SB 2016-047 - Universal Healthcare and Affordability Act (Debating)

[Southern Senator North Carolina Yankee]

The foreign national issue is one that has historically not been addressed simply because with so many problems rushing at you when you look at healthcare some of the less obvious, but still critical ones get pushed to the side. I watched the episode of Question Time on C-Span the week before last and this was an issue with NHS that was being talked about by Prime Minister Theresa May.


As for the Co-ops, I have long been a fan of a including as many forms of competition in the market place as possible because I think it reduces costs to have options. Sometimes the free market does not always equate to more choice, I just like I oppose the monopolization imposed by gov't, I also oppose monopolization imposed by circumstances within the private market. I think co-ops are a great example of a way to provide a public service especially.

Also, I think when people don't have to be covered for stuff they don't need like maternity care at age 70, and get plans that cover what they need, that will save people money and reduce the cost barrier to universal coverage.

Two days ago I sent a gigantic PM to Blair about this matter and I have been toying with the idea of making a big speech or doing it piecemeal because there are several issues that have to be addressed and we have to learn the lessons that we experienced as some one who had a front row seat in 2009 and 2012, That, it is easy to slap down everyone is covered on paper, ignore the details and say "we have single payer, or we have universal coverage", but the reality exposes just how broken the situation is.

I would also hope that post-reset we have a greater degree and attempt at accuracy with regards to healthcare, costs, coverage and problems. I would also assume we have inherited all of the ACA's cost difficulties as well.

[Southern Senator North Carolina Yankee]

When it comes to the Medicare buy-in, am I to assume there will be premiums attached especially to the higher ends of that $90,000 spectrum?


I am not as familiar with Medicare as I should be, though I am very familiar with Medicaid. Very familiar with it.

Medicaid charges no premiums, portions of Medicare charge premiums but others do not. While Medicaid is in the worse shape, I am unsure of taking it and dumping it wholesale into Medicare, which has its own problems largely driven by the generalized healthcare cost issue as well as aging demographics. 

I am also uncomfortable with completely removing people from experiencing the costs of their healthcare decisions. If anything, we need to front load the future costs down the road of health decisions made now, like diet/smoking etc, so as to reduce the generalized inflation these form a contributing factor towards. You could also price in the usage of preventative care, versus lack thereof. This way the incentives push in the right direction and even if they don't change behaviors at least they are paying for the costs of their decisions as opposed to it being spread across all healthcare consumers like in real life, or in this case, it would be tax payers.

Also selecting a single cutoff leads to what is known as a coverage cliff at $90,000. This issue came up in 2014 and was the primary reason why shua recommended and formulated the sliding scale premium subsidy to gradualize the drops off in coverage. I have experienced these first hand in both Medicaid and the Food Stamp program and I can tell you they are very disruptive and often force people to decide between two bad options.

[Southern Senator North Carolina Yankee]

When it comes to the Medicare buy-in, am I to assume there will be premiums attached especially to the higher ends of that $90,000 spectrum?

I'd think there would be.  That will probably need to be clarified in future amendments to the bill.  In essence, Medicare parts A, B, C and D are scrapped as all Medicare recipients are covered for the same services (which are drawn from Fritzcare).

I don't see that transition clearly established in the text, so yea I guess amendments are needed.

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If the federal government is going to offer public plans to most people on a means basis, why would we need to maintain two different single-payer systems?

Both Medicare and Medicaid face serious but slightly different problems. If they are going to be consolidated and I am all for consolidating them, but there has to be a transition process both to protect those currently in the programs and to alleviate the stresses that both systems are facing.

This is by design not a single payer system, unless I am mistaking. Section 2 creates co-ops that will compete with this system and the bill also references private for-profit insurers in that section as well. Section 4 gives authority to states to adopt a single payer system and the use of the term "means" based, likewise. Also Medicare is not a single payer system because Parts of it charge premiums.

But in terms of what I think you mean, not merging Medicare and Medicaid doesn't necessarily imply keeping two "gov't" systems.

You could accomplish Medicaid's mission in multiple ways, especially if you are creating non-profit competition. Medicaid's target audience is not barred from the market except for reasons of affording access. For instance, an "adequate" (as in adequate enough to accomplish the objective) subsidy to by private insurance could provide the same level of coverage as medicaid with people using the subsidy to buy private or federal co-opt, federal public option, regional public option, regional co-opt or any number of alternative insurance providers.

Medicare's target audience provides you with less flexibility because their age makes it difficult to insure them through the private market and possibly even with non-profit co-ops.

If you want to consolidate the whole healthcare system, I would make three recommendations:
1) Don't call it Medicare because the structure is fundamentally different
2) Have complete lateral competition or at least the potential for competition across all categories of healthcare. So a Senior could buy a private plan or a co-opt plan, likewise a lower income person could as well. At the same time Bill Gates could opt for the Gov't plan.
3) Have all players charge premiums and then focus the means based coverage on the premium side as opposed to the benefit side (biggest difference between the 2009/2012 plan and the 2014 bill). Bill Gates would pay 100% of his premium, even if he opted for the Gov't plan. There would be variance to the formula for Seniors, vets and the like. I think a premium based system is critical because it allows for higher reimbursement rates, as well as stability for the gov't plan to an extent that solves the crisis of doctors not accepting gov't plan patients, which is a problem with Medicaid currently and becoming a bigger one for Medicare as fears of its insolvency loom. Another factor in this problem (which I discussed with Blair in a PM last night), is the excessive amounts of red tape, which is also a problem with Obamacare. We have to simplify the paperwork and minimize the work load that is keeping doctors in their office and treating fewer patients.

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The public plans won't make services free of charge.  I would be fully on board with incentivizing preventative care.

If we want all Medicare plans to cover the same things as Fritzcare (we can consider whether to offer specialized plans instead, of course), then a sliding scale premium could work here.  Do you remember the formula shua had written up in 2014 or where he posted it?

Well we did have equalization of covered items. Plus it helped that previous bills pretty much nuked private coverage unintentionally so that was starting from scratch, making it easier. That being said, if we want to contain costs, we shouldn't be opposed to specialized plans tailored to a particular person.

As for the formula here it is:

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Co-pays and Deductibles were capped for all providers at 5% of income.

This was a truly consolidated system we were dealing. So the formula was applied differently for certain groups and the public option (ANHC or Fritzcare) was favored as the primary option for care for Vets, Seniors and Active Duty Military:

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[Southern Senator North Carolina Yankee]

Oh okay that makes more sense; I was worried that the majority would piggyback onto that part of the plan.

I think we're looking at a very strong piece of reform, especially in regards to the amount of choice that consumers have

I agree, it is certainly heading in a strong direction, at least structurally.

[Southern Senator North Carolina Yankee]

I will acknowledge that the one component of the 2014 bill that I had "least understanding" of was exact mechanics of the CIEP and risk pools. Yes, I can read what it says but my feel for how that would function practically was never as strong as the portions I wrote myself or had influence over. If memory serves me that was largely the work of Duke and Lumine, so people who generally know what they are doing.

I might hazard to suggest that having them, might alleviate some of the problems that Obamacare experienced regarding who was signing up and was not, but relative improvement in that regard is not something that I could speak to directly.

[Southern Senator North Carolina Yankee]

As someone who's never had to use any form of US healthcare my knowledge is very much weighted towards outcomes rather than the actual process of getting healthcare.

Gets back to the vague post I made in Scott's thread about learning just how long the road is.


When it comes to outcomes, and especially outcomes relative to cost you are dealing with three things that interconnect.

1. Availability of qualified professionals
2. Availability of Technology
3. Pricing Mechanism (Pay for services rendered or overall outcomes)

Also the combination of technology and transparency of cost/quality allows (in some instances of healthcare) to expand choice and the range of options for their care, just as much as this bill does with choice in coverage.

I think we are going to end up having 3 to 4 bills on healthcare. 1. Access and related Cost concerns (This Bill), 2. Healthcare Delivery and Quality (Includes 3 point list above), 3. Healthcare IT, and 4. Liability Reform.

[Southern Senator North Carolina Yankee]

I have PMed GM Kalwejt and asked him to give us a budgetary analysis.

Did he say how long it would take to provide such analysis?

[Southern Senator North Carolina Yankee]

I have PMed GM Kalwejt and asked him to give us a budgetary analysis.

Did he say how long it would take to provide such analysis?

He didn't get back to me at all, and now he's on leave from the GM office, apparently.

Ugh...

     Well this might take a while. I'll get the hot chocolate going.

Hmm, sounds temping, but I prefer not to drink so early in the morning.

[Southern Senator North Carolina Yankee]

I have PMed GM Kalwejt and asked him to give us a budgetary analysis.

Did he say how long it would take to provide such analysis?

He didn't get back to me at all, and now he's on leave from the GM office, apparently.

Ugh...

     Well this might take a while. I'll get the hot chocolate going.

Hey so instead of waiting on budgetary analysis, if the sponsor wants to come up with his own budgetary proposal and gives sources and calculations to GM Kal, then Kal can agree or veto the cost. I wouldn't mind helping do it at all, either. Just so we can get the ball rolling on such an important issue.

Kalwejt always presents such great potential and opportunities, but he always leave you but a taste and a tremendous hunger thereafter.

[Southern Senator North Carolina Yankee]

I have PMed GM Kalwejt and asked him to give us a budgetary analysis.

Did he say how long it would take to provide such analysis?

He didn't get back to me at all, and now he's on leave from the GM office, apparently.

Ugh...

     Well this might take a while. I'll get the hot chocolate going.

Hey so instead of waiting on budgetary analysis, if the sponsor wants to come up with his own budgetary proposal and gives sources and calculations to GM Kal, then Kal can agree or veto the cost. I wouldn't mind helping do it at all, either. Just so we can get the ball rolling on such an important issue.

Kalwejt always presents such great potential and opportunities, but he always leave you but a taste and a tremendous hunger thereafter.

As a famously published novelist, I do not want to disturb his work. (Giv mi good unemployment #'s, k thx)

The qualities I described above are perfect for a novelist.

[Southern Senator North Carolina Yankee]

My main suggestion is to have costs slashed for those making $90,000-$150,000 if possible, alongside special discounts for individuals or families with at least one member serving in the military(reserves and coast guard included) for more than four years.

I don't think that's completely necessary as we're going to have lateral competition across all income groups.  And I would think that families would already be covered under the plans of service members who choose to go with AtlasCare.

As for veteran families and families of active duty, I would recommend an amendment as they are not explicitly mentioned. During the course of the amendment, consideration of full premium support versus a discount (I am assuming through a relatively higher % of premium support) would be in order. I would certainly consider the former for families of active duty and possibly the latter for veteran families, but there are arguments in both directions on both groups.

[Southern Senator North Carolina Yankee]

Yes, I made the same case two months ago when the underlying text relied on the two traditional programs and merged them together under Medicare, likely expanding Medicaid's problems to the Medicare population on top of worsening the solvency situation.


To begin with I think even the 20 cents on the dollar recovery is optimistic. You cannot get blood from a stone so for a good number of poor uninsured that will effectively be zero or close to it.

Medicaid as a system is not the same as public option in this text or the public option in the 2014 bill. Medicaid doesn't charge premiums. The public option here would charge premiums. Also the public option has to function in a way that maintains access to healthcare networks since it is not an entitlement anymore. If it loses networks, it will lose insured patients not just among those who who can pay for it, but also those who cannot since by creating a subsidy that people can take to any provider on the exchange competing for that group of patients, it creates a degree of separation from the public option and the subsidization. The public option has to work for that money. That means it has to be dynamic, it has to innovate and incorporate new technology/medicines much quicker than Medicaid or Medicare can and it has to be able to provide a competitive provider network. If no one accepts patients with that plan, then the plan in question is worthless and people will go to private options, co-ops, state plans or what have you.

Medicaid and Medicare can only be changed by Congress because they control the quality, content, and amount of care internally, politically only congress can change them at all and then political pressures often make that impossible as well. If you get rid of both, move the subsidization to its own entity based around premium support on a sliding scale and the content requirements for a particular group is moved as well, and then as its own entity, you have the public option that charges premiums like everyone else and has to compete. That is what I mean by a "market competing" public option and you can have complete lateral competition across all sectors of the healthcare market including seniors, vets etc.

I think we agree on principle though. We need healthcare coverage that can maintain its provider networks, offer quality care and do so by competing among others for the money of empowered healthcare customers, that regulation should be minimized to improve that situation as well and that HSA's play a significant role in the equation.

However, I don't think an HSA+Private Plans combo will work for seniors, active duty military or what have you since the risk pricing is too high to make it practical. So if you want to address the portion of the healthcare system that is covered by Medicare, The VA or Tricare you need some form of public option in case no private options are viable for that group of patients.

Otherwise the alternative is to continue with a healthcare system that is segmented and to which reforms address only 45% 50% or 60% of the healthcare market, thus don't fix the problems of cost in their entirety.

[Southern Senator North Carolina Yankee]

Did we ever get that budget analysis or is that still waiting. I would like to move this along if possible because as I said there are three to four parts to an overall healthcare reform with this being just first and they all tie together. For instance reforms to the delivery and healthcare records would tie into this as well.


Once we have the analysis, which will primarily be the cost of the subsidy we will have a good idea of how best to move forward.

Other costs will be transition costs and administration changes/savings since several healthcare programs will be eliminated and replaced with the public option on the one hand and the subsidy and its administrative capacity on the other.

[Southern Senator North Carolina Yankee]

Scott Cost analysis? Timeline? Update? Status Report?

[Southern Senator North Carolina Yankee]

RL CBO told a congressional hearing I was watching that Obamacare costs $110 billion a year between the subsidies and the medicaid expansion, most of it ($70 billion) being Medicaid.

Perhaps that it is a useful starting point.

[Southern Senator North Carolina Yankee]

Also note, that since the program would inherit the costs of existing programs like Medicaid and MEdicare, it would also inherit the funding streams.


The payroll tax under the pre 2014 system was like 7% and attempts to find alternatives meant with little interest and so in frustration Shua and I selected that option in 2011. That tax was slightly reduced at one point and maintained in the 2014 bill as the primary funding mechanism.

As for residual financial resources, the 2009 Act transferred the assets of Medicare and Medicaid into the ANHC (Don't blame me, I voted against that bill), and would have been carried over as well. Though inside those probably should have been divided up in a way to ensure that resources paid into the system for seniors or VA or Tricare were still devoted to ensuring those groups quality of care.

[Southern Senator North Carolina Yankee]

The program doesn't just inherit the costs of Medicare and Medicaid, though.  Remember that one program's recipients are being automatically transferred into a bigger program and the other is being phased out in favor of a voucher system for current recipients to help them transition.  That's a huge difference between what this bill does, and Obamacare.

So one of the questions we're trying to address is if the program lowers budgetary costs in the long run via Medicaid phaseout or increases them by the introduction of a public option + startup funds for co-ops.  I'm inclined to believe this lowers costs, but overhauls of this degree shouldn't be passed without a price tag.  And we're limited in terms of what current healthcare figures can tell us in determining that.

Yes, I get that, but between Obamacare and medicaid you have a pretty good understanding of what it takes to ensure the lowest income rungs. As I said, it is a starting basis to understanding the costs of the program.

You can then more easily jump from there to calculate a realistic figure than, if just started from scratch.

[Southern Senator North Carolina Yankee]

Lets assume that 22 million of the poorest costs $120 billion. I think it is safe to assume that such a subsidy would cost close to $200 billion to $300 billion. Though that doesn't include the costs for seniors since theoretically that starts with a revenue stream.

[Southern Senator North Carolina Yankee]

See, this is why I asked for a volunteer to crunch the numbers for us, because I'm terrible at math in general and have only a vague idea of what we're drawing these figures from.

So, we take $200-300 billion to pay for the subsidies and subtract the remaining Medicaid costs after a set period of time?  Can we undo the Medicaid expansion in the states that signed up for it with the ACA?

Yes, but we can post some of the facts here to move us in that direction

It was always figured that insuring the uninsured would cost $100 billion (2007 estimates). So the $120 million is not far off though I will note it only covers have the uninsured. So allowing for inflation and underestimating the cost, $200-$300 billion is not that far off for the 50 million or so people who either don't have insurance or are being covered or helped through the ACA.

If you look at the chart (which goes by household), the subsidies taper off to 75% at 200% of poverty level, 45% at 300% of poverty level and since it is formulaic there are no cliffs. It is a gradual descent.

What is 300% of poverty level for the average household?

https://www.healthcare.gov/glossary/federal-poverty-level-FPL/
$24,300 for a family of 4

So a family of for making 72,000 or so is getting 45% of their health insurance premium subsidized. 


https://www.statista.com/statistics/245347/total-medicaid-enrollment-since-1966/

70.5 million are are on medicaid. 12 million seem to have been added since ACA took effect.

http://kff.org/medicaid/state-indicator/total-medicaid-spending/
Total Medicaid Spending for FY2015 $532 Billion $70 billion or so is for the expansion under the ACA.

[Southern Senator North Carolina Yankee]

I think we should look for other sources for cost estimates.

[Southern Senator North Carolina Yankee]

Yes, separating out the costs associated with the administration, formation and such of the public option would make it easier to find out what the Sliding scale subsidy costs as it is.


Also another thing is that there may be ways to improve the subsidy as well, but we should look into that once we know the costs for the current structure.

[Southern Senator North Carolina Yankee]

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Single payer is about $3 Trillion a year. If you assume some costs are wastes and that 17% of GDP number can be reduced somewhat. You are still looking at $2 trillion or in that range of 2-3.

Thankfully we are not doing that.

[Southern Senator North Carolina Yankee]

Sorry, I don't know why I just noticed this but this would have to be the most expensive bill ever passed in the history of the republic if these numbers were accurate.  The United States spent $2.9 trillion total on healthcare in 2013 which is about $9,255 per person.  There is no way these numbers are anything close to accurate; either Dkrol added several too many zeros or something went completely wrong in his calculations.

I'll seek to have this revised.

Actually I don't think it is wrong.

Historical NHE, 2015: NHE grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP). Medicare spending grew 4.5% to $646.2 billion in 2015, or 20 percent of total NHE. Medicaid spending grew 9.7% to $545.1 billion in 2015, or 17 percent of total NHE.Dec 2, 2016

Medicare+Medicaid is 1.1 Trillion.

800 billion might actually be low balling the cost.

[Southern Senator North Carolina Yankee]

Reposting this here.

So before people go crazy let me state clearly what does this.

1. Expands Regional Involvement in Healthcare.

- It is easy to write up and bill and have Nyman make all decisions and both Conservatives and Liberals have presented plans that do just that. Aside from the subsidy, a few minimal regulations and public option (which I will explain later, so please hold off the guillotine), most every major decision regarding the nature of the healthcare system will and can be determined by the Regional Governments. This will therefore stimulate discussion and activity and regional elections by having elections of real consequence at that level. This will include but is not limited to the decision of whether or not to have single payer/individual mandate. With the passage of this bill, that will become a regional decision.

It is important to consider healthcare as an issue, but it is also important to remember that this is a game and the things we do policy wise should stimulate the game and the regions, not shut them down.

2. Yes there is a public option in this bill. But guess what, we already have public Option(s) and the "s" is important. Depending on which special group you are, you have your own little siloed public option. This bill takes all those public options and consolidates them into one federal public option, and paves the way (if a regional opts for such) for everyone to have alternatives. This means that seniors, vets, the poor, will now have greater access to choice and quality healthcare, will preserving the important promises we have made to our seniors etc.

3. Replacing the multitude of public options with one public options enables us to eliminate a metric f@$kton of government programs and offices that will now longer be necessary, or to trim down others that will remain with a smaller objective.

4. This is the Middle Ground on healthcare between a one sized fits all, top down program, and the real life healthcare situation which I think everyone agrees is a mess. It borrows from non-single payer systems that still ensure universal access like Germany, expands the degree of local control and expands the competition and choice to greatest number of healthcare consumers. In the process of doing so, it consolidates the roll that Nyman plays in healthcare, bringing simplicity, lower cost and higher quality to those who currently depend on Medicare, Medicaid, the VA, etc.

5. This was a massive bipartisan effort and there are elements that all sides can get behind. I am especially grateful for the hard work and patience (especially patience) of Senator Scott, as well as the contributions of Senator PiT (whose math skills were invaluable), President Dfw, Vice President Goldwater and numerous, numerous others. I also want to do like wise for former and hopefully soon to be Representative Potus, who while probably not thrilled with the overall proposal, some of his recommendations from his proposal this spring are present or shaped similarly to those he proposed, including untaxed HSA's and the incorporation of age into the formula was inspired by his use of age along with income in his tax credit proposal.

[Southern Senator North Carolina Yankee]

I will also note once again that once we reform the public health care, it will be necessary to then pursue with reforms to other aspects of health care including but not limited to:

1. Delivery
2. Medical Records
3. Technology
4. Tuition Inflation
5. Malpractice Liability
6. Drugs
7. Mental Health

These will best be handled in subsequent bills and if attempted here would make this bill too large and complex.