<p>Maybe it is because most of the people in MA were already insured in the first place before the reform. I believe the numbers were around 92-93% were already insured in MA before and now about 3% are still uninsured. In theory, those 3-4% that did not have insurance before should be the ones that would frequent the ER, but then maybe those are mostly young people who do not have a lot of health care needs in the first place.</p>
<p>Or 3-4% change in number of insured does not significantly effect the total number of ER visits.</p>
<p>Well in a rural area there is a cost-benefit issue as to the cost of maintaining a single under-utilized facility vs. two under-utilized facility. I mean, that rural emergency room may cost less to staff than the typical urban urgent care center – it’s called “emergency” but if they see half a dozen patients on busy day, then it really isn’t an issue in terms of health care costs. Maybe for the sake of keeping insurance companies happy, they should set up a separate sign in sheet in for urgent care, and put a sign over the door that says “Emergency + Urgent Care Center”. </p>
<p>I don’t want to give you a bad time at all. I think you should have asked someone local where you could go for medical care and then gone wherever they directed you. Emergency vs. urgent care is not a meaningful distinction when you are out in the boonies. </p>
<p>It’s a very serious problem in an urban area where the room is crowded to the gills, and a roomful of patients with ear infections and strep throat and sprained ankles is causing delays for treatment of patients with gunshot wounds and heart attacks. But that’s not the situation you were in. How many others were in that emergency room waiting for treatment when you go there? How long did you have to wait?</p>
<p>Actually when I went in, they said, “We’ll send you over to the Urgent Care part of the emergency room,” which was in another part of the hospital. And I of course said, Great, I don’t want to get in the way of people with actual critical care needs. Eventually I saw a perfectly nice nurse practitioner.</p>
<p>The whole place was not crowded at all. I didn’t see any ambulances arrive while I was waiting around, and I don’t think my friend who was waiting outside the emergency room with the bikes (for three hours) saw many ambulances, if he saw any. He certainly didn’t say anything about exciting trauma teams arriving.</p>
<p>But I’ve noticed that when I ask for directions, people always, always assume I have a car. That’s fine for me; I have no problems getting around. But if you are a poor mother with two sick toddlers and no car, and people design the system assuming that you do have a car, it IS a problem. And a facility that is “only” ten miles away is difficult to get to if it requires two transfers on infrequently-running bus lines.</p>
<p>Just wanted to respond to a couple of posters. Someone was suggesting the unsubsidized subscribers are fairly rich and should consider themselves lucky. In Ca I don’t think you are all that rich if an individual makes $45,960 and a couple makes $62,040. In fact, it is very hard to stay above water with those incomes. It is a disaster if the couple now has to spend $13,000 for a high deductible insurance plan, much higher than they currently pay.</p>
<p>Someone else suggested if I want to go to Cedar Sinai, then pay for it myself. For your information, it is not just Cedar Sinai, the largest outpatient network in my community is not accepting insurance from the exchanges. These networks are punitively narrow. There will be many doctors who I currently can see who will be shut out of the network. Read this article:</p>
<p>Finally, someone else said just buy a policy off the exchange. In California, the policies off the exchange are identical to the ones on the exchange, except you now have the privilege of paying a ton more than the people on the exchange for the same policies. Consumer choice has become a relic never to be seen again in Ca.</p>
<p>I know I should just shut up because I am a self-centered, uncaring, unfeeling jerk. :)</p>
<p>I have yet to be able to get through the log in for the exchange but did look at the individual policies for the 3 companies in NJ on the exchange. What really bothers me is that of all the plans, only 1 offers an out of network component. That does not give a parent with an out of state college student much in the way of choice. It’s either that plan or pay the college an additional health insurance fee. Is it just NJ or other states, too that don’t have out of network in the exchanges?</p>
<p>NJ small group plans are not out yet, but I have a feeling that they will also mirror the individual plans as well. A previous poster gave a link to the Urban.org that says:</p>
<pre><code> “Insurers providing small group and nongroup coverage in or out of the exchanges will only be allowed to offer plans that fit into four tiers of actuarial value (AV)7bronze (60 percent AV), silver (70 percent AV), gold (80 percent AV), and platinum plans (90 percent AV)”
</code></pre>
<p>Does that mean that only the people with large group plans and more buying power will be allowed to get the better insurance? So even if we want to pay even more, we’re NOT allowed? Please tell me I’m wrong.</p>
<p>CF, the car vs. no-car thing is a regional issue. When my daughter was living in Washington Heights in NYC and broke her foot, I’m sure that no one thought she would be driving to any emergency room. (I’m guessing she took a cab that day, because it’s hard for me to envision her hobbling up and down the steps to the subway stations with a broken foot). You are right that in the burbs it’s a different dynamic – I’m just saying it’s not a universal issue.</p>
<p>That income is above the median California income. Maybe it’s hard to stay above water, but you’ve got a lot of people swimming around in the depths below you if you’re at that income. </p>
<p>But this prattling about consumer choice ignores the free market. Insurance companies could offer policies that included Cedars Sinai. No law prevents them from doing so. But Cedars Sinai is a very expensive hospital, so the insurance policies would cost a lot of money, so probably not very many people would buy them except people who were very sick, which would even drive the prices up higher.</p>
<p>How much of a surcharge would you be willing to pay, to get Cedars Sinai and all the doctors you’d like to have? $10,000 a year? $20,000 a year? More? There’s no free lunch. You want to buy an insurance policy that is only marketed to healthy people. Well, you can’t.</p>
<p>You’re right, calmom, but there are not many regions where the majority of adults don’t have cars. New York City and… where else in the US? Maybe Washington DC proper. And maybe some areas in the South that are heavily populated by the elderly, but even there, I think you’ll find that the majority of people have cars. It’s rare that you can call up some establishment, ask them where they are located, and not have them start to tell you how to get there by car.</p>
<p>Cardinal Fang, why are you obsessed with Cedar Sinai; I just told you many doctors and hospitals are shut out of the network. If you read the article I provided you with, it suggests there is a strong possibility of rationing for people with exchange policies. Yeah, it is great you have insurance but good luck trying to get anyone who will see you in less than 4 months.</p>
<p>jbsmom – the gold and platinum plans look better to me than anything that has been available on the individual market for ages. In California the exchange plans are very much limited in terms of how they are structured in terms of deductibles and copays – so every one within each tier group is completely identical, but for the differences in networks. I don’t know if the other states are being that restrictive.</p>
<p>The “AV” (actuarial value) distinctions just reflect the way the statisticians rate the plans in terms of what typical benefits will be in relation to premium cost. For example, you can set up a plan with a higher deductible and lower copays, or a lower deductible and higher copays, and have the math come out to be roughly the same for that tier. I was surprised to discover that the copays on the California silver plans are 20%, because I thought silver was supposed to be the 30% tier – but I guess the $2000 deductible for those plans makes a 20% copay the actuarial equivalent of a plan with a smaller deductible and higher copay. </p>
<p>I think that for care outside your geographic area, you can look into plans that support a “Blue Card” – which I think is what Blue Cross/ Blue Shield offers. Just because it isn’t listed as a benefit on the exchange site doesn’t mean they don’t have it – contact the insurer directly or talk to an agent about your questions. Also, look for the insurers that offer “multistate” plans – that doesn’t mean that one plan is effective for all states, but it does mean that the insurer has committed to selling plans on the exchanges in all 50 states (I think 30 states in the first year) – and those companies by definition will have networks in every state where they are on the exchanges. It may be something that you have to get from the insurance company by special request. For example, when my daughter was in college in NY with a policy in California, they wanted a document confirming her college enrollment. Once they had that on file, then she would have been able to get treatment anywhere in NY if needed.</p>
<p>You know these exchange policies remind me of the individual dental policies with limited networks. Every time I investigate them, I find only the less reputable and mediocre dentists participating. Every good dentist will have nothing to do with them.</p>
<p>CF, maybe I’'m more of an urban rat, but I know lots of people who live in SF who don’t have cars. My son is in Seattle and lived quite a while without a car; now he has a car but ex-wife doesn’t. It’s not a huge problem. I do think that the proliferation of zip cars in urban areas has made it much more feasible to go without actually owning a car. I realize that poor people are not in a position to rent zip cars, but my point is the middle-income city dwellers are part of a growing culture in which car ownership is not the norm - a car is something you rent on occasions to do shopping or take a day trip, but day-to-day there is greater reliance on walking and urban transit. </p>
<p>I’m not denying that it is a problem for many – it’ s just not a universal issue, and tends to be less of an issue in the high density urban areas because of better transit systems.</p>
<p>Thursday night we got the news that the daughter of H’s friend who was the best man at our wedding was hit by a car on her bike Tuesday morning. She is a freshman at UT-Austin. Am just getting sporadic updates via her mom’s Facebook page, but she has a broken neck… has limited movement in her arms and hands, and no movement in her lower extremities. Has been on/off ventilator and had a feeding tube inserted and a tracheostomy today. They’re hoping to transfer her to Texas Institute for Rehabilitation and Research at the Houston Medical Center by mid-week. Of course, her full recovery is of utmost priority, but with her injuries, this will likely be a years-long recovery and I hope that they have sufficient insurance to cover it… not that they wouldn’t seek out the absolute best care regardless of insurance, but an injury like this could bankrupt many families.</p>
<p>Calmom, our current plan is a BCBS PPO with the blue card/suitcase and out of state networks. It is being eliminated at our next renewal. The only individual plans now being offered for 2014 are EPOs, no out of state or out of network. These are the plans offered directly from BCBS, not exchange.</p>
<p>I’ll have to do some digging into Aetna, they dropped out of the NJ exchange in September. Their plans are still the metal plans, but maybe they will allow use of out of state network.</p>
<p>Calmom, thanks for your help on the thread. You have been a Calm mom of reason.</p>
If you had seen the premiums in those pools, you wouldn’t be complaining about yours. </p>
<p>That’s where the disconnect comes. You’ve been getting insurance for years at below-market rates so you have sticker shock when you are confronted with paying something that is far closer to what the average has been overall for people who have been able to get insurance via the private market. </p>
<p>I’ve also been buying at a discount rate, but I have more awareness of what the market has been for others around me – so I understood all along that when they got rid of the discount, I’d be paying more. So the rates look pretty good to me.</p>
<p>They don’t look “unaffordable” even paying full cost any more than my EFC was “unaffordable”. I won’t be paying much more for individual insurance than I had to pay back in the days when I was a single mom paying for coverage for myself and two kids – I could budget for it then, I can budget for it now.</p>
<p>I don’t think it’s easy, but but I don’t think it’s impossible either. </p>
<p>I’d like to see a change in the law for the people who are in the “valley” of earning between 400-500% of the poverty law. I think it has to change because the existing framework is just an incentive for tax fraud, especially for self-employed individuals whose earnings are not always easily verifiable, and whose business expenses have always been easy to pad. </p>
<p>As a policy matter, I don’t think they should give those people (with “those people” = me) an advanced tax subsidy because it’s getting ridiculous when the government starts paying out cash subsidies to people with median level or above household income – but I think that we should get an alternative tax deduction similar to a tuition or childcare deduction, that phases out over time and gives us tax credit related to our income. That is, perhaps rather than a 9.5% cap on insurance costs, the ratio of premium to AGI should be set on a sliding scale of 11%-$15% until it phases out when the income-tiered percentage exceeds the value of a benchmark Silver plan for that individual.</p>
<p>Or maybe they could allow the cost of excess premiums to be included as a Schedule A medical expense. Obviously there should be a cap of some sort so that rich people can’t go out and buy “Cadillac” plans and write off the entire costs of inflated premiums. But I do think that I could live with some sort of tax relief that became gradually less generous as my income went up.</p>
<p>“I know I should just shut up because I am a self-centered, uncaring, unfeeling jerk.”</p>
<p>Just to be clear, this thread is to ask for help. Granted the people who are helpful all support ACA but picking fights with them is not the way to go about it because they are researching the heck out of it to be helpful to everyone. At this point, I would suggest asking specific questions that may help you figure out what to do or leave this thread rather than try to pick fights. That will only lead to losing posting privileges.</p>