2017 Politics open thread, March 19-25

Any thoughts on politics this week?

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160 thoughts on “2017 Politics open thread, March 19-25

  1. And just to show how crazy this world has become, Ross Douthat is now pushing the Singapore healthcare model, which is a pretty darn nanny statish system

  2. Maureen Dowd is well worth reading today

    I guess it had to happen sometime.

  3. I have moved to the total acceptance stage of the Trump presidency. If you can ignore the damage he is doing, it is actually quite fun to watch. I tune in to Spicer’s briefings whenever possible. He is not cut out for that role at all. He isn’t able to lie and spin like Kelly Anne and just gets angry. He always looks like he might actually have a heart attack at the podium. Tomorrow’s Comey briefing should be fun!

  4. The Singapore health system won’t work here until we have consistent pricing for services and tests. Case in point – my husband had an overnight procedure done at Penn. Penn billed $ 66,000+ and our insurance company paid $ 3,389. If I didn’t have insurance, they would expect us to pay the full boat. We must have one price.

    I remember when health insurance covered hospital visits, cancer treatment to a set amount and a few other things, everything else was out of pocket. In my area, Oxford Insurance came in and all the doctors had it as their insurance. At that time I paid doctor visits out of pocket. When my first child was born in 1980 our pediatrician charged $ 18.00 a visit – this was considered high, but it was Princeton. About three years later an office visit went to $ 50,00 a visit because a lot of people signed up for comprehensive insurance. In 1984 my daughter had her second ear operation at CHOP. We had 100% hospitalization and I was perplexed when I got a bill for $ 64.00. We had a family business and I called my FIL to find out why I was being billed Turns out CHOP gave our insurance company an early pay discount and then turned around and tried to bill us for the discount. This was the beginning of rampant billing and uncontrollable costs.

  5. The thing with Singapore is that it is actually a single payer model, just with really high co-pays and the mandatory savings. So I suspect the government is setting or pushign downwards many of the prices

  6. Here is what I don’t understand. With the move toward making older people pay 5x as much as the young, someone 62 years old making 26k a year is looking at $1200/month with $5k deductible under the best case scenario after all proposed reforms. Even with the proposed tax credit it’s $900 a month. The math just doesn’t work.

    What does someone like Mick Mulaney expect that 62 year old to do? He says it will all
    work out. Does he actually believe that? Or is he simply comfortable with the idea that someone who is 62 making 26k a year should just go without.

  7. Rhett – If a basic plan charged 62 year olds 1200 a month with a 5 K deductible (under ACA in MA it was 600 a month with 3k deductible, but with more premium support in the middle and expanded Medicaid at the low end), it would be a quick Congressional step to a form of Medicare for 50 plus. I don’t have a study to back this up, but anecdotally lower income pre-seniors simply did without until they hit 65, and started to get treatment for everything. Often it was a bit late, but it improved their health status immediately. Fewer and fewer over 50s outside corporate, union or otherwise structured employment (and as the gig economy becomes more and more normalized for people of all ages and circumstances that number will grow) have group health plans.

  8. We don’t have a single reason why we consider healthcare important. It isn’t clear to what extent we want healthcare to improve quality of life (for example, making low income people in their 50’s/60’s feel better and able to engage happily in activities of daily life) and to what extent we want healthcare to improve national health statistics, which in my opinion overweight mortality as a negative outcome. My acquaintances with chronic health conditions (fibromyalgia, MS) oppose European style healthcare because they observe that most countries have less treatment for chronic conditions, probably because treatment helps people feel better (and so is of value to the people) without eliminating symptoms/changing the final outcome/improving health statistics, i.e. the number of people with MS doesn’t change.

    I recall an analysis that showed smoking saves money on healthcare, by helping people die earlier. I am not convinced of the statistical (vs. anecdotal) merits of some/much preventative care for relatively healthy populations.

  9. WCE,

    This is a few years old, but interesting nonetheless. Thin and healthy people are expensive.

    “Van Baal and colleagues created a model to simulate lifetime health costs for three groups of 1,000 people: the “healthy-living” group (thin and nonsmoking), obese people, and smokers. The model relied on “cost of illness” data and disease prevalence in the Netherlands in 2003.

    The researchers found that from age 20 to 56, obese people racked up the most expensive health costs. But because both the smokers and the obese people died sooner than the healthy group, it cost less to treat them in the long run.

    On average, healthy people lived 84 years. Smokers lived about 77 years and obese people lived about 80 years. Smokers and obese people tended to have more heart disease than the healthy people.

    Cancer incidence, except for lung cancer, was the same in all three groups. Obese people had the most diabetes, and healthy people had the most strokes. Ultimately, the thin and healthy group cost the most, about $417,000, from age 20 on.

    The cost of care for obese people was $371,000, and for smokers, about $326,000.

    The results counter the common perception that preventing obesity will save health systems worldwide millions of dollars.”

  10. “The model relied on “cost of illness” data and disease prevalence in the Netherlands in 2003.”

    Interesting, but I think that this makes the study very non-transferable to our patient population. Per 1,000 smokers, how much is spent in the Netherlands per year on bronchitis care? In the US? Per 1,000 obese adults, how much is spent on MRIs? Also, joint replacements (a cost of the highly-functional older cohort) are a big slice of the pie. Everything costs more in the US – however, I doubt it scales linearly. I don’t know what the frequency for AICDs, gastric bypass, palliative chemo and radiation are in the Netherlands and how that compares (just listing off some very expensive things which may improve individual outcomes but likely do little to improve population outcomes). Which means that some things are comparable, and some are wildly different. It would be very interesting to repeat the study with a US population and US costs of care.

  11. ” My acquaintances with chronic health conditions (fibromyalgia, MS) oppose European style healthcare”
    I have a close friend with fibromyalgia who really wants single payer in the US.

    It is all anecdotal, anyway.

  12. “Interesting, but I think that this makes the study very non-transferable to our patient population.”

    If you assume that everything costs more in the US, and that the US spends more on end-of-life care than the Netherlands, that would suggest that smokers save even *more* health care costs in the US than in the Netherlands.

  13. The big reason why Medicaid costs are so high have little to do with irresponsible poor people.

    “Although three-quarters of Medicaid recipients are either children or young adults, they account for only one-third of costs. The elderly and disabled constitute the other one-quarter of recipients, but they represent two-thirds of costs.”

    https://www.washingtonpost.com/opinions/medicaid-is-out-of-control-heres-how-to-fix-it/2017/03/19/05167e9e-0b2e-11e7-a15f-a58d4a988474_story.html?hpid=hp_no-name_opinion-card-b%3Ahomepage%2Fstory&utm_term=.a4566840164a

  14. Agree with Mooshi about the elderly/disabled accounting for most Medicaid costs. In general, 1% of the population accounts for ~1/3 of medical costs and 10% of the population accounts for ~2/3 of medical costs. The question of how we deal with those facts- and how we continue to deal with changes to those facts if the population skews more and more elderly- is left as an exercise to the reader.

  15. Some smokers get expensive end of life care, but the large number who succumb to heart attacks don’t run up many health care costs. They also don’t live long enough to need nursing home or Alzheimer’s care.
    And they may not get much from Social Security either, compared to Totebaggers.

  16. oppose European style healthcare because they observe that most countries have less treatment for chronic conditions,

    She must assume, as a given, that she’ll be able to remain middle class or above until she hits Medicare age. What else can it be when the new plan says that if she falls out of the middle class, but doesn’t end up destitute, she’ll have to do without her $5,000/month MS meds.

  17. “Doesn’t Medicare — not Medicaid — cover the elderly and disabled? Well, yes, but there’s a giant omission: nursing home and other long-term care.”

    Perhaps one of the more important semantic questions of our day is whether LTC is a medical expense.

  18. Anon@6:08 was me. I think the distribution of care is very different. If we spend twice as much on health care in the US, it is not evenly distributed. Therefore, I think if a smoker’s care costs x in the Netherlands, you cannot assume that it costs 2x in the US. It might cost 3x, it might cost 1.2x. I don’t think it scales. We do things very differently here – we are much more willing to spend money on “futile” therapy than the dutch are, from my very limited understanding of their system.

  19. “Smokers get expensive end of life care too, just earlier.”

    And perhaps for, on average, a shorter duration?

  20. “With the move toward making older people pay 5x as much as the young, someone 62 years old making 26k a year is looking at $1200/month with $5k deductible under the best case scenario after all proposed reforms. Even with the proposed tax credit it’s $900 a month. The math just doesn’t work.”

    I believe that Obamacare capped how much higher medical insurance cost for old people relative to young, with that cap being less than the overall difference in costs, forcing the young to subsidize the old.

    I also believe that most of the country’s wealth is held by older people, who’ve had a lot longer to accumulate wealth.

    So if one starts with the assumption that the poor old people need to have medical insurance, and for that to happen the costs must be subsidized, does it make more sense for the young to subsidize them, or the wealthy elderly?

  21. The problem with so much of Medicaid’s budget going towards nursing homes for the elderly is that it distorts the debate. People look at the Medicaid budget and see a lot of money being spent, and they assume that money is going to poor obese opioid addicts with too many kids who refuse to work. But most of the budget is going to 90 year old senile grandmas. If people understood where the money goes, they might have a different emotional reaction to the Medicaid issue.

  22. I also believe that most of the country’s wealth is held by older people, who’ve had a lot longer to accumulate wealth

    That must mean any given elderly person is wealthy. That’s what the new plan assumes as the amount of the subsidy is a small percentage of the added cost.

  23. So if one starts with the assumption that the poor old people need to have medical insurance, and for that to happen the costs must be subsidized, does it make more sense for the young to subsidize them, or the wealthy elderly

    The new plan doesn’t adjust for income. A billionaire 62 year old and a 62 Walmart greeter get the same 4K tax credit.

  24. No Rhett. For a single American (this is national average I believe the Ryan plan has some regional weighting in it), a bronze plan covers (large deductible) for 550 dollars a month at 50 to 1000 a month at 64 (goes up every year). 25000 a year income gets a 292 a month flat tax credit 50 to 64. 110000 a year is the point where the credit goes to zero.

  25. Meme,

    Ah – the constant changes to the amazing plan they’ve had 7 years to craft are hard to keep up with. 708/month on $25k/year seems a little high.

  26. we are much more willing to spend money on “futile” therapy

    This is one of the main issues with our system.

  27. “People look at the Medicaid budget and see a lot of money being spent, and they assume that money is going to poor obese opioid addicts with too many kids who refuse to work.”

    Why do you assume that this is what people think? IME, most people don’t have a clue what Medicaid covers, who is eligible, or, for that matter, how terribly ineffective it is.

  28. or, for that matter, how terribly ineffective it is.

    What is your preferred alternative?

  29. “But most of the budget is going to 90 year old senile grandmas.”

    Not true.

    “About three-quarters of all Medicaid spending on services pays for acute-care services such as hospital care, physician services, and prescription drugs; the rest pays for nursing home and other long-term care services and supports. Medicaid covers more than 60 percent of all nursing home residents and 40 percent of costs for long-term care services and supports.”
    http://www.cbpp.org/research/health/policy-basics-introduction-to-medicaid

  30. how terribly ineffective it is.

    The federal and state governments spent $460 billion on Medicaid last year. Is it really feasible that this buys nothing? Gottlieb’s article prompted two scholars affiliated with the Kaiser Family Foundation to publish a paper looking at this question. Julia Paradise and Rachel Garfield conclude “…the Medicaid program, while not perfect, is highly effective…Furthermore, despite the poorer health and the socioeconomic disadvantages of the low-income population it serves, Medicaid has been shown to meet demanding benchmarks on important measures of access, utilization, and quality of care.”

    To what degree are poor outcomes the result of poor treatment compliance due to the generally low level of cognitive ability and executive function among Medicaid receipts? Presumably, poor treatment compliance comes from the same place that has them on Medicaid to begin with.

    http://humanevents.com/2014/10/29/analysis-is-medicaid-really-that-bad/

    They obviously have an ideological ax to grind so keep that in mind. Just note how the Medicaid managed care patients differ from the fee for service patients.

  31. “Gottlieb’s article prompted two scholars affiliated with the Kaiser Family Foundation to publish a paper looking at this question. Julia Paradise and Rachel Garfield conclude “…the Medicaid program, while not perfect, is highly effective…”

    Gottlieb’s article is consistent with the results of the Oregon study, which was conducted by a group of highly-respected economists at top universities. (Amy Finklestein, one of the two PIs on that study, is a professor at MIT who won the Bates award given annually to the economist under the age of 40 who is judged to have made the most significant contribution to economic thought and knowledge.) Who is Julia Paradise? “Ms. Paradise earned her Bachelor of Arts from Cornell University and Master of Science in Public Health from the University of North Carolina-Chapel Hill.” http://kff.org/person/julia-paradise/

    So, I’m not convinced.

  32. How about something like this?

    “Let’s build a new health program for low-income Americans, one that pays primary care physicians $150 a month to see each patient, whether they are healthy or sick. That’s what so-called “concierge doctors” charge, and it would give Medicaid patients what they really need: first-class primary care physicians to manage their chronic cardiovascular and metabolic conditions. Then throw on top of that a $2,000-a-year catastrophic plan to protect the poor against financial ruin. The total annual cost of such a program would be $3,800 per person, 37 percent less than what Obamacare’s Medicaid expansion costs. Hell, put the entire country on that kind of plan, along with giving people the opportunity to use health savings accounts to cover the rest.”

    https://www.forbes.com/sites/theapothecary/2013/05/02/oregon-study-medicaid-had-no-significant-effect-on-health-outcomes-vs-being-uninsured/#4bdc07c06043

  33. Medicaid patients what they really need: first-class primary care physicians to manage their chronic cardiovascular and metabolic conditions. Then throw on top of that a $2,000-a-year catastrophic plan to protect the poor against financial ruin.

    How do they pay for their meds, labs, scans, etc? The article says “use health savings accounts to cover the rest.” How do you contribute enough to cover you needs when your income is so low and your chronic health problems are ongoing?

  34. Scarlett,

    Does the generally acknowledged failure of the 401k/IRA system give you pause when you consider how effective HSAs are going to be?

  35. Your argument from authority at 9:42 is ridiculous. The critique is either correct or it isn’t.

  36. Rhett – also, the administration of FSAs and HSAs sucks. It is more hoop-jumping – you often have to submit supporting documentation with your receipts and go back to your doctor and get them to send something in. It is a huge PITA even for people with ample cognitive capacity.

  37. Ok, was it published in a peer-reviewed journal by top names in the field? Or was it an article written by two public policy “researchers” at Kaiser, who are biased in favor of the ACA and Medicaid expansion?

  38. L,

    Not to mention if you oppose the young subsidizing the old then you need to have the young contribute to HSAs and invest the money to help pay for their market rate insurance. All the evidence we have of the average person’s ability to manage that process says it’s going to be a disaster.

  39. Yeah, what Rhett said – concierge doctors don’t pay for cholesterol testing, or glucose test strips. In general people who have a concierge doctor have a comprehensive health plan that covers medications, labs, specialists, radiography, etc. There is a “donut hole problem” for all of the care between the basic primary care and the catastrophe.

    The vast majority of medicaid patients are medicaid patients because at some point their executive function has been found wanting – too poor, mental illness, demented, too young. To expect that they just need a catastrophic plan, a Dr. Quinn and a HSA is crazy.

    Also, the statement that Medicaid is spending too much money on 90 year olds is not incompatible with the statement that 68% is going to acute care services. The very old require a lot of acute care.

  40. Scarlett,

    If they disagreed with your ideology you’d dismiss it. So let us move on to the substance of your proposal – how does someone put enough in an HSA to cover ongoing chronic illness if they are barely above the poverty line?

  41. Seattle puts on a 3 day health clinic with free health care that serves about 4,000 people. The top 3 services most in demand are dental, vision, and testing (e.g. x-rays, ultrasounds, lab tests). Over half of the people who use the clinic have some form of insurance – but it didn’t cover the cost of testing (or vision or dental care).

    Offering people a doctor but not covering any of the prescriptions, tests, etc. that the doctor is going to order leaves a huge gap.

  42. Scarlett, you attacked the person (Bachelor of Arts! At Cornell!), now the foundation (KFF! A tool of the liberals!!). Let’s attack the argument.

    (Also, you left out a big part of her qualifications: “Ms. Paradise served for 11 years in HHS’ Office of the Assistant Secretary for Planning and Evaluation and on detail to President Clinton’s Task Force on National Health Care Reform, and earlier, as policy staff at the Blue Cross and Blue Shield Association and the Centers for Medicare and Medicaid Services (then HCFA)”).

  43. Rhett, all of those are valid questions. But the best and only study we have tells us that people on Medicaid are no better off on actual health outcomes than the uninsured. The current system is not meeting their medical needs. Why not try another approach? Having a concierge doctor who gets to know them might help them manage their medical conditions.

  44. Why not try another approach?

    I’d be fine with that. You just have to address those valid questions. A concierge doctor doesn’t do a lot of good if you can’t afford the drugs, labs, or scans, PT etc. that are required to manage your ailments.

  45. I was chatting about healthcare rationing last night with an engineer from the U.K. and he observed that in Europe, they simply don’t provide people over a certain age (he said ~70 and a person who has lived in Russia said it used to be 65 there) with expensive medical services. I don’t know to what extent that is true, but it certainly sounds like access to, for example, heart surgery for the elderly is limited in at least some European countries.

    I’m not sure I can trust a summary that uses “cut the mustard” instead of “cut the muster” and I doubt Finn will either. :)

  46. So we use some of the money we are wasting on Medicaid to pay for those things.
    The point is that the narrative on the left — that reducing Medicaid expenditures will hurt the health of the poor — is simply not supported by the data. As much as someone from Kaiser with a background in government bureaucracy wants to believe that Medicaid is effective, the numbers just aren’t there.

  47. is simply not supported by the data.

    One study. Can I have anything I want in terms of policy if I have one study that supports my idea?

  48. So we use some of the money we are wasting on Medicaid to pay for those things.

    So your theory is to have Medicaid pay for all the meds, scans, labs, PT etc. that the concierge provider thinks is warranted will end up being cheaper that the current fee for service model for Medicaid? Keeping in mind that +60% of Medicaid is already provided by capitated MCOs not fee for service. I’m not quite sure all your math adds up but it’s worth a try. It is however a far cry from the Forbes proposal you linked to earlier.

  49. “Why not try another approach?” Because you don’t throw the baby out with the bathwater. If you look at the data, more people die in hospitals than anywhere else. We should do away with hospitals. You cannot assume that Medicaid coverage on the whole doesn’t work overall based on one study without considering the contributing factors. Education – do people understand what preventive and continuing care means and why it should be a priority? Do the providers seeing patients with diabetes have adequate time and resources to educate these people about diabetes and the long term effects of not managing it. People like you and I have a diagnosis like that and understand what it means or we understand that we need more information to take care of it. We know where to find the information. We feel entitled to the information and the support. Education is a massive part of managing health care and a massive time suck. We don’t do it well for the commercially insured, we don’t do it well for the poor.

    Also we need to consider Access. If people have health insurance but they can only see their provider between 9-4 pm they will still turn up in the ER. So many of the poor do not have the time to take off to get something checked until it threatens their ability to keep working. Also they do not understand how something small like a cough could mean something more serious (see above) so they wait until they absolutely cannot go any further. We also need to consider the geography of the available providers. You may have a lot of providers available to a population but if they aren’t near public transit or walkable then they may as well be on the moon. $5 Means a lot to these people. Also for the children who are in Medicaid, a barrier to access for them may well be a lousy parent who doesn’t always take them. Shall we cut them off because their parent is lame or undereducated or should we look at ways to understand why the parents aren’t bringing kids in for their shots and consider different ways in which we might motivate them to do so?

    I’ve said it once, and I’ll say it again – many, not all, but many of these people do not act as you or I might act. They are not necessarily motivated by the same “rewards” that you and I are motivated by. It is an entirely different culture in many cases.

  50. Rhett, I do approve a QALY criteria for healthcare. I just want to know what it will be (and that it is actuarially sound for decades, and that I can buy private insurance where I believe it’s inadequate) before I become enthusiastic about government as the primary provider/funder of healthcare.

    I’ve already expressed my support for the “utility model”, where a fixed ~5% profit is provided to highly regulated companies in exchange for long-term system and capital management. Based on the condition of the schools, roads and bridges around me and the numbers for social security for my generation, I don’t trust government to fund healthcare “adequately”.

    If the government manufactured chemicals, I wouldn’t trust it to appropriately fund compliance with environmental laws, either. (Recall chemical contamination levels in the former Soviet Union compared to the capitalist U.S.)

    Fundamentally, I believe in capitalism (or regulated capitalism) with government as enforcer of rules more than I believe in government enforcing rules against itself.

  51. “we are much more willing to spend money on “futile” therapy”

    I think the problem here is people are willing to spend other people’s money on “futile therapy” for their loved ones.

  52. “I also believe that most of the country’s wealth is held by older people, who’ve had a lot longer to accumulate wealth

    That must mean any given elderly person is wealthy.”

    That’s logically fallacious.

  53. WCE, there is no such country called “Europe”. Which country was your engineer talking about, and does he know anything more than simple hearsay? Keep in mind that “Europe” contains wealthy countries with state of the art medicine like Germany, Switzerland, and France, as well as countries that are poorer and that have historically had not so great medical systems (Poland, Romania). Which country?

  54. “I’m not sure I can trust a summary that uses “cut the mustard” instead of “cut the muster” and I doubt Finn will either. :)”

    I’ve heard the terms “pass muster,” and “cut the mustard” (not to be confused with “cut the cheese”), but I’m not familiar with “cut the muster.”

  55. “The problem with so much of Medicaid’s budget going towards nursing homes for the elderly is that it distorts the debate.”

    That was kinda my point.

  56. Rhett, my point that the conclusion you drew from my point was fallacious.

    Just because the elderly, on average, have more wealth than the young, on average, does not mean all elderly are wealthy.

  57. Mooshi, the specific countries the people I was talking to lived in/were from were the U.K. and Russia. I think Switzerland, Germany, France and Scandinavia have pretty good healthcare and public healthcare in wealthy states would look like that.

  58. Just because the elderly, on average, have more wealth than the young, on average, does not mean all elderly are wealthy.

    As I read the new plan, the cost of insurance can be 5x the cost to the young but the flat subsidy is limited to 2x that of the young*.

    * starting at $2,000 a year for those under age 30, increasing in $500 increments per decade in age, up to $4,000 a year for those 60 and older.

    http://www.usatoday.com/story/news/politics/2017/03/08/republican-health-care-bill-facts/98917660/

  59. Russia barely has a functioning healthcare system. Come to think of it, they barely have a functioning economy. I doubt we would ever want to look at them as a model. Hmm, well, maybe Trump would

  60. public healthcare in wealthy states would look like that.

    I thought you favored federalism? If a state hits the economic skids their citizens should do without rather than having the federal government move money from prosperous states to struggling states.

  61. There are other studies showing that Medicaid patients fare no better than the uninsured, but those were retrospective studies. The Oregon study was a rare opportunity to conduct a randomized trial on the question. To the best of my knowledge, there aren’t any similarly rigorous studies that contradict its findings. Medicaid has been around for half a century. That would seem to be plenty of time for advocates to demonstrate its effectiveness.

  62. Scarlett,

    What’s your point? You haven’t been arguing for no Medicaid, you’ve been arguing for Medicaid with some $150/month concierge provider and some yet to be determined plan for paying for lab, meds, PT, etc.

  63. I think Canada has a pretty good healthcare system, but until it’s a closed system (no one crosses the border for urgent, important care), it’s hard to know if it’s a better system. It quite likely is a better system for people with cystic fibrosis.

    I’m not convinced a U.S. healthcare system would be as good as a Canadian system, partly because of our attitude toward funding public goods. I think if the U.S. had public healthcare, Minnesota and the Dakotas would have health outcomes much like Canada’s and other states would differ more from Canada because population demographics drive health statistics more than healthcare.

    We’ll see if the Affordable Care Act can be improved to become actuarially sound, likely by raising taxes to fund subsidies for the sick/poor. I don’t expect any improvement under the current President.

  64. Maybe I have been lucky with how our HSA’s have been administered but I love them and find it to be really seamless. We use our insurance cards and they run it through the system and then we use the HSA debit card to pay the bill at the negotiated rate. I get access to the insurance negotiated rate, which is far better than anything I could individually negotiate with the provider. I have one person in our family that will typically hit the individual deductible but otherwise, we are rolling over about $2,000-$3,000 per year for future healthcare costs. Neither of us have cadillac plans – DH’s company is just really large and mine uses ADP’s payroll and benefit service which provides insurance for over 500,000 people in the U.S. Knock on wood, we haven’t had catastrophic illnesses and our children’s chronic conditions are well managed at their current ages without frequent need for medical intervention.

  65. @Mia – I had no problems with my FSA previously. Then my company switched providers. The new provider is a royal PITA and questions EVERYTHING. Demands receipts for every single transaction, but often months later. I’ve started saving/scanning all receipts, but it’s still a pain to find them once the company comes back questioning things. UGH.

  66. I think it is FSA versus HSA that may be the distinction. Can’t say that anyone has ever asked for more support for HSA reimbursements. Completely self-administered for reimbursements. I always keep the backup but I assume someone could commit fraud there. I think I have only used dependent care FSA’s and got too nervous about the use it or lost it aspect of the health expense FSA’s to really consider it.

  67. @Ivy – that ticks me off as well and the reason they are doing that is because they get to keep any unused funds. So maybe if they annoy you enough you might leave a few dollars on the table, which for one person may not seem like a big deal but when you multiply that across thousands of their participants you can understand their tactics.

  68. @UTL – That makes sense. It’s just such a contrast with the old provider which was seamless and easy.

    The FSA company also makes it extremely difficult to get at our Parking TRIP $$. The debit card does not work, and there is no online claim. It must be FAXED or mailed. In 2017!! I don’t use it, but my coworkers do. The debit card for transit works fine, and I haven’t had issues with the dependent care either ( but of course I only have to submit a few receipts a year before that $$ in exhausted).

  69. My Kroger pharmacy used to maintain a record of all my FSA-qualified purchases, and I’d just get them to print that out and send it in with my form. You might ask your pharmacy if they do that.

  70. We won’t even get into FSAs being only available from your employer. Why not let people set up their own FSA with the vendor of their choice? IIRC you don’t need an employer’s participation to set up an HSA.

  71. At the end of 2016 CVS had a sale, IIRC, all CVS brand stuff that was FSA eligible was 20% off.

  72. “I had no problems with my FSA previously. Then my company switched providers. The new provider is a royal PITA and questions EVERYTHING.”

    I had the reverse experience. Up until 2016, the FSA provider was a PITA, often rejecting valid claims for no apparent reason– my typical response was to simply re-file the claim, and it would often get approved the 2nd or 3rd time.

    I’m not sure if the provider changed, but the process was changed in 2016 and modernized (submission of documentation via website instead of fax!!), and thus far I’ve not had a single claim rejected, and processing time has also gone down.

  73. “Russia barely has a functioning healthcare system.”

    Isn’t the life expectancy quite low there? Perhaps that is someone’s answer to, as WCE would say, actuarial soundness of SS and Medicare.

  74. “should we look at ways to understand why the parents aren’t bringing kids in for their shots and consider different ways in which we might motivate them to do so?”

    I remember small kid time, all the kids in my class getting marched to the cafeteria, rolling up our sleeves, and getting shots.

  75. On a totally different topic, who has been enjoying the Comey hearing today?

  76. I have a private HSA with a BofA credit card. I charge prescriptions, doctor copays, dentist bills, and even my medicare payments on it for the year before I start collecting SS payments (restricted spousal only until 70 – one more baby boomer benefit that is going away).

  77. Isn’t the life expectancy quite low there?

    The stereotype is that it’s all vodka and cigarettes all the time, but I have no idea if that’s actually true.

  78. “On a totally different topic, who has been enjoying the Comey hearing today?”

    Too busy at work to follow it. Any bombshells?

  79. not sure if there are any bombshells but it appears a tad embarrassing for Trump

  80. “should we look at ways to understand why the parents aren’t bringing kids in for their shots and consider different ways in which we might motivate them to do so?”

    The biggest reason in Colorado is because you can claim an exemption for your kids for any reason. So it’s much easier for parents to just sign the form at school enrollment that they are declining vaccines than it is to take their kids to the doctor to get them. They’ve talked about changing the law requiring parents to get the formed signed by a doctor, but that hasn’t gotten off of the ground.

    And the primary issue with the anti-vaxxers is stupidity, not lack of motivation.

  81. According to that article, funding is the issue
    “Russia’s government recently announced plans to cut the budget for health care by 33 percent next year, bringing annual spending down to just $5.8 billion. That’s a level of funding equivalent to spending on health in Latin American or developing Asian countries, according to a recent report by Natalia Akindinova, director at the Center of Development Institute of Moscow’s Higher School of Economics.”

  82. It’s not so much the CVS charges as it is every single dentist, vision, and copay being questioned. These things seem like no brainers, but it seems that they trust that CVS and Walgreens are marking FSA-eligible items correctly, while Northwestern Hospital may be charging me for non-qualified expenses. It’s maddening.

  83. @DenverDad – I was talking about the Medicaid CHIP parents. We would think, well its free why wouldn’t you go? But they don’t. Sometimes they don’t go even when a cab is sent FOR them. Do they not love their kids (maybe yes, maybe no), are they anit-vaxx (don’t think so), are they lazy (possibly), do they not really understand the value and importance of vaccines (YES) do they have more pressing issues in their daily lives (YES). There are a lot of different reasons they might not do this. I don’t claim to know understand it, I just worked in it long enough to know that I don’t understand it and my logic is not necessarily applicable.

  84. Moxie, it’s a hassle they don’t have time for, and a lot of them likely don’t understand the importance of it.

  85. @Denver, you are more succinct than I. That may be partially why there is underutilization even when there is insurance.

  86. Apparently Ryan is marking up his own bill after committee but before floor. CBO will score it before the vote. A tweak to mitigate the high cost to lower income pre Medicare folks. I guess they’ll have to pass the bill to find out what’s in it.

  87. “The biggest reason in Colorado is because you can claim an exemption for your kids for any reason.”

    DD – this is my SIL, with a + to the stupidity comment. and I can see it being a potentially huge issue in the small box-canyon-ski resort where they live. Lots of folks like her who don’t vaccinate their local kid, rich folks from other countries where maybe vaccination isn’t really a thing come in for a week with e.g. whooping cough, and a bunch of the local kids catch it because they are not vaxd.

  88. I am grateful whenever highly slanted coverage or fake news is pointed out to me. I am also grateful to Meals on Wheels, the national organization, for setting the record straight when the administration spokesman did not even have enough information to do so effectively – he could have said that federal funding for Meals and Wheels is primarily under the Older Americans act, which the President’s budget manifesto does not target by name.

    I frankly had no idea it was heavily government funded – I thought it was a private organization for which the govt subsidy was entirely through the charitable tax deduction. I think that what would be good reporting is for the news media to document the direct fed and state payments to private and religious organizations that do the hands on work of assisting those in need. People who swear they don’t get any help from the government (apparently SS and Medicare don’t count) also don’t realize that a lot of private charity is both directly and indirectly funded by government.

  89. “(apparently SS and Medicare don’t count)”

    Meme – I’m afraid many people view SS & Medicare as “getting their money back” for having paid into the system over their working lives, so those are not assistance. I’m agreeing with you, but in discussion with (more) senior family members this is a common mindset.

  90. People who swear they don’t get any help from the government (apparently SS and Medicare don’t count) also don’t realize that a lot of private charity is both directly and indirectly funded by government.

    Yes, I’ve seen that too.

  91. “I’m afraid many people view SS & Medicare as “getting their money back” for having paid into the system over their working lives, so those are not assistance.”

    To the extent that those people don’t receive from those programs more than they paid into it, aren’t they correct? And isn’t that exactly how the system was sold in the first place?

  92. Last week, I so wanted concierge medicine or at least my childhood GP who did house calls.. I had to take sick kids and inlaw to be seen by different doctors. It would have been much more efficient for one medical practicioner to see all the patients in my house.

    The anti/lax vacers drive me crazy. The thing is people count on good medical treatment in place of prevention. They haven’t had a situation where treatment has failed so, prevention is not highly valued.

  93. “I’m afraid many people view SS & Medicare as “getting their money back” for having paid into the system over their working lives, so those are not assistance.”

    That’s one of the key features in my mind – nearly everyone contributes and nearly everyone benefits. I have always thought the same thing with the unemployment insurance program, whether that is technically funded by your employer or not – it is part of your compensation. I mean – thinking that they are not getting any “help” from the government is not correct, but feeling as though it is a program that they “paid into” and had a hand in funding IS correct. Government-run or not.

  94. Say what you will about Obama, but I was able to get a solid day’s work done when he was President. I’m checking the news so frequently now its cutting into my productivity! This stuff needs to settle down -I can’t do this for 3.7 more years.

  95. MBT – the other thing that I’m finding is that I feel I need to check multiple sources because of fake news, media biases or click bait before I can determine the correct interpretation of facts. I’ve always looked at various outlets to inform my opinions but so many of them have done some sliding off the rails that I feel I need to check more then the 2/3 opposing sides that I did in the past.

  96. Yes, I check and recheck everything these days.

    My husband keeps saying that his big fear about the future is that he can’t see how the country can ever move forwards again, given the incredible levels of distrust. How do we fix that?

  97. WCE, I think that is probably true in other professions as well. Reading the long obits in the WSJ, its striking how many successful people came from humble roots.

  98. Now that it appears that the wave of bomb threats aimed at Jewish community centers was not, in fact, perpetrated by anti-Semitic Trump supporters, perhaps the media will drop that particular narrative.

    “Fake hate crimes committed by progressives are by this point so familiar that they are practically a cliché. When a Muslim woman at the University of Louisiana at Lafayette was attacked and had her hijab ripped off, two things happened: One, the Left insisted that this announced the coming wave of pogroms against Muslims in the Age of Trump; two, people who follow this sort of thing began betting how quickly she’d be exposed as a fraud. It did not take long. Incidentally, her name has been kept out of media reports, even though she faces potential charges herself for filing a false report. These hoaxers should be publicly named, as there is no legitimate reason to protect their identities.There were other fake hate crimes attributed to Trump enthusiasts: Zeeshan-ul-hassan Usmani of Cary, N.C., says that he planned to leave the United States after an Islamophobic assault on his son following harassment by neighbors who named-checked Trump. School officials say there is no evidence that attack ever happened. A gay man in Santa Monica claimed to have been assaulted by Trump partisans, but the attack seems not to have happened. The San Francisco homeowner who raised a swastika flag was not a Trump supporter but a Trump opponent. A catalogue of similarly false, exaggerated, or distorted hate crimes has been assembled by Reason.”

    http://www.nationalreview.com/article/445495/bogus-hate-crimes-trump-conservatives

  99. So why are the Republicans ripping themselves apart trying to pass this total piece of crap, Rube Goldberg, rushed through, joke of a healthcare plan?

  100. But if they do manage to pass this thing, and it turns into the very predictable disaster (rates shooting up, deductibles shooting up, people being sold “healthcare” plans that cover nothing, people dropping coverage due to unaffordability, hospitals getting slammed with uncovered costs), then the Republicans will own it. That should be making them shudder.

  101. They’ll just deny that it’s happening. We’re in a post-factual world.

  102. You know, if my life and the lives of my friends weren’t at stake, I would so be popping corn and sitting back cheerfully in my recliner to watch.

  103. @DD – did you read the WaPo’s fact check of the Time article?

    https://www.washingtonpost.com/news/fact-checker/wp/2017/03/23/president-trumps-cascade-of-false-claims-in-times-interview-on-his-falsehoods/?utm_term=.fbb2a5de8ce5

    I don’t get it. Everyone hates this bill – Left, Right, Moderate. No one can defend it. It doesn’t make sense. The Senate says they won’t pass it. But it must pass TODAY. How is that a victory for Republicans? Because they can say that they “repealed” Obamacare? They repealed Obamacare in the House a dozen times already, but they’ve never passed a workable solution that actually made it through. This isn’t that either.

    And Trump with his empty threats. UGH.

  104. Trump is purely about transactions and doesnt care about the content of anything. It is doubtful that his ADHD-addled brain actually focused long enough to even read a few of the details in the plan. He simply wants to chalk up the deal – yep, I repealed Obamacare, now lets move on. The bigger question is why any Republican would be voting for this, knowing the bad press it is going to get as the plan goes into effect.

  105. If I were a Republican MoC, I would be betting that in a year Trump will be gone and the Koch brothers will still be there.

  106. I paste this excerpt I got from Vox about a free market solution with a mandatory universal catastrophic care policy, and nothing more. No medicare, no medicaid, no employer health plans. Only a “mandate” for the government to require a percentage of take home (for those who work in the recorded economy) to be placed in a health only savings account for approved spending (bureaucracy can always find a way to continue itself). The excerpt doesn’t deal with the following, but Immunizations and child checkups could be made available for kids at school (that would be up to the states and localities), and public institutions (again a local matter) might have to be reestablished to care for those children and adults who because of physical disability or mental illness cannot care for themselves and whose families cannot care for them either. However, everyone will have free choice (except for pay diversion to the health savings accounts). And 50K a year is his suggested floor for catastrophic coverage to kick in. If that sounds Dickensian, that it because it is.

    David Goldhill, the author of Catastrophic Care, has a yet more radical vision:

    First, we should replace our current web of employer- and government-based insurance with a single program of catastrophic insurance open to all Americans—indeed, all Americans should be required to buy it—with fixed premiums based solely on age. This program would be best run as a single national pool, without underwriting for specific risk factors, and would ultimately replace Medicare, Medicaid, and private insurance. All Americans would be insured against catastrophic illness, throughout their lives.

    Proposals for true catastrophic insurance usually founder on the definition of catastrophe. So much of the amount we now spend is dedicated to problems that are considered catastrophic, the argument goes, that a separate catastrophic system is pointless. A typical catastrophic insurance policy today might cover any expenses above, say, $2,000. That threshold is far too low; ultimately, a threshold of $50,000 or more would be better. (Chronic conditions with expected annual costs above some lower threshold would also be covered.) We might consider other mechanisms to keep total costs down: the plan could be required to pay out no more in any year than its available premiums, for instance, with premium increases limited to the general rate of inflation. But the real key would be to restrict the coverage to true catastrophes—if this approach is to work, only a minority of us should ever be beneficiaries.

    How would we pay for most of our health care? The same way we pay for everything else—out of our income and savings. Medicare itself is, in a sense, a form of forced savings, as is commercial insurance. In place of these programs and the premiums we now contribute to them, and along with catastrophic insurance, the government should create a new form of health savings account—a vehicle that has existed, though in imperfect form, since 2003. Every American should be required to maintain an HSA, and contribute a minimum percentage of post-tax income, subject to a floor and a cap in total dollar contributions. The income percentage required should rise over a working life, as wages and wealth typically do.

  107. That article is depressing as hell. I guess I’m going to be getting all my health care in Mexico.

  108. Singapore does something like that, with mandatory health savings accounts and catastrophic coverage. But the catastrophic coverage is single payer, which has the effect of pushing down prices for everything.

  109. I remember as a grad student paying 400, 50 dollars a month to the Boston Lying In Hospital with a balloon payment at the end, for my first child’s birth. My stipend was 300 dollars a month, and my rent 90. I was 22, on the welfare/charity ward, 30 beds with partitions, no a/c but pavilion windows, smoke wafting around. On July 15, no less, so 90 degrees and treated by the greenest resident, forceps, episiotomy, spinal. We got through it fine. Times and expectations change, though.

  110. In the pre ACA world, it was common to see policies that capped hospitalization coverage at 20,000. A lot of the skimpy “healthcare” plans in those days limited the expensive, catastrophic coverage, for the very reasons I keep explaining over and over – primary care is cheap and easy for insurers to throw into a plan. Catastrophic coverage is where the costs are, and why premiums are high. The only way to offer a truly lowcost plan is to limit catastrophic coverage in some way.

  111. The big open wards have been shown to lead to higher hospital-based infection rates, so from a public health standpoint, this kind of lowcost setup is not a great idea.

  112. I am mostly libertarian/conservative, but I have reluctantly come to the conclusion that single payer, with the option to buy more comprehensive/more pleasant coverage might really be the only viable solution.

    We aren’t going to let children go without medical care because their parents are idiots, oor poor, or lacking in executive function, suffer from mental disease, or are somewhat incompetent or irresponsible. Insurance companies can’t stay in business if people can wait until they are sick to buy coverage.

    Medical care is expensive and wonderful. I think the conversation would be much more productive if the cost issue was laid out clearly. It costs a lot to hire highly trained individuals. It costs a lot to produce specialized equipment, and to have trained staff on hand to run it in emergencies. Pretending that things should just be cheap, because expensive is unpleasant is not productive, but that seems to be the politicians we have.

  113. And on Call the Midwife, some babies and mothers come through fine too. But then a bunch of others died.

  114. “Singapore does something like that”

    I don’t think the US, or any other country, can really use Singapore as a model, for this or just about anything else.

    I’m curious to see how long Singapore continues to thrive without Lee Kuan Yew.

  115. Everything that Pseudo just said. All of it.

    And the bill is dead now. Hallelujah! It’s a gift. I can still afford to retire on schedule and get a nicely subsidized plan.

    Move on, Mr. President and Mr. Speaker.

    Tea Partiers in my district posting constantly on our Congressman’s FB page, move on. They tried. Win some, lose some.

    Let’s get Gorsuch seated, taxes cut, regulations eliminated. Let the Democrats worry about healthcare.

  116. “Boehner and Obama are laughing hysterically right now.”

    Who knew it was this complex?

  117. The big open wards have been shown to lead to higher hospital-based infection rates, so from a public health standpoint, this kind of lowcost setup is not a great idea.

    They would also lead to massive HIPAA violations.

  118. I’ve never seen the studies about big open wards leading to more infections, if doctors wear gloves and wash their hands between pelvic exams.

    And HiPAA has a “good enough” provision. We take sensitive histories in places where there is only a curtain separating patients. If you keep your voice as low as possible, then it is okay. It turns out intent matters a lot, and no one is making Trauma bays (often 6-7 patients in a giant room) put in real walls.

  119. “Diabetes can easily cost around $300/month in supplies. (Test strips being a huge part of that – it’s hard to get them for <$1/each – in the US.). That is an unrealistic expense for most people to add on to their budget. "

    I was wondering about something like renal failure requiring dialysis. Dialysis, along with other costs I assume someone in that condition would also have, could take someone near or over the $50k deductible for consecutive years, which for many may not be sustainable, especially since the time required for dialysis would make it difficult to keep a job.

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