One of the biggest challenges facing the country right now is getting skyrocketing medical costs under control. The hope of proponents of the health care reform law that the Supreme Court upheld last month was that it would help reduce overall costs.
But it now appears that one of the effects of the Affordable Care Act will be to eliminate a popular method of cutting health insurance costs. High-deductible health plans won't be able to meet regulations set by the Department of Health and Human Services, which means the use of such plans in conjunction with health savings accounts could disappear.
What HDHPs Do
With homeowners insurance and many other types of coverage, customers can choose from plans with a range of deductibles that apply before benefits kick in. The higher the deductible, the cheaper the policy -- but the more you have to pay out of pocket before the insurance company starts to pick up the bill. The idea behind high-deductible health plans is the same.
HDHPs got a big boost in 2003, when the government created health savings accounts. HSAs allowed people to set money aside to help cover deductible payments and reap tax benefits, in the form of a tax deduction for money contributed to the HSA. According to the HSA Coalition, 11.4 million people had HSA plans as of January.
Why HDHPs Could Go Away
The problem with the new law, as the HSA Coalition sees it, is in the way that it calculates medical loss ratios. Under health care reform, insurance companies in the small group or individual market have to spend 80% of the premiums they collect on medical costs, with only 20% going to administrative and other costs. Another section of the law addresses plans that are eligible for exchanges, which many individuals and small businesses will rely on for coverage.
As you might expect, the calculations get complicated in a hurry. But the big issue is that under regulations from HHS, the amount that patients spend out-of-pocket to pay their deductibles on HDHPs isn't included as a medical cost for purposes of determining the medical loss ratio. Rather, only expenses that the insurance company pays count as medical losses to meet the guidelines.
Under most health-insurance plans, the HHS regulations would make sense. Counting copayments or other out-of-pocket costs under plans designed to provide comprehensive coverage would make the entire idea of a medical loss ratio meaningless.
But with health insurance that carries high deductibles, the intent is a lot different. These policies used to be called "catastrophic health insurance" because their initial purpose was only to cover costly injuries and illnesses that most people wouldn't face in any given year. The HSA Coalition cites figures that only 5% of policies end up with claims that exceed the deductible amount.
Massachusetts residents have already seen changes to HDHPs under Romneycare, the state health insurance reform plan which many say provided the model for the federal plan. Under Massachusetts law, high-deductible plans only meet standards for minimum creditable coverage if they go beyond federal requirements in several ways, including offering preventive care visits that aren't subject to the deductible, covering a broad range of medical benefits, and not imposing limits on certain services. Moreover, HDHPs must be offered alongside HSAs or health reimbursement arrangements.
Obamacare Could Kill One Type of Cheap Health Insurance
Myth 1: Obamacare is being partially funded by a $500 billion cut to Medicare.
Reality: Funding for Medicare will actually increase over the next 10 years. However, the rate of increase will drop, partially due to more aggressive prosecution of fraud and a reduction in overpayments to insurance companies.
In fact, the ACA has already increased funding to Medicare in some ways. It has increased the minimum rebate on drugs, extended coverage to smaller hospitals, set up public health screenings for Medicare recipients, and it introduced a discount to help cover the Medicare "doughnut hole" on prescriptions. The plan is to eliminate the doughnut hole by 2020.
Myth 2: Obamacare will introduce "death panels" that will severely ration care and will force elderly patients to commit suicide or submit to euthanasia.
Reality: Introduced by Sarah Palin in 2009, the idea that health care reform will lead to euthanasia is one of the most persistent lies myths surrounding Obamacare. There have been several versions of this claim; the most recent is that the Independent Payment Advisory Board will ration care and will make end-of-life decisions for patients.
In truth, the IPAB is basically powerless. It will make health care policy recommendations to Congress, which will then have the ability to pass or reject those suggestions. The president, in turn, will have the power to veto Congress' decisions -- as he can with any other piece of legislation.
Ironically, death panels already existed before health care reform -- but they were run by your insurance company. Insurers have regularly denied coverage for pre-existing conditions, canceled policies on sick patients, refused to pay for vital, life-saving operations, and otherwise made financially-based decisions about who would get to live and who would be left to die.
According to one congressional report, three insurance companies -- UnitedHealth (UNH), WellPoint (WLP) and Assurant (AIZ) -- saved $300 million by canceling policies on over 20,000 sick people over a five-year period. The new health care law will make many of these practices illegal. In other words, rather than creating death panels, Obamacare will actually abolish them.
Myth 3: Obamacare will force the middle class to pay for health care for poor people and illegal immigrants.
Reality:Many health care reform critics have argued that America already has a universal health care option: emergency rooms. After all, the argument goes, when people without insurance find themselves in desperate need of medical attention, they can always find help in ERs, which are required by law to open their doors to anyone in need of care. Consequently, critics claim, poor people can get health care without passing the charges on to the middle class.
But this health care isn't free -- in fact, standard treatment through a primary care physician is far cheaper than crisis care in an ER. Many hospitals aggressively bill emergency patients -- and their insurers -- to recoup the inflated costs of such care. Even so, they come up short.
So who covers the shortfalls? Well, a significant source of hospital funding is taxes. For the rest, hospitals make up their ER losses by inflating the prices that insured customers pay -- and according to the Center for American Progress, this amounts to a $1,100 yearly "hidden tax" on health insurance. Put simply, emergency room care is already funded by taxpayers and the insured middle class.
Granted, Obamacare will extend Medicaid to lower income families, and will subsidize health insurance for people who make up to 400% of the poverty line. On the other hand, it will also require people who can pay for health insurance do so, and will more aggressively prosecute Medicare fraud. More to the point, it will levy a 0.9% tax on households making more than $200,000 per year, and will increase taxes on medical machinery manufacturers, pharmaceutical companies, and insurers. Thus, it will, in all likelihood, actually reduce the burden on middle class families.
Myth 4: Obamacare is a socialist program.
Reality: Socialism is a system under which the government directly runs a nation's industries. Under this standard, New Deal programs like the Works Progress Administration and the Tennessee Valley Authority could, arguably, be considered socialist. After all, they represented instances in which the government directly employed people to build and administer power plants and other public works that generated income.
Obamacare, on the other hand, will work through private companies. Rather than directly providing health insurance, either through a national program or through some sort of public option, the government will require that people deal with private insurers. Far from competing with private industry, the health care law will likely give it a lot of new customers.
Myth 5: Obamacare will bankrupt small businesses by making them pay for their employees' health insurance.
Reality: The basis of this claim is a requirement that companies with more than 50 "full-time equivalent" employees must offer affordable health insurance to their workers. The insurance in question must not cost more than 9.5% of the employee's annual salary and must pay for at least 60% of covered health care costs.
A big part of the disagreement over the impact of this requirement lies in how you define a "small business." According to the government, the cutoff line between a small and a large business is 50 "full-time equivalent" employees. In other words, if a company's weekly work load totals more than 1500 hours -- the equivalent of 50 employees working for 30 hours per week -- then it is, officially, a large business, and is required to provide a competitive health insurance option.
As a side note, Obamacare contains a pretty significant tax break for businesses with up to 25 employees that offer health insurance.
At best, as Forbes observed when an early version of the regulations was floated, costs for high-deductible health plans could rise significantly. At worst, insurers may simply choose not to offer them.
Losing HDHPs might not seem like a huge deal. But they actually represent one of the best chances to rein in health-care costs over the long haul, for one key reason: They give you the patient an economic incentive to pay more attention to what you spend on your care. Without such incentives, the current system, in which it's almost impossible even to find out what you'll pay for care -- let alone try to negotiate more reasonable charges -- will continue to lead to the inefficiencies that made reform necessary in the first place.
Motley Fool contributor Dan Caplinger was annoyed to lose his high-deductible plan when he moved to Massachusetts, although he's fortunate enough to have decent coverage (at least for now). You can follow him on Twitter here.