BBO Discussion Forums: Has U.S. Democracy Been Trumped? - BBO Discussion Forums

barmar, on 2017-March-01, 09:58, said:

Not right. Obamacare gained coverage for individuals through an expansion of the Medicaid program which is different from Medicare. Medicaid is a program providing medical care for those in poverty that is done through the Federal/State welfare systems. The federal government provides some money, but the brunt of the money to pay for the costs is supplied by the states (70% comes to mind, but don't quote on that).

In Obamacare, they provided medical coverage to additional people by changing the eligibility requirements, so that persons with incomes up to 140% of the poverty level could participate in it. The original Obamacare law tried to force States to accept this expansion by withholding all Federal Medicaid funds if they didn't. However, the Supreme Court ruled such coercion illegal. All states had to the option to opt out of expanding Medicaid if they desired. I think 31 states opted to expand Medicaid and 19 didn't.

Medicare is the medical coverage for seniors over 65 and is covered by a payroll tax all wage earners pay.

rmnka447, on 2017-March-02, 02:05, said:

There seem to be funding problems associated with all of the US attempts to provide health care. Since other western nations seem to be able to handle the problem it is obvious that the US is missing something, or there is something in the US system that precludes a straight forward solution. What is it?

ldrews, on 2017-March-02, 08:08, said:

That you don't tax people enough to put in place a European style health system, and that hospitals charge way too much for procedures.

rmnka447, on 2017-March-02, 02:05, said:

You are wrong. The ACA (known as Obamacare) expanded Medicaid, not Medicare. There was a slight benefit added to Medicare - wellness visits - but the expansion was in Medicaid. This is the part that most Republican controlled states refused to do which led to the S.C. ruling that allowed the federal government to start exchanges for those states that refused to comply.

Two major problems with funding Medicare and Social Security is the earnings cap of $118,500 on FICA taxes, and that the wealthy do not have to pay taxes on capital gains into these social programs.

jogs, on 2017-March-01, 17:53, said:

You'll have to take that last line to the next Trump rally as I bet most here in the WC find it more offensive than cute or funny. I know I found it unnecessary and offensive.

Would you have reported the very same license plate on the car of a Latino, Asian, or Caucasian?

akwoo, on 2017-March-01, 22:59, said:

"Imagine no posessions, I wonder if you can..."

I guess you can. John Lennon would be proud. But the rest of us are more realistic. No attempt at a utopian society has ever succeeded, and those were just small experiments with people who were presumably committed to the ideals. "Imagine" trying it with an entire country.

rmnka447, on 2017-March-02, 02:29, said:

Oops, I always get them confused. I guess when I get to the age where I can take advantage of Medicare, I'll keep them straight. I don't think I'm likely to ever need Medicaid (knock on wood).

Winstonm, on 2017-March-02, 08:42, said:

Goes to show that context is everything.

There's probably a number of bridge players with "NO TRUMP" license plates. I wonder how many of them are Republicans who now regret it.

barmar, on 2017-March-02, 08:51, said:

He would. I'm pretty sure he could imagine no having apartment on Central Park West just to store his fur coats. But I may be wrong.

Cyberyeti, on 2017-March-02, 08:29, said:

Part of the problem is the cost of drugs. Canadians apparently pay the second highest drug prices, after the US. We pay, according to a recent CBC news story, on average 4x what people in New Zealand pay. Americans pay still more. This includes so-called generic drugs, where the cost of development has long been recovered by the original maker, so this seems likely to be mostly obscene gouging.

Part of the problem is too many tests. Doctors have pressures to order multiple tests, often to provide a placebo like assurance to patients. Perhaps also to avoid litigation. I have a bad back, with occasional sciatica on one side and femoral nerve pain on the other. I imagine many doctors would send me for an x-ray or MRI. My gp discussed this with me and said that either would be a waste of money. Clinically the diagnosis is obvious, and the problem isn't bad enough to warrant surgery, so there is no meaningful chance that imaging would alter treatment. So we agreed not to do it. My guess is that in the US, and with many Canadian doctors, I'd simply have been referred to radiology.

Part of the problem is the extremely high incomes doctors make in the US.

Part of the problem is the profit motive behind hospitals

As an example of the results, my wife had to have a procedure a number of years ago. There was a wait list in BC (although it ended up far shorter than we were originally told) so I researched the cost in the US. The Cleveland Clinic wanted 125,000 for a procedure that would probably not require even one night in hospital. The cheapest I found was Oklahoma at 11,500. The cost to the government in BC was 5,000. And the success rate in BC matched that of the Cleveland Clinic.

As long as a society runs health care as a profit centre for the major players, with no mechanism nor incentive to keep costs or profits under control, then the results are predictable.

Having said that, if you have the money, then the US does provide the best care in the world. Thus the question is one of priorities. Maximal care for those fortunate enough to afford it, while leaving millions with terrible care and economically crushing those in-between, or providing worse (but still pretty good) care to everyone at a significantly lower cost.

mikeh, on 2017-March-02, 09:52, said:

While at was at the Netherlands Cancer Institute, we frequently analysed US data sets and compared them to Dutch ones. Sometimes this led to bizarre findings. For example, I encountered a US brain metastatis patient that had some 20+ brain tumours that apparently had been treated individually at 20+ separate admissions. In the Netherlands, we would normally treat two and sometime three or four tumours individually, but normally bundled in single admissions. Patients with 5+ tumours would always get a single full-skull treatment.

I first thought it was a very unusual case or, more likely, a data management error, but my boss told me that it is normal practice since it allows hospitals to write 20+ invoices instead of one for basically the same treatment (except for the added delay and inconvenience to the patient who needs 20+ admissions instead of one).

mikeh, on 2017-March-02, 09:52, said:

Yes, a big part of the problem is the profit motive throughout the medical industry. This in general distorts incentives for manufacturers and providers. It means that drug makers don't want to invest in cures for rare conditions, because there won't be enough sales to recover the costs. It means that hospitals encourage doctors to order more tests, but insurance companies discourage them (because they're footing the bills). I'm sure we've all heard horror stories of patients not getting necessary treatment, because their insurance company refused to pay.

Basic health care should not be market-driven, it should be a right of all citizens.

There is also the assumption that people will be insured and thus not bearing the cost, so the (for profit) hospitals push the costs up, insurance premiums go up and less people can afford them.

barmar, on 2017-March-02, 13:06, said:

I agree but there are millions in the U.S. who disagree - at least at the ballot box, even when they don't know that Obamacare and the ACA are the same things.

barmar, on 2017-March-02, 08:58, said:

Hi Barry, the next day after we drop out of WZ pair, I played with George.
After disagreement on one hand I made my revenge by buying and wearing "No Trump" cap.

Cyberyeti, on 2017-March-02, 13:24, said:

Having worked in the health industry, I have always found it ironic that Sarah Palin put forth the concept of government "death panels" as something new when there already is an insurance company death panel: the board of directors.

So, when it comes to that $1 million treatment for cancer, would you rather have the government decide if it is necessary or do you trust Wall Street to make that decision?

Vampyr, on 2017-March-02, 00:08, said:

It was expansion of Medicaid. The federal government offered to cover the cost for a limited time. Then the cost goes to the state. Governors said no thanks.

The states that refused to expand Medicaid coverage were primarily the same ones that opposed the ACA, i.e., Republican-controlled states. This was not a fiscal decision but an ideologically-drive one, and that decision has not turned out so swell for those states.

It is ironic that these states that cared so little about their poor citizens that they ignored those persons' needs in favor of participation in a partisan anti-Obamacare solidarity strike have found their Medicaid costs rising twice that of the states that did expand their Medicaid. Turns out expansion was a positive for the states and the poor of those states and not the financial catastrophe predicted.

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Winstonm, on 2017-March-02, 08:37, said:

My response was in response to and in terms of a post that suggested expanding Medicare to cover everyone as a solution to the healthcare issue. In another comment, I pointed out that Medicaid not Medicare was the program expanded in ACA.

You forget to mention that in order to make ACA work, they cut Medicare by $786MM in reduced payments for services so the funds could be diverted to help fund ACA.

Indeed, Warren Buffett has suggested that the caps on FICA taxes be eliminated as a means of extending the viability of Medicare and Social Security. But no one seems to be willing to get out front of that suggestion by proposing legislation. With the political polarization, addressing how to make entitlement programs sustainable is impossible. So likely no solution will be faced until we reach a critical point of failure of these programs.

Winstonm, on 2017-March-02, 14:57, said:

A significant number of voters voted as they did because Obamacare/ACA failed them.

If you will recall, when Obamacare was proposed, proponents made a great deal of hay about how people in the individual insurance market were forced into "fake insurance" -- insurance policies with high premiums and high deductibles without great coverage. They averred how ACA would fix that.

Well, it hasn't. ACA can say it has increased healthcare insurance coverage, but unless that coverage results in actual patient care then it really is a phony claim. Healthcare implies care not just coverage. So the critical issue is "What is the care delivered to the patient?" If you have insurance with all the coverages you could imagine but the deductible precludes you from obtaining that care, then the insurance is really just as "fake insurance" as before ACA. Voters who are in this situation recognized this and voted accordingly.

Perhaps the most poignant examples occurred on a town hall debate between Bernie Sanders and Ted Cruz on healthcare.

A woman who was a nurse said that her family policy through ACA cost her $800/month and had a $9000 deductible. She said that she had had some screening tests that indicated she might have a specific cancer. However, follow up testing to confirm and define the cancer costs several thousand dollars. Because of the deductible and her financial situation, she can't afford to pay for the tests, so must go on not knowing if she does have a cancer growing inside of her that will eventually kill her and leave her children motherless.

To be fair, OTOH, another woman with MS said that private insurance that she could get wouldn't cover an MS drug she needed that would help her have some semblance of a normal life. She was able to qualify for Medicaid under ACA. Medicaid did allow her to obtain this drug, so she's back to a pretty normal life.

These two women probably define the ends of the spectrum of healthcare issues. How do we make sure both obtain/keep the right medical care?