Obamacare 5 years later. Crow, anyone?

[Armitage72]

This is actually a win for Republicans.

They get the benefit of joining their malcontented base in shaking their fist and grumbling, while at the same time avoiding the calamitous political fallout of causing millions of people being denied access to healthcare.

They also get to make another 10 - 20 repeal attempts so it looks like they're actually doing something.

"We need to try to repeal the ACA again. Who hasn't taken their turn yet? Bill, you submit the paperwork this time."

 

[Shalamar]

They also get to make another 10 - 20 repeal attempts so it looks like they're actually doing something.

"We need to try to repeal the ACA again. Who hasn't taken their turn yet? Bill, you submit the paperwork this time."

I have no problems with the Republicans repealing Obamacare...

As long as they have something else to replace it with!

 

[Biscuit]

Can you enlighten me on this?

Yes. I will assume you are under the same misconception about health insurance deductibles as Emily Cat.

Why do you say so? I don't follow you here.

This is actually a concern of mine - some Bronze plans have $4000 or $5000 deductibles. Sure the premium is low, but if you end up in the ER or admitted to the hospital, you WILL get a massive bill. So I'm not really sure what you think a deductible is, and how it works...

The deductible is not the total amount you have to pay before insurance pays for anything. It is the total amount you pay until insurance covers everything. Up until your annual deductible you will, depending on your plan, have fees and percentages of the cost of care you receive. Its like insurance acts as a discount plan until you reach your deductible.

Case in point. I have a $6000 deductible and I just had a hernia operation. True story but I am going to round some numbers for convenience. There were three different groups billing me for the operation - the surgeon, the hospital, and the anesthesiologist.

Surgeon billed my insurance - $1,200.00
I paid him $100 for the surgery and a $60 co-pay on my first visit

Hospital billed my insurance - $6,000.00
I paid the hospital $800.00

anesthesiologist billed my insurance $900.00
I paid the anesthesiologist $65.00

Factor in another $30.00 copay for my primary care physician and another $25.00 in meds I paid $1,080.00 for my surgery.

Assuming I had no insurance and could negotiate the same discounts my insurance company did I would have paid $8,100.00 plus full cost for meds and doctor visits.

If insurance covered nothing until I reached my deductible I would have paid $6,000.00 and insurance covered the remaining $2,100.00

(ETA: Before anyone asks, no I had not any any previous medical claims this year or even last year.)

 

[RandFan]

Case in point. I have a $6000 deductible and I just had a hernia operation. True story but I am going to round some numbers for convenience. There were three different groups billing me for the operation - the surgeon, the hospital, and the anesthesiologist.

Surgeon billed my insurance - $1,200.00
I paid him $100 for the surgery and a $60 co-pay on my first visit

Hospital billed my insurance - $6,000.00
I paid the hospital $800.00
anesthesiologist billed my insurance $900.00
I paid the anesthesiologist $65.00

How were these figures calculated? What is the basis? Why didn't you pay $1. each or why didn't you pay more?

 

[Meadmaker]

Yes. I will assume you are under the same misconception about health insurance deductibles as Emily Cat.



The deductible is not the total amount you have to pay before insurance pays for anything.

No, that's not correct. At least the way it is usually defined, a deductible is indeed the amount you pay before insurance pays for anything.

What you described in your post is what most plans call "out of pocket maximum".


And just to keep things confusing, there are certain services that are covered by most plans with no deductible. For example, some preventive care services are often covered at 100% with no deductible.

 

[RandFan]

wiki

In an insurance policy, the deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses.[1] In general usage, the term deductible may be used to describe one of several types of clauses (see below) that are used by insurance companies as a threshold for policy payments.

 

[ponderingturtle]

I am very relieved to learn I will not be losing access to affordable health insurance as I am sure many self employed people across the country are today.

I had this pipe dream fantasy that the court would rule against it and we would get single payer instead.

Not with this congress. If they had ruled against it they would have happily killed it off.

 

[ponderingturtle]

I've heard right wing yappers talking about the high deductible problem all year, and I have a question.

Are we talking about HSA based plans here? I suspect we are.

For those not familiar, my employer offers multiple plans. One of them is based on a Health Savings Account. You pay a very low premium, but you have a very high deductible, at least a few thousand dollars annually. You also get to open up a Health Savings Account, which is a tax free account. You pay no tax on anything you put in, as long as you spend it on health care. Also, unlike the Flexible Spending Account with which it is often confused, you don't lose the unspent money. It stays yours forever.

If you are young and healthy, and your employer offers it, you are foolish if you don't choose that plan.

Now, the interesting thing about all of this is that HSA plans were driven entirely by the right wing. They love them. It's private enterprise. They help keep costs down. They're exactly what the right wing ordered......but now the yappers are whining that those plans are available under Obamacare?

So, just to get the facts straight, are there plans out there that have $3,000 deductibles, but aren't HSA based? If they are, as I suspect, HSA plans, then the right wing is whining about something they invented themselves.

Possibly family plans. We had a non HSA qualifying plan with a $1500 deductible for an individual as one of the options where I work a few years ago. The family version of that might have had a $2500 deductible.

Not sure how those stand now with the changes in our employee management and implementation of the ACA. I am now on my wifes plan so it doesn't make a big difference to me.

 

[Cleon]

Well, I guess we know what the Republicans' theme for 2016 will be.

 

[Shalamar]

Well, I guess we know what the Republicans' theme for 2016 will be.

"Vote Republican: We'll take away your health insurance!" ?

 

[Emily's Cat]

True, but $4,000 or $5,000 is better than the full freight you'd have to pay if you didn't have insurance. I agree that the ACA is an improvement, but only a small one. I do see it as a step towards single-payer, which is (IMO) a consummation devoutly to be wished.

Gotcha.

Might not be better than the county write off that some people without insurance used to get

My concern is for people who don't understand how insurance works, and really don't know what they're buying. Those are the ones that I worry most about. There are some people (not sure how many, but I know two personally), who have found themselves in a really sucky position. They are mandated to have insurance... but can only afford the cheapest plans. Even with a subsidy they have very limited income, and it's still a cost they didn't previously have. Now they're in a position of paying a premium they really can't afford, for a benefit that will bankrupt them if they actually have to use it.

 

[Spindrift]

In an insurance policy, the deductible is the amount of expenses that must be paid out of pocket before an insurer will pay any expenses.[1] In general usage, the term deductible may be used to describe one of several types of clauses (see below) that are used by insurance companies as a threshold for policy payments.

Except that Federal law requires certain things be paid by the insurer without a deductible such as physicals, pap tests, etc.

Also the insurer negotiates rates. So while the doctors bill may be $1000, the negotiated rate can be much less and that's all you are responsible for.

I have a high deductible plan ($5000) My daughter spent 3 hours in the ER. The bill was over $10,000. The negotiated rate was about $4500.

With medical insurance the deductible is when the plan kicks in. So after the deductible is met, you are still on the hook for the co-pays up to an out-of-pocket maximum. In my case, $7000.

When I selected this plan, I calculated the difference between what I was paying in co-pays with a no-deductible plan and the premium difference and even though I've met the $7000 out-of-pocket for the year, I will be paying less than I would have in premiums with the other plan. Plus I have a bad knee and now I can get it fixed this year and it won't cost me a cent and I can go to as many physical therapy sessions as I really need and there's no co-pay.

 

[Emily's Cat]

I will assume you are under the same misconception about health insurance deductibles as Emily Cat.

Which would be an erroneous assumption, seeing as Emily's Cat is a health actuary working for a health insurance company, and who develops benefit pricing models and is heavily involved in product pricing . If there's one thing I know, it's health insurance benefits and nomenclature.

The deductible is not the total amount you have to pay before insurance pays for anything. It is the total amount you pay until insurance covers everything. Up until your annual deductible you will, depending on your plan, have fees and percentages of the cost of care you receive. Its like insurance acts as a discount plan until you reach your deductible.

No, I'm sorry - you have confused Deductible with Out of Pocket Maximum.

The Deductible is the amount you are responsible for before insurance begins to take a part of the cost. Once you hit the Ded, you will pay a portion of the costs for each service, and the insurance company will pay the remainder.

The Out of Pocket Maximum is the maximum amount you will have to pay in that contract year. Once you hit the OOP, the insurer pays 100% of the costs, and you pay nothing.

A couple of variations: Not all services are subject to deductibles; many plans have office visits set at a copay, and the deductible is waived. This means that you pay a fixed fee for office visits from day one, and the insurer pays the rest.

It's also possible to have a "cliff" plan - one in which the deductible and the OOP are the same. In those cases, you pay 100% of the costs below your Ded/OOP, and 0% of those costs above the Ded/OOP

Case in point. I have a $6000 deductible and I just had a hernia operation. True story but I am going to round some numbers for convenience. There were three different groups billing me for the operation - the surgeon, the hospital, and the anesthesiologist.

Surgeon billed my insurance - $1,200.00
I paid him $100 for the surgery and a $60 co-pay on my first visit

Hospital billed my insurance - $6,000.00
I paid the hospital $800.00

anesthesiologist billed my insurance $900.00
I paid the anesthesiologist $65.00

Factor in another $30.00 copay for my primary care physician and another $25.00 in meds I paid $1,080.00 for my surgery.

Assuming I had no insurance and could negotiate the same discounts my insurance company did I would have paid $8,100.00 plus full cost for meds and doctor visits.

If insurance covered nothing until I reached my deductible I would have paid $6,000.00 and insurance covered the remaining $2,100.00

(ETA: Before anyone asks, no I had not any any previous medical claims this year or even last year.)

This sounds most like my first caveat - services subject to copays are not subject to Ded. Although in truth, I strongly suspect that $6000 is your OOP, not your Ded.

 

[Skeptic Ginger]

I have a lawyer friend in another forum that sometimes makes some excellent points. He believes Scalia is not acting on partisan ideology. I think Scalia believes that, but I also think he's unaware of his underlying partisan biases. I investigated by searching for other cases where Scalia's legal opinion sided pedantically. And I found it.

This would tend to support Scalia consistently being a pedantic interpreter of legislative language, except... where this review of Scalia's book points out.
Reading Law: The Interpretation of Legal Texts By Antonin Scalia and Bryan A. Garner

Scalia and Garner reject (before they later accept) Easterbrook’s warning. Does an ordinance that says that “no person may bring a vehicle into the park” apply to an ambulance that enters the park to save a person’s life? For Scalia and Garner, the answer is yes. After all, an ambulance is a vehicle—any dictionary will tell you that

At this point one might say Scalia stuck to his principles**

But Scalia and Garner later retreat in the ambulance case, and their retreat is consistent with a pattern of equivocation exhibited throughout their book.

And this is interesting here and given Scalia's rational that money is speech:

But it is a curious example for a textual originalist to give. The relevant constitutional provision—“Congress shall make no law abridging ... the freedom of speech”—does not mention non-verbal forms of political protest, and Scalia and Garner insist that legal terms be given their original meaning lest the intent of the legislators or the constitution-makers be subverted by unforeseen linguistic changes. “In their full context,” they assert, “words mean what they conveyed to reasonable people at the time they were written—with the understanding that general terms may embrace later technological innovations.”

** Except I still think there are two ways to read "state" in that section of the ACA: 1) state as in governing body, not states, which should have been plural; 2) state exchange whether the state uses its own or the federal version it is still the state's.

 

[RandFan]

Also the insurer negotiates rates. So while the doctors bill may be $1000, the negotiated rate can be much less and that's all you are responsible for.

When I lost my job I lost my insurance. I was preparing for gastric bypass surgery at the time. When I lost my insurance I scrambled to find a way to get the surgery and that including medical vacationing and cash negotiation.

I offered negotiation. The lowest price before negotiation that I could find in the Continental United States for Gastric Bypass was $20,000 (package deal). I could get that reduced by about 10% if I paid cash. Some groups will not negotiate BTW and those who do the "negotiation" feels like buying a used car. You just wonder how much you will get taken for.

When I got Medicaid I qualified for and got my surgery. I also got the subsequent bill (paid for by insurance). Total hospital, anesthesiologist and hospital bill? $9,000. Kinda makes my $2,000 discount that I had "negotiated" look like a sucker's special.

So, I asked one of my clients (medical billing) why I was unable to negotiate a better deal. Simple, volume. It's like the difference between wholesale and retail. I could only offer a one time deal to a surgeon. An insurance company can offer a lifetime of income.

 

[Dread Pirate Roberts]

So, just to get the facts straight, are there plans out there that have $3,000 deductibles, but aren't HSA based? If they are, as I suspect, HSA plans, then the right wing is whining about something they invented themselves.

The only plan provided by my company has a $2,500 individual and $5,000 family deductible, and it's not an HSA. It's been at that level for at least the past 4 years.

 

[Tony Stark]

All I have to say is that Republican scumbags that wanted the SCOTUS to rule in their favor can can go **** themselves. You are the bad guys (many people would have literally died if they ruled in your favor). Thankfully Kennedy and Roberts ruled on the side of good so they are not too bad in my view even though they are Republicans and I generally hate Republicans.

 

[Aepervius]

An insurance company can offer a lifetime of income.

And now think if this is done on a country wide level with a government health insurance...

 

[Skeptic Ginger]

The only plan provided by my company has a $2,500 individual and $5,000 family deductible, and it's not an HSA. It's been at that level for at least the past 4 years.

Does having a work option prevent you from getting a different plan on your own through the exchanges?

What is the monthly cost for those plans? Add a little more than $200/month to that payment for the lower deductible plan and you have your actual premium. Is it outrageous or not?

I'm not sure what you are complaining about, or am I misreading your post?

 

[ZirconBlue]

Which would be an erroneous assumption, seeing as Emily's Cat is a health actuary working for a health insurance company, and who develops benefit pricing models and is heavily involved in product pricing .

Oh, so you're to blame?