HIPAA costs ?

[mykidslovedogs]

Hi Martha,

Good conversation! I can tell we do not share the same philosophy, but that's what makes these forums so much fun!

One thing you're forgetting is that employer-sponsored health insurance premiums are only composite rated (averaged) with groups larger than 10 employees. Small employers (2-10 employees) make up a huge percentage of those offering employee benefits, and their benefits are usually age-banded. Thus, those over the age of 50 get killed pricewise in the group market. oftentimes, and individual or family plan is 2-3 times less expensive for someone in that age category. For an employee over the age of 50 who is not receiving benefits for spousal coverage, an individual plan for the spouse can save thousands of dollars (if the spouse can qualify for coverage).

I understand your point about those born with congenital illnesses, but if their parents had had their own individual policy at the time of birth or adoption, that child would have been granted guaranteed issue onto their parent's plan and the parents would not then have to worry about qualifying for coverage for a sick baby later on. Yes, different States have different regulations and not all carriers do business in every State, but if it came down to moving or facing financial devastation, then wouldn't you just choose not to move? It's not like people don't have choices. Why would you move if you knew you were going to face financial devastation because of health insurance problems? Also, in general, insurance carriers do not rate based on PERSONAL claims experience. Rates are increased based on industry trends and utilization of large groups of members within geographical areas. Therefore, the cost of that child's coverage is not going to inflate any higher than any other person within the insurance carrier's membership. Lastly, if that carrier happens to go out of business or stop doing busines in your state, then the child would be granted creditable coverage towards pre-existing condition exclusions on the state-guaranteed plan if they do not have a gap in coverage. Buyer beware. When purchasing health insurance, be sure to choose a carrier that has had stability in your state for many many years.

As a matter of fact, I do have my own individual insurance policy. I do not want my health insurance to be tied to my employment. That is my CHOICE. I know you are going to ask me about the people who can't afford it, but here is what I have to say about that....There is always going to be a MINORITY of people who cannot afford health insurance. It is a fact that in a capitalistic society, some will be better off than others. I don't know the actual statistics, but I am confident that more people CAN afford it than CANT, and a very large percentage of the uninsured actually CAN afford it but choose not to buy it. Life is not fair. For those who cannot afford their own coverage, there are many many government sponsored programs for discounted and even free services. Here are a few of them:

Bureau of Primary Health Care - This government run web site will help you find a clinic that will give you medical care, even if you have no medical insurance or money.

Centers for Disease Control National Breast and Cervical Cancer Early Detection Program - Guide for women looking for low-cost mammograms and pap smears.

Centers for Medicare and Medicaid - A government run website for people with or needing medicare or medicaid

Insure Kids Now - Now, you may have one less thing to worry about. Your state, and every state in the nation, has a health insurance program for infants, children and teens.

Medicare - Compare Medicare Prescription Drug Plans; Formulary Finder.

Partnership for Prescription Assistance - The Partnership for Prescription Assistance brings together America's pharmaceutical companies, doctors, other health care providers, patient advocacy organizations and community groups to help qualifying patients who lack prescription coverage get the medicines they need through the public or private program that's right for them.

My last point...You say that we are a rich country, yet you point out that national health insurance is important because there are so many poor. Are you willing to give up 50% or more of your hard- earned income to pay for everyone else's healthcare needs? What is wrong with each of us doing the best we can to take care of our own financial needs? Yes, it is unfortunate that some will not be as well off as others, but if we move to a national healthcare system, we are going to compromise the very thing that makes the United States the leader in health care technology and innovation - competition! If we nationalize healthcare (and I mean a purely socialized form of healthcare and not one where people are given a basic level of care with the option to supplement with their own insurance because we already have that...) then we are going to lose good doctors, and compromise the quality of care in our country. After all, why would anyone want to become a Doctor if they knew their income potential would be limited?...If the government were to nationalize care, I can guarantee that Doctors would be paid pennies on the dollar compared to what they make now. Do you really believe that most Doctors would stay in the business just for humanitarian reasons? Some will, but our young people will not choose health care careers if they are forced by the goverment to care for everyone at the same government-mandated rates.

Well, that's how I see it, but I would love to hear your point of view! And...thanks for welcoming me to the forum!

[Rich_in_Tampa]

Originally Posted by mykidslovedogs

...Yes, different States have different regulations and not all carriers do business in every State, but if it came down to moving or facing financial devastation, then wouldn't you just choose not to move? It's not like people don't have choices. Why would you move if you knew you were going to face financial devastation because of health insurance problems?

Hope none of us has or will face devastating illness, but I work with this all the time.

I can tell you that a system which forces an already-besieged patient and family to move out of state mid-crisis just to get better coverage is not a good system. Uproot family, home, and friends when you need them most? No thanks!

Mykidslovedogs, not implying you personally meant it in this way, but to describe that as a "choice" borders on the cynical. Surely Americans deserve better than that.

[mykidslovedogs]

Actually, what I was saying is that if you were sick, and you already had good coverage in your state, then why would you move, thus creating a problem for yourself to get coverage in the new state? Martha had stated that it can be hard to obtain coverage in a new state if you move when you have a pre-existing condition, which is true. So my point was, "then why would you move?" People have the choice to stay right where they are.

[Rich_in_Tampa]

Originally Posted by mykidslovedogs

Actually, what I was saying is that if you were sick, and you already had good coverage in your state, then why would you move, thus creating a problem for yourself to get coverage in the new state? Martha had stated that it can be hard to obtain coverage in a new state if you move when you have a pre-existing condition, which is true. So my point was, "then why would you move?" People have the choice to stay right where they are.

OK, gotcha. Too much text in one message for me to digest .

[Martha]

Originally Posted by mykidslovedogs

Hi Martha,

Good conversation! I can tell we do not share the same philosophy, but that's what makes these forums so much fun!

Yup. We disagree on a lot.

One thing you're forgetting is that employer-sponsored health insurance premiums are only composite rated (averaged) with groups larger than 10 employees. Small employers (2-10 employees) make up a huge percentage of those offering employee benefits, and their benefits are usually age-banded. Thus, those over the age of 50 get killed pricewise in the group market. oftentimes, and individual or family plan is 2-3 times less expensive for someone in that age category. For an employee over the age of 50 who is not receiving benefits for spousal coverage, an individual plan for the spouse can save thousands of dollars (if the spouse can qualify for coverage).

True about the rating of small employers. It is a big problem. The employer can't afford the insurance. The employees often can't either, or end up with exclusions in their coverage. If the employee is perfectly healthy they do ok, but plenty of people in their 50s are close to uninsurable.

I understand your point about those born with congenital illnesses, but if their parents had had their own individual policy at the time of birth or adoption, that child would have been granted guaranteed issue onto their parent's plan and the parents would not then have to worry about qualifying for coverage for a sick baby later on.

Fine until the kid is an adult and can't buy insurance.

Also, in general, insurance carriers do not rate based on PERSONAL claims experience. Rates are increased based on industry trends and utilization of large groups of members within geographical areas. Therefore, the cost of that child's coverage is not going to inflate any higher than any other person within the insurance carrier's membership.

But, there is individual underwriting which may result in them not selling you a policy or selling at a very high cost. Plus, there is a dispute as to how much "reunderwriting" occurs resulting in increasing premiums based on individual experience.

Lastly, if that carrier happens to go out of business or stop doing busines in your state, then the child would be granted creditable coverage towards pre-existing condition exclusions on the state-guaranteed plan if they do not have a gap in coverage.

But, if they are not HIPAA qualified, there may be a waiting list or a preexisting condition waiting period. There is no federal law which would bar a preexisting condition waiting period if coming off of an individual plan. And the insurance might not be affordable.

Are you willing to give up 50% or more of your hard- earned income to pay for everyone else's healthcare needs? What is wrong with each of us doing the best we can to take care of our own financial needs? Yes, it is unfortunate that some will not be as well off as others, but if we move to a national healthcare system, we are going to compromise the very thing that makes the United States the leader in health care technology and innovation - competition!

Fifty percent of my income? Where do you get such a number? We pay more already in the United States for healthcare than many countries with universal care, and those countries often have better outcomes.

If we nationalize healthcare (and I mean a purely socialized form of healthcare and not one where people are given a basic level of care with the option to supplement with their own insurance because we already have that...) then we are going to lose good doctors, and compromise the quality of care in our country.

I don't buy this. Plus, we do not guaranty people a basic level of care. There are resources as you mention, but many get turned away. I just read an article about the "free clinic" in my neighboring Wisconsin. They can't come close to treating everyone who seeks care. And the resources are often only for the very poor. A middle class person without insurance can easily be financially destroyed by a medical problem. Do we really need to have people lose their retirement funds and home to pay for necessary care?

[Martha]

Want to add one more thing. Lack of insurance increases the likelihood you will die.

We compared mortality of a nationally representative cohort of insured and uninsured near-elderly people with stratification by race; income; and the presence of diabetes, hypertension, or heart disease, using propensity-score methods to adjust for numerous characteristics. Lacking health insurance was associated with substantially higher adjusted mortality among adults who were white; had low incomes; or had diabetes, hypertension, or heart disease. Expanding coverage to the near-elderly uninsured may greatly improve health outcomes for these groups.


http://content.healthaffairs.org/cgi...tract/23/4/223

More than 40 million Americans are subject to greater health risk because they lack health insurance. Research studies consistently show that working-age Americans who do not have health insurance have poorer health and die prematurely (now we are up to 46 million uninsured.)

http://www.rwjf.org/research/researc...id=1041&ia=132

[mykidslovedogs]

Originally Posted by Martha

Yup. We disagree on a lot.
"True about the rating of small employers. It is a big problem. The employer can't afford the insurance. The employees often can't either, or end up with exclusions in their coverage. If the employee is perfectly healthy they do ok, but plenty of people in their 50s are close to uninsurable."


I'm not sure I understand how to post your quotes in my response but here goes....In my state, all group coverage is guaranteed-issue. You cannot be denied coverage or have policy exclusions on an employer-sponsored health plan. If you are self-employed, you can also qualify for guaranteed issue coverage with no exclusions or pre-existing condition waiting periods.


"Fine until the kid is an adult and can't buy insurance."

In my state, if you are a child on a parent's INDIVIDUAL health plan, you can keep that policy throughout the rest of your life. Once you turn 19, you simply come off of the parent's plan, and you roll over to coverage under your own social security number with no re-underwriting.


"But, there is individual underwriting which may result in them not selling you a policy or selling at a very high cost. Plus, there is a dispute as to how much "reunderwriting" occurs resulting in increasing premiums based on individual experience."

That's why you want to buy the policy while you are still healthy because the rate you are given at policy inception will define all future increases. Your rates will never be increased after that based on PERSONAL claims history, but only on industry trends and utilization among the entire carrier's membership.


"But, if they are not HIPAA qualified, there may be a waiting list or a preexisting condition waiting period. There is no federal law which would bar a preexisting condition waiting period if coming off of an individual plan. And the insurance might not be affordable."

In my state, there would be no need to come off of an individual plan onto a HIPAA plan. Once you have individual coverage, it it guaranteed renewable. If the plan ceases to exist, then you become HIPAA eligible (I don't know about other state laws on that issue).


"Fifty percent of my income? Where do you get such a number? We pay more already in the United States for healthcare than many countries with universal care, and those countries often have better outcomes."

The reason we pay more for healthcare than other countries with universal care is because our technology and innovation is so much better. (I have a feeling that you believe the insurance carriers are simply ripping us off, but I do not believe that is true.) We pay more for better services and timelier service. In the U.S, we don't have to wait for heart surgery when we need it. I'm sorry for the misstatement. What I believe is that if we go to a national healthcare system, our tax rates, in general, will increase to more than 50% (The tax bracket I am in right now is already 50%, so I believe a national healthcare system will make it even worse.) I don't know about you, but I put in about 60 hours or more per week at my job, and I do mind being forced to give half of my income away for the welfare of other people. I don't mind giving my share, but half is an awful lot!

"I don't buy this. Plus, we do not guaranty people a basic level of care. There are resources as you mention, but many get turned away. I just read an article about the "free clinic" in my neighboring Wisconsin. They can't come close to treating everyone who seeks care. And the resources are often only for the very poor. A middle class person without insurance can easily be financially destroyed by a medical problem. Do we really need to have people lose their retirement funds and home to pay for necessary care?"

Why doesn't the middle class person buy their own health insurance while they are healthy? At $300 or less a month for an individual policy, it is certainly affordable for the middle class. That's less than a trip to Disney Land.

[macnjus]

Amen Martha -

"A middle class person without insurance can easily be financially destroyed by a medical problem. Do we really need to have people lose their retirement funds and home to pay for necessary care?"

I would add that this could also happen to a person with a several million dollar net worth, decidedly above "middle class".

They shouldn't call the prices paid by insurance companies as "discount prices", rather, they should refer to list prices as "uninsured person surcharge". In many cases, the reason some people with low net worth choose not to insure is that it does them no good, as when they incur a large charge, they simply can't pay it anyway, they become yet another sad medical bankruptcy case. Thus, it is the relatively well-off, who desire insurance but can't get it for some reason, that are the only ones who actually pay the "uninsured person surcharge".

In my opinion, medical service providers who take insurance and medicare payments should not be allowed to charge more than around 20% more for that service to an uninsured person.

[Martha]

Mykidslovedogs, the quote thing is a bit of a pain. You can cut and paste quotes from a prior post by bracketing the quotes like this: [quote ] insert what you want to quote here [/quote ], leaving the space out between "e" and "]"

You are in one of those expensive guaranty issue states where HIPAA is not so important. Only a few states are that way. Most other states give few rights once you are in the individual market. Federal law only protects the HIPAA eligible, those coming off from group plans or moving from one group plan to another. The only rules HIPAA has that effect the individual market are (1) individual policies are guaranteed renewable (with some exceptions, including termination of the plan itself) and (2) states have to have a mechanism in place where HIPAA eligible people are offered some sort of insurance policy. There is no cost regulation and if you lose your individual policy there is no federal law which will guaranty coverage elsewhere.

So, if you are not in a guaranteed issue state, and you are not HIPAA eligible, you may not be able to buy insurance at any cost. (Unless you move to NJ or some other guaranteed issue state.) If you lose your individual health insurance, even if you are insurable you will have a pre-existing condition waiting period when you buy into a new individual plan.

I am fortunate to live in Minnesota. It has the greatest percentage of insureds in the United States. It does this without breaking the bank. There is a risk pool that covers more people than any other risk pool in the US. The rates are limited to between 101% and 125% of average individual plan rates. For those that can't afford the risk pool and are not eligible for medicaid, there is a sliding fee plan, Minnesota Care.

[Martha]

Mykids, I don't think that insurance companies are ripping us off in any way that isn't just in the nature of insurance (though some of the executive compensation is a disgrace). Instead, I think that the insurance model is not a good way to pay for health care. An insurance company's interest is to make money. They want to insure healthy people and drop them when they get expensive. This is the nature of insurance. Because of that problem, we need government interference of one kind or another.

I refuse to believe that it is irresponsible for people not to buy health insurance on the individual market when they are healthy. They buy through their jobs because that is the way it has been for years. It is almost always cheaper for the employee to go that way. Man, people have enough problems in life without thinking about all the bad things that can happen if they didn't buy the right kind of insurance at the right time. You can't just turn that history around by saying what should have happened. The American religion of personal responsibility wants us all responsible for our own portfolio, our own retirement plan, our own children's education, and now healthcare. This is overwhelming in an increasingly complicated world. When people are overwhelmed, they often check out and do nothing.

We also have no idea how the individual market would have worked. If employers hadn't got into the group coverage business, it could be that only healthy people would have been able to get health insurance and the government may have had to step in sooner to regulate the individual market.
I always thought it was a bad idea to tie insurance to employment.

[mykidslovedogs]

Martha,

I am actually NOT in a guarantee issue state, but in my state ALL EMPLOYER SPONSORED HEALTH PLANS are guaranteed issue so no employees can be denied coverage or have exclusions on their policies, regardless of age, and we have a high risk pool HIPAA plan that anyone who is uninusurable can qualify for. Yes, the rates are higher due to the fact that is is guaranteed issue, but it is still better than having no insurance at all.

The individual and family market in my state is medically underwritten, and that is OK with me.

I guess we will just have to agree to disagree on the personal responsibility issue. I just don't think there is anything wrong with it. If I decide to have kids, then I should be ultimately be responsible for their education, not someone else. If I decide to live an unhealthy lifestyle, then I should be responsible for the healthcare costs associated with that. If I want to retire young, then who better to manage my portfolio than myself and those I pay to help me? If I want to retire at all, then I should be the one to plan in advance by saving money for the future and purchasing the proper insurance to protect my assests as I get older. These are just basic responsibilities. If someone is going to check out because it is so complicated, then let them suffer their own consequenses. We reap what we sowe.

There is already enough goverment regulation in the insurance industry and in the healthcare industry. Medicare and Medicaid, I believe, are two of the primary reasons for extremely expensive health insurance premiums. Here is why I believe that. Just think of the general philosophy. In order to fund Medicare and Medicaid we have to tax people. The amount of money that the government raises to pay for Medicaid and Medicare is not enough to cover our healthcare provider's basic exepenses (overhead, equipment, employees, LIABILITY INSURANCE, and the general costs of doing business.) Therefore, Doctors have to charge more to the PRIVATE sector in order to compensate for the pennies on the dollar that are paid to them by Medicaid and Medicare. The higher prices that are passed on to the private sector trickle down to the INSURED in the form of higher health insurance premiums. Higher health insurance premiums mean fewer people will be insured. Fewer people insured means more people on Medicaid, and more people on Medicaid means higher costs for the private sector, and so on and so on.... the more the government gets involved, the worse the problem becomes...

I believe and agree with you that some regulation is definately necessary, but I think it would be disastrous to nationalize the entire system. There has to be a happy medium in there somewhere. I think it is inexcusable and irresponsible for people to wait until they are in dire straights and then expect someone else to bail them out. We are all going to either live a full healthy life, die, get sick or become disabled at some point. It is irresponsible to pretend we are invinceable and expect someone else to take care of us because we failed to plan ahead.

[Rich_in_Tampa]

Originally Posted by mykidslovedogs

These are just basic responsibilities. If someone is going to check out because it is so complicated, then let them suffer their own consequenses. We reap what we sowe.

I have been following this discussion, and have a few words from the front line (Mykids - I'm a doctor with a lot of years in primary care and cancer care). The arguments you give are cogent, but I almost always hear them with such fervor from people who are blessed with good heatlh and adequate resources.

Unfortunately, we're outnumbered. There are millions of hardworking folks who don't choose to get sick, and don't follow a lifestyle that makes them sick. They just get sick. Cancer, heart disease, debilitating diseases, on and on. And despite their best efforts, they go from "gettin' by" and sick to impoverished and sick. Impoverished and sick is not a good thing to be in the current system.

And their are ready-to-retire folks who planned and saved for decades and now are sensibly afraid to retire because of health insurance fears or costs. Lots of gaps in the system. If you don't happen to be caught by any of them, all the better for you. But I feel it is important and right to think about those who are caught through no plausible cause or choice of their own. Yes, we subsidize their care, but they are far from well-cared for.

We need a safety net desperately.

[mykidslovedogs]

Rich in Tampa,

I really am not a calloused insensitive person. I understand that there are so very many people that don't choose to get sick, but why oh why can't they have planned better while they were young and healthy? Even paying regularly for a $2000 deductible/100% high deductible healthplan, kept in place for life, is better than going into financial ruin. We pay for our own home owner's insurance, we pay for our own car insurance, some are even smart enough to purchase their own life insurance so their loved ones won't be financially devastated when they die....so why do we think it is up to others to pay for our health insurance/healthcare costs? Most of us will get sick or disabled someday...Especially now that people are living longer and longer...so why is it so bad to ask people to plan for that?

Maybe the people you work with didn't know better, so they depended on employer-sponsored benefits all of their lives and then lost their benefits when they became unemployed. It's too bad that someone didn't teach them about the long-term consequences of depending on employer-sponsored health insurance.

I am fortunate enough to be healthy right now, but I have had in place, for many years, a plan to protect myself in the case that I do become ill, and it is a personal, high-deductible, HSA compatible health savings account. So far, I have saved so much in premiums that I have been able to save, on a tax-deductible basis almost two times my deductible. Therefore, if I get sick, I already have my own safety net in place to protect myself. My deductible is $5150.00. Since I have already been able to save almost $10,000, I basically don't have to worry about any healthcare costs for at least two years if I get sick. Granted, I have made my savings a priority, so I have sacrificed things like vacations and a big, fancy house in order to plan for an early retirement. What is so bad about asking others to do the same thing, so that I don't have to sacrifice even more to pay for their healthcare costs?

I really don't want people to have to suffer. That's why I feel it is so important for us to teach our young to plan ahead. Simply saving for retirement is not enough. We need to teach our young to insure and protect their assets IN CASE the unthinkable happens. Granted, some are sick from birth, but for those that could have planned, why? Why do we need the goverment in everything?

We DO have some safety nets. Unfortunately, they are government-sponsored, so they lack quality. Why do people think that nationalizing health insurance will give us anything better that what we already have? I fear that all "nationalized healthcare" will be is a bigger and even more poorly managed Medicaid system.

What I am saying is that there doesn't have to be gaps in the system. Let's work on changing the cultural entitlement mentality. Let's encourage people to purchase coverage for themselves when they are young and healthy instead of teaching them to depend on employer sponsored benefits. What is so wrong with teaching our young to take care of themselves...to plan for the worst case scenario so that they don't end up like the millions of hardworking folks who never purchased good health insurance while they could qualify for it, and who ended up in financial ruin because of it?

[Martha]

Originally Posted by mykidslovedogs

Martha,

I am actually NOT in a guarantee issue state, but in my state ALL EMPLOYER SPONSORED HEALTH PLANS are guaranteed issue so no employees can be denied coverage or have exclusions on their policies, regardless of age, and we have a high risk pool HIPAA plan that anyone who is uninusurable can qualify for. Yes, the rates are higher due to the fact that is is guaranteed issue, but it is still better than having no insurance at all.

I misunderstood your post. What state are you in? In any event, federal law does provide that if an employer purchases group coverage, the insurance company cannot exclude someone from the group. However, the insurance company may in fact underwrite the group and decide not to bid on coverage. Also, there is portability in that you can switch jobs and join the new employer's group plan. The same rules do not apply to the individual market, which is for the most part not regulated.

We reap what we sow.

Rich addressed this point well but I feel the need to comment. I have many stories. I know a woman whose husband was killed a few months ago. He was an LPN, and earned not a whole lot. She stayed home with the kids. After he died, she could buy continuation insurance through COBRA for a period of time. She had to cash in his retirement account to pay the premiums and pay living expenses, like the mortgage, while she tries to find work. If she doesn't find a job she is in deep trouble as she will run out of money. She essentially has no work experience. I hope she finds a job with benefits. I hope she finds a job period.

I know a woman who worked in a health food store. No health benefits. Little money in the family. She had a lump in her breast. She delayed going to the doctor because of the cost. It was cancer and she died. Maybe 20 years before she should have bought an individual insurance plan, but she didn't. Hardly anyone does--the individual market is only 4% of the market. Time goes by. You lose the job that provided insurance. You get one that does not and you no longer can afford to buy.

There are a number of people who have jobs that pay $20,000 or $30,000 a year. They get along if they have insurance through work. Some do. Some don't. A job loss, a divorce, a death in the family, can lead to catastrophe. I believe most of them are doing the best they can with the resources they have. There are 46 million uninsured. This number is increasing every year. More and more employers are dropping health plans. This is more than a failure of personal responsibility. This is a national problem.

HSA's are fine if you have money and are healthy.

I understand that there are so very many people that don't choose to get sick, but why oh why can't they have planned better while they were young and healthy? Even paying regularly for a $2000 deductible/100% high deductible healthplan, kept in place for life, is better than going into financial ruin. . . .

Let's encourage people to purchase coverage for themselves when they are young and healthy instead of teaching them to depend on employer sponsored benefits. What is so wrong with teaching our young to take care of themselves...to plan for the worst case scenario so that they don't end up like the millions of hardworking folks who never purchased good health insurance while they could qualify for it

And why would you assume that the individual market will be better? It is only 4% of the total market. Given that it is such a small part of the total market I wouldn't call people who didn't buy into it poor planners. The market itself has changed tremendously over the years. Know anyone who has had the same individual insurance plan for 40, 50 years?