BBO Discussion Forums: Affordable and Quality Health Care - BBO Discussion Forums

Taking Cherdan's suggestion seriously I googled a bit and brought up

https://www.cbo.gov/...r1628senate.pdf

This is the CBO saying what it is saying. It's 49 pages, I have read some of it. An aside: Yesterday I was doing some home repair on a water softener and the company emailed me the manual. After some heavy reading I called them back to ask just what the hell the manual was saying. They were sympathetic and helpful. This CBO document has some similarities to the water softener manual.

I want to start with some assumptions.
1. For the moment at least, single payer is not on the table. This doesn't mean that we won't get there, but I want to skip over it for now.
2, The "repeal and replace" plan is in serious trouble. Maybe the Rs' will get together and ram something through but for now we should be looking to other possibilities.
3. There is at least some remote chance that sanity will prevail and there will be some agreement somewhere to the right of the middle to try to do something that is not embarrassingly stupid, cruel or both.
With that in mind I have a couple of thoughts, not really new.


We should think of Medicaid as being largely separate from the rest of the ACA. At least for most recipients, Medicaid is either very cheap or free for the participants. There is no reason we need to have an exchange to provide Medicaid, and there is no reason we need to penalize a person for not signing up for it. Presumably people will sign up for a program that provides them with free medical care. The question here would be how broadly to we wish to provide it, meaning both to how many people and what it would cover.

Yes, I understand it is not that simple. There is the fed-state collision on who decides what and who pays for what. And there are some people out there who are in such bad shape they can't manage to avail themselves of something that is free. Or they will refuse to do so. So yes, there are problems. But my main point is that with Medicaid, the first and foremost issue is how generous we wush to be and can afford to be. If that is agreed to, then I think the rest can be worked out.

Next, we need to think about what we should do with people who could afford health insurance but would rather spend the money elsewhere. These folks, some of them and eventually most of them, will have serious accidents or contract serious diseases. The plan is to do what? If they were all healthy one minute and dropped dead the next minute, there would be no problem. But that's not the way things go.

Now I want to think a bit about the phrase "Medicare for all". If we look a little closely, we might see an interesting point. When I turned 65, or maybe it was up to 66 by them, I became eligible for Medicare. There is more to it than that. Being 65/66 entitled me to something at no charge. I could also sign up for part B. Far better coverage, but at a price. I had to take it then or lose it (more precisely take it then or have it be far more expensive later). I signed up for B, as would anyone with even half a brain. I have a supplemental plan. I pay extra for this, it does more.

Now here is how this might relate. Let's look at Medicaid. Poor people need health care. No doubt about it.Quite possibly they need it more than the well off do. And certainly their kids need it. In analogy with Medicare, we could have something where if someone is at some level of poverty we give them free care at some level. A higher level plan would be available, but there would be a charge. And then they could supplement that if they wished, in this case it would be entirely a matter of market forces.

Maybe this would not fly. But what I think is needed is some preliminary thought as to just what it is we hope to accomplish. Right now the main goal appears to be to cobble together something that will fulfill a pledge to repeal and replace, and the issue of what the replacement will accomplish is of secondary importance, the goal is to have something, really anything, that can be sold as fulfilling the pledge.

Ken Just to be clear Medicaid is no longer just for the poor. I believe the cut off is now 140% of the poverty line. Medicaid has doubled its share of the federal budget the last few years. Which raises the question what if any limits to the budget are there?

Many posters here advocate to increase the eligibility to Medicaid. As usual the question is will evil Republicans vote to push millions off Medicaid while saintly Democrats vote to push millions more on.

My guess is in 2018 there will be more voters in favor of free health care

mike777, on 2017-July-13, 07:48, said:

Well, it's not just for the very poor. But largely I think there is room for discussion here. I believe that as things stand now, Medicaid is binary. There is a line. Beneath it you have Medicaid and it is very good. Above it, just a little above it, and it is gone. And someone at 141 % of the poverty line is going to have a seriously tough time affording unassisted coverage at anywhere near that level. I think, but I am not at all sure, that there is some middle spade where the kisd are still eligible for Medicaid even if the parents are above the line and not eligible.

But my general thrust is that we need to think through as a country just what seems reasonable and what we can afford.

I have often posted that I believe this country has been very good to me. I could cite many examples, but I'll skip that. I think it is good for everyone to help people do better. I suspect that many of my fellow citizens agree with this. Obama once addressed some of this, but very clumsily, with his "You didn't build that" . This was an insulting and divisive way to get at a point that I think has merit. We all gain if we help people do better. I favor taking this view seriously, and I think that it would have broad support if presented correctly. Health care is certainly a part of this.

kenberg, on 2017-July-13, 08:49, said:

The ACA allowed states to expand Medicaid and many did, but not all. Without state expansion, a large group of working poor in these states neither qualify for Medicaid or have access to the subsidies of the ACA.

Winstonm, on 2017-July-13, 09:08, said:

And Trumpcare rolls phases out this Medicaid expansion, and actually puts Medicaid on a budget.

This and the reducation in subsidies are presumably responsible for the vast majority of the people who would lose health insurance. Under Obamacare there were plenty of people who opted out of health insurance because the penalty was lower than the premiums.

kenberg, on 2017-July-13, 08:49, said:

Ken I don't thing the discussion is focused on what seems reasonable and what we can afford. Perhaps or not the discussion should be what you suggest but it is not.

the discussion starts health care is right; if you disagree you are evil and we can dismiss you.
the discussion starts with everyone and that means everyone is entitled to good quality health care...

Ken. There are people out there who read the CBO report for you, and them write up summaries and explanations. They are called "journalists". You used to be able to buy their writeups in a bundle of
paper delivered to your door step every morning, combined with news reports, some entertainment stories or sports coverage. These days you can read their writeup essentially for free on your computer screen if you use a Web browser, the only cost being that they also automatically display some advertising content.

Let us know if you need help finding such writeups.

cherdano, on 2017-July-13, 11:01, said:

The problem, obviously, is that it is difficult to know which writeups to trust.

mike777, on 2017-July-13, 10:15, said:

Mike, you seem to have a penchant for overstatement. The discussion is whether or not a basic minimum level of healthcare should be considered a right in a developed country such as the U.S.A.?

There is no judgement of evil for the opposition - judgement like that is reserved for the religious right.

So, with that out of the way, let me ask you, Mike: who in the U.S.A. do you believe is not entitled to a basic minimum level of healthcare?

Winstonm, on 2017-July-13, 12:01, said:

Winston a basic minimum level of health care is called good healthcare or do you consider it bad health care and just how do progressives view people who don't believe health care is a right and an entitlement ....your post supports my viewpoint more than you seem to realize

the discussion starts with your post...not with Ken's viewpoint...my point

I am happy to hear that you and other liberals don't view the denial of health care as evil or bad


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as for the CBO predictions...I have posted numerous pieces of evidence over the years on how their predictions are worthless, often worthless

mike777, on 2017-July-13, 13:20, said:

You didn't answer the question. Who is not entitled to basic healthcare?

I don't view "people" who disagree as either good or bad. I consider their arguments. I have not seen an argument that persuades me why everyone should not have some accepted minimum standard of healthcare.

I don't know about CBO being worthless - they are often inaccurate but usually get the basic direction right. That 14 million gained health coverage under the ACA instead of the 22 million the CBO projected doesn't mean their estimates are "worthless".

You tend to a binary viewpoint. Good/bad. Worth/Worthless. That's not a realistic viewpoint.

mike777, on 2017-July-13, 13:20, said:

No, Winston's expressed viewpoint is quite different from your characterization of it.

mike777, on 2017-July-13, 13:20, said:

No, the discussion starts with your post in 2008.

mike777, on 2017-July-13, 13:20, said:

No, the CBO predictions are not worthless, even though sometimes not borne out -- as can happen with all serious economic predictions.

Winstonm, on 2017-July-09, 15:12, said:

One of the big claims for ACA was that it would reduce emergency room visits thus savings lots of money expended for extremely expensive healthcare by getting people into more regular forms of healthcare delivery that are cheaper.

The following is an article I found that seems fairly balanced as it refers to several studies of emergency room data. It certainly shows that emergency room usage has not gone down with ACA.

http://www.politifac...-use-obamacare/

Uninsured visits to emergency rooms were down but they were offset by increased Medicaid and private insurance visits. So basically since Medicaid is essentially free to those enrolled in it, the public is still paying for those visits by the formerly uninsured except it's just coming out of a different bucket.

All I was saying in my original comments was that as you significantly increase the amount of people with real health care insurance, the total demand for healthcare being sought will significantly increase. You can't ever expect to reduce health care costs in that scenario unless you provide increased capacity to deliver health care. It's simple supply and demand. If you don't increase healthcare delivery capacity, then you'll drive up health care costs and create scarcity which results in rationing of those services and possibly even less quality of delivery. Ultimately, that will mean some people will have access denied or delayed a la the VA. And we know that has resulted in some veteran's deaths.

Simply providing insurance isn't a panacea. It has to be accompanied by a concomitant serious look at how to expand healthcare capacity. But that's not how the discussion is being framed.

rmnka447, on 2017-July-13, 14:02, said:

It should be noted that emergency room care is not the worst possible health care...it is the best, the best of the best health care in the history of health care. The docs and nurses are the best of the best

billw55, on 2017-July-13, 11:28, said:

No this is not difficult.

Speaking of Medicaid.

nbc news reports over 400 doctors in 30 states busted for 1.3 billion Medicaid fraud.

mike777, on 2017-July-13, 14:22, said:

Are you a health care professional, Mike? Have you ever worked in an E.R.? I have. E.R. doctors are like any other doctors. They range from great to poor. Many are inexperienced. E.R. nurses tend to be adrenaline junkies who simply love the pace of E.R.

To say it is the best of the best is BS. Sorry.

rmnka447, on 2017-July-13, 14:02, said:

First, thank you for posting from a reasonable source. If you noticed, the general viewpoint was that ER use had gone up slightly since the ACA - but not from uninsured patients. There are many reasons from my experience why that could be so - a lot of it from either lack of knowledge or simply laziness about finding and using a primary care doctor.

Secondly, I am not a fan of the ACA - only in that it was the only thing that politically could be passed at the time. I think we will have to go to a single payer system in order to control costs.

Winstonm, on 2017-July-13, 18:47, said:

I will stand by post...ER doctors and nurses are the best of the best in the history of health care....it is not repeat not in any way minimum health care.

Sorry to hear in your experience ER docs and nurses are like any other doctors and nurses. Sorry to hear in your experience you found Many to be inexperienced or junkies. To answer your question, yes I have many close relatives and very close friends in the field. I would add that for most of my youth I and my family and our neighbors doc was the ER room....I grew up in the generation where the ER room was the family doc.

to say the least at my current age I seem to visit docs....dentists....eye docs...etc more in one year then I did in my first 21 years. thankfully....not the ER...yet

zzzzIt all makes me believe the stats that most of health care goes for paying for the last 6 months we are alive.

Perhaps if we all can die 7 months earlier we can cut health care costs 50%.


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Speaking of costs...the last few months yet again drive in point how we bring our family members to the doctor, etc and costs have never repeat never come up one time...AMAZING In an era where you hear that a simple bed pan can costs thousands or a bandaid or asprin....I can envision costs of a million bucks for who knows what..these docs are doing....

cherdano, on 2017-July-13, 11:01, said:

True enough, but it puts one more intermediary into the mix. I found table 5 of the actual report to be of interest, for example, and this might or might not show up in a newspaper article.

Returning my general thoughts:

Going back to when the aca was first put through I have thought it important to distinguish between the parts where the exchanges and the complications that go with them were involved and the parts where the exchanges were not necessary. An increase, or a decrease, in Medicaid coverage does not have anything to do with exchanges, as near as I can see. When the aca first got going, the increase in the number of people receiving Medicaid was touted as one of its major successes. OK, but for that we did not need all the extra baggage of exchanges. And now, as 22m are going to lose coverage if the Senate plan goes through, I would like to know how this relates to exchanges, in particular I would like to know how much is simply a dramatic cut back in Medicaid.

Here is why I think this is important: There are issues involving how much the government should be assisting people, and there are issues involving the general administrative structure of doing it. Expanding or contracting Medicaid is largely linked to the first, the exchanges are linked to the second. Views on the first may not correlate closely with views on the second.

Quite possibly none of this matters since, as near as I can tell at present, there is very little interest in doing anything good anyway. The Senate/Presidential interest is in passing something, anything, it doesn't matter what it is, that can be sold as repeal and replace. So discussion of merit is beside the point. That's very too bad, but I am still interested in how much is a scaling back of Medicaid and how much is a redoing of the exchanges.