[will_brown]

Great read.

I am a co-founder of a health care start up, offering patients primary care for $20/month ($15/month corporate plan) and a $20 copay to see the Dr. or $10 copay to see a ARNP or PA. All out of pocket, we do not accept insurance or medicare, as it would drive up our cost.

Unfortunately, the future of our start-up is uncertain because of Patient Protection and Affordable Health Care Act ("ObamaCare"). Specifically, when the new law goes into full effect, patients will no longer be able to pay out of pocket for medical care. Obviously our start-up is geared towards underinsured and uninsured patients, so in the future our business model will likely be unlawful. Of course it is great these patients will have health insurance coverage, but their access to and quality of primary care will likely go down and their costs will go up.

[dragonwriter]

> Specifically, when the new law goes into full effect, patients will no longer be able to pay out of pocket for medical care.

I am pretty sure that the new law requires most people to purchase medical insurance (with some exceptions that are covered by existing/expanded safety net systems like Medicaid), and subsidizes some medical insurance purchases, but I'd be very interested in a citation to the supposed prohibition on patients purchasing medical care directly. (Now, there are certainly deductible limits which may limit the amount patients may be required by insurers to pay out of pocket for things which are otherwise within the scope of the coverage of the insurance they have, but that's a very different thing than being prohibited to pay out of pocket.)

[will_brown]

>I'd be very interested in a citation to the supposed prohibition on patients purchasing medical care directly.

This is the whole idea of the penalty/tax. If a patient does not purchase insurance, and for example needs to go to the ER, then that patient will receive the penalty/tax from the IRS for not having a gov. approved health insurance plan and they will receive a bill for the actual government healthcare plan (premium payments and co-pays). The same will be true of walk-in clinics, or offices with membership plans - they will be required to report the uninsured, so the effect will be deterring the uninsured from availing themselves to affordable care, because it will no longer be affordable but any care will result in the government penalty and the actual bill (premium) for the government healthcare plan.

If you are sincere here is the a cite to the Supreme Court Case: http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf (See page 7-8 regarding the individual mandate and IRS "penalty") here is an excerpt:

"Beginning in 2014, those who do not comply with the mandate must make a “[s]hared responsibility payment” to the Federal Government. §5000A(b)(1). That payment,which the Act describes as a “penalty,” is calculated as a percentage of household income, subject to a floor based on a specified dollar amount and a ceiling based on the average annual premium the individual would have to pay for qualifying private health insurance. §5000A(c). In 2016, for example, the penalty will be 2.5 percent of an individual’s household income..."

Do they come out and say uninsured are bared from simply paying out of pocket for medical care? No, but they do not need to say it, because on a practical level, the only way this is enforceable is requiring medical providers to report uninsured patients and disallow them to simply pay out of pocket - in my opinion this will put an end to walk-in clinics, membership based practices, and care such as CVS minute clinics. The one way these practices will stay around is if they get in bed with the insurance companies, but: 1. it will limit patient access to care (you can no longer choose your provider and pay out of pocket, but you will be mandated who you can see by your insurance plan) and 2. drive up the cost of care (the only reason we can offer $20/month $10-$20 copay is because the cost of billing insurance/medicare is removed from the equation).

[lifeguard]

>> patients will no longer be able to pay out of pocket for medical care

Untrue. Patients can still buy supplemental care in addition to Obamacare if they desire it.

[will_brown]

Well of course my statement becomes untrue when you qualify it by saying "in addition to Obamacare if they desire it." I am talking about uninsured, the majority of our patients. Perhaps I could have added the word "uninsured" to my sentence:

uninsured patients will no longer be able to pay out of pocket for medical care

That said your statement is very optimistic that the uninsured/underinsured patients who we cater to will not only be able to afford insurance in the future but be able to pay out of pocket for healthcare "if they desire". It is more like if they can afford it, which they cannot which is why they are uninsured now. Keep in mind many primary care copays are $50-$100 under existing insurance plans, which is going to be very difficult for these patients to pay under any circumstance, but especially in light of their new found insurance expense (maybe even an additional government penalty expense). At least now an uninsured can come to us and get antibiotics for $30 ($20 1st month payment and $10 to see the ARNP or PA).

[lifeguard]

California and Washington have subsidized plans in the exchange for people around the defined 'poverty level'.

These exchanges are just starting. Obamacare is being phased in and also resisted by some local governments. Half the states haven't even set up exchanges yet.

Your language is loaded or at best vague:

> uninsured patients will no longer be able to pay out of pocket for medical care

That could be re-written, "My business model is no longer viable in competition with the new insurgence exchanges created by Obamacare."

Or, "My business model was based on the ignorance of my poor customers and now obamacare makes it clear to them they can get it easier than paying cash every visit."

Hang in there and pivot. America is only getting sicker.

[will_brown]

>My business model was based on the ignorance of my poor customers

1. The majority of patients are otherwise uninsured and cannot afford health insurance, so if they need primary care they pay out of pocket. Google walk-in clinics and get a feel for the typical "co-pay" for a walk-in clinic in your area and compare the same to our cost.

2. Some of our patients are insured, but they prefer not to use their insurance for primary care visits, because: a. they can not see the primary doctor they want; b. it takes a few days before their primary can schedule an appointment; and c. using insurance their co-pay is significantly more expensive than joining our network.

Our model is serving a need to uninsured not because they are "poor or ignorant" as you suggest, but because uninsured need primary care. Many other practices offer memberships, so this our model is not unique but I have not come across any that offer memberships at our prices - feel free to find one, it might exist.

>"now obamacare makes it clear to them they can get it easier than paying cash every visit."

Almost all insured and medicare patients pay out of pocket per primary care visit, it is called co-pay. However, in addition to the patient out of pocket co-pay either medicare or their insurance is getting billed...which drives up the cost of the patient healthcare, and guess what the patients are paying these costs in the form of FICA and/or insurance premiums.

[lifeguard]

So your problem with obamacare is there will no longer be any uninsured.

[will_brown]

Honestly, we are assisting uninsured people see doctors when they are sick at $20/month $20/visit maximum and as little as $15/month and $10/visit.

Instead of driving the point home by asking what you are doing to assist uninsured sick people in need - for all I know you may be a Doctor who takes a sabbatical 6 months of every year to Africa to set up medical clinics, but somehow I doubt it - I will just ask you please go Troll else where as HN seems to be all filled up with your kind, or at least have the courage to not hide behind an anonymous identity while attacking what people do in this world.

Though I had not said such before and you read it into my comments, perhaps it is fair to say I have a problem with Obamacare and my problem is that everyone will be insured, because I think a plan for universal healthcare should remove insurance companies entirely because they are responsible for a significant portion of the high cost of healthcare in the US - and we simply do not need a middleman and the associated costs when there is universal healthcare.