Why are we so paranoid about having choices?

[NW-Bound]

I've updated my post to show that the OOP subsidy is not as much as I first thought.

 

[Gatordoc50]

That isn't the point. Whenever you say everyone thinks, or does, or even says anything you will be wrong, unless you are talking about basic metabolic processes. Sometimes there will not even be a clear majority thinking one way or another, about anything.

That's why I said that I stand corrected. My hypothesis was incorrect. Universal access to care is obviously not everyone's goal. Can I get 9 out of 10?

 

[2B]

I stand corrected. Those that think we shouldn't have a system that provides for universal access to healthcare are free to speak up as you have. No blood, no foul.

I am not saying I'm against or for universal access to healthcare but I thought anyone can walk into any emergency room and receive heathcare. That sounds pretty universal to me. I'm not stating my opinion on any hypothetical health insurance alternatives. My point was that there is no point in bringing up these types of issues. It is also my understanding that it violates the forums rules.

 

[2B]

Income of 25K: premium for silver plan of $10,028 subsidized down to $1,129, OOP max of $4,500.

Income of 100K: premium for silver plan of $10,028 no subsidy, OOP max of $12,700.

So, yes, the low income people still have to pay quite a bit. Note that the OOP does not include the premium, so the total medical cost for a major illness will be up to $5,629 for the low-income couple, vs $22,228 for the high-income pair.

You are highlighting my prediction for multiple news articles beginning early next year. People having subsidized coverage not being able to pay their copays and OOP max. Poor is poor. I've been there.

I recently visited a new doctor. They had all my insurance verified and told me what I would be paying for the office visit before I saw the doctor. Since I met my deductible, I was only going to pay $38; but if it was $238, they might have wanted cash up front.

 

[NW-Bound]

With my $10K deductible, I have had healthcare providers wanting a lot up front, anywhere from 50% to 100% of the eventual cost after it gets settled with the insurance. The amount can be from $100 to $3K. The hospital is where they want 100% up front, for an outpatient minor surgery (but with general anesthesia) that ended up costing $3K (and where the surgeon got $300!).

The only exception is my long-time internist. He billed me later after the insurance bounced back the charge due to not meeting deductible.

 

[Texas Proud]

Heck.. I can't quite understand why we can't construct the policy exactly the way we want..I want the deductible to be X, co-pay for primary care to be Y, and out of pocket max to be Z and so on. The insurance companies know exactly how these variables affect the MLR profile, and they are capable of crunching the numbers and coming up with a bid for your rates.. at least the big ones are.

I understand, 90% of the people may not want that much flexibility -- but I can see a lot of people wanting to tweak just one or two parameters from a fixed set of choices.

Now that the underwriting is completely taken out, this should be rather simple.

I would love to have a gold plated bronze which will qualify for HSA right now!

I would like that also.... and I do have choices when I am choosing my auto insurance and they can tell me the cost of my choice PRIOR to me making it final...

 

[Mulligan]

I would like that also.... and I do have choices when I am choosing my auto insurance and they can tell me the cost of my choice PRIOR to me making it final...

I would love a 10k deductible with a 10k yearly max HSA deduction. Oh and cancel my male maternity care, drug rehab, and mental health if you can, too please!

 

[Rpharmer]

There's a subsidy for the premium, then there's another subsidy for the OOP part to help with the deductible. This 2nd one is not as well-known as the 1st. The following Web page is a calculator to help one figure out both subsidies: Subsidy Calculator | The Henry J. Kaiser Family Foundation.

As an example, I entered in the following info to see for myself: family of 2 married adults of age 60, non-tobacco users, no dependents, my ZIP code.

Income of 25K: premium for silver plan of $10,028 subsidized down to $1,129, OOP max of $4,500.

Income of 100K: premium for silver plan of $10,028 no subsidy, OOP max of $12,700.

So, yes, the low income people still have to pay quite a bit. Note that the OOP does not include the premium, so the total medical cost for a major illness will be up to $5,629 for the low-income couple, vs $22,228 for the high-income pair.

I was also looking at the Kaiser calculator's figures, in particular the OOP max of $4500 for the couple making $25,000. Something clicked with me, and so I read it again. Kaiser's wording is that the OOP max "can be no more than $4500." It turns out that this means that the insurer CAN offer a much lower OOP max than $4500 -- it just can't be higher than that, for this couple.

Since I've only researched actual plans for singles, I can't say what couples will find. But, entering a comparable figure for a single man, making $16,000, Kaiser says that the OOP max can be no more than $2250. And, in my zipcode, I find a BCBS plan with an OOP max of only $500, among several others. My guess is that, the closer you get to 100% of the FPL (ie, "virtual" Medicaid in a state that's not expanding Medicaid,) OOP costs may approach a very low number. Zipcodes may turn out to be a harsh variable. And averages are going to be difficult to parse.

 

[NW-Bound]

Thanks for pointing this out! I thought the OOP limit was set by the law. I did not know that it could be varied from plan to plan.

It would seem that this limit would become the deciding factor for people who expect to incur some expenses beyond simple doctor office visits.

 

[NW-Bound]

ACA could have lowered the 133% subsidy floor to 100%, couldn't it?

It appears to me it's all about money, how much the states pay vs the Fed. Yes, it's always about money.

 

[audreyh1]

Thanks for pointing this out! I thought the OOP limit was set by the law. I did not know that it could be varied from plan to plan.

It would seem that this limit would become the deciding factor for people who expect to incur some expenses beyond simple doctor office visits.

Most of the plans I looked at had the same max OOP within $350 no matter what the "metal".

 

[2B]

Thanks for pointing this out! I thought the OOP limit was set by the law. I did not know that it could be varied from plan to plan.

It would seem that this limit would become the deciding factor for people who expect to incur some expenses beyond simple doctor office visits.

When I looked through the policies available to me, the max OOP and the premium were the primary factors in comparing costs. We usually have few medical bills outside our annual check ups so having low prices for office visits are not a big factor.

The ones available to me vary considerably. Some have individual deductables and some are family deductables. Since there are only two of us, the individual deductables are also preferred. A big event only has to be half as big for an individual than a family.

 

[47]

Thanks for pointing this out! I thought the OOP limit was set by the law. I did not know that it could be varied from plan to plan.

It would seem that this limit would become the deciding factor for people who expect to incur some expenses beyond simple doctor office visits.

I think the OOP Max variation is more due to cost-sharing at low income levels.

I still believe that OOP limit as a general number is set by the law.

 

[modhatter]

Yes.

The late Sir John Templeton who was a philanthropist once said that he believed that the healthcare recipient must be made to contribute something, and that a all-you-can-eat system can never work.

Of course none of the other countries' single-payer systems is all-you-can-eat. There's always a gatekeeper, and there has to be one. The deductible and the copay serve to encourage the healthcare recipient to take better care of him/herself.

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.

http://video.pbs.org/video/1050712790/

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.

 

[NW-Bound]

Perhaps single-payer systems do not have gate-keepers per se, but a mechanism to control costs, much like HMOs here. I think I have read on this forum descriptions of how the care providers in some countries are rewarded for providing the same care but at a lower cost. That sounds simple, but requires detailed and meaningful metrics. We do not even have that for Medicare.

 

[MichaelB]

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.

 

[audreyh1]

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.

How many of those folks would be eligible for Medicaid? A lot?

 

[NW-Bound]

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.

Yes, but how about the OOP limit after subsidy? Is it a simple function of the income? Independent of the metal level, and all nuances of copays, etc...?

 

[2B]

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 think I've seen policies with a lower max OOP but none above. Sometime the OOP is calculated per individual on a plan with 100% coverage kicking in for that person with other plans having a family OOP before full coverage.

 

[MichaelB]

Yes, but how about the OOP limit after subsidy? Is it a simple function of the income? Independent of the metal level, and all nuances of copays, etc...?

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

 

[modhatter]

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.

 

[MRG]

Food, rent or insurance? Easy choice if your working for minimum wage.

MRG

 

[NW-Bound]

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.

 

[modhatter]

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.

 

[Mulligan]

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.

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.