Even though the blogosphere is going nuts right now over what is happening with health care reform, the bottom line is going to be what happens in the future when the average fairly non-political person needs health care. What is the actual bottom line for the average consumer? I'm going to avoid the numbers about the premiums because there are so many diaries mentioning them right now. And the insurance premiums aren't the real issue, I believe. People are willing to pay premiums as long as they get satisfaction from their insurance. It's insurance that doesn't really provide any care that will get Democrats in trouble over this bill. More after the fold.
Full disclosure: I used to have very good employer-provided health care. At that time, I would have readily equated insurance with health care, because I could simply walk into a doctor's office, pay a small co-pay, pay about $20 for my prescriptions and all was good.
After I lost that, I tried on the individual markets, and was denied for pre-existing conditions. At that point, I would have said that a provision getting rid of pre-existing conditions was all that was needed, because I still believed that insurance would get you health care.
I finally found insurance through AARP (I am 52 years old.) The first insurance that I got through them was truly junk insurance. It paid nothing at all until you had paid your $5000 deductible. In other words, a doctor's visit meant that I paid the entire amount (usually about $80 for just a primary care physician). I also paid all prescriptions. After the $5000, they paid only a portion of my care up to $10,000. This was $10,000 out of my pocket, not $10,000 in medical costs. On top of that, it had no prescription coverage. The only "plus" was that I paid negotiated rates, not full rates. At that point, obviously my view of insurance changed again, as I realized that insurance does not equal access to health care. I avoided going to the doctor at all for anything.
AARP finally negotiated better insurance. Although I still have a $5000 deductible, I also have $40 co-pays for doctor's visits, a prescription plan, and some preventative screenings are free. This is much, much better, since I get help with normal health costs, not just the extraordinary ones.
So what will this health care bill provide? I'm going to quote the House bill here, since I think that it may be as good as we get. Remember, the following numbers are probably the best we can expect.
"Consumer costs" are called "cost-sharing" in these bills. Here is the language about cost-sharing in the House bill:
The term ‘‘cost-sharing’’ includes deductibles, coinsurance, copayments, and similar charges, but does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services.
In other words, "cost-sharing" is the bottom line of what the consumer pays for covered health care with approved doctors. So what does the insurance company need to pay upfront?
NO COST-SHARING FOR PREVENTIVE SERVICES.—There shall be no cost-sharing under the essential benefits package for—
(A) preventive items and services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention; or
(B) well-baby and well-child care.
I'd like to give one caveat here. My insurance company has decided that it can change the designation of "preventative screenings" to be "diagnostic screenings" if anything is found during the screening. No, this isn't legal, and I'm fighting through my state's insurance regulators. However, this is the kind of thing that we need to expect when these laws go into effect.
Going back to the bill, so how much does the consumer need to pay per year?
...the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).
And what services does it guarantee?
COVERED BENEFITS.—Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package—
(A) the annual deductible for such benefits
may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary;
(B) there may not be annual or lifetime
9 limits; and
(C) the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).
MINIMUM SERVICES TO BE COVERED.—Subject to subsection (d), the items and services described in this subsection are the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services, including emergency department services.
(3) Professional services of physicians and other health professionals.
(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services, including behavioral health treatments.
(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.
(9) Maternity care.
(10) Well-baby and well-child care and oral health, vision, and hearing services, equipment, and supplies for children under 21 years of age.
(11) Durable medical equipment, prosthetics, orthotics and related supplies.
And how much will this cost the consumer up front? Well, that is the crux of it:
COVERED BENEFITS.—Covered benefits under the program shall be determined by the Secretary and shall be consistent with the basic categories in the essential benefits package described in section 222. Under such benefits package—
(A) the annual deductible for such benefits may not be higher than $1,500 for an individual or such higher amount for a family as determined by the Secretary;
(B) there may not be annual or lifetime limits; and
(C) the maximum cost-sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).
So the bottom line in the House bill is: no more than a $1,500 deductible for individuals and higher for families, and no more than $5000 a year total cost for individuals and $10,000 for families.
The problem is that this could be good or bad insurance depending on how the policy is written. Partially, this will depend upon the actuarial value of your individual plan. Here is an explanation of actuarial value:
"Actuarial value" is a summary measure of a health insurance plan’s benefit generosity. It is
expressed as the percentage of medical expenses estimated to be paid by the insurer for a standard
population and set of allowed charges. An actuarial value may also be referred to as a "benefit
rate." One purpose of an actuarial value is to distill all the benefit and enrollee cost-sharing
provisions of a health insurance plan into a single number, for easier comparisons among plans.
The actuarial values permitted under the House plan are:
LEVELS OF COVERAGE.—
(1) LEVELS OF COVERAGE DEFINED.—The levels of coverage described in this subsection are as follows:
(A) BRONZE LEVEL.—A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan.
(B) SILVER LEVEL.—A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan.
(C) GOLD LEVEL.—A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan.
(D) PLATINUM LEVEL.—A plan in the platinum level shall provide a level of coverage
that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan.
So what is the bottom line to the actual consumer? Well, for an individual policy, the deductible is capped at $1,500, and annual expenses is capped at $5000. That is better than the first insurance I got through AARP, but potentially worse than what I have now, depending upon the presence or absence of co-pays and prescription plans.
And I believe that that is what it will come down to. Will people see help most years with their "normal" health care costs-normal doctor's visits, a prescription plan. Or will they have deductibles that must be met before anything is paid? Unfortunately, I don't see anything in the bill at all addressing this, other than dictating certain AV's. And whether people love or hate their insurance is probably going to be dependent upon what level of insurance they can get. Perhaps the exchanges will be able to force the issue. I hope so, or people are going to be very, very mad about being forced to buy this insurance.
I'm in the camp right now that we have to hold our noses and accept what the Senate gives us as long as it isn't drastically different than the above. But I think that some simple language in the bill dictating reasonable co-pays and a prescription plan would have made this far more palatable and made the insurance companies dislike this bill far, far more.
If anyone has any information that contradicts what I've said above, please weigh in. I would love to update this diary with better news than what I've reported.