Healthcare insurance and retirement - again!

[MichaelB]

A Medicare participating provider does not have to see original Medicare enrollees. If the provider chooses to see one, then the provider must follow the participation agreement.

This is only primary care, correct? There doesn't seem to be a similar issue with most physicians with other specializations.

My understanding of healthcare in the US is that primary care physicians are poorly compensated, and as a result, not enough new practitioners are pursuing this role, choosing instead other specializations. IOW, this is currently a problem for geriatric primary care but quickly becoming one all primary care.

 

[ivinsfan]

Actually both!

As an example, last year we got a letter from Kelsey-Seybold, a medical provider where we live, that their office would not be accepting traditional Medicare coverage any longer. If you care to review:

Doctors The Woodlands Texas | The Woodlands Clinic | Kelsey-Seybold Clinic

Many doctors have dropped out of Medicare in this area and I could list them, but I don't want to waste the bandwidth.

That's a little alarming as far as future trends, in this state MN we don't seem to have that happening, just one more things to fret over and that proves that once you hit 65 your worries about medical care aren't over.

 

[MBSC]

This is only primary care, correct? There doesn't seem to be a similar issue with most physicians with other specializations.

I edited my post to say Medicare participating physicians, as participating hospitals must accept enrollees. A number of providers in the mental health field do not accept Medicare.

 

[aja8888]

I clicked on it just to see what it says. They do accept some Medicare Advantage plans. One is called KelseyCare, did they create their own Medicare Advantage plan?

Is this common? Is this a large provider in the area?

Yes they do take Medicare Advantage plans, but we have traditional Medicare. MA plans are not popular in this area as they are very restrictive. We like choice of doctors and providers which MA doesn't provide here. KS is pretty big here and I believe they opted out of traditional Medicare because it competes with their MA plan.

Really crazy stuff, this U.S. healthcare mess.

 

[target2019]

The discussion is interesting. In the interest of keeping it on topic, some questions. If quality of healthcare is a priority, is there a way to compare the kind of healthcare we could expect in the US or moving? If so, then how do we estimate the real, total cost? How do we go about making this an option? Realistically, health care abroad is only an option if relocation is viable.

This is hard to measure. From what I've seen and discussed with others abroad, you pay higher income taxes to cover the cost of universal coverage. The alternative is to follow the US path, pay less income tax, and have the health insurance go where the market takes it. As for measuring quality, I think longevity statistics could tell us a thing or two.

 

[ivinsfan]

I would urge anyone reading this thread who has done any type of military service to see if they are eligible for VA health care.

Senator on the emergency front, my DH had a chronic condition detected thru the VA.The usual course is to monitor until a problem occur. He had a problem occur, made a regular visit to the VA clinic in St Cloud, who sent him promptly to the nearest hospital (not VA) before we left the building we were given paperwork to give to the business office at the hospital saying the VA would be responsible for any and all charges.

The VA has many little satellite clinics around, it pays to know where each one of them are located if you have a sudden problem and aren't sure if it's an emergency.

On the downside some cardiac surgery was required and since we had BCBS insurance he got on the surgery schedule at the non VA hospital within 10 days. The day before the operation he got a call from a VA scheduler ready to get him a non emergent apt at a VA doctor and start down the road to surgery which they said could take 60-90 days.

 

[GTFan]

+100. I worked in the actuarial field for 23 years, specializing in personal auto insurance. Ziggy has is right on target - you need the personal mandate to make the coverage work if you get rid of the exclusion for pre-existing conditions. And the subsidies make the coverage affordable for lower-income people.

That's exactly why they are going to get a lot of blowback from insurers if they keep the pre-existing rule (which apparently cannot be repealed since it's not part of the budget-related stuff that can be forced through the Senate). Insurers will either make the insurance unaffordable or remove themselves from the market if they are forced to take all comers without mandated coverage.

Here's a good article explaining this:
https://www.washingtonpost.com/news...ning-to-face-a-rude-awakening-over-obamacare/

Anyone that says that you don't need mandates with this provision really doesn't understand how it works.

 

[GTFan]

I was not suggesting Medicare be opened up to everyone under 65 aka the Public Option. I suggested it as a potential alternative to kicking 10 million people to the curb who would be negatively financially impacted if the subsidies were pulled away.

It's actually 22 million, counting the expanded Medicaid states where the feds provided the money under the ACA. That's scheduled to go away too if you believe what they're pitching (or be replaced by block grants, in which many states will likely remove the expansion).

[mod edit]

 

[eta2020]

I would urge anyone reading this thread who has done any type of military service to see if they are eligible for VA health care.

I looked at it briefly. It seems to have income limits way lower then ACA Cliff.

I don't know how practical it is for most people who are FI.

 

[aja8888]

That's a little alarming as far as future trends, in this state MN we don't seem to have that happening, just one more things to fret over and that proves that once you hit 65 your worries about medical care aren't over.

Correct, over 65 means you can enter another healthcare system. If you want excellent coverage and the ability to choose physicians and hospitals, it's costly. The drug cost issue is very confusing, changes frequently, and appears to be out of control.

This weekend, I did a mock up on the Medicare.gov site to see which Part D plan would work best for my DW for 2017. Logging in her 9 meds and comparing plans indicated we could save $1,911 OOP annually by switching to an AARP plan out of her current Humana. This comparison varies by Zip code!

 

[NW-Bound]

Well the quality will vastly vary between Florence and Sicily in Italy. (just to give example)

No, the blog I read was about a patient living in a large Western capital city.

I often wonder if the healthcare is really that good in a crowded city. We know that rural areas do not have as good healthcare for many simple reasons. For example, how do we force specialists to relocate there against their will? But too big a city may not be good either because of crowding conditions.

And people often quote statistics relating healthcare costs to longevity. It shows US citizens have a shorter life than people in other developed countries, despite spending more. That is irrefutable. But what is the reason? Making observations is always a lot easier than understanding the causes.

I can think of many hypotheses, but will throw out a few I can think of on top of my head. Of course these are just hypotheses, but I hope researchers and policy makers would know about these kinds of things to prove or disprove them. One cannot fix something if he does not know how it broke.

Here are a couple of hypotheses. What if Americans are just, gasp, sicker than the world? So, it costs more for healthcare, but if we do not spend more than other nations, our longevity would be even shorter? If so, then we must take better care of ourselves, meaning getting better at prevention. How do Americans rate in terms of diabetes, high BP, obesity, etc...?

And then, I keep hearing about expensive treatments that only prolong a patient's life for a month or two. For example, doctors at Sloan-Kettering made the news when they refused to use certain cancer drugs that did not do much for the patients, other than ruined them financially.

So, look at the country as a whole. Suppose we spend $1M to treat 1 out of 100 patients and extend his life 1 year. We have boosted the average lifespan by 1/100th of a year. The payback is $100M per year of increased average lifespan.

Now, if we take that $1M and treat all 100 patients with $10K each. We could not help the unfortunate patient, but extend the life of the other 99 patients by 1 year. We have just boosted the average lifespan by 99/100th of a year. The payback is now $1M per average year of increased lifespan.

So, how do other countries handle experimental and expensive drugs and treatments? If they do not concentrate on the unfortunate patient, they will have better statistics to show.

 

[REWahoo]

This weekend, I did a mock up on the Medicare.gov site to see which Part D plan would work best for my DW for 2017. Logging in her 9 meds and comparing plans indicated we could save $1,911 OOP annually by switching to an AARP plan out of her current Humana. This comparison varies by Zip code!

You probably already know this, but you might also compare the annual cost of her prescriptions under that AARP plan (including the deductible and "doughnut hole" costs) vs. purchasing them directly using discounts available through GoodRx.com. I found we could save several hundred dollars a year by buying a Part D plan as a back-up but purchasing all our meds from local pharmacies using goodrx discounts.

 

[Senator]

I looked at it briefly. It seems to have income limits way lower then ACA Cliff.

I don't know how practical it is for most people who are FI.

I looked at it too, and if you are a disabled vet, you can get it. 100% free. I got out of the service in 1982, and was labeled with a 10% disability in November of 2013. 31 years later.

The only reason I looked into getting VA healthcare is so I could get a veteran's ID card, so that I could get 10% off at Home Depot and Lowes. I initially did not even consider I was disabled. The application was successful, and it got me my Home Depot discount and free healthcare. Plus a small monthly tax-free stipend.

If you worked in any type of noise environment in the service, see your county Veterans Affairs office. I have mentioned this to several people, and they all got 10% disability and VA care.

 

[samclem]

Anyone that says that you don't need mandates with this provision really doesn't understand how it works.

There are things we could do to "encourage" people to get coverage that could augment the present government [-]fine[/-] [-]tax[/-] whatever.
And I want to put this in perspective: If a person chooses to go without health insurance despite the very many things that are being done (paid for by other people) to make it affordable (OOP caps, Medicaid expansion, income based subsidies for both the premiums and co-pays, provisions that serve to limit total health care costs to a set % of income, etc), then they are deliberately making a decision to not pay their share and have others take on a responsibility that should be theirs.
So, maybe the information about a person's health insurance coverage status (covered/uncovered--no information on their actual health or use of medical services) should be as available as their other financial information. Maybe it should be used as part of their credit rating (surely a person with an unlimited exposure to medical costs is a less attractive borrower.) Maybe current and potential employers should be able to see if their employees/applicants are making responsible choices (an employee without medical insurance is less likely to take the steps needed to stay healthy and come to work). This information would be useful to employers and others when a person seeks a security clearance, bonding, or a job with access to company funds or sensitive information (a person who isn't covered is more likely to have a very critical need for a big pile of cash in a hurry. Stealing is one way people have met needs like that in the past). Would auto insurance companies find that people who make irresponsible decisions regarding their health care and their financial risk also are less responsible drivers, and need to price that into their policies?

All of this can be done without any government collection of data or any cost to the government, and it would induce at least some people to get covered. It's not the government telling people they have to buy insurance or pay a fine/go to jail. It is just allowing private entities to share information that they already have--banks, lenders, and merchants do this already with financial information, and it does serve to help people behave in a more financially responsible manner. Why should the health insurance status of a person be information that is not handled the same way?

And, as part of any overhaul, we should seriously look at how much free medical care "society" owes to a person who has not taken the steps needed to get covered despite everything that has been done by "society" to make that affordable. One reason people don't buy insurance is because they perceive there is a safety net: They really don't believe the risks are very great. The risks should be great, and well publicized.

None of this is government coercion (in fact, it is less so than the existing IRS-enforced mandate). It is just allowing private entities to make decisions using data that other private entities already have, and a cessation of government's role in forcing private entities (health care providers) from giving away their property (some uncompensated health services).
The above suggestions are intended as a means to get people to participate in whatever scheme is devised, or if the present one is extended. No politicians were harmed in the creation of this post.

 

[NW-Bound]

Excellent idea!

I just recall that the state of AZ has the requirement of liability insurance for vehicle collision like most or all states. However, one can "self-insure" by purchasing a bond for at least $40K and present such proof of bonds to the state.

Few do the bond thing, and in fact I personally know of nobody, simply because the liability can run to a whole lot more than that $40K. So everybody buys insurance. However, one cannot call the insurance requirement coercive, because if you have the means to cover your liability, you do not need to buy vehicle insurance at all.

So, perhaps if an individual can pledge some large amount of money in a bond to self-insure, he also does not have to buy health insurance at all. If he worries about exceeding his bond, he can buy supplemental insurance for beyond that amount.

Say hello to a plan with a deductible of $200K. I'd bet it's cheap. I want one.

PS. The deductible would not be annual, but rather lasts until you reach 65. So, the younger you are, the higher that deductible has to be, balanced with the higher risk of illness as you get older. Actuaries will have fun figuring this out.

 

[daylatedollarshort]

I am quite flexible in my mind about moving. I grew up in Communist country. Then I spend my working years in great place for my profession. Moving to another country after FIRE date does not look strange to me a bit.

I can obtain high quality insurance in Spain for 70 bucks a month. All 401k and IRA accounts are shielded from Wealth Tax plus we will get 2 000 000 euros Wealth tax free allowance and Spain will benefit from us spending money in their economy. Looks like win win to me.

That EU passport will come handy in few years.

A few years back after a trip overseas DH brought home a magazine article on expat communities living in Mediterranean villas in Spain. It was kind of wild after their real estate bust what a villa costs there compared to a tract home in the Bay Area. We can also live in the EU and sometimes I wonder if we are stupid not to just move. Long term care seems to be half the cost at most in many EU countries as well compared to the U.S. so we wouldn't have to worry about that bankrupting us some day when we are old.

I just checked the prices and there are 5 bedroom villas there for $200K USD. Not too shabby for a worst case option if we can't get or afford health insurance here.

 

[daylatedollarshort]

401K and IRA are generally protected. Personal residences are generally protected.

ERISA 401Ks are protected uner federal law but the rest may vary by state law and federal law does not have 100% protection for all IRAs or non-ERISA 401Ks.

 

[Senator]

And, as part of any overhaul, we should seriously look at how much free medical care "society" owes to a person who has not taken the steps needed to get covered despite everything that has been done by "society" to make that affordable. One reason people don't buy insurance is because they perceive there is a safety net: They really don't believe the risks are very great. The risks should be great, and well publicized.

You are 100% correct, unfortunately when a person is dying and without healthcare coverage, they will get taken care of. 100% guaranteed. Think babies and dying women. That is why the cost needs to be covered by a tax, maybe a payroll tax, not a voluntary premium. It may have to double the existing payroll tax.

In MN, we have mandatory car insurance. Yet many people do not have it. The 'other' driver carries un-insured motorist coverage instead. The people continue to drive, even though they get caught several times. They do not pay they fines either. I see it on their background checks all the time, of course I send them on their way to another landlord. It is mandatory, but people do not feel obligated to make one person pay so someone else can drive. It's not a person's life.

The USA would never allow someone to be left behind with regards to healthcare. It is a safety net so large people can gamble as it will always be there.

 

[pb4uski]

That's exactly why they are going to get a lot of blowback from insurers if they keep the pre-existing rule (which apparently cannot be repealed since it's not part of the budget-related stuff that can be forced through the Senate). Insurers will either make the insurance unaffordable or remove themselves from the market if they are forced to take all comers without mandated coverage.

Here's a good article explaining this:
https://www.washingtonpost.com/news...ning-to-face-a-rude-awakening-over-obamacare/

Anyone that says that you don't need mandates with this provision really doesn't understand how it works.

I agree, but another approach might be to prohibit denying coverage for pre-existing condition only if you have had continuous coverage similar to what they do for group health insurance... that would provide a strong incentive to keep insured without an individual mandate because you could be denied coverage for preexisting conditions if you don't keep health insurance in force.

Today, HIPAA helps to assure continued coverage for employees and their dependents, regardless of preexisting conditions. Insurers can impose only a 12-month waiting period for any preexisting condition that has been diagnosed or treated within the preceding 6 months. As long as you have maintained continuous coverage without a break of more than 63 days, your prior health insurance coverage will be credited toward the preexisting condition exclusion period.

If you have had group health coverage for at least 1 year and you change jobs and health plans, your new plan can't impose another preexisting condition exclusion period. If you have never been covered by an employer's group plan and you start a new job that offers such a plan, you may be subject to a 12-month preexisting condition waiting period. Federal law also makes it easier for you to get individual insurance under certain situations. You may, however, have to pay a higher premium for individual insurance if you have a preexisting condition.

 

[Tadpole]

I don't see how it would work without the FEHB rates going up significantly. There are maybe ~3M federal employees and ~12M people signed up for ACA. I checked my state and the total FEHB monthly premium for an individual is about half of what it would cost on ACA. Not sure of the reasons for the price differences, one might assume the ACA is a much riskier pool.

Did you look at the total cost of the plans or just at the employee share of the cost? The average total costs in WA state of FEHB Self Plus One plans is:
Type, Mo. Premium, Yr.Premium
CDHP $1,203.55 $14,442.54
Value $1,083.96 $13,007.56
HDHP $1,126.46 $13,517.52
High $1,565.09 $18,781.09
Standard $1,310.30 $15,723.57

If it is hard to read, the first value is the type of plan, the second value is the average monthly premium over all the plans available in the state of WA, and the last number is the total yearly cost average (12* second number). If ACA plans cost more than this, WOW (something must be done about our health care system).

 

[eta2020]

You are 100% correct, unfortunately when a person is dying and without healthcare coverage, they will get taken care of. 100% guaranteed. Think babies and dying women. That is why the cost needs to be covered by a tax, maybe a payroll tax, not a voluntary premium. It may have to double the existing payroll tax.

In rest of the developed world Health Care is mandated just like income tax is mandated. And if you can not afford it (child, retiree, unemployed) you will get it for free.

 

[daylatedollarshort]

Now, there are a lot of factors involved. Maybe my circumstances were more fortunate. I know it is just anecdotal evidence, and so one has to be careful before making generalizations.

Statistical comparisons between the U.S. and other countries are available:

"This analysis draws upon data from the Organization for Economic Cooperation and Development and other cross-national analyses to compare health care spending, supply, utilization, prices, and health outcomes across 13 high-income countries: Australia, Canada, Denmark, France, Germany, Japan, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.....In 2013, the U.S. spent far more on health care than these other countries. ....Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions. "

U.S. Health Care from a Global Perspective - The Commonwealth Fund

 

[donheff]

There are things we could do to "encourage" people to get coverage that could augment the present government [-]fine[/-] [-]tax[/-] whatever.
And I want to put this in perspective: If a person chooses to go without health insurance despite the very many things that are being done (paid for by other people) to make it affordable (OOP caps, Medicaid expansion, income based subsidies for both the premiums and co-pays, provisions that serve to limit total health care costs to a set % of income, etc), then they are deliberately making a decision to not pay their share and have others take on a responsibility that should be theirs.
So, maybe the information about a person's health insurance coverage status (covered/uncovered--no information on their actual health or use of medical services) should be as available as their other financial information. Maybe it should be used as part of their credit rating (surely a person with an unlimited exposure to medical costs is a less attractive borrower.) Maybe current and potential employers should be able to see if their employees/applicants are making responsible choices (an employee without medical insurance is less likely to take the steps needed to stay healthy and come to work). This information would be useful to employers and others when a person seeks a security clearance, bonding, or a job with access to company funds or sensitive information (a person who isn't covered is more likely to have a very critical need for a big pile of cash in a hurry. Stealing is one way people have met needs like that in the past). Would auto insurance companies find that people who make irresponsible decisions regarding their health care and their financial risk also are less responsible drivers, and need to price that into their policies?

All of this can be done without any government collection of data or any cost to the government, and it would induce at least some people to get covered. It's not the government telling people they have to buy insurance or pay a fine/go to jail. It is just allowing private entities to share information that they already have--banks, lenders, and merchants do this already with financial information, and it does serve to help people behave in a more financially responsible manner. Why should the health insurance status of a person be information that is not handled the same way?

And, as part of any overhaul, we should seriously look at how much free medical care "society" owes to a person who has not taken the steps needed to get covered despite everything that has been done by "society" to make that affordable. One reason people don't buy insurance is because they perceive there is a safety net: They really don't believe the risks are very great. The risks should be great, and well publicized.

None of this is government coercion (in fact, it is less so than the existing IRS-enforced mandate). It is just allowing private entities to make decisions using data that other private entities already have, and a cessation of government's role in forcing private entities (health care providers) from giving away their property (some uncompensated health services).
The above suggestions are intended as a means to get people to participate in whatever scheme is devised, or if the present one is extended. No politicians were harmed in the creation of this post.

I have wondered/speculated about some of these things as part of a replacement/modification of the ACA without mandates. More draconian approaches might include waiving the pre-existing condition exemption for a year or two for people who drop coverage. An area that troubles me on all these individual responsibility approaches is what about kids. I hate to see the sins of the parents visited upon the children. How can they be covered when parents choose not to be.

 

[samclem]

I agree, but another approach might be to prohibit denying coverage for pre-existing condition only if you have had continuous coverage similar to what they do for group health insurance... that would provide a strong incentive to keep insured without an individual mandate because you could be denied coverage for preexisting conditions if you don't keep health insurance in force.

It would provide a strong incentive only if:
1) We, as a society, are prepared to follow through. To really let an uninsured person who is diagnosed with cancer be faced with a health insurance bill of $5k per month (probably typical of what an insurer would need to fairly price it at). I don't think society is at that point, and without a real consequence, people will continue to cheat.
2) People were (generally) good at estimating the likelihood of rare events and of taking appropriate action ("I'm healthy now, but I could get sick/injured and then need insurance and be unable to get it at affordable prices. I need to stay covered to prevent that") . The evidence shows they generally aren't good at making these assessments. If they were better at this, we'd sell far fewer lottery tickets and have far higher retirement savings rates.

 

[daylatedollarshort]

I agree, but another approach might be to prohibit denying coverage for pre-existing condition only if you have had continuous coverage similar to what they do for group health insurance... that would provide a strong incentive to keep insured without an individual mandate because you could be denied coverage for preexisting conditions if you don't keep health insurance in force.

We tried doing the HIPPA thing before and the insurance companies pulled every trick in the book to try to deny our application - never sending the info, not answering calls, just delay, delay delay hoping we'd give up. This was pre-ACA when rescission was standard business practice for the insurance companies. Then when we were finally approved it was over $2K a month in premiums with a large out of pocket max limit.

It was a very high stress time for us, we had kids at home that we needed to insure and we almost could not. I thought with the ACA all those kinds of shenanigans and sleepless nights were over - until I woke up Wednesday morning.