Health care and real estate, two important areas of interest to me and to the US economy, are due for some changes in 2011. I have no better crystal ball than anyone else, but here are some of the things I expect:
Health care reform will have to be re-reformed. No, I don't think the Republicans will actually repeal it all. If they do, they're dumber than I thought, because they would then get caught in the same quicksand the Democrats have been in for the past two years. There will, however, be some necessary changes.
The first thing to go will be an unrelated part of the law that forces people to 1099 anyone to whom they pay more than $600. That's a ridiculous burden on small business, and of course it doesn't belong in health care reform in the first place. It will vanish quickly.
Next will come a revision in the way physicians get paid. In a recent survey by The Physicians Foundation, a majority of physicians (60%) said health reform will compel them to close or significantly restrict their practices to certain categories of patients. Of these, 93% said they will close or significantly restrict their practices to Medicaid patients, while 87% said they would close or significantly restrict their practices to Medicare patients.
Because Medicare guidelines are a guarantee of access to care, if physicians cease to see Medicare patients it will impact both their incomes and Medicare's entire structure. Congress can't let that happen, because seniors vote and starting next year Boomers turn 65 at a rate of 10,000 a day.
Instead, we will have -- and welcome -- death panels: caps on what can be spent on treatment of the elderly at the end of life unless it is life-extending with high quality of life as the outcome. No more chemo that extends life by three weeks during which the patient is suffering.
And the ability for seniors to have a free consultation with a physician about how to plan for end of life, prepare the necessary documents, and make their wishes known. This alone will prove a cost-cutter, since many seniors do not want extreme measures used to keep them alive, but haven't properly documented their desires to the people who will make those decisions when they can no longer do so themselves.
We will also see further explosive growth in online health information sites and support groups as people realize they are going to have to pay higher deductibles and co-pays and finally undertake the responsibility for their own health. This will be slow, but has already begun. A few more years of 30% premium increases to cover costs for the underinsured (because the Republicans may well repeal the individual mandate or it may be found unconstitutional) and most of us will be nursing each other.
Now that we have life and death out of the way, here's what may happen in real estate:
The loan modification programs that aren't working will go away. HAMP and HAFA have helped about 300,000 people out of a possible fifteen million foreclosures by the end of 2011.
Instead, one of two things will happen, depending on what the banks, who hold all the cards, want. Either there will be another wave of foreclosures, or loans will finally be written down to the current market value of homes, allowing more people to stay in their homes. Probably there will be some of both.
FHA and VA mortgages, which have always been assumable by a borrower who could qualify, may become assumable for buyers who can't, since there's almost no one left in the country who can qualify for a mortgage under the current standards. This will stimulate the lower end of the market, which has gone away since the first-time home buyer credits expired.
The wraparound mortgage and the seller carry back, gone since the days of high interest rates in the early 80s, will be back. These are financial products that allow a seller who has to sell or wants to sell but doesn't want to injure his/her credit with a short sale to sell to a non-qualifying buyer. Done correctly, the wrap and the carry back can be very advantageous to both buyer and seller, and were the way people built up real estate empires with no money down. If you wanted to, you could do that now. Sooner or later, people have to move for work or other reasons, and they become more willing to sell under unusual conditions. These may surface at the high end of the market, where in Arizona there is a 9-13 year supply of $1,000,000+ homes on the market. The lease purchase will also become more common.
I am an optimist, so I predict (think) these things will happen. Pessimists may comment below. Happy New Year.
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As a participant for 40 adult years in Canada's system, (adult = important qualifier, indicates 'eyes wide open'), I always wonder about "lack of personal responsibility" accusations re people and health care. I, and other Canadians, read Adelle Davis in the early 1970's, and never looked back in personal responsibility, learning more across years. (Who chooses to spend life's time unnecessarily messing about with health issues!)
Further, I worked in a hospital as a teen in the American heartland - met very very few who treated health casually, 'knowing they'd be looked after'. I think this accusation is a myth except for perhaps a portion of the population convinced through advertising and other prompts to believe they are helpless. Blame/anger is unhelpful; remedy need not be punitive - remedy may be to inspire confidence!!
RE: "... most of us will be nursing each other." As a returnee denied an HSA, referred for "insurance for uninsurable" but unable to afford, I have no coverage. (Insufficient quarters for 'senior' version for several more years.) I share lots of info with others uninsured or underinsured - we already go some distance "nursing one another"!
RE:" law forces 1099 anyone ... pay more than $600." I'm with you! ($600.00? whose clever idea?)
Re future reform: see Canadian costs/outcomes!
Without exception patients wanted to consider these situations and let their wishes be known.
To some extent true, but not totally.
There will be no "death panels", something impossible in our current permutation of health care oversight. The government, and the insurers, may place "caps on what can be spent on treatment of the elderly at the end of life unless it is life-extending with high quality of life as the outcome." But life prolonging treatments will not and cannot be denied to patients or families who insist on them. This will be strictly enforced by plaintiffs attorneys and state and local regulation of the practice of medicine.
As a practicing physician, I cannot countenance the consequences of withholding life prolonging treatments against the wishes of a patient or family. A stint as a defendant in a medical malpractice trial, facing a state licensing board action, or even responding to peer review in my hospital for allowing my patient to die prematurely against his wishes or those of his family are far too high a price for me.
The right thing is to require me to offer, but not demand, counseling, so that the patient and family can make an informed decision.
This is all that is proposed.
The efficacy and prognosis will be through the inter-state highway process of health care IT, maintained by the medical providers and HHS, which provides the latest information at the medical provider and patient's fingertips.
The cost is where free enterprise steps in to provide better business models and patient-centric services.
The insurance companies will lose their ability to dictate life and dealth. They will become just like your other insurances: auto, home etc. and may even offer rebates to the patient based on treatment options.
When all the pieces of health care are re-arranged to a patient-centric view and the right busniess models implemented, the cost will come down naturally. And then it becomes a quality of life issue, as it should be.
In both cases I would most deeply recognition of myself as an autonomous being of dignity, in charge of my personal affairs. Both questions are relevant: how I might be treated if recovery could bring continued decent quality of life for me to share with those around me, and a review of my choices should should severe deterioration and/or physical suffering appear unavoidable.
I think it's clear that potential outrageous outcome from either of these choices is a concern openly appreciated. The best intent with either is acknowledgment of personal autonomy, honoring inherent dignity of human life. Over-emphasis on $$ could lead us out of heart driven, compassionate, deliberation.
Increased non-profit hospice options will go far to address the first (compassionate care when life quality is severely permanently compromised). We may be no where close to comfortable open discussion for the latter (end of life choice).
These concerns badly need 'ordinary citizen input'. There is a built-in "lack of respect for personal autonomy" by having these discussions stay only in "expert" realm.
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On its face, I don't think that is such a bad thing at all. Having been in the healthcare industry for 20+ years, I have seen a lot of abuse/neglect, i.e., demented/Alzheimer patients on 30+ meds at a time or undergoing procedures to prolong their life. What a waste! What quality of life do they have & why must the taxpayer pay for this? Let them go in comfort and dignity without further prolongation.
On the other hand, its frightening to think of government being "in charge" of death panels.
http://www.youtube.com/watch?v=1TmDybKt2cc
This is addressed in several ways in the data laden lecture found at link:
1) different cultural attitudes of who/what 'government' is;
2) all HC systems (all countries) face the issue of cost for treatment that only briefly prolongs life, sometimes without quality being assured (or maybe in the USA genuine positive patient outcome is sometimes to known unlikely!?) Obvious cases in most public operated, non-profit, systems are often judged as prolonging suffering by procedures that are invasive and ultimately unhelpful.
First, I think "living wills" can name chosen individuals who are charged with following guidelines described by the will maker. (?)
Second, if a living will is missing - wild idea but I wonder about a group within the community, chosen for diversity, unpaid, to review cases - sort of like "jury of ones peers"? (I'm not sure how it would be set up, how long 'review committee members' would serve, surely at least some family representation on imagined committee if family available, ... much thinking needed here! Part of point is to release medical community from the burden of decision?)