Mandatory Health Insurance ????

[breck]

I read an article in the paper yesterday about mandatory health insurance, and wanted to get some feedback from all of you about this topic. The AMA just had a meeting in Chicago where they called for mandatory health insurance for anyone who makes more than five times the poverty level. This included any individual that makes $49,000 per/year, and any family of four that has a combined income of $100,000 per/year. The article stated that of the 46 million people who don't have health insurance 5 million (11%) do not have coverage. I personally think this is a step in the right direction. $49k per year comes out to roughly $24.50 per hour. I presently pay $130 per month for my coverage, so I don't think it is unreasonable to force people to use 5 hours of their monthly pay to have coverage. Why should the taxpayers, employers, and the insured have to eat these costs of the uninsured who can afford to have insurance?? It doesn't make sense. I personally think this $100,000 for a family of four is way low. I don't have exact statistics but I think only about 10% of the people in this country make that much money, maybe even less. Why not lower the bar even more? Let's face it people can't manage money well and there is no reason others should have to pay for that. Look at all these fools who got money from the federal government to "rebuild" their lives after hurricane Katrina and went and blew it on vacations, season tickets to the Saints games, divorce lawyers, erotica products, and Girls gone wild videos. I do not have any problems with victimless crimes but when society has to bear unneccesary burdens for the carelessness of others there is a problem. Your thoughts???

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[Doctor Bagel]

I think mandatory health insurance is a good idea. I'm wondering why they didn't think of this sooner...? I have a couple questions off the top of my head:

-how will it be enforced? If someone comes into the ER w/o insurance, would you fine them? what if they just don't have money? Is there a better way to enforce it?
-what about people with pre-existing conditions who would have to pay high premiums? just because their salary is higher than the poverty level doesn't necessarily mean they would be able to pay for their coverage
-could the gov't establish/regulate an insurance program which kind of resembles medicaid or medicare except people would pay premiums? this would also be supplemented by gov't funds, that could give partial coverage to people who fall just outside the requirements for medicaid or medicare or people with pre-existing conditions

i'm not too knowledgable about health insurance, so I apologize in advance if these questions sound naive

These are all issues that have to be sorted out. With health insurance premiums costing upwards of $900/month for many families, it's hard to say that it's easily affordable, especially if you're in a high cost of living area. I don't think someone who made $49k/year in San Francisco has much leverage to pay hundeds of dollars a month in insurance. Also, we are going to have to address the pre-ex exclusions. If insurance companies have to pay for pre-ex conditions, they'll charge you more. If they can exclude it, the taxpayers are still stuck with the bills for all those pre-ex conditions, including pricey things like diabetes, heart disease, cancer, etc.

To require mandatory insurance, I think there's going to be have to be some system or way to make it more accessible to people. In one way, premiums should go down if more people are insured because the if the pool is larger, the risk is more diversified. One possible minor solution would be to enact cobra like legislation for private insurance. As it is, if you're continuously covered under a group plan, you don't get stuck with onerous pre-ex exclusions. Depending on your state, people covered under private insurance can be royally screwed because continuity of coverage doesn't always apply. These people who would be looking to private insurance are exactly those sort of higher wage earners who aren't insured.

 

[emtp6811]

The problem that I see is that it is addressing the wrong end of the right issue. Most of the people who are uninsured and not paying for thier care out of pocket are those who are not making less than $49,000 per year: Read lower middle class. They can't afford to pay for the medical insurance thier company offers much less self-insure, but they make too much to qualify for medicare or medicaid. THESE are the people that need to be taken care of. The income qualifications that the AMA is recommending are for the most part people that can afford to pay out of pocket anyway.

If you are requiring ANYONE to purchase insurance that they cannot afford, I can guarantee you they will buy the least expensive high deductible insurance they can find, so really they are still under-insured and continuing to contribute to the problem.

Also, there have been a lot of providers and facilities getting dinged lately because they are not billing at the contracted rates for the insurance. As soon as they find out that you have a high deductible and are paying out of pocket or from an HSA, they bill you at the full fee schedule price.

 

[breck]

I think mandatory health insurance is a good idea. I'm wondering why they didn't think of this sooner...? I have a couple questions off the top of my head:

-how will it be enforced? If someone comes into the ER w/o insurance, would you fine them? what if they just don't have money? Is there a better way to enforce it?

Great Question. The answer is, it probably won't be enforced. So the term mandatory is a little misleading here. In the original article that made me write this post it said "No one would go to jail for refusing to buy coverage. The AMA instead suggested using the tax code to enforce compliance. There would be incentives such as tax credits for people who buy insurance and higher taxes for those who don't." Chicago Sun Times (Wednesday June 14, 2006 pg 14). I don't advocate sending people to prison, that certainly would not lead to a reduced burden for taxpayers. I think they should just take it out of peoples paychecks. God knows there are plenty of other things that are automatically deducted from peoples checks, why not fees to cover health insurance too? Force people to make a wise decision. We try and force people to where seat belts, secure their children in automobiles, and in some states where helmets while riding motorcycles. Imagine if we could just have someone standing by everyone's car and strapping them and their children in securely. Good idea, but not practical. Imagine if we could automatically deduct health insurance fees from paychecks, good idea and practical. I would certainly agree to providing people with options for their coverage plans, but not the option to not have it. (but it will probably be a cold day in hell before this happens)

 

[breck]

These are all issues that have to be sorted out. With health insurance premiums costing upwards of $900/month for many families, it's hard to say that it's easily affordable, especially if you're in a high cost of living area. I don't think someone who made $49k/year in San Francisco has much leverage to pay hundeds of dollars a month in insurance.

I agree that there are many issues that will need to be sorted out. I don't have a family but I am paying $130 dollars per month for my health insurance, and this isn't through my employer. So when I divide $900 by four and come up with $225 per month per person I can't help but think that it seems a little high. If exlawgirls plan meets my plan right in the middle we're looking at about $180 per month times 4 for a family = $720. This means two days of your monthly workload cover your families health insurance. Lord, some people have car payments close to this by choice. Which brings me to the next point.

[/QUOTE] it's hard to say that it's easily affordable, especially if you're in a high cost of living area. I don't think someone who made $49k/year in San Francisco has much leverage to pay hundeds of dollars a month in insurance.[/QUOTE]

I'm renting in Beverly Hills right now and driving a Bentley and there is no room left over for insurance, surprise Does living in a high cost area mean you can't afford insurance or you can't afford to live in the high cost area. I live in Chicago (not Beverly Hills) and one bedroom apts (~350-400 square feet) are renting for $1200 per month. I don't know what rent prices are like in SanFran but the point is if I couldn't swing my health insurance I would move to another, cheaper, area of chicago that would make it possible. If San Fran doesn't have any cheap areas to live then the solution is to move, not give up health insurance. Many people would refuse to do that, this is why I proposed, in the above post, that the cash should be taken out of their paychecks; so they won't be choosing a desirable living area over health insurance.

 

[Miami_med]

I read an article in the paper yesterday about mandatory health insurance, and wanted to get some feedback from all of you about this topic. The AMA just had a meeting in Chicago where they called for mandatory health insurance for anyone who makes more than five times the poverty level. This included any individual that makes $49,000 per/year, and any family of four that has a combined income of $100,000 per/year. The article stated that of the 46 million people who don't have health insurance 5 million (11%) do not have coverage. I personally think this is a step in the right direction. $49k per year comes out to roughly $24.50 per hour. I presently pay $130 per month for my coverage, so I don't think it is unreasonable to force people to use 5 hours of their monthly pay to have coverage. Why should the taxpayers, employers, and the insured have to eat these costs of the uninsured who can afford to have insurance?? It doesn't make sense. I personally think this $100,000 for a family of four is way low. I don't have exact statistics but I think only about 10% of the people in this country make that much money, maybe even less. Why not lower the bar even more? Let's face it people can't manage money well and there is no reason others should have to pay for that. Look at all these fools who got money from the federal government to "rebuild" their lives after hurricane Katrina and went and blew it on vacations, season tickets to the Saints games, divorce lawyers, erotica products, and Girls gone wild videos. I do not have any problems with victimless crimes but when society has to bear unneccesary burdens for the carelessness of others there is a problem. Your thoughts???

Um, does anybody but me see a problem with asking the government to force people to buy something they don't want to buy? Maybe a better solution might be to look at the why people aren't buying insurance. I have it for a family of 3 with a high deductible and pay close to $400 a month. We are all healthy and in our 20s.

The whole system is confused. Let's relegate insurance to catastrophes and use the dollars wisely. You don't use car insurance to buy an oil change. A PCP could lower rates to a level where more people would pay them if they didn't spend half their time fighting for approval and all of their money paying coding experts and people to try and collect $7 from the insurance company for a denied claim. Cut out the paper pushers and the system becomes more affordable. No middle men are involved, and people can get paid in cash at the gatekeeper level. This frees more dollars for other purposes. Medicine should work more like a business, with some market consideration to services and some incentive for cash conservation on the part of the doctors and the patients.

Why should we write a bad system into law? Oh yeah, the insurance companies will lose money if we don't. I assure you that doctors and most patients will lose in the long run.

 

[breck]

The income qualifications that the AMA is recommending are for the most part people that can afford to pay out of pocket anyway.

Yes. These are the people who will be required to purchase insurance. Is it going to solve the uninsured/underinsured health crisis?? Heck no. But we've got to crawl before we can walk. At least it's a start.



[/QUOTE] Also, there have been a lot of providers and facilities getting dinged lately because they are not billing at the contracted rates for the insurance. As soon as they find out that you have a high deductible and are paying out of pocket or from an HSA, they bill you at the full fee schedule price.[/QUOTE]

What fee schedule do they bill you at if you have no insurance?? I honestly don't know, but I'm assuming the high one. So this probably isn't a reason to not have health insurance. It sounds like the problem here is the insurance people are fu--ing the underinsured people over, HUGE. I would say this problem needs to be directly addressed. The solution isn't to forgo buying health insurance it's to establish rules to prevent insurance companies from doing this.

 

[breck]

Um, does anybody but me see a problem with asking the government to force people to buy something they don't want to buy? Maybe a better solution might be to look at the why people aren't buying insurance. I have it for a family of 3 with a high deductible and pay close to $400 a month. We are all healthy and in our 20s.

The whole system is confused. Let's relegate insurance to catastrophes and use the dollars wisely.

Relegating insurance to catasrophes is not the solution. If an individual does not want to spend money on a doctors appointment, this happens all the time, small problems become huge ones. If one thinks they are healthy they will try and save cash by not going to the doctor, even if they have a family history that is contraindicative to this notion. Who cares about my cholesterol levels? I feel great. Do I have high blood pressure? I don't think so, I feel great!! This goes on for several years and all of the sudden this person winds up with arteriosclerosis and maybe a nice heart attack or stroke to go with it. Now a problem that could have been easily identified and controlled with diet, excercise, and a few prescription drugs blows up b/c this person wasn't being forced to buy something they didn't want to buy, and as a result did not go in for annual checkups. Now, b/c they do not have insurance, the vascular or neurovascular surgeon, the hospital, and the taxpayers get to shoulder the costs of surgery, hospital stay, and those nice little pills that they should have realized they needed to take a long time ago. And you want me, and yourself, to pick up those fees b/c you think its wrong to force someone to pay for something that they will ultimately need. It's not a matter of if the body will break down, it's just a matter of when. So force them to buy the damn insurance and prevent the extra costs that will inevitably arise from this and bite everyone else in the ass.

 

[breck]

I have it for a family of 3 with a high deductible and pay close to $400 a month. We are all healthy and in our 20s.

If you and your spouse or mate were making $100,000 dollars per year $400 bucks would be 8 hours worth of work. You can't honestly tell me that that is unreasonable. What if your child (I'm assuming the 3rd member is not in their 20's) wound up with leukemia or something like that and you guys didn't have insurance at all?? Everyone else would eat the cost. You are responsible enough to know you need insurance, unfortunately a lot of other people aren't.

 

[Doctor Bagel]

I agree that there are many issues that will need to be sorted out. I don't have a family but I am paying $130 dollars per month for my health insurance, and this isn't through my employer. So when I divide $900 by four and come up with $225 per month per person I can't help but think that it seems a little high. If exlawgirls plan meets my plan right in the middle we're looking at about $180 per month times 4 for a family = $720. This means two days of your monthly workload cover your families health insurance. Lord, some people have car payments close to this by choice. Which brings me to the next point.

You can't assume what other people's insurance will be based on yours, especially if you're young. What I do know is that my parents pay $800 a month for their medicare supplemental insurance through my dad's former employer -- this is absolutely the cheapest, good insurance they could get. My brother pays $900 to insure his family of four, none of whom have health problems. If I choose to use cobra and keep my health insurance, my premiums would be $550/month for both me and my husband, and we already have a $3k deductible. Depending on your age and health, insurance can cost a lot of money.

 

[f_w]

Funny enough it is usually the mid-20s healthy guy who will tell you how affordable health insurance is. After all, he can get his coverage for [insert small number <200 here] !!
(try to go out and buy insurance for a self-employed female in her 50s who has essential hypertension. Good luck !)

The main reason why 'the community' has to foot your bills for medical care if you don't pay is EMTALA. Hospitals are not allowed to turf you out or refuse care if you can't pay. As a result, the penalty for not carrying health insurance is not as big as it could be, if you happen to get sick there is allways the ER. Maybe if people bled to death in hospital parking lots, more people who have access to insurance would actually buy it. Also, the pressure on society as a whole to come up with a comprehensive approach to healthcare coverage would be a bit higher. By enacting EMTALA, the goverment thought they could get an unsightly problem solved, not by providing healthcare but rather by dropping the problem into the hospitals lap. Now that the inner city hospitals are crumping under the load of uncompensated care everyone gets their panties in a bunch because the prospect of folks dying on the way to a suburban ER becomes real.

A first step towards more widespread enrollment in health insurance would be to divorce it from specific employers. Make the premiums for health insurance fully tax deductible. Extend cobra like benefits in the sense that once you have health insurance, you can keep it indefinitely, even if you go to a new employer. And because it is tax deductible, there is no difference whether the employer buys it for you as a 'fringe benefit' (and it doesn't show up on your W2), or whether you buy it yourself.

That way, people could decide on a healthplan early on in their life and stick with the same insurer throughout. If later in life, health problems develop, you are not at risk of loosing coverage for these problems through the 'preexisting conditions' cr## (the equivalent of buying health insurance in the car insurance market would be a policy that insures you for everything but accidents that occur while changing lanes).

Right now, insurers don't have to compete for patients as their customers. Their customer are the employers. As a result, customer service from health insurers is atrocious. If the consumer was the buyer of health insurance, companies would be forced to compete. 'Switch your coverage to GEICO, all preexisting conditions of your current coverage accepted'. Once you turn 65 and medicare kicks in for the basic stuff like hospitalizations, your full-service policy can be carried over to a supplementary plan. Also, health insurers could offer long-term contracts with sort of a 'risk-reserve' component. While you are young, you can buy additional coverage protecting you against the normal proliferation of your premiums with advancing age.

Also, make health insurance subject to interstate commerce rules. It is big enough of an industry that subjecting it to the whims of the individual state AGs doesn't make sense. If you move from one state to the other, you can stick with your old plan. They might adjust your rate to account for regional difference in healthcare prices, but your overall plan remains intact.

 

[docB]

By enacting EMTALA, the goverment thought they could get an unsightly problem solved, not by providing healthcare but rather by dropping the problem into the hospitals lap.

As far as politicians are concerned EMTALA did solve their problem. They are able to tell everyone that they have a "safety net" without raising taxes to pay for it. Everyone eventually pays for it because we pass the cost of treating the uninsured on to the insured but those politicians didn't lose any votes over raising taxes.

And the ERs don't provide free primary care. If you show up at any of my hospitals with a nonemergent problem EMTALA doesn't apply to you and you will be asked for cash up front before you get whatever it is you want.

 

[f_w]

And the ERs don't provide free primary care. If you show up at any of my hospitals with a nonemergent problem EMTALA doesn't apply to you and you will be asked for cash up front before you get whatever it is you want.

Well, all too often they do provide services that could be provided in a more cost effective manner by a PCP or community health center. And 'nonemergent' or not, you are still stuck to provide the screening exam sapping up your resources.

Your signature line hits the nail on the head.

 

[RuralMedicine]

Also, there have been a lot of providers and facilities getting dinged lately because they are not billing at the contracted rates for the insurance. As soon as they find out that you have a high deductible and are paying out of pocket or from an HSA, they bill you at the full fee schedule price.

Perhaps I'm misunderstanding something but most providers have a standard fee scale and bill according to that. The difference is that medicare/medicaid (and some private insurance) only will pay a certain percentage of what you bill them. Actually billing your self pay patients on a lower scale is what gets you in trouble. [Now we offer a sliding scale so based on your income you can qualify for a percentage deduction just like medicaid (which helps itself to a 75% deduction in our state) it's only fair I think. But many providers do not (and perhaps can not) do that.]

 

[breck]

Maybe if people bled to death in hospital parking lots, more people who have access to insurance would actually buy it.

Pardon the ignorance but would anyone like to provide a quick overview of EMTALA. I don't even know what this stands for

 

[f_w]

Emergency Medical Treatment and Labor Act

In the good old days, nonpublic hospitals had the option of performing a 'wallet biopsy' on their patients in the ER waiting room. You had to either provide proof of insurance, or you had to put down a deposit before you where seen. If you couldn't provide evidence of your ability ot pay or a deposit, you were provided with the address of the next public hospital and booted out the door.

This led to unsightly messy situations: Mommy and kid arriving dead at the public hospital, heart attacks receiving delayed treatment because the private hospital would throw the patient in a contracted private ambulance and drop them at the county hospital 1 hr away etc.

In their wisdom, congress in 86 passed EMTALA. It stipulates a couple of things like:
- everyone presenting at an ER has to receive a 'screening exam' by a 'licensed independent practicioner' to determine whether an emergent medical condition exists
- patients have to receive initial treatment if an emergency exists
- patients can only be transfered from one hospital to another in a certain set of circumstances e.g. if a required service is not available at the initial hospital
and so on.

The intentions where somewhat noble, the result is the mayhem we have in the EDs these days. Because EMTALA is the only 'right to healthcare' people outside of the prison system have, the EDs can't fight of the tide of patients seeking care.

 

[Miami_med]

I have it for a family of 3 with a high deductible and pay close to $400 a month. We are all healthy and in our 20s.

If you and your spouse or mate were making $100,000 dollars per year $400 bucks would be 8 hours worth of work. You can't honestly tell me that that is unreasonable. What if your child (I'm assuming the 3rd member is not in their 20's) wound up with leukemia or something like that and you guys didn't have insurance at all?? Everyone else would eat the cost. You are responsible enough to know you need insurance, unfortunately a lot of other people aren't.

Well, I won't pretend that I could change your mind, but I think that this is a flawed argument. I don't make $100,000 a year, and when I do, my insurance won't be $400 a month. The assertion that I have to spend 8 hours to work and pay you against my will is flawed. The idea that I should be able to make such a stupid decision and still have unlimited access to care is also flawed. I do not understand the ideal of a "right to care." This has simply made medicine so expensive that we have made it impossible for people to afford it.
I wouldn't be against a rule that required insurance to be purchased up to a degree before any safety nets will protect you, though implementation would be difficult. I have a right to be stupid in America.

The insurance system is a MESS! The emergency rooms are a bigger MESS! If you have any questions about this, please come by my community hospital here in Miami on a Saturday night. You can stand between the woman vomiting outside because there are no seats and the guy in handcuffs.

Governments are inefficient. For all its faults, U.S. healthcare has the best response times and speed in the world. Everyone may have access to care in many other countries, but most non-emergent issues take a long time to get resolved. These systems are heavily flawed as well.

The interference of the government in healthcare is huge, but it is just beginning. I assure you that soon all sorts of political whims will be attached to receiving medicare dollars (Pay for Performance, EMR, etc...). It will completely stifle all entrepeneurial advancement in the healthcare field, as these whims will change, will be pushed by political pressure with no regard to cost, and will never be compensated. That is not good. It promotes politics over efficiency. Efficiency will actually make healthcare more affordable.

The whole system needs a makeover. Why should we write the current dysfunctional system into law?