Federal Judge Strikes Down Part of Obamacare Law

[turbo]

I bolded your first sentence because I'm not sure you've supported ANY of your posts on the subject - repeating unsupported posts, regardless of how many times, does not make it accurate or factual. With that said, let's take at look at how you opened the post - followed by how you closed it.


"A little history - The GOP previously wanted to mandate health insurance coverage. It was not an idea favored by the Dems."" support for this specifically - and THIS PARTICULAR MANDATE please - not some other language.

This has been demonstrated and supported by links to previous GOP health-care plans in this very thread. The GOP didn't call it a mandate, but "personal responsibility".

"During the writing of the present bill, Baucus and the Dems on the Finance Committee rejected such a mandate and incorporated a public option as a way to achieve savings and cut premiums. The problem was that their draft was supported by NO Republicans."

How do we verify any of this including the cost saving guarantees of a public option?

We cannot verify any guarantee of cost-savings, of course, but that was Snowe's stated reason for opposing the public option.

"The mandate should never have been included in the bill, and it wasn't by any means the choice of the Dems. By forcing reconciliation, the GOP managed to lock the Dems into a bill crippled with a mandate instead of a public option." This sounds like opinion to me.

If you want to call this opinion, fine. Go for it. The GOP made it clear that they would filibuster any up-or-down vote in the Senate, so the only way that the health care bill could be enacted was if the Senate version was reconciled with the House version which contained a public option (which had to be removed, of course). What was left was essentially a combined version which was crippled by the mandate, which was the only way that Snowe would allow the Senate bill out of the committee.

It looks to me that you've presented an idea that Republicans used a mandate to prevent Democrats from pushing through the "public option" - that is Government single payer health care - is this correct?

The GOP has been proposing mandated coverage for over a decade. That would add more customers to the insurers' pool, and the insurance companies were all for it. A public option would have undercut the insurance companies. Health care reform without expanded coverage would not have saved us money (IMO) because we would still have a huge pool of uninsured people driving up the costs of health-care by tying up ERs, thus a mandate of some sort (which the GOP and the insurance companies want) was necessary to get the expanded coverage in lieu of a public option.

The GOP used their filibuster powers to prevent the Senate from voting on a bill that might have included the public option (House version), so that reconciliation was the only option. That doomed the public option. I don't think that was an unintended consequence, do you?

 

[Zefram]

Second, Ryan's exchanges are state based, not federal, so sign up would be at the state level which does not offend the US constitution if it was mandatory;

The ACA's exchanges are state-based.

Finally, Ryan suggests insurance enrollment would be done at, e.g., "places of employment, emergency rooms, the Division of Motor Vehicles", which implies the option is put in front of you at the time as an option; a blind auto enrollment could be done by simply processing the tax rolls or SSN lists.

Processing tax forms is an acceptable auto-enrollment mechanism under his bill ("Such mechanisms shall include automatic enrollment through various venues, which may include emergency rooms, the submission of State tax forms, places of employment in the State, and State departments of motor vehicles.").

 

[WhoWee]

This has been demonstrated and supported by links to previous GOP health-care plans in this very thread. The GOP didn't call it a mandate, but "personal responsibility".

We cannot verify any guarantee of cost-savings, of course, but that was Snowe's stated reason for opposing the public option.

If you want to call this opinion, fine. Go for it. The GOP made it clear that they would filibuster any up-or-down vote in the Senate, so the only way that the health care bill could be enacted was if the Senate version was reconciled with the House version which contained a public option (which had to be removed, of course). What was left was essentially a combined version which was crippled by the mandate, which was the only way that Snowe would allow the Senate bill out of the committee.

The GOP has been proposing mandated coverage for over a decade. That would add more customers to the insurers' pool, and the insurance companies were all for it. A public option would have undercut the insurance companies. Health care reform without expanded coverage would not have saved us money (IMO) because we would still have a huge pool of uninsured people driving up the costs of health-care by tying up ERs, thus a mandate of some sort (which the GOP and the insurance companies want) was necessary to get the expanded coverage in lieu of a public option.

The GOP used their filibuster powers to prevent the Senate from voting on a bill that might have included the public option (House version), so that reconciliation was the only option. That doomed the public option. I don't think that was an unintended consequence, do you?

I think the basic formula of CRAP(in) = CRAP(out) is true for any legislation in excess of about 100 pages.

As for the "mandate", it seems we agree the particulars vary. The "personal responsibility" Republicans speak of is not the specific "mandate" found in the Bill - is it?

As for saving money with ANY plan that expands coverage - just not realistic.

 

[Al68]

Now that the mandate has been ruled unconstitutional by a single Federal judge, we have right-wing pundits claiming that the Democrats were responsible for championing the mandate at the behest of the insurance companies. That is 180 degrees wrong. It's what they had to settle for to get a single GOP senator to support the draft bill. When I pointed out that the insurance companies and hospitals would likely file amicus briefs in support of the mandate during the appeals process, right-wing apologists said that of course they would because the Democrats were in the pocket of the insurance companies (paraphrasing).

Your "paraphrasing" is fraudulent, assuming you were referring to me as a "right-wing apologist", but nobody else said any such thing, either. I never suggested that Democrats were "in the pocket of the insurance companies". I said that insurance companies advocated the mandate passed by Democrats, and being fought for now in the courts by Obama. I never made any assertion about the motives of Democrats.

Attacking the motives of those who disagree is not an argument, it's a logically fallacious act of desperation and a de facto acknowledgment of an inability to make a legitimate logical argument.

And you continue to dodge my the actual point of my response to your claim. Which was "why would conservatives be surprised" at what you "pointed out", but has been obvious and well known to everyone for years?

Is "right-wing apologist" a political slur? It's certainly insulting and derogatory, not to mention completely fraudulent.

This dishonest revisionism is happening all over the country in right-wing circles...

LOL.

 

[mheslep]

Processing tax forms is an acceptable auto-enrollment mechanism under his bill ("Such mechanisms shall include automatic enrollment through various venues, which may include emergency rooms, the submission of State tax forms, places of employment in the State, and State departments of motor vehicles.").

I said blind auto enrollment, which I don't favor, could be done by tax rolls, that which is already on the books, requiring no input from the citizen. All of Ryan's examples, tax forms, going to the DMV, etc, coincide with some active acknowledgment from the citizen. Whatever form of signing up is chosen, as long as it holds with his declaration:

If individuals do not want health insurance, they will not be forced to have it.

I'm fine with it, as that is surely not what we have with the ACA.

 

[mheslep]

...Second, Ryan's exchanges are state based, not federal, so sign up would be at the state level which does not offend the US constitution if it was mandatory;

The ACA's exchanges are state-based.

The ACA has a central, singular, federal exchange, called the "Health Insurance Exchange" ( Sec 301). Also, the ACA says it will allow "State-based Health Insurance Exchanges" (Sec 308), largely at the discretion of "The Commissioner", that must behave similarly to the federal exchange. Furthermore "The Commissioner" may terminate the state's operation of the exchange and take it over (308.c.2). By contrast, Ryan's plan proposes no federal health exchange, only state exchanges. More importantly, as Ryan http://www.hillsdale.edu/news/imprimis/archive/issue.asp?year=2010&month=02" the real difference lies in who pays for the creature:

...allow me to clear up a misperception about insurance exchanges: it makes absolutely no difference whether we have 50 state exchanges rather than a federal exchange, as long as the federal government is where the subsidies for consumers will be located. In other words, despite what some seem to believe, both the House and the Senate versions of health care reform set up a system in which, if you are eligible and you want a break on your insurance premium, it is the federal government that will provide it while telling you what kind of insurance you have to buy [under ACA]. In this sense, the idea of state exchanges instead of a federal exchange is a distinction without a difference.

http://docs.house.gov/rules/health/111_ahcaa.pdf

 

[WhoWee]

The ACA has a central, singular, federal exchange, called the "Health Insurance Exchange" ( Sec 301). Also, the ACA says it will allow "State-based Health Insurance Exchanges", largely at the discretion of "The Commissioner", (Sec 308) that must behave nearly identically to the federal exchange. Furthermore "The Commissioner" may terminate the state's operation of the exchange and take it over (308.c.2). By contrast, Ryan's plan proposes no federal health exchange. More importantly, as Ryan http://www.hillsdale.edu/news/imprimis/archive/issue.asp?year=2010&month=02" the real difference lies in who pays for the creature:

They have learned NOTHING from the fiasco known as Medicare (or Medicaid).

The exchange is the one true chance they have of reforming health insurance under this legislation.

IMO - to perhaps over-simplify - all they need to do is design 3 or 4 standard policy options that can be sold/purchased anywhere in the country - with premiums adjusted to location - the carriers will save hundreds of millions (legal, administrative, marketing, and a host of compliance associated costs) and the savings will be passed through the system.

 

[WhoWee]

Let me clarify - I want to start over < repeal the whole mess > that aside, there is a way to make the exchange idea work to sell policies across state lines and create competition.

 

[Al68]

Careful what you wish for my friend, the last time you went down this path, you lost the ability to use the term Neo-con.

You just used it! Are you exempt from forum rules? :!)

Seriously, I made an unanswered request to clarify whether the prohibition on "Marxist" is only on using it to refer to a person, or a more general prohibition on using the word at all. (If the latter, I just violated the rules, too.)

The same should go for "neo-con". Is there a general prohibition on using the words at all, or just a prohibition on using them to refer to a person, or as an insult or political slur?

 

[Zefram]

The ACA has a central, singular, federal exchange, called the "Health Insurance Exchange" ( Sec 301). Also, the ACA says it will allow "State-based Health Insurance Exchanges" (Sec 308), largely at the discretion of "The Commissioner", that must behave similarly to the federal exchange. Furthermore "The Commissioner" may terminate the state's operation of the exchange and take it over (308.c.2). By contrast, Ryan's plan proposes no federal health exchange, only state exchanges. More importantly, as Ryan http://www.hillsdale.edu/news/imprimis/archive/issue.asp?year=2010&month=02" the real difference lies in who pays for the creature:

http://docs.house.gov/rules/health/111_ahcaa.pdf

...that's not the ACA. The "ACA" refers to what was formerly H.R. 3590, the Patient Protection and Affordable Care Act, and is now a public law, P.L. 111-148 (and P.L. 111-151). This is what during the long legislative process would've been known as "the Senate bill."

What you're referring to is the bill passed by (only) the House in November 2009, the Affordable Health Care for America Act. Subtle difference: one is law and one is not. And, of course, one of the major differences between the House's legislation and the Senate's legislation is that the House preferred a national exchange and the Senate preferred state-based exchanges.

If you look up the actual ACA, specifically section 1311, you'll find that exchanges are designed and operated by the states (unless a state prefers to have the federal government operate an exchange for it). This process is actually happening right now, though it's still in its early stages. To date, 48 states and D.C. have sought and been awarded first round grants to start planning what their exchanges are going to look like. If you want a look at how different states are approaching this issue, http://statereforum.com/implementation-priorities/implementation-priority-1 is a good collection of publicly available resources.

But yes, ACA's exchanges are state-based.

 

[mheslep]

...that's not the ACA. The "ACA" refers to what was formerly H.R. 3590, the Patient Protection and Affordable Care Act, and is now a public law, P.L. 111-148 (and P.L. 111-151). This is what during the long legislative process would've been known as "the Senate bill."

What you're referring to is the bill passed by (only) the House in November 2009, the Affordable Health Care for America Act. ...

My mistake, you are correct of course. I lost track of the final law amidst the original House bill X, Senate Committee Y markup, Senate Committee Z, Reconciallation ZZ, etc, with several thousand pages each.

... But yes, ACA's exchanges are state-based.

The actual ACA contains clause after clause on what the state exchanges may or may not do and how they may do it. It is clear that the staff hired to answer the state exchange phones will be 'state - based', beyond that I cite Rep Ryan again:

...allow me to clear up a misperception about insurance exchanges: it makes absolutely no difference whether we have 50 state exchanges rather than a federal exchange, as long as the federal government is where the subsidies for consumers will be located. In other words, despite what some seem to believe, both the House and the Senate versions of health care reform set up a system in which, if you are eligible and you want a break on your insurance premium, it is the federal government that will provide it while telling you what kind of insurance you have to buy [under ACA]. In this sense, the idea of state exchanges instead of a federal exchange is a distinction without a difference.

http://www.hillsdale.edu/news/imprimis/archive/issue.asp?year=2010&month=02

 

[Zefram]

The actual ACA contains clause after clause on what the state exchanges may or may not do and how they may do it.

Exchanges are required to serve 11 functions under the ACA. These are fairly basic things like certifying plans, running a toll-free assistance hotline, operating a web portal, allowing plan comparisons, and verifying eligibility for tax credits. Things that would seriously limit the utility of an exchange, should the exchange not be able to do them.

It is clear that the staff hired to answer the state exchange phones will be 'state - based', beyond that I cite Rep Ryan again:

Er, what? Ryan's own bill extends a refundable federal tax credit into the individual insurance market (i.e. his state exchanges) for "qualified health insurance" to be defined by HHS through the administrative rulemaking process. Aside from that, I can't tell if he's being disingenuous in minimizing the differences between state-based exchanges subject to federal guidelines and a single national exchange or if he just doesn't know.

 

[mheslep]

...
Er, what? Ryan's own bill extends a refundable federal tax credit into the individual insurance market (i.e. his state exchanges) for "qualified health insurance" to be defined by HHS through the administrative rulemaking process. Aside from that, I can't tell if he's being disingenuous in minimizing the differences between state-based exchanges subject to federal guidelines and a single national exchange or if he just doesn't know.

Ryan's tax credit to individuals has nothing to do with his state exchanges (which are voluntary in any case). The tax credit is only "qualified" to go for what's reasonably known as health care insurance, similar to the way the IRS now qualifies the health care insurance tax exclusion for employers. There is no tinkering of minutia by bureaucrats to determine exactly what kind of defined benefit plan qualifies for the tax break.

...The term `qualified health insurance' means any insurance constituting medical care which (as determined under regulations prescribed by the Secretary)--
`(A) has a reasonable annual and lifetime benefit maximum, and
`(B) provides coverage for inpatient and outpatient care, emergency benefits, and physician care.

http://thomas.loc.gov/cgi-bin/query/F?c111:1:./temp/~c111gAF77i:e35401:

BTW, could you explain the differences under PPACA "between state-based exchanges subject to federal guidelines and a single national exchange" [from the original House bill], of which you believe Ryan either disingenuously minimizes or is simply ignorant? That is, aside from who answers the phone and sets up the web site. The distinctive differences are lost on me.

 

[Zefram]

BTW, could you explain the differences under PPACA "between state-based exchanges subject to federal guidelines and a single national exchange" [from the original House bill], aside from who answers the phone and sets up the web site? The distinctive differences are lost on me.

An exchange has numerous capabilities, potential services and functions that it can integrate with the existing health policy apparatus. We know that on a basic level it's a marketplace that allows for apples-to-apples comparisons between all available plans. But expanding on the 11 required base functions can be done (and in many states it will make sense to do so) . You seem to be taking a very limited view of an exchange's potential capabilities so it's worth thinking through some of them:

• Outreach/marketing. This goes beyond simply establishing and figuring how to make best use of navigators, it involves actively targeting historically uninsured groups. In some states it will make sense to do this by geography, in others by ethnicity, and so on. States generally have certain goals built around expanding coverage within certain populations and exchange marketing is going to become one of the primary ways to achieve those goals in the next few years.
• Eligibility and enrollment. This gets at the intersection with existing health programs and systems. States have tools for determining eligibility for public programs and managing enrollment but, with a more fully integrated and more standardized eligibility structure, now there's a chance to streamline the process for a significant chunk of state populations such that the confusion and inconvenience of churning between eligibility statuses is minimized. The decisions on how to bridge the gaps between existing health e&e systems (and potentially integrate them horizontally with similar human services functions also being served by states) are going to be very sensitive to local conditions.
• Customer Service. This is the part that seems to be of the most interest to you, though it's certainly not the only function served by exchanges.
• Reporting and plan performance. Data-driven improvement on the provider side is a huge part of ACA but data-driven improvement on the payer side can be achieved using exchanges. Which data is going to be collected and who's going to be collecting it are the primary questions that need to be answered on that front. Presumably different states will be focusing on things like fraud detection, quality measures, customer satisfaction, etc. Continuous improvement programs in exchanges are a good example of something that will be best designed at a more local (i.e. state) level.
• Plan management. Someone has to determine which plans are going to be in the exchange. What are the guidelines for that process? How will Medicaid managed care organizations in the state be incorporated (will the state use the opportunity to try and bring down its managed care expenses)?
• Employer relations. The relation of the individual market to the small group market needs to be determined (should they be merged?). Not only will decisions about the size of employers allowed and encouraged to enter the small business exchange have to be made, links between the exchange and the local business community will need to be fostered and the services provided by the small business exchange will need to be determined.
• Provider relations. Links between the exchange and the provider community are also crucial, particularly in encouraging provider participation/buy-in.
• Actuarial analysis. Plan standardization into actuarial tiers will require actuarial analysis on the part of whoever is operating the exchange; the same is true of premium rate increase oversight (which is subject to state-designed standards).
• Financial management. Exchange sustainability and transparency is going to be a crucial issue once exchanges start gearing up for operation.

So what's the difference between one national exchange and smaller state-based exchanges? State-based exchanges have flexibility in approaching these problems, meaning each one is likely to look different as it adapts to address local conditions (in the same way that all 51 Medicaid programs are unique, even though each is subject to the same base federal guidance). Provider and employer relations, for example, require local interaction between local leaders. Integrating exchange information systems with other state systems (e.g. the state's Medicaid information systems) takes on a very different character if the state owns or contracts out the exchange.

The governance of exchanges is very different under a state-based model. Policy decisions and operational guidance of the ACA's exchanges will occur at the regional level, or within a state's existing Health Authority or other state HHS structure (or, potentially, even within an Insurance Department), or a state might hand exchange governance off to a public-private or private entity. The combination of decisions made by the local exchange governance body and the authorizing legislation passed by the state legislature will determine the capabilities and character of the exchange.

You could create a grid with an exchange's capability model (from thin to robust capabilities) on one axis and its market characteristics on the other (i.e. competitive to regulated). Then each quadrant gives you a different model that an exchange might take. Competitive exchanges with relatively thin capabilities are characterized as information aggregators, in that for the most part they simply collect and present information to consumers in an organized fashion. This exchange will likely allow any plan meeting minimum federal standards to be sold through it. At the opposite extreme (robust capabilities with heavier regulation), you get a market curator model, which has a significantly more robust end-to-end consumer experience and likely selects participating plans in the exchange in some fashion. The other quadrants give you purchaser- and retailer-oriented exchanges with varying levels of functionality.

A single national exchange obviously doesn't allow for this level of variation. Nor would local governance entities dominate under a national exchange. You would, in all likelihood, get simplified standards and an exchange with much more limited potential functionality. And it certainly wouldn't be tailorable to meet the particular health policy goals of each state and build upon previous efforts. It would still most likely not be particularly attuned to local concerns. For reference, the national exchange proposed last year was an active purchaser of health plans governed by a new subdivision of HHS. If the state-based exchanges decide to be active purchasers (California's exchange, for example, will be), bids are submitted to and evaluated by local authorities, not officials in HHS.

So yes, ACA's exchanges offer substantially more local autonomy and variation than simply letting state people answer the phones.

 

[WhoWee]

Typically, anything that increases bureaucracy will increase cost - would you agree?

The greatest current obstacle to a free market (competitive pricing) is state controlled regulation - every state currently has it's own rules. An insurance carrier that wants to insure people in 50 states needs (at a minimum) 50 duplicate compliance departments.

Now, the Federal Government is heaping regulations on top of this pile and mandating an expansion of coverage.

How (other than cut backs in service) can this possibly save money?

Sometimes the answer is to UNRAVEL the tangle and start over - this is one of those opportunities. If the intention is reform - then we need to simplify, untangle, streamline, and taper the whole regulatory process - not complicate it to the point that an agent and a recordskeeper need a law degrees.

 

[Zefram]

Typically, anything that increases bureaucracy will increase cost - would you agree?

The greatest current obstacle to a free market (competitive pricing) is state controlled regulation - every state currently has it's own rules. An insurance carrier that wants to insure people in 50 states needs (at a minimum) 50 duplicate compliance departments.

Now, the Federal Government is heaping regulations on top of this pile and mandating an expansion of coverage.

This is a bit bewildering. It sounds like you're arguing for simplification and standardization of insurance market rules, which at the very least would require a base, uniform federal standard. Then every state would be operating under the same rules. That, of course, is what's happening here. Exchanges will organize the individual market which, by and large, will be something of a simplification. One of the main goals of an exchange is to encourage competition on price and quality alone, instead of allowing insurers to compete on risk (thus limiting access, as well).

Same thing with the actuarial tiers and essential benefits package. Austin Frakt put it well a few weeks ago (he was talking about Medicare voucher proposals here but the principle is the same):

The whole point of a market-based system is to harness the power of consumer choice. But consumers can’t send meaningful signals if the market has an incomprehensible structure. One of the conditions for a competitive market is fully informed participants. The notion that seniors–or anyone–can meaningfully shop in a market with an unlimited number of plans that vary in all possible ways is ludicrous. (There is already evidence that beneficiaries don’t optimally select among the scores of Part D plans available now and that reducing the number of available plans would increase welfare.) The Medicare supplement (Medigap) market is a good model of competition within standardization. Making products more similar encourages competition. Allowing them to vary along a small number of dimensions helps consumers make sensible comparisons consistent with individual preference. Isn’t that the point?​

As I went through above, state exchanges will have different functionalities, they'll look a bit different in different states, but they'll still be enforcing virtually the same set of rules. Setting up uniform minimum standards is a necessary first step toward allowing plans to be sold in other states' exchanges, should states wish to allow that (although it's worth noting that certain multi-state plans will be offered in exchanges immediately). I suspect that many states will be considering that in a few years; even now, several states are considering the possibility of participating in a multi-state exchange. If Maine's experience is characteristic, though, there's likely some dissension within those states. In Maine the legislature is intrigued by the idea of a multi-state exchange (which I think would be interesting to see in New England), but the executive branch folks who would be involved in operating and interacting with that exchange prefer one limited to just their own state.

How (other than cut backs in service) can this possibly save money?

There's a lot going on with the ACA but at the center of it is the attempt to balance increased access, quality improvement, and cost growth reduction. The exchanges are a piece of the puzzle but obviously they're the piece (along with the simplification and expansion of Medicaid eligibility) that's aimed primarily at access. A degree of quality improvement is built into exchange functionality, though as I mentioned above how much of a degree will be up to the state operating the exchange. The cost control strategy revolves around simplifying the consumer's experience, providing (to steal Frakt's phrases) a comprehensible market structure that allows for meaningful choice, and promoting competition on the price and quality of plans only.

I think something along those lines is a necessary step if you want to try and slow cost growth but, again, the primary goal of the exchanges is to get more people covered in a well-functioning market. The larger cost control attempts appear in the rest of the ACA, outside of the insurance reform piece. Those are aimed more at improving the way we deliver care, though the excise tax is also expected to be a large cost control in the long run.

 

[WhoWee]

The "base rules" were already well established before the recent legislation. Medicare sets the reimbursement schedules. HHS and HIPPA/MIPPA control all information. The state and federal agencies control provider services, training, product, techniques, reporting, and general administration. The state departments of insurance control the carriers and their products, operations, marketing and administration.

I look at the insurance code in the same way a contractor looks at building codes. If you build to the highest code - every building will be compliant.

Simplification could mean raising the standard - while reducing the administrative costs.

 

[Zefram]

The state departments of insurance control the carriers and their products, operations, marketing and administration.

Was your complaint not specifically that "every state currently has it's own rules" ?

Simplification could mean raising the standard - while reducing the administrative costs.

Indeed. That's exactly the aim here.

 

[WhoWee]

Was your complaint not specifically that "every state currently has it's own rules" ?

Indeed. That's exactly the aim here.

Let me start by disclosing that I work with these rules on a daily basis. Further, IMO, Medicare and the CMS should not be the models for moving forward.

With the exchange plan, we have an opportunity to streamline and simplify insurance regulation. This is an opportunity to shrink government and bureaucracy AND reduce legal, administrative, and operating expenses at the carrier level.

However, if all 50 states design their own custom exchange (in addition to their existing 50 departments of insurance) - it will further complicate administration and compliance. It will also expand the size of Government and increase legal, administrative, and operating expenses at the carrier level.

 

[mheslep]

... first step toward allowing plans to be sold in other states' exchanges, should states wish to allow that (although it's worth noting that certain multi-state plans will be offered in exchanges immediately). ...

Visibly the states never have for health care in modern times. How are you able to now say that they will, with no certain rule in place in PPACA that allows individuals to go buy care across state lines as is granted in Patient's Health?

 

[Zefram]

With the exchange plan, we have an opportunity to streamline and simplify insurance regulation. This is an opportunity to shrink government and bureaucracy AND reduce legal, administrative, and operating expenses at the carrier level.

There's a trade-off that has to be made. Opting for complete standardization and centralization instead of granting states more autonomy would be attacked as a federal power grab, with bureaucrats in Washington ignoring the boots on the ground in the states who understand local conditions and needs. Granted, the exchanges that were authorized in the ACA often don't get credit for what they are anyway, but I think the benefits of this structure can outweigh the drawbacks, if they're implemented with the intent of achieving various health policy goals pursued by the states. After the last election, in many states that's far from certain.

Visibly the states never have for health care in modern times. How are you able to now say that they will, with no certain rule in place in PPACA that allows individuals to go buy care across state lines as is granted in Patient's Health?

At present, federally-mandated across-state-lines purchasing is pushed by conservatives because it's designed as a mechanism for deregulation; for the same reason, it's opposed by most liberals. With uniform base regulations operating in every state's exchange, most of the left's rationale for opposing federal action to allow out-of-state plans to sell in state exchanges evaporates. It still can be used to get around state-set regulations that go beyond ACA's baseline but that's less worrisome, as that's very different than wholesale deregulation of the insurance market. Now, diluting the insurance market in an area isn't necessarily a good idea for bringing prices down but the free-for-all version of interstate purchasing being pushed by many conservatives will at least be more politically viable, as it's much less problematic in the presence of federal minimum standards.

I'm not sure what you're referring to with Patient's Health, but going back to Ryan's Patients' Choice Act, note that it doesn't allow blanket interstate purchasing (à la the Shadegg bill or the repeal-and-replace law). The only bit related to interstate purchasing in it concerns the exchanges:

(g) Regional Options-

(1) INTERSTATE COMPACTS- Two or more States that establish a State Exchange may enter into interstate compacts providing for the regulations of health insurance coverage offered within such States.
(2) MODEL LEGISLATION- States adopting model legislation as developed by the National Association of Insurance Commissioners shall be eligible to enter into an interstate compact as provided for in this section.
(3) MULTI-STATE POOLING ARRANGEMENTS- State Exchanges may implement a multi-state health care coverage pooling arrangement under this title.​

If you've read the ACA, this concept should look very familiar.

 

[mheslep]

I'm not sure what you're referring to with Patient's Health, but going back to Ryan's Patients' Choice Act, note that it doesn't allow blanket interstate purchasing (à la the Shadegg bill or the repeal-and-replace law). The only bit related to interstate purchasing in it concerns the exchanges:

(g) Regional Options-

(1) INTERSTATE COMPACTS- Two or more States that establish a State Exchange may enter into interstate compacts providing for the regulations of health insurance coverage offered within such States.
(2) MODEL LEGISLATION- States adopting model legislation as developed by the National Association of Insurance Commissioners shall be eligible to enter into an interstate compact as provided for in this section.
(3) MULTI-STATE POOLING ARRANGEMENTS- State Exchanges may implement a multi-state health care coverage pooling arrangement under this title.​

If you've read the ACA, this concept should look very familiar.

Yes ...Choice Act, but despite that reference I was actually thinking about the more recent proposal from Ryan here:

Interstate Purchasing. Currently, individuals and families can purchase health insurance only in the States in which they live, because insurance companies are prohibited from selling polices outside their respective States. Thus the consumer is prevented from purchasing coverage from another State that might offer more suitable, or more affordable, coverage.

This proposal breaks the lock, allowing each individual to use the refundable tax credit toward the purchase of health insurance in any State. This will greatly expand the choices of coverage available to the consumer, and also will encourage broader competition and diversity among insurers, who will be able to sell their policies to individuals and families in every State, as other companies do in other sectors of the economy. After analyzing Federal Employee Health Benefits Program [FEHBP] preferred provider organization [PPO] prices, the Government Accountability Office reports: “We found that FEHBP PPO hospital prices differed by 259 percent and physician prices differed by about 100 percent across metropolitan areas in the United States, after we removed the geographic variation associated with the costs of doing business such as rents and salaries, and differences in the types of services provided.”

Allowing consumers to shop across State lines will balance State regulation of health insurance. Individuals no longer will have to pay for health benefits mandated by their home States that they do not need; they will be able to choose policies from States whose mandates better fit their personal circumstances. States will then have an incentive to balance their insurance mandates against costs to remain competitive with other States.

http://www.roadmap.republicans.budget.house.gov/plan/#Healthsecurity

 

[Al68]

This is a bit bewildering. It sounds like you're arguing for simplification and standardization of insurance market rules, which at the very least would require a base, uniform federal standard.

I don't want to speak for WhoWee, but the biggest obstacle to a free market caused by state regulations is not just that each state has different regs, but that citizens are not free to buy "out of state" insurance. Lifting that prohibition would end the necessity of each insurer having 50 different sets of regs to comply with, but would require no uniformity among state regs, or any federal standard. Each citizen could buy insurance from whichever state, and whichever company, he determined offered the best type of policy for him.

 

[WhoWee]

There's a trade-off that has to be made. Opting for complete standardization and centralization instead of granting states more autonomy would be attacked as a federal power grab, with bureaucrats in Washington ignoring the boots on the ground in the states who understand local conditions and needs. Granted, the exchanges that were authorized in the ACA often don't get credit for what they are anyway, but I think the benefits of this structure can outweigh the drawbacks, if they're implemented with the intent of achieving various health policy goals pursued by the states. After the last election, in many states that's far from certain.

I think you've touched on the heart of the issue. The Federal Government already controls every aspect of health care (as I've explained in earlier posts). The individual states control insurance regulations - which restricts trade and increases costs. The Feds don't want to unravel/untangle the "mess" at the state level - because it will look like a power grab.

I agree, the boots on the ground - the people most familiar with the problems are (IMO - once again) ignored.

 

[SW VandeCarr]

I don't think this can be compared to auto insurance. I can opt out of car insurance, I just won't be able to drive. The government can't require us to insure our bodies. That's a bit much.

I predict that in the future we will be required to get a license to operate our bodies.

 

[nismaratwork]

I predict that this Wednesday's vote to repeal the bill has been suspended already. Oh well, maybe next time someone won't snap in the reddest state on earth.

 

[WhoWee]

Here's a little update on health care reform progress. I think we can all agree the insurance industry has been portrayed as the bad guys - correct?

Also, I've disclosed in nearly every thread on the topic that I'm professionally active in the insurance industry.

Accordingly, (I can't post specific carrier information) effective January 1, 2011 - several carriers have issued pay cuts of up to 50% to their career agents. That is, the commission-only sales force was notified that compensation for new business would be paid at a much lower rate. One example was for direct appointment reductions from 20% to 10% on health insurance products - other sub-agent agreements have comparable cuts.

Again, these agents work on a commission only basis and work very hard to build a book of business.

But who knows, if this strategy works, perhaps the same formula can be applied to Government workers - a 50% reduction of pay (and benefits - they have them - insurance agents typically don't) could lessen the deficit.

 

[nismaratwork]

Here's a little update on health care reform progress. I think we can all agree the insurance industry has been portrayed as the bad guys - correct?

Also, I've disclosed in nearly every thread on the topic that I'm professionally active in the insurance industry.

Accordingly, (I can't post specific carrier information) effective January 1, 2011 - several carriers have issued pay cuts of up to 50% to their career agents. That is, the commission-only sales force was notified that compensation for new business would be paid at a much lower rate. One example was for direct appointment reductions from 20% to 10% on health insurance products - other sub-agent agreements have comparable cuts.

Again, these agents work on a commission only basis and work very hard to build a book of business.

But who knows, if this strategy works, perhaps the same formula can be applied to Government workers - a 50% reduction of pay (and benefits - they have them - insurance agents typically don't) could lessen the deficit.

Whaaaaat? I don't think people hate insurance AGENTS... it's the system as a whole, the costs imposed, and profits made by the corporation as a whole. I imagine that salaries and benefits for the people selling plans probably is about the same as any job, and cutting it seems cruel and without any benefit except to those people who the public DOES hate; the C class execs, and other upper management, and major investors who get concentrated profit. After all, it's hard to blame TONS of faceless investors within the 401K range of investment.

btw, I didn't know that you worked in insurance. You have my condolences.

 

[WhoWee]

btw, I didn't know that you worked in insurance. You have my condolences.

I wear many hats.

The trend I see (with respect to insurance agents) is towards a less educated, lower paid, higher turnover, telemarketing format. This model requires people call in and be enrolled by a faceless person who can't possibly gauge the individual needs nor tailor solutions that fit their clients in both the short and long term.

Assuming healthcare reform fixes ALL of the problems in the under age and Medicare eligible categories - greatest concern is Long Term Care. Medicare does not address the needs of person beyond the first 100 days in a skilled nursing facility. Needless to say, long term nursing home care care is expensive and most people have no protection - many sign over their homes and go on Medicaid - another problem surely.

 

[nismaratwork]

I wear many hats.

The trend I see (with respect to insurance agents) is towards a less educated, lower paid, higher turnover, telemarketing format. This model requires people call in and be enrolled by a faceless person who can't possibly gauge the individual needs nor tailor solutions that fit their clients in both the short and long term.

Assuming healthcare reform fixes ALL of the problems in the under age and Medicare eligible categories - greatest concern is Long Term Care. Medicare does not address the needs of person beyond the first 100 days in a skilled nursing facility. Needless to say, long term nursing home care care is expensive and most people have no protection - many sign over their homes and go on Medicaid - another problem surely.

That's a disturbing trend... I can't see how under-educated employees will pay off for the consumer (not that such is the point). I'm sorry that your industry is changing in such an unfortunate way, and I know exactly what you mean about the lack of skilled nursing, the involvement required for nursing care, and frankly... just plain old NURSES. We are in trouble, whatever the cause (we don't need to agree), we can agree that trouble is-ah-comin'

 

[WhoWee]

That's a disturbing trend... I can't see how under-educated employees will pay off for the consumer (not that such is the point).

Have you ever called 1-800-Medicare and asked a specific question?

 

[nismaratwork]

Have you ever called 1-800-Medicare and asked a specific question?

Yes... I've also been hit in the head with a car's trunk. Very similar in a kind of ephemeral, but lasting way.

 

[WhoWee]

Yes... I've also been hit in the head with a car's trunk. Very similar in a kind of ephemeral, but lasting way.