<p>Well racinreaver, they are, in Washington.</p>
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<p>The Silver plans have to have an actuarial value of 70%. The insurance companies come to that by looking at their data and projections about average use. You and I have no way of knowing how the different deductible levels and the difference between a 90% or 80% copay plays out in that big-picture actuarial figure – but that’s where the numbers come from that result in big premium differences, assuming the same company and network. (Again, with different companies & networks, or HMO vs. PPO, then the anticipated cost for all the services also factors in).</p>
<p>The only advantage that we consumers have is that we have personal knowledge about our own current and anticipated health care needs, and our health care spending habits. As of 2014, the insurance company is basing the premium figures on averages – they can’t set our rates by our health-spending history any more. So we can use that information to figure out the program that is best for us. </p>
<p>Yes, it does take a spreadsheet to work it all out, and yes - it probably is a complicated task for people who aren’t already used to shopping for insurance on their own. I imagine that many people who really can’t afford the risk of the deductible are enticed into a Bronze when they would be better served by the Silver, especially if they qualify for cost-sharing subsidies; and on the other hand I think that many people are paying needless premium dollars for Gold and Platinum plans when they typically see a doctor only a few times a year, because they are afraid of the deductible. </p>
<p>But if it helps - do keep in mind that the different structures you are seeing are actuary equivalents, within each metal tier. So you may find it helpful to frame your analysis as to what is best for you by asking yourself whether you think that your use of particular medical services is about average, or more than average, or less than average. Of course you don’t really know what “average” is – I’m just suggesting this as an alternate way of thinking about the problem if entering a ton of numbers on a spreadsheet seems daunting.</p>
<p>What will happen is that those who are uninsured, or who are underinsured in that they cannot afford to pay insurance bills, is the same thing that is happening now. The bills don’t get paid. The fact of the matter is that a bill of $6K has more of a likelhood of being paid than one of $60K. I’ve personally seen families just throw up their hands and run, when hit with something that they have no chance of ever paying off. Let the credit take the hit for 6 years or so. But it can be worked out, then maybe some agreement can be reached. Also some money in the pot, albeit just a bit from those who ignore the insurance requirement. Also, some who get the supplements now just might eke out the money to pay the premiums when earlier, it just was not possible. In my son’s case. $6K a year in premiums was not going to happen. With tax credits, and lowering of insurance rates in general now in our state, we are talking $1K out of pocket. Now we are talking turkey. He just might pay them himself!</p>
<p>As to seeking care outside the US, I actually have a dear friend who traveled a lot for business outside the US, but could not afford the cost of insurance when he was younger due to his health history. Somehow he got lucky enough that his major illnesses(ruptured appendix, heart attack) took place while he was traveling in other countries – he got excellent care hospitals in Mexico and in western Europe and was very grateful that he had gotten sick abroad rather than at home. Now that he’s older he’s on Medicare, of course. </p>
<p>I know that when I got seriously ill many years ago while traveling in New Zealand I had equivalent or better care than I could have gotten in the US, and certainly less costly treatment (though I had excellent insurance at the time, so it really didn’t matter – my US policy ended up reimbursing me the $45 it cost for my treatment abroad, so in a sense my insurance company was also fortunate that I chose to come down with pneumonia in a country with a nationalized health system). </p>
<p>I think that it’s a myth that the US health system is the “best” – I think that health care is pretty good in all western, industrialized nations and that the people who live in those countries are generally better off in terms of access to health care.</p>
<p>I don’t know how much of a myth that US health system is the "best " is. My son was treated at a center where they come all over the world, and some of those kids were at the end of their line in New Zealand, to name a country, and many other countries, and found remission or NED here. But that was the world I lived in for some years. I know many who had nighmarish experiences in getting any treatment here in the US.</p>
<p>My best friend nearly died overseas, and was air vaced at great expense, treated and is fine, has been fine for 20 years now after treatment here. The same with my husband’s colleague. Both say the same thing–that the care they received there, was on the surface a lot better, gentler, and personal. The doctors cried with them as they said they could not save them and it was the end of the line. At Mayo and Cleveland clinics, they were not happy with the brutality and impersonal care they received. But they were treated and survived a death sentence from abroad. </p>
<p>My mother is from Japan and she would spend a whole day waiting for a doctor to see her under her national insurance there. Accepted it as her lot. We sail into her doctor’s office, and other doctors for her check ups and have lunch after and are home in a couple of hours. She complains bitterly that the Spiriva that keeps her breathing costs her $60 a month here after insurance and it only cost her $10 in Japan., but she had to spend 6-8 hours in a clinic waiting for it each month. Here we get a 3 month supply and are out of there in 30 minutes or less. I think it depends on the circumstances as to where you will get the best care.</p>
<p>I can tell you that if you are on Medicaid here, finding a personal doctor and treatment for anything not immediately life threatening is a challenge. My husband’s cousin has permanent disablement of his hand after an injury. Couldn’t find a doctor to work on it–with his Medicaid coverage.</p>
<p>Thank-you for this post. This is the stuff that does not show up in statistics.</p>
<p>BTW - My sister works in a hospital. She thinks people will be outraged when they learn they can no longer get routine care in the ER. It’s quick, easy, and in many cases it’s free.</p>
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<p>I don’t think that the care on Medicaid will be “better” - I think it will be about the same, but free. My son can’t just waltz over to Children’s Hospital any time for the fun of it - he called with an apparent emergency, and they treated his son. It is not where they go for routine treatment. </p>
<p>In the past, Medicaid recipients in Washington were typically enrolled in a managed care system, so for grandson, Medicaid=Group Health. That has changed so I don’t know what it will be down the line - I don’t think my son knows either. Grandson qualifies because of SCHIP – you can see the income levels for that here: [Benefits.gov</a> - Washington Children’s Health Insurance Program (CHIP)](<a href=“http://www.benefits.gov/benefits/benefit-details/1615]Benefits.gov”>http://www.benefits.gov/benefits/benefit-details/1615) </p>
<p>(I think you can see that SCHIP is a program for lower income, but NOT poverty level in Washington and many other states – I mean, when my son was still married and working full time, he was the sole provider for his family and his income was well under the $57K level for a 3-person household – although he had employer-provided insurance at the time so wouldn’t have qualified).</p>
<p>I think its great that Washington is attempting to rebrand Medicaid with a more positive level to reduce the stigma attached to it. </p>
<p>No one deliberately renders themselves poor in order to qualify for Medicaid, unless they are in the situation of having extreme health care needs and the system leaves them with no choice. That’s the result of means testing: people who have to render themselves destitute in order to get care for critical or chronic conditions. </p>
<p>Other than that, there’s not much of an incentive, given the lifestyle changes that come with being poor. The ACA system of tax subsidies provides a good path that allows people to earn and save more and still afford health care, so it incentivizes people on the lower end of the economic spectrum to work to improve their situation.</p>
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It’s not “free” - it’s costly and it ties up services. It’s never been “quick” or “easy” where I live either – I once sat with my son in an emergency room for 4 hours, midnight-4am, until his acute symptoms subsided and we gave up and went home, figuring we could last until morning and see our regular doctor.</p>
<p>A big reason why emergency rooms are so chock full of Medicaid patients, some there with minor,non life threatening, non urgent maladies is bcause that’s the only place they can go for health care. Ask your doctors if they will take Medicaid. It’s alarming how many do not. Something I have seen in the last 10 years that is a step up is that some hospitals are setting up non urgent care centers as well as ERs and triaging some of the patients over there, so that there is not that back up. But no envy for anyone who has to sit through that. </p>
<p>When my one son was touring colleges, he got an ear infection, a very painful one in a city outside our, where I knew no one. Couldn’t find a doctor anywhere. Called went to a hospital, a very good one too, and was so directed to their non emergency clinic which would have meant an all day wait. We have/had insurance and we could pay as well, so i found a private Urgent Care in suburb outside of that city and got the matter addressed very quickly. What a difference money can make. He was in so much pain, too. Not life threatening but in enormous pain. This is the sort of thing people have to tolerate in our country, I know. I don’t know how much better it would be in Japan or any other random country.</p>
<p>" I’m not saying a lot of wealthy people are really going to apply for Medicaid, but if the cost of insurance goes way up, with less in network providers, people qualify for Medicaid, why not? Why stick around in a job till age 65, waiting for Medicare? "</p>
<p>You do know, don’t you, that Medicaid in Washington has an assets test, a limit on what your car can be worth, and what is called a “Medicaid spend-down”? That is, if your assets are above a certain level, even in one quarter, you have to spend them down before your Medicaid payments kick in? My friend with liver cancer has been wrestling with this one for years! Basically, he goes to Fred Hutchinson the first day or so of every quarter, they conduct the tests, he gives them every spare dollar he has, and then - AFTER THAT - he qualifies for Medicaid. </p>
<p>Maintaining Medicaid status in “liberal” Washington Stat is hard work. I can’t begin to tell you how many times the refugee who lives with me (and has substantial medical needs) has been cut off, through no fault of his own, and I WORKED for DSHS, the agency that provided Medicaid!</p>
<p>I know Calmom. I too have spent as long as 9 hours in the ER with my child after he fell out of a tree and broke both arms. But, that’s what she said and in her city there is a huge population of low income people who use the ER for routine care and don’t pay. Not all of them are jam-packed. It depends on location. She described the stuff they get treated but I won’t go into that here. I just think sometimes we get hung up on how terrible the old system was and for some it obviously was but the new system is clearly not without it’s flaws. She also said she’d be surprised if some of these folks sign up for anything if they have to pay as much as one thin dime. Not everyone who is uninsured is struggling to buy insurance. That’s an odd myth I’ve seen tossed around a lot lately. That’s all I’m saying.</p>
<p>Mini, NY does not have an assets test, but if your income is over by a dollar for what you say it is, in a given month, you do not qualify. Or if it’s over the threshhold just for hat month. But they don’t ask about assets or check them. So it differes by state. NY State is extending Medicaid and we’ll see if it takes some of the stigma from it, and more importantly if more doctors witll take it. Right now we are having issues with doctors and medical centers not signing up to take the ACA market insurance. A lot is going to have to shake out next year. </p>
<p>Non payment at hospitals is a huge problem Don’t even have to be low income to be a deadbeat there. I know some folks, my brother included, who ran up huge hosptiatls bills that were not all covered with insurance and just put up the white flag, took the hit on their credit for 6 years or so and just refused to pay.</p>
<p>Maryland bumped up the amount paid to doctors for Medicaid patients by an average of 24% in preparation for more patients moving into the program. Since there is the possibility my daughter could be on medicaid after she leaves her Dad’s policy, depending on her income of course, I have checked on all of her doctors and specialists. They all take Medicaid patients.</p>
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<p>The Oregon Health study and the Romneycare experience in MA found little decrease in ER usage. If I am not misremembering it Oregon might actually have gone up for the newly covered population. </p>
<p>It is a bummer that there are a lot of drug seekers in the ER faking pains and the docs have to prescribe the or risk medical board complaints.</p>
<p>So another WA thing to add from a provider perspective (darling wife, not me). Medicaid in WA is rebranded as private insurance but with Medicaid reimbursement rates. For a provider to accept that private insurance, they MUST accept Medicaid patients also. </p>
<p>It’s tough enough to pay the bills with current insurance reimbursement rates that have gone down over the past two years for primary care. Because Medicaid pays so much lower, providers and clinics subsidize the WA Medicaid plan by seeing the patients at a loss. It only works because so many people here are insured and can afford cash-pay rates. It would never work in an area with a critical mass of Medicaid patients.</p>
<p>So the Obama Administration today announced they are delaying the start of the enrollment period in 2014 until Nov 15. This is so nakedly machiavellian that it is laughable. It shows how confident they must be feeling.</p>
<p>Mini, Washington had an assets test, pre-ACA. The ACA does away with the assets test and goes to income only. </p>
<p>There is a reason for that, and it is intentional. ACA is a step toward a national health care system. It wasn’t politically feasible to go all the way, but the basic concept is that everyone will have health care, and people will be asked to pay what they can afford toward their care. </p>
<p>Obviously, “what they can afford” is based on some arbitrary criteria, plus there are a few glitches that hit people in certain income or family situations pretty hard – but it designed based on averages, not individual circumstances. An income only based system was created because that is the easiest to monitor and can be piggy backed on the existing federal income tax system.</p>
<p>Magnetron, you do know that one of the effects of ACA is that it raises the Medicaid reimbursement rates, don’t you?</p>
<p>“If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer? In 2008, a group of investigators conducted a worldwide study of cancer survival rates, called CONCORD. They looked at 5-year survival rates for breast cancer, colon and rectal cancer, and prostate cancer. I compiled their data for the U.S., Canada, Australia, Japan, and western Europe. Guess who came out number one?”</p>
<p>[The</a> Myth of Americans’ Poor Life Expectancy - Forbes](<a href=“http://www.forbes.com/sites/theapothecary/2011/11/23/the-myth-of-americans-poor-life-expectancy/]The”>The Myth of Americans' Poor Life Expectancy)</p>
<p>"surgical patients on Medicaid were nearly twice as likely to die before leaving the hospital than those with private insurance.</p>
<p>Medicaid pays hospitals and doctors less than 60 percent of what private insurers pay. Indeed, Medicaid reimbursement rates are so low that hospitals, on average, lose money on every Medicaid patient they treat. As a result, most doctors refuse to see Medicaid patients, forcing the poor to get care through hospital emergency rooms." </p>
<p>[Why</a> Medicaid is a Humanitarian Catastrophe - Forbes](<a href=“http://www.forbes.com/sites/theapothecary/2011/03/02/why-medicaid-is-a-humanitarian-catastrophe/]Why”>Why Medicaid is a Humanitarian Catastrophe)</p>
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<p>Yes, I’d read that - they want to raise it to the level of the Medicare reimbursements. She won’t survive (as in loses money, not just makes less) on Medicare rates either, and has stopped accepting new Medicare patients. Large hospital organizations are keeping primary care rates artificially low, operating at a substantial loss, in order to use them as gateways to expensive services and drive out independent practices. </p>
<p>Patients who see a hospital-affiliated PCP end up being about 50% more expensive than one who sees an independent provider, yet insurance companies pay the hospital-affiliated docs more.</p>