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

[Associate Justice PiT]

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.

[NeverAgain]

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.

[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.

[NeverAgain]

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 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...

     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.

I honestly don't know anything about budgeting and haven't even helped write a budget since I was Northeast Governor some years ago.  Believe me when I say that math is not my strong suit.  I don't even know how to begin with this.

I think the fundamentals we need to look at are a) how much AtlasCare will cost in total, b) the Medicare savings gained from people opting for AtlasCare plans, c) the costs and savings associated with what is essentially transforming Medicaid into a voucher program that will likely be phased out in the near future as people shop around for better plans, and d) the prescription drug tax benefit for private customers.

Anyway, I haven't slept a wink for the last day and a half, so now definitely isn't the time for me to jump into all of this.  If anyone knows someone in this game with actuarial expertise, I suggest you ring them up ASAP.

[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.

[Kingpoleon]

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.

[The world will shine with light in our nightmare]

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.

[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.

[The world will shine with light in our nightmare]

NeverAgain is working on a budget analysis currently, so I'll pick this back up when he's done.

[Potus]

Allow me to come to the table with a coherent, opposing view of things.

These policy "innovations" like insurance cooperatives and the public option are treated as though they're a shift in the paradigm of healthcare. That's not the case, however. In reality, we've been moving toward control of healthcare decisionmaking, investment, and costs by a vast bureaucracy for a few generations now. The directly state-controlled components of healthcare have been complemented with various maybe-maybe-not-state-controlled components, like the cooperatives in question. But, the cooperatives aren't the major shift presented in this legislation. The public option is  a more significant step down our current path.

Public healthcare has a pretty troubled history outside of outright patient satisfaction surveys. Medicaid, in particular, has been linked to no changes in health outcomes relative to being uninsured. That's a pretty significant black mark on the program. Medicare has a slightly, but not much, better track record on health outcomes. Both programs suffer from narrowing networks, limited choice, and an outdated Soviet-style payment negotiation system.

The narrow network/choice limitation issues are also linked to the problem of expensive private insurance. It has to do with reimbursement rates in the Medicaid and, to a lesser extent, Medicare programs. Allow me to get a bit into the weeds here. A procedure costs $100,. An uninsured patient is billed the full $100 by the healthcare provider, but will likely only pay $20 of it. Healthcare providers are limited in their ability to collect debts, something I'm not opposing, so the uninsured patient will end up paying only their initial $20 payment. The healthcare provider bills a Medicaid patient the same $100. The state/regional Medicaid bureaucrats respond saying, "We will pay you $60." The purchasing power of Medicare/Medicaid that the healthcare providers are forced to accept that.

In caring for these two patients, the healthcare provider has provided $200 worth of care and received $80 in payment. This leaves $120 as uncompensated care. In this cost, there is a lot of market information that won't be fixed by government fiat, such as the scarcity and quality of talented doctors, PAs, nurses, etc. This is why we are willing to pay so much for our healthcare, and why medical jobs pay so well.

Now, a commercially insured patient goes in for that same $100 procedure. The insurance companies reimburse healthcare providers "at-cost w/a haircut" for the sake of the example, let's say a 5% haircut. The healthcare provider has provided an additional $100 in care with $120 in uncompensated care. They are for-profit institutions, so they add an additional $30 to the bill to attempt to turn a profit. The commercial insurer is billed $250 for a $100 procedure. The healthcare provider has made $12.50 in profit under this scenario.

The commercial insurer will, in response to higher payouts, increase health insurance premiums. This makes health-improving, quality private insurance further out of reach for working class people, who begrudgingly accept Medicaid as a poor substitute.

Many healthcare providers dodge the issues inherent in public healthcare by refusing to accept, leading to limited choices for the poor and elderly.

The Affordable Care partially recognized the opportunity to "bend the cost curve" by shifting uninsured patients from their very low reimbursement rates to Medicaid's better-but-still-bad reimbursement rate of 60%. In our scenario above, this reduces the uncompensated care passed off to private insurers by $40.

For some reason, the law's authors didn't take the extra step to shifting people to quality private coverage that can travel with them through life, the workforce, and health status. They instead chose to expand what is commonly agreed upon as the worst health insurance in the Western World. This is my case against expanding public insurance to larger swathes of the population. The end result will be reductions in access and quality while increasing the cost of insurance that guarantees access and quality. I suggest a different approach be taken.

The first step should be to strengthen the ability of the patient to govern their own healthcare and insurance. A standardized, formula-based annual contribution to a health savings account, designed to suit the Senate's liking, would be a monumental shift in direction for our healthcare industry. I would like to see health savings accounts be able to cover the cost of insurance offered on a liberalized, competitive exchange.

There should also be a broad liberalization of the healthcare marketplace. Lower barriers to entry, lift rules against capital investment, allow more universities to build medical schools, reduce the effect of broken courts on the marketplace, streamline the ability of new drugs and treatments to reach patients, and so much more. We've never really tried this in modern healthcare, but other successful opening of markets suggests it will be very successful.

I could talk further about an alternative bill, but chances are that this chamber will want to continue with this version of the bill because work has already been put into it. Happy to be on hand for something different, should you desire.

[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?

[The world will shine with light in our nightmare]

Don't worry, I haven't forgotten about this or anything.  I just PMed NeverAgain for an update.

[NeverAgain]

My sincere apologies for the tardiness. I take this completely on myself for not being forthcoming, I was working hard on trying to get a clear and accurate cost for the bill. I had a lot done, and then the tab in which I had stored my post cleared, deleting everything. I am now using Google Docs, as it auto-saves, but I do not blame my computer, it was a mistake and I take full responsibility for my tardiness. I will be working on it all tonight, and can try to promise it to be done either tonight or tomorrow. I thank everyone for their patience and understanding.

[Leinad]

Any update on this, now that NeverAgain is back from his illness and we have a Deputy GM?

[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.

[The world will shine with light in our nightmare]

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.

[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.

[The world will shine with light in our nightmare]

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?

[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.