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.

“Medicare is the VA on steroids”

You need to read:

“Americans With Government Health Plans Most Satisfied”
http://www.gallup.com/poll/186527/americans-government-health-plans-satisfied.aspx

As I said, I have yet to use it, or my Tricare secondary insurance-don’t plan to unless I sustain a serious injury at work or some such-and since I’m the one responsible to the contractor I work for-overseeing jobsite safety is part of what I do-it wouldn’t be wise for me to do something stupid myself...

Not only is it done by people with money, but it is also often hidden in the coding, so that the $$$ for a major and more expensive procedure is paid out for what actually was a minor and much less costly one-it nearly happened to my guy a few months ago-on the copy of the bill he got, somehow a backyard mishap-getting a stepped-on piece of railroad tie removed and foot stitched had morphed into a surgery complete with another consulting physician-to the tune of $7500. He said this is too weird, and showed it to me.

I told him call your secondary insurer and give them the code numbers on all line items-he did, the insurer went apes***, thanked him and filed a complaint-you see that happen all the time with workers comp billing, too. If I were king, I’d not only fine the fraudsters, I’d have them en la carcel, tambien...

I would also love to have cafeteria plan Medicare, too-damn near everyone I know never or barely uses it-healthy lifestyle and working hard is more common in rural areas-most of us pay cash, don’t get drugs and would likely only use catastrophic coverage-so we should be able to buy just that.

You never stop paying for Medicare-that is what pisses many of us off-I payed for it all the time I worked for someone else, and I still do working for myself-whether you work or not, it is deducted from your SS check-or in my case, my SS benefits as a widow. I’d be more than willing to pay more for private, cafeteria insurance coverage that I-NOT the government-choose...

You don’t get it

Medical care should not be the preview of the government. Let the free market deal with it

Single payer is a disaster. You are dealing with insurance not health care

You have the same mind set as McShamey

No you need to quit pushing single payer

Why the heck are you on FR?

Move to Canada if you wNt single payer

+1. I don’t understand his posts. Read post 49 and tell me what you interpret it to imply.

If my greed is focused on another group at their detriment then it is immoral.

I just can’t see another side to it.

The reason ordinary patients pay so much is to make up for the losses on Medicare patients.

There are more loses on "Medicare" patients than on Medicaid patients?
Or dazzled and blinded by all the BS, did you actually intend to say "Medicaid???"

I double down on my guess that you are a Jonathan Gruber Wannabe....

Do you have a copy of the Gruber fold-out?

I guess I better start re-reading this entire thread from scratch tomorrow.

If there was a Gruber fold-out mentioned anywhere I must have missed it...

49 is in response to his post at 40

His posts only make sense if he was at DU

He seems to think that if we don’t go single payer no one will be able to figure out their own health care.

His analogies are pointless

Your first guess is at least correct.....

How am I a Gruber wanna be? I hate govt involvement in health care. The fraud of both Medicaid and Medicare is hurting true health care

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