<p>H has a number of medical conditions. Since leaving corporate life and the expiration of his COBRA, the only coverage he has been able to get is that provided through our state (I also only have individual coverage and can’t add him to my policy). The coverage is fair; the price is insane. I know that in 2014, insurers will no longer be able to reject him on the basis of his pre-existing conditions, but what I’m not clear on is whether they will be able to charge such a high premium that it will be tantamount to a rejection. He has more than three years before he can turn to Medicare, so we are hoping we can save some bucks under the new law. Looking for for a glimmer of hope here…</p>
<p>Wish I had a crystal ball and could answer your question. I have a similar question as we also have individual coverage. (My state does not offer group medical insurance to self-employed individuals. We are paying through the nose for it. )</p>
<p>I’ve gotten answers that run the gamut. I think that at this point, no one really knows what the future holds in store for medical insurance.</p>
<p>So some of its depends on your state (and the state’s individual exchange.) However, if your family of two earns less than $60,600 (400% of the federal poverty line), he is guaranteed to be able to get Medicaid coverage at no more than 9.5% of income. (I don’t know how it works when the other spouse gets workplace coverage.) He cannot be rejected.</p>
<p>Am I allowed to link this:</p>
<p>[How</a> will Obamacare hit premiums? Let?s break down the numbers.](<a href=“http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/29/how-will-obamacare-hit-premiums-lets-break-down-the-numbers/]How”>http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/29/how-will-obamacare-hit-premiums-lets-break-down-the-numbers/)</p>
<p>The Washington Post has had several articles trying to give more details.</p>
<p>actually, a lot of depends on your state. I think I just read that the insurers in Vermont have recently published their plans for next year, along with rates. Other states aren’t even close to figuring out what they may or may not do.</p>
<p>I think there is a 1 to 3 max ratio between the cheapest and most expensive policy.</p>
<p>Note: Insurers are not stupid. In setting the max price, they will assume an older sick person. Then the lowest cost is 1/3 that, which is exorbitant for a young healthy person.</p>
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<p>Yes, and no. Your rate will be no different from the rate anyone else gets - exorbitant. If everyone has to pay that rate, then it can’t be considered “rejection”.</p>
<p>You have to pass the bill in order to find out what’s in it.</p>
<p>With the implementation of the health exchanges, premiums will not be based on previous usage or diagnoses. Additionally, insurance companies on the exchange will want to be competitive so that they get the volume. Through the increased volume of people with insurance, they are able to build a better risk pool and keep costs down. That’s the idea behind making sure kids are covered until age 26 on their parents’ plans, for example. That is the low risk age group. They help balance the high risk patients. </p>
<p>Now that insurance can be sold across states, there are a lot of insurance companies trying to get on the health exchange in many states. They are all developing their own strategies on how to provide the best services at the lowest costs and some have gotten very innovative with their strategies.</p>
<p>Additional controls have been put in place to assure that the insurance companies can’t just milk those who purchase their plans. One of those controls is that there are limits on how much money can be used for purposes other than paying claims. 80% of their funds must go to paying claims or they have to give reimbursements to their customers. They are also making significant changes to their customer services practices because people will have a choice in where they get their insurance and customer service makes a big difference to people these days. </p>
<p>I just left a position with an insurance company and they were working hard to get administrative costs down, with bonuses and raises being based on meeting those goals. They used a measurement of cost per member per month for all administrative/overhead costs. </p>
<p>While none of us can know for sure until it is in place, I think I would prefer to be shopping for insurance on the exchange than having to take what my employer decides is the best deal for the company. I think it would be really refreshing to have real choice and not have to keep changing doctors when I change jobs because my current ones aren’t providers for the new insurance plan. I would love to be able to pick exactly what I want from who I want and get good customer service because they want to keep my business.</p>
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<p>But there are two counter-factors which will prevent the bald-faced gouging which they’ve always engaged in. </p>
<p>First, the medical loss ratio piece of ACA means that an insurance company must spend 80% of its aggregate premiums on medical care for its subscribers (I think it rises to 85% in a couple of years). If they take in more than that, they must rebate it to the subscribers. So they can’t just charge whatever the traffic will bear, as they did in the past. Or if they do, they’ll have to pay it back. The subscribers will see those rebate checks for exactly what they are: The amount the company would have overcharged them if they could have gotten away with it.</p>
<p>Second, millions of new subscribers will be coming into the pool, subscribers who are on average younger and healthier than the current pool. This will drive down the medical loss ratio which, because of the 80% rule, will prevent runaway premiums.</p>
<p>It may be that the insurance companies, like some employers, will take advantage of the confusion and wildly jack up rates at first. But after a year or two of sending out big rebate checks, they’ll stop.</p>
<p>So what I’m getting here is that while my H will no doubt be in the category of most expensive policies, insurers won’t be able to customize coverage on a case by case basis, i.e., set a particular price for his policy based on his particular pre-existing conditions. My gut tells me that he will be paying less for coverage in 2014–keeping my fingers crossed.</p>
<p>You can find arguments for every possible scenario and we’ll have to see what happens when the exchanges open in October to know for sure. However, I think the premiums will start out on the low side because they will be competing for that initial wave of new customers.</p>
<p>Pertaining to post #8 @2016BarnardMom – on the idea of changing doctors when one changes jobs. What do we know about the rules for doctors in participating with various plans including those in the state exchanges. Are we going to go through a transition where docks are changing their alliances as well?</p>
<p>Watching this discussion with great interest. My ex-H just informed me last week that he will be retiring within the next 18 months. My health insurance is through his work family plan (this is how our state interprets “family coverage”, that an ex-spouse remains covered as long as they are eligible for no other insurance), and so is D2’s (high school senior). He told me he probably will not take COBRA, as will probably be “too expensive” – he will be about 62 when he retires, and figures he will be able to pick up a high deductible plan easily. He is in very good health. If he does not take COBRA, I can’t take it… So if it plays out this way, D2 and I are going to lose our health insurance soon.</p>
<p>I am only 50 and have a small consulting business (1 person, just me). It is pretty profitable, but I may have to shutter it and take a ‘real job’ for health insurance depending on how this plays out. Which I would hate – I like being my own boss. Am hoping to talk him into splitting the cost of COBRA so he, I, and D2 can all be covered for another 18 months after he retires. But another complication – he is moving out of state when he retires, and I am not sure how good the coverage would be on any of his available plans if he lives “out of network”.</p>
<p>I haven’t looked into pricing plans yet – not sure they will give me a solid quote without an awful lot of information. But have no idea what to budget for this, either.</p>
<p>Mom22039, the short answer is “maybe”. The long answer involves another part of the ACA law, which is a provision for a structure called an ACO, or Accountable Care Organization. This provision encourages hospitals, surgicare centers and individual physicians to join together (without giving up their private practices) to take on patients jointly. ACO members share medical information which decreases overall costs (e.g., you get an x-ray in the hospital ER, then the independent physician doesn’t require you to get a second x-ray when you’re referred, since your doctor will have access to the hospital’s x-ray). The physician and hospital will receive grants from the government based on quality outcomes, rather than being paid based on how many procedures they give you. In other words, before, the doctor got more money if you had more tests and visits, regardless of whether your health improved; under the ACA, the doctor in the ACO will get paid more if the combined hospital and physicians can show that their patients experienced better medical outcomes. That will be difficult to show, and healthcare groups are working very hard to capture that aggregate data. </p>
<p>There may be less jumping around of docs since they’ll be joining ACO groups, and the insurance plans will contract with ACOs instead of trying to get individual docs to sign onto their pay scales.</p>
<p>Any law that deals with healthcare is complicated, and there will no doubt be unforeseen problems to deal with. However, in general the the law tries not just to provide access to care for lower-income and high risk patients, but also to reduce redundant care and give financial incentives for improved clinical outcomes.</p>
<p>My understanding is that there is some sort of “doughnut hole” that was unforseen that will affect the middle class. They will make too much money to get subsidized insurance and will end up footing the whole cost. I’ll see if I can find the link.</p>
<p>Anecdotally, I work in healthcare, not insurance, and the docs are talking about dropping insurances, not adding more. Specialists are talking about their services being a la cart, like cosmetic surgery, where consumers would pay out of pocket.</p>
<p>I was exposed to this recently with my daughter. We went to a specialist in NYC who didn’t accept insurance. I had to pay out of pocket for his services and will get reimbursed if insurance covers it. It was quite a bit of money and I wouldn’t be able to do it often.</p>
<p>The healthcare industry as a whole is very concerned.</p>
<p>intparent, definitely look into what is available private pay. I was paying my very expensive COBRA premiums and worried to death about what I would do when COBRA runs out. When I finally researched and applied for a private plan I found that the benefits were comparable to my expensive former employer COBRA plan, but less expensive. It was a pleasant surprise and I actually felt silly for hanging onto COBRA for so long. The initial application process can be a real pia with detailed questions about your medical history.</p>
<p>We have a health exchange in MA.</p>
<p>The MA experience is that we have a “health connector” - see [url=<a href=“https://www.mahealthconnector.org/portal/site/connector]here[/url”>https://www.mahealthconnector.org/portal/site/connector]here[/url</a>] - because there is both an employer and an individual mandate for health insurance. According to people I know who have policies through it, it has worked well: they don’t pay a ton for relatively basic plans and they have real access to doctors. (A few tenants, for example, do this.) </p>
<p>You can get more basic plan information and look up pricing if you follow the Commonwealth Care link and poke around. The plan pricing is in, I think, 3 tiers that adjust by income. As I scan the list, I see $182 as the most expensive choice but I don’t know how that works or anything more than it being on a list. The plans differ on things like copays - one tenant has a plan with a $0 copay, for example - and caps on what a member must spend out of pocket. </p>
<p>These seem to me to be real insurance policies, better than are often provided by employers and certainly better than what is often sold to small businesspeople (like sole proprietors, etc.). </p>
<p>As to issues, I’m not aware of any problems people have had with the policies. There must be some but they haven’t received publicity. The main issue with the program so far has been that fewer people are choosing to go uninsured so the state has reaped less in penalties than expected. There was also a problem with people only adding coverage for short periods - when they needed it - and then dropping it in between but they’ve been closing that loophole (with stuff like enrollment periods). </p>
<p>The biggest issue the hospitals have been facing - according to the press - is that they still have large uncollectables. But not from MA residents anymore. They have large uncollectables - in the tens of millions - from NH and Maine residents who aren’t insured and who thus walk on bills. We haven’t heard large objections from hospitals, perhaps because they are getting more bills paid - which the hospital associations say is a huge deal. (In CA, for example, they claimed - before the big economic downturn took root - that they were losing over $11B a year from unpaid bills. If people have insurance, some portion of these get paid, by which I mean they get whatever they get paid by the insurer, which I’m sure is much less than the claimed face amount.)</p>
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<p>And the insurance company doesn’t care. I am part of a mutual company for auto/homeowners, and I get the rebate checks. All they want to do is charge enough so that they don’t take a loss on the 80%, and make their money on the 20%. Still the same for the insured. They pay more because they are in a pool that has a higher level of claims.</p>
<p>Yes, there will be some insurance companies that try to price the 80% closer to “average” but, one bad year can wipe them out. So the question becomes: How many standard deviations from “average” do you charge to have a high certainty of not taking a loss on the 80%?</p>
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<p>And, what do you base that on? Just because someone can get it, doesn’t mean they will buy it. Younger healthy subscribers are not buying it now when it is 1/5 the cost of the highest premium. Why would they buy it when the costs goes up to 1/3 the cost of the highest premium?</p>
<p>Oh, you think because they want the financial security of being insured. What if I am not insured? Oh too bad I need a liver transplant and don’t have insurance. Oh, wait a minute, I can go buy insurance now since the insurance company can’t deny me coverage for pre-existing conditions. So, why pay for expensive insurance when you don’t need it, and can then buy it when you do need it?</p>
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<p>Uhh, no. Such things were (easily) foreseen (and reported).</p>
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<p>This was precisely the argument against the Massachusetts plan on which Obamacare is modeled. And yet Massachusetts residents have almost universally chosen to get coverage – 98%, to be exact. It’s the state with the lowest rate of uninsured, by a very long shot. And remember, they aren’t required to get insurance. But it turns out, when offered an affordable option, people overwhelmingly DO want insurance. </p>
<p>The liver transplant argument is a red herring. You’re apparently not aware of this, but people get medical care for other, less catastrophic things. Most people actually WANT to get routine and preventive care, and annual screenings. Most people WANT to have their prescriptions covered. Most people WANT to be able to go to the doctor when they have a lesser illness or injury. And most people understand that it’s in their overall financial best interest to have insurance. </p>
<p>But I do buy your argument about private for-profit insurance companies being far more concerned about their bottom line than about their subscribers’ health. You make a great case that we should kick these vultures out of our medical lives, and go to single-payer.</p>
<p>Bravo, LasMa! Especially your last point.</p>