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Old 11-14-2013, 01:26 PM   #121
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An added thought I found interesting. Several years ago, I was in Wall Mart checking out. I remember reading in the papers that Wall Mart finally offered an insurance policy to it's full time employees. So I was making chit chat with the check out girl and happened to ask her if she was working full time or part time there (she mentioned she was tired). When she said she was full time, I said to her. "Well at least you get insurance now."

Her answer was this, "Well yes they have a policy, but I'm not participating in it." I asked her why not, and she told me this. "Well, first we have to pay 1/2 of the cost, then the policy has a $2,000 deductible before I can even use it." What good is that? "I don't have that kind of money".

I'm relaying this story to bring you into the world and mindset of people who work for not much more than minimum wage. It is very different world from yours and mine, and so is the way they view what having insurance should be. Now I know this is just one girl I spoke with, but it would be my guess that many like her look at it the same way.

And there is where I feel the ACA Exchange plans miss the mark. She was a young and probably healthy girl. Looked to be in her early thirties perhaps. The kind of healthy people needed in the pool, but chances are very good that she will not be tempted by any of the affordable high deductible plans.
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Old 11-14-2013, 01:29 PM   #122
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Food, rent or insurance? Easy choice if your working for minimum wage.

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Old 11-14-2013, 01:50 PM   #123
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One way to fix it is to give people no choices: give them basic universal healthcare but tax them, and that gives them the impression of free healthcare. And if the tax proves painful to the low-income workers, we can raise the minimum wage as many propose.

Does the above work? I don't know, but found some statistics that may be relevant.

Australia, Canada, and the UK are three representative countries with single-payer systems. Here are their minimum wage and also the buying power as computed in US$. As they all have higher cost of living than the US, the buying power is more meaningful than the wage itself.

CountryMinimum WagePurchasing Power
Australia$33.4K$21.0K
Canada$22.8K$17.6K
UK$19.9K$17.4K
US$15.1K$15.1K

So, looking at just those numbers, one can easily conclude that the US most underpays its lowest income workers. But I am not sure if it is so. The above numbers are gross incomes. We do not tax low-level incomes, and in fact even have earned-income credits. So, we must compare net incomes, and I do not have numbers for that.
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Old 11-14-2013, 02:09 PM   #124
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One way to fix it is to give people no choices: give them basic universal healthcare but tax them, and that gives them the impression of free healthcare. And if the tax proves painful to the low-income workers, we can raise the minimum wage as many propose.

Does the above work? I don't know, but found some statistics that may be relevant.

Australia, Canada, and the UK are three representative countries with single-payer systems. Here are their minimum wage and also the buying power as computed in US$. As they all have higher cost of living than the US, the buying power is more meaningful than the wage itself.

Country Minimum Wage Purchasing Power
Australia $33.4K $21.0K
Canada $22.8K $17.6K
UK $19.9K $17.4K
US $15.1K $15.1K
So, looking at just those numbers, one can easily conclude that the US most underpays its lowest income workers. But I am not sure if it is so. The above numbers are gross incomes. We do not tax low-level incomes, and in fact even have earned-income credits. So, we must compare net incomes, and I do not have numbers for that.
Interesting statistics NW-Bound. Where did you find that? Of course I agree on the single payer with amounts deducted in the form of taxes. But these people who work for low wages, would probably be taxed according to their incomes. My only hope would be that they could actually see a doctor if they got sick, as I mentioned these higher deductible plans do not benefit them very much.
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Old 11-14-2013, 02:10 PM   #125
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One way to fix it is to give people no choices: give them basic universal healthcare but tax them, and that gives them the impression of free healthcare. And if the tax proves painful to the low-income workers, we can raise the minimum wage as many propose. Does the above work? I don't know, but found some statistics that may be relevant. Australia, Canada, and the UK are three representative countries with single-payer systems. Here are their minimum wage and also the buying power as computed in US$. As they all have higher cost of living than the US, the buying power is more meaningful than the wage itself.
CountryMinimum WagePurchasing Power Australia$33.4K$21.0K Canada$22.8K$17.6K UK$19.9K$17.4K US$15.1K$15.1K
So, looking at just those numbers, one can easily conclude that the US most underpays its lowest income workers. But I am not sure if it is so. The above numbers are gross incomes. We do not tax low-level incomes, and in fact even have earned-income credits. So, we must compare net incomes, and I do not have numbers for that.

I have thought about this a bit, and although it is not logical, I prefer the "head in the sand" way instead of outright taxation or big premium jumps being cost shifted onto me. This meaning a "VAT" tax. It may well wind up costing me more, but I get the satisfaction of knowing even the fully abled bum who just likes to drink his vodka will have to pay for it too when he goes to buy his bottle. This way we do have true healthcare for all, which I am mostly in favor of to begin with. Of course the risk of the "VAT" in my mind is the slow ratcheting up of the percentage like some local governments seem to do a lot with the sales tax.
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Old 11-14-2013, 02:16 PM   #126
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I'm afraid that is not true. When you study all the countries with single payer, you will see that they vary considerably. Many do not have gatekeepers at all. Some have very small co-pays as well, without high deductibles. So it depends on which country you look at.

Video: Sick Around the World | Watch FRONTLINE Online | PBS Video

As for the high deductible plans for the poor. I agree with another poster on their point to a degree. Unfortunately, IMO for someone who is really low income and has been using a free clinic or county hospital for their care, I don't think having to purchase a plan that would cost them even $100 (with subsidy) a month is going to be very appealing to them, when there is such a large deductible that comes with it. Also, consider if they have no assets, are renting and live pay check to pay check, they are not exactly afraid of "losing it all" if they get sick.

So unless there is a plan for them that is very reasonable, where they can get actual care and medicine when there sick, I don't think the incentive is there to buy a high deductible plan. I am in favor of what the ACA has brought us in terms of stopping the outrageous practices of the insurance companies. But in terms of getting the lower income people to purchase plans, I don't think it will succeed based on the type of plans I see offered for them that are reasonable in cost.
I don't know how representative we are here in Missouri, but there are some plans in my metro area that might be reasonable. For example, the lowest cost Silver plan ($16000 MAGI, age 57 male) from Coventry One has a premium of $45/mo, and a zero deductible! No charge for PCP OV's, and $5 generics. But you may be right, that some people are sufficiently satisfied with the low or no cost clinic/public hospital option instead. Having worked in those environments, that is not my impression -- but I encountered a lot of unhappy patients in the elite suburban hospitals, too! I guess we'll see...
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Old 11-14-2013, 06:00 PM   #127
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Yes, cost sharing assistance lowers the total OOP. See pages 13 &14 of this brief on premium assistance and tax credits. http://www.fas.org/sgp/crs/misc/R41137.pdf
Yes, I have read that document, and just read it again. As described, the OOP subsidy is based strictly on income, but that seems contradictory to what other posters reported.

Table 6 of the document is shown below. Are these step functions ("cliff") between income levels, or is there a smoothing line between them?



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Interesting statistics NW-Bound. Where did you find that?...
Source: List of minimum wages by country - Wikipedia, the free encyclopedia.

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I don't know how representative we are here in Missouri, but there are some plans in my metro area that might be reasonable. For example, the lowest cost Silver plan ($16000 MAGI, age 57 male) from Coventry One has a premium of $45/mo, and a zero deductible! No charge for PCP OV's, and $5 generics. But you may be right, that some people are sufficiently satisfied with the low or no cost clinic/public hospital option instead. Having worked in those environments, that is not my impression -- but I encountered a lot of unhappy patients in the elite suburban hospitals, too! I guess we'll see...
That's almost free health care, considering that taxes have not been raised on this income level to pay for this new benefit.

As to the quality of care, both the UK and Australia have a parallel private insurance. I do not know if that is supplemental or in lieu of the public health service.
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Old 11-14-2013, 07:16 PM   #128
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Absolutely, at very low income levels, subsidized Silver plans have actuarial values of 94%, by law. Very low cost to the patient. That's exactly why I'm skeptical of the assumption that these patients won't eventually enroll.

I've become gun-shy, however, about terming it "free" care -- I've learned to say little or "no cost to the patient." Holds down some of the obvious (albeit accurate) reactions about who ultimately is paying!
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Old 11-14-2013, 07:18 PM   #129
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I have thought about this a bit, and although it is not logical, I prefer the "head in the sand" way instead of outright taxation or big premium jumps being cost shifted onto me. This meaning a "VAT" tax. It may well wind up costing me more, but I get the satisfaction of knowing even the fully abled bum who just likes to drink his vodka will have to pay for it too when he goes to buy his bottle. This way we do have true healthcare for all, which I am mostly in favor of to begin with. Of course the risk of the "VAT" in my mind is the slow ratcheting up of the percentage like some local governments seem to do a lot with the sales tax.
That they do; but at least the off the books guy who makes most his income selling pills pays that sales tax.

In our state there is no tax on food or prescription drugs or medical or dental services.

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Old 11-14-2013, 08:16 PM   #130
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Yes, I have read that document, and just read it again. As described, the OOP subsidy is based strictly on income, but that seems contradictory to what other posters reported.
I believe the table reference may be outdated, it came out before the final rules.
The cost sharing reductions don't kick in until below 250%FPL with a silver plan.

See pg 11/12 of this document http://www.cms.gov/CCIIO/Resources/F...r-bulletin.pdf

It has to do with keeping the AVs a certain levels.

The kaiser calculator doesn't show cost reductions until 250%FPL
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Old 11-14-2013, 09:00 PM   #131
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Thanks.

Looks like the laws leave a lot of discretion to the HHS secretary. This may mean the actual brackets and schedules will be subject to changes in the years ahead as they are tweaked.
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Old 11-15-2013, 10:26 AM   #132
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ACA maximum out of pocket limit is set at the same amount as the high deductible and HSA eligible plans. For 2014 that is $6350 individual / $12700 family.
I believe that those figures are for in-network only. Looking at a bronze Blue Cross PPO in my area, for example, although the maximum in-network out of pocket is $6,350 as you said, there is also an additional maximum out-of-network out of pocket of $12,700 (individual), so the potential total individual maximum out of pocket is $6,350 + $12,700 = $19,050. That's what the website is showing. Is this your understanding, as well?

Complicating things further, I believe that for out-of-network expenses, Blue Cross only counts toward out of pocket the amount which they consider "usual and customary", which can be substantially lower than the actual bill.
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Old 11-15-2013, 10:32 AM   #133
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..........

Complicating things further, I believe that for out-of-network expenses, Blue Cross only counts toward out of pocket the amount which they consider "usual and customary", which can be substantially lower than the actual bill.
That is what BCBSKC told me.

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Old 11-15-2013, 10:45 AM   #134
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I believe that those figures are for in-network only. Looking at a bronze Blue Cross PPO in my area, for example, although the maximum in-network out of pocket is $6,350 as you said, there is also an additional maximum out-of-network out of pocket of $12,700 (individual), so the potential total individual maximum out of pocket is $6,350 + $12,700 = $19,050. That's what the website is showing. Is this your understanding, as well?

Complicating things further, I believe that for out-of-network expenses, Blue Cross only counts toward out of pocket the amount which they consider "usual and customary", which can be substantially lower than the actual bill.
As far as I know this is how health care insurance has always been in the US, and that does not change with ACA implementation. Insurers either have separate cost sharing for out of network or simply do not cover it at all (typical of HMO). Emergency room care gets some new protection, but not much else.
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Old 11-15-2013, 10:50 AM   #135
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Michaelb,

You are 100% correct. I learned that 'the hard way'.

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Old 11-15-2013, 10:50 AM   #136
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I believe that those figures are for in-network only. Looking at a bronze Blue Cross PPO in my area, for example, although the maximum in-network out of pocket is $6,350 as you said, there is also an additional maximum out-of-network out of pocket of $12,700 (individual),
That's typical, mine doesn't count any out-of-network expenses. But that is not new, they have always done that. Emergency room visits usually count regardless
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Old 11-15-2013, 11:21 AM   #137
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I believe that those figures are for in-network only. Looking at a bronze Blue Cross PPO in my area, for example, although the maximum in-network out of pocket is $6,350 as you said, there is also an additional maximum out-of-network out of pocket of $12,700 (individual), so the potential total individual maximum out of pocket is $6,350 + $12,700 = $19,050. That's what the website is showing. Is this your understanding, as well?

Complicating things further, I believe that for out-of-network expenses, Blue Cross only counts toward out of pocket the amount which they consider "usual and customary", which can be substantially lower than the actual bill.
I don't think the two max OOPs get added together.

And, yes, with an out-of-network expense, you have to file your own claim, and the insurance company will only pay the provider at their usual rates which is what is used for the max OOP calculation, and the provider can choose to bill you for the difference (what the insurance company didn't completely pay for).
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Old 11-15-2013, 11:22 AM   #138
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I don't think the two max OOPs get added together.
They get added together according to both my state website and Blue Cross's own website.
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Old 11-15-2013, 11:42 AM   #139
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They get added together according to both my state website and Blue Cross's own website.
Interesting thanks.

There was absolutely no hint of this in all the website reading I have done.

Of course, with an out-of-network provider you are vulnerable to balance billing which is not counted toward the out-of-pocket max anyway, so those limits are pretty ephemeral regardless.

You just have to do your best to make sure your provider are in network, or that you know the expense ahead of time if you go out-of-network.

Medicare has protections from balance billing - it's simply not allowed.

But Medicare doesn't have a max OOP as far as I know, something some relatives woke up to horror when they were contemplating expensive cancer treatment with a 20% copay with no max OOP limit. They had dropped their Medigap insurance the year before because it was "too expensive".
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Old 11-15-2013, 12:24 PM   #140
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Interesting thanks.

There was absolutely no hint of this in all the website reading I have done.

Of course, with an out-of-network provider you are vulnerable to balance billing which is not counted toward the out-of-pocket max anyway, so those limits are pretty ephemeral regardless.

You just have to do your best to make sure your provider are in network, or that you know the expense ahead of time if you go out-of-network.

Medicare has protections from balance billing - it's simply not allowed.

But Medicare doesn't have a max OOP as far as I know, something some relatives woke up to horror when they were contemplating expensive cancer treatment with a 20% copay with no max OOP limit. They had dropped their Medigap insurance the year before because it was "too expensive".
+1 to everything anethum wrote. I've never know it to be different. Do agree that Medicare is so much better in this respect, something I'm looking forward to. While it doesn't have a $ OOP limit, it does limit specific coverage, such as hospital stays.
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