Originally Posted by suzzer99
It would be nice if we could have something like a "just the facts" Obamacare thread with no partisan bickering and pissing contests. Impossible I know.
The problem with the "just the facts" on Obamacare is that a lot of the facts are not known yet or are having to be revised because they are not viable, make no sense, or the CBO mis-scored it based on false data and assumptions. The facts that are known are simply not viable and more represent welfare than insurance. Additionally, people don't know what insurance actually is and what it is not. They have just been told that the insurance companies are evil and this is how the government will help you get back at them.
Some issues that you may want to ponder:
Insurance was never meant to pay first dollar benefits on health maintenance. The reason why other kinds of insurance remains relatively cheep, for example, is that your home owners policy doesn't come out and paint your house when its needed. The states and now the fed (PPACA) have turned health insurance into welfare.
Pre-existing illness is a straw-man argument because there have been regulations in place that prevents an insurance company from denying anyone coverage based on pre-existing conditions. Its call "guaranteed issue". Look it up. The only reason an insurance company can take action on a pre-existing illness is if the insured didn't have major medical coverage within 'x' number of months before getting the new coverage. And even if they didn't have coverage, the pre-existing rules only apply to the actual condition and only apply for a specified length of time. One other thing, if it is proven that the person lied on their application for insurance about a condition, the normal course of action is to re-evaluate the insured or groups premium rates to correctly account for the inaccurate information.
Group vs one-life major med coverage. With the exception of a couple states, group and one-life health insurance is considered the same thing and they both follow the same legally mandated rules. The term "Like" coverage is used to indicate that the insured had coverage of the same type before the new coverage was in-force. One exception is alternative healthcare plans, such as a temporary medical plan is not considered a "Like" coverage. Temp health plans are a stop gap product that has limited coverage for a limited length of time. It is not a replacement for major medical coverage but rather a plan that can be purchased when someone is between jobs or other life events. Punishment for selling a temp medical plan as a replacement for major medical can cause an agent to have his license revoked. Most insurance companies track agents and insureds to make sure the consumer doesn't screw himself by misusing temp medical plans.
MLR - minimum loss ratio. Its also called the 80/85 rule (based on group size). This is the dagger that is intended to simply collapse the insurance industry. The rule is that if an insurance company does not pay 80%/85% of the premium collected for direct claims expense, then the remainder of the premium must be returned to the insured or group. In other words, if the insurance company pays 75% of premium collected in a plan year, 5% of premium must be returned to the consumer. The insurance company gets to keep 15-20% of premium for agent commissions, marketing, and administration expenses. That sounds fair and that is what the promoters of ACA ran with. Typically, they forgot the most important thing - reality. This works great until you have an insured that has claims that total, for example, 3000% of the premium collected. By law, the insurance company must "reserve" funds for future claims and claims spikes. By definition, these funds are not included in the 80/85% and must be funded within the 20/25% of the premium. There simply isn't enough premium to properly fund an insurance plan and the 80/85% rule makes sure of that. The only way to fund a plan is to raise rates. Government backed plans can lose money every year and never go out of business. In other words - welfare.
Reporting and payment requirements and MediCare: Medicare has no particular reporting or payment requirements in terms of settling a claim within a time period. MediCare routinely takes 12-18 months to settle a claim. Insurance companies have 30 to 45 days if the claim was submitted without any deficiencies (meaning all the information the insurance company needs or has questions about).
Doctor reimbursement: Medicare pays anywhere from 25-75% of what a private insurance company ends up paying for a specific service. The physicians and hospitals offset the loss from MediCare patients my increasing the fees privately insureds must pay. There is a little negotiating room for the private insurance company to attempt to reduce the claims cost but it is no where near 25-75%.
Rate Indexing: This is complicated but I will just say that there is no way that a single person can be singled out for rate increases. Every state that I know of uses some type of rate indexing that limits increases by not allowing the highest rate and lowest rate within a plan to be no more that 'x' percentage points apart. Additionally, indexing also considers the weighted mean of the rate range to make sure that the rate indexing is similar to a bell curve. I would bet that a lot of people within the issued policy that you uncle had insurance through got similar rate changes.
I could go on but I won't.
Oh - your uncle needed to join a professional or industry organization multiple employers trust (MET) that allows him to be considered part of a larger group and therefore pre-existing conditions would never have been an issue. His agent should have told him that. The membership fees are a few bucks a year.