Ask the question, expect many different answers: What is affordable health care?
"When you ask regular people about what they can afford, they will give you very low numbers," said Linda Blumberg, a senior fellow with The Urban Institute's Health Policy Center.
But despite what people may say, spending data tells a different story, Blumberg contends. It suggests that when you "look at people of different incomes and how much they're actually spending... it's much higher than what they tell you they can afford," she said.
For the working poor, experts acknowledge market-rate health insurance is unaffordable.
Enter Medicaid expansion, the ambitious -- albeit controversial -- effort to sign up for coverage people in households making below 133 percent of the federal poverty level. The government defines the 2013 poverty level as a yearly income of $11,490 for a single-person household.
Oklahoma leaders seem -- so far, at least -- committed to coming up with, as stated by Gov. Mary Fallin, an "Oklahoma plan" to reduce the numbers of the uninsured, an alternative to Medicaid expansion.
Within that goal, however, the question remains about what might be a reasonable contribution to collect from the category of lower-income patients who might be eligible for government-subsidized care. Under current federal regulations, those newly enrolled in Medicaid expansion wouldn't pay monthly premiums.
For an "Oklahoma plan," the state-commissioned Leavitt Partners report presented a few ideas on appropriate "cost-sharing" to impose on individuals.
With any new state plan, "Leavitt also recommended we pursue maximum available cost-sharing," said Buffy Heater, director of planning and development for the Oklahoma Health Care Authority, speaking to a group of about 80 Tulsa business leaders at a July 17 forum organized by the Tulsa Regional Chamber. "So what this means is, cost-sharing, that's the co-pays, that's the deductible and co-insurance that we always pay on our private health plans."
That "maximum available" may reflect federal policy, itself undergoing changes to wring more financial contributions from Medicaid enrollees, who could be asked to pay as much as $4-8 per doctor's visit. In the past, Medicaid has required many enrollees to pay only a "nominal" fee for many visits.
While Blumberg described varying concepts of what's affordable, she said there's a "very broad consensus" that people with earnings below the Medicaid expansion threshold "really don't have anything extra to contribute."
Opinions differ, however, on the budget impact of the Affordable Care Act, also known as Obamacare, that's leading to these changes. The federal deficit means cost concerns influence government at all levels.
Concerns about cost affect individuals as well, of course.
"Whenever you're talking about folks that are, of course, lower income, there is always a concern that any dollar amount assessed to them might be seen as a barrier to care," Heater said. "However, in the vein of trying to promote personal responsibility, it is that cost-sharing that Leavitt recognizes the state wants to embrace."
The goal of Medicaid expansion and any "Oklahoma plan" is to get more people to sign up for some kind of medical coverage, thereby reducing levels of uncompensated care, such as when people show up at a hospital emergency room unable to pay for costly treatment that might have been avoidable with regular health care visits.
Before the passage of the Affordable Care Act, the state had begun its own program, Insure Oklahoma, to try to reduce the numbers of the uninsured.
Participants in the Insure Oklahoma individual plan -- which currently has an enrollment threshold of 200 percent of the federal poverty level -- are advised before enrolling that they may have to pay monthly premiums of up to $192 monthly. (Total out-of-pocket health care costs, including co-pays, are supposed to be capped at 5 percent of a family's gross income.)
Attitudes vary among lawmakers about what's the best course for the state to follow, especially with Insure Oklahoma facing a federally-imposed expiration date.
But some clearly see Insure Oklahoma as a model for the state to follow.
"What the Leavitt report does is, asking for Insure Oklahoma basically on steroids, is basically what it's looking at," said state Rep. Arthur Hulbert (R-Fort Gibson) at the same chamber forum.
He said he liked the Leavitt report because it may reduce two of the most costly facets of health care: "acute care hospitalizations," referring to hospital stays that may start in the emergency room, and "emergent care rates", which relate to the number of emergency room visits, essentially.
As for costs shared by individuals, Hulbert -- a self-described "conservative Republican" -- spoke about how the Leavitt report "promotes personal responsibility."
He described how increased costs as a disincentive to care can actually be a good thing, praising the recently increased federal guidelines.
"I have private insurance ... whether it's a co-pay or deductible, a lot of times that makes it slower for me to access health care. Well, a lot of times, you can heal on your own and make better choices. So I think that $4-8 is an appropriate co-pay, it gets you to think about it," said Hulbert, who owns a health care consulting business.
The Leavitt report also outlines, as Heater put it, "appropriate reductions" in cost-sharing.
For example, the state could "incentivize the use of seeking appropriate follow-up care by waiving the associated copayment," the report states.
It continues: "The benefit to this type of approach is that it rewards individuals who act accountable for their care and access the system appropriately." And if a treatment plan isn't followed, "a higher copayment amount can be reinstated."
Blumberg noted that the Affordable Care Act's much-discussed general push to get more people to sign up through health insurance exchanges includes the caveat that if coverage costs more than 8 percent of a person's income, then a person choosing to not purchase insurance would avoid the tax penalties imposed under the law.
Raising the cost-sharing imposed on poor families could potentially keep them from signing up. "Those are people that are barely getting by," Blumberg said.
She also described the danger of focusing too much on keeping health insurance premiums low for families and individuals.
"There are people out there with really low premiums today, but the coverage they have is essentially garbage," Blumberg said.
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