Commenter The Moar You Know is telling a story that we’ll hear more this fall as his company’s rates spiked:
We lost our grandfathered status with UHC. Today we got the bad news. Looks like Bronze for us unless we’re willing to eat a 40-50% premium hike; even if we were willing, we can’t. We don’t have the money.
I really don’t want to sound like one of those guys, but I will: this is not what I expected Obamacare would allow. I don’t know what’s happening with larger employers but this small company is not happy today.
There are two components of the price increase. The first is medical trend which is just a fancy word for the cost of services rendered. That probably would explain a five to ten percent hike (I can’t say more without seeing claims data, and I really don’t want to look at claims data….). The second is mostly PPACA related.
There are two PPACA related themes that contribute thirty to forty points of the rate increase. The first is enhanced benefits. This is the coverage of maternity care, this is the removal of lifetime limits, this is allowing adult children up to age 26 to stay on a parent’s policy. Preventative screenings are also part of this deal. However, these enhanced benefits probably only add slightly to pricing.
The most important part of TMYK statement is that his plan lost grandfathered status. This explains most of the price increase. There are two types of grandparented plans. The first are the grandfather plans. These are plans that were in existance before PPACA was signed. People and companies who had these plans were allowed to renew these plans as long as there were no substantial changes (no benefit changes, co-pays barely moved, deductibles constant etc). Insurance companies were free to offer these plans or pull these plans at will. The grandfathered plans are a declining segment of the group/employer sponsored insurance market, and a very small component of the individual market by mid-2015.
Grandmother plans are individual plans that were supposed to go away on 1/1/14 and be replaced by ACA compliant individual plans. The entire furor over the ‘If you like your insurance, you can keep it” produced the grandmother kludge. States were allowed to elect to keep non-ACA compliant plans available to be sold to current policy holders for up to three years. The grandmother plans would be consided adequate coverage for mandate/tax penalty purposes. Some states elected to go full grandmother, others allowed grandmother plans for a year or two, and others just sent everyone to the Exchanges for 1/1/14.
That history is important because the big difference between the grandparent plans and ACA compliant plans is underwriting.
The grandfathered group plans that TMYK had were underwritten on company experience and individual beneficiary medical history. All PPACA small group plans are underwritten against the entire community. This is a massive underwriting change. As I wrote in February 2014 this change has significant distirbutional impacts.
Community underwriting elimintates gender as a factor of underwriting so men now have to bear some of the cost of pregnancy risk. It also spreads the cost and risk of pre-exisiting conditions throughout the entire universe of small groups covered by a single insurer in a state. This is a major change that will have people screaming this fall as rates resort for the 2015 open enrollment period…..
On average, the total cost of premiums to insure the same people in the same groups with experience or statistical underwriting versus community underwriting will be the same. However the distribution of those costs will be wildly different. Groups that are more male and/or healthier in general will see significant rate increases due to underwriting changes. Groups that are more female or statistically likely to be sicker than average will see flat rates or decreases.
My bet is that TMYK’s company was relatively healthy compared to similar companies, and thus they weren’t high utilizers compared to demographically similar companies. Community underwriting means they are subsidizing sicker populations with increased rates.
The TLDR: 75% PPACA responsibility for rate increase.
EconWatcher
We’re going to see that unfortunate quote–“if you like your plan, you can keep it”–once more playing on a continuous loop. In this case, not without some reason, I have to say.
Is there any help available for companies that genuinely would get priced out?
La Caterina (Mrs. Johannes)
If the small groups are going to be underwritten on a statewide basis, why not throw them into the insurer’s underwriting pool with the state’s large groups? Did the PPACA shape the underwriting rules to favor the large groups, i.e. corporate lobbyists?
Another Holocene Human
My employer has an older pool and we’re semi rural with high prices (little legitimate competition) and we’re getting hammered. As a union rep I’m between a rock and a hard place because on the one hand I have people who need the plans and on the other hand I have dozens of employees who came in with military insurance or spouse’s better insurance or who put all their kids on Medicaid (yes, the wages are low). So I can’t bargain to put all the money on healthcare. I talked to the company guy and he admitted that Medicaid expansion getting held up is part of the reason our prices go up and he even volunteered that he’d love to see single payer! Healthcare has turned into a big fat loser for a smallish (1500 employees, 400 retirees) employer.
I think we were grandfathered but brought into compliance.
Richard Mayhew
@EconWatcher: Not really, as it is not a government action causing the cancellations, it is an insurance company deciding to stop offering a grandfathered plan.
Grandfathered plans have an open life span until there is either no enrollment in a particular plan OR the insurer decides, for business reasons, to stop offering coverage. Everyone is used to insurance companies being assholes. This is just another case of a particular insurance company being an asshole. That, I think, is a much easier PR battle to win.
Richard Mayhew
@La Caterina (Mrs. Johannes): If a large group is fully insured (ie the insurance company bears the risk of a million dollar claim) then I think (but I am not sure) that the pool is state-wide, but I need confirmation.
However most large (500+) employers are self-insured. They bear the risk of a million dollar claim (they might buy re-insurance and stop-loss insurance, but they bear the risk.) The insurance company that has their name on the ID card is purely a back-end service administrator without putting their cash at risk. In this case, the risk pool is MegaEvilCorp alone.
brendancalling
I haven’t been able to pay my premium since renewing due to cost increases. But healthcare.Gov now sas I’m poor enough for Medicaid, so I’m waiting on a call from my state office.
Baud
In a healthy political system, this would be the time you look at the ACA and fix the kinks in the system.
Oh well.
Kylroy
I helped administer individual plans a decade ago (they had the same allowance for individual underwriting as small groups), and rates would always shoot up after 5 or so years – maybe not a 40-50% increase, but definitely 20-30%. It involved enticing healthy people into signing up for a new plan with lower rates that required they be re-underwritten, thus allowing massive rate hikes on the people who couldn’t pass underwriting and were stuck in the old plan.
I’d guess most people getting this sticker shock are on individual plans that are at least four years old. In the pre-PPACA days, they could get new plans with lower rates (if they were healthy), but that’s no longer available since insurers are no longer allowed to cherry-pick healthy customers.
hoodie
I wonder if some of this sticker shock is a marketing ploy taking advantage of the ACA. This year, our company got an initial quote from BC that represented a 28% increase. We went to UHC for a quote and got something that was more like 8%, but a different provider network and some benefit differences. Went back to BC with that and they cut their increase to 12% for our existing plan. WTF? Do they plan to make it up in the future, or was 28% some sort of bullshit opening position? We can get the increase down to 4% by changing prescription copays for “non-preferred” drugs. I’m wondering whether we’d be better off with the 12% increase and our current prescription plan rather than going for the seemingly more attractive 4% increase, which is probably what they wanted all along. We’ve played this BC/UHC game several times pre-PPACA, with similar results. You wonder how small companies can effectively bargain considering the massive asymmetry of information in the negotiations.
Betty Cracker
@Baud: Nah, in a truly healthy political system, this would be where we’d look at the amount we’re spending/getting and what the rest of the industrialized world is spending/getting and say fuck this bullshit — Medicare for all.
Another Holocene Human
@Betty Cracker: If that 55+ Medicare thing had passed, that would have been huge. For one thing, it would have provided an alternative to those fucked retiree health programs. For another thing, it would have provided good, affordable coverage to people forced out of the workforce during that age range. It also would long term bring down Medicare prices because Medicare is doing a lot of catch-up work on people who went years without medical coverage.
geg6
I expect to get fucked. The university is self-insured with Highmark administering. I cannot imagine the world where Penn State goes with UPMC, even to save money for itself or the employees but they could prove me wrong. Won’t really know for a couple of months.
boatboy_srq
@Betty Cracker: Agreed. Wonder when the US will stop viewing the GOP as a political entity and start viewing Rethuglicanism as a treatable condition.
ruemara
@brendancalling: I’d say call, my experience with them was having to ask. And then they took it back without a word too.
I’m also sorry the income fell to put you into the Medicaid pool. I know that whole dance of can afford the policy to start, cannot afford it afterwards.
gene108
Could have had some catastrophic claims. This is what happened to us, when we had a similar rate hike in the past.
It does not take a lot to move a small group plan’s premiums from being affordable to unaffordable. One heart surgery, one premature baby, etc. and the premiums go up a lot.
Eric S.
Slightly OT but I had a VERY brief discussion of health care costs with The Girl’s mother this past week. Her opening statement was that insurance companies were raising prices because Obamacare forced them to provide coverage for poor people for free, i.e. no premiums paid.
Three times I told her that her understanding was wrong. That the insurance companies were paid premiums for everyone covered either by the person, the person’s employer for via government subsidies. She absolutely refused to accept it and stopped the conversation with “I don’t want to argue.”
Richard Mayhew
@Betty Cracker: Agreed, and now how do we get there?
FlipYrWhig
@Eric S.:
This is precisely why Republicans oppose Obamacare. That’s what they understand it to be — another form of “welfare” — and they begrudge it immensely.
Derelict
I have had this happen on an individual plan. Before ACA took hold in Vermont, the top-of-the-line plan was costing me $495/mo with a $500 deductible. Upon implementation of ACA (or at least Vermont’s badly bungled implementation), premiums went up 10% while the deductible on direct medical tripled, the deductible on drugs quadrupled, and co-pays were implemented. This year, premiums went up another 15%. Next year, the forecast is for another 25%.
Yeah, I’m not a happy camper.
Kylroy
@Richard Mayhew: Implementation-wise: having been around for the trainwrecks of initial signup for both Medicare D and ACA plans, I always thought the way to expand Medicare was to gradually lower the sign-up age with each passing year. This would prevent a (politically exploitable) logjam from a huge number of new people being added to the program, and would slow changes in the covered population so costs wouldn’t radically shift from year to year.
How to make it happen politically? No clue.
FlipYrWhig
@Betty Cracker:
Do you think American doctors would ever let that happen? It’d hit them squarely in the wallet, no?
khead
@FlipYrWhig:
Yes. Very much this. Even after I explain to wingnuts that my sister – who could not get coverage before ACA – is actually paying for her policy they still think she is waiting for the government truck to deliver free tbone steaks and insurance to her.
Eric S.
@FlipYrWhig:
If her argument had been “the government is giving poor people money” or “the government is paying for poor people’s health insurance” I would have understood the argument. I would have defended the policy on various grounds.
Her argument that insurance companies collect $0.00 in premiums for insuring The Poors was baffling to me. This is (willfully?) not understanding the elevator pitch for PPACA. And we’re not talking a ride to the top of the Sears Tower here. Just a ride from the 1st floor to the 2nd.
FlipYrWhig
@Eric S.: She is confident she understands what it REALLY is, which is the government giving out free goodies. That’s what all conservatives believe at the deepest level that Democrats do when they get into power. Any proof to the contrary will be disregarded.
Belafon
@Kylroy: I read somewhere that LBJ believed that would happen after Medicare passed.
Eric S.
@FlipYrWhig:
::sigh:: I know. This is why I tell a friend of mine “I vote for any Democrat over any Republican for any office on any day.” I only make one exception. I vote straight Green Party for the Cook County Water Reclamation District.
scav
@Eric S.:
Do we all do that?! Are there enough of us that they win?
Betty Cracker
@Richard Mayhew: I don’t know. Maybe when the phrase “socialized medicine” becomes utterly ineffective as a boogeyman, a rational conversation will be possible, but I don’t think I’ll live to see it.
@FlipYrWhig: If it’s entirely up to the AMA, maybe not. But it shouldn’t be entirely up to the AMA. I’m actually surprised by how many healthcare professionals I know are ready to see the system blown up and rebuilt along more rational lines. They hate the insurance companies and malpractice lawyers too.
Davis X. Machina
@Another Holocene Human:
Thank Joe Lieberman when you see him. Because with 60 votes in the Senate, you can pass anything.
richard mayhew
@Kylroy: Completely agree, from a plumbing point of view, dropping eligibilty a year every year is the gradual glide slope of success with plenty of opportunities to fix things early on before the entire population has to get onto the new platform. That would be way too easy.
My question is always political, how do we get 218-51-1-5 on board?
Another Holocene Human
OT: just peeked in at GOS, saw a 500+ comment thoughtful post about African Americans and the Democratic Party and a circa 150 comment post whining about how Sanders rox, BLM sux, and what happened at NN15 was engineered by neo-liberal HRC fanatics.
So business as usual over there but maybe a glimmer of hope that the sane people outnumber the asshats?
Bobby B.
I’m rooting for you, but when you end up explaining away flaws like this you end up fighting only to prove a system unfalsifiable and it becomes a religion. There are people getting hit by this and they’re not going to console themselves with philosophy, they’re going to look for demagogues to tell them there’s an easy answer.
Another Holocene Human
@richard mayhew: Do one of those multi-year bills?
Vote the bums out?
So many people you talk to really believe the stupid stuff, the crazy stuff, the vicious stuff. That is why we have stupid, crazy, and vicious pols.
Another Holocene Human
@Bobby B.: Did you read the same OP I did?
Some people were lucky duckies in the old system and they are getting hit with bigger bills. Ya, that sucks, but it was part of the cost of redoing the system.
eta: the old system was in a familiar cost-death spiral. it wasn’t sustainable
mai naem mobile
@Eric S.: I remember when the initial pieces of the ACA were being implemented and I had a ‘discussion’ with a wingnut idiot. She was blaming ACA for her friend having to have a $1 copay for a couple of meds when she hadn’t had to pay a copay before. I ofcourse was telling her the positives of the ACA just in the early stages. I told her about the kids’ caps being cancelled and the no preexisting for kids.
Then I told her about letting adult kids being able to stay in till 26. Her reply to me was that
it was 28 before and she would not budge. These people just make up their own facts
Davis X. Machina
Leaders. Who know how to lead, with leadership.
Also bullyarmfiresidepulpittwistingchats.
It’s like sports. The team that wants it more always wins.
gene108
@La Caterina (Mrs. Johannes):
Large groups do not need to be underwritten in an insurance pool / community rating. They have enough members enrolled in their plan that they can be underwritten based on their actual population, i.e. there are enough lives in a large group plan for their claims to be statistically significant for underwriters.
In small groups this is not the case.
One thing I notice, in this past year, is the ACA increased the size of what can qualify as a small group plan (at least in New Jersey) from employers with 50 lives to employers with 100 lives, so more mid-sized employers can be in the small group market, where they will get pooled / community rated increases based on the state approved rates for plans of their size.
Fr33d0m
@Richard Mayhew: Don’t expect a chance to beat-up Obama to respect logic. It didn’t last time.
Jim, Foolish Literalist
@Davis X. Machina: You forgot schmoozing. If Obama had invited Mitch and Orrin and Olly and Kay Bailey H. over for an afternoon of cribbage and snickerdoodles, they would have gone all bipartisan and shit.
I love the way they cite Clinton as proof of this. They guy Newt Gingrich impeached. (Does anyone else remember a quote from Gingrich that bering in the same room with Clinton always left him feeling giddy, or something like that? I’ve googled it and come up empty, but I swear that was a thing.)
aimai
So: some people were getting a better deal ontheir health insurance than other people before the ACA and now the true costs of health care for everyone is being revealed? I’m unsurprised. We have employer sponsored health insurance through my spouses’s small employer and we have always had very high deductible and really don’t know what the coverage is. It hasn’t had to kick in for us–we always pay for everything out of pocket thanks to the deductible. But I know that one family has had both a traumatic brain injury (the wife) and cancer (the husband). They are friends of ours. Even a policy that was originally underwritten based on some notion that men are healthier than women, or that the women are older and not having kids anymore, or whatever can be thrown for a loop by expenses like that.This is why we have insurance in the first place. The logical solution is to put all small group/employer insurance into a huge statewide pool. Or just move on to single payer. Maybe when small employers start kicking up a fuss we will be able to move on to the next stage of theACA.
Davis X. Machina
@Fr33d0m: This is politics — logic doesn’t enter into it.
Fr33d0m
@Another Holocene Human:
And that explanation will fall flat amidst the onslaught of Repugnicon demagoguery. Seriously, That’s all he’s saying, and he’s right.
Fr33d0m
@Davis X. Machina: Exactly.
Richard Mayhew
@Jim, Foolish Literalist: Cribbage and snickerdoodles sound really good right now… I’ll take just one and I don’t care which
Jim, Foolish Literalist
@FlipYrWhig: “The government takes MY money to give THEM free stuff” explains the last 40, maybe 50 years of our politics. At least in my extended family.
Eric S.
@scav:
I don’t think so. I’ve never seen them listed as the incumbent. I’ve converted about a half dozen friends so far. One step at a time.
Another Holocene Human
@aimai:
This. These tiny pools are a crock.
scav
@Eric S.: We’ll get there.
The Raven on the Hill
Told ya two years ago. And three years ago. And six years ago, though my worst fears have so far not materialized.
How can the Democrats claim to be the party of the people when this is what they do the the people?
My family can just afford a bronze plan. I’ve just told my doctor I won’t take important tests because we need the money for other things. Thanks, Obama.
The Raven on the Hill
@Bobby B.: and there is an easy fix. Several different easy fixes and all of them have well-heeled opponents. People will believe the damndest things, but they won’t be wrong if they believe that the government and the insurance companies colluded to squeeze more money out of them while providing half-assed health care.
Why should anyone adopt philosophical resignation in the face of that reality?
Jim, Foolish Literalist
@The Raven on the Hill: so you were better off, insurance-wise, pre-ACA?
The Raven on the Hill
@aimai: @Another Holocene Human: Guess I’m just one of the eggs to be broken so the omelet can be made.
Richard mayhew
@The Raven on the Hill: I know your heart is in the right place but your data is not. Re the friends right on the edge of subsidy eligibility… If they are unsubsidized, at those rates they don’t face the mandate as there is no affordable insurance available. Pre place, they are probably uninsurable just guessing based on age.
I agree there are much better ways of financing accessible healthcare for all, but that is not the choice available. It is and was PPAca or nothing
brendancalling
@ruemara: Thanks for the good wishes. I’m a freelancer, and it’s very difficult to estimate my income. For example, at the current job they liked me well enough to extend my contract my another three months. Now, they’ve decided the opposite, and I’ll probably get axed. So my income will fluctuate from $15K to $0.
Jim, Foolish Literalist
@The Raven on the Hill: so you were better off, insurance-wise, before the ACA was enacted?
The Raven on the Hill
@Jim, Foolish Literalist: Yes, but that because I was younger and had employer insurance.
Like I keep saying when discussing this: “This isn’t a great system. It isn’t even a good one. But it’s better than what we had before.” And I advise people to sign up. It’s a crappy system, but it’s better than nothing.
The PPACA leaves the basic problem of the for-profit insurance health care system—the huge financial incentive to overtreat—is still with us. And given how powerful the insurance lobby has proven, how effective its demagoguery has been, this failing system could hang on for decades. There’s going to have to be a transformation in politics before we are willing to regulate the industry, let alone abolish it completely.
Jim, Foolish Literalist
@The Raven on the Hill: It would be easier to take you seriously if you would start with the acknowledgement that the flawed ACA was the best were were going to get, and leave the infantile “Thanks Obama” crap at home.
Or take it over to Eschaton or FDL, where I assume Obama’s inherent evil is a known fact and still the starting point for all discussion.
Kylroy
@The Raven on the Hill: “The PPACA leaves the basic problem of the for-profit insurance health care system—the huge financial incentive to overtreat—is still with us. And given how powerful the insurance lobby has proven, how effective its demagoguery has been, this failing system could hang on for decades.”
You do realize that those two statements are opposed, yes? Insurers have every incentive to treat as little as possible, providers (at least in most pre-PPACA payment schemes) have every incentive to overtreat.
Mnemosyne (iPhone)
In case Moar comes back to this thread, when this came up last time, I strongly advised him/her to complain to the state of California, because this sounds like insurance company shenanigans, and the state is really going hard after health insurers right now. One letter from the Department of Insurance or the Attorney General may be enough to have the rate magically lowered. And getting your state assemblyperson and state senator involved won’t hurt, either.
The Raven on the Hill
@Jim, Foolish Literalist: This is Obama’s big achievement. If he wants the cred, he can take the heat too.
If it looked to me like the Democratic leadership had put up some sort of fight, I might be willing to say this was the best deal possible. But instead the Democratic leadership caved and caved and caved to the insurance industry, just like they did with the big banks. Now, I suppose there’s a case to be made that we are currently a plutocracy, and because of it this was the best we could get. Perhaps it’s even true. But I don’t believe that our democratic institutions have completely failed, and will not argue that position. Why do you?
Richard Mayhew
@The Raven on the Hill: From an insurance company point of view, we make our money in one of two manners.
1) We’re a funny looking hedge fund with a bizarre cash flow model as we invest our reserves to generate above normal rates of return (some insurance companies make a killing doing this, but it is more of a life/massive reinsurance type of business model)
2) Pay out less in claims than we collect in premiums.
Insurers very seldom want to pay a claim that they can avoid paying. Excessive utilization, and high cost utilization are the things that we try really hard to not pay. Usually the simplest way of not paying for excessive utilization is to get the member/patient to never have that excessive utilization in the first place as we’ll use network exclusions for that 1 doc who refers everyone for an MRI that complains of back pain, we’ll use pre-authorizations before back surgery, we’ll use step therapies for treatment decisions etc. The goal is to get the member/patient back to health at the lowest possible cost.
3) Providers under the fee for service model want to order every goddamn test possible and keep you in for an extra night just in case.
4) #2 and #3 produces lots of mutual head butting and expensive lawyers.
5) Kaiser and other integrated payer providers have slightly different incentives.
Richard Mayhew
@The Raven on the Hill: Ben Nelson, Joe Lieberman, Mark Warner, Max Baucus, Blanche Lincoln, Mark Pryor, Mary Landrieu, Jim Webb, Evan Bayh, Kent Conrad, Claire MacCaskill, Mark Warner —
Blue Dog Coalition
Either group if they act united in conjunction with Republicans create single chamber blocking coalitions unless some of their members defect to voting for health insurance reform. Under the rules of the Senate, all of those potential defectors had to be on board (there weren’t 51 votes for a filibusterless Senate in the summer of 2009 as those 12 plus traditionalists (Leahy/Levin etc) weren’t radicalized enough by Republican behavior).
A messy, imperfect bill is democracy in action.
The Raven on the Hill
@Kylroy: The insurance industry only gets paid if it funds treatment. And these days the percentage they can take is limited to 15% (the medical loss ratio) (or I think 20% in some cases) depending on the type of insurance. So how to increase profits? There is only one way: spend more on treatment. The mandate also requires that everyone be in the system, but bronze plans, the ones the working poor can afford, only pay on average 60% of expenses. So everyone pays the insurance companies. The wealthier customers pay more, routinely, because of the habitual overtreatment that is US practice, while the poorer have to put off care.
Kylroy
@The Raven on the Hill: “The insurance industry only gets paid if it funds treatment.”
People still have to pay their premiums even if their claims are denied. It’s true in the big picture, but no insurance company ever wants to be known as the one where it’s super easy to get claims paid.
“And these days the percentage they can take is limited to 15% (the medical loss ratio) (or I think 20% in some cases) depending on the type of insurance. So how to increase profits? There is only one way: spend more on treatment.”
This is a valid point, though I’m not sure the culture of insurance companies has completely changed from the denial focus of pre-2014.
Richard Mayhew
@Kylroy: @The Raven on the Hill:
Spearking as someone who spends an amazing proportion of my week looking to minimize payments, there is a whole lot more money to be made by minimizing pay-outs and increasing our operating margin above the 85% MLR even if we are slightly too good at that and have to refund premiums than needlessly paying out claims to high cost providers.
Paying out a lot in claims to high cost providers for high cost procedures in order to increase the non-medical side of the equation (the 15% MLR) would work if there is no competing insurer and if there is minimal movement of healthy customers to other insurers. On the Exchange the high paying structure strategy means high premiums which means most people are priced out of the product as most people on Exchange are getting subsidies and their subsidies are tied to the price of a low cost Silver. In the group insurance market, customers are stickier than on the Exchange, but groups will leave if they can get the same benefit structure and a close enough network for $10 per member per month. Your strategy to generate an extra two dollars of administrative float has a pricing differential of $12 pmpm.
I am not seeing the strategy that you suggest in my day to day life.
Jim, Foolish Literalist
To a great extent, we do have the democratically elected government we deserve. Nobody I can think of lost a seat in Congress for the Senate because that ACA didn’t go far enough
By your own account, you situation is worse because you lost a job and got older. Given your history, I’m sure you could, in your own little Naderite mind, blame both on Obama.
The Raven on the Hill
Richard Mayhew, I appreciate your engaging me, the work you have done explaining the system, and the advice you have given here. I don’t agree, though. I’ll cover some of why here.
@Richard mayhew: “Re the friends right on the edge of subsidy eligibility… If they are unsubsidized, at those rates they don’t face the mandate as there is no affordable insurance available.” You’re referring to the older couple? You’re right about the mandate, of course, but going without health insurance is awfully risky thing for people over 55 to do, even if they are in apparent good health. And if they are willing to pay, and have a large tax credit, there is even so there’s the problem of unexpected income, where a modest windfall that takes the couple over 4xFPL can lead to a clawback of thousands of the tax credit.
@Richard Mayhew: [retracted]
As to testing, doctors nowadays are taught to rely on tests rather than diagnostic knowledge. I’m not quite sure when this change in it came in in education and practice came in—1980s? 1990s? In any event, the result is more testing. In my experience the cost-cutting measure of relying on physicians assistants to replace doctors has a paradoxical effect: the PAs I have had contact with are poor diagnosticians and tend to treat problems scattershot. They way we finance care in the USA has affected practice in a way that increases the amount of care, and this has lead to enormous overpricing as well: that can be seen clearly in pharmaceutical pricing.
@Richard Mayhew: the Blue Dogs are there largely because the big money supports them. Some things might have been pushed past them, even so. As far as I can see, the Democratic leadership, especially in the Senate, and Obama himself simply did not try very hard. The Senators I get—their jobs, prestige, and power depend on the money. Obama I can only wonder at. I do not understand the hold the financial services industry has on him, but it is profound.
In any event, I think we are more or less on the same side, and let us hope for better laws and customs soon.
The Raven on the Hill
@Richard Mayhew: “I am not seeing the strategy that you suggest in my day to day life.”
Then I retract my remarks. (Sorry, our posts crossed.) Still, the USA pays around twice as much for care as the high-income world and the insurance industry is making its percentage on it. Perhaps the moral hazard on the clinic and hospital side has worked its magic. It is certainly true that most doctors treat without regard to cost, so I suppose it is possible that that clinic and hospital management have run up the costs. Or perhaps there is something in the number of tests run, numbers of treatments administered, and expensive pharmaceuticals purchased. I suppose it could be largely pharmaceutical costs, or perhaps overtreatment at end of life.
Perhaps the real experts, people like Uwe Reinhardt, know something of this, or perhaps its all buried somewhere in proprietary documents. It is not possible that the prices have gotten so high without someone making a lot of money on it.
The Raven on the Hill
@Jim, Foolish Literalist: “By your own account, you situation is worse because you lost a job and got older.”
And also because the ACA provides the poorest and most expensive care to the working poor.
“Nobody I can think of lost a seat in Congress for the Senate because that ACA didn’t go far enough.”
True, though as the problems of the system wear on us, that may change. One never knows what the public will believe, though. Someone really did say “You keep your government hands off my Medicare,” clueless though that is.
“Given your history, I’m sure you could, in your own little Naderite mind, blame both on Obama.”
I am fond of quoting the remark of a much more radical person: “Of course you can vote for the lesser evil. You get less evil.” So, no, I was never a Naderite.
Why do you believe that Obama did the best job possible? There seems to me no way of knowing that at all. Yet you seem to find it necessary.
The Raven on the Hill
@Richard Mayhew: Costs. The other problem with relying on the insurance industry to reduce the costs of care is that this necessarily reduces your industry’s profit. I don’t think there’s any financial services industry that is willing to do that. So serious cost savings, if they are to be achieved, will have to come from government, the medical profession itself, or, just possibly, patient organizations. :-(
mclaren
So now are you people finally ready to admit that Richard Mayhew’s hand-waving and smoke-blowing is nothing but the same old bullshit?
Have you people finally realized that the ACA is just another way of bulldozing bushels of cash from your bank accounts into the hands of greedy corrupt medical devicemakers and greedy corrupt doctors and greedy corrupt hospitals and greedy corrupt for-profit health insurers?
The plain fact of the matter remains that the ACA contains no cost control measures of any significance.
When Mayhew doubletalks his bafflegab about “There are two components of the price increase. The first is medical trend which is just a fancy word for the cost of services rendered,” what Mayhew really means is:
Short version?
The ACA didn’t stop every America from getting priced out of health care when they get sick, it just slowed the process down slightly.
mclaren
@Richard Mayhew:
That’s a flat-out lie.
And I can prove it.
Source: “Rising Health Care Costs,” AHIP website, 2015.
Source: “The Facts About Rising Health Care Costs,” Aetna website, 2015.
I’ve been pounding the table about this for years now, and Richard Mayhew has studiously ignored every fact I’ve cited, every report I’ve linked to, every piece of evidence I’ve cast light on.
Mayhew’s response to my continuing deluge of facts on this forum represents a microcosm of the American health care system’s response to individual sick patients: total contempt, utter disdain, complete megalomaniacal greed-choked swaggeringly arrogant disregard for anything but money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, money, and more money.