Thursday, October 13, 2016

A Bit More on the Health Care Topic

There is growing alarm at what may be happening to Obamacare premiums with the coming year. In some jurisdictions they are predicted to rise exponentially; in other jurisdictions, carriers are pulling out of the market because -- they say -- they can't make a profit.

"They can't make a profit." Oh, too bad, so sad. In fact, this is an all-purpose but unverifiable excuse for ceasing coverage of undesirable customers, in unfashionable areas, and otherwise going back to the previous selective model of patient coverage or non-coverage as the case may be. We don't know the details of insurance companies not making a profit under Obamacare. Where does the money go?

Under Obamacare, they've been able to charge high premiums and keep raising the premiums year by year; they've been able to charge high co-pays and high deductibles too, effectively ensuring that they don't pay out anything for most patients most of the time, but they are able to collect extraordinary amounts of money from those patients month by month.

It's been a tremendous boon to the health insurance cartels, and yet they whine that they can't make a profit and must raise premiums and deductibles beyond any rational measure, or they must leave the Obamacare marketplace. Well, good riddance.

My own suspicion is that this is a pre-planned move to enable the long-delayed single payer health insurance/health care provision for most patients while reserving private insurance for the most well-off.

There are several single payer models already in operation in this country: VA-Tricare/IHS/Medicare/Medicaid/HMOs and PPOs. They all provide relatively low cost, relatively decent and accessible health care to a variety of constituencies. (HMO and PPO can be very expensive or not so much depending on which constituency category you're in.)

Expanding each of them or all of them to provide essentially universal coverage and access to health care would be a fairly simple task. It could have been done long ago, but the for-profit model of health care coverage was paramount.

And so, no. The simple fix was endlessly delayed.

But in my view, Obamacare was meant as a stop-gap at best, and it functions as something of a pre-paid payoff to the insurance cartels. They've been paid hundreds of billions of dollars over the last few years while providing little or no actual coverage for most patients who essentially pay out of pocket (subsidized or no) to the cartels, and pay extraordinarily high deductibles and co-pays, which limits insurance company exposure to essentially nothing at all for most patients. Yet they whine and whine that they can't make a profit. Well, too bad.

Except I'm sure they were quite aware of the ultimate goal: single payer and universal coverage. The private insurance market and for profit model can't provide universal coverage, and we see under Obamacare, it essentially doesn't provide any coverage for most patients most of the time. They pay the insurance cartels a monthly fee (whether subsidized or not) and they pay out of pocket for all their routine care. Thus most households actually never receive any benefit from their health insurance at all.

The definition of a scam, right?

But we see the same thing throughout the for-profit private insurance business. Most of the time, the insurers receive regular payments from their clients while paying out nothing at all on their behalf. And when they do pay something, it is generally only after the client has paid much more in premiums and deductibles.

In the for profit health care insurance model, however, everything is taken to an extreme. Monthly premiums totaling ten thousand a year or more are common; deductibles of $5,000 or $6,000 on top of premiums are also common, so for many households, out of pocket health care expenses of $15,000 to $20,000 before insurance pays a dime on their client's behalf is routine. Of course, most people won't have $15,000 or $20,000 in annual health care expenses, ever. So insurance will never pay anything on their behalf, ever. And they can't make a profit under the circumstances? Well, isn't that special....

But I think it is intentional and pre-planned. In some places, insurers have been pulling out of the market; that trend seems to be accelerating. In some places, remaining insurers are jacking up premiums by up to 60% and more. At the same time, they're cutting coverage to the barest minimum. So they're seeking greater up front payments while reducing the risk of payout (already low) to practically nothing.

Why should people even bother under those circumstances? But isn't that the intent? Make a product that costs a fortune but can't be used, and watch the customers turn their backs or complain so loudly that something must be done. Well, something can be done, and that is to jettison the for profit insurance model for the majority of people and reserve it specifically for an upscale clientèle who will cheerfully pay through the nose so long as they are assured special access and special care whenever they so desire.

Leave the Rabble to the expansion of one or another single payer system that provides basic care at relatively low cost, places limits on access, but can keep them (the Rabble) from spreading their diseases to the Overclass, and can keep them well enough long enough to be useful to their Betters.

Win-win, right?

That's where this has  been headed all along, I think.

Just as a note, I've had HMO coverage for decades, first with Kaiser in California and now with Presbyterian in New Mexico. I ran into some serious issues with Kaiser when I presented at the ER with pneumonia and they suspected I had tuberculosis -- because their flow chart red-flagged New "MEXICO" when they asked where I'd traveled. Even when I explained over and over again that I had never traveled to MEXICO, it didn't matter. I was red-flagged as exposed to tuberculosis, and that was that.  (Albeit, I did have some symptoms consistent with tuberculosis because I had gone untreated for pneumonia for two months...)

Kaiser HMO coverage cost about $1,100 a month, all but $400 or so was employer paid. It seemed remarkably high since I rarely used it. There were no deductibles, and co-pays were low, in the $10 range for routine care; nothing much over $75 - $100 for specialist/outpatient care. I insisted on being treated as an outpatient for pneumonia. If I had agreed to be hospitalized, there would have been no out of pocket cost. As an outpatient I was charged a co-pay of $10 each time I saw a doctor. There was one specialist I paid $100 to. There was a $4 charge for each prescription I took during the course of treatment.

It was generally quick and easy to see providers when necessary. But I rarely had a need. So, apart from the bogus tuberculosis diagnosis and very poor treatment in the ER that time, I had few complaints.

I currently have a Medicare Advantage plan through Presbyterian Healthcare in New Mexico. This requires some travel, as there is no Presbyterian facility nearby -- the closest is 17 miles away, but I use facilities in Albuquerque, 40 miles or so west since that's where my doctors are.

Doctors, plural. Right now, I have a primary health care provider -- who I haven't seen for months because I'm under specialist care: a rheumatologist, a hematologist/oncologist, and a pulmonologist.

Labs are no cost, and I get blood drawn at least once a month to monitor my condition(s). Specialist visits are $50 co-pay. That added up the first couple of months I was seeing specialists, but now it's only every three to six months for each one. There's a $5 co-pay to see my PCP. I had a CT scan which is normally billed at a $300 co-pay, but because I had it at their hospital, my co-pay was only $108, as it was billed at inpatient rates which are lower than outpatient rates.

If I need hospitalization, there is a $325 per day co-pay -- for the first three days. After that, no charge.

Prescription coverage is included, but it's hard to figure out just what the charge will be, as there are five tiers, and there is a gap in coverage when total cost for prescriptions is over $3,700 (or something) -- and I'm pretty close to that now.  One of my prescriptions is over $355 a month and another is close to $600 a month of which I would pay 40%.  If I take them both next year, I will be well into the coverage gap by summer, and that will increase my co-pays from about $140 a month for all prescriptions to around $700. Oh boy.  After total payment for prescriptions reaches $4,950, my co-payment drops to 5% of the cost of medications or less, depending. Since it won't take that long to get there... I guess that's good.

Access to care is somewhat dicey due to communications problems between providers... yet once we figured out what the hang-up was, things smoothed out a bit, and once I saw the specialists, followup was relatively easy, and contact and communication is relatively swift and sure. Haven't used the ER, so don't know how that would work. (There's a $65 co-pay if I wind up in the ER.) Ambulance service is included ($75 co-pay) which apparently includes ground ambulance from out here in the country where I live to a hospital in Albuquerque or in a serious emergency, helicopter ambulance to ABQ at no additional charge.

I can use an out-of-network urgent care clinic here without going to Albuquerque in most cases ($65 co-pay) and without getting pre-approval. If I use the Presbyterian urgent care clinics in Albuquerque (but that's 45 minutes away, not exactly "urgent") there's no co-pay.

There are endless other charges and details, but that's the basics of it. All I pay monthly is whatever Medicare premiums are ($106 a month right now I think, what they will be next year hasn't been announced yet.) 

So it's a pretty good deal all things considered, but it costs a lot more than Ms Ché's coverage which is through IHS and Medicare. She pays nothing for prescriptions, nothing for care directly through IHS, or First Nations clinics, and she pays the standard Medicare 20% co-pay for specialist care outside IHS. She has to go to Albuquerque too, because that's where the IHS facilities are, but she also gets care at UNM hospitals and clinics in ABQ, and at First Nations clinics in ABQ. This totals a few hundred dollars a year for her care in addition to Medicare premiums, whereas my care is costing a thousand or more out of pocket on top of Medicare premiums. (This year, I'm anticipating about $1,600 out of pocket.)

It's not a bad deal considering how much others are paying out of pocket with essentially no insurance contribution at all.

But it could be so much simpler for them if they were part of a single payer program that actually covered most medical expenses.

That, I think, is coming and not too long in the future. However, it will take a Nixon in China moment, and of the two candidates for president (who have a chance to win) Hillary is probably the one to do it -- because of her long-time "no you can't" and "it will never happen" statements about it. Trump says a lot of things, none of which seem to be operative for more than a few minutes, but his "plan" has always been Obamacare "repeal and replace" with no specificity of what to replace it with, just that it will be "wonderful."

The fact is private for profit insurance doesn't work for universal coverage -- it can't. The for-profit model of health care will have to be ditched if universal access and coverage is the goal. The end of the Obamacare for profit model is just about nigh. The only rational replacement is single payer, and that is what I predict will happen sooner rather than later.

No comments:

Post a Comment