Low Income Subsidy Match Rate: Fill & Download for Free

I'm writing this in Summer of 2017 in the midst of Congressional & public debate about the American Health Care Act (U.S. House Bill) & Better Care Reconciliation Act (U.S. Senate Bill) which have both been labeled “TrumpCare.” In assessing the situation, here's what I've proposed to my Congressional delegates. (If you like what I have to say, please relay these suggestions to your Senators and House Representative as well.)Eliminate the Employer Health Care Tax Deduction for direct purchases of group health insurance plans by employers. This can't be allowed anymore if we are to move forward in any direction. As President Obama repeatedly highlighted, this status quo is an accident of history and the principal-agent problems caused are what distorts everything else.Change rules to allow insurance premiums to be paid from Health Savings Accounts (HSAs) and/or Flexible Spending Accounts (FSAs) and lift the limit on tax deductible employer contributions to HSAs to the current threshold for the "Cadillac Tax" on high priced health-care plans. I believe that is $10,200 for individuals and $27,500 for families. That way, employers' cost of employee compensation stays stable and they don't suddenly lose the expected tax benefits on that part of employee compensation. The reason that I pick these numbers is because they are already established thresholds. (I also know that Congressional Republicans have been touting HSAs as a possibility for many years.)Transition all people who are accustomed to receiving group health insurance as an employment benefit to purchasing health insurance in the individual market. This will be politically scary and potentially very ugly, but we are in a time of policy crisis right now and – to borrow a line from Winston Churchill (made once again famous by Mayor Emmanuel of Chicago – we shouldn't let a serious crisis go to waste. Given that the PPACA-mandated public exchanges exist and operate and use the same vocabulary as employers like "Open Enrollment," it is conceivable to put together outreach programs that would get people used to signing up for health insurance with their employer to simply switch the place that they sign up for health insurance.As a matter of compensation fairness, an important thing we have going for us that the ACA required employers to report the value of health care premiums on W2s. This means that everyone now has several years of documentation of the value of their compensation. That can be used as a baseline for establishing HSA contribution levels. I envision that there would be a requirement that employers payments into the updated HSAs would match (or exceed) the employer expenditures on premiums in either the year of the legislation's passage or the year preceding the legislation taking effect — whichever is greater. (In other words, if the bill passes in 2017 but the transition doesn't take full effect until 2020, employers wouldn't be able to spend the intervening years gutting existing benefits in order to have a lower baseline for the HSA contributions.) Furthermore, I’d envision the HSA contributions being subject to the same laws and regulations as salaries/wages, meaning that employer contributions couldn’t be arbitrarily cut from one year to the next without employee consent.Pointing people to the public exchanges would be an obvious default, but individual market shopping (backed by employer HSA contributions) could happen through any number of mechanisms. Health insurance companies could still work with employers and/or Labor Unions to offer discounted rates as a benefit for employees who choose to sign up directly with the insurer, employers and/or labor unions could expand that benefit further by offering employees access to private exchanges (I understand that Walgreens and Sears do this for their employees already and IBM and Time Warner do this for their retirees), individuals could work with a private broker, or individuals so-interested could just shop on their own based on who their preferred health care provider actually works with. (I'm very sensitive to the narrow network problem between insurers and care providers.) Anyone who fails to enroll themselves should be automatically enrolled via the public exchange into a qualified Bronze-level plan unless they explicitly opt-out with a valid reason.Consolidate the administrative mechanisms for transmitting Medicaid funding from the Federal Government to State Governments into the administrative mechanisms for transmitting ACA subsidies for low-income Americans to private insurers. While there is much I don't understand to with regard to the complexities of the Medicaid funding formula, it is conceivable to simplify the way that money flows out of the United States Treasury into both private AND public insurance programs. In this conception, Medicaid programs would be full-premium-subsidy public insurance programs (with a combination of Federal and State funding) for qualifying low-income Americans. This potential bureaucracy reduction is likely to have some level of appeal to Republican policymakers. I also have no objection to the premium subsidies being accounted for as tax credits, provided that they are operationally the same to individuals and families relying on them. (Note here that we are strictly talking about Medicaid. I think Medicare is best left untouched right now.)Provided that requirements for universal coverage are met under all three of these approaches, enable and allow individual States to do one of three things with their Medicaid programs:Have Medicaid enrollment be restricted to qualifying low income citizens. (Just as now.)Allow states to open up their Medicaid programs for buy-in from any state resident who wants the presumably lower rates with partial or even no subsidy. States choosing to do this would effectively be making their Medicaid programs a public option. (Many States already allow people on disability to buy into Medicaid.)If so inclined, sunset their publicly-run Medicaid program and enroll low-income residents into qualified Bronze-level private insurance plans that offer some acceptable number of health care providers & hospitals within some acceptable distance of where the enrollee lives. The explicit understanding would be that the households who would otherwise be qualified for Medicaid wouldn't have any undue premium liability with the insurer and that the State would be legally on the hook to guarantee that. (I understand that Florida and Mississippi already do this, that Iowa has done this to mixed results, and that North Carolina, Illinois, and Oklahoma are exploring this. At the end of the day, however, I am principally interested in how California and Californians handle this and have limited interest in fighting other states with how they manage their already state-run programs.)You can also check out Ian McCullough's answer to What is the conservative argument against Obamacare and what solution to the problems with our healthcare system would they offer instead?, which I originally wrote in 2013 (despite me not identifying as a Conservative). Much of that still applies, and the other answers are insightful as well.

US Answer:Some added context on jobs & etc. since the original post:Baby Boomers are finding it (extra) tough to find decent jobs: For baby boomers, job hunts prove to be dauntingLow wage jobs in the suburbs go wanting, so companies innovate (a’la San Francisco & Silicon Valley GOOGLE buses, only, it’s AMAZON, this time): As low-wage jobs shift to Twin Cities suburbs, some companies offer their own shuttlesNote that these two articles from the Minneapolis Star-Tribune demonstrate the demographic problems that I mentioned below. It’s mostly low wage jobs & the worker pool in the suburbs can’t get to those jobs due to distance and costs. Older workers looking for higher wage jobs? Screwed!The AMAZON solution is taken directly from the Silicon Valley playbook on transporting workers from where they live to the job site. However, there’s a huge fly in the ointment. It takes a large employer, or group of cooperating employers, to make this process work. (Free to the workers, but still, expensive for the employers. AMAZON’s 24/7 schedule allows the buses to go both ways full, which saves the expense of deadhead runs.)PS. A solution, on a much smaller scale, was used in the ’70s & ’80s in the Twin Cities where an MTA shuttle bus would arrive at a suburban company’s door & bring the workers to and from common bus node at the company’s shift change.Example, NCR Comten to & from Roseville Shopping Center. For a short while (in winter), I’d ride that bus & its connections to & from my home in SE Minneapolis (1983 ~ 1985).(Original post starts here.)Today, I went shopping. The place was absolutely full of “Jobs Available” signs. The average salary? $9.00/hour, or about $18,000/year.Rent in the area for a 1br apt? $ 750/mo = $9,000/yearAverage transportation costs (Older car, Gas, Insurance, & repairs) =~ $3,000/yearObamacare tax/Premiums = $350/mo (after subsidies) = $4200/year (Hope that you don’t get sick! The deductibles are in the $5,000+ range)Food = $400/mo = $4800/yearClothes = $50/mo = $600/year (includes coin laundry costs)So, let’s see: $9,000 + 3,000 = 4200 + 4800 + 600 = $22,800/yearAnd, that doesn’t even cover a movie, TV, (Free) Obama Phone, or anything else. …Any other questions?//SUPPLEMENT: Additional notes in relationship to more comments:I forgot FED Income Tax, State Income Tax, and FICA+Medicare Tax. I’ll ignore Minnesota’s 3+% Income Tax, but the FED = 10% & FICA = 7.65%, so reduce the $18,000 by approx $2392, reduced from $3177 by the standard deduction (as listed for 2015’s tax year Pub 17).I calculated for a FTE job at 50 weeks of work, with paid holidays. Obviously, the job offers are mostly for PT Jobs, although, some had a fine print listing for FT & PT.The financial numbers for the obamacare costs were actual quotes for an ACA signup listing for a single person (pre-subsidy, if any). Comments were mentioned about off-ACA individual Plans from BC/BS. In Minnesota, BC/BS abruptly terminated all individual plans as of 1 Jan 2017! Also, the very same plan jumped 78% from 1 Jan 2013 to 1 Jan 2016!//ADDED: To the commenters & everyone else who reads this Opinion/Answer.The numbers that I quoted are for a single adult with few assets in the outer ring suburbs of Minneapolis & St. Paul. The wage rates & ads on the street for retail pay are also for these areas.Public transportation is extremely limited. The main expenditures for the Bus & Light rail lines are to & from the downtown areas & are oriented for folks commuting to & from those jobs. There are *no* cross suburb bus operations.Bicycle commuting, or walking, only works for about 6 months of the year. After that, a car is absolutely critical. (Extremely few taxis & they are quite expensive.)Obamacare - BC/BS pulled out. No competition &, without subsidies, the individual market rates for a single person exceed $500/mo. And, are JUMPING next year. (Yes, it was the Gov. of Mn. who deplored the explosion in rates.)Food. Yea, maybe you can do better. Then again, the inexpensive vegetables at the Apple Valley Farmer’s Market are available for a few short weeks. The Minneapolis & St. Paul farmer’s markets are also limited in availability. Otherwise, It’s beans & weens w/lots of spaghetti to economize.Clothes. You can economize here by buying second hand at a thrift shop. Just remember laundry soap & coins for the washer & dryer. Kitchen stuff & etc., too. Miss-matched second hand does work.Did I mention Cell Phones? The cheapest (non-subsidized obamaPhone) plan these days is about $10 ~ $15/mo. Tax? $2.50 ~$3.75, for a total of $150 ~ $225/year. You buy the phone. (Min cost for a used phone for an example plan, Republic Wireless? $100 on eBay. A T-Mobile Phone? $35 on eBay. (As actually tested. Used, no broken glass & works!)Oh! And internet? At your Public Library. In the case of the example below, the closest Public Library with Internet Access (during Library Hours) 8 miles away (but can be reached in an hour, depending on time, with a Bus, one Transfer, and a 1/4 mile walk).No Cable/Satellite TV, just over the air local stuff and a used TV, or a small flatscreen unit.So, here’s a job offer example (see the photo below.) It is 2–1/2 miles from the nearest rental apartment complex and that complex is another 2–1/2 miles the other way from the nearest large grocery stores (CUB & Target), albeit, there is a Walmart 200 yards away on the other side of that *nasty* industrial road.//Even More ADDED:It’s the inability to fill the jobs at the current price. This especially the case where a homeowner has lost his/her job & faces foreclosure. These examples are, obviously, tragic, but very real.Read through the many responses. Note that one (my favorite) states that folks who lost their (good paying ) job went ahead & took some of these jobs even as they went into foreclosure.I love that one as I had the opportunity to go through 600+ foreclosed homes over a 3+ year period working (indirectly) for a bank.Three things stood out. They stayed in the home until:The 6 month (Minnesota Law) redemption period ended;Winter, without heat, forced them out;or they found another job that paid better somewhere elseThey took those lower paid jobs while having (for those 6 months) an effective free rent (if they could pay the water, electricity, and gas bill)Finally, they bailed & went somewhere else where they had a chance at surviving. Either immediately, or later, taking what they could & abandoning the restIn the area that I specified, it would take two full time jobs at that wage to survive considering expenses & taxes. … And, that’s why I mentioned that the jobs went wanting. Not because folks were lazy, but because they couldn’t ultimately survive on them.Note that some other answers stated “well, I was somewhere else, where it worked”, or “I was single & doubled up with someone”, or “this, or that, expense is not realistic - followed by another stating, yes it is”.

Well the basic problem is that those of us who are helping professionals still do have our own bills to pay and our own families to support. Even just having an office requires rent and utilities and other professional expenses. Some of us do offer some amount of reduced-fee or sliding-scale therapy, but mostly those options are pretty limited because, well, your plumber probably wouldn't do the work for you for a tenth the normal price because you really needed it, either, nor would you probably do your job for a tenth your normal paycheck because your boss said he needed it. (I'm sorry if that sounds harsh -- it's not intended to. Just don't act like someone is being a horrible person for saying that their pro bono slots are full or for quoting you a rate you can't pay.)That said, here are some options.* If you are very low-income, such that you qualify for publicly-funded health insurance (Medicaid), then that insurance should cover therapy, although there is likely to be a copay.* Similarly, if you are of an age or disability status to access Medicare, it will cover therapy, but you may have a copay.* You should be able to purchase insurance under the Affordable Care Act, with relevant subsidies if you are low-income, and those plans also must have some coverage for therapy, although you should check into the details of what is covered and how restrictive the networks are before making a decision about which option to purchase.* The social service agencies that other answerers are mentioning are mostly not providing free therapy, they're providing therapy to Medicare, Medicaid, and other ACA-insurance-funded clients. But there may be some specific places local to you that have funding from other sources. (For example, the Wellness Center in the Boston area provided free therapy for people living with cancer... until their donors all found out they were getting ripped off by Bernie Madoff and the funding vanished overnight. For another example, my synagogue offers a free medical clinic staffed by professionals who volunteer their time.)* Universities and other graduate schools where therapists are trained may have in-house free or reduced-rate clinics. You'll be getting therapy probably from prelicensure interns, but they're working under supervision. Frankly, the community mental health clinics are *also* heavily staffed by prelicensure clinicians.* There is a really cool organization in the area of Hartford, CT, called Volunteers in Psychotherapy, which does private fundraising to pay therapists to offer therapy under the following system: you do four hours of documented community service, you get to schedule an hour of therapy. Part of what is so cool about that is that doing community service is also a great thing to do if, say, you're depressed or anxious or lonely or whatever. Not appropriate for people who might need emergency help, but very good for more garden-variety folks. I know they are trying to clone their model in other areas, not sure of the progress of that.* There are, of course, various forms of self-help and unlicensed (and untrained, and mostly illegal) clinicians out there. If reading a self-help book helps you, then go for it. There are some very good ones out there. If an app is able to help you, great, fine, I have no problem with that. I don't think it's wise to work with unlicensed folk, particularly if you have substantial psychological problems, both because of the safety issues and the fact that being unlicensed means that they are also unregulated and probably illegal -- it could be anyone doing any old crap they felt like. Obviously, talking to a nice person about your life is not something that can be regulated, but if you have real problems that you'd like help with, this is a field where it really does help to get someone who has the right level of skills and training. Personal referrals are the best way to find your way to someone who will be a good clinical match for you. If the first person you speak to isn't a good match, try a few others; we understand that not everyone is a good match for everyone.Hope that helps.