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America’s Real Health Care Debate: How To Stop Insurers From Robbing Us Blind

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America’s Real Health Care Debate: How To Stop Insurers From Robbing Us Blind

health care

Reprinted with permission from AlterNet.

Previously, I argued that Democrats must reclaim and reframe Congress’ healthcare debate to make Dems the party protecting freedom.

In brief, freedom is coverage, we need to move beyond Congressional Budget Office scores and frame other critical components of the Affordable Care Act.

Remember, freedom is coverage. Now, repeat after me…

Caps matter

With passion!

Caps matter

Maximum out-of-pocket caps.

Caps matter

No more lifetime caps.

Caps matter

Because you don’t choose to get sick, you just do.

Why It’s Important

Because your maximum “out of pocket” caps are the key to good insurance.

Because Republicans juggle the numbers and avoid discussing the bottom line. Insurance is not just monthly premiums or deductibles, it is the total level of exposure in each plan.

What does the Swampcare team Say?

It’s always about choice.

Senator Ted Cruz, on Sunday’s This Week with George Stephanopoulos promoted his Consumer Freedom Option, saying, “If you want to buy a plan with all the bells and whistles, with all of the mandates under Title One, you can buy that plan. Those plans will be on the market, those plans will have significant taxpayer money behind them. But on the other hand, if you can’t afford a full Cadillac plan, you should be able to buy another plan that meets your needs. So, the Consumer Freedom Option gives you the consumer choice, whether to go with the full Cadillac or a skinnier plan that is a lot more affordable” and later “If we lower premiums, that’s a win/win for everybody.”

Lots of choices, lower premiums, backed up with some significant taxpayer dollar.

What’s not to like?

What Happens In Real Life?

In real life, no one wants to believe tragedy will strike them.

Life is hard enough without walking around thinking today is the day you’re getting hit by a truck or diagnosed with MS. One of the big protections introduced by the ACA was the elimination of lifetime caps on coverage under the 10 Essential Benefits.

It is an option people would gamble away. And as one would imagine, it is also coverage many insurers would eliminate in the new “skinnier” plans.

What Republicans don’t discuss much is what happens when someone goes “skinny” and bets wrong. It goes without saying the patient will probably go bankrupt and maybe even die. U.S. hospitals nationwide already carry mountains of patient debt, and the re-introduction of lifetime caps will force them to provide health care for more people who can’t pay.

As Amanda Marcotte of Salon recently pointed out, lifetime caps were eliminated under the ACA for the 10 Essential Benefits only. So, if gone, even consumers in employer plans may find themselves facing more limited coverage and more bankruptcies. And Marcotte notes employers can choose whatever state they do business in to create their plan. Where does your company have offices?

When it comes to insurance, no lifetime caps matter.

In real life, everyone faces mundane, commonplace but expensive procedures like knee surgery.

And again, the ACA provides annual maximum out-of-pocket caps, which rise every year for inflation, for individuals and families. This year, the maximum out-of-pocket cap for an individual is $7,150 and the maximum out-of-pocket cap for a family of four is $14,300. Sure, that’s a lot of money, but again, it’s a cap that can prevent bankruptcy or financial ruin.

We all like some choice, and ACA coverage includes Bronze, Silver, Gold and Platinum plans, ranging from 60% to 90% of costs covered. In all the plans, these annual maximum out-of-pocket caps act as a critical backstop. You bet a little, but not the house—literally. And the insurance company pays 100% after you hit those out-of-pocket caps.

When it comes to insurance, annual out of pocket caps matter.

In real life, Americans allocate a higher percentage of GDP to healthcare than any industrial nation.

One of the more humane principles created in the ACA is the sliding “cap” on percentage of personal income going to healthcare. For individuals and families making 100% to 400% of the federal poverty level, the cap ranges from 2% of income for someone making very little money to 9.5% of income for those at the top of the range. If your monthly premium was above the income cap, the government covered the gap.

Known as the premium tax credit, this “income cap” principal guides the calculation of the subsidy people receive each year to supplement their costs. In 2017, the subsidies range was $11,880 to $47,520 for an individual and for a family of four it was $24,300 to $97,200.

Think about it again. The ACA basically says, for any family of four living on less than $90,000 a year, you shouldn’t spend more than 10% of your income on health care. And we will offer assistance to keep it below that cap.

Pretty damn good.

When it comes to insurance, annual percentage of income caps matters.

In real life, old people get a lot sicker than young people and everyone gets old.

Social Security, Medicare and the nursing home elements of Medicaid ease the journey. And the ACA added a “cap” on the maximum spread of premium costs based on age at 3 to 1. The current Senate and House plans shift the ratio to 5 to 1, but who knows what would happen in new state-created plans without restrictions. The CBO reports this one change will make health care unaffordable for millions of elderly Americans.

Just one more cap in a long list of ACA caps (they call them rules and regulations) that stabilize people’s lives economically.

When it comes to insurance, a 3-to-1 age cap matters.

What Should Dems Say?

Talk more about the ACA effect on the middle class.

Media coverage has rightfully been focused on the devastating effects the Senate and House plans will have on the poor, elderly and disabled. But the ACA helps middle-class individuals living on $40,000 a year and a family of four living on less than $90,000 a year too.

Democrats need to give specific examples of families and individuals with middle-class incomes and drive home how the removal of coverage and caps will affect them.

The ACA protects everyone, even people in employer plans.

The 10 Essential Benefits cover all health care plans nationwide and insure every employer plan and every state exchange plan cover essential benefits including substance abuse, mental health and maternity. The ACA elimination of lifetime caps applies to every plan nationwide. Ditto the maximum out-of-pocket costs for individuals and families.

Democrats need to hammer home the potential effects of Swampcare on employer plans, too.

Who covers the costs when someone goes “skinny” and has a very bad health day?

In their brave new world of infinite plan options, what happens when someone bets wrong?

When someone picks a cheaper plan with a reinstated lifetime cap, and has a Steve Scalise moment, we can assume bankruptcy at a minimum and millions in unpaid bills. From 2010 to 2016, personal bankruptcies have been cut in half. This trend would reverse. Will states pick up the slack? Will more people slide into poverty and end up in Medicaid? Will hospitals take on even more debt?

Democrats need to engage Republicans and their pundits with specific examples, walking through the step-by-step reality of a skinny plan. Instead of allowing Tom Price to bloviate, get specific and talk about one person and one scenario at a time. Joe Blow takes a skinny plan with a lifetime cap, has an accident and is disabled for life. What happens? Joan Blow takes a plan without adequate mental health coverage and her kid tries to commit suicide. What does she do?

Under the ACA the insurance company paid—now who does? And why is that better?

The Bottom Line

The Republican solution—free markets and choice—is a return to the bad old days. When you scratch below the surface, it doesn’t add up. Insurance works best with a large pool (mandate), core coverage (10 Essential Benefits) and a limit on maximum out-of-pocket costs (caps).

Caps matter. A lot.



  1. Jim Samaras July 17, 2017

    There’s always waste when the government gets involved.

    That is why, to paraphrase Abraham Lincoln, government should do only those things that a man can’t do better for himself.

    If 300 million Americans were free to buy health insurance for themselves, just as they buy their own life and home and car insurance, then that little gecko on television would offer us health insurance with a little more coverage for a little less cost.

    And he wouldn’t be the only one. Insurance companies and hospitals would be working night and day to get our business. Quality would go up, and prices would go down. It’s already happened with laser eye surgery. It used to cost $2,200 per eye. Now it can cost as low as $500 per eye. That’s the way free enterprise competition works…every time.

    But when the government gets involved, costs go up, waste and fraud go up, essential medical services are denied or unavailable. These are the hallmarks of government healthcare bureaucracies around the globe.

    1. Counterpoint: you’re a racist coward who supports treason.

      1. Jim Samaras July 18, 2017

        Your stupidity knows no bounds

    2. Beethoven July 18, 2017

      You say that when the government gets involved, costs go up and waste and fraud go up. Yet the facts don’t support your claim. Out of every dollar the Medicare program takes in (through premiums), it pays out over 97% in coverage of medical services, and pays out less than 3% in administrative expenses (salaries, office rent, etc.). On the other hand, for every dollar private insurance companies take in, the Affordable Care Act limits them to a maximum of 15% in administrative expenses, and before the ACA was passed, many insurance companies paid out over 20% in administrative expenses. Most of those administrative expenses are the type that the government simply doesn’t have to deal with, such as stockholder profits, high CEO salaries.

      Also, while I acknowledge that there is waste and fraud in the Medicare program, there is also a lot of fraud by medical insurance companies, as prosecutors are kept busy handling such cases. And I question the assumption that there is more waste in the Medicare program than there is in private insurance; I would like to see some reliable, factual evidence on that question, not simply someone’s unsupported claims.

      You claim that people would buy health insurance just as they buy car and house insurance. But many people don’t buy car insurance even when it is legally required, and many others buy only the minimum that the state requires them to have in order to get a car tag. Many mortgage companies include the cost of house insurance in the monthly mortgage payments because they assume that too many people would not buy house insurance if they had a choice.

      Under the present law, hospitals are required to accept patients and treat them whether they have insurance or not, and without regard to their ability to pay. (By the way, that law was passed during the presidential term of Ronald Reagan, with his support.) Would you support changing the law so that if a person chose not to purchase medical insurance that was available to them and affordable, and then required major medical services (say, for developing cancer or being paralyzed by a car accident), that the hospital could simply refuse to treat them if they couldn’t pay? What if you, yourself, chose not to purchase medical insurance, or chose a minimum plan with a low lifetime cap and high deductibles so you could save money, then required major medical services that you couldn’t pay for, because your medical bills were so high you had to file bankruptcy? Would you be OK with the hospitals refusing to provide you with medical care?

      Most of the hospitals are already treating so many people who don’t have any, or adequate, insurance and can’t pay the bills, that the hospitals are having trouble paying their own bills, and if the ACA gets scrapped without something better replacing it, or if Medicaid’s budget is cut drastically, as the TrumpCare bill would do, quite a few hospitals will be closing because they can’t pay their bills.

      You say, “If 300 million Americans were free to buy health insurance for themselves….” But the truth is that quite a few of those 300 million Americans don’t buy life insurance, because they can’t spare the money for the premiums after buying their food and medicine and paying the rent. And many of them don’t buy house insurance because they can’t afford to buy a house. And many of them don’t buy car insurance because they can’t afford a car. If they have no money left over after buying the bare minimum of food to sustain them, and paying for the medicine they need to stay alive, and paying rent on the cheapest tenement apartment they can find, how are they going to buy health insurance?

      1. Jim Samaras July 18, 2017

        Costs for insurance HAVE gone up! $1600 a month with a $10,000 out of pocket max for the common family of 4 that I would consider as catastrophic insurance is unconscionable (another house payment) that before all the mandates would have been about $500. So to me that means those limits on administrative fees are hidden someplace else hence the fraud. Those pesky stockholders haven’t gone away. If your numbers are correct I applaud Medicare for watching expenses. I’ve never had a problem with that program as taking care of our seniors should be a high priority. Perhaps more oversight on it would prevent much of the fraud that goes on.

        Responsible people would buy insurance. Of course nobody gets turned away at an emergency room but any tax refund they may be entitled to should go directly to the hospital as a “spanking” for not having health insurance just as a fine and loss of the privilege to drive accomplishes the same end with car insurance scofflaws and if that doesn’t teach them jail time does.

        Not having adequate ins would not be an option for me and would never choose a deductible that I would consider not affordable. This should be taught in any economics class in high school.

        The cuts in Medicaid are also tied to an Immigration bill which would mandate any new entrant to the US have the ability to sustain himself and family for 1 year and wouldn’t qualify for any welfare for 5 years after entry which would save Medicaid untold sums. That’s where those cuts come from not pushing granny off the cliff.

        Of those 300 million Americans there will always be a percentage who live hand to mouth for a variety of reasons. To those who don’t buy life, house or car insurance I say don’t buy a house or car because it’s beyond your means. Do you go to a restaurant without the money for a tip? To those in dire need that are truly unable to help themselves I’m all for helping but again, oversight must be maintained to insure we the taxpayers are not being snookered out of hard EARNED dollars

        1. johninPCFL July 18, 2017

          In the 2004 thru 2009 timeframe, insurance costs went up AT LEAST 15% per year, and averaged over 20% across the period. BEFORE the mandates. My insurance was already over $1200 per month in 2009.

          Then, it dropped to $900 and over the last eight years has risen to $1600 per month. That’s a far slower increase than in the preceding, pre-ACA timeframe.

          In GOP lingo, my healthcare insurance costs were cut dramatically.

          1. Jim Samaras July 18, 2017

            I agree they were headed higher. What’s your out of pocket john?

            How about putting the FDA to work for us instead of big pharma. Test foreign manufactured drugs to be certain they’re safe for consumption then enact tort reform so loser pays. Price for ins drops faster than Madonnas’ panties

          2. johninPCFL July 19, 2017

            In 2009 it was $10k (and yes, I kept an unused Visa card to handle it) but this year it’s $7150, I think. I also opted for an HSA policy that I now keep my deductible in.

            The one thing the ACA didn’t count on was that the Inscos would still find a way to gouge. For instance, even though my individual deductible is $7150, it was a huge shitfight to get that when they (unilaterally) decided that my “family policy deductible” applied to my single-person, single-event accident (even though my wife is covered by Medicare, my children are all grown, and none are on my policy) and told me that my out-of-pocket costs were really going to be $14,300. Once I appealed to the federal government and they got involved, the “mistake” was corrected.

            “Tort reform” is a huge lie. The cost of medical malpractice to the average practice was 1.5% in 2008 and is about 2.4% today, and that includes “defensive medicine”, insurance, lawyers’ fees, and settlements. Of that, 82% is “defensive medicine”. Would you change your business’ internal practices (i.e. get rid of tests) to save the 1.5% of revenues you might not be sued for in the event of a change in the law, even though your patients are more than willing to pay those costs now?

            “A new study reveals that the cost of medical malpractice in the United States is running at about $55.6 billion a year – $45.6 billion of which is spent on defensive medicine practiced by physicians seeking to stay clear of lawsuits.

            The amount comprises 2.4% of the nation’s total health care expenditure.”

          3. Jim Samaras July 19, 2017

            Tort reform would be helpful in all areas not just the medical field. Too many ambulance chasing attorneys in cottage industries taking advantage of businesses and individuals insurance companies nationwide. I’ve opted out of insurance for my small business as I’ve discovered if there’s no insurance there the attorneys drop the client quickly but I suppose that conversation better saved for another day.

            Still, paying 1600 per month with that large a deductible is insane john. Glad to hear the “mistake” has been corrected

          4. johninPCFL July 19, 2017

            Old age has its disadvantages. On the bright side, under the Senate plan just defeated, it’d be $8000 per month.

          5. Jim Samaras July 19, 2017

            I was no fan of that program myself. I hope a general repeal doesn’t hurt you because I feel that’s where we’re going

          6. johninPCFL July 20, 2017

            Mitch the Bitch s going to bait all the GOP into a “general debate” on the House bill, then after all debate has closed, he’ll enter “one more amendment”, which tosses out all of the sponsored amendments and completely replaces the guts of the bill just debated and amended with completely new language, likely either a re-institution of the original House bill language or some other complete repeal language.

            It’s all bullshit subterfuge and I hope the Dems refuse the bait.

        2. Beethoven July 18, 2017

          I haven’t checked this out, but am relying on what I heard on the news channels. A couple of months ago, Trump said something about passing a law that prohibited illegal immigrants from qualifying for welfare or Medicaid until they had been in the country for five years. The news reporters who talked about his proposal were wondering why he didn’t know that such a law had been passed, if I remember right, in the 1990s.

          1. Jim Samaras July 18, 2017

            So an immigrant that making 14K, 50-60 years old needing a knee replacement say can buy the Cadillac plan for 900 a month with an 850 subsidy paying 50 per month. Total out of pocket 800. Great place America

        3. Independent1 July 19, 2017

          Everything you posted is a blatant lie!! None of those out of pocket costs or premiums even remotely relate to a policy that fits ACA guidelines. You are a lying fool!!!

          1. Jim Samaras July 19, 2017

            Another genius that thinks he knows, huh. Dickhead…

          2. Independent1 July 19, 2017

            I’m not genius! But I’m not a corporate lackey with my head up my rear end like you are!!!

    3. Independent1 July 19, 2017

      Sorry but private industry, where companies have to make a profit, will never do anything at as low a cost and as efficiently as the government because they’ve always got to factor in something that ensures they make maximum profits; usually something that’s detrimental to our environment or peoples’ lives..

      Your post is nothing but a pipe dream that if it was allowed to run without government control would end up with only the elite owning health insurance and everyone below the top 10-20% of income earners dying at around 55 years old because the elites would figure out how to screw everyone they consider to be a peon and force them into poverty and early deaths.

      It’s already happening in GOP-run states where Republicans have created nothing but shell governments that essentially do little or nothing for their citizens. The life expectancy of people in GOP-run states is 2-6 years younger than in Dem states, and 21 of the 24 states with the highest percent of people living in poverty are GOP-run states – and all 25 of the states with the most people broke and on the verge of bankruptcy are also GOP-run states.

      You need to stop living in your fantasy land!!!

      1. Jim Samaras July 19, 2017

        Your post is laughable from the first sentence you goofl! Government efficiency? LOL….who’s the fool here?

        1. Independent1 July 19, 2017

          Like you’ve been told dirtbag, the government runs Medicare eons times more efficiently and at far less costs than the private sector insurance. Like I said: you’ve got to stop living in your corporate lying fantasy land!!

          Every time the private sector tries to run something, costs, pollution and people dying skyrocket!!! Just take the fiascos that had gone on with the private sector trying to run prisons!!! And the lives that those thugs running prisons distroyed!!

          And actually with the private sector trying to run schools!! Magnate schools are rampant with corruption and failed results and dirtbag DeVos is trying to foist more illiteracy on the entire U.S. population!!

          Which is exactly what dirtbag Trump is trying to let the private sector do far more of today!! Ruin more peoples’ iives!!!

          1. Jim Samaras July 19, 2017

            The private sector is responsible for making America the great nation it is! You’re the dope and you will realize that 16 years and beyond after conservative rule….fool. The people are waking up to liberal “values” which are no values at all.

          2. Independent1 July 19, 2017

            “The private sector is responsible for making America the great nation it is!”

            Is that some kind of joke?

            All the private sector in America has ever done is to work tirelessly at trying to suck as much money from the middleclass taxpayers that it can muster!! In exactly what way has the private sector made America great??

            By working tirelessly to get out of paying their fair share of taxes?? With 200 of the fortune 500 in any given year paying zero in taxes even though they make millions/billions in profits??

            By thousands of millionaires/billionaires doing the same thing??

            While they both can see that America’s infrastructure is collapsing around them because they refuse to pay their fair share of keeping America running??

            By working tirelessly to get legislation passed that allows them to get around every environmental law which ends up with thousands of Americans dying every month because of the pollution they cause?? Causing America to be the largest per capita polluter on the planet???

            By destroying our country and environment at every opportunity just so they can reap obscene profits and buy more yachts and vacation homes??

            You really are a corporate puppet; aren’t you!!!

          3. Independent1 July 19, 2017

            And if you think America is such a great nation, why is it 15th in the world with respect to people living here being happy with their lives?

            Is capitalistic socialism really so important that it’s really worth making just about 20% of the population wealthy enough to enjoy their lives while the other 80% of Americans struggle to live from day to day??

            You need to read this article comparing what it’s like for the average person to live in a capitalistic socialism like America to a true democratic socialism like in Denmark.

            VIDEO: People in Denmark Are a Lot Happier Than People in the United States. Here’s Why.


          4. Jim Samaras July 19, 2017

            Good article Inde but with a population about the size of Chicago I’d think it may be an easier task than 350 million. Happiness really does come from within. I’ve been on both sides and never happier when riding high vs average. While the article and video make it sound quite appealing I’ve also learned “all that glitters is not gold” An article from the lefts’ bible warns to be careful what you wish for:


          5. Independent1 July 21, 2017

            What a ridiculous article from the times!! Only a moron such as you would look at the situation and complain about people paying more taxes. It’s only people like you that think it’s necessary to get super rich and actually accumulate more money than you ever deserved to have and then keep on wanting more as billionaire after billionaire in America has proven.

            You don’t think the people living in Denmark know they’re paying high taxes?? And yet even with that ARE FAR HAPPIER on balance than people in America? What’s wrong with you morons that you can’t see that your priorities are corrupted?? That living in life ISN’T ALL ABOUT ME???

            You people are sick; sick with greed and the lust for money!!

            What a joke you are!!!!

          6. Jim Samaras July 21, 2017

            Who’s really the moron here? Any money we’ve accumulated is certainly deserved and I don’t know why this is beyond you other than the fact you don’y have the gray matter to accomplish such a feat. Of course you find it easier to bash the doers than to acquire any wealth yourself.

            “With one of the highest tax rates in the world — at 56 percent for top earners — big salaries mean mostly bigger taxes to sustain the welfare state. Many young Danes just don’t see the point of putting in years of effort into studying for a bigger salary eaten up by taxes.”
            They have headaches beginning over there too you left wing retard.


          7. Independent1 July 21, 2017

            And more distorted right-wing propaganda. With research studies showing that Danes are on average far happier than Americans those supposedly unhappy young Danes, based on your right-wing jurryrigged polling results, are clearly in the minority!!!

            Go stuff it somewhere lowlife!! You’re doing nothing but proving my initial point that you’re mindset in living is IT’S ALL ABOUT ME!!!

          8. Jim Samaras July 21, 2017

            And mine show research that disputes your left wing propaganda. You’ll see who’s in the minority next November when you continue to lose your ignorant, moochy base

          9. Phil Christensen July 22, 2017

            Good thread. But you’re using facts and logic on a Leftist.

          10. Jim Samaras July 22, 2017

            I know…..Our facts and logic mean nothing but theirs are akin to coming from the mount

          11. Independent1 July 21, 2017

            Why is it you insist on linking to articles that have clearly been written by a right-wing bigot who was probably paid by the Koches to write an article clearly based on idiotic right-wing propaganda??

  2. Phil Christensen July 18, 2017

    If the government was serious about providing healthcare, then health insurance premiums would earn a tax-credit, capped and indexed for inflation.

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  3. johninPCFL July 18, 2017

    “What Republicans don’t discuss much is what happens when someone goes “skinny” and bets wrong. It goes without saying the patient will probably go bankrupt and maybe even die. U.S. hospitals nationwide already carry mountains of patient debt, and the re-introduction of lifetime caps will force them to provide health care for more people who can’t pay.”

    A ladder broke under me, I broke my back, and I have something near $500,000 in surgery and hospitalization costs to date. Thanks to ACA, I’m not declaring bankruptcy (some 60% of pre-ACA bankruptcies were “medically induced”), I have no fear of my injury now being a “pre-existing condition” mandating a 500% increase in premiums, and I can still have medical issues in the future that insurance will cover (no caps.)

    I didn’t plan on a catastrophic injury, and I did have my own (not employer provided) insurance policy.


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