US Healthcare insurance

[ThinkerX]

17 minutes ago, Kalbear said:

The ACA hasn't collapsed. It isn't close to collapse. As usual, @ThinkerX was called delusional because you said something very delusional.

Then how do you account for insurers pulling out of the marketplace, continuing increasing premiums, ridiculously high deductibles that make even 'good' policies all but worthless, and skyrocketing medical costs?  Are these indicators of a healthy system?

[Kalbear]

14 minutes ago, ThinkerX said:

Then how do you account for insurers pulling out of the marketplace, continuing increasing premiums, ridiculously high deductibles that make even 'good' policies all but worthless, and skyrocketing medical costs?  Are these indicators of a healthy system?

They're indicators of a flawed system in some areas, yes. The notion that it is going to collapse is delusional, given how successful it has been overall.

Your situation isn't unique, but it also isn't the norm. 

[Altherion]

Here's a timely CNN article about this. It's hard to say what exactly is the norm as this informational territory is extremely propaganda heavy. However, it is not at all obvious to me why the current trends should not continue. Imagine that you are a pharmaceutical company or health care provider executive. Why wouldn't you charge more? Obviously, if you double the price of a popular medicine or something of the sort, you might get dragged in front of Congress and may need to backtrack... but why not increase it by something like 10%? Then, if you're an insurance executive, you pretty much have to increase premiums correspondingly. And finally, if you're an employer offering insurance, you have to either accept the loss or pass the costs on to your employees. There's simply no reason for the costs not to keep growing significantly faster than inflation which means that somebody has to pay -- and since the insurance companies won't operate on a loss, one way or another, that can only be the taxpayers who can afford it.

[ThinkerX]

1 hour ago, Kalbear said:

They're indicators of a flawed system in some areas, yes. The notion that it is going to collapse is delusional, given how successful it has been overall.

Your situation isn't unique, but it also isn't the norm. 

It will collapse when enough people in the marketplaces decide the policies cost too much to bother with and go without insurance.  The tax penalty, even if increased, will not be enough to make up the gap.  The next step - not that far off, will be major insurers going out of business, unless bailed out.  My prediction is that will happen before the end of the next presidential term UNLESS major changes are made immediately, which is highly unlikely given political deadlock.

 

Now, WHEN (not if) the major insurers start pushing for bailout, will you support them?

[Kalbear]

I'll go with a bailout WHEN (not if) any of your predictions take place. 

[Iskaral Pust]

50 minutes ago, Altherion said:

Here's a timely CNN article about this. It's hard to say what exactly is the norm as this informational territory is extremely propaganda heavy. However, it is not at all obvious to me why the current trends should not continue. Imagine that you are a pharmaceutical company or health care provider executive. Why wouldn't you charge more? Obviously, if you double the price of a popular medicine or something of the sort, you might get dragged in front of Congress and may need to backtrack... but why not increase it by something like 10%? Then, if you're an insurance executive, you pretty much have to increase premiums correspondingly. And finally, if you're an employer offering insurance, you have to either accept the loss or pass the costs on to your employees. There's simply no reason for the costs not to keep growing significantly faster than inflation which means that somebody has to pay -- and since the insurance companies won't operate on a loss, one way or another, that can only be the taxpayers who can afford it.

First, ACA gifted cheap coverage to low income people and that expense had to be borne by everyone else who buys insurance.  Second, low socioeconomic status is unfortunately correlated with a lot of lifestyle-related health problems like diabetes, cardiovascular disease, tobacco use, substance abuse, morbid obesity, etc.  Third, people who previously lacked coverage probably did not use preventative screening, early treatment, etc so they have an outsize incidence of chronic conditions above and beyond the socioeconomic effect.  All of this cost is being loaded on everyone else with health insurance who earn more than $48k (approx median income).  It's a huge stealth tax, completely unacknowledged.  The early cost estimates were deliberately low-balled by the insurers to help get the new system approved.  And now, as predicted, we see the costs spiraling up to where we knew they would have to be.  

Insurers even complain that low income people buy subsidized policies for a few months, receive very expensive treatments for a serious condition and then drop coverage as soon as the treatment is complete.  They know that they can re-start coverage in the future if/when they have another health problem so there's no point paying even the subsidized premiums in the meantime.

And there is every incentive for pharma and device manufacturers to raise prices because there is no-one bargaining against them. 

The whole system creates an enormous surge in demand for care with no responsibility attached, it allows unfettered price gouging, and the poor schmucks footing the bill have no say in the matter and no alternative. 

[Ariadne23]

49 minutes ago, Iskaral Pust said:

First, ACA gifted cheap coverage to low income people and that expense had to be borne by everyone else who buys insurance.  Second, low socioeconomic status is unfortunately correlated with a lot of lifestyle-related health problems like diabetes, cardiovascular disease, tobacco use, substance abuse, morbid obesity, etc.  Third, people who previously lacked coverage probably did not use preventative screening, early treatment, etc so they have an outsize incidence of chronic conditions above and beyond the socioeconomic effect...Insurers even complain that low income people buy subsidized policies for a few months, receive very expensive treatments for a serious condition and then drop coverage as soon as the treatment is complete.  They know that they can re-start coverage in the future if/when they have another health problem so there's no point paying even the subsidized premiums in the meantime.

 I can absolutely see how fully covered preventative care is significantly driving up costs (and I've noticed that PCPs are bilking the shit out of that covered annual physical), but I'm not sure I follow a couple other things. Aren't the subsidies paid with tax dollars? If so, how does that affect costs for insurers? And isn't it not possible to pick up and drop insurance as needed? I thought people buying on the exchange were limited to an open season absent qualifying circumstances just like employees?

Is it possible that the costs of fully covered preventative care, and the medical profession's response to that, are big enough to be doing this on its own? If so, I can see how these effects on premiums and coverage were not fully anticipated because the bill authorized HHS to determine what care was "preventative" and fully covered after the bill was passed. Of course, that was probably a stupid thing to do.

[Altherion]

2 hours ago, Iskaral Pust said:

Insurers even complain that low income people buy subsidized policies for a few months, receive very expensive treatments for a serious condition and then drop coverage as soon as the treatment is complete.  They know that they can re-start coverage in the future if/when they have another health problem so there's no point paying even the subsidized premiums in the meantime.

Are you sure that it is possible to do this? Obviously, if one could only pay the insurance when one needs treatment, that is no longer even insurance, it is simply extremely subsidized treatment, but I don't think they'd allow something so blatant.

1 hour ago, Ariadne23 said:

Is it possible that the costs of fully covered preventative care, and the medical profession's response to that, are big enough to be doing this on its own? If so, I can see how these effects on premiums and coverage were not fully anticipated because the bill authorized HHS to determine what care was "preventative" and fully covered after the bill was passed. Of course, that was probably a stupid thing to do.

I don't believe preventative care or any sort of non-catastrophic condition is fully covered by the subsidized plans. If somebody paying $15K+ per year is not getting much out of their insurance, I don't think poor people would get much more out of their subsidized plans. I think Iskaral Pust's point was that the people who signed up for health care because it was suddenly being subsidized and they'd be fined for not doing it did not get preventative care earlier in life and are therefore more likely to have problems even beyond what one would expect based on their low income.

[Ariadne23]

5 hours ago, Altherion said:

I don't believe preventative care or any sort of non-catastrophic condition is fully covered by the subsidized plans.

Appointments, procedures, etc. considered "preventative care" under HHS regulations (like birth control?) are 100% covered, no copay, no coinsurance, not subject to your deductible, under ALL plans post-ACA. This is one of the major policy accomplishments of the bill. This includes an hour-long annual physical, so part of the PCP game now is to book as many of these as you can so you can see the person for 30 min, charge for an hour, and build room into your otherwise never-ending crush of 10 min appts.

On a practical note, as an individual, might as well read the HHS list and get all the "free" preventative care you want since you're paying for it anyway.

ETA: Here is the list. I'm reminded, looking at it, of all the children's health services that are covered and that we could all be complaining about the result of providing all this fully covered medical care to previously uninsured children. Or it could be all the unlimited "free" obesity and STD counseling.

[Aemon Stark]

12 hours ago, Iskaral Pust said:

First, ACA gifted cheap coverage to low income people and that expense had to be borne by everyone else who buys insurance.  Second, low socioeconomic status is unfortunately correlated with a lot of lifestyle-related health problems like diabetes, cardiovascular disease, tobacco use, substance abuse, morbid obesity, etc.  Third, people who previously lacked coverage probably did not use preventative screening, early treatment, etc so they have an outsize incidence of chronic conditions above and beyond the socioeconomic effect.  All of this cost is being loaded on everyone else with health insurance who earn more than $48k (approx median income).  It's a huge stealth tax, completely unacknowledged.  The early cost estimates were deliberately low-balled by the insurers to help get the new system approved.  And now, as predicted, we see the costs spiraling up to where we knew they would have to be.  

Well, wasn't the whole point to improve access and coverage for people with marginal or unstable socioeconomic status? And it's not that low socioeconomic status is simply correlated with "lifestyle-related" problems so much as lower income, education, and social stability are significant determinants of lower health status. 

Otherwise we should not overrate the important of screening and "early" treatment on the burden of chronic conditions. Yes, there are occasionally the types who "don't see doctors" and come in half-dead but that's not the rule. 

Insurers even complain that low income people buy subsidized policies for a few months, receive very expensive treatments for a serious condition and then drop coverage as soon as the treatment is complete.  They know that they can re-start coverage in the future if/when they have another health problem so there's no point paying even the subsidized premiums in the meantime.

Does this "free rider" effect occur commonly? There aren't so many "serious" conditions that are simply resolved after a single course of treatment. 

And there is every incentive for pharma and device manufacturers to raise prices because there is no-one bargaining against them.

 

I don't think bargaining is enough; you need direct regulation and limitations on patents and new drug approvals. 

The whole system creates an enormous surge in demand for care with no responsibility attached, it allows unfettered price gouging, and the poor schmucks footing the bill have no say in the matter and no alternative.

So is the solution "single payer"? Of what type? 

[Iskaral Pust]

If someone drops individual coverage they cannot re-start coverage until the next enrollment window.  The insurance companies claim that lots of subsidized policyholders are doing exactly that, effectively gambling that any new medical problem can defer treatment for a few months (consistent with their coping strategy prior to having any coverage).  But this could be exaggerated by insurers who are applying for rate increases.  Opacity abounds in this system.  

BCBS in one of its rate increase filings to the state bodies said that 5% of policyholders incur 75% of their cost.  That's consistent with what I saw in employer plans before they all start pushing their employees to the exchanges instead. 

Aemon - the only rational structure is single payer with a private option.  Health care does not fit a market system.  Of course the intent of ACA was to expand coverage, but there was deliberate dishonesty about the extent of cost and who would bear it.  (Ariadne - most of the added cost is borne by the original pool of insured; the direct tax contribution is negligible).  

ACA creates a surge in demand of new consumers with no responsibility (they can consume an unconstrained amount of treatment with no responsibility for their own contribution to their health care needs, e.g. lifestyle factors) while the suppliers to the system are able to set prices as high as they want.  The people footing the bill have zero ownership over the situation, and can even opt out of the system as their own personal threshold for acceptability is breached.  It is guaranteed to become a spiral unless the system is changed. 

[Ariadne23]

Lots of new info for me there, thank you. Guess I'm pretty much in agreement.

[ThinkerX]

So I shall repeat my question to Kalbear for the other posters in this thread.

At this rate, unless significant change occurs, we are looking at the collapse of several major insurers by decades end.  Would you support bailing them out, as per the TARP act? 

[Ariadne23]

Some of the focus on lifestyle choices may stem from the fact that screening and counseling for smoking, obesity, addiction, and STDs are 100% covered, pre-deductible, as preventative care, while care for other conditions are not.

They maybe is not wholly fair, or good policy.

But my medical expenses last year were so high that I was actually able to take the deduction for spending over 10% of household income on them, so I freely admit a certain amount of bias and general pissed off-ness at the current situation.

[Altherion]

27 minutes ago, The Great Unwashed said:

Obamacare could very likely have been the worst of all possible compromises, but one thing it has done is ensure that any conversation about reforming health care will absolutely not be able to include an argument for returning to the status quo. Any such national conversation will have to include the people who were excluded from the former system.

Are you sure? I agree with you that the previous status quo is highly problematic, but Obamacare itself is also highly problematic and any alternative to it is likewise problematic. More specifically, Obamacare was a massive wealth transfer from the middle class to health care providers, insurance companies and the poor. You are saying that the poor will defend Obamacare and this is certainly true. However, there is a limit to how far one can squeeze the middle class and there is nothing obvious preventing the insurance companies from testing this boundary. Furthermore, it is not clear that all the poor will continue to benefit: as has been discussed in previous iterations of this thread, there are now several areas which are close to being with no insurance provider willing to service them because it's just not profitable.

What I believe you are alluding to is that if Obamacare continues on its current path and ultimately becomes unsustainable, there will be impetus for a more socialized form of medicine such as a public option or price controls. However, keep in mind that anything of the sort will be strongly opposed by the insurance industry and health providers so it's also not likely to happen. Thus, our current situation is a current status quo which screws over the middle class and is quite likely unsustainable, a previous status quo which screws over the poor and any option which doesn't screw over a large sector of the population strongly opposed by powerful forces. It's not at all clear who will prevail should changes be inevitable.

[sologdin]

2 hours ago, The Great Unwashed said:

many of them are in poor health because they were shut out of the insurance system for years, and in some cases for decades, so that healthy people could enjoy reduced insurance costs. Those premiums that middle class people were used to paying were only able to exist because the externalities for those particular price points were pushed off onto people who were deliberately excluded from the system by insurance companies. 

ZOMG this. and of course a rational society doesn't feed itself poisons and then complain about being poisoned.

[Inigima]

I agree with Iskaral that healthcare is fundamentally incompatible with a market-based system, and have agreed since the ACA was a twinkle in Obama's eye. I appreciate that the ACA has allowed access to healthcare for those previously shut out of the system, but I really think single-payer is the only practical way forward.

[Ariadne23]

If nothing else, in the meantime, I just want to be able to not lose any unused funds in an HSA at the end of the year. Is it that way with FSAs as well? Honestly I cannot keep up with what's what.

Single-payer would be great.

[Aemon Stark]

3 hours ago, Ariadne23 said:

Some of the focus on lifestyle choices may stem from the fact that screening and counseling for smoking, obesity, addiction, and STDs are 100% covered, pre-deductible, as preventative care, while care for other conditions are not.

They maybe is not wholly fair, or good policy.

These are basic primary care-level screening issues. What "other conditions" do you have in mind? 

I find these continual points about "lifestyle choices" troubling. 

[Iskaral Pust]

Aemon - "lifestyle choices" has become the polite euphemism for the obesity effect on health care consumption and costs, especially Type 2 diabetes and consequent problems like strokes, amputations, etc that require lifetime care and medication and, unfortunately, are often coincident with patients who don't correct their diet and exercise regimens as urged by their physician and thereby progressively worsen their condition.  You're a doctor, I'm sure this isn't a shock.  For working age people, obesity is one of the largest factors increasing the utilization and cost of health care.  If it is largely/partially self-inflicted (depending on circumstances of the individual and judgment of outsiders), should that cost be borne by others?  Same applies to smokers with lung cancer. 

For the elderly, the bulk of the cost is still tied up in prolonging the last few months of life -- generally in great discomfort -- for people who are clearly dying.  But that's a whole other topic this country is unwilling to tackle yet. 

 

Ariadne -- HSA's do roll over.  Contribute every cent you can to them because you'll need that tax-free accumulation to help pay your medical costs in retirement.