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Old 11-11-2013, 06:21 PM   #41
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Originally Posted by ShokWaveRider View Post
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.
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Originally Posted by M Paquette View Post
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").

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Originally Posted by ziggy29 View Post
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.

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Originally Posted by ziggy29 View Post
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:
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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.
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Old 11-11-2013, 06:23 PM   #42
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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

Quote:
...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.
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Old 11-11-2013, 06:36 PM   #43
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Well, one consolation is that pregnant women will help pay for us old guys and our colonoscopies, PSA tests, etc.
And Viagra!
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Old 11-11-2013, 07:29 PM   #44
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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
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Old 11-11-2013, 08:27 PM   #45
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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.
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Old 11-11-2013, 09:47 PM   #46
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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...
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Old 11-11-2013, 10:10 PM   #47
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And Viagra!
Not covered by Medicare .....
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Old 11-11-2013, 10:50 PM   #48
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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.

Quote:
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.

ProductFull PremiumYour 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.
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Old 11-12-2013, 05:31 AM   #49
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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.
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Old 11-12-2013, 06:18 AM   #50
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Not covered by Medicare .....
Fair enough. It's not like women on Medicare are getting pregnant, either....
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Old 11-12-2013, 11:06 AM   #51
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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...
There is addition cost sharing support if FPL is below 250% but only for silver plans. Other than that your subsidy is calculated from the cost of the 2nd lowest cost silver plan available to you. The subsidy can be applied to any plan.
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Old 11-12-2013, 12:05 PM   #52
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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...
To qualify for "cost-sharing" subsidies, which can reduce your deductible, out-of-pocket-max, various co-pays, etc., you must choose a Silver plan. You must also meet more stringent income requirements. The "premium" subsidy, on the other hand, can be applied to any metal-level plan. In other words, there are two distinct types of subsidies, and it is not always clear which ones are being discussed. But most people have focused on the premium subsidies, since they are available to incomes up to 400% of FPL.

Not everyone who gets a premium subsidy will also qualify for the additional cost-sharing subsidies. You must have a MAGI in the lower income ranges to also qualify for cost-sharing subsidies.

For example, in the extreme, where MAGI is between 100% and 150% of FPL, a plan's actuarial value must be 94%. AV is complicated. But one way of raising it is by lowering a plan's deductible and OOP max, and that is what some plans have done.

In this example, using a MAGI of $16000 (roughly 139% of FPL), I found a plan with a $250 annual deductible and a $500 out-of-pocket max. It is, as required, a Silver plan. So, it's premiums are somewhat higher than the Bronze plan. But the Bronze plan cannot offer cost-sharing subsides, and it's comparable deductible in this plan was $5000, with an out-of-pocket max of $6250. It's actuarial value is estimated to be 60%.

Lower actuarial value plans, and high-deductible plans, are appropriate for many people, such as those who anticipate lower medical expenditures. Their goal may be to keep premiums lower, and insure against large, perhaps unpredictable events. Some people maintain that that is how all insurance decisions should be approached.

But the ACA requires the coverage of known, pre-existing conditions. If you are taking several expensive prescriptions, for example, that have no generic equivalent, or you have a medical condition that you know requires expensive treatment, a high deductible, high OOP max, low actuarial value plan may not make economic sense for you. What you will save with twelve low premiums could be overwhelmed by your other out-of-pocket costs.

These are my personal interpretations of the ACA, guided mostly by reading the Kaiser Family's healthcare reform articles.
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Old 11-12-2013, 12:59 PM   #53
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To qualify for "cost-sharing" subsidies, which can reduce your deductible, out-of-pocket-max, various co-pays, etc., you must choose a Silver plan. You must also meet more stringent income requirements. The "premium" subsidy, on the other hand, can be applied to any metal-level plan. In other words, there are two distinct types of subsidies, and it is not always clear which ones are being discussed. But most people have focused on the premium subsidies, since they are available to incomes up to 400% of FPL.

Not everyone who gets a premium subsidy will also qualify for the additional cost-sharing subsidies. You must have a MAGI in the lower income ranges to also qualify for cost-sharing subsidies.

For example, in the extreme, where MAGI is between 100% and 150% of FPL, a plan's actuarial value must be 94%. AV is complicated. But one way of raising it is by lowering a plan's deductible and OOP max, and that is what some plans have done.

In this example, using a MAGI of $16000 (roughly 139% of FPL), I found a plan with a $250 annual deductible and a $500 out-of-pocket max. It is, as required, a Silver plan. So, it's premiums are somewhat higher than the Bronze plan. But the Bronze plan cannot offer cost-sharing subsides, and it's comparable deductible in this plan was $5000, with an out-of-pocket max of $6250. It's actuarial value is estimated to be 60%.

Lower actuarial value plans, and high-deductible plans, are appropriate for many people, such as those who anticipate lower medical expenditures. Their goal may be to keep premiums lower, and insure against large, perhaps unpredictable events. Some people maintain that that is how all insurance decisions should be approached.

But the ACA requires the coverage of known, pre-existing conditions. If you are taking several expensive prescriptions, for example, that have no generic equivalent, or you have a medical condition that you know requires expensive treatment, a high deductible, high OOP max, low actuarial value plan may not make economic sense for you. What you will save with twelve low premiums could be overwhelmed by your other out-of-pocket costs.

These are my personal interpretations of the ACA, guided mostly by reading the Kaiser Family's healthcare reform articles.


Thanks for the info.... it is helpful....

But, it would seem that the cost sharing plan is not something that you can get after the fact.... IOW, if your income was high when you sign up and they think you do not qualify for the premium subsidy... when it comes time to file your tax return you will get the subsidy.... However, I do not see them going back and paying for any of your OOP expenses that you might have qualified for if you had started with the low income...


I doubt any of this will affect me, but you never know....
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Old 11-12-2013, 01:38 PM   #54
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Thanks for the info.... it is helpful....

But, it would seem that the cost sharing plan is not something that you can get after the fact.... IOW, if your income was high when you sign up and they think you do not qualify for the premium subsidy... when it comes time to file your tax return you will get the subsidy.... However, I do not see them going back and paying for any of your OOP expenses that you might have qualified for if you had started with the low income...


I doubt any of this will affect me, but you never know....
Who knew that socialism could be this hard?
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Old 11-12-2013, 04:28 PM   #55
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Thanks for the info.... it is helpful....

But, it would seem that the cost sharing plan is not something that you can get after the fact.... IOW, if your income was high when you sign up and they think you do not qualify for the premium subsidy... when it comes time to file your tax return you will get the subsidy.... However, I do not see them going back and paying for any of your OOP expenses that you might have qualified for if you had started with the low income...


I doubt any of this will affect me, but you never know....
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Who knew that socialism could be this hard?
Yes, there are lots of pesky details that the geniuses in DC didn't think through.
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Old 11-12-2013, 05:34 PM   #56
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Thanks for the info.... it is helpful....

But, it would seem that the cost sharing plan is not something that you can get after the fact.... IOW, if your income was high when you sign up and they think you do not qualify for the premium subsidy... when it comes time to file your tax return you will get the subsidy.... However, I do not see them going back and paying for any of your OOP expenses that you might have qualified for if you had started with the low income...


I doubt any of this will affect me, but you never know....
You are welcome. I think you're right that the cost sharing subsidy may only be an "up front" option, when your deductible and other parameters are determined upon enrollment. I can't recall what I've read about this specifically, outside of the enrollment/eligibility process. (I'm afraid that I tend to forget the details that I don't think will involve me -- there are so many -- and then there's my diminishing supply of neurons!)

The premium subsidy does seem easier to adjust after the fact (or during the year, when you report an event that would impact it.) That part is addressed in the application. But you certainly have to do a little more digging on the cost sharing rules, that's for sure. My guess is that it is all addressed in the law itself, but that is laborious reading, and the index isn't much help in getting you to the parts you're interested in. So, that's why sites like this are such a help. Thanks, ER's!
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Old 11-12-2013, 07:52 PM   #57
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The more choices IMHO, the more opportunities for getting duped by the insurance companies. I have over 80 plan choices. WHY? All I need is one good option. I really am having a difficult time in choosing. I am concerned that if I choose one, and omit to read every word of the plans small and large print I will be short something.

Insurance companies spend their lives trying to confuse people as to what coverage they get at what cost. We do not have a healthcare problem we have an insurance problem. Let us fix the insurance problem and the healthcare will take care of itself.

PS. Healthcare.gove has been working fine for me in FLA. Why are we still complaining about it?
Aren't the metal levels supposed to fix that? Are you shopping outside of the exchange? Granted it is still a pain in the official website.. but there are other websites to see the options available easily..

Once you determine the metal level you want, you just keep going up from the lowest premium till you find a network you can live with.
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Old 11-12-2013, 08:41 PM   #58
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Yes, there are lots of pesky details that the geniuses in DC didn't think through.
As the oft used cliche goes.. Perfect is the enemy of the good.

The only question we need to ask is "is this better than what we had?".

For a lot of people who needed access to health care and were shut out the answer is most definitely yes. But unfortunately for some.. not so much.

I confess I am philosophically pro-ACA. But I do see the warts it has too.

For everyone who complains vocally on TV about their insurance rate going up.. way up.. if I were the reporter I would ask the following questions..

1) Did you check if you qualified for a subsidy.

2) Did you know that the insurance company was under no obligation to renew your policy even without ACA.

3) Do you know if you had an annual cap on your policy? How much was it?

4) Do you know if you had a lifetime cap on your policy? How much was it?

5) Did you make any claims in the past 3 years? How was your experience?

6) Are you in any age threshold.. such as going from 39 to 40, or 49 to 50? This may explain some or most of the premium increase.

7) Would you place some value on guaranteed-issue of insurance? i.e. you cannot be denied coverage due to pre-existing conditions?

If even after all this they are upset about the premium increases, they are genuinely affected and they do need to be listened to sympathetically. They are one of the genuine losers in this shake-up, however well-intentioned it is.

I understand it is hard to make someone understand some issues that didn't actually happen to them. But it is not like insurance horror stories were non-existent before. But somehow all the media coverage is all totally virgin coverage as if all the reporters were born after July 2013.
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Old 11-12-2013, 11:02 PM   #59
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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.

I am not arguing your premise that to each their own in terms of health care cost. But I think your $3,500 figure is missing a zero at the end.

Here is a more representative link.
http://transform.childbirthconnectio...omparison1.pdf

Note that these graphs DO NOT include anesthesia charges and newborn care charges as per the footnote. Ouch!! Just cut her up and pull it out, then pack it up all to go!

These are 2010 figures, and you may have to add 30-40% to those numbers now.

I have had various women go through pregnancies in my family over past few decades and I don't know what a "birth center" is. The birth center costs seem quite tempting and are somewhat in line with your $3,500 number. Maybe they just have one midwife with some vaseline.. not sure how it works. But hospital deliveries in Metro areas are definitely in the five figures. Prenatal care is not included in these figures.
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Old 11-13-2013, 07:14 AM   #60
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The only question we need to ask is "is this better than what we had?".
That is a false dilemma. Instead we need to consider the full range of options, not just "this or that." It goes to the very subject of this thread.

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If even after all this they are upset about the premium increases, they are genuinely affected and they do need to be listened to sympathetically.
It's not made right by "listening to them sympathetically." These people just want what they had before this ACA became law: the contract they had between themselves and their insurer (two private parties that both deemed the arrangement to be mutually beneficial).
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