After a few years, The states only have to pickup 10 percent of the costs of medicaid expansion. It’s a good deal for the states economically and morally to pick up the tab.
Healthcare is rationed in the United States. It is rationed by affordability. With ACA, this is now declining.
One reason the United States has the most expensive healthcare in the world is Americans pay more. We pay more for drugs. Medical devices. Hospitalitzation costs. Administrative costs. Surgeries. Doctors. Education for doctors. Nurses.
Healthcare is heavily subsidized in the United States. It has been estimated that the employer backed healthcare subsidy is approximately $250 billion a year. That is the highest income tax expenditure that exists. Those who receive employer paid healthcare and then complain about ACA subsidies shouldn’t throw stones.
The United States now has the lowest percentage of uninsured people in its history because of ACA. If miore states expanded medicaid the percentage of uninsured would decrease more.
Fewer people are running into financial trouble due to healthcare costs because of ACA.
We live in AL, and the state medicaid costs produce a lively discussion. AL isn’t as prone to raising taxes as some states. States still have to balance their budgets.
Agree @dstark - our health care model has been company/employer coverage paying a heavy portion of family/individual coverage, until 65 and Medicare. Some people covered under Medicaid, Medicare Disability. The gap of uninsured has eventually triggered ACA.
The paradigm changes can/are/will be painful for some/many.
Each portion of healthcare is going to bleed out profits as much as they can - so look at all the drug ads we are subject to on TV and in magazines!
Blending in wellness into our healthcare insurance model where you had to have a diagnosis (illness) for coverage and no wellness benefits (which would be cost saving, but foreign to the insurance model). Look how long that has taken, and is still very limited IMHO.
Having some form of health care coverage in the US benefits all. But it will be a process to get there.
Local/States rights and Federal laws are going to continue to be struggle. How passionate people are behind various ‘causes’.
Why do we pay more for health care? Because we have a very thriving economy, free market system, and profit is the American way of thinking. Do you want a MD trained in the US or elsewhere? I think Europe takes care of themselves in medical training, and some other countries too. However a MD that is US trained is at a pretty high standard. My DD is friends with an Indian trained dentist who is trying to get into US dental school - she just finished a master’s degree in public health at a US school that also has a dental school - obviously from a wealthy family (I believe her uncle is her benefactor). Her credentials from India are career-limiting.
We also pay a lot for our Military, including the latest technology for the military. The Swiss spend a lot per capita too.The US benefits from global stability. For example, I can see a real issue with keeping international waters safe and what it takes with Naval ships/costs and the federal budgeting process.
Alabama is screwing up economically and morally by not expanding medicaid. The people of Alabama are paying for the medicaid expansion and the people of Alabama aren’t getting the expansion. This hurts the health of the people and the economy of Alabama.
We don’t have a free market system in healthcare in this country. Neither do other first world countries.
Alabama is attracting a lot of business. It is a business friendly state. Better economy in many areas.
Charities are trying to help in some of the poor economy areas - for example a town like Selma which doesn’t seem to have changed any since the 50’s/60’s as far as any opportunities. The poor there are poor and no real opportunities; Edmundite Missions (Catholic) help with feeding and social services. I do think there is a bit of a bigger pool of poor spread out in country where it is more difficult to serve.
I don’t know what state you live in @dstark but the Medicaid expansion will go through eventually here in AL. There are other pressing things on state expenditures.
Every country rations health care. In some countries, the rationing is by availability of personnel or equipment. In some countries, the rationing is intentional (e.g., “We won’t pay for the latest very expensive procedure that shows very little benefit but that companies/doctors have done a great job of marketing in the US” or “We just wait a few years before adding expensive drugs to our list and negotiate very hard with manufacturers since they can’t introduce it without us” or “We won’t pay for extensive procedures or hospitalization for what is probably the last year of life”). In Canada and the UK, one can buy supplemental insurance on top of the province or country-provided free care. In the US, we ration by ability to pay and whether or not your job pays (and pays well or not) for insurance. We have many fragmented payers (insurance is state-regulated) and they have very weak bargaining power. Congress prevents Medicare from bargaining with drug suppliers. As @dstark points out, we have tax subsidies for employer-paid insurance but not for individually paid insurance (what sensible public policy outcome does this support?). I think a McKinsey study found that a hospital had to have a back office capable of dealing with something like 170 different payers and much money is spent on seeking reimbursement from insurers and negotiating with them when they don’t pay.
@SOSConcern, poverty is a harder problem. Education is important and ensuring adequate health care are part of the solution. The world economy is not going to generate well-paid jobs for inadequately prepared people. Unhealthy (or malnourished) folks probably will be handicapped both in their attempts to get an education and work productively. Alas, the fact that education is funded by impoverished local municipalities and directed by states that are financially and sometimes intellectually challenged (e.g., when the educational agenda is more focused on eliminating the theory of evolution than encouraging scientific education) makes the problem of providing an adequate education harder. And state decisions on health care may also be problematic. More importantly, if one thought a central government response would work and federal tax money were needed, having to work through local funding mechanisms would probably make people like @dstark and me quail at giving more money to local authorities we might feel are misdirected (at best) and morally challenged (at worst) efforts to spend our tax money. But, education and healthcare are only part of the problem. Cultural transformation is probably necessary for better education to work and doing that would be both hard and controversial.
So, returning to the focus of the thread, neither @dstark or I are likely to retire in Alabama. For me, I’m trying never to retire but I will make locational decisions and the options include Massachusetts, California, Western Canada and maybe Oregon and Florida (the least likely option). I would have put New Mexico or Arizona in the mix but these have been completely vetoed by ShawWife and could put Colorado in the mix as well. But, I think we will limit things to two locations (although we share a house in Quebec, which will need major renovation or more likely a tear-down and start over in the next few years).
I do like Oregon. I could definitely live there. I would have to check the estate tax rules there. If I remember correctly, the estate tax is kind of brutal in Oregon. The estate tax starts at a relatively low number and the tax rate is pretty high for a state. I have been to West Canada a few times and I like it there too.
But…I don’t think I am really moving. My wife grew up in Marin. I think we are staying here. The one thing that may push us to move is if my oldest daughter moves out of the SF bay area. Then, we may rethink. Maybe.
The strength in families, friends, can all be considerations in quality of life for choosing where to live - and how healthy we stay as we get older; how much medical intervention. Many people do want to travel some while physically able. We all work out our priorities.
One bad crime situation, and one may rethink where they are living as well, or one really bad car accident.
People do get use to the pros and cons of various areas.
I wonder if water shortages/droughts in certain areas has people thinking differently, or energy costs, extra taxes, etc.
Some people are attracted to various retirement communities. We have at least 5 more years to sort things out, and a home to downsize from.
’ If I remember correctly, the estate tax is kind of brutal in Oregon." - For most of us, state estate tax won’t matter. Spouses are exempt. If other heirs need to pay extra state taxes after the first million… oh well. (ditto for federal estate tax… but $5million exemption)
Income tax is brutal in Oregon. Over just $8,400, you pay 9% income tax, and it goes up to 9.9% at 125K, if I remember it right. Great place for benefits if you don’t make much money, painful if you do.
In Washington state, we are rated as the #1 most tax regressive state. We’re number one! We’re number one! We still aren’t dumb enough to vote in an income tax, because people don’t trust the legislature. However, we do have some pretty decent benefits, so it may not be as regressive as it seems.
@colorado_mom Those are great links. When the estate and the heirs are in different states, how does the residency apply? Is it for the estate tax it’s the state where the estate is located and for the inheritance tax where the heir resides?
Thanks, @colorado_mom. Good question @Iglooo. We noticed that in Canada there is no gift tax and in the US there is no tax on receipt of gifts. So, Canadians can give to US taxpayers and no one pays tax. But, I don’t know how it works between states.
With estate tax, it should be pretty easy at the moment to avoid federal estate tax, but with a $1 MM cap, avoiding state estate tax might be harder. I suspect that if one of us died sooner, the other would have the spousal exemption and spend that down before going to other assets so that would reduce or eliminate state estate taxes. We are accumulating additional assets in a trust that is exempt from federal and (I think) state estate taxes. But, based upon the map in @colorado_mom’s post, we would have to be careful if we end up in Massachusetts and Oregon. If it is two other states (say, California and Oregon), we have to think carefully about which becomes the domicile for tax purposes.
I was surprised about the TN info, but their situation there is a bit unique - I imagine it all plays out OK for long time residents. When you live a place a long time, you get adjusted to the pros and cons on that area and that state.
