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Thread: My Idea to Solve Healthcare in this Country

  1. -1
    LouPhinFan's Avatar
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    My Idea to Solve Healthcare in this Country

    I mentioned awhile back in a thread that I had some ideas about how to fix healthcare in this country. I've finally had some time to put my thoughts down and since the ACA comes online in a little over a week this is as good a time as any to post my ideas. Perhaps you can think of somethings I haven't.


    Disclaimer: I work for Humana Health Insurance. One of the largest healthcare companies in the US. I've worked with insurance and healthcare for almost a decade now. I know how the system works, for the most part.


    While I work for an insurance company, I think for profit healthcare is not the best way to do it. But unfortunately that's the system we have and its not going away anytime soon. Millions of your fellow Americans are employed by health insurance companies as well as the supporting industries (printing, claim auditing, etc). If we ditched the insurance industry now, a lot of people would be out of jobs. So we have to learn to improve the system we have now.




    Medicare Part C: The central theme of my plan is Medicare Part C and how it works as replacement for Medicare. Undoubtly most of you have false impression of it, no idea what it is, or how it exactly works. Per his comments in one of the debates from the last election, it sounds like Obama has no idea either, but its not surprising.


    Medicare Part C in its simplist definition is basically Medicare replacement administered by an insurance company instead of government Medicare. Insurance companies apply to CMS (Center for Medicare/Medicaid Services) to be able to offer replacement plans to the of age public. CMS reviews the plans that the companies offer and either approves or denies them based on factors such as cost to the member, benefits (copays ect), network adequecy (providers in certain counties in a given state), etc. The plans HAVE to cover all of the same things that Medicare covers (diagnosis, treatments, etc) and CANNOT be subject to pre-existing conditions. Medicare members CANNOT be turned away by a plan.


    There are multiple companies that offer multiple types of plans (depending on geographical area). During the open enrollment (in the fall) members can both choose which company (Humana, Aetna, etc) they want to go with and then what type of plan (HMO, PPO, etc) they want. And then over the course of the year that they have that plan, they can decide if they want to keep the the plan or switch or if they don't like the company then they can change companies all together during the next open enrollment. They can even decide they don't like Part C all together and just go back to regular government Medicare A & B. Part C plans offer members more than government Medicare can offer like various gym programs, 24 hour nurse hotlines, Rx coverage, etc. So in this enviorment insurance companies are in constant competition with each other at the individual level. Competition is always good for the consumer, no? Companies strive to be as efficient as possible. I'm sorry, but private companies almost are ALWAYS more efficient than government. Efficiency improves profits.


    Insurance companies have to have their plans and costs approved by the government every new plan year or they can't sell their plans. Insurance companies get a payment from CMS for each person enrolled in their plan. CMS also watches very closely how the insurance companies market their plans to the public. Its very regulated. During one of the debates when Obama said insurance companies target "healthy seniors" for their plans, that's simply not true and is just your regular old liberal talking point scare tactic. CMS won't allow that and it doesn't make good business sense. Companies want as many people enrolled in their plans, no matter their age. Its illegal for them to turn any senior away.


    It really is a very successful government-private partnership. Its one that many people don't fully understand or even know that much about.

    (Part 2 follows in the next post)


    Insert pithy saying here.

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    LouPhinFan's Avatar
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    Now, how do we turn this type of partnership into coverage for all Americans?

    I propose that the government use the exchange concept that they're already going to use in the ACA. A healthcare tax is taken out of each worker's pay check (but no insurance premium). Companies with a number of employees over a certain amount also pay a tax per employee to help cover the cost. This is similar to how its done now as currently the system most employers use split the premium between them and the employee.

    Insurance companies create insurance policies and apply to the government to allow them to sell the plans as part of the healthcare. Government would review the plans to insure that they have the proper basic coverage that they most have and that copayments/deductible/coinsurances aren't unnecessarily high. Perhaps they can offer a handful of plans with most being of no extra charge with varing level of benefits and perhaps allowed to mix in a few plans that a member can pay a small monthly extra premium (also agreed upon between the government and insurance company) that has enhanced benefits (lower copays, better Rx coverage, etc). The "free" plans (plans that don't cost anything extra) would most often be utilized by young people or people that don't use healthcare all that often but still need some kind of coverage. The pay plans could be options for older Americans or Americans that use healthcare more often. No one can be turned down by a plan and there are no pre-existing conditions. All that I've just described has been in use by Medicare Part C since it's inception. It is nothing new and could easily be ported over to the commercial American worker side from the Medicare side.

    Medicare Part C has a yearly open enrollment period each fall. A yearly open enrollment for commerical workers should probably be in a different time of the year, perhaps the spring time (April or May). Again the worker would be able to choose a different plan offered by the company they're with or choose a different company altogether if they aren't happy with how they're treated by that particular insurance company. The government can track which insurance companies are thought of best and supply that information to Americans to help them choose. If an insurance company is going to offer plans in a certain state (or county) then they must offer a certain minimum number of polices to allow people to have options from which to choose. There is going to be some variations. A worker in Boise or Fargo will probably have less policies and companies to choose from than a worker in LA, Dallas, Louisville, or Miami. But they will still have some choices and coverage.

    Some employers in this country have Administrative Services Only (ASO) policies. What this means is that they pay a fee to an insurance company to administer the policy like sending out cards, processing claims, use of their network providers, etc but when the insurance company writes a check to a provider for member services, the payment comes out of a bank account that the company funds. The employer owns the policy, not the insurance company. If an employer feels this a better option for them then they should be able to keep this as an option for their employees but the employee should also have the exchange plans as an option to them as well. If an employee opts to stay with the company ASO policy then the healthcare tax is not taken out of their check and the employer is not to pay the corporate tax for that employee.
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    trojanma's Avatar
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    2013 Dolphins LogoTannehill 17Dolphins Homer
    Lou,

    I have always respected your opinion on healthcare because of your unique position of your job.
    Couple thoughts and questions.

    How is the first page of your plan any different from what we have now?
    What is the plan for people that are unemployed or underemployed?
    How is your plan going to tackle cost containment? It can't all be improvement in "efficiencies"? or is it like the Ryan plan where the cost over-runs go to the seniors.
    Are you not concerned that this plan is going to look like a giant wealth transfer from Gov't to the private insurance industry?
    Kind of like privatizing social security?
    If I misunderstood anything in your post I apologize.

    FWIW here is my take healthcare insurance "system"

    I would eliminate the link between healthcare and your job.
    No more saddling of healthcare costs to small business. No more people hiding in certain jobs simply because of the benefits. No more employers shirking peoples wages and hiding them as healthcare benefits.
    Nonetheless everyone needs healthcare coverage. As a physician I cannot stress the importance to that.
    That being said the rest looks a lot like your plan.

    Connect the access to healthcare to your tax return. Everyone has to file one unless you are claimed as a dependent.
    If your income is zero that is fine you file anyway.
    Like You, there would be some sort of national flat tax for healthcare replacing the current deductions.
    This would connect with an competitive market/exchange of plans from free on up with improved benefits.
    The Free plan would only cover the healthy employed like the young college grads. You can opt out(for example for religious reasons) but you are already paying the tax so you might as well do it.

    There are two other groups that I had not mentioned.
    1. Minors who aren't covered as dependents need a subsidized plan that offers a robust amount of care.
    2. People in Poverty. Who need to have access to some bare bones subsidized plan a la medicaid not one of the private free plans. Lets say people up to 300% of poverty can get this based on a sliding scale that is deducted from their taxes.
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