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In the News
Interesting articles, trends and stories about the insurance industry
Under recently announced plans Seniors enrolled on medicare will be able to choose plans which limit co-pays for insulin. President Trump endorses a deal designed to benefit a significant group of US citizens.
Who is eligible for this plan to cap insulin prices?
Anyone aged 65 or over and suffering from diabetes (types 1 or 2) and in particular anyone who will turn 65* before the end of March 2021.
Approximately 25% of seniors suffer from diabetes. That is 14.3 million people. But not all of them are enrolled on Medicare. Of those who are, it is estimated that six out of ten are already enrolled in a Medicare Advantage plan, or Medicare part ‘D’ which will cover the new benefit.
Check our article on: How to signup for Medicare at the age 65?
The cost of insulin is one of the greatest worries that sufferers of diabetes experience. Over 30 million American citizens are affected. Most of them depend on insulin to maintain their blood sugars at normal levels and protect them from major complications, such as heart disease and kidney failure.
People suffering with diabetes are no more likely to be infected by COVID-19 than other groups but the evidence is, that they are more likely to suffer worse outcomes.
Read our article on: Do Medicare plans cover Coronavirus treatments & costs?
*If you are a member of a group plan (employer sponsored) you will be automatically enrolled into Medicare when you turn 65. It will be YOUR responsibility to ensure that your new policies meet your specific needs. In the first instance, contact your plan coordinator.
What can you expect in this plan to cap insulin prices?
Enrollees who opt for drug plans which offer the new insulin benefit would pay a maximum co-pay of $35 per month. There may be a small increase in the monthly premium but the net saving is estimated to be worth between $400-$500 each year.
By opting for the new ‘supplemental insurance plans ‘beneficiaries will not only save money they will also have the security of a fixed budget and avoid the unpredictable fluctuations in drug prices.
At list prices, insulin treatment can cost as much as $5,000 per year. Although insured patients do not pay that much, they are exposed to co-pays which rise (inexorably) in line with rising list prices. We are all aware of anecdotal evidence that individuals, unable to afford their prescribed doses of insulin, may try to get by with reducing their dosage; a dangerous and sometimes fatal choice!
When will the new benefit of the plan to cap insulin prices come into effect?
The new benefit comes into effect on January 1st 2021. That seems a long way off, BUT you will need to make sure that your plan for 2021 will cover your needs in these new circumstances and that must be done during OPEN ENROLLMENT which begins November 1st 2020. Now THAT, is not so far away. Contact your exchange and review your options.
How to proceed?
You need to be certain that your provider is a participant in the program and that your specific insulin needs are covered – including pen and vial for the various formulations (rapid-acting, short-acting, intermediate-acting, and long-acting versions)
Remember, not all insurers are signed up for this scheme and not all plans will include your prescribed medication on their formulary.
According to Seema Verma, Head of Centers for Medicare and Medicaid Services, there are 1750 plans that offer prescription drug coverage to Medicare recipients and participate in the ‘enhanced’ plans providing supplemental (insulin) benefits. Don’t leave it to chance!
Talk to your exchange, review your coverage. You may find a change of metal band, say from silver to gold, will now give you better value for money. You may also benefit from the peace of mind offered by a 5* rated provider. Perhaps your savings could give you cover for Vision, Dental or possible future Medical expenses.
Make the most of this opportunity
Early last month President Trump announced that tests for COVID-19 infection would be included in the ten Essential Health Benefits (EHB) specified in the Affordable Care Act (ACA).
NOW, two major health insurers HUMANA and CIGNA have come forward with an ADDITIONAL commitment to waive out-of-pocket costs for the treatment of patients infected by COVID-19.
We will discuss more about Coronavirus Treatment cost waived off by Humana and Cigna, but before let’s let’s look at how much it costs to treat COVID-19.
Coronavirus treatment cost
It is too soon for anything but educated guesses. These suggest that the cost of COVID-19 hospitalization and treatment could average over $20,000 per person. For most citizens with health insurance, either individual or group (employer), the average out-of-pocket expense would be $1,300.
The US Centers for Disease Control and Prevention (CDC) projection is for between 2.4 and 21 million citizens to need hospitalization and that a significant proportion of these will need intensive care, e.g. respiratory therapy.
Actual costs will depend on severity and any chronic or underlying conditions. There are anecdotal reports of charges exceeding $34,000.
It is clear that the US, in common with most other countries worldwide, faces a massive threat from COVID-19. This is an easily spread ‘flu-like disease for which there is, as yet, no known cure. The World Health Organization (WHO) estimates that 80% of those infected will recover without needing special treatment (see the article on self-isolation during Coronavirus pandemic).
Does Medicare insurance cover Coronavirus?
Those most at risk are ‘seniors’ and individuals with chronic or underlying pulmonary conditions. With the benefit of Medicare and Medicaid, these are the groups most likely to be covered by health insurance. Both Medicare and Medicaid are bound by the terms of the ‘Families First Coronavirus Response Act’. This act passed by Congress (3/16/20) requires most private health plans to cover coronavirus testing with no cost-sharing.
Medicare and Medicaid have stepped beyond the terms of the act to include COVID-19 treatment with no cost-sharing. They have been joined by Humana and Cigna. It is likely that other health insurers such as Anthem and Aetna will follow suit; there is, however, no federal obligation to do so.
At a time when it is important to slow the spread of the disease, it is critical to maintain ‘social distancing’ and to facilitate testing and treatment. The actions of these organizations remove the main factor (finance) which deters even insured individuals from accessing tests and treatment.
Read more about: Does Medicare plans cover Coronavirus tests and treatments
There is a general agreement that the practice of ‘balance billing’ (see our article) should be reviewed. IN PARTICULAR Humana and Cigna have indicated that they would resolve issues that arise when service is delivered by an out-of-network provider, especially when the patient is not advised or is unable to make a decision. Humana CEO Bruce Broussard says “we will keep it [a surprise billing dispute] between the provider and the company” [the insurer].
Read our article on healthcare surprise billing
In a further move to: –
- Ease the pressure on medical offices
- Lessen the need to leave home (social distancing, see our article…)
the major players in the health insurance industry are encouraging the use of TELEMEDICINE and easing pre-authorization requirements.
There are, of course, some limitation
- Some large employers run their own (self-insurance)
schemes and may not offer the same EHB nor be bound by the terms of the FFCR act – most companies will adopt these new standards but all members of group schemes should check with their HR dept
- The private health insurers’ cost waivers are (currently) time gated, namely MAY 30th 2020 (or defined by some term such as ‘for the duration of the Coronavirus crisis)
- In all cases the actual terms of your plan will vary between insurance companies. You should check with your insurer
- IF you have a ‘short term’ plan it is unlikely to offer you the benefit of these changes. You should: –
- Check with your insurer
- Discuss your circumstances with a health insurance exchange to determine the best alternatives. You may, for example, qualify for a Special Enrolment Period
The Private Exchanges, such as TrueCoverage obviously regret the circumstances which necessitated these changes.
Clearly, these changes are intended to improve the operation of the market and the service provided to meet immediate, individual client and societal concerns. The changes may be expedient in the short term but, in the longer term it may prove difficult for the ‘healthcare industry’ to revert to a system which was already coming under criticism.
Much of the cost of these changes is being absorbed by the insurers and, less obviously, by service providers and the pharmaceutical companies.
We must wait to see but we should probably brace ourselves for a root and branch rebalancing of the prices we pay for each element of our healthcare.
The purpose of the ‘exchanges’ is to ensure that everyone has the opportunity to consider and compare insurance plans that best meet their needs.
Do medicare plans cover Coronavirus? The brief answer is YES. Medicare plans do cover coronavirus (COVID-19) tests and treatment. Covid-19 lab tests and the costs of hospitalization are covered by Medicare Part A and Medicare Part B. Lab tests are ‘free’. There will be zero out of pocket expenses, co-pays or co-insurance, for the test itself or relevant office visits. Treatment is a separate issue and will generally be subject to the terms of your personal plan health insurance.
If there are dependent children (below age 16) in the household they will be covered by CHIP and, subject to your State legislation, eligible for free testing and treatment.
Citizens on Medicaid should check with their local benefits office. States must meet the conditions described above but many are more generous.
If you have the three symptoms of COVID-19
- New (dry) continuous cough
- High temperature
- Breathing difficulty
you should call your provider (virtual check-in, SEE SECTION, TELEHEALTH below). DO NOT visit without an appointment. DO NOT travel by public transport.
If you have a MEDICARE ADVANTAGE PLAN you have access to COVID-19 lab tests and medically necessary hospitalizations, but you should check with your plan provider about coverage and costs.
Medicare coverage includes: –
- Tests for COVID-19: You pay no out-of-pocket costs. The coverage applies both to the test itself and to the visit in which the test was administered
- Medically necessary hospitalizations. This includes hospital stays which are extended because you have been diagnosed with COVID-19 and might otherwise have been discharged from the hospital following a prior inpatient stay.
- All Medicare Prescription Drug Plans (Part D) will cover the cost of anti-viral treatment (injections) when a viable vaccine has been approved.
Medicare Advantage plans offer the same benefits but you should check the terms of your plan with your insurers. Advantage plans may offer additional telehealth benefits beyond the ones described above. Check with your plan about your coverage and costs.
Advantage plans are permitted to waive cost-sharing for COVID-19 lab tests.
The Families First Coronavirus Response Act passed through the House and Senate on March 18th. The act extends coronavirus coverage for free testing to Medicaid beneficiaries and group health insurance plans.
Estimates suggest (The American Action Forum) that the federal government is committing approximately $1.3 billion in federal healthcare spending for testing and around $56.3 billion for other Medicaid costs.
This gives a clear indication of the value of your Medicare card to you AND to would-be fraudsters. The COVID-19 scare will only heighten the threat of opportunistic or planned misuse. You should treat it with same respect and level of security as your credit cards.
Telehealth & related services [drawn from Medicare.gov, Medicare and Coronavirus]:
In response to the unprecedented demand for medical services, Medicare has temporarily expanded its coverage of telehealth services. “These services expand the current telehealth covered services, to help you have access from more places (including your home), with a wider range of communication tools (including smartphones), to interact with a range of providers (such as doctors, nurse practitioners, clinical psychologists, and licensed clinical social worker). During this time, you will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. This will help ensure you are able to visit with your doctor from your home, without having to go to a doctor’s office or hospital, which puts you and others at risk of exposure to COVID-19”.
FINALLY, we remind you that a test for COVID-19 infection which gives a negative result does NOT MEAN that you are immune from the disease nor does it convey any immunity.
You must continue to observe the SOCIAL DISTANCING (see our article on Social Distancing, Quarantine and Islocation) regulations, maintain high standards of personal and environmental HYGIENE, and the levels of ISOLATION appropriate to your household.
Read our article on COVID-19 by taking care of yourself you are taking care of all of us?
“and millions more Americans will have the choice to ditch their private insurance and enter a high-quality public plan” Elizabeth Warren (Warren for President, January 2020)
Does Elizabeth Warren have a health care policy that can build on the Affordable Care Act (ACA)? Can she use the provisions of the Medicare and Medicaid platforms to make the health care dollar go further?
Is Medicare for all an affordable option?
Healthcare costs are a major concern for the American voter. After 10 years of the ACA, 55% of the general public take a favorable view of the act (85% among Democrats) and even Republican voters are less inclined to repeal the ACA; they rate opposition to the ‘single payer’ approach (Medicare for all) more highly [KFC tracking poll Feb 2020].
This article looks at the Warren proposals in three steps.
- How much do we pay now and what do we get?
- What are the inefficiencies and weaknesses of the existing system?
- What does Elizabeth Warren propose?
How much do we pay?
Most of us are insured through our employers. Even with sponsorship the ‘average’ family of four pays over $12,500 (employee insurance contributions and out-of-pocket expenses). Self-employed and other self-insured individuals will pay rather more. Out of taxation the states and Federal Government spend another three trillion dollars.
In total, as a nation, we spend almost one dollar in five on health care. This is nearly 2x the contribution made by other leading developed countries to their population’s healthcare.
What do we get?
Despite the investment in health care, the current health care system delivers worse health outcomes than that in comparable developed countries. Average longevity for both men and women and infant mortality are key examples.
At the same time, under the current system 28.5% of Americans have no health insurance at all (U.S. Census Bureau) and another 41% are under insured (The Commonwealth Fund). Two out of three bankruptcies in the US (approximately 500,000 families p.a.) are on account of medical problems (American Journal of Public Health).
What are the inefficiencies?
There are some 1,000 health insurance companies in the USA. Of these, the top ten account for 50+% of the revenue and the top 100 approximately 95%. In itself this is not unusual in a commercial market subject to normal market forces and where the customer has freedom of choice. When it comes to health, very few of us choose to be ill!
There are two major aspects of this which inherently affect the premium cost of coverage.
- By having so many insurers in the market individual companies (carriers) spread their risks across a smaller pool of customers and therefore need to charge more in premiums
- Providers (Doctors, Hospitals, Specialists, Carers and Pharmacists for example) are faced with vast administrative problems in dealing with multiple payers (the insurers). As a consequence, the cost of administration within the current US health care system is put at 8%. By comparison similar countries spend 2%.
What are the weaknesses?
The intention of The Affordable Care Act (Obamacare) was to make health care affordable and accessible by all Americans. History and events have demonstrated just how hard this is. At one extreme we have “if you can’t pay, I can’t treat you” and at the other extreme “Yes I can treat you AND you don’t need to worry about the bill”.
In today’s political environment neither extreme is realistic. But in reaching for an acceptable (affordable) solution we have arrived at a compromise that which is NEITHER affordable, NOR universally available.
- Approximately 50% of healthcare funding is paid for by consumers (you and me) through insurance premiums paid to (profit-making) insurance companies
- The other 50%, paid for (indirectly by us) from taxes, is spent by the government, on our behalf, on subsidies, on medications, and on Medicaid
- The ‘networks’ intended to provide competitive medical treatment, care and medication actually limit choice and create opportunities for ‘balance’ and ‘surprise’ billing
- There is little or no control over the prices of medications (prescription drugs) charged by pharmaceutical companies. Some drugs are 3x more expensive in the US than in Canada. The US spends 1.5‑3x as much on prescription drugs as other high-income countries and between 1.4-2.5x on general physicians’ average salaries (Journal of American Medical Association, JAMA).
What does Elizabeth Warren propose?
Warren makes no secret of her intention to introduce a ‘Medicare for all’ solution. She argues that a ‘single-payer’ non-profit-making insurer, i.e. the government, can more efficiently administrate a Universal Health Care Program.
Her calculations suggest she can achieve her goals by reigning in the profits of insurance companies, the profits of the ‘pharmas’ and eliminating up to 80% of the administrative overhead.
In her manifesto, Warren promises that in the first year of her presidency she will establish a government-run ‘Medicare for All’ option to challenge the existing privately-run schemes. She leaves the choice with the consumer, confident that over time they will opt for the flexibility and value that an all-inclusive Medicare program can offer.
By the end of her “first term” Warren plans “critical health system reforms to save money and save lives”. Her aim is to complete a full transition to ‘Medicare for all’!
Whatever her convictions, Warren will need to convince her own party and then the Left, Right and Centre in Congress and in the Senate if she is to put them into practice
Read about: Bernie Sanders Medicare for all Explained
Read about: Pete Buttigieg’s healthcare plan
Healthcare policy was the central issue during the 2018 mid-term elections which led to the democrats winning a majority in the House of Representatives. Among the leaders in the race for nomination for the democratic candidacy the common theme is, ‘affordable healthcare’. The reason is clear. 95% of Americans say Medicare is important to them! And no wonder. Approximately 18% of the American Gross Domestic Product (GDP – the value of all the goods and services produced each year) is spent, either by us or by the government, on HEALTHCARE.
Every candidate has endorsed their own distinct health care policy. Bernie Sanders ‘MEDICARE FOR ALL’ is based on a ‘single payer’ concept which would abandon private health insurance plans altogether. Mike Bloomberg espouses the concept of a PUBLIC HEALTH INSURANCE option run by the government to compete with private insurers and set standards in terms of both cost and effectiveness.
Pete Buttigieg’s healthcare policy has as its ultimate goal ‘universal coverage’, an aim he shares with Sanders. But Buttigieg’s approach is to expand Medicare access to ‘All Who Want It’ (it is currently only available to seniors, and adults with defined chronical conditions).
Buttigieg’s plan for expanding healthcare coverage through Medicare would begin by extending the public insurance option to: –
- Low-income individuals in states that have refused to expand Medicaid
- Individuals who forgo (sponsored) employer coverage because it is too expensive
- Middle-income individuals and families, uninsured because of cost. The intention is to offer subsidies on plans purchased either through the market place or the public option.
The Buttigieg healthcare policy will require drastic changes to the way in which the country divides the spend on funding the health of the nation. On our behalf the federal and state governments spend around $1.5 trillion (Medicare, Medicaid, other insurance programs, and subsidies). We, the public, spend nearly as much again on co-insurances, co-pays, and deductibles. In total, as nation we spend 18% of our income on healthcare.
It is no wonder that ‘would be’ presidents devote so much of their time considering how to spend it and in persuading us that they have the best healthcare policy.
They do have a common goal: to provide accessible health care and consistent high standards of service to the whole US nation. The word ‘accessible’ is a term which embraces both ‘affordability’ and the ‘geographic’ availability of the necessary services.
The questions is how?
We, the American nation, pay almost 2x the average among the top ten developed nations for our healthcare and on most measures our outcomes are less favorable. We are neither more efficient nor more effective.
What are the solutions?
BERNIE SANDERS would introduce a universal program called ‘Medicare for all’ under which the benefits provided by Medicare Part A, Medicare Part B, Medicare Part C and Medicare Part D are combined in a single all-embracing healthcare policy called Medicare For All. Implicit in this healthcare policy is the concept of ‘the single payer’ i.e. the federal (state) government. He argues that this will reduce the inefficiency of having multiple payers (the insurance companies) and multiple suppliers (the health care providers). It would also reduce/eliminate the role of the health insurance exchanges. Sanders wants to achieve this in single step. Most healthcare policy analysts, even those sympathetic to the concept, agree that to move from the current mix of public/private funding would be hugely disruptive.
Read more: Bernie Sanders Medicare for all explained
MIKE BLOOMBERG answers the same questions. He sees value in private insurance and in the need for the security that public funding gives to disadvantaged members of society. He offers to deliver a Medicare level of service provision through an Affordable Healthcare Plan. This plan would be run by the Federal Government with premiums restricted to 8.5% of household income. His plan will be optional. Those who wish to remain privately insured may do so. Bloomberg expects the cost of private insurance to decrease in the face of a major competitor in the market. Bloomberg offers a long term and sustainable choice for the individual to choose one, the other or a combination.
Read more: Mike Bloomberg’s Affordable Healthcare plan
PETE BUTTIGIEG, like Bernie Sanders, sees Health Care as a right. He has a long-term aim to move from private insurance to solely government-funded programs. His approach is to offer the option of getting coverage though ‘a public insurance’ alternative. In this way, Buttigieg hopes that if plans available to you from your employer or on the market place are unaffordable you can choose ‘the public insurance’ alternative and find a plan that is affordable. He distinguishes his position with the slogan ‘Medicare for all who want it’. He makes no secret of the fact that he expects sustained competition from the public insurance ‘alternative’ to result in a ‘Medicare for all’ outcome. He makes no prediction as to how long this will take.
THE THREE FRONTLINE CONTENDERS for the Democratic nomination plan to put constraints on the price of branded drugs, and to eliminate the exposure to high costs of unexpected medical bills from out of network providers such as anesthetists and ambulance services. In doing so they will have to battle not only with the House and the Senate but also with the reluctance of the pharmaceutical industry to adapt to new market forces and the task of re-orienting the focus of a workforce numbering 16 million.
Just recently the TrueCoverage team wrote an article ‘MEDICARE FOR ALL EXPLAINED’ and concluded that while the Democratic party had a distinctly different approach to funding national healthcare from the Republicans, they had yet to find ‘a policy which values enterprise and recognizes that the demand for ANYTHING FREE is infinite.’ In this article, we consider Mike Bloomberg’s stand on ACA and his vision of an affordable healthcare plan.
Whereas Sanders talks of ‘Medicare for all’ Bloomberg’s idea is to introduce an affordable healthcare plan, federally run, as a public option alongside the privately insured ACA. Read about Bernie Sanders take on Medicare for all: Read more
The public insurance option would be aimed initially at the uninsured and low-income families in states which have not expanded Medicaid under ACA.
Mike Bloomberg’s ‘affordable healthcare plan’ can be described as having three objectives. They are to: –
- Extend coverage to those who cannot afford now afford it
- Widen the range of health services
- Reduce/control prices and charges for treatment and medication.
Extend the coverage
The public health insurance (PHI) option would be administered by the federal government (not for profit) but paid for by customer premiums. The same tax reliefs and subsidies would apply as for plans bought on the health insurance exchanges. Individuals would be allowed to keep their private insurances.
At the same time some of Bloomberg’s ‘health care price capping’ and ‘cost control’ initiatives would make ACA compliant plans more affordable and increase the uptake of private health insurance. Currently, approximately 28 million Americans do not have health insurance and a further 41 million are thought to be under-insured.
Some counties do not have full (or any) health insurance coverage. Mike Bloomberg’s stand on ACA would remove this injustice by bringing PHI to the market place.
Widen the range of services
Approximately 30% of US citizens do not visit their dentist regularly, nor do they seek preventative care for hearing and vision. Bloomberg intends to include these as Medicare options and for all states to include oral health services for all adults in the ‘Medicaid’ program.
Reduce/control prices and charges
It is generally agreed that the cost of providing healthcare in the USA is too high (nearly 2x that of other developed countries). The evidence suggests that in many areas (for instance, life expectancy and infant mortality) the outcomes are worse than in other advanced nations.
Extending coverage and widening the range of services are not, in themselves, going to reduce the cost of treatment and care. They should, of course, improve overall outcomes, e.g. life expectancy and infant mortality.
Bloomberg’s approach is to ‘cap’ individual’s premiums to 8.5% of household income. This may be good news to us as individuals but will make additional demands on federal taxes.
He proposes various other caps. For example, on out-of-network charges and most significantly, on the price of medications including prescription drugs. Bloomberg’s affordable healthcare plan would restrict US drug prices to 120% of the average price charged in other advanced nations. To illustrate the problem, some prescription drugs are available in Canada for approximately 30% of the cost of the same drug in the USA. This may be good news for the US citizen with a chronic need but could have a huge revenue/profit impact on major US pharmaceutical companies.
The main influence on our choice of drugs is the pharmacist who fills our prescription. Bloomberg proposes to ban payments to pharmacists by drug companies seeking to obtain preferential treatment. No one should be incentivized to persuade us to buy a branded drug when the generic alternative is just as effective.
As we describe, Bloomberg offers a range of ideas to promote competition and efficiency while maintaining the ethical standards of Medicare, Medicaid and the ACA.
One further idea is to create a permanent reinsurance program. This is common practice in most areas of insurance. It encourages insurers to insure themselves, i.e. spread their risk of having to meet extreme claims. This would enable them to reduce premiums to their clients: Bloomberg claims by 10%.
Bloomberg vs Trump
No one seriously argues that the US health care system is either more efficient or more effective in terms of outcomes than health care systems in other advanced countries.
- The US spends 17-18% of its GDP on health care while the average developed country spend is 8-9%.
- Access to care, the US score lower than other developed countries on the following measures: –
- Practicing doctors -19% per person
- Practicing nurses -25% ~
- Acute beds -26% ~
- In the US 10% of all Americans have no Health Insurance coverage compared with 99-100% coverage in the ten other countries in a recent JAMA study.
Donald Trump takes a laissez faire approach, reckoning that market forces will eventually determine a health care system where demand is met at an affordable price without the intervention of the federal government and minimal involvement of individual states.
The single payer system proposed by Sanders is entirely at odds with Republican ideology and is indeed not widely endorsed by his own party. It would involve the complete dismemberment of existing structures.
In broad terms we devote some $3.5 trillion on the US health care system ($ spent either directly by us as individuals or indirectly through federal and state taxes). About 16 million people are employed within the system and millions more in supporting industries, such as pharmaceuticals and insurance.
Bloomberg’s proposals deserve consideration for their recognition of the multi-dimensional nature of the problems health care faces and the need to build on existing structures for the benefit of the whole nation.
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