
Obamacare’s sinking safety net - mkane848
http://www.politico.com/agenda/story/2016/07/obamacare-exchanges-states-north-carolina-000162#ixzz4EHzkVt8w
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noobermin

      Before the ACA, there were a handful of ways insurers could balance their risk 
      pool. One big tactic was just to avoid covering sick people, filtering out
      individual customers who appear likely to need lots of expensive medical care.
      But Obamacare made that type of discrimination illegal: One big selling point
      of the law was that everyone would be eligible to sign up.
      

Companies that profited off of denying helping people with pre-existing
conditions are finding they can't profit anymore? Allow me to play a little
ditty on the world's tinniest violin for them.

The honest reality is that these costs did exist before, it's just they were
paid by the sick in our society by dying, while the health insurance companies
skimmed off the cream from the healthy. No free lunch, right? So this cost
existed, only by law, it was pushed onto the healthcare companies after the
ACA

It is quite bad though, as the article details, costs have reached 100% of
premiums at least in NC it looks like. That is unsustainable, and since the
ACA went ahead with requiring healthcare companies to help pull this off,
without something like a public option to cover say the super sick, this isn't
good news.

All around, this is a bad. But it's not like ACA made it worse, it just made
the costs appear somewhere else, and as the article states, absent of any new
policy, that cost will shift back to the sick who will have to die again.

~~~
belovedeagle
> denying helping people with pre-existing conditions

This is literally the definition of insurance: insurance is a pool of risk,
entered into by a large number of people _who have not incurred a certain rare
circumstance_ , against the possibility of them encountering that
circumstance. This isn't insurance companies being greedy! What if all
insurance worked this way?

~~~
jmiwhite
Health insurance is different from most other forms of insurance, though -
auto insurance, for example, doesn't pay for oil changes to mitigate the risk
of expense of future liability claims.

~~~
ZeroGravitas
At least in my country it is very common for auto insurance companies to pay
to have windscreen chips repaired, as it's cheaper than waiting for the whole
window to fail (possibly causing am accident in the process).

~~~
jmiwhite
True, but that's still not preventative any more than a tooth filling is
(Sorry, switched industries, but I think it still makes sense).

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hardcandy
As a self-employed developer I have an ACA plan and I can tell you first-hand
it feels like a total fraud. I pay $300/month but also have a $6k deductible,
which means the plan doesn't really pay for anything until I've already spent
$6k out of pocket. I have no problem with a $6k or even $20k deductible
because I work hard to remain healthy but then my premiums for what is
essentially a catastrophic policy should be much lower (around $75/month).
Fortunately I can afford the extra amount, but I can see how it would be
extremely painful for a family at the median income. My MD friends tell me the
economics are based on people who work diligently to improve their health
subsidizing people who could care less and actively sabotage themselves (e.g.
non-compliant diabetics who eat like crap and don't medicate...not even
diabetics as a whole). Unless and until the conversation about personal
responsibility starts it seems hopeless. Whatever Obamacare started out trying
to be, it has been twisted into something else and badly needs reform.

~~~
karmajunkie
Just out of curiosity, when did you make the move to self-employment and the
individual exchange?

I was self-employed for years prior to the advent of the ACA, and my
experience was that my premiums were about the same, deductibles were the same
or higher, PPOs were out of the question, and I was rolling the dice on
whether I could even get coverage for myself or my family because of
preexisting conditions. If that market were in place today, getting coverage
would be an impossibility for myself and my wife, who is a cancer survivor,
leaving us to the high-risk pools where the premiums would be in the 5 figure
range annually.

Yes, the ACA has some problems, but if the right wing in Congress hadn't been
so hell-bent on making it fail to the detriment of all constituents, chances
are we'd have something that works a bit better (if still imperfectly.)

~~~
hardcandy
I've been self-employed for about a decade. Prior to ACA I had catastrophic
insurance with IIRC about a $10k deductible for 25% of the ACA cost. But I was
a healthy, non smoking male in my mid 20s (back then) with no pre-existing
conditions. If you had pre-existing conditions then it doesn't surprise me
that your ACA rates were the same or lower, which illustrates what ACA really
is: a subsidy (tax) helping out the (mostly) old and (mostly) chronically ill
paid for by the (mostly) young and (mostly) healthy. I prefer not to think of
it as red-versus-blue partisanship and instead in objective economic terms.
Personally I have no problem subsidizing people who are born with chronic
illnesses, or fall on hard times; I have a few cancer survivors in my
immediate family and I've seen the impact it can have. But I don't think that
we should be subsidizing people who have diseases borne of negligence (adult
onset diabetes and other obesity related diseases) who refuse to do anything
to help themselves and as a result consume extreme amounts of health care
resources. It's becoming clear that for the time being at least demand far
exceeds supply in the health care services market, and that means having to
decide how and when to ration care. I can afford to pay inflated ACA rates and
I can afford to pay for private concierge-style care in the face of a supply-
demand imbalance in the market. But what about the middle class family making
$50k/year who is now spending 20% of their net take home income on health
care? Unfortunately there aren't many easy answers in this debate and it's
especially difficult to even start the discussion given how polarized it has
become.

~~~
rogerbinns
Why should people who live further north have to subsidise those in more
southern sunnier climate and are more likely to get skin cancer? Why should I
as a non-rock climber subsidise those that do? Why should those without
children subsidise those who do? Why should those in walkable cities subsidise
those who drive more in less walkable ones? Why should those who have taken a
vow of abstinence subsidise those who haven't? For virtually everyone there
are always some discretionary choices they make that increase their health
risks.

There is a fix, but it involves government taking a big picture view. Stop
subsidising bad food, and ensure people have as good access to "good" food as
they do to bad. Provide youth centres and similar community access to places
where people can get into the habit of exercise. Examine transit and see how
to get people to spend less time sitting in cars. See what can be done about
improving the quality and happiness of all citizen's lives. All of this isn't
instant or a magic wand, but is something that can collectively help a lot
over time.

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qserpent
I don't know anything about the details of this situation. But maybe someone
else here does.

How is the US so inefficient at healthcare? We spend more per person (or per
GDP?) than many (most?) other countries and we get less in return.

Where is this money going?

~~~
snuxoll
Administrative fees, paying too many MD's to do work that PA's and NPP's could
accomplish if they were allowed to, as well as paying high salaries because
our education costs have skyrocketed so we have people leaving school with
tens to hundreds of thousands of dollars of debt to enter the medical field.
People abusing the emergency room (especially Medicaid members) for the
sniffles instead of going to an urgent care or a family practice.

Oh, and let's not neglect that hospitals have no choice but to jack up prices
to insane rates because insurance companies will just negotiate them down
heavily.

The whole system is messed up.

~~~
jjnoakes
If the insurance companies are successfully negotiating the prices down so
low, shouldn't they have more money?

~~~
snuxoll
This part only affects the _underinsured_.

Let's say you have some crazy medical test, like an MRI. It costs roughly
$2,000 to run the test (totally random number out of my hat). If a hospital is
negotiating a contract with an insurance company, and says "An MRI costs
$2,000 here" the insurance company will say "We will pay you $500".

So, to make sure they can be correctly compensated by insurance carriers they
instead say "An MRI costs $8,000", the insurance company will then say "Okay,
we will pay you $3,000". It's total luck to get the correct amount, so you
will usually WAY over compensate and end up getting more than you NEED to be
reimbursed in return, just to provide a safety net for insurance carriers
messing around with you.

Under most cases people with amazing low-deductible plans are fine, they pay
their $500 deductible for the year plus 20% of the remaining and make off
quite well for the procedure. People with high deductible plans (like mine)
get screwed, I would end up having to meet my $2,500 deductible and _then_ pay
20% after that (up to my annual out of pocket max, which is $5000).

Because hospitals have to play this stupid game with insurance companies, it's
rare that you can get charged the "real" price of any procedure or lab time.
People without insurance can negotiate extremely discounted rates based on
financial need, but if you are _under_ insured you are stuck with whatever
contracted rate the facility has with your insurance company.

~~~
toomuchtodo
Why don't insurance companies own the vertical and purchase healthcare
providers, in order to control costs?

It seems like cost controls are the root of the problem.

~~~
snuxoll
Some do, they're called HMO's (Health Management Organizations), Kaiser
Permanente being a prominent one. A lot of people don't like having to see a
doctor not part of the organization without going through headaches, however,
which lead to the prevalence of modern PPO's.

~~~
dragonwriter
> Some do, they're called HMO's (Health Management Organizations), Kaiser
> Permanente being a prominent one.

KP is an HMO, and does own its provider network rather than contracting with
providers (for most things, at least), but that's not a defining
characteristic of HMOs. Many HMOs have contracted, rather than insurer-owned,
provider networks.

~~~
wahern
But the issue is still the same: the network of doctors you can see is very
much restricted. And in any event, the way Kaiser is structured (at least in
Southern California, where a friend is a Kaiser doctor), the doctors are
employed by separate legal entities which contract with the hospitals. So it's
kind of a distinction without a difference. HMO implies vertical integration
where incentives line-up differently than when providers and insurers are more
at arms length.

That said, PPOs also have in-network restrictions. They're looser, but PPOs
are also often significantly more expensive.

In my limited experience, it's not the network restrictions per se, but that
people want to continue going to a specific doctor or to a specific hospital.
My relative who is a partner at a law firm rails against Obamacare because of
the ridiculous premiums her firm has to pay. But they only pay those premiums
because she demanded a policy that allowed her to continue seeing the same
doctor she's seen for over 20 years. She's smart and almost always votes
Democratic; the cognitive dissonance in her rants would be comical if it
weren't for the fact that so many people exhibit that kind of thinking.

I use Northern California Kaiser and love it. For one thing, it's ridiculously
inexpensive, all things considered. And I don't expect the kind of
relationship with my doctor portrayed on television. Kaiser is very
technologically savvy and data driven. (Though that doesn't mean they used the
latest & greatest tech). Their doctors are disciplined to attend to patients
efficiently. I've never felt rushed or anything of the sort (even during the
48 hour birth of my son), but neither the doctors nor staff will linger
unnecessarily.

But because Kaiser works as a holistic entity, some people may feel neglected.
Kaiser dis-intermediates you from the doctor and his personal staff.
Appointments are booked on the web or via a call center. For illnesses, you
first contact the Kaiser nursing call center, where a nurse and on-call doctor
will do a preliminary diagnosis over the phone and often even write a
prescription. For common injuries like sprains, etc, you might be scheduled to
see a doctor at their sports injury center or similar specialized department,
which at my medical center is conveniently (and I doubt coincidentally)
located across the corridor from the imaging department. Follow-ups with a
doctor will often use their electronic messaging system (basically, web mail).

I _love_ that aspect of Kaiser because I appreciate the effort that goes into
reducing costs and improving outcomes. For people who want to feel coddled by
their doctor and his staff, or use them as an outlet for their anxiety, it's
probably a nightmare.

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ozy23378
Politico.com :D

