General Discussion
Related: Editorials & Other Articles, Issue Forums, Alliance Forums, Region Forums"Max out of pocket"? Everybody is missing the most basic point.
If you go on the exchanges, one of the most crucial data items you see now is "Maximum out of pocket." That says that, in the very worst case, that is how much you will spend a year no matter what medical treatments you require. Brain tumors? Breast cancer? Run over by a bus? Lymphoma? Caught in a house fire? All of the above? Doesn't matter. That is the most you will spend for all your treatments.
There is a lot of talk about "keeping the policy we like". Well, you tell me what the maximum out-of-pocket is for a pre-ACA policy?
You cannot tell me because virtually all of these policies were written to limit the out-of-pocket FOR THE FREAKING INSURANCE COMPANIES. Your maximum was unlimited because in the worst case, if your illness reached the annual or lifetime cap, it is ALL on you. The insurance company walks away.
This most basic point seems to be completely lost. Before ACA, the individual carried all the risk. The insurance companies were simply payment managers without taking very much of the risk. That all changes with ACA. With ACA, the insurance companies take the risk. And that, after all, is exactly what insurance is for.
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plcdude
(5,309 posts)features that is not getting reported on. Thank you.
SharonAnn
(13,773 posts)If you have 6 months of chemo treatment, for example, and it starts in October and finishes in March the following year, you'll have Max Out Of Pocket EACH YEAR!
This is no different from the way it has always worked, but people need to understand this. The may figure they can handle $10,000 but if they understood that was EVERY YEAR, they might change their mind.
Bolo Boffin
(23,796 posts)Because between dealing with the illness, the chemo, and the medical bills, sticker shock on just paying $12,000 out of hundreds of thousands will probably not be a complaint.
BlueStreak
(8,377 posts)Many insurance companies have been downright ruthless in the past, cancelling people that were not profitable to them. They are, after all for-profit companies that need to pay their CEOs tens of millions of dollars every year.
And that isn't even limited to the "wild, wild, west" of individual insurance. I was in a group plan with a small business that had about 80 employees under coverage. A lady on my staff was diagnosed with stage-4 breast cancer and she went through all sorts of chemo and radiation over 24 months. By the end, the insurance company was pushing us to put her on disability so that they could get her out of the company's risk pool.
The next step after that would have been cancellation of her coverage -- possibly after a COBRA period, but "fortunately" (for the insurance company) she just died and solved the problem.
ejpoeta
(8,933 posts)You know what I find funny.... I remember the people who would complain about these things before.... They would complain about how much they had to spend, what the insurance covered and didn't cover.... Now they complain about the ACA and how terrible it is. I know my brother didn't even believe me when I told him that his wife could be denied insurance because of pre-existing conditions. This was when he said insurance companies should be able to sell over state lines. This would mean competition. I tried to explain to him that insurance companies would then all move to the state with the least regulations and sell from there. There are rules in this state (NY) to make the insurance company cover certain things. And who has choices to pick and choose insurance?? it's whatever your employer decides to offer you. And they are going to offer you the plan that costs them the least amount. At least with these exchanges he'd get the competition he wanted. Of course, he has that insurance through his employer that he didn't get to choose anyway. And I suppose that is what he wants.... glen beck told him the ACA is bad, so it is bad.... nevermind that glen beck has boatloads of money and will be able to afford to get whatever medical care he needs.
Wounded Bear
(58,656 posts)Needs to be shouted loud and often.
NoOneMan
(4,795 posts)...my premiums. $138 for a family of 4 per month. Thats it. No more. No hidden fees.
If you think $10K limit or so is a good deal, you are fucking nuts or suffering Stockholm Syndrome.
BlueStreak
(8,377 posts)Please tell us more about this policy that covers a family of 4 against all medical risks, never requiring your to pay a penny more than your $138 premium no matter what medical situations come up and guarantees your coverage will not be cancelled as long as you make that $138 payment on time every month.
What is the name of that insurance company?
If this is not complete BS, then I will bet it is a group policy provided through an employer, union, or government agency. Or perhaps you are referring to a Medicare Plus policy.
The issue the ACA deals with is insurance purchased by INDIVIDUALS.
NoOneMan
(4,795 posts)I don't have limited access in anyway. There isn't a single trick to induce me to choose between food and care. I don't even have to make that premium payment on time for my coverage; if I can't make it the government will assist.
What is the name of that insurance company?
BC Ministry of Health. Plan is call MSP (Medical Service Plan). There are no tiers. There is a single plan for the poorest to the wealthiest robber barons. It covers all necessary medical services and puts everyone in the same queues.
then I will bet it is a group policy
I purchase this as a self-employed individual, because I don't have an employer to do it for me (though they do).
Or perhaps you are referring to a Medicare Plus policy
Medicare is far inferior to this.
The issue the ACA deals with is insurance purchased by INDIVIDUALS.
The ACA is an overwhelmingly shitty "fix" to a slow motion disaster drowning your nation and bankrupting the country. Again, you have to be insane or suffering Stockholm Syndrome to slurp this shit up. Its like someone handing you a SOLO cup and asking you the bail water while the Titanic goes under.
That's exactly why I responded, despite the "baby steps" and "path" bullshit. You want to tell me how wonderful these out-of-pocket maxes are? To any sane person in a country that cares about its people, what you hail as wonderful is fucking ridiculous. Until you can be convinced of that, you will never realize just how big your disaster is and how much you need real change.
BlueStreak
(8,377 posts)
Zorra
(27,670 posts)Congratulations! You have full on succeeded.
All my Canadian friends love Canada's healthcare system.
I ask them "Hey, Gordy, how do you like your healthcare system?"
They answer "What's not to like? It's free, eh?"
I grew up a few mile south of the BC border, and used to go to Canada to get my medical and dental care done. It was good care, and at a way better price than I could get without insurance in the US.
As a matter of fact, I live in AZ now, and have dental insurance. But sometimes I go down to Mexico for dental work, because it is still cheaper than some dental work I get done here that is covered by my insurance.
NoOneMan
(4,795 posts)Because very great things are painted as impossible to make hoards of people settle for the art of shit, polished as a political win. There is something far greater out there worth fighting for and spending political capital on. I hope the people in the US figure it out, though I predict a lukewarm success of Obamacare may take the wind out of the sails of future reform
SolutionisSolidarity
(606 posts)We probably don't have 15. And apparently the next candidate in the queue is Hillary Clinton, so it doesn't look like the Democratic Party is interested in moving any further to the left. So people would have to demand it, and "legitimate" outlets will not honestly report on Single Payer due to the influence Insurance Companies, Hospitals, Medical device manufacturers, Pharmaceutical corporations and other medical fat-cats have with their advertising budgets. Coupled that with a xenophobic culture that rarely travels and the only thing that most people "know" about single payer is that they make you wait 8 months before seeing a doctor.
grahamhgreen
(15,741 posts)pork? No pet program or project? Not a one of them?
Did we try?
B Calm
(28,762 posts)Insurance companies need competition!
IronLionZion
(45,442 posts)because they can't afford to wait for single payer.
A regulated insurance market is a big step in the right direction.
And when the BC ministry of health decides what is covered and not covered and what reimbursements rates they will pay, you don't have a lot of choices do you?
Demo_Chris
(6,234 posts)ErikJ
(6,335 posts)That's what our vets get in the US.
Fumesucker
(45,851 posts)And how the ACA is going to inevitably lead to single payer.
I guess perspectives really do differ.
SomeGuyInEagan
(1,515 posts)To a single person, every single one of them envies the pre-ACA United States and would shed their coverage in a heartbeat if they could.
Well, that is what my Repub friends say.
laundry_queen
(8,646 posts)Just because one Canadian is the loudest here on DU doesn't make them the most popular opinion. Most Canadians I know still think the ACA is crap, but (as I am) are hopeful it leads to something better. But we aren't holding our breath.
I live in a province where I don't even pay premiums for my family of 5. And I get all the same things that BC poster mentioned (I've lived in BC too) but no premiums. Can't beat that.
NoOneMan
(4,795 posts)They either think the ACA has saved America or they think Obama is the worst president in US history (details are sometimes lost in translation and most don't even understand what a deductible is to begin with). Just anecdotal is all. In any case, despite whatever moaning they have about single payer, no one I've talked to would take the US system over their own. Its not even a question.
KG
(28,751 posts)
JDPriestly
(57,936 posts)is second best. It was the best our pitiful government was willing to give us. When it fails (and it will) we will move to single payer.
Rainforestgoddess
(436 posts)In British Columbia.....
I have to say I'm glad my friends in the USA are getting an improved system, but there's still a long way to go. (and the talking points about wait lists and terrible care here are hyperbole. At the end of the day, I'd rather every one get good care than some few who can afford it get excellent care, a lot get adequate care and a lot more get no care)
LiberalFighter
(50,928 posts)Anyone that had seen what was already out there were wanting a Single Payer plan that was based on what about 13 different countries have for their national insurance plan. Canada included. Basically piecing pieces from all the others to create our own. Failing that, Medicare for All.
We didn't succeed on that end but now that we have ACA and many of the states have forced the management on the federal govt there is a chance it will get closer to Single Payer.
Response to NoOneMan (Reply #9)
lostincalifornia This message was self-deleted by its author.
Blanks
(4,835 posts)and the point that so many seem to be missing. In that brief period of time when the democrats had control of congress and the White House - they took on two very powerful industries (insurance and banking).
Both the ACA and Dodd-Frank didn't go far enough, but if the democrats can capitalize on this 'tea party sponsored government shut down' and take control of congress again in 2014 - they can pick up where they left off.
If we make them.
area51
(11,909 posts)enough
(13,259 posts)If this is available, people should know about it, and how to get it.
NoOneMan
(4,795 posts)It can't be found in the US. I don't think anything reasonably sane and "affordable" could in fact. What I am doing is challenging the entire US paradigm of health insurance, which--as long as it exists--will ensure the insanity and pain continues
BlueStreak
(8,377 posts)ACA is a shitty solution. It is the Heritage Foundation's Republican plan for keeping unscrupulous insurance companies in charge and continuing to gouge Americans for about 2-3 times what services actually should cost.
But the ACA is a huge step forward from where we have been, and we should take that step.
One of the really strategic things about the ACA is that is institutionalizes the ideas of standardized benefits that can be easily compared, and a transparent exchange where one can go to make these comparisons. If, after a couple of years under this improves PRIVATE framework, we aren't seeing substantially better value in the product PRIVATE companies are offering, then the political state will be set to introduce a PUBLIC option to the exchanges.
For that to happen, we have to make this first step successful.
eggplant
(3,911 posts)oldhippie
(3,249 posts)Insurance companies are not supposed to take on risk. If they did that they would fail. They exist to facilitate sharing risk and cost among their customer base. The premiums are set with actuarial statistics to share the risk equitably. The company itself, if it is managed correctly, gets none of the risk. That is true for both profit and non-profit companies. Too many people think of insurance as only cost sharing. It is not.
NoOneMan
(4,795 posts)And I must suggest, if people begin viewing these entities in this manner, it brings forth the question: what is the purpose of more than one of these entities? What benefit does it give a population to segment it into separate pools, insofar as the correct measures are taken legal to ensure responsible, competitive operation (which currently, the magic market is supposed to ensure)?
BlueStreak
(8,377 posts)Perhaps it is a matter of semantics, but in my view, managing risk is PRECISELY what insurance companies do. Yes, insurance companies try to limit their risk whenever they can. It is always a struggle to get insurance companies to do this. But they can take the full risk and still make a handsome profit. There is no inherent conflict between taking on the entire risk and being profitable. It is simply a question of actuarial calculations.
And I certainly take your point that the larger the pool is, the lower the actual risk is to the insurance entity. After all, we don't all get leukemia at the same time. And there is no escape from the logical conclusion that the lowest cost solution (i.e. the solution where the premiums have the lowest amounts to cover the "unknown" element) is a single pool that includes everyone.
And in a nationalized system, you can take that one step further, and eliminate the "unthinkable catastrophe" element from the premiums altogether. This would be, for example a case where 5 unclear reactors explode, resulting in much higher levels of cancer for a generation. The taxpayers can simply agree that in the event of such a catastrophe, the taxpayers will provide the extra funding if and when that arises. So there is no need to make everybody pay premiums to cover those extreme situations that are highly unlikely to ever happen.
Lars39
(26,109 posts)Not if your treatments go into the next calendar year, then you get to start all over meeting your deductibles and out-of-pocket limits, ACA policy or pre-ACA policy.
BlueStreak
(8,377 posts)I said "That says that, in the very worst case, that is how much you will spend a year no matter what medical treatments you require."
progressoid
(49,990 posts)Because of my wife's condition, we deal with it every year. In fact, we're still paying off creditors for this years' deductible. If we're lucky, we'll have it payed off just in time to do it all over again in January.
Lars39
(26,109 posts)We have to try to do that, too. Out of pocket limits are still too high.
BlueStreak
(8,377 posts)Most pre-ACA policies left the individual in the position of being the insurer of last resort. They were written to limit the INSURANCE COMPANY's out of pocket maximum. With the exchange, you do have choices that give you a real range of out-of-pocket max, and they cannot refuse you because you already have a condition.
Again, this seems to be a fundamental point that most people are completely missing.
Lars39
(26,109 posts)the cap in order to be in trouble money-wise. Medical debt that snowballs because out-of-pocket limits are too high is just another slow way towards bankruptcy.
Demo_Chris
(6,234 posts)According to the Kaiser Calculator and using the national average setting:
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $600,000 per year and purchasing a Silver level plan has a max out of pocket of $12,700 -- or about 2% of their income.
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $200,000 per year and purchasing a Silver level plan has a max out of pocket of $12,700 -- or 6% of their income.
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $40,000 per year and purchasing a Silver level plan has a max out of pocket of $10,400 -- or 26% of their income
Note that this max out of pocket does not include premiums. This family of three earning $40,000 a year and hitting that max will actually pay at LEAST $13,000 during that single year, or about 32% of their income. To purchase this Silver level plan they will have to pay a national average rate of $216 per month.
beachbum bob
(10,437 posts)BTW if that family 40,000 gets hit with open heart surgery...how much is that going to cost in the end....max?
Little chance of losing their home or be facing bankruptcy. Unlike present policies
Demo_Chris
(6,234 posts)That is assuming, of course, that they HAVE that much saved in the first place. Otherwise they might well discover that no surgery is taking place since they cannot come up with their portion.
beachbum bob
(10,437 posts)And deductible? Good lord do all people never had insurance or gone to the doctor before? Ignorance is chilling
dsc
(52,162 posts)and I have to pay it before I see my doctor the next time.
beachbum bob
(10,437 posts)BTW what's copay on the surgery under your present policy. If I have out patient procedure I have to pay $100 for it...and my instance picks up everything else....I don't pay the entire out of pocket limit and that is what too many people are missing here....clearly ignorant how the system works with health insurance
dsc
(52,162 posts)I have the same type of thing. But I can see if one has a chronic condition those, in my case 70 dollars, adding up over time.
Response to Demo_Chris (Reply #31)
whopis01 This message was self-deleted by its author.
Lars39
(26,109 posts)or if you have a chronic condition, etc. We shouldn't have to go into debt every single year in order to get the health care we need.
BlueStreak
(8,377 posts)And now you are complaining that the ACA policy still requires you to pay part of the expense?
Lars39
(26,109 posts)One that is usually overlooked by those who have had no reason to know it exists.
BlueStreak
(8,377 posts)I mean, if one has a persistent condition that requires, say, $100K a year in ongoing treatments/medications, no insurance company would sell you a policy that covers that pre-ACA. With ACA they have to cover you, and the annual out of pocket is absolutely limited.
Maybe it is still higher than you wish it were, but surely that is better than what has existed prior to ACA.
Lars39
(26,109 posts)But when anyone talks about the yearly out-of-pockets, the huge limit is glossed over. $8-10,000 that must be met every year before insurance kicks in and pays 100% is draining people's income. I don't know if the people who talk about these yearly amounts are well off, young or never had serious health problems or what, but it gets very frustrating to those of us who do have serious conditions. Even if it was a one-time accident, easily contained within a year's time...$10,000 is like buying a car for most people, taking probably 5 years or more to pay off.
beachbum bob
(10,437 posts)Max out of pocket...if you go in for a procedure. You pay the copay... Then insurance picks up rest. You don't pay 10,000....that is max out of pocket...not copay. Geesh
Lars39
(26,109 posts)You pay a co-pay, then the insurance company pays a percentage after you have met the deductible, then you pay your percentage. I've had percentages of 90-10, where insurance pays 10, and I've had percentages of 80-20 and 70-30, depending on the policy.
beachbum bob
(10,437 posts)You pay the copay procedures... The office call. The doctor the hospital stay...you clearly do not understand health insurance. Max out of pocket does not have to be met to have insurance payout...
Lars39
(26,109 posts)BlueStreak
(8,377 posts)Premium: The monthly fee for your insurance.
Deductible: How much you must kick-in for care first, before your insurer pays.
Co-pay: Your cost for routine services to which your deductible does not apply.
Co-insurance: The percentage you must pay for care after you’ve met your deductible.
Out-of-pocket maximum: The absolute max you’ll pay annually.
See the page for a more detailed description of each. Basically, for other than the preventive care, you have to pay EVERYTHING until you reach the deductible or max out-of-pocket.
nashville_brook
(20,958 posts)slipslidingaway
(21,210 posts)JDPriestly
(57,936 posts)courts and in medical care. And it's the co-pays and lifetime and annual caps on insurance company responsibility for paying medical costs that force people to default on the cost of their medical care.
Thanks so much. This is why ACA's policies are so much, much better than the cheaper policies people are losing.
Demo_Chris
(6,234 posts)According to the Kaiser Calculator and using the national average setting:
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $600,000 per year and purchasing a Silver level plan has a max out of pocket of $12,700 -- or about 2% of their income.
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $200,000 per year and purchasing a Silver level plan has a max out of pocket of $12,700 -- or 6% of their income.
* A family of three, ages 45, 45, and 21, all non-smokers, earning a combined income of $40,000 per year and purchasing a Silver level plan has a max out of pocket of $10,400 -- or 26% of their income
Note that this max out of pocket does not include premiums. This family of three earning $40,000 a year and hitting that max will actually pay at LEAST $13,000 during that single year, or about 32% of their income. To purchase this Silver level plan they will have to pay a national average rate of $216 per month.
ProSense
(116,464 posts)There is a new tax on the high-income earners and the wealthy.
Reported when the law passed in 2010:
http://www.nytimes.com/2010/03/24/business/24leonhardt.html
Krugman in 2011:
What would real action on health look like? Well, it might include things like giving an independent commission the power to ensure that Medicare only pays for procedures with real medical value; rewarding health care providers for delivering quality care rather than simply paying a fixed sum for every procedure; limiting the tax deductibility of private insurance plans; and so on.
And what do these things have in common? They’re all in last year’s health reform bill.
That’s why I say that Mr. Obama gets too little credit. He has done more to rein in long-run deficits than any previous president. And if his opponents were serious about those deficits, they’d be backing his actions and calling for more; instead, they’ve been screaming about death panels.
Now, even if we manage to rein in health costs, we’ll still have a long-run deficit problem — a fundamental gap between the government’s spending and the amount it collects in taxes. So what should be done?
- more -
http://www.nytimes.com/2011/02/18/opinion/18krugman.html
It's the law, 2013:
A new Net Investment Income Tax goes into effect starting in 2013. The 3.8 percent Net Investment Income Tax applies to individuals, estates and trusts that have certain investment income above certain threshold amounts. The IRS and the Treasury Department have issued proposed regulations on the Net Investment Income Tax. Comments may be submitted electronically, by mail or hand delivered to the IRS. For additional information on the Net Investment Income Tax, see our questions and answers.
Additional Medicare Tax
A new Additional Medicare Tax goes into effect starting in 2013. The 0.9 percent Additional Medicare Tax applies to an individual’s wages, Railroad Retirement Tax Act compensation, and self-employment income that exceeds a threshold amount based on the individual’s filing status. The threshold amounts are $250,000 for married taxpayers who file jointly, $125,000 for married taxpayers who file separately, and $200,000 for all other taxpayers. An employer is responsible for withholding the Additional Medicare Tax from wages or compensation it pays to an employee in excess of $200,000 in a calendar year. The IRS and the Department of the Treasury have issued proposed regulations on the Additional Medicare Tax. Comments may be submitted electronically, by mail or hand delivered to the IRS. For additional information on the Additional Medicare Tax, see our questions and answers.
http://www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions
It's Obamacare.
http://www.democraticunderground.com/10023715400
Demo_Chris
(6,234 posts)None of those seem to address what I posted or even the topic of this thread.
The numbers I posted came from the Kaiser Subsidy Calculator. Not opinion, not spin or creative interpretations, numbers. If you have a problem with them don't blame me, take it up with the President. He's the one who thought this made sense.
ProSense
(116,464 posts)They will be taxed to pay for the law.
Demo_Chris
(6,234 posts)You know, the subject of this thread.
I said the max out of pocket scale favors the affluent, and showed numbers to back this up.
ProSense
(116,464 posts)"I said the max out of pocket scale favors the affluent, and showed numbers to back this up. "
...the entire law can be framed as "favors the affluent," who can afford medical coverage before even when they had a pre-existing condition.
You know damn well the out of pocket caps are to help all Americans.
The fact that the tax on high-income earners and the wealthy is in place to help fund the law means that it's not a "gift" to the wealthy.
That point is pure BS.
I'm sure you know that, though. LOL!
Demo_Chris
(6,234 posts)Why isn't this wonderful cap scaled to income?
If someone earning 40K a year gets hammered with a 10K deductible and co-pay they aren't getting treatment. If it's legal to do so, the insurance company and hospital are gonna want cash in advance, and so sorry if you cannot pay. But for the affluent, who are being asked for only a couple percent of their income, it just means cancelling their next trip to Switzerland. Hell, they probably wouldn't even be asked for it up front as everyone knows they're good for it.
Obviously, some cap is better than no cap at all. Only an idiot would argue that. But the law as written turns this into yet another gift for the affluent at the expense of the poor. I posted the numbers.
ProSense
(116,464 posts)"So you are arguing the fairness of a cap of 26% for the poor and 2% for the wealthy?
Why isn't this wonderful cap scaled to income?"
...you're desperately seeking to justify a lame point. A cap is a cap.
Should premiums be "scaled to income" despite the tax?
Flatulo
(5,005 posts)Since the average American's net worth is nothing, *any* large deductible will be devastating. For most low-income earners, that max out-of-pocket might as well be a million bucks.
JDPriestly
(57,936 posts)The issue about the max out of pocket would be easy to change.
I note that the family with an income of $40,000 has a max out of pocket about $2,300 lower than the family with a higher income.
That can easily be changed. There will be many such minor changes to the bill in the future.
I would prefer single payer. That would tax according to the size of the wage and have no or a very small max out of pocket for everyone. That's the best.
I lived in Europe for years -- various countries. I had two babies and raised them through early childhood on single payer insurance. The structure varied from country to country. I absolutely loved it. I would strongly recommend it for the US. It could be organized and regulated at the state level. Some of the programs were directly government managed (the UK), and some were managed by non-profit companies. Both systems worked far better than our insurance system.
It is horrible to be told that a provider you want is not on your plan. Never happened to me in Europe. Happened to me here several times.
It is horrible to have to change your insurance plan because your boss decided to get something that is cheaper for him or because you get a new job. This often means that you have to change your doctor and start all over again.
It's awful to have moderately high blood pressure in your 50s, a very stressful job and an insurer too cheap to just prescribe the medicine you need. But that is America's insurance company system for you.
Demo_Chris
(6,234 posts)
grantcart
(53,061 posts)JDPriestly
(57,936 posts)
pnwmom
(108,978 posts)annual out of pocket -- it's tremendously better than pre ACA.
Logical
(22,457 posts)In July and you get a $16,000 bill over 2 years of treatmentl. He is bankrupt.
beachbum bob
(10,437 posts)You have copay per claim and max out of pocket. I could have a procedure that has $200 copay and the insurance picks up the other $4800....max out pocket means what it means. If my policy has $10,000 max out of pocket...I could have 50 such procedures in a year...
Logical
(22,457 posts)
cynzke
(1,254 posts)At the next renewal of the annual contract for that "In Name Only" health insurance policy, the insurance company could kick you off the policy even though you may still be ill!
BlueStreak
(8,377 posts)They just sent out 2 million cancellation notices, which proves the point that there never was any real coverage. They only covered the patients that were profitable.
fleabiscuit
(4,542 posts)Insurance companies must see that 80% of what you pay, actually goes to benefits. Imagine what might be returned to you if car insurance had the same requirement. I know it's not the same, but still interesting IMHO.
lostincalifornia
(3,639 posts)BlueStreak
(8,377 posts)What good is insurance that can be cancelled when you really need it?
lostincalifornia
(3,639 posts)did not need health insurance
Maedhros
(10,007 posts)but it does not do such a great job with making health care affordable.
One of the biggest problems we face with regard to health care in America is that getting sick will bankrupt you. $6-10K out-of-pocket is a lot of money to the average American. Wage stagnation has left even middle class Americans with very little flexibility in their budgets to absorb these kind of medical costs.
While the ACA may represent a first step, more work is needed.
beachbum bob
(10,437 posts)Maedhros
(10,007 posts)Out-of-Pocket Expenses
Most health insurance plans don't pay 100% of the cost for absolutely everything related to your healthcare. Your plan probably requires you to pay part of the costs, such as a copay when you visit the doctor. All costs for covered services that you pay for are called "out-of-pocket expenses" because you pay for them out of your own pocket. These costs include copays, coinsurance, and deductibles.
Out-Of-Pocket Maximum
An Out-of-Pocket maximum is the most that you should have to pay for your healthcare during a plan period (usually one year). Before reaching the out-of-pocket maximum, you pay for part of your medical care, such as copays and coinsurance. Once you have paid the amount set by the out-of-pocket maximum, your insurance will pay 100% of the allowed amount for your covered healthcare expenses, up to a preset benefit maximum. Note that ineligible expenses -- such as elective plastic surgery -- aren't counted against your out-of-pocket maximum.
My point was that some people cannot afford $6-10K out of pocket. Why was that hard to understand?
Flatulo
(5,005 posts)They cost $3000 per procedure. That means I'll be bankrupt every year for the rest of my life.
beachbum bob
(10,437 posts)And its NOT $3000 bucks....where do you come with this.
Flatulo
(5,005 posts)Or am I not understanding the difference between a deductible and copay?
whopis01
(3,514 posts)Be careful about which plan you sign up for - the one good thing is that you know you have a regular expense and can use that to see which plan balances out the best for you.
You can have a copay, a deductible, coinsurance, and a max out of pocket.
When you go in for the procedure you will pay the copay first. Then (depending on the procedure) you will have to pay until you meet your deductible. Once that deductible is met (for the year), you will pay a portion of the cost (coinsurance) until you reach your out of pocket maximum (if you do). Then you won't pay anything more.
Simplifying it greatly - if you assume you have $12,000 in expenses a year (4 procedures at $3k each), your annual out of pocket will be roughly either
1) Deductible + (12,000 - Deductible) * CoInsurance%
or
2) Max out of pocket
whichever is less.
Your out of pocket maximum won't be $12k - it will be more like $6k or less. I believe people are seeing the $12k number when they put in for multiple family members. Even with that, there is a $6k per individual / $12k per family max.
Looking at a bronze plan here (the third plan listed) :
http://www.healthpocket.com/individual-health-insurance/bronze-health-plans#.UnGKbhB2hG8
You would be paying $6,150 - pretty close to the out of pocket max. With the other bronze plans you would hit the max of $6,350.
Looking at a silver plan:
http://www.healthpocket.com/individual-health-insurance/silver-health-plans#.UnGLCRB2hG8
Under the first one listed you would pay $4,800. Under the second one you would pay $4,000. Under the third you would pay $2,500.
So then you would need to look at the premium differences between the various plans and account for that to see which is actually the best for you.
The reality is that you are still going to have some pretty hefty expenses - but it won't be $12k/year.
BlueStreak
(8,377 posts)CANCELLATION !!!!!
Because it isn't profitable. And because they can.
And once canceled, you wouldn't be able to buy any new coverage unless your state had a special high cost pool.
So let us keep this straight. Nearly 100% of the individual policies before ACA were crap. They all have pretty brochures, and some of the companies did a nice job for people who didn't get very sick. But when you got expensive, you were gone, period.
There is no question that some of the ACA policies are expensive. There is no question some people are having to face some very difficult decisions. But ultimately that is because the ACA requires companies to actually offer real insurance instead of the crap they have been getting away with.
And there is no question that the refusal of certain Republican Governors to accept the Medicaid expansion is one of the most grotesque, inhumane acts of any government in the past half century. Maybe it doesn't match the inhumanity of Uganda, the Congo, or even Syria, but it really should be discussed in those terms. It truly is a human atrocity, and for purely political purposes.
Flatulo
(5,005 posts)Lars39
(26,109 posts)
AtheistCrusader
(33,982 posts)Edited out. I was ... I dunno, drinking heavily or something.
BlueStreak
(8,377 posts)here and in Congress, is INDIVIDUAL insurance?
This ACA roll-out doesn't affect you at all if you are on an employer group plan.
AtheistCrusader
(33,982 posts)I'll edit it out of the conversation. My bad.
kestrel91316
(51,666 posts)premiums under $50/mo, I think even I can handle that. And if I can't, friends and family will help out without bankrupting themselves.
pnwmom
(108,978 posts)For the people who have said that there is almost no amount out-of-pocket that they could afford -- at least maybe there is a chance that they could get help from some family members.
I am paying for a policy for a young woman who's living with us (friend of our kids who needed a place to live) because I couldn't stand the idea of something happening to her that could cost a tremendous amount of money -- and not being able to help. Now she can get a great policy and I'll know exactly what the worst could be, if she got in a car accident or something. And it's an amount we could afford to help with.
BlueStreak
(8,377 posts)It is tempting to say a Republicans wouldn't reach out and help the young lady because they are too selfish. But I know some Republicans who really would do that.
I think the main difference is the ability to have empathy when you are not PERSONALLY in the situation. This is what Republicans seem to really struggle with. What would that ACA-hating Republican do when their "Christian values" told them to offer a home to the young lady? She isn't family so she cannot be added to the family's policy. And without the subsidies, you are probably talking at least $300 a month for a decent policy. Would a Republican pay that in addition to giving the young lady room and board? Maybe?
I just don't think they would ever consider that circumstance until it was right in their face.
Republicans: "If my life is good, then there are no problems."
pnwmom
(108,978 posts)cancelled her off her insurance when she left home.
And she had every right to leave home, believe me -- the situation was terrible.
I was so angry with the mother. Just couldn't imagine how she could cut her off from health insurance. And not tell her either -- so when we tried to renew individually, she was turned down because there had been more than the allowed 2 month gap. I had to find another decent company that would take her. This was when I got my health care education -- I was shocked to find out that only the most expensive policies covered maternity care. But how could I get a policy for a young woman without that (just in case . . . you never know)?
So I am very happy about the new choices we have now -- much better!
Bluenorthwest
(45,319 posts)afford basic care, go beg. It is nice that you are helping, but also very sad that this is seen as something acceptable. How many are there like your friend who don't have you?
pnwmom
(108,978 posts)and I hope lots of other people, too.
kestrel91316
(51,666 posts)lancer78
(1,495 posts)Has No deductible, No Max out of pocket, and no coinsurance. This is a marjetplace plan with Blue Cross/Blue Shield of Tennessee.
lancer78
(1,495 posts)BlueStreak
(8,377 posts)CFLDem
(2,083 posts)Humanist_Activist
(7,670 posts)through either the exchanges or my work(if it was affordable), since she has a chronic health condition, we would have met the maximum out of pocket(10 thousand+ dollars a year) every year. This represents over a third of our income, excluding premiums. That means bankruptcy, year after year, for the foreseeable future, until single payer kicks in. Oh, and I guess we would have to change her doctors a LOT, because no doctor's office is going to accept a second appointment when you have outstanding bills you can't pay to them.
I don't understand this whole thing about maximum out of pocket, I guess it will help people avoid bankruptcy if the condition being treated is one shot, and is cured within a year, then someone making 35-40 grand a year may be able to eat that cost without going to bankruptcy court. But for people with chronic conditions, who make 10-30 grand a year or so, and have anywhere from 2 thousand to 10 thousand dollar expenses due to those conditions, whether it is capped or not doesn't matter, after a certain point it doesn't matter, because you can't afford either the cap or hypothetical much higher expenses.
Warren Stupidity
(48,181 posts)
Glassunion
(10,201 posts)I had a plan that would have met all of the requirements of the ACA, however the greedy insurance company dropped the plan, then our rates were higher, with a higher max out of pocket. We could not keep the plan we liked, not because Obama lied, but because the insurance company saw an out with the plan we had locked into for years.
http://www.democraticunderground.com/?com=view_post&forum=1002&pid=3915996
BlueStreak
(8,377 posts)I feel like I should know the answer. I believe this is the case:
Under the ACA, we will have to enroll in policies each year during the open enrollment. An insurance company could choose to offer to extend a policy, but they don't have any obligation to do this. An insurance company could decide to pull out of a state altogether if they think they can't make enough money. In theory, it is possible that next year it could be a completely different set of companies offering insurance on the exchange in a given area, and the prices and networks could be entirely different.
Can anybody confirm or correct that?
It seems to me that is an inherent problem of depending on private for-profit companies. Maybe it won't actually be a big problem in practice, but it seems like we could go through this "2 million people canceled" Faux News cycle every year.
OTOH, if insurance companies decide to play those games, that could give rise to a movement to get a public option so that we will have some stability.
slipslidingaway
(21,210 posts)now we start on the next year!
slipslidingaway
(21,210 posts)are covered under your plan. When we selected our plan a few years ago it was more costly per month, but it did allow us to access to several providers that we needed a year later ... who could have predicted.
Imagine the choice between hospitals that have done two bone marrow marrow transplants and hospitals that have done hundreds ... something to think about when looking at the monthly premiums.
BlueStreak
(8,377 posts)In my county, the only "name" insurer on the exchange is Anthem. I have an Anthem policy currently that has a pretty good provider network. Everybody I've needed to see has been in network. When I had to change PCPs (because my PCP decided to switch to a concierge practice) I had a decent pool of Docs to choose from.
Well, it is as if Anthem is just saying "Screw you, Indiana. You don't have any competitors for us, so we're going to shove a really crummy provider network up your ass. They consciously put together a whole new network for the ACA plans, and it is horrible. Only includes the lowest rated hospital system in the county, and only has about 10% of the Docs practicing in the area.
Fortunately there is another no-name company that has a couple of policies in the Exchange, and they have a terrific network -- basically includes any Doc I'd want to see and includes all the major hospitals including the Indiana University system. I have researched them and they were formed about a decade ago to serve the Medicaid community here. They seem to be capable of doing the job, so I'm not going to play Anthem's games.
Definitely research that provider network. Don't assume it is a good network. Don't assume that it wil be the same network the company has offered in the past. Some of these companies are really screwing with this.
slipslidingaway
(21,210 posts)it does make a difference.
