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What are your thoughts about mid-level providers?

Old 11-05-20, 05:39 PM
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What are your thoughts about mid-level providers?

I recently finished a residency program and have had plenty of time to work with NPs and PAs. However, behind the scenes, there has been a trend over the years where NPs (whether DNP or APRNs) have been advocating for independent practice and greater compensation as apparently their representative bodies have lots of lobbying power. I have seen some questionable and often adverse outcomes specifically with NPs on the inpatient side. I have also seen many DNPs address themselves as doctor (since they have the doctorate of nurse practice degree) to patients, which could create confusion. I think it is kind of wild that certain NP programs (specifically online-mill type programs with limited clinical hours) can have virtually unsupervised practice right off the bat, while residents with 4 years of school + residency training still need supervision. Some of the data advocating for NP outcomes being better than physicians seem to be low quality data published particularly in nursing journals. I have even noticed trends with PAs lobbying for greater autonomy and there has even been debate to change their title to something more autonomous, which I don't blame since it's kind of an odd description. I think mid-level providers have a solid place in healthcare and can benefit patients, but it is amazing how NPs/APRNs are attempting to "level the playing field" in terms of no supervision with vastly different hours of training, and there has been quite a bit of animosity aimed towards physicians at the same time. It is kind of baffling to be honest.
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Old 11-05-20, 06:38 PM
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Over the past 35 years I've had 3 GPs, two of them doctors and my current, a nurse with letters MSN, ANP-BC, WHCNP-BC, CPT. They have all had their pluses and minuses re: my health. First was a straight forward doctor. I had no real issues other that the occasional sickness or injury. I did get sore throats requiring antoibioticx about every 128 months, for which he prescribed courses that worked. 22 years ago I moved to Portland and started seeing a new doctor. He took further interest in my thoughts that my sinus, sore throat and unusual allergy issues stemmed from my boatbuilding days. Sent me to a top allergy specialist. That started me on a very expensive inhalant, soon followed by another equally expensive one. They made my life radically better and my wallet lighter; at time a lot when insurance didn't cover.

The past six years I've been going to this nurse. Now she isn't a doctor and when that is needed, she sends me elsewhere and that has several time been very expensive. But ... she also listens and is willing to suggest non-traditional approaches. After my first physical with her, she said she'd been going over her notes and seeing my observations re boatbuilding and allergies; that I had mentioned we all knew in boatbuilding circles that acetone carried the resins dissolved in it through our skin where they went to the liver. She said she knew of a natropathic medicine that cleaned the liver of toxic chemicals, that it was a 90 day mini-chemo, not a lot of fun and did I want to try it? I said yes. $50 for the horse pills to be taken once a day. She was right. Not something I want to do again, but it was life changing. Conditions I'd lived with 30 years that I knew I was taking to the grave cleared almost entirely. The full squirt of each inhalant to each nostril every night is down to just enough of a squirt to feel I got something every 5 days. I get to do normal things. I can actually go to bed without taking a shower, sleep and not regret it in the morning. Before the "chemo" that would have been a sentence to a day of hell.

She has also convinced me to go non-dairy. Not as big, but also life-changing.

I learned a lot from that second doctor re: heart, cholestero; high and low. (Heart health was his specialty and he told me once he stressed it because he didn't like his patients dying.) He started me on a fundamental diet change to incorporate Omega 3s (21 years ago). I probably wasn't ready to hear what my current provider has for advice until I went to her. (She's also a lot younger than me and wouldn't have been practicing yet.) I think it is our job to look for the strengths of our providers and their shortcomings, both in training'/background and as humans. In other words, a real part of our health care is on us.
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Old 11-05-20, 06:51 PM
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Honestly? It's all unobtainium for people in my situation in the working/lower middle class. The longer America goes down the current heath care/insurance path, it's simply like the movie Elysium.

In my limited experience with health care, back when we still had health insurance in 2016, I was surprised how the nurse practitioners that I witnessed were more capable than the doctor overseers. It seemed like the doctors were used to delegating tasks to nurses or nurse practitioners, while the nurse practitioners had a more hands on experience with the patient.

One thing (out of several) that comes to mind was a particular doctor that made three attempts to do a spinal tap on my wife years ago (meningitis case) for which he had to abort and ask the nurse practitioner to take over. The NP did the spinal tap in one try without fanfare.

Not sure if that's what you're talking about, but consider it a viewpoint from a lay person.
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Old 11-05-20, 08:53 PM
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I’d say for the kind of treatment you’re seeking a NP’s education is what’s important in the comparing to a PCMD. The unique skills ONP’s have to offer in the delivery of quality care helped me tremendously in going through my care and treatments especially in educating and advising me, they were a wonderful part of my medical team. NP’s are also an increasingly important critical part of health clinic work in rural areas and especially with the increasing health care needs of the older generation.
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Old 11-05-20, 09:00 PM
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Yeah, as a health care provider, caregiver for older family, and as a patient, I've had wildly mixed experiences with NPs. Some were very good. One nearly got me hospitalized due to negligence. While I've also had mixed experiences with MDs and DOs, it wasn't quite as dramatically different between the good and bad.

Generally speaking, even with the better NPs, the worst I can say is that they tend a bit too much toward woo. In part that's because they're limited in what they can prescribe or authorize, so they're tempted to substitute placebo, panaceas and BS. But, hey, that works for some patients.

The most common issue I've had with MDs (not so much with DOs), and seen as a health care provider and caregiver for my family, is that some doctors seem disinterested and perfunctory. Fortunately that hasn't been my experience as a patient with the VA the past couple of years, but that's due in part to very public pressure on the VA to improve. And it seems to be helping.

As a patient I've had better experiences with PAs than with NPs. Part of that may be due to the level of supervision. But most PAs I've met were former military -- corpsmen, medics, etc. -- and usually male. I'm not sure which factor made the difference, since most military corpsmen and medics were male anyway. Most NPs I've met were women, although I've met a couple who were men. I've never had any preference between men or women as health care providers so I'm reasonably sure my own biases aren't a factor in my impressions. Mostly it seems to be a difference in the overall approach.
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Old 11-06-20, 03:05 AM
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I have had the good fortune to have decent health care due to caring professionals vice a good medical system. Overall, I feel it is the individual and their relationship with the patient that makes the biggest difference in this somewhat dystopian version of "for profit" health care.

Over the decacades, I have had "gold plated healthcare," military healthcare, and "state supplied, basic healthcare."

The disconnect in our system between services "covered" by plan X or plan Y and the expensive duplication of said services "just across the street" but "out of network" is outrageous, and painfully laughable.

The easiest example I can give is drug stores... literally across the street from one another... with massively different prices for the same drugs and you the patient having to jump through hoops to figure out which one is "in contract" with your plan. I have seen the same thing with MRIs.

I have Canadian engineer friends covered under the same plan as myself (working for the same company, on assignment to US) who tell me our HC system is a joke, and anything but a "system."

So, again... I have been lucky to find and keep caring professionals... DO, MD, and NP alike... but I agree with the "Elysium" reference to our overall system.
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Old 11-07-20, 08:48 PM
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Interesting input above. I agree there is definitely a place for these professions in healthcare, especially in underserved areas, and the NPs and PAs I work with are amazing. I think there is absolute value in an RN perspective who see the medical system from another perspective. I am just concerned about the training differences and it affecting patient outcomes in the setting of unsupervised practice. I think for bread-and-butter cases it makes sense, but thinking long term about the complex patients, it could pose serious risk. There are evens books on this, for example this 2020 book that provides a decent look into the history and where things stand now. And I want to add, even for places with NPs that are supposedly "supervised" can virtually go unsupervised for many reasons, which again could promote adverse outcomes. I see an NP myself but have the luxury of realizing what needs to be done. I worry about other patients who may not be provided optimal high quality, evidence-based, care. This is also being expressed by the PA field too. The training difference is substantial. NP organizations such as the AANP are pushing really really hard for treating NP as = to MD/DO. I really worry too that hospital organizations will prioritize profit by hiring more NPs at the expense of patients.
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Old 11-10-20, 03:10 PM
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Old 11-10-20, 03:19 PM
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It’s criminal what my monthly medical insurance payment is each month. My local primary doctor care is good. For other things I feel like a cow going to market.
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Old 11-10-20, 03:33 PM
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Originally Posted by Hondo Gravel View Post
It’s criminal what my monthly medical insurance payment is each month. My local primary doctor care is good. For other things I feel like a cow going to market.
Indeed.

My quotes through my company for Blue Cross for 2021 are $2,605.59 or $2,636.49 per month. That's for me, my wife, and my last kid at home who is a 21 year old college student.

I'll be looking into the ACA again this year, but if it's like the last 4 years the obscene deductible will make us start our 5th year without coverage.
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Old 11-10-20, 03:42 PM
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Oh F it I will say what mine is ... Frikin $730 a month! I have Blue Cross rip-off. But other companies are worse. I have pre existing conditions so I’m concerned about that. Last hand surgery was botched and was that great meat market experience ... good thing I’m smoking some chicken and enjoying some Colorado Gatorade and Van Halen is on the radio....
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Old 11-10-20, 04:22 PM
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Originally Posted by Hondo Gravel View Post
It’s criminal what my monthly medical insurance payment is each month. My local primary doctor care is good. For other things I feel like a cow going to market.
Originally Posted by FiftySix View Post
Indeed.

My quotes through my company for Blue Cross for 2021 are $2,605.59 or $2,636.49 per month. That's for me, my wife, and my last kid at home who is a 21 year old college student.

I'll be looking into the ACA again this year, but if it's like the last 4 years the obscene deductible will make us start our 5th year without coverage.
Originally Posted by Hondo Gravel View Post
Oh F it I will say what mine is ... Frikin $730 a month! I have Blue Cross rip-off. But other companies are worse. I have pre existing conditions so I’m concerned about that. Last hand surgery was botched and was that great meat market experience ... good thing I’m smoking some chicken and enjoying some Colorado Gatorade and Van Halen is on the radio....

At the risk of this being sent to the political forum... I note that both of you are from Texas... are you aware that Texas chose not to accept the Medicaid expansion option...

Texas is one of nearly 20 states yet to expand its Medicaid program under the Affordable Care Act (ACA), and is home to the largest number of uninsured Americans of any state in the country. For many of the state's 5 million uninsured, this decision has left them without an option for affordable health insurance.
https://www.healthinsurance.org/texas-medicaid/

You boys best go out and find a local "medicine man" for your care.
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Old 11-10-20, 04:50 PM
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Originally Posted by genec View Post
At the risk of this being sent to the political forum... I note that both of you are from Texas... are you aware that Texas chose not to accept the Medicaid expansion option...



https://www.healthinsurance.org/texas-medicaid/

You boys best go out and find a local "medicine man" for your care.
Yup I’m well aware the Medical Expansion Option was rejected by our geniuses that never left the back 40 I will go to the local Hondo Bruja for basic ailments. Mexican witch that can cure you and I swear it is good medicine. Probably mind over matter but anyways worth the 20 bucks.
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Old 11-10-20, 05:54 PM
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I haven't been sick enough to seek help from conventional medical care for years, but one of the last times I was I got care from a NP. Her training was limited to drugs and surgery, but wasn't opposed to healthcare and we worked out something that got me back to being healthy again.
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Old 11-11-20, 03:43 AM
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Gotta admit, I can't complain about my medical coverage the past couple of years. I'm a veteran so between the VA and Medicare pretty much all of my expenses are covered.

But before I turned 60 I neglected my health for years and it nearly killed me. I couldn't have afforded health insurance with or without the ACA. So I went from no visits to doctors for almost 20 years, to nearly weekly medical appointments for a year or so between 2018-'19. This year has been a bit slower only because the pandemic delayed most non-urgent/emergency visits.

I did switch from the local public hospital after encounters with indifferent ortho docs (my shoulder was badly injured when I was hit by a car in 2018) and incompetent NP for my thyroid problem. My mom got great care from that same system, so I was surprised to find them so unsatisfactory for my purposes. But we had very different temperaments. Mom enjoyed being doted on. She didn't dislike aging and the benefits of being catered to. Her NP was terrific (since retired). I hate getting older and resented being assigned to a "geriatric" clinic when I turned 60. And I really disliked the dismissive attitudes from my NPs toward my valid concerns. The last straw was having my thyroid meds discontinued because the NP clearly did not know what she was talking about. I ended up in urgent care again over that screw up.

The VA has been an entirely different experience, about 95% positive, but that's due to being in Texas and DFW in particular. Pressure and advocacy by state and federal representatives helped ensure our system works pretty well. Some other regions, especially along the Gulf Coast and SE US, have serious problems. But that's always been a problem with federal agencies. Some regions have always had ingrained cultural problems that hinder efficiency and quality. I used to work for the federal gummint too, as a safety inspector, and I noticed some dramatic differences in work ethic when we got employees who transferred from anywhere in the southeastern US. Judging from what I hear about the VA in the SE, it seems the problem is systemic. Fixing that will take a massive, concerted and consistent effort.

Now that I'm eligible for Medicare I have other options, but I've postponed making any changes due to the pandemic. I'll probably opt for other doctors outside the VA system next year. Because it's a teaching institution the VA is great for some stuff, particularly emergency, urgent care, surgery and specialty treatments. But not as good for some chronic and longterm health maintenance stuff. My neck is getting worse from multiple injuries and aging. I'd like to find a good clinic for that problem. I want to avoid surgery if possible, and while I have prescription pain meds I dislike using them because they make me drowsy. There are a couple of sports medicine clinics and I think they work with Medicare, so those are possibilities.
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Old 11-11-20, 07:21 AM
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Originally Posted by genec View Post

You boys best go out and find a local "medicine man" for your care.
I've been doing that for me and my family since November 2016, which is the last time we had health insurance.

It still ticks me off that I had affordable health insurance before the ACA went into effect and the rates had risen to unaffordable levels for me and my family afterwards.

Plus, the whole "your kids could stay on your insurance until 26 if not in college" was a lie.

Yes, we could add a non-college kid above 18 to our health insurance but the insurance companies just added in the premium cost of another adult. Which means it was the same as just buying a separate policy for that under 26 year old non college kid. Which has been affirmed every year when I look into ACA coverage for us and the ACA will not allow non college children between the age of 18 and 26 on your family application. They have to apply separately.

Not to mention the annual tax penalty added to your income tax for not having health insurance. Which for us was about $2,300 per year. That's just the federal government pouring salt into your wounds. Pre-2019 of course.

Pure genius. You can't afford health insurance, so the government increased the amount of income tax you owed.

The bottom line for me is that to give health insurance to more poor people, health insurance got taken from lower income working class people that had insurance before. Whether due to premium price increases when buying direct, or due to employers shifting to hiring only part time people or the proliferation of gig economy contractors to avoid paying those high cost benefits to employees.

Per the US government, there's only something like 29 million of us, so it's better than before, right?

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Old 11-11-20, 08:38 AM
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Originally Posted by FiftySix View Post
I've been doing that for me and my family since November 2016, which is the last time we had health insurance.

It still ticks me off that I had affordable health insurance before the ACA went into effect and the rates had risen to unaffordable levels for me and my family afterwards.

Plus, the whole "your kids could stay on your insurance until 26 if not in college" was a lie.

Yes, we could add a non-college kid above 18 to our health insurance but the insurance companies just added in the premium cost of another adult. Which means it was the same as just buying a separate policy for that under 26 year old non college kid. Which has been affirmed every year when I look into ACA coverage for us and the ACA will not allow non college children between the age of 18 and 26 on your family application. They have to apply separately.

Not to mention the annual tax penalty added to your income tax for not having health insurance. Which for us was about $2,300 per year. That's just the federal government pouring salt into your wounds. Pre-2019 of course.

Pure genius. You can't afford health insurance, so the government increased the amount of income tax you owed.

The bottom line for me is that to give health insurance to more poor people, health insurance got taken from lower income working class people that had insurance before. Whether due to premium price increases when buying direct, or due to employers shifting to hiring only part time people or the proliferation of gig economy contractors to avoid paying those high cost benefits to employees.

Per the US government, there's only something like 29 million of us, so it's better than before, right?
In spite of your view of "the US gubbermint," keep in mind that it was Texas that chose to refuse the Medicaid expansion. I am not saying that ACA was perfect, by any means... it needs tuning, not dismissal. It needs to work for everyone.

I have had coverage ranging from "gold plated" employer policies to "military" to "ACA public option" and while they did vary in quality, the latter was quite sufficient for basic coverage and did not fail me. But then the states where I was living at the time DID accept the Medicaid expansion...

And certainly one thing to keep in mind, at the time ACA was enacted... the cost of healthcare in America was rising at unprecedented rates. That still needs to be fixed... we have far too much waste and unused redundancy in our "for profit" system, and the system itself is not consistent from State to State... coverage I had on the west coast was quite different from coverage I had in Florida, for instance. (Part of that was the cost for care... too high, and part of that was who the practitioners were, that I was assigned to... I had one good MD and two marginal NPs... and the MD was leaving the state... go figure... all this to just keep some basic prescriptions filled)

I think "the gubbermint" CAN do a better job of ensuring that healthcare is available to all... we just need to understand the need to do so as a basic right... certainly a pandemic has given us insight into this dilemma.
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Old 11-11-20, 09:41 AM
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Originally Posted by genec View Post
In spite of your view of "the US gubbermint," keep in mind that it was Texas that chose to refuse the Medicaid expansion. I am not saying that ACA was perfect, by any means... it needs tuning, not dismissal. It needs to work for everyone.

And certainly one thing to keep in mind, at the time ACA was enacted... the cost of healthcare in America was rising at unprecedented rates.
My view is of course my "anecdotal" first hand experience over the last 4 years. Nothing is changing the fact we haven't had health coverage for what will become 5 years straight.

A few years ago, I was offered to move to Portland, Oregon for employment after a contract job I did there. Trouble was, the salary offered was only 10% greater than my Texas salary and my move wouldn't be funded in any amount. Maybe the health insurance premiums would have been lower, but I couldn't afford to live there due to the higher cost of living at that time.

All that means is that I was as likely to get health insurance in Oregon as much as I could in Texas.
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Old 11-11-20, 11:38 AM
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With regard to Mid-Level Providers...

Over the last 20 years (going back further really has no bearing). I have been treated by the complete range of various Letters/Numbers i.e. DO, MD, NP, PA etc. The ratio of seeing a PA to an actual MD is about 3 to 1. I have actually been treated by a PA when seeking emergency medical help. In that particular case I'm sure I was triaged and it was determined that an ER MD was not required. My wife is also seen by a PA. I have no complaints regarding the treatment or outcomes, it's just that you really have to take that extra look in order to determine if you're being treated by an MD or a PHD. I've noticed that most PA are referred to as "The doctor will be in to see you" etc. I just wish that these differences were presented during the examination. I'm not sure it would make a difference, but it would give me the opportunity to request that I see an actual MD the next time I go in.
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Old 11-11-20, 12:07 PM
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Growing up in France i have a hard time thinking the U.S. has anywhere near good healthcare costs for it’s citizens. Thankfully through my workplace i do have good coverage with an excellent HMO and with minimum cost to me but it’s still not what i would have in France, especially, if i had a life threatening condition, was without a job or had a much lower income and a few years ago I would have paid nothing (0) for excellent cancer care in France.

There are enough good universal coverage plans in other countries that it surprises me that people here don’t demand better affordable, quality health care through there state(especially) and federal politicians. Perhaps too many people have bought into the conservative demonizing of an equal access universal social insurance program. As insurance costs rise and health care access recedes for people who are sick and the middle/lower class or poor perhaps the thinking will change. I can only hope…….
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Old 11-11-20, 01:37 PM
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Originally Posted by genec View Post
At the risk of this being sent to the political forum... I note that both of you are from Texas... are you aware that Texas chose not to accept the Medicaid expansion option...



https://www.healthinsurance.org/texas-medicaid/

You boys best go out and find a local "medicine man" for your care.
I finally had time to look through that link. It looks like the Medicaid expansion added (or would add) people that were up to 135% or 138% of the poverty income level. There's a whole lot of people well above that level that don't have health insurance in this country, including myself.

https://www.kff.org/uninsured/issue-...nded-medicaid/ from here https://www.kff.org/uninsured/
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Old 11-11-20, 02:38 PM
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Originally Posted by FiftySix View Post
I finally had time to look through that link. It looks like the Medicaid expansion added (or would add) people that were up to 135% or 138% of the poverty income level. There's a whole lot of people well above that level that don't have health insurance in this country, including myself.

https://www.kff.org/uninsured/issue-...nded-medicaid/ from here https://www.kff.org/uninsured/
Yeah... it isn't perfect... and indeed it puts the biggest burden on those most likely just eking out a fair living... and all along it is a leash on working folks to stay attached to an employer.

Got a better solution for a nation with ever increasing "for profit" health care costs? Low cost high deductible coverage with lots of loopholes and caveats??? Local country doctor willing to trade beef and chicken for birthing babies??? Nixon wanted a universal HMO system... but was never able to implement it. As someone said, 'Nobody knew health care could be so complicated'
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Old 11-11-20, 03:12 PM
  #23  
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Originally Posted by FiftySix View Post
I finally had time to look through that link. It looks like the Medicaid expansion added (or would add) people that were up to 135% or 138% of the poverty income level
The ACA provides subsidies for incomes up to 400% of the poverty level. That's $80,000 for a family of three. With Texas not participating in the expansion program your deductibles are more and your tax credits are less and it makes medicaid participants ineligible for premium subsidies to offset the cost of private coverage in the exchange.
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Old 11-11-20, 05:18 PM
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Originally Posted by clemsongirl View Post
The ACA provides subsidies for incomes up to 400% of the poverty level. That's $80,000 for a family of three. With Texas not participating in the expansion program your deductibles are more and your tax credits are less and it makes medicaid participants ineligible for premium subsidies to offset the cost of private coverage in the exchange.
True. When one applies at the ACA* market place you get to see how much of a subsidy you receive. It's a sliding scale relative to a family's income, as would be expected.

Below are literal screen shots when I was shopping at the ACA market place in November 2019 for my wife, my last college kid, and myself. I figure my shopping this coming weekend will result in similar numbers. Premiums can get pretty low with Bronze plans, but the deductibles are something else entirely.

*healthcare.gov





Last edited by FiftySix; 11-11-20 at 05:21 PM.
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Old 11-11-20, 07:25 PM
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Originally Posted by FiftySix View Post
Below are literal screen shots when I was shopping at the ACA market place in November 2019 for my wife, my last college kid, and myself. I figure my shopping this coming weekend will result in similar numbers. Premiums can get pretty low with Bronze plans, but the deductibles are something else entirely.
reread the third sentence in my last post….
i just did an estimate for a california plan for a 60 year old making $70,000 a year with a 50 year old wife and 20 year old son and the price for a gold plan ranges from $488 to $590 a month after a ‘federal/state’ $656 subsidy and for a 0 deductible, $15 drug and $30 doctor visit, $600 a hospital stay and all costs are ‘tax deductible’. But then i guess this state takes better care of it’s citizens healthcare than Texas, but then this state also eagerly enrolled in the expansion program.

For a comparison to the bronze plan you showed, here, with the subsidy, it would be $324 a month with a individual $6900 or 3 person family 13000 oopmax and no cost for anything after that.
Both of those plans also offer preventative services for free and health savings account options which have additional tax benefits.
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