48

So I'm having this argument. I see people on the news testify that if Obamacare is repealed, then they won't be able to pay for their preexisting condition and will die.

However, the opponents argue that Medicaid will foot the bill and treatment is never denied, even in the days before Obamacare.

Which is true? Does Obamacare cover more than Medicaid? It's hard to find sources on this because I feel like every article somehow dodges this question.

EDIT: Hey guys, the answers here are all insightful. Don't forget to play nice. I'm assuming we all have similar moral compasses on what is right and what is wrong. None of us believe that people deserve to die because of health issues or poverty, but it can be easy to misconstrue each other when we talk about differing plans. Regarding the original question, some stats in the answers provided have shown that there is a gap left open by Medicaid, something I didn't know existed.

Script Kitty
  • 843
  • 6
  • 15

5 Answers5

59

In a nutshell, the income threshold necessary to qualify for Medicaid (the poverty line prior to Medicaid expansion) is lower than the amount of income needed to pay for the medical care that Medicaid provides to people who are eligible for it.

For example, if you need dialysis to stay healthy (which is not ER room care), it costs more than $70,000 per year. And, if you need this care and don't get this care, you die in a matter of weeks or months.

This is one example and actually not a great one in terms of health care access because there is actually a special end stage renal disease program in Medicare that covers this particular treatment if you are uninsured. But, there are many conditions that have the same cost/risk profile as end stage renal disease, in that they require long term, regular, expensive care to avoid a dramatic shortening of your life, for which there is no special coverage. For example, there is no counterpart to Medicare if you have ALS or advanced stage MS.

If you do not qualify for Medicaid and do not have health insurance at the time you need health care, possibly because you cannot afford health insurance at the market rate, which is on average $16,351 per year for a family of four, then the only health care you can insist on having provided to you is ER care necessary to stabilize your condition pursuant to EMTALA (the Emergency Medical Treatment and Labor Act). And, many people who do not qualify for Medicaid at the poverty line cutoff level cannot afford to buy market rate health insurance.

But, care that stabilizes your condition from an ER is not sufficient to keep people alive. Therefore, some people who lose Medicaid will die from lack of access to health care.

Basically, pre-ACA, if you are at risk of dying for lack of medical care, you have to quit any job that pays you above the poverty line even if you could earn more but not enough to pay for health insurance. Lots of working class people with serious health problems did this prior to the ACA.

Moreover, a study looking at medical records for 30,000 people as a random sample compared death rates before and after Medicaid expansion (to 138% of the poverty line) and expanded private health insurance covers under the ACA due to mandates and credits (which apply up to 400% of the poverty line), and demonstrated statistically that 50,000 lives were saved by the ACA over a three year time period. The Washington Post, which reviewed the data found that this was an underestimate and that 87,000 deaths avoided was a more accurate figure. In addition, $12 million of costs were saved and about 1.3 million people who would have been harmed from lack of medical care without dying avoided that harm.

Presumably, death rates would rise again if it was contracted and there were more uninsured individuals.

About two-thirds of the lives saved involved death arising from sepsis associated with pressure ulcers and adverse drug events according to the Washington Post account.

For a family of four in 2016 the relevant ACA income cutoffs were as follows:

100% of poverty line: $24,300

138% of poverty line: $33,534

400% of poverty line: $97,200

(tax credits can be applied in advance rather than when a return is filed if your income is $60,750 or more which is 250% of the poverty line).

This was causally related to the fact that:

As of the end of 2015, the number of uninsured nonelderly Americans stood at 28.5 million, a decrease of nearly 13 million since 2013.

Note that this data implies that roughly 1 life is saved per year per 1000 additional people with health insurance.

ohwilleke
  • 79,130
  • 11
  • 224
  • 303
  • 1
    So couldn't we expand medicaid instead of using obamacare? I know Obamacare is just insurance, but the end result is the same and the cost of administering treatment is the same, so even bother with Obamacare? – Script Kitty Mar 02 '17 at 01:24
  • 8
    We could enact Medicaid for all, or Medicaid up to 400% of the poverty line, or would could enact Medicare for all. The ACA chose to subsidize private health insurance between 138% and 400% of the poverty line in lieu of doing that, but there are multiple approaches that could have worked. – ohwilleke Mar 02 '17 at 01:26
  • This is a good post. I can't think of any benefits there are to making health insurance more accessible instead of just health care. It would probably just be better to expand medicaid then IMO – Script Kitty Mar 02 '17 at 01:50
  • 10
    Expanding Medicaid very much isn't really viable, however, because it relies on paying providers far below market rates for services rendered (much less than the VA or Medicare or private insurance pay), and assumes that providers subsidize their Medicaid losses with profits from other kinds of care. Therefore, many providers don't take Medicaid and there are long waiting periods. Medicaid would be 50% more expensive if it paid market rates. http://kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D – ohwilleke Mar 02 '17 at 02:02
  • 26
    @ScriptKitty the cost of adninstering the treatment is largely irrelevant in the USA, because the Healthcare Industry is what its name says: it's a profit-making industry (and it includes the health insurance companies). But unless somebody can figure out how to persuade turkeys to vote for Thanksgiving, there isn't much chance of dismantling that industry and turning it into a public service, which is the way universal health care is run in other countries where it is funded (much more cheaply) from general taxation. – alephzero Mar 02 '17 at 04:31
  • 5
    ... and of course a Healthcare Industry looks for the most profitable conditions to treat, even if it has to invent them. Convince me that the basic reason why "more than 20% of US children suffer at some stage from a debilitating mental illness or disorder" (https://www.nimh.nih.gov/health/statistics/prevalence/any-disorder-among-children.shtml) isn't simply that parents are a soft touch for paying any amount of money you want to ask for, if they think something is "wrong" with their kids and you can fix it! – alephzero Mar 02 '17 at 04:38
  • 5
    @ScriptKitty 'expanding medicaid' is essentially the 'single payer' model. We could have done that but we didn't for a variety of reasons. There was a 'public option' along those lines in the original ACA proposal, however. (It was removed.). –  Mar 02 '17 at 04:42
  • 6
    @alephzero there's lots of reasons, and I'm not about to convince you, however, one of the reasons is that we have a much better understanding of mental health year after year. We're still a long way from fully understanding the brain but compared to even 40 years go, we know so much more. –  Mar 02 '17 at 04:44
  • 2
    @blip You’re absolutely right that we understand more, and some portion of the increased diagnosis of these issues is due to increased understanding and awareness, but we’d be fools not to suspect that at least some other portion of that increase is due to the predatory practices of a near-fraudulent industry. – KRyan Mar 02 '17 at 15:35
  • @KRyan we agree on that point! There's definitely motivations from the for-profit industries involved. –  Mar 02 '17 at 16:20
  • 2
    @alphazero While health insurance company profits, marketing and gate-keeping costs do add to the cost of health care, by far the main reason that U.S. pays more for healthcare than any other country is that providers of all sorts from nurses and doctors to hospitals to drug and device sellers are all paid much more (often twice as much) as those in other comparably affluent countries for the same services. A fragmented health insurance market and a ban on price control by Medicare largely drives this reality. – ohwilleke Mar 02 '17 at 16:20
  • @ohwilleke not entirely true: http://www.careeraddict.com/top-5-countries-with-the-highest-paid-salaries-for-doctors (regarding the salaries). –  Mar 02 '17 at 16:21
  • @blip There is no doubt that the U.S. overall pays much more to providers for fewer services from providers. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective and US pay to medical professionals is very high even in cases when it isn't the absolute highest. For example in this study U.S. GPs and nurses were the best paid in the world and specialists were third. http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1316&context=key_workplace – ohwilleke Mar 02 '17 at 16:37
  • @ohwilleke I agree we pay well, but the greater costs really have to do with the broader for-profit system. I'm just wary of jumping on the actual doctors as being the problem, as they really aren't. –  Mar 02 '17 at 16:55
  • @blip Pay for doctors and nurses is a real part of the problem. Pay for other providers is also part of the problem. Pay for providers generally is a bigger part of the problem in magnitude than profits and administrative costs at insurance companies, although that is also part of the problem. People are reluctant to focus on doctors for a variety of reasons, but the reality is that their unusually high pay, in part due to supply shortages because medical school capacity has not grown and in part due to market failure, is an important driver of higher medical costs in the U.S. – ohwilleke Mar 02 '17 at 17:24
  • @ohwilleke it's a matter of opinion, I suppose, but in terms of the total percentage, the actual doctor salaries are just a drop in the bucket. The hospital and incidental costs are so much higher (and, not surprisingly, seemingly so much more arbitrary from hospital to hospital). –  Mar 02 '17 at 17:27
  • @blip Doctors are 20% of the total directly and an additional percentage indirectly, the largest component of cost after hospitals (which includes some indirect physician costs). https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/downloads/highlights.pdf Other medical professionals and dentists included brings it to 27%. – ohwilleke Mar 02 '17 at 17:32
  • 1
    Let us continue this discussion in chat. –  Mar 02 '17 at 17:33
  • 1
    A tangent to this discussion (for me at least), is the following question: How does it make sense to have health insurance attached to who your employer is or isn't? I had a job with a small company (~20 people) where I was close to the owner, and saw him struggle to find something affordable to the company and half-decent for employees. After jumping ship to a large corporation, I've now got pretty dang good medical benefits. I'm same person, same family, same job duties, superior benefits. Doesn't make sense to me. – eflat Mar 03 '17 at 00:06
  • @eflat Strictly a matter of historical accident, worthy of a separate question. Employer provided health care basically dates to union driven concessions in the 1950s and relates back to Prussian ideas about the role of a manufacturing employer vis-a-vis employees. – ohwilleke Mar 03 '17 at 00:23
  • 2
    @ohwilleke Actually it started in the 1940s. There were wage controls in place during World War II, so employers tried to find other ways to entice people to come work for them. – David Mar 03 '17 at 14:06
  • " ... pre-ACA, if you are at risk of dying for lack of medical care, you have to quit any job that pays you above the poverty line ... lots of working class people with serious health problems did this prior to the ACA." I'd like to see a citation for this, especially because labor force participation has decreased significantly since 2008. – David Mar 03 '17 at 14:07
  • 1
    The linked study -- that purportedly shows that Obamacare saved 50,000+ lives -- says that improvements in hosptial safety / quality procedures are responsible for the decrease in deaths. This is a significant achievement, but I don't see how this relates to the ACA (and I didn't see that mentioned anywhere in the report). – David Mar 03 '17 at 14:16
  • 3
    @David it was a very common situation in the past decade or so. Those people working at Home Depot? They don't like that job. It doesn't pay well. But for a lot of contractors, it was the only way to get insurance. People have gotten divorce so that one spouse could qualify for medicaid. Having to depend entirely on employers for health insurance is a burden for the consumer and increasingly, a burden for the employer. –  Mar 03 '17 at 15:00
  • 1
    @blip I'd still like to see some hard data. I do agree that employer-provided insurance is a problem; however, this started as a way for employers to attract employees during WWII when wage controls were in place i.e. because of government regulation. – David Mar 03 '17 at 16:03
20

Obamacare, not unlike health care in general, is very complex. There's lots of key provisions that one could use in that set of arguments.

Just one of them is the pre-existing coverage clause. Prior to Obamacare, an insurance company could deny you coverage for any pre-existing condition. This could be as mundane as taking ADD medicine.

That means nearly anyone could be told "no, you don't get insurance". And if one is making an OK living, they don't necessarily qualify for Medicaid.

So that's one of the big problems we had that was fixed with Obamacare. People that just couldn't get insurance, were then able to get it.

As for "treatment is never denied" that typically refers mainly to emergency rooms and even that is hardly universally true. Regardless, what an ER covers is merely a fraction of what health care needs people have and if it comes down to having to go to the ER, odds are the condition is too far gone in many cases.

Community
  • 1
  • 1
    "Prior to Obamacare, an insurance company could deny you coverage for any pre-existing condition." This is simply not true, or at the very least hugely overstated. Insurance portability has been the law in the US since the mid-1990s; as long as you had prior coverage, you cannot be denied coverage for any pre-existing condition. And even if you didn't have prior coverage, the pre-existing condition exclusion only applies for a maximum of 18 months (IIRC). – David Mar 03 '17 at 13:47
  • 3
    @David it absolutely is true. I've lived through that. Many people have. You are confusing 'continuing coverage' and individual plans. Continuing coverage refers to group plans. –  Mar 03 '17 at 14:55
  • 1
    The phrase is "continuity of coverage". I did not realize that didn't apply to individual plans. However, those plans only constitute about 10% of the private marketplace, so I would still say this overstates the problem. (It was clearly still a problem -- but one that could have been resolved by amending HIPAA to include individual plans instead of introducing 15000 pages of new legislation.) – David Mar 03 '17 at 15:43
  • 3
    @david "only 10%" is a huge number of people. Also note that a lot of people don't have individual plans BECAUSE they can't get/afford them...therefore having to keep a crappy job just for the insurance. –  Mar 03 '17 at 16:40
  • I have to downvote. Making it easier to get insurance later may make people wait to get insurance. There is no evidence that the net result is lower mortality. In fact, the actual mortality numbers have increased since Obamacare passed. – Brythan May 03 '17 at 18:02
  • 1
    @Brythan that's exactly why there was the 'penalty' fee with Obamacare. The bill took that exact issue into consideration. As for mortality rates...I'm not literally answering a literal interpretation of the question title. I was answering the body of the question (which on second read, makes the title rather misleading). –  May 03 '17 at 19:57
9

However, the opponents argue that Medicaid will foot the bill and treatment is never denied, even in the days before Obamacare.

Emergency care is not denied. But if you wait until something becomes an emergency, there's a good chance that:

  1. It will cost an absurd amount of money to treat, and

  2. You may not survive despite the best care.

Here is a story about a 12 year old boy who died of an untreated cavity. The cavity was not an emergency, and so wouldn't be treated without coverage or payment, until the infection had spread to the point where even two surgeries and weeks of hospital care couldn't save his life.

While this example is, obviously, uncommon and extreme, the basic pattern is not uncommon. I know many doctors and nurses who complain about this pattern repeating at the places where they work.

It's particularly a problem with the homeless or mentally ill who are unable to pick up medications or do proper wound care -- though that may be almost impossible to fix until we can solve poverty and mental illness. But lack of insurance and lack of affordable care kills people and raises the cost of health care.

To what extent Obamacare solves the problem is, of course, a contentious issue. But to claim that there is no problem because you can't be denied emergency care is just wrong. Emergency care is not all there is to health care.

David Schwartz
  • 2,451
  • 12
  • 13
  • 2
    The 12-year old boy did have access to Medicaid. The fact that Medicaid doesn't work for a lot of people does not eliminate the fact that this death was not due to a "lack of coverage", as is frequently claimed. But +1 for "To what extent Obamacare solves the problem is, of course, a contentious issue". – David Mar 03 '17 at 13:56
  • @David had he had decent coverage, it would have never led to the emergency situation it led to. Whether or not Obamacare would have solved that specific case is of course debatable, but it's not debatable that Obamacare brought decent insurance coverage to tens of millions of people. –  Mar 03 '17 at 14:58
  • @blip It is eminently debatable. (1) We still have about 30 million uninsured, and the ACA enrollment numbers include at least 4.7 million parties whose prior plans were canceled because of ACA. (2) It's not clear to me that Obamacare plans are any more "decent" at least if you factor in the ever-increasing costs. – David Mar 03 '17 at 15:55
  • @blip You also seems to be assuming that people with "decent" coverage -- i.e. access to preventive care -- will take advantage of it. (Thereby decreasing overall cost.) That is a debatable proposition as well; that was in fact the premise behind HMO-style plans in the 1990s, and as we now know that did not help control costs. – David Mar 03 '17 at 15:58
  • 4
    @David The point is that if all you have is emergency care, you get terrible outcomes, so the argument that as long as people have emergency care there's no problem is nonsense. That's all I'm using that incident to show. – David Schwartz Mar 03 '17 at 18:43
0

How does Obamacare save lives?

It does not, by it's self save lives. The general argument is that, in the long run having health insurance will result in better heath care, and that the life expectancy and quality of "everyone" will increase.

I see people on the news testify that if Obamacare is repealed, then they won't be able to pay for their preexisting condition and will die.

In any large system there will be outliers, but in general this is overly dramatic. For people that are "poor enough" medicaid will provide care. It may not be the most awesome care ever, and in may cases that care may only cover the most cost effective options, but people on medicaid can see the same doctors that people without medicaid can. That said, people on medicaid are not entitled to (though medicaid) the same level of care that a millionaire would be able to afford.

There is however a gap between "poor enough" for medicaid to kick in and "rich enough" to afford any and all medical procedures. If you live in that gap then things become more interesting.

Health insurance is/was supposed to be a risk avoidance strategy. On a personal level your supposed to pay more in to it, then you get out of it. On a group level, your group is supposed to pay more in then the group takes out, allowing for more flexibility and cheaper coverage. On the national level the same is true. There should be more income then there is out go.

Where the real trick comes in is pre-existing conditions. Without pre existing conditions, it's historically cheaper to have no heath insurance and pay out of pocket for your normal medical expenses. Big expenses like surgery or long term care are a risk. You would generally try to avoid that risk with insurance.

However pre-existing conditions were generally not covered by insurances. If they were covered it was in a group plan, or the individual paid a higher premium.

But with all that said, these people testifying are mostly, more then 7 years old. They survived before the ACA so if we were to repeal the ACA they would likely survive again, though they may have to devote more of their assets to medical care.

However, the opponents argue that Medicaid will foot the bill and treatment is never denied, even in the days before Obamacare.

Again, there's no such thing as 100%. But even before the ACA emergency life sustaining medical expenses were not an issue. Every ER, hospital, and (I think even doctors office) was required to give life sustaining care. Now this may not amount to much more then stabilizing the patient. But, for example, a hospital could not discharge a patient if the likely result would be death.

Which is true? Does Obamacare cover more than Medicaid?

These things are not the same thing. Medicaid is, at it's core, a bunch of money to pay for medical expenses for people that can not afford medical care. "Obamacare" is, at it's core a statement that everyone should have insurance, and some tools to help people get that insurance.

For most people "Obamacare" did not reduce the cost of medical care. In fact, for most people it increased the cost. For people with long term medical issues the overall cost of medical care may have been reduced.

For example many people claim that they get their "Obamacare" for $100 a month. But what is really happening is that the other $300 a month is being deducted from their tax returns. If their tax return is less then $300 a month then they get no tax return, but the government (other tax payers) eats the difference.

In addition the cost of health care has "exploded" in recent years, in part due to the cost of administrating health insurance.

However heath insurance in general tends to cover more issues then medicaid in general. Rather that coverage is better or not is a matter of opinion.

coteyr
  • 1,896
  • 10
  • 18
  • Medicare is a non-need based federal program for people age 65+. Medicaid is a need based program co-administered with the states that requires less than poverty line income if not expanded. This post confuses the two. – ohwilleke Mar 02 '17 at 19:15
  • I alwayse get them confused editing. – coteyr Mar 02 '17 at 19:16
  • 3
    This is confusing a few concepts. Yes, ERs are (supposed) to not refuse service. "Life sustaining" care is a much broader and wider thing than just the ER room, though. –  Mar 02 '17 at 19:17
  • Also, the 'most people' statement...citation? It's probably true in particular semantics/context, but there's arguments just as valid the other way as well. Health Care overall went up in price, absolutely. But the reality is that millions were now able to afford it--which they could not do previously. –  Mar 02 '17 at 19:18
  • 1
    It's hard to find one source to cite them all but http://time.com/money/4503325/obama-health-care-costs-obamacare/ is pretty good. http://time.com/money/4209465/is-obamacare-working/ is a good point/counter point. "Even with help paying premiums, many moderate-income Americans are finding that their deductibles and copayments are so high they cannot afford to use their insurance." – coteyr Mar 02 '17 at 19:33
  • 7
    people on medicaid can see the same doctors that people without medicaid can This is not true. Many doctors will either refuse Medicaid, or refuse to take new patients who have Medicaid. – Beofett Mar 02 '17 at 20:01
  • 1
    @coteyr it's definitely a semantic issue, I suppose. I agree Obamacare didn't reduce overall health care costs in general. It did make having access to millions of people much more affordable. Whether it being 'more affordable' was still 'affordable' in practice is certainly debatable. –  Mar 02 '17 at 20:08
0

The US life expectancy changes since Obamacare was passed are not encouraging.

Determining causality in this sort of thing is difficult-to-impossible. It could be that there is an external factor that is depressing the life expectancy data; something unrelated to Obamacare. But it is certainly remarkable that in the wake of Obamacare, life expectancy in the US, which had been reliably increasing by 1-3 years per decade, slowed their increase, then actually fell for one year. The year 2015 is only 0.2 years ahead of 2010.

Raw data here.

William Jockusch
  • 3,959
  • 1
  • 12
  • 22
  • ..."there's a chance that the latest data, from 2015, could be just a one-time blip. In fact, a preliminary analysis from the first two quarters of 2016 suggests that may be the case" –  Dec 09 '17 at 03:34
  • True. It's also possible that the 2010-15 slow gains are unrelated, or a blip in the data with some other cause. We will never know. Hence the data are suggestive, not probative. – William Jockusch Dec 09 '17 at 12:21