7 ms·

If I start a fire insurance company, and I have a policy that you can sign up even if your house is currently on fire, I'm unlikely to stay in business. Anyone

If I start a fire insurance company, and I have a policy that you can sign up even if your house is currently on fire, I'm unlikely to stay in business. Anyone worried about house fires could simply wait and, if they did have a house fire, sign up for my insurance after the fact. This is why pre-existing conditions are "special" - they are fundamentally incompatible with a free market insurance system. And it is, partially, why American insurance was cheaper previously - insurance companies could simply deny expensive customers and let them die to keep premiums low for the healthier subset of the population they covered. Republicans were elected to get rid of the "bad part" of ACA - mainly the individual mandate. Saying you want to get rid of that is the exact same thing as saying you want to re-introduce pre-existing conditions, they go hand-in-hand. Either we deny coverage to those that are already ill, or we force everyone to have insurance (ACA, single payer, public option, whatever).

losvedir 10y ago
> Either we deny coverage to those that are already ill, or we force everyone to have insurance This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.
- tdaltonc 10y ago
  What would you call it?
  - ianai 10y ago
    Shared bargaining power.
ctdonath 10y ago
It's more like winning a state lottery, where the monthly payout will be terminated if you leave the country for any reason. There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time). This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.
- kmicklas 10y ago
  > making it illegal to not have coverage isn't acceptable. How can you possibly think that?
  - ctdonath 10y ago
    You're fined if you don't have coverage (and that being a robust government-specified plan, not simple catastrophic insurance). It's stupid to require the poor to pay for plans they don't need/want/afford, and for rich to pay for plans when they can pay their own way. MANY people opt to pay the fine as substantially cheaper than compliance. And it's a safe guess that the political "Left" would be screaming outrage if the "Right" were compelling people to buy private-sector products (health insurance) they didn't want or afford.
    - kmicklas 10y ago
      > It's stupid to require the poor to pay for plans they don't need Poor people don't need health insurance? Doesn't everyone need it? If anyone didn't need it it'd be the rich. > /want Too bad. If we let people not have health insurance we might as well legalize suicide by the same argument. > /afford So people who can't afford it should just... die? > and for rich to pay for plans when they can pay their own way. You have to be pretty rich for health insurance to not make sense. Not just like upper middle class. If you're suddenly diagnosed with some rare disease you could easily see medical costs in the hundred thousands per year.
      - ctdonath 10y ago
        Many people don't have much income but are quite healthy, easily able to go years without medical services (yes, in fact a great many people do). All they need is "catastrophic coverage", but that alone is illegal under ACA. Likewise the rich. If you're earning millions per year, you don't need ACA-imposed "$50 co-pay" type coverage for common services totaling under $100,000/yr. (Listen to Rush Limbaugh rant about such issues: forcing him to buy ACA-approved health coverage is stupid; he could buy the hospital if need be.) Comes down to marketplace & choice: it's my life, and my money, who are you to force me (under threat of violence from the state) to buy what you consider sufficient coverage? Let's discuss fixing systemic problems with narrowly targeted solutions, yes, but don't fine me $3000/yr for preferring to pay my own way out-of-pocket completely up to $10,000/yr.
platz 10y ago
With regards to pre-existing conditions, Ryan's plan talks about continuous coverage policies. Under a "continuous coverage" policy, a person with a pre-existing condition would need to avoid having any gap in insurance coverage in order to avoid paying more for insurance or being denied outright. So if you lose your job and your health coverage, insurers would be able to deny you coverage. But if you never have a gap, then you can't be discriminated against. Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.
- hackerboos 10y ago
  So turn the entire population into H1B visa employees. Leave and you lose your health coverage forever?
- jly 10y ago
  I think what Steve King said makes sense to me - protections like 'blanket no denial for pre-existing conditions' could incentivize waiting to purchase insurance until a condition arises, which compromises the system. The gap solution, though, is not a great idea. If someone falls under a certain level of economic or other hard times and incurs a gap for even a very brief duration, it is in my opinion a very harsh penalty to use that as an excuse to deny them coverage. This is especially true when many families pay a large amount for existing coverage. The only tenable solution is to force everyone to have coverage. If that's the answer, I see no better implementation than single-payer.
bentruyman 10y ago
Precisely. Insurance with pre-existing condition is just health care. You are not insuring against anything. My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.
tomjen3 10y ago
The problem is that you have a tripple system. You have the insurance for unlikely but expensive accidents/cancer/etc which is what insurance is good for; you have subscriptions for things like annual health screenings, common care etc and finally you have subsidies for those who have shit health. It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children. There is no need to require everybody to buy an overprized service bundle.
bduerst 10y ago
This issue is specifically solved with the limited ACA enrollment period. You don't wait to have an appendectomy.
gwbas1c 10y ago
I think it's much more complicated then that. Perhaps a different analogy is better: There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance. Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them. Then there are the people who prefer paying for things out of their pocket as they go. The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.
iaw 10y ago
The ACA in it's current form is probably comparable to a fire department in your analogy. As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.
- jly 10y ago
  I'm not sure if you're being downvoted here, but I think this is the right answer. The major problem in the system and with the ACA is that it continues to try and operate health care in a capitalistic free market. Due to the lack of choice by patients and the fact that they cannot reasonable refuse needed care because of price, the system falls apart. I believe the only acceptable solution is a single-payer system where the government is able to set pricing limits on services - like medicare/medicaid already work. This is the only way the costs can be reasonable for the consumers of the care.
  - iaw 10y ago
    Thanks for the support, it's strange that more people don't openly acknowledge that the medical system isn't a free market.
lutorm 10y ago
I don't understand why people are so opposed to the "mandate". We have the same thing in so many other places, only those are handled by paying taxes for things you might not need. I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different? If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.
- Tactic 10y ago
  I am opposed to the mandate because it requires me to purchase something from a private party just because I am alive. If you want everyone to pay something, we (as you pointed out) have something for that, it's called taxes. And that's what pays for your other "insurance" examples. (And don't bring up auto insurance. I don't have to have it, I can choose to not own a car.) But by involving private companies you have creates perverse incentives that I have no sway or visibility into. If we want to socialize health care then lets do that, but lets not introduce a private party middle man that not only disconnects the payer from the consumer but has a government mandated client base of the whole US. I am opposed to it because it is a horrible individual rights breaking precedent.
  - lutorm 10y ago
    But transportation taxes also require you to purchase something from a private party. You just hand your money to the government, who does the purchasing for you. Don't get me wrong, I'm a strong believer in single payer health care (I'm from Sweden), but in the absence of that, whether you pay the money in taxes or directly to a private end party doesn't seem that different to me. (And the US Supreme Court apparently agrees, since the mandate was upheld as constitutional.)
    - Tactic 10y ago
      Yes. And I have a semblance of input to the government. Again, I am fine if it is decided that we need to raise taxes to cover such things. What I am against is the government telling me I have to buy something. It is a precedent that is sure to get abused and distorted in the future. If it is allowed it will not stop at health insurance. Business has too active a hand in the US government as it is. How much worse will it get when they start greasing the palms to make sure they too have a required audience? Edit: (Forgot) Yes, the supreme court upheld it. That doesn't make it right, just constitutional. If an amendment to the constitution is required, then so be it. Seriously, it has me considering moving to another country.
enknamel 10y ago
Why don't we have two systems? One of guaranteed healthcare for the expensive conditions and one of insurance against everyday issues and accidents. So single payer towards things like cancer and insurance for getting checkups, having a cold, going to the ER, etc. Could some middle ground solution like that work?
- jakewins 10y ago
  A problem there is that some of the most expensive chronic conditions (CVD, Diabetes) can be substantially improved by preventative care. Hence: The actor paying for chronic care is the one incentivized to provide great preventative care, separating the two will create incentives with negative patient outcomes and cost for chronic illness. Another less obvious issue is that by splitting healthcare payment between actors, they are weakened against an increasingly monopolistic healthcare provider market. One key reason US healthcare is expensive today is that insurers are weak vs. healthcare providers - splitting them up would further reduce their ability to negotiate better prices. While there's some truth to the argument that US healthcare is expensive because it pays for much of the worlds medical research, there is plenty of truth to the argument that the rest of the west gets better prices because their single-payer insurance is a massively strong negotiating party fighting for good prices for patients.

losvedir 10y ago

> Either we deny coverage to those that are already ill, or we force everyone to have insurance This is the crux of it, but I wish people would stop calling this "insurance". While I agree that all Americans should have some degree of guaranteed healthcare, shoehorning this into the concept of "insurance" is a recipe for failure.

tdaltonc 10y ago
What would you call it?
- ianai 10y ago
  Shared bargaining power.

ctdonath 10y ago

It's more like winning a state lottery, where the monthly payout will be terminated if you leave the country for any reason. There was law requiring insurers to accept you if you switched insurers without a break in coverage; just tweak that law to address common reasons for brief breaks in coverage (say, if you notify & pay either insurer to cover the "gap" within a reasonable amount of time). This and other problems can be addressed with objective & focused solutions. No need to take over the entire health insurance industry just to fix a few systemic problems. ...and making it illegal to not have coverage isn't acceptable.

kmicklas 10y ago
> making it illegal to not have coverage isn't acceptable. How can you possibly think that?
- ctdonath 10y ago
  You're fined if you don't have coverage (and that being a robust government-specified plan, not simple catastrophic insurance). It's stupid to require the poor to pay for plans they don't need/want/afford, and for rich to pay for plans when they can pay their own way. MANY people opt to pay the fine as substantially cheaper than compliance. And it's a safe guess that the political "Left" would be screaming outrage if the "Right" were compelling people to buy private-sector products (health insurance) they didn't want or afford.
  - kmicklas 10y ago
    > It's stupid to require the poor to pay for plans they don't need Poor people don't need health insurance? Doesn't everyone need it? If anyone didn't need it it'd be the rich. > /want Too bad. If we let people not have health insurance we might as well legalize suicide by the same argument. > /afford So people who can't afford it should just... die? > and for rich to pay for plans when they can pay their own way. You have to be pretty rich for health insurance to not make sense. Not just like upper middle class. If you're suddenly diagnosed with some rare disease you could easily see medical costs in the hundred thousands per year.
    - ctdonath 10y ago
      Many people don't have much income but are quite healthy, easily able to go years without medical services (yes, in fact a great many people do). All they need is "catastrophic coverage", but that alone is illegal under ACA. Likewise the rich. If you're earning millions per year, you don't need ACA-imposed "$50 co-pay" type coverage for common services totaling under $100,000/yr. (Listen to Rush Limbaugh rant about such issues: forcing him to buy ACA-approved health coverage is stupid; he could buy the hospital if need be.) Comes down to marketplace & choice: it's my life, and my money, who are you to force me (under threat of violence from the state) to buy what you consider sufficient coverage? Let's discuss fixing systemic problems with narrowly targeted solutions, yes, but don't fine me $3000/yr for preferring to pay my own way out-of-pocket completely up to $10,000/yr.

platz 10y ago

With regards to pre-existing conditions, Ryan's plan talks about continuous coverage policies. Under a "continuous coverage" policy, a person with a pre-existing condition would need to avoid having any gap in insurance coverage in order to avoid paying more for insurance or being denied outright. So if you lose your job and your health coverage, insurers would be able to deny you coverage. But if you never have a gap, then you can't be discriminated against. Rep. Steve King said " If we guarantee people that we will - that there will be a policy issued to them regardless of them not taking the responsibility to buy insurance before they were sick, that's the equivalent of waiting for your house is on fire and then buying property and casualty insurance.

hackerboos 10y ago
So turn the entire population into H1B visa employees. Leave and you lose your health coverage forever?
jly 10y ago
I think what Steve King said makes sense to me - protections like 'blanket no denial for pre-existing conditions' could incentivize waiting to purchase insurance until a condition arises, which compromises the system. The gap solution, though, is not a great idea. If someone falls under a certain level of economic or other hard times and incurs a gap for even a very brief duration, it is in my opinion a very harsh penalty to use that as an excuse to deny them coverage. This is especially true when many families pay a large amount for existing coverage. The only tenable solution is to force everyone to have coverage. If that's the answer, I see no better implementation than single-payer.

bentruyman 10y ago

Precisely. Insurance with pre-existing condition is just health care. You are not insuring against anything. My guess is that if Republicans want to remove the individual mandate AND the pre-existing condition clause, they're going to have to at least allow for some grace period to allow those currently enrolled in ACA to move to another plan with the pre-existing condition clause still in place.

tomjen3 10y ago

The problem is that you have a tripple system. You have the insurance for unlikely but expensive accidents/cancer/etc which is what insurance is good for; you have subscriptions for things like annual health screenings, common care etc and finally you have subsidies for those who have shit health. It would be much better to split the system into those three components: a relatively cheap insurance that you would be unlikely to ever draw on, an optional subscription service that you probably would just pay out of pocket at whatever doctor you trust at whatever price you could get and then something for those who have expensive, preexistent conditions, which is either a government scheme, charity or a required insurance that parents have to take out on their children. There is no need to require everybody to buy an overprized service bundle.

bduerst 10y ago

This issue is specifically solved with the limited ACA enrollment period. You don't wait to have an appendectomy.

gwbas1c 10y ago

I think it's much more complicated then that. Perhaps a different analogy is better: There are the people who just are bad at organizing their life, and can't really get it together to purchase insurance. Then there are the (cough) normal middle class people who can either write a check every month or have their employer write the check every month for them. Then there are the people who prefer paying for things out of their pocket as they go. The problem is that, as a civilized society, we need to make sure that the people who can't "get it together" are still insured, and the people who prefer paying out of their pocket as they go pay a fair price too.

iaw 10y ago

The ACA in it's current form is probably comparable to a fire department in your analogy. As others have pointed out the true problems in our system revolve around medical providers price-gouging, someone who is ill and seeking medical attention is not operating within a free market due to the duress of their situation, but we still use free market principles to justify the massive profit margins of the companies that sell to ill people under duress.

jly 10y ago
I'm not sure if you're being downvoted here, but I think this is the right answer. The major problem in the system and with the ACA is that it continues to try and operate health care in a capitalistic free market. Due to the lack of choice by patients and the fact that they cannot reasonable refuse needed care because of price, the system falls apart. I believe the only acceptable solution is a single-payer system where the government is able to set pricing limits on services - like medicare/medicaid already work. This is the only way the costs can be reasonable for the consumers of the care.
- iaw 10y ago
  Thanks for the support, it's strange that more people don't openly acknowledge that the medical system isn't a free market.

lutorm 10y ago

I don't understand why people are so opposed to the "mandate". We have the same thing in so many other places, only those are handled by paying taxes for things you might not need. I can't avoid buying "invasion insurance" by not paying for the military. I can't avoid buying "transportation insurance" by not paying for roads. Why is paying for health care any different? If anything socializing health care costs makes more sense than transportation infrastructure, because the needs are so unpredictable and beyond the individual's control and the costs so potentially huge.

Tactic 10y ago
I am opposed to the mandate because it requires me to purchase something from a private party just because I am alive. If you want everyone to pay something, we (as you pointed out) have something for that, it's called taxes. And that's what pays for your other "insurance" examples. (And don't bring up auto insurance. I don't have to have it, I can choose to not own a car.) But by involving private companies you have creates perverse incentives that I have no sway or visibility into. If we want to socialize health care then lets do that, but lets not introduce a private party middle man that not only disconnects the payer from the consumer but has a government mandated client base of the whole US. I am opposed to it because it is a horrible individual rights breaking precedent.
- lutorm 10y ago
  But transportation taxes also require you to purchase something from a private party. You just hand your money to the government, who does the purchasing for you. Don't get me wrong, I'm a strong believer in single payer health care (I'm from Sweden), but in the absence of that, whether you pay the money in taxes or directly to a private end party doesn't seem that different to me. (And the US Supreme Court apparently agrees, since the mandate was upheld as constitutional.)
  - Tactic 10y ago
    Yes. And I have a semblance of input to the government. Again, I am fine if it is decided that we need to raise taxes to cover such things. What I am against is the government telling me I have to buy something. It is a precedent that is sure to get abused and distorted in the future. If it is allowed it will not stop at health insurance. Business has too active a hand in the US government as it is. How much worse will it get when they start greasing the palms to make sure they too have a required audience? Edit: (Forgot) Yes, the supreme court upheld it. That doesn't make it right, just constitutional. If an amendment to the constitution is required, then so be it. Seriously, it has me considering moving to another country.

enknamel 10y ago

Why don't we have two systems? One of guaranteed healthcare for the expensive conditions and one of insurance against everyday issues and accidents. So single payer towards things like cancer and insurance for getting checkups, having a cold, going to the ER, etc. Could some middle ground solution like that work?

jakewins 10y ago
A problem there is that some of the most expensive chronic conditions (CVD, Diabetes) can be substantially improved by preventative care. Hence: The actor paying for chronic care is the one incentivized to provide great preventative care, separating the two will create incentives with negative patient outcomes and cost for chronic illness. Another less obvious issue is that by splitting healthcare payment between actors, they are weakened against an increasingly monopolistic healthcare provider market. One key reason US healthcare is expensive today is that insurers are weak vs. healthcare providers - splitting them up would further reduce their ability to negotiate better prices. While there's some truth to the argument that US healthcare is expensive because it pays for much of the worlds medical research, there is plenty of truth to the argument that the rest of the west gets better prices because their single-payer insurance is a massively strong negotiating party fighting for good prices for patients.