Below, excerpts from a piece by Joanne Kenen that originally appeared in Health Affairs.
Kenen is a health care journalist and author who spent more than a decade covering health policy on Capitol Hill. Here, she delves into the stopgap insurance plans that the federal government designed to cover patients suffering from pre-existing conditions while they wait for the final phase of the Affordable Care Act to roll out in 2014. (Following Kenen’s post, you’ll find my comment on what I see as the core of the problem.)
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Conservatives Snipe at Preexisting Condition Insurance Plans
By Joanne Kenen
“The Affordable Care Act is barely a year old, and its earliest initiatives are already coming under intense scrutiny . . . . Near the top of the list is the so-called Preexisting Condition Insurance Plans, the stopgap program created under the law to cover millions of uninsured people with preexisting medical conditions. So far, enrollment in the eight-month-old program has fallen far short of expectations: Just 12,000 people had signed up as of February 2011. Now health reform critics are citing the program’s failings as indicative of a disaster to come:
“’If the feds can’t manage this little project,’ wrote Indiana Gov. Mitch Daniels in a typical swipe in the Wall Street Journal, ‘What should we expect if they attempt it on a scale hundreds of times larger and more complex?”
“The low enrollment rate has flummoxed many health policy experts, who if anything had worried that the program would quickly be oversubscribed. “I don’t think anyone knows why the take-up is so low,” says Wharton health economist Mark Pauly. Indeed, in its original assessment of the Affordable Care Act, the Congressional Budget Office had estimated that 200,000 would enroll in the program. The actuaries at the Centers for Medicare and Medicaid Services predicted that 375,000 would sign up. Those numbers were expected to exhaust the $5 billion that Congress authorized for the Preexisting Condition Insurance Plan long before the pools’ anticipated closure at the end of 2013” when private sector insurers will be required to cover the sick as well as the healthy.
“The Department of Health and Human Services has now responded with a range of measures to boost enrollment, including partnering with the Social Security Administration to market the program to the roughly three million people who apply for federal disability payments each year. Meanwhile, amid the strange politics of 2011, many congressional Republicans now propose to repeal the Affordable Care Act and the Preexisting Condition Insurance Plan along with it—and, instead, install a new system of state-run ‘high-risk’ pools that Republican lawmakers say would be designed to function much better than the one now in place.
High-Risk Pools Have Mixed Record
“But state-run high-risk pools have long had a mixed track record. The oldest date back to 1976, when Connecticut and Minnesota set pools up with the goal of covering expensive high-risk people while simultaneously removing them from the private individual health insurance market in order to stabilize it. About a dozen states added high-risk pools from 1988 to 1992, amid heightened national concern about the uninsured. Before passage of the Affordable Care Act in 2010, thirty-five states had set up pools. . . . But total enrollment in all of those states put together reached only about 200,000—a drop in the vast bucket of the uninsured. Even as the state high-risk pools grew, both the numbers of uninsured people and the cost of insurance in the non-group market kept rising.
“The single biggest reason that the pools didn’t have more impact was money. The pools are costly to operate, so premiums are high—125–200 percent, sometimes even more, of the standard premium in the individual market, plus copayments, high deductibles, and steeper charges for older and sicker beneficiaries. And all of those fees still don’t cover the costs for a population that is, by definition, in poor health and typically undergoing costly medical care. Even high premiums alone aren’t enough to pay the cost of the pools, which was $2.3 billion in 2008. Financing varies by state, but premiums cover roughly two-thirds of the costs of the programs, and states have to fill the gap. Some states have turned to general revenues; others have taxed health insurers or imposed tobacco taxes, or have drawn on tobacco settlement funds.
“Because encouraging even more enrollment in the state pools would have meant that states would have to raise even more money, there was in effect a natural limit on how large they would grow. The Preexisting Condition Insurance Plan in the Affordable Care Act was thus intended to build on the states’ experience but to create pools that were more affordable; were available nationwide under a more consistent set of rules; and would reach some of the people who had previously avoided the state pools, presumably because of the high premiums. Under the law, states were given a choice: either set up their own federally funded Preexisting Condition Insurance Plan within the law’s framework, or let the federal government step in and run the pool for the state.
“As the program went into effect in the summer of 2010, twenty-seven states created their own pools, building either on their existing pools or on other programs aimed at insuring high-risk populations. Two dozen states, including the District of Columbia, chose to remain under the federal umbrella; the Department of Health and Human Services then contracted with a nonprofit health insurer to run those pools: the Government Employees Health Association Inc., which provides health plans to government workers and retirees.
“For people like Linda Jean Limes Ellis, who lives outside Cleveland, the new pool was her only hope for coverage. Laid off from her office job at an auto insurance company at age 60, she exhausted her COBRA benefits (a provision of the Consolidated Omnibus Budget Reconciliation Act of 1986) and was rejected by private insurers because of chronic conditions and prior surgery on a rotator cuff. Her husband, Ronald Ellis, age 72, has Medicare; she isn’t old enough. “If you’re like me, you don’t have an employer, you can’t get on with a spouse, you can’t get qualified for Medicaid, you can’t get Medicare, and there’s this vast wasteland from 62 to 65,” Linda Ellis says.
“Exhausted and financially stressed by having to negotiate discounts and payment plans every time she needed to see a doctor, have a test, or fill a prescription, Linda Ellis signed up for the preexisting condition pool in late 2010. That gives her some protection, but the couple is still scrambling to pay bills, she says.
Understanding Low Rates of Participation
“The Preexisting Condition Insurance Plans, of course, were designed as a temporary three-and-a-half-year bridge to 2014, when the state insurance exchanges are set to open and insurance companies must take everyone, regardless of health status. That meant that the pools had to begin operation quickly and then prepare to go out of existence a few short years later. So for federal and state officials alike, “energy was focused on getting the thing up and running” in a few short months, says Jean Hall, an authority on high-risk pools at the University of Kansas, who suffers from lupus and has in the past experienced her own difficulty obtaining health insurance. As a result, Hall says, officials are only now “catching their breath and now doing” the sort of sustained, broad-based outreach that has long been needed to boost enrollment in other government programs, such as the Children’s Health Insurance Program.
“It’s also the case that the Preexisting Condition Insurance Plan was expressly designed not to destabilize existing high-risk pools or the rest of the health insurance market. To enroll in the new plans, people had to be uninsured for at least six months, meaning that anyone who currently had health insurance through an existing high-risk pool could not join. Not everyone got the message. For instance, a woman calling herself “Elsa123” posted on an online news site that she had been in the Kansas pool since 2004 and was wondering “where is my share of the $36 mil that Kansas received for the new High Risk members.”
“It’s clear why Elsa might be interested. In the existing state pool, she pays $422 a month for a policy with a $10,000 deductible. In the state’s new Preexisting Condition Insurance Plan option, she’d pay $72 less per month, and her deductible would drop to $2,500. But in order to make the switch, she would have to go without coverage for six months—not a great option for someone in poor health. “I haven’t heard anyone report—and I probably would have if it was a significant phenomenon—that people are leaving one and going bare to get into the other,” says Amie Goldman, the Wisconsin high-risk-pool director and current National Association of State Comprehensive Health Insurance Plans chair.
“So if Elsa is out, who might be in? Information about the people who have bought into the new federally sponsored pools is so far anecdotal, but they appear to be a pretty sick group, with multiple coexisting medical conditions. That would make them similar to the group already enrolled in state high-risk pools. According to the University of Kansas’s Hall, who surveyed the trade literature, the average state risk-pool enrollee is between forty-four and fifty-five years old, has four to six chronic conditions, and visits six to eight physicians on a regular basis. . . .
Obama Administration Adjustments
“The Obama administration admits that enrollment overall has lagged expectations and announced steps to broaden outreach and boost enrollment. For 2011, new premium rates and benefits were announced, giving people more choices in how plan benefits were structured and also giving the option of a health savings account. And on February 10, 2011, the Department of Health and Human Services announced that new resources were being made available to the media, consumer groups, states, health care providers, and others to increase awareness of the program. A news release from the department also noted that large commercial insurance carriers, such as WellPoint, Humana, UnitedHealth Group, and several Blue Cross/Blue Shield plans, had begun including information on the plan in all letters to consumers to whom they denied health coverage.
“Of course, if enrollment in the new preexisting conditions pools were suddenly to surge, that could create another set of problems entirely. It’s not clear how long the $5 billion set aside for the program would last. As a result, enrollment might have to be capped, eligibility rules tweaked, or premiums raised. The best-case scenario may be that the pools will grow steadily, but not explode, between now and 2014, when new state-based health insurance exchanges and an expanded Medicaid program will absorb even the highest-risk adults. (Note: Under the Affordable Care Out, insurers are now required to cover children, despite pre-existing conditions.). The ACA explicitly calls for the new pools to shut down then, and many expect the older state risk pools to similarly fade away.”
Republicans Challenge Plan’s Start-Up
Meanwhile “congressional Republicans continue to push their strategy to repeal the Affordable Care Act and replace it with an as-yet-undevised alternative—one that would appear to include a new version of strengthened and expanded high-risk pools. Given the current budget-cutting zeal, it’s not clear how robust their preferred alternative pools would be. James Capretta and Thomas Miller of the American Enterprise Institute have estimated that the federal government would have to spend $15–$20 billion annually for high-risk pools to make substantial inroads in covering the uninsured. Even now, as Congress debates cutting heating oil subsidies for low-income people, it’s unclear whether congressional Republicans intend to make that kind of money available.”
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As Kenen’s article makes clear, the essential problem here is money. It is all but impossible to insure a small pool of very sick people at a price that either government or patients can afford. A state plan with a $10,000 deductible and a $422 monthly premium is simply not going to be affordable for most middle-income Americans. And, as she indicates, it is not at all likely that conservatives will come up with the $15 to $20 billion a year that would be needed to fund state high-risk pools.
The only way to cover the cost of treating patients suffering from five chronic diseases is for everyone to join one pool: young and old, healthy and sick. This is what insurance is all about–diluting the risk that any one of us will find herself alone, crushed by medical debt. This is why we need an individual mandate. (Keep in mind: no one will be forced to sign up for insurance; everyone will have the choice of paying a penalty instead. Those penalties will be used to help finance the larger pool. At the same time, those who pay the penalty will be getting something for their money: the security of knowing that if they fall ill and decide they need insurance, the pool exists and they will be able to buy coverage. Insurers cannot reject them because they are sick).
But it takes time set up the rules and fund the subsidies needed to create a national health plan that aims to cover all Americans. Insurance exchanges must be created; a list of “essential benefits” that all insurers must cover has to be drawn up; regulations must be set for insurers; community clinics must be expanded so that 32 million uninsured Americans don’t wind up in ERs (the Affordable Care Act provides funding to increase the capacity of community health clinics by 50 percent); the pool of nurses, nurse practitioners and primary care doctors willing to work in the areas where they are most needed must grow (the ACA provides generous loans and scholarships that will attract the caregivers we will need.)
This is why the final stage of reform–universal coverage–will not become a reality until 2014.
In the meantime, some provisions that expand coverage already have taken effect:
- Health insurance companies are prohibited from excluding children suffering from pre-existing conditions
- Young adults can now stay on their parents plan until they turn 26.
- The law eliminates co-payments for preventative screenings
- Insurers can no longer cancel coverage of already-insured patients who get sick, except in cases where the policy holder commits fraud.
- Small employers who want to offer coverage to employees are eligible for subsidies.
Between now and 2014, reformers are working to address the sky-high cost of care. We must rein in health care inflation , or premiums will quickly become unaffordable–even in the larger pool. Today, the Centers for Medicare and Medicaid (CMS) is encouraging doctors and hospitals to experiment with different ways of delivering care that would lift quality while paring costs. To that end, CMS is helping providers form “Accountable Care Organizations” that will let physicians and hospitals share in the savings if they can achieve better outcomes by collaborating to coordinating care. CMS also promises bonuses to "medical homes" that succeed in managing chronic diseases–and keeping patients out of the hospital.
As for the conservative cririque of the Prexisting Condition Insurance Plans reformers never saw them as more than a stop-gap measure designed to disappear in 2014. No one thought this was a solution– ithe ACA's architects understood that this was just a rather rickety bridge that would provide some protection for patients like Linda Ellis until universal coverage kicked in.
To pretend that the failure of the Preexisting Condition Plans to cover all uninsured Americans signals that the larger reform project is doomed is truy perverse.
At a healthcare conference I attended two months ago, there was a session on high risk pools. In some states, the medical loss ratio for these pools exceeds 300% which means premiums cover less than one-third of medical costs incurred by enrollees. Another factor not mentioned in the post that makes these policies unaffordable for many is that insurers are allowed to charge applicants between 55 and 64 years old, four times as much as people in their 20’s. Under PPACA, the maximum age band for the average risk population is “only” 3 to 1. At the same time, insurers tell me that, on average, the 55-64 population overall uses 5 to 7 times as much healthcare as people in their early 20’s.
The nature of health insurance is that a comparatively small percentage of members account for a hugely disproportionate share of total costs. In most large plans, including Medicare, in any give year, 40%-50% of claims costs are incurred by 5% of the enrollees. For Medicaid, it’s even worse, in part, because of long term care costs. According to AHIP and others, about 160 million people today, including family members, get their health insurance through an employer. Employers spend roughly $4K per person on average to provide this coverage, or a bit more though the variance is considerable among employers depending on the size and age distribution of each workforce. I’ve read that there are 4-5 million people nationwide who could benefit from a high risk pool. It could easily cost a minimum of $10K each in medical claims per year to cover this population. From a political standpoint, this is a lot of money for relatively few people, many of whom are too sick to even vote. With budgets at all levels of government under severe stress, and premiums unaffordable for all but the wealthy, this is a problem that defies an easy solution.
I am also skeptical about how much money can be pulled in from forcing everyone to buy health insurance or pay a penalty. What we’re really talking about here are the young and healthy. If they purchased insurance, their premiums would be at the low end of the 3 to 1 age band, and many would probably opt for the least expensive, so-called Bronze plan. If they chose to pay the fine instead, it would raise significantly less money.
I’ve said before that if we want to make insurance affordable and bend the medical cost growth curve, we should stop paying for services, tests, procedures and drugs that either don’t work or cost more than they’re worth. We could also do a much better job with end of life care including providing and paying for palliative care consults. Price and quality transparency tools would be helpful, especially for referring doctors so they could more easily steer their patients to the most cost-effective providers while substantive tort reform, could, over time, reduce defensive medicine. If all those efforts fail, we’ll probably eventually wind up with age based rationing.
Last year I was diagnosed with type II diabetes, & my employer had three layoffs. I live in Dallas, but was born in Calgary.
I wondered about this, so I asked BCBS. The Texas high risk pool would charge $15,000/year premium & a $14,000/year deductable.
No private company will insure me.
I’m keeping a tight grip on my Canadian passport…
Barry–
The conventional wisdom has it that twenty-somethings and even people in their early 30s don’t feel that they really need insurance– they’re young, healthy and feel immortal.
But it turns out that the conventional wisdom is wrong. If you take a close look at that group you find that just like older people they tend to buy insurance–if they can afford it.
The twenty-somethings who don’t have insurance are in the lower and lower-middle end of the income spectrum.
No one likes walking around uninsured. Even a 24 year old knows he can be hit by a car.
Under the ACA a great many 20-somethings and 30-somethings will qualify for pretty generous subsidies. There is every reason to believe that they will use those subsidies to buy insurance.
So I think there will be many young people in the pool and this will help make insurance affordable for all of us.
In addition, the ACA increases the capacity of community health clinics by 50%. These clinics represent an optimal way to deliver high quality, low-cost care.
Today, both low-income people and many young people use these clinics. By expanding them by 50% we’re providing a place for many of the 32 million who are now uninsured to get continuing care that will be much less expensive than getting care at an ER— and much better than getting care at a retail clinic in Walgreens.
You are right that 5% of the population is much sicker than the rest of us and these people need much more care.
In every other country in the developed world, that 5% gets the care they need.
And we have decided that in the U.S. we too, want to make sure that they receive the treatments they need. This is what “universal coverage” means. There is no political dilemma here.
Of course I agree that we don’t want to waste money on ineffective treatments. But under the ACA providers that reduce the waste and achieve better outcomes at a lower price will receive bonuses. There will be financial penalties for waste. (After operating for two years Accountable Care Organizations will share in any losses, just as they share in any savings.)
Bottom line: other develped countries are able to cover everyone, including the very sick. We can too.
But this will mean cutting back on overtreatment. Today, much of that overtreatment goes to the wealthiest segment of the population: people who have angioplasties that provide no permanent benefit; people who have knee replacements without trying physical therapy first; people who aren’t sick but nevertheless see 7 different spepciaists rather than going to a primary care doctor to see if he can diagnose and treat their problem (if, indeed they have a medica problem); people who undergo back surgery, etc.
People on Medicaid have a harder time gaining access to surgeons and speciaists so they are less likely to be overtreated. (Hospitals must patch up anyone who comes to an ER, but there is no law requiring surgeons or specialists to take Medicaid patients.)
Bob–
You are lucky to have a Canadian passport.
In 2014 you’ll be covered but until then, I understand why you’re nervous.
In many states the high-risk pools are not affordable.
But aren’t you eligible for hte federal high-risk pool? Premiums will be less though perhaps not low enough.
Maggie –
While I’m hopeful about the potential of ACO’s to spend healthcare resources more efficiently, I’m only cautiously optimistic at best for a number of reasons.
First, on the positive side, primary care doctors have the most potential to steer patients toward the most cost-effective providers. To do that, however, I think we will need to provide them with more and better tools to help them identify just who those providers are. If they can do it successfully, the potential bonus income could be a significant percentage of their total compensation.
On the other hand, patients will be allowed to see providers outside of the ACO network and may not have to pay a higher co-pay to do. In effect, then, assigning a patient to an ACO is more of an accounting concept than an HMO concept. It would be better if ACO’s operated more like tiered networks and patients also paid a lower premium if they joined a more cost-effective ACO.
Hospitals may not make good leaders of ACO’s even though they have the most management infrastructure and are best able to afford the IT investments. The problem is that they are high fixed cost businesses. If they do the right thing and drive less utilization of healthcare resources, any bonus they may earn will be more than offset by lost revenue from lower utilization.
It’s also troubling that an ACO can choose a reimbursement model that, in the first two years, will protect them from exceeding budgeted costs but reward them if they save money and meet quality standards. That sounds like a heads they win tails taxpayers and premium payers lose approach.
Lower utilization can come in a number of different ways, all with different drivers. Hospitals could reduce avoidable harm through use of checklists, more attention to hand washing and standardized procedures in the OR, among other things. Better discharge planning can help to reduce readmissions as well. If we want surgeons to perform fewer unnecessary procedures, more frequent and vigilant utilization review and auditing will probably be necessary. Drug costs could be cut if doctors more consistently prescribed generics when they are available. To reduce unnecessary or redundant imaging, substantive tort reform will probably be required, especially as it relates to failure to diagnose cases. Better care coordination could result from widespread implementation and use of interoperable electronic medical records which would not require an ACO structure. Finally, insurers fear that the formation of ACO’s led by large hospital groups could lead to even greater concentration of market power which the FTC and DOJ both need to be mindful of.
So, in the end, when it comes to ACO’s, I’m hopeful but far from confident that they will accomplish what we hope they will.
Barry–
You write: “primary care doctors have the most potential to steer patients toward the most cost-effective providers. To do that, however, I think we will need to provide them with more and better tools to help them identify just who those providers are.”
You are aassuming that most chronically ill patients suffering from diabetes, chronic heart disease, knee pain, back pain, etc. need to see specialists.
This simply isn’t true.
Patients suffering from chronic diseases need doctors and nurses who can teach them how to help manage their diseases. Often, this means trying low-tech treatments such as physical therapy, inexpensive pain-killers and acupuncture.
Too many people use a cardiologist as their primary care doc.
(I had a close friend who did this. His top-of-the llne Manhattan cardiologist recommeded several surgeries– and he went through with all of them.
But his cardiologist never really diagnosed what was wrong with him. (He claimed that he had figured out what was wrong with my friend, but none of his surgeries really helped him.)
My friend died alone one night when he was 52. This was totally unexpected–which is not uncommon for patients suffering from heart disease.
But a good primary care doc would have told him that he needed to exercise (which he never did)l ose some weight, and, most importantly) reduce the stress in his work life. (He ran an exatraordinarily successful company that he and his brother had started 25 years earlier. They had become multi-millionaires, But the business (and his brother) was killing my friend. He didn’t need to make more money.
As Dr. Rick Lippin (a regular Health Beat reader) says, there are two important questions that a primary care doc should ask all patients:
“How are things at home?”
“How are things at work?”
How many specialists ask these questions? Not many.
Whetner a doctor talks to and listens to patients are factors that cannot be easily measured when evaluating the care that doctors offers
Research (and experience in other countries suggsts that primary care docs and nurse practioners (who are trained to spend more time talking to and listening to patients) often do this best
In recent years we have been doing far more surgeries than any other country in the world, and there is no evidence that this is improving the heatlh of the nation.
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“You are aassuming that most chronically ill patients suffering from diabetes, chronic heart disease, knee pain, back pain, etc. need to see specialists.
This simply isn’t true.
Patients suffering from chronic diseases need doctors and nurses who can teach them how to help manage their diseases. Often, this means trying low-tech treatments such as physical therapy, inexpensive pain-killers and acupuncture.”
Maggie –
Patients with back and knee pain are finding that insurers are increasingly requiring that they try physical therapy first before surgery is approved. For those with heart disease and diabetes, the biggest problem, even for patients who have a good PCP, is non-compliance. One major cause of non-compliance is that the adverse consequences are deferred if your problem is early stage diabetes, hypertension or high cholesterol. To remove financial barriers, more insurers are adopting zero co-pays for maintenance drugs to mange these conditions as well. To start an exercise regimen or to stop smoking is far easier said than done for many patients. They know they should do it and they don’t need a PCP or nurse to tell them. Smoking is more addictive for some than others while exercise is time consuming and not fun for many non-athletes including myself. By contrast, for people with bad vision who need to wear glasses or contact lenses because they can’t read or drive if they don’t, compliance is usually 100% because the adverse consequences of non-compliance are immediate.
My cardiologist is also my PCP. I met him because he also does my employer’s corporate physicals. 80% of his practice is primary care. Also, if he recommends surgery or refers a patient for a test that leads to surgery, he doesn’t benefit financially from that treatment. I think he’s great and a very cost-effective practitioner. When PCP’s need to refer patients to specialists, they need good information about who the most cost-effective, high quality providers are. They generally don’t have it now.
Even perfect compliance is no guarantee against an untimely bad outcome. Case in point: the famous runner and author, Jim Fixx. Mr. Fixx suffered from heart disease and died at age 52 of a heart attack while running. Perhaps he would have died even sooner if he wasn’t so vigilant about his exercise regimen. Who knows? Despite perfect compliance, a piece of plaque can break off at anytime and form a clot which can trigger a heart attack. The point is, as you often correctly point out, that healthcare anecdotes aren’t worth much. We can all cite them to illustrate a point we want to make.
As for primary care doctors, even if we raised their pay and had enough of them as well as NP’s, to spend adequate time with patients, there will still be plenty of cases that need to be referred to specialists and hospitals. They need better tools than they have now to help them identify who the most cost-effective, high quality specialists and hospitals are.
Barry–
As many people have pointed out, it is very difficult to measure the quality of care that an individual physician provides–unless it is poor.
The pool of specialists that an individual physician treats is too small– a few patients can skew averages. Moreover, other doctors are usually involved in treating those patients — a surgeon, a rehab specialist, a hospitalist– and that, too, can skew results.
This is why most programs that reward for quality of care do not reward individuals; instead they reward teams.
In large settings like Kaiser where many doctors are looking at the same patient chart, it is possible to monitor whether individual doctors are following “best practice” most of the time. If they aren’t, questions will be raised.
This, I think, is the best way to ensure that most doctors are practicing somewhere between the middle and the right section of a bell curve.
“As many people have pointed out, it is very difficult to measure the quality of care that an individual physician provides–unless it is poor.”
Maggie –
If we could steer business away from the poor practitioners, it would be a good step in the right direction. However, even if the vast majority of doctors already achieve quality that falls within the middle to right side of the bell curve, the prices they command for a given service, test or procedure can vary widely based more on market power than competence and which hospital they are associated with or employed by. Even Medicare and Medicaid pay different hospitals within the same region different prices for similar work depending on whether they are a teaching hospital or not and other factors, including political influence. Sometimes the same doctor doing the very same procedure in the same way on similar equipment in two different hospitals can generate very different total bills, including hospital charges. If referring doctors had tools to allow them to easily ascertain this information, they could steer their patients to providers, especially hospitals and surgeons, who charge less for similar work without any demonstrable differences in quality. Tiered networks, which I also support, could accomplish the same goal.
Does anybody know if that woman in the Cleveland area who used up her COBRA, then moved on to HIPAA guaranteed issue? This is very expensive, but people who lose health insurance must be given coverage under HIPAA.
And I wonder if the Pre-existing plan allows a person to avoid the HIPAA coverage? Can a person finish COBRA coverage, go uninsured for six months, apply for individual health insurance, be denied…and then qualify for the pre-existing condition insurance plan?
I have met people who should take this route, but they are too afraid to go without insurance for six months. These are people who have saved for retirement, have assets, and are willing and able to pay high premiums, so they have avoided the federal plan that could save them money and would be better coverage than the HIPAA plans.
Barry,
You are absolutely right that some doctors charge more than other in the same communnity for the same procedure.
But I doubt that most doctors would steer patients to the least expensive doctors. If they did that, many of their colleagues would be very upset with them. (And if your colleagues are upset, you don’t get referrals.)
One way to figure out which doctors are less expenisve is to look at the list of doctors in your insurers’ network and see you takes Medicaid. If a doctor is willing to accept Medicaid this may mean that he charges less. (Or it may simply mean that he feels an obligation to help Medicaid patients.)
Real estate is probably the best indicator of prices. A doctor in an expensive area will charge more to cover his overhead.
Finally, sometimes a doctor charges less because he has difficulty attracting patients. And this can be a sign that there is a problem with his competence — or it may just be a matter of personal style . ..
As a Canadian, you right winged Americans floor me being the only 1st world croutny that does not tend to the health and well-being of its citizens. Don`t even get me started on the right winged propaganda that is shoved down your throats about how our Canadian health care system is apparently broken and flawed . Newsflash folks it works extremely well for us. You don`t see individual Canadians going bankrupt or in massive debt because they can`t pay their medical bills and EVERYONE gets medical care no, there are no waiting lines, we choose our on doctors etc .But yet you think nothing of spending trillions upon trillions of dollars on war in far away lands ..Go figure. America sure does have its priorities straight now doesn`t it folks!!References :
jhonatan–
“Canada is the North American country where everyone has a right to healthcare: the U.S. is the North American country where everyone has the right to carry a gun.”
(Paraphrasing– can’t remember who said this, but how true.)