Instead of focusing on Republican and Democrat division, now that the details of Obamacare are steadily beginning to operate in the real world, we’re finding common ground for Democrats and Republicans.
On 8/20/13 in “President: ‘Health Insurance is a Right,’” we saw that the President’s statement actually supports repeal of the individual mandate, since not exercising a right, such as the right to vote, is not a taxable event in the US.
This week, again, we find an opportunity for Republicans as yet another provision of Obamacare is “delayed.” Instead of arguing for repeal of the entire law, or defunding the entire law, Republicans should be focusing on the use of the “delay,” which in effect removes the provision from becoming law for another year.
What’s going on now in the world of delay? This one is significant. As “The NY Times,” reported on 8/12/13, in an article by Robert Pear entitled, “A Limit on Consumer Costs is Delayed in Health Care Law,” (it’s also reported elsewhere search for delay of OOP max, [Out Of Pocket max])Pear states, “…the administration has delayed until 2015 a significant consumer protection in the law…”
Are you a loser? The only ones really affected are employees who choose an employer-sponsored group health plan that uses multiple payers for coverage, such as one provider for medical benefits and another for prescription drug benefits.
What was supposed to happen was that unlike before the PPACA, out-of-pocket expense maximums under the PPACA are supposed to include copayments in determining WHEN a person reaches the maximum amount of out-of-pocket expenses for a plan year.
What does that mean? First, how much were the limits supposed to be? Under the PPACA, the LIMIT, the MAX beginning in 2014 was supposed to be $6,250 for an individual and $12,500 for families.
Did that mean that you would not pay more out-of-pocket than $6,250 or $12,500? NO. Again, NO. All the out-of-pocket maximum limit said was that copayments would go into the consideration of reaching the out-of-pocket maximum, not that you would be done paying when you reach that maximum.
Seems weird, but actually, out-of-pocket maximum doesn’t mean that you don’t pay after you reach it. Instead, it means that once you reach that number, $6,250 individual or $12,500 family that you get the coverage offered under your plan at 100 percent if you use network providers.
So, if you choose a 60 percent coverage plan, (bronze) then you pay your deductible, you pay co-payments, and for covered services, using network providers, you pay 40 percent. After you pay those amounts and they add up to either $6,250 or $12,500, you would get 100 percent of coverage for services or devices or drugs covered by your plan without being required to pay more money out-of-pocket. However, co-payments frequently were excluded from going into the amounts you paid, and now with the delay, for separate drug plans can continue to be excluded.
The numbers of $6,250 and $12,500 come from Health Savings Account plans, those plans that people LOVE because they’re frequently less expensive than other insurance plans that I HATE because they frequently leave people under-insured in the event they actually need to use insurance in a particular year. For those plans, the OOP MAX is arguably more important than for others because they are HIGH DEDUCTIBLE plans, meaning that individuals already have to pay out more money for medical care in addition to premiums.
The problem is that employers have to coordinate their administration of health plans if they use more than one provider, such as one provider for medical and a different provider for a drug plan in order to be able to keep track of how much a person has paid out of pocket. Because of this administrative problem, the law on limiting the OOP Max is delayed.
This delay tactic, already used by the administration several times, means that the particular delayed provision is in effect not law for that year. For subsequent years, the Act itself recognizes its dependence on funding, so that each year through funding decisions, specific provisions of the PPACA will or will not function as the law of the land.
For instance, it’s reasonable to think that provisions of the Act dependent on funding and annual adjustments to that funding will be sensitive to budget decisions that adjust that funding. Any place that the Act talks about a dollar amount, whether it’s out-of-pocket maximum or how much we can be charged by insurers such as the 80/20 rule is subject to change. These changes, each YEAR or every few years will determine whether things get worse or better for consumers under Obamacare in a given year.
For Republicans, the fact that the Democratic Administration is setting the example for this approach, by delaying provisions such as the employer mandate, and now the OOP Max provision should silence their, “Repeal it all,” battle cry in exchange for smaller changes they can achieve through funding and delay. In other words, Republicans and Democrats agree, parts of that Act cannot be enacted as of now.
Because parts of the Act depend on each other, Republicans should be pointing out the hardships caused to states where only part of the Act is effective and other related parts are delayed or inapplicable. Republicans already missed this chance for states that opted out of Medicaid expansion that will face reduced reimbursements for certain hospital expenses because those reimbursement rates were lowered BASED ON the fact that by choosing Medicaid expansion, funding for those patients would have reached the hospitals via expanded Medicaid instead of older reimbursement models.
Hopefully, Republicans, who are supposedly trying to resurrect an image of working for more than simply rich Americans will open the discussion of other changes that should accommodate the delay. For instance, perhaps the $6,250 and $12,500 out-of-pocket provisions for high deductible plans should be lowered to $2,000 and $4,000 to leave room for consumers to live through the year while employers and providers get their acts together rather than leaving affected consumers vulnerable to limitless costs in co-payments.
Each opportunity missed by Republicans is simply a sign that they have not changed their tune. Instead of using opportunities to show that they are willing to change and sacrifice their narrow mean-minded philosophy in exchange for a broader view that acknowledges the diversity of the American people, they don't respond and the Democrats come across as “working on it,” and the Republicans continue to come across as babies trying to beat the legitimate political system that passed Obamacare.
