Is ObamaCare even sustainable?

May 20, 2014 15:39:14 GMT pjohns1873 said:

Do you really believe that the relative paucity of enrolees to ObamaCare from among The Young Invincibles is simply due to poor "marketing"? Or to the "scare tactics" of Those Nasty Old Republicans? 

(By the way, many who do qualify for healthcare insurance, under ObamaCare, would simply be forced into Medicaid--which about half of all doctors do not accept, according to my understanding.) 

And your point that "competition" is not harmed whenever all businesses are subjected to the same regulations misses the point, viz.:  All businesses--and especially small businesses, operating on razor-thin profit margins--are harmed as regarding their ability to stay afloat.    

In 2013 it was estimated that 20% of Americans didn't have health insurance (up from about 15% in 2007) and most of those came from the 50% of Americans that received wages of less than $30,000/yr and had a net gross income of less than $15,000/yr. Yes, there were probably some "Young Invincible" that didn't have insurance but the "Young Invincibles" refers to those earning more than this income.

When I read the statistics that about 2/3rds of those that didn't believe they could afford the insurance provided by the ACA didn't know that they would be entitled to subsidies to reduce their costs I can only assume two fundamental reasons. Either they were "uninformed" which is a marketing problem related to Obamacare or they were convinced by someone else that they couldn't afford the insurance. The only one's stating that people couldn't afford insurance under Obamacare were Republicans from what I witnessed.

Do you have another logical explanation for why these people didn't believe they could afford the health insurance when most actually could have afforded the insurance because of the subsidies? Remember they stated the only reason they didn't sign up was because of a perceived lack of affordability because they were unaware of the subsidies. Why would they think that?

When referring to "razor-thin" profit margins I find that very interesting. Small enterprises actually have the highest profit margins if we exclude the profits taken from the enterprise by the owner(s). If we look at a small retail store that is owner operated then we can assume they have a 100% mark-up on the goods they buy and sell. That means that there is a 50% "gross profit" (Line 5 on Form 1040 Schedule C) on the sale price of the "goods" they sell but from this they have to pay for rent and other expenditures (the other expenditures on Schedule C) . A good business plan for a small business would ensure that "all other" expeditures equal less than 1/2 of the "gross profits" on Line 5 (or 1/4th of gross revenue) so that the "Net Profit" from the enterprise (i.e. what the owner gets and pays taxes on) is 25% of gross revenue (Line 31 on Schedule C).

Some of the other "expendatures" that must be accounted for on Schedule C are Line 26 (wages), Line 19 (profit sharing if applicable), Line 23 (that can include payroll taxes), and Line 14 (that can include health insurance). In a viable business plan for a small enterprise of these expeditures, plus the other expenditures on Schedule C must be accounted for based upon 25% of gross sales for a typical small enterprise business plan. Of course the larger the small business the more of gross revenue can be used for these expenditures because the profit margin can be reduced for the owner while the owner will still receive more "income" from the enterprise (e.g. a 15% profit margin on gross revenue of $500,000 is $75,000 while a 25% profit margin on gross revenue of $200,000 ins only $50,000).  Of course if a person doesn't have or follow their business plan they could lose their shirt because the expendtures can exceed the gross revenues but if they have a good business plan and follow it they won't. Good business plans are based upon reality and not wishful thinking.

www.irs.gov/pub/irs-pdf/f1040sc.pdf      

Large enterprises work on a much smaller profit margin. For example, when I worked at Boeing, it's business plan called for an 8% profit margin on gross revenue.

What you seem to be demanding is that we, the taxpayers, need to subsidize small enterprises that don't have or don't follow a good business plan and I disagree with that. Yes, some enterprises that are not based upon a sound business plan could go out of business but I don't believe that the taxpayers should be subsidizing incompetent business owners that don't have and follow a viable business plan where they can earn a profit.   

Yes, there is a problem with private medical clinics that provide primary care that will not accept new Medicaid (and Medicare) patients because of the "underpayments" (i.e. payments less than the actual cost of a service) by Mediciad/Medicare. Hospitals that receive other government subsidies are required to accept Medicaid/Medicare patients. The resolution to that problem is simple. Raise the compensation to the medical providers for services provided so that they don't lose money treating Medicaid (and Medicare) patients.

We can also note that raising compensation for basic medical services (that private clinic provide) it would also lower costs at hospitals as well because Medicaid/Medicare don't pay the hospital enough either so they can't afford to actually treat someone at the "prinary care" level so often the doctor just refers the patient to a specialist that generally charges 5-times more and can afford to treat the patient.

Increasing payments for primary care can actually reduce total costs of health care services because it can avoid the high costs of treating illness that isn't detected early by annual check-ups (primary care) and it would also reduce the death rates for many illnesses that can be cured if identified and treated early enough.   

With all of this said don't forget the most imporating factt. I still don't like Obamacare but it is all we have currently. In addition to that the only other proposal on the table is "Single-Payer" (UHC) that I oppose more.

Excluding my proposal for an "Employer Mandate" there are no other proposals that address the problem. Republicans haven't proposed anything to address the problem nor have you made any proposal to address the problem. You even refer to the "Young Invincibles" but haven't made any proposals that would protect the "taxpayer" from having to fund their medical expenditures when they occur and they will occur. Even young people get seriously ill and require expensive medical services.

May 21, 2014 20:40:23 GMT pjohns1873 said:

Well, we certainly agree that a single-payer system would not be a good thing. But I would not oppose it even "more" than I oppose ObamaCare, as you do. I would oppose it; but I oppose ObamaCare even more strenuously. 

I would guess that many of those who are "uninformed" as regarding the subsidies provided by ObamaCare are those whom many of us describe as "low-information" types; which is to say, it is not because of poor communication skills on the part of Democrats--or disinformation on the part of Republicans--that they remain blissfully ignorant.  Most are probably much more concerned with finding a date for the weekend, or just hanging out with their friends, than they are about acquiring up-to-date information as regarding healthcare insurance. 

Yes, the solution to exceedingly low payments by Medicare and Medicaid may be "simple"--in theory, anyway--but a president who has cut funding to Medicare in order to fund his signiture legislation is probably not in any mood to place his signature on legislation that would increase funding to it.  ,

There were two proposals in 2009. One was the House "single-payer" proposal and the other was the Senate "ACA" proposal. Had the House proposal for a single-payer system been adopted into law there would been virtually a zero possibility of ever changing it. We would have been stuck with a huge tax and spend government welfare program of a scope greater than Medicare/Medicaid combined. At least with Obamacare there are enough "problems" that it warrants review and revision but, as we both admit, those problems wouldn't have existed under a single-payer system.

The only problem with a single-payer system is the cost in taxation, the increase in the size and scope of federal authority and that it would be all but impossible to replace with anything else.

I want a "smaller" government and not a larger government which is why I repeatedly advocate an "employer mandate" that reduces the size and cost of the US government related to health care. With the "employer mandate" there would be no "insurance exchanges" for example and we know all of the problems with the insurance exchanges.

An interesting comment on the "low-information" types, that I don't disagree with, because we found that the lowest enrollments were in "Republican" controlled states. Does that imply that "Republicans" tend to be "low-information" types? We can note that there have been studies that indicate that those with lower IQ's tend to hold conservative political ideologies. Taking this line of reasoning one step further, based upon what we know, if we assume that the "low information" types do hold conservative ideologies, where correlation indicates a connection, then what little knowledge they had related to Obamacare they probably obtained from conservative Republicans politicans that were doing everything possible to discourage people from signing up for Obamacare.     

An interesting like of reasoning but it still takes us back to the Republican campaign to prevent enrollement in Obamacare.

We must admit that in the end a huge problem was with "low intelligence" types regardless of any other consideration and you can't blame any program based on the fact that people are stupid. Remember the old saying, "You can lead a horse to water but you can't make them drink." If Obamacare was the best thing since sliced bread there would still have been stupid people. The problem is how do we address the issue of stupid people?

May 23, 2014 0:25:05 GMT pjohns1873 said:

Actually, I spoke of "low-information" types; whereas you are speaking of low-intelligence types.  Let us not confuse the two. 

The mere fact that "the lowest enrollments" in ObamaCare may be found in Republican-controlled states does not necessarily imply even correlation--let alone causation. It is a bit like one's observing that, say, the lowest level of gum chewing occurs among people wearing turtleneck sweaters: Even if it is true, so what?  

I agree with you that a single-payer system would inevitably result in an increase in taxation, as well as an increase in "the size and scope of federal authority"; and that these are not good things. Still, I find ObamaCare even more odious than single-payer would be. (Thankfully, I am not required to participate in ObamaCare, as I have ACA-compliant healthcare insurance through OPM--FEHB insurance--but many others are not so fortunate.)

While I would correlate low-intelligence with low-information types I do believe that I cited correlation and not causation. Of course correlation can reflect causation but that is not always the case.

What we also agree on it that both Obamacare and Single-Payer suck and only disagree with which one we individually dislike the most. We can also note that the majority of Americans aren't even effected by Obamacare at all. Only about 20% of Americans potentially benefit from it and only about 1/2 of Americans have an "income tax" burden (unrelated to Social Security/Medicare tax burden) that will be stuck paying for it.

There are those that do fall into the "Medicaid" group that simply can't afford health care services at all. I don't have much of a problem with Medicaid from a government standpoint because it is a state run program that only receives federal funding. The only problem is that since it was created in 1965 that it was never adequately funded until the expansion under Obamacare. Where I do have a problem with the expansion under Obamacare is that they States are not being required to carry their share of the funding (Medicaid is supposed to be equally funded by the State and Federal government).

The part I really disagree with is the tax/spend welfare program under Obamacare for working Americans. I don't believe there should be a necessity for the federal government to subsidize either individual workers or businesses with a wealth redistribution program funded by the taxpayers. That's why I advocate an "Employer Mandate" where the labor of the worker is the foundation for the funding of their medical (insurance) needs. When tied to the actual hours that the employee works it is not "wealth redistribution" but instead is compensation for the labor of the worker.

No one can claim that a worker receiving compensation for their labor is receiving the "redistribution of wealth" from someone else. Even though it would be mandated by regulation it would also voluntary on the part of the employer because if the employer doesn't want to pay the compensation then they don't have to hire the worker. Some would try to argue that this would reduce employment but I don't see that happening because employer hire people because they need the work done to earn a profit. Employers don't hire people just to give the person a job.

Would my proposal for an "Employer Mandate" lead to higher prices? Perhaps but it wouldn't be much of an increase and it would be far less than the tax/spend wealth redistribution through taxation that Obamacare is going to create. I'd far rather spend a couple of percent more for a product or service than to spend even more than that in taxation to fund a larger federal government.

The "Big Question" on this thread is whether Obamacare is sustainable and long term I don't believe it is. I don't believe any large scale tax and spend welfare system is sustainable long term. Social Security and Medicare are floundering financially in the future and Obamacare faces that same fate IMO. It won't fail today, or next year, or even ten years from now but eventually it will fail. Limited tax and spend government welfare programs can be affordable but not large scale tax and spend welfare programs over the long term.

What I have found is that large scale tax and spend welfare programs address "symptoms of problems" as opposed to addressing the "problem" and that is the case when it comes to Obamacare for working Americans. The problem is a "compensation from employment" issue for workers and that is what needs to be addressed. If all employment provided health care insurance as a compensation benefit we wouldn't have any necessity to be concerned with workers that can't afford health care.        

May 24, 2014 1:03:12 GMT pjohns1873 said:

Your response (as usual) is thoughtful. I do not agree with all of it; but it is well-reasoned, nonetheless.

I do believe that ObamaCare will (eventually) affect all Americans seeking healthcare, adversely.  That is because of what Sarah Palin and others have referred to (rather ineloquently, perhaps) as "death panels."  (Whereas I would prefer to avoid unnecessarily inflammatory language--"death panels" is a term that does not naturally lend itself to reasoned discussion--I believe the gist of the observation is correct:  The Independent Payment Advisory Board--or IPAB, for short--will begin instructing doctors as to what procedures they may or may not perform, irrespective of those doctors' best judgment.  The elderly are likely to be especially vulnerable, as expensive procedures that might extend life for only a few more months, or even a few more weeks, may be routinely nixed, due to cost-benefit considerations.  Besides, most healthcare spending is done by seniors; so what better way to rein in costs than to target end-of-life care?)   

Using Medicare as an example people that can afford it will purchase supplemental health insurance that will cover procedures that would not otherwise be covered under Obamacare. Of course the "poor" will unquestionably be screwed because the poor are always getting screwed but they will still be better off than they would be with no insurance.

May 24, 2014 17:15:23 GMT pjohns1873 said:

May 24, 2014 11:21:17 GMT ShivaTD said:

Using Medicare as an example people that can afford it will purchase supplemental health insurance that will cover procedures that would not otherwise be covered under Obamacare. Of course the "poor" will unquestionably be screwed because the poor are always getting screwed but they will still be better off than they would be with no insurance.

It is my understanding that the ACA will not allow procedures, not certified by the IPAB, to be performed, and then paid by supplemental insurance--or even paid by the patient, out-of-pocket.

This is a matter of enormous importance, it seems to me.

That is a misunderstanding being propagated by Republican politicans and Fox News from what I've seen.

The Independent Payment Advisory Board (IPAB) is only tasked with addressing Medicare spending, not general medical services, to reduce costs without adversely affecting the coverage or quality of benefits for those on Medicare. It has no authority related to private insurance plans or what medical service providers can do. It is true that some supplemental private insurance is linked to Medicare (Plan B) and it can be affected but wealthy people can still purchase other private insurance or pay "cash" for any medical services they want. 

As noted though "poor people" get screwed because poor people can't afford procedures that aren't covered when they depend on government "insurance" alone but the only way that could be addressed is if there were basically no restrictions on medical services at all. I don't believe Republicans are in the mood to lift all restrictions on medical services being provided for under government "health insurance" programs. Republicans won't even allow the government to pay for abortions and many even oppose the government paying for birth control.

May 25, 2014 18:50:34 GMT pjohns1873 said:

Yout (rather severe) distaste for anything "propagated" by either "Republican politicians" or "Fox News" is duly noted.

However, even the American Action Forum, in October of 2012, noted the following:

"The upshot is clear. While IPAB appears to be [officially] barred from recommending rationing health care, raising revenue or premiums, increasing cost sharing, or restricting benefits and eligibility, its mission will inevitably endanger access to existing care and innovation in new therapies.

"Although rationing is an unpopular and ungracious term IPAB may bring Medicare dangerously close to a rationed system.  It will become more difficult to make appointments with providers of all sorts, thereby restricting care.  On top of which, a provider will not offer a poorly-reimbursed, but effective, treatment, unless there does not appear to be a therapeutic alternative.  'Rationing' will occur in complex and often subtle ways, and patients may never know that they could have received a more effective treatment."

Here is the link:  americanactionforum.org/sites/default/files/IPAB.pdf

If we, as a society, truly wish to ration healthcare--to ensure that those without any healthcare insurance are given something, as a tradeoff for our giving less care to those who currently have healthcare insurance--let us, at least, be upfront and candid about it.

What I very much object to is the (quite fatuous) claim that some people can be assisted, without our doing anything whatsoever to negatively impact others. 

You should also note my (rather severe) distaste for anything "propagated" by either "Democratic politicians" or "MSNBC, MSN or other News sources" that resort to political propaganda.

It should also be noted that the American Action (Forum) Network is a right-wing organization that is resorting to pure propaganda in the cited opinion. The IPAB cannot violate the law, period. Claims in the opinion piece notwithstanding it cannot violate the law. As noted in the opinion the IPAB is expressly limited to addressing Medicare and predominately Part B and Part D to reduce costs and it cannot "ration" health care services.

Finally the statement that "patients may never know that they could have received a more effective treatment" is utter nonsense. Medical research will continue, trials for new treatments will continue, the results of those trials will be published in medical journals and publications, the articles in those medical publications will be reported by the news media and on the internet, and both medical professionals and people throughout society will be very much aware of these advances in medicine.

How anyone can believe Medicare funding for "effective medical treatment" won't be authorized by the IPAB is patently absurd.

What is accurate is that the IPAB is fundamentally limited by law to only addressing about 23% of Medicare expenditures and that has absolutely nothing to do with the rest of Medicare and has nothing whatsoever to do with Obamacare or private insurance and medical services.

What is ironic is that "Republicans" have correctly claimed that the "savings to Medicare" promised by Democrats when Obamacare was passed wouldn't happen because the IPAB wouldn't be able to reduce the spending by Medicare enough to realize those mythical savings. The promised savings were "smoke and mirror" savings and that is a fact. The IPAB doesn't have the statutory authority to ration medical services that would be necessary to cut the expenditures.

The Republicans can't "have their cake and eat it to" on this issue. Republicans were correct that the Medicare savings promised by Democrats supporting Obamacare were "smoke and mirrors" accounting because the IPAB can't, under the law, realize the savings promised. Here they argue just the opposite of what they previously argued because they're now arguing that the IPAB can violate the law but it can't.

What is even more ironic is that House Republicans have proposed the repeal Obamacare (disolving the IPAB) and then they used the "smoke and mirror" savings to Medicare in their theoretical "balanced budget proposals" that would never balance the US budget.

May 26, 2014 23:30:26 GMT pjohns1873 said:

I would not be especially astounded if some of the figures set forth by Republicans are inaccurate also. But that is hardly the point here.

The IPAB is an outgrowth of President Obama's fetish for reining in healthcare costs.  And the most effective way to accomplish that mission is to target the largest users of healthcare services--i.e. the elderly and the chronically ill--by rationing their healthcare. 

Oh, it is not likely to be done in an overt manner--a manner in which it would be obvious that the law was being violated--but, as the article suggests, less-effective procedures (which are also less expensive) may be routinely ordered.  And this is a pretty good working definition of healthcare rationing, it seems to me.    

By the way, I am becoming increasingly frustrated as concerning the matter of how to source...well, just about anything. You don't much like it if the source is a Republican. Or Fox News Channel. (And you have expressed a similar distaste for CNN and MSNBC.) And now you do not care for the American Action Forum, which I recently cited...

Actually the IPAB is a fraud because it can't really do very much at all. It cannot deny payment for medical procedures that are proven to be clinically effective. It can prohit payments for "medical treatments" that have not been subjected to clinic trials such as "herbal elixirs" that remind me of the patent medicines of the 19th Century that millions of people still used (e.g. herbal weight loss "pills" sold today). It can also prohibit payments to pseudo-science treatments that have not been subjected to clinical trials.

As Republicans correctly noted in the past the projected saving to Medicare were smoke-and-mirror savings that will not be realized because the IPAB can't prohibit any treatment that has been proven to be effective based upon clinical trials. All it can prohibit payment for are unproven pseudo-science medications and procedures and that is a very small issue to address.

I cite all different sources but I know how to sort out the facts from the opinions. The American Action (Forum) Network did provide some facts but it also express opinion that is unsupported by and actually contradicted the facts it was expressing. The American Action (Forum) Network stated with accuracy the statutory limitations to the IPAB and then in expressing "opinion" ignored those statutory limitations and I pointed that fact out.

Fox News, CNN and other media sources commonly do the same thing. The key is in being able to understand the difference between the "facts" and the "opinions" as often, for political reasons, the opinions contradict the facts.