Ogulitsa Alandira Mabiliyoni Amadola Mu MLR Otsutsana
The Affordable Care Act, yomwe inakhazikitsidwa mu 2010, inapanga kusintha kwakukulu kwa malamulo omwe amagwiritsidwa ntchito ku inshuwalansi. Chimodzi mwa kusintha kumeneku chinali lamulo lolamulira ndalama zomwe ndalama zomwe makampani a inshuwalansi amagwiritsira ntchito polemba ndalama, kusiyana ndi ndalama zothandizira.
A ACA isanayambe, makampani a inshuwalansi angathe kukhazikitsa malangizo awo.
Amishoni a inshuwalansi a boma amayang'ana kafukufuku wodalirika kuti insurerrs akufunsidwa, ngakhale kuti ndondomekoyi sinali nthawi zonse. Ndipo ngati inshuwalansi inali ndi ndalama zambiri zowonongeka, panalibe njira yowonjezeretsera olamulira kapena ogula.
Koma ACA inapereka chiwerengero cha mankhwala ochepetsa chiwerengero cha mankhwala (MLR), chomwe chimapereka kuchuluka kwa ndalama zomwe amapereka ndalama zothandizira. Mu msika waukulu wa gulu, inshuwalansi ayenera kukhala ndi ndalama zosachepera 85 peresenti pa ndalama zachipatala komanso khalidwe la thanzi labwino . Misika yamagulu ndi yaing'ono, malo ake ndi 80 peresenti. Choncho a inshuwalansi amatha kuthera ndalama zambiri kapena 15 peresenti ya ndalama zothandizira ndalama (malinga ndi momwe malonda akugulitsira msika wa gulu lalikulu, kapena m'msika wamagulu ndi gulu laling'ono), ndi ndalama zina zonse zomwe zimaperekedwa kwa inshuwalansi Kusonkhanitsa kumafunika kugwiritsidwa ntchito pazinthu zamankhwala ndi zinthu zomwe zimapangitsa kuti odwala akhale ndi thanzi labwino.
"Gulu lalikulu" kawirikawiri limatanthawuza ma inshuwalansi omwe amagulitsidwa kwa olemba ntchito ogwira ntchito oposa 50. Koma ku California, Colorado, New York, ndi Vermont, mapulani a magulu akuluakulu amagulitsidwa kwa olemba ntchito ogwira ntchito oposa 100, popeza msika wa magulu ochepawo umaphatikizapo antchito omwe ali ndi antchito 100.
Kodi Milikiti Yotani Anali MLRs Asanafike ACA?
Malamulo a ACA a MLR anayamba kugwira ntchito mu 2011. Zisanayambe, pafupifupi awiri mwa magawo atatu aliwonse a inshuwalansi anali atagwiritsa kale ntchito ndalama zambiri za anthu awo pa zachipatala, koma panalibe njira yothetsera mavuto omwe analipo ' t.
Ndipo zinali zosiyana kwambiri kuchokera ku msika umodzi kupita ku wina. Malinga ndi kafukufuku wa Government Accountability Office, 77 peresenti ya mabungwe akuluakulu a inshuwalansi ndi 70 peresenti ya mabungwe oyang'anira mabungwe ang'onoang'ono omwe anali atagwira ntchito kale anali atalandira kale malangizo atsopano a MLR mu 2010 (asanayambe kugwira ntchito), koma 43% za ndalama zowonjezera pa ndalama zachipatala chaka chomwecho. Ndipo molingana ndi deta ya CMS, 45 peresenti ya anthu omwe ali ndi inshuwalansi ya malonda pamsika m'chaka cha 2010 adakonzedwa ndi ndondomeko zomwe zimagwiritsa ntchito ndalama zosachepera 25 peresenti ya ndalama zowonongeka pazondomeko.
Ndikofunika kuzindikira apa kuti pafupi 7 peresenti ya a ku America ali ndi malonda pamsika, pamene 49 peresenti ali ndi malonda mu msika wogulitsidwa ndi abwana, kuphatikizapo olemba akulu ndi ochepa.
Ndalama zothandizira nthawi zonse zakhala zochepa pamene inshuwalansi ikhoza kuphimba miyoyo yambiri ndi kugula ndondomeko iliyonse.
Ndicho chifukwa chake zofunikira za MLR zili zovuta kwambiri kwa mabungwe akuluakulu a bungwe kusiyana ndi kagulu kakang'ono ka ogulitsa malonda.
Kodi MLR Imalimbikitsidwa Bwanji?
Malamulo a ACA a MLR amagwiritsidwa ntchito pazinthu zonse zogulitsa inshuwalansi m'magulu a anthu, magulu ang'onoang'ono, ndi magulu akuluakulu, kuphatikizapo ndondomeko zazikuru ndi zazikulu. Koma sizikugwiritsidwa ntchito pazinthu zodzipangira okhaokha (zochuluka kwambiri kwa abwana, ndizofunika kwambiri kuti azidzipangira okha, m'malo mogula malonda awo antchito; 61 peresenti ya ogwira ntchito onse omwe ali ndi chithandizo chogwiritsidwa ntchito ndi ogwiriridwa ndi eni-inshuwalansi zolinga).
Pa July 31 chaka chilichonse, mabungwe a inshuwalansi amalembera ku CMS ndi ndalama zomwe adzigwiritsira ntchito komanso ndalama zapadera kuyambira chaka chatha.
Ogwirizanitsa amaonedwa kuti adakwaniritsa zofunikira za MLR ngati amagwiritsa ntchito ndalama zokwana 85 peresenti ya ndalama zoyambilira zapadera pazochipatala ndi kusintha kwa khalidwe, ndi 80 peresenti ya magulu ang'onoang'ono komanso mapepala apamsika pamsika pa chithandizo cha mankhwala ndi kusintha kwa khalidwe.
Ogwirizanitsa omwe sagwirizana ndi zolingazi ayenera kutumiza zopereka kwa ogwira ntchito, makamaka kubwezera iwo pa malipiro omwe anali apamwamba kwambiri. Zolinga za MLR zinagwira ntchito mu 2011, ndipo mayeso oyambirira a rebate anatumizidwa mu 2012. Kuyambira mu 2014, ndalama za rebate zakhala zikugwiritsidwa ntchito ndi a MLR omwe ali ndi zaka zitatu, osati MLR wam'mbuyomu.
HHS ikhoza kupereka chilango cha ndalama kwa azinesi zomwe sizimapereka chidziwitso cha MLR, kapena zomwe sizikugwirizana ndi zofunikira za rebate.
Ndani Amapezetsa Ziphuphu?
Mu 2017, anthu pafupifupi 3.9 miliyoni adalandira mphoto ya MLR, mwachindunji ku makampani awo a inshuwalansi, kapena kudutsa mwa olemba ntchito awo. Izi ndizofupi ndi 1.2 peresenti ya chiwerengero cha US, kotero anthu ambiri sapeza mphoto ya MLR. Inde, malamulo a ACA a MLR amangogwiritsira ntchito ndondomeko zokhazikika zomwe amagwiritsidwa ntchito ndi ogwira ntchito komanso malonda awo pamsika. Sagwiritsiranso ntchito ndondomeko ya gulu la anthu omwe ali ndi ngongole, kapena Medicare ndi Medicaid, yomwe imakhudza anthu ambiri (koma pali MLR malamulo a Medicare Advantage ndi mapulani a Gawo D, ndi mapulani ochezera a Medicaid ).
Koma ngakhale pakati pa zolinga zaumoyo zomwe zikugwirizana ndi malamulo a ACA a MLR, ambiri akutsatira ndipo sayenera kutumiza kufufuza kwa rebate. Ndipo kutsatila kwakhala bwino pakapita nthawi. 95 peresenti ya anthu omwe ali ndi malonda paokha malonda anali ndi mapulani omwe anakwaniritsa zofunikira za MLR mu 2016 (mosiyana ndi 62 peresenti ya mamembala mu 2011). Msika waukulu wa gulu, 96 peresenti ya olembetsa ali mu mapulani omwe anakumana ndi malamulo a MLR mu 2016, ndipo mumsika wa magulu ang'onoang'ono, 90 peresenti ya anthu olembetsa analembedwera ndi ndondomeko za MLR-zovomerezeka mu 2016.
Milandu ya MLR imachokera ku bizinesi yonse ya inshuransi mu gawo lililonse la msika (gulu lalikulu, ndi gulu / gulu / gulu). Kotero ziribe kanthu kuti ndalama zomwe mwakhala mukuzigwiritsira ntchito mumagwiritsira ntchito ndalama zotani, kapena ndalama zonse zomwe gulu lanu laganyu linagwiritsidwa ntchito pa ndalama zonse zachipatala. Chofunika ndi chiwerengero pamene ndalama zonse za inshuwalansi zikuphatikizidwa, komanso poyerekeza ndi ndalama zonse zomwe inshuwalansi zimagwiritsira ntchito ndalama zowonjezera ndi kusintha kwa khalidwe.
Mwachiwonekere, sikungagwire ntchito kuyang'ana MLR payekha, chifukwa munthu amene akhalabe wathanzi chaka chonse angakhale ndi madola mazana angapo potsutsa, poyerekeza ndi madola masauzande angapo pa mapepala, pamene munthu wodwala kwambiri mwina angakhale ndi madola mamiliyoni ambiri muzinenelo, poyerekeza ndi madola zikwi zochepa pa madola oyambirira. Mfundo yonse ya inshuwalansi ndikutsegula anthu onse pangozi kudera lalikulu la anthu ogulitsa inshuwalansi, kotero ndi momwe MLR ikulamulira, komanso.
Pa msika wina aliyense, inshuwalansi zomwe sizikugwirizana ndi malamulo a MLR zimangotumiza kufufuza kwa rebate mwachindunji kwa aliyense. Koma mu msika wogulitsidwa ndi abwana (gulu lalikulu ndi gulu laling'ono), inshuwalansi imatumiza kufufuza kwabwanayo kwa abwana. Kuchokera kumeneko, abwana akhoza kugawira ndalama kuti alembetse, kapena agwiritsenso ntchito rebate kuti achepetse ndalama zoyenera kutsogolo kapena kuti apindulitse antchito.
Milandu ya MLR siyinalipire msonkho, koma pali zina zomwe iwo ali (kuphatikizapo nthawi imene olembetsa omwe amagwira ntchito pawokha amachotsa msonkho wawo pa msonkho wawo). IRS imalongosola msonkho wa zopereka za MLR kuno, ndi zitsanzo zambiri zochitika.
Kodi Ziphuphu Zili Zambiri?
Zowonjezera zowonjezera zinali zapamwamba kwambiri kwa 2011 kusiyana ndi zomwe zakhala zikuchitika zaka zotsatila, kamodzi kokha mabungwe oyang'anira inshuwalansi adagwiritsa ntchito malamulo atsopano. Chaka chilichonse, CMS imafalitsa deta yomwe ikuwonetsa ndalama zonse za rebate ndi ndalama zowonjezera za mabanja m'mayiko omwe adalandira mphoto. M'zaka zisanu ndi chimodzi zoyambirira, maboma a MLR adabweza pafupifupi madola 3.24 biliyoni kwa ogula:
- $ 1.1 biliyoni chaka cha 2011 (mabungwe omwe anatumizidwa mu 2012)
- $ 504 miliyoni mu 2012 (mabungwe omwe anatumizidwa mu 2013)
- $ 333 miliyoni mu 2013 (rebates anatumizidwa mu 2014)
- $ 469 miliyoni mu 2014 (mabungwe omwe anatumizidwa mu 2015)
- $ 397 miliyoni mu 2015 (zopuma zomwe zinatumizidwa mu 2016)
- $ 447 miliyoni mu 2016 (zopuma zomwe zinatumizidwa mu 2017)
Mu 2017, munthu wamba amene adalandira mphotho ya MLR anatenga $ 113, koma amasiyana kwambiri kuchokera ku mayiko ena. Anthu a ku California amene anapatsidwa mphotho ya ndalama zokwana madola 599, pamene anthu 11 m'mayiko ena sanapindule konse, chifukwa onse a inshuwalansi m'mayiko amenewo anakwaniritsa zofunikira za MLR.
Ogwiritsira ntchito amatenga miyezi ingapo pachaka akudziŵa zomwe ayenera kupereka pa chaka chomwe chikubweracho, ndipo ziwerengerozi zikuyang'aniridwa kawiri ndi boma ndi boma. Koma malingaliro azaumoyo akhoza kusintha kwambiri kuyambira chaka chimodzi mpaka lotsatira, ndipo malingaliro omwe inshuwalansi amagwiritsira ntchito samakhala otsiriza kukhala olondola. Choncho malipiro a MLR amakhala ngati akumbukira, ngati mabungwe a inshuwalansi amatha kuwononga 80 peresenti (kapena 85 peresenti mumsika wa magulu akuluakulu) za ndalama zothandizira pa zachipatala komanso kusintha kwa khalidwe.
Mwachitsanzo, mu 2017, pamene inshuwalansi anali kukhazikitsa malonda a msika wawo pa 2018, panalibe kukayikira kwakukulu ngati bungwe la Trump lidzapitiriza kupereka ndalama zothandizira kugawa ndalama (CSR). Potsirizira pake, Administrationyo inathetsa ndalamazo, koma izi zinabwera patangopita masabata angapo kuti anthu ayambe kulemba, ndipo maiko ambiri anali atakhazikitsidwa kale. Ogwirizanitsa anawombera nthawi zambiri kuti athe kusintha mavoti awo masiku omwe amatsogolera kulembetsa, koma mabungwe ambiri adalangiza kale inshuwalansi kukhazikitsa malire awo poganiza kuti ndalama za CSR zidzathetsedwa, ndi ndalama zochepa zowonjezera zomwe zingagwiritsidwe ntchito ngati Ndikumaliza.
Koma ku Louisiana, olamulira omwe adatchulidwa mu September 2017 (mwezi umodzi chisanafike CSR ndalama zathetsedwa ndi boma la federal) kuti mabungwe a inshuwalansi a boma adatulutsa mitengo malinga ndi lingaliro kuti ndalama za CSR zidzathera, ndipo palibe ndondomeko yosungiramo ndalama yomwe ingasinthe malipiro awo ngati boma lidafuna kupitiriza kupereka ndalama kwa CSR kwa inshuwalansi. M'malo mwake, boma linaneneratu kuti malamulo a MLR angagwiritsidwe ntchito kuti awulandire pamapeto pake, ndi olembetsa omwe amalandira mpumulo kuyambira mu 2019, ngati atatha kukhala ndi ndalama zowonjezera kawiri kwa CSR (kudzera pa ndalama zapamwamba komanso ndalama zowonjezereka za boma).
Pamapeto pake, izi sizinachitike, popeza ndalama za CSR zinachotsedwadi. Koma njira ya Louisiana yomwe ilipo ndi chitsanzo cha momwe malamulo a MLR angagwiritsire ntchito pofuna kutsimikizira kuti ogula amatha kutetezedwa pomwe pali zosatsimikizirika kuti mapeto amatha bwanji kuyerekezera ndi ndalama zowonjezera.
Kodi Malingaliro Othandizira Zosamalonda Za Demokalase angasinthe bwanji Malamulo a MLR?
Mu March 2018, Pulezidenti Elizabeth Warren (D, Massachusetts) adayambitsa Bungwe la Consumer Health Insurance Act , lomwe cholinga chake ndi kukhazikitsa ndi kuteteza inshuwalansi ya umoyo kwa ogula. Gawo loyambirira la lamuloli likufuna kuwonjezereka zofunikira za MLR ku msika wa gulu ndi gulu laling'ono kwa 85 peresenti, kuwalumikizana ndi zofunikira zomwe gulu liripo.
Lamuloli likugwirizanitsidwa ndi atsogoleri ambiri otchuka a Senate, kuphatikizapo Maggie Hassan (New Hampshire), Bernie Sanders (Vermont), Kamala Harris (California), Tammy Baldwin (Wisconsin), ndi Kirsten Gillibrand (New York). Koma sizingatheke kuti tipeze kuyendetsa mu Congress mpaka ngati Democrats ali ndi ambiri.
Kotero kwa nthawiyi, malamulo omwe alipo tsopano a MLR akhoza kukhalabe m'malo. Koma Consumer Health Inshuwalansi Act ikugwira ntchito ngati njira ya komwe Democrats angakonde kupita ngati atabwereranso ambiri, kotero ndizotheka kuti tikhoza kuona zovuta zowonjezera kwa inshuwalansi m'zaka zam'tsogolo. Kuti adziwe bwino, ambiri a inshuwalansi, makamaka pa msika wawo, akhala ndi MLRs zoposa 80 peresenti m'zaka zingapo zapitazo. Zina zakhala zoposa 100 peresenti, zomwe sizingatheke ndipo ndizo chifukwa chake ndalama zowonjezera zakhala zikuwonjezeka kwambiri kwa ogulitsa malondawo mwachiwonekere sangathe kugwiritsa ntchito zambiri pazinenezo kuposa momwe amasonkhanitsira ndalamazo.
Koma kwa ena a inshuwalansi, kusinthana kufunika kwapamwamba kwa MLR m'misika ya gulu limodzi ndi yaing'ono idzawakakamiza kuti azigwira bwino ntchito. Koma mbali ina ya ndalama, anthu amatsutsa kuti malamulo a MLR sagwirizanitsa othandizira kuti azikakamiza odwala (zipatala, madokotala, opanga mankhwala, ndi zina zotero) kuti achepetse ndalama zonse kuyambira pomwe ndalama zowonjezera zimatha kungosungidwa kuti zisunge ndi kuchuluka kwa ndalama za chithandizo chamankhwala. Ogwiritsira ntchito ndalama amangogwiritsa ntchito ndalama zochuluka zogulira ndalamazo, koma kwa ogula, ndalama zowonjezera zingapitirize kuwonjezeka pazinthu zomwe sitingathe kuzipeza popanda kuthandizidwa.
> Zotsatira:
> Magulu a Medicare ndi Medicaid Services. Pulogalamu ya Odziwitsa Anthu ndi Kuyang'anira Inshuwalansi. Kugonjetsedwa kwachipatala.
> Magulu a Medicare ndi Medicaid Services. Chidule cha Mndandanda wa Zotsatira za Kuwonongeka Kwachipatala cha 2016 . Inanenedwa ndipo inasindikizidwa mu 2017.
> Ofesi ya boma ku United States. Komiti Yanyumba Yanyumba Yophunzitsa ndi Ogwira Ntchito. Inshuwalansi Yathanzi Labwino: Zizindikiro Zoyambirira Zimasonyeza Kuti Inshuwalansi Ambiri Akhoza Kugonjetsa kapena Kutaya Zotsatira Zatsopano Zotsata Zamankhwala . October 31, 2011.
> Warren, Elizabeth. Senate.gov. Mtundu wa Chitetezo cha Inshuwalansi ya zaumoyo . Yatulutsidwa March 2018.