Healthcare Reform

[Merge]

The ACA had little to do with "care" and little to do with "affordable".

No matter your opinion on the bill, you can't ignore that there are many, many people who now have access to healthcaare who didn't before. whether it was from covering preexisting conditions or expanding Medicaid etc... you may not like how it was implimented but at its core it was absouletely about care.

The affordable part is certainly debatable though.

 

[HALL85]

No matter your opinion on the bill, you can't ignore that there are many, many people who now have access to healthcaare who didn't before. whether it was from covering preexisting conditions or expanding Medicaid etc... you may not like how it was implimented but at its core it was absouletely about care.

The affordable part is certainly debatable though.

We also have a bunch more people who essentially now own a car but can't afford the gas. What good is having insurance if you can't afford to use it? Sadly the ACA (nor will this new plan) fix our system.

 

[Pirata]

You missed the subtlety. HRWA vs. SHIT act.

 

[shu09]

We also have a bunch more people who essentially now own a car but can't afford the gas. What good is having insurance if you can't afford to use it? Sadly the ACA (nor will this new plan) fix our system.

I don't get this. Isn't the entire point of having insurance to protect you from something you can't afford?

 

[knowknow456]

And with a large number of small businesses pooling together, your examples will have no effect on the pool.

I think his post is a bit theoretical,

I appreciate your thoughtful replies. Yes, I have been theoretical but I do want to discuss the real world application. I am working from the following theories -
1. Unhealthy small businesses will always join every pool.
2. Healthier businesses will not join a pool if they find a better option

Your theory is the combined purchasing power of the pool will be great enough that "going it alone" won't produce sufficient savings. I agree in any singular case but is there an aggregate that undermines this theory.

Some questions that I don't know the answers to
1. Is there one insurer (i.e, Aetna or Horizon) who wins the bid to offer insurance to the pool?
2. Is participation in the pool to be mandated?
3. If not, will other insurers be allowed to quote "outside" the pool? (If yes, this will put stress on the "no sense going alone" theory. Every small business will need a quote from inside and outside the pool to make sure they are making the best decision)
4. Does everyone in the pool have the same plan or can I keep my plan?
5. What constitutes a small business? 50/100/500 employees?

There are other questions but my point is blaming politicians and lecturing unimpressive people is fine but not helpful. The issues are complex and this is only one very small subset of healthcare. I will be the first to admit I don't know what is the best answer but I continue to try and learn.

 

[HALL85]

You missed the subtlety. HRWA vs. SHIT act.

I'm a little slow this morning John....

 

[HALL85]

I appreciate your thoughtful replies. Yes, I have been theoretical but I do want to discuss the real world application. I am working from the following theories -
1. Unhealthy small businesses will always join every pool.
2. Healthier businesses will not join a pool if they find a better option

Your theory is the combined purchasing power of the pool will be great enough that "going it alone" won't produce sufficient savings. I agree in any singular case but is there an aggregate that undermines this theory.

Some questions that I don't know the answers to
1. Is there one insurer (i.e, Aetna or Horizon) who wins the bid to offer insurance to the pool?
2. Is participation in the pool to be mandated?
3. If not, will other insurers be allowed to quote "outside" the pool? (If yes, this will put stress on the "no sense going alone" theory. Every small business will need a quote from inside and outside the pool to make sure they are making the best decision)
4. Does everyone in the pool have the same plan or can I keep my plan?
5. What constitutes a small business? 50/100/500 employees?

There are other questions but my point is blaming politicians and lecturing unimpressive people is fine but not helpful. The issues are complex and this is only one very small subset of healthcare. I will be the first to admit I don't know what is the best answer but I continue to try and learn.

That first statement is flawed to begin with. No one looks at their employee base as Unhealthy or Healthy as a reason to provide insurance. I'll leave the rest of your questions to those that are more qualified. I characterize a small business as less than 100 employees.

 

[Pirata]

No matter your opinion on the bill, you can't ignore that there are many, many people who now have access to healthcaare who didn't before. whether it was from covering preexisting conditions or expanding Medicaid etc... you may not like how it was implimented but at its core it was absouletely about care.

The affordable part is certainly debatable though.

I chose my words carefully. I said "little" to do with care. Yes, pre-existing conditions was an issue that was addressed. (BTW, one that affected my life greatly).

Not having insurance does not always equate to not having access to care. Talk to our friends in Canada and the UK about the difference between Insurance and Access.

Before ACA, people had access to care, albeit there were some gaps that existed and needed to be addressed. ACA did not address all the gaps and in many cases reduced access to care while increasing people's costs.

One example is a person year who gets sick has to go to the doctor. Assuming they had no insurance, before ACA, they went to the doctor and had to pay out of pocket. After ACA, they had to purchase $2-4K (or more) worth of insurance but still had to pay out of pocket because of the high deductible. Same care except that they likely had less choice because before ACA they went anywhere they wanted to. With ACA, their new insurance company forced them to an in-network provider.

That is just one of a many scenarios.

Add in Medicaid, Medicare, Clinics, ETMALA, and Hill-Burton and people had options for care through those mechanisms.

In short, if you were old or poor, or had a medical trauma, you options for care whether by grant or by government insurance.If you had a job, even if your employer did not pay for all or part of your healthcare, you had options for care.

ACA had some good things but overall let's not kid ourselves about what its intent was. It was a stepping stone to single payer (read: US Government Health Care Insurance.)

It did nothing to address health care Cost.

If you want to debate this topic, start with understanding Payers, Providers, and Patients and go from there.

 

[Merge]

I don't get this. Isn't the entire point of having insurance to protect you from something you can't afford?

Exactly. The ACA was never meant to be, "get a plan and go to the doctor as often as you want". I've always made the argument that it shouldn't be cheap to go to a doctor. Insurance should be there to allow you to go to the doctor when you need to without fearing the burden of bills you will not ever be able to pay.

It wasn't a magical solution to everything but there were several steps in the right direction.

 

[SPK145]

I appreciate your thoughtful replies. Yes, I have been theoretical but I do want to discuss the real world application. I am working from the following theories -
1. Unhealthy small businesses will always join every pool.
2. Healthier businesses will not join a pool if they find a better option

That thinking may be flawed. A small business with a healthy population may/should still join a pool for the potential longer-term effects of risk mitigation. (They would be stupid not to.) Nobody remains healthy 100% of the time. One catastrophic event for a small company will kill their premiums. It's the old-strength in numbers principle, economies of scale.

 

[knowknow456]

A small business with a healthy population may/should still join a pool for the potential longer-term effects of risk mitigation. (They would be stupid not to.) Nobody remains healthy 100% of the time.

I agree.

If there is no "out of pool" alternative, by definition the business stays in the pool. If there is an out of pool option, the business will pick the better option on a year by year basis.

Risk mitigation works better if there is a penalty for opting in or out. A two year waiting period or a 10% surcharge.

 

[Pirata]

I don't get this. Isn't the entire point of having insurance to protect you from something you can't afford?

Insurance is a relative simple game of odds played by the insurer and the insured.

The insurer bets the event won't happen and the insured bets the event will happen. When the price of the bet costs more than the cost of the event, it does not make sense to take the bet.

Insurance comes in other forms than straight insurance. Things like extended warranties, annuities, survivor benefits, etc.

One problem with health insurance is that it packages too many and too dissimilar events, some with higher likelihood of occurring than others.

Just remember that like at the casino, the house never loses.

ACA forced alot people into the casino. Most lost, some won.

 

[Merge]

ACA forced alot people into the casino. Most lost, some won.

That's the thing though... Everyone was already in the casino except some went in without paying and expected the government to pony up if they "won" (trying to stick with the analogy)

We spend tens of billions of dollars each year in the form on uncompensated care for treatment of the uninsured. It was time to recognize that we are already all in the pool together and everyone should pay the fee to join. That used to be a conservative viewpoint (personal responsibility)

 

[Pirata]

That's the thing though... Everyone was already in the casino except some went in without paying and expected the government to pony up if they "won" (trying to stick with the analogy)

We spend tens of billions of dollars each year in the form on uncompensated care for treatment of the uninsured. It was time to recognize that we are already all in the pool together and everyone should pay the fee to join. That used to be a conservative viewpoint (personal responsibility)

For the most part, I agree with this, particularly on the catastrophic/long-term illness/high cost non-optional procedure side.

 

[Merge]

For the most part, I agree with this, particularly on the catastrophic/long-term illness/high cost non-optional procedure side.

You are pretty much describing the plans on the exchange.

 

[Pirata]

You are pretty much describing the plans on the exchange.

I am not well versed on the plans themselves. If what you say is accurate, would that bring us full circle to ACA not being about care?

Is the structure of the plans such that it provides little support for routine health visits, is it then more of a tax that was levied so the that former non-payers are now contributing to the catastrophic fund. Politically it was sold as "Affordable Care" but in reality did it simply shift the funding for care that was already being provided?

I realize I am painting with a broad brush.

Does it also bring us back to Hall85's OP and points that both parties have let us down and we still have the gaps that should bu have not been filled?

 

[Merge]

If what you say is accurate, would that bring us full circle to ACA not being about care?

Not at all.

The exchange plans were designed in tiers of bronze (cheapest plans which have very high deductibles) to platinum plans (expensive plans with low deductibles) This allowed an opportunity for healthy people to "get into the pool" giving them peace of mind about a catastrophic illness but also allowed sick people who may have had a preexisting condition or had been kicked off a private plan for whatever reason, obtain coverage.

How do you insure that unhealthy population of people who need insurance the most? You get more healthy people in the pool.

s the structure of the plans such that it provides little support for routine health visits, is it then more of a tax that was levied so the that former non-payers are now contributing to the catastrophic fund. Politically it was sold as "Affordable Care" but in reality did it simply shift the funding for care that was already being provided?

Preventative care is free in all plans. I feel like you are trying to win an argument instead of understanding the law honestly. You have described things you would want in the law (covering preexisting conditions, catastrophic coverage) but are not seeing that the law was written in a way that would allow that to happen.

Does it also bring us back to Hall85's OP and points that both parties have let us down and we still have the gaps that should bu have not been filled?

Absolutely. The ACA passed in 2009 without republican support/input because republicans were thinking about 2010 (which worked incredibly well politically) The "repeal" bill will likely pass without democratic support/input because democrats are thinking about 2018.

I think both parties would prefer to have a partisan bill passed than give a win to the sitting president.

 

[Pirata]

I feel like you are trying to win an argument instead of understanding the law honestly. You have described things you would want in the law (covering preexisting conditions, catastrophic coverage) but are not seeing that the law was written in a way that would allow that to happen.

Not trying to win anything. Just to be clear, I am not arguing against you but more against aspects of the ACA. The points you bring up are good and provide a solid basis for discussion.

I think I agreed that covering pre-existing conditions (for people who are transitioning from one insurer to another) was in the ACA and a good thing. To the extent catastrophic and other things are covered that is good also.

How do you insure that unhealthy population of people who need insurance the most? You get more healthy people in the pool.

This is an area where I start to have trouble with. I agree that your statement is is true. My difficulty is with the mandate that healthy people are forced to subsidize unhealthy people. The force part is the part I have trouble with.

The problem with my position of his is that a solution might have to include denial of service for the people that chose not to be covered but then show up with a broken arm. I don't advocate denial of service. I do advocate penalties for people who do what I just described.

Preventative care is free in all plans.

That is partially true. The term they use is "Preventative Services" which when you look under the cover is mostly screening. The actual care to treat the problem is subject to deductibles and co-pays. It's a little like that credit monitoring commercial where the bank guard doesn't stop the robbers he just alerts the bank that they are being robbed.

Again, I am not trying to argue with you directly. At the highest level, I think the ACA had more to do with political posturing for votes and power and amounted to a new tax on a particular cohort. There were some things that were addressed that were good, but overall it missed the mark and had bad consequences for business and for the cohort that was insured and now is not, or is now paying more for worse insurance then they had. Some people did benefit, I will grant that.

 

[HALL85]

Well the plan is out now, and from what I've seen so far pretty much what has been expected. I was pleasantly surprised to see HSA's in the plan and both the individual and employer mandate's rolled back. Medicaid growth will be tied to inflation which also makes sense rather than tying it to the medical CPI. Also giving more control back to the states where it should be.

 

[Merge]

This is an area where I start to have trouble with. I agree that your statement is is true. My difficulty is with the mandate that healthy people are forced to subsidize unhealthy people. The force part is the part I have trouble with.

That's how insurance works though. Healthy people subsidize unhealthy people.

The problem with my position of his is that a solution might have to include denial of service for the people that chose not to be covered but then show up with a broken arm. I don't advocate denial of service. I do advocate penalties for people who do what I just described.

Which creates a whole new set of problems as well though. People who can't afford health insurance who have an accident, now can't afford to pay that penalty let alone the actual treatment.

Again, I am not trying to argue with you directly. At the highest level, I think the ACA had more to do with political posturing for votes and power and amounted to a new tax on a particular cohort. There were some things that were addressed that were good, but overall it missed the mark and had bad consequences for business and for the cohort that was insured and now is not, or is now paying more for worse insurance then they had. Some people did benefit, I will grant that.

I agree. It didn't fix everything and it created problems as well.
I think we should be working to fix it.

In my opinion - during a discussion about healthcare reform, you need to make sure that people have access to both insurance and healthcare regardless of previous medical conditions or how sick they currently are.
I think most of us are on board with that.

The ACA was designed specifically around that basic premise. You just can't accomplish those points without a mandate and you can't have a mandate without a penalty.

I think I agreed that covering pre-existing conditions (for people who are transitioning from one insurer to another) was in the ACA and a good thing.

Only for people who are transferring between insurance? Not for people who lose a job and can't afford cobra?

 

[Merge]

I was pleasantly surprised to see HSA's in the plan

Just strengthening another investment tool for wealthier individuals. Will do little in regards to actual healthcare.

both the individual and employer mandate's rolled back.

and they only accomplish that by paying insurance companies through 2019 - after that the plans will all be dead because the healthy people left the pool.

Doesn't appear that it has the support to pass as written so far though.

 

[Section112]

Just strengthening another investment tool for wealthier individuals. Will do little in regards to actual healthcare.

Wrong! HSA's allow people to put money aside to pay for insurance costs not covered by insurance. Especially useful for folks that have high deductible plans, small business owners who are not allowed to make pre-tax contributions (one of the F'd up stipulations of ACA) and employees whose employers do not offer FSAs or HSAs. It allows people to take control/make a contribution to their own health expenses. This is a good thing when people have an option to put money aside to pay for healthcare. Working people that is. Not everyone is wealthy but for people not eligible for an FSA at least this is an option. Under ACA business owners cannot make pre-tax contributions to an HSA and are not eligible for an FSA either. Again the law really hurt small businesses. This might be the one thing in the new law that will help small businesses. Does not go far enough from what I have read but this one thing will help. You are a smart individual but don't always fall for the left talking points please.

 

[HALL85]

Wrong! HSA's allow people to put money aside to pay for insurance costs not covered by insurance. Especially useful for folks that have high deductible plans, small business owners who are not allowed to make pre-tax contributions (one of the F'd up stipulations of ACA) and employees whose employers do not offer FSAs or HSAs. It allows people to take control/make a contribution to their own health expenses. This is a good thing when people have an option to put money aside to pay for healthcare. Working people that is. Not everyone is wealthy but for people not eligible for an FSA at least this is an option. Under ACA business owners cannot make pre-tax contributions to an HSA and are not eligible for an FSA either. Again the law really hurt small businesses. This might be the one thing in the new law that will help small businesses. Does not go far enough from what I have read but this one thing will help. You are a smart individual but don't always fall for the left talking points please.

Well said. This is where I think we diverge views with Merge. I prefer a system where an individual has choice (rather than forcing/mandating) and provides an incentive to save and direct their earnings responsibly. Government should be a safety net to ensure those in need (falling below a threshold) have access to care. These are not mutually exclusive ideas.

 

[Merge]

You are a smart individual but don't always fall for the left talking points please.

I will clarify because I probably wasn't clear.
I am not against HSA's at all. I love the idea of HSA's and put away $5,500 per year into mine at work.

How does lowering the penalty for non medical expenses from an HSA do anything for healthcare? They are trying to make it a more attractive investment option. It is likely included in the bill because of investment lobbyists who want the updates. It's fine, I will take advantage of it... but the increases and lower penalty are just not things that will impact the cost of care or outcomes.

 

[HALL85]

but the increases and lower penalty are just not things that will impact the cost of care or outcomes.

Neither the ACA nor this bill will effect the actual cost of care, just how its going to be paid for.

 

[Section112]

Neither the ACA nor this bill will effect the actual cost of care, just how its going to be paid for.

Unfortunately that is correct. Both bills still haven't touched tort reform or got deep into the rising costs which is truly unfortunate. The lobbyists win again.

 

[knowknow456]

I am not well versed on the plans themselves.

Here is one plan ACA acceptable for a single individual. It is not from the exchange. It does meet minimum essential coverage. I edited for speed but will clarify if you have questions. Doctor must be in network.

Deductible $2500
Maximum out of Pocket $5000
Unlimited Benefit and lifetime maximums

Doctor office visits - Generally 100% after deductible and $30 copay
Preventive Care - Physicals, GYN, PAP, Mammogram, Prostate Screen, Colon screen, Immunization - 100% covered, no deductible
Diagnostic Procedure (Lab work) - 100% after deductible
Hospital Care - 50% after deductible
Emergency Care & Outpatient Surgery - 50% after deductible
Mental health, Substance abuse and Alcohol abuse Services - 50% after deductible
Prescription Drugs 50% after deductible
Diabetic Care, Home health care, hospice, Infertility, OT PT Speech therapy - 50% after deductible.

Cost = $475/month

 

[Pirata]

Which creates a whole new set of problems as well though. People who can't afford health insurance who have an accident, now can't afford to pay that penalty let alone the actual treatment

Prior to ACA if you had no insurance and had a broken arm you go to an Emergency Room, they set and cast you arm and discharge you. You pay nothing.

When I said "penalty" I meant that in this type of situation their should be a better mechanism for the hospital to recover their costs.

 

[Pirata]

I think I agreed that covering pre-existing conditions (for people who are transitioning from one insurer to another) was in the ACA and a good thing.

Only for people who are transferring between insurance? Not for people who lose a job and can't afford cobra?

When I wrote what I wrote I was envisioning the scenario where a person chooses not to purchase insurance at all. Then, years later at age 38 they find they have a thyroid issue. They then want to buy insurance and want the insurer to pay for the treatment. I am not suggesting we leave the person out in the cold. I am suggesting we do not force an insurer to have to pay for the treatment the same as for someone who has paid premiums.

With regard to your scenario about Cobra, there are multiple versions of that scenario. I live that situation many times in my work with my employees and new hires. I'd first say that "can't afford" often has a "choice not to pay" component in it. That statement is worth of much discussion but that is for another time. Back to your scenario, I would include a "loss of job-no cobra-new job" scenario wherein the pre-existing condition would be covered. I would like to see some qualifiers in that scenario with some means testing that would recover some or all of the cobra premiums, i.e. addressing the "can't afford" vs "chose not to pay".

 

[Pirata]

Here is one plan ACA acceptable for a single individual. It is not from the exchange. It does meet minimum essential coverage. I edited for speed but will clarify if you have questions. Doctor must be in network.........

........Cost = $475/month

Thanks for the example.

I am familiar with the Law and familiar with MECs but had not looked at specific policies.

Your example echos some of the chatter I have heard.

On the surface, I'd say $475 a month is reasonable amount given that the person is bearing the entire cost of the coverage. The deductible is high on an absolute basis but not on a relative basis to a $475 monthly.

On the flip side, my guess is a single person, making $20 and hour and having no coverage would take the penalty. Roughly $1,000 vs. $5,700 for a plan that would likely not pay any benefits. In that situation, the $1,000 equates to a tax that provides nothing for the single person paying the penalty, but will be redistributed in some fashion to others.

 

[Merge]

Prior to ACA if you had no insurance and had a broken arm you go to an Emergency Room, they set and cast you arm and discharge you. You pay nothing.

When I said "penalty" I meant that in this type of situation their should be a better mechanism for the hospital to recover their costs.

I agree and believe an "access tax" - a penalty for having the means to buy insurance but choosing not to is appropriate.

We all have the right to be treated at a hospital in an emergency (thanks to Reagan) if people do not have the personal responsibility to ensure they have insurance, they should be paying a penalty.

 

[Merge]

When I wrote what I wrote I was envisioning the scenario where a person chooses not to purchase insurance at all. Then, years later at age 38 they find they have a thyroid issue. They then want to buy insurance and want the insurer to pay for the treatment. I am not suggesting we leave the person out in the cold. I am suggesting we do not force an insurer to have to pay for the treatment the same as for someone who has paid premiums.

We have basically solved that problem through a mandate. It's not th prettiest policy to come out of Washington, but so much cleaner and easier to implement than what you are e suggesting.

 

[Section112]

Here is a summary of some of the tax provision changes in the proposed law (posting if readers are interested):
http://www.journalofaccountancy.com...cpald&utm_medium=email&utm_campaign=23Jun2017

 

[SPK145]

Can any of you health insurance experts tell me why it's fair that I have to pay the same for family coverage for a family of me, my wife, and one child as a family that includes a husband, a wife, and 5 kids???

Seems unfair and downright mean to me.

 

[Section112]

Yea and why do people who can't have babies have to pay for maternity coverage? And why do I have to pay for dental that I cannot ever use. In my plan there is one doctor in the plan that I could go to 35 miles away for a super limited reason and that will only have partial coverage. I don't want either coverages and will never use either and both are being forced on me.

 

[Merge]

Can any of you health insurance experts tell me why it's fair that I have to pay the same for family coverage for a family of me, my wife, and one child as a family that includes a husband, a wife, and 5 kids???

Seems unfair and downright mean to me.

Good question. Was that always the case?

I've only paid attention to family coverage since I got married 13 years ago so I have no idea what the coverage was like before that.

 

[SPK145]

Good question. Was that always the case?

I've only paid attention to family coverage since I got married 13 years ago so I have no idea what the coverage was like before that.

Yes

 

[Merge]

Yes

Saw this on a blue cross website "The size of your family doesn't necessarily determine what you spend on doctors and prescriptions. A healthy family of six could spend less than a married couple with chronic conditions."

Hard to argue against your point though. Logic would seem to suggest that each person in a pool is a risk and costs should go up with each addition. Maybe it started when we wanted to encourage population growth or something and it's impossible to get rid of now. Fair point though.

 

[knowknow456]

That's how insurance works though. Healthy people subsidize unhealthy people.

I thought your response was really interesting and deserves more discussion. My experience is that many people (not all, but many) view health insurance as a two way transaction. I buy this policy and I use it. The concept of subsidizing other people doesn't actively enter into the transaction.

I often hear people ask - "Why do I have to pay for something I don't use?" It is an important question and one that is difficult to answer. If you don't believe that healthy people subsidize sick people no amount of math will answer that question.

 

[HALL85]

Can any of you health insurance experts tell me why it's fair that I have to pay the same for family coverage for a family of me, my wife, and one child as a family that includes a husband, a wife, and 5 kids???

Seems unfair and downright mean to me.

So here is the answer to your question. Reason one is the cost to administer more premium levels. Much easier to have one tier instead of multiple. We are self-insured, so that number of children in the plan goes into our pool. At the end of the day everyone shares and that cost for the pool.