With House Republicans on the verge of passing a long-awaited health care overhaul, the future of US insurance coverage hinges on three words: essential health benefits.

The GOP’s proposal to let states define on their own which benefits all insurance plans must cover — prescription drugs? hospitalizations? childhood vaccinations? mental health? — would fundamentally reshape insurance for millions of Americans. It would likely drive down premiums, as plans with skimpier coverage would spring up in states which granted more flexibility. But it could drive up costs for individuals, by leaving them responsible for far more out-of-pocket expenses.

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  • Im delighted I live in a civilized nation which has single payer universal health coverage for all and drug costs are regulated. I cannot understand why every first world nation can do this except the United States.

  • i have to agree why do i have to pay for things on my way my insuarnce i’m never going to use. The gap you are talking about people may have to pay, the already paying them and insurance price are already going up every year and deductible are going up too, so you tell me how the affordable care act is helping the middle class, all it is doing is making us pay more to help people that want help themselves, this country making people more and more lazy

    • Emergency room care is the most expensive of all and your taxes are picking up the tab. Obamacare is not perfect but its a good deal for everyone except the wealthy who are asked to pay a little more as the price of being a community. Its only logical.

  • Let me follow up speaking as an acute care surgeon who provides urgent and emergent surgical care to anyone who comes to the hospital ER. I take care of everyone the same way regardless of the ability to pay. I frequently teach my patients about how their insurance works and help those without get enrolled in MediCal (California’s MediCaid). I include a discussion about costs and where they come from including that I will bill them or their insurance separately from the hospital, pathologist and anesthesiologist. I also tell them they will have to pay something out of pocket based upon the insurance contract they have. Finally I disclose verbally and in writing what my charges will be. This is new information for many people. No one, hospitals included, will tell people what the hospital cost for appendicitis or cholecystitis will be. This is partly due to the charge master game of billing to maximize payment.
    People want honesty and knowing what their doctor and facility will charge them as what as what portion of that their insurer will cover is honesty that will also impact cost. The fundamental problem with the ACA and the AHCA is neither reduces the cost of delivering healthcare, just insurance. If we add full disclosure and transparency reporting by providers, hospitals, facilities and insurers patients can make affordable choices based upon limits imposed by their insurance and budgets.
    I wrote a bill calling for disclosure and transparency of health care costs and shopped it around the California legislation. No one would touch it for fear the insurers and hospitals would stop funding their campaigns and put up a fight. No one locally or nationally really has a commitment to reducing healthcare costs. That is the fallacy of our politically driven healthcare reform.

    • Eileen, you just hit the nail on the head! Not many understand this is the true problem and that the government isn’t working to solve the true problem. The charge masters ARE a game! We need to go back to basic indemnity insurance, no PPO’s, and transparent pricing so consumers know what they are paying for.
      Have you contacted the National Association of Health Underwriters with your bill idea? They have people who can get it looked at.

    • Karissa,
      Thank you too, it’s great to talk to people who care. I’m kind of a bleeding heart too. That’s why as an agent, I try my best to match coverage to people with an eye toward them not going bankrupt as well.
      Take care and have a great weekend!

    • Agree. Doctors fees should be regulated. They dont deserve to be paid five to ten times the average wage. They are only specialists they arent gods. And they can be replaced.

  • Insurance should protect people financially from a catastrophic event. Heath Savings accounts and tax deductions should cover the rest.

    • Yet that is not the way the American healthcare system operates. I am lucky enough to have a job that offers a good HSA plan which I take part in; BUT, I am a young, low healthcare user so my HSA is already really close to the amount my deductible would be in the case of a catastrophic health event. I also do not have children and my spouse can use his employer insurance. Because I work for a large company, the very comprehensive insurance is spread across 5,000+ employees, which is a healthy size for a risk pool. Those in the individual market who have lower incomes generally do not have the means to set up and regularly contribute to a HSA, and with the Medicaid expansion allowances being rolled back, I fear this will have a negative impact on those communities.

  • In Texas, pre-ACA, most medical policies sold already provided comprehensive benefits, without having the govt mandate “essential health benefits”. I don’t see why it will be any different now, if the AHCA passes. Policies will still have the essential basics: hospital coverage, doctor coverage, testing, etc etc. People are smart enough to know what they are buying. If there isn’t hospital coverage it has to be disclosed by law. I wonder where Mr. Weil is getting this theory that suddenly insurance carriers are going to carve out benefits from their policies that are needed in order to make the policies palatable to buyers in the first place!

    • In large employer-based plans, the employee rarely has a choice in plan options, so if the company changes plans to be less comprehensive, then the individual employee doesn’t end up with very good options: take the skimpier plan being offered by your job or decline employee coverage to make a go at it in the individual market. Also, you specifically say Texas; what about other Americans? Finally, the theory comes from the fact that this WAS happening (maybe not in your part of Texas) prior to ACA. I don’t understand why people think it is okay for insurance companies to place any kind of spending cap on a beneficiary who has been steadily paying their premiums and deductibles – so you get cancer and 6mos to a year into expensive treatment and rehabilitation and the insurance company can just STOP PAYING!? And you’re okay with that outcome?

    • Karissa Loper, it’s an unfortunate reality of healthcare financing (which is the purpose of insurance) that someone has to mind the till. Insurance by its nature can’t be a bottomless well of unlimited funds. There must be controls and limits, or else insurance becomes too expensive for everyone. Hence, what has happened under Obamacare.

      The limits I’ve seen on policies pre-ACA were usually $1 or $2 million for a member’s lifetime. Very rarely did a policy have a dollar limit on a specific treatment or disease, except for things like chiropractic care. In my 30+ years in the insurance industry, I’ve only seen two people – TWO – ever reach that lifetime limit. And they were able to move on and find new insurance with a new lifetime limit, or other resources through their communities and providers.

      I’m very sympathetic to people with terrible and expensive health conditions. Cancer treatment, as you mentioned, can be financially devastating, among other things. Most insurance, even pre-ACA, provided plenty of benefits to cover most cancer treatments.

      Nowadays, if you’re on an ACA policy, you probably have a $6,850 deductible before your plan will pay anything at all. And your premium for that high deductible plan is as much or more than you were paying for your pre-ACA copay plan with a $2,500 deductible.

      Without limits, NO ONE can afford insurance. We can either have choices provided in the free market and take personal responsibility for choosing coverage that meets our needs; or, we can have the Federal government dole out our health care in the way they see fit. It hasn’t worked under Obamacare. Let’s give this new plan a chance to bring back the choices in the marketplace.

    • I admittedly do not have 30+ years in the industry. I am a public health professional, so my perspective is very different, I think. I deal with those at the lowest income levels and the providers and community health clinics charged with serving them on a regular basis. To me, the idea that in my state of Nevada, where many adults only accessed a general practitioner for the first time under Medicaid expansion, that they will be put back in their former positions is…wrong. These are people who work full-time jobs, sometimes more, just not jobs that seem to pay a very good living wage for the area or offer any benefits, like PTO or paid sick leave.

      On the topic of healthcare financing, I do have questions on which I hope you are willing to engage: how much “should” the average person pay for their healthcare services and needs in a given year? My deductible + annual out-of-pocket is $5,500, and I don’t think that is too much to ask me to pay in one year if I really need to use my healthcare services. Of course, my monthly premium via my very good employment-based insurance, is very low, and I have a robust HSA. But, I feel very blessed to have this coverage, as I know this is not the case for about half of the American population. It is my impression people want to pay very little for health insurance, but still get very high quality and comprehensive care and coverage; I don’t think this is realistic.

      But, I don’t agree with many of the other allowances in this bill, because unlike other insurance products, healthcare insurance IS different. The scope of what can be considered a preexisting condition is too broad. I don’t understand the argument of men not having to pay for maternity care, are they not also fathers? Do they not want the mothers of their children to have good and timely prenatal and birth care? Why is it fair to charge me a higher premium as a woman of child-bearing age, when I have absolutely no plans to have a child AND I have an active birth control prescription? Shouldn’t those types of considerations be made, then, if it is all about individual choice in the market. Oh, but wait, won’t you be penalized by insurance companies if you can’t maintain continuous coverage? How is that different from a mandate, other than where the money ends up?

      Healthcare service can often be an inelastic product – when needed, most patients do not have the knowledge, and in rural communities the physical ability, to be picky about where they go or what therapy they choose. There is no common menu of prices so you know what an MRI “should” cost, etc. Health literacy in this country is abysmal, and it is very disheartening to me to hear first-hand stories from Nevadans who have been sold bad choices they didn’t have the knowledge base to know were bad.

    • I agree with everything you have said here. It’s such a complicated issue, and no solution will ever be able to prevent someone from falling through the cracks. I don’t agree with rolling back the Medicaid expansion, not sure why they did that, but with the upcoming review in the Senate, it’s possible they will tweak it so that some of the provisions that make sense will stay and others will go.

      As far as how much should the average person spend on healthcare, you’re right, most people want to pay little and receive much. Your cost of $5,500 sounds about right for the average person, and that’s for good employer coverage. Many people are paying much more than that, with insurance coverage, and others are just not able to pay for coverage at all. With the AHCA, everyone will get a tax credit to help pay for insurance. I don’t think it’s the best solution, as many people can’t pay full premium and then get reimbursed. Maybe that is another provision they will change before it’s passed.

      Maternity care. Pre-ACA, maternity care was not included in individual medical policies at all in Texas. I don’t know about elsewhere. Some carriers offered maternity coverage as a rider. That way, if a man purchased an insurance policy and wasn’t covering his wife, or didn’t intend to have children, he didn’t have to pay the extra premium for maternity coverage. If a woman purchased it and didn’t intend to have children, she didn’t have to pay extra. But if she did plan on having children, she could add the maternity rider.

      Likewise, a small employer had the option of including maternity coverage in their group plan or not including it. Most small employers included it because they had women and men of child-bearing years on their plans. But, there were a few who had mostly older workers, or workers who had finished having their kids, and opted not to include maternity and saved about 5% off their premium. That’s what this is about; it’s about having options in the marketplace that are determined by each state. It’s not about limitations, it’s about choices.

      Some states could opt to allow higher premiums for women, and yes, that’s not always fair because what if you don’t plan on having a child? But think about this: the ACA, as of 2010, started requiring every policy and group plan to cover maternity, regardless. And that increased the premium for everyone.

      Switching gears: The 30% penalty in the AHCA would be for someone who goes more than 63 days without coverage, and the penalty would only last for 12 months. After that, it would go away. If we are going to cover pre-existing conditions, there has to be a way to keep control on people hopping onto an insurance policy just to get their expected medical expenses covered, then hopping back off. A 30% surcharge can deter that from happening, and can also defray some of the cost of covering that person.

      There is no perfect solution. And, there are so many different perspectives on the issue. We are all standing around the elephant, and we each can see a portion of the elephant (our own perspective based on our own experiences), but not the whole elephant. The problem is, the people we rely on to piece it all together, haven’t been able to do so.

      We do need better price transparency from healthcare providers and better consumer information on coverage. Your example of MRI prices, they vary greatly, and are mostly governed by which insurance plan you have. Consumers should have more control over their healthcare dollar, and that comes from education.

      I applaud you in your service as a public health professional. You see the everyday turmoil of people just trying to get by and still get healthcare.

    • Thank you for the conversation, Brenda. It is very complicated, and I hope this plan (hopefully with some Senate tweaks) will create more choice, lower costs, lower prices, and improve health outcomes for the nation. I am skeptical, but I want to be optimistic. I think Eileen above makes a good point re: we tend to discuss only insurance and not what mechanisms are driving the costs of care. And since so much of the price one pays is dependent on the insurance plan negotiation, it is just too convoluted, and regional differences in cost of living, etc. will always have a role as well.

      I also just want people to be able to go to a doctor, or make it through an episode of sickness and injury, and do so without going bankrupt. 🙁 I’m a bleeding heart. I constantly think of all the what-ifs too, and how easy it can be for people to fall through those cracks if they or their advocate are not paying close attention.

    • Hello Brenda! Very insightful thoughts on the current state of health reform in this country. I’m from the Center for Health Journalism, and I’d love to discuss your views a bit more. I can be reached at amobi@usc.edu.

  • All 3 branches of the Gov, must be forced to use whatever health plan they pass. Let’s shame them into either improving the plan and/or use the same provisions for their families.

    • I agree. if the coverage is good enough for all americans, then the 3 branches should be held to the EXACT same standard.

  • I already, as a middle-class worker with a full and a part time job, pay the first $4000 of my insurance 100%. To people in my boat this will not make any difference, maybe I will actually pay less or maybe it will not change at all. My state has MA health which probably would not change so all those getting free insurance would continue with the state program. Need to learn more about this but I agree there are certain things that can be dropped in certain cases.

  • So premiums will drop. (I’ll believe that when I see it). But coverage, ie ER, hospitalization, imms, meds, etc will be cut drastically. I foresee a huge increase in healthcare related bankruptcies, not to mention an overall decrease in the health of our nation, which is already pretty low, compared to other nations. If < 20% of the populace approves of this (according to the polls), who exactly are our elected representatives "representing"?

    • precisely!!! Our “representatives” are not representing the will of their constituents!! Time for us to make some changes starting in 2018.
      Better believe I’ll be doing something about it! Write your representatives!! daily!!!!

  • This is going to be like having no insurance at all the middle class people will not be able to afford the insurance for pre-existsing conditions and you are taking away all the other coverages plus the deductibles are going to go up if we can even afford to go to the doctors. This is going to be a total disaster if it passes. I did not appreciate the way you crazy people talked about Jimmie K and his baby he was telling the truth and you just don’t want the American people to hear it you all do not have a conscience or a heart or you would not be writing up such a health care bill as this. What if some of these health issues was your child, wife, mother, father, sister, brother, or a very close relationship and you was on a very limited income? We as American people are not stupid all of you in Washington trying to push this thru so fast should have the same insurance you are trying to push over on the middle class people and the lower class people which is about the same as nothing . None of you that have wrote this policy have a conscience or a heart for the American people you just want to erase anything that Obama had anything to do with it should not be about politics it should be about the health and well being of the American people. We as Americans are watching everything very closely and there will be other elections!!!! We will be strong you may hold us down for a little while and mess things up D. Trump but you can’t do wrong and get away with it that’s what my Bible tells me and God is the Judge over all. My Prayer is Gods hands be over America!!!!

    • “We as American people are not stupid…” Ummmm, look at who got elected to head the executive branch. Look at who got elected to control the House. Look at who got elected to control the Senate. Now look at who is crafting this bill. You might want to retract your statement…

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