The ACA choice space is a mess. In some counties in 2023 on Healthcare.gov a single insurer offers more than twenty bronze plans. There can be substantial within insurer and metal level domination possibilities happening.
I’m going to pick on Tuscarawas County, Ohio because that is where my in-laws live and I visit the county a couple times a year. AultCare offers twenty one bronze plans. They are all EHB only so the entire premium is eligible for subsidy. Some of the plans are priced massively below benchmark so for a single 40 year old, an Ault Bronze could be zero premium up to 250% Federal Poverty Level (FPL). Other plans are priced above the benchmark so there is always a net premium.
For the plans that are priced so that an individual could see a zero premium plan, there are a lot of options. There are plans with an $8500 deductible, other plans with $7000 deductibles, a few plans with $8250 deductibles. Each of those plans come with and without pediatric dental services. The inclusion of pediatric dental benefits increases premium by a few bucks. Between these plans, they all share the same insurer, the same network, the same customer service center, the same formularies for prescription drugs. They share a lot. They vary on benefit richness and premiums. And if someone is seeing multiple zero premium plans, premium is irrelevant within this subset of choices.
So how do people make their choices? Are people who are enrolling kids picking the pediatric dental versions while the no-kids on the policy folks picking the equivilent policy without the pediatric dental benefit as that benefit is worthless to them? If people are seeing both the $7000 and $8500 deductible versions at no premium, are they picking the $7000 deductible for a richer benefit at the same cost?
This is messy as hell and it is just within a single county and single insurer. I strongly suspect that dominated choices are being routinely made which increases individual exposure to cost-sharing and leads to higher premiums collected by insurers.
I suspect this mess works to increase bad PR for Obamacare. People end up feeling ripped off because something ends up costing more than they expected (their expectations don’t have to be realistic). And they complain loudly to their friends and family and the antipathy for the ACA grows.
There’s plenty about health care that leaves me feeling ripped off but I have enough of a financial cushion to bear it and enough cynicism to expect it.
@Ohio Mom: Agree. That said, I suspect there is a small subset of folks who know they couldn’t have afforded any insurance and/or who had a pre-existing condition. I would also note that “more expensive than I thought it would be” was already a feature of previous health insurance; we’re conditioned to expect to be screwed. The days of fabulous health insurance benefits were already gone.
I remember that one of the “arguments” against ACA was that it would get people used to being able to get insurance, and we may have passed that horizon–which, with any luck and effort, will lead to people agitating for BETTER options rather than for eliminating the ACA. Yes, I am dreaming.
Damn, I was hoping for some Iron Maiden! 🎸🤘
@Ohio Mom: Completely agree. When I published my first dominated plan choice paper, a grad student reached out to me for a very productive Zoom session on their idea on how do people react when they realize that they were screwed retrospectively.
Is some of this – create multiple slightly different / kinda similar plans – simply a way to get more visibility on Healthcare.gov? “This company has 15 Talc plans, they must be big and comprehensive, I probably should pick one of them.”
Would it make sense to tell the companies – “Quit spamming Healthcare.gov. You can post a maximum 3 plans per metal band per county and that’s it.” Would that work? Any down-side?
Thanks for all you do.
Yeah, I was thinking that would be an apropos title for a debate about who were the real guitar gods of heavy metal music. :-)
@Another Scott: WHY YES, YES INDEED
Multiple projects are in the pipeline about things you’ve mentioned in your comment… more to come later.
@David Anderson: Another tool that might be helpful for folks: set up a questionnaire that results in filters/ranking. There are already some filters on healthcare dot gov but I could see making those filters better able to address specific issues. I was able to find what I wanted, because I dig into these things, but, as others note, I can see being overwhelmed pretty quickly.
Relevant to the confusion of choices — I was left behind by the jargon starting with the second sentence.
@rm: By “domination”, David means paying more for a plan than one that give the same or better objective benefits. The plans are structured by too many insurance companies to confuse buyers and make them pay more than they should.
@narya: On one hand, in Canada everyone expects to have insurance but they often complain that it should be better.
On the other hand, all I ever hear from my fellow Americans about the Canadian system is negative propaganda they’ve internalized. So I think a special cultural quirk of Americans makes it impossible to have nice things — if it’s imperfect that means government can’t do anything.
@narya: There is something like that for Part D plans. You go to the site, you type in your Zip Code and the meds you take regularly. The site then lists your options and you can see what is the best deal for you.
(I admit I leave this to Ohio Dad who Loves, Loves, Loves anything automated. Who am I to deny him his pleasures?)
So this year I’m using Mutual of Omaha and the CVS a mile away. This fall we will repeat the process. Maybe I’ll keep this set-up, maybe I won’t. I am attached to my pharmacy staff though. Depending how things shake out, it might be that I consider paying a bit more to keep them.
For anyone not yet of Medicare age who is wondering, “Yeah that sounds fine but what happens if in the middle of the year you need to start taking a new drug that you didn’t include in the list?” Yup, that’s one of the reasons I shake my head No whenever someone says Medicare for All! I say, MedicAID for all.
@narya: Pretty much anyone over 50 has a preexisting condition whether they know it or not. So I don’t think it is a small subset.
Before ACA I paid for insurance for about four years before they dropped me for a not serious pre-existing condition that I had told them about when I applied for the insurance. They were fine with accepting my premiums until I eventually went to a doctor and tried to run the bill through my insurance.
@Ohio Mom: I am eligible for Medicare in July–but I don’t currently take any meds, which is what is making it a little challenging for me. I figure I’ll go with CheapPlan for the remainder of the year . . .
@sab: Yup. I got rid of my (known) pre-existing condition last year, so I am, for the time being, at one end of the bell curve. Even though I was last trying to get insured, pre-ACA, in 2006, the absolute terror of it sticks with me. I was working in the bakery, so also at risk of physical injury of some kind (got lucky there, too).
I hope that, as people’s work lives change–e.g., one is unlikely to spend 40 years at the same company, which has excellent health insurance coverage–that the agitation for continual improvements continues
ETA: and by “improvement,” I also include the original post, i.e., a better path through an absolute thicket of choices, without a clear understanding of the real differences among those choices.
Anonymous At Work
If this is PR (negative for Obamacare, and positive for smaller insurance companies), is that why the countries in your chart are not the dominant markets, like Franklin, Cuyahoga, or Hamilton in Ohio, for example? I see Wayne in MI and Waukesha in WI and the closest to large counties in Nebraska, but every other county on the list is large town~ish rather than metropolitan.
@narya: Every state has an agency that provides assistance with navigating Medicare choices.
Here in Ohio, my local Council on Aging put me in touch with their volunteer coordinator, who matched Dad and me to one of her volunteers. We met him at the library and he gave us a tutorial on all our options. Without a sales pitch, which is a danger when you use an insurance broker to tutor you.
You probably have a Council on Aging or similar organization where you live. As Sab says, it’s unusual to reach Medicare age without a known pre-existing condition but you can’t be the only one and whomever you talk to should know how to help you pick a Plan D (if you go the traditional Medicare route instead of an Advantage Plan).
@sab: Your comment reminds me of the joke where the older doctor asks a medical student, “What do you call someone who is perfectly healthy?” “I don’t know.” “Someone who hasn’t had a full work-up yet.”
@Ohio Mom: You’re so right about if you need to add a new medicine. My recent experience is that the company (Humana) dropped/lessened coverage for an existing med. $50 for 3 months has jumped to $600 for 3 months.
The “Medicare for All” folks don’t know what they are talking about.
The Kropenhagen Interpretation
@skerry: Not to say there’s a fully fleshed-out, agreed upon plan; but I’m pretty sure the Medicare for All folks aren’t envisioning something primarily administered by for-profit business.
Ok there is no WAY “Within Metal Domination” is about INSURANCE. It’s OBVIOUSLY an AC/DC album. Sheesh…
@Ohio Mom: So true.
Everyone has the pre-existing condition of living. Some have more because they are human animals and animals are never perfect. Ever. Those of us who make it into the eighth decade and beyond will almost always have them, as the nature of aging, and wearing out. Of course we have Medicare, which mostly helps but which is almost always never enough. It is a tough call this health insurance thing because life comes at all of us and we never know which way it will swing. Now, add on the health insurance not give a damn about actual healthcare industry and everything about it is a hot mess. The ACA cleaned up a bit of that, until the companies figured out how to screw that up, which is to overload most people, giving them so much choice that making a good one is almost impossible. So what we end up with, in this society is endless choice, with many hidden pitfalls, that costs way too much and screws the customer 17 ways from Friday. Does any health care insurance company make this easy? Of course not, that would cut into that bottom line, that one marked profit. And yes I’ve owned 2 companies and fully understand that a level of profit is necessary to stay in business. But screwing the customer to get there is not the way to be any kind of decent company. So name me a health care insurance company that doesn’t use screwing the customer to make a profit.
@Ruckus: Absolutely. Three things should NOT be for profit, IMO: health care, education (at least through high school, arguably a bit beyond), and prison/corrections. We could argue about some others as well, but those for sure.
All I have to do is look at my parents: between the two of them, a quadruple bypass, two replaced knees, seven fused vertebrae, COPD, dialysis followed by a kidney transplant, hearing aids, and bladder cancer. They have good insurance (thank you, sheet metal workers’ union) and can afford anything not covered by that, but they are the exception. And they SHOULD NOT BE.
@skerry: Holy Moley, that’s a big jump. I had no idea something like that could happen.
IF all goes well, Biden’s plan to limit Medicare out-of-pocket drug costs to $2,000 a year should kick in in 2025. Just two more years…but it could be a long two years for some of us.
@The Kropenhagen Interpretation: Well that vision of theirs is incompletely imagined. They are probably decades too young to actually have dealt with Medicare (why Bernie does not know better is another question).
Ohio Son has traditional Medicaid and it is the best coverage any of the three of us has ever had. Now the state of Ohio would like to push him into a Medicaid HMO (the better to allow the legislature’s friends to skim money) but so far I have been successful in fending that off.
The Kropenhagen Interpretation
@Ohio Mom: I just wanted to distinguish between people who just use Medicare for all as a slogan and people who literally want to expand specifically Medicare to cover everyone.
I agree, Medicaid for all would be immeasurably better. Not Medicare age, just work with insurance a lot.
Would some technical changes be enough to handle this sort of plan spam, or are we stuck with this going forward? What about a rule that would say that an insurer cannot offer more than, say, 3 distinct plans per metal class. Sure, there *might* be four options, but unless we have some kind of limit, it looks like we’re drowning here.
@Jesse: there is a proposal in the current NBPP-2024 to go to either 3 or 10 plans per carrier per metal per network