[I’m not sure this is entirely correct as it is complex.]
This is a possible reinsurance model PPACA replacement scheme:
US citizens and lawfully present persons of a US resident household shall be eligible for coverage as per the PPACA.
The federally subsidy eligible expenses of each eligible issued policy shall be:
1. 85% of Medicare Part A scope coverage provider payouts,
2. 80% of Medicare Part B scope coverage provider payouts, plus
3. 80% of prescription drug coverage provider payouts on a policy.
Uncle Sam shall pay a share of the federally subsidy eligible expenses of each eligible policy equal to 30%,
plus 1/6th of each policyholders’ household premium calculation percentage below 400% of FPL that is above 40%.
[The 30% is to mainly cover the costs of chronic condition people.]
A policyholders’ premium calculation percentage shall be the lesser of 100% or 25 times:
their statutorily expected household monthly income,
less the HUD fair market rent for a two-bedroom apartment,
less vehicle loan obligations when computed on a monthly or 30-day basis,
less vehicle insurance obligations when computed on a monthly or 30-day basis,
less court-ordered obligations due, including child support, fines and costs, when computed on a 28-day, 30-day or monthly basis,
less expected student loan repayment expenses when computed on a monthly or 30-day basis,
less other amounts the coverage issuer justly deems reasonable and specific for college attendance when averaged to a proper extent by the month over an appropriate time period,
less other monthly or corresponding amounts the coverage issuer reasonably deems to be mandatory,
divided by 1/12th the annual FPL amount for the covered household size.
The statutorily expected household monthly income shall be the sum,
for each person of the household at least 19 years of age,
excluding the primary caregiver in the household for the under full-time school age children of the household,
the:
1. the hourly computational wage rate for the household’s state*100[what can be expected from working retail],
reduced by two-thirds if a full-time college student
and a photocopy of the student’s college ID or proof of tuition payment is on file with the coverage issuer,
2. if higher, the person’s income last stated by the policy purchaser, or person,
3. if lower, the person’s net income stated reasonably accurately not more than 70 days ago by the policy purchaser, or person,
for no more than four months of the policy year.
Hourly computational wage rates for 2026 shall be assumed to be as follows:
1. AK, HI, WA, CA, OR, NJ, NY, MD, MA, RI, DC - $16/hour
2. CO, AZ, IL, NB - $15/hour
3. ME, VT, VA, UT, FL - $14/hour
4. GA, MI - $13/hour
5. NM - $12/hour
6. AL, MS - $10/hour
7. other states $11/hour.
[States with severe winter weather may be given a lower rate than their statutory minimum wage rate.]
Extractable profit to not exceed:
1. 1% of the Medicare amount, plus $100, for each inpatient episode paid within 30 days of initial correct provider billing and within 60 days of initial provider billing,
2. 1% of the Medicare amount, plus $8, for each other provider bill paid to the contracted amount within 30 days of initial correct provider billing and within 60 days of initial provider billing,
3. $1 for each off-patent drug prescription paid for, $3 if for 90 days,
4. $5 for each patented drug prescription paid for within 30 days of the policy year, $15 if for 90 days, and
5. $20 for each recombinant drug provision paid for within 30 days of the policy year.
Administrative related and in-house care costs shall not exceed the extractable profit limit, any applicable reasonable state law limit, or any policy limit. All issued policies shall have a reasonable percentage of premium limit stated within the first 1000 characters of any initial normal course of access policy specific marketing page.
Insurers may, with reasonable 30-days online posted notice, raise premiums of a PPACA policy type to reasonably expect to reach the extractable profit level based on actual and reasonably forecast expenses during the calendar year, subject to a 5% monthly premium rise cap.
Any funds left over after claims on PPACA policies have been paid for the calendar year and profit extracted shall be paid over to Uncle Sam.
There shall be a customer premium payment grace period, to 11:59PM of the third Friday of each month, for the third and fourth full coverage months of the policy.
There shall be a customer premium payment grace period, to 11:59PM of the fourth Friday of each month, for the remaining months of a policy.
Great post (the good news first).
Are you planning to repeal EMTALA, and pass a Federal law to prevent enforcement of existing State laws which forbid denial of care for nonpayment?
Great post (now the bad news).
The insurance model can’t be fixed.