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ACA repeal wheels in motion vs The Twilight Zone and railroad switch yards.....
Equating military servitude with economic contributions harkens back to the Civil War, when you could buy your way out of serving. But generally, conscription and taxation are substantially different subjects.
That said, I felt and still feel that Selective Service is sexist. It arbitrarily singles out one half (give or take, we don't need exactitude here) of the populace.
Saying you like something like national Medicare doesn't address the pricing issue. Do you support "free" care, a la Part A? Even for Buffett? What about the copay for people who can't afford it?
Or do you favor income based premiums as in Part B with IRMAA? If so, should premiums cover costs for people who can afford them, or should they be higher than cost or lower? What if someone is indigent? How would you deal with subsidizing their premiums? I'm not up on this aspect of Medicare, but at first glance, it looks like a crazy quilt of programs.
Perhaps as a fan of the ACA you're thinking about Part D, which not only uses IRMAA, but is priced entirely by private insurers. It's still called medicare. It too has its own program to help the indigent called Extra Help. But you might get subsidies from your state as well, e.g. NYS's EPIC program (income up to $100K).
Premium prices, income adjustments, inflation adjustments, cost sharing, donut holes, federal subsidies, state subsidies, ... Saying "national medicare" barely begins to address the questions you've been asking.
In this sense it doesn't matter whether insurers handle payments (ACA), or a single payer handles payments (also allowed by ACA, but Medicare is the more common example). Whatever machinery is used for the claims processing still has to be funded.
I, family, and friends actually have been on many of these forms, or levels, of Medicare. It can be complex, but many states have free help for that maze. It's not all that much of a maze, turns out, though I thought a few years ago it might be a crazyquilt, until I had experience. For most everyone I know (including doctors) it seems to work pretty well most of the time. My wife's HMO-type medicare plan has zero premium but nontrivial deductibles; includes PDP. Mine costs more but is much wider as to caregivers, and no co-pays and the like. Separate PDP. All seems reasonable. It sure is efficient to deal with and efficiently (cheaply!) run, say experts. Doctors may not love it but every one I have asked has said it is comparatively painless to deal with and better for their practice than the endless staff dicking with private insurance. Doubtless it is actuarially unfair in some, maybe many, senses. SS and taxes, man. I have experience of only a very few acquaintances on Medicaid. Sure, funded it all has to be; I will let you explain to everyone how it currently is and how it should be. It is droll that you consider me a fan of ACA. Not sure I know enough to be a fan. But compared with what? Did you describe your plan and I missed it?
This contains further enlightenment, at least for me:
Just to be clear, when you write that the subsidy programs are not a crazy quilt and that you know people on these various forms, you actually do mean the subsidy programs: QMB, SLMB, QI, QDWI? Then there are also the Dual Eligible variants: QMB Plus and SLMB Plus.
In contrast, parts A-D are relatively straightforward. I've been helping people for years with this stuff - across state lines, even ex pats. That's where some of the rules get really interesting.
One person I helped was also on a MA (as opposed to a MAPD) plan. Generally speaking, it's more expensive to subscribe to separate MA and PDP plans. That is, unless you're getting help with the PDP plan, typically as a retiree or veteran.
The drug coverage needs to be a creditable, meaning that it is at leastactuarially equivalent to Medicare Part D coverage. That's not my term; its written into Medicare.
As defined at 42 CFR §423.56(a), drug coverage is creditable if the actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare prescription drug coverage,
Part C plans are private plans, run by for-profit companies with their own rules on what they cover and how much they pay. By definition they can't be easier for providers to deal with than private insurance since they are private insurance.
>> Part C plans are ... run by for-profit companies / You are mistaken here, I believe.
You are both correct, to an extent:
"Medicare Advantage plans are sometimes referred to as Medicare Part C. They are Medicare-approved private health insurance plans for individuals enrolled in Original Medicare, Part A and Part B. When you join a Medicare Advantage plan, you are still in the Medicare program and must continue paying your Part B premium.
Medicare Advantage plans provide all of your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. They generally offer additional benefits, such as vision, dental, and hearing, and many include prescription drug coverage. These plans often have networks, which mean you may have to see certain doctors and go to certain hospitals in the plan’s network to get care."
For the sake of argument, let's say that MA insurance companies are not-for-profit. Make that substitution in my text, and nothing changes. These are still private insurers, and so doctors cannot be finding them easier to deal with than private insurers. That sentence still makes no sense.
I did look at the Wiki line that says most Medicare Advantage plans are administered by non-profit insurance companies. What is "most"? 80%, 90%? This is something you've expressed concern about. Certainly it's well more than half?
Was quoting doctors, not making it up myself. Will be sure and tell the next one who mentions it that he cannot be correct in what he says, and will cite your extensive analytical work, if only it were published and not in some minor forum, as some have been encouraging you to do.
Was speaking from personal experience, wider than some, about straightforwardness, and yes, for sure.
Will remind executive acquaintances at BCBSMA and Tufts (including head of former) that they are small regional nonprofs. They might point out that that's part of the problem.
I am certain you must be right in what you conclude, if only we could tell what those conclusions were.
Yes, please do tell your doctors that your MA coverage is with a private insurer, since they seem to be confused on that point. They appear to think they're not dealing with a private insurer, or perhaps you misunderstood what they meant (e.g. that dealing with your MA private insurer was easier than dealing with ACA private insurers).
Alternatively you could direct them to the BCBSMA medicare glossary that makes it clear that MA insurers are private:
Medicare Advantage Plan
A health plan, such as a Medicare-managed care plan (HMO or PPO) or private fee-for-service (PFFS) plan offered by a private company with a Medicare contract. An alternative to the Original Medicare Plan.
This is important to keep in mind when suggesting MA as a model for ACA. They're just different variants of the government farming out health care coverage to private companies. Remember, ACA also uses non-profit insurers, it even tried to build them from scratch and called them CO-OPs. (Currently, there are only five remaining, as all but six folded, and one just converted to a for-profit company.)
My conclusions: Seeing something on the internet (especially Wiki) doesn't make it true, and experiential information can be misleading.
As KFF observes, in some states, regionals dominate. It even gives Tufts as an example. That makes them big fish in small ponds, still small from a national perspective.
Some regionals include: BCBS Mich: 57% of Mich market (621K): 0.4M SCAN Health Plan: 7% of Calif. market (2.24M): 0.2M BCBS Minn.: 39% of Minn market (511K): 0.2M UPMC: 15% of Penn market (1.02M): 0.2M Medica Holding: 25% of Minn market (511K): 0.1M (plus 91% of ND's 22K market) HealthFirst: 11% of NY market (1.24M): 0.1M Universal American Corp (Texas): 0.1M Guidewell (BCBS FL): 8% of Fla market (1.67M): 0.1M Spectrum Health: 18% of Mich. market (621K): 0.1M Tufts: 43% of Mass. market (246K): 0.1M (plus fewer than 1K in RI) UCare Minn: 18% of Minn market (511K): 0.1M Henry Ford Health: 11% of Mich. market (621K): 0.07M Centene: 20% of Oregon market (339K): 0.07M Ministry Health: 15% of Wisc. market (411K): 0.06M PH Holdings: 22% of LA market (250K): 0.05M BCBSRI: 71% of RI market (73K): 0.05M BCBSMA: 18% of Mass. market (246K): 0.04M
Given your familiarity with the various subsidy programs, perhaps you could help with a question that I haven't researched yet:
How do these programs coordinate with MA, or are they strictly limited to original Medicare? I ask this because you mentioned high deductibles in some MA plans, and additional premiums (above the Part B premiums) for some other MA plans. Anyone needing subsidies would obviously need help with these fees.
Not certain if this info will help but beginning this year the SF retirement system changed the setup, leaving only two choices: Kaiser, or a United Health MA.
With respect to United Health, previously it was available as a secondary insurance to Medicare, and that's how I used it for many years. I had the standard Medicare ID card, and a separate United Health ID card. Now I have just the one United Health MA card (although I surely am not getting rid of that Medicare card). The providers would need to bill both Medicare and then United Health, so the process was pretty inefficient from their end, but worked very well from my perspective.
Now the providers apparently need bill only United Health, and they take care of all of the payment issues for the provider, which should make life a bit easier for them, I expect (and hope). Haven't had enough experience yet to compare results from my end. With the MA that SF purchased I was able to keep all of the doctors & hospitals that I have been using for many years, so no problem there. But I imagine that's one of the more expensive MA options when purchasing such a plan, and may not be available for individuals.
Additional Notes: • SF is unique in CA in that it is both a City and a County. I have no idea if that made a difference in the type of PPO plan that it was able to provide. • SF retirees are charged a premium for the additional health coverage, with the Kaiser coverage being significantly less expensive than the United Health. However, the United Health coverage is better: for instance, it covers my hearing aids, allowing one replacement every two years if necessary. At $2500 each, that adds up quickly.
Howdy @Old_Joe With the plan you note; do you still pay a monthly premium (usually deducted from Social Security) that may be paid to Medicare or United Health? Does my question make sense? Just curious with all the variables. Catch
@catch22- Hi there, catch! Yes, we still pay the regular SS deduction plus the additional premiums that I just noted in an add to my comments above. I say "we" because my wife and I both have individual SF retirement plans, as we were both city employees. She is somewhat unusual as teachers go, because she was able to contribute both to SS and to the California State Teachers Retirement Fund. Because of that we have separate and identical retirement health benefits. OJ
Clearly by private the doctors I have spoken with mean chiefly employer insurance, as opposed to Mass. MA nonprofs. I've had no need or interest to query about ACA efficacy, or lack. Theirs was more a 'Tufts or gov way easier than Anthem.' Oh, one ER nurse did tell me that their ACA-patient experience represented a major improvement, but that's emergency work and possibly not applicable more widely, dunno.
Your entirely obvious and true conclusion about online info and anecdote is not what I queried either, but it's annoying to again ask someone so thorough to be constructive and specify how you think HC things should be structured.
I said nontrivial deductibles, not high. We have Mass. MA (HMO model) and also Medicare supps, but surely you know all that. Information on plans, their coordination, and subsidies hereabouts:
I'm not surprised that this sort of plan exists, it's just something else to read up on. Lots of people like Kaiser, but as you implied, the problem with switching to Kaiser is getting a completely new set of doctors. Not something you want to do if you've been with your doctors for years.
I did a quick check for individual MA plans in SF, and United Healthcare isn't even offering one. So you're right, your plan isn't available generally.
I gave you two principles I expect any design to comply with:
1) All people should get adequate health care at a price not exceeding what they can afford (for the wealthy, it will almost by definition be at a price less than they can afford).
2) No natural person or group of natural people should be singled out to support the system. Only businesses and/or the public at large may be taxed for subsidies.
I did forget a third. #1 and #2 set upper bounds on what people should pay. I forgot the lower bound rule:
3) People's care should be subsidized only to the extent necessary to bring the price down to what they can afford.
Asking for a design is like asking for a 2700 page document that took a year to create. I won't say that I don't care at all about the design, but so long as it can meet the principles above, I'll be satisfied.
We can, for example, look at MA to see where it satisfies these principles and where it fails.
Let's start with the fact that the (private) MA insurance companies receive payments according to how sick their policy holders are. In other words, their rack rate is determined by medical underwriting. Now you don't see that because it doesn't affect what you're paying, but it's there just the same.
We know two things from this: The insurer is getting a total fee from the government and from policy holders combined based on the condition of policy holders, and the insurer has calculated an actuarial cost for each policy holder.
(I hope I don't have to keep saying "give or take"; we know that actuarial science isn't exact.)
Suppose I, as a MA policy holder, pay more than that my cost (plus overhead, profit, etc.). Then someone else would be paying less than their cost. (We can't all be paying our cost or more, because then the combined payment would exceed the insurer's fee.). So my payment would effectively subsidize someone else. That's a violation of #2.
Thus I should pay up to the cost of my policy (plus overhead, etc.)
The actual amount a policy holder is charged for MA insurance is a part B premium and possibly an extra premium directly to the insurer. Part B premiums cover around 1/4 of the typical person's medical loss. Any extra premium paid to the insurer isn't going to make up the remainder. So virtually all MA policy holders are paying less than the cost of providing their coverage.
That means, as a MA subscriber, I'm getting subsidized. If I were a (wealthy) person who could afford to pay more, this would violate principle #3. There are two choices - reduce the cost (e.g. fewer benefits) or increase the amount I'm charged.
If the plan design sets a floor on benefits (e.g. 10 essential services), then the only option is to charge wealthy people more so that they're not getting subsidized. But at this point we're not discussing what the plan should cover so much as how it should be priced.
I should point out a fundamental difference between Medicare (or MA) and individual insurance. Medicare is a contract with the government, just as SS is a contract with the government. I agree to pay in for at least 40 quarters, and the government agrees to provide me insurance below cost. So you can't conclude from this writing that I'm saying actual Medicare is priced too cheaply. I'm just using it as a model.
So now we know that ideally I should pay the cost of my policy (plus overhead, etc.) But what if I can't afford that? Principle #1 says that the all-in cost has to be affordable. I'm not defining affordable here, though we may reasonably assume that it will be some well-defined dollar amount per year, however the formula is concocted. That will serve as a ceiling to how much I pay over the year.
There are various ways we could implement that ceiling. We could say set the premium at this amount and then policy would cover my expenses 100%. That's not a great design, because it encourages overuse. We could set the premium lower and add the difference to the deductible. That's better, and a lot of ACA plans do this. The problem is that this discourages use with a high deductible.
What we might have to do is relax principle #3 a little. We can say that in the worst case (paying all premiums and maxing out on usage) the plan is still within my ability to pay. But I might pay less if I don't max out on my plan.
Then the insurer is free to offer different types of plans that allocate risk differently. Pay more up front (platinum) and get a lower cap and lower copays. That's shifting the risk from me for a price (my expected total cost is higher, even if my worst case is the same). Or maybe I pay less up front but with higher copays and a higher cap.
I hope you begin to see how these few principles really do shape the pricing aspect of a program. I'm not going to write the remaining 2699 pages to explain how I might define "affordable", how one structures insurance to protect companies against going bust (e.g. via reinsurance), how (or whether) to set a limit on insurers' profits, etc.
Notice also that these principles and the writing above is compatible with both private insurance and government single payer. Picking the latter can open lots of possibilities - more negotiating power to drive down provider costs, less overhead, etc. But it's not necessary to make this work.
I'm not describing how to build an insurance market. I'm not discussing mandates, because my requirements lead to a system where people do get fair value and pay fair prices (or less, after subsidies). So it doesn't become necessary from a purely economic perspective to force people into the system. It's desirable for other reasons to have everyone participate (disease control, healthier more productive populace, etc.), but you're not going to have death spirals if you can't force enough people to pay more than a fair price (subsidize others) for what they're getting.
If you're wondering how the insurers (or single payer) gets paid, go back and take another look at MA. I showed that virtually everyone is already underpaying, and the system works. It's supported by taxes. Not on the few - those who hold policies - but on everyone. Just like your school system. Because it benefits everyone. (And just like your school system, some of the taxes could be on wealth/property, rather than income. Or just like the ACA, some of the taxes could be on businesses instead of individuals.)
This is all you get. Constraints for the system, and best wishes in spending a year designing a system of your very own.
One can argue that the problem of healthy people dropping out is not an adverse selection problem (and it's one I've addressed). ACA relies on healthy people because it is overcharging them.
If you view insurance in terms of cohorts (groups of people with equal risks), and charge each cohort according to its risk level, it doesn't matter if you lose an entire cohort. The 30 year olds are charged less because on average they cost less to insure. The 40 year olds are charged a bit more, and so on. With each cohort charged what they cost, each cohort stands on its own.
But that's not the real adverse selection problem. The real problem is people gaming the system. Buying insurance when they need a service (thus underpaying), and dropping it otherwise. This is a problem even within a cohort. There are a few different approaches, but IMHO none is satisfactory.
One is to make insurance compulsory. For example, charge a penalty equal to the cost of insurance. Then, if someone wants to go to the doctor without paying the copay, fine, that person is overpaying for that individual service by personal choice. Anyway, the insurer has received (via the penalty) the needed premium, whether an individual chooses to take advantage of the insurance or not.
Another is to refuse to cover people for pre-existing conditions, at least for some waiting period. A small example is dental insurance where you may have to wait six months before it covers cavities. There's general consensus that this is not a desirable approach.
Another is to require people to pay a penalty to get back in. That's the current Republican proposal, and it's been pretty well discussed. What hasn't been mentioned in this context is this is the approach that Medicare takes. If you wait before you sign up for Part B or Part D, you'll be charged a higher premium. Not just for a fixed period of time like the Republican replacement plan, but for life. Of course for Medicare participants, "life" is a bit shorter than for ACA participants.
You can relax my #3 requirement a bit more, and underprice insurance for everyone. Not so much that it's an entitlement. But enough to motivate most people to buy in. Still some adverse selection that the government would have to cover (pay for), but hopefully not outrageous. I'd like to see this modeled.
If health care is strictly an entitlement, then you've effectively made insurance compulsory. A different way to do it, but same effect for the purpose of dealing with adverse selection. Maybe you can do this (provide health care as an entitlement) and tax the heck out of people based on how much they could have afforded to pay had the care been voluntary. Hard to design such a tax, harder to support it politically. It might work theoretically though likely not in practice, given US politics.
I might have a shot creating one based on the latter post (adverse selection), as it's more focused. I've also a draft sitting somewhere about making insurance more attractive by charging people for what they receive (rather than having one cohort subsidize another).
The other post was meant to address your feeling that I hadn't stated what I had in mind. I felt that I had by giving design objectives, while I left an actual design as an exercise for the reader.
The more one looks at a design, the more one sees how much is interrelated. Have you heard, health care is complicated? I wrote way back that I was quite impressed with the design of the ACA. Regardless of what one thinks about what the ACA does, it is well designed. There really is a reason for all those pages.
These confound (not really the right word) your pricing principles while seeming to partly conform, correct? (not being facetious):
(MO'Brien Wapo just now) Obamacare [forces] healthy people to buy insurance (or pay a fine) and [gives] poor and sick people income-based subsidies that rise as premiums do. The first part tries to keep premiums from rising too much, and the second part insulates a lot of people from it if they do. The result is a stable enough market even with this year's average 22 percent rate hike. Trumpcare ... manage[s] to keep the insurance market from imploding for the reverse reason. ... while it wouldn't require healthy people to get covered — and, in fact, would nudge them not to by penalizing them when they did buy a plan rather than when they didn't — it would make insurance too expensive for a lot of older and poorer people to be able to afford. Pushing those higher-cost people out of the market would push down premiums for everybody else, who would also be allowed to buy cheaper plans that didn't cover as much. This combination of younger people buying barebones plans and older people not being able to buy any plan is what would, in the CBO's estimation, keep the insurance pool's ratio of healthy-to-sick people at a sustainable level. Suppose the GOP did turn its $85 billion magic asterisk into an $85 billion subsidy for older and poorer people. Sure, more of them would get coverage, but that's not the end of the story. The insurance pool would now be sicker, and there's nothing that would get more healthy people to sign up. If anything, the opposite. That's because more sick people would mean higher premiums, and higher premiums would mean fewer healthy people buying insurance — sending premiums up even more.
Not certain if this info will help but beginning this year the SF retirement system changed the setup, leaving only two choices: Kaiser, or a United Health MA.
With respect to United Health, previously it was available as a secondary insurance to Medicare, and that's how I used it for many years. I had the standard Medicare ID card, and a separate United Health ID card. Now I have just the one United Health MA card (although I surely am not getting rid of that Medicare card). The providers would need to bill both Medicare and then United Health, so the process was pretty inefficient from their end, but worked very well from my perspective.
Now the providers apparently need bill only United Health, and they take care of all of the payment issues for the provider, which should make life a bit easier for them, I expect (and hope). Haven't had enough experience yet to compare results from my end. With the MA that SF purchased I was able to keep all of the doctors & hospitals that I have been using for many years, so no problem there. But I imagine that's one of the more expensive MA options when purchasing such a plan, and may not be available for individuals.
Additional Notes: • SF is unique in CA in that it is both a City and a County. I have no idea if that made a difference in the type of PPO plan that it was able to provide. • SF retirees are charged a premium for the additional health coverage, with the Kaiser coverage being significantly less expensive than the United Health. However, the United Health coverage is better: for instance, it covers my hearing aids, allowing one replacement every two years if necessary. At $2500 each, that adds up quickly.
I've reproduced my earlier comments so as to provide continuity for some additional information. With respect to some of the points being discussed regarding cross-subsidization, here is a little additional perspective on the SF setup.
As msf noted earlier, retirement MA plans are a different kettle of fish from non-retirement plans. However, here in SF, I believe that we have essentially two side-by-side systems, one for current employees, and one for retired. An essential difference of course is the fact that Medicare is the primary provider for the retirement plan, but not for the active plan.
However, with respect to cohorts or pools, SF has contracts with Kaiser and United Health for both active and retired employees, thus creating two pools with very similar characteristics other than age bands. The retired pool will certainly be requiring more care per person than the younger pool, so it would be expected that (ignoring the Medicare component) the premiums to United Health or Kaiser would be significantly higher for the retired pool.
I don't have any actual figures, but this would seem to be an ideal situation for cross-subsidization: by charging the active younger group more than actuarially indicated, the premiums for the older group could be reduced. This situation is somewhat unique compared to a non-captive open market pool, because all of the issues regarding non-coverage, pre-existing conditions, or gaming can be controlled as all employees, current or retired, are required to have ongoing coverage. I can't see any way that a setup like this would work on the open market.
@Old _Joe: A couple of questions if I may. Under my plan if medicare does pay , my plan doesn't pay . I found this hard to believe , but that's the way it works. Does your secondary plan follow this also ? This year those in retirement found they were being removed from drug coverage , but given part of their premiums back. Does your secondary cover drugs or do you use part d in medicare. If anyone else cares to chime in feel free to. Derf
@Derf- As I mentioned, this Medicare Advantage (MA) situation just started in January, and I haven't yet enough experience to compare it to the previous plan. That previous setup had Medicare pay up front (with the annual deductible), and then United Health would cover the remaining balance (after meeting their annual deductible) up to a certain maximum (I'd have to research that number). United also covered a significant portion of the drug expenses under the previous setup, and still does. Like most plans, they tend to substitute the cheapest drug versions that they can, but as long as the stuff works that's fine. Because of that coverage, we don't need Medicare Part D.
All in all, it's been very good coverage, but the City negotiators are a very seasoned and experienced bunch, and are able to drive a decent bargain. Of course the size of the insured pool is a big help also.
If you have any additional questions I'll try to answer them as best I can.
Hi @Derf You noted: "Under my plan if medicare does pay , my plan doesn't pay . I found this hard to believe , but that's the way it works." >>>I will presume "my plan" means a supplemental healthcare insurance plan to pay what is not covered by Medicare. Medicare is the 1st payer (generally speaking) and then supplemental insurance. Do I understand your statement properly?
@Old_Joe You noted: "and then United Health would cover the remaining balance (after meeting their annual deductible) up to a certain maximum" The "annual deductible", and a question. Is the deductible a dollar amount you have to pay to fill a deductible payment gap. I know United has a high deductible supplement plan ($2,200) but I recall it is not available to the public directly; but perhaps to a group such as a city or county. Being curious about this most complex area.
If investing were this complex (for my mind), I'd probably be in CD's only.
Thanks you two. I check back in the morning. Catch
Comments
That said, I felt and still feel that Selective Service is sexist. It arbitrarily singles out one half (give or take, we don't need exactitude here) of the populace.
Or do you favor income based premiums as in Part B with IRMAA? If so, should premiums cover costs for people who can afford them, or should they be higher than cost or lower? What if someone is indigent? How would you deal with subsidizing their premiums? I'm not up on this aspect of Medicare, but at first glance, it looks like a crazy quilt of programs.
Perhaps as a fan of the ACA you're thinking about Part D, which not only uses IRMAA, but is priced entirely by private insurers. It's still called medicare. It too has its own program to help the indigent called Extra Help. But you might get subsidies from your state as well, e.g. NYS's EPIC program (income up to $100K).
Premium prices, income adjustments, inflation adjustments, cost sharing, donut holes, federal subsidies, state subsidies, ... Saying "national medicare" barely begins to address the questions you've been asking.
In this sense it doesn't matter whether insurers handle payments (ACA), or a single payer handles payments (also allowed by ACA, but Medicare is the more common example). Whatever machinery is used for the claims processing still has to be funded.
For most everyone I know (including doctors) it seems to work pretty well most of the time. My wife's HMO-type medicare plan has zero premium but nontrivial deductibles; includes PDP. Mine costs more but is much wider as to caregivers, and no co-pays and the like. Separate PDP.
All seems reasonable. It sure is efficient to deal with and efficiently (cheaply!) run, say experts.
Doctors may not love it but every one I have asked has said it is comparatively painless to deal with and better for their practice than the endless staff dicking with private insurance.
Doubtless it is actuarially unfair in some, maybe many, senses. SS and taxes, man.
I have experience of only a very few acquaintances on Medicaid.
Sure, funded it all has to be; I will let you explain to everyone how it currently is and how it should be.
It is droll that you consider me a fan of ACA. Not sure I know enough to be a fan. But compared with what? Did you describe your plan and I missed it?
This contains further enlightenment, at least for me:
https://newrepublic.com/article/141439/medias-failure-correct-republicans-obscene-trumpcare-lies
Here's the Medicare subsidy link I gave above (trimmed slightly):
https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html
In contrast, parts A-D are relatively straightforward. I've been helping people for years with this stuff - across state lines, even ex pats. That's where some of the rules get really interesting.
One person I helped was also on a MA (as opposed to a MAPD) plan. Generally speaking, it's more expensive to subscribe to separate MA and PDP plans. That is, unless you're getting help with the PDP plan, typically as a retiree or veteran.
The drug coverage needs to be a creditable, meaning that it is at leastactuarially equivalent to Medicare Part D coverage. That's not my term; its written into Medicare. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/CreditableCoverage/downloads/2009-06-29_CCDisclosure2CMSUpdatedGuidance.pdf
Part C plans are private plans, run by for-profit companies with their own rules on what they cover and how much they pay. By definition they can't be easier for providers to deal with than private insurance since they are private insurance.
I suspect the reason why the doctors find it easy to deal with these insurers is that they don't file claims; payments are capitated. Nothing to do with public vs. private.
https://www.medicare.gov/claims-and-appeals/file-a-claim/file-a-claim.html
>> Part C plans are ... run by for-profit companies
You are mistaken here, I believe.
You are both correct, to an extent:
"Medicare Advantage plans are sometimes referred to as Medicare Part C. They are Medicare-approved private health insurance plans for individuals enrolled in Original Medicare, Part A and Part B. When you join a Medicare Advantage plan, you are still in the Medicare program and must continue paying your Part B premium.
Medicare Advantage plans provide all of your Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage. They generally offer additional benefits, such as vision, dental, and hearing, and many include prescription drug coverage. These plans often have networks, which mean you may have to see certain doctors and go to certain hospitals in the plan’s network to get care."
Reference
Overview para3 end
I did look at the Wiki line that says most Medicare Advantage plans are administered by non-profit insurance companies. What is "most"? 80%, 90%? This is something you've expressed concern about. Certainly it's well more than half?
Actually not. Wiki misses again.
"Not-for-profit plans accounted for 29 percent of Medicare Advantage enrollment in 2011".
https://www.managedcaremag.com/archives/2013/1/medicare-advantage-loses-its-advantage
The largest insurers are United Healthcare, Humana, Kaiser, and Aetna. I do tend to forget that Kaiser's in the mix. Aside from Kaiser, I suspect you'd be hard pressed to find much money going to non-profits (despite the existence of small regional non-profits).
http://www.modernhealthcare.com/article/20160326/magazine/303289995
http://www.allgov.com/news/where-is-the-money-going/medicare-advantage-a-goldmine-for-health-insurance-companies-150721?news=857009
Here's a whole page of links to articles by the Center For Public Integrity documenting the "Medicare Advantage Money Grab".
https://www.publicintegrity.org/health/medicare/medicare-advantage-money-grab
And a HealthAffairs blog that suggests "Even heavily regulated Medicare Advantage commercial plans are designed to push people in poor health into traditional Medicare in order to avoid actually paying for care."
http://healthaffairs.org/blog/2012/02/15/medicare-and-commercial-health-insurance-the-fundamental-difference/
Holding out MA as a model of an efficient (and non-profit), single-payer alternative to the current ACA structure is just, well, strange.
Now that we've dealt with this minor distraction, did you say that you found the subsidy programs for Medicare straightforward?
Was speaking from personal experience, wider than some, about straightforwardness, and yes, for sure.
Will remind executive acquaintances at BCBSMA and Tufts (including head of former) that they are small regional nonprofs. They might point out that that's part of the problem.
I am certain you must be right in what you conclude, if only we could tell what those conclusions were.
Alternatively you could direct them to the BCBSMA medicare glossary that makes it clear that MA insurers are private: This is important to keep in mind when suggesting MA as a model for ACA. They're just different variants of the government farming out health care coverage to private companies. Remember, ACA also uses non-profit insurers, it even tried to build them from scratch and called them CO-OPs. (Currently, there are only five remaining, as all but six folded, and one just converted to a for-profit company.)
My conclusions: Seeing something on the internet (especially Wiki) doesn't make it true, and experiential information can be misleading.
As KFF observes, in some states, regionals dominate. It even gives Tufts as an example. That makes them big fish in small ponds, still small from a national perspective.
Concrete numbers (2016) may help illustrate this:
UnitedHealthCare: 3.8M
Humana: 3.1M
Kaiser: 1.3M
Aetna: 1.3M
Cigna: 0.5M
Anthem: 0.4M
WellCare: 0.3M
Some regionals include:
BCBS Mich: 57% of Mich market (621K): 0.4M
SCAN Health Plan: 7% of Calif. market (2.24M): 0.2M
BCBS Minn.: 39% of Minn market (511K): 0.2M
UPMC: 15% of Penn market (1.02M): 0.2M
Medica Holding: 25% of Minn market (511K): 0.1M (plus 91% of ND's 22K market)
HealthFirst: 11% of NY market (1.24M): 0.1M
Universal American Corp (Texas): 0.1M
Guidewell (BCBS FL): 8% of Fla market (1.67M): 0.1M
Spectrum Health: 18% of Mich. market (621K): 0.1M
Tufts: 43% of Mass. market (246K): 0.1M (plus fewer than 1K in RI)
UCare Minn: 18% of Minn market (511K): 0.1M
Henry Ford Health: 11% of Mich. market (621K): 0.07M
Centene: 20% of Oregon market (339K): 0.07M
Ministry Health: 15% of Wisc. market (411K): 0.06M
PH Holdings: 22% of LA market (250K): 0.05M
BCBSRI: 71% of RI market (73K): 0.05M
BCBSMA: 18% of Mass. market (246K): 0.04M
Given your familiarity with the various subsidy programs, perhaps you could help with a question that I haven't researched yet:
How do these programs coordinate with MA, or are they strictly limited to original Medicare? I ask this because you mentioned high deductibles in some MA plans, and additional premiums (above the Part B premiums) for some other MA plans. Anyone needing subsidies would obviously need help with these fees.
With respect to United Health, previously it was available as a secondary insurance to Medicare, and that's how I used it for many years. I had the standard Medicare ID card, and a separate United Health ID card. Now I have just the one United Health MA card (although I surely am not getting rid of that Medicare card). The providers would need to bill both Medicare and then United Health, so the process was pretty inefficient from their end, but worked very well from my perspective.
Now the providers apparently need bill only United Health, and they take care of all of the payment issues for the provider, which should make life a bit easier for them, I expect (and hope). Haven't had enough experience yet to compare results from my end. With the MA that SF purchased I was able to keep all of the doctors & hospitals that I have been using for many years, so no problem there. But I imagine that's one of the more expensive MA options when purchasing such a plan, and may not be available for individuals.
Additional Notes:
• SF is unique in CA in that it is both a City and a County. I have no idea if that made a difference in the type of PPO plan that it was able to provide.
• SF retirees are charged a premium for the additional health coverage, with the Kaiser coverage being significantly less expensive than the United Health. However, the United Health coverage is better: for instance, it covers my hearing aids, allowing one replacement every two years if necessary. At $2500 each, that adds up quickly.
With the plan you note; do you still pay a monthly premium (usually deducted from Social Security) that may be paid to Medicare or United Health? Does my question make sense? Just curious with all the variables.
Catch
OJ
Your entirely obvious and true conclusion about online info and anecdote is not what I queried either, but it's annoying to again ask someone so thorough to be constructive and specify how you think HC things should be structured.
I said nontrivial deductibles, not high. We have Mass. MA (HMO model) and also Medicare supps, but surely you know all that. Information on plans, their coordination, and subsidies hereabouts:
https://www.tuftsmedicarepreferred.org/plans
http://www.mass.gov/anf/budget-taxes-and-procurement/oversight-agencies/health-policy-commission/patient-protection/health-insurance-open-enrollment-and-waivers.html
http://www.mass.gov/eohhs/consumer/insurance/masshealth-coverage-types/masshealth-family-assistance.html
http://obamacarefacts.com/insurance-exchange/massachusetts-health-insurance-exchange/ --- note differently named duplicate buttons
HTH, but I am thinking this is nonresponsive to your questions.
https://www.americanactionforum.org/research/primer-medicare-advantage-employer-group-waiver-plans/
I'm not surprised that this sort of plan exists, it's just something else to read up on. Lots of people like Kaiser, but as you implied, the problem with switching to Kaiser is getting a completely new set of doctors. Not something you want to do if you've been with your doctors for years.
I did a quick check for individual MA plans in SF, and United Healthcare isn't even offering one. So you're right, your plan isn't available generally.
1) All people should get adequate health care at a price not exceeding what they can afford (for the wealthy, it will almost by definition be at a price less than they can afford).
2) No natural person or group of natural people should be singled out to support the system. Only businesses and/or the public at large may be taxed for subsidies.
I did forget a third. #1 and #2 set upper bounds on what people should pay. I forgot the lower bound rule:
3) People's care should be subsidized only to the extent necessary to bring the price down to what they can afford.
Asking for a design is like asking for a 2700 page document that took a year to create. I won't say that I don't care at all about the design, but so long as it can meet the principles above, I'll be satisfied.
We can, for example, look at MA to see where it satisfies these principles and where it fails.
Let's start with the fact that the (private) MA insurance companies receive payments according to how sick their policy holders are. In other words, their rack rate is determined by medical underwriting. Now you don't see that because it doesn't affect what you're paying, but it's there just the same. We know two things from this: The insurer is getting a total fee from the government and from policy holders combined based on the condition of policy holders, and the insurer has calculated an actuarial cost for each policy holder.
(I hope I don't have to keep saying "give or take"; we know that actuarial science isn't exact.)
Suppose I, as a MA policy holder, pay more than that my cost (plus overhead, profit, etc.). Then someone else would be paying less than their cost. (We can't all be paying our cost or more, because then the combined payment would exceed the insurer's fee.). So my payment would effectively subsidize someone else. That's a violation of #2.
Thus I should pay up to the cost of my policy (plus overhead, etc.)
The actual amount a policy holder is charged for MA insurance is a part B premium and possibly an extra premium directly to the insurer. Part B premiums cover around 1/4 of the typical person's medical loss. Any extra premium paid to the insurer isn't going to make up the remainder. So virtually all MA policy holders are paying less than the cost of providing their coverage.
That means, as a MA subscriber, I'm getting subsidized. If I were a (wealthy) person who could afford to pay more, this would violate principle #3. There are two choices - reduce the cost (e.g. fewer benefits) or increase the amount I'm charged.
If the plan design sets a floor on benefits (e.g. 10 essential services), then the only option is to charge wealthy people more so that they're not getting subsidized. But at this point we're not discussing what the plan should cover so much as how it should be priced.
I should point out a fundamental difference between Medicare (or MA) and individual insurance. Medicare is a contract with the government, just as SS is a contract with the government. I agree to pay in for at least 40 quarters, and the government agrees to provide me insurance below cost. So you can't conclude from this writing that I'm saying actual Medicare is priced too cheaply. I'm just using it as a model.
So now we know that ideally I should pay the cost of my policy (plus overhead, etc.) But what if I can't afford that? Principle #1 says that the all-in cost has to be affordable. I'm not defining affordable here, though we may reasonably assume that it will be some well-defined dollar amount per year, however the formula is concocted. That will serve as a ceiling to how much I pay over the year.
There are various ways we could implement that ceiling. We could say set the premium at this amount and then policy would cover my expenses 100%. That's not a great design, because it encourages overuse. We could set the premium lower and add the difference to the deductible. That's better, and a lot of ACA plans do this. The problem is that this discourages use with a high deductible.
What we might have to do is relax principle #3 a little. We can say that in the worst case (paying all premiums and maxing out on usage) the plan is still within my ability to pay. But I might pay less if I don't max out on my plan.
Then the insurer is free to offer different types of plans that allocate risk differently. Pay more up front (platinum) and get a lower cap and lower copays. That's shifting the risk from me for a price (my expected total cost is higher, even if my worst case is the same). Or maybe I pay less up front but with higher copays and a higher cap.
I hope you begin to see how these few principles really do shape the pricing aspect of a program. I'm not going to write the remaining 2699 pages to explain how I might define "affordable", how one structures insurance to protect companies against going bust (e.g. via reinsurance), how (or whether) to set a limit on insurers' profits, etc.
Notice also that these principles and the writing above is compatible with both private insurance and government single payer. Picking the latter can open lots of possibilities - more negotiating power to drive down provider costs, less overhead, etc. But it's not necessary to make this work.
I'm not describing how to build an insurance market. I'm not discussing mandates, because my requirements lead to a system where people do get fair value and pay fair prices (or less, after subsidies). So it doesn't become necessary from a purely economic perspective to force people into the system. It's desirable for other reasons to have everyone participate (disease control, healthier more productive populace, etc.), but you're not going to have death spirals if you can't force enough people to pay more than a fair price (subsidize others) for what they're getting.
If you're wondering how the insurers (or single payer) gets paid, go back and take another look at MA. I showed that virtually everyone is already underpaying, and the system works. It's supported by taxes. Not on the few - those who hold policies - but on everyone. Just like your school system. Because it benefits everyone. (And just like your school system, some of the taxes could be on wealth/property, rather than income. Or just like the ACA, some of the taxes could be on businesses instead of individuals.)
This is all you get. Constraints for the system, and best wishes in spending a year designing a system of your very own.
One can argue that the problem of healthy people dropping out is not an adverse selection problem (and it's one I've addressed). ACA relies on healthy people because it is overcharging them.
If you view insurance in terms of cohorts (groups of people with equal risks), and charge each cohort according to its risk level, it doesn't matter if you lose an entire cohort. The 30 year olds are charged less because on average they cost less to insure. The 40 year olds are charged a bit more, and so on. With each cohort charged what they cost, each cohort stands on its own.
But that's not the real adverse selection problem. The real problem is people gaming the system. Buying insurance when they need a service (thus underpaying), and dropping it otherwise. This is a problem even within a cohort. There are a few different approaches, but IMHO none is satisfactory.
One is to make insurance compulsory. For example, charge a penalty equal to the cost of insurance. Then, if someone wants to go to the doctor without paying the copay, fine, that person is overpaying for that individual service by personal choice. Anyway, the insurer has received (via the penalty) the needed premium, whether an individual chooses to take advantage of the insurance or not.
Another is to refuse to cover people for pre-existing conditions, at least for some waiting period. A small example is dental insurance where you may have to wait six months before it covers cavities. There's general consensus that this is not a desirable approach.
Another is to require people to pay a penalty to get back in. That's the current Republican proposal, and it's been pretty well discussed. What hasn't been mentioned in this context is this is the approach that Medicare takes. If you wait before you sign up for Part B or Part D, you'll be charged a higher premium. Not just for a fixed period of time like the Republican replacement plan, but for life. Of course for Medicare participants, "life" is a bit shorter than for ACA participants.
You can relax my #3 requirement a bit more, and underprice insurance for everyone. Not so much that it's an entitlement. But enough to motivate most people to buy in. Still some adverse selection that the government would have to cover (pay for), but hopefully not outrageous. I'd like to see this modeled.
If health care is strictly an entitlement, then you've effectively made insurance compulsory. A different way to do it, but same effect for the purpose of dealing with adverse selection. Maybe you can do this (provide health care as an entitlement) and tax the heck out of people based on how much they could have afforded to pay had the care been voluntary. Hard to design such a tax, harder to support it politically. It might work theoretically though likely not in practice, given US politics.
No solutions, just less bad alternatives.
The other post was meant to address your feeling that I hadn't stated what I had in mind. I felt that I had by giving design objectives, while I left an actual design as an exercise for the reader.
The more one looks at a design, the more one sees how much is interrelated. Have you heard, health care is complicated?
You're never gonna get anywhere with that attitude
Recent analyses of actual behaviors, which you likely have seen:
http://www.motherjones.com/politics/2017/03/kansas-medicaid-expansion-obamacare-aca
https://www.washingtonpost.com/national/health-science/americans-worry-cheer-as-congress-moves-to-upendthe-affordable-care-act/2017/03/21/813ea29a-0a7e-11e7-b77c-0047d15a24e0_story.html
http://www.vox.com/2017/3/22/15012970/congress-health-reform-lies
https://www.axios.com/why-deductibles-would-rise-under-gop-plan-2322246232.html
https://www.nytimes.com/2017/03/21/upshot/fewer-americans-would-be-insured-with-gop-plan-than-with-simple-repeal.html
(MO'Brien Wapo just now)
Obamacare [forces] healthy people to buy insurance (or pay a fine) and [gives] poor and sick people income-based subsidies that rise as premiums do. The first part tries to keep premiums from rising too much, and the second part insulates a lot of people from it if they do. The result is a stable enough market even with this year's average 22 percent rate hike. Trumpcare ... manage[s] to keep the insurance market from imploding for the reverse reason. ... while it wouldn't require healthy people to get covered — and, in fact, would nudge them not to by penalizing them when they did buy a plan rather than when they didn't — it would make insurance too expensive for a lot of older and poorer people to be able to afford. Pushing those higher-cost people out of the market would push down premiums for everybody else, who would also be allowed to buy cheaper plans that didn't cover as much. This combination of younger people buying barebones plans and older people not being able to buy any plan is what would, in the CBO's estimation, keep the insurance pool's ratio of healthy-to-sick people at a sustainable level.
Suppose the GOP did turn its $85 billion magic asterisk into an $85 billion subsidy for older and poorer people. Sure, more of them would get coverage, but that's not the end of the story. The insurance pool would now be sicker, and there's nothing that would get more healthy people to sign up. If anything, the opposite. That's because more sick people would mean higher premiums, and higher premiums would mean fewer healthy people buying insurance — sending premiums up even more.
+++
As is, massive redistribution from poor to rich:
https://pbs.twimg.com/media/C7iYAGoXwAAil_8.jpg
http://www.urban.org/sites/default/files/publication/89071/2001188-who-gains-and-who-loses-under-the-american-health-care-act.pdf
Regards,
Ted
davidrmoran
9:18AM
davidrmoran
11:02AM
davidrmoran
1:08PM
I've reproduced my earlier comments so as to provide continuity for some additional information. With respect to some of the points being discussed regarding cross-subsidization, here is a little additional perspective on the SF setup.
As msf noted earlier, retirement MA plans are a different kettle of fish from non-retirement plans. However, here in SF, I believe that we have essentially two side-by-side systems, one for current employees, and one for retired. An essential difference of course is the fact that Medicare is the primary provider for the retirement plan, but not for the active plan.
However, with respect to cohorts or pools, SF has contracts with Kaiser and United Health for both active and retired employees, thus creating two pools with very similar characteristics other than age bands. The retired pool will certainly be requiring more care per person than the younger pool, so it would be expected that (ignoring the Medicare component) the premiums to United Health or Kaiser would be significantly higher for the retired pool.
I don't have any actual figures, but this would seem to be an ideal situation for cross-subsidization: by charging the active younger group more than actuarially indicated, the premiums for the older group could be reduced. This situation is somewhat unique compared to a non-captive open market pool, because all of the issues regarding non-coverage, pre-existing conditions, or gaming can be controlled as all employees, current or retired, are required to have ongoing coverage. I can't see any way that a setup like this would work on the open market.
Under my plan if medicare does pay , my plan doesn't pay . I found this hard to believe , but that's the way it works. Does your secondary plan follow this also ?
This year those in retirement found they were being removed from drug coverage , but given part of their premiums back. Does your secondary cover drugs or do you use part d in medicare.
If anyone else cares to chime in feel free to.
Derf
All in all, it's been very good coverage, but the City negotiators are a very seasoned and experienced bunch, and are able to drive a decent bargain. Of course the size of the insured pool is a big help also.
If you have any additional questions I'll try to answer them as best I can.
You noted: "Under my plan if medicare does pay , my plan doesn't pay . I found this hard to believe , but that's the way it works."
>>>I will presume "my plan" means a supplemental healthcare insurance plan to pay what is not covered by Medicare. Medicare is the 1st payer (generally speaking) and then supplemental insurance.
Do I understand your statement properly?
Medicare payment structure:
https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html
@Old_Joe
You noted: "and then United Health would cover the remaining balance (after meeting their annual deductible) up to a certain maximum"
The "annual deductible", and a question. Is the deductible a dollar amount you have to pay to fill a deductible payment gap. I know United has a high deductible supplement plan ($2,200) but I recall it is not available to the public directly; but perhaps to a group such as a city or county.
Being curious about this most complex area.
If investing were this complex (for my mind), I'd probably be in CD's only.
Thanks you two. I check back in the morning.
Catch
Good luck to your wolverines this sweet 16 !
Derf
Yes, it is, but I have no idea what the formula might be that establishes the deductible amount.
Oh, wait...