Whats next for healthcare

Okay, time to start writing about healthcare policy again.

My first thought is that anyone who can get on Exchange, get on Exchange. The best case scenario of a repeal and replace action is dropping the tax based individual mandate and going to the far more coercive and expensive continuous coverage quasi-mandate. Continual coverage means that as long as an individual does not have a gap of insurance coverage, insurers can’t medically underwrite that individual to either higher premiums or deny pre-existing conditions for a year or more or not write a policy at all. So if you can afford to and even if you really can’t, start building a history of continual coverage.

Next I’m just going to grab a couple of tweets from some very good wonks:

The most important short term impact of this op-ed, assuming it is a policy position is that the poor-shaming Medicaid waivers that tie Medicaid to work requirements will go through in thirty three seconds or less.

Cost control is out the door. So insurers and more notably, providers will be snorting the finest coke off the tight asses of the best hookers again. This is more on the provider side instead of the insurer side. The hard work to get healthcare costs to grow only slightly faster than the economy will be junked.


Any Republican plan will include throwing more tax advantages at HSA’s (which are great for people who are truly insuring against hit by the meteor events AND have money) and telling everyone else to pay more for their own care, so the final wonk is right on:



55 replies
  1. 1
    gogol's wife says:

    Thank you for being a good person who’s trying to help other people.

    The next time I meet a Trump supporter, or even just a “I just don’t like Hillary” person, I’m going to point-blank ask them: “Why is it so important to you to take health insurance away from millions of people?”

  2. 2
    Baud says:

    My plan is to not get sick.

  3. 3
    rikyrah says:

    So much upsets me about the election, Mayhew. But, I know that they are going to kill people. People will die because of their actions. People will die. 😭😭😭😭

  4. 4
    WereBear says:

    @gogol’s wife: Good plan.

    BTW, Richard, myself and a few volunteers are planning the CouldHappentoYou project, a “virtual AIDS quilt” where people share how they are in danger now from lack of medical care. Your articles, heavily simplified, will give me plenty of material. Thanks!

  5. 5
    TK says:

    @gogol’s wife: They’ll just give you some b.s. rant about socialism and their individual liberty to die of treatable illness if they want to.

  6. 6
    Baud says:

    @gogol’s wife: Tell them to ask Trump to help them out with their healthcare needs. He’s a rich and successful businessman, right?

  7. 7
    JPL says:

    I assume that they will repeal the bill on day one, to be effective 2018. That way they can buy some time.
    Let’s remember that Obamacare bankrupted Medicare. Every senior that you know, let them know it’s a lie.

  8. 8
    jayackroyd says:

    In the tiny minority here who thinks that the party that brought us unfunded Medicare part D will discover that medicaid expansion is a state issue, and that governors don’t find free money nearly so repugnant once renamed FreedomCare. Ala KYNect. I’d even not be surprised if they raise the medicaid ceiling. Trump’s base is expecting improvement.

    The “stakeholders” don’t want to see utilization driven down. Ryan lives in a bizarre fantasy world where he devises really bad, really unpopular public policy.

  9. 9
    beth says:

    I have a spouse with cancer and his COBRA coverage ending next spring. I’m quite terrified about what happens next. I’ve had to go to part time work status so no work insurance for me. My state only has one private insurance option which is going from $600 to $900 per month in Jan if I stay with a silver plan. I just feel shattered by this election. At least before I had some hope of maybe keeping some money for retirement.

  10. 10
    Matt McIrvin says:

    @rikyrah: People have already died: the assumption that the ACA is going away has caused multiple suicides.

  11. 11
    debbie says:


    Such was my hope back in 1995 when I lost my job. Didn’t work out. Hopefully, your experience will be different.

  12. 12
    debbie says:


    At the very least, he could tell them how to write off the costs.

  13. 13
    D58826 says:

    @rikyrah: But since those people are the OTHER and voted d, its a feature not a bug.

  14. 14
    TK says:

    @jayackroyd: That’s a damn good point RE: utilization rates.

  15. 15

    @Baud: You could also die quickly. I’ve heard that recommended.

  16. 16
    Weaselone says:

    @rikyrah: I wouldn’t worry. Unless it’s somebody you know you will have to go out of your way to find out about all the deaths. It’s not as though the media will give it much press.///

  17. 17
    JMG says:

    @Weaselone: Don’t be so sure about that. As a former media member, I can tell you that TV in particular loves to show someone suffering on camera so the shut-ins who watch can say, “how awful.” But they won’t go find those stories, they will have to be brought to them. Otherwise, it’ll just be the usual fires and fatal automobile accidents.

  18. 18
    Percysowner says:

    I know it’s a narrower issue, but any woman who does not want to get pregnant in the next 3-10 years should get herself an IUD or long term birth control now, because I’m reasonably sure that mandated coverage of BC will be out the window. My kids just got married and will be thinking about having a kid sooner than 3 years, so I’m putting away money to get them to a clinic after they have a child so they have the money to keep choice in their future.

    Thsi may not be your area, but what are the chances that Pence’s lovely idea that any BC that men don’t control i.e. barrier methods, (maybe the diaphragm will pass muster, although I’m not holding my breath) are really abortion will get passed into law? I’ve read one article that reassures me somewhat, but I’d like another opinion.

  19. 19
    jayackroyd says:

    @TK: The whole idea of Medicare privatization is cost control through decreased utilization by increasing out of pocket costs. I say this is Ryan’s bizarre fantasy world because prevention is often better than delayed treatment in cost terms.

  20. 20
    jayackroyd says:

    @Percysowner: Heckuva point.

  21. 21
    Baud says:

    @Iowa Old Lady: Dying might hurt my campaign. Or help. I can see either scenario.

    @Percysowner: I say low chances. I don’t think they are there yet politically.

  22. 22
    Baud says:


    prevention is often better than delayed treatment in cost terms.

    But not better than denied treatment.

  23. 23
    BillinGlendaleCA says:

    @Baud: …and if you do, die quickly.

    @Iowa Old Lady: Darn you to heck for beating me to it.

  24. 24

    @jayackroyd: yep, but lower utilization in year 1 with a cost explosion in year 10 is outside the budget framework plus suffering is a way to get closer to god (let me tell you about my aunt’s funeral after she died from multi-core organ cancer, the priest went on how she served the ministry of suffering to be a good example for all of us who did not have to suffer… he could go fuck himself)

  25. 25
    Peale says:

    “Medicaid to work requirements”

    Question…how does that work? Does that mean if you have a very poor paying steady job you’re eligible, but if you are temporary or get laid off you lose Medicaid?

  26. 26

    @Peale: The Kentucky 1115 waiver said that anyone who qualified for Expansion had to either be working, volunteer for state approved activities or take part in job training requirements to qualify for Medicaid expansion.

  27. 27
    JPL says:

    @Peale: It is also difficult to work, if you have a debilitating decease.

  28. 28
    WereBear says:

    @Percysowner: Pence’s lovely idea that any BC that men don’t control i.e. barrier methods, (maybe the diaphragm will pass muster, although I’m not holding my breath) are really abortion will get passed into law?

    Jeezum Crow, they aren’t even trying to fake it any more, are they?

  29. 29
    Peej01 says:

    How are they going to enforce Medicaid work requirements for those in nursing homes, considering that they are a huge chunk of Medicaid costs?

  30. 30
    gvg says:

    I have been having gloomy dreams where the people dying, not just from the healthcare cuts, but welfare cuts crawl into Congressional offices and the steps of the Whitehouse to die publicly blaming those unchristian hypocrites. The welfare and food stamp workers will also probably have staffing cuts…I think they should hand out to the people they have to say your benefits ended or are denied and these are the people who voted for it….list with addresses, especially local addresses. Of course that might also be considered a threat if the person is angry enough so they have to be careful.
    The economic disaster caused by a group of childish minds being in control may be harder for the general public to see the blame although it shouldn’t be. It’s not just that Trump is an idiot, the last few years have shown that ALL republican officials are really pig ignorant and don’t allow themselves to know it. We wouldn’t have that problem if the general public wasn’t also clueless. I am not exactly expert myself, just a few college courses, but enough to know really stupid when I here it. Of course during those courses, especially macroeconomics I noticed how hard people fought about accepting the observed facts. You can argue about why, but you can’t argue what has already happened and documented..an economy is not like a business. Also a lot of businesses are run surprisingly badly anyway.

  31. 31
    bemused says:


    Scrooge Prince Ryan who would not even say Trump’s name before the election if he could avoid it was suddenly chipper and beaming at his presser right after. Then seeing the two of them sitting together, I swear Ryan was about to jump in Trump’s lap and nuzzle him.

  32. 32
    ArchTeryx says:

    @gvg: It won’t help. There was a case not long ago of someone who, Arab Spring style, set themselves on fire on the steps of Congress. The local news didn’t even bother to cover it. We’re just disappeared down the memory hole here.

  33. 33
    ArchTeryx says:

    @Peale: Rather like with SNAP, it’s just a stealth way to throw off as many people as possible. If you work, you make too much to get it. If you don’t work, you violate the work requirements, and don’t get it anyway.

  34. 34
    Weaselone says:

    @JMG: that’s what I meant. The media is unlikely to cover it outside the occasional special interest story, and unlike emails they’ll get bored with those stories quickly.

  35. 35
    Barbara says:

    Richard, I consider you to be one of my safe spaces for information and I look forward to reading your updates and analysis. And, if I may be so bold, that’s saying something, coming from me, who is an expert on many of these programs. Ryan’s effort to tie Medicare instability to Obamacare is of course 100% fraudulent, but he doesn’t care. However, he has a devil’s dilemma in front of him: Say he will privatize Medicare for people over the age of 50 and the tremors will be felt all the way back in his own district, not to mention in Florida, Arizona, Maine, Pennsylvania and West Virginia — the states with the oldest populations in the country. Say that it will wait for people who are under 50 means that people under 50 might be mightily pissed off to be forking over 3% of their wages just so other people can get benefits they never will. That includes people who are between 35 and 50 and have been paying in for more than 10 years, maybe even more than 20. That’s why the notion that his plan will not hurt current beneficiaries and people over 50 is ridiculous. You just can’t impose such a massively transparent inequity on that many people. Medicare has long term sustainability problems that are tied almost exclusively to the ridiculously high cost of health care in the U.S., on a per unit basis and on an absolute consumption basis. We consume more of it and we pay more for every item we consume. Vouchers get at none of that. I really think that deep down, Ryan is simply bamboozled by the complexity of it all. Also, anyone in Maine, now would be a good time to start writing and emailing Susan Collins (who has been hiding under her desk since at least late June) on a daily basis for her views on the privatization of Medicare. Same for Shelley Moore Capito in West Virginia, Pat Toomey in Pennsylvania, Rob Portman in Ohio, Marco Rubio in Florida and the Arizona senators, one of whom is up for reelection in 2018. These are places where Medicare is not just the lifeline of seniors it is the lifeline of the health care sector and local economies. Even in a reconciliation scenario, they need 50. We need 3 defections.

  36. 36
    Barbara says:

    @Peej01: They always exempt the LTC crowd. The proportion of state Medicaid expenses tied to nursing home inhabitants varies a lot by state. Certainly, in nearly every state Medicaid expenses go disproportionately to support such people, but there are relatively fewer of them in every state, and in some states like Louisiana, the proportion of non-LTC to LTC is really high. You can look at KFF (dot) org if you really want to find information on subjects like this. It’s easy to get educated. There are a lot of resources out there, and this is one of my most trusted sources.

  37. 37
    rikyrah says:


    Thsi may not be your area, but what are the chances that Pence’s lovely idea that any BC that men don’t control i.e. barrier methods, (maybe the diaphragm will pass muster, although I’m not holding my breath) are really abortion will get passed into law? I’ve read one article that reassures me somewhat, but I’d like another opinion.

    This is the other side that has caused me to lose sleep: what is going to happen to vulnerable women. Their lives are at risk too.

  38. 38
    Jumbo76 says:


    My dad said this to me a few years back. I’m a type 1 diabetic, and I said, that’s fine for you, but what about me? He’s currently on Medicare and needs both his knees replaced. He voted for Trump.

  39. 39
    MomSense says:


    It’s also difficult to volunteer in rural areas because the money you spend putting gas in your vehicle to get there is money you don’t have for food, water, electricity, heating, and other basics.

  40. 40
    dr. bloor says:

    Cost control is out the door. So insurers and more notably, providers will be snorting the finest coke off the tight asses of the best hookers again. This is more on the provider side instead of the insurer side. The hard work to get healthcare costs to grow only slightly faster than the economy will be junked.

    The “Broad Brush” approach is an excellent way to get progressive providers on board precisely when we’re most needed. Well done, Richard, very well done indeed.

  41. 41

    Is he on Medicare Advantage or traditional Medicare? Medicare Advantage could see interferon placed on a worse cost sharing tier but since he is 65+, he is mostly safe.

  42. 42
    Tokyokie says:

    I propose everybody use a variation of this phrasing in regard to every supporter of the GOP:

    Alice Walton wants more money.
    So your grandmother has to die.

  43. 43
    Juice Box says:

    I was trying to put off knee replacement for a few years, but I think that maybe I need to get the replacement sooner rather than taking a chance on later.

  44. 44

    @Baud: but if you do, be sure to follow the republican plan and die quickly – drawn out pain and suffering is a bitch

  45. 45
    Elaine Benis says:

    Thank you for this info. I’m 55, retired and my COBRA from my last job ends late spring. I was counting on Obamacare. I also live part of the year in Mexico where I can get great medical/dental care locally for very, very reasonable prices. Lots to mull over.

  46. 46

    @Elaine Benis: If you speak the language and have a steady income, Mexico is beautiful

  47. 47
    Elaine Benis says:

    @Richard Mayhew: Yes it is. I fall in love with this lovely country & it’s people more and more each day. And as a bonus, the vast majority of the other expats here are like-minded liberals too. :-)

    As for Spanish, I’m far from fluent (but improving) but many Mexicans have some English or someone more fluent will step in to translate, etc etc. Really not a huge barrier.

  48. 48
    Ohio Mom says:

    Something I did not understand until I had a kid on the autism spectrum is that Medicaid, along with SSI, is what adults with disability depend on for living expenses. Medicaid for our folks isn’t just health coverage, it’s where the funding for things like group homes, job coaches, day programs, transportation, etc. comes from.

    I don’t know a lot about the details yet because my kid still is a teen, and I am just beginning to learn how to navigate these systems, and they are very arcane and byzantine. But I am very concerned about what happens if SS and Medicaid change shape significantly, up to and including being privatized.

  49. 49

    @Ohio Mom: Odds are that Legacy Medicaid won’t change much initially under any plan… the danger is that if Medicaid is block granted like TANF was in 1996, then there will be an insufficient inflation adjustment so covered lives in 2032 goes down dramatically as inflation ate 30% of the purchasing power of the nominal dollar allocated.

    Or we get hit with a massive recession with millions out of work and state Medicaid budgets are raided to cover other revenue short falls even as demand goes up dramatically.

  50. 50
    EBT says:

    @Ohio Mom: Remember that SSI comes from the general treasure, not the SSA, so it has all the stability of tissue paper right now.

  51. 51
    James the Sad says:

    My husband and I are in Florida and both our insurers have left the exchange: United Healthcare and Coventry. We are looking at $400 – $500 more a month in premiums. Don’t know where that $ will come from.
    Might end up uninsured.

  52. 52
    Sasha says:

    Question for you Richard.

    Although I’m a beneficiary of the ACA (wouldn’t be able to afford insurance without it), I’ve a friend who’s an Obamacare loser: He lives in Florida, makes over $60K (doesn’t qualify for subsidies), and the premium for him and his little girl have increased dramatically. Any suggestions to help his sitch?

    His BCBS ppo went from $800/yr to $1200+ per month. Moved to Humana, but still pays over $10K year.

    Any suggestions are appreciated. Thanx!

  53. 53
    Sasha says:

    Also, he’s self-employed as a photographer.

  54. 54
    LongHairedWeirdo says:

    @gogol’s wife: You need to learn to frame a bit better.

    “I couldn’t have voted for anyone but Hillary; so many millions of people are going to lose health insurance; thousands will die each year.” (Be ready with followup: the deaths aren’t going to be from big events because ERs will treat those – “no, they’ll die from the small manageable things like diabetes, high blood pressure, and stuff like that. Sure, the heart attack or stroke still gets the best treatment in the world – but that doesn’t help for long without expert follow-up care, and the ER doesn’t provide that. And besides – a lot of those people will be scared to go to the ER and hope it’s a migraine or indigestion, until it’s too late. The ER has to treat them, but it can still send them a bill for 20-30 grand – or more!”

    That is: don’t say “You are an asshole”. Say “Oh, I’m a good person, so I couldn’t do that.” No apologies, no “but I’m sure you had a good reason” (especially not if said sarcastically!), just “Oh, I had to vote for Hillary; she was going to save thousands of lives, and now they’re going to die.”

    “But Trump will bring back jobs”?
    “Hah! The party of layoffs and offshoring bringing back jobs? No. They’ll just talk a good show, to keep snowing the media… and the rubes, of course.”

    (Note: you didn’t call that person a rube! In fact, there are no real rubes. The rubes are always someone else. “I’m sure *YOU* are smart enough to realize that the GOParty of layoffs had no intention of helping create jobs… but think of those poor people who are being lied to!”)

  55. 55
    LongHairedWeirdo says:

    @Elaine Benis:

    I sympathize. I’m a database guy; I’m part of the cream of the SQL Server crop. I wanted to work Microsoft SQL Server support so bad I could taste it – the best set of the broadest *and* deepest problems to improve my skills.

    I could end up doing that (as a contractor) only because of Obamacare. My contracting firm had the worst health insurance ever – a 60/40 split, with a yearly and lifetime limit so low that I was horrified.

    So I bought on the exchange, and got a fine policy for a fine price from a fine company. Then, at the next available opportunity, I bought straight from the company – the WA exchanges were a quasi-government agency, accountable to no one, and with all the administrative incompetence you’d expect from such a thing. (Some of the people were good, and sharp – but oh, dear lord, I think *I* could have run the organization better, and I’m a hard-core “individual contributor”.

    I’d also thought of going indy – becoming a consultant. But now, that dream is dashed. I have chronic fatigue. Did you know that can present as a heart condition? So I’ve got this battery of heart-health tests showing I’m fine – but I’ll guarantee you if my old pre-existing issues didn’t make me a “never sell to this guy”, that would have clinched it.

    And repeat after me: “All the GOParty of incompetence had to do was denounce a serial sexual assailant, with no governmental, legislative, legal, military, or foreign policy experience, a man who violates their “social conservative” mores completely, who cried out against free trade, the GOP’s favorite issue… all they had to do was say, we messed up on him – vote for her.”

    And they didn’t. They put the nation at risk.

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