My Proposal for Near Medicare-scope, Lower Cost Coverage Policies for Long-Term Uninsured Americans

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.]

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.

“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.”

If you see my home page here, that is what I have advocated and still do.

However, once the federal government subsidies coverage, then rigid rules are needed for subsidized coverage.

The Comcast Cable and McDonald’s Food Plan need not apply for federal subsidy listing.

“let the market solve the problem”

The problem mainly is the federal government Article I, Section 8 patents that make drugs expensive and account for ~80% of the pre-existing condition problems.

If the federal government doesn’t cough up the bucks to keep Mr. Drug User supplied with patented drugs and alive, some leftist judge will Roe v. Wade the federal patent system for drugs.

In 2012, the Chinese government declared drug patents to be allowable only in the national interest - i.e. the patented drugs generally had to be sold below cost of possible pirate copies.

“people had to pay for their elective office visits, check-ups and drugs”

For 80%+ of covered adults, each office visit will have a substantial cost both in a co-pay and a loss of rebate money.

Many young men won’t retain the office visit coverage.

Here’s the question:

Whatever your plan is. Whatever it covers, or doesn’t. Whatever the re-insurance mechanism is, or isn’t.

Will you allow non-payers to be turned away, and will you allow non-payers who get less than payers do to sue?

I don’t think it will only be young men who don’t buy that-I realize not everyone wants to live a natural lifestyle-without processed food or any drugs, doc visits only for real illness or injury, etc-but there are a lot of people like me out here who do just that-we pay concierge for minor emergencies, elective stuff, etc, too. I’d like to see insurance that would pay for some natural remedies to be tried before drugs for those of us who chose that-it is probably safer and certainly less costly.

The only 2 doc-in-the-box places in this county that have stayed in business have both a D.O. who is into naturopathic cures and an acupuncturist on staff-both places are owned by the same Chinese doc. The only surviving drugs-all-the-time clinic is being closed and investigated for overprescribing psychotropics and opiates to doctor shoppers and others-talk about using the insurers for an ATM...

I couldn’t agree more-as soon as everyone realized that we’re not all going to die because the govt is not holding everyone hostage, they would calm down and like it...

I’m technically “old”-and I don’t take drugs or go running to docs-even people in their 80’s run their own ranches and businesses here-so the “old” in BFE aren’t elevating risks and costs-but you don’t see many overweight people of any age out here either...

Medicare is nothing but a racket and a hog trough for a chosen few-and not only to you pay into it all your working life, you continue to pay in after 65 via deduction every month from your SS check for the premium. I have Medicare with Tricare as my secondary-Tricare is very careful about keeping you from being screwed, even if Medicare is not, and will tell the insured person if they are being scammed. However, I’ve never used either one, don’t intend to unless I’m dying-if I want something elective, I’ll pay concierge as I always have-it is way, way cheaper, I get personalized service and there isn’t a book of paperwork that puts my info out there...

I’m not rich-just a working class person with a working class income living in a rural area with the same class of people...

Actually, MrT5 was career military-so Tricare/Tricare for life are my benefits as surviving spouse of a service member-and he always appreciated being thanked for his service. One of the underwriting agencies of Tricare also underwrites a part of the secondary insurance retired LEO’s and firefighters in some cities get as a benefit-my guy-a retired LEO working now as a private consultant-has it. They are just as vigilant as Tricare is in protecting the insured from being cheated or scammed.

“Medicare is nothing but a racket and a hog trough for a chosen few”

Medicare works well for most covered persons.

There is fraud in the billions, perhaps about 1 to 2% of the total program outlays.

This fraud is generally done by people with money and it could be recovered often if companies could get a paid a percentage of recovered amounts, payable by the fraudsters.

“Will you allow non-payers to be turned away”

Deductible collection will be up to the providers, doctors, hospitals etc.

As for premium payments, from my standard plan at my home page:

“POLICY PAYMENT PROVISIONS

“Unconditional state/hospital premium payments, partial or full, [to subsidize or prevent loss of coverage] shall be accepted by ‘insurers’.

“A coverage provider may otherwise discontinue coverage if any amount in excess of $60 for a policy is then more than fifteen business days late.

“A coverage provider may loan premium payment money to their policy holders whose coverage they may otherwise terminate at an interest rate not to exceed the IRS rate and with all other financial impositions not to exceed $20 per premium payment amount due not timely made.

“After 2018, deposits may be made, up to a total of 13 times the policy’s monthly premium (less the last federal subsidy received on the policy under this act) with the ‘insurer’, as the ‘insurer’ and Secretary of HHS shall specify.

“Each such deposit shall be held in trust for the ‘insurer’ (and for the depositor, after the policy term,) and shall not be subject to non-federal garnishments of any kind.”

I know almost none of you like proposals of more than one page, but I have made multi-page proposals so you can find out my thoughts on a subject.

“How about reimbursing your doc twenty dollars for a visit? ....
Medicare under pays horribly. It is why so many docs no longer take such patients”

My proposal only limits what the covered person would pay, not what the doctors get paid:

“all but Part B amount co-insurance of the first $1,200 (based on Medicare pricing)”

That $1,200 of Medicare equivalent care might actually cost a total of $1,600, with the covered person paying a total of $240 and the insurer paying $1,360.

If in your area, the insurer share would cost $1,550, then expect to pay higher premiums than in most of the rest of the nation.

If you were a woman running a doctor’s front desk, you would not want to spend two minutes finding a particular insurer’s patient payment share amount book and then another two minutes finding the proper amount for the service.

I piggyback on Medicare rules to save people time and needless aggravation.

“I have an idea why don’t we get the government out of healthcare retirement and income redistribution. Let people keep what they make.”

Doors and dinner plates of places where children live and eat might bear this notice:

By taking food, medical care and housing that we have worked hard to pay for, you agree to provide for our food, medical care and housing costs once we reach age 65.

Doors of places where children might go to school might bear this notice:

The Red Wing School District no longer provides “free” education. Please ask your parent or other older person to pay tuition in exchange for support in their old age. The current market rate runs about $2/month after age 65 for each month of schooling. People who live debauched lifestyles reasonably expect about $4/month since they will die sooner.

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