Abathengi Bamukele Amabhiliyoni Amadola Ezingxenyeni zeMLR
Umthetho Wokunakekelwa Okuncintisayo, okwenziwe ngonyaka ka-2010, wenza izinguquko ezishisayo emithethweni efakazela ukutholakala komshuwalense wezempilo. Enye yalezi zinguquko kwakuyisimiso esilawula iphesenti yama-premium ukuthi izinkampani zomshuwalense kumele zizisebenzise izindleko zezokwelapha, ngokungafani nezindleko zokuphatha.
Ngaphambi kwe-ACA, izinkampani zomshuwalense zingakwazi ukubeka iziqondiso zazo.
Abomishwalense bombuso bomshwalense bazobukeza i-premium justification ukuthi abahlinzeki bomshuwalense bahlongozwa, nakuba inqubo yokubuyekeza yayingavamile njalo. Futhi uma umshuwalense enezindleko eziphakeme kakhulu zokuphatha, kwakungekho okuningi endleleni yokusebenzisa abalawuli noma abathengi.
Kodwa i-ACA inqume isidingo sokulahlekelwa kwezidakamizwa (MLR), esichaza amaphesenti amaningi amaphrimiyamu abaqashi abangasebenzisa izindleko zokuphatha. Emakethe amakhulu, ama-insurer kumele asebenzise okungenani amaphesenti angama-85 amaphrimiyamu ezindleko zezokwelapha kanye nokuthuthukiswa kwekhwalithi yezempilo . Emakethe yeqembu ngalinye namancane, umbundu ungamaphesenti angu-80. Ngakho-ke inshuwalense ingakwazi ukuchitha imali engama-15 noma engu-20 yemali engenayo yemali ezindleko zokuphatha (kuye ngokuthi ngabe i-plan ithengiswa emakethe yeqembu elikhulu, noma emakethe yeqembu ngalinye namancane), kanye namanye ama-dollar ayimali eyisikweletu ukuqoqa kufanele kusetshenziswe ezenzweni zezokwelapha nezinto ezithuthukisa izinga lokunakekelwa kwezempilo labaguli.
"Iqembu elikhulu" ngokuvamile lisho izinqubomgomo zomshuwalense ezithengiswa kubaqashi abanabasebenzi abangaphezu kuka-50. Kodwa eCalifornia, Colorado, New York, naseVermont, izinhlelo eziningi zeqembu zithengiswa kubaqashi abanabasebenzi abangaphezu kuka-100, njengoba imakethe yeqembu elincane kulawo mazwe kubandakanya abaqashi nabasebenzi abangaba ngu-100.
Yini eyayiyi-MLRs Umshuwalense Ngaphambi kwe-ACA?
Imithetho ye-ACA ye-MLR yaqala ukusebenza ngo-2011. Ngaphambi kwalokho, cishe izingxenye ezimbili kwezintathu zama-insurers empeleni sezivele sezichitha iningi lamaphrimiyamu omalungu awo ezinkampanini zezokwelapha, kodwa kwakungekho indlela yokubhekana nalabo ababengekho ' t.
Futhi kwahluka kakhulu kusukela emakethe eyodwa kuya kwesinye. Ngokuhlaziywa kwe-Office Accountability Office, amaphesenti angama-77 ama-insurers amakhulu eqembu kanye namaphesenti angama-70 e-insurerrs ezinkampani ezincane kakade abhekana nemikhombandlela entsha ye-MLR ngo-2010 (ngaphambi kokuba iqale ukusebenza), kodwa amaphesenti angu-43 kuphela abaqashi bemakethe ayesebenzisa ama-80% yemali engenayo ye-premium ezindleko zezokwelapha kulo nyaka. Futhi ngokusho kwedatha ye-CMS, amaphesenti angu-45 abantu abanomshwalense wemakethe ngamunye ngonyaka ka-2010 ahlanganiswe amapulani asebenzisa okungenani amaphesenti angama-25 emali engenayo yezindleko zokuphatha.
Kubalulekile ukuphawula lapha ukuthi amaphesenti angaba ngu-7 kuphela aseMelika atholakala emakethe ngayinye, kanti amaphesenti angama-49 anikezwa emakethe exhaswe ngumqashi, kubandakanya abaqashi abakhulu nabancane.
Izindleko zokuphatha zihlale ziphansi lapho umshwalense engakwazi ukumboza izimpilo eziningi ngokuthenga ngayinye.
Yingakho izidingo ze-MLR ziqinile kunezinkampani ezinkulu zomshuwalense ngaphandle kweqembu elincane nabanomshwalense bemakethe.
I-MLR Imithetho Iphoqelelwe Kanjani?
Imithetho ye-ACA ye-MLR isebenza kuwo wonke amapulani aqinisekisiwe ngokugcwele kumakethe, ngabanye, nasezimakethe ezinkulu zeqembu, kuhlanganise nezinhlelo ezizukulukazi nezinkulu. Kodwa akusebenzi kumacebo okuzikhokhela (okubaluleke kakhulu kumqashi, cishe kungenzeka ukuthi azimele, kunokuthenga ukuthengwa kwabasebenzi bawo; amaphesenti angu-61 kubo bonke abasebenzi abanokuqashwa okuxhaswe ngumqashi bahlanganiswa ngaphansi kwe-self-insured amapulani).
Ngo-Julayi 31 unyaka ngamunye, ababheki bomshuwalense babika ku-CMS ngemali yabo yokusebenza kanye nezindleko kusukela ngonyaka odlule.
Ababambisicelo babhekwa ukuthi bahlangabezane nezimfuneko ze-MLR uma bechitha okungenani amaphesenti angu-85 ama-premium eqenjini elikhulu ekunakekeleni ukwelashwa kanye nokuthuthukiswa kwekhwalithi, kanye nama-80% eqembu elincane namaphrimiyamu omakethe emakethe ekunakekelweni kwezokwelapha kanye nokuthuthukiswa kwekhwalithi.
Ama-insurers angahlangabezani nalabo okuhlosiwe kufanele athumele izikhwama kubanikazi bezinqubomgomo, ngokuyikhokha ukubuyisela ukuthi yiziphi izikweletu eziphezulu kakhulu. Izidingo ze-MLR zaqala ukusebenza ngonyaka ka-2011, futhi ukuhlolwa kokuqala kokukhishwa kwezimali kuthunyelwe ngonyaka ka-2012. Kusukela ngo-2014, inani lemali ekhokhelwa isaphulelo lisekelwe ku-MLR yesilinganiso seminyaka emithathu, kodwa kunomthetho we-MLR wangaphambi konyaka.
I-HHS ingafaka izijeziso zemali kubanini bomshuwalense abangabika idatha ye-MLR, noma lokho kungahambisani nezidingo ze-rebate.
Ubani Othola Ukuphikisana?
Ngo-2017, cishe abantu abayizigidi ezingu-3.9 bathola izikhwama ze-MLR, ngokuqondile ezinkampanini zabo zomshuwalense, noma abadlulile kubaqashi babo. Lokhu kungamaphesenti angu-1.2 kuphela abantu base-US, ngakho-ke abantu abaningi abatholi izikhwama ze-MLR. Yiqiniso, imithetho ye-ACA ye-ACA isebenza kuphela kumalungiselelo axhasiwe aqashwe ngumqashi kanye nezinhlelo zomakethe ngamunye. Azisebenzi ezinqenjini zeqembu elizimele, noma ku-Medicare ne-Medicaid, ehlanganisa inani elikhulu labantu (kodwa kunezimiso ezihlukile zeMLR zeMedare Advantage kanye neZingxenye D, kanye nezinhlelo zokunakekela ezilawulwa yi-Medicaid ).
Kodwa ngisho naphakathi kwezinhlelo zempilo ezitholakala emithethweni ye-ACA ye-MLR, iningi liyalandela futhi akudingeki ukuthi lithumele ukuhlolwa kwe-rebate. Futhi ukuhambisana kuthuthukisiwe ngokuhamba kwesikhathi. Amaphesenti angama-95 abantu abanezimpilo zemakethe ngabanye bahlanganiswa yizinhlelo ezihlangabezane nezidingo ze-MLR ngo-2016 (ngokungafani namaphesenti angu-62 kuphela wamalungu ngo-2011). Ezimakethe ezinkulu zeqembu, amaphesenti angama-96 wabhalisile asezinhlelo ezahlangabezana nemithetho ye-MLR ngo-2016, futhi emakethe amancane, ama-90% wabhalisile ahlanganiswe nezinhlelo ze-MLR-ezihambisanayo ngo-2016.
Ukuhlukunyezwa kwe-MLR kusekelwe ebhodini lonke le-insurer kumkhakha ngamunye wamakethe (iqembu elikhulu, kanye neqembu ngalinye / elincane). Ngakho akunandaba ukuthi yimaphi amaphesenti akho akhokhelwayo asetshenziselwa izindleko zakho zezokwelapha, noma yimaphi amaphesenti ama-premium eqenjini lakho lomqashi asetshenziselwa izindleko zezokwelapha eziphelele zeqembu. Okubaluleke kakhulu inani lapho wonke ama-premiums e-insurer ayohlanganiswa, futhi kuqhathaniswa nenani eliphelele umshwalense osetshenziselwa izindleko zezokwelapha nokuthuthukiswa kwekhwalithi.
Ngokusobala, ngeke kusebenze ukubheka i-MLR ezingeni elilodwa, ngoba umuntu ohlala enempilo unyaka wonke angase abe namadola angamakhulu ezimbalwa ezitatimendeni, ngokulingana nama-dollar ayizinkulungwane ezimbalwa, kuyilapho umuntu ogula kakhulu kungenzeka ukuthi inezigidi zamaRandi ezinkampanini, ngokuhambisana nezinkulungwane ezimbalwa zamaRandi ezinkampanini. Iphuzu eliphelele lomshuwalense ukuhlanganisa wonke umuntu engozini enkulu kubantu abaningi be-insurers, ngakho-ke yiyo indlela iMLR ilawula ngayo, futhi.
Emakethe ngayinye, ababhalisi abangahlangabezani nezidingo ze-MLR bamane bathumele amasheke okubuyisela ngqo kumnikazi wezinqubomgomo ngamunye. Kodwa ezimakethe ezixhaswe ngumqashi (iqembu elikhulu neqembu elincane), umshuwalense uthumela isheke sokubuyisela kumqashi. Ukusuka lapho, umqashi angakwazi ukusabalalisa imali yokubhalisa, noma ukusebenzisa isaphulelo sokunciphisa amaphrimiyamu esizayo noma ukuthuthukisa izinzuzo zabasebenzi.
Ukuhlukunyezwa kwe-MLR ngokuvamile akukakhokhi intela, kodwa kunezinye izimo lapho zikhona (kubandakanya nezimo lapho ababhalisile abaziqashile bekhipha ama-premium abo ekubuyiseleni kwentela). I-IRS ichaza ukukhokhwa kwezikhwama ze-MLR lapha, ngezibonelo eziningana zezibonelo.
Zingaki Izimpindiselo?
Izindleko eziphelele ziphakeme kakhulu ngo-2011 kunokuba zenzeke eminyakeni eyalandela, uma ama-insurers esetshenziselwa imithetho emisha. Unyaka ngamunye, i-CMS ishicilela idatha ebonisa inani lemali yokukhokha kanye nezaphulelo ezilinganiselwe zamakhaya esifundazweni ngasinye esathola izikhwama. Eminyakeni eyisithupha yokuqala, ukubuyiswa kwe-MLR kubuyiselwe kuma-dollar 3.24 billion kubathengi:
- $ 1.1 billion ngonyaka wezi 2011 (izikhwama ezithunyelwe ngo-2012)
- $ 504 wezigidi ngo-2012 (izikhwama ezithunyelwe ngo-2013)
- $ 333 million ngo-2013 (izikhwama ezithunyelwe ngo-2014)
- $ 469 million ngo-2014 (izikhwama ezithunyelwe ngo-2015)
- U-$ 397 wezigidi ngo-2015 (izikhwama ezithunyelwe ngo-2016)
- $ 447 million ngo-2016 (izikhwama ezithunyelwe ngo-2017)
Ngonyaka ka-2017, umuntu ojwayelekile othole isaphulelo se-MLR uthole u-$ 113, kodwa wahluka kakhulu kusuka kwesinye isimo kuya kwesinye. Abantu baseCalifornia abazuze ama-rebate bathola isilinganiso samaRandi ayi-599, kuyilapho abantu basezifundazweni ezingu-11 bengenaso isaphulelo nhlobo, ngoba bonke abatshuwalense kulawo mazwe bahlangabezana nezimfuneko ze-MLR.
Ababambisisi bachitha izinyanga eziningana unyaka ngamunye bethola ukuthi ama-premiums abo kufanele abe ngunyaka ozayo, futhi lezo zindleko ezihlongozwayo zihlolwe kabili ngama-actuaries kahulumeni nesifundazwe. Kodwa izimangalo zezempilo zingashintsha ngokuphawulekayo kusukela ngonyaka owodwa kuya kwesinye, futhi izilinganiso ezenziwa ngabashuwalense azihlali zigcina zilungile. Ngakho izikhwama ze-MLR zisebenza njenge-backstop, uma kwenzeka abaqashi bephela bengadingi ukusebenzisa amaphesenti angu-80 (noma amaphesenti angama-85 emakethe yeqembu elikhulu) yamaphrimiyamu ezindleko zezokwelapha kanye nokuthuthukiswa kwekhwalithi.
Isibonelo, ngo-2017, ngenkathi ama-insurers ebeka amanani emakethe ngayinye ngo-2018, kwakungekho ukungaqiniseki okukhulu ngokuthi ngabe Ukuphathwa kwe-Trump kuzoqhubeka nokuhlinzeka ngemali yokuxhasa imali yokunciphisa izindleko (CSR). Ekugcineni, i-Administration yaqeda leyo mali, kodwa leso sinqumo safika amasonto ambalwa ngaphambi kokubhalisa okuvulekile, futhi amanani emazweni amaningi asevele esungulwe. Ababambiseneli bavame ukubhekana namazinga amaningi ukulungisa amazinga abo ezinsukwini eziholela ekubhaleni, kepha eziningi sezivele zeluleka abanikazi bomshuwalense ukuthi basebenzise amazinga abo ekucabangeni ukuthi imali ye-CSR izoqedwa, ngamanani okusekela okuphansi angase asetshenziswe uma lokho kungenjalo 's ekugcineni kube yilokho.
Kodwa eLouisana, abalawuli abaphawula ngoSepthemba 2017 (inyanga ngaphambi kokuba i-CSR ishintshwe yi-federal federal) ukuthi izinkampani zomshuwalense esifundazweni zifake amazinga ngokusekelwe ukuthi imali ye-CSR izophela, futhi bekungekho uhlelo lokusekela olulungele ukulungisa lezo zindleko uma uhulumeni wesifundazwe enquma ukuqhubeka nokuhlinzeka ngezimali ze-CSR kubanini-inshuwalense. Esikhundleni salokho, umbuso wacacisa ukuthi imithetho ye-MLR ingasetshenziselwa ukuyihlunga ngokuhamba kwesikhathi, nabhalisile abathola izikweletu kusukela ngo-2019, uma bephelelwa ngemali ephindwe kabili ye-CSR (nge-premium ephezulu kanye nokuxhasa ngokuqondile kwezimali).
Ekugcineni, lokho akuzange kwenzeke, njengoba imali ye-CSR imisiwe ngempela. Kodwa indlela yaseLou Louisiana kuleso simo yisibonelo sokuthi imithetho ye-MLR ingasetshenziswa kanjani ukuqinisekisa ukuthi abathengi ekugcineni bavikelekile ezimweni lapho kungenakuqinisekiswa ukuthi izimangalo zizophela kanjani uma kuqhathaniswa nemali engenayo ye-premium.
Iziphakamiso Zokunakekelwa Kwezempilo Kwezidemokhrasi Zizoshintsha Kanjani Imithetho Ye-MLR?
Ngo-Mashi 2018, uSeninkulu u-Elizabeth Warren (D, eMassachusetts) wabeka uMthetho Wokuvikela Umshwalense WezeMpilo yabathengi , okuhlose ukuqinisa nokuvikela umshuwalense wezempilo kubathengi. Ingxenye yokuqala yomthetho idinga ukwandisa izidingo ze-MLR emakethe yeqembu ngalinye namancane amaphesenti angama-85, ebenza bahambisane nezidingo zeqembu elikhulu zamanje.
Le mithetho ixhasiwe yiSenate Democrats, ehlanganisa iMaggie Hassan (New Hampshire), uBernie Sanders (Vermont), Kamala Harris (California), uTammy Baldwin (Wisconsin) noKirsten Gillibrand (eNew York). Kodwa akunakwenzeka ukuthola ukulandelana kweCongress kuze kube nini uma amaDemocrats eningi.
Ngakho-ke, okwamanje, imithetho yamanje ye-MLR kungenzeka ukuthi ihlale isendaweni. Kodwa uMthetho Wokuvikela Umshuwalense Wezempilo Wabathengi usebenza njengomgwaqo wendlela lapho amaDemocrats angathanda ukuhamba uma aphinde athole iningi, ngakho-ke kungenzeka ukuthi sibone imikhawulo eqinile kuma-insurer esikhathini esizayo. Ukuze kucace, abaningi bomshuwalense, ikakhulukazi emakethe ngayinye, baye baba nama-MLRs ngaphezu kwama-80 amaphesenti eminyakeni embalwa edlule. Ezinye ziye zaba ngaphezu kwamaphesenti angu-100, okucacile okungaqiniseki futhi okuyingxenye yeziphakamiso ze-premiums eziye zakhula ngokuphawulekayo kulabo abathengisi bemakethe ngokusobala abakwazi ukuchitha okuningi kuma-claim ngaphandle kokuqoqa ama-premium.
Kodwa kwabanye abatshuwalense, ukushintshela kwimfuneko ephezulu ye-MLR emakethe yeqembu ngalinye namancane kuzobaphoqa ukuba baphumelele. Ngakolunye uhlangothi lwemali, abantu bayaphikisana ngokuthi imithetho ye-MLR ayinakugqugquzela abahlinzeki besikhwama ukuba bafake izingcindezi kubahlinzeki bezokwelapha (izibhedlela, odokotela, abakhiqizi bezidakamizwa, njll) ukunciphisa izindleko jikelele kusukela amaprimiyamu angavuswa nje ukuze agcine kanye nezindleko zokunakekelwa kwempilo ezandayo. Abashuwalense kumele bachithe ingxenye enkulu yalezo zimali ezikhokhelwayo ezindleko zezokwelapha, kodwa kubathengi, ama-premium angakwazi ukuqhubeka emazingeni angenakulinganiswa ngaphandle kokuxhaswa kwe-premium.
> Imithombo:
> Amasevisi e-Medicare naseMedicaid Services. Isikhungo Sokwaziswa Komthengi kanye Nokuqapha Umshuwalense. Isilinganiso sokulahlekelwa kwezokwelapha.
> Amasevisi e-Medicare naseMedicaid Services. Ukufingqwa koMphumela Wokuphulukiswa Kwezokwelapha ngo-2016 . Ibiwe futhi ishicilelwe ngo-2017.
> Ihhovisi lase-United States I-Accountability Account. IKomidi leNdlu yeNdlu yezemfundo kanye nabasebenzi. Umshwalense Wezempilo Ozimele: Izikhombisi Zokuqala Zikhombisa ukuthi Abaningi Ababhekisi Bayizobe Baqedile noma Baqede Isimiso Esisha Sokulahlekelwa Kwezokwelapha . Okthoba 31, 2011.
> Warren, Elizabeth. I-Senate.gov. Umthetho Wokuvikela Umshwalense Wezempilo . Kwafakwa ngo-March 2018.