[kenberg]

Ok, I am getting there, but I have not arrived yet.


My tentative understanding:

Suzy, with her three kids, lives in state X where they ahve the expanded Medicaid.
She:
a. Gets Medicaid
b. Does not need any further insurance
c. Does she have to go on the site at all? Maybe to say "I am Suzy and I am receiving expanded Medicare in state X?

Now her cousin Sandy is also poor, also has three kids, and lives in state Y w/o the expanded Medicaid
She:
a. Gets only the lesser version of Medicaid
b. Is required by law to get insurance since the lesser Medicaid does not meet standards
c. Cannot get any financial help for the insurance she is required to purchase.
d. It would seem there would be a market for some modest insurance here. Namely a policy that would cover items that are not covered under her current Medicaid but are covered under expanded Medicaid. Are such policies offered? If she can somehow manage to get one, then she has satisfied requirements?
e. Fining this woman for not buying a policy she cannot get seems pretty crazy. Or maybe she is exampt from the fine because she lives in Y?


I know that this is getting technical. The whole thing seems to get opaque very fast. For example, I have no idea of how much better, or more costly, the expanded coverage is. I had the feeling that the old Medicaid in the old version already covered most things, but maybe that is wrong. I am not totally out of touch with the part of the world that is just barely hanging on, but my knowledge of any details is very limited.

[mike777]

kenberg, on 2013-November-17, 21:22, said:

Ok, I am getting there, but I have not arrived yet.


My tentative understanding:

Suzy, with her three kids, lives in state X where they ahve the expanded Medicaid.
She:
a. Gets Medicaid
b. Does not need any further insurance
c. Does she have to go on the site at all? Maybe to say "I am Suzy and I am receiving expanded Medicare in state X?

Now her cousin Sandy is also poor, also has three kids, and lives in state Y w/o the expanded Medicaid
She:
a. Gets only the lesser version of Medicaid
b. Is required by law to get insurance since the lesser Medicaid does not meet standards
c. Cannot get any financial help for the insurance she is required to purchase.
d. It would seem there would be a market for some modest insurance here. Namely a policy that would cover items that are not covered under her current Medicaid but are covered under expanded Medicaid. Are such policies offered? If she can somehow manage to get one, then she has satisfied requirements?
e. Fining this woman for not buying a policy she cannot get seems pretty crazy.


I know that this is getting technical. The whole thing seems to get opaque very fast. For example, I have no idea of how much better, or more costly, the expanded coverage is. I had the feeling that the old Medicaid in the old version already covered most things, but maybe that is wrong. I am not totally out of touch with the part of the world that is just barely hanging on, but my knowledge of any details is very limited.

1) Ken there are millions of single moms...they need help, mnillions.
2) Ken there are millions who don't own a car or cell phone..they need help. millions
3) zzKen,ou are rich ..... own a car and cell phone you need to pay more much more....

[kenberg]

mike777, on 2013-November-17, 21:25, said:

1) Ken there are millions of single moms...they need help, mnillions.
2) Ken there are millions who don't own a car or cell phone..they need help. millions
3) zzKen,ou are rich ..... own a car and cell phone you need to pay more much more....

I understand this. Well, except for the part about being rich. But I am trying to understand some details here.

I guess (??) that Medicaid is one of those Fed programs run by the states so that my statement that Medicaid (old version) covered quite a bit might be true or untrue depending on where you live?

Anyway, I accept that people need help, that's not at all my question. Medicare and the ACA both are addressing the problem of the needy, and I suddenly realized that I am very unclear about how they interact.

[Trinidad]

mike777, on 2013-November-17, 16:24, said:

Rik, again docs and nurses are just a small part of the system, who owns all the other huge parts. For example, the offices, computers, tech, xy and mri machines. Who owns the medical equip and medical supply companies, who owns the drug companies..etc etc.

All in a similar way as I described for the docs: The government(s) or the private practices own the buildings and equipment. There is one pharmacy outlet chain, controlled by the government. (Just like there is only one liquor store chain, under government control.) Obviously, the government does not own the drug manufacturers. That is where government control stops.

mike777, on 2013-November-17, 16:24, said:

Wow are you joking about all the private info the govt knows in Sweden?

No, I was not joking. It scared the #### out of me when I came to Sweden, but after a year, I was really happy with it. It works so smoothly. But you need to remember: Few people have access to this information. Computers do the work. No actual person is looking at the data about me.

Rik

[helene_t]

Trinidad, on 2013-November-17, 15:18, said:

The situation in the USA is very different from the Swedish situation. In Sweden "the government" knows literally everything about you, among others: your doctor, your pensions, the amount of money in your bank accounts, your employer, your salary, your employment history, how much rent you pay or what you have paid for your house, the amount and interest rate on your mortgage, and many other things (I could imagine that they knew what bridge clubs I was a member of).

I guess this wouldn't happen in Sweden, where the government knows even which animal species you belong to:

cat summoned for jury service

Yes, the degree of civic registration makes life in Scandinavia smooth. Changing address in Denmark is just filling in your social security number and your new address on a form at the post office (I am sure most people do it online nowadays). Then everybody who needs to know your new address gets it. I once had to chance my social security number. Since this is a very unusual event (there is probably not more than one person per year that changes SSN), I feared that it would cause a lot of troubles like pension funds losing tracks of me (all government registries but also many private ones use SSN as key). But no, everybody got my new SSN automatically.

When I came to the UK, first thing was to go to the town hall to ask to be registered. I got the question: "what do you want to register for?". Apparently there is nothing that prevents you from being registered at one address for council tax, at another address for national tax, a third address for voting etc. I would have to show up at several different government offices in person to get all the registration done. It is simpler once you live in the country already, but still. And whenever some private entity wants me to provide "proof of address", what they want is utility bills!

[kenberg]

The Steig Larsson character Lisbeth Salander had great appeal to me and I think to many Americans. From what Rik says about the ability of the Swedish government to keep track of everyone, her resourcefulness in staying under the radar seems even more heroic. Of course it is fiction. Btw, I looked up the spelling of Larsson and, along the way, found that the original Swedish title of the book translates as Men Who Hate Women. I very much agree with the change of focus of the new title.


How much the government should know about our lives is a difficult question.In theory, if the gov wants a sample of my DNA, I don't really mind, I am not engaged in any criminal activity. As far as I am concerned, we could replace Social Security numbers by DNA code. That's in theory. Still, it seems creepy.

[ArtK78]

kenberg, on 2013-November-17, 21:22, said:

Ok, I am getting there, but I have not arrived yet.


My tentative understanding:

Suzy, with her three kids, lives in state X where they ahve the expanded Medicaid.
She:
a. Gets Medicaid
b. Does not need any further insurance
c. Does she have to go on the site at all? Maybe to say "I am Suzy and I am receiving expanded Medicare in state X?

Now her cousin Sandy is also poor, also has three kids, and lives in state Y w/o the expanded Medicaid
She:
a. Gets only the lesser version of Medicaid
b. Is required by law to get insurance since the lesser Medicaid does not meet standards
c. Cannot get any financial help for the insurance she is required to purchase.
d. It would seem there would be a market for some modest insurance here. Namely a policy that would cover items that are not covered under her current Medicaid but are covered under expanded Medicaid. Are such policies offered? If she can somehow manage to get one, then she has satisfied requirements?
e. Fining this woman for not buying a policy she cannot get seems pretty crazy. Or maybe she is exampt from the fine because she lives in Y?


I know that this is getting technical. The whole thing seems to get opaque very fast. For example, I have no idea of how much better, or more costly, the expanded coverage is. I had the feeling that the old Medicaid in the old version already covered most things, but maybe that is wrong. I am not totally out of touch with the part of the world that is just barely hanging on, but my knowledge of any details is very limited.

Ken:

If you are on Medicaid, that is the end of the story. There is no issue of Medicaid failing to meet any requirements.

The states that refused the Medicaid expansion did so for purely political reasons. The federal government is picking up 100% of the costs of Medicaid expansion for the first several years, and 90% thereafter. So the idea that picking up 10% of the costs of Medicaid expansion several years down the line is too expensive is just a complete joke. It is cutting off your poor to spite your political opponents.

[Trinidad]

When I went to the USA to study at MSU (Go Spartans!), the first thing they did was send me to the university's International Center. There, they handed me a pile of forms that was 8 inches thick. (The package didn't come in an envelope. It came in a box.) My first impression was that the International Center was an extremely bureaucratic organization and boy, I hated them... Until I realized that these were all forms required for US government agencies, the university, the State of Michigan, the city of East-Lansing and I don't remember what. The international Center had merely gathered all these forms in one package, so I could fill them all out and be done with them (except for those places where I had to be in person, but they gave me a "shopping list" of where I needed to go). Obviously, each piece of paper started by asking for my name, address, date of birth, etc. and I had to fill out the same things over and over and over again.

I am very grateful to the MSU International Center for the incredible service of giving me such a package. It must have saved me weeks of work to gather all the forms.

When I moved to Sweden, about five years later, it went a lot easier. I had to show up at the tax office to get me registered and fill out one form (perhaps it was 2, 3 or 4 pages, but then the Kingdom of Sweden knew everything they needed to know). That was it.

Rik

[kenberg]

ArtK78, on 2013-November-18, 07:42, said:

If you are on Medicaid, that is the end of the story. There is no issue of Medicaid failing to meet any requirements.

I favor simplicity wherever it is possible so this appeals to me. Suzy and Sandy both have Medicaid, I have Medicare, we can all go on w/o having to think about how the ACA applies to us. It doesn't. Well, excpet that Suzy gets a better deal than Sandy because she lives in the right state.

ArtK78, on 2013-November-18, 07:42, said:

The states that refused the Medicaid expansion did so for purely political reasons. The federal government is picking up 100% of the costs of Medicaid expansion for the first several years, and 90% thereafter. So the idea that picking up 10% of the costs of Medicaid expansion several years down the line is too expensive is just a complete joke. It is cutting off your poor to spite your political opponents.

If this is indeed the whole story it would seem odd for states to reject the plan. I would expect them to find it difficult to explain to voters. Also I don't really understand why the dollar figure on increased Medicaid should be particularly high. Do you, or does anyone, know just what sort of things the expanded version now covers that the old one did not?

Once I start thinking about details I realize I don't know many. Here is another sample. We have heard that, with these canceled policies, getting a new and satisfactory policy could be expensive. Two possible reasons come to mind. One is the obvious one. If you insure against more expenses, the policy will cost more. Another is less clear. As I understand it, having large participation with these new policies is necessary to make the books balance. Now this problem cannot be simply because of the better coverage. If I make a choice between two policies, one more extensive than the other, the premiums are set so that the books will balance no matter which policy I and others opt for.
So I am missing something here.

[kenberg]

Trinidad, on 2013-November-18, 08:12, said:

When I moved to Sweden, about five years later, it went a lot easier. I had to show up at the tax office to get me registered and fill out one form (perhaps it was 2, 3 or 4 pages, but then the Kingdom of Sweden knew everything they needed to know). That was it.

Rik

Sounds good to me. You might find the following amusing. I mentioned that my wife Becky had both knees replaced. That's not the amusing part. The staff at the hospital is excellent. This guy was explaining how/when the decision will be made on how much physical therapy she gets. He explained that contrary to what Republicans say, the government has nothing to do with it. It all comes down to the insurance companies. Then he caught himself and realized that he had perhaps spoken out of turn. "I hope you are not a Republican". Which probably could have put him in an even deeper hole. Anyway, I assured him that no I wasn't a Republican and, anyway, I was far more interested in Becky's treatment than I was in politics.


One of the many good things about the staff there is that they are fun to chat with. Becky gets treated by both a physical therapist and an occupational therapist. The treatments from the physical therapists are far and away the more painful. I asked the occupational therapist if in therapy school they are given a psychological test and those who score high on sadism are encouraged to select physical rather than occupational therapy. She assured me that occupational therapists also sometimes give painful treatments.

[Trinidad]

kenberg, on 2013-November-18, 06:53, said:

How much the government should know about our lives is a difficult question.In theory, if the gov wants a sample of my DNA, I don't really mind, I am not engaged in any criminal activity. As far as I am concerned, we could replace Social Security numbers by DNA code. That's in theory. Still, it seems creepy.

The government obviously knows a lot about you (IRS, Medicaid, Social Security, ..., NSA). The difference is that it is all fragmented in the USA and integrated in Sweden.

I would think that if the NSA or the FBI wanted to know more about Kenberg, they can search quite a few separate databases and find out all about you, without you ever knowing it. Of course, the Swedish "NSA" can look in the integrated database and know all about Ken Svensson. But Ken Svensson has the advantage that the data is structured around him, e.g. his tax form is automatically filled out for him.

At the moment, I am fighting this battle about my social security pension in the Netherlands. The tax office has taken the money for this pension (which is their job), but somehow they didn't tell this to the agency that will pay out my social security pension (if I will ever reach the retirement age). I keep calling and writing to each office. I get friendly replies, but they won't solve it because each side always thinks that the problem is on the other side of the fence. Many of us know similar problems where you get send from one place to another and back. This will happen much less in Sweden: there is no fence.

Now, I have a professional working on this problem. Fortunately, my boss is paying for him, but this simple example makes it clear how much money can be saved and how much irritation can be prevented by connecting these databases. No wonder Swedes are such happy people.

Rik

P.S. I hope all goes well for Becky. (And that the paperwork will be the worst part of this.)

[kenberg]

My father died in 1977. I saw to it that all of the doctors were paid. All but one. I kept getting this wrong bill from one of them I would call, the office staff would aree that the bill was wrong, but apparently they could not get the computer to agree. Eventually I wrote to them and told them I was tired of talkling about it. If they ever sent me a correct bill, they would get a check by return mail They never sent a correct bill, I never sent a check.

These foul-ups can be very frustrating. When we moved, maybe seven years ago, we got a new telephone number. We still get calls from people who want to collect money from the previous owner of that number . The calls had finally dropped off but his wife recently got out of jail and now the collectors (only a few) are back in action. (His wife went to jail because the two of them were cooking meth or something like that, and when they got arrested he ratted out his wife. She went to jail, he walked. Or so Becky understood from news stories. I can't tell you if they had a happy re-union now that she is out.)

[awm]

As I understand it, the medicaid expansion does not change (at all) what medicaid covers. It is an expansion of WHO medicaid covers to include slightly more affluent (but still poor by most standards) people.

Because ACA was supposed to cover these people via medicaid, subsidies for private insurance were not arranged at their income level. Since some states refused to expand medicaid there are people who are "too poor" for subsidies but "not poor enough" for medicaid. While in principle they may then be fined for failing to have insurance, there is an exception if insurance is too high a cost relative to income.that they probably fall in. So they likely remain uninsured. It is somewhat baffling how the governors of these states will explain to their constituents turning down free money for their state "because Obama" but a majority of residents in these (often poorer than national average) red states seem accustomed to voting against their economic interests.

[ArtK78]

kenberg, on 2013-November-18, 08:31, said:

If this is indeed the whole story it would seem odd for states to reject the plan. I would expect them to find it difficult to explain to voters. Also I don't really understand why the dollar figure on increased Medicaid should be particularly high. Do you, or does anyone, know just what sort of things the expanded version now covers that the old one did not?

The rejection of the expansion of Medicaid by the Republican governors of the states that opted out was done purely for political reasons. Given the facts, it was entirely irrational of them to opt out other than if Obama wanted it then they don't want it.

I don't have the information on what the expansion of Medicaid consists of. I believe it is not so much treatment options but rather a broadening of the eligibility standards for coverage by Medicaid, thus increaing participation in Medicaid. Perhaps someone else can provide the information.

kenberg, on 2013-November-18, 08:31, said:

Once I start thinking about details I realize I don't know many. Here is another sample. We have heard that, with these canceled policies, getting a new and satisfactory policy could be expensive. Two possible reasons come to mind. One is the obvious one. If you insure against more expenses, the policy will cost more. Another is less clear. As I understand it, having large participation with these new policies is necessary to make the books balance. Now this problem cannot be simply because of the better coverage. If I make a choice between two policies, one more extensive than the other, the premiums are set so that the books will balance no matter which policy I and others opt for.
So I am missing something here.

Having a larger base of participants makes it easier to spread the risk. Even if a number of the participants might be higher risk participants than the makeup of the present pool of participants, the larger base of participants may reduce overall costs. Of course, one of the main principals of universal health coverage is that having everyone covered will result in more preventive care (which is lower cost) and less medical care (which is higher cost). Furthermore, if those who would otherwise have no choice but to go to the emergency room for any medical care have available to them private physicians or other clinics which are covered by insurance they will be more likely to avail themselves of the lower cost options.

It makes sense. Whether the goals are actually achieved remains to be seen.

[HighLow21]

mike777, on 2013-November-17, 21:07, said:

You must be rich...many do this

Definitely not rich, at least by the standards of where a higher income tax rate would start applying if I were drawing the tax map (or if Obama were). But yes I own a cell phone and an adorable little 2013 MINI Convertible and I recognize how wealthy that makes me.

I've always said that if you have cable you're rich. You can afford to junk $100+ per month on home entertainment.

[HighLow21]

awm, on 2013-November-18, 10:13, said:

As I understand it, the medicaid expansion does not change (at all) what medicaid covers. It is an expansion of WHO medicaid covers to include slightly more affluent (but still poor by most standards) people.

Because ACA was supposed to cover these people via medicaid, subsidies for private insurance were not arranged at their income level. Since some states refused to expand medicaid there are people who are "too poor" for subsidies but "not poor enough" for medicaid. While in principle they may then be fined for failing to have insurance, there is an exception if insurance is too high a cost relative to income.that they probably fall in. So they likely remain uninsured. It is somewhat baffling how the governors of these states will explain to their constituents turning down free money for their state "because Obama" but a majority of residents in these (often poorer than national average) red states seem accustomed to voting against their economic interests.

That's the key point and it's covered well in the book "What's the Matter with Kansas?" Year in, year out, lower and middle class whites in many states in the Great Plains, Rockies and South have been voting against their own economic interests. They have been placing ideology ahead of what is best for them. It's not inexplicable--but the explanations are cringeworthy. I'm not going to get into them here.

Suffice it to say, the Republican governors who rejected medicaid expansion do not need to answer to their constituents for their decision because the voter base agrees with them ideologically anyway. To them, government is bad, plain and simple. And trust me -- I don't care what explanation they give at the podium, or on the campaign trail, or how they spin it on Drudge or Fox News or Rush -- they rejected it to create an unseemly gap in Obamacare. The gap known as "too rich for Medicaid and too poor for Obamacare."

This is where Obama miscalculated. He never anticipated that so many states would reject what is essentially free money to help the working poor within that state. But they did, "because Obama." Issue after issue has demonstrated that it doesn't matter what Obama does--whatever he does, these people will oppose, obstruct, and sabotage him. All in the name of trying to make him fail and thereby help the Red team regain political power.

They may even succeed.

This is why I will never vote Republican again. The political leaders in that party are willing to harm American citizens deeply for the SOLE purpose of regaining power.

[blackshoe]

kenberg, on 2013-November-18, 06:53, said:

How much the government should know about our lives is a difficult question.In theory, if the gov wants a sample of my DNA, I don't really mind, I am not engaged in any criminal activity. As far as I am concerned, we could replace Social Security numbers by DNA code. That's in theory. Still, it seems creepy.

<tinfoil hat>It won't be long before the government will be in maternity wards putting GPS (and other data) chips in newborns.</tinfoil hat>

[ArtK78]

blackshoe, on 2013-November-18, 12:47, said:

<tinfoil hat>It won't be long before the government will be in maternity wards putting GPS (and other data) chips in newborns.</tinfoil hat>

And while most would argue that this is a bad thing, one cannot deny it has certain worthwhile aspects. I know that you are not one of them.

[Winstonm]

Here is where we stood prior to the ACA:

Quote

At Suburban Hospital in Bethesda, Md. — serving an affluent community at the gates of the National Institutes of Health — the average charge for simple pneumonia was $5,284. Compare that to $79,365 at Hahnemann University Hospital in Philadelphia.

Here are 3 important considerations about these charges: 1) They were not available to the public prior until the DHS released the figures in 2012. 2) Insurance companies do not pay these prices but negotiate a lower price - and those insurance prices are still unknown. 3) Medicare pays a calculated cost of service that is not the published price or the insurance-negotiated price.

I do not believe the claim that there are millions of Americans making healthcare decisions as it is impossible to make informed market decisions in opaque markets. What we have had are millions of Americans picking an insurance policy from a company chosen by employers from a small pool of companies while the unemployed and underemployed have had to fend for themselves.

The ACA will be an improvement if for no other reason than establishing minimum standards for insurance - how much it will help is up in the air.

[ArtK78]

I believe that I have mentioned before the bill for hospital services that I received after my (now ex-) wife nearly died after the birth of our third child.

A couple of days after the birth of our son, my wife nearly died from a kidney stone blockage. After several surgeries and a 4-week long medically induced coma, she managed to survive. All told, she was in intensive care for 5 weeks and one more week in the hospital, followed by another month of rehab in a nursing home.

A few months later, a package arrived. It was a bill from the hospital. The bill was fully paid by my medical insurance. Nevertheless, it was more than shocking. The total of the bill (which does NOT include services of the physicians) was over $6,000,000. I never did see the bill from the physicians or the other emergency services.

For those who believe in personal choice when it comes to healthcare, explain to me exactly how I was supposed to shop around for life saving care for my wife at the time when she nearly died? Should I have told the doctors to stop what they were doing and give me an itemized price list of their services along with their experience in handling such a case? Should I have called around to other hospitals in the vicinity (this was 1998, and the internet was still relatively in its infancy) and tried to price shop and check out the credentials of the hospital staff and the attending physicians? Of course not. Medical services, especially emergency medical services, are not like other services. When you need them, YOU NEED THEM, and there is no time to exercise personal choice in the choice of physicians or hospitals.