Question about Obamacare

[Tender Branson]

So, I didn't spend too much time following US politics in the last months because of the Austrian and German elections, but recently I read an article that the Obamacare website was launched and broke down right after it started (which is bad, because the people behind it could have known that millions will hit the page within a few hours after the start and the US has one of the best IT people out there who could have tested the page before the start ...)

But that's not what I'm interested in really:

After looking through those "marketplaces" (weird for an Austrian who has the evil socialist health insurance) where you can "shop" for individual "plans", I was reading something about "Bronze" plans, "Silver" plans, "Gold" plans and whatever other metal there was.

So, if you earn only a little each month and want the basic "Bronze" plan, you have some basic stuff/care included ? Are frequent surgeries included as well, because that's not what I found in the "10 essential care things" in the bronze plan.

I've also read that even though you HAVE a bronze plan, you still need to pay 40-100$ all the time you visit a doctor ? WTF ?

Can anyone explain this to an Austrian with an evil socialist health insurance where you don't have to pay anything to go and see a doctor or for repeated surgeries ?

I've also read that there are high "out of pocket costs" if you only have the "bronze" plan, while paying a lower share of monthly premiums (but still about 50-200$ a month).

Yet when you have a "platinum" plam, you have almost no "out of pocket costs" - but pay higher premiums.

If you already pay a monthly premium of 50-200$ a month on health insurance, why would you still have to pay ridiculously high amounts of "out of pocket costs" ?

How is that fair ?

Wouldn't it be better if everyone gets the same health care services (and by same I mean all), no matter if you pay a health insurance premium of 100$ a month or 500$ a month ?

...

Well, in the case of the US I guess it's a start for the 50 Mio. or so without insurance and better than nothing.

[Knives]

Adding to the questions, what does it exactly change about the way the healthcare system runs? (exclude bias) I'm asking because whenever you search for answers it's always like 'lines will increase' or 'poor people will now be better off' my question is simply what changes not what the results would be. Thankyu

[Franzl]

From what I understand (admittedly, it's not something I've followed very closely), not a whole lot changes except that Medicaid is expanded and subsidies are increased for low income people in need of insurance. And of course that people are obligated to be insured (otherwise forcing insurance companies to accept everyone wouldn't be a great idea).

Regarding the "insurance plans", that's just the worthless American health insurance for you. That's not only in ObamaCare, I know several Americans that are provided "health insurance" that includes co-payments of hundreds of dollars for relatively routine procedures.

Of course it's terrible, but it's not as terrible as if you have 20% of the population completely uninsured.

The truth is that the American healthcare system is a catastrophe for most people that aren't quite wealthy.

[7,052,770]

The idea is that everyone needs to have some "skin in the game," or else they'll always go to the doctor for every little sniff or bruise.  Therefore, there are 4 metal levels - bronze, silver, gold, and platinum - and you can either pay low premiums and high OOP costs at the doctor, and a sliding scale to high premiums and low OOP costs.

If you know you're going to be going to the doctor a lot and will hit your deductible and OOP max, it makes more sense to go on and pay the higher premiums and get a platinum plan.  If you are healthy and the type who hates to go to the doctor even if you're sick, it might make more sense to buy a bronze plan.

However, unless you're poor*, you're going to be paying deductibles and copays so that you still have to pay something, which incentivizes only going to the doctor when you actually need to.

*--People who make less than 250% of FPL, if they buy insurance on the exchange, get their copays and deductibles subsidized by the government in addition to their premiums.

[Mr. Morden]

Adding to the questions, what does it exactly change about the way the healthcare system runs? (exclude bias) I'm asking because whenever you search for answers it's always like 'lines will increase' or 'poor people will now be better off' my question is simply what changes not what the results would be. Thankyu

The basic idea is that:

1) Everyone is required to buy health insurance.  (Though many/most people with a job will still get it through their employer.)

2) The insurance companies are now required to take you on as a customer, regardless of any pre-existing conditions you have.

3) Low income people who would otherwise have trouble affording insurance are given subsidies to help pay for it.

[DC Al Fine]

So, if you earn only a little each month and want the basic "Bronze" plan, you have some basic stuff/care included ? Are frequent surgeries included as well, because that's not what I found in the "10 essential care things" in the bronze plan.

I've also read that even though you HAVE a bronze plan, you still need to pay 40-100$ all the time you visit a doctor ? WTF ?

Can anyone explain this to an Austrian with an evil socialist health insurance where you don't have to pay anything to go and see a doctor or for repeated surgeries ?

I've also read that there are high "out of pocket costs" if you only have the "bronze" plan, while paying a lower share of monthly premiums (but still about 50-200$ a month).

Yet when you have a "platinum" plam, you have almost no "out of pocket costs" - but pay higher premiums.

If you already pay a monthly premium of 50-200$ a month on health insurance, why would you still have to pay ridiculously high amounts of "out of pocket costs" ?

How is that fair ?

Wouldn't it be better if everyone gets the same health care services (and by same I mean all), no matter if you pay a health insurance premium of 100$ a month or 500$ a month ?

As Harry said, the idea is that you have some skin in the game so you don't overvisit the doctor (a somewhat common problem in the Canadian system).

Another reason for the co-pays/deductibles is that you can reduce your premiums by bearing some of the risk yourself instead of offloading it all on the insurance company. I do it on my car insurance and it works fine. I keep my high deductible in the bank and my insurance is much less. It paid for itself after 18 months or so.

The problem is of course, that poor folks won't be able to bear the deductible but will choose to take on the risk anyway to get a lower payment. This might be an issue depending on how high the "Bronze" deductible is or if the coverage is much less than the standard "Silver" plan. Could one of the Americans elaborate on the differences between the plans?

[muon2]

When we talk about health insurance, we are actually conflating two different aspects of health care management. One aspect involves the risk management, the traditional role of insurance. This part of a plan involves the unlikely but costly need for medical procedures like surgeries and serious illnesses. The other aspect involves budget management where one might anticipate a certain number of medical expenses for wellness care and minor illnesses over the course of a year.

The different plans allow the user to balance these two aspects. A person who is willing and able to handle their own budget management can opt for bronze and just cover their risk. Another person who has more budget constraints or has a more uncertain budget might choose a higher level plan.

An analogy with car insurance would be a bronze level plan with liability coverage only meeting the state minimum mandate for coverage. The silver plan might add collision coverage to the liability, but still have a significant deductible. The gold plan then adds a maintenance contract on top of the regular insurance for collision and liability. The analogy is not exact, since all levels of the exchange health insurance include some "maintenance", but it gives the idea. A better analogy would involve setting coverage and deductibles for all three parts of car insurance then prepackaging them into only four choices.

[Redalgo]

*--People who make less than 250% of FPL, if they buy insurance on the exchange, get their copays and deductibles subsidized by the government in addition to their premiums.

In some states. Mine does not allow subsidies for people making less than 100% of the FPL.

[7,052,770]

The metal levels are based on the actuarial value,  the percentage of medical costs the insurance company is expected to pay with that copay/deductible structure:
60 - bronze
70 - silver
80 - gold
90 - platinum

If you buy a silver plan, you can expect to pay around 30% of your costs yourself and the insurance covers the rest. This is of course just approximate.  If you get cancer and run up a $2 million bill, you'll meet your deductible and end up only paying maybe 2% of your costs that year. If your only claim is a couple of prescriptions,  you'll probably pay much higherthan 30%.  But overall, the aaverage person with a silver plan will pay around 30% of their medical costs themselves,  at least that's what the insurance company has designed

There's actually a 5th metal tier, catastrophic,  with less than 60% AV. It has much lower premiums, higher deductibles, and is only available to healthy young people.  It's probably not a very good buy, unless you know you can pay the deductible,  but if you want to risk it, it could save money.

[7,052,770]

*--People who make less than 250% of FPL, if they buy insurance on the exchange, get their copays and deductibles subsidized by the government in addition to their premiums.

In some states. Mine does not allow subsidies for people making less than 100% of the FPL.

Right. If you make less than 133% of FPL and your state doesn't expand Medicaid, you get nothing.  *facepalm*

Expect this to be a major issue in every governor election in the next few years.

[Redalgo]

Right. If you make less than 133% of FPL and your state doesn't expand Medicaid, you get nothing.  *facepalm*

Expect this to be a major issue in every governor election in the next few years.

I certainly hope so! I found out this morning the cheapest bronze plan I can get is from the MT Health Cooperative for $169 per month. It works out to being a $2.07 cut from every $9.21 I get per hour, gross, in wages. It's especially upsetting to me because I will still have to shoulder a 40% copay and would have the premium cut by a whopping 82% by government subsidies if I were to make just $2,500 more each year. If I can stop being underemployed soon it won't be a serious problem but otherwise this will deal a pretty fierce blow to my disposable income.

[Sbane]

*--People who make less than 250% of FPL, if they buy insurance on the exchange, get their copays and deductibles subsidized by the government in addition to their premiums.

In some states. Mine does not allow subsidies for people making less than 100% of the FPL.

Right. If you make less than 133% of FPL and your state doesn't expand Medicaid, you get nothing.  *facepalm*

Expect this to be a major issue in every governor election in the next few years.

I think the figure is 100% of the FPL from what I have read. I could be wrong though. They included the 100%-133% leeway because they knew some people wouldn't be sure of what their income would be, and if it went below 133% and they chose an exchange plan, they wouldn't get screwed. Of course they didn't account for the fact that Republicans are vindictive retards. Very unfortunate.

[Fmr President & Senator Polnut]

When we talk about health insurance, we are actually conflating two different aspects of health care management. One aspect involves the risk management, the traditional role of insurance. This part of a plan involves the unlikely but costly need for medical procedures like surgeries and serious illnesses. The other aspect involves budget management where one might anticipate a certain number of medical expenses for wellness care and minor illnesses over the course of a year.

The different plans allow the user to balance these two aspects. A person who is willing and able to handle their own budget management can opt for bronze and just cover their risk. Another person who has more budget constraints or has a more uncertain budget might choose a higher level plan.

An analogy with car insurance would be a bronze level plan with liability coverage only meeting the state minimum mandate for coverage. The silver plan might add collision coverage to the liability, but still have a significant deductible. The gold plan then adds a maintenance contract on top of the regular insurance for collision and liability. The analogy is not exact, since all levels of the exchange health insurance include some "maintenance", but it gives the idea. A better analogy would involve setting coverage and deductibles for all three parts of car insurance then prepackaging them into only four choices.

That's the issue for me... why the hell should it be that complex?

I have a private health insurance supplement to cover things that our system doesn't cover (unless you're young or really hard up) such as dental and optical, but I also have it for private hospital.

BUT, I don't think my private insurance is anywhere near that complicated.

Benefit : you can claim up to $xxx in a 12 month period and you will get back xx% of what you paid. Oh and pre-existing conditions are covered after 12 months.

I get Muon's point, but you can't really compare traditional 'insurances' like car and house and contents - because most people will only call on them a few times in their life... but most people are sick or require some cost-related health activity on semi-regular basis.

Mind you, the issue has to be significant cost controls, that is where a huge whack of the problem comes from.

[Sbane]

When we talk about health insurance, we are actually conflating two different aspects of health care management. One aspect involves the risk management, the traditional role of insurance. This part of a plan involves the unlikely but costly need for medical procedures like surgeries and serious illnesses. The other aspect involves budget management where one might anticipate a certain number of medical expenses for wellness care and minor illnesses over the course of a year.

The different plans allow the user to balance these two aspects. A person who is willing and able to handle their own budget management can opt for bronze and just cover their risk. Another person who has more budget constraints or has a more uncertain budget might choose a higher level plan.

An analogy with car insurance would be a bronze level plan with liability coverage only meeting the state minimum mandate for coverage. The silver plan might add collision coverage to the liability, but still have a significant deductible. The gold plan then adds a maintenance contract on top of the regular insurance for collision and liability. The analogy is not exact, since all levels of the exchange health insurance include some "maintenance", but it gives the idea. A better analogy would involve setting coverage and deductibles for all three parts of car insurance then prepackaging them into only four choices.

That's the issue for me... why the hell should it be that complex?

I have a private health insurance supplement to cover things that our system doesn't cover (unless you're young or really hard up) such as dental and optical, but I also have it for private hospital.

BUT, I don't think my private insurance is anywhere near that complicated.

Benefit : you can claim up to $xxx in a 12 month period and you will get back xx% of what you paid. Oh and pre-existing conditions are covered after 12 months.

I get Muon's point, but you can't really compare traditional 'insurances' like car and house and contents - because most people will only call on them a few times in their life... but most people are sick or require some cost-related health activity on semi-regular basis.

Mind you, the issue has to be significant cost controls, that is where a huge whack of the problem comes from.

I agree with things like copays, and the countries with universal health coverage really should look into instituting them. It makes you think twice about accessing healthcare. When there is a limited supply, it makes sense to make sure only those who really need it are accessing it. If you are just a little sick, maybe you should wait it out a couple days and take some OTC medications before you go to the doctor. In many countries there is no incentive for people to wait. Of course there should be an out of pocket cap to make sure sick people don't get hurt by this. Obamacare has it too, but disturbingly, only for in network costs.

[Fmr President & Senator Polnut]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

[Sbane]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

Hypochondriacs Polnut. And I hope I don't seem like an asshole, but sometimes people get a little too concerned about the kids. Especially if they want the day off from school.....

[DC Al Fine]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

Hypochondriacs Polnut. And I hope I don't seem like an asshole, but sometimes people get a little too concerned about the kids. Especially if they want the day off from school.....

Indeed, this is one of those "few people doing it a lot" problems.

[Fmr President & Senator Polnut]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

Hypochondriacs Polnut. And I hope I don't seem like an asshole, but sometimes people get a little too concerned about the kids. Especially if they want the day off from school.....

Is hypochondria really that big of an issue to structure health policy around them?

[Sbane]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

Hypochondriacs Polnut. And I hope I don't seem like an asshole, but sometimes people get a little too concerned about the kids. Especially if they want the day off from school.....

Is hypochondria really that big of an issue to structure health policy around them?

There is an overutilization of health resources, yes. People need to think twice about visiting the doctor.

[DC Al Fine]

For example - my GP charges $80 for a consultation and I get $36 back from Medicare.

One big reason for people going to the GP for less serious complaints is for medical certificates for work/school absences. The Federal Government passed a law two years ago to permit pharmacists to provide medical certificates for periods of no more than 2 days and they must be accepted by employers/schools.

Your point actually is more anecdotal, I don't know people who run to the doctor when they've got a cough or things that can be sorted out OTC or with rest.  The overwhelming majority of pay something in addition to their benefit. Granted, we're not on the same level as the UK... but even there, I don't know of anyone who has as lax an idea about seeing a doctor.

Hypochondriacs Polnut. And I hope I don't seem like an asshole, but sometimes people get a little too concerned about the kids. Especially if they want the day off from school.....

Is hypochondria really that big of an issue to structure health policy around them?

Purely anecdotal, but I have an uncle who practiced medicine in Canada for several years. He said about 1/4 of his patients with "new ailments" needed bedrest and OTC drugs, not a doctor.

[🐒Gods of Prosperity🔱🐲💸]

I doubt hypochondria itself is major issue in aggregate health care costs. It's more a desire to have the "best" care in any situation, that in reality may help very little or not at all.  Co-pays might encourage use of a less expensive drug in place of a more expensive one when either one has nearly the same chance of working - though this is limited by the fact that doctors typically do not know the price difference when they prescribe.

[Tender Branson]

Interesting.

A fee just to see the doctor has never existed here. But some form of it was introduced for the first time by our conservative/nationalist ÖVP-FPÖ government in 2001, but was scrapped after just 2 years because of massive criticism. The "outpatient center" fee (around 10$ per visit) was considered a burden on low-paid members of the society such as single mothers who work part-time and discouraged them to see a doctor, which led to the opposition calling it asocial. In the end, the Constitutional Court voted to scrap them.

Since 2004 again, every medical visit here is free of charge again (doesn't matter if you visit your personal doctor, or the outpatient center).

Not only that, the state health care carriers are also running surpluses each year.

That doesn't mean problems like crowded outpatient centers do not exist here: There have been reports in Vienna for example that outpatient centers are often full on weekends, because people don't want to wait until Monday to check their problems (the overwhelming majority - like 90% - of Austrian GPs are not open on Friday afternoon/Saturdays/Sundays).

In the meantime, this has been mostly solved with a combination of an information campaign by the doctors chamber/union that people should only visit if they have a serious problem and not because of a simple cold etc. and by requiring more doctors to open on weekends.

In general, it can be discussed to introduce a small fee of let's say 1-5$ to see a doctor, but certain segments of the society should be exempt: low-income persons, minimum-pension-receivers, unemployed persons, people on welfare, students, etc.

I'm generally against a level- or "metal"-based "car insurance like" health care system like Obamacare offers, because a life is not comparable with a car that can be bought again when it's fully damaged.

The SAME health care services must be available to ALL people, no matter if they are low-income or if they earn 1 Mio. € a year. Otherwise you are creating a class-based system in which, using a famous quote, "all people are equal, but some people are more equal than others".

Because I would be interested in what happens in the Obamacare system, if you are a low-income receiver and apply for a Bronze plan and get cancer ? Do you get the same care as someone with a Platinum plan ? Or do you have to pay more OOP costs than the other, if you need a ton of radiation sessions, chemo sessions, surgeries, therapy etc. ?

Don't you think a system like this is strange and "asocial" ?

[7,052,770]

Because I would be interested in what happens in the Obamacare system, if you are a low-income receiver and apply for a Bronze plan and get cancer ? Do you get the same care as someone with a Platinum plan ? Or do you have to pay more OOP costs than the other, if you need a ton of radiation sessions, chemo sessions, surgeries, therapy etc. ?

One aspect of Obamacare is that your OOP costs are limited to $6350 a year.  After that, the insurance company picks up everything.  So if you have a bronze plan and you get cancer, you won't end up paying more than $6350 for it.

The problem is that people who would not be able to afford $6350 are the people most likely to pick a bronze plan, because of the lower premiums.  I wish the law included a provision that you can't purchase a plan unless you prove you would be able to pay the OOP maximum, but it does not.

[Tender Branson]

Because I would be interested in what happens in the Obamacare system, if you are a low-income receiver and apply for a Bronze plan and get cancer ? Do you get the same care as someone with a Platinum plan ? Or do you have to pay more OOP costs than the other, if you need a ton of radiation sessions, chemo sessions, surgeries, therapy etc. ?

One aspect of Obamacare is that your OOP costs are limited to $6350 a year.  After that, the insurance company picks up everything.  So if you have a bronze plan and you get cancer, you won't end up paying more than $6350 for it.

The problem is that people who would not be able to afford $6350 are the people most likely to pick a bronze plan, because of the lower premiums.  I wish the law included a provision that you can't purchase a plan unless you prove you would be able to pay the OOP maximum, but it does not.

Preferably change the law in a way that people (especially those low-income ones with a Bronze plan) do not have to pay any OOP costs after treatments. Especially not more than 6000$ ... WTF ?

But that would require a Democratic supermajority in Congress and a will to do it (stand up against the Insurance companies). So, no chance in hell.

[jaichind]

There is really no difference on which doctors you have access to between the bronze, silver, gold or platinum plans for a given health insurer.  The only difference is the cost sharing when using health care services.  But as pointed out before there is a cap on that cost as well even if one were to go with a bronze plan.

But lets be clear, the plans offered on Obamacare exchange will pay doctors differently from a Medicad, Medicare and company sponsored health insurance.  
On the whole, company sponsored health insurance plans will pay doctors the most so the access to doctors will be the best under these plans.  After that would be Medicare which starting with Obamacare will pay less to doctors so the number of doctors what will take Medicare will start to shrink.  Right behind that would be the Obamacare health exchange plans.  And the worst payment to doctors would be Medicad.  Doctors would often refuse patients on Medicad because they would be treating them for a loss.  The same would also take place but to lesser extent for the Obamacare exchange plans as well as.

For me the cost sharing is not enough and it is based on basic principles and assumptions which others might not take.  I take a stance that health insurance should be like car insurance.  If makes no sense that to use health care services and there is insurance that the usage should come at no cost.  That will just lead to overuse.  I could make the same argument about water.  Water is necessary to survive but it does not follow that it should be free.  Doing so will just lead to overuse and an overpriced market for water.  I think that health insurance should cover catatstropic health services just like a car being banged up badly in an accident.  But for checkups just like oil change the user should pay the cost of such health care services and not need insurance.  And defining up what is "necessary" health care keeps on rising to include things like in vitro fertilisation in some states, like MA, just pushes the cost up more for people that really does not want or need it.