Posted on 08/18/2017 11:29:21 AM PDT by Brian Griffin
The US government should allow insurers to sell Pretty Good Quality (PGQ), Medicare-like policies with the federal government generally paying the percentages listed in parentheses of a person's maximum silver plan subsidy amount as premium subsidies.
The monthly basic drug coverage subsidy would be computed without adjusting for household income, so young, healthy and affluent people would want to buy drug coverage too.
The monthly basic drug coverage subsidy amount for coverage on a US citizen might be:
$1 for each year of age
less 20% if no recombinant auto-immune drug is covered
less 10% if no standard anti-HIV regimen is covered
less $8 if the covered person is age>11 & age<42 and no oral birth control medication is covered
plus $5 if the covered person is under age 6 and vaccines recomended for that age are covered by the basic plan, less $.1 for each vaccine which isn't free
plus $8 if the covered person is age>11 & age<14 and an HPV vaccine is covered by the basic plan, less $1.60 if the vaccine series isn't free
plus $1 for each year of age if the covered person is age>50
less 15% if no long-acting recombinant insulin is covered
less 2% if no standard anti-tuberculosis regimen is covered
A covered person's basic plan reduction amount shall be the sum of the applicable reductions marked with "less".
Except as below, PGQ insurers wishing to be federal subsidy eligible for such PGQ policies must offer by default coverage for:
1. (30%) EMTALA scope care,
with Medicare Part B level co-insurance & insurer-set ER & daily co-pays of no more than $300 in-network, or
with insurer Medicare Part A/B level (or such higher level as agreed or entirely fixed by state law (and federal regulation)), less
such patient share amounts, payout(s) out-of-network
2. (7%)* other essential, Medicare Part B scope in-network inpatient care such as operative/palliative cancer surgery,
with Medicare Part B level co-insurance & an insurer-set daily co-pay of no more than $250
3. (3%)* Medicare Part A equivalent (but with an insurer-set daily co-pay of no more than $100/day) in-network nursing home care
4. in-network office visits:
a. (7%) one office visit with a $10 physician assistant/$20 GP/$20 Ob-Gyn/$60 specialist/$20 physical therapy co-pay per monthly premium paid
b. (5%) a second office visit with a $10 physician assistant/$20 GP/$20 Ob-Gyn/$60 specialist/$20 physical therapy co-pay per monthly premium paid
A policy buyer may refuse to take subsidies for office visits, pay for all months of the policy and then get a prorated, insurer-set ~60% premium amount rebate for unused visits two months after the policy ends,
subject to payout stage prorating to prevent insurer claim payout loss on the particular coverages.
[If the second premium amount was $30/month and seven visits were unused, then a $126 rebate would be payable.]
c. (.5%) one office visit with a $10 physician assistant/$20 GP/$20 Ob-Gyn/$60 specialist/$20 physical therapy co-pay per hospital daily co-pay promptly paid
5. other (minimum Medicare Part B scope, excluding Part B drug treatment) in-network outpatient care
a. (6%) all but Part B amount co-insurance of the first $1,200 (based on Medicare pricing)
b. (4%) all but Part B amount co-insurance, with an insurer-set (minimum $3,000) annual payout limit
A policy buyer may refuse to take subsidies for this coverage, pay for all months of the policy and then get an insurer-set ~60% premium amount rebate prorated on the first $500 of coverage unused two months after the policy ends,
subject to payout stage prorating to prevent insurer claim payout loss on the particular coverages.
[If the second premium amount was $20/month and only $200 of the coverage used, then an $86.40=(.60*$20*12*($500-$200)/$500) rebate would be payable.]
6. drugs, with insurer-set co-pays/co-insurance no more than the higher of $4 or 20% of a typical cost of a prescription or treatment episode
a. basic plan drugs selected by the insurer, eligible for
(monthly basic drug coverage subsidy amount) premium subsidization
if the drugs are bought by the insurer on a percentage of basic plan coverage premiums paid basis
with a total drug cost of at least 130% of the federal drug subsidy amounts
[It is impossible to lose money on basic plan drug coverage, so most drugs will be stuffed into it.]
b. (4%+.8*the covered person's basic plan reduction amount) other medically essential drugs, including administration,
with an insurer-set ($10,000 minimum) annual payout limit**
7. (1%) emergency terrestrial ambulance service, at least at 50% of Medicare allowable amount, with an insurer-set ($600 minimum) annual payout limit, doubled if the total balance is paid in full
*These percentages to be multiplied by the covered person's age in years at the policy coverage begin date divided by 65. Young people are not likely to need cancer surgery, nursing home rehabilitation or Part B cancer drugs.
**If an FDA-approved medically essential drug is:
a. a recombinant drug with worldwide sales of less than $50 million in the penultimate fiscal quarter, or
b. an anti-neoplastic drug with an FDA indication against the covered person's cancer
proven by clinical trial to add at least 60 days of life expectancy in at least 20% of cases against that type of cancer,
the policy drug annual payout limit may be bypassed once during the policy term
upon the signed written request of the covered person and of a treating, licensed prescriber not financially related to the drug supplier
upon a form to be prepared and made available on the HHS website by the Secretary of HHS
if the supplier(s) of the drug agree(s) to pay all future related rebates and financial incentives to the insurer
and agree(s) to meet (and meets) the covered person's future need for the drug for the remainder of the policy year
in exchange for monthly payment amounts chosen by the insured paid first to the insurer supplemented by monthly payments
by the insurer of four times as much (but each no more than of 10% of the policy drug annual payout limit amount)
[On a policy with a minimum $10,000 drug coverage annual payout limit, the insured might have to pay $200/month.]
[If I was to offer you a carrot wrapped with $10,000 in Benjamin Franklins, you'd grab it.]
The federal government would reimburse the "insurer" for 90% of any remaining non-drug net claim payout losses on upfront fee pre-existing condition waiver policies.
[It's not 100%, so insurers will have to work to get good pricing. The 10% will have to be made up by charging regular customers slightly more.]
The federal government would reimburse the "insurer" for their net claim payout losses on coverage for other medically essential drugs at the rate of 80% for the amount matched by unsubsidized premium payment amounts and 70% for the balance.
[These reimbursement rates may seem excessive, but they pay for high-cost drug use that is the most costly pre-existing condition problem.]
PGQ insurers must mail, at least three business days apart, or text or e-mail a policy number and a password to the policy buyer within seven days of purchase to allow the policy buyer to selectively cancel by automated means default coverage, except for EMTALA care, down to a minimum 50% subsidy coverage level prior to the policy term. Such canceled coverage need not be reinstatable.
Such unwanted default coverage must also be deletable via all electronic means of making the first premium payment.
Plans would have a total annual limit set by the coverage provider, with a minimum of $50,000.
[The $50,000 would be enough for about two operations or the labor cost of one organ transplant.]
It shall only be possible to enroll during a PPACA special enrollment period.
Unless a person had PPACA qualified coverage at the time of enrollment, a person:
a. might have to pay a $2,000/($725 if a Lifeline/Obamaphone customer/program eligible household member) fee upfront (or as otherwise agreed) to the "insurer" to have:
I. pre-existing condition & non-EMTALA inpatient coverage within 280 days of policy purchase
II. Medicare Part B scope outpatient care, other than for office visits, within 90 days of policy purchase
[Note: the fee could be income-based and initially payable to the federal government, which has income tax information.]
b. may be unilaterally denied any insurer prior approval drug
c. may be unilaterally denied any other medically essential drug not in the insurer's basic plan
Policies may have a per-admission hospital inpatient deductible of up to $5,100,
to be decreased .5% and rounded down to a dollar multiple each day of coverage under the policy
after the first month down to no more than the annual Medicare Part A deductible amount.
[It would go to ~$4,400 in two months, ~$3,500 in three months and ~$2,500 in five months.]
[A high initial deductible is needed to more fairly deal with mandatory issue abuse ]
[ and sick people with Obamacare high-deductible "junk insurance" too expensive to use.]
[A $5,000 amount is a common PPACA bronze plan deductible amount, so don't have a cow, it could be costly, see below:]
In cases of birthing:
a. the applied deductible shall never be more than 60% of that hospital inpatient deductible
b. no deductible will apply to birthing admissions more than 290 days from coverage purchase or if the upfront fee was paid
An insurer may lower per-admission hospital inpatient deductible for a covered person based on their prior coverage.
For any month, if a person had EMTALA scope coverage plus other coverage with subsidy percentages totaling at least 24%, the coverage shall be considered qualified for PPACA penalty purposes.
[Of course, the whole unconstitutional PPACA penalty stuff should be totally tossed, but that probably isn't going to happen during the term of this RINO-run Congress.]
Note: To maintain the demand for PPACA coverage, some people other than myself might want to limit the availability of PGQ policies to those who have lacked coverage since 2015.
I ask Senators Nelson, McCain, Collins, Murkowski and others, why can't I, who hasn't had health insurance since 1994, buy such insurance?
Thousands of desperately sick protestors, whipped into a fury by Democratic demagogues, should not be allowed to deny affordable, potentially life-saving coverage to tens of millions of Americans.
People like me should not die or lose our homes to hospital bill collectors simply because Democratic "community activists" know how to stage protests.
My proposal is smaller - catastrophic medical coverage. I read last week that an individual high-deductible catastrophic medical insurance plan would run about $30 a month for a $1,000,000 plan that starts perhaps after the first $50k. That covers everything beyond what a working person can take a loan for - true insurance and nothing else. If FedGov is going to get involved at all, that is the most they should be willing to mandate.
If President Trump wants to increase the number of people with insurance, he should require that, and I’d bet he would have a lot of takers even among the young and healthy if insurance companies were allowed to set rates based on age and health. Don’t require me to buy coverage for birth control pills, no more than I’m required to buy car insurance for gasoline. If government is going to overreach at all, that is more than enough.
You lost me on “...with the federal government generally paying...”
What do both of you do with people who won’t pay anything—real freeloaders?
Do you allow tiers of private coverage on top of the public coverage?
“Do you allow tiers of private coverage on top of the public coverage?”
One would be perfectly free to buy the $50,000 to $1 million top-up coverage already recommended by someone here.
Yes, give people choices.
Emergency Medicine for max 3 days and only that . . . should be one choice?
Premium of every Adult covered should be adjusted for lifestyle, smoking, drinking, drugs, promiscuous sex, race care driver, risky life style.
“You lost me...”
The federal welfare state isn’t going away soon.
To make it go away would require at a minimum the repeal of the general income tax on the middle and working class people of the USA plus trade reform to give the welfare class sufficient job opportunities. Think of the 1834 Poor Law reform that was enabled by the English Industrial Revolution.
I hope my type of policies would be so effective and so popular that total federal health care coverage subsidies could be reduced.
“What do both of you do with people who won’t pay anything—real freeloaders?”
My personal preference would be to repeal the EMTALA, but that isn’t going to happen with our RINOs.
Perhaps their housing voucher, food stamp, EIC, etc. amounts could be debited to pay their share of future premiums after an unpaid hospital visit.
Hospitals like to get the deductible paid before arranging for the pain doctor to see the patient.
“Premium of every Adult covered should be adjusted for lifestyle, smoking, drinking, drugs, promiscuous sex, race care driver, risky life style.”
Smokers and drinkers are already paying sufficient adjustments via excise taxation prior to about age 60.
As for the race car driver, the auto insurance company often is making the essential adjustment.
Adjusting for illegal drugs and promiscuous sex is not practical.
Many HIV drugs are or soon will be off-patent.
I have proposed unhealthy food taxes, but no one here seems to want them but me.
You keep posting these hair brained useless suggestions
You obviously have never used Medicare. If you want to know what it’s like ask any doc or nurse. The reason ordinary patients pay so much is to make up for the losses on Medicare patients
“smoking, drinking, drugs, promiscuous sex, race care driver, risky life style”.
You forgot obesity and eating habits-sugar consumption, etc-and gun ownership-there is no reason for a private company or anyone else, for that matter-to have info about your personal life when you are PAYING for their product at the quoted price-that is why there are shared risk pools and why it is called “insurance”-the government has no business in it at all...
As a workers comp case manager, I can assure you that risky and dangerous occupations must pay higher rates than cubicle and sales jobs-race car drivers already pay more for insurance, too if it is their profession-I believe charging more money based on a person’s personal life is discrimination, never mind your personal life is no one’s f’ing business in the 1st place...
I’m all for cafeteria plan insurance-buy what you want today, change it up or down tomorrow if you decide to, paying accordingly more or less-that is how competition works-you are the customer, so you shop for the best deal...
“Don’t require me to buy coverage for birth control pills”
You can drop all types of drug coverage.
My plan covers things by default:
1. to satisfy the Maine senators and
2. to refute the Democratic claim that people are losing coverage by requiring people to choose to drop coverage
3. to make broader coverage more attractively priced.
However, my plan reapportions subsidy money to make basic drug coverage very attractively priced. Most pre-existing condition problems involve drugs.
The basic plan drug coverage is intended to include almost all drugs insurers think are good deals.
Young women generally will not buy coverage without birth control pill coverage. Most young men won’t retain the drug coverage. To give the young men a price break would not fly politically. To give people a price break if they don’t use the basic drug coverage is possible.
Most of the expensive drug pre-existing condition problems are dealt with by the 80%/70% federal reimbursements for coverage provider losses.
Medicaid and Medicare both exist. The question is not what to do with the poor or the elderly; that is (more or less) decided. The question is what would be sufficient for everyone else. If the public mandate is for catastrophic coverage, anything beyond that is a choice.
If someone who chooses no additional coverage wants birth control pills, they can pay for them or not get them. If someone with no additional coverage wants any other non-covered elective drug or procedure, the same answer applies. Private coverage should be allowed, just as all other private contracts are allowed.
“You obviously have never used Medicare.”
I live in Florida. My older relatives have used Medicare. It has worked quite well for them.
Most of what is lost on Medicare is due to fraud such as double billing, unnecessary tests other overcharges by the doctors and other providers-you are telling Noah about the flood...
Birth control pills save insurance plans money, making insurance premiums cheaper.
Births and congenital surgery are expensive.
Pills are made in factories and are cheap. Bangladesh offers free birth control pills.
“You keep posting these hair brained useless suggestions”
I have done my best. Feel free to do better.
It’s not as easy as you think - ask the Republicans in Washington serious about reform.
“You obviously have never used Medicare. If you want to know what it’s like ask any doc or nurse.”
My neighbors have both worked in the medical trade most of their working lives and are now on Medicare, Tricare, etc.
Mrs. Democratic Neighbor thinks all of us should be on Medicare.
That is an economic point and a good one, but it is not relevant. Saving private companies/individuals money is not the proper role of government. BC pills would not save catastrophic coverage plans money. Medical insurance is an economic transaction, and it should be up to the customer and the insurance company what is and what is not included. FedGov should not be involved at all. If they are to be involved, requiring catastrophic coverage should mark the upper limit of that involvement.
“I’m all for cafeteria plan insurance”
What I’ve done for office visits and outpatient care is to keep the benefits reasonable and to provide partial rebates.
This makes their coverage more like bulk purchasing deals than insurance, making picking and choosing both possible and fairly fair.
I’ve added coverage based on hospital co-pay days in case people need more office-based care.
Too Complicated.
Since we have broken the constitution and mandated insurance, let the market solved the problem.
No mandated benefits. Set the basement as the insurance company pays 0% and catastrophic coverage for anything over $25,000. For the young and healthy, paying the insurer negotiated rates would save them 50-80% compared to uninsured medical costs. $25,000 is not an insurmountable debt for a young working person. The combination should be very affordable.
For pre-existing conditions, I would not be adverse to a temporary subsidized high risk pool.
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