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Saturday, September 5, 2009

What health-care reform really means

We know, the United States spends more on health care than any other country. And yet ranks behind 18 other industrialized nations in medically preventable deaths. The United States is far down the list and other important categories as well, including the average number of years citizens live a healthy life. Spending more than $1 trillion on health reform may improve these rankings. And yet as Congress and the Obama administration struggled to agree on the nature of reform, it has become harder to understand how the current US system would actually change.

Here is a simple user's guide to understand this little better.

If you all are...

Insured through an employer

It is estimated that 53% of those insured through an employer get health benefits from their job. The current situation, is that employee contributions to job sponsored health coverage have more than doubled in the past decade. Plans, which are tax-free, are often more generous than those available on the open market. But workers can take their coverage with them if they switch jobs or are laid off.

Now how the reform could affect you

The upside;

If all employers are required to offer insurance, employer sponsored plans would never be eliminated. More regulation could reduce the chances that insurers would deny fair claims. A public plan could provide competition in the marketplace and drive down private insurers premiums.

The downside;

Lawmakers are considering taxes on some of the most expensive employee health plans. Thus taxing either employees directly or insurance companies. But insurers are likely to just pass this costs along to consumers, driving up rates. Other taxes could be levied to help cover the poor and the uninsured.

If you all are...

Insured independently, it is estimated that 5% of those insured independently by health insurance on the open market.

The current situation is that people who purchase insurance on their own pay the highest premiums, because they are not in a large risk pool and are evaluated based on their health profile. Choices for coverage’s are limited, and individuals must often buy insurance with after-tax dollars.

How the reform could affect you

The upside;

Regulation could prevent insurers from setting rates based on health or turning people away because of pre-existing conditions. If offered, a public option is likely to be available for individuals from the start. Lower income earners could be eligible for federal subsidies to help them purchase coverage.

The downside...

It’s hard for things to be any worse for people now buying their only insurance on the open market. Nearly all major aspects of reform would make this prospect easier and cheaper.

If you all are...

Insured through a public program, it is estimated that 26% are covered by Medicare, and/or Medicaid.

The current situation, those insured through public program are mostly seniors and many poor Americans who rely on Medicare and Medicaid to ensure them... for now. Baby boomers will soon stress the Medicare system, while states are struggling to meet Medicaid costs. Senior space, the gap in prescription drug coverage, and low Medicaid reimbursement causes many providers to reject these patients.

How the reform could affect you

The upside...

Pharmaceutical companies have agreed to cut drug prices to help close the prescription drug coverage gap. More Medicare focus on prevention and management of chronic disease could lower the overall cost of the program, ensuring its long-term stability.

The downside...

Lawmakers say increased efficiency could bring down Medicare spending, but they almost certainly would have to reduce coverage as well. Broadening eligibility criteria for Medicaid, which the House is proposing, would increase federal spending dramatically.

If you all are...

The owner of a small business, it is estimated that 62% of firms with three 299 workers offer health benefits.

The current situation for these small business owners is that more and more small businesses are dropping coverage for employees or reducing the proportion of insurance premiums they pay. This saves on cost, but sometimes means losing workers to big companies, which have larger risk pools and therefore can afford to offer more generous benefits.

The upside...

If a public plan exist did, small businesses could buy into it and be included in a larger risk pool, thus driving down the cost of providing coverage to employees. Companies with fewer than 10 or 25 employees, depending on which, if any, congressional proposal becomes law, could be exempted from reform provisions requiring employers to offer health benefits.

The downside...

Midsize companies could still be forced to offer small health benefits. Small businesses that employ low wage workers might have to pay a penalty if their workers receive federal subsidies to buy insurance.

If you are...

Uninsured, the current situation with the uninsured is that 15% lacked any type of coverage. People without insurance typically put off basic medical care and end up in emergency rooms when they get sick. They are often less healthy and more likely to develop chronic diseases, the cost of which must be absorbed by the entire healthcare system.

The upside...

Expansion of the Medicaid program could cover large ranks of the uninsured. Those forgoing insurance now because of the cost could be eligible for federal subsidies to purchase private insurance or buy into a public health insurance plan. That is if one existed.

The downside...

If the government requires individuals to have insurance, but does not require employers to provide it, the working uninsured will have to shop for insurance on their own. Plus some would be too poor to buy insurance, but not poor enough to qualify for Medicaid or a government subsidy.

The way the big players see it:

The insurance companies

Private insurers are making healthy profits now, but know they will lose a sizable chunk of customers when baby boomers move into the Medicare system. Insurers make money by setting rates based on the help of enrollees and turning down individuals with expensive pre-existing conditions.

What they like; current reforms proposals could require all Americans to get health coverage, giving insurers a huge pool of potential new customers.

What they don't like; any government run health plan could glue or Americans away from private insurance. Plus, new regulations could prohibit insurers from rejecting anyone for coverage or basing rates on health risk. To generate revenues and discourage overuse of health care, insurers could be taxed on some high in employer-based health plans.

The hospitals

Many community hospitals operate on thin margins, in part because of the low cost of Medicaid reimbursements and the expense of treating the uninsured. Emergency rooms are overflowing, and many hospitals are struggling to deal with outdated record-keeping systems.

What they like; federal investigations in information technology could help hospitals, modernize medical record-keeping. Getting coverage for the uninsured would mean hospitals could cut down on charity care. Tighter regulations on physician ownership of hospitals would benefit nonprofit community hospitals.

What they don't like; a public health insurance plan, which Congress is considering, today's reimbursement rates on Medicare, which pays less than private insurers. Hospitals can see gradual reductions in the hardship payments they receive to provide charity care, but which they use to cover other shortfalls.

The doctors

Dr. stays high malpractice insurance cost and a port system that encourages them to perform more tests and services rather than fewer, in order to avoid lawsuits. Low reimbursement rates have also led to a 30% shortage of primary care providers nationwide.

What they like; loan forgiveness programs for medical students who go into primary care, could he ease the shortage of their. Reimbursement reforms under discussion could reward doctors for keeping patients healthy rather than paying them based on services provided.

What they don't like; since the goal of health care reform is to lower the cost of healthcare overall, some doctors could see their incomes drop. A greater focus on prevention efforts, many of which do not require medical intervention, could also leave doctors with less to do and therefore reduce their pay in the process.

The health care plans;

There is a plan that is called a fee for service; what it means; we paid for medical services individually, each time we see a doctor and for every test or procedure he orders.

What you need to know; by providing more services, doctors and hospitals can charge more, which drives up health care costs. The all a cart structure also makes it hard to keep track of the total bill.

There is a plan called the Cadillac plan; what it means is a hyena platinum, often paid for by an employer, that covers most medical needs at little cost to the patient.

What you need to know; because consumers don't directly pay for services, they tend to overuse them. Congress is considering taxing these plans to generate revenue.

There is a plan called the public plan; what it means is a government run health plan that would compete with private ones on cost. What you need to know; a public plan could leverage its volume into lower costs and premiums, but critics claim it could put private insurers out of business.

And then there is the rationed care program; it means the claim that in a public plan bureaucrats will decide the quantity and quality of the care you receive.

What you need to know; it's the bogeyman that those opposed to major reform like to conjure up, but none of the reform proposals anticipates such a consequence.

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