Nice summary from Ways and Means on proposed changes to ACA released today...

[samclem]

If we are moving toward a free-er market in insurance one useful role for the government would be to >facilitate< the exchange of information and lubricate the machinery so that people have the info they need to compare products and selecting the right ones is easy.

Sellers of all types prefer a "sticky," opaque marketplace, it helps to keep their products from being easily compared to others, and keeps their margins higher.

For example: If we are going back to medical underwriting for the purposes of setting prices (it's not clear to me if are or not) it would be best for the consumer and the country if medical histories and exams for insurance were handled by a seperate entity from the insurance companies. It's a giant PITA to get 5 exams and fill out 5 histories in order to get prices from 5 companies. If there was a different entity that did the exams and gave either a single risk score or even a consolidated report to the insurers, it would open up competition a lot. The government can take steps to facilitate this, the insurance companies won't do it because it is not in their interest to make shopping around easy.

Likewise, the government should have a role in making it easy for people to compare the quality of the healthcare provided by various systems/docs/etc. No, I don't think there should be a government web page (because it would be unusable), but te government can mandate that the information be provided to third parties (and the govt should spot-check the validity of it--big penalties for cheating). Waiting times, infections, complications from common procedures, consumer satisfaction with the care etc.

 

[ShokWaveRider]

For me it would make health insurance unaffordable. $4000 per year does not go very far when insurance costs are $2500pm.

 

[Pilot2013]

It seems there may need to be a lot of recalculation in FIRECALC if HI goes back to pre-ACA days, and a new subsidy (from those poor schmucks still working) doesn't replace the ACA one to allow ER for others?

 

[donheff]

The danger here is that young people with little savings and little to lose will forgo HI, wait for years, and enroll in a top shelf plan if they develop a serious chronic illness with a minuscule penalty -- the 30% if for one year. Unfortunately the resulting risk segregation could drive up premiums for all or drive more insurers out of the markets.

But isn't that happening now, because the 'penalties' are so light?

I don't know if this 30% approach is better or worse than the current penalty process, I'm not sure if anyone can know, and maybe even the CBO report won't tell us - that 10 year outlook doesn't capture longer term effects, which aren't even that long term when some provisions are phased in over years to begin with.

And is the 30% surcharge for one year only? That's what people say in this thread, but that isn't clear to me one way or the other in what I've read so far. Anyone have a link?
-ERD50

I think mandates with penalties or increases in premiums could both work and, like you, I don't know where the sweet spot is. In earlier versions the rate changes were as much as 150% and permanent, 30%/one year (assuming the reports are accurate) seems like a very weak disincentive. I like the mandate a bit more since the penalty puts cash into the system that will somewhat defray the cost of providing emergency care to those who forgo insurance. But I really prefer a Medicare for all system with a wide choice of optional supplement approaches - and with a lot of effort toward improving Medicare's incentive structure over time.

 

[Montecfo]

Back in the old days (before Obamacare), health insurance companies provided their policyholders with indemnification only against future adverse medical events. They worked aggressively to avoid covering existing medical conditions. I went through this medical underwriting process many times - unpleasant, to be sure, but I considered it a necessary evil in order to keep insurance premiums reasonable.

My personal preference would be to return to the old days, where health insurance companies sold only indemnification against future adverse medical events, and allow some other mechanism to help pay the medical cost of existing conditions. Insurance companies shouldn’t be allowed to deny all coverage to someone with existing conditions, but they should be allowed to exclude existing conditions from coverage and let some other mechanism help pay for them.

So, what might this other mechanism to help pay for existing conditions look like? Who would pay the taxes to provide this benefit? How would this program be administered? Would we need to create a new health care bureaucracy, or can an existing bureaucracy be adapted? I have no idea - I’m not an expert in health policy matters, just a guy trying to avoid being financially ruined by the American healthcare system.

One of the big flaws of 0bamacare is you have pre-existing conditions covered, and no meaningful penalty for failing to have coverage. So then the people that buy insurance are already sick, and too often healthy people wait until they get sick to get coverage.

So you are correct in that, if you have a program that covers pre-existing conditions, that is not, in fact, "insurance". it is an entitlement program. So you either have to have a requirement to buy coverage (such as having pre-existing conditions not covered if you have a lapse in coverage, or requiring punitive back-charges for uncovered periods) OR you have to not cover pre-existing conditions.

If these items are not fixed, the plan cannot work as this is a fatal structural flaw.

 

[gerntz]

Looks like they're getting pushback from many members of their own party, with some planning to introduce alternative bills.

Probably true, but without substantial support; i.e., Pub majority, those plans ain't going anywhere. So they'll have the choices of supporting the Pub plan, voting aginst it & keeping Ocare, or sitting it out.

 

[pb4uski]

One of the big flaws of 0bamacare is you have pre-existing conditions covered, and no meaningful penalty for failing to have coverage. So then the people that buy insurance are already sick, and too often healthy people wait until they get sick to get coverage.

So you are correct in that, if you have a program that covers pre-existing conditions, that is not, in fact, "insurance". it is an entitlement program. So you either have to have a requirement to buy coverage (such as having pre-existing conditions not covered if you have a lapse in coverage, or requiring punitive back-charges for uncovered periods) OR you have to not cover pre-existing conditions.

If these items are not fixed, the plan cannot work as this is a fatal structural flaw.

Totally agree... you need to make not having continuous coverage so punitive that people will decide that it is better to keep their insurance. But at the same time we also need to make it more affordable by reducing health services costs and increasing the market. I personally would like to see health insurance decoupled from employment.. your policy is personal to you and there is no change if you change jobs so the individual market becomes one huge group.

 

[Winemaker]

......ridiculous drug costs. I had chemo and was given a drug after each dose....Claimed cost was 5K-7K per dose. In Canada -the cost is $60. Do you see a problem that has been addressed in the new plan?? This is just moving the chess pieces around on the board.

The costs of healthcare in Canada are subsidized by higher prices on other goods. For example, some snowbird friends of ours from Canada pay $40.00 for a cheapo bottle of wine that sells less than $10.00 here.

 

[simple girl]

I'm trying to keep up with this thread and what is currently being proposed, but am I am having a hard time understanding what exactly is happening with pre-existing conditions. So, regarding the current proposal, is this correct, from what I have read here?

1) you cannot be denied coverage for pre-existing conditions, because they can't change that part of the bill yet by the means they have available
2) however they can charge you more for pre-existing conditions, and essentially price you out of the market?
3) States may use Innovation and Stability Program grants to fund high-risk pools, and for other purposes

I have been looking at this site to compare the plans side by side, but am not sure I am understanding this aspect clearly.

Compare Proposals to Replace The Affordable Care Act | The Henry J. Kaiser Family Foundation

I am one of the many "wish we could retire early but have a serious pre-existing condition, so too scared to do it right now" group.

Does anyone see any potential advantage to getting on an ACA plan before all of this is instituted? i.e. we will already have coverage without having to go through underwriting, just need to maintain it?

 

[bamsphd]

Totally agree... you need to make not having continuous coverage so punitive that people will decide that it is better to keep their insurance.

While I agree sufficiently punitive continuous-coverage requirements can discourage healthy people from trying to game the system, I don't think most gaps are caused by gaming, especially among Americans with pre-existing conditions! This government report says:

Tens of millions of Americans with pre-existing conditions experience spells of uninsurance. ... nearly one-third (44 million) went uninsured for at least one month during the two-year period beginning in 2013.

While ER types normally have huge emergency funds, paycheck-to-paycheck more accurately describes most Americans. Imposing punitive continuous-coverage requirements on people who say lose a job seems like a "kick-'em-while-they're down" approach.

 

[exnavynuke]

I'm trying to keep up with this thread and what is currently being proposed, but am I am having a hard time understanding what exactly is happening with pre-existing conditions. So, regarding the current proposal, is this correct, from what I have read here?

1) you cannot be denied coverage for pre-existing conditions, because they can't change that part of the bill yet by the means they have available
2) however they can charge you more for pre-existing conditions, and essentially price you out of the market?
3) States may use Innovation and Stability Program grants to fund high-risk pools, and for other purposes

I have been looking at this site to compare the plans side by side, but am not sure I am understanding this aspect clearly.

Compare Proposals to Replace The Affordable Care Act | The Henry J. Kaiser Family Foundation

I am one of the many "wish we could retire early but have a serious pre-existing condition, so too scared to do it right now" group.

Does anyone see any potential advantage to getting on an ACA plan before all of this is instituted? i.e. we will already have coverage without having to go through underwriting, just need to maintain it?

1. Correct. Denial cannot be based on having a pre-existing condition under the current bill being discussed.
2. Premiums still have a "max range" so the premium for those using their insurance cannot be "too much" above those not using it. However, if you are without insurance for more than 63 days in the previous year then the current bill would allow a 30% surcharge to whatever premium you would get for the first year.
3. There are provisions for high-risk pools and some funding, though the current level of proposed funding is orders of magnitude below previous estimates of what is needed for such pools.

If you don't have insurance at all, getting it would negate the 30% surcharge in premiums for the first year you got insurance under the proposed rules.

 

[Winemaker]

Maybe for some. My 2017 subsidy is $8196. If I'm reading this right, my subsidy (i.e. credit) would be reduced to $3500.

My gripe is that the focus is in the wrong place. Once again they attempting to make HEALTH INSURANCE "affordable".

The real problem is the COST of HEALTH CARE.

This hit the nail on the head.

Any attempts to legislate costs is ludicrous. To control costs, we would have to limit services and reward/punish behavior, all of which I find unacceptable.

Currently, the plan is to pay doctors as a result of patient's improved health performance, which to some sounds pretty good. But is the same reason why doctors are dropping patients.

Some feel that those using tobacco products, drinking alcohol, owning firearms, eating sugar/high fructose corn syrup, eating animal protein, consuming farm raised seafood, GMO's, non-organic produce, caffeine, transfats, lard, baby formula and the latest poison, should be charged more for insurance. These currently legal products, but are just the refuted killer du jour.

Yeah, we beat down big pharma for their big profits in one thread, but in the other thread, we recommend this and that pharma for it's qualified dividend, bash whatever biotech buyout that creates LTCG, and allows for our 4% SWR.

Nothing passed by past, present or future legislatures is going to make everyone on this forum, or in the USA happy. Thanks to all for my vent.

 

[MichaelB]

Great link, SG. Thanks so much.

2) however they can charge you more for pre-existing conditions, and essentially price you out of the market?

Neither of the bills introduced yesterday address underwriting, so the current rules (no underwriting) would probably continue.

 

[simple girl]

2. Premiums still have a "max range" so the premium for those using their insurance cannot be "too much" above those not using it.

So they will be allowed to do medical underwriting to look at pre-existing conditions?

However, if you are without insurance for more than 63 days in the previous year then the current bill would allow a 30% surcharge to whatever premium you would get for the first year.

I understand that. That would not be our case as we currently have excellent insurance through my husband's employer and no way in hell would I ever let our insurance lapse. I've seen the cost of serious medical treatment.

3. There are provisions for high-risk pools and some funding, though the current level of proposed funding is orders of magnitude below previous estimates of what is needed for such pools.

Yep..I know...scary to me as makes me think the high risk pools will fail, there will be long waiting lists, super high rates, etc., etc. again.

If you don't have insurance at all, getting it would negate the 30% surcharge in premiums for the first year you got insurance under the proposed rules.

Right, but that is not our case. What I'm asking is - if there is medical underwriting allowed, and if we get on an ACA plan before that starts, will we then avoid the medical underwriting? And, if so, have less of a premium?

What I really don't understand is - if they can't refuse you for pre-existing conditions, and there is a limit on what they can charge even if you have a pre-existing condition - why the high risk pools? Is that limit so extreme the high risk pool would be cheaper? So confusing for me!

 

[simple girl]

Great link, SG. Thanks so much.

You are welcome! Now hopefully you can make more sense of it than me, lol!

Neither of the bills introduced yesterday address underwriting, so the current rules (no underwriting) would probably continue.

Oh, that is a huge relief...so why the high risk pools, then? Wouldn't you have to do underwriting to identify who goes in them?

 

[MichaelB]

Oh, that is a huge relief...so why the high risk pools, then? Wouldn't you have to do underwriting to identify who goes in them?

The high risk pools may be setting the stage to allow underwriting. It also may be for the states to assist people that can't afford individual insurance. It may be a way to invite some high risk people out of the regular pool and make insurance less expensive for everyone else. It may just be a red herring to distract people. We don't have enough information to know.

I think this level of detail is just not available, will not be for some time. Until then, I plan to continue with my ACA policy.

Edit to add - the KFF summary of the bills introduced yesterday says

Retain private market rules, including the prohibition on discriminatory premiums and pre-existing condition exclusions, requirement to extend dependent coverage to age 26

Their interpretation is that underwriting cannot be used for people with preexisting conditions.

 

[simple girl]

The high risk pools may be setting the stage to allow underwriting. It also may be for the states to assist people that can't afford individual insurance. It may be a way to invite some high risk people out of the regular pool and make insurance less expensive for everyone else. It may just be a red herring to distract people. We don't have enough information to know.

I think this level of detail is just not available, will not be for some time. Until then, I plan to continue with my ACA policy.

I see...if they are setting the stage for underwriting (which of course we can't know), then it would behoove us to get on a plan before new legislation is enacted allowing that. That is what I really need to keep my eye on. I don't think we have to act immediately, of course, but I do need to remain on top of upcoming legislation.

It is indeed very confusing that they are setting up those pools when underwriting is not allowed yet...and suspicious to me that those with pre-existing conditions will be targeted, as we do raise prices for everyone else who is healthy.

 

[MichaelB]

I see...if they are setting the stage for underwriting (which of course we can't know), then it would behoove us to get on a plan before new legislation is enacted allowing that. That is what I really need to keep my eye on. I don't think we have to act immediately, of course, but I do need to remain on top of upcoming legislation.

It is indeed very confusing that they are setting up those pools when underwriting is not allowed yet...and suspicious to me that those with pre-existing conditions will be targeted, as we do raise prices for everyone else who is healthy.

Perhaps I should not have written that? I was just covering a list of possibilities, not attempting to project the intentions of the authors. As far as I can see, in this proposal guaranteed issue continues unchanged.

 

[bamsphd]

Does anyone see any potential advantage to getting on an ACA plan before all of this is instituted? i.e. we will already have coverage without having to go through underwriting, just need to maintain it?

Under the current proposal there is no underwriting, just a penalty for a gap in coverage. Stay tuned for updates.

If/when you do get an ACA plan, under the current proposal you might want to pick an off-exchange ACA plan. It looks like whatever subsidies/credits are offered will apply equally to off-exchange policies, which makes me think at least the Federal exchanges have a limited life expectancy. Last open-enrollment I was extremely paranoid and went for his and her off-exchange ACA plans to maximize our chance of being able to keep our plans.

 

[simple girl]

Perhaps I should not have written that? I was just covering a list of possibilities, not attempting to project the intentions of the authors. As far as I can see, in this proposal guaranteed issue continues unchanged.

No, I'm glad you wrote it. It helps me see that I'm not the only one who can't figure out why they are creating high risk pools when there is no underwriting allowed yet per the proposal. I realize those are all just possibilities, no worries! You didn't freak me out. (not any more than I am already, lol!!!)

 

[simple girl]

Under the current proposal there is no underwriting, just a penalty for a gap in coverage. Stay tuned for updates.

If/when you do get an ACA plan, under the current proposal you might want to pick an off-exchange ACA plan. It looks like whatever subsidies/credits are offered will apply equally to off-exchange policies, which makes me think at least the Federal exchanges have a limited life expectancy. Last open-enrollment I was extremely paranoid and went for his and her off-exchange ACA plans to maximize our chance of being able to keep our plans.

Hmmmm...didn't realize there are "off-exchange ACA plans". I've only looked at plans and pricing on the healthcare.gov site. Where do you find plans off of that site? Would be good to have that in my back pocket to explore. Thanks!

 

[Hyperborea]

Has there been any information on how they plan to fund the tax credits in the new plan? A number of the taxes or limitations on deductions in the ACA that helped fund the subsidies under that are planned to be removed. Any numbers from the CBO on how much this bill will cost?

 

[bamsphd]

Hmmmm...didn't realize there are "off-exchange ACA plans". I've only looked at plans and pricing on the healthcare.gov site. Where do you find plans off of that site? Would be good to have that in my back pocket to explore. Thanks!

First to clarify, by off-exchange ACA plan I mean a plan not purchased through the exchange which meets all the ACA requirements but was not eligible for premium subsidies.

At least in my state, most of the insurers with exchange policies also offer off-exchange policies. Some offer essentially the exact same policies at the exact same price, others offer more expensive off-exchange policies with better health networks and/or better telephone support. In my state, I did not find any companies offering off-exchange individual policies who did not also offer on-exchange policies. Your state might be different.

While I did some Google searching and found online brokers listing policies, I had the best results simply visiting the websites for each company with an exchange policy.

 

[exnavynuke]

Has there been any information on how they plan to fund the tax credits in the new plan? A number of the taxes or limitations on deductions in the ACA that helped fund the subsidies under that are planned to be removed. Any numbers from the CBO on how much this bill will cost?

No cost analysis has been released at this time (I don't think one's been done yet from what I've read).

 

[EastWest Gal]

Hmmmm...didn't realize there are "off-exchange ACA plans". I've only looked at plans and pricing on the healthcare.gov site. Where do you find plans off of that site? Would be good to have that in my back pocket to explore. Thanks!

Exploring is pretty easy, actually. You can look at the insurance company websites directly. You can also call and ask questions. I looked both on and off exchange this year. There were a few plans off exchange that were slightly lower in premium costs, but the plan I chose on the exchange was the exact same price off the exchange. And since there's always the possibility of lower dividends and cap gains income putting us in range of subsidy qualification, after calling the insurance company in question, they recommended applying through the exchange.