The issue is, the new doughnut hole, created by an inability to pay for family coverage through employer-sponsored insurance, which under the ACA only has limits on how much premiums can cost for employees rather than limits on what can be charged to the employee’s family members and eligibility for Federal assistance or public insurance in the form of Medicaid.
First, the “resolution” I anticipate for the so-called glitch in the ACA that’s gaining attention as employees realize that their families aren’t poor enough to qualify for the elaborate credits and subsidies provided for under ACA and that they’re not rich enough to afford the cost of health insurance for their families through their employers, is that families will have separate insurance from breadwinner insurance. That separate insurance will be of lesser quality in terms of coverage received for cost and will likely be of the bronze or silver level on the new health exchanges.
My problem with the coverage of this feature of the ACA is that everyone is afraid of considering that perhaps, just perhaps, the doughnut hole is intentional. I believe that this so-called “Glitch” was actually a “Goal.”
What we know is that the President’s agenda was to get more people insured. In order to get people insured, the President very early on made it clear that his attention was directed towards those too poor to afford health insurance so that he insisted on a shift in law that “allows” parents to keep paying health insurance costs for their grown children and carrying them on their health insurance policies until the age of 26, and he adamantly adhered to requirements for federal credits and subsidies to help poorer individuals purchase insurance in the event they were not poor enough to be eligible for Medicaid. The President also supported the new tax on those who don’t have health insurance which became part of the law.
We also know that health benefits exchanges, a merely administrative change that’s supposed to make it easier for people to choose an insurance plan to pay for at different levels ranging from bronze to platinum is also a big part of the transparency/efficiency features the President supports. Those are supposed to go into effect in 2014.
We also know that in order to qualify for Federal subsidies and/or credits, even if they meet income limit requirements, that individuals will have to choose silver-level health insurance plans or higher rather than the cheapest plans offered.
But there are some obvious truths that many others, including those who call this new experience of the ACA a glitch seem reluctant to realize which those of us who are living middle class lives, who have experienced the calloused indifference the President has to any who are middle class unless they’re civil servant government and/or union protected positions, have realized and that’s that the President will not stop using the middle class as a piggy-bank until we are a two-class nation of poor and rich.
This is not a glitch in my opinion, but a goal. People affected by this new doughnut hole are going to be middle class families, whose breadwinners work for companies that offer insurance to them at low or even for free but whose families will no longer be able to be insured by those companies because their premiums have soared. These people who are being told that for this year they won’t be charged a tax because they’re unable to afford health insurance for their families through their employers, next year will flock to the health exchanges for worse coverage.
The alleged “glitch” accomplishes many goals.
First, the “employer burden” will be relieved by employees whom no longer having a realistic option for carrying their dependents on their employers’ plans. Employers happy, check.
Secondly, these new insurance hunters will flock to the health exchanges to find some health insurance for their families which will create real traffic and use of the sites that will be used by the Federal government to justify maintaining such sites regardless of the fact that the government itself is creating the need. Must keep Federal funding for health exchanges because look how useful they are, check.
Third, parents of adults who cannot afford health insurance will be no better and no worse off than before, since carrying their grown children on their employer-sponsored policies will no longer be an option with the new sky’s the limit premiums, they’ll pay for other insurance coverage for their grown children (of course with less-quality coverage). Letting parents pay for their grown children’s health insurance, check.
Fourth, poorer people who qualify for Federal subsidies and credits will likely in many instances have superior insurance in many cases to individuals who exceed income qualification for credits and subsidies because these subsidies only apply to health plans at the silver level or better whereas the forgotten middle class will not get Federal help and will likely choose bronze-level coverage. Lower the quality of the middle class to help everyone else, check.
To me, these results are not “glitches,” the President has consistently shown his indifference to the private-sector middle class all along even saying so (Yeah, we’re doing fine). What is stunning is that anyone still believes that the welfare of the private-sector, non-senior citizen middle class matters to the President at all.
Showing posts with label ACA. Show all posts
Showing posts with label ACA. Show all posts
Friday, February 8, 2013
Friday, November 16, 2012
Exercise: Insurance Companies Should Put Their Money Where Their Mouths Are
As part of the great American scam supporting all sorts of “wellness” and “preventive” services, (as I’ve said previously, a scam because these are FINITE costs inappropriate to be paying PREMIUMS for which are calculated by determining the RISK that an INSURER will have to pay for a specific treatment and spreading it around a POOL OF PEOPLE, and therefore charging PREMIUM MONEY to cover preventive and wellness costs that are FINITE is outside the business of “INSURANCE”), is a new study (funded how? By an insurance company, Kaiser Permanente) comes the headline, “Kaiser Permanente Study Finds Efforts to Establish Exercise as a Vital Sign Prove Valid,” (search Kaiser Permanente’s website from today, 11/16/12)exercise works to keep people healthier.
So what’s wrong with this picture? Still in the world of wellness and prevention, the services of exercise science physiologists with Master’s level education, as well as other tiers of exercise experts are NOT covered by health insurance. Instead? Kaiser Permanente will use the information to…you’ve got it, counsel patients about their lifestyles.
It’s time for companies like Kaiser Permanente to put their money where their mouths are, not on research that provides, “Uh, duh,” conclusions and “counseling” to support patients in exercising, but insurance coverage for treatment-oriented exercise programs.
So what’s wrong with this picture? Still in the world of wellness and prevention, the services of exercise science physiologists with Master’s level education, as well as other tiers of exercise experts are NOT covered by health insurance. Instead? Kaiser Permanente will use the information to…you’ve got it, counsel patients about their lifestyles.
It’s time for companies like Kaiser Permanente to put their money where their mouths are, not on research that provides, “Uh, duh,” conclusions and “counseling” to support patients in exercising, but insurance coverage for treatment-oriented exercise programs.
Friday, November 9, 2012
Do You Know What your Plan Says? Section 2715, ACA
It’s hard to imagine ever having to read more than the basic information that you receive about your health insurance policy, but it’s important to know that many situations arise when not knowing what your plan says can leave you with less or different health insurance coverage than you anticipated. In addition to providing the only source of information upon which you can make a completely informed decision, one of the key reasons for knowing what your rights are when it comes to the content of your insurance plan will frequently revolve around your right to appeal your insurance company’s decisions.
Start with the framework. While an insurance policy provides you with rights, it also creates rights for your insurance company concerning how they can avoid making payments or in more benign terms, explaining exactly what they do or don’t cover.
The ACA acknowledges the difficulty in getting information and understanding insurance coverage but does not go very far in terms of helping policy holders because of two factors, first that insurers want to be held to finite liability so that their documents are crafted to clearly indicate just how far coverage goes and in accounting for every detail the word count goes up precipitously. The second reason that the ACA provides limited additional assistance for individuals is a result of the length of the document which means that most of us will not read through the entire policy unless we need to.
What the ACA does do in section 2715, “Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions,” is in section (a) provide for SBCs, summaries of benefits and coverage to accurately describe the plan. This format is already commonly available in terms of a Summary of Benefits and Coverage documents prepared by insurers as online resources for insureds.
Note that section 2715 (b)(Requirements)(3)(Contents)(H) requires that SBCs include text warning and informing consumers that the coverage document itself must be consulted to determine the governing contractual provisions. This is important because although most of us rely on summaries of benefits, they are NEVER complete. Only the plan itself can be considered a binding document.
The Summary of Benefits and Coverage document must have contact information in terms of a phone number that you can use to get a copy of the actual policy or certificate that represents your policy. It should be noted that after your request, the plan has seven days in which to send you documents (including the option to send the material out on the seventh day which means you’ll get it later) if you request a hard copy BUT under section 2715 (b) (3) (I), there must be a web address that you can use to access the complete policy online. This is important in order to be able to access information in situations where time is of the essence.
Other helpful but not decisively valuable changes that we can expect include efforts at standardizing health insurance language to make it easier to compare the coverage provided by different plans and to better understand the definitions of various terms. While standardization is likely to be helpful, it does not solve the problem of the sheer complexity of health insurance documents. You will likely also need to consult with other resources to better understand what is or is not covered in the event you have questions about your healthcare coverage.
Start with the framework. While an insurance policy provides you with rights, it also creates rights for your insurance company concerning how they can avoid making payments or in more benign terms, explaining exactly what they do or don’t cover.
The ACA acknowledges the difficulty in getting information and understanding insurance coverage but does not go very far in terms of helping policy holders because of two factors, first that insurers want to be held to finite liability so that their documents are crafted to clearly indicate just how far coverage goes and in accounting for every detail the word count goes up precipitously. The second reason that the ACA provides limited additional assistance for individuals is a result of the length of the document which means that most of us will not read through the entire policy unless we need to.
What the ACA does do in section 2715, “Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions,” is in section (a) provide for SBCs, summaries of benefits and coverage to accurately describe the plan. This format is already commonly available in terms of a Summary of Benefits and Coverage documents prepared by insurers as online resources for insureds.
Note that section 2715 (b)(Requirements)(3)(Contents)(H) requires that SBCs include text warning and informing consumers that the coverage document itself must be consulted to determine the governing contractual provisions. This is important because although most of us rely on summaries of benefits, they are NEVER complete. Only the plan itself can be considered a binding document.
The Summary of Benefits and Coverage document must have contact information in terms of a phone number that you can use to get a copy of the actual policy or certificate that represents your policy. It should be noted that after your request, the plan has seven days in which to send you documents (including the option to send the material out on the seventh day which means you’ll get it later) if you request a hard copy BUT under section 2715 (b) (3) (I), there must be a web address that you can use to access the complete policy online. This is important in order to be able to access information in situations where time is of the essence.
Other helpful but not decisively valuable changes that we can expect include efforts at standardizing health insurance language to make it easier to compare the coverage provided by different plans and to better understand the definitions of various terms. While standardization is likely to be helpful, it does not solve the problem of the sheer complexity of health insurance documents. You will likely also need to consult with other resources to better understand what is or is not covered in the event you have questions about your healthcare coverage.
Monday, November 5, 2012
How Both Sides Botched the Abortion Issue: The ACA
Somewhere along the line politics on both Democratic and Republican sides became a battleground of extremes. Extremism, by definition represents the limits of a point of view, by definition leaving most reasonable Americans choosing the better of two not-so-great choices.
The ACA, as part of its preventive services includes requirements for essential health benefits, with an emphasis on preventive services and with provisions for women’s health services in section 1302b. (My objections to the preventive services provisions are many including their mislabeling as “free” since insurance premiums which rose on average 13 percent last year and are slated to rise 7.4 percent this year indicate that preventive services are “included” not “free.”)
It seems obvious to me that because of the expanded coverage of women’s health, especially sexual and reproductive health, specifically the Act’s failure to provide similar coverage for men including payment for certain procedures and free screenings for various diseases for men, the Act itself singled women’s health out for consideration by individuals weighing provisions of the Affordable Care Act.
In response, the benefits provided to women, segregated out from the male-female population by the Act also brought into question the ever-touchy issue of abortion. In this way the ACA itself became a back-door way for the most extreme pro-lifers to find a current platform to promote their agenda.
But what of abortion rights in this country? Before Affordable Care the nation had already begun to seriously chip away at abortion rights with the 2007 Supreme Court decision of Gonzales v. Cahart that upheld the Federal ban contained in the “Federal Partial Birth Abortion Ban Act of 2003.”
Now, with the renewed dialogue about abortion that has brought to light some of the most ignorant and anti-woman speech from elected officials and would-be elected officials that I’ve ever heard, it is Paul Ryan whom the focus should be on. If Mitt Romney is elected President, as Vice President, Paul Ryan becomes President of the Senate and the deciding vote in the event there is a 50/50 split among senators regarding a piece of legislation.
This role in an extreme America is a meaningful risk to abortion rights. (Some argue that the modern use of the filibuster would help prevent having the Vice President cast a deciding vote in the event of a tie.)
Once passed, legislation would have to be challenged on Constitutionality grounds in order to prevent it from becoming the law of the land, much like the Affordable Care Act became entangled in its assessment by the Supreme Court. If the Supreme Court considered an anti-abortion law constitutional, much like the Affordable Care Act, the anti-abortion legislation would have to be repealed or amended through the legislative process to prevent its policies from coming into play on a semi-permanent basis.
Another line of attack for the rights created in Roe v. Wade would be the Supreme Court reversing its own decision based on the merits of another case brought before it. This is the less likely route but remains a possibility which is why the makeup of the Supreme Court is important in terms of the views of its members.
The expanded coverage of women’s health was a very costly provision for women in the ACA in my opinion because it singled women out for superior coverage over males, and because its efforts to address contraception opened the door for those who are not only pro-life but whose agendas are so extreme they are only marginally supported even within the pro-life community to direct a national conversation of women’s bodies and women’s rights that incorporates ideas only supported in the most pre-modern countries in the world.
For me, each side’s inability to be responsive to the majority of people within their parties rather than the extreme and factionalized few of the many groups within the US has allowed us all to witness the weakness of the new extremism in both Democratic and Republican parties…It leaves people hopelessly polarized having to choose between two parties whose views likely do not reflect their own on many issues.
Regardless of the winner, it seems to me that we all lose. The winning candidate will reassure us that he represents “all” Americans but the nastiness of language, proposed policies, and the sheer unreasonableness of both sides and their ability to work with each other will leave those words of "working for all Americans" lingering in the air as merely another campaign lie.
The ACA, as part of its preventive services includes requirements for essential health benefits, with an emphasis on preventive services and with provisions for women’s health services in section 1302b. (My objections to the preventive services provisions are many including their mislabeling as “free” since insurance premiums which rose on average 13 percent last year and are slated to rise 7.4 percent this year indicate that preventive services are “included” not “free.”)
It seems obvious to me that because of the expanded coverage of women’s health, especially sexual and reproductive health, specifically the Act’s failure to provide similar coverage for men including payment for certain procedures and free screenings for various diseases for men, the Act itself singled women’s health out for consideration by individuals weighing provisions of the Affordable Care Act.
In response, the benefits provided to women, segregated out from the male-female population by the Act also brought into question the ever-touchy issue of abortion. In this way the ACA itself became a back-door way for the most extreme pro-lifers to find a current platform to promote their agenda.
But what of abortion rights in this country? Before Affordable Care the nation had already begun to seriously chip away at abortion rights with the 2007 Supreme Court decision of Gonzales v. Cahart that upheld the Federal ban contained in the “Federal Partial Birth Abortion Ban Act of 2003.”
Now, with the renewed dialogue about abortion that has brought to light some of the most ignorant and anti-woman speech from elected officials and would-be elected officials that I’ve ever heard, it is Paul Ryan whom the focus should be on. If Mitt Romney is elected President, as Vice President, Paul Ryan becomes President of the Senate and the deciding vote in the event there is a 50/50 split among senators regarding a piece of legislation.
This role in an extreme America is a meaningful risk to abortion rights. (Some argue that the modern use of the filibuster would help prevent having the Vice President cast a deciding vote in the event of a tie.)
Once passed, legislation would have to be challenged on Constitutionality grounds in order to prevent it from becoming the law of the land, much like the Affordable Care Act became entangled in its assessment by the Supreme Court. If the Supreme Court considered an anti-abortion law constitutional, much like the Affordable Care Act, the anti-abortion legislation would have to be repealed or amended through the legislative process to prevent its policies from coming into play on a semi-permanent basis.
Another line of attack for the rights created in Roe v. Wade would be the Supreme Court reversing its own decision based on the merits of another case brought before it. This is the less likely route but remains a possibility which is why the makeup of the Supreme Court is important in terms of the views of its members.
The expanded coverage of women’s health was a very costly provision for women in the ACA in my opinion because it singled women out for superior coverage over males, and because its efforts to address contraception opened the door for those who are not only pro-life but whose agendas are so extreme they are only marginally supported even within the pro-life community to direct a national conversation of women’s bodies and women’s rights that incorporates ideas only supported in the most pre-modern countries in the world.
For me, each side’s inability to be responsive to the majority of people within their parties rather than the extreme and factionalized few of the many groups within the US has allowed us all to witness the weakness of the new extremism in both Democratic and Republican parties…It leaves people hopelessly polarized having to choose between two parties whose views likely do not reflect their own on many issues.
Regardless of the winner, it seems to me that we all lose. The winning candidate will reassure us that he represents “all” Americans but the nastiness of language, proposed policies, and the sheer unreasonableness of both sides and their ability to work with each other will leave those words of "working for all Americans" lingering in the air as merely another campaign lie.
Thursday, November 1, 2012
Beyond “If I’m re-elected”: Pre-existing Conditions and the ACA
Tonight’s “news” will likely be the hysterical analysis of Mitt Romney’s slip today during a campaign speech talking about “if he’s re-elected.” Undoubtedly, regardless of the fact he corrected his error immediately, all kinds of malignant meanings will be gleaned, deciphered, and spewed regarding what Mitt Romney meant. My diatribe against this style of “reporting” is that it leaves us knowing no more than who would make a better stand-up comic.
Regardless of who wins, 2014 as it stands today, promises some changes with Affordable Care. One of those regards pre-existing conditions. OK, first find the law. In the Affordable Care Act appears in Subtitle C-Quality Health Insurance Coverage for All Americans, Part I-Health Insurance Market Reforms, Section 1201 which amends the Public Health Service Act (42 USC 300gg, et seq.) Then in Sub-Part I of the ACA the Public Health Service Act creates a new section 2704-Prohibition of Preexisting Condition Exclusions or other discrimination based on health status.
Framework: Recall this applies to qualified health plans, both employer and individual.
Of interest here is section 2701-Fair health insurance premiums and (a)-prohibiting discriminatory premium rates.
Under the ACA, the ONLY TWO JUSTIFIABLE REASONS UNDER THIS SECTION FOR RAISING PREMIUM RATES ARE AGE (Which allows 3 to 1 variation) and TOBACCO USE which allows for 1.5 to 1 variation. No one else can legally be charged more for insurance premiums based on a pre-existing condition.
While the heading is prohibiting discriminatory premium rates, unhealthy has never before been a protected group for purposes of anti-discrimination protection. Previously we relied on the protections provided by the Americans with Disabilities Act regarding discrimination for DISABILITY. On its face the Affordable Care Act changes protected classes and our definitions of DISCRIMINATION.
Under the ACA, no longer is age a protected class since higher rates can be charged to older citizens. No longer are activities of choice the distinction determining the higher cost of health insurance coverage since ONLY TOBACCO, not drugs, alcohol, overeating or a myriad of other elective activities are pinpointed for increased premiums.
While smoking is a bad choice (as arguably are overeating, being an alcoholic or a drug abuser), it certainly cannot be argued that AGE is a choice. In fact, age IS currently a protected criterion for discrimination protection OUTSIDE OF THE HEALTHCARE LAW.
So what’s the problem with such a confusing standard of cherry-picking (naturally based on some insurance analysis showing that being old and being a smoker somehow makes your odds of needing medical care greater than drug users, the obese, or an alcoholic)? The problem is funding.
The current forecast by all accounts is that funding Obamacare is going to present ongoing challenges. In spite of all the snipes about “math”, even for Democrats and non-partisan economists the funding required is not in the Act without additional and continuous funding allotments.
This will likely mean that the Act will be amended to include provision for charging more for new subsets of individuals beyond older citizens or those who smoke. Likely an obesity amendment is coming soon, mind you no such amendment is in the works, that’s just an opinion.
So what of establishing new concepts of what amounts to justifiable premium increases versus non-justifiable premium increases such as those expounded by the Affordable Care Act? The problem is that by turning on its head traditional classes of protected individuals, in this case older citizens, and by singling out a group of Americans whose health care should cost more based on their choices, i.e. smokers, we open the door to choosing anyone to include in a group that can be legally charged more for health insurance EXCEPT those with pre-existing conditions.
This is the cost shifting style of the President.
In 2014 “wellness” programs offered as part of insurance coverage will legally be allowed to incentivize people who stay a healthy weight or work out or do any number of good-health things through a reward system such as a rebate. But today’s rewards for losing weight should stand as a warning of tomorrow’s penalties for carrying around those extra pounds. Of course there is no wellness for reducing your age so that for older Americans, your premiums will remain, legally high under the Affordable Care Act.
We as a country need to address these concepts, where is the discussion of what discriminatory means when it comes to insurance rules under the Affordable Care Act?
Monday, October 29, 2012
Election and Beyond: Affordable Care and You
One of the confusing aspects of both the rhetoric and of the Affordable Care Act itself is that it’s a conversation that many of us have come into in the middle and therefore are playing catch-up in understanding its implications.
By now, it should be clear that the Affordable Care Act was primarily designed to get more people insured. Every provision is designed to make sure people get insurance and then to allot how to make that insurance coverage adequate.
Adequate coverage, including the administrative and financial obligations undertaken by the Federal government to implement Affordable Care means that there are budgetary concerns, and those are why several states challenged the legality of Affordable Care, money not coverage.
The Supreme Court upheld the ACA, but identified the tax on those without coverage as a tax (rather than a penalty, which the President and democrats would have preferred because of hostilities about increased taxes). The Supreme Court struck down proposed Medicaid funding changes where the Federal government would withhold all Medicaid funding if states did not expand Medicaid eligibility.
The media conversation since then has largely revolved around Medicare, and ultimately citizens 55 and older have been assured their Medicare coverage will not change BY BOTH SIDES. Similarly, for those citizens under 55 we have been assured that Medicare WILL change.
But what has less frequently been addressed is what happens to citizens who are not yet part of Medicaid or Medicare and their health coverage.
President Obama has touted some shorthand self-congratulation such as that beginning in 2014 lifetime limits will be removed from insurance plans. This means that if your medical expenses exceed lifetime limits imposed by insurance companies, you will still have insurance coverage rather than being liable for 100 percent of out-of-pocket expenses that go beyond lifetime limits. Naturally, this is designed to keep people insured, fulfilling the goal of the ACA.
Less publicized is how insurance companies will maintain their profits in order to remove lifetime limits which will mean reduced coverage where they pay less for essential health benefits or through increased premiums, or a combination of both.
President Obama has self-congratulated himself on provisions that prevent insurance denials for pre-existing conditions, but of course this insurance will cost individuals more than those without pre-existing conditions as it always has.
While arguably beneficial, these provisions do not come as benefits without increased costs to consumers.
Finally, President Obama self-congratulates about provisions for preventive care as part of the savings afforded to consumers who will be able to have illness diagnosed earlier based on the assumption that with preventive care coverage consumers will treat illness earlier which will translate into cheaper healthcare.
Preventive coverage should not be part of health insurance which, like all insurance is designed to cover contingencies of illness creating the need for assistance in paying for needed healthcare which is purchased by citizens through premium payments. Annual exams are not contingencies, they occur at known times for known costs and should not dilute coverage nor persuade citizens they’re getting a great perk from their insurers who make the money up by reducing coverage for needed medical care or by raising premiums, or both.
The public is onto this game as reflected in the lower utilization rates reported by insurance companies in the past year, eg fewer people are going to doctors. If you can’t afford needed treatment, the “gift” of covered testing to get a diagnosis is largely meaningless.
This brings up a direct way to understanding the “metal” categories talked about in the Affordable Care Act. Bear in mind two knowns: The first is that Affordable Care is designed to get people insured and the second is that insurance coverage DOES NOT mean healthcare, it is a means of paying for healthcare.
The requirements of the ACA cover plans that are not self-insured employer plans nor grandfathered-in plans, which leaves the majority of health plans REQUIRED to be qualified health plans under the Act and makes the metal divisions mandatory.
The metals, bronze, silver, gold and platinum are levels of coverage as provided in section 1302. Levels of coverage do not mean that plans will cover one thing or another, all plans will have to cover a little bit of a wide variety of medical care services referred to in the Act as ESSENTIAL HEALTH BENEFITS.
Essential Health Benefits refer to the RANGE of coverages NOT how much. That’s where the metals come in. Therefore, while all qualified health plans will cover the same types of things, the cost to consumers will vary widely.
Levels of coverage will amount to Platinum, covering 90 percent of medical expenses on average, Gold covering 80 percent of medical expenses on average, Silver covering 70 percent of medical expenses on average, and Bronze covering 60 percent of medical expenses on average. Beginning in 2014, post-election, exchanges in the states will list plans meeting these standards. Out-of-pocket expenses will vary based on the usual insurance distinctions of co-payments and deductibles.
Section 1401 and 1402 of the ACA provide for Premium Subsidies and Cost Sharing. First, these sections do not apply if you earn over about $90,000 a year for a family of four, period. In the case of those who are eligible, the Federal government provides for PREMIUM CREDITS to meet financial obligations of paying for insurance coverage at the SILVER level (70 percent). If a family chooses a plan for higher coverage, that share of premium dollars would NOT be eligible for the PREMIUM CREDIT.
For families at 250 percent of the Federal Poverty line an additional BENEFIT is available. In addition to PREMIUM CREDITS, on a sliding scale those families if enrolled in SILVER-LEVEL plans would be eligible for COST-SHARING credits which means that they would not have to pay the full 30 percent of co-payments and deductibles those families earning more than $55,000 a year would have to pay at the silver level.
The tax CREDITS established by the ACA for the cost of premium payments for families earning less than about $90,000 and for additional tax credits for those families earning less than $55,000 might be part of Mitt Romney’s reluctance to discuss which tax credits he would get rid of. Obviously, whether it’s likely or not, if Mitt Romney is arguing he will support REPEAL of Affordable Care, drawing attention to the removal of tax credits for middle class and lower income families would fly in the face of his claims he “cares” about the middle class. I believe that President Obama’s reluctance to self-congratulate about the metal classes is because it is a glaring example of how citizens are getting LESS coverage for LESS money, not exactly a math problem that we don’t understand (since the President, following Bill Clinton, has suddenly adopted mathematics as his strength).
Generally, those who are well will try to save money choosing lower-level plans, such as the bronze or silver plans, and those who have serious illness will opt for higher-level plans, paying higher premiums for greater coverage to avoid bankruptcy from out-of-pocket expenses. This formula is already causing Affordable Care Act experts to warn that over time the population will segregate itself into healthy and unhealthy as plan participants that will mean an increase in the premium costs of the gold and platinum premium rated plans because of the higher number of people actually needing their insurance coverage to cover costs of necessary medical care at levels that will prevent or ward off bankruptcy. This is referred to as Adverse Selection.
It will be interesting to see what new products the insurance industry comes up with such as supplemental plans to cover the inadequacies of basic insurance plans much like Medicare has today. Health savings plans will also probably be boosted as “reasonable” alternatives as most individuals who purchase bronze or silver level plans realize they’re getting the same crummy coverage provided by health savings plans and their partner high-deductible insurance plans.
By now, it should be clear that the Affordable Care Act was primarily designed to get more people insured. Every provision is designed to make sure people get insurance and then to allot how to make that insurance coverage adequate.
Adequate coverage, including the administrative and financial obligations undertaken by the Federal government to implement Affordable Care means that there are budgetary concerns, and those are why several states challenged the legality of Affordable Care, money not coverage.
The Supreme Court upheld the ACA, but identified the tax on those without coverage as a tax (rather than a penalty, which the President and democrats would have preferred because of hostilities about increased taxes). The Supreme Court struck down proposed Medicaid funding changes where the Federal government would withhold all Medicaid funding if states did not expand Medicaid eligibility.
The media conversation since then has largely revolved around Medicare, and ultimately citizens 55 and older have been assured their Medicare coverage will not change BY BOTH SIDES. Similarly, for those citizens under 55 we have been assured that Medicare WILL change.
But what has less frequently been addressed is what happens to citizens who are not yet part of Medicaid or Medicare and their health coverage.
President Obama has touted some shorthand self-congratulation such as that beginning in 2014 lifetime limits will be removed from insurance plans. This means that if your medical expenses exceed lifetime limits imposed by insurance companies, you will still have insurance coverage rather than being liable for 100 percent of out-of-pocket expenses that go beyond lifetime limits. Naturally, this is designed to keep people insured, fulfilling the goal of the ACA.
Less publicized is how insurance companies will maintain their profits in order to remove lifetime limits which will mean reduced coverage where they pay less for essential health benefits or through increased premiums, or a combination of both.
President Obama has self-congratulated himself on provisions that prevent insurance denials for pre-existing conditions, but of course this insurance will cost individuals more than those without pre-existing conditions as it always has.
While arguably beneficial, these provisions do not come as benefits without increased costs to consumers.
Finally, President Obama self-congratulates about provisions for preventive care as part of the savings afforded to consumers who will be able to have illness diagnosed earlier based on the assumption that with preventive care coverage consumers will treat illness earlier which will translate into cheaper healthcare.
Preventive coverage should not be part of health insurance which, like all insurance is designed to cover contingencies of illness creating the need for assistance in paying for needed healthcare which is purchased by citizens through premium payments. Annual exams are not contingencies, they occur at known times for known costs and should not dilute coverage nor persuade citizens they’re getting a great perk from their insurers who make the money up by reducing coverage for needed medical care or by raising premiums, or both.
The public is onto this game as reflected in the lower utilization rates reported by insurance companies in the past year, eg fewer people are going to doctors. If you can’t afford needed treatment, the “gift” of covered testing to get a diagnosis is largely meaningless.
This brings up a direct way to understanding the “metal” categories talked about in the Affordable Care Act. Bear in mind two knowns: The first is that Affordable Care is designed to get people insured and the second is that insurance coverage DOES NOT mean healthcare, it is a means of paying for healthcare.
The requirements of the ACA cover plans that are not self-insured employer plans nor grandfathered-in plans, which leaves the majority of health plans REQUIRED to be qualified health plans under the Act and makes the metal divisions mandatory.
The metals, bronze, silver, gold and platinum are levels of coverage as provided in section 1302. Levels of coverage do not mean that plans will cover one thing or another, all plans will have to cover a little bit of a wide variety of medical care services referred to in the Act as ESSENTIAL HEALTH BENEFITS.
Essential Health Benefits refer to the RANGE of coverages NOT how much. That’s where the metals come in. Therefore, while all qualified health plans will cover the same types of things, the cost to consumers will vary widely.
Levels of coverage will amount to Platinum, covering 90 percent of medical expenses on average, Gold covering 80 percent of medical expenses on average, Silver covering 70 percent of medical expenses on average, and Bronze covering 60 percent of medical expenses on average. Beginning in 2014, post-election, exchanges in the states will list plans meeting these standards. Out-of-pocket expenses will vary based on the usual insurance distinctions of co-payments and deductibles.
Section 1401 and 1402 of the ACA provide for Premium Subsidies and Cost Sharing. First, these sections do not apply if you earn over about $90,000 a year for a family of four, period. In the case of those who are eligible, the Federal government provides for PREMIUM CREDITS to meet financial obligations of paying for insurance coverage at the SILVER level (70 percent). If a family chooses a plan for higher coverage, that share of premium dollars would NOT be eligible for the PREMIUM CREDIT.
For families at 250 percent of the Federal Poverty line an additional BENEFIT is available. In addition to PREMIUM CREDITS, on a sliding scale those families if enrolled in SILVER-LEVEL plans would be eligible for COST-SHARING credits which means that they would not have to pay the full 30 percent of co-payments and deductibles those families earning more than $55,000 a year would have to pay at the silver level.
The tax CREDITS established by the ACA for the cost of premium payments for families earning less than about $90,000 and for additional tax credits for those families earning less than $55,000 might be part of Mitt Romney’s reluctance to discuss which tax credits he would get rid of. Obviously, whether it’s likely or not, if Mitt Romney is arguing he will support REPEAL of Affordable Care, drawing attention to the removal of tax credits for middle class and lower income families would fly in the face of his claims he “cares” about the middle class. I believe that President Obama’s reluctance to self-congratulate about the metal classes is because it is a glaring example of how citizens are getting LESS coverage for LESS money, not exactly a math problem that we don’t understand (since the President, following Bill Clinton, has suddenly adopted mathematics as his strength).
Generally, those who are well will try to save money choosing lower-level plans, such as the bronze or silver plans, and those who have serious illness will opt for higher-level plans, paying higher premiums for greater coverage to avoid bankruptcy from out-of-pocket expenses. This formula is already causing Affordable Care Act experts to warn that over time the population will segregate itself into healthy and unhealthy as plan participants that will mean an increase in the premium costs of the gold and platinum premium rated plans because of the higher number of people actually needing their insurance coverage to cover costs of necessary medical care at levels that will prevent or ward off bankruptcy. This is referred to as Adverse Selection.
It will be interesting to see what new products the insurance industry comes up with such as supplemental plans to cover the inadequacies of basic insurance plans much like Medicare has today. Health savings plans will also probably be boosted as “reasonable” alternatives as most individuals who purchase bronze or silver level plans realize they’re getting the same crummy coverage provided by health savings plans and their partner high-deductible insurance plans.
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