Why are we so paranoid about having choices?

[Rpharmer]

I remember that when I first heard about the different "metal levels" and how only the Silver plans would include the cost-sharing options (lower deductibles, OOP max, co-pays, etc), I thought, "Why is that? What if I like a Bronze plan..." But when we finally got to see the choices, and I started comparing them, I started to feel differently! Comparing Blue Cross to Coventry, then Blue Select with Preferred Care Blue, then Blue Saver vs Blue Classic vs Blue First, then factoring in the Metal levels... Well, I'm pretty good with spreadsheets, but mine became a monster. But, turns out, focusing on the Silver options helped me get to the bottom line pretty quickly -- I think. Won't know the "real" answer till sometime next year, but that's the nature of insurance, and illness or health.

And, there's always another open enrollment in twelve months (said the optimist?)

 

[rbmrtn]

I am dealing with that right now with my mom... her insurance company is refusing to pay legit medical bills because they were not 'pre-approved'....

I know people that have been in that. Had insurance on paper then had fight to get them to pay for what they were supposed to. You never really know if you have insurance till you try to use it.

 

[samclem]

I guess I have just described Medicare for all.

I do wonder why the shorthand is always "Medicare for all" instead of "Medicaid for all." Medicare is paid for with premiums collected from a payroll tax, and to be qualified a person/family needs to have been employed and paid in. Medicaid is paid for from the general fund (state and fed), and there are no requirements to have been employed. And, now there are no asset tests (in some states), though income tests remain.

Dispensing "free" money from the government's general fund to pay for the health care of all citizens bears a lot more similarities to Medicaid than to Medicare. I'm guessing "Medicare" is viewed more favorably, so that's the handle that is used. In practice, I think the jury is still out on whether the level of care, availability, etc would more resemble Medicaid or Medicare.

Choices: (Most) people like them because they want to have some input into what happens to them. Who among us has fewest choices? Infants, the institutionalized, the infirm/dependent. They are not "free" to the extent they must rely on others to provide for them. Next comes the poor, who have some options, but they are limited. In general, most people want to be independent, they resent dependency. Even at the feet of a benevolent benefactor who "knows what is best." We're just funny that way.

 

[ShokWaveRider]

I do wonder why the shorthand is always "Medicare for all" instead of "Medicaid for all."

Nope. Medicaid would Go away. Base Medicare would be funded via the tax roles like most other developed countries (and YES we may have to pay more). No different to other insurance premiums but paid directly from taxes. That way everyone who pays taxes contributes.

 

[samclem]

Nope. Medicaid would Go away. Base Medicare would be funded via the tax roles like most other developed countries (and YES we may have to pay more). No different to other insurance premiums but paid directly from taxes. That way everyone who pays taxes contributes.

But less than 45% of people pay Federal Income taxes, yet you want everyone to get this "free" health care. You are describing something much closer to Medicaid, not Medicare (if we must use an American program name). There's nothing wrong with that--is there?

 

[ShokWaveRider]

Works for Canada and everyone else. Would you rather they went without?

 

[Katsmeow]

I do wonder why the shorthand is always "Medicare for all" instead of "Medicaid for all."

The reason I use Medicare for All is not because Medicare is viewed more favorably than Medicare. It is because I am more familiar with Medicare and how it works since I've had family and friends on Medicare, including my husband. I just don't have the personal experience with Medicaid. I've found Medicare generally works well.

 

[M Paquette]

But less than 45% of people pay Federal Income taxes, yet you want everyone to get this "free" health care.

Excellent point. None of my damn kids paid me one red cent while growing up, but I was still expected to provide them with medical insurance, health care, AND the moochers even expected me to clothe and feed them. Buncha looters and moochers, ya ask me! Shoulda left them all out on the hillside...

Hint: About 46% of US Households owed no federal income tax for 2011. A significant majority of these still paid federal payroll taxes, as well as federal excise taxes, state, and local taxes of various sorts. TPC estimates that 61% of households paying no federal income tax are working households.[1] Further, most of these working households do pay taxes in other years. (Income and tax bracket may vary from year to year.)[2]

Removing services from people in years when they don't have sufficient income, and may be in greatest need of those services strikes me as being less than optimal.

1. Tax Policy Center, “Who Doesn’t Pay Federal Taxes,” TPC Tax Topics | Who Doesn't Pay Federal Taxes?

2. Tim Dowd and John B. Horowitz, “Income Mobility and the Earned Income Tax Credit: Short-Term Safety Net or Long-Term Income Support,” Public Finance Review (April 11 2011), p.p 619-652

 

[audreyh1]

I remember that when I first heard about the different "metal levels" and how only the Silver plans would include the cost-sharing options (lower deductibles, OOP max, co-pays, etc), I thought, "Why is that? What if I like a Bronze plan..." But when we finally got to see the choices, and I started comparing them, I started to feel differently! Comparing Blue Cross to Coventry, then Blue Select with Preferred Care Blue, then Blue Saver vs Blue Classic vs Blue First, then factoring in the Metal levels... Well, I'm pretty good with spreadsheets, but mine became a monster. But, turns out, focusing on the Silver options helped me get to the bottom line pretty quickly -- I think. Won't know the "real" answer till sometime next year, but that's the nature of insurance, and illness or health.

And, there's always another open enrollment in twelve months (said the optimist?)

On the other hand - I discarded Silver really quick when I realized I could save big on premiums and apply the savings toward the deductible instead - if needed.

Silver is like the plans we used to have, with high premiums because we had low doctor visit copays and low prescription copyays. I never had the bronze option before, and it's better for DH and me.

 

[Mulligan]

I do wonder why the shorthand is always "Medicare for all" instead of "Medicaid for all." Medicare is paid for with premiums collected from a payroll tax, and to be qualified a person/family needs to have been employed and paid in. Medicaid is paid for from the general fund (state and fed), and there are no requirements to have been employed. And, now there are no asset tests (in some states), though income tests remain. Dispensing "free" money from the government's general fund to pay for the health care of all citizens bears a lot more similarities to Medicaid than to Medicare. I'm guessing "Medicare" is viewed more favorably, so that's the handle that is used. In practice, I think the jury is still out on whether the level of care, availability, etc would more resemble Medicaid or Medicare. Choices: (Most) people like them because they want to have some input into what happens to them. Who among us has fewest choices? Infants, the institutionalized, the infirm/dependent. They are not "free" to the extent they must rely on others to provide for them. Next comes the poor, who have some options, but they are limited. In general, most people want to be independent, they resent dependency. Even at the feet of a benevolent benefactor who "knows what is best." We're just funny that way.

Sam, I think being able to distinguish the difference between those two terms as a middle class commoner such as myself, is a sign of becoming old. In my 20s and 30s I didn't know the difference between Medicare and Medicaid and used them interchangeably. Now, I clearly know the difference.

 

[ziggy29]

But less than 45% of people pay Federal Income taxes, yet you want everyone to get this "free" health care. You are describing something much closer to Medicaid, not Medicare (if we must use an American program name). There's nothing wrong with that--is there?

Medicare is funded with payroll taxes, not federal income tax. And a heck of lot more than 45% of the people pay the payroll taxes. And even those who haven't usually have for quite a few years.

 

[Katsmeow]

But less than 45% of people pay Federal Income taxes, yet you want everyone to get this "free" health care.

I agree with the comments on way more people paying payroll taxes. Regardless, when I said I favored Medicare for all I never said that I viewed it as free. I am well aware that it is not free. I also know that if it covered more people that there would need to be more money to pay for it. I am not one of those who believes that universal health care is free. Personally I am OK with raising taxes to pay for the things that I think should be provided through government.

 

[clifp]

I am not sure what my exactly options are. I have been able to look at the plan on HawaiiHealthConnect.com for more than month.

Still it seems in many ways I have less choices than before. My old plan (which I can keep and probably will despite a $40/month premium hike average last 10 years $20) didn't cover maternity, birth control, prescription drugs, and was very limited on mental health coverage. On the other hand 3 nights in the hospital would have probably cost me a $1000 or so and my max out of pocket was $3,000 . Even with the new ACA Gold plan 3 nights in the hospital is almost certainly going to cost me $2,000+ and $6,350 max out of pocket is a lot of money on top of $4500 worth of annual premiums. I'd gladly trade all of the other coverage I get from ACA for keeping my out of pocket at $3k vs 6,350.

Now we all have the same type of coverage and the only differences are premiums vs copays. I don't understand why we can't have a system where you have basic catastrophic insurance, and then add on additional coverage for additions, like maternity, prescription drugs etc.

I can do this with car insurance. I generally only keep collision on a car a couple of years. I also don't have road assistance, rental cars or any of the other things. What I do have is max out liability. I have relatively deep pockets and I'm not judgement proof. Being out hundreds of dollars isn't go to change my life being out hundreds of thousands will. Other people are different than can go with minimum liability, but carry collision, road side, because for them being out a couple thousand is big deal. But no one is going to sue them for a $1 million, cause they don't have it.

 

[savory]

We are having an interesting dinner conversation right now. As you consider the need for health care, perhaps this is worth considering. The mortality rate of black men is higher than white men who live outside of prison. That is, black men die at a younger age than white men. However, when you look at mortality rates of incarcerated white and black men, their mortality rate is the same. So what is difference? The conclusion is the access to health care. "These findings suggest that firearms and motor vehicle accidents do not sufficiently explain the higher death rates of black males, and they indicate that a lack of basic healthcare may be implicated in the death rates of black males not incarcerated." http://link.springer.com/article/10.1353/dem.0.0123

 

[bamsphd]

I don't understand why we can't have a system where you have basic catastrophic insurance, and then add on additional coverage for additions, like maternity, prescription drugs etc.

Maternity might not be your best example. Though there is no question that maternity coverage is very expensive and used to be optional. I think it is difficult to get a fetus to opt-in for insurance, regardless of how much they might need the coverage. I also don't think having a mother unable or unwilling to pay for maternity coverage is a good reason to deprive the fetus of such coverage.

Actually, based on a PBS program a few years back comparing the health systems in different countries, I think you want something similar to the Swiss system. As I recall it was described as mandatory insurance providing mandatory minimum coverage, with insurance companies competing by offering different "extras."

 

[samclem]

Works for Canada and everyone else. Would you rather they went without?

Strawman. I'm saying that universal health care that is provided to all citizens (without regard to what they paid, employment status, etc) is more similar to what we know as Medicaid than Medicare. That is all. We're not talking about Canada. But, since you did: Canada's health insurance system is paid for from their general fund (like US Medicaid, US Medicare is not). The Canadian system is administered by the provinces, not the Canadian government. (In the US, Medicaid is administered by the states, Medicare is administered by the federal government). And, most importantly, getting covered in Canada is totally disconnected from whether or not you've ever worked (like US Medicaid, not like US Medicare). So, if you want something like Canada's system here in the US, just call it "Medicaid for all" rather than "Medicare for all." I can't see why anyone would object to that.

Removing services from people in years when they don't have sufficient income, and may be in greatest need of those services strikes me as being less than optimal.

Sure, but I'n not sure it is responsive to the point I made ("Medicare for all" vs "Medicaid for all").

Medicare is funded with payroll taxes, not federal income tax.

True, and that's part of my point. (Well, kinda true. It's supposed to be funded by payroll taxes, but it has been running in the red since 2009. It's being funded by repayment of the built-up IOUs from the surplus years). But, yes, Medicare eligibility is linked to employment, which is why ShokWaveRider's plan for insurance not linked to employment is more like Medicaid.

And a heck of lot more than 45% of the people pay the payroll taxes.

Maybe more, but if so it isn't many more. The BLS says the "employment to population ratio" is 59%. The definition of "employed person" for this purpose is pretty liberal, and clearly all the people included don't pay payroll taxes: It includes:

Persons 16 years and over in the civilian noninstitutional population who, during the reference week, (a) did any work at all (at least 1 hour) as paid employees; worked in their own business, profession, or on their own farm, or worked 15 hours or more as unpaid workers in an enterprise operated by a member of the family; and (b) all those who were not working but who had jobs or businesses from which they were temporarily absent . . .

Now, those 15 and under account for about 21% of the US population. If we know (from above) that 59% of the remaining 79% are "employed", that means (.59 x .79 = .466) 47% of Americans are employed (and presumably paying payroll taxes--though the number is certainly lower due to the definition of "employment" we are using).

If we think of all the old folks who don't pay payroll taxes anymore but still pay income taxes, it's not very clear that more people, overall, are paying payroll taxes than paying FIT. For general discussion, the numbers are probably very close: in each case (FIT and payroll taxes), about 1/2 of the population at any particular time is paying the tax.

 

[Htown Harry]

I don't understand why we can't have a system where you have basic catastrophic insurance, and then add on additional coverage for additions, like maternity, prescription drugs etc.

Well, one consolation is that pregnant women will help pay for us old guys and our colonoscopies, PSA tests, etc.

This short article does a nice job of summarizing the benefits of an aggregated pool of insured folks. I don't agree with every line, but the concept is fundamental to improving health care insurance.
Why Should a Childless Man Have to Buy Maternity Coverage - Consumer Reports News

...another reason we know that buying insurance a la carte doesn't work: we've already tried it with maternity care...

Why so expensive? Because the only people who buy it are, naturally, people planning to have a baby. Insurers know this and price accordingly. As a consequence, this maternity "coverage" costs just about as much as paying cash for having a baby, which means it's coverage in name only.

 

[ziggy29]

Well, one consolation is that pregnant women will help pay for us old guys and our colonoscopies, PSA tests, etc.

And Viagra!

 

[haha]

This reminds me of something funny from a previous employer. We were given three choices for health care plans, but when I dug into two of them, it was clear that one of them was always superior to the other. So there were really only to choices that made rational sense.

This is very common in many choice situations. One choice dominates, in that there is no meaningful dimension on which choice B is superior to choice A. Yes many people will always chose B.

This social reality can be helpful under any government other than a social welfare government. It stinks when the clever, diligent ones will get stuck paying for everyone else.

This is one reason why I like Victorian fiction. Act stupidly or fecklessly and you will suffer and often enough so will anyone else who happens to be dependent on you. Horrible to a modern sensibility, but it had its upside.

Ha

 

[ziggy29]

This is very common in many choice situations. One choice dominates, in that there is no meaningful dimension on which choice B is superior to choice A. Yes many people will always chose B.

Sort of like the choices we have for my wife's insurance that her employer is offering to her (but not me). They are paying her full cost of a "Gold" level plan (roughly), and we could choose to upgrade to "Platinum" at our own expense. But there is NO scenario where it would save us more than $600 a year, and it would cost us more than $600 a year to buy into. You don't have to be Einstein to do that math.

 

[Texas Proud]

Someone posted that you have to get a Silver plan to get a subsidy...


Is this correct I thought it was based on the Bronze plan and applied to the Bronze plan....


If I am wrong, that might make a big change in my decision...

 

[rescueme]

And Viagra!

Not covered by Medicare .....

 

[pb4uski]

Someone posted that you have to get a Silver plan to get a subsidy...


Is this correct I thought it was based on the Bronze plan and applied to the Bronze plan....


If I am wrong, that might make a big change in my decision...

IIRC the subsidy is computed as the difference between the second lowest priced silver plan available to you and the requisite percentage of your household income (MAGI). And your net cost would be the cost of whatever plan you chose less the subsidy.

So the subsidy will be the same no matter if you chose a bronze, silver, gold or platinum plan and you'll personally pay the difference (or get the benefit if the cost of your plan is less than the second lowest cost silver plan). Below is an example of a couple in Vermont who have $50k income.

Your household's monthly subsidy:$430
With this subsidy, the average silver Couple plan will cost you:$404 per month.

View the chart below for the average costs of other metal level plans.

Product	Full Premium	Your Cost
Platinum	$1,177	$747 per month.
Gold	$996	$567 per month.
Silver	$834	$404 per month.
Silver HDHP	$841	$412 per month.
Bronze	$692	$262 per month.
Bronze HDHP	$713	$283 per month.

Premiums shown are averaged across insurers, and are for illustration only.

 

[clifp]

Well, one consolation is that pregnant women will help pay for us old guys and our colonoscopies, PSA tests, etc.

This short article does a nice job of summarizing the benefits of an aggregated pool of insured folks. I don't agree with every line, but the concept is fundamental to improving health care insurance.
Why Should a Childless Man Have to Buy Maternity Coverage - Consumer Reports News

I pretty much disagree with everything she wrote.

Fundamentally insurance should protect people from rare, but super expensive event. Maternity coverage fails both criteria.

Lost in the authors babble about $30K maternity bills, is a simple fact. According to several source on google the average cost for delivery in the US is $3,500. Now that is a decent chunk of change, put relatively small compared to the overall cost of having a kid. We already give parents a $1,000 tax credit and $3,400 deduction for a kid. Now that doesn't quite cover the average cost of hospital stay but it is close. If we want to encourage more kids give them another $1,000-$2,000 tax credit the year the kids is born

For a couple of years my roommate, was a Yale trained Nurse midwife. (Basically the equivalent of Physician assistant). As she explained humans have been having babies with high degrees of success for thousands of years, even before modern medicine. There is very little difference in mortality rates for normal pregnancy for well trained midwife in clinic, and obstetrician in hospitals . She worked with poor people (to pay back her nursing loans) in various parts of the country. The bill for her deliveries in most places was in the $1,000 to $1,500 even in Hawaii. Of course this is what poor people without insurance used. The well insured upper middle class folks always wanted hospitalization, drugs, and the whole 9 yards cause they weren't paying for it.

Now there was always a surgeon on a call if something went wrong but those are rare. For those problem pregnancies that is what you have insurance for. Once you hit your $6,350 max out of pocket your medical insurance covers the rest.

The same thing goes for Viagra, most insurance coverage for type 2 diabetes and birth control pills. These are neither super expense nor rare conditions. They for the most part are life style choices and the cost can be controlled if people are incentivized properly. For instance generic birth control pills can be purchase for $15-$20/month, but now that birth control pills are free there is no reason for woman not to go with slightly improved brand name birth controls bill that cost $80-$100/month.

So I am fine for having unusual/life threatening pregnancy being covered but not the run of the mill variety. If people want to protect against those type of risks they should pay for it.

 

[ziggy29]

Not covered by Medicare .....

Fair enough. It's not like women on Medicare are getting pregnant, either....