ACA stuff

[soyleche]

Here you go

[soyleche]

@twig93

@SredniVashtar

Also you keep using that work without explaining it. Are you referring to discrimination or what?

I’m referring to the fact that people in the individual market are sicker than those in the group market and insurers are not permitted to use premiums from the group market to subsidize* the premiums for those in the individual market. Only people in the individual market can do that. It got so bad in Iowa that every single insurer pulled out of the individual market because they couldn’t charge a high enough premium to cover the risk. You & I weren’t paying higher group rates to cover Member X in Iowa, only Iowans in the individual market were.

*Now the word subsidy is confusing here because it means different things in different contexts.

Let’s assume that group has claim costs of X per member, underwritten individuals have claims costs of 0.5X and individuals where underwriting is forbidden have claims costs of 1.5X. The insurer needs 20% to cover their expenses and turn a profit. Obviously this is hugely simplistic. Let’s also ignore inflation.

The premium for folks with group coverage will be 1.2X, pre-Obamacare the individual insurance would have been 0.6X, and post-Obamacare it’s 1.8X. And maybe on average an employer covers 75% of the premium meaning people in the group market are only seeing 0.3X coming out of their paychecks.

Now poor people in the individual market might get premium subsidies that reduce the amount that they pay. The insurer is both charging and getting 1.8X for each covered individual even though some individuals might be paying 1.2X or 0.6X or even $0. You and I are paying for that through our federal tax dollars, sure. So are people making actuary-level money who are in the individual market. That’s not what I’m talking about. Whether we’re in the individual or group market has no impact on that whatsoever.

What I’m talking about is that individuals making too much to qualify for a premium subsidy are paying 1.8X for insurance whereas you and I are only paying 1.2X. And those people are really feeling the pinch because they’re accustomed to paying 0.6X. And even the 0.6X felt like a lot to them because they see you & I “paying” 0.3X. Even if you account for the piece our employers cover though, our insurance is still a lot cheaper because the insurance company isn’t charging us in the group space for the extra sickness.

The federal government is charging all of us for the subsidies that go to the poor. Yes. Individuals are paying that too. But they expressly forbid the insurer from charging 1.5X to everyone. (Or since there’s more of us in the group market than the individual market they could probably get away with charging everyone 1.3X.) The insurer must charge you & me (plus our employers) 1.2X and they must charge the individual folks 1.8X.

It’s the 1.2X vs 1.8X that is unfair.

.

[SredniVashtar]

@twig93

It’s the 1.2X vs 1.8X that is unfair.

Okay, but it’s not 1.2 vs. 1.8.

The individual market is 10% sicker. And they have less claims than the group market, because they are lower income, and so avoid using any services.

Anyway, if you’re trying to say it’s possible to make Obamacare work better, I think everyone agrees, especially given the massive amount of sabotage. But you seem to also be saying that it’s worse than nothing, which I disagree.

[Mathman]

@SredniVashtar

And they have less claims than the group market, because they are lower income, and so avoid using any services.

That doesn’t sound super fair either, that they can’t get treated because they can’t afford it. Can we fix this while we’re at it? Throw Medicaid in the mix here as well.

And then chase down any inequities in Medicare? There are so many pockets of health care that aren’t fair.

Is this… are we just doing single payer with more steps? Or are we doing a lesson on the fair? It’s Sunday and I’m here for either or both.

[The_President]

@Mathman

are we just doing single payer with more steps?

yes.

[soyleche]

@JFG

Universal healthcare isn’t perfect but the current situation is an unsustainable mess. Unlike other types of insurance, everyone utilizes healthcare and society isn’t willing to completely turn their back on those who can’t afford medical care, including those who choose not to insure themselves even if they can afford it. We’re collectively on the hook anyway. Universal healthcare is a way to streamline that.

I have a PPO and still ended up with a $3k bill after insurance for an ER visit this summer. I could afford it but there’s a significant amount of our country’s population that couldn’t, so they go into debt, declare bankruptcy, or the hospital writes off charity care. There are insured people who don’t seek or proceed with recommended treatment because there’s still a huge price tag. I even paused seeking treatment but decided avoiding the small but real risk of death was worth it.

.

[JFG]

@SredniVashtar

Had to google “person X”. It’s a 17 year old with hemophilia that somehow costs a $million / month. Which is a lot, even for a hemophiliac.

If you want to complain a solution not able to handle that boy, try to ask yourself if what alternative is actually better, and whether that alternative is politically feasible.

Rs: All lives matter (until someone else has to financially contribute to sustaining it).

[JFG]

@NerdAlert

I barely worked in health, really only in stop loss, but hemophilia was one of those conditioned that was just insanely expensive, always lasered (which for those who aren’t familiar, a laser puts a higher spec deductible on that person because their claims are known to be high. This sounds cruel, but has no impact on the participant, only their employer - although I’ve often wondered if this has resulted in any employees being fired for the cost).

This is pertinent to twig’s comment about no pre-existing condition exclusion if there’d been continuous insurance coverage. What about when there are gaps in employment for whatever reason? Sure there’s the COBRA option, but that’s not cheap, especially burdensome with lack of an income, and there’s a time limit. I worked with someone who struggled to keep up with working while undergoing cancer treatment even with utilizing intermittent FMLA. Obviously they couldn’t not work because they needed insurance.

[JFG]

(Hopefully I’ve made @soyleche happy now.)

[soyleche]

Happier, at least…

[NerdAlert]

Oof, sorry, I didn’t read the thread title before I responded.

[JFG]

Something something herding cats something.

[JFG]

@twig93

@SredniVashtar

If you want to complain a solution not able to handle that boy, try to ask yourself if what alternative is actually better

Catastrophic reinsurance that is spread beyond just the members of the particular state and group/individual market.

Like…universal healthcare perhaps? That’s about as spread out as you can get.

(I’m trying @soyleche. The cats keep sneaking out.)

[Mathman]

You could carve out people who have annual spend above, say, the 95th percentile. Put them into a pool and spread that over everyone. The details with all of the retrospective true up, and trying to figure out if it’s one 95th percentile or if you set it separately for commercial vs Medicare could get thorny.

But ‘universal catastrophic coverage’ is tractable.

[Mathman]

Now if you did this, skewness is a thing. The top 5% represents about 55% of total cost of care - I don’t have the exact number but that should be pretty close.

[Nick_Papagiorgio]

@JFG

Rs: All lives matter (until someone else has to financially contribute to sustaining it).

Is this really an unfair position? Being guaranteed a right to live is not the same as being guaranteed the right to affordable healthcare. Not even close IMO.

[JFG]

What if that right to live is connected to affordable healthcare? How would person X live if affordable healthcare was out of reach? Or that kid born with cystic fibrosis? They’d live for awhile, but a shortened lifespan with suffering.

[soyleche]

It never says anything about the length of the life…

Of course, if you go too far down that road the “right to life” starts to become meaningless.

[JFG]

Taking the cystic fibrosis example, life span used to be in the teens. Now it’s age 50. You know, if you can afford it, both the parents when the child is young, then when that kid is grown and independent.

Or people who need organ transplants. Transplanted organs are going to those who most likely follow strict post-transplant care, and even then transplanted organs don’t last forever.

Is healthcare actually accessible if it’s not affordable?

[JFG]

I certainly don’t have all the answers, and if it was a quick easy fix it’d be solved already. But we cannot say that it’s not a significant problem.