The shifting sands of US Healthcare

One of the largest misconceptions that I have seen carried on is the belief that the PPACA or "Obamacare" is a program that can be repealed. It's not, and if only it were....

It's a giant truckload of loosely affiliated regulations, laws, taxes and new organizations, existing by now, largely in their own right as intended. Repeal what, at this point? Reading down will explain a bit better.


Those who read All 906 pages of it in 2010 are not dealing with the same thing today. It's similar, but then, not so much. That depends entirely on what area and specific thing we're talking about.

I found this last night and spent some time checking it out. One thing that is really nice is that each reference links back to something original or as close to it as they could manage.

This is 40 some changes made to the PPACA since it came along.

Some Highlights:

1. Medicare Advantage patch: The administration ordered an advance draw on funds from a Medicare bonus program in order to provide extra payments to Medicare Advantage plans, in an effort to temporarily forestall cuts in benefits and therefore delay early exodus of MA plans from the program. (April 19, 2011)

3. Subsidies may flow through federal exchanges: The IRS issued a rule that allows premium assistance tax credits to be available in federal exchanges although the law only specified that they would be available “through an Exchange established by the State under Section 1311.” (May 23, 2012) (Thread Note: Remember this one. It matters next)

5. Closing the high-risk pool: The administration decided to halt enrollment in transitional federal high-risk pools created by the law, blocking coverage for an estimated 40,000 new applicants, citing a lack of funds. The administration had money from a fund under Secretary Sebelius’s control to extend the pools, but instead used the money to pay for advertising for Obamacare enrollment and other purposes. (February 15, 2013)

6. Doubling allowed deductibles: Because some group health plans use more than one benefits administrator, plans are allowed to apply separate patient cost-sharing limits for one year to different services, such as doctor/hospital and prescription drugs, allowing maximum out-of-pocket costs to be twice as high as the law intended. (February 20, 2013)

Highlights of Changes by Congress:

29. 1099 repealed: Congress repealed the paperwork (“1099”) mandate that would have required businesses to report to the IRS all of their transactions with vendors totaling $600 or more in a year. (April 14, 2011)

30. No free-choice vouchers: Congress repealed a program, supported by Senator Ron Wyden (D., Ore.) that would have allowed “free-choice vouchers,” that the Hill warned “could lead young, healthy workers to opt out” of their employer plans, “driving up costs for everybody else.” The same law barred additional funds for the IRS to hire new agents to enforce the health-care law. (April 15, 2011)

31. No Medicaid for well-to-do seniors: Congress saved taxpayers $13 billion by changing how the eligibility for certain programs is calculated under Obamacare. Without the change, a couple earning as much as much as $64,000 would still have been able to qualify for Medicaid. (November 21, 2011)

A little good and bad mixed there, between the 1099 that really did have to go for an insane requirement of documenting daily commerce, to saying..ahem...$64,000 is too wealthy to get benefit from something every working American has spent a lifetime paying into? Oh really?

$64,000 IS a comfortable wage here in the Midwest, but I wouldn't describe it as wealthy. On the coasts or big cities, I'm not sure I'd even call it the high side of middle class? I could have sworn much of this was sold with suggestions of $250,000 or higher (much higher in some examples) being the 'wealthy' line.

That seems to have changed and in the wrong direction, with the cost of living rising quick in all other areas.

There is a bit more though. The Supreme Court:

39. Medicaid expansion made voluntary: The court ruled it had to be voluntary, rather than mandatory, for states to expand Medicaid eligibility to people with incomes up to 138 percent of the federal poverty level, by ruling that the federal government couldn’t halt funds for existing state Medicaid programs if they chose not to expand the program.

40. The individual mandate made a tax: The court determined that violating the mandate that Americans must purchase government-approved health insurance would only result in individuals’ paying a “tax,” making it, legally speaking, optional for people to comply.

Source: 40 Changes to ObamaCare...So Far

Areas bolded above matter for the ability to have passed a State Constitutional Amendment dramatically limiting and in some cases, outlawing cooperation between the State and the ACA in Missouri. In reference to the second part the Court did, Missouri also made it illegal for anyone outside the state to enforce fines or penalties for noncompliance with the ACA.

That is part of how many states set up to fight the impact of this. Especially the Med- Programs.

Here is the other big deal which is sitting there and waiting to pop......or not. It depends entirely on the Court right now and how they decide with it.

Sec. 1311 of the Affordable Care Act says that health insurance subsidies are available only “through an Exchange established by the State.” The IRS, however, interpreted the statute to mean that the subsidies also could be distributed through federal exchanges in the 34 states that declined to create their own exchanges.

Judge A. Raymond Randolph indicated he felt the statute was quite clear in repeating “seven times” in that section that the subsidies are available only “through an Exchange established by the State.” He indicated that it “is not up to the courts to fix” a problem that Congress may have created for itself. (Nor, we might add, is it up to the IRS to rewrite the statute in its regulatory interpretation.)

People whose state didn't make an exchange and are using federal ones, see it cheap right now against the law itself. It's been bent to make it cheaper in the short term with subsidies there isn't enough to fund.

Since there is no deadline for a state to establish an exchange, states could later set up an exchange to get the subsidy money if the court were to decide that the statute means what it says.

The case will likely then hinge on how Judge Thomas B. Griffith votes. It is impossible to determine how a judge will vote based upon oral arguments, but his questions seemed more skeptical of the government’s arguments than the plaintiff’s.

Source: Court Will Decide If ACA Language Bars Health Subsidies In 34 States

There is a lot going on and unfortunately, it's hard to get a straight line on much with how often it changes.

Hey Wrabbit - great thread!

The "problem set" that the ACA was attempting to solve for (some people debate this was its goal but for the moment,
I hope we can discuss this as an assumption) from the beginning is fairly straight-forward:

1. Eliminate pre-existing conditions clauses and sudden "high risk" removals from insurance plans as they hurt people, and lead to medical bankruptcy.
2. Work on lowering health costs through the same power that Medicare/Medicaid has - the power of numbers and bulk purchasing.
3. Eliminate the "insurance gap" for people in their early 20's.
4. Making monthly insurance rates affordable (since eliminating such a large insurance market in favor of a single-payer situation would cause heads to spin more than the ACA has...imo).
5. Come as close to Universal Health Care as the parameters of using the insurance industry, and expanded parameters for Medicaid would allow.

Thus the name the Patient Protection (insurance companies can't remove you for anything other than non-payment) and Affordable Care (working to reduce costs for health care and for insurance costs) Act.

The major concession needed for this whole thing to work was requiring a large enough pool of "insured individuals" to balance the costs of sick people being insured without fear of sudden eliminations or insurance ineligibility. Thus "Universal Compliance" was added in and the fur began to fly...

What we now have is a massive and burgeoning law that took these health care goals, plus one major requirement for it to work, and, by reason of...???, turned it into something unwieldy and riddled with weird and contentious "holes." Is this by design? A flaw inherent in the plan due to political bickering? Too many fingers in the pie? I'd be curious to know how you see it, Wrabbit...

Anyway, the end result is not yet the end result, as is to be expected with any such huge legislation. As you mentioned the very very important issue of whether or not states that opted out of the exchanges can offer the subsidies is still going through the legal meat-grinder. A key "game changer" was the SCOTUS decisions you mentioned that said the "TAX" (penalty for not having health insurance) could apply IN ALL STATES and the STATES could choose to NOT set up and Exchange. I think that was done in an effort to subtly gut the law, personally - a "win" that was a "loss." But the universal penalty was essential for the law to move forward in any form, and provided more fuel for political firestorms and repeal efforts.

My family benefits (currently, assuming the decision to allow subsidies in states that do not have exchanges holds) from the ACA. Others do not. I would like to see Congress actually sitting down and FIXING the PROBLEMS rather than sitting on their immobile duffs. Though in fairness, the perception of both the problems and what constitutes "fixing" differ greatly. (I have yet to see any viable alternative to the ACA that attempts to solve the list of very real problems the ACA has taken on, other than single-payer, of course, which has its own issues.)

If fixing the ACA means significant changes to the law to make the above listed goals happen more efficiently or with greater fairness, so be it - it is not some sacred document! If it means implementing something that requires a modicum of compromise, then DO IT! If a viable alternative can meet those goals and do it in a better way, then for the sake of all that's Holy, bring it forward!

Instead, we are caught in black & white thinking "repeal vs. implement." Really???? When has that EVER been the only choice????? Instead, the legitimate problems of Americans in obtaining and keeping health care have been turned into partisan talking points and election fodder footballs. In truth, we little voices do not have much say - it is the money that talks, and the lobbyists. That is how our government really works.

*sigh*

Is it wrong to want our government to actually solve problems created by predatory industries? And I do think the insurance industry has a strong predatory, bottom-line driven focus, which is evidenced by their profits and how they make them. It ain't charity or non-profit, which is how the insurance industry actually started out back in the day. It WAS one of the good-guys and still tries to take that shining shield of "we will protect you" into its current business PR.

Anyway, sorry to ramble and rant a bit, Wrabbit - it wasn't directed at you, for sure, just me tilting at windmills. Looking forward to monitoring the thread...

peace,
AB

Well since the ACA is now implemented, I feel like it is fine to let the cat out of the bag. What most supporters of the ACA, who actually know what is going on, have known for a long time is that the ACA is not a long term plan. It is a bridge to a single payer system.

It was a brilliant plan that the GOP either didn't see, or are acting like they didn't see. The ACA was written in a way so that it is impossible to repeal it. It is impossible to go back to the "old" system. The only option from here is to move to a full single payer system. This is why the GOP only has fake votes to repeal it while never proposing anything to replace it with...just flat out repeal it with no plan. They know they can't do that, but they also know that their base eats up these fake votes because it makes it look like they are doing something.

This is while I have always supported the ACA. Not because it is the perfect solution, but because it will get us to where we need to be with a single payer system.

The "problem" the ACA was designed to address wasn't that millions of Americans were not PROVIDED with healthcare rather that there were millions of Americans not PAYING for healthcare.

Payday for the healthcare industry - plain and simple.

Here's a question (rhetorical) - why didn't they add a provision that the act could be abolished if overall healthcare costs did NOT go down after X number of years? I mean, wasn't that the whole purpose in the first place? (as sold to us dumb 'mericans)

If the government itself, not the insurance/drug mfgs, wanted to provide health insurance (not healthcare) to those who didn't have it they could have done this with a ONE PAGE law! "All those who make less then 35k and do not have insurance, and want it, can sign up for Medicare."

This "law" was created by the insurance companies who knew all the details about your personal health spending, they set the premiums and the deductibles to make sure they paid out as little as possible. This was accomplished because the American Populace is the most ignorant, uneducated, simple minded populace of all time.

The populace does not know the most basic thing about their own economics. They do not understand the percentage of money they spend on each expense for living. They cannot read, or write, their own balance sheet. They think insurance is a prepaid PLAN and not a system whereby an company profits for refusing as many claims as possible.

The populace is so ignorant they parrot the insurance company created talking points to explain this fiasco without knowing the first thing about how insurance works to secure profits for the shareholders and the drug companies.

This was all made possible because the populace is 100 percent, 100 percent, mind controlled by the PR firms that create the memes used to enslave them. Ask any "American" if they want "socialized medicine" and you'll get a 2 minute meme lecture on the horrors of socialism. Ask them if the want "free healthcare" and they'll demand it, and they truly believe there is such a thing as free. Ask them if they don't mind paying for that free stuff and they'll say, "as long as it is fairly distributed" and they they'll shoot you for calling it socialism.

Let us note that the "healthcare" provided from this free system is one that only allows for the APPROVED healthcare. Chemo therapy is approved, even though the over 5 years remission rate for those taking it is nil - nil. But if I want to buy x, y or z to cure my cancer the "free" system will not pay for it as it is not approved. I can get Statins to control my cholesterol but I can't deduct the food I need to eat to reduce it. I can get mind altering drugs but I can't get nutrious foods. My food expenditure is taxed, my "free health" care payments are also going to be taxed. I am expected to avoid healthy food in order to pay a corporate insurance company money or I will be fined - let that fact sink it.

This "law" was such a mess that the only way the SCOTUS could allow it to happen was to call it a tax - 350 million people in the US and no one but Roberts was calling it a tax. He's a genius.

The populace deserves this and more. They are slaves with the mentality that makes slaves of yore look like Einsteins. The landscape of this country is going to look very different in two years, it most ways it will be unrecognizable to most, and it will all be as a result of the phenomenal ignorance of the people living today.

I know, I know for a fact, that using this same theme I could sell the population on "free cable." I could claim that entertainment and news is a basic human right. I can show people are happier and healthier when they have 1000 channels. I can show how if we all buy cable we'll all be better off as those who are now paying for cable will no longer have to subsidize cable for everyone. I can pass a law called the Entertainment Happiness Law. I will let the cable people raise their rates prior to the law and make another law that prevents them from lowering rates. And the populace will worship me.

a reply to: Wrabbit2000 the founders said that if we don't put medical freedom into the Constitution there will be come a day when it will turn into a medical dictatorship. they were right.

medical doctors kill and injure 15 .2 million Americans every year, millions of those are just from not washing their hands after going potty

a reply to: AboveBoard

I don't know how it could be said any better. There is certainly room to improve, and any future efforts should move towards that end rather than another 100 failed attempts to repeal.

. Medicare Advantage patch: The administration ordered an advance draw on funds from a Medicare bonus program in order to provide extra payments to Medicare Advantage plans, in an effort to temporarily forestall cuts in benefits and therefore delay early exodus of MA plans from the program. (April 19, 2011) - See more at: www.abovetopsecret.com...

Gee and to think that medicare was not even paying for itself already.

So much that even printing fiat currency, borrowing fiat currency, raising taxes on the evil rich by creating the 'alternative minimum tax' that was suppose to cover the difference!

But wait it get's better!

Then they created that medicare surtax on capitol gains that supposedly targeted them evil bloody rich folks, but hits every single American that has a pension,IRA,401 and other investment account!

Taking an advance on money that ain't even there ?

That is effing 'brilliant' !

Which is par for the course of the party that thinks money grows on evil rich trees.

a reply to: crankyoldman

If the government itself, not the insurance/drug mfgs, wanted to provide health insurance (not healthcare) to those who didn't have it they could have done this with a ONE PAGE law! "All those who make less then 35k and do not have insurance, and want it, can sign up for Medicare." - See more at: www.abovetopsecret.com...

The government itself is this countries largest 'private' health insurer.

Between Medicaid, and Medicare that accounts for over 100 million people.

1. That is larger than EU countries entire populations.
2. It is a 'single payer' that works by printing, and borrowing, and taxing the difference that hardly anyone is paying for.
3. Even since the creation of both programs of government ran 'healthcare' even 50 years later private health insurance runs circles around 'government' ran.

Better coverage, more coverage than what either medicare, and medicaid 'provide'.

So the reality is no the government does not want to provide anything that works, because if the did they would put themselves out of a job.

So they provide job security for themselves by writing trash laws that were not needed like the ACA.

Point of fact both Medicare, and Medicaid were created SPECIFICALLY for those who 'fall between the cracks' as they say.

If there was any 'uninsured' people left in this country it was the US government was doing the discriminating.

But of course under the Reagan administration a little know law was passed called the EMTLA

he Emergency Medical Treatment and Active Labor Act (EMTALA)[1] is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals to provide emergency health care treatment to anyone needing it regardless of citizenship, legal status, or ability to pay

en.wikipedia.org...

So when they say people were dying in the streets because they didn't have health insurance they were lying.

When people say the ACA is suppose to make healthcare 'cheaper' they were lying simply because anything government does is a cluster eff, and can be basically summed up as 'everyone is using it, hardly anyone paying for it'.

The only thing they want to is destroy the 'free market'.