Why are we so paranoid about having choices?

[Rpharmer]

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...

 

[NW-Bound]

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?

Interesting statistics NW-Bound. Where did you find that?...

Source: List of minimum wages by country - Wikipedia, the free encyclopedia.

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.

 

[Rpharmer]

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!

 

[haha]

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.

Ha

 

[rbmrtn]

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/Files/Downloads/Av-csr-bulletin.pdf

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

The kaiser calculator doesn't show cost reductions until 250%FPL

 

[NW-Bound]

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.

 

[anethum]

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.

 

[MRG]

..........

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.

MRG

 

[MichaelB]

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.

 

[MRG]

Michaelb,

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

MRG

 

[rbmrtn]

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

 

[audreyh1]

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).

 

[anethum]

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.

 

[audreyh1]

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".

 

[MichaelB]

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.

 

[pb4uski]

They get added together according to both my state website and Blue Cross's own website.

You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.

 

[audreyh1]

+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.

We didn't see limits on some of the cancer treatments. I just remember they were facing up to $36K a year in copays - mainly for chemotherapy drugs.

Anyway - it was resolved for them by one of those dubious "foundation grants" that pretty much look like kickbacks to me - to cover the copays while Medicare gets to pay the drug company's outrageous price for the rest.

 

[NW-Bound]

There was a story in the news about a San Diegan woman who lamented the loss of her pre-ACA plan with United Healthcare who got completely out of California individual HI market. She was kept alive with Stage 4 cancer for 7 years, at a total cost of $1.2M.

Her new ACA plan will not be accepted at the places that have been treating her.

 

[pb4uski]

There was a story in the news about a San Diegan woman who lamented the loss of her pre-ACA plan with United Healthcare who got completely out of California individual HI market. She was kept alive with Stage 4 cancer for 7 years, at a total cost of $1.2M.

Her new ACA plan will not be accepted at the places that have been treating her.

The same thing could have happened pre-ACA. Carriers routinely abandoned unprofitable markets. I'm not saying it would have, just acknowledging that it could have.

I wonder if she checked on networks before signing up for an ACA plan. If there are ACA plans that her provider accepts it may not be too late for her to make a change, but it won't be easy to change.

 

[NW-Bound]

The patient is Edie Sundby, a Stage-4 gallbladder cancer, in case anybody is curious to check on the Web for any follow-up story. I read her story again, and the problem seems to be that there's no ACA plan that has access to both places that are treating her.

The cost of $1.2M, and on going at that, is high. I wonder if other countries would spare no expenses to keep a terminal patient alive.

We would like to say that a human life is invaluable, but the fact is that if you are a victim of an fatal accident, such as a car crash, a freak accident in a public building, an airplane crash, the amount of compensation is only going to be about that much, I think. And that could be for a person in perfect health, with a long productive life in front of him, and who may have a young family to support.

It's a tough dilemma.

 

[MRG]

NW-Bound,

I agree, especially when we see how some cancer(or other serious illness) respond to modern medicine. Hopefully this and similar issues get resolved quickly.

MRG

 

[anethum]

You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.

I did call Blue Cross and they confirmed my understanding. I also discussed it today with a retired M.D. friend in my zip code who already signed up directly with Blue Cross for a PPO policy beginning 1/1/14, and his understanding was the same as mine.

 

[audreyh1]

I did call Blue Cross and they confirmed my understanding. I also discussed it today with a retired M.D. friend in my zip code who already signed up directly with Blue Cross for a PPO policy beginning 1/1/14, and his understanding was the same as mine.

This might vary by state, as I have never seen this language in our policies. I'll add it to my list of questions to ask over the phone. BCBS is not the same across states.

 

[modhatter]

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...

I just looked on my web sit again, and the lowest deductible for the lower cost plans $4750 Deductible. If you move up to a platinum plan on there, they have a plan with a $100 Deductible from a Nevada Insurance Co, and if you move into BCBS gold plan, they have one that has a $750 deductible, but cost $355 a month and which would cost the individual making $16,000 a yr. $144 a month (according to Kaiser Calculator) I used the age 34

So hopefully other states offer something better.

 

[ziggy29]

You should call them - I'm pretty sure that is not right - certainly not the way my BCBS policy works.

I'm looking at the BCBS TX plans available here, and one of the Bronze PPO plans shows a $6,000 deductible, AND a $6000 out of pocket maximum. Since it says "no copayments" for anything after the deductible is met, I'm pretty sure that the $6000 OOP max isn't an additional $6000 over the deductible. Different insurers and/or different states may do it differently; I'm not sure.