As I’ve mentioned before, I am the family “insurance guy.” I’ll get all sorts of questions about health insurance and how to work the system as well as possible. Last night I was on the phone with my little brother for an hour going through his open enrollment packet for work. He is looking to cover himself and his wife, and they are hoping to have a cousin for my kids sometime in the next fifteen months.
Insurance is confusing. This is their first open enrollment as a married couple. Additionally, his company decided to use a private exchange for the first time this year. That exchange has forty or more plans on it. He hit choice overload, and gave me a call.
He wanted me to tell him that Option 16 or 27 or 33 was the option he should choose. I can’t do that as making that type of choice is a massive set of value laden weights that varies depending on personal situation, health, expected health, risk tolerance and location. Option 16 might optimize on my criteria, expected health situation and my ability to take a surprise hit but Option 16 would have too narrow of a network for my sister in law.
So we talked for a while and presented a variety of scenarios that I wanted him and his wife to talk through before we talk again later this week. None of these scenarios are dispositive, they are designed to elicit the boundaries of an acceptable decision space.
Here are some of the questions that I wanted him to think over, and I think are useful as people look into open enrollment:
- Do you prioritize lowest possible monthly cost or lowest possible maximum cost or do you have a different cost optimization heuristic?
- Do you have the ability to take a $2,500 surprise expense through either cash on hand or cheap credit?
- What is your company throwing into the pot?
- How much of a deal breaker is an extra $50/month for Plan A versus Plan B? What is the deal breaker/indifference price point?
- Does your company partially fund an HSA for high deductible plans?
- How important is it for you to keep the same physical therapist for the next time you do something that reminds you that you are not eighteen anymore?
- Besides possible heavy Ob/Gyn usage this year, do you have pre-exisiting medical relationships/conditions that will need a lot of care?
- Does SIL have an established Ob/Gyn relationship or is that up in the air right now?
- If SIL has a typical, non-complicated pregnancy do you care that you are heavily steered towards a community hospital for labor and delivery instead of a top flight OB/Gyn hospital?
- If SIL has a complicated pregnancy do you care that you are heavily steered towards a community hospital for labor and delivery instead of a top flight OB/Gyn hospital?
- If you catch a case of 1 in a millionitis and the best treatment center is Mayo Clinic in Minnesota, do you want to be able to go on FMLA for three months to live with our cousins who are 10 minutes from Mayo and get treated there without concern OR do you want to be restricted to a world class medical center in your time zone that is only #10 in the world at treating this particular 1 in a millionitis?
- Do you have a PCP? No, then go get one you young idiot (that is just me speaking as an older brother)
There are a lot of value trade-offs in those questions. Being able to discuss and answer those questions honestly creates the accepted solution space, and from there, it is a much easier search routine. And the solution space that my brother and his wife find will be very different than the solution space my wife and I would find as we have a different situation and a different set of constraints than they do. But these are the types of questions that need to be thought about before buying health insurance during open enrollment either through work or through the Exchanges.
James Hare
just another argument for single payer. People are demonstrably terrible at making these sorts of judgments and with health insurance they’re dealing with imperfect information and a compressed timeline for making decisions. There’s no true price transparency for any medical services so just figuring out a reasonable baseline is difficult let alone planning for emergencies. The current system still seems designed to cause medical bankruptcies.
Richard Mayhew
@James Hare: Single payer can be confusing as hell as I would imagine that a US single payer system or Medicare for all will have its own combination of deductibles, co-pays, allowed amounts, proscribed services and other things that Medicare already has. Single payer solves some problems (mainly putting some serious pricing pressure on providers) but it is not a panacea for all problems.
Ohio Mom
Half of all people have below average intelligence ( not an original observation, that is taken from an old joke about doctors). The deck is very stacked against them when it comes to stuff like this.
Jim
The ACA has really brought out into the open the problem of “choice,” for better or worse (I think it’s a little of each). I’m on Medicare now. It does have choices, for supplemental plans, but those choices are relatively narrow, and they’ve been government-vetted for reasonableness. As a result, it’s been fairly straightforward for me to choose among them. Although the ACA choices also seem narrow (platinum, gold, bronze, lead), there are more participating insurance companies, and — it looks to me — vast differences in costs by state. I have a feeling things will settle out in the next few years, with the range of choices narrowing, making selection easier. But we’re definitely not there yet.
JPL
@James Hare: Trump mentioned, during the debate, how difficult it was to navigate different plans for his employees across state lines. That’s either another case for single payer or Tom Price’s plan. Price’s plan to shop across state lines is disastrous because it would be dependent of what services the insurance companies offered. Because of time constraints, he didn’t explain his solution. The media certainly hasn’t mentioned this part of the debate.
Davis X. Machina
Unpossible. I’ve been told the opposite right on these internets for a decade.
Did you know it would save so much money we wouldn’t actually have to pay any premiums? All paid by sin taxes.
Also, it’s the same thing as a public option.
Before the internet I was so woefully informed….
rreay
How are we supposed to make an informed decision with or without a brother like you? The answer, as best as I can tell is that we’re not supposed to
Last enrollment I had to decide between the just 4 plans my company offers. I figured I’d make my decision based on the in plan price of a very expensive prescription my wife takes, any other regular expenses are in the noise by comparison. That that one prescription could hit the out of pocket limit on a high deductible plan. Funny thing is that everyone I was able to reach was unwilling or unable to tell us what that cost would be until after we enrolled.
I eventually just said fuck it and decided that the potential price difference wasn’t worth the time or aggravation and rolled dice for a decision.
This of course means that the plan the dice chose wins. Next year unless there is some obvious difference we’ll just stick with what we have in order to avoid the pain of changing. I hate to give any of them a long term win over shit like this but I don’t see any other option that keeps me sane.
Chris
@rreay:
Yep.
As noted a few days ago, it’s amazing that there isn’t more public outcry over that.
Mnemosyne (tablet)
@rreay:
I take a couple of daily prescriptions (asthma and ADHD) and the first year was easy: I chose the HMO plan at work that had a $4 copay for generics instead of the one that had a deductible. The second year was a little harder to decide, because they added a prescription copay to the PPO plan. I may go back to the HMO next year because I really don’t like having to pay a percentage towards my deductible for regular (required) appointments — I’d rather have a copay.
rikyrah
thank you for your information. I’ll repeat it _ have learned more about Obamacare from reading your posts than pretty much any other place on the web.
Richard Mayhew
@rikyrah: First, thank you.
Secondly, these are not Obamacare specific questions.
These questions, or questions like them should be asked for any health insurance scenario in this country with the possible exception of the VA These questions should be asked for Medicare, they should be asked for employer sponsored coverage, they should be asked for Exchange, they should be asked for the Medicaid managed care, they should be asked for CHIP, they should be asked and thought about to figure out what your personal deal breakers are, what constraints you face, and what things you’ll trade away some of X to get more of Y.
Steeplejack
@Richard Mayhew:
Exactly. Just as an example from this post, how would “single payer” handle the question of whether you get to go to the Mayo Clinic or to that tenth-best treatment center?
Somebody will be making the decision, but it probably won’t be the patient. And then cue the cries of “Rationing!” and “Death panels!”
MPAVictoria
“Single payer can be confusing as hell”
Only if you want it to be. Seriously. Come to Canada. It just works.
RSA
@Richard Mayhew:
I had that same thought–great questions. Also, having recent experience with financial advisors and lawyers, I realize that a medical insurance advisor would be a good person to talk to; I guess that would be an insurance broker. I suspect there are hundreds of thousands of people in the U.S. who would be better off if (a) they could consult with such professionals and (b) such professionals were generally available.
Richard Mayhew
@MPAVictoria: I agree, if there is a political will to actually provide decent public services to the public, then single payer is not too complicated (show the Ohip card or whatever the provincial ID card, and wait until your name is called)
However, in my cynical judgement we, as Americans, are way too enthralled with choices so we’ll find ways to make it very complicated (look at US Medicare Part A, B, C and D plus supplementals).
Spring Texan
@Richard Mayhew: @Richard Mayhew: You are exactly right. It needn’t be complicated, but your cynical judgment on target and every iteration of anything in our healthcare system makes stuff even MORE complicated. Which is not fun for policyholders, programmers, or medical insurance workers but which creates a lot of jobs and runs up expenses.
“Choices” are way overrated.
Spring Texan
I also relate because I am MY family’s “insurance guy”.
Nutella
@rreay:
It’s true this is hard to do, but it’s a million times easier now than it was before Obamacare because now at least we have some idea what services are included in a given plan since Obamacare mandates the same list of services with the same descriptive language. Now you only have to struggle with the payment variations — not easy at all, as you say, but easier than it used to be.
Thoughtful Today
Please consider supporting:
Medicare Part E, Medicare for EVERYONE.
^ Currently supported by one Democratic Presidential candidate.
https://BernieSanders.com
…
I’ve personally seen Britain’s socialized medicine system in action, it was fast, effective, and compared to our Rube Goldberg profiteering system, far more efficient.
A in Ca
When I had to decide on a plan last fall for my family, I found that one Company BCBS had on their web site something like 37 different plans. At least, one could distinguish between Bronze, Silver, Gold plans (with the difference in deductible about the same as the difference in premium over a year.) Of course, it was impossible to figure out what paying an additional $5 (or 50, or 100) in monthly premium (for same level plan) would actually buy you.
Telephone ‘adviser’ for insurance company of course always recommended a higher-priced plan (and NOT buying through Obamacare/CoveredCA), with the argument that its network was wider, but of course could not say which doctor is in-network.
An insurance broker always recommended a plan looking exactly like one on insurer’s web site, but $30 more per month, so I guess that is their commission, although they claim that their services are free/covered by the insurance company The main difference between plans is often which doctors are in-plan or out-of-plan; if you already have a doctor, of course, you can ask him. (Luckily, none of us was sick recently, so we don’t know.)
Then the two local emergency rooms accept most plans, but warn that the doctor on shift may be out-of-network. So when you are on a stretcher in the emergency room, are you to tell the doctor to better call his colleague who is in-plan for your insurance (to avoid financial ruin)? Bizarre.
By comparison, my recent Medicare (supplement plan) enrollment was fairly simple, and choices somewhat clearer, with assurance that there was a minimal level of service.
So any given day, I’d vote for Medicare for all. If people less than 65 could enroll, at cost averaged out over their age group, it would be competitive, and save the nation millions.
(Now you hear occasionally about people deferring treatment until Medicare-eligibility, which of course, makes the eventual treatment more expensive.)