This kind of sums up just how outrageous the US healthcare situation is. You might expect this kind of advice if you lived in a Third World country with a military dictator, where all but the army were living in abject poverty.
The way it works is: Most people get insurance through their work. This is because the value of insurance is not taxable while salary is. If you don’t have it through work you can buy an individual plan on the open market. If you don’t have it and are poor you get Medicaid, which is like what you have. If you are 64 plus years of age you can go on Medicare which is like Medicaid but charge co-pays. If you don’t have health insurance you can pay out of pocket. If you are too poor to pay out of pocket and need to be hospitalized you can be declared indigent and there is no payment.
Any questions?
Medicaid is means tested, Medicare is not.
If you earn more than 133% of the poverty line, you’re SOL as far as Medicaid goes.
The problem is, you’re healthy and have no pre-existing conditions NOW, as far as you know. Tomorrow you could find out you DO have an expensive disease that you just didn’t know about yesterday.
A person of the female persuasion could find out tomorrow that she’s pregnant. The day after tomorrow she finds out her pregnancy is high-risk. No insurance? Oops. Later on she finds out the fetus also has a high likelihood of a serious and potentially expensive birth defect.
You could buy a mansion with the money it costs to have a high high-risk pregnancy and/or a child with perinatal difficulties.
Catastrophic medical problems can happen in an instant.
Yes, for sure. That makes a system that keeps changing disconcerting, even for people who have managed to stay healthy so far. As I’m getting older, I really want to be locked into a plan that I can’t later be completely dropped from if I get seriously sick. In theory an insurer should be willing to provide that, but if the regulatory environment keeps changing, who knows.
This is encouraging, I guess:
The biggest thing about ACA: It actually PASSED the US GOVERNMENT!
After 200+ years of yelling “Socialized Medicine!!” at any attempt to institute National Coverage for the Masses, Something was actually instituted.
No, it couldn’t remove the Insurance Industry from healthcare - and it certainly couldn’t upset the “Health Insurance From Employer” (has anyone actually thought about how did those two things get conflated?) model, and it couldn’t give those eligible for Medicare* an option, but, dammit, it was SOMETHING!
If it could have been expanded to include the (generally healthy**) employees, and have been combined with Medicare, we would have something close to a functional Federal Health Care System.
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- once you’ve been in enough “nice” medical offices often enough to have heard “Sorry, we don’t take Medicare”, you develop a desire to NOT be the one being told that. My old Doc was on top of Nob HIll; now my Doc is in the UC Medical Clinic. I can’t decide for myself to consult an endocrinologist - I now have to have a “Medically Necessary” formal Referral.
** - if you ain’t reasonably healthy, you probably ain’t employed.
Currently, that’s only because insurance companies are barred from denying insurance due to pre-existing conditions. Even if they don’t deny you they could demand premiums so high you are simply unable to pay them, such as a situation where the required monthly payment would exceed your gross monthly income. (Which has happened to my household in the past.)
This is incorrect.
Quite a few states do NOT provide Medicaid to able-bodied adults. Note I did not say healthy adults, I mean adults not officially on disability benefits, which are still not Medicaid, they’re Medicare. In more than one state Medicaid health coverage is only provided to children, once you’re an adult you’re on your own.
If you have the money.
Incorrect.
If you are indigent you are only guaranteed treatment for immediately life-threatening conditions. Otherwise no one is obligated to treat you if you can’t pay. Newly diagnosed with diabetes? No insurance? Can’t pay? Don’t qualify for Medicaid in your state? So sorry - come back when you’re in renal failure and imminent danger of death. Then we can put you Medicare and dialysis. Because that makes so much more sense than preventing the death of your kidneys in the first place. :rolleyes:
Even if they decide to treat you anyway you can be hounded for years to pay bills you can’t possibly pay, harassed by bill collectors, your financial credit ruined, etc.
Yeah, actually I have asked that question - it came about due to wage freezes during WWII. Employers couldn’t give employees a raise, but they could provide other benefits in lieu of one. Apparently offering this new fangled thing called “health insurance” was a popular one.
And here we are, decades later…
You left out that type of “insurance” that is now offered to people like me that don’t qualify for any type of subsidy. You pay some huge amount of money (it varies all over the place but it is growing quickly every year; figure many hundreds to a little over $1000 per month split between you and your employer - it is often much more for families). That sounds pretty expensive right? It certainly is but here is the capper.
All of that money isn’t for your healthcare unless you get into a really bad accident or have a chronic health condition. That is because high deductible plans are becoming increasingly common. That means you still have to pay everything but the most basic healthcare like an annual checkup yourself on top of all that money. You and your employer are paying for useless insurance for the typical person. You may have to spend $5000 - $10000 or more on top of your insurance costs before it kicks in a penny and the clock restarts every year so you are doubly screwed if you get a serious health issue that happens in December and spans two plan years. You may be looking at $20,000 or more of cold, hard cash out of pocket for one event despite the fact that you had really expensive health insurance the whole time.
Many people would like the option to self-insure (just pay for routine care and skip anything but catastrophic insurance) but you can’t do that effectively either. There is a fine at tax time if you try that but that isn’t the real problem. The real problem is that no one has any idea how much medical procedures cost until well after they are already done. Don’t think I am exaggerating at all. Even the doctors in small private practice can’t tell you because they don’t know themselves. The rates are negotiated by the insurance companies and there are countless variations on them. Unlike almost every other business model, the system isn’t set up to handle people that just want to pay their bill on the spot themselves and be done with it. Instead, everything goes through this massive bureaucracy that the insurance companies created and you find out how much the procedure cost anywhere from a month to years later.
I know this is a liberal leaning board but I think a lot of people are starting to realize that ObamaCare is indeed deeply flawed. For people with jobs, it turned already very expensive health insurance into completely unaffordable insurance (some people are now paying more for health insurance than for their housing payment and they still have to pay for most of their own healthcare on top of that if they have a high deductible plan). It is really just a horrendously expensive wealth redistribution law that hits the middle-class extremely hard. It would have been easier just to double the federal tax rate for everyone and call it a day because the effect is about the same.
It’s not that difficult. People in the US (before Obamacare) had private health care, usually provided by their employer, who might or might not chip in for part of the premiums. If you go to a doctor (all independent contractors), you usually have a copay (a basic amount you pay – in my case, it’s $30). The insurance company picks up the rest of the cost.
For hospital stays, it’s the same thing: you have a copay, and the insurance pays the rest.
There are multiple health insurers, some for profit and some not-for-profit. All have different plans that are negotiated with the employer. Some employers have multiple plans, but this seems to be happening less often.
If you’re not employed, you can pay the insurer directly (at a high price, since you can’t negotiate it like businesses can, and you’re paying it all). If you’re permanently unemployed, there’s Medicaid, which provides health care for low income people (even if they’re employed and their employer doesn’t provide it – they’re not required to). There’s also Medicare, a government-run program for those 65 and older that covers hospital stays, and which is an umbrella program for private insurers to provide doctors visits and prescriptions.
What gets complicated is what your plan actually covers, especially when it comes to prescriptions. In Medicare, you have to check out the various plans to make sure the ones you want have the medicines you want. These are usually spelled out relatively clearly, but the complexity makes it hard to understand.
Obamacare is more complex because it’s a mix of private and governmental regulations with the goal of keeping premiums low.
MEDICAID DOES NOT AUTOMATICALLY COVER POOR PEOPLE!!!
One more time - stop saying this because in many states it’s just not true. There are a LOT, and in millions, of adults who have NO insurance because they’re too poor to pay for it on their own and Medicaid in their state does not cover adults.
And it’s NOT just the unemployed poor - this also applies to millions of working poor people.
I just want to amplify something that Shagnasty touched on:
Even if you were moderately wealthy and figured you could pay what the insurance company pays for medical treatment so you won’t get insurance, you CAN’T pay the insurance company rate. It will easily cost you 10 times as much to get treatment if you are not covered by insurance.
Say you stay in the hospital for a few days. After you get out of the hospital, you will get a statement in the mail that is several pages long and adds up to, let’s say, $800,000. Then a few weeks later you will get an “explanation of benefits” from the insurance company. It will also be many pages long, but in summary it will say something like:
Hospital billed: $800,000
Insurance pays: $70,000
Your co-pay/deductible: $10,000
Hospital writes off: $720,000 (neither you nor the insurance are responsible for this amount).
Then for the next year, you will get additional bills from random physicians’ groups, labs, and various service providers that are handled similarly.
The $80,000 (the amount the insurance pays plus your deductible) is the rate the insurance company negotiated with the hospital. Only people who pay for insurance coverage are entitled to pay that rate. So even if you figured “Hey, $70,000 is a lot, but given all the money I’ll save over my life by not buying insurance, it’s worth it,” you can’t do that.
Now it is true that hospitals will sometimes negotiate the cash price down. But they will try to get as much of that as they can squeeze out of you.
The system has you over a barrel.
Let me try to break it down here. The US health care system is controlled by the insurance companies. There are many of them although each area of the country may only have a few. However, these companies can offer a variety of plans. The ACA at least made certain parameters (for example, that 80% of what they charged had to be used for medical care).
Some varieties are as follows:
HMO-usually the company covers most of your heath care if you get it from their preferred provider list but can refuse all care if you get it outside and you may have to jump through hoops to get it approved
PPO-there are “preferred providers” where the company contracts with them and will provide better coverage if you go to them but still some coverage if you go elsewhere
POS-this is “point of service” which is sort of halfway between HMO and PPO but every company defines it differently
There are also plans that basically pay the same to everybody
Now these insurance companies contract with individual doctors and hospitals to be on their plans. If you want to be on their plans, you agree to take their payments. However, they also contract separately with individual employers which means that contracting with one insurance company means you may have to take over a hundred different plans.
The insurance companies don’t make it easy to find out what they pay providers. You can get information but that means lists of their payments for hundreds of different procedures and types of visits and each of these lists is different for every plan.
There is another neat wrinkle in that the companies will always pay the lesser of what they allow or the provider charges. So, for example, if you take an average standard visit, the company may allow from 40-85 dollars. Remember, that this is just one of many companies. So-what the provider does is to price their services high enough not to lose out. Also remember that it’s difficult to be always checking allowable schedules and adjusting fee schedules, so most providers just set the prices high enough to make sure they don’t lose out. In the above case, most providers would probable set their price at about $120, to make sure that if one company jumps from $85 to $95 they will still be above this. What happens, though, is that the poor person with no insurance gets charged the full $120.
Now the insurance companies don’t want people to run up health care unnecessarily. Left to their devices, Americans will demand an MRI for every back pain. So there are disincentives, like copays and deductibles.
A deductible is the amount you have to pay before your insurance kicks in. This can range from nothing to $15,000.
A copay is what you pay for each visit or procedure. This can be a percentage or a fixed amount or both. So, for example, you might pay $30 a visit for your primary doctor and $60 for a specialist, and $300 a day plus 20% of the costs for a hospital stay.
If you want labs done, and you have an HMO, you might pay $10 at their lab but have to pay full price elsewhere.
If you have a PPO, you might pay 10% at an approved lab (where they agree to accept the insurance company paymnt as payment in full so it will be 10% of their contracted price) if the lab is in-network, but 20% if you go out of network. But wait-the company will pay 80%, but that is 80% of their contracted fee and you just went to a lab they don’t contract with (or more likely, your doctor drew blood in the office and didn’t realize that of the 700 insurances they contract with, yours has suddenly decided not to accept the lab they normally send to).
So-let’s say a test costs $50. The lab needs to make a profit so the contracted cost with your company is $100. However, company B actually pays $125. So the lab charges $200, to make sure they get that full $125. You go to your in-network lab and you pay $10 and the company pays $90. You go to the outside lab and the company pays it’s 80% of UCR which is $80. However, the charge is $200. So your “20%” is actually $120 (the actual $20 which is 20% and the balance billing of the additional $100)
Of course, this is after the deductible, which the company will credit to you as the $100 they pay. So, if you are in-network, you pay $100 and get that credited toward your deductible and if you are out of network, you pay $200 but only get $100 credited toward your deductible.
Simple, you say-why not just stay in network? Well, fist of all, the networks are constantly being renegotiated and the lists are not updated. In addition, there are carve-outs where doctors who do not meet certain standards or admit to the wrong hospitals can only participate with some but not all of the plans offered by a company. Where I am, if you are too far South from certain hospitals, one company will exclude you from all exchage plans but not other plans. Easy-you say, just ask the patient whether they bought their plan on the exchange. However, many people don’t know whether their company went through the exchange, they only know that they have Humana, or Aetna, or Blue Cross.
It is estimated that the cost per physician to deal with this is about $80,000 yearly.
Confused yet? Let’s talk about facility fees. Some hospitals try to make money by charging a “facility fee” because insurance companies pay more for the same procedure done at a hospital as opposed to a free-standing clinic. Makes sense for more complex procedure which might need extra resources and extra expenses. So the hospitals set up hospital-owned properties as satellites and charge an additional “facility fee” when you go there. So if you have your blood drawn at one of these places you might pay an additional $40 fee. Did you check your insurance policy? Hope so, because your insurance company being more aware of this tan you may have tacked on an additional $40 fee to you for getting your blood drawn there which doesn’t go to your deductible.
But wait, besides the different copays and deductibles depending on whether you have an HMO, PPO or POS, there is an entirely different set of numbers for family coverage.
If this sounds complicated to you, imaging how it sounds to the average person, who has little to no idea what a copay, deductible, out of pocket maximum, coinsurance or facility fee is, let alone what his or her numbers should be for each of these. If you want to see how complex it can be, go here and enter a random made-up person. Take a look at the options available. Go to their advanced information to see what they actually cover. When your head stops spinning, realize that this is just ONE health care company and you have to choose from up to three or four (if you’re lucky). (Feel free to use my local zip 22191-Prince William County and type in any date of birth you want-that’s all you really have to give them). Make sure you scroll right to see all the plans, and remember this is just the plans offered on the free market; there are also an entire set of exchange plans in addition to the individual employer-contracted plans. And this is why American health care costs so very very much.
I take simponi for ankylosing spondilitis. $1,000 dollars a month. $100 a month with insurance. Thanks to a recommendation on the Straight Dope, it is $5.00 a month with the manufacturer kicking in money or lowering the price for me. I don’t want to know why, I figure there is a guy who works at my insurance company whose only job is to find a reason to drop me.
If you do go to the link I posted, make sure you click on summary of plan and benefits at the bottom of each plan. That is one of the great perks of the ACA, that companies must spell out what they cover and what your payments are in this format. Believe it or not, this is a VAST improvement over the old system where it could be buried in your 50 page policy. It does make it easier to compare plans and I think it makes it easier for non-Americans to understand what we are dealing with.
BTW-I think its no secret I support single-payer healthcare for all. The cost saving from streamlining bureaucracy alone would be staggering. But not to worry, Trump wants to improve health care by letting companies sell insurances across state lines, meaning that they can set up in the most-favorable state and adhere to that state’s regulations which makes your choice of plans even greater. (Except that the only in-network hospital might now actually be in another state-pesky little inconvenience).
HMO plans also require you to select a primary care provider* (PCP) from their network that’s supposed to be your primary point of contact for healthcare services and depending on the plan you may or may not be required to seek this provider’s approval in order to see a specialist (this is called a referral). Also if you enrolled in an HMO plan, but fail to make a valid PCP selection (ie pick someone who’s both in-network & accepting new patients) you’ll simply be assigned one at random by the insurance company.
*Depending on the what the regulations are in your state and the insurance company you may have the option of choosing a nurse practitioner or physician assistant instead of an actual physician.
The issue is that you are blaming obamacare for that. THat isn’t Obamacare’s fault, that is the fault of our health care system being twice as expensive as any other nation.
I had premium jumps of 40% before Obamacare came into effect. If you use the rule of 72, that means after 2 years the prices have doubled.
Obamacare didn’t create this mess. Our health system has been a gigantic mess since the 1980s when prices started to diverge from the rest of the developed world. We are now at $10,000 per capita for health spending. The UK is at $3200, France is $4100. Even if the ACA had never been passed, we would be at the same spot we are now, where for most people ‘health insurance’ means paying several hundred dollars a month for a plan that doesn’t cover anything until you spend 5k or more.
The issue is, how do we fix it? We know how to fix it in theory, it is just that nobody wants to fix it because that means a variety of reforms that result in hundreds of billions, if not trillions, in reduced annual revenue for the pharma industry, hospital industry, medical device industry, physicians, etc. They are not going to give up 1/3 to 1/2 of their income without a fight.
A big fear with selling insurance across state lines is they will all do what the credit card companies did and move to a state with the fewest consumer protections. So the plans will be cheaper, but they will not cover much. That won’t solve the problem at all.
We do need competition in our health care system, but we need both public and private market forces. If selling insurance across state lines becomes a thing, there need to be mandated federal minimum consumer protections for all plans.
One of the basic problems this thread has highlighted is the fact that everyone talks about “how does the healthcare system in the US work?” when the US doesn’t have a healthcare system. It has 51 systems that overlap.
For the person that is still under the illusion that Medicaid pays the bills of the poor, perhaps in his state it still does. It certainly does not in many states. And I am going to go out on a limb here and say that the poster has no personal experience with Medicaid in his state. Could be wrong, but Medicaid doesn’t cover very many non-disabled people in any state so the odds are in my favor.
There are similar issues for private health insurance-it varies state by state. One of the major issues with ACA is that it set influential national standards for health care. That exposed a major problem-medical insurance standards in California or New York were far different than in Louisiana or Kentucky. With a national standard the drafters had the choice of either taking the entire country to the lowest level or raising it toward the highest level. They chose the latter. And the states whose costs suddenly climbed fought back. Hence the repeal Obamacare fight.