enabling them to get a patent and prevent competition for another 7 years, and therefore keep monopoly pricing.  

I'm not sure what the solution was.  I do think concerns about stifling pharma innovation are legitimate, but drug costs are truly out of control.

[aurora]

Jul 28, 2014 11:14:03 GMT -5 asdfjkl said:

www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/

If the Hobby Lobby case is any indication, I think UHC might be bad specifically for women.  However, I think a a sort of single-payer donut type UHC might work.  Preventative care and "catastrophic care" would be covered by the government.  But I have serious reservations about the willingness of our misogynistic government to cover regular reproductive healthcare without getting their dicks all in a twist about abortions and "responsibility" and moral hazard and all the other bullshit that keeps our government from acknowledging that women might fuck for some other reason than (a) to satisfy a man; or (b) to create a (white, republican) baby.

I am worried about women's health care regardless of who is paying, honestly.

That said, in a single (government)-payer system that refuses to cover abortions or contraception there could be no other conclusion but that church and state are not at all separated. Whereas with Hobby Lobby, it's the corporate person "who" is practicing a specific religion, not the government. I have to hope maybe more people would be up in arms about an explicitly religious government, right?

[aurora]

Jul 28, 2014 12:53:38 GMT -5 lg28 said:

asdfjkl

Abortion, which is covered under UHC in most of Canada is definitely still contentious from an insurance standpoint. I don't think you could include it in the US.
Even in Canada, not all hospitals will perform them (catholic hospitals won't) and there are private clinics to fill the gap.

Birth control is not free, as with any prescription medicine it isn't covered. Many local health units do offer it at a discount though.

Wait, is that a typo, or are no prescription medications covered?

[lg28]

aurora

Not a typo. Prescriptions aren't covered unless you're over 65. A lot of people have supplementary insurance through work to cover prescriptions.

[rugbywife]

Jul 28, 2014 13:47:24 GMT -5 aurora said:

Jul 28, 2014 12:53:38 GMT -5 lg28 said:

asdfjkl

Abortion, which is covered under UHC in most of Canada is definitely still contentious from an insurance standpoint. I don't think you could include it in the US.
Even in Canada, not all hospitals will perform them (catholic hospitals won't) and there are private clinics to fill the gap.

Birth control is not free, as with any prescription medicine it isn't covered. Many local health units do offer it at a discount though.

Wait, is that a typo, or are no prescription medications covered?

If you are prescribed medication during a hospital stay or meds that are administered at the hospital they are covered. So when I was in the hospital for 4 days PP they even paid for my OTC drugs of Advil, Tylenol a and stool softeners. When my mom had cancer her chemo, administered at the hospital was covered. Her pain meds and steroids were not. They would have been covered by extended healthcare insurance had she had it.

Quebec has a subsidized prescription plan that you must have I believe (there is a low premium based on income I believe) if you do not have extended healthcare insurance through your provider.

So...there is a market for insurance, it just isn't as big or as profitable. My extended health and dental insurance is paid for by my employer (my school board - but technically the province of Ontario) and it costs less than 2k a year (EDIT: I lied, I was looking at a document that didn't cover the entire year - the premiums for 12 months in 2013 were $4260)  It covers all my meds (I had a 6k lifetime limit on fertility meds), 1700 for dental a year, 450 for eyewear every two years, 12 massages a year, 400 dollars a year each for naturopaths,registered dietician s, osteopaths, chiro, and unlimited physio. My plan is a family and is covers my husband and kid.

[lg28]

Jul 28, 2014 15:02:05 GMT -5 Jennyanydots said:

Jul 28, 2014 14:49:49 GMT -5 lg28 said:

aurora

Not a typo. Prescriptions aren't covered unless you're over 65. A lot of people have supplementary insurance through work to cover prescriptions.

Yup - most people have partial coverage through their employee benefits (part of the system I noted upthread), although the co-pays are usually quite small. Some people with really great employer benefits (like my H's work) have a slush/flex fund that covers things that aren't part of the regular plan. So for example at my H's work, say you have to pay 10% of your prescription cost and your benefits cover the other 90%. That 10% can be submitted to his flex fund ($1000/year, I think?) and reimbursed. But his workplace has a very generous plan.

This is just for drugs you pick up at the pharmacy. Its not like you get a bill for morphine when you leave the hospital after surgery or anything.

Oh good point. aurora / you wouldn't pay for any drugs while you're in the hospital or receiving something like cancer treatment.

You WOULD pay for antibiotics for strep throat, or the BCP.

It cost me $4 to have a baby - the cost of parking.

[rugbywife]

Jul 28, 2014 15:14:59 GMT -5 lg28 said:

Jul 28, 2014 15:02:05 GMT -5 Jennyanydots said:

Yup - most people have partial coverage through their employee benefits (part of the system I noted upthread), although the co-pays are usually quite small. Some people with really great employer benefits (like my H's work) have a slush/flex fund that covers things that aren't part of the regular plan. So for example at my H's work, say you have to pay 10% of your prescription cost and your benefits cover the other 90%. That 10% can be submitted to his flex fund ($1000/year, I think?) and reimbursed. But his workplace has a very generous plan.

This is just for drugs you pick up at the pharmacy. Its not like you get a bill for morphine when you leave the hospital after surgery or anything.

Oh good point. aurora / you wouldn't pay for any drugs while you're in the hospital or receiving something like cancer treatment.

You WOULD pay for antibiotics for strep throat, or the BCP.

It cost me $4 to have a baby - the cost of parking.

Gah. 4 days of parking cost me $60.

My insurance only covers to semi private room so we had to pay $30 a night for my private room. But I still haven't received a bill for it.

[rugbywife]

Oh, and when my mom had cancer in Nova Scotia, with no extended health, her meds were $750 a month. Once she was considered palliative it was covered. So in her case it cost $6k to have (and die from) cancer (she lived 8 months and a week from diagnosis).

I am sure if my parents had been poor there would have been avenues to seek out for help for those costs.

[epphd]

Jul 28, 2014 13:00:39 GMT -5 ESF said:

Jul 28, 2014 11:13:26 GMT -5 debatethis said:

I know this is a widely accepted theory, but I don't buy it. Europe (and to a lesser extent, South America) is positively exploding with pharma/med devices/biotech R&D. These emerging markets are almost all in more "social medicine" friendly countries but they're still noting very large profits and by 2016 will be a full third of global pharma revenues.

If anything, I feel like that's been an argument trotted out by pharma ("development will be stifled if we don't make as much money!") for so long that people are starting to believe it.

Two inter-related problems with this.  First, there's a global market for health care goods.  The fact that Europe manufacturers pharma/med devices could still happen even if they weren't making enough from a European market for their goods, KWIM?  The bolded still holds true even though there are European manufactures.

Second, my understanding is that because most countries have price controls in place whereas the US does not, the US market gets charged higher prices that effectively subsidizing the lower prices paid by other countries.  So if the US did implement price controls, the bolded would still become true for everyone, because European manufacturers could not up-price the drugs for people in New York, KWIM?

Now, I'm highly skeptical of pharma's marketing budget, and I call into question some of its R&D --- for example, there was that allergy thing were the drug worked perfectly fine, but they just changed the container that dispensed it (ie invested a ton of R&D money into the non-drug component of the product), enabling them to get a patent and prevent competition for another 7 years, and therefore keep monopoly pricing.  

I'm not sure what the solution was.  I do think concerns about stifling pharma innovation are legitimate, but drug costs are truly out of control.

Asthma meds - including basic albuterol. Companies changed the propellant (because you know all the CFCs causing a hole in the ozone layer were from asthmatics) and walla - 7 year patent on fucking albuterol. And everything else in an inhaled form. Fuckers.