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

[Clyde1998]

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Sponsor - Senator Ascott (Ind)

I open up a period of debate on this bill.

[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.

[The world will shine with light in our nightmare]

As I've stated before, this bill is very much incomplete and there are lingering cost-related issues that exist within our healthcare system that still need to be addressed, particularly those which arise from shortages, logistical issues, liability costs, etc.  The bill in its current form provides a blueprint for how to guarantee coverage with a mix of private and public options, while allowing the regions to design their own programs and set their own regulations.

Originally I'd considered throwing out the ACA and starting from scratch, but I think we can keep the federal exchanges provided that we work out the necessary cost adjustments.

Unfortunately, I'm a little unsure how to drive down the costs that exist in the current system.  I would encourage Yankee and anyone else to submit some proposals that would achieve this.  One idea I had in mind was incentivizing hospitals and doctors to take a "less is more" approach to providing care; Germany (whose system is what inspired the framework of this bill) has a system which penalizes over-utilization of care on the part of doctors, but I'm not sure if or how that would work for a country like ours which bears the bulk of the medical and technological innovations that come out each year.  That, I think, is the major challenge we have to address.

[Associate Justice PiT]

     The rising cost of health care is always the 800-pound gorilla in the room.

[NeverAgain]

     The rising cost of health care is always the 800-pound gorilla in the room.

And somehow that gorilla always gets shot. And then never gets full healthcare coverage due to a pre-existing gorilla condition. RIP Harambe.

[Blair]

I was planning on doing a big post on this but as I've said to others I've had a hectic couple of days with a lot of RL stuff but I hope to get my thoughts on this done on the weekend, and start to work on what will be an absolutely brilliant piece of reform

[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.

[The world will shine with light in our nightmare]

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).

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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?

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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?

[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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[Blair]

In regards to the red tape issue that Yankee raised we agreed on coming up with a healthcare card based solution like we had in the past; which makes records digital (I know that France has the same problem with doctors essentially ripping off the state by giving themselves work they don't need) I'd want to wait until after we have the bill to pass this (I want to introduce some sort of ID like Estonia have)

I'd also want to wait until then to do Tort Reform so I know what we're actually dealing with. My overall, and simplified structure of healthcare would be the following...

National Insurance Option; supported by Govt funding but still requiring people to pay in. So basically the Public Option

CO-OPs: Given intial funding to get members+advertise but independent from that point on.

Regional Plans: We need some sort of agreement rather than saying 'let the regions do it', because we could easily have one region pass

[The world will shine with light in our nightmare]

Sorry - I haven't been avoiding this (well, not entirely, anyway ).  I just wasn't sure where to begin in redrafting the current bill and I got pretty confused doing so at certain points, so here's the new part of the law which addresses the government system:

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Under the formula, y is the subsidy (measured in terms of full cost of public option coverage) and x is defined as household income (measured in terms of poverty line).[/quote]

This isn't being offered as an amendment yet.  In essence, Medicare plans are transferred over to the new AtlasCare program by default and Medicaid recipients take subsidies if they choose to look for private plans.  Like Medicare, AtlasCare plans are sold individually and in parts.

My main concern is that I don't want AtlasCare to run into the same problems that Medicare has had, so this is where funding and cost reductions come into question.  I decided we should address those next if we're okay with this model.

[Blair]

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.

So under the current plan you could have a private insurance plan, yet sign on for Atlascare part D to get your medication? 

[The world will shine with light in our nightmare]

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.

So under the current plan you could have a private insurance plan, yet sign on for Atlascare part D to get your medication? 

Well, in America, you need to be enrolled in either Medicare Part A, Part B, or both, in order to qualify for prescription drug benefits.  I'll add that to the draft.

[Blair]

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

[Clyde1998]

The amendment by Scott has been deemed friendly, as it has come from the sponsor.
I have slight concerns about Section 6, I feel that there are certain situations where it wouldn't be possible, or ethical, to check a persons nationality prior to admittance - such as them being unconscious or in a potentially fatal situation.

Also, what is the likely cost to the Government of this when compared to the current system?

[The world will shine with light in our nightmare]

It's not an amendment yet.

The bill requires foreign nationals to have insurance prior to admittance into the country, not into hospice care, but I'll submit an amendment later on to clarify.

I think the GM will have to give us a final cost analysis before the bill goes to a final vote.

[Clyde1998]

It's not an amendment yet.

The bill requires foreign nationals to have insurance prior to admittance into the country, not into hospice care, but I'll submit an amendment later on to clarify.

I think the GM will have to give us a final cost analysis before the bill goes to a final vote.

That's okay. Thanks for clarifying.

[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.

[The world will shine with light in our nightmare]

I actually think that having separate healthcare bills would be a lot more convenient for us, and certainly less confusing, instead of having a grand debate about the healthcare system over one bill.  I'm going to amend the bill we have now with the changes that were proposed.

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Under the formula, y is the subsidy (measured in terms of full cost of public option coverage) and x is defined as household income (measured in terms of poverty line).

SECTION 6. TAX SUBSIDIES FOR PRESCRIPTION DRUGS

Individuals and families that are covered by private insurance or HICs shall be eligible for an annual tax credit not exceeding $5,000 to offset "out-of-pocket" prescription drug costs that exceed 5% of their annual income.

SECTION 7. FOREIGN NATIONALS

Foreign nationals visiting the Republic of Atlasia via visa must provide proof of insurance coverage prior to admittance into the country.  Permanent residents shall be eligible for private, non-profit, or public insurance.
[/quote]

If this is the model we're going with, it might be appropriate to ask the GM for a cost and budgetary analysis (unless the House makes changes, in which case we might want a budget analysis afterwards).

[Associate Justice PiT]

     I know some GMs in the past have declined to do cost analyses of works in progress. Given the scope of this project, I hope that will not be an issue in this case.

[The world will shine with light in our nightmare]

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

[The world will shine with light in our nightmare]

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...