Tag: Affordability

Programs that lower your costs if you have Medicare
Medicare only covers about half of a typical person’s health care costs. So, even with Medicare, many people struggle to afford premiums, deductibles and other out-of-pockets health care costs. Some people qualify for Medicare, which fills most of the gaps in Medicare. But, if you do not qualify for Medicaid, there are other programs that lower your health care costs.
1. Medicare Savings Programs. Depending on your income, Medicare Savings Programs, administered by Medicaid, help pay for Medicare premiums and coinsurance, even if you don’t qualify for Medicaid. There are three programs, Qualified Medicare Beneficiary (QMB), Specified-Low Income Medicare Beneficiary (SLMB) and Qualified Individual (QI). Income and asset limits, and how they are counted, are listed below for 2018, but vary somewhat by state. You should apply through your local Medicaid office.
  - Qualified Medicare Beneficiary (QMB)—100 percent of federal poverty level (FPL) + $20
    
    Income limit monthly depends upon where you live but is around
    
    $1,061 for individuals
    
    $1,430 for couples
    
    Asset limit
    
    Individuals: $7,730
    
    Couples: $11,600
  - Specified Low-income Medicare Beneficiary (SLMB)—120 percent of FPL + $20
    
    Income limit monthly depends upon where you live but is around
    
    $1,260 for individuals
    
    $1,711 for couples
    
    Asset limit
    
    Individuals: $7,730
    
    Couples: $11,600
  - Qualifying Individual (QI)—135 percent of FPL +$20
    
    Income limit monthly depends upon where you live but is around
    
    $1,428 for individuals
    
    $1,923 for couples
    
    Asset limit
    
    Individuals: $7,730
    
    Couples: $11,600
  No matter what state you live in, the first $20 of your income and the first $65 of your monthly wages are not counted as income. In addition, half of your monthly wages, after the first $65 is not counted, nor are food stamps. Some of your assets are also not counted, including your primary home, if you own it, your car, your wedding and engagement rings, a burial plot and $1,500 in burial funds, your life insurance with a cash value less than $1,500, and your furniture, household and personal items. Your bank accounts, stocks and bonds are counted.
  
  Tip: If your income is low but too high to qualify you for Medicaid, it is worth looking into whether you qualify for any of these programs. According to MACPAC, an independent agency that advises Congress on Medicaid policy, less than a half the people over 65 who qualify for the Qualified Medicare Beneficiary program (48%) are enrolled. And, an even smaller share of people over 65 who qualify for the Specified Low-Income Medicare Beneficiary program (28%) are enrolled. About one in seven people over 65 (15%) who qualify for the QI program are enrolled.
2. Extra Help with Medicare Part D prescription drug coverage: You may qualify for Extra Help, a program administered by Medicaid, which pays for some or all of the cost of your drug coverage. The amount of help with cost-sharing depends on the level of your income and assets. In 2018, you may qualify if you have up to $18,735 in yearly income ($25,365 for a married couple) and up to $14,390 in assets ($28,720 for a married couple). With Extra Help your drug costs are no more than $3.40 for each generic/$8.50 for each brand-name covered drug. And, depending upon your income, you may pay only part of your Medicare drug plan premiums and deductibles. You get Extra Help automatically if you have Medicaid or a Medicare Savings Program or receive Supplemental Security Income benefits. You can apply for Extra Help online here. (Some states have State Pharmaceutical Assistance Programs that provide even more assistance.)
3. Federally Qualified Health Centers (FQHCs) and other programs run by the Human Resources and Services Administration: FQHCs are located across the country and provide a wide range of services to underserved populations and areas on a sliding-feed scale. They might waive the Medicare deductible and coinsurance, depending upon your income.
4. Hill-Burton programs offer free or reduced care at Hill-Burton facilities in 38 states. Hill-Burton does not cover services fully covered by Medicare or Medicaid. Eligibility depends on your family size and income.
5. Veterans’ Administration: If you are a vet, the Veterans’ Administration (VA) offers low-cost services and prescription drugs directly. And, you can have VA coverage as well as Medicare.
Keep in mind that you may be eligible for Medicaid based on your income after paying for some health care costs. To contact your state Medicaid office, click here.

Here’s more from Just Care:
December 19, 2019
Choose your hospital emergency room carefully
Who knows when a hospital emergency will strike, but it is more frequently than you would expect. In 2015, there were 433 emergency room visits for every 1,000 people. To the extent possible, it is wise to be prepared and choose your hospital emergency room. A little homework while you are feeling good, can ease stress, reduce costs and mean better care. Here are three things you can do now:
1. Understand your hospital options and discuss them with your doctor. Different hospitals rank higher than others in the quality of care they deliver. Some hospitals are poor on patient safety. And, some offer better emergency care than others. A University of Michigan study linking emergency room care with patient outcomes shows a connection between the number of emergency room cases a hospital gets and patients’ survival, particularly for patients with life-threatening conditions. The busier the emergency room, the higher the survival rate. The study’s authors estimate that if all patients with serious conditions used the busiest emergency rooms, 24,000 fewer people would die each year. Do not rely exclusively on Medicare’s hospital compare tool; also check the Informed Patient Institute, which rates the usefulness of different online tools.
2. Identify the hospital you would want to use in an emergency. Traditional Medicare covers care at virtually any hospital. If you are enrolled in a Medicare Advantage plan or other commercial health plan, make sure the hospital is in network to ensure continuity of care after the emergency passes. Commercial health plans, including Medicare Advantage plans, must cover emergency care no matter where you get treated. But, your health plan may only cover follow-up care in a network hospital, unless your health is endangered.
3. Find the number of an ambulance in your health plan’s network that will take you to that hospital, share it with a health care buddy, a family member or friend, and keep it in a safe place. Traditional Medicare will cover any ambulance that complies with its rules. A commercial Medicare Advantage plan or other commercial health plan may only cover an in-network ambulance. Just Care offers tips for keeping your ambulance costs down here.
Here’s more from Just Care:
July 23, 2018
Health care has become increasingly unaffordable
A new paper by Ezekiel Emanuel, Aaron Glickman and David Johnson, published in the JAMA Network reveals that working people spend twice as much of their income on health care today as they did in 1999: A powerful signal that health care has become increasingly unaffordable.

The cost of health care has become so prohibitive that one in four Americans say that they postpone it. And, almost six in ten Americans (57 percent) worry about their ability to get and afford needed medical care.

Emanuel et al. create an “Affordability Index” that tracks the percentage of people’s income that is going to health care premiums over time, for the 178 million people receiving employer-sponsored health insurance. In 2016, the average was 30.7 percent. In 1999, it was less than half that, 14.2 percent. The researchers include both employee and employer contributions towards health care premiums in their calculations, assuming that if employers were not making these contributions, employees would see higher wages.

The raw numbers are staggering. The average premium for a family insurance policy in 2016 was $18,142. The median income was $59.039. Put differently, the average cost of health care coverage rose 4.7 times faster than income (213 percent v. 45 percent) between 1999 and 2016.

The pace of health care cost increases is unsustainable. Emanuel and his colleagues hope that their index can lead policymakers to pay attention to elements of the health care sector that are rising faster than others and rein them in.

A better way to go would be for Congress to enact improved Medicare for all. Click here to sign a petition to Congress.

Here’s more from Just Care:
November 8, 2017
Four ways Congress could weaken Medicare
Much like Social Security, Americans across the political spectrum prize Medicare. Medicare provides the anchor for their health security if they are over 65 or have a disability and offers peace of mind to their families. People love Medicare—a government health insurance program—even though they don’t love government. But, Republicans in Congress want to transform Medicare as we know it, turn it into a voucher program, even though it would mean shifting more costs to older adults, people with disabilities and their families.

Here are four ways Congressional leaders could weaken Medicare if Trump becomes President.
1. Republicans in Congress want to privatize Medicare and turn it into a defined contribution program. They want to give people with Medicare a voucher that contributes to some of the cost of their health care coverage and make them pay the rest. Congress could limit the amount of the voucher from one year to the next, shifting more costs to people with Medicare. They want to move Medicare from a defined benefit program covering all the care people need, to a defined contribution program. Sometimes they call this “premium support.” But, whatever you call it, it would inevitably mean forcing people to pay more for their health care. Commercial insurers likely would have few constraints on the premiums, deductibles and copays they charged, and people with Medicare would be left largely on their own to afford them.
2. Republicans in Congress want to do away with traditional Medicare. Seven out of ten people with Medicare still opt for traditional Medicare because it gives them the wide choice of doctors and hospitals anywhere in the country and the ease of access that they value. It is also extremely cost-effective, spending only two percent of its budget on administrative costs. And, it has done a far better job of reining costs than Medicare Advantage plans, offered by commercial insurers; at the same time, it has helped ensure the Medicare Advantage plans keep their costs in check to remain competitive. Moreover, the federal government is able to drive improvements to the health care system through traditional Medicare. Regardless, Republicans in Congress want to eliminate traditional Medicare, reducing people’s access to doctors and hospitals and driving up health care costs.
3. Republicans in Congress want to means-test Medicare even further. Like Social Security, Medicare is an earned benefit. People contribute to Medicare throughout their working life. Medicare covers people in America over 65 and people with disabilities who have paid in, regardless of their health or wealth. Already, Congress has passed a law forcing about six percent of people with Medicare—individuals with incomes over $85,000 and couples with incomes over $170, 000—to pay more for Medicare. Republicans in Congress want to increase premiums for middle-class and wealthier Americans even further threatening Medicare’s affordability. Also, the more that these individuals are asked to pay for Medicare, the more Congress positions Medicare as a welfare program and erodes support for Medicare.
4. Republicans in Congress want to raise the age of Medicare eligibility. People eligible for Medicare based on age can enroll when they are 65. Republican leaders want to raise the age at which people can enroll in Medicare to 67. Many Americans depend upon Medicare to provide them with health care coverage once they lose their employer coverage. While they can enroll in the state health insurance exchanges, the state exchanges provide neither the broad choice of doctors and hospitals nor the continuity of care that Medicare offers. Easy access to doctors and hospitals as well as continuity of care are especially important for older adults who use three times more health care than people under 65.
October 13, 2016
Clinton proposes plan to rein in some drug prices
Recognizing that government intervention is needed to rein in some drug prices, Hillary Clinton has proposed a plan to help ensure people in the U.S. can afford their life-saving medications, if she’s elected president. This new plan supplements her proposals for reining in drug prices more generally, establishing a panel to oversee the price of critical drugs. The panel would be empowered to penalize drug companies that hike prices substantially on life-saving drugs that have been available at far lower prices for a long time; it could also make reasonably priced drugs available.

While Clinton should be commended for bringing the issue of high drug prices into the spotlight of the presidential campaign, the devil is in her plan’s details. Practically, it’s hard to see how her proposal gets implemented in a way that serves the public interest. You can imagine a panel debating what it means for a drug price to increase substantially or how long a drug has to have been on the market for the panel to address its steep price. The efficacy of the oversight panel turns on who sits on it and panelists’ sense of what the right price of a drug should be.

Clinton is proposing panelists from the public health and consumer protection worlds, but her executive authority is limited. Arguably, most of Clinton’s enforcement tools require Congressional action. Congress would need to pass legislation establishing a panel to impose penalties on drug companies that raise prices on drugs too high. And, it would have to ensure the panelists were chosen for their independence, a stretch to say the least.

Congress has never been inclined to take action to rein in the price of drugs even though drug price negotiation is a top policy priority for Americans, so it’s hard to see why it would now. Members feign concern about prices and fail to act claiming they don’t want to stymy drug companies from innovating; PhRMA’s largesse when it comes to campaign contributions is formidable.

Presumably, Clinton has authority to have the FDA lift its ban on importation of drugs from abroad for personal use to ensure their affordability. But, it’s unclear how much help that would be. While it is illegal to import drugs from abroad for personal use today, millions of people already do so in order to afford their medications. No one stops them. And, the FDA has never prosecuted a person for so doing.

Also, the Bayh-Dole Act already gives the US government the executive authority to limit the price of many drugs that were developed with federal funds, though the government has never chosen to use its authority in the past 35 years under Democratic or Republican administrations. A Clinton administration arguably could choose to use its executive authority under Bayh-Dole or through a newly energized Consumer Financial Protection Bureau to ensure drug prices are reasonable.

The question remains whether there’s steak in Clinton’s proposals or are they all sizzle?

Here’s more from Just Care
September 8, 2016
Insurance premiums projected to rise a lot in 2017

The New York Times reports that health insurance premiums are projected to rise a lot in 2017. Insurers are requesting large price hikes from their state insurance departments. The Obama Administration, meanwhile, is working to remind people that states review all insurer requests for premium increases and often reduce them.

What’s most concerning is that one top health plan, Geisinger, based in Pennsylvania and known for delivering value–good care at reasonable cost–anticipates medical costs will rise by 7.5 percent in 2017. And, it is requesting a 40 percent rate increase. Its CEO claims Geisinger has been losing $30 million annually on its state health insurance exchange plans.

Other health plans in Pennsylvania are also seeking large premium increases from the state, according to the Pennsylvania Insurance Department. Health plans are seeking an average premium increase of 23.6 percent in 2017.

The explanation: People in the state health insurance exchanges are needing more care than projected. And, people in relatively good health are holding on to the health plans they had before the ACA passed.

Today, millions of people can buy affordable insurance on the state exchanges thanks to government premium subsidies in the form of tax credits. They can pay as little as $900 for annual coverage ($75 a month) because of a tax credit based on their income. This year, the government is spending $110 billion on this tax credit, which helps subsidize the premiums in the state exchanges. In 2017, about 12 million people will receive these tax credits according to the Congressional Budget Office. However, another 12 million will not benefit from these credits.

June 28, 2016
Medicare Part D drug costs rising
The private Medicare plan bait and switch continues. It wasn’t that long ago that copays in private plans were reasonable, affordable even, without Medicare supplemental insurance to pick up the cost. This year, Medicare Part D drug plans have moved from fixed copays to coinsurance, a percentage of the cost, for the majority of drugs they cover. Consequently, out-of-pocket prescription drug costs are projected to rise again for people with Medicare.

The advantage of traditional Medicare, beyond the wide choice of doctors and hospitals it offers anywhere in the country and easy access to care, has always been that it allows people to budget for their health care. With supplemental insurance, there are few if any out-of-pocket costs. And, while supplemental coverage can be costly, knowing health care costs for the year gives people peace of mind.

But, until Congress allows CMS to negotiate drug prices instead of permitting drug companies to charge astronomical prices, drug costs will continue to escalate for everyone. For now, Congress has chosen to penalize the public and reward the drug industry since insurers have limited if any ability to rein in drug prices. To keep premiums down, they simply shift more costs to their members.

The share of Medicare Part D drugs with coinsurance payments has been growing steadily in the last few years. According to Avalere Health, 58 percent of covered drugs in Part D plans now have a coinsurance payment. In 2014, about one in three drugs in Part D plans (35 percent) had coinsurance payments. Last year it was 45 percent.

The Medicare Advantage plans are also shifting increasingly to coinsurance payments for certain drugs. This year 26 percent of their drugs have coinsurance payments. You can expect that to increase.

Here’s more from Just Care on prescription drugs:
April 12, 2016
Kidney disease prevalent; many unaware
Kidney disease is prevalent in the U.S, posing huge health risks at enormous cost, according to a recent report by Rajesh Balkrishnan. In 2013, Medicare spent $81 billion dollars treating people with kidney failure (End-Stage Renal Disease) and chronic kidney disease. Fourteen percent of Americans, some 26 million adults, suffer from chronic kidney disease–loss of kidney function–and most are unaware.

People with diabetes and high blood pressure are most likely to get kidney disease. People with chronic kidney disease need a range of costly services. Twenty percent of Medicare spending on people over 65 is for treatment of chronic kidney disease.

Drugs alone typically cost $3,675 a patient under Medicare Part D or 46 percent more than other people with Medicare, whose average Part D costs are $2, 509. People with kidney failure average $6,673 in Part D drug costs, 2.6 times what other people with Medicare spend. And dialysis patients average $7,142 in drug costs.

People with Medicare eligible for a low-income program that helps pay the drug coinsurance or copays only spend one or two percent of total costs out of pocket. But, people who must pay the full share of out-of-pocket costs end up with large bills amounting to about 30 percent of total costs.

Medicare now covers a diabetes prevention program.

Here’s more from Just Care:
April 10, 2016
One in four people with Medicare spend around $11,500 yearly on health costs
Medicare only covers about half of a typical person’s health care costs. Medicare does not cover nursing home care or long-term home care, hearing aids, vision care or dental care. Most people would be shocked to know that the average out-of-pocket cost for people with Medicare was $4,734 in 2010. This represents a sizeable portion of the annual income of the typical person with Medicare.

Certain subpopulations of people Medicare are at risk of having to spend more than $5,000 a year on their care. People over 85 spend three times more out of pocket, $5,962, than people between the ages of 65 and 74, $1,926. And women spend on average more than men, $5,036 as compared to $4,363.

People who need substantial amounts of health care, about 13 million people, or one in four people with Medicare, typically spend $11,500 on their care. This can easily represent more than half of their income.

Here’s more from Just Care:
March 3, 2016
Medicare and Medicaid at 50: Their roles in our health care system
A 2015 article in Health Affairs by Drew Altman and Bill Frist speaks to Medicare and Medicaid at 50, looking at the numbers, their roles in our health care system, the challenges they face and emerging issues. Medicare, a federal social insurance program, helps ensure older adults and people with disabilities have affordable access to the care they need. Medicaid, a joint state and federal program, covers older adults, people with disabilities and people with low incomes.

The Medicare and Medicaid numbers:
- Collectively, they serve 111 million people, one in three Americans
- By 2025, they will serve 139 million people
- Ten million people have Medicare and Medicaid
- They are responsible for $1 trillion in annual health spending, 39 percent of national health spending and 23 percent of the federal budget
- They generate 43 percent of hospital revenues
- Median income for people with Medicare is $23,500 and with Medicaid is $15,000
The emerging issues:
- Will Medicare and Medicaid continue to be “open-ended” programs, with guaranteed benefits and no spending cap?
- Will they become increasingly privatized? Today, less than a third of people with Medicare are in private Medicare Advantage plans, but the number could increase. And, more than half of people with Medicaid are in private managed care plans.
- Will they shift more costs onto the people they serve?
- Will they continue to play a role in reshaping delivery of care and reform of our health care system?
To date:
- Expansion of Medicare and Medicaid eligibility and benefits; Medicare now covers people with disabilities and people with ALS and ESRD; Medicaid now covers people with incomes up to 138 percent of the federal poverty level in most states.
- Stronger financial incentives to improve quality and efficiency
- Polling data show both Medicare and Medicaid remain very popular. 72 percent of Americans have a favorable view of Medicare and 90 percent of adults 65 and older.
January 20, 2016