Trumpcare

[Brian]

I’ve browsed the last few pages of discussion here and that got me doing a little of my own research.

(Incidentally, I live in a country with a universal health care insurance system, namely Australia.)

 

Detailed OECD health statistics are available here.

What strikes me is how similar outcomes are for all OECD countries. For me the most significant feature is how rapidly health care costs as a percentage of GDP are escalating in all countries.

The similarities got me thinking about what actually most effects health outcomes.

 

I then checked how income effects life expectancy, especially in the USA as the only significant developed country without universal health care.

 

Firstly, across all countries, the Preston curve indicates that individuals born in richer countries, on average, can expect to live longer than those born in poor countries. However, the link between income and life expectancy flattens out. This means that at low levels of per capita income, further increases in income are associated with large gains in life expectancy, but at high levels of income, increased income has little associated change in life expectancy. In other words, if the relationship is interpreted as being causal, then there are diminishing returns to income in terms of life expectancy.”

 

The Association Between Income and Life Expectancy in the United States, 2001-2014

 

Interestingly, it isn’t so much access to health care that impacts on life expectancy as much as lifestyle and place of residence….

 

“In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time. However, the association between life expectancy and income varied substantially across areas; differences in longevity across income groups decreased in some areas and increased in others. The differences in life expectancy were correlated with health behaviors and local area characteristics.”

 

My conclusion…..

 

This is complex issue with a multitude of causal factors at work but basically in all developed countries health care systems are rapidly escalating into areas of diminishing returns in terms of expenditure versus health outcomes. What we are seeing is both a rapid escalation of life-style related illness and an unwillingness to accept illness and early death as a natural part of the variation of outcomes within any population. For me these are the main issues, as all developed countries have excellent conventional health care systems.

This is why I said earlier that it isn't about life expectancy. If you take the US and Denmark, for instance, the percent difference (not the percentage-point gap but the actual percent difference) between their respective numbers is 2%. There are so many other differences between the two cultures besides healthcare delivery funding models that trying to account for that variance with that one independent variable is pointless. In fact, if that were the metric to be used to evaluate healthcare systems, the number could be affected very rapidly (if disingenuously) by altering other factors instead.

 

The law of diminishing returns is unavoidable here because people die despite healthcare. An important question then becomes, are the parameters and thresholds to be determined organically by allowing the complex dynamic system to float or will we attempt to manipulate them? If the latter, what is the ideal target (and who makes the decisions associated with this manipulation)?

[Geof Nanto]

I'm not an American so I feel no right to criticize their system, but I'm grateful I live in a country where medical bankruptcies don't occur.  

 

As my last post spoke in general terms, I’ll add something about my specific case…

 

About 30 years ago I needed a huge amount of support to overcome both illness related to heroin addiction and recovery from addiction itself. Without access to extensive free medical services I suspect I would not be alive today.  I also needed a few years on income support and was given a rehabilitation pension. 

 

Hence, from a personal perspective, I have nothing but praise for our Australian universal health and social welfare system. (But, of course, I’m not claiming it’s perfect.)  

 

Now I rarely use the medical services and was beginning to resent the couple of thousand dollars that’s deducted from my income annually as a compulsory Medicare levy. However, last year I accessed the free program to treat the legacy Hep C infection I’d been carrying since my heroin addiction days. The old interferon based treatment had such terrible side-effects and a low success rate that I stayed clear of it. The new treatment is excellent and cleared my Hep C with virtually no side effects. The actually cost to the taxpayer for this treatment was well over $80,000 , of which my co-payments amounted to a few hundred dollars. (This almost free treatment is available to everyone with Hep C, with no other eligibility requirements.)  

[Brian]

I'm not an American so I feel no right to criticize their system, but I'm grateful I live in a country where medical bankruptcies don't occur.

 

As my last post spoke in general terms, I’ll add something about my specific case…

 

About 30 years ago I needed a huge amount of support to overcome both illness related to heroin addiction and recovery from addiction itself. Without access to extensive free medical services I suspect I would not be alive today. I also needed a few years on income support and was given a rehabilitation pension.

 

Hence, from a personal perspective, I have nothing but praise for our Australian universal health and social welfare system. (But, of course, I’m not claiming it’s perfect.)

 

Now I rarely use the medical services and was beginning to resent the couple of thousand dollars that’s deducted from my income annually as a compulsory Medicare levy. However, last year I accessed the free program to treat the legacy Hep C infection I’d been carrying since my heroin addiction days. The old interferon based treatment had such terrible side-effects and a low success rate that I stayed clear of it. The new treatment is excellent and cleared my Hep C with virtually no side effects. The actually cost to the taxpayer for this treatment was well over $80,000 , of which my co-payments amounted to a few hundred dollars. (This almost free treatment is available to everyone with Hep C, with no other eligibility requirements.)

Harvoni?

 

I'm told it is an impressive cocktail.

 

 

https://www.harvoni.com/support-and-savings/co-pay-coupon-registration

Edited April 13, 2017 by Brian

[Geof Nanto]

Harvoni?

 

I'm told it is an impressive cocktail.

 

 

https://www.harvoni.com/support-and-savings/co-pay-coupon-registration

 

 

The actual medication depends on which genotype ot Hep C the patient has. Mine was genotype 3 and the treatment was Sovaldi® and Daklinza® (sofosbuvir and daclatasvir) in 1 pill of each, taken once per day for 12 weeks. 

 

I checked out your link for Harvoni and note that it doesn't cover all Hep C genotypes. Also it only subsides 25% of the actual treatment cost which is over $80,000 in Australia. (I don't know what it costs in The USA.)

 

My impression of  American health care systems as regard to cost subsides is that they're patchy, even with insurance. A person can be well provided for, or not at all (and everything in between) depending on where they live, the nature of their illness, and their personal circumstances. 

[Brian]

The actual medication depends on which genotype ot Hep C the patient has. Mine was genotype 3 and the treatment was Sovaldi® and Daklinza® (sofosbuvir and daclatasvir) in 1 pill of each, taken once per day for 12 weeks.

 

I checked out your link for Harvoni and note that it doesn't cover all Hep C genotypes. Also it only subsides 25% of the actual treatment cost which is over $80,000 in Australia. (I don't know what it costs in The USA.)

 

My impression of American health care systems as regard to cost subsides is that they're patchy, even with insurance. A person can be well provided for, or not at all (and everything in between) depending on where they live, the nature of their illness, and their personal circumstances.

You impression is pretty accurate, I think.

[dust]

Interestingly, it isn’t so much access to health care that impacts on life expectancy as much as lifestyle and place of residence….

 

“In the United States between 2001 and 2014, higher income was associated with greater longevity, and differences in life expectancy across income groups increased over time. However, the association between life expectancy and income varied substantially across areas; differences in longevity across income groups decreased in some areas and increased in others. The differences in life expectancy were correlated with health behaviors and local area characteristics.”

 

My conclusion…..

 

This is complex issue with a multitude of causal factors at work but basically in all developed countries health care systems are rapidly escalating into areas of diminishing returns in terms of expenditure versus health outcomes.  What we are seeing is both a rapid escalation of life-style related illness and an unwillingness to accept illness and early death as a natural part of the variation of outcomes within any population.  For me these are the main issues, as all developed countries have excellent conventional health care systems.   

 

Sure, lifestyle must affect longevity. It's been my opinion that this is a more important factor than healthcare. For example in the 1980s, life expectancy for a vegetarian Adventist was ~84, nearly 8 years higher than the average Californian, which certainly suggests lifestyle as an important factor.

 

On the other hand, there are large differences between life expectancies among the world's richer countries. The highest is Monaco (89), where almost everyone is rich and has access to an excellent public health service and a healthy diet. There's a greater difference between the life expectancies of Australians and Americans than there is between Americans and Chinese (82.8, 79.3, 76.1 respectively). Differences between these nations obviously includes differences in lifestyle, but also major differences in access to and quality of healthcare.

[Gerry]

In 1981, medical expenses caused 8% of US bankruptcies. By 2009, that had increased to 62%. This is clearly a problem -- we are talking roughly 0.2% of Americans each year. So...

 

What changed so significantly during those three decades???

Please do not say that the cause of medical bankruptcies is related to the increase in governments involvement in medical costs.

 

However, this is an American issue that should shame us all into the most reasonable solution, UHC.  Now this is my POV, and I am sure that you do not agree.  But what difference does this make.  We both know that there will never be anything like UHC in America.

 

For the moment, that post with all the graph, and my inability to scale them, have left me a bit frustrated and I am worn down by the "he said.... She said" nature of the debate.  So I am going to be on the side line for a while.  I hope I can stick with this choice.

[Gerry]

The law of diminishing returns is unavoidable here because people die despite healthcare.

Again IMNHO, and I believe a demonstrative truth,  in America you are more likely to die [or live] because of your access to medical services based on your economic status.  That is, you find the personal cost of HC driving Americans away from HC services.

 

The ACA moved us away from this truth. I do not see a transition back to a market place HC system as improving HC services for most American.  I am convinced that the 60% plus of American households earning less that $50,000 per year will feel this pain the most.

Edited April 13, 2017 by Gerry

[blackstar212]

No, it is exactly not the Constitution. It is over a century of politicians and federal judges progressively ignoring the Constitution.

 

Personally, I think the Articles of Confederation were sufficient and would argue for the viewpoint of anti-Federalism if we had a do-over.

The articles of confederation. Funny how slavery was legal and you think those documents are sufficient. Duly noted.

[Brian]

In 1981, medical expenses caused 8% of US bankruptcies. By 2009, that had increased to 62%. This is clearly a problem -- we are talking roughly 0.2% of Americans each year. So...

 

What changed so significantly during those three decades???

Well...

 

Turns out that a little research reveals the oft-quoted statistics about US "medical bankruptcies" are highly distorted for dramatic political effect. The 60+% number for bankruptcies caused by medical expenses is, to put it bluntly, bogus. A more accurate analysis shows that medical expenses are a factor (not necessarily the primary factor) in just 17% of bankruptcies. Still too high, mind you, but the numbers presented as "fact" turn out to largely be propaganda.

 

There are a number of analyses available but this one does a pretty good job of identifying the issue:

http://m.content.healthaffairs.org/content/25/2/w74.full

Edited April 13, 2017 by Brian

[Brian]

The articles of confederation. Funny how slavery was legal and you think those documents are sufficient. Duly noted.

Do you actually know what the Articles of Confederation were, or when they were???

 

Lemme guess -- you think this is related to "the rebel flag," right?

[blackstar212]

Do you actually know what the Articles of Confederation were, or when they were???

 

Lemme guess -- you think this is related to "the rebel flag," right?

Not related to the rebel flag. It was the law of the land before the constitution....which was desperately needed....and needs more fine tuning.

[Brian]

Not related to the rebel flag. It was the law of the land before the constitution....which was desperately needed....and needs more fine tuning.

And what did the Articles of Confederation say about slavery?

 

For that matter, what did the Constitution say about slavery?

[blackstar212]

And what did the Articles of Confederation say about slavery?

 

For that matter, what did the Constitution say about slavery?

Absolutely nothing which is my point. Until the 13th amendment

[Gerry]

"god" help me...  I'm still here.

 

I have not read in depth Brian's link just scanned it for now.  From the article"

 

Other data on credit card payments support our previous contention that those with trouble paying all of their bills, not just medical expenses, are most vulnerable to bankruptcy.

 

This does not say here that prior to medical indebtedness, that trouble paying bills was commonly  a household issue and that was already placing these households at the edge of needing bankruptcy protections.  Secondly the implication, as I read this, is some people who live on the margin, our working poor, struggle with finances.  However these households while in debt are not households entering bankruptcy.  What it is clearly saying, as I read this, is if you have an economically challenged household, medical debt will escalate [instantly?] your situation to the point of needing bankruptcy protections.

 

What I also read is a pejorative suggestion that these households were already no better than dead beats by their nature. For a unskilled household to struggle with bills is not an indication of a fundamental character flaw.

 

To personalize this...  My daughter and her husband while working 80+ hours a week earn just above what 70% of households earn.  The husband is employed through a temp agency which renders him vulnerable to intermittent layoffs.  He does this because these temp jobs pay 150% to 200% of the pay for typical  unskilled labor.  These "typical  unskilled" jobs  are easy to get, but they also do not assure a 40 hour work week.  

 

His skill, an Art major, is an area that is hard to find full time employment.

 

When he is between placements they struggle and might fit into the papers pejorative suggestions,  that is their household is tending toward dead beat status.  It is fortunate their health care is provided for by her employer.  Their household is in the 70th percentile of American house holds.  If my daughter lost her position, and depending on the insurance she might secure, their household's  ability to pay their medical costs could force them into a very weakened situation.  Going from the working poor to an  impoverished household is a thin line.

 

If in the worst of all circumstances medical bills pushed their total indebtedness to the point of needing bankruptcy protections, the cause of the bankruptcy would be medical costs even given the associated other economic stresses.

[Gerry]

Absolutely nothing which is my point. Until the 13th amendment

Not true.

 

 

Slavery is seen in the Constitution in a few key places. The first is in the Enumeration Clause, where representatives are apportioned. Each state is given a number of representatives based on its population - in that population, slaves, called "other persons," are counted as three-fifths of a whole person. This compromise was hard-fought, with Northerners wishing that slaves, legally property, be uncounted, much as mules and horses are uncounted. Southerners, however, well aware of the high proportion of slaves to the total population in their states, wanted them counted as whole persons despite their legal status. The three-fifths number was a ratio used by the Congress in contemporary legislation and was agreed upon with little debate.

 

In Article 1, Section 9, Congress is limited, expressly, from prohibiting the "Importation" of slaves, before 1808. The slave trade was a bone of contention for many, with some who supported slavery abhorring the slave trade. The 1808 date, a compromise of 20 years, allowed the slave trade to continue, but placed a date-certain on its survival. Congress eventually passed a law outlawing the slave trade that became effective on January 1, 1808.

 

The Fugitive Slave Clause is the last mention. In it, a problem that slave states had with extradition of escaped slaves was resolved. The laws of one state, the clause says, cannot excuse a person from "Service or Labour" in another state. The clause expressly requires that the state in which an escapee is found deliver the slave to the state he escaped from "on Claim of the Party."

https://www.usconstitution.net/consttop_slav.html

[ralis]

"god" help me...  I'm still here.

 

I have not read in depth Brian's link just scanned it for now.  From the article"

 

This does not say here that prior to medical indebtedness, that trouble paying bills was commonly  a household issue and that was already placing these households at the edge of needing bankruptcy protections.  Secondly the implication, as I read this, is some people who live on the margin, our working poor, struggle with finances.  However these households while in debt are not households entering bankruptcy.  What it is clearly saying, as I read this, is if you have an economically challenged household, medical debt will escalate [instantly?] your situation to the point of needing bankruptcy protections.

 

What I also read is a pejorative suggestion that these households were already no better than dead beats by their nature. For a unskilled household to struggle with bills is not an indication of a fundamental character flaw.

 

To personalize this...  My daughter and her husband while working 80+ hours a week earn just above what 70% of households earn.  The husband is employed through a temp agency which renders him vulnerable to intermittent layoffs.  He does this because these temp jobs pay 150% to 200% of the pay for typical  unskilled labor.  These "typical  unskilled" jobs  are easy to get, but they also do not assure a 40 hour work week.  

 

His skill, an Art major, is an area that is hard to find full time employment.

 

When he is between placements they struggle and might fit into the papers pejorative suggestions,  that is their household is tending toward dead beat status.  It is fortunate their health care is provided for by her employer.  Their household is in the 70th percentile of American house holds.  If my daughter lost her position, and depending on the insurance she might secure, their household's  ability to pay their medical costs could force them into a very weakened situation.  Going from the working poor to an  impoverished household is a thin line.

 

If in the worst of all circumstances medical bills pushed their total indebtedness to the point of needing bankruptcy protections, the cause of the bankruptcy would be medical costs even given the associated other economic stresses.

 

 

Gerry,

 

Could you quote in such a way that anyone reading this will know who wrote it and when. If you click on the bottom right corner you can edit and quote from there. There is a little quote icon on the toolbar on the editor.

 

Thanks

Edited April 13, 2017 by ralis

[ralis]

Trump is threatening to deny funding for the ACA to force Democrats to the bargaining table. More authoritarian autocratic bullying.

[MooNiNite]

Trump is threatening to deny funding for the ACA to force Democrats to the bargaining table. More authoritarian autocratic bullying.

 

losing 10 trillion wasn't enough. deductibles increasing dramatically and insurance increasing by %100 wasn't enough, ACA is garbage. Everything got dramatically worse under ACA and Obama. 

[Gerry]

losing 10 trillion wasn't enough. deductibles increasing dramatically and insurance increasing by %100 wasn't enough, ACA is garbage. Everything got dramatically worse under ACA and Obama. 

 

As an advocate for an American UHC system, I too am not a fan of the ACA.  It was rat sausage made by rat politicians.  The worst of those rats were the democratic rats that worked against making the ACA better.

 

What is interesting is this  "deductibles increasing dramatically and insurance increasing by %100 100% wasn't enough" argument is not generally true.  There are segments of the insured population for which it is more true than not.  Those segments of the insured population are the ones sold out by the rat [fuck] politicians.  These concerns could have been avoided.  These concerns can still be worked on.

 

Insurance companies that make even one cent of federal money in the health care domain should be mandated to provide coverage in the exchanges in all states in which they do any business be that public or private.

 

All health care insurance providers should be mandated by law to be converted into non-profits or be compelled to cease business.

 

A public option should be established with Medicare as the design.  Individual cost would not be uniform across this domain with the variable premiums determined by factors such as gross income.  There should be no "in network" or "out of network" structures.  Participation in this should be voluntary and premiums for these services should be progressive and based on a fixed maximum percentage of an individuals gross income.  If you choose not to be part of the Public option, you could buy private HC insurance.  You could opt to be uninsured, but more conversation would be needed about this choice.

 

To be clear about Medicare as it exists today.  MEDICARE IS NOT FREE HC!

• One needs to recognize that Medicare as structured now is not free HC.  If you paid Medicare taxes for less than 30 quarters, the standard Part A premium is $413. If you paid Medicare taxes for 30-39 quarters, the standard Part A premium is $227.  There are co-pays/deductibles too.

   

• The standard Part B premium amount in 2017 is $134 (or higher depending on your income). However, most people who get Social Security benefits pay less than this amount. This is because the Part B premium increased more than the cost-of-living increase for 2017 Social Security benefits. If you pay your Part B premium through your monthly Social Security benefit, you’ll pay less ($109 on average). Social Security will tell you the exact amount you'll pay for Part B in 2017.  (My wife and I each pay $402.00 per quarter for part-B.    Part B only pays 80% of the cost of services.  Many participants in Part B also buy  secondary insurance to cover this "hole".  Often those secondary plans cover the Part D expences.

   

• Part D premiums range from $10-$100 per month (depending on the plans available in your area and on the partiular plan you choose). The maximum deductible—the amount you must pay out-of-pocket before Medicare will contribute to your prescription costs—in 2017 is $400.

   

So what could be done? You could start by  making these premiums higher or lower by an adjustable set of metrics.  In so doing you create a public option with adjustable premiums.  Those in the highest gross income categories would be "means tested" out of the public option at the point that an individual private policy became more cost effective.

 

No one need be compelled to use the Public Option, but everyone would be be able to buy into it.  I would eliminate Medicaid, VA, CHIP, Native American Affairs HC administrations.  Just one administration for the one public option. Some of the former Medicaid clients could "buy in" but their cost might be near to zero.  {However I would rather that every user pay some amount based on their gross income.}

 

In addition to this public option, private policies sold by the non-profit insurance market should be roughly competitive.   The coverage in both Private and Public plans should be uniform, cover the same basic fixed set of items, but the private insurers might offer coverage for things not on the basic list.  These private non-profit HC insurers would of course be allowed to pair for profit product such and home, auto, and life insurance with their plans.  [see France for limits on payment of services to providers.]

 

Deductibles schedules would be standard with out-of-pocket limits set by one's Gross income. Like wise for co-pays for Dr. visits and Rx costs.  This might be another area for the for profit policies to compete on.  One company might reduce deductibles as an incentive.

 

The public option would be managed by private insurance companies, mostly the same companies, and they too might offer incentives to enhance the list of standard coverage as an enticement to have you as a customer.

 

 

Related though not actually part of a HC system is the absolute need to enhance the tax burden of the top 20% + of gross income households.  Most of this, and why the 20% target mentioned, is the removing of the cap on taxable income for the SS fund.  It is capped now at approximately $125,000.  All gross income must be included.

 

After that the minimum tax rates on the top 5% of gross income need to be enhanced.  On the top 1% it needs to be significantly adjusted.  And then on the top 0.5% of gross incomes it needs to be just plain painful.

 

Edited April 13, 2017 by Gerry

[Gerry]

Gerry,

 

Could you quote in such a way that anyone reading this will know who wrote it and when. If you click on the bottom right corner you can edit and quote from there. There is a little quote icon on the toolbar on the editor.

 

Thanks

 

 

Those were my words,  my daughter.  I still need to read, then read again, the paper in Brian's post.

 

When I wrote "I have not read in depth Brian's link just scanned it for now.  From the article"" I was referring to the link Brian posted.  It is an article on the rate of bankruptcy and the "real" effects of medical expenses on bankruptcy. I still need to read, then read again, the paper in Brian's post. 

 

Edit adjustment:  In my original posting I did use the quote button to quote a single line from Brian's link.

 

This is Brian's link

Edited April 13, 2017 by Gerry

[Brian]

Thanks for going into such detail, Gerry!

 

I think there is much merit in what you have posted. When I put on either my analyst hat or my MBA ha I see big red flags waving; still, it is a thoughtful proposal and that is exceedingly rare among politicians and Internet denizens alike.

[Gerry]

Brian,

 

I just killed a 1000 word RE to you explaining what was still missing from that post, and my pointer on my HYPER sensitive touch pad floated over a link to whothefuckknowswhat.  POOFF! it was all gone.

 

I'll do it again later.  I will re-say what my wife likes to say, "Everyone thinks they should get HC for free.   Well it has to be paid for some how!"

[Gerry]

 

Deductibles schedules would be standard with out-of-pocket limits set by one's Gross income. Like wise for co-pays for Dr. visits and Rx costs.  This might be another area for the for profit policies to compete on.  One company might reduce deductibles as an incentive.

I think it is France where there are co-pay, upfront service costs, paid at the time of the medical service.  However the nonprofit insurance Company has to pay back those fees in a narrow time window.  [i think under 10 days]  It would be easy enough have them returned on a sliding scale related to your  gross income.  My crazy ass brother that "earns" about $15k gets back $20 of the $25 co-pay for his doctor visit.  I get back $1 from my co-pay.  A child's visit has 100% return.    Maybe you add a "you got to stop living in your doctor's office" fine and after my 8th visit in a month I get a co-pay bill for an additional $10/visit that month.

 

"Everyone want to get HC for free.  Somebody has to pay for it!"

 

In France when they do not return the co-pays on time, the company gets fined.

Edited April 13, 2017 by Gerry

[Gerry]

Thanks for going into such detail, Gerry!

 

I think there is much merit in what you have posted. When I put on either my analyst hat or my MBA ha I see big red flags waving; still, it is a thoughtful proposal and that is exceedingly rare among politicians and Internet denizens alike.

 

Brian it is HC costs!  There will always be a big red flag.