Professional Woodworkers and The Affordable Care Act

[Paul Wunder]

http://boss.blogs.nytimes.com/2013/11/06/a-small-business-starts-to-navigate-obamacare/?src=dayp

I am posting, NOT to be political but simply to pass on an article from today's New York Times written by Paul Downs, a custom Cabinetmaker from Philadelphia as he looks at the impact on his business of the new Health Insurance law. Paul is an official member here although he has never posted. This article will be one of a series written by him over the next few weeks. I know that we have many professionals here (I am not).

I hope that this subject matter doesn't cause problems here and I do think it may be useful. I suspect that the moderators will follow this closely.

[Matt Day]

This thread will likely get moved soon, but I enjoyed the article and look forward to his next article. I didn't know the ACA is based on age, sex, ZIP CODE, and tobacco use.

Thanks for posting.

[Mike Henderson]

Good, balanced article. Thanks for posting.

Mike

[Mark Carlson]

I liked the article and will look for his updates on how he makes out.

[Phil Thien]

Yep, I enjoyed the article as well, look forward to more updates.

In fact, I appreciate how the article avoids the politics of the issue.

[eugene thomas]

I really hope they mods do move this to proper forum.

[David Kumm]

One of the new requirements is that there can't be as large a price difference based on age as their used to be. Older people will be getting a benefit and young people will be subsidizing them. One reason why the system needs the young people to sign up. Employers with older workers are likely to see the impact of that- at least initially. Among my business clients, the group policies seem to be holding up. The people with individual policies are seeing cancellations and bigger increases. That is here in WI. I suspect different markets are different. Dave

[Earl McLain]

We're seeing the same thing in Indiana David, though our main small group carrier has not released our 1-1-2014 renewals yet. The downside on the Marketplace and SHOP offerings in our area is that the networks are incredibly narrow--with no coverage outside the network (for the most part--life threatening emergency being the main exception).
earl

[Paul Wunder]

In Connecticut, the networks are limited to the state of Connecticut. While CT has great hospitals, there appears to be no coverage that would enable someone to go the The Mayo Clinic or Johns Hopkins for specialized care if needed. I don't know if most commercial plans today have similar restraints. Maybe this will change over time with experience and listening to the public.

Some good news: A small businesswoman in CT (a friend) currently has a group policy that covers herself and her teenage daughter and pays almost $24K annually. I researched the CT marketplace for similar benefits and coverages and found a Blue Cross "Gold Plan" at <$15K. She was thrilled

[Wade Lippman]

Some good news: A small businesswoman in CT (a friend) currently has a group policy that covers herself and her teenage daughter and pays almost $24K annually. I researched the CT marketplace for similar benefits and coverages and found a Blue Cross "Gold Plan" at <$15K. She was thrilled

I lost my group insurance 2 years ago; they said I didn't have enough income to be considered a group. I was paying $14,000 for a family.
The only non-group I could find was $31,000, and it wasn't as good. I was rather upset.
Before the first insurance expired I found a group set up under the first phase of Obamacare for early retirees for $15,000 with somewhat better coverage than my original plan. I was thrilled.
Next year I can get even better insurance for $14,000. I am a happy man.

I am surprised though that a Gold plan for mother and daughter would be $15,000 Here it would be $8,000 for platinum. Maybe we are talking about different things.

[Steve Rozmiarek]

My small business's plan's for all our employees where cancelled, and a the cheapest in exchange option doubled the out of pocket and doubled the premiums for everyone. We were able to switch companies to find a similar plan to the old ones, out of exchange, but it changes the networks, so some of us lost doctors, and will only be able to use the cheaper rates for 2014. After that, we will apparently all be forced to go to a more expensive plan that none of us want. Interesting to see the extreme disgust from the usually ambivalent employees over that. Every one of them opted to stay outside of the exchange. This is a mess for my business and our people.

[Pat Barry]

I really hope they mods do move this to proper forum.


Its already in off topic, where else can they move it?

[Brian Elfert]

Its already in off topic, where else can they move it?

I suspect it started in another area and got moved to Off Topic.

I looked at the Minnesota exchange last night for the heck of it. (I have coverage through work.) I am in my 40s and do not smoke. My cost as a single person was right about $250 a month and it covers 100% after $750 deductible. That price does not include tax credits. My employer pays over twice what coverage through the exchange would cost. I also have to pay 20% of any medical bills so the exchange plan is actually better.

[Phil Thien]

I suspect it started in another area and got moved to Off Topic.

I looked at the Minnesota exchange last night for the heck of it. (I have coverage through work.) I am in my 40s and do not smoke. My cost as a single person was right about $250 a month and it covers 100% after $750 deductible. That price does not include tax credits. My employer pays over twice what coverage through the exchange would cost. I also have to pay 20% of any medical bills so the exchange plan is actually better.

I am an a state-run pool in Wisconsin. I have a bad back, so I wasn't able to get a conventional policy. While I never had or intend to have back surgery, the underlying problem is right there on film, and so three insurance companies turned me down, and I went into the high-risk pool. My premium was $1225 every three months.

They are closing that pool effective Dec. 31, and sent me a letter telling me to check-out the exchanges.

I had my wife check and I can go on her policy (they can't turn me down), and my cost will be about $700 every three months (saving $500 over what I have now).

I hope these threads can remain non-political. It is interesting to me to hear what others I feel I've come to know and respect are doing about their insurance, without any rants.

[Val Kosmider]

It is truly wonderful to have an objective discussion on the ACA.

Yes, there a re a LOT of bad people in this world who would think nothing of trying to profit from the needs of others, but at its core, a national health plan is not a bad idea.

As this example points out, there are plusses and minuses to the plan, but better disclosure can't be hurtful IMHO.Every article I have read which attempts to shoot down this ACT always has a bogey in it which makes the discussion moot. This article, and the gentlemen's real experience sets forth a plausible program as envisioned by its founders. Has to be helpful and informative to many , both insiude and out of the woodworkiung community. Thanks for posting.

[Thomas S Stockton]

I think one of the key things for small employers is to find an agent that understands the ACA and the various state exchanges. It can be really confusing and a lot of brokers are not up to speed and see it as a threat to their business.
Tom

[Doug Ladendorf]

Paul, thanks for posting that article. I wouldn't have seen it and will be going back for his followup. I appreciate reading about one small business owner navigating through the new landscape. It sure beats all the posturing one way or another. I've been getting my insurance through my employer and still paying quite a bit. Haven't checked out the exchange yet but am inspired to try - site willing.

[Paul Wunder]

One of the "rules" of the ACA is that all insurance companies offering medical insurance must now pay out $.80 of each $1.00 charged in premiums back to the insured as benefit payments. If the insurance company does not meet this goal they must refund the difference to the insured leaving $.20 of each dollar for admin, claims processing, commissions and profit. This "capping" has been in effect since 2012 (I believe) and that is partially the reason that some plans chose to cancel policies rather than compete. Also, each policy now offered for 2014 must meet a minimum "basket" of standard medical treatments, services, conditions and must offer policies to people regardless of prior existing conditions. There can be no annual limits or lifetime caps on the insurance company's obligation to pay a claim(s). Think major illness (cancer, back problems, etc).

[Jim Barstow]

I'm one of those "unlucky" people whose rates jump considerably. (I quote unlucky because I make enough so that I don't get a subsidy.) I got a notice that I'll be paying over 1/3 more. The reason I'm not happy is not the money per se but the reason for the rate increase. My rates go up because those of us that were on individual plans or who couldn't afford insurance now are treated as a "group". The overall health of the group has declined because there are more sicker people in that group thus rates increase.

I see the ACA as a small step in the right direction but I'd also show up in the polls as someone who doesn't like it. I wanted a single payer system ("medicare for all") which would have evened the risk out across the whole population.

[Ken Fitzgerald]

I would like to thank the participants so far for keeping to information and not allowing this to become political!

It's nice to see some restraint to keep the thread and posts within the guidelines of the TOSs!

Thanks again!

[Wade Lippman]

I see the ACA as a small step in the right direction but I'd also show up in the polls as someone who doesn't like it. I wanted a single payer system ("medicare for all") which would have evened the risk out across the whole population.

I am sure about half the population agrees with you, but the other half want nothing at all; so this is a compromise. You know the joke about a camel being a horse designed by a committee.

[David Weaver]

One of the "rules" of the ACA is that all insurance companies offering medical insurance must now pay out $.80 of each $1.00 charged in premiums back to the insured as benefit payments. If the insurance company does not meet this goal they must refund the difference to the insured leaving $.20 of each dollar for admin, claims processing, commissions and profit. This "capping" has been in effect since 2012 (I believe) and that is partially the reason that some plans chose to cancel policies rather than compete. Also, each policy now offered for 2014 must meet a minimum "basket" of standard medical treatments, services, conditions and must offer policies to people regardless of prior existing conditions. There can be no annual limits or lifetime caps on the insurance company's obligation to pay a claim(s). Think major illness (cancer, back problems, etc).

Or renal failure. The biggest claims I've ever seen in annual data are related to renal failure.

It's not necessarily good that individuals who can afford to have major medical insurance only and pay out of pocket for all routine services can no longer do that, but the system needs the healthy financially secure individuals to buy coverage (and the younger ones, too, now that there's an age rating limitation) or the whole thing just won't work. The flip side of it is that groups that are very old with high claims experience will be able to afford coverage easier. There's no free lunch, but there is a case where your lunch is bigger than mine and you give me some food, at least that's how I'd describe it.

I'd imagine a lot of people who had better coverage will end up with bronze coverage once they can do drop down box shopping. It'll just be too tempting to choose the lowest premium when the annual increases are double digit year after year, and the incentivization for which individuals pick up coverage on exchanges vs. which pay the excise tax for skipping coverage will encourage the average policy age to increase, which will drive up premiums more.

For some reason, it sticks in my head that the minimum loss ratio was 85% and not 80%, but I haven't seen anything about those aspects for a while.

[Paul Wunder]

David,

It appears that large groups require an 85% ratio and perhaps smaller groups are OK with 80%. I am not smart enough to figure it ou. But I copied the following from Healthcare.gov. I think that either ratio is an improvement toward protecting against future rate increases.

80/20 RuleThe 80/20 Rule generally requires insurance companies to spend at least 80% of the money they take in on premiums on your health care and quality improvement activities instead of administrative, overhead, and marketing costs.
The 80/20 rule is sometimes known as Medical Loss Ratio, or MLR. If an insurance company uses 80 cents out of every premium dollar to pay for your medical claims and activities that improve the quality of care, the company has a Medical Loss Ratio of 80%.
Insurance companies selling to large groups (usually more than 50 employees) must spend at least 85% of premiums on care and quality improvement.
If your insurance company doesn’t meet these requirements, you’ll get a rebate from your premiums.

[Brian Kerley]

I've got individual coverage, don't qualify for subsidies, but I will be saving $300/mo on the new exchange plans for similar coverage to what I am receiving now for my family of four. I also can get maternity coverage before, which was impossible to get previously.

I also received a check last year from Aetna due to the 80/20 rule, so at least I know that is in effect and working.

I would've preferred single-payer, but I'll live with this compromise for now.

[David Weaver]

Personally, I hope we figure out how to repair DNAand genese before there's single payer. Who knows, though, once we learn to do that, we'll want to learn to do something else. As far as the loss ratio requirements, I'd imagine that 80-85 percent is pretty much where groups are before the act (though I don't know). You can't find out from insured groups what their claims are unless they decide for some odd reason to tell you. I've seen groups (because we use experience to model cash flows) that have had renewals where there has been almost no increase (you'd have to figure that's because the groups experience was favorable, but their rate wasn't doing enough to reflect it), and groups that have had increases like 35% (you know they have no loss ratio issues). I have seen some also where the claims are greater than the premiums. Those leave you scratching your head, you'd think the insurer would figure that out pretty quickly when the group has several hundred individuals in it.

Whether they were at 84% on average or 79%, or whatever else, only individuals outside of the norm for one reason or another will see much of a discount or rate cut because of the rule. The groups on the other side of it will probably see bigger increases than they otherwise would have because the groups who were more profitable will do less subsidizing of the groups that were less - especially in non profit insurers.

There's not much real cost control in the bill. There are goals and dictates, but not a lot of "how" to go along with the "what", so unless a group is a beneficiary of specific things (like older pre-medicare individuals or folks with pre-existing conditions), cost increases will continue and the overall average per capital will do the same. (There's nothing really at this point to keep health care as a share of GDP from increasing until we just don't like the price).

When you think about why rates are where they are, a lot of it is utilization and demand. Can you imagine what demand will be if DNA repair and adjustment becomes commercially viable? Or repair to genes? I am predisposed to melanoma. I'd be all over a gene fix to genes that would otherwise regulate cell division if they weren't troubled.

[Rod Sheridan]

Thanks Guys, this is very interesting even to an outsider like me................Rod.

[Phil Thien]

(There's nothing really at this point to keep health care as a share of GDP from increasing until we just don't like the price).


I guess that is the crux of the matter. Everything else is a shell game, I suppose.

So as I said earlier, I am current on HIRSP (Heath Insurance Risk Sharing Pool) in the state of Wisconsin. I am on HIRSP because of my bad back, conventional insurers turned me down.

HIRSP has (I believe) an 80% cap, and a couple of years ago, I got a refund to the tune of $700 at the end of the year. I was a bit floored because I had assumed the pool was subsidized by the state, and those insurance companies licensed to sell health insurance within the state. I had always figured the premiums were a fraction of the claims.

So when I got that check I realized that this wasn't necessarily so. And then I started asking some of my friends what they were paying for insurance and realized some of them were paying as much as I was.

It seemed kind of odd to me that here I was, lumped in with the guys with MS, ALS, heart/lung issues, various forms of cancer, AIDS, etc., and we (as a group) hadn't exhausted our premiums, and the premiums seemed quite reasonable.

Maybe that year was a fluke.

Maybe there are a lot of people like me (I don't make claims, if I'm lucky I'll never undergo back surgery). So us healthy but risky members of the pool are subsidizing the larger consumers?

Don't know, but it was a SHOCK to get a $700 check. Of course, my wife ripped that check out of my hands so fast I got a paper cut deep enough to nearly require stiches. I'd have loved explaining that to the claims people.

[David Weaver]

Don't know, but it was a SHOCK to get a $700 check. Of course, my wife ripped that check out of my hands so fast I got a paper cut deep enough to nearly require stiches. I'd have loved explaining that to the claims people.

I don't know much about state pools. Health care is extremely regional. The average coverage here is probably gold level, and a lot of the insurance is from non-profits. further south and west, I understand that's not so much the case.

I know the check scenario well, though! Happens to me, too (though it's usually me cashing something out on paypal or selling a guitar or something). "you'd better not spend any of that on tools!!" is what I usually get. :)

[Paul Wunder]

There are programs under the auspices of Medicare to reduce the annual percentage rate of growth of per-capita cost of Medicare. Some of these programs seem to be working. The per capita growth rate of Medicare costs has been either flat or well below the cost growth rate in the Commercial market in the last few years. Some of these efforts are:

Cutting costs in Durable Medical Equipment (scooters, power wheelchairs, etc) by putting these programs out to bid on a nationwide basis to selected vendors. The Federal government has been chasing fraud. The "Scooter Store" a nationwide firm advertising "free Medicare paid scooters" was raided last year and shut down. This was a big catch; unfortunately several thousand employees lost their jobs.

Providing Diabetes supplies through mail order was a cash cow for hundreds of companies charging Medicare exorbitant fees. Medicare put these supplies out to bid to 17 national vendors who are providing the supplies at 50-60% lower prices than before.

Medicare has been challenging Hospitals to prevent seniors from returning to the hospital within 30 days of original discharge by improving the discharge process and requiring hospitals to follow up seniors: Are you taking your medicine? Did you have a follow-up appointment?

Medicare has started refusing to pay hospitals for extra costs due to their error: catheter infections, hospital acquired infections. Just two examples. Interestingly, most hospitals, rather than fighting this effort have seen this as a way to provide better patient care. Medicare is providing financial incentives to hospitals who surpass national norms in quality.

Medicare started a pilot program, complete with seed money to the participants. Last year 17 medical practices across the country became "Accountable Care Organizations" My family Physicians are one of those groups. I notice better follow through from my doctors regarding tests, recommendations and treatments. Their staff calls to remind us to take tests or to make an appointment with a specialist. Medicare is seeding the cost of additional staff, but holding the "ACO" to a higher standard of care. The ACO's will split any savings with Medicare that are achieved without compromising quality care. We receive regular independent surveys regarding recent doctor visits and encounters.

Electronic Health Records (now required by Medicare) seem to be helping doctors prevent duplicate testing. Each of the medical practices that we go to is now connected to each other so my health status is available to all.

Prescriptions are being written electronically to reduce errors.

My physicians and hospitals automatically give us printouts of each visit detailing: diagnosis, other relevant conditions, ongoing meds, recommended care plans and follow-ups.

[David Weaver]

Those are all fairly minor changes, though. And they are one-timers. The bigger cost savings from what I understood from the original bill were just flat out cuts in reimbursement rates. There was definitely a problem with lack of care items, like bed sores and wounds, etc (my wife worked in wound care, still does to some extent, I guess). There is also a cut in Part D participant drug prices, a "discount", but I don't know how that will play out (aside from the fact that it will be 50% off of retail, and the discount is not available to MAPD), it may just shift the cost of drugs non-medicare payers.

The commercials for products before where folks were always saying "don't worry, we'll bill medicare and it'll be no cost to you" did bother me quite a bit. If they can get rid of that stuff, I'd be pleased. I don't know how the ACO information will go for staffing, though, as medicare reimbursement rates haven't kept up with general medical inflation over the last 15 years, not remotely close, and planned freezes in the rates are going to cause decreased staffing or decreased staff pay, and not more. i had a discussion with someone not long ago who works in a physician practice and who said their reimbursements have been cut 27%, and they've had a pay freeze because of it. I don't know where they got 27%, I haven't seen any cuts of that amount, but maybe in some combination or business setup, the way they get theirs paid to them have been cut 27%.

As far as the hospitals go, they're just weathering it so far. I think the average margin for hospitals around here in the last year is approaching 1-1.5%. That's dangerous territory for individuals who rely on community hospitals.

[Earl McLain]

I'm quite impressed with several things about this thread...
1. The civil tone of the discussion--if we'd get the same behavior from both sides of "The Aisle" (and from the media), we'd have a better solution in place already.
2. The general knowledge of the group--even the MLR (medical loss rebate) difference between small group (<50 ee's, 80%) and large group (85%). A lot of insurance people don't know that--and there are a very small percentage who know how to help an employer calculate the distribution!! (okay, i'm one who can...and i'm proud of our agency for being committed to training and technology)
3. The opportunity to hear from consumers who have taken the time and effort to arm themselves with information.
4. That folks among this group would understand WHY many plans needed to be cancelled. No requirement to cancel them, but it's almost impossible to be effective in filing for so many amendments on existing plans.

I would caution that while we may see some very recognizable insurance company names in our respective exchanges, but the provider networks have tended to be much smaller than what we've come to expect. I'd expect the retail (non-exchange) networks to narrow as well, but those will usually be broader. Just know that seeing a name that you've known to have a huge network--carefully look at the network they are offering for the plan you consider. (those of us who need to see a specialist or might want to visit an emergency room in a different state for a non-life threatening emergency might want to be especially careful--think 10 stitches for a foot cut on a beach in Florida billed at $4,000 with no coverage to help).

Someone suggested selecting an agent who has sought education on the topic--wise advise. I am greatly impressed with some of our competitors in our area, and with many of the folks that are in my online study groups. At the same time--i'm equally embarrassed for my industry when I listen in to some of the Q & A sessions on webinars--it's simply sad. It's not a time to "sell" health insurance, it's an opportunity to provide the most valuable service that we could have imagined--and far too many "agents" have squandered that chance.

Thanks to all for keeping it peaceful--be careful out there!!
earl

[Wade Lippman]

Someone suggested selecting an agent who has sought education on the topic--wise advise. I am greatly impressed with some of our competitors in our area,

That isn't my experience. I gotten 7 contradictory answers to what I thought was a simple question. I didn't think there could be 7 contradictory answers.

Don't they have to cover out of network emergency care? (ie. the 10 stitches in Florida)

[Art Mann]

As far as I know, there are only two ways to control costs on health care - or anything else for that matter. They are (1) price controls and (2) competition. Most of the initiatives to control Medicare costs have been of the first type. This method has some very undesirable consequences. Where I live, many of the doctors no longer accept Medicare patients because the level of compensation is insufficient to cover costs. I have heard proposals to force doctors to accept Medicare patients but this will lead to other undesirable consequences. First of all, the level and quality of care will go way down as doctors turn their offices into high speed patient treatment mills. Secondly, a lot of doctors will simply retire. Finally, fewer people will choose to become doctors because the cost of entry is too great for reduced compensation. Many locations already don't have enough primary care physicians and the situation could get worse - much worse.

The other method of cost control, competition, has not been in effect in the US in several decades. The reason is that there is no connection between the person receiving the treatment and the person paying the bill. That is the nature of the current health insurance industry. Why should I, as a consumer, try to minimize treatment costs if the amount I pay is always a fixed deductible? The company I retired from initiated a program in which they raise my deductibles, which saves them money, but give me a substantial cash sum of money for health care expenses. If I exercise my own discretion to control treatment costs, I get to keep that money for health care expenses in future years. I now have a strong motivation to minimize my costs. Apparently, my company is happy with the arrangement as it has been in place for a while now and I am happy because I am accumulating cash in a medical savings account to use when I really need it. I wish the government would adopt such a program.

[Brian Elfert]

Many employer health plans now require employees to pay 20% or more of the cost of any medical care up to a yearly maximum on out of pocket costs. There is still the problem of nobody knowing how much the care will cost before using it. My employer requires I pay 20% of whatever amount the insurer has negotiated with the provider up to yearly max of around $3,000.

My employer also offers an HSA plan, but the deductible goes from $250 to $2600 for an individual and the company puts $800 into the HSA. The HSA plan really only makes sense for someone who is very healthy and never uses medical care.

[David Weaver]

Many employer health plans now require employees to pay 20% or more of the cost of any medical care up to a yearly maximum on out of pocket costs. There is still the problem of nobody knowing how much the care will cost before using it. My employer requires I pay 20% of whatever amount the insurer has negotiated with the provider up to yearly max of around $3,000.

My employer also offers an HSA plan, but the deductible goes from $250 to $2600 for an individual and the company puts $800 into the HSA. The HSA plan really only makes sense for someone who is very healthy and never uses medical care.

High deductible plans also make sense for people who have high normal costs for healthcare if they are of the type that offers a high deductible but 100% compensation for covered services after the deductible is met. It's the folks who use moderately that don't win with that model, though. The most important thing to me as an insured is not necessarily the deductible, but clear communication of what's covered and what's not, and most importantly, the annual out of pocket limit on covered services.

I would love to see greater specification of costs up front as Art says, but if it was really easy to do, we would already see it. It would be nice to see it implemented a little at a time for services that are easy to specify. Right now, you can do legwork and call around and get prices in some cases, and get individual agreements on the price. Insurers are aware of that, too, and in my case, I get emails from the insurer (and I'm sure others do, too) that offer to find members the least expensive place to get imaging, etc, done. In my case, once i've met my deductible, that only matters on principle, but if I had a 20% copay, after a few scans, that can amount to several hundred dollars of copay.

[Bob Turkovich]

The HSA plan really only makes sense for someone who is very healthy and never uses medical care.

I can only compare to my retiree health care plan (pre-Medicare) and it's the exact opposite when you take the monthly premiums into account. The PPO plan (i.e., 20% co-pay, $0 deductible) doesn't beat the HSA plan until you have approx. $3800 in medical bills accrued annually. Up to $3000 in bills, the out-of-pocket cost for the PPO plan is actually $500 worse.

You need to also remember the funds you put into an HSA account are tax-deductible if you itemize (up to a certain amount depending upon your coverage, individual, +spouse, + family, etc.).

[Brian Elfert]

On our HSA plan for an individual the deductible is $2600 and the maximum out of pocket is $3500 including deductible. Our HSA plan covers 90% once the deductible is satisfied. Basically, one would need to have $11,600 in non-preventative medical expenses before the plan would cover 100% of all costs. Preventive care, including prenatal and postnatal, is covered 100% with no deductible.

[Ken Fitzgerald]

I want to again....thank everyone for keeping the subject to information......and request that we keep personal opinions out of this. Personal opinions quickly turn to political statements.

Again...thanks for keeping on subject......and away from political comments.

[Brian Elfert]

I can only compare to my retiree health care plan (pre-Medicare) and it's the exact opposite when you take the monthly premiums into account. The PPO plan (i.e., 20% co-pay, $0 deductible) doesn't beat the HSA plan until you have approx. $3800 in medical bills accrued annually. Up to $3000 in bills, the out-of-pocket cost for the PPO plan is actually $500 worse.


I do not use the HSA plan today. My health care claims so far for the year are $3,400. My out of pocket cost is $1040 so far this year. I will pay $1,440 for my share of my health insurance plan. My total cost for medical care for the year will be right around $2,500 if I don't need more care.

If I used the HSA plan my claims would still be $3,400. My out of pocket cost would increase to $1,880. I would pay $1,224 for my share of my health insurance. My total cost for medical care for the year would be right around $3,100. I took into account the $800 the company puts into the HSA.

This is a good exercise to do as open enrollment is right now. For me this year, HSA would have cost me $600 more than the traditional medical plan and I have fairly low medical expenses. HSA plans can be set up all different ways and might make sense for some. I didn't include after-tax versus before-tax as that would be almost impossible to calculate.

[Steve Rozmiarek]

Because the conversation went to HSA's, I'm curious if anyone else feels the same as me. I want a simple, high deductible, no copay policy. I use it as a major medical plan. I also like HSA because of the tax benefits and the ease of applying little things to the larger deductible. For me, our $5,000 per family deductible HSA plan came out to much lower out of pocket per year than anything else out there, as calculated by premium plus total out of pocket costs. We're not that old, not having any more kids, and mostly healthy though, so it's probably different for others. I liked it because I knew exactly how much medical would cost me no matter what. That is the plan I lost, question is, is anyone else looking for that type of solution?

[John Sanford]

In Connecticut, the networks are limited to the state of Connecticut. It would seem in smaller states, or for people who work and live in different states (how many folks living in Connecticut work in NY, and have doctors in NY, etc....) this could be a big problem.

[Paul Wunder]

It would seem in smaller states, or for people who work and live in different states (how many folks living in Connecticut work in NY, and have doctors in NY, etc....) this could be a big problem.

It certainly came as a surprise to me....and it most certainly must affect thousands of people who border NY from Connecticut or who just need the special skills of New York hospitals. But as I previously mentioned, CT is blessed with a number of nationally ranked hospitals. It does concern me that people in less populated states may have fewer choices.

One of the major advantages of Medicare is that a person can obtain care anywhere in the U.S. Most hospitals accept Medicare and most NYC metropolitan area Physicians do too. I am fortunate to be covered by Medicare so that this first iteration of the AFA Exchanges does not affect me.

[John Sanford]

Or renal failure. The biggest claims I've ever seen in annual data are related to renal failure. Dialysis is expensive, and also effective. Which, from a pure bean counters perspective, is a bad thing. The patient just keeps on keepin' on, and needs dialysis routinely, because IIRC most folks who go on dialysis don't come off it until they shuffle off this mortal coil. While dialysis has, from the individual treatment standpoint, gotten less expensive over time, as well as become more effective, it has become more expensive per patient over time because the patient longevity has gone up faster than the cost has gone down.

This sort of dynamic has played out across a wide range of medical treatments, which is one of the reasons for the increase in medical costs. Put simply, our health care abilities have gotten all the low hanging fruit, and from a cost standpoint we are into the realm of 20%/80%, where 20% of the care consumes 80% of the cost.


There's no free lunch, but there is a case where your lunch is bigger than mine and you give me some food, at least that's how I'd describe it.
"give" is not the term that many would use.

From a practical standpoint, I question why they would use ZIP in HEALTH risk assessment. Age, sex, and tobacco use all make some sense. ZIP though? Not really, unless it's basically a form of reverse redlining, i.e., charge higher rates in the wealthier ZIP codes in order to mask subsidy collection.

[John Sanford]

It does concern me that people in less populated states may have fewer choices. Well, for many of the less populated states, it may not make much difference. Out West, the less populated states face the problem of distance, not legal boundary. For the vast majority of people who live in Montana, restricting their network to just Montana isn't likely to change much. Rhode Island and Delaware, on the other hand, can easily be getting hosed by this, especially RI, which, based on my understanding of their economic situation, isn't in nearly the fine position you've described for Connecticut. Rationally speaking, why should they be? Connecticut and Mass. are right next door, with their world class medical facilities. In the same vein, if one has lived in NW Indiana their entire life, why sweat it that Gary doesn't have any top tier medical facilities? Chicago is right next door.

This is actually has the potential to be a huge problem for a significant part of the population. By court order, millions of non-custodial parents are required to provide health insurance for their children. Previously, many policies supported networks that would spill over into border regions of adjoining states. Now what?


One of the major advantages of Medicare is that a person can obtain care anywhere in the U.S. Most hospitals accept Medicare and most NYC metropolitan area Physicians do too. I am fortunate to be covered by Medicare so that this first iteration of the AFA Exchanges does not affect me. Yes, but not only is Medicare age restricted, it's also, apparently, becoming less popular with health care providers, a trend that shows no sign of reversing.

[Dan Hintz]

From a practical standpoint, I question why they would use ZIP in HEALTH risk assessment.

Profiling, maybe? I imagine areas heavy with drug use, violence, etc. would be more costly on the healthcare scale...

[Scott Shepherd]

Had a good friend of mine that has a decent job at a place that employs about 1000 people across the US tell me that they got the call from corporate last week. The company was paying for all their healthcare costs for them and their families. Not a bare bones plan, but a nice, good plan with low deductibles, etc. Company now says they have no choice but to stop paying for families because of the changes. If they continued to pay for the families under the new regulations, it would cause them to go out of business. The cost to cover a wife and 2 kids- $700 a month out of his pocket. So where his cost was zero before, it's now $8400 a year increase in his costs. If they don't do that and get it on the exchange, it's still a net increase, no matter what the cost will be. So it's not a matter of their plan was poor and it was being cancelled, it was a matter of the employer saying it was going to do grave financial harm to their company if they continued under the new requirements.

There are a lot of people there with families. Lots of blue collar workers making $40,000 a year. How someone making $40,000 a year can take a $8400 increase in costs is beyond me. Those people are losing some really good healthcare insurance. I honestly don't know what most of them are going to do. They can't afford $8,400 a year more. Most of them can't afford $1000 a year more. $8,400 a year isn't "we can eat out less" money, that's "we can't pay the mortgage" money.

[David Weaver]

From a practical standpoint, I question why they would use ZIP in HEALTH risk assessment. Age, sex, and tobacco use all make some sense. ZIP though? Not really, unless it's basically a form of reverse redlining, i.e., charge higher rates in the wealthier ZIP codes in order to mask subsidy collection.

There is a true difference in claims costs by different geographies. I don't know why that is (if providers charge more, if utilization is higher, if general health is worse...), but I know that it exists because I've seen it for 15 years when costing future cash flows from different region. It's not like one region is twice as much as another, but it's plenty substantial enough to affect rates.

If you think of the ratemaking items in insurance that are allowed, they are things you'd like to know so that if you were betting on your accuracy, you'd have a better chance. Geographic region is one of those things that is statistically significant.

[Steve Rozmiarek]

There are a lot of people there with families. Lots of blue collar workers making $40,000 a year. How someone making $40,000 a year can take a $8400 increase in costs is beyond me. Those people are losing some really good healthcare insurance. I honestly don't know what most of them are going to do. They can't afford $8,400 a year more. Most of them can't afford $1000 a year more. $8,400 a year isn't "we can eat out less" money, that's "we can't pay the mortgage" money.

Scott, I think that the average Joe doesn't care one whit what the 80/20 rule is, they just know that the reality of the situation is that they now cannot afford insurance. This major flaw gets covered up so quickly in the discussion of details, that it gets ignored. Like it or not, the healthcare law doesn't look feasible with these kind of situations out there. I used my company earlier for an example. We have a one year window where we can get by without the rates going up, but the company cannot afford to pay double in 2015, and we will have to pull coverage at that point too. What else can we do?

[Phil Thien]

There are a lot of people there with families. Lots of blue collar workers making $40,000 a year. How someone making $40,000 a year can take a $8400 increase in costs is beyond me.

I think someone making 40k a year with two kids is going to get some subsidies, aren't they?

[Ty Williams]

From a practical standpoint, I question why they would use ZIP in HEALTH risk assessment. Age, sex, and tobacco use all make some sense. ZIP though? Not really, unless it's basically a form of reverse redlining, i.e., charge higher rates in the wealthier ZIP codes in order to mask subsidy collection.
I would argue that it's likely to result in LOWER costs in richer areas since they're lower risk to the insurer.

Geographic location (ZIP code) is highly correlated with socioeconomic status. Socioeconomic status is highly correlated with several factors that affect what your total healthcare costs (to the insurer) are likely to be. To use a specific example local to me, if your ZIP code is 43016 (Dublin, Ohio) it's much more likely that you are a white collar worker and receive regular preventative medical care (both factors which lower total healthcare costs) than if your ZIP code is 43066 (rural Delaware County, Ohio) where you're probably either a farmer (PTO raises possibilities of injuries that result in your landing in more than one field at a time) or factory worker (which raises possibilities of you being crushed by a load of steel) and probably aren't as likely to seek preventative medical care. So those two locations would see very different healthcare profiles even though you can drive between them in 7-10 minutes.

It's all based on actuarial tables, which do correlate to geographic location.

[John Sanford]

I would argue that it's likely to result in LOWER costs in richer areas since they're lower risk to the insurer.

Geographic location (ZIP code) is highly correlated with socioeconomic status. Socioeconomic status is highly correlated with several factors that affect what your total healthcare costs (to the insurer) are likely to be. To use a specific example local to me, if your ZIP code is 43016 (Dublin, Ohio) it's much more likely that you are a white collar worker and receive regular preventative medical care (both factors which lower total healthcare costs) than if your ZIP code is 43066 (rural Delaware County, Ohio) where you're probably either a farmer (PTO raises possibilities of injuries that result in your landing in more than one field at a time) or factory worker (which raises possibilities of you being crushed by a load of steel) and probably aren't as likely to seek preventative medical care. So those two locations would see very different healthcare profiles even though you can drive between them in 7-10 minutes.

It's all based on actuarial tables, which do correlate to geographic location.

Except your factory worker's injury is going to be covered under workman's comp, as quite possibly the farmer's injury will as well. Those are, for the moment, completely unaffected by PPACA, although there may very well be second order effects on those down the road.

While I suspect that the ZIP info gathering is tied to socio-economic status, I'm just a bit too cynical anymore that think that it's only so that the insurer can properly rate the RISK. I think it's more a matter of rating the HOW MUCH THE MARKET CAN BEAR potential. Those higher risk, lower income areas aren't going to be paying for themselves, and since the plans themselves are already set up to have the young subsidize the old and men subsidize women, it wouldn't surprise me in the least to see some rich ZIP getting tapped for a lot more than their risk profile costs in order to subsidize poor ZIPs.

[Scott Shepherd]

I think someone making 40k a year with two kids is going to get some subsidies, aren't they?

They didn't need subsidies before, so someone that needed no subsidies by anyone else is now forced to enter a program that requires someone else pay for it?

Forget it's $40,000 a year. Bump it to $80,000 a year. That's still a 10% cut in your pay. I'm don't know many people out there today than can take a 10% pay cut. Not blue collar workers, that's for sure.

Not to mention that new plan they are forced into now has a $6000 deductible where they had a $1000 deductible before. Not to mention that their doctor who has been their family doctor since the kids were born is no longer an option to them. Really sad situation for a lot of people. Both my parents have lost their primary care doctors because of this. The doctors have opted to go in a different direction and if they want to remain patients, they have to have $1000's a year out of pocket. Telling a senior citizen with medical issues that they have now lost their primary care doctor isn't a desirable outcome in my opinion.

[David Weaver]

I would argue that it's likely to result in LOWER costs in richer areas since they're lower risk to the insurer.

Geographic location (ZIP code) is highly correlated with socioeconomic status. Socioeconomic status is highly correlated with several factors that affect what your total healthcare costs (to the insurer) are likely to be. To use a specific example local to me, if your ZIP code is 43016 (Dublin, Ohio) it's much more likely that you are a white collar worker and receive regular preventative medical care (both factors which lower total healthcare costs) than if your ZIP code is 43066 (rural Delaware County, Ohio) where you're probably either a farmer (PTO raises possibilities of injuries that result in your landing in more than one field at a time) or factory worker (which raises possibilities of you being crushed by a load of steel) and probably aren't as likely to seek preventative medical care. So those two locations would see very different healthcare profiles even though you can drive between them in 7-10 minutes.

It's all based on actuarial tables, which do correlate to geographic location.

Preventive medical care actually increases medical costs. I remember talking to some health actuaries when comments about cost were being made, and they said something along the lines of "that's absurd, the data shows higher costs with more preventive care. Don't you think the policies would cover more preventive care if it lowered claims?"

As far as geographies go, the kaiser family foundation is a non-partisan foundation with excellent excellent data on all sorts of things. Here's a per capital expenditure list by state (keeping in mind that it is not normalized for age, or percentage employed, etc):
http://kff.org/other/state-indicator/health-spending-per-capita/#table

I would imagine there is some correlation between age and the chart, though it doesn't explain it all.

http://www.statemaster.com/graph/peo_med_age-people-median-age

Aging top to bottom in this list is probably worth about a 15% difference.

As far as occupations go, care costs are somewhat specific, especially after retirement. There's definitely a difference in expected lifetime, but there are some blue collar jobs where data doesn't seem to show that and some where it seems to show it very strongly. At least in some cases with those, the retiree and late-life employee health bears out that (think of construction trades, etc, that have been exposed to asbestos, etc, over their working lifetimes, working in confined spaces).

I'm a big surprised how big the geographic component is above in kaiser's data vs. age is sort of surprising to me, but I'm used to seeing data mostly from the region where I live (I don't specifically work in health care and am no expert, just have contact with numbers at work).

There may be coverage issues in some of those western states that have low average costs, and to some extent, the NY, Maine, PA area has very high levels of coverage - not just in numbers covered, but in the level of benefits such that it doesn't cost individuals as much to go get medical care.

[David Weaver]

KFF.org's calculator says that the cost to the EE with a family of 4 and a 40k income would be limited to about $2k, and if they got the silver plan, would have an out of pocket limit of about $4500.

IIRC, someone at 80,000 would also get a subsidy, but obviously not as much.

Certainly there will be folks who are not as well off after all of the changes.

[Brian Elfert]

I'm wondering if employers aren't using ACA as an excuse to reduce healthcare costs. My employer is offering the same healthcare plans as they have since 2009 and the employee premiums are exactly the same for 2014 as they were for 2013.

I don't quite understand what changes the ACA made that would cause an employer to go from covering 100% of a family plan to dropping coverage altogether. Why wouldn't they do something like cover 80% and have the employee cover the other 20%?

[David Weaver]

If an employer didn't have qualifying coverage before, they could end up paying more, including more family coverage since the dependents stay on longer, etc.

IF they have low income employees who go to the exchange because of subsidies, they end up paying a nondeductible excise tax for those individuals, and if their coverage isn't qualifying coverage, they pay the excise tax on all -30 if someone goes to the exchange.

I think some just don't want to deal with providing coverage any longer if they can't control the costs. Since the excise tax is based on FT employees, it's easier to bring people below that line (30 hours), which we've seen.

If you have an employer who provides generous coverage and always has, then it's more an issue that the employer believes that it's a priority in principle or an advantage to them for hiring and retention.

Each employer probably has different reasons. Some received steep renewals, and there may be some correlation between renewals and desire to stop offering coverage.

[Larry Edgerton]

I find it rather ironic that they call it the "Affordable Health Care Act", and then my premiums go up 42% for the same coverage. Affordable for who?

I will no longer have full time employees, I lose money.

Larry

[Paul Wunder]

Some companies are using the 2014 timing of the AFA and exchanges to just exit from the cost or hassle of providing employee medical insurance. Frankly, in many cases it is a no-win situation for a firm. I retired from IBM years ago and part of my retirement agreement was that IBM will always offer my spouse and I medical insurance at a company subsidized cost. IBM has over 100K retirees and each year they spent millions of dollars and management energy looking for multiple medical plans at various price points and features to offer to their retirees all over the country.

This year, IBM threw in the towel and told all of its retirees to join a commercially sponsored "Medicare Exchange" (run by Towers Watson Co.). IBM sent all of the retired employee's subsidies to this firm and they offer all flavors of medicare policies (Supplemental, Advantage, Drug, Dental, Vision, etc). This firm maintains an "Exchange Website" (similar to the Government, but it works). I was able to find the same plan that IBM offered previously, so I am OK. My IBM subsidy is being applied against the policy cost. There will be winners and losers in this process.

I spent much of my IBM career in Corporate Finance. For the most part, we self-insured our various insurance plans out of respect for the employees, but it cost us a fortune to administer, in addition to the actual insurance cost.

I think that this Outsourcing will be the direction for providing insurance to active and retired employees in the future. The trend will be for companies to outsource the whole process to "Commercial Exchanges." Some employers will be honorable, such as IBM, and will continue to subsidize the cost. Other firms will use this opportunity to reduce their subsidies and perhaps blame it on the AFA.

We'll see

[Dave Sheldrake]

Reading this reminds me just how lucky I am to live where I do. I have to admit I don't understand the US system at all well but what I believed was you guys have to pay for medical care, over here we get "at source" deductions (that amount to very little) for employees and that's it...done...no matter how much it costs for anybody to be treated it's all paid in full. If a person is unemployed those payments are made for them by the government and they get the same level of healthcare.

Here you can get private health care but all it really means is you see the same Doctors just have a shorter wait.

When my late Mom broke her Femur she was given the exact same level of care as if she had been her Majesty Queen Elizabeth. (the British term, "treated like Royalty")

Am I right to think over there the people who can least afford it will be hit the hardest?

cheers

Dave

[David Weaver]

Not really. There's a limit on how much of your income will be spent for health care, and above that amount you are subsidized (under the new law). Under prior law, you had to spend your money until you were pretty much insolvent and then qualify for medicaid after that.

The difference here is that generally health care has no wait. You'll get the same type of treatment your mother got even for basic routine services unless you live so rural that you have to travel for health care.

But we sure do pay for it as a percentage of GDP, and for things like drugs, we subsidize the rest of the world.

[Mel Fulks]

Won't that percentage of income thing result in more unreported income? Feds say its a big deal now.

[Dave Sheldrake]

Our Drug costs are £7.80 (about 11 bucks) per class of medicine, I take Warfarin (and will do for life) but as the different pills are just different weights of the same thing I only pay £7.80 every 3 months when I get a new prescription from the Doc. Cancer sufferers are exempt from any drug costs no matter how much or what they need.

The system there (with your new law) makes some sense, when Mom broke her Femur, off to the hospital, 9 inch metal plate installed and 19 weeks recovery (she was 72 at the time) in her own room in the hospital. Didn't cost a "dime". For hospital or *needed* medical treatment here there is no reducing period before things change. What you get on day one is what you always get.
Sure if you want nice shiny teeth with fascias on them or cosmetic things like that then it's paid for but nothing with any medical need is charged.

I never really knew anything about the US system, I just see the News Media over here saying that President Obama is coming under fire over it all (but none of the media actually say why)

best wishes

Dave

[Scott Shepherd]

The system there (with your new law) makes some sense, when Mom broke her Femur, off to the hospital, 9 inch metal plate installed and 19 weeks recovery (she was 72 at the time) in her own room in the hospital. Didn't cost a "dime". For hospital or *needed* medical treatment here there is no reducing period before things change. What you get on day one is what you always get.

Didn't cost her a thing? Sure it did. She paid into it (if she pays taxes) for a long long time. In fact, she's probably paid a lot more in taxes than the bill would have been. I worked in the UK for a short period some time ago. There was no shortage of taxes. If you tax me and then tell me something is free, that's not true by any means. Let's be honest, NOTHING is free when it comes to services provided by any government. I also remember working with a senior citizen that had trouble swallowing. I asked him why did didn't have surgery to correct it. He told me they wouldn't do the surgery because it wasn't life threatening. It would take him 1 hour to each a small sandwich. To him, his quality of life was not so good, to them, he was still eating so it wasn't life threatening.

The system here worked Dave. Most people had private insurance and most people's employers paid for it. In an effort to take care of those that didn't have insurance, we tore apart the system that worked for everyone else instead of figuring out a solution for those without insurance. For the final cost of this all, we could have paid for private insurance for all of the people that didn't have it and come out way ahead. We've now created so many new federal systems and departments, all those costs could have just been giving directly to people to buy them healthcare many times over.

[David Weaver]

Won't that percentage of income thing result in more unreported income? Feds say its a big deal now.

I guess it depends on what the definition of is is.

It looks like they are specifying the subsidies as non-income items. I tried to log in to healthcare.gov the first day it was up, because the price of the policies has huge implications for my work. Of course, you couldn't get information at that time at all, but had you been able to, it would've required personal information and an SSN from last year to determine the subsidy amount. Then you would get a premium quote, I guess, tailored to your prior year's AGI.

The conclusion being that you pay the price for coverage on the exchange and the implicit combination of paying for insurance and receiving a subsidy is ignored. I'd imagine calling it taxable income would have been unpalatable.

[Mark Bolton]

Didn't cost her a thing? Sure it did. She paid into it (if she pays taxes) for a long long time. In fact, she's probably paid a lot more in taxes than the bill would have been.

Maybe true for that single accident but likely not true for a lifetime of care and definitely not true for a lifetime of care for the vast majority of the US who are in the doctors office on a regular basis.

Some seat of the pants math would say an average employee working 45 years paying perhaps an average of 20k+ (likely high for average employees especially if they have family deductions) per year in state and federal taxes over their working lives. That about 900k total. If 10-15-20 percent of that went to health care you may only be talking 100-200k over a lifetime.

I know many seniors today who have put 200k in health care coats in their rear view mirrors years ago and are still scheduling multiple doctors appointments per week.

I know the systems outside the US usually run on a higher percentage of tax but my rough numbers are based on average people I've known. Probably averaging 50k+/year over their careers, single for a lot of it, and healthy. They are the highest payers into the system most of which average close to 40% in annual taxes (my gf pays about 38%).

Doesn't take into account the fact that the majority raise families and pay less taxes than that.

It would be interesting to know what the average US citizen uses in total health care dollars over a lifetime.

[Mark Bolton]

Extremely impressive thread. Have read it from the beginning and headed back for a re-read. What a wealth of knowledge.

[Dave Sheldrake]

Hiya Scott,

I meant on top of the contributions via tax Mom had always made. Tax is very high here, but I don't mind paying it in reality, I get back so much for what I pay and even if I pay over the top compared to what I use I try to remember the overflow will go to those less lucky than I have been.

From the very little I understand about the new US system there seems to be two split sides, those who think it's better and those that think it's worse with no real middle ground.

best wishes

Dave

[Andrew Joiner]

http://www.sawmillcreek.org/images/misc/quote_icon.png Originally Posted by Mel Fulks http://www.sawmillcreek.org/images/buttons/viewpost-right.png (http://www.sawmillcreek.org/showthread.php?p=2177924#post2177924)
Won't that percentage of income thing result in more unreported income? Feds say its a big deal now.


I guess it depends on what the definition of is is.



In Oregon ( I assume all states will be the same) the application asks for your income in 2014. So your subsidy is based on 2014 income! No mention of taxable income or gross income, just income.

I just met with the only agent in my area that will get me started on health coverage. The agent said if you overestimate your income you pay more for coverage, if you underestimate you pay less for insurance but no penalty. You may have to pay back the discount you got on coverage if your 2014 income is way off.

I was a self employed cabinetmaker but now I'm retired and live off investments. My income varies year to year.

I have a 5K deductible health insurance policy. I've had it over 30 years. It's never paid a dime for medical costs. At 62 I'm healthy but couldn't shop around because of pre-existing condition rules. I considered it bankruptcy insurance to cover major medical bills. I pay 3k a year and it hasn't been cancelled (yet).

A big benefit of the new law is colonoscopies and yearly exams are preventive care and cost nothing out of pocket. In the past colonoscopies (family history) and yearly exams have cost me a lot. In my case I will probably pay about 1k a year with the new law and pay way less for my actual medical costs.

[Scott Shepherd]

Maybe true for that single accident but likely not true for a lifetime of care and definitely not true for a lifetime of care for the vast majority of the US who are in the doctors office on a regular basis.

I think if that math was true then there would be no such thing as car insurance, health insurance, life insurance, extended warranties for appliances or cars.

The math points in the opposite direction, that the vast majority of people will never use what they have paid in. Any other reality and those systems mentioned would cease to exist.

[Ty Williams]

The system here worked Dave. Most people had private insurance and most people's employers paid for it.
I can tell you that if you think the system here worked you were among the fortunate and (comparatively) affluent. It never worked for me. When I was a kid, I was on my mom's insurance (nurse at a major hospital) and things were fine. Then I got out of college and had several full time jobs, none of which offered benefits and I couldn't afford it on my own because I was working full time in a supposedly middle class job and was still hovering around the poverty line. I got sick and didn't have insurance. Because I wasn't insured, the doctors flat out told me that they couldn't treat me, I had to go back home and wait until it was life-threatening before I could come back and they'd be able to treat me. Of course, after that I had a pre-existing condition and no insurance would touch me even when I offered them good money. Finally, I got married and my wife has good insurance via her work (research scientist at the same hospital my mom worked at, actually). Now, the insurance company calls the pharmacy and changes my prescriptions without asking my doctor. The insurance also tells me that I'm only allowed to go to PT fewer times than what both my doctor and my physical therapist think I need. I have to schedule over a year in advance for an EGD. I waited over 9 hours to be seen the last time I had to go to the ER.

The "old" system in the US didn't work for a lot of people. I personally don't think the new system will work any better, but that's a different problem.

[Scott Shepherd]

I can tell you that if you think the system here worked you were among the fortunate and (comparatively) affluent. It never worked for me. When I was a kid, I was on my mom's insurance (nurse at a major hospital) and things were fine. Then I got out of college and had several full time jobs, none of which offered benefits and I couldn't afford it on my own because I was working full time in a supposedly middle class job and was still hovering around the poverty line. I got sick and didn't have insurance. Because I wasn't insured, the doctors flat out told me that they couldn't treat me, I had to go back home and wait until it was life-threatening before I could come back and they'd be able to treat me. Of course, after that I had a pre-existing condition and no insurance would touch me even when I offered them good money. Finally, I got married and my wife has good insurance via her work (research scientist at the same hospital my mom worked at, actually). Now, the insurance company calls the pharmacy and changes my prescriptions without asking my doctor. The insurance also tells me that I'm only allowed to go to PT fewer times than what both my doctor and my physical therapist think I need. I have to schedule over a year in advance for an EGD. I waited over 9 hours to be seen the last time I had to go to the ER.

The "old" system in the US didn't work for a lot of people. I personally don't think the new system will work any better, but that's a different problem.

That's exactly the problem Ty. You needed the help and the system had a flaw that prevented you from having the care you needed. We could have fixed that without wrecking the system that did work for hundred's of millions of people. You might have it now, but my parents have now lost their doctors because of it. So who won? You? Certainly not them. So instead of fixing it so it worked for everyone, we've created something that works for people like you, but them causes havoc on others. I don't consider that a win.

I spend a lot of my adult life problem solving and following great leaders in that field. This problem is, and always was, fairly easily solvable. It's been solved many times over in small scale test markets and it worked great. However, there doesn't seem to be anyone interested in actually solving the problem.

[David Weaver]

Ty - when you got out of college, there was very likely major medical insurance available for very cheap - especially given your age. The trouble is most people looked at the insurance situation and decided since major medical only covered major events (though some policies had little kickers in them for certain routine things, or drug plan cards, etc - I had a relative with that type of plan, it offered major medical coverage and two free dr. visits a year), they would just forgo it entirely (or didn't even go that far and never contacted any indpendent agents, etc, to see what coverages they could get for cheap).

IIRC, when I got out of college, major medical only cost me about $50 a month 15 years ago. I've heard of others in different regions with major medical only/ high deductible plans that were in the $60-$70 a month range. Those policies likely won't ever pay you any benefits unless you have something really major, but what they do manage to do is get you negotiated prices for standard services and in more recent times, access to set up an HSA.

Because of the limitations to age ratings under ACA (which significantly favors pre-medicare aged older individuals, but works conversely for younger individuals) and the removal of pre-existing condition exemptions, etc, it would actually be much more expensive to get coverage now at the lowest level than it would have been to get major medical or high deductible coverage before and pay an average years' expenses out of pocket. And you'd still end up paying most routine care out of pocket on top of the cost of care. So you're probably right, if you're the average person coming out of college and gainfully employed, it may be a worse situation now. The provisions of the bill are the way they are to try to get younger individuals into purchasing coverage because the economics depend on it when, for example, a person age 60 is paying only half of their expected cost of claims in terms of premiums (based on the rates I've seen so far).

[Curt Harms]

I'm wondering if employers aren't using ACA as an excuse to reduce healthcare costs. My employer is offering the same healthcare plans as they have since 2009 and the employee premiums are exactly the same for 2014 as they were for 2013.

I don't quite understand what changes the ACA made that would cause an employer to go from covering 100% of a family plan to dropping coverage altogether. Why wouldn't they do something like cover 80% and have the employee cover the other 20%?

The kick for many will come in 2015. I purchase my own health insurance. I have a PPO from Aetna with a $2500 deductible. If I renew that by around Thanksgiving, I can keep it for one more year with a premium increase of about 10%. If I don't renew, my premium for the replacement Aetna plan will go up about 125% and my deductible will double, to $5000. As things stand now, I'm delaying the inevitable by one year. I haven't looked into alternatives yet.

[Brian Elfert]

Are colonoscopies always going to be considered preventative care now? My health insurance considers it preventative care and covers 100% if I schedule a routine colonoscopy without symptoms. If I go to a doctor with some sort of symptom and he/she refers me for a colonoscopy I have to pay 20% and my deductible applies.

I had a small business from 1996 to 2000 with four young single full time employees. It cost me around $100 a month per person for full comprehensive medical insurance. It was cheap because everyone, including myself, was younger than 30 years old at the time and all males so no maternity costs. I paid 100% of the cost because it was so cheap.

[Paul Wunder]

"Are colonoscopies always going to be considered preventative care now? My health insurance considers it preventative care and covers 100% if I schedule a routine colonoscopy without symptoms. If I go to a doctor with some sort of symptom and he/she refers me for a colonoscopy I have to pay 20% and my deductible applies."


The following is taken from the Health and Human Services website. PSA's are covered as a preventive service @ 100%, colonoscopies are not. (Some Marketplace plans may cover it @
100%

Under Medicare, Colonoscopies for screening are covered at 100%. If the Doctor finds a polyp during a screening, it becomes a Surgical procedure covered at 80%. Weird!

Free preventive servicesAll Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment (https://www.healthcare.gov/glossary/co-payment) or coinsurance (https://www.healthcare.gov/glossary/co-insurance). This is true even if you haven’t met your yearly deductible (https://www.healthcare.gov/glossary/deductible). This applies only when these services are delivered by a network provider.



Abdominal Aortic Aneurysm one-time screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/talk-to-your-doctor-about-abdominal-aortic-aneurysm) for men of specified ages who have ever smoked
Alcohol Misuse screening and counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/heart-health/drink-alcohol-only-in-moderation)
Aspirin use (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/heart-health/talk-with-your-doctor-about-taking-aspirin-every-day) to prevent cardiovascular disease for men and women of certain ages
Blood Pressure screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-your-blood-pressure-checked) for all adults
Cholesterol screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-your-cholesterol-checked) for adults of certain ages or at higher risk
Colorectal Cancer screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-tested-for-colorectal-cancer) for adults over 50
Depression screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/talk-with-your-doctor-about-depression) for adults
Diabetes (Type 2) screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/diabetes/take-steps-to-prevent-type-2-diabetes) for adults with high blood pressure
Diet counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/diabetes/eat-healthy) for adults at higher risk for chronic disease
HIV screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-hiv) for everyone ages 15 to 65, and other ages at increased risk
Immunization vaccines (http://healthfinder.gov/HealthTopics/Category/doctor-visits/shotsvaccines/get-important-shots) for adults--doses, recommended ages, and recommended populations vary:


Hepatitis A (http://www.vaccines.gov/diseases/hepatitis_a/index.html)
Hepatitis B (http://www.vaccines.gov/diseases/hepatitis_b/index.html)
Herpes Zoster (http://www.vaccines.gov/diseases/shingles/index.html)
Human Papillomavirus (http://www.vaccines.gov/diseases/hpv/index.html)
Influenza (Flu Shot) (http://www.vaccines.gov/diseases/flu/index.html)
Measles (http://www.vaccines.gov/diseases/measles/index.html), Mumps (http://www.vaccines.gov/diseases/mumps/index.html), Rubella (http://www.vaccines.gov/diseases/rubella/index.html)
Meningococcal (http://www.vaccines.gov/diseases/meningitis/index.html)
Pneumococcal (http://www.vaccines.gov/diseases/pneumonia/index.html)
Tetanus (http://www.vaccines.gov/diseases/tetanus/index.html), Diphtheria (http://www.vaccines.gov/diseases/diphtheria/index.html), Pertussis (http://www.vaccines.gov/diseases/pertussis/index.html)
Varicella (http://www.vaccines.gov/diseases/chickenpox/index.html)


Obesity screening and counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/diabetes/watch-your-weight) for all adults

Sexually Transmitted Infection (STI) prevention counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for adults at higher risk
Syphilis screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for all adults at higher risk
Tobacco Use screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/diabetes/quit-smoking) for all adults and cessation interventions for tobacco users


There is a separate list for women

[Paul Wunder]

Adding to my previous post, the following are the preventive care services for WOMEN that must be provided by an insurer under the AFA:


Preventive health services for womenMost health plans must cover additional preventive health services for women, ensuring a comprehensive set of preventive services like breast cancer screenings to meet women’s unique health care needs.
Comprehensive coverage for women’s preventive careAll Marketplace health plans and many other plans must cover the following list of preventive services for women without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.
This applies only when these services are delivered by an in-network provider.


Anemia screening (http://healthfinder.gov/HealthTopics/Category/pregnancy/doctor-and-midwife-visits/have-a-healthy-pregnancy) on a routine basis for pregnant women
Breast Cancer Genetic Test Counseling (BRCA) (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/cancer/talk-with-a-doctor-if-breast-or-ovarian-cancer-runs-in-your-family) for women at higher risk for breast cancer
Breast Cancer Mammography screenings (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-tested-for-breast-cancer) every 1 to 2 years for women over 40
Breast Cancer Chemoprevention counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/cancer/talk-with-a-doctor-if-breast-or-ovarian-cancer-runs-in-your-family) for women at higher risk
Breastfeeding comprehensive support and counseling (http://healthfinder.gov/HealthTopics/Category/pregnancy/getting-ready-for-your-baby/breastfeed-your-baby) from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
Cervical Cancer screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-tested-for-cervical-cancer) for sexually active women
Chlamydia Infection screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for younger women and other women at higher risk
Contraception (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/choose-the-right-birth-control): Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
Domestic and interpersonal violence screening and counseling (http://healthfinder.gov/HealthTopics/Category/everyday-healthy-living/mental-health-and-relationship/take-steps-to-protect-yourself-from-relationship-violence) for all women
Folic Acid (http://healthfinder.gov/HealthTopics/Category/nutrition-and-physical-activity/nutrition/get-enough-folic-acid) supplements for women who may become pregnant
Gestational diabetes screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/talking-with-the-doctor/gestational-diabetes-screening-questions-for-the-doctor) for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
Gonorrhea screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for all women at higher risk
Hepatitis B screening (http://healthfinder.gov/HealthTopics/Category/pregnancy/doctor-and-midwife-visits/have-a-healthy-pregnancy) for pregnant women at their first prenatal visit
HIV screening and counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-hiv) for sexually active women
Human Papillomavirus (HPV) DNA Test (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-tested-for-cervical-cancer) every 3 years for women with normal cytology results who are 30 or older
Osteoporosis screening (http://healthfinder.gov/HealthTopics/Category/doctor-visits/screening-tests/get-a-bone-density-test) for women over age 60 depending on risk factors
Rh Incompatibility screening (http://healthfinder.gov/HealthTopics/Category/pregnancy/doctor-and-midwife-visits/have-a-healthy-pregnancy) for all pregnant women and follow-up testing for women at higher risk
Sexually Transmitted Infections counseling (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for sexually active women
Syphilis screening (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/get-tested-for-chlamydia-gonorrhea-and-syphilis) for all pregnant women or other women at increased risk
Tobacco Use screening and interventions (http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/diabetes/quit-smoking) for all women, and expanded counseling for pregnant tobacco users
Urinary tract or other infection screening (http://healthfinder.gov/HealthTopics/Category/pregnancy/doctor-and-midwife-visits/have-a-healthy-pregnancy) for pregnant women
Well-woman visits (http://healthfinder.gov/HealthTopics/Category/everyday-healthy-living/sexual-health/get-your-well-woman-visit-every-year) to get recommended services for women under 65

[Scott Shepherd]

If you'd like to get an eye opening experience with all this, a couple of guys created a site that pulls off all the same sites the ACA does and you can essentially, use the site that's broken now, through their site. Took them 3 days to create it and it works. Go figure.

However, the frightening part is to start playing around with the income and plans. The part that I think is going to fire up a lot of people is that if you want a Gold plan (in my zip code), you're looking at $1,800 a month. If you make $30,000 a year, then you get that subsidized 100%. So the poorest people will be able to select plans that will cost the working class $1800 a MONTH and they'll get them for nothing. The working people will have to get the lowest coverage because it's all they can afford. It's really stunning to see what happens with the numbers. How a part time employee that makes $20,000 a year can have a better plan than someone that makes $100,000 a year is bizarre.

I think when people find out that they can only afford the bronze plan when people without jobs are getting the platinum plans people are going to come unglued.

The site is thehealthsherpa.com - Check it it out for yourself.

[Dave Sheldrake]

Hey Scott,

I've just been mucking about with that using a friends zip code but my real family information.

That's some wacky figures it spits out!!

cheers

Dave

[Sam Murdoch]

I think when people find out that they can only afford the bronze plan when people without jobs are getting the platinum plans people are going to come unglued.

The site is thehealthsherpa.com - Check it it out for yourself.

I don't think that the above statement is accurate. As I understand it the size of the subsidy will be based on - your income - the number of people in your household - and the price of the benchmark silver plan in the town or county where you live.

[Scott Shepherd]

I don't think that the above statement is accurate. As I understand it the size of the subsidy will be based on - your income - the number of people in your household - and the price of the benchmark silver plan in the town or county where you live.

That's information directly from the same site the government is using. If you enter a person that's 40 years old, single, enter $10,000 for income, then look at the platinum plans (you have to scroll to about page 9-10), then do the same thing with someone making $80,000 a year, same plan. Since the person with no, or low, income gets subsidized, they can get a plan that's $1,800 a month for no out of pocket monthly premiums, so it's very much an accurate statement that someone without a job can get far nicer plans than someone making $80,000 a year. I don't know many people making $80,000 a year that can make a $1,800 a month payment.

[Dave Sheldrake]

That's information directly from the same site the government is using. If you enter a person that's 40 years old, single, enter $10,000 for income, then look at the platinum plans (you have to scroll to about page 9-10), then do the same thing with someone making $80,000 a year, same plan. Since the person with no, or low, income gets subsidized, they can get a plan that's $1,800 a month for no out of pocket monthly premiums, so it's very much an accurate statement that someone without a job can get far nicer plans than someone making $80,000 a year. I don't know many people making $80,000 a year that can make a $1,800 a month payment.

In reality that's pretty much the way it works here as well, healthcare is paid as part of our taxes, the more that is earned the more tax you pay ergo the more healthcare you pay. Down the other end of the scale somebody with a very low or only state funded income gets it paid for them and gets the same level of care.

Fully private healthcare from somebody like BUPA here can cost up to £1,700 a year (about $2,500) but for that you get pretty much everything, private hospitals etc etc for a family of 4 (two adults in their 40's and two children under 10 with both adults being smokers) more typically it's around £1,000 a year ($1,500)

It does seem to be very expensive over there

cheers

Dave