Ways to Make Health Insurance Plans Better and Cheaper
This site and the ideas presented here are based on experience and understanding of the need to find balance between all the players in the healthcare system, with the understanding that change happens slow, and that Government and Private Industry operate in very different ways with competing interests. Another important aspect related to healthcare is that it needs to be fundamentally “local”. People need basic healthcare services where they live; from people in their own individual communities; and not located 25, 50, or over 100 miles away from their homes.
Primary Healthcare Programs (different provider pay rates) : Primary Healthcare Programs
Previously submitted HHS/CMS Public Comments:
- HHS Public Comment Reducing Regulatory Burdens of PPACA 12 Jun 17
- HHS Public Comment of PPACA Regulations 17 Feb 17
Where we are Today…
In general, PPACA (Obamacare) has not delivered on the promises of Affordable and High Quality Health Insurance that were made when it was created and signed into Law, other than Medicaid expansion. It’s unfortunate; but we must accept the reality of where we are today. We must also remember that many parts of the Law “end” by 2026, less than 8 years from now, under Congressional Budget Rules.
Today, the healthcare system is primarily run by large hospital networks, and large pharmaceutical firms. PPACA promoted the consolidation of healthcare Providers (hospitals buying doctors groups) and limited the options for negotiating drug prices with Pharmaceutical companies, as the drug costs are added together with medical costs in health plans to reach the Individual out-of-pocket health plan maximums each year. Note that Medicare separates the drug costs from medical costs, which allows for better negotiation of drug prices. In addition, many 1,000’s of doctors are now cash-only; and even hospital networks are now offering cash-only options.
Ideas for improvements, click Title links for Details
How to have Better Health Insurance Plans
- Implement a “New Standard” for the Actuarial Value Calculator (AVC) – change the “basis” of costs and utilization from the “national average per-capita (per-person) cost” of healthcare in the entire Country to the “median per-person” cost. This should have approximately a 25% to 30% “decrease” to Health Plan Actuarial Values, from today’s values.
- Establish new “Out-of-Network” limits for what a person can be charged by an Out-of-Network Provider. Allow for billing a multiple of Medicare rates for services provided at an In Network provider that is a Medicare provider; and for extending negotiated discount rates for non-covered medical services at contracted network providers.
How to have Cheaper Health Insurance Plans
- “Separate” the Medical and Pharmacy Out-of-Pocket Maximum health plan expenses into two (2) separate categories, just like we do with Medicare today. This would allow for better Prescription Drug pricing negotiations; and allow people to pick a plan that best fits them, depending if they need better medical or better Rx benefits.
- Re-establish the High Risk Reinsurance Pools, on Federal and State Levels, utilizing a Medicare rate shared-risk model. Since 1% of people spend ~30% of the dollars, and 5% spend 50% of all dollars, the Reinsurance Pools could realistically decrease the cost of a health insurance plans by 20% to 30%.
Prescription Drugs – Lowering Costs and Increasing Availability
Improved Prescription Drug cost management and availability of low-volume and older generic drugs is in the process of being addressed by soon-to-be-formed new Not-for-Profit or Non-Profit Consortium’s that plan on owning, manufacturing and distributing prescription drugs. However, there are many details that still need to be addressed on how they would operate for the benefit of all. One solution is for them to operate by adopting historical models of Regulated Industries that have limits on their Profitability.
Marketing & Enrollment Thoughts
Get the Government out of selling health insurance. The Government does not even sell Medicare Plans directly, as they allow the Insurance Companies and other Agencies to sell Medicare Plans. There are steps being taken to mimic Medicare enrollment; and get the Government out of Health Insurance sales. It is important to note that Government selling duplicates what the Private Sector is doing; and is draining Medicaid dollars at the same time, due to having created a complicated and duplicate process for Medicaid enrollees.
Address Unintended Discriminatory Rules
Modify or remove some of the unintended “Discriminatory Rules” that are within PPACA. Believe it or not, while unintended, some rules, that were written into PPACA as Law, have resulted in what most people would consider discriminatory practices. The rules need to be addressed in order to make access to health insurance and healthcare more equitable.
Establish a “Healthy Living Rewards Program” with Guidelines
Think of it as a “Health Rewards Program” that helps pay for your health insurance and your healthcare expenses, based on where and how you spend your money.
Medicare and Employer Health Plan Cost Note
One must remember that even Traditional Medicare costs ~$200~$300 per-month per-person, as each person must purchase Parts B, C and D, except for those also covered under Medicaid. Only Part A is covered at No Cost, for most people, with only a few exceptions. Part B is “income-based”, meaning the more you make, the more you pay, for Part B. In addition, people getting their Health Insurance through their Employer typically pay $100’s per-month per-person for their health insurance plan too. These monthly costs for health insurance plans do not include the $1,000’s in co-payments and deductibles that people still have to pay.
Healthcare System Modeling
New Healthcare System Model, based on a Chemical Reactor, for AI Modeling, Healthcare is a Complex Chemical System.
This educational site provides details on some areas of health insurance and the health insurance markets. There are also Ideas and Suggestions for ‘fixing’ the system, by topic. The pages will be updated as time allows; however, this is a side project created by consolidating personally created educational content dating back to 2007.