Monday, January 16, 2017


I know everyone hates Obamacare, but there's this thing called the Affordable Care Act that's actually pretty good, and I hope it sticks around.

Seriously though, I would say that I'm a fan of ACA and I think it will be a mistake to repeal it with no replacement in mind.  Some stuff about ACA that is really great:

--No denials for pre-existing conditions.

--Free preventive services for women

--No copays on birth control -- something that's actually CUT BACK on abortions

--Premium equality that keeps insurance companies from charging exorbitant amounts just because you're over 50 or a woman

--End of lifetime caps on medical spending.

Just to name a few things.

One thing that some people argue about is the mandate to purchase insurance.  For the record, I read that Republicans were in favor of this mandate prior to it becoming a staple of ACA.  Anyway, there SHOULD be a mandate to have health insurance.  Because hospitals have a mandate to treat people who are having an emergency, which is something that you don't have in any other industry.  You can walk into an ER and be treated without any proof that you can pay.  Where else can you do this?  You can't walk into a car dealership and get a car without proof you can pay for it.  You can't walk into a supermarket and buy a candy bar without proof you can pay! Yet you can easily wrack up tens of thousands of dollars in hospital bills without any money in the bank or health insurance.

So until we start saying that hospitals can turn away people from the ER (which obviously, would be horrible), then there NEEDS to be a mandate that people should have health insurance.

Everyone needs health insurance.

But if there are any better ideas out there than ACA that Paul Ryan is keeping secret from us, I'd certainly be open to listen to it.  God knows, the ACA isn't perfect.  But it's just better than taking away health insurance from 20 million people.


  1. You are entitled to your own opinion but not your own facts.
    Various republicans have presented several alternative plans for healthcare/insurance reform. Harry Reid wouldn't bring up them up for debate.
    If you've paid any attention at all, there's this guy named Tom Price who's been in the news a fair bit recently who presented a plan numerous times to the legislature.

    1. Link? I have seen article upon article saying there's no replacement plan and literally no reasonable replacement plan. Ever. And I read the news a lot.

    2. Many Republicans and Republican-linked think tanks have offered alternatives, including Mr. Price. The issue is that the party itself has not picked any of those plans as an official "replacement."

      Healthcare Triage did an excellent piece back in November covering the various proposals -

      The major question right now is whether the House and Senate leadership can get the moderate, fiscal hawk, and religious parts of the party to actually agree on specifics. So far, there is no evidence of that happening.

    3. Yeah, I've been reading a lot about it and never heard anything held up as The Replacement. The plan from Price leaves a lot of gaps in coverage, and goes back to the issue of refusing care for pre-existing conditions, which is ridiculous. You can't get something for nothing.... the only way to pay for health care for sick people is for healthy people to not wait to enter the pool until they're actually sick. One way or another, we'll pay for it when they end up in the ER.

      I wish there were another way. And I really wish this didn't have to be a partisan issue. I wish the Congress could all work together to fix issues with ACA. More than anything else, I'm frustrated with partisan politics... as are a lot of people, which is probably part of why Trump got elected.

    4. So I see you agree there are other plans. You just don't like them.

    5. Fizzy, I think part of the problem people have with the preventative care mandate as it stands is that it is much cheaper to pay the penalty fee each year than it is to buy insurance. So why buy it now when you are healthy when you can just wait until you know you need major medical care and then buy it since they cant refuse to sell it to you?? I agree there are some good pints in aca like no maximum lifetime limits. and you really shouldn't equate hospital care with buying candy. And I actually have a friend who makes 8 bucks an hour. The cheap plan even with subsidies was 300 bucks a month. Which sounds great until you realize it would be more than an entire paycheck for her... Yet she makes too much to qualify for medicaid services.

    6. Anon: The reason to do it is that if you get unexpectedly sick and are in the ER, you won't go into debt to pay your medical bills. That happened to a friend of mine who let his insurance lapse without realizing it.

      Kassy: I've never seen that plan you mentioned brought up without having to search for it just now (despite the fact that I read a lot about healthcare), which makes me think that they realize it's no better than ACA. Certainly it's not being pushed forward as the replacement for ACA right now.

    7. So, once again, you agree there are other plans.
      They need to be debated in the legislature and committees.
      Something Harry Reid prevented dozens of times while he headed the senate.

  2. Generally speaking, we are all in deep doo-doo.

  3. Price does have something of a plan. It has to do with giving grants to states for their high risk insurance pools. I had one of these plans. It would not cover the my heart (a pretty minor congenital abnormality that was the reason I was in the pool to begin with.) And I was about 25 and extremely healthy at the time. Buying private insurance through the individual market was a total racket before ACA. High risk insurance pools were an expensive non-fix. And that's Price's plan. So there you go.

  4. You sort of hit the nail on the head. "Yet you can easily wrack up tens of thousands of dollars in hospital bills without any money in the bank or health insurance." And you can walk away completely.
    Sure, you get lots of nastygrams, your credit rating takes a hit, depending on where you live you'll pay a portion of that debt through a tax refund. But only if you file a return application, which I'm told a significant portion of the population doesn't. So I guess it's okay that the hospital is out that money?
    Maybe I misunderstood the use of the word "Affordable". A friend of mine owns her business and once the website stopped crashing she looked up her premiums. The fine for not getting the "affordable" coverage was lower than the premium she would have been charged.
    The rising cost of healthcare is not the problem, it's a symptom.
    Hospitals, clinics, physician's offices all have their own debts that they need to pay off.
    Testing of drugs is expensive (and yet we have an almost limitless supply of guinea pigs sitting on death row, but that's another debate).
    Medical school is expensive. I'm told that doctors being churned out today are handed a diploma and a bill for a million dollars or more. It's hardly surprising that the majority of students in American medical schools are not American citizens.

    1. "The fine for not getting the "affordable" coverage was lower than the premium she would have been charged."

      Well, I don't think it's that surprising that the cost of getting health insurance is more than the cost of not getting health insurance. The fine should simply be enough to make people feel like it's worth it to get the health insurance, given that it's actually nice to have health care outside of the ER.

    2. It is not true that the majority of students in American medical schools are not American citizens (1). Also, medical school (while expensive for sure) does not cost anywhere near a million dollars (2).

      This is a good link to see what is going on with health care costs:


  5. I agree everybody needs health insurance.
    But not the "affordable" care act plan which is everything but affordable.
    For our family (individual+spouse+children, we pay $2,500 per month. Yes you read it right! Remember when you were saying your daycare was expensive! I am sure it does not compare to that amount.
    And you would think with this sticker price, our plan would be the greatest on the market. Not at all! My daughter broke her arm - and a copay of $90 for each X-ray and $50 for the visit. Total: about $700!! Strep throat? $50 copay for the visit. etc, etc, etc.....
    So yes I can't wait to see what Trump will come up with!

    1. Actually, my daycare cost $40,000 the year i was bitching about it, so it actually exceeds that amount :) But yes, I agree, it's a lot. I agree it's too much to expect a middle class family to pay. Hmm... what if instead of making health care insurance like a flat tax, make it sliding scale based on income? So you wouldn't be expected to pay the same amount as a millionaire for a service that every human being should be entitled to. I'm sure that will be part of the Republicans' new plan!

      I want to be excited about something better than ACA, because I know it has problems. But I worry that it won't, because the Republicans don't have a stellar record of helping the middle and lower classes.

    2. "every human being should be entitled to health insurance" Completely agree. The scale based on income is a great idea!
      Let's see what they come up with. And if they could get rid of the "in-network/out of network"- it would be wonderful. I HATE switching doctors because either I have to switch insurance or doctors drop mine without warning... I feel that every individual should be free to chose his/her own doctor. I have known my ob/gyn for 13 years and she is dropping my insurance.
      Was the $40,000 for daycare for both kids? if yes, it is comparable to what I paid for my kids and I know the feeling... There was a time my paycheck was not enough to cover daycare for 2 kids.

    3. I agree with everything you said. My issue is a lack of optimism that the Republicans will fix anything, only make it worse. Why not work on improving the system we have in place instead of starting fresh with something that will have a new set of problems?

    4. Not sure which state this person lives in. In my state (Washington) you can enroll any child in the kids medicaid - regardless of your income - and pay a sliding fee for premium based on that income. We enroll two individuals plus kid and we pay more like $650/month this coming year -after our premiums increase. And this is without qualifying for a subsidy. Maybe there's a huge difference in each state in terms of what plans are available and their prices? ... All I know is having shopped on the individual market prior to ACA the options now are a) Much better b) Actually much cheaper, for those paying the full freight. It definitely sounds expensive compared to employer sponsored plans. But you are in the marketplace because that's not an option. So at least you have an option!

    5. One issue is that the govt has been providing money to states to bridge the gap to expand Medicaid. Unfortunately, certain Republican governors have turned down this money because... they hate their low income residents? I actually have no idea why they would turn down free govt money to help their residents get health care, other than to make ACA fail.

      That's what pisses me off the most. Health care should NOT be a partisan issue. Both sides should be working together to help everyone get health care affordably!

    6. This comment has been removed by the author.

    7. Actually governors in Republican states didn't take the money because the money came with a time frame and strings.
      So Medicaid would expand adding thousands of people to the Medicaid roles. After a few years that federal subsidy would disappear and the states would have a huge unfunded mandate on their hand.
      Unlike the federal government, they have a balanced budget requirement and can't print money.

    8. Actually, Kassy, in a few years, the federal subsidy goes from 100% to 90%--it doesn't disappear. Specifically, while the Federal government pays 100 percent of the cost of Medicaid expansion for 2014 through 2016, that share falls to 95 percent in 2017, 94 percent in 2018, 93 percent in 2019, and levels off at 90 percent for 2020 and beyond. And even paying that 10% is probably better than subsidizing all the people who use the ER for their health care.

      This is why I'm glad you deleted that line you wrote about not having a discussion about this if you don't know all the facts. I'm happy to be able to educate you. ;)

      Seriously though, nobody knows everything about ACA. It's confusing as hell. But we shouldn't treat this as a partisan issue that we're slinging mud about. We SHOULD be educating each other in a nice way in order to find the best system to help our fellow Americans. You seem really angry and I'm not sure why.

    9. Actually, not one word of what I have said has been untrue.
      The only quibble would be reduced instead of disappear.
      That still adds significant cost that the state now has to shoulder.

      And as you well know, doctor work that is unpaid is just that, unpaid.
      The ER doesn't just get an infusion of money from magical money trees(like the federal government does) when it sees a bunch of patients that don't have a pay source.
      And even though it may charge $7,000 for a 2 hour ER visit, virtually(added just in case there is 0.01% that do)no one on this planet actually pays that.

      And yes, I deleted the line. I realized it was snarky and shouldn't have sent it and deleted it almost immediately.

      And yes I am angry. The government is killing my job. Which is weird(not really as the government screws up everything it touches practically) as the government gives a lot of lip service to what it calls primary care but then almost every thing it does actually hurts primary care.

      Obamacare is admittedly only a small part of it. However, according to almost any measure, Obamacare has failed to do what was promised(as predicted by almost anyone who bothered to look at it at all)

    10. Kassy: I agree that ACA has major issues. However, now that I've read about Price's plan, that doesn't sound like the solution either. What do you, as a PCP who obviously cares a lot and is educated about health care, think would be a good solution? I genuinely don't know the answer.

    11. It can be a long discussion and one I don't have time for in the 5 minutes before my lunch second ends.
      However, at the core, we have insurance pay for all kinds of things that it shouldn't pay for. The care of an internist or family doctor in the clinic is really cheap. The absolute most expensive thing I do(excision of a malignant skin lesion that requires revision of the wound for closure) costs about $400. I do one of those once or twice a year. The most expensive thing I do frequently would be a level 5 new pt OV. Obviously a patient only incurs that cost only once at most and only if they have extensive history or problems. That charge is about $175 or so.
      Typical OV is about $70-$90. Even sick patients are seen 4-6 times/year. For a total cost of under $600. Labs, if prices not ridiculously inflated, costs under $100/year to monitor DM/HTN/cholesterol/CKD/gout/thyroid. For a grand whopping total of <$1000 for my really sick patients to see me in clinic all year.
      It shouldn't involve insurance at all. Most people could afford that(especially if there insurance premiums dropped 20%). And my rates would go down as I wouldn't have to have an army of staff to fight with the insurance company to get the $70.
      For those who truly can't afford the <$500( for the medium chronically ill pt), than a tax-funded slush fund(HSA, FSA, whatever name/alphabet soup you want to attach to it) could be used that would not run thru the insurance clearance but would just be used to pay for 'primary' health care.
      This $500 for the poor to relatively poor is far less than the amount wasted on insurance for the same service.
      And please, can I stop writing a dissertation for everyone with a cold just so the insurance company will pay me. All that really needs to be said is 'URI'.
      For specialist procedural care(in the office I would make same argument as above) than insurance is more likely needed but if we aren't wasting millions on processing $70 claims than there will be more for the more expensive procedures.

    12. My concern is if we made people pay out of pocket for PCP visits including prev med, would they go even if they could afford it? Would women get their yearly paps and breast exams if they had to pay out of pocket? Some would but I bet there are plenty who would skip it. And then you end up with more serious, costly conditions.

      I like the idea of giving all people a tax-funded slush fund specifically for outpatient health care that they could use entirely at their discretion, based on how much income they have. And then save health insurance for hospitalizations and surgeries and the like.

      Unfortunately, the American public is extremely resistant to change and I highly doubt anything that far from our current system will ever be passed. And the truth is, I worry that no matter what, the govt will just muck it up. I have no trust in them anymore.

    13. At some point some personal responsibility has to come into play.
      Never mind that no organization recs yearly PAPs(despite the fact that virtually all GYNs do them) and breast exams are actually rec'd against by the USPTF as well as ACOG(I believe on ACOG, I am sure on USPTF) as there are far more false positives than true findings.
      But fine, make preventative care covered. Just don't cover your routine f/u for chronic conditions. And if you don't care enough about your HTN/COPD/Asthma/DM/CAD/etc to spend far less than your cable bill on it, than I really am just not sure why I should either.

      But I'll just concede that too just to make the point. Mandate a minuscule percentage of your income to go into this 'slush' fund and then a progressive tax to cover the rest of the 'slush' fund. Everyone contributes a little(Even if you make $10,000 a year and contribute $100[that is 1%]) and those who pay taxes cover the rest. But with essentially no administrative costs from either the government/patient/or doctor side it would save a ton of money. %20+ of every dollar that comes into my business is spent collecting the money I am owed. Drop that to 1-2%(front desk staff pay essentially) and we've saved millions(if not billions).

    14. Ideally, I think personal responsibility should come into play, but realistically, I don't think it will. If a patient doesn't take care of their diabetes, what do we do when they arrive at the hospital in florid renal failure or septic from the osteo they never had treated? Unless your answer is to let them die at the door, the cost will be passed on to everyone else.

      100% agree that paps are overdone. I have yearly IUD checks and the OB will just "throw on" a pap since they're down there, in spite of never having a positive and being negative for all HPV on testing. I think I got involved in an argument about that on here ages ago. But there is certainly other prev med that's worthwhile.

  6. There is nothing affordable about Obamacare-this year my premiums went up $100 a month, I am now skirting $1000 a month for my healthcare. The website is trash and keeps crashing, the doctor directories are inaccurate, I could go on and on, but I say, if the Republicans are going to pull a rabbit out of their hats, let's do it now.

    1. People are paying a lot more than I am. What state are you in? I get decent care. I and my husband aren't 100 percent "well." We are young and active but with more than our share of bad luck. And I am grateful to have the plan I have and be able to pay for it. It allowed my husband to leave a job that was killing him to work for himself. It costs more, of course, than having your employer foot part of the bill. But we can afford it and we are NOT well off. Health care is a basic cost like food and housing. Costs are too high. That is not ACA's fault. It's at least a first draft to address the problem. There is no rabbit unless the Republicans want to get behind Medicare for everyone. That would be great!

    2. I looked what it would cost me and my family to go on Obamacare. $13,000/yr for the crappiest plan with $10,000+ deductible and 50% coinsurance once deductible met.
      And it is, in part, the ACA's fault as it mandated coverage for things that aren't really needed to be covered. Cheap things become expensive when a subsidy is applied(she college cost, home prices with easy mortgages for some examples within last decade or so)

  7. If you got rid of 75% of the admin, stopped all payments from hospitals & the like to lobbyists and "causes" that were not directly for the welfare of patients, dumped 80% of the lawyers,

    health care would be affordable.

    The other part of the problem? Get Saturday am appts. for specialists. Get 70% PCP's & 30% specialists vs. 30% PCP & 70% specialists. Pay the PCP's more and keep adding NP's and PA's.

    Stop making the EHR's cost millions of dollars and take a lot of that $$$$ that Miss Judy F is making into health care.

    After that, start charging McD's a load of taxes for the contributions they and others make to problems in health for that abomination they call food. Do food trucks with real food and show people how to make it in schools and other learning channels.

    Health care will be affordable for any one.

    1. Even better, we could eliminate life prolonging treatments on terminal patients that results in spending more on the last 6 months of their life than on the entire rest of their life.

    2. Slippery slope here-who makes the decision, the grieving family who wants you to pull out all the stops-or YOU?

    3. If it's a slippery slope, I'm not sure why we always have to err on the side of keeping people alive as long as possible. We should err on the side of ending pointless suffering. What's worse... to pull the plug on one 90 year old who might have lived another ten years in good health, or to make thousands of 90 year olds go through pointless painful procedures that likely do nothing to prolong their lives? In this country, we always err on the side of the former. Why???

      All I know is that my own grandmother was offered and given surgeries at the end of her life when she was essentially in a coma that the doctor knew (and told us) she would never emerge from. We were allowed to do it... and FORCED to do it because one family member wanted it. It was horrible. Just because we can do something, it doesn't mean we should.

    4. One short step away from saying "Well, no hope here, just let me give her this shot and it will be all over." Death squad, anyone?

    5. If you want to scare people, you can call it Death Squads. Or you can call it:
      Letting nature take its course
      Letting people die with dignity in their own homes rather than in a hospital with twenty tubes in their bodies

      If you ask most people, they want: to die with dignity, in their home, with their loved ones, without being a burden. They don't want to live as long as possible at any cost.

    6. Good point-people should make their wishes known in advance!

    7. One point I can agree fully with Fizzy.
      How many times have I stood in the ICU with a patient's family while they just completely ignore everything on the patient's living will.

  8. I live in Canada (where health care is 'free') and everyone is forced to pay in. The money comes through general revenues, so income tax, business tax, consumption tax, etc. Health care accounts for up to 40% of our provincial budgets, so we really do get taxed at a high rate. But no one goes bankrupt because of medical bills (unless they get sick in the US!). Forcing everyone to pay in works well because everyone goes through stages in life where they tend to be higher users of the system (ie. start and end of life).

  9. The issue is someone has to pay the bill. For all things people like the bottom line is like auto insurance the good drivers pay for the bad drives. For ill people, their will need to be healthy people that pay for the care. This is the basis of any kind of insurance. People don't like to pay for something they don't use. I don't like paying for care insurance since I haven't been in an accident "knock on wood" in nearly 30 years. Yet we are legally required, in my state, to carry car insurance if you want a legally registered car. For health insurance, everyone really needs to by into it to make it work. The risk pool should be huge to make it affordable.

    As mentioned above advance care planning needs to take place sooner and not during an ICU visit or in the ED. If someone has a chronic disease the seed needs to be planted close to the time the shock has warn off. Then needs to be discussed as the disease progresses. The discussion needs to be about, at some point the benefit of treatment will likely hasten demise, or the likelihood of benefit will be miniscule. What are you goals at this point?

  10. I thought the whole point of ACA was to manipulate people into deciding that socialized medicine would be better than having people take personal responsibility. We're headed that direction.

    Before Obamacare, my family premium was under $800 per month. The "affordable" care act hit, and the premium immediately went to $1200. It's gotten even more "affordable" since then, and at over $2,000 per month, my insurance costs more than my house payment. My deductible used to be $200; it's now an "affordable" $1200. My out-of-pocket max used to be $1,000; it's now triple that. Not only have my copays doubled, but I only have a copay for the first 3 office visits of the year; after that, then entire visit is charged toward my deductible. I have a different definition of "affordable" than the politicians do.

    Despite the law, many families don't have insurance. They don't think they can afford it. I think the 2016 penalty tax for not having insurance is $2085. That's less for the entire year than I pay every month. How is that a penalty? It's a whopping $24,000 a year savings! If the true goal was to force people to buy insurance, then then penalty would be double what the premium would have been if they'd just gone ahead and bought insurance.

    I think our society has to decide what it wants. If we say that everyone must have insurance, then the only way to do that is for government to provide the basics to everyone and give people the option of upgrading coverage on their own. That raises taxes. Or do we say that we want people to take personal responsibility for their lives? My personal inclination is to have the government get out of people's lives and not pay for any medical care (except continuing with seniors who are just getting what they spent their entire working life paying for). Let people hire the doctors they like. I wonder how much the cost of care would come down if insurance companies and all their red tape were eliminated.

  11. Fizzy, What's worse... to pull the plug on one 90 year old who might have lived another ten years in good health, or to make thousands of 90 year olds go through pointless painful procedures that likely do nothing to prolong their lives"

    The same can be said for criminals and the death penalty then. Why is it better to keep 1000 guilty people alive just in case 1 might be innocent? Big old waste of money to house and feed everyone. Once they are pronounced guilty, off with their heads. Same logic. But I bet the 90 year old and the innocent person might feel different if we erred on the side of life instead of cost savings. That being said all written living wills should be honored to the T regardless of family opinions. And it is hard as hell to watch someone you love starve to death because of refusal of a peg tube. I made that decision for a loved one and it haunts me every day.

    1. I am against the death penalty because is it applied extremely inequitably among races, and it is at least twice the cost to apply the death penalty compared with non death penalty cases. I don't really think the comparison is appropriate though, because one involves murdering someone and the other involves simply allowing nature to take its course with comfort provided so they don't suffer through it. I think you made the right decision for your loved one. Don't let it haunt you.

  12. I am so glad you are such a big fan of ACA. Before ACA my insurance cost me $50.00 a month and I had a $350.00 a year deductible. I did not have maternity coverage. But I really did not need it being 60 years old and had a vasectomy 25 years ago. My wife was 60 and been in past menopause since she was 50. I also use to get 35 to 40 hours a week. We were doing OK. Then ACA came and made my whole life so much better. My company sent me a letter telling me my coverage did not qualify because it did not have a maternity rider on it. So it was canceled on Dec.31 2010. In addition, because of the hourly requirements that ACA has in it, my hours were cut to 24 to 28 hours a week. MY property taxes have gone up. Our food prices have gone up.My utilities have gone up. I have state medicaid. Oh boy are they fun people. Every couple of months they decide somewhere I have gotten a huge raise and make $20,000 more a year than I do. Sure wish my bank account knew about this huge increase the medicaid computer assigns to me. I have to reapply about 3 times a year. Yea, ACA has really made our life better.

  13. Thanks to the ACA, I no longer have insurance of any kind. I had wonderful insurance. $137 a month, $2k deductible, $20 doctor copay, $50 ER copay. Then along came Obama and his excellent ideas. Now, I cannot afford insurance at all. I'm exempt from the fine. But I'm still screwed no matter what. Thanks for that.