TrumpCare, Pre-Existing Conditions, and “Continuous Coverage”

By Lambert Strether of Corrente.

Let me begin by summarizing (from this excellent post by Jane Timm of NBC) what we might politely call Trump’s intellectual journey on health care policy:

As GOP lawmakers begin the process of repealing President Obama’s landmark legislation, it’s worth taking a look at the eight times Trump has changed his position on Obamacare since announcing his bid for president more than a year and a half ago:

1. Repeal Obamacare. Look to Canada for inspiration.
2. Repeal Obamacare. Cover everybody.
3. Repeal Obamacare, but ‘I like the mandate’
4. Repeal Obamacare. Replace it with something.
5. Repeal Obamacare. Not everyone will be covered.
6. I do want to keep parts of it, we might just amend it.
7. Begin to repeal on day one.
8. ‘Be careful’ — don’t take the blame!

Do Trump’s views even matter? Some answer no, arguing that Trump will just delegate everything to Mike Pence, Tom Price, and the rest of the Republican nomenklatura. We’ll see, but I don’t think The Donald sliced through not one but two party establishments like a hot knife through butter with the goal of handing off power to the Mikes and Toms of this world. So Trump’s views matter. We just don’t know what they are! Interestingly, Zeke Emmanuel met with Trump on health care policy. His reaction: “I found him engaged, curious, and he asked a lot of thoughtful questions and had a lot of opinions, as you might expect.” So, whatever the reasons for Trump’s shifting positions, I don’t see them as random. Or focus-grouped, either. So there’s that).zd

That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that’s sensible, since pre-existing conditions skew old, and Trump’s base is older. Covering pre-existing conditions is also the right thing to do, as Trump himself seems to recognize:

Trump has consistently supported requiring insurers to cover those with pre-existing conditions, a regulation called guaranteed issue. “I would absolutely get rid of Obamacare,” Trump said in a February 25 during the Republican primary, but “I want to keep [the provision regarding] pre-existing conditions. It’s the modern age, and I think we have to have it.”

(“Guaranteed issue” is the polar opposite of “medical underwriting,” where, in short form, heatlh insurance companies decline to sell you their product if they determine you are likely to use it[1].) So, millions can breath a sigh of relief? We’ll get to that, but millions there are. From a new study by the Kaiser Family Foundation:

We estimate that 27% of adult Americans under the age of 65 have health conditions that would likely leave them uninsurable if they applied for individual market coverage under pre-ACA underwriting practices that existed in nearly all states. While a large share of this group has coverage through an employer or public coverage where they do not face medical underwriting, these estimates quantify how many people could be ineligible for individual market insurance under pre-ACA practices if they were to ever lose this coverage. This is a conservative estimate as these surveys do not include sufficient detail on several conditions that would have been declinable before the ACA (such as HIV/AIDS, or hepatitis C). Additionally, millions more have other conditions that could be either declinable by some insurers based on their pre-ACA underwriting guidelines or grounds for higher premiums, exclusions, or limitations under pre-ACA underwriting practices. In a separate Kaiser Family Foundation poll, most people (53%) report that they or someone in their household has a pre-existing condition.

(If you think about it, life itself is a pre-existing condition. The body is frail, and gets more frail as we age. Shit happens.) So, suppose ObamaCare were repealed tomorrow. How many people with pre-existing conditions would lose their coverage? This is as much as we know:

An estimated 22 million people would lose their insurance if Congress and Trump implemented the changes outlined in the most recent reconciliation bill [that is, the plan proposed by the Republican nomenklatura

The 22 million thrown off the rolls would be disproportionately likely to have pre-existing conditions, simply because they self-selected for coverge in the first place. And many millions adult Americans with employer covered never be covered again if they lose their jobs and with that, coverage of their pre-existing conditions. Terrible optics, even if we leave the moral issue out of it. In any case, covering pre-existing conditions is very popular:

[T[he provision is one of the most popular aspects of Obamacare; it’s favored by 69% of the respondents to a recent Kaiser Family Foundation tracking poll, including 65% of Republicans.

* * *

At this point, let me interject that the Democrat establishment is choosing to #resist on behalf of a benefit that is not universal. ObamaCare doesn’t cover everybody, either in reality or in principle, and at best, what the Democrats want to do is return to a status quo ante where millions still suffer and die for back of care, because markets. Well played!

* * *

So, pre-existing conditions: We’ll keep them. Which is what the Republicans did when they passed the ” Restoring Americans’ Healthcare Freedom Reconciliation Act” to repeal ObamaCare, which Obama vetoed. Vox:

The bill, introduced by Georgia Rep. and Health and Human Services Secretary-designate Tom Price, left some parts of Obamacare standing, like the requirement that insurers cover young adults through age 26. (That provision is very popular, and possibly harder to tackle through the reconciliation process.) It also left the requirement to cover Americans with preexisting conditions partially intact.

The wee problem is that Price’s bill — and Trump doesn’t necessarily agree — also wants to get rid of the ObamaCare mandate to buy insurance or face a tax penalty. (Granted, the mandate is riddled with exceptions, but whoever would have thought that using the IRS to enforce the purchase of a hated commercial product would have created public relations problems?)

The Senate parliamentarian ruled that all the parts of Obamacare that it repealed — Obamacare’s insurance subsidies, Medicaid expansion, the law’s tax increases, and its mandate to purchase coverage — could be dismantled through reconciliation.

Why is eliminating the mandate a problem? Because when you require guaranteed issue but don’t require everyone to buy in, you create a death spiral:

That’s because healthy individuals would often choose to take their chances without coverage. If they got sick, they could buy a plan in the next enrollment season — and then drop it as soon as they received treatment. The likely result: Premiums would skyrocket and only the sickest Americans would remain insured.

So, you need a club to force people into the market (because markets, also freedom) that’s not the mandate. The current Republican candidate — which, again, doesn’t mean it’s Trump’s — is called “continuous coverage.” Price’s bill includes it:

Price’s Empowering Patients plan, like Obamacare, requires insurance plans to offer coverage to all patients regardless of how sick they are. But the Empowering Patients plan, unlike Obamacare, would let insurers charge sick people more if they did not maintain “continuous coverage.”

ObamaCare Facts gives the detail on how “continuous coverage” would work, as proposed by Price’s bill:

In simple terms, the “Continuous Coverage Exclusion” says “if you don’t have continuous coverage, you don’t have guaranteed issue coverage!”

More specifically, the “Continuous Coverage Exclusion”:

  1. Makes it so insurers can charge you more and exclude coverage preexisting conditions for up to 18 months upon entering a contract (an 18 month preexisting conditions exclusion period”, see page 150 of Price’s law for his version).
  2. … but only if you have a gap in coverage of more than 63 days before entering a new contract.
  3. Meanwhile, anyone who can’t get private coverage can buy into a high-cost sick-pool.

So it turns out that TrumpCare creates second-class citizens, just as ObamaCare does, but using a different mechanism:

CONSIDER: If you forget to pay your bill because you changed your charge card, you can be priced out of coverage for life and have to pay a higher fee for life under this plan. You could also have a lapse in coverage if your insurance application or payment was lost by the bureaucracy. A person could get sick, forget to pay their bill, get dropped, then have to wait 18 months to get treated and die waiting under this plan. The only alternative would be a high-risk pool (an insurance pool for those with pre-existing conditions) which would likely charge very high rates and be state run. Thus, sick people would be forced into high priced government-run healthcare if they wanted to survive, while the rich and healthy would get to continue their plans at lower rates. Please note that “lower rates” are essentially the only benefit of excluding sick people in this way.

And do note that insurance companies have every incentive to game “continuous coverage” by “losing” your payment, sending correspondence to the wrong address, and so on. Given good enough IT, medical underwriting would creep right back in, just as it has under ObamaCare with narrow networks and pricing by zip.

Conclusion

I know it will never happen, but I’d love it if Trump decided to stick it to zombie-eyed granny starver Paul Ryan and smarmy liberal goodthinkers Pelosi and Schumer by lowering the age-limit for Medicare to zero by executive order. Why not? That flight of fancy aside, it’s good that covering pre-existing conditions is a bipartisan consensus — even if a universal benefit like simple, rugged, and proven Medicare for All is not. We’ll have to watch how badly the Republicans screw us, and how complicit the Democrat establishment decides to be.

NOTES

[1] Times-Picayune: “My childhood home was destroyed by a tornado two days before Christmas in 2015. The insurance agent who brought my father a check told him that he’d been a great customer. Why? Because my parents had been paying for insurance since 1979 and hadn’t filed a claim until that tornado. On the other hand, when my house was destroyed by floodwaters in August 2005, I was quickly deemed a bad customer. I told my car insurance agent that I wanted to buy a renter’s policy from him, and he said he couldn’t sell me one. ‘You filed a claim after Katrina,’ he said.” So, like that.

Print Friendly
Tweet about this on TwitterDigg thisShare on Reddit0Share on StumbleUpon0Share on Facebook0Share on LinkedIn1Share on Google+1Buffer this pageEmail this to someone
This entry was posted in Health care, Politics on by .

About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.

95 comments

      1. Lambert Strether Post author

        No, I wish I did, which is why I qualified my statement. On the other hand, Obama seems to have taken a rather expansive view of what executive orders can do…

        My larger point is that there’s really only one way to cut the Gordian knot, which is single payer. So far as I can tell, the Republicans are tinkering round the edges of their already Republican plan. Yes, they will make matters materially worse with the changes, which means making a system already far below world standards even moreso.

        Reply
    1. pat b

      mostly via budgets…
      If the President submits a budget assuming a different medicare age,
      then it’s easy enough to fight for that. It can’t be fillibustered
      but it may affect the deficit.

      Reply
  1. Roger Smith

    Thank you for this Lambert. I love your healthcare plan/feature breakdowns. They are very helpful, especially when trying to cut through the noise!

    Reply
  2. JR

    Continuous coverage is about the only real alternative to the mandate, if the Republicans were serious (which they are not). While continuous coverage offers the potential advantage that free-riding is more strongly deterred, which should lead to overall lower premiums, it would disproportionately harm those who are less educated, poorer and in less stable, more overwhelming situations.

    For example, if you have keep copies of your checks, send payments certified mail/return receipt requested, and reconcile or review your account on a monthly basis, keep records of when you should be getting bills from the insurance company – the ability of an insurance company to play games is limited. (Note that limited is not the same as zero.) Depending on situation and background you might have no idea that you should do this nor the time/energy/resources to do so.

    One could, of course, imagine ways to mitigate those negative effects, but that really is not likely to happen.

    Reply
    1. Code Name D

      I don’t agree. The “free rider” problem distorts the issue of afordabity. Young people do not buy coverage because they can not aford it – regardless of weather they want it or not. Issurance is so expensive its pricing people out of the markets.

      So called “continus coverage” is a typical market solution. “Can’t aford it? Well we will ceep raising rates until you can. If you can aford it, we will keep rasing rates until you can’t.”

      There still are no price controles.

      Reply
  3. Frank Stain

    Are people that hate the mandate because it’s government coercion really going to like the Continuous Coverage imperative? The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance. The imperative of Continuous Coverage says: ‘Do not go without health insurance, because if you get sick, you won’t be able to afford any’.
    This replaces the soft nudge of the mandate with the the very firm stick of inevitable financial ruin and uncurable sickness if you make a mistake and get sick when you didn’t expect to. Why is this preferable to a mandate? Because you can still gamble?
    A subsidiary point: are junk catastrophic plans going to count for purposes of Continuous Coverage once they ditch community rating? Those plans aren’t going to provide anything like the $$ in the system that allow for coverage of pre-ex conditions.

    Reply
    1. ProNewerDeal

      “The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance”

      The mandate is an ATROCIOUS penalty that penalizes people who cannot afford to purchase a crapified health insurance premium, or those that can “afford the premium” but don’t have $6K in emergency savings with which to pay the annual deductible – e.g. can NOT afford to actually use the “insurance”. Reminder: US personal adult median income is ~$30K, & net wealth is ~$37K, so this would cover a large portion if not a majority of USians that you are poor-shaming by saying “fail to be good citizens”.

      Reply
      1. Frank Stain

        I was sort-of quoting the elite liberal line, not trying to poor-shame. But surely it makes sense to call a financial penalty ‘soft’ in comparison to the much harder penalty of financial ruin + incurable sickness if you mess up by gambling you won’t get sick, and then you do.

        Reply
      2. Roger Smith

        Atrocious indeed. It is a way to divert attention from the real problem and blame the perceived personality faults of random people you do not know. With all the talk of Trump being some variation of fascist, I cannot figure out how people reconcile this mandate (or forced auto insurance mandates).

        I have noticed that a lot of the Obama administration’s “legacy” or general work was made by fudging numbers and not actually solving any of the problems at hand. Charging people for not buying a service they already could not afford as a way to punish them into making your numbers look good seems to fit the bill.

        Reply
        1. marym

          The mandate was the trade off to the insurance companies for guaranteed issue.

          Had the ACA been a system that provided universal affordable insurance which in turn provided universal affordable access to healthcare, there would have been a case to be made for it, but as we know….

          Reply
      3. J

        The insurance is for ‘catastrophic’ coverage only. There are many, many scenarios where you could have an MI, stroke, major trauma, cancer, etc. and end up with surgical, hospital, nursing home and rehab costs running into the $1M+ range. The insurance prevents you from complete financial wipeout; it doesn’t exist to make your PCP appointments or Lipitor “free” every month.

        Second point, we can argue all we want about who’s going to pay for healthcare in this country – the individual, the employer, the government, or some combination thereof. Healthcare will be unaffordable to a large degree based on how fat and sick the US population is. It doesn’t matter who’s paying when the average healthcare consumer is now 50+ years old with a BMI of 30+, has diabetes, hypertension, sleep apnea, asthma, and continues to smoke, eat fast food, not exercise and has no intention to change.

        Last point, we do not ration care at the end of life like other countries with single payor systems do. Most of a person’s total lifetime cost of care comes in the last 6 months of life. An enormous amount of savings could be achieved by stopping futile care at the end of life. In my experience, hardly any Americans die at home, everyone dies in an ICU on a ventilator, with multiple IV drips running, often on dialysis too. This is insane. We as a society have to find somewhere to draw the line where certain things shouldn’t be done – like dialyIng 90 year olds…

        Reply
        1. cocomaan

          On the other side of the end of life care cost concerns is that Americans treat their bodies like crap DURING life. Americans, as an insurance pool, are just awful.

          3 in 4 are overweight? 35% are obese? Aging population? Rising infant mortality? Rising adult mortality?

          If we really want to bring costs down, we could start with getting up and walking around a little.

          Reply
          1. nycTerrierist

            People eat too much processed food filled with sugar, bad fats, hormones and preservatives. What could possibly go wrong on a steady diet of dreck?

            We need to work on making healthy food available and affordable for everyone.

            Reply
            1. cocomaan

              We can “work on” making good food available for everyone, but maybe people need to “work on” it themselves as well. Raising your own food is something everyone used to know how to do. Within the space of two generations, that understanding is gone, yet we’re mystified when a set of ag conglomerates swoop in to prey on people who don’t take any responsibility for making a single calorie of their own food.

              I only have so much sympathy on this issue, especially coupled with the sedentary lifestyle. Should we also “work on” getting Americans off the couch? What does that even mean?

              Reply
        2. Code Name D

          So we are back to blaiming the consumer for crapified healthcare. As of obesity is something that can be solved by skipping a few meals.

          Reply
    2. steven

      I don’t think anyone is addressing frank’s point which is:

      In what way is creating a penalty, which tells people who cannot maintain consistent coverage that they can be permanently locked out of the market, better than the individual mandate? The brunt of both approaches is borne by the same people and both approaches inflict pain to coerce behavior. The mandate is a penalty that can be removed at any time by buying a subsidized guaranteed issue policy and the ACA had mechanisms in place to make it feasible to get into coverage. Under repeal, If you have a coverage gap you then face much higher premiums or refusal of needed coverage with no mechanism(such as substantial enough subsidies) to ever be able to afford to get back into the market. Saying that this is better because the government isn’t forcing you to buy insurance, when no one goes without insurance if they can afford it in the first place, seems rather silly. Pushing these people into high risk pools has been tried numerous times in this country and has never worked out as the costs are always enormous and there is never the public will to subsidize the pools to the extent needed to keep them afloat.

      We know perfectly well that the republicans have no intention of providing the level of subsidy that is necessary to get everyone covered because they don’t believe that doing without health insurance/health care is a problem that government should be trying to fix.

      As for lambert’s statement about trump not shaking things up in order to hand power to others:

      Trump doesn’t care about policy and has no views on how his power should be used other than to aggrandize his own name. He is a dreaming narcissist whose views change 10 times in a day depending on what he thinks is expedient. He is the perfect malleable president for congressional republicans, an amoral blank slate driven only by his vision of himself as benign dictator. There is no way to counter the clear and organized agenda of the republican establishment, that now completely controls congress, unless you have some coherent policy view of your own. Donald Trump is going to rubber stamp the republican party’s agenda and then claim that everyone’s problems are solved and most of his supporters will be stupid enough to believe all their problems have disappeared because their all powerful proto-fascist daddy figure waved his big d!#k around and said it is so.

      Reply
    3. Lambert Strether Post author

      > A subsidiary point: are junk catastrophic plans going to count for purposes of Continuous Coverage

      I believe that’s an open question.

      I should caveat that I have the bad characteristic of really hating to break down very, very stupid policy proposals (it was a weakness of mine as a debater). So there are details of the Republican plans that I just haven’t mastered. That’s why I tried to keep this post very simple.

      Reply
    4. Evan Waters

      I find a lot of conservatives are big on this moralistic “PAY FOR YOUR MISTAKES!” approach. If you make one slip-up in guaranteeing continuous coverage, too bad. Not our fault.

      To them this kind of economic suffering builds character.

      Reply
  4. Brian Gates

    LOL at all the people desperately wanting to take Trump at his word. Do you see how the man speaks, his cabinet of pre-civil-rights-era segregationists and billionaire slumlords? I just can’t understand how this continuous blind intellectualizing of his plans fits anywhere with what I see as NC’s socialist/hyperregulated capitalist leanings and ambitions.

    Reply
    1. justanothercommenter

      it doesn’t. but because this site’s main focus is that all of the problems in the u.s. are because the democratic party isn’t leftish enough, it has led to a huge blind spot regarding how destructive the republicans policies are. i was able to go into business for myself because i knew i would be able to get decent health insurance through the aca. and though i don’t make as much money as i did when i was an employee, i have a much greater quality of life.

      and, oh yea, i have now acquired a disqualifying pre-existing condition so i am up the creek once the gop gets done with repeal and gfy.

      Reply
    2. cocomaan

      If you are paying attention, Lambert has been writing these Obamacare columns for years. If we took Obama at his word, the mandate wouldn’t exist because it wouldn’t be a tax, for instance.

      Trying to figure out where Trump is going to position himself on this issue is the real subject of this article, not taking Trump at his word.

      Reply
      1. Brian Gates

        Thats precisely my point. Lambert (and yves) have been kicking ass and taking names with all Obama’s misleading and rumbling. But then they take Trump at his word despite his outward scorched earth campaign at everything good that remains…

        Reply
        1. hreik

          Probably Trump himself doesn’t know where to position himself on almost any issue. Remember, when his law firm interviews/ questions him they always bring / send 2 lawyers b/c he’s so apt to deny what he says…. lol… So 2 witnesses are there to confirm his ‘statements”.

          Reply
        2. hunkerdown

          Well, the Democrat Party shouldn’t have had private positions or tried to exploit the voter for corporate and personal gain (Maddow’s apologetics for Gruber’s frankness at MSNBC), and they wouldn’t be having this problem.

          Reply
        3. Yves Smith

          What bullshit. We can’t judge Trump by his actions because he hasn’t taken any save browbeating some auto companies and not toning down his rhetoric much on his plans normalize relations with Russia despite lots of pressure and criticism.

          The press has pointed out repeatedly that Trump’s cabinet nominees and other key advisors hold contradictory policy views, including in some cases even to the subset expressed pretty consistently by Trump. So contrary to your noisy claims, looking at them doesn’t tell one as much as you’d like to believe.

          Trump has recently taken to saying not to do anything re Obamacare, to let the Democrats continue to own it. He may have figured out first, that the death spiral will worsen, and as the program becomes less popular, it will be less risky to intervene and two, (as Lambert pointed out) whoever, provides a Federal policy for the formerly uninsured is perceived to be responsible for the whole healthcare industry (which is not entirely inaccurate, since IIRC something like 60% of health care spending is actually Federally funded). So better to let the Dems be perceived to be the owners of all the health industry ills.

          Reply
          1. Normal

            Could this be the strategy?

            1. Accelerate the death spiral
            2. Offer the population an awful alternative
            3. A desperate population accepts the awful alternative as better than what they have now

            Reply
            1. Yves Smith

              I don’t think it’s that, although it could be.

              I think it’s simpler. Trump recognizes doing anything regarding Obamcare is messy. It’s also not a priority of his. He does not want Congress working on anything other than his pet issues.

              So his message is if they wait, they are not losing any opportunity because the death spiral will progress and doing something later will be no harder and probably easier than now.

              Reply
              1. Lambert Strether Post author

                > He does not want Congress working on anything other than his pet issues.

                In other words, he doesn’t want to repeat Obama’s mistake in 2009; staking everything on ObamaCare as opposed to, say, dealing with the foreclosure crisis.

                Reply
                1. aab

                  So far, he seems to be demonstrating a lot of political skill. I wish it was the service of better policies. But if he:

                  a) Never brings back TPP or the other hideous “free” trade deals;
                  b) Keeps us out of the Russian war;
                  c) Doesn’t even nibble at Social Security, Medicare and the Medicaid expansion;
                  d) Shuts down the CIA; and
                  e) Puts Paul Ryan in the corner with a binkie…

                  …That’s a whole lot of good coming out of a Faustian bargain of an election. And that list seems reasonably plausible. We need so, so much more. Letting the ACA death spiral is going to be very bad for millions of people. But what the establishment Republicans were talking about doing is even worse. What Hillary was planning to do to it would probably have been worse, and her destruction of the rest of the safety net would have been catastrophic and would have definitely gone through.

                  I’m exhausted just as a commenter with all the people coming here strawmanning and prevaricating. I shudder to think what you guys are wading through that I never see. (By the way, thank you for everything you do, Yves, Lambert, Jerri-Lynn and Outis. Oh, and awesome pro bono lawyer dude.)

                  Reply
          2. ChiGal in Carolina

            Better? As a political calculation maybe. Certainly not better for anybody’s health.

            Not that you would fault Trump for that.

            Reply
        4. Lambert Strether Post author

          > then they take Trump at his word

          Do consider reading the post, where I wrote:

          Trump’s views matter. We just don’t know what they are!

          How is that taking Trump at his word? And where I wrote:

          That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that’s sensible…

          And how is that taking Trump at his word? Trump “seems” to, because he’s been consistent on the matter (at least for Trump). Of course, Trump is a politician (as I point out, pre-existing condition coverage is popular) but Trump is a politician (so he may wish “to be seen to” preserve the coverage, which tees up the later discussion of continuous coverage).

          But do continue to caricature the post! Readers will find it entertaining (up to a point…) Then again, you may be happier at Kos. Try it!

          Reply
    3. Lambert Strether Post author

      > all the people desperately wanting to take Trump at his word

      Not sure who “all the people” might be, which rather robs your comment of whatever point it might have had, no?

      Do consider actually reading the post; the first paragraph should allay your heartfelt concerns about desperation, in the post at least.

      Reply
  5. Tom

    Excellent, excellent snapshot of where we stand during this moment of calm before the storm (or rather, this moment between the current storm (ACA disintegration) and the next, bigger storm (ACA replacement).

    Reply
  6. Waldenpond

    This was for voteforno6

    Here’s what I found:

    [There is no Constitutional provision explicitly giving the president the power to issue executive orders. Article II, Section 1 (“The executive power shall be vested in a President of the United States of America.”) and Article II, Section 3 (“he shall take Care that the Laws be faithfully executed) have been cited as a grant of this power. Even so, presidential executive orders have the legal force of law if made pursuant to an Act of Congress. The authority for such orders can be either inherent or implied. The power is inherent when the executive order is derived from the powers conferred upon the President as commander-in-chief or, in international situations, as head of state; the power is implied when the order represents a reasonable interpretation of the powers expressly granted to the President under the Constitution.]

    and……

    [Only two Presidential executive orders have been overturned by the courts. The first involved a 1952 presidential order issued by President Truman, Executive Order 1034, placing the nation’s steel mills under federal control in order to prevent labor strikes from affecting steel production and thus hurting the national economy.[1] The U.S. Supreme Court determined that the Truman Order was unconstitutional because it overstepped the boundary between executive and legislative powers, holding that President’s power to issue the order must stem either from an act of Congress or from the Constitution.[2].

    The second executive order overturned by a court was issued by President Clinton. Executive Order 12954 prevented the federal government from entering into contracts with organizations that hire replacements for striking employees.[3] The court determined that the Order was regulatory in nature and preempted by the National Labor Relations Act, which guarantees employers the right to hire permanent replacements.[4]]

    My understanding is the executive orders are legitimate if congress has not acted. With all the talk of mcr for all, basic income, ubi, unions, outsourcing, taxing the parasite class and guillotines, that movement needed to win or it will be crushed and I imagine the Ds and Rs will quickly rectify this in the next 2 to 4 years so if the wealthy were unfortunate enough to get someone like Sanders who might do something like this, it will be off the table.

    Reply
    1. grayslady

      Executive orders mostly work for issues that don’t require congressional funding approval. Based on your excellent brief summary, Trump could probably lower the age of Medicare by Executive Order, but then he would have to find a way to pay for it. My memory may be faulty, but I believe that only Congress can impose taxes, not the President, so Trump would still need to propose a method of paying for Medicare-for-all that Congress would approve. Even if he found a way to pay for healthcare that didn’t require congressional funding approval, if the funding source was considered to be too outrageous, Congress could impeach him.

      Reply
      1. Waldenpond

        Rs were complaining that just 9 of Os eo totaled $31 billion. There are lists of executive order disposition tables and the difficulty of cataloging the costs of executive orders is historical so I am not sure funding is the issue.

        Also, I’ve found a history of eo relating to medicare…. adjustments to programs, experimental programs etc that require funding and none have been overturned. I haven’t been able to find if age adjustments or income adjustments have been made to programs by executive order although, if I understand correctly, all ages are eligible for medicare based on ss disability eligibility.

        Reply
      2. Lambert Strether Post author

        If my fantasy of a Trump executive order did happen, I doubt very much that Congress would impeach him; Medicare for All would be wildly popular. Yes, it would be a crossing the Rubicon moment, but one of those is on the way anyhow….

        Reply
        1. aab

          Haven’t we crossed the Rubicon already? We have the CIA dumping “golden showers” allegations against the incoming President that are so weak the head of the media entity that published the leak used social media to essentially disavow the story. If there’s some other river crossing closer to the city it’s going to have to involve more tangible weapons than words being used within the “homeland.” Please, let’s not cross that one. (Also, everyone’s invited to my house for artisanal cocktails should the use of “homeland” to refer to the United States of America unironically ever end.) Cheese straws and fresh guacamole for freedom!

          Reply
  7. ProNewerDeal

    0bamaBots & H1llaryB0ts spent years trashing Social Democrats/Sanders voters as “unrealistic” “far-left” “fair-dusty” “un-pragmatic”.

    Perhaps it was psychological projection, because IMHO 0bama & H1llary were un-pragmatic.

    Imagine if 0bama earnestly tried to implement MedicareForAll in 2010? 0bama could’ve stayed sold-out to the other monopolistic industries that own US pols. Even the most strident left 0bama critics like say Glen Ford would have to say, “look, 0bama is a war criminal, has dictator-murdered US citizens without due process, tried to raise the social security age for GenX & younger, pursued the TPP; but 0bama deserves 1 prop for implementing MedicareForAll & saving 45K USians/yr per Harvard Public Health”.

    But no, 0bama & H1llary insist on staying sold-out to all major BigBiz groups. Fighting even 1 of them ala FD Roosevelt “I welcome their hatred” to investment bank$tas, is excessively pragmatic for these DLC neoliberal Reagan-clone scumbags.

    Reply
  8. Eureka Springs

    Price’s Empowering Patients plan, like Obamacare, requires insurance plans to offer coverage to all patients regardless of how sick they are. But the Empowering Patients plan, unlike Obamacare, would let insurers charge sick people more if they did not maintain “continuous coverage.”

    Why doesn’t ‘insurance’ pay sick people for lost work time? At the very least while sick one should not have to pay insurance at all.

    And of all the uninsured people I know (granted they are in thier 40’s and 50’s) I don’t know one who is happy about it or uninsured because they are trying to get away with something. They are making a choice between a roof over their head, decent diet, lower stress, than if they tried to buy something which wouldn’t help them much, if at all.

    Reply
  9. Clive

    From an insurance industry point of view, certainly in the U.K. market which I doubt is significantly differently to the U.S., insurers hate complex underwriting. They either want scheme-compliant customers or, if those customers turn up and are found to be wide of scheme, they’d simply rather not have them as customers.

    If an insurer is forced to take whatever business rolls up at its door, one way of avoiding having to specialist underwriting is to simply use pricing to deter anyone with a functioning brain cell from ever actually buying a policy. In other words, the fact that you genuinely need underwriting is used to whack the premium or the co-pay up. Okay, technically you are not denying coverage but in practice that’s exactly what you are doing because most people will (certainly under the ACA) just pay the fine.

    What the politicians — who know diddly squat about insurance product design — hadn’t counted on though is, as noted though (correctly) above, you still get a death spiral because a lot of just-above-impoverished and slightly to moderately-severe unwell people will still enter the pool because they realize that even expensive (in-effect catastrophe) insurance is still better than pay-as-you-go. What you’re going to deter is a mass market of impoverished or just-above-impoverished but slightly unwell (some sort of pre-existing condition which probably won’t result in huge claims — a significant proportion of the potential pool will be this class of customer) potential customers who, in bulk, would contribute the vast proportion of your float (the reserves to pay out claims), because they think, usually correctly, they won’t make a mega huge claim and are paying money for nothing.

    If any changes in U.S. healthcare policy is considered which involves, to some extent, insurance (assuming Single Payer is off he table, which, however lamentable, sounds like reality) then policy makers really must consult with insurance marketing experts. Failure to understand consumer behavior in this industry will result in policy failures — yet again. None of this is new or not throughly understood — travel insurance has a vast trove of market and customer data to determine who chooses to take out medical expenses cover, who doesn’t and why they don’t (i.e. chose to spin the roulette wheel and risk not having coverage).

    All of which makes me think — remind me again what is so wrong with Single Payer?

    Reply
    1. oho

      ‘ remind me again what is so wrong with Single Payer?’

      Of all the black swans out there—-I’d bet that the most likely black swan is Trump expanding Medicare to under-65’s in some form.

      Seriously. Nixon to China >>> Takes a jingoistic, nationalistic, hotelier w/massive health insurance bills to like the idea of dumping those costs onto the government.

      Trump is already on record liking drug re-importation from Canada and sticking it to Big Pharma.

      (but again, it’s the most likely of unlikely events)…and I’m not holding my breath

      Reply
      1. Carla

        ‘ remind me again what is so wrong with Single Payer?’

        It treats everybody the same, something the 1% absolutely cannot abide.

        A decade ago, I was traveling in Italy with a friend. When we were staying in the beautiful walled city of Lucca, he developed an infection in his index finger. We asked at our B&B where he might get treatment and were directed to the ER of a hospital about 2 blocks away. We joined a couple of other people in the waiting room and after about 5 minutes, someone came and took my friend to an examining room. Nobody in the ER spoke English and we had no Italian. About 10 minutes later, my friend emerged with a neatly bandaged finger and a prescription for antibiotic ointment written in Italian. He explained to me that they had lanced the finger, drained the pus, applied a disinfectant, and bandaged him up. When he took his credit card out to pay, they smilingly waved it away. You see in Italy, if you are hurting, you receive care and treatment because you are a human being.

        American one-percenters just can’t stand that. Apparently it somehow robs them of their specialness.

        Reply
        1. Thor's Hammer

          During my first week of employment in Vancouver Canada the financial secretary of the company called me into the office. “Have you received your Care Card yet?

          “I’m a f—-ing Yank– Don’t I have to become a landed immigrant to apply?

          “You are in a civilized country now– we don’t allow anybody to go without health care.”

          I filled out a single page form and was immediately covered for all medical expenses including my pre-existing cancer. Administrative cost for universal coverage– a fraction of the bureaucratic overhead doctors face in the US in order to comply with the ACA & Medicare regulations.

          During my stay in Canada I never stood in a line waiting to see a doctor or was placed in a room awaiting a fly-by visit by a doctor seeking to maximize his “production” as is often the case in the USA.

          Reply
      2. Oregoncharles

        Trump claimed to support single=payer until he ran for the Republican nomination. As you say, it serves his business interests. He continued to say things that sort-of implied for some time after seeking the nomination. So plausibly, it’s his real preference. If he has one.

        The biggest problem is that it would really require Congress, at least for the funding, which would be substantial. Maybe he could fake that on an Executive Order, but it would be a big risk.

        Reply
        1. Yves Smith

          The big problem with Trump is he obviously has few principles, as in things he stands for. He actually does seem to natively be an old Javits Republican, not that that is even remotely where he is now.

          So many Republicans were opposed to his rise that the one who would sign on were really retrograde (Jeff Sessions, as an example). And Trump seems cool with that, as in he does not seem to demand that they moderate some of their stances as the price of getting power they’d never have achieved otherwise.

          Reply
    2. grayslady

      The favorite method of U.S. insurers to avoid paying for true insurance is to eliminate potential service providers. For example, under your Obamacare policy, all forms of contraception are supposed to be covered; but if no gynecologist in your network performs IUD insertions, then, essentially, you are denied coverage. Happens here a lot with surgical specialties, wherein no doctor in a particular network is qualified to perform certain surgeries even though Obamacare allows for coverage.

      Reply
      1. Carol Sterritt

        Well, I don’t really even have a doctor, as my regular doctor quit Adventist Health services back in July. The clinic where he worked made it clear it was my fault I am without a physician, as after all, it was my doctor who quit. This wouldn’t be so upsetting except during my last visit in June he realized I probably have a heart valve problem or carotid artery problem. The clinic is telling several of my friends the same thing – its not their responsibility to assign a doctor to them or help in any way. The fact that there is a serious lack of physicians in this rural county is something no one with power or authority here wants to address. Insurance mandates are meaningless in terms of patient welfare if there aren’t any health providers who will see patients.

        Reply
    3. J

      Single payor means, by definition, that those providing care (physicians) have no choice in terms of reimbursement. You either take the rates the government offers you, or you do not practice medicine. Now, Medicare already pays about 20 cents on the dollar compared with a mix of commercial insurers. Medicaid even less than that. Mind you, these rates are so low there’re oftentimes below the break even cost of providing care, and Medicare puts you though the ringer with respect to compliance and paperwork.

      I chuckle when Medicare for all gets pitched as a solution…you’ll see a mass exodus of doctors from practice to early retirement or a concierge care only model.

      Reply
      1. hreik

        This is not really accurate. Visits to docs are reimbursed at about 90%. Surgical and other procedures, less so. Overall about 80% of charges allowed by Private Insurance.

        It’s Medicaid that pays abysmally to docs, not Medicare.

        Reply
      2. sj

        You know, I’m getting rather tired of the argument that Medicare payments are so abysmal. Doctors will leave, boo-hoo, yadda yadda.

        Under the system we have now, those potential losses just get shifted to the uninsured. I just had a medical procedure and reviewed the billing from the hospital.

        Cost of the procedure: $6600. Write off for insurer: $5564 Payment by me (since I had not met the deductible) $1036. My insurance company paid nothing.

        Now, I’m lucky. I have insurance, and I had been stashing money into an FSA account and so I actually had the $1K. But in what world is it okay to penalize those unable to afford insurance by charging them six times as much as they write off for an insurance company. I

        The whole healthcare-for-profit business is obscene. It’s the “for profit” part that is subsuming the time of doctors and their staffs. Not the “patient care” part.

        The so-called doctor exodus is a red herring. If someone becomes a doctor so that they roll in the money, I don’t want to be their patient. Let them leave. Maybe we can actually get back to a healer model.

        —-
        Lot’s of interesting articles to be found with this search:

        https://www.google.com/#q=how+much+time+to+doctors+spend+working+with+insurance+companies
        —-
        I’m not even going into the fact that so often doctors start out so deep in debt they might feel the need to gouge their patients. That a different, if related, issue.

        Reply
        1. Clive

          Agree 100 percent.

          In the UK clinicians cannot get work in the private sector unless you are NHS consultants. Insurers have no way of assessing clinical competency outside of the NHS. In effect, the insurance companies outsource clinical competency evaluation to the NHS. I do not get at all why this would not have to be the case in US Single Payer. Medicare / Medicaid eligibility would be essential to allowing clinicians to do insurance work, unless the insurance industry duplicated their clinical competency assessments.

          Reply
          1. PlutoniumKun

            Similarly in Irelands much messier health system (a blend of direct provision and subsidised private insurance) . Consultants, and other physicians, are almost all government employees, working on contracted hours, but are free to pursue private sector work outside these hours – as hospitals are mostly owned by private companies or non-profits, they simply sit in the same office, using the same equipment after their contracted hours, the difference being that the work is billed to the patient or insurance companies. The system makes it very hard for any doctor to work independently.

            Incidentally, its widely known in the health world that private hospitals have worse outcomes than big public hospitals (especially teaching hospitals). They may provide an aura of exclusivity and luxury, but market demand means that they will always focus on narrow profitable areas, which means that patients who have other medical needs find they don’t have back up. So if you are in one for your heart bypass and an unexpected medical problem pops up (say, an allergic reaction to some medication), there isn’t another specialist on hand down the corridor who can run down and offer help and advice to the coronary surgeon, as there would typically be the case in a big teaching hospital. Most doctoers with a choice will always send their family to the latter over an exclusive clinic. Its one of the many dirty little secrets of private health care.

            Reply
            1. PlutoniumKun

              I’d just follow on to this one anecdote I know from a now deceased in-law who was a General Practitioner in a rural area in Northern Ireland, and the son of a GP. He described the NHS as a goldmine for GP’s. The reason was that most GP’s who had practices outside wealthy middle class enclaves actually earned much less than was thought. Most doctors would simply not charge those patients who they knew couldn’t afford it, and compensate a little by overcharging the local bank manager or lawyer. He said he remembered regularly leaving his house in the morning to find baskets of eggs, vegetables and meat on the doorstep left by local small farmers in gratitude for their families free treatment. But the doctors representatives simply pretended this didn’t happen when the NHS was formed and claimed a much higher average wage for doctors. So he said it was actually the NHS that pushed most family doctors into the well paid middle classes.

              Likewise, my dentist told me the story of why so many older dentists owned rental property in Dublin, and why Ireland ran out of dentists for 2 years in the mid-1950’s. The NHS had negotiated a ‘per filling’ rate with dentists when the NHS was formed. But the invention of the diamond headed drilling bit meant that what was once half a days work for a dentist could be done in 20 minutes. So dentists proceeded to fill several decades worth of patients teeth with fillings within a year – and a flood of Irish dentists joined the goldmine. It took two years for the NHS bureaucracy to work out why the dental sector was draining the system and change the rules. In the meanwhile, the flood of dentists returned to Ireland, investing their windfall in rental properties.

              Which is a roundabout way of saying that its vital that any new healthcare system must ensure that medical practitioners are waged employees of the government, not independent contractors, otherwise they will always work out a way to game the system.

              Reply
  10. John k

    Trump’s base is 50+. So what if he drops Medicare to 50+? Even somebody 45 would be happier thinking he would be covered in five years. And 50-65 is more in need than 35-50.
    Midwest would be happy, and lots of reps from Midwest… just trump proposing this would give it a life of its own… and make dems look like pikers.

    Course, this would someday be expanded, dooming health insurance… does trump owe them anything? Didn’t that industry donate to her?
    Meanwhile, other corps should be happy to get their sickest workers covered… always puzzled other industries haven’t lobbied for Medicare expansion.

    And with talk of changing Obamacare, why isn’t Bernie jumping up and down for Medicare expansion?? Do all dems have undying fealty to insurance?

    Reply
    1. reslez

      > why isn’t Bernie jumping up and down for Medicare expansion?

      Clearly Bernie hasn’t learned the art of the deal. But I think everyone figured that out after the primary.

      As many problems as there are with Medicare I honestly believe expansion is the only way for Trump to square this circle. In addition it’s the best solution for the country in the short-term. Think of how many billions of dollars will be saved on administrative overhead alone.

      I don’t see how Trump or the Republicans can get around Obamacare repeal, it was a core campaign promise. He can drag Congress along with promises of privatizing it in the future. That’s a battle I’m willing to fight. Maybe they’ll try to privatize it at the same time, though. I think they’d have to preserve a “public option” either way, simply because there are tons of seniors the health insurers won’t touch with a 50 foot pole.

      Reply
    2. MyLessThanPrimeBeef

      Contrasting with Medicare for all, Medicare from 50+ on is the lesser of 2 evils (the other being keeping the status quo).

      In the spirit of ‘not letting good be the enemy of perfect,’ i am interested and would like to know more…if more people are advocating this.

      Why should people die because they can’t afford healthcare? Why should people go into debt to get treated? This is more important than no college education without free tuition.

      Reply
      1. Carla

        I agree. In the spirit of ‘not letting the good be the enemy of perfect,’ we should only let people 49 and under die because they can’t afford healthcare.

        Who needs people 49 and under, anyway?

        Reply
    3. craazyboy

      Lambert enumerated all the Trump positions, but one I remember from about hallway thru the primaries was Trump said something to the effect that we have company provided insurance, and Trump would propose “something else” for people not covered by their employer plan.

      So this would be people working without a employer plan, those not in the workforce, and the phenomenon of finding out “retirement age” is not really 65, but could very well be 50 – 55, whether you like it or not. These cases are supposedly now covered by O Care. But Medicare is cheaper – because it has price controls! I think the simple things like doctor visits are half the price of what insurance pays out to providers. The downside is sometimes doctors try wriggling out of Medicare patients if they can get the higher paying insurance covered people. But if anyone in Congress is truly worried about the cost of O Care to the government, Medicare would be lower. Plus, they can charge for it. Right now I think they ding your SS check for around $130/month.

      Reply
      1. MyLessThanPrimeBeef

        Do medical schools take those students who can pay more over those paying less (including spending at school cafeterias, etc)?

        Why should doctors only take patients (by wriggling out) whose insurers/whoever is footing the bill pay more?

        Reply
      2. Carol Sterritt

        Doctors were unwilling to deal with MediCare way back in the 1990’s. And that was before Obama made sure that half a trillion bucks worth of cuts to MediCare would occur. (This was his bargain with Republicans to get the ACA to pass – hey, we’ll just take the budget-deficit aspect of ACA out of MediCare provider payments.)

        Reply
    4. FluffytheObeseCat

      “why isn’t Bernie jumping up and down for Medicare expansion?”

      https://berniesanders.com/medicareforall/

      The libertarian trolling in this comments section gets a little too much some times. The MSM’s artless disdain for (and active downplaying of) Sanders policy on “Medicare for all” does not equal Sanders being too quiet about it. It equals an aggressive effort to diminish his efforts.

      Reply
    5. Lambert Strether Post author

      > What if he drops Medicare to 50+? Even somebody 45 would be happier…

      Teddy Kennedy, before Obama bewitched him, had a plan to drop Medicare’s eligibility age by 5 years every year until all were covered. That would an easier approach than dropping eligibility to zero immediately…

      Reply
  11. Jim A.

    I’ve never been a fan of the “on your parent’s policy until age 26” policy. It seems carefully constructed to help those who are “middle class” from a social point of view but poor because of the current, crappy job market. And it specifically regards as “undeserving poor” those who have difficulty paying for healthcare but whose parents don’t have decent jobs with benefits. So no helping hand for them. It would be FAR better IMHO to try and make healthcare affordable by those of moderate means.

    Reply
    1. Art Eclectic

      Well, we’re talking about two entirely different things. Healthcare is delivered by doctors, nurses, medical facilities.

      Insurance is a for-profit industry that doesn’t deliver healthcare, they deliver profits back to their shareholders.

      The problem in our national health discussion is the necessity of insurance in the first place. They are basically just a middleman extracting profit from the system while delivering no actual health care. They are a parasite feeding off the host.

      Reply
  12. Anne

    “Let’s see…do you like the deck chairs arranged in conversational groupings, or do you prefer them to be lined up facing out toward the ocean?”

    Yeah, that’s all this is about: rearranging the deck chairs on this Titanic of an insurance system; how is this not blindingly obvious?

    Reply
  13. Greg L.

    Assuming he wanted to do it, how would Trump get a “Medicare for 50+” plan past Congress?

    Are there enough Republicans to sign on with Democrats on that idea? Maybe, possibly, in the Senate, but surely not in the House…?

    Republicans have pinned all of their hope on the notion that true “competition” solves the cost issues. (Never mind that there is more evidence to the contrary: i.e., monopoly solves cost issues). It seems they will want to test that theory until it fails.

    Reply
  14. David Carl Grimes

    Who knows? Trump may surprise us by converting Obamacare to single payer Medicare for all. If that happens, the Republicans will rule for generations and the Democrats will wither and die a slow and agonizing and much deserved death.

    Reply
    1. ProNewerDeal

      in a “only Nixon can go to China” way, Trump could slash payments the Fed Gov (Medicare, Veterans Affairs, etc) pays for pharma, physicians (iirc $175K median salary in US vs $105K in Canada for generalist family physician), etc benchmarked to Canada, & in doing so, brag “I am make tremendous deals! believe me!”). If another pol like 0bama did the sam exact thing, many Rs would cry rivers & label him a Commie.

      Reply
  15. james wordsworth

    The crazy thing is that Medicare for all has a solid business argument in its favor (although not for the AMA or big pharma, or big insurance). All companies pay similar amounts for coverage per employee (no more time spent wasted with analyzing plans), so a level playing field, while not as good as a field tilted in your favor, is better than one tilted against you. Great for small companies trying to get new employees, Individuals can start their own businesses without having to worry about losing health benefits (or the high costs of small plans). Everything about medicare for all screams economic efficiency (you know, having doctors doctor, not spending 50% of their time arguing with insurance companies).

    Of course this all flies in the face of the american mantra of self reliance … and that is where a great economic argument gets destroyed by the reality of a messed up culture in a modern world. Self reliance is great, but in an urban modern world, cooperation works better.

    Reply
    1. ProNewerDeal

      +1 IIRC 1 of the US auto mfgers explicitly claimed that the factories in Canada were more cost efficient for them, solely due to the health care costs.

      It is as if US business leaders are adherents to neoliberal religion, that for-profit businesses will ALWAYS in ALL product/services provide a better product/svc per $ cost than a government or nonprofit private org can.

      The same scenario exists with info tech, ppl wil bitch about Microsoft as OS vendor or office suite software vendor, when they could pay for corporate-level support from Ubuntu Linux or LibreOffice. They bitch about getting jacked by Oracle or SAP ERP, when say 10 MNCs could found a nonprofit dedicated to creating industrial/MNC-level ERP software that could be installed on-site or cloud-computing hosted. Etc.

      Reply
  16. Ep3

    Yup Yves sounds just like car insurance. You can get it, but it will be very difficult to get the premiums that we advertise because we will find some reason, any reason, to raise your rates.

    Reply
  17. Dr Duh

    My idea, which helps ameliorate but doesn’t solve the problem of the uninsured is to incentivize physicians to provide charity care. As it stands, you take significant risk for minimal to no reward.

    The uninsured don’t pay and Medicaid pays pennies on the dollar compared to private insurance. To make matters worse these are typically the sickest and the unhealthiest patients, i.e., they put off coming in so their disease is often at a crisis point and have bad nutrition, obesity, tobacco addiction and weak social support systems. They are bad outcomes waiting to happen. To cap it off, they are the most likely to sue you, they have stronger economic incentives to do it and have less social trust in physicians.

    I know plenty of people (mostly anesthesiologists) who routinely complain about being paid despite being compelled to do all this work and take all this risk (including non-trivial risk to their own health from needle sticks and the like). I think that a big part of the resentment is that they are compelled to provide charity care as a condition of maintaining their privileges at the hospital.

    Instead, let physicians write off charity care at their standard rates, i.e., I normally get $903 to come in at midnight and take out someone’s ruptured appendix then take care of them in hospital for a week and provide follow up care for 90 days, but if the person is uninsured, I can deduct the $903 from my adjusted gross income as if it were a charitable donation. Further, physicians could be protected from civil liability for charity care. Though they would still be subject to criminal liability for criminal misbehavior and professional sanctions for substandard care, a bad outcome would not lead to a lawsuit.

    I think the most important thing is that this would remove the compulsion to work for free. Most physicians and certainly anyone who has started in the past 10 years didn’t do it for money. There’s far more money and less stress in finance or tech. Most physicians like taking care of people. It’s certainly the best part of my day, but being forced to do something sticks in the craw.
    While this would certainly push up physician income.

    Reply
    1. OH

      You have said that the un-insured do not pay. I can assure you that the un-insured receive a bill. Even at the emergency room.

      Reply
  18. Richard

    Why are people so naive and stupid about this. You cannot withdraw preexisting conditions. Why is this even uinder discussion?

    I’ll tell you why this is under discussion.

    THERE IS NO SUCH THING AS BONA FIDE INSURANCE FOR HEALTH!!!!

    Yes, private insurance can and does exist… for the wealthy.

    But if you are going to pay for people’s health, the word ‘insurance’ must disappear. Itt becomes simply an extension of the taxing authority with a health scheme created by and for the people. Simple as that, Paid for by taxes. Is that clear enough?

    But Americans must always ‘insure’ everything.

    Reply
  19. meeps

    Thanks for the extra detail regarding the ‘continuous coverage’ conditions.

    The 18 month contract term reeks of post-ACA era grandfathered plans (my spouse’s employer has a 12 month no coverage contract term) which is the very feature that prices us out of it. People who were priced-out under Obamacare are in for another brain-freeze should the incoming administration order up another self-licking ice cream cone.

    I’m concerned that Pence will declare that having two X chromosomes is a pre-existing condition, but that’s a subject for another post.

    Trump seems to have some opportunity to cultivate an image as the ‘most beautiful deal-maker ever’ if he can deliver an improved Medicare For All plan. Of course, there’s a risk that Republicans will crapify it first and then claim they delivered. But that strikes me as equally risky for Trump and the Republicans. Obama should never have staked his name and the reputation of the Democrats on Romneycare. They lost all credibility and the party is going extinct. I have a low opinion of Trump’s branding but I suspect he thinks it’s just great! It’d be inept beyond measure to sully it with something even worse than Obamacare. I’ll refrain from placing odds just now…

    Reply
  20. dejavuagain

    In the old pre-existing conditions day, the other game played by the insurance companies was to challenge insureds for failing to disclose pre-existing conditions to the insurance company. Even if the insured was not aware of the existence of the pre-existing condition, the insurance company would deny coverage. So, in every big claim, the insurance company would simply deny coverage. Good luck.

    And, I was the victim once of an insurance company “losing” my check, and cancelling my health insurance. Scary walking around without health insurance for a few months.

    Reply
  21. OH

    The problem is, insurance does not protect you from bankruptcy! You pay in $2500 a year, times ten years, that’s $25,000. Over 30 years it’s $75,000. Plus, not only do you pay deductibles, you pay 20% of the cost because the coverage is also only 80%!
    It should be real straightforward, you should pay “premiums”, and the insurance should just take care of all the rest, you should never have to pay anything else.
    That is how it will be when we finally get a Public Option.

    Reply
  22. Scott

    Transcendian modeling was created for a new nation from the bottom up. It turns insurance coverage from a liability to an asset by basing the currency on the pooled equity of citizens insured from birth, when it is cheap.
    Transendian modeling overcomes the flaw in Marxist Socialist derivations where the state gets all and pays the elites with access to all of everybody’s property the state has taken. Does this by creating private wealth using Whole life coverage.
    Healthcare of the citizenry is an order of Defense. It is the responsibly of a legitimate government to Defend & Educate. Defense from Disease is as crucial to the power of the nation as defense from other people.
    As we know, real businesses have insurance.
    The US was long able to provide freedom as anarchy till now it has to reckon with the need of an absolute Civilization.
    FDR gave us an image, a vision, of Civilization as a Government that served all the people.
    Financial Terrorists aim to have government serve only themselves.
    My model is similar, though uses the name I made up The Insurodollar, to Duke academics pushing Baby Bonds. It is funny how academics get big press, and go on vacation.
    The slavers own us, as I designed my system we own ourselves.
    Working classes do not typically keep great records. The US has become criminalized as using the American people as the reinsurers of the reinsurers. (AIG story)
    Thanks.

    Reply

Leave a Reply

Your email address will not be published. Required fields are marked *