Health Care Reform

[ToshoftheWuffingas]

Just an anecdote from the socialist health gulags of the UK.
A friend turned 60 at the same time as the Oxford moot in mid August so I couldn't go to his party. Shortly afterwards he got the standard postal bowel cancer check that everyone gets automatically at that age. I have had several already. It came back positive, he went for a check, was admitted to hospital and has had a length of his large intestine removed and is back at home. Speedy and there is not one bill to worry about. The concept of a bill never enters our heads.

[Primula Baggins]

Yes, but you will never be as lucky as we are in the United States, because freedom.

(To get sick and die, mostly, but it's the principle of the thing!)

[Holbytla]

Just an anecdote from the socialist health gulags of the UK.
A friend turned 60 at the same time as the Oxford moot in mid August so I couldn't go to his party. Shortly afterwards he got the standard postal bowel cancer check that everyone gets automatically at that age. I have had several already. It came back positive, he went for a check, was admitted to hospital and has had a length of his large intestine removed and is back at home. Speedy and there is not one bill to worry about. The concept of a bill never enters our heads.

I'm kind of in the same boat with regards to healthcare. Not the cancer part, but the coverage. I've never paid an insurance premium. I've never paid much of anything beyond a $5 or $10 co-payment. Never had any medical bills to speak of, and that includes dental, mental health and vision care coverage for six people.

Like your healthcare system though, it was never free. Somewhere, somehow, someone is paying for that service. Be it through taxes or in lieu of wages, the system is being funded by us. There never was nor will there ever be such a thing as a free lunch.

I have been very fortunate in that regard, and I know that I am in the extreme minority. It does come with a price though. Starting pay where I work was just under $12.00/hour with free healthcare, weekends off and overtime, 28 years ago. A great job back in the day.
Today starting pay is $12.50/hour with free healthcare, 2 days off in the middle of the week and fewer benefits. I don't know how much the cost of living has increased since then, but I know gas prices alone have tripled.
We have free healthcare that isn't free. So do you. The difference is that you pay for yours through taxes instead of income.

[vison]

The other difference is that everyone is covered.

I've never thought we had "free" health care and I bet Tosh never has, either.

I do pay a premium, as I've said before it's $128 a month for my family of 3. I have to pay for prescriptions, dental care, and glasses. But there is a limit to the amount of prescription expense, after that they're "free".

My dad was a working man. He and my mum raised 6 kids on his wages. My mum stayed home and worked raising kids, etc., and I suspect she actually worked harder than dad did. At the end of his working life he had a very good job, well-paid, and excellent benefits. They could, and did, have an RV, they traveled all over North America (including to Mississippi!) and then cruised and flew over much of the world.

That sort of job for the sort of guy my dad was no longer exists. He worked for the city of Surrey. The guys working there now, doing the sort of work he did, are not paid as well as he was and their benefits are not as good. Like the auto workers and steel workers and others. I don't think those days, or those jobs, will ever come back.

[Primula Baggins]

I hope it will someday be possible to make Americans understand that covering everyone means spending much less on health care as a whole—especially if no one is profiting from selling and administering the coverage, as with Medicare.

I suspect that this will happen when individual states adopt single-payer plans and the economic advantages of this start to become obvious. Isn't that more or less what happened in Canada, vision?

[vison]

The circumstances are so different, though! We never had the mess that you have now, with rapacious insurance companies, and, after all, medical care in those days was relatively primitive in comparison. Costs were low, even allowing for inflation, etc. Still too high for a lot of people, though.

You guys have this VAST weight on you, with decades of the medical system digging its roots deeper and deeper. I really don't see any rational way out of it, except I guess state by state or even city by city?

Government health insurance was brought in by the great Tommy Douglas, a firebrand preacher and socialist in Saskatchewan. He wanted to put an end to the situation where people could not afford to go to the doctor or have an operation. The doctors bitched and moaned, but in the end, yes, the benefits were obvious.

Our hospitals have always, to my recollection, been publicly funded from sales taxes. They still are. Doctors are not state employees, as a rule, although some are.

[Holbytla]

Just for the sake of reference, I would like to know how many people in the US opted out of available healthcare, because they didn't want to spend the money on the coverage, opted to spend the money on something else, like a car or a house, chose not to work, chose not to contribute to the healthcare system.

As has been said, somehow someway everyone has to contribute to the healthcare system. I am not referring to the truly indigent people fyi.
I'm just curious as to how many people choose not to pay and what that effect has on the system.

You can't opt out of taxes. What will be the material difference if everyone is forced to contribute to the system?

[Primula Baggins]

If everyone has to buy insurance, the idea is, then we won't have people whose diabetes is treated for the first time when they have gangrene in both feet, or heart disease when they need a quintuple bypass. That's why Obamacare mandates that preventive care such as checkups and mammograms and pregnancy visits and well-baby care has to be covered at 100% by all new insurance plans, including yearly renewals of existing plans. They also can't charge any copay. The idea is that this will reduce the number of people who don't get treated for serious problems until they're catastrophically ill and requite tens of thousands of dollars worth of surgery and treatment.

And it is in fact true—this works. This is why every other First World nation can cover all its citizens and pay far less as a percentage of GDP for health care than we do.

[Cenedril_Gildinaur]

I just did my annual benefits re-enrollment at work. It seems there is now a cap of $2,500 on how much I can put into my FSA (Healthcare Savings Account). This did not exist before. So I looked a little and found it in Obamacare.

FSAs are one of the few good features in our rather messed up medical system. I would have recommended expanding them, not limiting them. It is curious that this reform does the opposite.

[JewelSong]

FSAs are one of the few good features in our rather messed up medical system. I would have recommended expanding them, not limiting them. It is curious that this reform does the opposite.

What could be the reasoning behind such a cap? (I'm not saying I would agree with the reasoning, but usually there IS some kind of method to the madness.)

[Cenedril_Gildinaur]

I have no clue why someone would want to put such a cap in place.


Actually, that's not true/ I do have an opinion on why one would want a cap in place, but the reason is not to improve our healthcare system. The reasoning for such a cap is to reduce the amount of control people have over their own healthcare and make them more dependent on 3rd party payments. Force people to pay out of pocket until they demand reforms so that they don't have to pay out of pocket anymore.

[axordil]

The problem with FSAs, in terms of actually administering them, is that they require you have some idea of what your expenses will be in any given year, since any unspent money in them goes poof (or rather, becomes the carrier's) at the end of the year. Unlike HSAs, there's no rollover from year to year.

Thus, while they may be a good fit if you have a chronic condition where you can accurately predict, say, the amount of insulin you'll use next year, they're prone to either over- or under- estimation, both of which make them rather less useful. Put too much in and one of two things happens: you lose it or you find ways to spend it that aren't necessary. Put too little in and you're effectively uninsured the latter part of the year.

I would never recommend an FSA as sole coverage for those reasons. As an adjunct for, say, a high-deductible major medical policy, if you have one of those aforementioned chronic conditions? Or if you have a procedure that falls into the category of "I need this soon, but it's not critical?" Sure--but those are niche markets.

[Voronwë the Faithful]

FSAs are one of the few good features in our rather messed up medical system. I would have recommended expanding them, not limiting them. It is curious that this reform does the opposite.

What could be the reasoning behind such a cap? (I'm not saying I would agree with the reasoning, but usually there IS some kind of method to the madness.)

The reason is that people have been abusing FSAs and HSAs and using them for non- health care purposes in order to get larger tax breaks. The new law not only caps the amount of the HSAs and FSAs (but to an amount still considerably greater than the average employee contribution to their health plan), it also restricts what they can be used for in order to try to curb the abuses.

[Cenedril_Gildinaur]

The problem with FSAs, in terms of actually administering them, is that they require you have some idea of what your expenses will be in any given year, since any unspent money in them goes poof (or rather, becomes the carrier's) at the end of the year. Unlike HSAs, there's no rollover from year to year.

Thus, while they may be a good fit if you have a chronic condition where you can accurately predict, say, the amount of insulin you'll use next year, they're prone to either over- or under- estimation, both of which make them rather less useful. Put too much in and one of two things happens: you lose it or you find ways to spend it that aren't necessary. Put too little in and you're effectively uninsured the latter part of the year.

I would never recommend an FSA as sole coverage for those reasons. As an adjunct for, say, a high-deductible major medical policy, if you have one of those aforementioned chronic conditions? Or if you have a procedure that falls into the category of "I need this soon, but it's not critical?" Sure--but those are niche markets.

The solution to that isn't to limit the FSA but to enable roll-over. That way people can donate much to it when they are healthy and draw much from it in an emergency without losing money from incorrect forecasting of the future.

Saying that they are using them for tax breaks is an odd charge, considering any money not used is lost. My own FSA always asks for a full accounting of any charge that looks even the least bit unusual. I once tried to submit a claim for something I thought would be covered but wasn't, and they took the time to send a nice long letter explaining why it wasn't covered.

If the law is changed to curb abuses AND limit the amount one can put into the account, then the law is doing one thing that makes sense and one that makes no sense. Lumping them together into a package deal doesn't mean that the contribution cap is right.

[axordil]

The solution to that isn't to limit the FSA but to enable roll-over.

Then it would be an HSA. HSAs are legally paired with high-deductible plans. That combination works if you're both relatively well-off (so you can afford to sock money away) and relatively healthy (so that money doesn't get constantly eaten up)...but it also has a measured tendency to make people put off treatment, to "save their money" for "something big." This often becomes a self-fulfilling prophecy.

The other lurking problem is that an HSA is actually a financial instrument/account of some sort, not merely a pool of funds for health care. It can be an FDIC insured savings account, or something with inherent risk attached. If the latter, it's subject to market fluctuations. That's often glossed over. That's also where the abuse comes from that V-man mentioned. FSAs aren't as prone to it for the reasons you note, but HSAs can be rolled over into tax-deferred retirement accounts.

Now if you want to talk about an HSA that could be rolled over into Long-term care costs--a sort of health-care equivalent for Whole Life--I'd be intrigued.

There are rumblings about altering the "use it or lose it" rule for FSAs. I rather suspect the admin costs of them would rise to compensate for the money carriers won't get to keep from unspent funds.

Disclosure--I use an FSA equivalent for child care, a DCSA.

[Maria]

We are switching to a HSA/high deductible insurance option next month. I'm currently on my own company provided traditional health insurance, but since their coverage is crap for non-network providers- I'm switching to my husband's policy and my company is going to increase my pay the amount they'll save by not having me on their policy.

It's a win/win for us. Non-network on my husband's policy still isn't *good*, but it's better than mine, and we'll stash my pay increase into the the health savings account.

We'll still have to use that for expenses, but my insurance policy really angered me when they informed me that non-network doctors had a separate $2000 deductible and furthermore, they'd only apply 18% of what I'd actually paid towards that separate deductible. I do not wish to be associated with them any more.

[Cenedril_Gildinaur]

Eliminating the end-of-year penalty would not mean it is no longer an HSA. It means the relatively healthy (which means young people) can put away money that they won't use until they need it when they are no longer relatively healthy (which means older people). It is an HSA as long as it can only be used for health care.

One of the sticking points of our medical model is how to pay for expensive care late in life, and solutions such as Obamacare are designed to find a way to make the healthy pay for the treatment of the unhealthy. Roll-over HSAs would enable a person who is healthy to save until he is no longer healthy, which means he would be less dependent on others. Lowered dependency is something that is notably absent from Obamacare.

[Maria]

The HSA we signed up for is an inheritable asset.

[axordil]

The HSA we signed up for is an inheritable asset.

Right. It's an account that you *own* and can do things with. That's why it's a potential tax dodge, unlike FSAs.

[axordil]

Again, neither FSAs nor HSAs can ever substitute for major medical coverage. FSAs and HSAs are designed to cover expenses for relatively minor non-preventive procedures (I believe HSA/HDHP plans cover preventive costs as a rule...not sure about FSAs). You can be an Olympic decathlete and draw the short genetic straw for cancer, or get hit by the proverbial truck, or for that matter, simply be pregnant and develop complications.