No, the government tends not to bind itself like that. The penalty for being uninsured is something that only applies to individuals and is the part that would be struck down if the SC rules against. In my understanding.
No. The mandate is a requirement that you buy it if you don't otherwise have it. If it's struck down, then people won't be forced to buy it if they don't otherwise have it. End of story.
The health care mandate is to buy health insurance, not health care. That's a very important distinction.
2: If the mandate is struck down, the whole plan either turns into a single payor or collapses into a heap. Almost certainly the latter.
No, the mandate is to buy health insurance from a private company or face sanction. Alternatives would be a general tax to provide health care (Medicare) or else a means to buy public insurance from the government (public option).
Neither of those were in Obamacare care because the point was not to provide healthcare or health insurance but to sell the American people as slaves to private insurance and income streams to high finance, with the federal government being the enforcer
Closest analogy is the fugitive slave act. If SCOTUS uses Dredd Scott as an precedent, the Obama cultists may get their victory.
You're correct that the individual mandate requires some people (mostly everyone, but not quite), to obtain or maintain a certain minimum amount of health insurance coverage either from their employer, or by purchasing it individually, or through public sources such as Medicaid, Medicare, or one of the veterans' programs.
If it gets struck down the result will be that people are no longer required to obtain or maintain coverage. Other parts of the statute may or may not go down as well -- exactly what would happen is an issue that is currently being briefed before the Supreme Court, in parallel with the constitutionality of the mandate itself and of some of the Medicaid provisions.
HG, the scenario you suggest isn't on the table -- that would be basically rewriting the statute as opposed to striking a particular piece as unconstitutional. The argument you make is, however, similar to some arguments that supporters of the statute make as to why the mandate is constitutional and indeed not very different from other types of governmental regulation that have been permitted for a long time.
4: I wouldn't be so sure. (Of course, a court might rule that the mandate was inseverable from the rest of the law, and strike the whole thing down on that basis.) Something would have to replace the mandate, but there are a lot of options besides single payer (which is the least likely of all possible outcomes).
It moot speculation anyway, since the mandate won't be struck down.
8: What would replace the mandate that wouldn't trigger massive amounts of adverse selection?
It moot speculation anyway, since the mandate won't be struck down.
How do we know this?
9: It's not impossible they could kludge something together with other weaker sticks like open enrollment periods, but unlikely, especially without Congress lifting a finger.
One other detail the Newt brought up during a debate. Gingrich said something like this: If a person chooses not to have or buy health insurance, that person would have to pay a fine which supposedly would offset some of the cost if that person used an ER.
Or something like that. It was during a debate, and Gingrich also was conflating the Mass law with the Federal law, so the details are probably garbled.
Does anyone know what happens if someone refuses to have or buy health insurance?
We don't know it won't be struck down. Striking it down would only be as ridiculous as Bush v. Gore was.
10:Cause Lemieux says so, of course. Only a complete psychotic blithering idiot could find a single slight constitutional problem on the ACA, say the Democratic legal scholars.
Look, if the IRA was designed to not only not give you a tax break if you didn't buy the stocks of six specific companies, but fined you for so not investing, you would see something comparable to the mandate.
The US has taken the fall-back position that at least the guaranteed-issue and community-rating provisions should be struck down along with the mandate if the mandate comes down (obviously their primary position is that the whole statute is constitutional and should stand). The argument is made at pages 44 to 56 of the brief linked below. It's basically because of the adverse selection problem.
http://aca-litigation.wikispaces.com/file/view/U.S.+brief+on+severability+%2811-393+%26+11-400%29.pdf
Although the Court could still decide to uphold those portions if the mandate goes down, it would be pretty surprising for it to do so in light of the government's position.
The US has taken the fall-back position that at least the guaranteed-issue and community-rating provisions should be struck down along with the mandate if the mandate comes down (obviously their primary position is that the whole statute is constitutional and should stand). The argument is made at pages 44 to 56 of the brief linked below. It's basically because of the adverse selection problem.
http://aca-litigation.wikispaces.com/file/view/U.S.+brief+on+severability+%2811-393+%26+11-400%29.pdf
Although the Court could still decide to uphold those portions if the mandate goes down, it would be pretty surprising for it to do so in light of the government's position.
Sorry for the double-post, I'm not sure how that happened.
12: Are you sure you're not mixing up Gingrich and Romney? Romney described the Massachusetts mandate as a fee to offset the cost of free emergency care in a recent debate. I suppose Gingrich could have used the same framing before Obama was elected.
12.3:A fine, collected by the IRS
I just looked through PPACA, and it doesn't seem to dedicate the penalty money to any fund. But money is fungible.
It's not impossible they could kludge something together with other weaker sticks like open enrollment periods, but unlikely, especially without Congress lifting a finger.
The assumption that Congress doesn't lift a finger is untenable, because if Congress doesn't lift a finger we're left with a giant adverse selection problem and an insurance industry that's screaming bloody murder. (Assuming the court doesn't rule that the mandate is inseparable from the rest of the law, and just strike down the whole thing, which is silly but not more silly than ruling the mandate unconstitutional in the first place, so as long as we're imagining, who knows.)
You could imagine deadlock, where Republicans use the court ruling to push for total repeal, and Democrats try to replace the mandate with some alternative structure. But I can't see that deadlock persisting for long. Maybe I'd be surprised. (Of course, as I said, this is all idle speculation. The mandate won't be struck down.)
I continue to despair at the support this shit gets from people on my side of the aisle. I hope it gets struck down so the country is actually forced to confront the issue that basic healthcare should be provided by the govt. just like police, fire, and any number of other things with perverse incentives.
I hadn't seen the brief on severability. That does make it more likely that the court would rule those few provisions inseverable, and strike them down together. That also seems like a supremely stupid position for the administration to take. Talk about preemptive surrender. Jesus.
Look, there is an interesting question here.
This has always been a power of the individual states. Indiana can require you to but private car insurance and also regulate insurance companies within the state, thereby limiting your options. If they regulated the options down to one private insurer, I don't know that there would be a federal constitutional problem. I don't know.
But, AFAIK, such power has been reserved to the states. There is no federal insurance for long-distance truckers, not a federal law requiring insurance. If I am not mistaken, a long hauler pretty much has to deal with every state on her path.
Why? Why is there no federal law to require car insurance?
I'm pretty sure the penalty goes to the Treasury. (That's what the US said in its lead merits brief on the mandate, linked below. Page 54.) You can argue the extra revenue helps offset the cost of uncompensated care if you like, I suppose. The federal government certainly does bear a large portion of those costs. But to make that argument really work the feds would have to share a portion of the penalty money with the states and the various private providers who bear the rest of those costs, and I'm pretty sure PPACA doesn't have any provision for doing that.
http://aca-litigation.wikispaces.com/file/view/U.S.+brief+for+petitioner.pdf
What 22 fucking said.
23:I presume Obama is trying to intimidate SCOTUS, telling them they will take the heat for thousands dying.
I hope it gets struck down so the country is actually forced to confront the issue that basic healthcare should be provided by the govt.
In fact, for decades and decades, there was no Affordable Care Act, and the country was not forced to confront this issue.
When Congress did address the issue, the Affordable Care Act is what it coughed up - even after two consecutive historic repudiations of the Republicans at the polls. I can't see any evidence that a better political environment is on the horizon.
No idea what their actual thinking was, so this is pure speculation, but HHS may actually have felt that the guaranteed-issue and community-rating provisions would do more harm than good (because of the adverse selection problem) if the mandate was severed and struck down.
Also (maybe in addition, maybe in the alternative), some of the merits arguments for the mandate work significantly better if you maintain that the mandate was an absolutely necessary part of a larger scheme of regulation. And it's really tough to do that if you're also saying that the rest of the scheme stands on its own.
HHS may actually have felt that the guaranteed-issue and community-rating provisions would do more harm than good
Of course they do -- they send the insurance companies into a death spiral. I'm not normally one for heightening the contradictions, but where it means putting a gun to the health insurance industry's head, I'm all for it.
18: 12: Are you sure you're not mixing up Gingrich and Romney?
I could very well be doing that. There was a back and forth on the topic. What struck me was that as long as the law was fining those slacker low-life poor people the audience loved it.
Aside from who brought it up, is there such a provision in the law?
In fact, for decades and decades, there was no Affordable Care Act, and the country was not forced to confront this issue.
Health care costs and middle class incomes look very different today than they did 40 years ago. That's why it will have to be confronted.
I hope it gets struck down so the country is actually forced to confront the issue that basic healthcare should be provided by the govt
a lovely fantasy.
sadly, we are unlikely to ever get a congress that's liberal enough to pass a law enacting free health care.
30: Crashing the mechanism by which the employed portion of society pays for its care with no clear replacement in sight might be putting a gun to a lot of heads outside the insurance industry.
I'm not normally one for heightening the contradictions, but where it means putting a gun to the health insurance industry's head, I'm all for it.
Got it. But I'm not sure that the Administration disagreeing with you on that particular approach counts as "preemptive surrender" (as urple put it).
31:Poor people may be covered by Medicaid and subsidies, until Republicans slash them. The fine/penalty will typically hit the healthy 25-35 year-old making $40k.
Obama Is Not On Our Side ...Yves Smith
The "mortgage settlement" has disgusted and enraged me to the point of thinking of leaving the Internet. Just fucking corrupt and evil.
35: Well, it's a pre-emptive statement that the pre-ACA status quo is preferable to single payer. I disagree with the administration on that.
I think 29.2 is right. The mandate is an incidental but necessary part of a comprehensive scheme, a scheme that, other than the mandate, isn't remotely a close call in Commerce Clause terms.
Bob, if Congress wanted to mandate insurance on commercial trucking, I don't doubt they could do it.
Widget, I'm not following this particularly: do you think there are any votes for the 'it's a tax' position?
That's why it will have to be confronted.
Eh. Not necessarily. It's very easy for me to imagine things getting so much shittier than they are now, or were at any time in living memory, without any effective political movement to fix it.
29.2 makes sense. 30 is my rough response to 29.1, although I think people seriously overestimate the amount of gaming of the system that would occur (i.e., the extent of actual adverse selection), especially in the short term. Most people who can afford health insurance purchase it, and aren't willing to risk going without it on the hope that if they get sick they'll be able to go out and buy a policy. I mean, what if they have a sudden heart attack? Etc. Is that risk worth bankruptcy?
Health care costs and middle class incomes look very different today than they did 40 years ago. That's why it will have to be confronted.
Hmm, yeah, well, the Republicans have a plan for that. Make Medicare a voucher system. Personally, as woeful as the Democrats are, I'd rather go with their plan.
What 22 fucking said.
Somehow he said it without making everyone want to punch him in the face for being such a smug asshole, though. Take notes.
38.2 is the only response I have seen from establishment lawyers for years. "If the gov't wanted to mandate you to buy Cap'n Crunch instead of Cheerios, and fine you for not buying cereal, I don't doubt they could."
Not fine-grained, detailed or historical enough. I need an exact analogy. There have been infinite opportunities for an exact analogy.
I thought of looking into ports and harbors.
It's very easy for me to imagine things getting so much shittier than they are now, or were at any time in living memory
It's already going to happen. I see no reason to amp the "the govt funnels your money directly to corportations" up to 11 in the meantime. SS will be next. "Everyone needs a retirement, here's the list of mutual funds you will be required by law to purchase from".
Health care costs and middle class incomes look very different today than they did 40 years ago.
41 gets it right. "If you weren't paying so much of your hard earned income in taxes, you'd be able to afford health insurance. That's why we're proposing a real solution for America's healthcare system: a national flat tax!"
40: Adverse selection has already hit the individual market. In most states, people with normal incomes can't buy health insurance if they aren't employed or COBRA-ing it. Companies are making these decisions and in an economy with 9% employment, offering coverage is increasingly not required to hold employees. Making it possible to game the system for an individual makes it more plausible for a company to not offer coverage.
I think I've also heard 29.2 from a member of a group preparing an amicus brief.
Count me still a reluctant ACA supporter. I think it sets up mechanisms that will, if deadlock leaves them in place, make it politically easier to improve it. Lose it, and we get to roll the dice again in 10-30 years.
46: I don't think most of the activity in the individual market is the result of deliberate gaming, though, which is the big fear if you have guaranteed issue and community rating but no individual mandate. It's the result of many individuals being actually priced completely out of the market, as you say. Fix that, and I think the overwhelming majority of people buy, if they can afford it. And the subsidies in the ACA stay in place, with or without the mandate (presumably). (The subsidies are wholly inadequate, which is a problem and will make the adverse selection issue worse than it should be, but that's a separate issue.)
37: I guess I don't read it that way, because I don't see a path to single-payer from striking the mandate down but leaving guaranteed-issue and community-rating in place. At that point, if there's no legislative action, the adverse selection problem becomes crippling for private insurers. So instead, to avoid that problem, there's likely to be some legislative action. But is there any reason to think that the legislative action would be enactment of single-payer? With the situation in Congress being as it is?
I mean, I take it your argument is that the Administration should be willing to (a) advocate for the adverse selection scenario before the Court, and then if they win (b) play hardball and use the leverage created by the adverse selection scenario to force a single-payer plan through. And I get that you're criticizing them for lacking that willingness. But I don't see how that equates to the policy preference you're suggesting.
I think it sets up mechanisms that will, if deadlock leaves them in place, make it politically easier to improve it
That has been working out really well for the last forty years, in education, health care, job security, pensions, golly, everything!
Who says the administration even wants single-payer in the first place? They're centrist and corporatist.
So instead, to avoid that problem, there's likely to be some legislative action. But is there any reason to think that the legislative action would be enactment of single-payer? With the situation in Congress being as it is?
The people in Congress want to do what corporations want, not what Friedrich von Hayek and Ronald Reagan want. If insurance companies suddenly want single-payer, and a lot of business owners have their desire to no longer be forced to pay their employees' insurance premiums over their desire for poor people to stay poor, Congress will listen. This scenario is not that ridiculous. Republicans could even become the party of universal health care, just like they are apparently now becoming the party of internet freedom and the party of anti-TSA sentiment.
48: I don't know if it is gaming or not, but it sure was adverse selection.
43.1 -- Bob, I don't know what you want. Is 49 CFR 387.301(a)(1) insufficient example for you?
38.3: Not sure. I've looked at some of the issues, but haven't done much on the taxing power side. My very cursory impression is that there's an argument there, but the cases are really old and it's hard to predict reliably what the Court would do today in a politically charged case.
But Judge Kavanaugh did indicate he was sympathetic to the taxing power argument in Seven-Sky, though he ultimately didn't go all the way and he voted against jurisdiction on Anti-Injunction Act grounds rather than voting to uphold on the merits. And he's not a terrible proxy for the younger conservatives.
I was unclear -- I meant to ask whether you think there are any votes for the Kavanaugh/Fourth Circuit scenario. Let's them avoid gutting Raich (for example) and all the other stuff done on CC grounds, but also lets them avoid endorsing 'Obamacare.'
(I think K probably sees himself on any short list for promotion in a Romney Admin -- and wouldn't be shocked if that loomed larger than the extreme economic conservatism logic some people have seen behind his dissent. If Brown had been on the panel instead of Silberman, this might have been smoked out.)
It's going to be hilarious when bob finishes turning into a sovereign-citizen tax protester.
56: Oh, you mean not upholding it under the taxing power, but holding that the Anti-Injunction Act bars jurisdiction and kicking it down the road? I can't pretend to be close enough to count votes on that one. I wouldn't discount the motives you're suggesting, but my gut feeling is that they'd be overcome (particularly for Justice Kennedy) by the urge to provide certainty on the constitutionality of a really major federal statute.
Another route to a similar result would be the as-applied analysis endorsed by Judge Sutton in his concurrence -- that wouldn't provide certainty about all applications of the statue, but you could write it in a way that made it clear that the bar for an as-applied challenge would be high enough that the regulatory scheme as a whole would survive. I still think it's an unlikely scenario, though.
Of course, Justice Thomas might just think it really is a tax. Can't rule that out.
58: Oh, he'll calm down a lot once there's a Republican president. Seriously.
61:No institutional memory
I was calling for armed insurrection before Bush v Gore. The signing statements and the illegal invasion made the entire Bush administration not lawful, and I was quoting Spinoza...
...aw hell, why do I bother with the fucking cultists.
Just as there was no policy of Bush's that a wingnut would not support, there is absolutely, a word not used lightly, nothing Obama could do that would cause most of you to not vote for him.
The huge monumental difference between Jets and Giants fans. Totally different, like totally.
62: "No institutional memory" s/b "RTFA". RTFA.
and a lot of business owners have their desire to no longer be forced to pay their employees' insurance premiums over their desire for poor people to stay poor,
I know I've said this a billion times here, but this is so CRAZY. There is a great reason for nearly every corporation to prefer single-payer, and yet.
Thanks for this discussion, widget et al.
I will, in fact, make clear my pleasure at 29.2: I had assumed that this was the essential argument, but hadn't been aware of the formal severability argument. Really, thanks again, widget.
Going quasi-presidential in this thread because I really shouldn't be discussing these things.
No, the mandate is to buy health insurance from a private company or face sanction. ... [T]he point was not to provide healthcare or health insurance but to sell the American people as slaves to private insurance and income streams to high finance, with the federal government being the enforcer
Fortunately, bob, Obama is so incompetent that he included a provision in the ACA that every state exchange offer at least one OPM-approved (i.e. federally approved) qualified plan from a non-profit or cooperative insurance carrier. Why, he was so careless as to include appropriations for seed funding for cooperatives.
Now, there is still an argument that a true public option (Medicare for all) would have been better public policy because of its leverage to negotiate down provider prices, but the complaint "I don't want to be forced to line the pockets of insurance company shareholders" is a red herring, because no one is being so compelled.
It's not impossible they could kludge something together with other weaker sticks like open enrollment periods,
This is exactly what will happen, in the unlikely* event that the individual mandate is struck down and declared severable. It would be a messy kludge, but it would very likely suffice to stabilize the market (at some cost to sick people). Recall that the individual mandate is pretty weak sauce: modest penalty, weak enforcement, lots of exemptions (i.e. for economic hardship). Most of the newly insured will be insured because it will be a good deal for them to buy subsidized coverage. The carrot is as important as the stick.
The assumption that Congress doesn't lift a finger is untenable, because if Congress doesn't lift a finger we're left with a giant adverse selection problem and an insurance industry that's screaming bloody murder.
This is exactly right.
*"unlikely" not because I think the mandate will be upheld (I don't have a firm opinion either way), but because it is highly unlikely to be overturned on its own. There is a very straightforward legal case for non-severability (the plain language of the statute). If the majority of the court is willing to make a baldly political decision to overturn the mandate with a weak legal case, why wouldn't they make the comparatively easy ruling that the entire statute goes with it?
68: A pleasure, though I should make clear that 29.2 is more my interpretation of the way the arguments work together than anything the government has actually said.
69, 70: That is an amusing choice of pseudonym if I'm interpreting it properly. But I may be overreading it.
Hm. I wonder if the states' argument for Medicaid expansion nonseverability was crafted to make it look moderate by comparison to strike down all the private insurance regulations along with the mandate. (I agree severability of everything non-mandate would not make sense.)
The fine/penalty will typically hit the healthy 25-35 year-old making $40k.
This isn't true, by the way. I could explain why, but I don't feel like spending all evening correcting bob's factual errors.
Yay to Kermit as well, for providing perspective. I lurve you guys (gals, whatever) when you do this.
I wonder if the states' argument for Medicaid expansion nonseverability was crafted to make it look moderate by comparison to strike down all the private insurance regulations along with the mandate.
Interestingly, the government has conceded that the Medicaid expansion could be considered non-severable. That conclusion follows from one of the government's argument for the severability of the rest, namely that the plaintiffs lack standing for everything except the mandate and Medicaid.
I met your son or grandson, depending, at the local kiddie museum with your grand or great-grand whatever in tow.
Huh. Brinksmanship begets brinksmanship, I guess, I guess.
Obama is so incompetent
Obama is not incompetent at all, in any way.
As far as the rest of your bullshit, I have no idea who the fuck you are, and you provide no links, so the cultists can believe your every word, but I sure don't have to.
There is no federal insurance for long-distance truckers, not a federal law requiring insurance.
Once again, bob is talking out his ass. In actual fact, any company wishing to operate a commercial vehicle across state lines must obtain a registration number from the Motor Carrier Safety Administration (a "USDOT sticker"), one of the requirements for which is proof of adequate public liability insurance.
Damn it! I just swore I wouldn't spend all evening correcting bob's factual errors, and here I go again!
you provide no links, so the cultists can believe your every word, but I sure don't have to.
Look up section 1334, subsection 3 of the Affordable Care Act, and then go fuck yourself while you're at it.
Back before tabbed browsers, that would have been much harder.
81:So where do I sign up for my "non-profit" or "cooperative" in Texas? I just remembered why that was considered inadequate, it is because most of the non-p and cooperatives were Wellpoint scams.
How is the sign-ups going so far? What percentage have chosen the non-profit in Mass, and the other states that have set up exchanges?
Obama and his tools can sure run the bullshit. Yves Smith has been struggling for days on the mortgage agreement language.
Who is paying Obama? If it ain't you, you are the one getting screwed.
Shit, bob is not going to believe Kermit. Not after Iran.
What percentage have chosen the non-profit in Mass?
All seven of the top seven insurers on the exchange are non-profit. Try doing some rudimentary fact-checking sometime, you may find that it strengthens the impact of your rhetorical questions, or at least deters you from posing embarrassingly wrongheaded ones.
We must nuke American health care delivery, payment, and insurance systems in order to save them! It's a runaway china syndrome!
at least deters you from posing embarrassingly wrongheaded ones.
You must be new here. And by here I mean "the Internet".
McManus is being a bit troll-y here, but President Kermit's take on all of this sounds a bit Panglossian, I must say.
So: after it's all implemented (assuming it will be) in 2013 (or 2014?), anyone in any of the 50 states can purchase (or have purchased through an employer, perhaps?) a health insurance plan provided by a non-profit or cooperative insurer? Do such non-profits and coops currently operate in all, or even most, of the states of the union? and if not, will the ACA force the states to come up with non-profit options to meet the requirements of the new law? An unemployed person (or a semi- or seasonally-employed person) will be able to purchase health insurance through the exchange, and, what with all the non-profits and cooperatives offering policies, this will be entirely affordable, once adjusted for income or the lack thereof, to the un- or semi-employed person?
Totally confused here, and completely biased, admittedly, toward single-payer (it streamlines everything, and also it's more economically just), but sincerely asking.
88 was me: sorry!
(My parents currently groan under the yoke of a Canadia health care system which sends an in-home health care worker to their apartment every morning to make their breakfast and to make their bed, and to do other light housekeeping. And that's quite apart from the in-home nursing care. Will this Soviet-style mode of oppression be available to Americans under the ACA, I wonder?)
88: anyone in any of the 50 states can purchase (or have purchased through an employer, perhaps?) a health insurance plan provided by a non-profit or cooperative insurer?
I'm unclear on that as well; my understanding, muddled, had been that only people not covered by employer plans, or else in 'small group' plans, will be eligible for the exchanges in the first place. If every state includes at least one non-profit or cooperative insurer, great, but it's not clear to me that every citizen will be able to participate in it.
The states are rolling out their plans for compliance at their own paces. People in shitty states will likely be looking at shittier sets of options. This is far from the optimal solution, but I'm ultimately with Minivet in 47.2.
An unemployed person (or a semi- or seasonally-employed person) will be able to purchase health insurance through the exchange, and, what with all the non-profits and cooperatives offering policies, this will be entirely affordable, once adjusted for income or the lack thereof, to the un- or semi-employed person?
More of the unemployed and semi-employed will be eligible for Medicaid than before (including the childless, who tend to be left out of everything). The subsidies are on a sliding scale designed to keep the premiums a modest percentage of income - though that percentage goes up with income too.
Single person, making minimum wage for 40 hrs * 50 weeks means income $14,500, so 126% FPL and newly eligible for Medicaid.
Single person, age 30, income $20K: premium after subsidy $1,019/year, 5.1% of income.
Single person, age 30, income $40K: premium after subsidy $3,800/year, 9.5% of income.
Family of 4, age 30, income $40K: premium after subsidy $1,982/year, 4.95% of income.
That, of course, assumes the mandate, exchange setups, medical loss ratio, cost control measures, etc. keep costs from growing too fast. And copayments/deductibles/etc. are supposed to have some kind of subsidies to stay affordable too, but I found that part of the law much less comprehensible. Too damn many moving parts.
I'm skeptical of the utility of nonprofit insurers on the exchanges. It's a good thing all else equal, but nonprofits can be just as big moneygrubbers as for-profits when it comes to healthcare.
90: There will also be state exchanges for small-business insurance, and subsidies to small business that offer insurance; states can at their option combine the individual exchange with the small-business exchange.
I'm glad that people on this thread know quite a bit about the ACA, as I don't, and I'll have to know something about it for when I come back to the US, but couldn't we just pass a system that isn't so fucking complicated? I live under a mandate right now; I welcomed it.
There are some things I need to do here that are outside of the basic health insurance plan that's provided here because it's a fundamental human right; those are subject to a system like the American one, with networks and co-pays and so on. I dread having to deal with that.
Will this Soviet-style mode of oppression be available to Americans under the ACA, I wonder?
No, alas. Title VIII of the ACA did create a voluntary long-term care insurance scheme (the CLASS Act), but the HHS has already announced that it will not implement it, and it is highly likely that the provision will be repealed in the next year.
The problem is that it is mathematically impossible to structure an actuarially sound plan with affordable premiums if participation is voluntary (there's that individual mandate thing again!), and no member of Congress wants to repeat the experience of the Medicare Catastrophic Coverage Act of 1988 (repealed the next year before it went into effect).
Long term care is expensive, and will require some combination of higher taxes and mandatory premiums. We as a society have not faced up to that reality yet.
All that said, there are a number of carrots and sticks in the ACA to encourage delivering health care in lower cost settings--physicians office instead of emergency room, home health nurses instead of physician visits, etc. So I think we will see a lot more use of home health services for frail elders and chronic disease patients in managed care environments.
will the ACA force the states to come up with non-profit options to meet the requirements of the new law?
Sort of. The Office of Personnel Management (that's the feds) will contract with non-profits and/or co-ops to cover all 50 states (any plan can initially limit itself to 30 states, but eventually every OPM-qualfied plan will have to cover all 50). These plans will be contracted in exactly the same way as the federal employee health benefits program, only with different risk pools. The states have to allow these OPM-approved plans on the state exchange, whatever local rules apply otherwise. It's all kind of Rube Goldberg-ish (and would not have been necessary if Martha Coakley hadn't been such a jackass, because the House bill called for a national exchange rather than state exchanges, and the House version would probably have prevailed in a conference committee on this point), but it does represent a backstop with some of the features of a public option.
this will be entirely affordable, once adjusted for income or the lack thereof, to the un- or semi-employed person
Yes and no. The ACA makes provides for premium subsidies up to 400% of the federal poverty line (i.e. up to about $80K for a family of four), and has much more generous eligibility for Medicaid. So there is a significant redistributive element to it. At the same time, health care is fucking expensive in this country -- it consumes almost 20 cents on every dollar of national income -- so there's no getting around the fact that the average person is going to pay a lot of money to get care (and this is true even if the employer nominally pays for the policy). Sure, it's shocking to think "If I'm an average person, I need to pay more for health care than I pay in taxes," but that's the fact. And while I'm more than sympathetic to the arguments for Canadian style single-payer, it wouldn't change the fact that people are still going to pay a lot more money than they would like.
One of the oft-overlooked aspects of the ACA is the provisions to attenuate the unsustainable long term cost trend (this is Peter Orszag territory -- in his view, universal coverage was as much the bait to get liberals to sign onto cost controls as a good unto itself). If the cost control provisions don't work, or if they aren't allowed to stand, then the cost of premiums will quickly outstrip the capacity of subsidies to make them affordable.
Sure, it's shocking to think "If I'm an average person, I need to pay more for health care than I pay in taxes,"
Upon reflection, that's misleading.
The point remains that health care is dreadfully expensive, and the costs will have to be borne broadly across the population (ideally in a progressive, solidaristic fashion). There is no magical socialized medicine fairy to give us all free health care.
nonprofits can be just as big moneygrubbers as for-profits
Blue Cross Blue Shield NC is non-profit, and as Wikipedia notes: "In the past Blue Cross Blue Shield has been sued and fined for denying due medical treatments to its customers and for underpaying doctors. BCBSNC has also come under fire for a failed attempt to convert to for-profit status in 2003, a year in which it posted a record profit of $196 million and most customers saw their rates rise by more than 10%."
83: What percentage have chosen the non-profit in Mass, and the other states that have set up exchanges?
um, bob, a large employer in MA could easily be dealing with a for-profit insurer like Cigna or United. All of the other major insurers operating in the individual and small-group market place are non-profits. Blue Cross Blue Shield has been mumbling about reorganizing as a cooperative instead, but nobody has argued for for-profit status.
And MA has had community rating (by age and zip code) for the individual market for a long time. We were in a bit of a death spiral.
89: For dual eligibles (that is poor old and/or disabled people on both Medicaid and Medicare0 it probably will be under the new blended rate.
99: What blended rate are you referring to? I thought PPACA didn't do any big national reforms for dual eligibles, just mandated a dedicated office in CMS for them and a bunch of pilots to see what else made sense. Some states might try to get big reforms approved on their own - viz. Jerry Brown's proposal.
100: Minivet, I'm not sure, and I only heard the term at a conference recently put out by someone who created two HMO/medical practices in the Boston area. He was very interested in the possibilities afforded by the ACA.
Je may have just been talking about managed care contracts under capitation for groups like his which invest a lot in nurses doing home outreach. The guy who used the phrase was Bob Ma/sters about whom there's a blurb here.
Kermit is doing god's work in this thread. I (thus far) endorse everything he's said.
Kermit is doing god's work in this thread. I (thus far) endorse everything he's said.
Minivet, thanks for 91, 92. It looks like the KFF website linked in 91 might be a good source for overall information about the structure of things to come.
Blue Cross Blue Shield NC is non-profit
Exactly. Oh boy, we're going to be required by law to buy from these fuckers.
liberal enough to pass a law enacting free health care.
Free to whom? Somebody is paying. Probably all of us, through income taxes. Which of course, not everyone pays. So free to those with no income tax bill, I guess.
If you think the Department of Defense has a bloated budget, HHS or whoever will administer the free health care will make DoD look like a bunch of pikers.
I hadn't read Kermit's input. nevermind.
I have the same problem I always did with the mandate and subsidy set up, and I think that something in the last couple of years reinforces my skepticism.
The basic problem: Whenever there's a mandatory fee and provision for a subsidy, the payment is very, very often due before the subsidy arrives. And it's not uncommon at all for various sorts of mistakes both to delay a subsidy - sometimes for months or even years, in cases of my own and those of folks I know - and to mess up the amount, requiring further adjustments. And meanwhile, the payments keep being due. This happens again and again and again and again, to everyone who's got any kind of need that involves alleged eligibilities for subsidies.
What's different right at the moment is that more folks who aren't in general terms poor and needy got to experience the same thing, with HAMP. A check with the Google suggests that of the $48 billion allocate for what's very like subsidies for needy mortgage owners, less than 10% got spent on them. A whole lot of people asked for help they thought they were due, and waited, and waited, and waited, and got nothing. Getting nothing at all is another part of the common experience of dealing with subsidies, by the way, even when you're quite sure you fit all the criteria and maybe have even been affirmed in this judgement by someone in a local office of whatever agency.
And what prospect is there that, if it survives, the subsidy part of the mandate element of ACA will be run one scrap better than HAMP, and so many predecessors?
(There is a way to avoid this particular pitfall: you can adjust the amount due up front based on the same criteria that would be use to determine eligibility for a subsidy. But this mandate wasn't set up that way, and in any event, it's still vulnerable to people wanting their payment without the wait involved in eligibility checking, saying things like "you gotta pay the regular amount now, and we'll send you a refund if it turns out you're due one".)
108: I mean, I'd prefer a government-run system, but destroying the employer system and just giving everyone a voucher up front (no matter what their income) would be better.
Interestingly, in MA, Medicaid will pay for care retroactively if you're found to qualify (looks back 30 days or something.) Our private subsidized insurance doesn't, but it will continue to cover you through the end of a month even after you're no longer eligible for the subsidy.
Bostoniangirl: SSI works that way now, and in fact it's a standard thing. Any competent SSI lawyer will tell you you're going to get rejected, appeal, get rejected, appeal, probably get rejected, appeal if so, and get approved. It's an entirely predictable process. The settlement payment is nice, but in the meantime it's a couple of years that a person has to live through somehow. There's a reason there's a lot of suicide and death by self-neglect during that stretch.
The basic problem: Whenever there's a mandatory fee and provision for a subsidy, the payment is very, very often due before the subsidy arrives. And it's not uncommon at all for various sorts of mistakes both to delay a subsidy - sometimes for months or even years
That isn't the way the exchange subsidies will work. The consumer will be quoted the net premium after subsidy on the exchange, and that's what they will pay to the insurer. The insurer will effectively front the consumer the money and then pocket the imputed tax credit.
All is not perfect, though: if your income tax return subsequently shows that weren't eligible for the subsidy you claimed (say, because your income fluctuates), the IRS will claw back the excess on your federal tax return. The potential for voter backlash on this point is underappreciated, IMO.
69, 70: That is an amusing choice of pseudonym if I'm interpreting it properly. But I may be overreading it.
I also find Kermit's choice of pseudonym amusing/puzzling, because there's an actual Kermit Roosevelt (III) who seems both (a) to be more-or-less the Mineshaft-lurking demographic and (b) certainly qualified to be making the sort of comments our KR is making here.
110: I'm well aware of the SSI thing. In Massachusetts you would get money from the department of transitional assistance which is less than what you'd get from SSI, but then they claw back once you get your retro payment.
What I'm talking about is that if you got care in a hospital, applied for MassHealth and then were found to qualify the medical care would be paid for even though you weren't enrolled when you got the care. No bills to you.
112. That guy looks about 17, it must be a fake pic.
TLL: If you think the Department of Defense has a bloated budget, HHS or whoever will administer the free health care will make DoD look like a bunch of pikers.
Inside your head, sure. In the real world, when the federal government actually administers a health care programme, it does a better job than the private sector, and it does it considerably more cheaply.
http://mcr.sagepub.com/content/61/4/495.abstract
http://www.washingtonmonthly.com/features/2005/0501.longman.html
This is pretty much what you'd expect if you looked at other countries, too.
Or you can just go with "you want your healthcare from the DMV? hur hur hur".
Also, I don't mind the budget of the DOD, per se. I mind what it's being used for. Go right ahead and spend that much on the care and well-being of our citizens.
112: You can check his Wikipedia image if you like -- it's not more than a few years old, he's holding his new book. (Except that it's not quite that new anymore, I guess.)
I was in fact thinking in 71 that it would be amusing if KR III were the intended reference, rather than one of his forebears.
Oh, okay, Bostoniangirl. Thanks. :)
That isn't the way the exchange subsidies will work. The consumer will be quoted the net premium after subsidy on the exchange, and that's what they will pay to the insurer. The insurer will effectively front the consumer the money and then pocket the imputed tax credit.
It's actually a little more complicated than that. The consumer will qualify for an annual premium tax credit based on income. They can then choose how much of that tax credit to take in advance, and apply that advanced premium tax credit against their monthly premiums. KR is absolutely right that taking too much APTC in advance may have adverse consequences at tax time. We're spending a lot of time thinking about how to explain that in the Exchanges.