September 24, 2016

I've Changed my opinion about....

......The Affordable Care Act, better known as Obamacare. Now, before you shoot daggers at me, I will add that the system we had before Obamacare was a dismal failure, too. Sick people were denied coverage. Life-saving tests were unaffordable for many. Insurance companies could decide a treatment was not warranted and people would die. Those without employer-provided policies who didn't have any dreaded "pre-existing conditions"  faced back-breaking premiums, deductibles, and limitations. Bankruptcies happened.


So, where are we? The unfettered for-profit system prior to 2010 was a train wreck. The ACA is headed to a future where premiums are too expensive to pay because competition has disappeared. Health care companies have figured out they are better off walking away from customers if they are too sick. The fines for not have health coverage are so low that many younger people are better off paying the penalty rather than hundreds of dollars a month for coverage with huge deductibles and a tiny network of providers. Some states have only one company in their health exchange. That is a guarantee for failure.

Some will argue the answer is obvious: make Medicare an option for everyone. The system works. There is fraud, sure, but there is fraud in the private model, too. There is fraud in Social Security but I've never met anyone who wants that essential service terminated. Heavens, there are billions of dollars of waste and fraud in the Pentagon, but we must have a defense system.

With tens of millions of additional customers and no more need for subsidies,  the government could afford to increase what is paid to providers. Drug price negotiation would become standard practice. Medicare has few exclusions and even fewer limits on coverage. Those who need it could get it.

I think there would still have to be some form of private option. We are just too independent and fearful of total government control to make Medicare the only health insurer. The insurance companies would be happier because the healthier people would probably choose a private company, allowing for lower premiums and a decent share of the market. Medicare Advantage programs and Medigap policies would still be available.

Obamacare was pushed through a very reluctant Congress. The law was massive, poorly written, and based on conclusions that have not come true. As structured it will not survive much longer. But, if it collapses do all the people who were unable to get insurance before, or excluded from life-saving procedures, get tossed under the bus again?

Like a few other hot button topics in today's America, health care remains a subject whose mere mention can trigger more heat than light. I really hesitated to write this post for fear of a tsunami of "I told you so" or "this political party or that does or does not have any answers."

The point of this post is actually more of admitting that changing one's opinion about something important can be admitted publicly. Humans change their minds and change their opinions on a regular basis. But, I am convinced that too often we refuse to admit those changes for fear of what others may say and think.

So, I am putting myself on the line here by saying I have changed my mind about the Affordable Care Act's ability to solve our healthcare problems.

I trust you to not throw me to the wolves.



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44 comments:

  1. I am in complete agreement...having been a benefit consultant for almost 40 years I have seen the price of health insurance become totally unaffordable to the vast majority of those who are not fortunate enough to have good employer sponsored health insurance. The answer could be provided on a Big Chief tablet:

    1. Extend Medicare to all.
    2. Raise the Medicare tax to properly fund it.
    3. Pay the providers a fair price


    Insurance companies could sell Med Sup policies to everyone and collecting premiums for Medicare for all would not be an issue since it would be a payroll tax. I predict some form of this will happen within 10 years.


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    1. The previous totally market-regulated approach meant insurance companies would deny coverage to people who needed it. The current system is financially unsustainable.

      No one has provided a valid alternative. Selling across state lines won't work because of the difference in state regulations and requirements. And, that still leaves 50 million people at the mercy of companies whose sole motivation is profits.

      Your prediction of 10 years or less is probably accurate. There is really no other option.

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  2. I think Single Payer is the answer. Like you said, let's make Medicare available to everyone. It works. The mechanisms are already in place, so there would be no need for a lot of additional software. You just change the parameters for age from 65 to 0. I think for-profit health companies need to disappear. The whole idea was immoral from the start - people making a profit off others' misery. Doctors need to be salaried like nurses and techs and everybody else in the health care industry. It works at the world's best hospital: Mayo Clinic. Thanks for taking up this prickly subject and allowing readers a forum to discuss it.

    Rin

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    1. Thanks, Rin. I am surprised I changed my opinion on this subject, but in doing so I hope to stimulate some good discussion and maybe some workable ideas.

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    2. Just a comment about Mayo Clinic: Mayo Clinic in Rochester no longer accepts Medicare assignment as full payment for physician charges (for non-Minnesota residents). We are still in the process of understanding the financial implications of this for other services (labs, radiation treatment etc)... So I expect to see other providers follow suit. What then? Good post... Just wanted to share this because it has dire implications for elderly health costs.

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  3. When Obamacare passed, it was a watered down version of what our President knew would REALLY help. The PUBLIC OPTION was canned. And the single payor system was canned. This left the INSURANCE COMPANIES still in charge of our health care as a nation-- a very sad proposition.That said, the ACA has been a lifesaver for Ken and me for the past 2-3 years..we finally were able to get affordable health insurance! Retired, but not eligible for Medicare yet= a tough situation in America. THIS YEAR, since the INSURANCE COMPANIES have decided they are not reaping enough rewards from all of us signing up, and are leaving the exchanges, the system breaks down. Somehow we need a health care system that does not allow insurance companies to rule the roost. With a non working Congress, and republicans who have been re elected on health care lobbyists money, I don't know how this change will happen.. I can only hope we made a start and maybe somehow we can keep going on this.I am holding my breath as we wait for Nov. 1 and see what the ONE INSURER left in Maricopa County will be offering and charging us.. we have a couple of years yet to Medicare... It's a complex issue, I share this frustration.. but I imagine whatever is offered would have to be less than what the INSURERS themselves would charge me and Ken on the open market.I have a friend in her 50's who has a business with her husband, no employees..they pay over $1200 a month for a basic policy.Not eligible for exchange subsidy.(And that was LAST YEAR before the rates are planned to skyrocket once again..)

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    1. Betty faces the third change in her insurance in 3 years after her insurers pulled out of Arizona. She has 2+ years to go before Medicare. We may have to try for a very basic policy and roll the dice. Her networks keeps shrinking, with some specialists are over 30 miles away and have English as a secondary language...not comforting.

      Look at what is happening with drug prices...EpiPen the most recent. With health for sale to whomever can pay whatever is asked, we will begin to see emergency rooms swamped again, and people dying from lack of medical care.

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    2. Same here, three different insurance police sin 3 years! We will have to do the same: See what'a offered and roll the dice, I am 63 and Ken is 62--we have a couple more years to sweat it out.Makes me want to start exercising more and eat better!! LOL!!!

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  4. Yes for single payer! None of this will ever happen as long as it's a republican held congress. Hopefully the millennials can change this for their era, but it will be too late for us.

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    1. I hope it isn't too late for us or the next generation back. My youngest daughter is self-employed and faces a very, very scary medical care future if things don't change.

      The ACA is not working. Single payer? Maybe, but I see that as politically next to impossible for the foreseeable future.

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    2. Now wait a minute Mary. The ACA was put together and passed by a Democrat congress- against most of the suggestions of the President. This is the strongest issue that made me vote for Pres Obama the first time. I was SO disappointed that his party did not back him- at all.

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    3. With solid Republican opposition I think the Democrats kept watering the bill down in hopes of some bipartisan support. When that failed they were stuck passing what was left.

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  5. I agree with Madeline. I also think, since it was Hillary who first advocated for a better system and Obama couldn't get it all through the stubborn wall of congress, we might see something more workable after she's elected. Or, if drumpf gets in we may see what Russia has to offer.
    b

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    1. Maybe we can move to Mexico and get the national insurance for 2 years!! No, I can't pack boxes one more time!!!!!

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    2. Sell everything and start fresh. T-shirts, shorts, and flip-flops..what else do you need? !!!

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  6. When I had my splints put in my doctor offered me a deal, half price for cash. Basically he was telling me that private insurance was a $15,000 problem.

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    1. My last trip to the ER equaled 4 hours and $12,600 for a few tests and pills. Thank goodness for Medicare and supplemental.

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  7. Obamacare is not failing. It is falling into place exactly as it was written. It was written to fail so that the sheeple would come to the conclusion that a single payer system would be better. My ACA health provider filed bankruptcy after being in business for only 11 months. As Obama raised the poverty levels, and as my income dropped and my health insurance costs skyrocketed, I found myself qualified and forced into Medicaid. Can you imagine that? I earn $30,000 a year and I no longer qualify for the subsidies, can no longer afford to purchase a health care insurance plan on my own and am now forced to go on government assistance.
    Personally, Obama is a genius. He managed to fool the American people and based on the responses here (most are clamoring for Single Payer) everyone will soon get their wish. Obama was extremely successful.
    The Republicans want health insurance to be sold across state lines. That will increase competition and force prices to come down. I would prefer that option rather than being at the mercy of some government agent for my health care.

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    1. I disagree that selling insurance across state lines would change anything, but I welcome your opinion and understand your frustration. My 30+ years of buying on the individual market has bounced me and my family from one problem to another. Over the years it has consumed up to 27% of my yearly income. That isn't right.

      I was hoping the ACA would show us a path forward, but to this point, it has only highlighted the problems inherent in the entire system.

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  8. Hello Bob. I appreciate your bravery in tackling this subject. I was never for the ACA and I have a lot to say but I’ll stay with this one important point. What most people don’t realize is that if an individual chooses not to purchase a health insurance plan, they will pay a penalty. How is the penalty paid? It comes from their tax refund. The penalty is $695 or 2.5% of household income whichever is greater. For example, an individual files their taxes and they’re going to get a $700 refund. Congratulations! Oh wait, you didn’t have an ACA plan which will cost you $695 so you’ll be getting $5 back. Congratulations! Okay one more point, I recently spoke to a Canadian who said their health care system works well unless they get sick, and that’s when the wealthier Canadians come to the U.S. where they can get an appointment right away and pay out-of-pocket for services. I don’t know what the answer is but I do appreciate that you’ve started dialogue which is so important. And I’m just so happy that you’re still blogging!

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    1. The 2.5 % figure is the one that will cause problems. If you earn $50,00 and don't have insurance your penalty will be $1,250. But, that might be less than 2 months of insurance coverage that offers huge deductibles, a limited network, and all sorts of restrictions. So, paying $1,250 might be a wise financial decision for someone.

      I still enjoy blogging and being part of these fascinating discussions!

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  9. The irony is that the healthy young people who voted for Obama in the first place are the very ones not signing up for the ACA, thus dooming it to failure. I guess I kind of agree in Medicare for all -- or a single payer system; I don't know what the difference is -- but it would have to be mandatory. Also, remember that we spend about 17% of our national income on health care. And a lot of people can't pay anything at all. So one way or another, with or without the insurance companies, with or without a single payer system, it's still going to be expensive.

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    1. I believe you are correct about young folks. The penalties for not having insurance are too low to motivate anyone to participate.

      As long as drug companies can charge $600 for something that costs a few dollars to manufacture, things will remain seriously out of wack. AS long as a simple broken arm can cost close to $20,000 to repair, things will remain seriously out of wack. As long as medicare is prohibited from negotiating drug costs nothing will really get better.

      But, a single payer system (Medicare) currently works. Why can't we give it a chance?

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  10. A couple of additional points:

    1. The ability of the government to negotiate better drug prices for Medicare was traded away by the Democrats and obama as part of the ACA, to insure the support of the drug companies. Anyone who was for the ACA and is facing much higher prescription prices, well, you might have to look in the mirror for the culprit.

    2. There is at least one state that has absolutely zero ACA insurance companies left, meaning you cannot get coverage. But do people realize that will not stop the penalty owed for not having coverage under the ACA rules? Can you say "what a ridiculous system?" And wait until other quirks start to surface from the passage of a bill that nobody in Congress ever read in its entirety.

    I was not a proponent of the ACA and it was passed with zero Republican Congresspeople voting for it. That is not how laws should be passed in this country, especially when polls showed a large majority of Americans against its passage at the time. This was by design to get to a single payer system, and it has been one of the biggest reasons for the poisoned relations between the two major parties.

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    1. There are many reasons for the poisoned relationships between the political parties, but the ACA seems to be at the top of the list.

      On the flip side several tens of millions of citizens now have coverage, can't be denied coverage due to pre-existing conditions, and receive important screening tests at no cost to the individual.

      What is to become of them? I have absolutely no idea, but is not going to be Obamacare in its present form.

      Thanks, Chuck.

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    2. Additional thought. My wife found out yesterday that her GP is ending his practice, and he cited the ridiculous costs and regulations forced upon his practice by the ACA. People can disagree but he is quite vocal about it, like the hundreds/thousands of Drs abandoning their practices around the country. BTW, he is becoming a Hospitalist, so the 997 patients he had have to find new Drs.

      We have largely a retirement area here, meaning many are on Medicare. People might say, what's the problem, just find another GP. Unfortunately, many of the GPs in this area have already stated they are accepting no more Medicare patients. So much for everyone here stating that we need Medicare across the board. Do that and watch how many Drs exit the field completely, especially those somewhat older.

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  11. I've been part of single-payer, government-run medical plan for over 40 years - U.S. military healthcare. I and my husband have absolutely no complaints, and we've always been able to choose our own doctor (other than when he was on active duty), and gotten top-notch care over the years. We've either had no, or ridiculously low, insurance premiums, and out-of-pocket expenses have been negligible as we have the weight of the government negotiating for lower prices with providers and drug companies.

    IMO, the free market response to U.S. healthcare has become a disaster. Greed on the part of drug companies, insurance providers, medical technology, and even medical professionals (although just think what it costs these days to earn your M.D.) have combined to make healthcare unaffordable. The ACA has been a temporary solution, but with insurance companies still running the show it's crumbling. A move to single payer for all seems to be the way to go. Single payer works, and works well, in other countries, and citizens there receive excellent medical care. For the most part we here in the U.S. have been denied information about those systems. Still, single payer would be a huge change for most people, different and without adequate information on how it works people are understandibly scared by it. I may be wrong, but I believe Clinton at one point advocated for lowering the age for Medicare (another single payer system that works) as well as letting younger citizens buy into it. That may be the way to ease into a single payer system for the entire country.

    I wish our media would cover actual facts, with stories about how single-payer healthcare operates in other countries (although I've just about given up on the media in this country). All we ever seem to hear though are anecdotes about someone who didn't receive what they considered adequate or prompt care in Canada and so they came to the U.S. and paid out of pocket for care. It's made to seem like it's a major problem in Canada, when actually less than 2% (<0.02) of the population comes here for care, and often times the treatment is for highly complex medical issues, like neurosurgery. We need more stories about the Americans who are going to Mexico or Malta (just two examples) to receive top-notch medical care that they can no longer afford here in the U.S.!

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    1. Excellent summary of the problem, Laura. Thank you.

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    2. Single payer works for us as well- 35 years of military health. The catch? You cannot sue the government about health care. That hasn't been a problem for anyone I, personally, know. Less lawyers in the pot would help many of us.

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  12. The ACA was a very messy political compromise, so it's not surprising that it has been messy and disappointing in practice. Even with serious flaws, rising premiums, and the squeeze on primary care doctors, however, it has saved lives -- including that of my brother, who no longer had access to health insurance after coronary bypass surgery at age 43. Most Americans believe two things about health care: (1) that we have the best medical care in the world and (2) that the private sector can provide services more efficiently and effectively than the public sector. Neither of these beliefs is supported by the data, but beliefs have consequences. We won't be able to adopt a workable, more effective and less costly single payer system until people are willing to give up these beliefs. -Jean

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    1. Point #2 is true, if the private sector is allowed to not cover sick people, cancel policies when too expensive, and treat customers strictly as profit and loss figures on a spreadsheet.

      Of course that makes them more efficient, which is fine if you manufacture widgets, but not so good for human beings.

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    2. I agree with stepintofuture. In American we are under the impression we have the best health care.We don't.In fact maternal mortality (childbearing women) rates have gone UP recently. We do heart surgeries and interventions that are not shown to actually increase life expectancy, at huge cost.Many other countries have safer care. It's hard for the average citizen to understand what "evidence based care" is. It means you don't get to tell your Doctor you want a surgery or a procedure or a pill because you read about ti in a popular magazine. Your care and coverage will be determined by what studies and data show WORK or not. This annoys the crap out of Americans who are used to high levels of INTERVENTION which can actually hurt them in the long run! Canadians and others countries dole out care in a different manner.O f course people with more money who want to DEMAND different care can go pay for it in the US since Doctors and hospitals here are happy to take their money. Ahhh--what a complex issue. Also, as others mention, the ACA is a messy bill-- but it was not written that way-- it is a horrible compromise, but at least we got the ball rolling.Ken and I have saved approx. $25,000 over 2 years in premiums.My sister in law was UNINSURABLE since she suffered a heart attack at age 40. At 56, she finally got health insurance!!!!!! I hope somehow,some way, our leaders figure this out.. SOON! But I am not holding my breath.

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  13. Brave of you to venture into this topic, Bob. ;-) It's a very important one and I don't have any answers, but agree that the ACA is a disappointment for several reasons with some successes. The level of care (good vs bad) seems to be regional in the stories I hear. We have a really good regional h/c system that has expanded and acquired many of the doctors and facilities in the area. While this might sound less than ideal, it's great when your docs are on board. Our GP is great and only in his 40's, so we're hopeful we can keep him for a while.

    I too question the people who think insurance companies selling across state lines will solve anything. A previous employer in the next state offered me the option of coverage in my state. The docs in my state weren't 'in network' and I paid dearly for everything that year. My docs 'took' my insurance but I paid most of the fees because -- out of network. The way healthcare has evolved, it's tough to use any services economically without being in network. And more & more that means a specific healthcare system (Kaiser, Duke, your local biggie, etc.)

    I'm always intrigued by those who believe Canadian and British healthcare is not good and they 'come here' when they have health problems. We happen to have grown kids in each country and they are all happy with their healthcare. Among them we've had grandchildren born (virtually free), a breast cancer scare with the accompanying biopsies, surgery, etc., and all were served well, professionally and without medical bills. So I am not buying the rumors about how much better US healthcare is. When I visited my daughter in the UK for her surgery, the main difference I noticed was that we spend more money on the facilities and furniture here in the US...ours are newer and snappier. Probably because they're all competing, and marketing new facilities is easier. But we're paying for it! Just my two cents.

    We need single payer IMHO. And those who wish can purchase private care above and beyond.
    --Hope

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    1. Your real life experience with the Healthcare systems in Canada and Britain is helpful...thank you.

      A single payer option, notice the word,option, is most likely in our future. Private insurance for the rich, healthy, or lucky ones among us can continue as well.

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    2. Hope - your comment made me remember the last time I had a mammogram back on the mainland. Stepping into the women's breast center (it had some fancy name I can't remember) was like walking into an exclusive spa with its plush carpets, lovely teak paneling, comfy chairs, china tea cups for your coffee or tea while you waited, thick terry robes to wear during your exam, etc. Everyone spoke in hushed tones. All I kept thinking was "who is paying for this?" and "why?" because the actual mammogram was no different than I had received previously in less luxurious surroundings.

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  14. Bob,

    Very brave indeed. I agree that we are headed for Medicare for all. It would have eventually happened even without the ACA. And the old teacher in me wants to make sure that everyone has an accurate history of why Medicare was not allowed to negotiate drug prices with the addition of Part D. It was not because of the ACA.

    http://economix.blogs.nytimes.com/2013/11/19/medicare-part-d-republican-budget-busting/?_r=0

    The Epi-Pen fiasco is just one example of this.

    We need some smart people and some better ideas.

    Rick in Oregon

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    1. Very interesting article Rick. Thank you for sharing!

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  15. I was an accountant that worked for both a traditional hospital that accepted most insurances, which generally pay 80/20 and negotiate rates and also for Kaiser Permenente who gets paid a flat amount per month.

    The problem with our entire medical system is that it is in the best financial interest of doctors, hospitals drug companies etc for people to be sick. If people don't get sick, they don't make any money. Case in point...attending a budget meeting in the traditional hospital the comment was made Yeah! H1N1 (a few years ago). Kaiser Permenente on the other hand gets paid the same each month whether the member is sick or not. It is in their financial best interest to keep its members healthy! When I had Kaiser coverage, they made sure I got all preventive treatments and were also far more willing to give alternative options a try. Also, the doctors had final say on treatments, not the HMO financial side...so patients get the treatments they need. Unfortunately where I live now, Kaiser is not an option.

    While I agree with Medicare for all, it will not solve this problem of upside down health care and run away costs, as it is a traditional model of payment. I would love to see a Medicare that was administered similar to Kaiser. When the financial incentive is to keep people healthy, we will all be healthier and the costs will decline dramatically.

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    1. I have heard good things about the Kaiser model for several years. There is an overall push in the field of health care to pay more to keep people healthy, which seems like the obvious goal of healthcare anyway!

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  16. Bob, I have thought before that if I needed a running mate for president, a liberal to balance my conservative as it were, that you might make a fine choice. :)

    It takes guts to acknowledge that ACA is not working and not likely to start working. Frankly, the administration bet pretty heavily on it, pushing through legislation that public opinion was so divided about based on the concept that we would 'get over it' after it was in place for a few years.

    Personally, I'm open to looking at expanding/creating a single payer system but much like extending social security to all ages, there simply aren't funds to cover it. Medicare, similar to social security, is believed to become insolvent within the next few decades. This is not to say that it will cease to exist, simply that adding a large number of recipients is not likely to be supportable.

    As for Britain, or other European countries providing great single payer health insurance successfully, the UK governmental debt is 90.6% of GDP, US is about 71.8% (2014). Another way to look at is that the UK is #20 on the national debt list while we are 36. At some point, they will have to pay the piper, and then the free medical care and bon bons will be out the window. We need a sustainable, functioning system. And regardless of political party, we don't have one.

    Personally, I have never had health insurance. First not being able to afford it, and then just when it was within reach the ACA was passed and rates skyrocketed. I am one of those who pay the penalty. Our plan to deal with continually rising rates? My husband is leaving his job at the end of the year. That will allow us to sign up for health insurance on the exchange and be subsidized! Foolishness.

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    1. Thank you, but politics is too insane for me.

      Medicare might become more sustainable if the income level for taxes was raised, Medicare negotiated lower drub prices, and the addition of tens of millions of younger people, many of whom are healthier, helped moderate what is being spent.

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  17. The ACA allowed me to retire at age 60. I don't qualify for a subsidy but we are scraping together the premiums until I become Medicare eligible in a couple of years. i am very grateful to be able to purchase health insurance even though it is our single largest expense.

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    1. Betty is still 2 years away from Medicare. Her current carrier is pulling out of Arizona next year leaving her with only a few choices in the open market. We won't qualify for subsidies either so I can only image what our costs will be in 2017.

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