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The Intercept - February 23, 2020

*"*The need to find in-network providers is only the beginning. The plan’s “Forms and Information” web page alone contains more than 100 links. Although some of those links offer employees assistance and education, a lot of administrative functions are represented. They include a set of ten documents on plan provisions and limitations, a “Co-payment Book” listing out-of-pocket costs for various services and providers, and a set of twelve forms. One of them, the “appeals form,” lists eleven categories for appeal including “late filing,” “maximum benefit,” “no prior authorization,” “non-covered service or supply,” and “non-PPO to non-PPO referral.”

DESPITE A HIGH-PROFILE battle with the leadership of Nevada’s powerful Culinary Union leading into the caucuses on Saturday, Bernie Sanders emerged with a decisive victory — even dominating other candidates among culinary workers themselves, according to entrance surveys.

The big fear expressed by union leadership was the loss of the health care plan workers fought for several years to achieve. But union members who caucused for Sanders against the advice of their leadership may have been better analysts of their own financial system than pundits expected: Indeed, if Sanders does manage to enact his Medicare for All plan as it’s written, their coverage will improve.

A review of the Culinary Union’s health plan documents, along with other data sources, shows that it’s done an excellent job under difficult circumstances. The review also shows that the union’s members would be much better off under Medicare For All, and that this plan – like virtually every plan – is held back by deep flaws in today’s healthcare system.

First, the backstory: The Culinary Union’s Local 226 administers an employer-funded health plan called the Culinary Health Fund (CHF) for its Las Vegas members. Union leaders reacted angrily when Sanders, at a town hall, told its members that their employers would save $12,000 per employee under Medicare For All, and that they’d see that money in their paychecks. They fired back again after a barrage of online criticism from Sanders supporters.

“Workers should have the right to choose to keep the healthcare Culinary Union members have built, sacrificed for, and went on strike for 6 years, 4 months, and 10 days to protect,” union leader Geoconda Argüello-Kline said in a statement.

The union is proud of its health plan, and understandably so. They fought hard for it, and its coverage outdoes most employer-funded plans. Still, the union’s members would be much better off under Medicare for All. The same is true for most, and probably all, of today’s union plans. So why are so many people demanding the “choice” to keep them – especially if that means preserving some of the worst flaws in today’s system?

The Culinary Health Fund has done good work.

The union’s plan, as well as the infrastructure it has built, are impressive.

The plan runs its own well-regarded clinics, and some doctors are salaried rather than fee-for-service. This reduces insurance profit-taking (the plan likely has some form of reinsurance for especially costly cases) and removes incentives for physicians to over-treat, a problem that’s likely to get worse as investors and hospitals continue to buy up medical practices.

Workers don’t make premium contributions from their paychecks. That doesn’t mean the plan is “free.” Most economists believe employers compensate for benefit costs by reducing wages. But it does add a level of predictability to workers’ household budgets.

This puts the Fund’s members well ahead of the curve. The Kaiser Family Foundation’s 2019 survey of employer benefits found that 5 percent of workers in large firms, and 31 percent in smaller firms, pay no portion of their premiums. For those that do pay a premium, the average worker with employer-based insurance paid $1,242 for single coverage and $6,015 for family coverage.

There are no deductibles in this plan, either, which means members don’t need to pay a certain amount themselves before coverage kicks in. Here, too, they’re doing well compared to most other workers. The Kaiser survey reports that 82 percent of workers with employer health insurance have a deductible, and that the average deductible for single coverage is $1,655 (rising to $2,271 in small firms).

Co-pays (a flat rate per visit or treatment) and coinsurance (where the patient pays a percentage of the cost) are another area of out-of-pocket expense. Here, too, the CHF plan beats most employer coverage. There are also no co-payments or coinsurance for in-network primary care or some forms of specialty care. When these costs occur, co-payments are typically $25 for primary doctors and $40 per visit for specialists, and coinsurance is typically in the 18 percent range. These and other patient costs are relatively modest when they occur, when compared with other such plans.

There are copayments for in-network hospital and outpatient facility care, but there is no coinsurance. Again, the plan is ahead of the curve. Two-third of covered workers in the U.S. must pay coinsurance in these facilities, at an average rate of 20 percent. That can add up extremely fast.

But its members could do better.

Even this above-average plan falls seriously short of the coverage its members would receive under Medicare For All.

The maximum amount CHF members could pay out-of-pocket for their own care is $6,350 per person per year, $12,700 per family. That means households covered by the plan are not protected from financial catastrophe.

If the coverage is that good, how could they incur those expenses? First, the benefits listed above are for in-network services, and it can be challenging for working people to find in-network providers. They may have a pre-existing doctor relationship, or may find themselves taken to an out-of-network hospital after an accident. (Provider access is limited in Las Vegas, but that can cut both ways when it comes to finding in-network care.) ...
Read full report at The Intercept