Healthcare Reform Megathread: Can I sell my organs to pay this hospital bill?

The Something Awful Forums > Discussion > Debate & Discussion > Healthcare Reform Megathread: Can I sell my organs to pay this hospital bill?

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Willa Rogers: Mar 11, 2005

Spiritus Nox posted:

So I saw a while back that Trump was planning on an EO to destroy the individual mandate and basically nobody's talked about it since then. Is that still a thing? Can he not do that? Am I just crazy?

The IRS has issued a statement saying it was going to enforce the mandate, contrary to Trump's announcement earlier this year that people could leave the question blank as to whether they were insured and not be questioned further or have the penalty levied.

But I think the IRS commisioner's term is nearing its end, which means a Trump nominee who likely will not enforce the mandate. Trump's also trying to get no-mandate language inserted into the tax-reform bill currently before Congress.

# ¿ Nov 8, 2017 22:56

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# ¿ May 3, 2024 05:14

Willa Rogers: Mar 11, 2005

Crashrat posted:

Why the gently caress are they even waiting? Why aren't they signing up literally the minute they found out?

On a different note.

I've seen people jumping through quite a bit of hoops with this enrollment period on income verification if they had big changes in their income. Apparently Healthcare.gov doesn't actually have a clear process for how the income verification is supposed to work. So, for example, if you're self-employed you should be able to just submit a spreadsheet of how you more-or-less predicted your income for 2018.

I've heard from people that they've turned that spreadsheet in and received a notification that they needed further documentation. They would get 4+ emails, each saying the same thing about additional documentation, all within a 48hr period. They'd get a phone call for each email, and a letter would be mailed to them as well.

What was needed? They were never told. Try to call Healthcare.gov and apparently no one knows and has no way of knowing. It basically boils down to "just keep sending things."

That spreadsheet is apparently not enough. They basically want the spreadsheet, last year's 1040 / schedule C / and all calculation worksheets, 1099s, proof of deposits...the works. Basically the same level of documentation you'd need to prove income for a mortgage.

I wonder if that's related to the fact that under the prior administration Equifax Workforce Solutions won a $330 million, multiyear contract to provide income verification. Maybe Equifax was cut off from their contract after the data theft and hasn't been replaced?

On the other hand, healthcare.gov (as well as many of the state-based exchanges) has always been a clusterfuck when it comes to tracking verification documents.

# ¿ Jan 11, 2018 19:13

Willa Rogers: Mar 11, 2005

Invalid Validation posted:

Some states want to verify if you have money stashed away in an account but a state like Kentucky does not care.

For the purpose of the ACA, do you mean? Because I don't recall any part of the Act's being asset-based (except for longterm care under Medicaid, which had always been the case).

# ¿ Jan 11, 2018 19:50

Willa Rogers: Mar 11, 2005

Even before this administration there were numerous ways to get an exemption from the penalty: https://www.healthcare.gov/health-coverage-exemptions/hardship-exemptions/

Sounds like you'd qualify for at least a couple of them, especially having medical debt. But be sure to fill out the exemption form and submit it well in advance of April 15.

When I moved cross-country twice a few years ago I filed for and received an exemption, even though I didn't neatly fit into one of the exemption categories. I just added a couple paragraphs of a typed narrative describing My Hell Year and enclosed it with the form.

Please don't feel bad about asking for an exemption; there are lots of people who can't afford even minimal coverage, especially in non-expansion states.

# ¿ Jan 18, 2018 04:32

Willa Rogers: Mar 11, 2005

^^^ I'm one of the boomers who has deferred care bc I can't afford the stratospheric deductibles for the only insurance I can afford, given the 3x multiplier allowed under the ACA. Two more years till Medicare. Three of my boomer friends have died in the last 16 months due to cancer that was diagnosed while they were uninsured, and in all three cases my friends put off seeking medical care. All three friends were ultra-lefties, too, contrary to boomer-hatred mythology.

With the consolidation of corporate hospitals and their buying up doctors groups even urgent-care facilities have jacked their prices, especially by tacking on "facility fees":

quote:

After her 8-year-old daughter was nipped by a dog, she took her to a local urgent care center and left with a bill for more than $500. The child was treated with antibiotic gel and a simple bandage during her 15-minute visit, according to the South Florida Sun Sentinel, which reported on the incident last year.

Because the center was owned by Baptist Health South Florida, the hospital-based system slapped a $275 facility fee on top of the $233 doctor�s bill. The woman�s insurance refused to pay half the fee and Romaniello argued she would have gone elsewhere had she known about the extra fees beforehand.

***

Connie Peterson, 67, a retired graphics designer who lives in Iowa City, Iowa, also experienced the sting of facility fees. She was aghast after receiving a bill for nearly $26,000 in facility fees from an outpatient surgery center where she spent less than an hour.

�I was livid when I received the bill,� said Peterson. She spent months trying to get an explanation that made sense to her. �All I wanted was an itemized bill to let me know exactly what I�m paying for. I never got that,� she said.

Peterson had three procedures to remove nasal polyps during her 45-minute stay at the Iowa City Ambulatory Surgical Center in April. The center billed more than $8,000 in facility fees for each one, bringing the total to $25,872. She had to pay $1,086 of that.

https://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

And "balance billing," in which patients are responsible for out-of-network costs beyond their control for in-network facilities, remains a problem in all but a handful of states:

quote:

Surprise bills, also known as �balance bills,� are part of the complex way that health care is paid for in the U.S. Insurers form networks as one way to slow rising health care costs, in part by getting doctors and hospitals who join to agree to negotiated rates, which are generally lower than their usual fees. Out-of-network hospitals and doctors can set their own fees and "balance bill" patients for the portion insurers don't cover.

Some patients choose to go out of network because they want a specific doctor or hospital. But, as insurers shrink networks, some patients may be unable to find an in-network provider. And others may get a balance bill after choosing an in-network hospital, only to learn later that the anesthesiologist or the lab were not included in their insurer�s network. Balance bills can run into thousands of dollars.

While the problem predates the Affordable Care Act, the president�s signature health care law largely sidesteps the issue. It says only that insurers must not charge policyholders higher copayments for emergency department services at non-network hospitals because patients often can�t choose where they go. Medicare, however, strictly limits how much patients can be balance billed by doctors who don't participate in the program.

***

Even then, as Johnson in Milwaukee learned, you might still get billed. In her case, the urgent care center was in network. But the doctor group overseeing the care was not. Hence the $356 bill, which Johnson paid. Even her insurer was surprised, she said.

# ¿ Jan 29, 2018 22:57

Willa Rogers: Mar 11, 2005

I've been interested in what the numbers say about increases in independent contracting as a form of employment so I went looking on bls.gov. Here are two charts (one is seasonally adjusted) that track the monthly stats for non-ag workers (caveat: a huge number of ag workers are self-employed):

If I'm reading it correctly, there were a half-million more non-ag independent contractors this January than there were a year ago January, whether seasonally adjusted or not.

I could only find stats (on kff.org) for type of insurance coverage from 2013 through 2016, and employer-provided insurance was pretty static: 50 percent of Americans were covered by employer-provided insurance in 2013, which figure dropped to 49 percent for 2014, 2015 and 2016.

# ¿ Feb 6, 2018 18:05

Willa Rogers: Mar 11, 2005

One of the various suggested changes to the ACA in congressional proposals last year (I think it was in one of the Republican bills) was tying current-year subsidy eligibility to one's *prior* year's income.

Since so many subsidy-eligible people are either self-employed or in jobs that don't provide insurance that would be great, but such a change would have to include mechanisms (as exist now) to report change in employment status and a qualifying life event to enroll or re-enroll in an individual plan.

# ¿ Feb 6, 2018 19:56

Willa Rogers: Mar 11, 2005

Rhesus Pieces posted:

https://twitter.com/usofcare/status/960860727471992832

Heads up, we've got an AstroTurf group that refuses to disclose its donors slinging centrist "above politics" pablum in an effort to get ahead of increasing support for Medicare For All.

I certainly feel better knowing that "bipartisan solutions" for healthcare are being sussed out by the likes of Bill Frist and led by a 10-year executive of UnitedHealth.

# ¿ Feb 6, 2018 21:11

Willa Rogers: Mar 11, 2005

From the Bloomberg story about the new astroturf group:

quote:

Mark McClellan, a top health official in the administration of president George W. Bush and director of the Margolis Center for Health Policy at Duke University, is working with the group and anticipates focusing on curbing costs and improving quality, particularly in state Medicaid programs.

�It�s very hard to have sustainable access to affordable care for people if the cost of health care is so high and rising,� McClellan said. But costs for one party are typically income for another. �There may well be some difficult discussions ahead.�

Just lol that they're going after Medicaid, the costs of which are about half of those that the government spends to subsidize private insurance, rather than mentioning the possibility of pharma, provider or private insurance price controls. I guess it figures inasmuch as obamacare exchange plan enrollment is about one-third of that under expanded Medicaid (even with states opting out) and that Medicaid recipients are more satisfied with their insurance than those covered by private insurance (including that provided by employers). Gotta nip that single-payer cost reduction & overall satisfaction in the bud!

Looking forward to the "difficult discussions" that determine that Medicaid recipients "need more skin in the game" (as Gov. Northam recently claimed), less mental health or dental care, and more workfare-type draconian solutions.

# ¿ Feb 6, 2018 21:45

Willa Rogers: Mar 11, 2005

baquerd posted:

My out of pocket max is 1500, can I get screwed for more than that having a kid with out of network shenanigans? How can I protect myself from the wandering doctors that "consult" and charge thousands on the way through?

Have your kid in one of the handful of states that has strong consumer protections against "balance billing."

eta a link to a fact sheet about balance billing.

Willa Rogers fucked around with this message at 00:40 on Feb 9, 2018

# ¿ Feb 9, 2018 00:35

Willa Rogers: Mar 11, 2005

This bit makes me crazy:

quote:

Think about big changes that have happened in the country, (like) marriage equality. That didn't start the year before laws were changed. That started decades before laws were changed. There needs to be a movement and effort to establish successful change that occurs beyond just the current year.

It's just more bullshit along the lines of "The ACA will pave the way toward single payer," although you aren't hearing many of the elected Dems who once spouted this say it anymore.

And you can practically see Slavitt's flop sweat in trying to say something nice about M4A while he and his little group of assholes got together for the express purpose of stopping it.

If there's an upside, it's that this group is bound to fail--not only because people immediately saw it for what it was and called it out, but because there's nothing else left to do wrt our healthcare system than either work toward radical reform or continue to prop up the status quo.

What in the world is he saying about "medicare is for olds" and thus needs to be changed before moving to a broader population?

# ¿ Feb 9, 2018 05:30

Willa Rogers: Mar 11, 2005

http://www.ibtimes.com/political-capital/why-are-drug-prices-going-democratic-power-players-help-pharmaceutical-industry

quote:

When they were first conceived in the 1960s, PBMs held out the promise of using their power to negotiate price discounts, and in recent years, three companies � OptumRX, Caremark CVS, Express Scripts � have accumulated control of the vast majority of the market. That consolidation in the $250-billion-a-year market has not coincided with lower drug prices for consumers. Instead, spending on prescription medication spiked 20 percent between 2013 and 2015, according to Harvard researchers. This year, drug prices for Americans under age 65 are expected to rise nearly 12 percent, almost five times the expected growth in wages for 2017.

In October, lawyers representing Cigna policyholders brought a class action case against the insurer, asserting that, through its deal with OptumRX, the company had illegally conspired to inflate the drug prices charged to thousands of its policyholders.

Cigna, the complaint alleged, either independently or in conjunction with a PBM, required pharmacies to jack up the prices of their prescription drugs � sometimes to more than the full price of the drug. After the patients would pay the inflated fee, usually for generic medicines, the pharmacy would funnel the difference between the drug�s original price and its newly-elevated price, also referred to as the �clawback� or �spread,� to either the insurer or the PBM, according to the suit.

The suit also alleged that the pharmacies were contractually prohibited from alerting patients of the practice or directing them to lower-priced options. In a February report, Bloomberg obtained contracts prohibiting pharmacists from publicly criticizing the PBMs or recommending less expensive ways to purchase the drugs, such as paying the pharmacy directly out of pocket.

The system, lawyers argue, is a violation of the promise that a policyholder�s payment is a shared �copay� between the consumer and the insurer � and that the consumer will never have to pay more than insurers are paying a pharmacy for the covered medication.

�PBMs can serve a helpful role in managing drug insurance, and copays can be a useful strategy when applied to expensive drugs with similarly effective lower-cost alternatives that are assigned lower copays,� Harvard�s Kesselheim told IBT. �But when copays are high and there are literally no other alternatives, then patients have a problem.�

The clawback practice is far from uncommon, according to a June 2016 survey of 640 pharmacists, conducted by the National Community Pharmacists Association. Only 16 percent of respondents said PBMs imposed clawbacks fewer than 10 times per month. More than a third said the practice occurred more than 50 times on a monthly basis, and nearly half said it happened between 10 and 50 times over the same period. A full 87 percent said the clawbacks �significantly affect their pharmacy's ability to provide patient care and remain in business.�

The survey buttressed the lawsuits� allegations that pharmacists were prevented by �gag clause� rules from telling patients about the alleged scheme or lower-cost alternatives � even if the patient asked. Nearly a fifth of the pharmacists who participated in the study reported �gag clauses� preventing them from telling patients about cheaper options more than 50 times a month, and 39 percent said it happened between 10 and 50 times.Those cheaper options mainly included paying out of pocket � meaning patients paid more for their drugs using their insurance than if they had simply paid the cost of the drug without involving their insurance provider.

�It's really not insurance, is it?� Randal Johnson, the president and CEO of the Louisiana Independent Pharmacies Association, told New Orleans TV station Fox 8 of the alleged Cigna and UnitedHealthcare schemes. �I mean, what is that if you go in and they're negotiating a price for you, and it's actually costing you more to acquire the drug with your insurance than you could if you walked in off the street and you didn't have insurance?�

While the PBMs allegedly extracted the spreads from the pharmacies, it�s unclear whether the insurers or their PBMs are pocketing the difference between what they�re allegedly pushing the pharmacies to charge and the drugs� wholesale prices.

�We don�t really know what happens to the money. That�s where the lack of transparency makes everything very confusing,� John Norton, the communications director of the National Community Pharmacists Association, told IBT.

�I could break into Fort Knox easier than being informed by the PBMs or insurers the portion of the clawback amount retained by either the insurers or the PBMs,� said Susan Hayes, a founder of and principal at the consulting firm Pharmacy Outcomes Specialists. But unless sponsoring companies � usually very large ones � are contracting directly with their PBMs, in which case the PBM keeps all of the clawback, the insurer and the PBM are probably splitting that spread, she said.

# ¿ Feb 15, 2018 18:31

Willa Rogers: Mar 11, 2005

cis autodrag posted:

Wouldn't that just make the bill repealing the tax penalty unconstitutional? The aca as passed is constitutional. Another act modifying it creates an unconstitutional condition. Therefore striking down the penalty repeal is the simplest and most fair resolution.

The problem is that the mandate wasn't actually repealed; instead, the tax act reduced the penalty to $0.

quote:

First, the tax cut act does not repeal the individual mandate as such. Rather it zeros out both the dollar amount and percentage of income penalties imposed by the mandate. Section 5000A remains in the statute and still provides:

quote:
An applicable individual shall for each month beginning after 2013 ensure that the individual, and any dependent of the individual who is an applicable individual, is covered under minimum essential coverage for such month.

https://www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/

# ¿ Mar 1, 2018 17:58

Willa Rogers: Mar 11, 2005

Virtue posted:

A months supply of a single medication could cost the insurance company more than that annual premium. I�m surprised it isn�t higher.

Hmmm. Hmmmmmmm.

# ¿ Mar 3, 2018 04:27

Willa Rogers: Mar 11, 2005

silence_kit posted:

I suspect that the �workout logs� thing is kind of overblown and the West Virginia teacher is hamming it up for dramatic effect. What is likely the case is that if she doesn�t do a moderate amount of physical activity and log it with a free pedometer or automatically on her phone�s pedometer, she won�t receive a $500 credit. If she only does a fraction of the steps requirement, she will only get a fraction of the credit.

Employee "wellness" programs have been proven to be pretty ineffective at lowering employer premiums--although they are effective as far as giving employers more control over employees' personal lives and privacy preferences. I'm pretty sure such programs have been found to discriminate against certain racial and socioeconomic groups.*

Whether such programs have the material effect of artificially hiking premiums against wellness "credits" or just give out gift cards to those willing (or compelled) to cede their personal autonomy and privacy they're still wrong & immoral, and have done nothing to curb the rise in employer-provided healthcare premiums and out-of-pocket employee costs. They don't work, and have never been proven to work.

eta: *and the programs also discriminate against people with disabilities.

quote:

I have a similar program at my work. It�s not as Draconian as the teacher makes it sound. It sucks that her premiums are greatly going up though�people really need to start applying pressure to providers and drug and device companies to lower costs.

Or, alternatively, we could demand that the people who work on our behalf and have the actual power to regulate those industries aren't financially dependent on them, nor allow those industries to write the legislation that purportedly serves to regulate them.

Willa Rogers fucked around with this message at 01:43 on Mar 5, 2018

# ¿ Mar 5, 2018 00:12

Willa Rogers: Mar 11, 2005

Do Workplace Wellness Programs Work? Usually Not

quote:

The Kaiser survey found that 71 percent of all firms think such programs are �very� or �somewhat� effective, compared with only 47 percent for greater employee cost sharing or 33 percent for tighter networks. (Recent research on public employee plans in Massachusetts found that tighter networks were associated with large savings.)

What research exists on wellness programs does not support this optimism. This is, in part, because most studies of wellness programs are of poor quality, using weak methods that suggest that wellness programs are associated with lower savings, but don�t prove causation. Or they consider only short-term effects that aren�t likely to be sustained. Many such studies are written by the wellness industry itself. More rigorous studies tend to find that wellness programs don�t save money and, with few exceptions, do not appreciably improve health. This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.

However, this doesn�t mean that employers aren�t right, in a way. Wellness programs can achieve cost savings � for employers � by shifting higher costs of care onto workers. In particular, workers who don�t meet the demands and goals of wellness programs (whether by not participating at all, or by failing to meet benchmarks like a reduction in body mass index) end up paying more. Financial incentives to get healthier sometimes simply become financial penalties on workers who resist participation or who aren�t as fit. Some believe this can be a form of discrimination.

The Affordable Care Act encourages this approach. It raises the legal limit on penalties that employers can charge for health-contingent wellness programs to 30 percent of total premium costs. Employers can also charge tobacco users up to 50 percent more in premiums. Needless to say, this strikes some people as unfair and has led to objections by workers at some organizations, as well as lawsuits.

What could go wrong "encouraging wellness," especially under a Republican Congress?

quote:

While many individuals may have privacy and discrimination concerns about their employers collecting biometric and health information, those with a stigmatized health conditions may have even stronger concerns. Even in the face of financial penalties, including higher health insurance premiums, most people offered the opportunity to participate in workplace wellness health screening programs decline to do so. Current federal law (the ADA and GINA) limit inducements employers can use to encourage workers and their family members to disclose information to wellness programs.

Legislation pending in Congress, HR 1313, would alter the legal landscape. Under this bill, workplace wellness programs would be deemed in compliance with the ADA and GINA if they comply with the ACA � which limits incentives only for health-contingent wellness programs, and which does not address other practices governed by the ADA and GINA. Nearly 90% of workplace wellness programs that ask for personal health information are not health contingent programs. As a result, under most programs, there would be no limit on penalties that could be applied to workers, spouses, and dependent children who decline to provide sensitive personal health and genetic information, and other rules on information collection practices would no longer apply. In addition, HR 1313 specifies that the �insurance safe harbor� provision of ADA applies to workplace wellness programs, notwithstanding any other provision of law. When ADA was enacted in 1990, the safe harbor had allowed insurers and employer health plan sponsors to use information, including actuarial data, about risks posed by certain health conditions to make decisions about insurability and about the cost of insurance. This meant certain practices � such as excluding pre-existing conditions or charging people more based on health status � were not considered to violate the ADA ban on discrimination. After the Affordable Care Act prohibited such practices, EEOC rules clarified that the insurance safe harbor does not apply to workplace wellness programs, even if they are offered as part of a group health plan. HR 1313 would reverse that decision.

Even under Obama, "wellness" programs faced legal challenges on the basis of discrimination (olds, in this instance--a group I forgot to include in my prior group of adversely impacted minorities, those in lower socioeconomic groups, and people with disabilities):

quote:

While the courts have yet to fully weigh in, the commission has had mixed success in limiting the ability of employers to strong-arm their workers. It also faced pressure from the White House and others to avoid derailing employers� efforts, which were seen as central to containing health care costs.

But the new rules represent an interpretation the AARP finds problematic since they represent the final word on what the agency finds permissible. They �enable employers to pressure employees to divulge their own confidential health information and the confidential genetic information of their spouses as part of an employee �wellness� program.�

�On average, these penalties would double or even triple those employees� individual health insurance costs,� the AARP contends in its lawsuit.

But at least there are privacy safeguards, right? Wrong.

quote:

In a California Law Review paper, my coauthors and I found that there are insufficient protections for employee health data, leaving workers vulnerable to privacy invasion and employment discrimination. Most notable, wellness program vendors are able to amass a trove of health information through questionnaires and medical exams. Laws such as the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act prohibit employers from collecting health data information from employees, but certain rules exempt health data collection by wellness programs.

Often employees are not informed before joining a wellness program that vendors may sell the health information they collect. This does not appear to be well-known among employers, either. Some vendors are for-profit entities and are not connected to a health insurance carrier, which means that much of the information their programs collect exists in a legal gray area, since that information is not protected by laws such as the Health Information Portability and Accountability Act (HIPAA). Generally, HIPAA requires the consent and notice of the patient before private health information acquired at a doctor�s office, clinic, hospital, or other health care provider is transferred to third parties. But for stand-alone wellness program vendors who are not considered health care providers, the information they collect is not covered by HIPAA, and they may sell health data to third parties without informing employees. This puts employees at risk of having their data used unlawfully and could create legal liabilities for employers.

Even if a wellness program vendor does not sell the information it collects, employees� data may still be compromised due to data breaches. In my earlier research I discovered that large databases containing health information are an attractive target for hackers. Workplace wellness programs can therefore put employees at risk if the data is not strongly secured; a hack could result in medical identity theft or personal health information being sold to data brokers. This may also create liability for employers if they do not provide adequate oversight in keeping employees� data secure.

But employers love these programs, and they wouldn't lie!

quote:

In 2009, Safeway CEO Steven A. Burd launched a public relations and political campaign claiming that his company had seen a stunning drop in health care costs after implementing a wellness program. In an opinion piece for the Wall Street Journal, Burd said that Safeway had begun testing employees� tobacco usage, weight, blood pressure, and cholesterol levels in 2005 and tying financial incentives to their results. Burd called this program �completely voluntary� in the same paragraph that he explained individuals who didn�t pass these tests had to pay $780 more in annual premiums, or $1,560 more for family plans. This kind of doublespeak is par for the course in the world of corporate wellness, where avoiding a financial penalty is often framed as getting a discount.

Simply by instituting wellness programs, Burd wrote, �we have kept our per capita health-care costs flat (that includes both the employee and the employer portion), while most American companies� costs have increased 38% over the same four years.�

As it turns out, almost none of Burd�s story was true. As the Washington Post�s David Hilzenrath discovered, Safeway implemented its wellness program in 2009, not 2005, and only about 14 percent of its workforce was even eligible to participate in it. Safeway did manage to keep its health care costs down�by raising deductibles in 2006, shifting more of the cost of health care onto employees.

There is absolutely nothing good about these programs, and the only reason they exist today is because employers, insurance companies and members of Congress want them.

# ¿ Mar 5, 2018 05:17

Willa Rogers: Mar 11, 2005

quote:

About 40 percent of Americans report skipping a recommended medical test or treatment and 44 percent say they didn�t go to a doctor when they were sick or injured in the last year because of cost, according to a new national poll from NORC at the University of Chicago and the West Health Institute.

The February survey of more than 1,300 adults offers new insights into how Americans feel about the costs of healthcare and how they report those costs affect their medical decisions and personal finances. While $3.3 trillion was spent on healthcare in the U.S. in 2016 � 17.9 percent of Gross Domestic Product � the new national poll finds three-quarters of Americans do not think we get good value for what our country spends on healthcare.

***

In the survey [...], about 30 percent said that over the last year they had to choose between paying for medical bills or basic necessities like food, heating or housing. But people say they are not only facing tough choices; they are scared. More people fear the medical bills that come with a serious illness than fear the illness itself (40 percent vs. 33 percent). Those who reported skipping a recommended test or treatment were about two times more likely to fear getting sick (47 percent vs. 24 percent) and to fear the costs of care (60 percent vs. 27 percent).

***

The survey also revealed Americans are not only delaying but also going without recommended care such as tests, treatments and doctor visits. About one-in-three respondents report they did not fill a prescription or took less than the prescribed dose to save money. Dental care also suffered. Nearly half say they went without a routine cleaning or check up in the last year, and 39 percent say they did not go to the dentist when they needed treatment.

More than half of survey respondents report serious financial consequences due to the costs of healthcare. Thirty-six percent say they have had to use up all or most of their savings, 32 percent report borrowing money or increasing credit card debt, and 41 percent say they decreased contributions to a savings plan because of healthcare expenses.

Some healthcare bills came as a surprise to many Americans. Over half of respondents said they received a medical bill for something they thought was covered by their health insurance, and a similar proportion reported receiving a medical bill that was higher than they expected. Strikingly, more than a quarter of respondents reported having a medical bill turned over to a collection agency within the past year.

http://www.westhealth.org/press-release/survey2018/

From the topline results:

# ¿ Mar 27, 2018 19:06

Willa Rogers: Mar 11, 2005

It's interesting that poll questions about single-payer always frame the question along the lines of "Would you favor a government-run system even if it meant you paid higher taxes?" instead of, e.g., "Would you be willing to pay a fixed 5 percent more in federal income taxes toward healthcare instead of fluctuating insurance premiums and out-of-pocket costs?" Same with poll questions that ask about sentiment toward "government-run healthcare" but not about our marvelous current system of private-insurance gatekeepers/skimmers.

PerniciousKnid posted:

Employer-provided group health insurance is the best insurance in the country, why wouldn't many people be satisfied with it?

Because of ever-increasing out-of-pocket costs combined with overly restrictive narrow networks--the same issues as the individual private-insurance market, only slightly less burdensome because of larger risk pools. Not to mention the "family glitch" within the ACA that determines employee affordability without factoring other family members.

Satisfaction surveys usually show Medicare/VA/Medicaid at the top, followed by employer-provided insurance, then by individual insurance.

# ¿ Apr 7, 2018 17:33

Willa Rogers: Mar 11, 2005

PerniciousKnid posted:

Do people usually attribute this to their specific plan, or to a rise in health costs in general?

Usually it's the rise in health costs in general. But year after year, more people are having problems actually being able to use their insurance, mainly because of the increases in out-of-pocket costs (even among employer-provided insurance) that have been far greater than increases in salary year after year.

The ACA pegs the cost of insurance premiums to one's annual income, but allows annual out-of-pocket costs to be as much as one-third to one-half of one's net income, whether insured individually or as part of a group plan. Hence one-third of those with serious and ongoing health issues skipping or deferring at least some medical care, according to one survey I saw last year. The lack of pricing controls on prescription drugs is particularly onerous for those with serious health conditions.

And that's not even dealing with the issue of "balance billing," in which out-of-network providers working for an in-network hospital results in full-cost, non-covered care for people. Here are some (depressing) facts about balance billing.

# ¿ Apr 7, 2018 18:50

Willa Rogers: Mar 11, 2005

Remember the olden days in dnd aca threads, when it was contended that $7,000/year in out-of-pocket costs would only be a thing for those seriously ill, in which case those out-of-pocket costs would be a bargain?

Instead, those out-of-pocket costs are in play when the doc has you get an MRI, or when you tell the doc during your "free" annual physical that you're concerned about a symptom or two and the "preventive" turns into the "diagnostic."

# ¿ Apr 12, 2018 20:46

Willa Rogers: Mar 11, 2005

Reminder that high deductibles caused 25 percent of people with serious medical conditions to not seek care last year.

# ¿ Apr 12, 2018 20:55

Willa Rogers: Mar 11, 2005

More proof that the "bending of the cost curve" is due to high deductibles that result in people deferring diagnosis & treatment:

quote:

High-deductible plans have become commonplace, a deterrent used by companies to lower health care costs by discouraging unnecessary tests or treatments. Evidence for that link has mounted since the Great Recession 10 years ago, when deductibles began to soar: People increasingly deferred medical care, putting off elective surgeries and doctors� visits. National health care spending slowed as a result.

But a recent study of women with insurance plans that carried deductibles of at least $1,000 underscores the danger to consumers required to shoulder a greater share of those costs.

Women who had just learned they had breast cancer were more likely to delay getting care if their deductibles were high, the study showed. A review of several years of medical claims exposed a pattern: Women confronting such immediate expenses put off getting diagnostic imaging and biopsies, postponing treatment.

And they delayed beginning chemotherapy by an average of seven months, said Dr. J. Frank Wharam, a Harvard researcher and one of the authors of the study, published earlier this year in the Journal of Clinical Oncology.

�Slight delays added up to long delays,� Dr. Wharam said.

While the study did not look at how the women fared after treatment, cancer doctors warn that even short gaps between diagnosis and treatment can affect the outcome. Survival rates are higher for patients with some cancers if they are treated early.

�What we see here is an unintended consequence of sharing costs,� said Dr. Ethan Basch, the director of cancer outcomes research at UNC Lineberger Comprehensive Cancer Center, who was not involved in the study.

"unintended," lol. The insurance industry had wanted high deductibles for forever before it was given the chance to write them into the ACA.

quote:

About half of all covered workers in the United States are now enrolled in plans with a deductible of at least $1,000, and many must pay several thousand dollars in medical bills before their plans even start to cover their care. About 11 percent of covered workers have a deductible of at least $3,000, according to a survey of employer benefits by the Kaiser Family Foundation. Employers are increasingly offering these plans � and more frequently giving their workers no other option.

While high-deductible plans are meant to encourage people to think twice about whether a test or treatment is necessary and if it can be done at a lower price, �it�s also frankly to impede their use of these services,� said Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center.

The plans are succeeding in reducing the use of care. �The question is, at what cost?� Dr. Bach said.
High-deductible plans pose a problem, say researchers who have studied them, because patients do not always distinguish between the care they should get and what they can do without.

***

Two years ago, when Rochelle Ness was 37, with three children under 6 years old, she learned she had breast cancer. The policy she had through her husband�s job had a deductible of $2,250 and required she pay a total of $11,500 toward her yearly medical bills.

She did not know how she would come up with the money, but having lost two family members to breast cancer, she did not consider delaying treatment. �That was scarier to me,� she said.

Now saddled with medical debt, Ms. Ness is also fighting to get her insurer to pay for the six Neulasta injections needed to help prevent infections during chemotherapy.

Her husband�s employer did not offer a savings account to accompany the high-deductible plan, and they still owe about $25,000. �We have maxed out our credit cards trying to pay medical expenses,� she said.

Ms. Ness, who received financial assistance from the Samfund, said she is now trying to come up with the money for additional treatments, including physical therapy and a hearing aid for the hearing loss resulting from chemotherapy.

Living paycheck to paycheck, the family is struggling to find any extra money to pay for their children to go camping or join a sports team.

�We were able to manage our medical bills back then,� she said. �It�s nearly impossible right now.�

# ¿ May 6, 2018 20:46

Willa Rogers: Mar 11, 2005

The Phlegmatist posted:

And this is the industry that took years to implement ACA's out-of-pocket caps and I'm still not sure that it even works correctly. Most of the single payer offerings don't address provider costs as a central part of the bill, which is a quick ticket into a tiered system like Greece and China have.

Bernie's Medicare-for-All legislation addresses provider costs; Medicare-for-Some calls for "incentivizing" providers + pharma, which is dem-speak for "we'll ask them nicely, but we're still beholden to lobbyist money."

And of course the ACA's "caps" on out-of-pocket costs don't work correctly; they're completely irrelevant to balance billing, which is still a thing across the vast majority of states. That's leaving aside the issue of the ACA's calling for annual expenditures of one-third to one-half of one's net income toward out-of-pocket costs for those making the royal salary of, say, $20k/year.

quote:

Medicare for Any is an amazing step in that direction since it globs Medicaid, TRICARE and the VA into Medicare which gets Medicaid the gently caress away from state control, which is what we need to do. At the same time it prevents employers from passing costs to employees by keeping them on private insurance. So it's a pretty big victory if we can get that passed, shove the nongroup market on to Medicare and then use that as a launching point for UHC. But it's from evil centrist snake people and therefore...is bad!

It's bad because it takes the closest we have to an NHS-style system (VA) and the closest we have to a Canadian system (Medicaid) and subverts them into a (further) privatized Medicare system. It's bad because it requires considerable out-of-pocket costs that can be--and have been--added at any point in time, thus exacerbating economic insecurity. It's bad because, like the ACA, it's means-tested garbage devised by legislators who have never had to worry about fluctuating incomes or how to pay off balance billing or having to pay off a $1,000 emergency.

But most of all, it's bad because it's a weaksauce smokescreen to shut down the single-payer movement, and it's another piece of bloatware and blowjob to private industry that is designed to not impede the corporate cash upon which our elected officials rely.

# ¿ May 28, 2018 22:13

Willa Rogers: Mar 11, 2005

zonohedron posted:

Okay, I'm not saying there's anything good about making anything part of Medicare, because I really don't know enough to say, but surely no one's saying that Medicaid or the VA are systems to emulate, right? You're only saying they'd be even worse (somehow) if blobbed into Medicare? Because I think of Medicaid and I think of doctors not taking it and states doing their best to cripple it, and I think of the VA and I think of interminable bureaucracy and wait times. If someone asked me "would you prefer your current high deductible plan with its random copays, or free access to both Medicaid and the VA?" I'd take my just-about-adequate plan in a microsecond.

Bernie's legislation builds upon the best aspects of Medicare (near-universal acceptance by providers; provider cost controls) with Medicaid (no out-of-pocket costs; also provider cost controls), and federalizes the system so states can't gently caress with it. Here's a summary.

# ¿ May 29, 2018 05:01

Willa Rogers: Mar 11, 2005

A good piece on how pharmacy-benefits management--and, particularly, mail-order requirements--is posing a danger to people with cancer:

quote:

Imagine the terror of being diagnosed with cancer.

Your doctor writes up your prescription, which you pray is going to save your life. You go to the hospital or oncology clinic�s in-house pharmacy. The medicine is right there on the shelves, but you�re told the only way your insurance will cover your medication, which might cost $10,000 or more per month, is if you get it through the mail.

So you go home empty-handed and wait. If you�re lucky, the medicine will arrive in just a couple of days. But it could be up to a month before delivery of the drugs.

Uncounted numbers of Ohio cancer patients don�t have to imagine this dilemma. They have experienced it because health insurers and the pharmacy benefit managers hired by insurers dictate it.

They require that prescriptions be filled at mail-order pharmacies that are often owned by the pharmacy benefit managers rather than allowing patients to get the drugs immediately, down the hall at your hospital.

�Rather than filling a prescription I have on the shelf, I have to tell the patient they have to go home and wait for a phone call from the pharmacy and arrange having this medicine sent to you,� said Christine Pfaff, pharmacist for the Zangmeister Center, a Columbus cancer treatment facility. �I can�t give it to you today. Your insurance won�t allow it.�

Health-care providers say the goal is to start treatment as soon as possible, because delays can be detrimental to their patients� health.

�New diagnosis, with medications as good as we have today, speed to therapy is important. Even a few days can make a difference,� said Curt Passafume, vice president of pharmacy services for OhioHealth.

Insurers and their pharmacy-benefit managers like to tout mail-order operations as a convenient alternative. But in the world of expensive cancer drugs, the companies use their clout to force patients away from hospital- or clinic-based pharmacies and into their own mail-order operations.

It creates another revenue stream for pharmacy benefit managers, or PBMs, the little-known middlemen in the health-care system. PBMs are hired by insurers or employers to negotiate prices and rebates with drug makers, decide which medications are covered, and set rates paid to pharmacies.

�Maximizing profits�

Elvin Weir of Blacklick is battling advanced colorectal cancer. He recently was told that his health plan, Blue Cross and Blue Shield of Michigan, would cover his new chemotherapy pills only if he filled them through Alliance Rx�s mail-order pharmacy. Two times he ordered the medication, and two times he faced big problems, he said.

The first time, he was forced to wait nearly two weeks for his medicine, and then was given incorrect instructions on dosage. The pharmacy said to send the pills back so they could be destroyed � all $20,000 worth of them.

The second time, Weir said he was shorted pills.

Both times, he was asked to wait while the mail-order pharmacy got its act together. And both times, the 52-year-old Weir refused, unwilling to further delay the fight against the cancer growing inside him.

His oncologist told him, �we know that if we don�t have you on chemo medication, it spreads like wildfire,� Weir said. �To have the oncologist use words like �wildfire� and these guys saying �well, let�s just wait� � I�m not waiting. That doesn�t work for me.�

Helen Stojic, a spokeswoman for Blue Cross Blue Shield of Michigan, said Weir�s access to his drug, Lonsurf, was restricted by its manufacturer, Taiho Oncology, to preferred providers, and that is why he had to get it from a mail-order pharmacy. Pfaff, however, said the Zangmeister pharmacy had the drug on its shelves � because it�s one of the preferred providers.

Behind the thicket of reasons Weir couldn�t get his medicine at his cancer clinic lies a common motive, said Ted Okon, executive director of the Community Oncology Alliance, a national group representing community cancer centers.

�This is not about expediting the cancer drug,� he said. �It�s about jockeying for control and maximizing profits.�

Ohio cancer-care providers said that forcing patients into mail-order pharmacies seriously disrupts the continuum of care they receive at cancer centers.

�It takes much longer� for outside, mail-order pharmacies to fill prescriptions for cancer drugs than does the Cleveland Clinic�s in-house pharmacy, said Scott Knoer, the clinic�s pharmacy director.

The cancer centers all say that they can deliver the best care when lifesaving drugs are in the same place as doctors, non-pill treatments and patient records.

�It�s very frustrating, for as much as we want to take care of our patients, the (health) plan or the PBM is forcing them to their mail-order plans,� said Julie Kennerly, assistant pharmacy director at The James.

Josh Cox, a member of the Ohio Board of Pharmacy and pharmacy director for Dayton Physicians Network, said that half of the network�s cancer patients are forced to use such far-away pharmacies, and he has seen many cases in which patients had to wait as long as a month to get their prescriptions delivered.

Cox likened it to a case of acute infection.

�There�s no physician on the planet who would say, �We can either give you IV antibiotics now, or we can give them in two weeks,�� he said.

The pharmacists say the reason pharmacy benefit managers crowd patients into mail-order pharmacies is simple: With many cancer drugs carrying the biggest price tags, rebates from drug makers, and profit margins, the benefit managers want to keep that money for themselves.

Knoer called the companies �classic middlemen,� billing billions, but �adding little value.�

OhioHealth�s Passafume said that for every 100 new drugs that came onto the market in the 1990s, about eight or nine had to be filled at specialty mail-order pharmacies. Today, it�s about 40 percent of new drugs, primarily expensive, long-term therapies for oncology, neurology and rheumatology disorders.

There is financial incentive to limit distribution because �rebate dollars flow back and forth. It�s millions of dollars,� Passafume said. �Drug manufacturers and distributors decide on limited distribution and then patients have to deal with the delays, prior authorization.�

�Patient safety issue�

The Dispatch has been examining the role of pharmacy-benefit managers in Ohio and on the national stage. The little-known companies have tremendous power in contracting with health plans, negotiating rebates with drug makers and setting reimbursements to pharmacies.

One of the benefit managers, CVS Caremark, is accused by some pharmacists and lawmakers of using its dominance in Ohio�s Medicaid program to gouge taxpayers and drive community pharmacies that compete with the CVS chain out of business.

Cox said CVS Caremark � which says it has a firewall between it and CVS retail operations � forces many patients away from the specialty pharmacy in his 44-physician group and into CVS Specialty Pharmacy. CVS Caremark, ExpressScripts and OptumRX control 85 percent of the country�s $320 billion annual pharmacy business.

Okon, of the Community Oncology Alliance, said that the number of cancer patients being forced into mail-order specialty pharmacies has �mushroomed� over the past year. That�s because PBMs and health plans realize that expensive oncology drugs are increasingly available in pill form and thus can be provided by a far-away company, he said.

�The PBMs realize that�s a gold mine,� he said.

CVS spokesman Michael DeAngelis said that company does not engage in unfair trade practices. He also said that his company is unaware of a cancer patient waiting a month for medicine. Typically, he said, it arrives in less than a week.

�CVS Specialty and CVS Caremark�s mail service pharmacy have robust quality assurance processes to ensure prescriptions are filled and dispensed accurately,� he said in an email. �Both have been accredited by URAC, the leading health care accrediting organization that establishes quality standards for the health care industry.

PBMs and insurers �have the option to select CVS Specialty as the exclusive pharmacy for specialty medications,� DeAngelis said. �Among the reasons a client may choose this option are to manage costs, achieve better outcomes for plan members through our ability to have a full view of the patient�s profile and not just their oncology therapy, and to take advantage of our industry-leading tools and programs to manage and improve patients� adherence to their medication therapies.�

Regardless of the company doing it, David Balto, former policy director for the Federal Trade Commission, said there�s an inherent conflict in allowing companies to act both as pharmacies that fill prescriptionsand as the companies that decide which pharmacies get paid.

�Consumers are losing the opportunity to go to the pharmacy of their choice,� he said.

For patients, losing that choice forces them to rely on someone they�ve never met on the other end of a phone.

Weir, the cancer patient, said that it�s like dealing with a �call center.�

�These guys are a nebulous cloud. They have no clue as to who I am, what my personal circumstances are, and frankly, they don�t care,� he said.

Janet Whittey, chief pharmacy officer for Mount Carmel Health System, likes to send patients home from the hospital with the medications and information they need to continue treatment without disruption. But more and more, it�s not possible.

PBMs �are shifting as much to their mail order as possible,� Whittey said. �This is patient-safety issue for us.�

Whittey said that �when you leave the hospital, you�re already under stress. We don�t want a break in their treatment plan. If the doctor prescribes (a medication) and they find it�s not covered, or have to wait for pre-authorization or delivery, it delays treatment. ... We want patients to go home without delays in treatment.�

Children�s hospitals are not immune from growing requirements for patients to use mail-order pharmacies.

�There are instances where this affects pediatrics as well,� said Gina Bericchia, spokeswoman for Nationwide Children�s Hospital. �Ensuring rapid access to medications while also ensuring cost-effective therapy options are utilized is challenging.�

http://www.record-courier.com/news/20180603/pharmacy-benefit-manager-system-keeps-meds-from-cancer-patients

# ¿ Jun 4, 2018 20:39

Willa Rogers: Mar 11, 2005

In 2016 the average rate increase was 25 percent across all states. Back then, liberals were claiming that the subsidies would "shield most consumers."

edit: that was 2017, not 2016.

Willa Rogers fucked around with this message at 23:42 on Jun 4, 2018

# ¿ Jun 4, 2018 23:39

Willa Rogers: Mar 11, 2005

Reik posted:

Anyone on the exchange that qualifies for the APTC is not affected by premium increases because the premium they pay is a fixed percent of their income. The increases do affect people above 400% FPL or people that purchase off the exchange.

To some extent subsidized enrollees on the exchanges are shielded by the income threshold, although the convoluted formula for affordability's being based on second-lowest-cost silver plan in a given area adds an unpredictable twist:

quote:

The cost assistance amount you get each year uses the second lowest cost silver plan (SLCSP) as the �baseline� plan for determining cost assistance. So for instance, if you qualified to have your tax credits capped at 9.5% of your household income, you would receive the exact amount of credits for the SLCSP, less for higher-cost plans, and more for lower-cost plans. Use form 8962 (Premium Tax Credit Form 8962 and Instructions).

The affordability exemption uses the lowest cost bronze plan to determine if the cheapest marketplace plan was affordable. Use form 8965 (Health Coverage Exemptions and Instructions).

The average price of bronze plans is used to determine the max penalty anyone would have to pay for not having coverage. Calculate the fee with the worksheet found in the instructions of 8965.

And that's setting aside the "family gap" in which affordability for employees is based on one employed family member and doesn't factor in non-working spouses & children.

But from the start enrollees in the marketplace have overwhelmingly been those who qualify for subsidies (because people grossing $50k/year don't want to pay or simply can't afford $8,000/year in premiums and $7,000/year deductibles--especially if they're younger/healthier), which further depletes the pool for a given insurance "product" in a given area.

The subsidies thresholds also tend to bucket younger/healthier people into bronze plans--which while more affordable than higher metal-tier plans gives them less financial protection in the event of having to actually use their insurance.

It's a confusing, means-tested mess for most people.

# ¿ Jun 5, 2018 16:38

Willa Rogers: Mar 11, 2005

Mr. Nice! posted:

That was Joe Liberman, not centrist dems. PPACA had a government option included originally. Lieberman killed that provision. Just like Marco Rubio killed risk corridor payments by kneecapping CMS with bullshit budget riders in subsequent years.

The PPACA in it's original form had problems, but it would have been a functional bill and provided true UHC with a private option for those that feared gubmint insurance.

That's untrue; Lieberman was the sole "Democrat" who killed the amendment that would have opened up Medicare to those aged 55+ but it was the House that passed a public option in their bill and the Senate Finance Committee (led by Baucus, Obama's handpicked ACA killjoy who turned the legislation over to his former-Blue Cross-lobbyist chief of staff) that killed the public option:

quote:

The first proposal, by Senator John D. Rockefeller IV of West Virginia, was rejected 15 to 8, as five Democrats joined all Republicans on the panel in voting no. The second proposal, by Senator Charles E. Schumer of New York, was defeated 13 to 10, with three Democrats voting no.

The votes vindicated the middle-of-the-road approach taken by the committee chairman, Senator Max Baucus, Democrat of Montana. Mr. Baucus voted against both proposals, which were offered as amendments to his bill to expand coverage and rein in health costs.

�There�s a lot to like about a public option,� Mr. Baucus said, but he asserted that the idea could not get the 60 votes needed to overcome a Republican filibuster on the Senate floor.

According to The Hill, only half of the Democratic senators supported a public option when push came to shove.

"It will never survive a filibuster" was also the excuse Harry Reid used to exclude the amendment for reimportation of prescription drugs from the final bill--even though a majority of GOP senators voted for it.

Of course, we discovered later that Obama earlier had made secret handshake deals with PhRMA and the American Hospital Assn. to exclude a public option (and to preclude any legislation that would rein in PhRMA). See, also, the rotating-villain hypothesis.

It's astounding how, nearly a decade after the legislation was crafted, the hagiography of the Democrats' being well-intentioned populists thwarted by the Evil Joe Lieberman continues to dwarf the truth.

eta: As far as the cost-sharing subsidies, that onus is squarely on Dems who didn't appropriate continuing funding as they did the premium subsidies; Dems claimed that that had been a "drafting error."

# ¿ Jun 10, 2018 16:40

Willa Rogers: Mar 11, 2005

B B posted:

Do you know of any articles about these deals?

https://www.huffingtonpost.com/miles-mogulescu/obama-the-public-option-t_b_772514.html

https://www.huffingtonpost.com/miles-mogulescu/ny-times-reporter-confirm_b_500999.html

http://www.latimes.com/nation/la-na-health-pharma14-2009aug14-story.html

https://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html

# ¿ Jun 10, 2018 17:35

Willa Rogers: Mar 11, 2005

VitalSigns posted:

Wasn't it prohibited by law from charging lower prices than private insurers

I'm not sure how the House bill that included a public option was structured, but I do recall Schumer, in the early days of the legislation being crafted, declaring that any public option had to be priced "on an even playing field" with private insurance.

The co-ops were supposed to replace the ephemeral public option but the vast majority of them ceased operations during the first few years of the marketplace. By 2018, only four co-ops still operated out of the original 22.

# ¿ Jun 10, 2018 18:21

Willa Rogers: Mar 11, 2005

Discendo Vox posted:

It is unlikely that PPACA would have passed without those backroom deals. Lieberman was the remaining point of a long edge of pols worried (not without reason) about the millions and millions in attack ads they'd face if groups like PhRMA or AHA threw their weight against the bill.

Lieberman was the bogeyman that Dems have claimed responsible for killing the public option, when it was Obama & Baucus & Reid who actually did so, with the help of other Dems.

You're correct inasmuch as Dems' being beholden to lobbyists' money made them dance to their pipers' tunes. But the lack of a public option, drug-pricing controls, and Medicare expansion was pretty much baked into the legislative cake from the start--which is why Obama's "support" of those things was nonexistent to tepid during the crafting of the bill.

# ¿ Jun 10, 2018 18:26

Willa Rogers: Mar 11, 2005

Discendo Vox posted:

ACA's success in improving healthcare was not incidental. The motivated reasoning on display here is...impressive.

Yep; thanks to the ACA we now have tens of millions of people who don't seek medical care every year because of high out-of-pocket costs, thus "bending the cost curve" of medical spending!

# ¿ Jun 10, 2018 19:17

Willa Rogers: Mar 11, 2005

The people who've most benefitted from the ACA are those who qualify for expanded Medicaid (in those states that have expanded it) and those with pre-existing health conditions who weren't able to obtain coverage prior to the ACA.

It's punitive toward olds because of the 3x multiplier falsely labeled as "community rating" and it's punitive toward those who can't afford the premiums toward a silver-level plan (the only tier that allows cost-sharing reductions).

It's also passively punitive toward employed people with stay-at-home spouses (family glitch); toward those who have no control over out-of-network practitioners billing them in in-network facilities; and toward those whose health is reliant on prescription drugs the prices and markets for which private insurers and pharmacy-benefit managers have struck opaque monopolies that result in out-of-pocket prices for drugs sometimes being cheaper than insurance "coverage" for those drugs.

The legislation touted as "health insurance reform" was written by the health-insurance industry (among other "stakeholders" like PhRMA) to preclude both meaningful government oversight and meaningful insurance reform.

# ¿ Jun 10, 2018 20:36

Willa Rogers: Mar 11, 2005

People on Medicaid now outnumber those in the private-insurance ACA marketplace by a factor of three to one--so yes, tens of millions of people have benefitted by the closest the ACA had to a single-payer program.

Those of us relegated to overpriced private marketplace insurance with nominal "coverage," those who live in states that didn't expand Medicaid, and those who can't afford to go a doctor because of high out-of-pocket costs (40 percent of those with private insurance), not so much.

# ¿ Jun 10, 2018 21:21

Willa Rogers: Mar 11, 2005

PT6A posted:

It's not the closest thing to a single-payer program, it's government-funded health insurance.

The government pays for Medicaid and Medicare healthcare by paying for the insurance, regulating the insurance rates, and requiring uniform coverage. It also sets rates on providers.

I don't care if you want to call it Medicare-for-All or Aunt Bertha; it's essentially single-payer. I think you're confusing the term single-payer with nationalized healthcare a la NHS or the VA.

# ¿ Jun 10, 2018 23:38

Willa Rogers: Mar 11, 2005

PT6A posted:

By that logic, every insurer is a single-payer system unto itself, at which point the term loses meaning.

Not at all; private insurers do not have to abide by government controls on premium or provider pricing (beyond the weaksauce regulations within the ACA).

But the greatest difference between single-payer insurance and private insurance is that with a plan like Bernie's Medicare-for-All legislation, private for-profit insurance becomes irrelevant--thus saving tens of billions of dollars now spent toward for-profit middlemen that add no value for healthcare "consumers."

# ¿ Jun 11, 2018 01:43

Willa Rogers: Mar 11, 2005

Paracaidas posted:

https://twitter.com/tonyleys/status/1006947130500624384

At least now they're finally running poo poo like a business!

Something like 80 percent of all Medicaid recipients are now covered under for-profit managed-care plans, including (especially) ultra-blue states like California. I think the last figure I read for California was that 90 percent of Medicaid recipients were in MC plans. (One in three people in the state are now covered by Medicaid.)

Private profiteers in the Medicaid sector are doing really, really well--even when they don't meet standards of care. Here's California, e.g.:

quote:

In anticipation of the Obamacare rollout, officials in California and elsewhere boosted their payments to managed-care companies because they expected Medicaid costs to increase as newly insured patients rushed to the doctor or emergency room after going years without coverage. But those sharply higher costs didn't materialize � and insurers pocketed more money as a result, especially in California.

Moreover, California's payments keep flowing steadily even when patients fare poorly. Two of the most profitable insurers in California � Centene and Anthem � run some of the worst-performing Medicaid plans, according to medical quality scores and complaints in government records.

http://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html

And the ACA was a boon to private managed-care plans, giving them revenue and profits they'd never seen before:

quote:

Before the ACA expansion, California's Medicaid plans collectively were barely in the black, with $226 million of net income for 2012 and 2013 combined. Traditionally, these insurance contracts have yielded slim profit margins of 2% to 3%. California said it aims for 2% when setting rates, based on prior claims experience and projected costs.

But in the years since the health law took effect, many health insurers have posted margins two or three times that benchmark.

Centene's Health Net unit in California enjoyed a profit margin of 7.2% from 2014 to 2016. (Centene acquired Health Net for $6.3 billion in March 2016.) Anthem's profit margin in California's Medicaid program was 8.1% for 2014 to 2016.

Investors have cheered those results. Shares in Anthem have more than doubled since January 2014, when the Medicaid expansion began. Centene shares are up 50% since the company purchased Health Net last year.

***

In 34 states and the District of Columbia, Medicaid managed-care profits more than tripled to $3.9 billion in 2015 from $1.1 billion in 2013, according to consulting firm Health Management Associates' analysis of insurance filings. Those figures don't include California.

[ibid.]

So yeah: state and federal governments are gonna save money using MCOs rather than traditional FFS, but even the best part of the ACA, Medicaid expansion, ensured that the bloodsucking sector would get their non-inconsiderable vig.

eta: Medicaid MCOs have to have an 85 percent medical-loss ratio, but it's hard to see how that's meaningful to reining in costs when it results in profits for those plans tripling within two years.

Willa Rogers fucked around with this message at 22:30 on Jun 13, 2018

# ¿ Jun 13, 2018 22:26

Willa Rogers: Mar 11, 2005

mila kunis posted:

Wait lmao, so the government is subsidizing employer insurance anyway? Kind of blows the "we shouldnt have universal healthcare because people love their employer care" talking point that right wing democratic shills were propagating out of the water.

It's not just subsidized; it's the largest tax break among all:

Excluding from tax of employer contributions to employee's health insurance costs ($854 billion)
Reduced tax rates on dividends and long-term capital gains ($649 billion)
Exclusion from tax on contributions and gains in 401(k)s and other defined contribution plans ($624 billion)
Expanded child tax credit ($526 billion)
Exclusion from tax on contributions and gains in defined benefit pensions ($470 billion)
Earned Income Tax Credit ($363 billion)
Charitable contributions deduction ($261 billion)
Obamacare health insurance subsidies ($231 billion)
Mortgage interest deduction ($217 billion)
State and local tax deduction ($208 billion)

https://money.cnn.com/2018/06/11/pf/taxes/biggest-tax-breaks/index.html

# ¿ Aug 10, 2018 00:33

Willa Rogers: Mar 11, 2005

Reik posted:

HCA is a garbage provider system. I'm pretty sure most major insurers cut them out of their networks in the last couple years.

That's not at the heart of the matter, though: It's balance billing, part of the new normal that accompanies a system of ultra-narrow networks:

quote:

Despite the surprise, Calver asked from his hospital bed whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David's is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital's prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

Then the bills came.

***

Following his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor who does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver's, where insurers will pay for needed emergency care at the closest hospital � even if it is out of network � but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there's a huge loophole: Those state-mandated protections don't apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds. Federal law governs those health plans � and it does not include such protections.

"Several" states = handful of those outlawing balance billing--and even in that case, there are loopholes, like the one above.

Balance billing is outlawed at the federal level for people insured under Medicare. The same should be true for all insureds, whether under an Obamacare plan, an employer's self-insurance plan, or an employer's standard group plan.

At least outlaw it in emergency situations, in which one doesn't have the opportunity to consent to out-of-network care at an in-network facility.

eta: It does seem as if the hospital "overcharged" the patient, as hospitals are wont to do--but that's a logical consequence of the regulatory captured ACA, which didn't set cost limits on providers, insurance premiums, or pharma.

etaa: Love the kicker to that story, which is pretty much :shrug:

personified:

quote:

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

"should" lol. As if the hospital isn't gonna send your rear end to collections & destroy your credit rating before you can file an appeal with your private insurer.

Willa Rogers fucked around with this message at 20:28 on Aug 28, 2018

# ¿ Aug 28, 2018 20:18

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# ¿ May 3, 2024 05:14

Willa Rogers: Mar 11, 2005

Raldikuk posted:

The only caveat here is that "preventative services" are covered right away, including prescriptions. Generally the formulary for preventative prescriptions is pretty thin and there are only a few preventative services covered under law (and many have gimmicks to gently caress you too; like colon cancer screening is covered, but if they end up biopsying a polyp then that isn't covered).

Same with "free" mammograms; that's pretty much true with all the preventive-vs.-diagnostic "free" stuff covered under the ACA.

There are numerous anecdotes about people going to their "free" annual physicals, and then when the doc asks if they have any concerns and they deigned to bring them up, they were billed for the exam as diagnostic, rather than preventive. I remember one woman's story in particular; her friend cautioned her to not bring up anything on her own, but then she honestly answered her doc's query and mentioned something then bam! Billed out in full.

# ¿ Sep 12, 2018 02:05

The Something Awful Forums > Discussion > Debate & Discussion > Healthcare Reform Megathread: Can I sell my organs to pay this hospital bill?

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