Repeal or replace?

Diogenes said:
The Biden Administration, leveraging Democrat majorities in both chambers of Congress during 2021 and 2022, enacted and extended temporary enhancements to Affordable Care Act (ACA) premium subsidies that effectively masked the true extent of rising health insurance premiums for higher-income enrollees.

Under the original ACA framework, premium tax credits were available only to households earning between 100% and 400% of the federal poverty level (FPL)—roughly up to $54,000 for an individual or $111,000 for a family of four in 2021.

Households above that threshold faced the full brunt of escalating premiums, which had been climbing due to factors like increasing medical costs, hospital prices, and insurer risk adjustments.

However, the American Rescue Plan Act (ARPA), signed by President Biden in March 2021, eliminated this income cap entirely while also boosting subsidy amounts across all eligible levels, capping out-of-pocket contributions at no more than 8.5% of income for benchmark plans.

This change, passed via reconciliation on a party-line vote with Democrats holding a slim House majority and a 50-50 Senate (broken by Vice President Harris), made subsidies available to anyone whose premiums exceeded that income threshold, including high earners previously ineligible.

For higher-income ACA enrollees—those above 400% FPL, often professionals or small business owners paying full price pre-2021—the ARPA created the illusion of affordability.

Premiums for marketplace plans rose an average of 4-7% annually during this period, driven by broader healthcare inflation, but the new subsidies absorbed nearly all increases.

For instance, a 60-year-old couple earning $85,000 (just over 400% FPL) might have seen their unsubsidized benchmark plan premium jump from around $1,200 monthly in 2020 to $1,400 by 2022, yet their post-subsidy cost dropped to under $600 monthly—or effectively zero for many plans—thanks to federal credits covering 60-80% of the bill.

The administration's messaging amplified this, with Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) touting that "four out of five enrollees" could find plans for $10 or less per month, a statistic that held true only because of the hidden taxpayer-funded backstop.

Critics, including Republican lawmakers and policy analysts from groups like the Paragon Health Institute, argued this shifted the burden onto federal spending—ballooning from $34 billion in 2021 to over $100 billion by 2024—without addressing underlying cost drivers like drug prices or provider consolidation.

The temporary nature of ARPA's subsidies (set to expire after 2022) was downplayed in public outreach, with Biden's team framing them as pandemic relief rather than a structural fix, allowing enrollees to perceive stable or falling costs amid actual premium hikes.

In 2022, with Democrats retaining their congressional edge (a narrow House majority and 51-49 Senate after the Georgia runoffs), the Inflation Reduction Act (IRA)—another reconciliation bill signed in August—extended these enhancements through 2025 without Republican input.

This bought three more years of subsidy insulation, further obscuring premium growth for high earners.

By then, enrollment had doubled to over 16 million, with about 20% of new enrollees being higher-income households drawn in by the "no cliff" policy.

Yet, insurers baked in expectations of continued federal support when filing rates, leading to a feedback loop: subsidies encouraged higher list prices, which in turn justified larger credits.

For a family of four earning $130,000 (above 400% FPL), a 2022 benchmark premium might have risen 5% to $1,500 monthly due to factors like GLP-1 drug costs and post-pandemic utilization, but IRA subsidies reduced their share to around $900—less than under pre-ARPA rules—while the government footed the rest.

The administration's CMS fact sheets and enrollment ads focused on "record-low premiums" and "savings for millions," rarely disclosing that these were propped up by $64 billion in additional spending or that expiration loomed in 2025, potentially exposing enrollees to 75-114% average increases.

This approach hid costs from higher-income enrollees by design: the subsidy formula automatically adjusted to absorb rises, preventing "sticker shock" at checkout on HealthCare.gov, while public narratives emphasized accessibility over fiscal trade-offs.

Substantiation comes from nonpartisan analyses like those from the Kaiser Family Foundation (KFF), which show that without these enhancements, high earners would have paid full freight on premiums up 20-30% cumulatively from 2021-2022 due to market dynamics.

The Congressional Budget Office estimated the extensions added $383 billion to deficits over a decade, disproportionately benefiting middle-to-upper-middle-income groups (e.g., 1.5 million enrollees above 400% FPL by 2024) at taxpayer expense.

By structuring the policies as short-term and bundling them into massive reconciliation packages amid economic recovery, the Biden team avoided standalone debates on the long-term price suppression, leaving enrollees unaware that their "affordable" plans relied on a temporary veil over systemic cost pressures.

As a result, when open enrollment previews for 2026 emerged in late 2025—post-expiration—many faced projected doubles in out-of-pocket costs, revealing the hidden escalation only after the Democrat window closed.


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Yeap


NANCY NEVER BROUGHT SHIT TO A VOTE SHE DIDNT ALREADY HAVE THE VOTES FOR


NO SILLY GAMES
 
Now, back to the topic of the thread, @Life is Golden.

The introduction and expansion of health insurance—starting with Blue Cross/Blue Shield plans in the 1930s, accelerating with employer-sponsored coverage during World War II wage controls, and culminating in Medicare and Medicaid in 1965—dramatically increased demand for medical services. More patients could afford care, leading to higher volumes of visits, procedures, and hospitalizations.

  • Early insurance models (especially nonprofit Blues plans) negotiated discounted fee schedules with physicians to keep premiums affordable. By the 1950s–1960s, "usual, customary, and reasonable" (UCR) reimbursement caps limited what doctors could charge insured patients, even as uninsured cash-pay rates remained higher. Medicare's adoption of UCR in 1965, followed by periodic fee freezes and relative value scale reforms (e.g., the 1989 Resource-Based Relative Value Scale), further constrained growth.
  • Supply-side expansion: Insurance-driven demand spurred a rapid increase in the number of physicians. U.S. medical school graduates doubled from ~7,000 per year in 1965 to over 15,000 by 1980, fueled by federal capitation grants under the 1963 Health Professions Educational Assistance Act. This oversupply competed away potential income gains, especially in urban areas.
  • Administrative and practice costs: Insurance introduced billing overhead, prior authorizations, and paperwork that eroded net income. By the 1970s, physicians spent increasing time on non-clinical tasks, with malpractice insurance premiums also rising sharply after liability crises (e.g., mid-1970s and mid-1980s).
Real-world data bears this out:
  • In constant dollars, average physician net income grew modestly from ~$150,000 (2023-adjusted) in the early 1960s to a peak of ~$250,000 by the late 1980s—far from "vast" relative to the tripling of insured Americans (from ~50% in 1950 to >80% by 1970).
  • Post-1990s managed care (HMOs, capitation) and Medicare payment reforms caused real income stagnation or declines for many specialties until the mid-2000s.
In short, while insurance expanded the patient base, institutional price controls, competitive supply growth, and rising overhead ensured physician incomes improved only incrementally—not commensurately with the public's embrace of coverage. The primary beneficiaries were hospitals and insurers, not doctors.


 
evince said:
My name is not desh
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It's not "Evince", either.


This you, Desh?

evince said:
they come from my very first name on the internets.

My very first name was deshrubinator.

I coined it in late 2002.

I saw the lies streaming out of the Bush admin to march us to war and had to talk to people abut them.

thus I entered the internets
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evince said:
I thought I would clear it up for the newbies who didnt know me back then.

That is why you will see people here call me Desh.

once shrub was gone I needed a new name.

if I recall I spelled it wrong.

I cant remember what the misspell was, I bet someone can.
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Foy anyone still trying to discuss the thread topic:

Medicare, enacted in 1965 and implemented in 1966, had a modest short-term positive effect on physician incomes, followed by long-term stagnation and relative decline in real purchasing power.

It did not produce sustained, substantial income gains despite massively expanding access to care.

1. Initial Boost (1966–1971)Medicare immediately insured approximately 19 million elderly individuals, many of whom previously could not afford care. Hospital and physician visits by seniors rose 30–50% in the first few years.

The program adopted "usual, customary, and reasonable" (UCR) fees, allowing doctors to charge their prevailing rates—often higher than Blue Cross discounts—with no effective cost controls initially. As a result, real net physician income rose about 20–25% from 1965 to 1971 (AMA data, CPI-adjusted).

Specialists, particularly surgeons and radiologists, benefited most from the surge in hospital-based procedures.

2. Cost Controls and Stagnation (1972–1980s)

Nixon’s Economic Stabilization Program (1971–1974) froze physician fees under Medicare, halting income growth.

Professional Standards Review Organizations (PSROs), introduced in 1972, added utilization review and increased administrative burden. The Medicare Economic Index (MEI), implemented in 1973, capped annual fee increases to inflation in practice costs—typically 2–4% per year—systematically undercompensating for rising malpractice premiums and overhead.

Consequently, real physician income flatlined from 1973 to 1985; in constant dollars, average net income in 1985 was lower than in 1971.3.

RBRVS and Managed Care Era (1989–2000s)

The Resource-Based Relative Value Scale (RBRVS), implemented in 1992, replaced UCR with a formula that favored primary care over procedures. High-earning specialists such as cardiologists and orthopedists saw real income cuts of 10–30%. Medicare Fee Schedule updates repeatedly reduced conversion factor increases below the MEI, and from 2002 to 2014, fees were effectively frozen or cut under the Sustainable Growth Rate (SGR) formula. Private insurers adopted Medicare’s RBRVS and utilization controls, compressing fees across all payers.4. Long-Term Outcome
  • 1965: Real net physician income approximately $180,000 (2023 dollars) — pre-Medicare baseline.
  • 1971: Approximately $230,000 — peak post-implementation.
  • 1985: Approximately $210,000 — impacted by fee controls and MEI.
  • 1995: Approximately $220,000 — affected by RBRVS cuts.
  • 2010: Approximately $240,000 — prolonged stagnation.
Despite Medicare patients growing from 19 million to over 60 million by 2020, physician income grew far slower than GDP, total healthcare spending, or hospital and insurer revenues. Primary care gained modestly from RBRVS, while procedural specialists lost ground.

Medicare’s documentation, coding, and prior authorization rules increased overhead by 15–20% of revenue.

Conclusion

Medicare expanded patient volume but institutionalized price controls that prevented commensurate income growth. Physicians traded higher workloads for lower per-service payments and rising bureaucracy. The program enriched hospitals (through DRGs with built-in margins) and insurers, but left physician real income stagnant for decades.



 
Tbird19482 said:
And all those MAGAS in states like GA, FLA, AL, SC, TX and many others let them go hungry, die from lack of healthcare , and maybe even go bankrupt.
Fact is these states depend on all the federal programs that will be cut because of the BBB the most and when those programs are gone it will hurt them big time.
But who care they voted for it and got what they wanted so let them suffer.
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*yawn* This same old lie again.

MAGA isn't a person or a State.
Most federal government welfare goes to California, Illinois, and New York.
 
Medicaid, enacted alongside Medicare in 1965 and implemented in 1966, had a limited and uneven impact on physician incomes—positive for a small subset of providers, negligible or negative for most, and never commensurate with the program’s massive expansion of coverage to low-income populations.

1. Low Reimbursement Rates from the Start
  • States set Medicaid fees, typically 50–70% of Medicare rates and far below private insurance (often <50% of billed charges).
  • Early participation was voluntary and low: By 1970, only ~40% of physicians accepted Medicaid patients regularly, concentrated in urban safety-net hospitals, community health centers, and a few specialties (pediatrics, OB/GYN, psychiatry).
  • No demand surge for most doctors: Unlike Medicare’s elderly (a high-utilizing group), many Medicaid enrollees were healthy children or non-elderly adults with irregular care needs. Volume increases were modest outside high-poverty areas.
2. Short-Term Income Effects (1966–1975)
  • Modest boost for safety-net providers: Pediatricians, general practitioners, and hospital-based physicians in inner cities or rural areas saw 10–20% revenue growth from newly insured poor patients.
  • Negligible for specialists and suburban practices: Most surgeons, cardiologists, and office-based physicians either refused Medicaid (due to low pay and paperwork) or saw few eligible patients.
  • Real income impact: AMA surveys show no aggregate physician income growth attributable to Medicaid. Any gains were localized and offset by administrative costs and bad debt from unpaid balances.
3. Long-Term Stagnation and Disincentives (1975–Present)
  • Chronic underpayment: Medicaid fees have lagged Medicare by 20–40% for decades. By 2020, national average Medicaid-to-Medicare fee ratio was ~72% (Urban Institute), with states like New York and California at ~50%.
  • Access barriers: Low fees led to persistent physician shortages in Medicaid. As of 2023, ~30% of physicians still do not accept new Medicaid patients (KFF).
  • Managed care shift (1990s–2000s): States moved Medicaid to capitated HMOs, further reducing fee-for-service income. Primary care doctors in plans gained stable (but low) per-member payments; specialists lost procedural revenue.
  • ACA expansion (2014+): Added ~20 million adults, increasing volume—but fees rose only temporarily (2013–2014 primary care parity with Medicare, since expired in most states). Net income effect: minimal.
4. Long-Term Income Trajectory (Selected Benchmarks, 2023 $)
  • 1965 (pre-Medicaid): Aggregate physician income unaffected.
  • 1975: Safety-net pediatricians/FP/GP: ~5–10% revenue from Medicaid; specialists: <2%.
  • 1990: Medicaid ~8% of total physician revenue nationally (AMA); real income contribution ~flat.
  • 2010: ~10% of revenue; primary care in high-enrollment states gained modestly; most others saw net income drag from low fees and denials.
  • 2023: ~12% of revenue; real per-physician Medicaid income lower than Medicare or private pay due to fee gaps and higher no-show rates.
5. Key Mechanisms of Income Suppression
  • Fee inadequacy: Medicaid pays less than cost for many services (MGMA data: overhead often exceeds reimbursement).
  • Administrative burden: Complex eligibility, prior auth, and delayed payments increase overhead by 15–25% per Medicaid claim vs. commercial.
  • Crowd-out effect: In some markets, Medicaid expansion displaced higher-paying uninsured cash patients or shifted volume from private plans.
Conclusion

Medicaid expanded access but did not improve physician incomes broadly—and often reduced net earnings for participating providers. Gains were confined to a minority in high-volume, low-income settings (e.g., FQHCs, academic centers) who received supplemental payments or grants. For the majority, Medicaid imposed lower fees, higher hassle, and no compensatory volume surge. Unlike Medicare, it never delivered a systemic income windfall—and in many cases, subsidized care at a loss. The program’s fiscal beneficiaries were states (via federal matching) and hospitals (via DSH payments), not physicians.


 
The ACA Medicaid expansion (effective 2014 in participating states) had a small, temporary, and highly uneven positive effect on physician incomes—far from commensurate with the ~20 million newly insured adults.

Most gains accrued to primary care in expansion states, were short-lived, and were offset by low baseline fees, administrative costs, and market saturation.

1. Volume Increase (2014–2016)
  • Enrollment surge: ~14 million added by 2016 in 32 states + DC; total ~20 million by 2023.
  • Utilization spike: New enrollees (mostly healthy adults 19–64) increased office visits ~20–30% in expansion states (JAMA studies). Preventive and chronic care demand rose sharply.
  • Primary care focus: Family medicine, internal medicine, and OB/GYN saw the largest patient influx; specialists (e.g., orthopedics, dermatology) saw minimal Medicaid growth.
2. Temporary Fee Bump (2013–2014)
  • ACA Section 1202: Mandated 100% of Medicare rates for primary care E/M codes in Medicaid for 2013–2014, fully federally funded.
  • Income boost: Participating primary care physicians in expansion states saw 10–25% revenue increase from Medicaid patients during the two-year window (Urban Institute).
  • Expiration cliff: After 2014, most states reverted to pre-ACA fees (~60–70% of Medicare). Only ~10 states maintained partial parity.
3. Post-2014 Income Reality
  • Fee regression: By 2016, national Medicaid-to-Medicare fee ratio fell back to ~66% for primary care (MACPAC). Real per-visit income from Medicaid dropped below 2012 levels in most states.
  • Volume vs. reimbursement trade-off: Higher patient loads did not offset low fees. MGMA data: Medicaid visits generated ~40% less net revenue per RVU than Medicare.
  • Specialist exclusion: Proceduralists saw no meaningful income gain—few expansion adults needed elective surgeries, and Medicaid surgical fees remained <50% of private rates.
4. Net Income Effects by Provider Type (2023 $)
  • Primary care in expansion states:
    • 2012: ~$12,000–$15,000 annual Medicaid revenue per physician.
    • 2014 (peak): ~$18,000–$25,000 (fee bump).
    • 2023: ~$14,000–$18,000 (volume up, fees down).
    • Net real gain: ~$2,000–$5,000/year vs. pre-ACA—<2% of total income.
  • Primary care in non-expansion states: No change.
  • Specialists: <1% revenue from expansion adults; many refused new Medicaid patients.
  • FQHCs/academic centers: Larger gains via PPS wraparound payments, but not office-based physicians.
5. Offsetting Pressures
  • Administrative load: Prior authorizations, eligibility churn, and billing denials increased overhead 15–20% per Medicaid claim (AMA surveys).
  • No-show rates: ~25–30% for Medicaid vs. <15% commercial—eroding effective income.
  • Market saturation: New patients filled schedules, reducing ability to see higher-paying private patients.
6. Aggregate Physician Income Impact
  • National level: Medicaid expansion contributed <0.5% to total U.S. physician income growth 2014–2020 (Health Affairs).
  • State variation: Highest gains in early adopters with sustained fee parity (e.g., California, Michigan); near-zero in low-fee states (e.g., Texas, Florida—non-expansion).
Conclusion

ACA Medicaid expansion increased patient volume but failed to deliver sustained income growth for physicians. The 2013–2014 fee parity was a brief windfall that evaporated, leaving most doctors with more low-paying patients and higher overhead. Primary care in expansion states saw modest, transient gains (~2–5% net income); specialists and non-expansion regions saw none. The policy expanded access and benefited hospitals (via reduced uncompensated care) and states (via federal dollars)—but physician incomes remained constrained by Medicaid’s structural underpayment.

 
evince said:
And lots of asshole can’t remember the real name of the Democratic party
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I've never had any difficulty remembering the official name of the Party of the Jackass, Desh.

I can call the 'Crats whatever I like, Desh.

Members of the Democrat party are called Democrats, Desh, they aren't called Democratics.
 
Diogenes said:
I've never had any difficulty remembering the official name of the Party of the Jackass, Desh.

I can call the 'Crats whatever I like, Desh.

Members of the Democrat party are called Democrats, Desh, they aren't called Democratics.
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And your list of names is what?
 
Diogenes said:
The ACA Medicaid expansion (effective 2014 in participating states) had a small, temporary, and highly uneven positive effect on physician incomes—far from commensurate with the ~20 million newly insured adults.

Most gains accrued to primary care in expansion states, were short-lived, and were offset by low baseline fees, administrative costs, and market saturation.

1. Volume Increase (2014–2016)
  • Enrollment surge: ~14 million added by 2016 in 32 states + DC; total ~20 million by 2023.
  • Utilization spike: New enrollees (mostly healthy adults 19–64) increased office visits ~20–30% in expansion states (JAMA studies). Preventive and chronic care demand rose sharply.
  • Primary care focus: Family medicine, internal medicine, and OB/GYN saw the largest patient influx; specialists (e.g., orthopedics, dermatology) saw minimal Medicaid growth.
2. Temporary Fee Bump (2013–2014)
  • ACA Section 1202: Mandated 100% of Medicare rates for primary care E/M codes in Medicaid for 2013–2014, fully federally funded.
  • Income boost: Participating primary care physicians in expansion states saw 10–25% revenue increase from Medicaid patients during the two-year window (Urban Institute).
  • Expiration cliff: After 2014, most states reverted to pre-ACA fees (~60–70% of Medicare). Only ~10 states maintained partial parity.
3. Post-2014 Income Reality
  • Fee regression: By 2016, national Medicaid-to-Medicare fee ratio fell back to ~66% for primary care (MACPAC). Real per-visit income from Medicaid dropped below 2012 levels in most states.
  • Volume vs. reimbursement trade-off: Higher patient loads did not offset low fees. MGMA data: Medicaid visits generated ~40% less net revenue per RVU than Medicare.
  • Specialist exclusion: Proceduralists saw no meaningful income gain—few expansion adults needed elective surgeries, and Medicaid surgical fees remained <50% of private rates.
4. Net Income Effects by Provider Type (2023 $)
  • Primary care in expansion states:
    • 2012: ~$12,000–$15,000 annual Medicaid revenue per physician.
    • 2014 (peak): ~$18,000–$25,000 (fee bump).
    • 2023: ~$14,000–$18,000 (volume up, fees down).
    • Net real gain: ~$2,000–$5,000/year vs. pre-ACA—<2% of total income.
  • Primary care in non-expansion states: No change.
  • Specialists: <1% revenue from expansion adults; many refused new Medicaid patients.
  • FQHCs/academic centers: Larger gains via PPS wraparound payments, but not office-based physicians.
5. Offsetting Pressures
  • Administrative load: Prior authorizations, eligibility churn, and billing denials increased overhead 15–20% per Medicaid claim (AMA surveys).
  • No-show rates: ~25–30% for Medicaid vs. <15% commercial—eroding effective income.
  • Market saturation: New patients filled schedules, reducing ability to see higher-paying private patients.
6. Aggregate Physician Income Impact
  • National level: Medicaid expansion contributed <0.5% to total U.S. physician income growth 2014–2020 (Health Affairs).
  • State variation: Highest gains in early adopters with sustained fee parity (e.g., California, Michigan); near-zero in low-fee states (e.g., Texas, Florida—non-expansion).
Conclusion

ACA Medicaid expansion increased patient volume but failed to deliver sustained income growth for physicians. The 2013–2014 fee parity was a brief windfall that evaporated, leaving most doctors with more low-paying patients and higher overhead. Primary care in expansion states saw modest, transient gains (~2–5% net income); specialists and non-expansion regions saw none. The policy expanded access and benefited hospitals (via reduced uncompensated care) and states (via federal dollars)—but physician incomes remained constrained by Medicaid’s structural underpayment.

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Grok?

Go get facts
 
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