Well...what do you think of Obamacare now?

Premiums for self-insured and fully insured employer plans are comparable. In 2015, the average premium of single coverage in employer-based plans was:

• Self-insured: $6,275
• Fully Insured: $6,208

Meanwhile in the individual marketplace this year, the average premium for a platinum plan for a 42-year-old is about $5,800. So the idea that there are radical differences in risk between these pools is unfounded.

 

One very important difference here is the self-insured employer funds do not go to the insurance company while the fully insured employer does pay those premiums to the insurance company.

 

You are not getting it. Those prices of whose bank account they are putting those premiums into for each of their employees is what matters here.

 

Was your point not that the health of the risk pool (and thus the cost of coverage) differs substantially between self-insured and fully insured plans? Clearly that's not the case.

If you were arguing something else, I'm all ears.

 

Some small businesses cannot start up or continue to grow and pay for loaded up ObamaCare health insurance policies for their full time employees. That is why you now see the moves to part time workers and non expansion beyond 50 workers per business. ObamaCare stifles economic growth and innovation. The new ObamaCare normal is ~ 1% per capita economic growth. In a robust US economy that metric is ~ 3%. There is activity to provide self insurance to small companies but clearly the large companies have the advantage. Innovation and the healthy creative destruction involved in a free market economy is reduced by ObamaCare.

The contribution of the Medicaid expansion is that for the first time it makes all poor people eligible for Medicaid (in that respect it's the opposite of block granting, which is designed to make it easier to kick people out of the program). The states I mentioned are all using the Medicaid expansion--not to mention the new exchanges--to test these HSA and premium assistance approaches. Without the ACA, they wouldn't be doing this.

Block granting would allow the states to provide better coverage to more people. For example providing catastrophic health policies to low income people with high deductibles in combination with a funded debit card for routine medical expenses and a provision that anything left over at the end of the year would accumulate into the next year would reduce health care spending and would provide coverage in case of cancer or kidney failure. The best insurance allows the patient to be a consumer but protects against very serious conditions. Governors have been asking for block granting for years before ObamaCare. And Health Savings Accounts were established by the same legislation that created Medicare Part D.

What I meant is that by requiring mandated coverages and artificially driving up the price of health insurance fewer people will purchase ObamaCare policies. Again the 12 million were net additions to Medicaid. And there are better ways to reform Medicaid to provide better care at less cost. Also if our labor force participaton rate and U6 unemployment stats were at typical levels those 12 million might have jobs and not on Medicaid.

Your charts do not show data prior to the start of the ACA. The rate of change of health care costs has been going down since the early 00's. This trend has merely continued after the ACA was passed.

According to the Centers for Medicare and Medicaid Services national health CARE expense growth rate (yes it still goes up every year) has been going down every year since 2002. The growth rate in 2010 was ~ 4% which is approximately equal to the sum of the inflation and population growth rates (~ 4%). Health Insurance rates have indeed been increasing a much higher rate due in part to expanding insurance plan mandates and covering the costs of brand name drugs among other things ??

http://www.wsj.com/articles/SB10001424052970204792404577227050656680024

The data & projections post ObamaCare show a return to the years of 6 - 7% increase per year in health care spending. That's hardly a convincing argument in favor of ObamaCare.

Tort reform is not in the ACA.

http://www.politifact.com/truth-o-m...nthony-weiner/tort-reform-health-care-law-no/

That's not true at all. The reforms to Medicaid proposed by, for example, Paul Ryan in his road map are designed to cover more people in a cost effective way by using both premium support and funded health savings accounts.

And buying across state lines allows the health insurance consumer to choose among many options. I've been in that market in the past and have seen policies with the same basic coverage and deductibles with premiums literally half of what I was paying in CA. The only difference were coverage mandates such as marriage counciling, chiropractic, and accupuncture. Those I don't need or choose to pay for out of pocket. Let the consumer make the decisions - not a small group of experts (who can't agree among themselves) in a small room.


Bottom line IMO - we didn't need a 2000 page ObamaCare bill to make the reforms to the old system to fix known problems. The net effect has been ~ 10 million added to Medicaid, higher premiums, cost savings on Medicare due to cost controls (aka rationing), and a projected return to the 6 - 7% rate of increased health care spending.

 

Much of the health insurance industry is provided for by "not for profit" organizations so there is no profit for the insurance company and those "for profit":insurance companies must compete with the "not for profit" insurance companies. For example about 1/2 of all of the insurance companies that provide Blue Cross / Blue Shield health insurance are not-for-profit companies today.

Additionally about 1/2 of all health services costs are paid for by the government. There's very little "profit" associated with health insurance in America today.

 

That is true but the Republican proposals limited compensatory and punative damages to the victims as opposed to focusing on limiting compensation to the attorneys. A cap on attorney fees is the most logical means of addressing tort reform without harming the victims of malpractice by reducing compensatory and punative damages that should never be limited.

Those that require Medicaid can't afford even $1 in insurance premiums and can't afford to fund health savings accounts.

Health savings accounts to supplement high deductable health insurance are only financially viable for upper middle income households that can afford unsubsidized private insurance because the annual funding required for the high deductable insurance and HSA exceeds the cost of normal full coverage insurance. People have this misconception that High Deductable Insurance (HDI) combined with Health Savings Accounts (HSA) cost less that Full Coverage Insurance but that is an erroneous belief because it actuall costs more to fund the HDI/HSA than the premium costs and co-pays of the FCI.

 

The self-insured employer's pool belongs to that employer's number of employees. They are not counted under the insurance company's pool because they do not pay health claims from the insurance company's bank account. All big corporations who are self-insured "ERISA" are all acting as their own insurance company. It is hidden because they use the insurance companies network for a small fee.

The employed population is the healthiest, therefore seldom require healthcare. This population is not under one big pool. So now what is left: Medicare is the most expensive for obvious age related health issues. People on Medicaid are of all age groups and many of them are healthy so they too seldom use their Medicaid insurance.

The reason why Medicaid cost so much is due to the fact that all states contracted with private insurance companies to handle their Medicaid pool. The average cost for each Medicaid adult was $3500 per year paid by the state to the insurance company. The insurance company contracted with Physicians in a capitated agreement where a list of people in that area were assigned to that doctor. The doctor got a set fee amount each month for each Medicaid member whether they receive care or not. The doctor makes money on all those people assigned to him or her that never needed care. They also got bonuses for not sending Medicaid members to specialists.

Now Obamacare comes along and adds another 20 million to Medicaid. If states managed this population without using the private insurance companies, the cost would have been minimal because those newly enrolled were most likely healthy. Think of it this way, if all states handled their own Medicaid population where the insurance company is not required, the cost would drop significantly simply because most people on Medicaid are young, healthy and poor and seldom will use healthcare services.

The biggest cost to the healthcare system are people that are on Medicare and Medicaid and most are in nursing homes with chronic health problems. This is less then 5% of the entire population. The problem with our high cost is most of our healthcare dollars is not going to healthcare providers. It is going to all of the stock holders and all of the other parasites taking our money.

 

The best way to implement tort reform is to set up medical review boards. Take the process out of the litigation world.

For low income people the process involves both premium support and funding of an HSA (or medical debit card as Paul Ryan's Roadmap includes). My experience is the opposite - it was less expensive to purchase a high deductible policy and fully fund an HSA. Plus the funds deposited in an HSA accumulate and actually become an IRA after age 65. After a couple of years of accumulating money in an HSA the annual yearly deductible is covered if needed. The accounts can be used for Medicare premiums (yes recipients have to pay premiums for Medicare) and Medicare supplemental insurance premiums. The HSA makes a consumers out of people because they are spending their own money until the deductible (and out of pocket maximum) is reached. If a person has a condition in which they use up the deductible and out of pocket maximum every year then the high deductible might not make sense.

 

And you have some data to support either of those assertions?

You're going to have to elaborate on how sticking someone with no disposable income into a high deductible plan constitutes "better coverage." Or why it requires a block grant financing structure.

The argument for inducing price sensitivity via HSAs is sound, except it doesn't work for low-income households. If you don't have any money to spend on health services, price exposure is irrelevant.

I can't tell from the latter sentence if you're attempting to downplay what's occurred or if you honestly don't realize how astonishing that is.

The CMS actuaries' current estimates have reduced to just over 5% through the end of the decade. As impressive as the Medicare reforms in progress right now have been, they can't reverse the aging of the population. The ongoing slide of the Baby Boomer generation into old age (and associated uptick in the intensity of their health resource use) is going to be with us for a long time.

You seem to be arguing that the tort reform provisions were underfunded rather than nonexistent (the President agrees with you, which is why every single budget he put forward called for increasing the funding allotted to the states to reform their tort laws). The tort reform language in the ACA was actually lifted from Paul Ryan's Patients' Choice Act, interestingly enough. Yet Ryan's Budget Committee never could find the funds for this. Particularly odd given how many GOP-controlled states there have been in recent years. Tort reform is apparently not a priority for the national or the state parties.

The point of across state lines legislation is to deregulate state insurance markets. It "saves money" by allowing plans to cover less services and cover fewer people, not attacking the underlying drivers of cost growth in the system.

Beyond that, this argument is based on an outmoded understanding of insurance markets, one in which insurers should basically be indemnity plans that just cut a check based on whatever a provider wants to charge. Then sure you can have all providers in network and do that without ever setting foot in the state where your customer resides. That's how it used to be and it was inflationary precisely because competition between indemnity plans is extremely weak and ineffective at holding down provider price or cost growth. We're in an era of managed care now, where insurers attempt to add value and compete with each other on premiums by negotiating down prices with providers. And that requires a strong local presence.

A few years ago RWJF did a very good issue brief on why state-level policies allowing out-of-state competition have invariably failed:

The ACA isn't even half that long and most of it isn't dedicated to insurance reforms (though creating functioning insurance markets is a big deal, long-term), it's dedicated to improving health care delivery, training more medical professionals and expanding capacity, building up our public health infrastructure, rooting out fraud in the public insurance programs, and streamlining some of the FDA's approval processes. This is comprehensive reform, not bumper sticker slogans and magic wand waving.

Thus far the indicators on coverage, cost, and quality have all been very good.

 

When a state provides a capitated payment to a Medicaid managed care organization to manage a population, that payment has to be actuarially sound. Many people incur few medical costs; a small number of people incur a lot. Paying claims as they arise on a person-by-person basis or providing upfront an actuarially sound payment for a population of people are not actually that different financially.

The vast, vast majority of health spending is absolutely going to health care providers.

- - - Updated - - -

Indeed! That's why one has to actually have their own money for this to work. It doesn't make sense for the Medicaid population.

 

Something is fishy here. This apparently compares one insurance plan costing over $20,000/yr ($1,700/mo) which is way above the cost of insurance for any household with an employer provided health care insurance that only costs $12,000/yr ($1,000/mo).

While two years old the average cost of full coverage insurance for a houshold was $16,000 and it didn't matter if this was a private health insurance policy or an employer paid insurance policy.

Either the amount paid for by the employer was substantially more than $500 or the benefits were substantially less than the "silver" plan through the PPACA because there's no way that the enterprise could offer health insurance for a family for only $12,000/yr when the average cost was $16,000/yr.

It can be assumed that Obamacare plans that cover those with preconditions, cost more than private plans that excluded those with pre-conditions because of the very high costs of medical services for those with pre-conditions. Did it result in a cost increase of $4,000 more per year for a family policy is highly debateable because the "pre-condition" typically relates to just one member of the household and not all members of the household. Without actually submitting information to secure a quotation I was unable to find out the actual cost in Arizona for a silver plan but do know that nationally the costs of the health insurance dropped for 2015.

http://www.examiner.com/article/average-cost-of-obamacare-silver-plans-decreases-slightly-for-2015

Admittedly a 0.2% drop in prices doesn't represent a lot but it's certainly far better than the consistant increase in health insurance costs before Obamacare.

Finally a few items of importance were clearly omitted from the post.

How much of the annual premium for the Obamacare plan is being covered by the federal subsidy?

Why isn't your employer providing group health insurance?

If the Obamacare insurance is so expensive why didn't you purchase private insurance outside of the subsidized exchange? No one's being forced to use the exchange and there are still lots of qualifed private health insurance plans that a person can purchase.

 

Combination of premium support with a medical expense debit card. The debit card could be used for additional premium support and/or routine medical expenses. Low income earners would be covered against catastrophic illness and common health issues. This allows low income earners and families access to all of the health care system (not just those accepting Medicaid). The debit card system could be set up so that recipients could accumulate totals yearly and then convert to an IRA after age 65. Per the Ryan Roadmap:

http://www.deseretnews.com/media/pdf/349985.pdf

 

I imagine most of that debit card would be eaten up in paying premiums. Average per-person Medicaid spending a few years ago was over $4,000 per adult and almost $2,500 per child--and those numbers are held down by the fact that Medicaid pays much lower unit prices for health care than does commercial insurance.

The reality is that health status is negatively correlated to income, meaning lower income populations tend to be sicker and have more chronic conditions (this, by the way, is why the ACA created a special option within Medicaid for states to better meet the chronic care needs of that population).

So now imagine RyanWorld has come to pass. The ACA's consumer protections are gone, which means the guaranteed issue rules that allow folks with checkered medical histories to shop for insurance like anyone else are gone (though Ryan claims to retain this in that document, the re-introduction of high-risk pools for "individuals who would otherwise be denied coverage due to pre-existing medical conditions" makes it pretty clear he really doesn't). The community rating rules that focus insurers' attention on the health of their entire population and prevent individuals from being penalized for their health status are gone.

So let's imagine a family of four just below the poverty level whose annual health costs are average for the Medicaid population: $13,000 ($4K/parent and $2.5K/child). However, that's what they cost in Medicaid, where let's say prices are roughly 53% of what they are in commercial insurance (going by Medicaid rates being ~66% of Medicare rates and Medicare rates being ~80% of commercial rates). At commercial prices, that family is costing more like ~$24,500 per year.

Let's generously assume they haven't been frozen out of the commercial market and put on a waiting list for one of Ryan's high risk pools. They go for a bronze level of coverage, i.e. 60% actuarial value, with a $13,700 family deductible. Their insurer, free to match their premium to their individual expected cost as closely as possible, quotes them a premium of $10,800 (easy apples-to-apples, side-by-side comparisons of competing plan offerings and the competition that encourages are, of course, now a thing of the past).

They apply Ryan's $5,700 tax credit and the $5,000 in their debit account. That just about covers their annual premium cost. Leaving the entirely of the $13K+ out-of-pocket expense to be covered by this family that makes ~$24K per year.

If you want to transition this population into commercial coverage, you've got to be very thoughtful about how you're going to achieve that.

 

He's got that all covered. The link is to the original Ryan Roadmap - it's been updated since then but the insurance part of it is intact. It's a roadmap and not a detailed policy paper. But it is focussed on giving more control of an individuals health care decisions to that individual and to provide each individual access to the entire health care system and not to those facilities only accepting Medicaid. Getting as much gov out of health care as possible is a good thing.

 

It's basic economics - there is a disincentive to hire workers full time and to hire full time workers over the total number of 50. The employer mandate was postponed initially and still is postponed. There is the dismal economic growth, the untypical large difference between U6 and U3, and the very low labor force participation rate plus analysis by the CBO. And more information here:

http://obamacarewatch.org/?s=part+time

http://www.cnbc.com/2014/09/09/bill-for-small-business-big-bucks-fewer-jobs.html

See Ryan Roadmap proposal upthread. That's of course federal but states could do the same with block granted monies.

The decline of the health care costs rate of increase to ~ 4% took place before ObamaCare. The actual data after ObamaCare show a reversal of this trend.

Cutting Medicare and ObamaCare is still increasing health care costs by 6 - 7% (which is what the charts say) is not a good sign. With regards to Medicare it should be reformed into a premium support system similar to the plan that which federal employees have. We almost made that transition in the late 90's (Breaux - Thomas commission). Clinton was in support but a blue dress changed the politics.

All that is needed is to review the positive results in Texas and other states which have passed medical tort reforms. There is no need to spend additional money studying something which is well proven to reduce medical costs.

The point is not how health care is delivered (which is a factor) but what coverages are mandated by the various states. The consumer of health care services is more qualified to decide what coverages, deductibles, HSA compatibility, limits, co-pays, and annual out of pocket maximums are best for him.

I suppose if you reduce the font size the page count can be reduced. But that would make it hard to read - but then again no one actually read it so no worries.

All those reforms could and should have been handled separately. ObamaCare creates a system based on high priced (due to coverage mandates) health insurance, forces everyone to purchase these high priced policies (except for self insured businesses as you point out), and provide subsidies to the low income workers. It relies on the young and healthy to support the elderly and sick (the difference between premiums is 1 : 3 (modified community rating) - before ObamaCare it was ~ 1 : 5 (Source - Disinherited by Furchtgott-Roth & Meyer - 2015). More than half of the state ObamaCare Co-Ops are bankrupt and by law their deficits must be paid by the existing insurance companies in the respective states. And United Healthcare has warned that it will most probably withdraw from ObamaCare due to historical losses. ObamaCare was well intentioned but is full of unintended consequences and does not address medicare reform.

 

This seems like tacit acknowledgement that you're aware that what you're suggesting hasn't happened.

It's a talking point that doesn't hold up to empirical scrutiny.

Yes, as I pointed out it doesn't make any sense. Like most of what Ryan churns out it's pretty poorly thought out but lends itself well to sloganeering.

The ACA's delivery system reforms started about 4-5 years ago. And, as you pointed out, the slowdown continued under the ACA--something no one thought possible. The fact that this development is apparently ho hum these days is a testament to how far we've come.

The much greater than expected slowdown in health spending growth took most of the wind out of the premium support model's sails. Per capita Medicare spending growth is so low (it was actually negative for a while) that premium support can't actually save more money than the program is already savings.

What positive results would those be? Premium growth in Texas from 2003 to 2011 was right around the national average, and growth in health spending from 2003-09 was actually higher than the national average over that period (49% in Texas vs. 41% nationally).

The only positive results I've heard have been with regard to provider malpractice premiums and the incidence of settlements against them. Which is swell for providers, but the fact that this didn't translate into any savings for consumers or the system severely undermines the argument that Texas-style tort reform is the key to cost containment.

The roadmap you linked to promises "Benefits by the Same Standard Used For Member of Congress. Plans offering coverage through an Exchange will have to meet the same statutory standard used for the health benefits given to Members of Congress."

Do you dislike Ryan's benefit mandates as much as you dislike the ACA's? As for changing the age rating rules from the current 3:1 to 5:1, I would consider that a fairly minor tweak, not some enormous policy change. You're rooting around the edges here.

The co-ops are failing because Congress has purposefully pulled the rug out from underneath them. They're non-profit start-ups that were subsequently denied the start-up funding the law intended for them. That isn't an "unintended consequence," the GOP Congress has purposefully changed the law to try and kill them.

And yes, the ACA addresses Medicare reform. The entirety of Title III of the law is Medicare reform. It's been nearly six years--might be time to drop the "nobody's read it" canard and start learning what it actually does.

 

Well, we could end government involvement in healthcare and give the entire assessment back to the patients/the people.

But we sure wouldn't want to do that!

 

The links from the Galen Institute and CNBC show that it has. And the CBO has forecast a similar effect. Your WaPo article compares only 2013 to 2014 - the employer mandate considered critical to the performance of ObamaCare has not been implemented yet.

Ryan makes sense. Getting the gov out of !/6 th of the US GDP will result in market forces improving the US health care system. Letting individuals decide what health insurance options are best for them (including individual self insurance) is basic to individual responsibility and choice. Safety nets will be provided but a system like ObamaCare designed by a handful of experts (like Johnthan Gruber) which has been illegally changed over 50 times since its implementation cannot possibly effectively meet the needs and be as efficient as individuals making free market decisions.

The reduction of health care costs occurred before the implementation of ObamaCare. ObamaCare has been slowly rolling out (all the provisions have not yet been put into effect including the employer mandate, the cadillac tax, and the medical devise revenue tax). Even so trend line is pointing up for health care expense rate of annual increase.

Federal employees were not forced into the ObamaCare exchanges. Says a lot right there. If ObamaCare is that great then why not ??

The coops are failing because they priced their insurance products too low. More than 400,000 had to look for insurance elsewhere and for more expensive premiums.

What are the Medicare that the ACA implements ?? Nothing but cost cutting (rationing) and IPAB. That does not address the cost of entitlements and the effects on the US national debt.


A post I did from another forum.

 

You claimed that "you now see the moves to part time workers" due to the employer mandate. Neither of your links showed that. At best they suggest voluntary part time employment has risen, which is a very different thing than what you're claiming.

As for the delay of the mandate, it's been in effect for employers with 100 or more employees all this year (i.e., it would've impacted plans those employees chose starting in the fall 2014 open enrollment). Two-thirds of employees in the U.S. work for employers of that size. Another 28% of the workforce is employed by employers with fewer than 50 employees: employers that are not subject to the mandate. So the number of employees for whom the mandate is pending--for the next week anyway--is rather small.

You understand that the roadmap you shared is based on selling insurance through regulated exchanges, right? If that's "getting the gov out of 1/6th of the US GDP" then that process is already well underway.

No one with employer-based group insurance was forced into the exchanges. But I agree, it would've been a good idea to do so, at least for federal employees!

Pricing decisions were made based on the availability of start up and transition funds promised to them under the ACA (breaking into a new insurance market, particularly for an insurer starting up from scratch and competing against long-established companies, is really, really hard). The GOP rescinded those funds in an attempt to destroy the co-ops, limit consumer choice, and reduce competition. Mission accomplished!

The APHA has a decent summation of the biggest ticket delivery system reforms here.

As far as I can tell, the "Texas miracle" you cite is entirely about increasing the number of physicians in the state. As I already noted, health spending, costs, and insurance premiums have not seen improvement relative to the rest of the country.

Now perhaps the number of physicians has increased but Texas is still doing abysmally on that front. The AAMC's 2015 State Physician Workforce Data Book has them in the bottom ten states when it comes to active physicians per capita.



They're even worse when it comes to active PCPs per capita (4th worst in the nation) and active surgeons per capita (3rd worst in the nation). Access for their population is similarly bad: they're 6th worst in the nation for states in terms of percentage of adults reporting not seeing a doctor in the past 12 months due to cost, and 3rd worst nationally in terms of percent of adults who don't have a personal doctor.

Describing this as a "miracle" is bizarre.

 

There is much evidence already of the shift in anticipation of the employer mandate. You aren't seriously arguing that there will be no effect on employees hours due to the ObamaCare employer mandate are you ?? Here is a list:

https://www.google.com/?gws_rd=ssl#q=ObamaCare+employer+shift+full+time+employees+to+part+time


The mandate was delayed again in the budget omnibus bill just passed.

The co-ops failed because they underpriced and the R's refused to bail them out. The exchanges will get their business but the insurance will be more expensive.

There is nothing wrong with exchanges. In fact they are very convenient. I used ehealthinsurance.com extensively when I was in the private insurance market. The difference that the fed gov did not control the coverage mandates - the states did. I could easily compare policies with the same deductible and out of pocket maximums, etc ... with other states by using zip codes.

The number of physicians grew significantly in TX after tort reform. That is a fact.

 

The deductibles average between 6000-10,000.00/ year, rendering coverage virtually worthless unless you have a catastrophic condition, even then you will owe your deductible and out of pocket.that is if you can find a hospital and doctor on staff at that hospital that is listed on your plan. Only those that earn enough are subject to the mandate and those that dont earn enough j
Have no mamndate or penalty there is no mandate requring they apply for medicaid. And if there was such a mandate many states did not expand medicaid, so still many uninsureds . only those that already had and could afford health insurance prior to the PPACA are really subject to the mandate and HHS stupid required benefits that you must pay for regardless if you will ever need them such as maternity and newborn care. This law is and will continue to fall apart on its own.

 

Well if that is actually true there appears to be little reason not to go all the way to a single payer system.

 

Yes. On another forum one poster had the exact same thing happen to him - insurance costs and coverage that met their requirements which was cancelled. He then had to pay much more for more coverage than he needed and with deductibles that basically made him uninsured unless he contracted a very serious illness. But that's the scam - force people to pay more for coverage they don't need in order to fund the subsidies for low income people who can't pay for the expensive policies again for coverages they do not need. Instead of allowing the free market to work the gov experts have designed a system to provide cadillac policies to all funded by redistribution from the young and healthy.

 

No, it isn't. That's the legal upper limit, the bronze tier. Two-thirds of shoppers choose silver plans, which have lower deductibles (and, depending on income, are eligible for cost-sharing subsidies that further reduce the deductible). Another ten percent bought gold or platinum level plans.

Weighted by enrollment and ignoring the cost-sharing subsidies, the average deductible is around $3,000. Not cheap, but a fairly standard high deductible plan. Once you factor in that ~60% of shoppers are getting cost-sharing reductions that lower their deducible, the average drops even more.