I just want to repost how some (mostly southern) states could accidentally get quasi-single payer on the individual market with near universal coverage of the 100-400% Federal Poverty Level cohorts.
Alabama could have an individual market single payer plan next year.
It would be mostly unintentional and massively expensive to the Federal government but most people could be covered at a high actuarial value.
Here is how an accidental single payer system in Alabama could be created.
Right now, Alabama is due to have only a single insurer on the Exchanges in 2017. They would be the de facto single payer for the exchanges.
Subsidies are based on the cost of the price of the second least expensive Silver plan. The individual premium responsibility is defined as a percentage of the family income for a given income level as defined by the Federal Poverty Level. A person who earns under 400% FPL is only on the hook for the calculated family contribution amount for the 2nd Silver. The gap between the premium of the 2nd Silver and the personal contribution is the Advanced Premium Tax Credit (APTC).
If there is a large gap between the premium of the least expensive Silver plan and the second least expensive Silver plan, the buyer benefits. They get the full APTC and then they just have to make up the difference between the lower priced #1 Silver and APTC with money out of their pocket.
Philadelphia had this happen in 2014. Andrew Sprung looked into this:
Last year, low-income buyers in Southeast Pennsylvania got a windfall….
The windfall stemmed from the fact that the cheapest Silver plan in the region, Independence Blue Cross’s Keystone HMO Silver Proactive, was much cheaper than the benchmark second-cheapest plan (also a Blue Cross HMO), to which the subsidies are keyed. The difference was large enough to all but zero out the premium for a lot of low-income buyers.
Last year, almost all of Health Federation’s clients who were eligible to shop in the marketplace bought the cheapest Silver – which, thanks to CSR, had a deductible of $0 and wonderfully low copays – but also cost most of them nothing or next to nothing in premiums.
So how would accidental Single Payer with very low premiums work in Alabama?
Blue Cross and Blue Shield of Alabama would offer a simple HMO or EPO as the #1 Silver. It would be priced at an actuarial fair level where BCBS of Alabama could be profitable but not obscenely so. They would also offer another Silver, maybe set up as a PPO national network with all of the bells and whistles. This would be priced 50% higher than the first Silver. Gold and Platinum plans would be based on the basic HMO/EPO model with slightly richer benefits so a basic Gold would be less expensive than the bells and whistles #2 Silver.
The bells and whistles PPO would be the subsidy setting benchmark so bells and whistles would be fully subsidized. However the #1 Silver would benefit from the massive gap between the #1 and #2 Silver so for quite a few low income families their monthly premiums would be zero. For individuals who make under 200% FPL, the combination of a rich APTC and Cost Sharing Reduction (CSR) subsidies would allow them to buy platinum(ish) coverage for a few dollars per month with low deductibles. Individuals and families making between 201% and 400% FPL could be buying subsidized Gold coverage for less than their expected personal contribution.
Individuals who make 250% FPL could buy basic Bronze plans for almost nothing out of pocket. These individuals are probably in the group where Bronze is a reasonable gamble.
Hacking the exchange system like this would lead to significant enrollment growth in the 175% FPL and above cohort because the plans will have gotten significantly less expensive so the value proposition becomes a whole lot better. It would be an enrollment expansion and a one time profit center for BCBS of Alabama as other insurers would see the hack and see if they could get back into Alabama in 2018 or 2019. The Feds would spend more money on premium subsidies as enrollment skyrockets but this Administration and a probable future Clinton administration would be fine with that. This could be a triple win.
On the Road and In Your Backyard
Brachiator
I wish that the presidential contenders would look at how the ACA is actually working instead of immediately moving to Medicare for all and other proposals.
Cathy Notestine
Because the “single payer” system has worked SO well for the VA Hospital system?
Barbara
Alabama is the 23rd largest state with nearly 5 million people and for its size has a remarkably concentrated payer market. We could make ACA work well in conjunction with some innovative thinking on the provision of first dollar primary care services (not just preventive care).
Barbara
@Cathy Notestine: It’s not a single payer system. Veterans can use the VA system in varying degrees of preferential status, but VA coverage does not displace private coverage. We don’t have a single payer system except for Medicare for people over 65, and even that isn’t really a single payer because most retirees (at least) have supplemental coverage through private payers of one kind or another (e.g., through employers or privately purchased or Medicaid). And of course, those who are over 65 can still use the VA if they are VA eligible. Sarcasm doesn’t translate well in text so if you mean something different from what I assumed you will need to elaborate.
Mike J
@Barbara: Also keep in mind that before Bush the dumber, the VA had the best outcomes for the lowest price. Cycling 100s of thousands of people through the meat grinder and putting people who don’t give a shit in charge really seems to have wrecked it.
Barbara
@Mike J: The efficiency and quality of the VA has has waxed and waned over the years, and much also depends on local conditions. It just has too much potential as a political and patronage football.
Chyron HR
@Cathy Notestine:
So how’s God-Emperor Trump’s middle-class tax hike workin’ out for ya?
daveNYC
Plus I think the VA is more an example of socialized medicine than it is of single payer.
Repatriated
@Barbara:
But at least it’s a politically-responsive football. Privatizing it gets veterans’ care dispersed into the general healthcare system where problems can be easily ignored.
At best, privatizing the VA would trade patronage appointments for vastly larger and concentrated lobbying/grifting opportunities.
The system that cares for our veterans should be as visible and responsive as our system that turns civilians into veterans in the first place, especially since we have an all-volunteer military.
NonyNony
Ah – so a single-payer “plan” that a Republican can love!
randy khan
@NonyNony:
It depends – who gets the money?
Barbara
@Repatriated: I am not arguing for privatization, which has been occurring to one degree or another for a long time, it’s just that if you put a VA hospital in every district you are going to find extreme variability in quality because not everyone is going to be able to recruit the same quality of personnel, both management and health care.
Ohio Mom
This could be a naive question but one thing I wonder about statistics describing the VA system is that they don’t have typical patients. Other health systems have every age group, from infants on up, while the VA is mostly men, many with very complicated medical needs.
When statisticians calculate the system’s effectiveness, do they take all that into account? If you’re a pediatrician in a general practice, you’re going to look a lot more successful when you are mainly treating strep throats and simple broken bones than if you are working with who knows what at the VA.
Villago Delenda Est
Clearly some Rethug politicians need to get on this right now and correct it so the undeserving poor get no breaks at all.
Villago Delenda Est
@daveNYC: Having lived under honest-to-gosh socialized medicine while on active duty, I can tell you that it’s great.
Brachiator
@Ohio Mom:
Excellent point. I don’t know how well this is taken into account in discussions about the VA.
lee
Also keep in mind a lot of the problems with the VA can be solved the old fashioned way with money.
Thanks to our optional war in the desert, the number of those eligible for VA benefits increased by N but the funding did not increase the same amount and in some cases funding was actually denied (TBI research is one thing).
David Anderson
@Ohio Mom: The best studies will attempt to risk adjust VA and non-VA populations with a variety of complex statistical and data analysis techniques so that the comparison will be Gala apples to Braeburn apples
Ruckus
@Mike J:
@Barbara:
As a vet who uses the VA system I can tell you that it actually does pretty well. The big problem is of course, as it always is, money and the local upper administrative staff. I’ve used 3 different clinics within the same administrative area and it is run well but the non medical staff is overworked/understaffed and has to leave after 7 hrs no matter the patient load. Within the last two years it’s almost impossible to get anyone on the phone and numbers have been changed/no longer given out to seemingly keep patients from calling. Example, if you have a problem with a prescription, you can no longer call the pharmacy with the number to get the problem fixed, you have to go down to the clinic and make it more crowed. For me that’s a 45 mile drive or train ride. If I still worked full time…..
And it goes on. And I’m seeing the medical staff now being under staffed. I’ve gone several times without a primary, which means I can not get an appointment, I have to go to the clinic and sit and wait, hoping for an opening.
This makes the care sound worse than it is, the waits are really no longer than I hear people using civilian medical services around here and the care, once you get in seems to be great. And not all vets get free care. If you earn too much you don’t get in at all unless you are a medal of honor awardee. If you make more that a minimum amount you pay copays for everything. My most expensive year I paid $3900. Almost everyone pays copays for medication.
Ruckus
@Ohio Mom:
It is different sure. But less so than one might imagine. But there is a no longer almost invisible number of women in the military and that means women vets. There are a higher number with missing limbs, cancer and some illnesses, like Parkinson’s for example have a higher incidence but I think that comes from better screening and primary health care than the general public. If you are a vet you get coverage, if you aren’t you have to be able to afford it. That changes the dynamic. I had private insurance till 2005 and started using the VA after that.
Villago Delenda Est
@Ruckus: Triage in the field has improved, but the catch is, a lot of wounds that were once mortal no longer are, but have long term needs to be tended to. Losing an arm or a leg was often fatal, now not so much (see Tammy Duckworth, hero pilot) but care for the injured vet is expensive.
So the VA’s burden has increased, but the funding is not forthcoming because it is FAR more important to give tax breaks to parasite billionaires than it is to care for those who gave arms and legs to fight this country’s increasingly stupid battles.
Ruckus
@Villago Delenda Est:
QFT
And as it’s been for at least the last 70 yrs. I was sort of trying to make the same point, because there are a lot of vets and while many have severe wounds, like Tammy, many more really are just normal stuff. But a lot of people in the civilian world with that normal stuff don’t get good or any health care. So it looks like the VA has an abnormal load. They don’t, other than the wound care. What they do have is a more than fully utilized system.
Michael J Allen
@daveNYC: Correct. If you want “socialized medicine” on a smaller scale in the US there are also a couple of deals like Kaiser Permanente. Like the VA, docs etc. on salary and everything in one location. I chose that plan when I lived in San Francisco and Washington DC.
Michael J Allen
@Villago Delenda Est: This blog needs an up/down vote function. You summed up a lot of the VA situation perfectly.
Michael J Allen
We forget that 70-80% of Americans who have health insurance are on a deal arranged through their employer, including all government employees. So all the ACA policies are utilized by a minority of people. (The ACA also has various regulations that apply to everyone’s policies.)
Barbara
@Ruckus: I can’t begin to tell you the intricacies of how the VA works, but in addition to local differences, there are priority accessibility differences that often result in different classes of vets having different experiences in terms of waiting times and accessibility to certain types of treatment. Moreover, in some cases delays occur because the VA hospital serves a population that has a higher than normal uninsurance rate, and thus relies on the VA more than average. One of my SIL’s is a vet and she relies on the VA for everything because she was unemployed for a long time. A lot of people in her circumstance would not seek care from the VA if they have private insurance.
Barbara
@Michael J Allen: In 2017 employer provided insurance accounted nationally for just under half of the population. Source.
Excluding PR, the range is 36% (NM) to 60% (Utah). There is NO state where that number is 70-80%. The average for Medicare is 14% and for Medicaid it is 21%. It’s hard to use Medicaid as a benchmark because there is such a disparity between expansion and non-expansion states. Even the non-expansion states like Texas and Wisconsin have 17% of their population covered under Medicaid.
Ruckus
@Barbara:
I went with the VA because I had no other choice and it was there. I have been surprised by the health care I’ve received. As I stated I had job provided HC insurance and that was from 65 to 06 except for my navy time. I went without till I went to the VA. My experience is that the VA is actually quite good. But. The But is that you have to have patience. But tell me any healthcare system where that isn’t true. Also tell me of any vets who have never hurried up and waited. I won’t hold my breath. I’ve seen people get up and tell the receptionist that they can’t wait any longer and they leave. Yeah, one less person in front of me. There are morons in all walks of life who think they deserve 100% of your time and energy. Because. Vets are no different. But I always had to wait when I had insurance and even when I paid cash.
I was like your SIL, I knew someone who worked at the VA during the 70s and she told me that it was horrible. It may have been, it isn’t now, at least locally for me.
A very nice thing is that if a doc thinks you need a test, you get the test, be it an MRI or a lab test and everything inbetween. I also know that a lot of vets in the LA system have to take a bus to the hospital if their clinic doesn’t offer a particular service. Some of the outlying or smaller clinics may not have an MRI for example, it just isn’t cost effective. The LA hospital has at least 4. I know this because I’ve been in all of them.
And yes care is rationed upon need. Tell me any healthcare system that doesn’t do this. What I really like about the VA is that the actual medical care, on a patient level is not connected to money. The speed at which you get said care may not be as fast as some think they deserve but it is fair and equitable health wise.
Ohio Mom
@David Anderson: Thanks. That is good to know.
My neighbor is a pharmacist at the VA. Part of the time she is dispensing, the other part she is reviewing charts of patients with more than one complex condition to look for things like meds that shouldn’t be taken together.
That sounds like an important, if tedious, job to me. It makes me feel proud to know veterans are getting thoughtful and thorough care.