[Jolie]

Originally Posted by jjjoy

I don't see how HSAs and tax breaks help those with low incomes manage health care costs better. When you're not making much, your medical expenses could easily outstrip the taxes that you owe. HSAs mean having to estimate your health care costs ahead of time. The money comes out of your paycheck, buffered by the tax benefits. So instead of getting a paycheck for $800 every two weeks, you get a paycheck for, say, $750 with $80 going to your HSA. Now you have to pay your health care bills out of pocket... let's say $150... and send the receipt in for reimbursement from you HSA. For a low-income worker, it's an awful lot of work for not much savings. For any substancial expense, there's no way they could put enough aside into an HSA to make a difference. Tax breaks have the advantage of not having to guess how much one's future health care expenses will be. Still, they don't help you if you're faced with an $1,800 bill now. You have to wait til next April to deduct the expenses. And again, for those in a low income category, expenses can quickly run over whatever taxes are owed, meaning a rather low limit on the assistance such breaks offer to low income people.

jjjoy,

I respectfully disagree with your assessment of medical savings accounts. I currently have a high-deductible plan with a medical spending account. The plan covers recommended preventive care at 100% regardless of deductible. Other care is paid out-of-pocket (via our medical spending account funded by payroll deduction and employer contribution). Because of the type of insurance I have, I know down to the penny exactly what my maximum financial responsibility is for healthcare expenses for the entire year, including dental, vision and Rx drugs. (When I say "my", I actually mean for my entire family.)

Now granted, based on our income, I can afford a higher deductible than most people. I budget for the full amount that I might potentially have to pay for the year. That money is set aside in a medical savings account and can't be used for anything other than healthcare expenses. If we are healthy and utilize fewer services than expected, the money rolls over, either into next year's healthcare spending fund, or long-term savings. If we reach our maximim out-of-pocket expenditures (and drain our yearly medical spending account), our coverage kicks in 100%. So it is very easy to predict our expenses in terms of the maximum amount we will have to pay in a year for healthcare services.

As for funding the spending accounts, tax breaks, payroll deductions (which would be small in the case of low-income participants) and government contributions would be used to create medical spending accounts (eligible to be used for healthcare expenses only) that participants would use to pay their healthcare expenses up until the point they meet their deductible. Deductibles would be based on income levels. Very low income recipients would have small deductibles. Higher earning participants would have to meet a higher deductible before having their coverage "kick in". This set-up accomplishes 2 important tasks: It requires financial participation in relation to a participant's ability to pay. I firmly believe that in any social program, participants take "ownership" and utilize resources more appropriately when they have at least a small financial stake. It would also enable and encourage participants to make cost-effective decisions regarding their spending. If they opt to go to the ER rather than a clinic for a non-urgent issue (such as a cold), they will have to pay for that out of their spending account. That will create incentives to utilize resources wisely, something I think we can all agree that Medicaid does not do.

[BlueRidgeHomeRN]

Originally Posted by lindarn

Tricare, the military insurance for military members, is also a good option. If they can make the command decision to cover reservists they can make the command decision to cover the American public.

Sorry, but as a vet, daughter of a vet, and mother of two active soldiers, I disagree.

Tricare covers military men and women in service to our country and their families, who tend overall to take good care of themselves AND are obligated [at least for themselves] to take all measures indicated to follow up on ordered care.

If individuals without insurance want Tricare, they can raise their right hand and take the oath, too. Then, they'll have job, and insurance, and can travel the world for all sort of adventures just like our hard working troops are now.

[BlueRidgeHomeRN]

Originally Posted by Jolie

That will create incentives to utilize resources wisely, something I think we can all agree that Medicaid does not do.

AMEN, sister!

See my earlier post about a $2 co-pay if you have any trouble understanding WHY!

[jjjoy]

Originally Posted by Jolie

Deductibles would be based on income levels. Very low income recipients would have small deductibles. Higher earning participants would have to meet a higher deductible before having their coverage "kick in". This set-up accomplishes 2 important tasks: It requires financial participation in relation to a participant's ability to pay.

Can we get private health insurance to buy into this idea of having different deductibles based on payer income? Sounds like a good idea. I can see how that would work with tax breaks and HSAs but I don't see a *necessary* linking of the two ideas (tax breaks/HSAs and variable deductibles). As it is, we currently do have tax breaks/FSAs without income-related deductibles. So we could theoretically have income-related deductibles with or without tax breaks/HSAs.

I'm not sure how HSAs are intended to help, though. Is the main point to incentivize the personal saving of money for health care costs? Kind of like IRAs? Because it seems like an an extra layer of paperwork otherwise and you still end up having to have the money on hand to pay for bills up front - or put it on credit, not something we really want to encourage for those living on the edge financially. Those who are financially savvy enough to maximize their tax savings through HSAs would seem to be the very people who already are good savers and don't need an incentive.

Is the thought that with the tax break on HSA money, those who currently haven't saved enough to cover health care costs now will be more motivated to put money aside? Because again, it seems that such an incentive would be much more motivating for those in higher income brackets than lower income brackets since the savings for lower income families wouldn't be that great versus having to pay a little more taxes and have their money immediately.

Just thoughts and questions!

[Jolie]

Originally Posted by jjjoy

Can we get private health insurance to buy into this idea of having different deductibles based on payer income? Sounds like a good idea. I can see how that would work with tax breaks and HSAs but I don't see a *necessary* linking of the two ideas (tax breaks/HSAs and variable deductibles). As it is, we currently do have tax breaks/FSAs without income-related deductibles. So we could theoretically have income-related deductibles with or without tax breaks/HSAs.


This type of plan already exists in the world of private insurance. My family's plan is thru BC/BS. The idea of variable deductibles is that individuals can choose the plan that best meets their budgets. Would you rather pay higher premiums for a lower deductible plan, or save on premiums and pay a higher deductible? We have relatively low healthcare expenses, and prefer to save on premiums, so we expose ourselves to a higher deductible. The medical savings account allows us to budget for the out-of-pocket expenses associated with that higher deductible, thus avoiding unplanned healthcare expenses. My proposal would involve enrolling lower income recipients in plans with lower deductibles that they could budget for and meet with their medical savings accounts. Their premiums would be subsidized.

I'm not sure how HSAs are intended to help, though. Is the main point to incentivize the personal saving of money for health care costs?

Yes.
Kind of like IRAs? Because it seems like an an extra layer of paperwork otherwise and you still end up having to have the money on hand to pay for bills up front - or put it on credit, not something we really want to encourage for those living on the edge financially. Those who are financially savvy enough to maximize their tax savings through HSAs would seem to be the very people who already are good savers and don't need an incentive.

Medical savings accounts are an important part of the plan because each individual recipient needs to have a financial incentive to utilize healthcare resources wisely and frugally. If a recipient can now go to the ER and never be held responsible for paying a bill, why would they inconvenience themselves by scheduling a clinic appointment instead? If recipients are required to contribute to their own healthcare costs (as we insured now do), they will become more responsible about how they spend healthcare dollars.

Is the thought that with the tax break on HSA money, those who currently haven't saved enough to cover health care costs now will be more motivated to put money aside? Because again, it seems that such an incentive would be much more motivating for those in higher income brackets than lower income brackets since the savings for lower income families wouldn't be that great versus having to pay a little more taxes and have their money immediately.

Just thoughts and questions!

Tax braks, tax credits, any means of encouraging participants to plan, budget and save for their healthcare expenses is a positive, and a necessary component of any healthcare reform.

[ZASHAGALKA]

Originally Posted by Mschrisco

Ouch. Aren't the poor being irresponsible just by being poor?

Yes. That should be obvious.

For abled-bodied people, poverty is a choice. We do people no favors by excusing and subsidizing such choices.

From a hierarchy of needs, we limit people by taking away their needs. We might provide the lowest base of that pyramid of need, but we do so at the expense of the self-actualization of the higher Maslov needs. THIS is a fundamental reason why the poor have no hope and no self-confidence. Why should they, when the message we send, in countless ways, is that you're too much of a loser to even bother to try.

I don't subscribe to the notion that poverty is a state of being beyond the control of those that experience it.

In fact, there are two simple actions that serve to avoid that state of being: full time employment, and dual parenthood. Failing to do those things, in able-bodied people, IS a choice.

Oh to be sure, baby-daddies can be complete jerks. They can lie, cheat, beat, or just disappear. However, CHOOSING your baby daddy IS STILL a choice. There seems to be little introspection into such choices anymore, and WHY should their be: the gov't will bail out your bad choices. Not to mention, the gov't being a child's Uncle Daddy does little more than subsidize those behaviors: lying, cheating, beating, scramming. Why should a dad be a step-up kind of guy, when Uncle Daddy is awaiting in the wings to take their place?

Subsidizing poverty is not compassionate.

Oh I know, I know - 'He Who Must Not Be Named' will change all of this with his politics of 'hope'. That and a buck will buy you a cheap cup of coffee. Hope absent empowerment is empty. Subsidizing poverty isn't empowerment. You can't deny access to a person's higher Maslov needs and then credibly claim the goal of aiding in the fulfillment of such needs. That message itself, in action, is fundamentally dis-empowering, not to mention, contradictory.

In this, I am the one being an advocate for the poor. I am the one saying there is something more profound in their potential than is currently being tapped. I am the one being compassionate. I am the one sending a more powerful and more self-actualized message than 'don't even bother'.

Or, let me turn it around. IF poverty ISN'T a choice, then credibly explain to me why those that are poor SHOULD bother to even try to change their fate? The very idea that poverty isn't a choice strictly implies that nothing can be done to change it. If it can be changed, then how, if NOT through the employment of better choices?

Health care isn't a right; it's a personal RESPONSIBILITY.

~faith,
Timothy.

[jjjoy]

Originally Posted by Jolie

Medical savings accounts are an important part of the plan because each individual recipient needs to have a financial incentive to utilize healthcare resources wisely and frugally. If a recipient can now go to the ER and never be held responsible for paying a bill, why would they inconvenience themselves by scheduling a clinic appointment instead? If recipients are required to contribute to their own healthcare costs (as we insured now do), they will become more responsible about how they spend healthcare dollars.

MSAs are an incentive to budget ahead of time for anticipated health care costs - not necessarily an incentive to utilize health care resources wisely and frugally. If a main concern is over people who already haven't been able to budget well enough to cover initial basic health care costs, I don't see that MSAs would be that much of an incentive to change their behavior. And what if they don't contribute to their MSA? Or would that be mandatory? What happens when they tap out their HSA? What's the point of saving a few hundred dollars here and there if all it takes is one little health hiccup and it's all gone?

If the problem is the inability to get patients to pay at any level for their ER visit, then I don't see that MSAs or subsidized health insurance coverage helps. It would STILL be cheaper to just get the *free* service. Now why can't hospitals recoup any of their costs from these patients who shirk their bills? Why can't they garner wages or sue or do whatever else other bill collectors do? I'm sure there are reasons, but that seems like an issue that goes well beyond how health care is provided in this country.

Why AREN'T there 24/7 low-cost clinics right next door to ERs? Then at least if a patient shirks their bill at the clinic, it's only a $400 bill and not a $14,000 bill. And is there any way to keep a simple office visit with a routine diagnostic and maybe a one-time prescription from costing up to $400?

I certainly don't have the answers! But for me it's helpful to be able to discuss these things and look at the different angles.

[HM2Viking]

I agree with Linda. Allowing individuals and compnies to buy into a Tricare style insurance program is good social policy. It achieves substantial administrative simplification and cost savings, establishes a plan with consistent appropriate benefits and forces private insurers to compete with each other to provide best care IAW evidence based standards.

The other part of this is to mandate participation in financing the health care system by employers and individuals. In other words "pay or play." Its not IF you are going to carry coverage its WHICH coverage you are carrying. Some companies and individuals may prefer purchasing insurance through a medicare for all plan others may choose to use a private insurer. The reality is that we as a nation must flatten the curve of health care inflation and the big dollars that we can attack are in the admnistrative area. Consistent benefit sets are an essential part of reining in the administrative cost monster. Also the private insurers must accept all comers. We can also specify that Administrative costs may not exceed 5% of health costs. I could support a role for private health care insurers AS LONG AS THEY OPERATE WITHIN THE SAME ADMINISTRATIVE COST RATIO AS TRADITIONAL MEDICARE. If they want to make a profit their profits come from cutting their administrative costs to 3%. (Medicare's actual administrative cost is 3%.) We would in effect allow them to make a profit only through aggressive administrative cost cutting. 1$ of health care should purhase 97 cents NOT 69 cents of care.

[Jolie]

[quote=jjjoy;2693831]If the problem is the inability to get patients to pay at any level for their ER visit, then I don't see that MSAs or subsidized health insurance coverage helps. It would STILL be cheaper to just get the *free* service.

But the service can't continue to be "free"! Individuals must be required to contribute to their own healthcare costs, or we will never reign in costs.

The MSA exists to give individuals an effective method to plan, budget and cover their expenses up to the deductible. If they spend it wisely, they can obtain more services.

Now why can't hospitals recoup any of their costs from these patients who shirk their bills? Why can't they garner wages or sue or do whatever else other bill collectors do?

Frankly, I'm all for that. Responsible people contact healthcare providers and work out discounts and payment plans. The irresponsible ones should be tracked down.

Why AREN'T there 24/7 low-cost clinics right next door to ERs? Then at least if a patient shirks their bill at the clinic, it's only a $400 bill and not a $14,000 bill.

In my area, there are low cost clinics in every area of the city. They are under-utilized because some people expect (and get) free care by shirking ER bills, or passing off expenses to taxpayers via Medicare. Why go to a clinic and pay $25 when you can go to the ER for free? That is why it is fundamentally necessary to make individuals ultimately responsible for their own healthcare utilization and costs.

And is there any way to keep a simple office visit with a routine diagnostic and maybe a one-time prescription from costing up to $400?
[quote]

By getting third party payors out of routine healthcare. My doc bills $60 for a physical with labwork if you pay out of pocket at the time of service. She gets the money immediately and her staff spends no time filing claims. She bills over $400 for the exact same service to insurance, since she has to send specimens to the lab of choice of the insurer, wait months for payment and pay her office staff to file claims.

My sister is an internist who was once offered a position in a "concierge" practice. Patients paid several thousand dollars per year for all of their out-of-hospital healthcare needs, and had 24/7 access to a physician in the practice. She declined the offer, thinking that it seemed too "elitest". She now regrets that decision, as her friend in the practice is able to offer excellent 1:1 care to her patients without insurance interference, and has a number of hours each month to devote to pro-bono care. My sister's insurance-based practice does not have the time or financial resources to do either.

[pickledpepperRN]

I fail to understand how paying for one man to make more than $120 million in one year is cost effective.
What am I missing?
HOW can the profit motive work so very well?

Good luck with the "Blues" if you actually suffer a disabling expensive illness.

Janet was an RN for years but after being diagnosed with several incurable diseases she went on disability and struggles to cover the cost of her healthcare. She's a talented pianist and an advocate for Single Payer healthcare reform in America

http://www.youtube.com/watch?v=DKXEiGjNCME

HSA can run out quickly when you can no longer work.