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Old 05-28-2017, 11:06 PM   #21
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The one big advantage that New York State has over other states, is that insurance companies cannot discriminate based on age. So a 21 year old pays the exact same amount that a 64 year old pays. There are only two states that I know of where this is true. The other one is Vermont. Furthermore, if the AHCA, as it stands, ever becomes law, not only will older people benefit from this rule but they also get a higher federal tax credit.
That is good to know. Thanks for posting. New York would be a lot less hassle to move to than Portugal for our gap years if we need affordable coverage from whenever the ACA ends and Medicare begins.

One of the front runners for the next California governor's race is making universal coverage a key part of his platform, so I'm hoping even if we don't really get universal coverage we at least end up with some affordable health insurance options for us pre-Medicare seniors here.
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Old 05-29-2017, 06:54 AM   #22
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There are plenty of insurance examples that utilize age as a factor. Would you argue for "community" rating for car insurance? Imagine such a system where you paid the same car insurance rates regardless of age, sex, accident history, driving record, or vehicle. Do you think the dynamics of such a system would lead to higher overall rates or lower?

Even Vermont has given up on its single payer "Medicare for all" solution, when they figured out it would require a 11.5% payroll assessment and up to 9.5% of individual income. (That is even suspect in terms of whether ti would have fully funded the program.)

There are many aspects of health insurance that drive me bonkers from a libertarian perspective (including the fact that the WW2 price controls ended up generating the employer-sponsored beast we see today).
Well, first and foremost, I don't read Michael's post as advocating anything... just explaining the status quo, so your first paragraph is WAY off base.

While it is true that Vermont abandoned single-payer based on cost concerns... its individual market is similar to one big group (no age-rating, no medical underwriting, etc.) and seems to function well at a reasonable cost compared to many other parts of the country (a HDHI plans cost about $440/month/person).

I totally agree with you on the last part... our current problem with heth insurance is an unintended consequence of that government intervention that resulted in the individual market being marginalized... if we could roll that back and have every person own their own health insurance (like they do with other insurance) then the individual health insurance market would be bigger, more diverse and hopefully more efficient.
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Old 05-29-2017, 07:42 AM   #23
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Well, first and foremost, I don't read Michael's post as advocating anything... just explaining the status quo, so your first paragraph is WAY off base.
Michael wrote:
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The segmentation is artificial, it adds substantial cost overhead, and the only purpose is to artificially lower the price for one segment, at the expense of all others.
That is making a value judgement. I gave one example (of many that can be given) where the same kinds of market segmentation is done.

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While it is true that Vermont abandoned single-payer based on cost concerns... its individual market is similar to one big group (no age-rating, no medical underwriting, etc.) and seems to function well at a reasonable cost compared to many other parts of the country (a HDHI plans cost about $440/month/person)..
My economic issue with this (and with the ACA and even the proposed replacement) is that a major issue with the ACA is the issue of adverse selection. Those who are young and healthy (and pay way more than their share using a single community rated no preexisting conditions) have no reasons to join the party (buy health care) unless forced, or it is given to them (by employer or on a parents plan). Those who are older (and paying less than what they would be paying using age as a discriminator) or unhealthy will join the plan. The results are (as we are seeing and will continue to see) an ever increasing amount of high cost patients in the plan. The result of this is that plan prices increases, just reinforcing the viscous cycle. This is not politics, it is simple actuarial truth. A leveraging factor is the issue with American's health in general (overweight and sedentary and eating a bunch of foods that are bad for you).
[/QUOTE]

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I totally agree with you on the last part... our current problem with heth insurance is an unintended consequence of that government intervention that resulted in the individual market being marginalized... if we could roll that back and have every person own their own health insurance (like they do with other insurance) then the individual health insurance market would be bigger, more diverse and hopefully more efficient.
I think the answer (as much as anything can be an answer) lies somewhere on this road. There must be some sort of weaning from employee sponsored health care to a system where all are treated fairly from a tax perspective in order to have a robust and large risk pool. Where I differ from many of those on this board (hey, I am an old geezer too and what I am saying would cost me money) is that insurance pools must be at least somewhat reflective of the risk factors of those in the pool in order to avoid adverse selection issues.
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Old 05-29-2017, 08:34 AM   #24
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.... My economic issue with this (and with the ACA and even the proposed replacement) is that a major issue with the ACA is the issue of adverse selection. Those who are young and healthy (and pay way more than their share using a single community rated no preexisting conditions) have no reasons to join the party (buy health care) unless forced, or it is given to them (by employer or on a parents plan). Those who are older (and paying less than what they would be paying using age as a discriminator) or unhealthy will join the plan. The results are (as we are seeing and will continue to see) an ever increasing amount of high cost patients in the plan. The result of this is that plan prices increases, just reinforcing the viscous cycle. This is not politics, it is simple actuarial truth. .....
I agree that if you compare annual premiums to annual costs that community rating is unfair to the young and advantageous to the old. However, over a lifetime it would all even out ... someone would "overpay" when they are young and would "underpay" when they are older.... just like what happens with permanent life insurance... your "overpay" compared to term life insurance rates when you are young and "underpay" when you are older... or another way of thinking of it is that when you are young that you are prepaying to get favorable rates when you are older.

The reason to "join the party" is to have insurance coverage if you are one of the relatively few young people to have a significant health event or accident and to gain access to more affordable health insurance coverage when you are older.

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.... I think the answer (as much as anything can be an answer) lies somewhere on this road. There must be some sort of weaning from employee sponsored health care to a system where all are treated fairly from a tax perspective in order to have a robust and large risk pool. Where I differ from many of those on this board (hey, I am an old geezer too and what I am saying would cost me money) is that insurance pools must be at least somewhat reflective of the risk factors of those in the pool in order to avoid adverse selection issues.
The problem with what you propose is where to draw the line... the ACA draws it in one place (3:1 IIRC) and AHCA would draw it in a different place (5:1 IIRC) vs VT/NY/group at 1:1.

A part of the adverse selection issue is people buying insurance only when they become sick. While I would prefer to mandate coverage it is clear that as a society we are not keen on doing that so the next step would be to deny coverage for existing conditions for a period of time unless someone has had continuous coverage (which AHCA includes as I understand it)... IOW, there is a penalty that could cost you a lot or bankrupt you if you don't continuously carry health insurance coverage... those who are short-sighted or have little to lose will likely decide not to sign up anyway but that is their choice and they will need to live with the consequences.

As a society we have lots of experience with large group coverage and it seems to work ok so I would like to see an approach that creates a huge group with the same approach as group coverage with a couple tweaks as appropriate in the circumstances... and adjust as needed for issues that arise.
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Old 05-29-2017, 10:35 AM   #25
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Large group policies charge the same premium for all members of the group and do not differentiate for gender, age, health, previous conditions, or anything else. They also require everyone in the group to hold the same policy coverage. It seems to work. There certainly is no complaint at all about the pricing.

Individual insurance sets prices based on factors such as age, but that is a business model that was developed to exclude groups, divide the marketplace into small segments, underwrite, price them individually, and deny coverage to many. The segmentation is artificial, it adds substantial cost overhead, and the only purpose is to artificially lower the price for one segment, at the expense of all others. Age is just one condition used to underwrite, there really is no limit to the factors that can be used to segment a human population.
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That is making a value judgement. I gave one example (of many that can be given) where the same kinds of market segmentation is done.
No value judgment in my post, it was a simple observation about insurance. Let me state it differently. The insurer can assess one broad market risk, and price accordingly, for the entire group. The insurer can also divide the market into smaller risk segments. Doing so has one primary purpose, which is to limit the risk group, assess, underwrite and price to each individual risk group. By definition, this will benefit some and exclude others. The group health insurance marketplace, which is considered effective and successful here in the US, does not operate on these principles. This is because there is no benefit or advantage to the group.

The total risk does not change, no matter how you segment or aggregate risk, it just spreads it around differently. The total cost of health care for universe also does not change. What market segmentation does do is add cost to the insurer, and also incentive to insurers and policyholders alike to exploit the segmentation scheme for personal benefit or profit.

If the goal is to enroll young policyholders, age rating might be one way to do that. If, however, the goal is to maximize enrollment across the entire population (age, genders, zip codes, health status, etc) there is no segmentation scheme that will make it easier to achieve that goal.

Health insurance cannot cost less than the helath care it intermediates. One way to reduce the cost of health insurance is to reduce unproductive overhead and then focus on containing and eliminating cost of health care itself in the US. But that's a different discussion.
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Old 05-30-2017, 05:29 AM   #26
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Individual
-----------
Catastrophic: $158-$193
Bronze: $320-$370
Moving to New York state for the community rating is on my list of options should the need arise. Healthy persons also have the option of moving to Tennessee. TN continues to allow the sale of low cost underwritten major medical plans through the Farm Bureau. It should be noted that the probability of TN DOI changing FB's designation from "rural health organization" to "health insurance company" is higher than NY changing from community rating.

60 yr old Individual in Knoxville:

$2500 deductible/$3750 MOOP (HSA eligible): $210/month
$5000 deductible/$10,000 MOOP: $150/month

Farm Bureau Health Plans
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Old 05-31-2017, 12:42 PM   #27
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An important note about health care in NY State...COBRA lasts 3 years here, not 18 months. I quit about 18 months ago and I still have 18 months of eligibility left.
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Old 05-31-2017, 09:39 PM   #28
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I agree that if you compare annual premiums to annual costs that community rating is unfair to the young and advantageous to the old. However, over a lifetime it would all even out ... someone would "overpay" when they are young and would "underpay" when they are older.... just like what happens with permanent life insurance... your "overpay" compared to term life insurance rates when you are young and "underpay" when you are older... or another way of thinking of it is that when you are young that you are prepaying to get favorable rates when you are older.

The reason to "join the party" is to have insurance coverage if you are one of the relatively few young people to have a significant health event or accident and to gain access to more affordable health insurance coverage when you are older.



The problem with what you propose is where to draw the line... the ACA draws it in one place (3:1 IIRC) and AHCA would draw it in a different place (5:1 IIRC) vs VT/NY/group at 1:1.

A part of the adverse selection issue is people buying insurance only when they become sick. While I would prefer to mandate coverage it is clear that as a society we are not keen on doing that so the next step would be to deny coverage for existing conditions for a period of time unless someone has had continuous coverage (which AHCA includes as I understand it)... IOW, there is a penalty that could cost you a lot or bankrupt you if you don't continuously carry health insurance coverage... those who are short-sighted or have little to lose will likely decide not to sign up anyway but that is their choice and they will need to live with the consequences.

As a society we have lots of experience with large group coverage and it seems to work ok so I would like to see an approach that creates a huge group with the same approach as group coverage with a couple tweaks as appropriate in the circumstances... and adjust as needed for issues that arise.
So, suppose I am 21 and healthy, but I have no employer provided health care. I'm supposed to pay 3X - 5X rates because someone told me that over my lifetime it will even out? OK, sure that sounds like a good idea. That $600 a month buys me a lot of other things that I need. A car, movies, fun times with my friends. I won't get sick (because I'm invincible), and if I do start to have health problems, I sign up at that point. I don't have tons of money, so what the .... I will let it ride. If I get sick I go to the hospital where they must take me, insurance or not.

It's that simple. Without forcing people to play (which the ACA tries to do but doesn't really succeed at) -OR- by refusing coverage for preexisting conditions/refusing care (which we as a society won't do), the existing structure can't (and won't) work.

Ask yourself this. How many young people would pay social security if given the option to opt out? I am opposed to the ACA (or socialized medicine in general), but if there is to be insurance for all, it should be some sort of minimal, catastrophic care only plan which needs to be funded directly (e.g. by income tax or sales tax). By minimal, I mean minimal - which the ACA certainly is not.
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Old 06-01-2017, 01:19 PM   #29
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Actually a 21 year old in my state can buy a high-deductible ACA catastrophic plan for about $240 a month (no subsidy) so perhaps that suits your fancy better.
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Old 06-02-2017, 10:40 AM   #30
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One other thing about health care in NY State worth mentioning that I only found out about today

There is a "Protection from Surprise Bills and Emergency Services" law:

New York’s New “Surprise Bill” Law Rolls out New Health Insurance Protections for Consumers | Families USA

A couple of snippets from that article:

"Consumers who receive emergency services will not have to pay more than their usual in-network cost sharing and/or copayments
, regardless of the network status of the providers. The emergency service providers and health insurers will have to negotiate the fees directly."

"Consumers who receive other out-of-network medical services when there were no in-network providers available, or when they did not receive the disclosures required by law, are also protected. Consumers in these circumstances can assign their claims to the out-of-network providers and also pay only their usual in-network cost-sharing. In this situation, too, the bill is then worked out directly between the provider and the health plan."

Until I retired I didn't pay much attention to health care but 'knew' it was more expensive in New York but the more I find out about the rules and regulations in New York the happier I am.
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Old 06-02-2017, 10:57 AM   #31
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One other thing about health care in NY State worth mentioning that I only found out about today

There is a "Protection from Surprise Bills and Emergency Services" law:

New York’s New “Surprise Bill” Law Rolls out New Health Insurance Protections for Consumers | Families USA

A couple of snippets from that article:

"Consumers who receive emergency services will not have to pay more than their usual in-network cost sharing and/or copayments
, regardless of the network status of the providers. The emergency service providers and health insurers will have to negotiate the fees directly."

"Consumers who receive other out-of-network medical services when there were no in-network providers available, or when they did not receive the disclosures required by law, are also protected. Consumers in these circumstances can assign their claims to the out-of-network providers and also pay only their usual in-network cost-sharing. In this situation, too, the bill is then worked out directly between the provider and the health plan."

Until I retired I didn't pay much attention to health care but 'knew' it was more expensive in New York but the more I find out about the rules and regulations in New York the happier I am.
Two years ago, when I had my 12-day stint in the hospital, I had gone to the ER first and was later admitted. But the hospital was not in-network. However, because my hospital stay was a result of an ER visit, I was covered as if the hospital was in-network. My insurance company and the hospital had to fight it out (and they did!) over what the IC would pay the hospital, but I was not liable for anything beyond the maximum copay/coinsurance/deductible as stated in my policy (thanks to that law). And I could not be balance-billed, of course (although the hospital tried to bill me for an extra ~$500 which I got them to ignore).
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Old 06-02-2017, 11:49 AM   #32
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New York also limits Medicare balance billing (excess charges) to 5% for most services instead of the federal limit of 15%.

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A New York State law limits the amount that Medicare nonparticipating physicians (physicians who do not accept Medicare assignment) may charge - no more than 5% above Medicare’s approved amount. This limit applies to all services except certain home and office visits for basic medical examinations, (those represented by procedure codes of 99201 to 99215 and 99341 to 99353). For services billed with these procedure code numbers, the federal limit of 15% above Medicare’s approved amount applies. Medicare’s approved amount for health care services and supplies is shown on the beneficiary’s MSN.

Source: https://aging.ny.gov/HealthBenefits/...dules/Mod4.pdf
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Old 06-02-2017, 05:55 PM   #33
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And the cost of healthcare in NY may become even cheaper in the near future. Passed in the Assembly now on to the Senate where it only trails by one vote for passage.

"On Wednesday, May 27, the New York State Assembly passed the “New York Health Act” universal health care bill (A. 5062/S. 3525) by a vote of 92 to 52. New York Health would provide universal, comprehensive health care to all New Yorkers without premiums, co-pays, deductibles, or limited provider networks."

https://www.healthcare-now.org/blog/...e-legislation/

Link to the full bill: New York State Assembly | Bill Search and Legislative Information
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Old 06-06-2017, 03:46 PM   #34
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Oh boy. The thought of moving back to NY is sort of sad but sort of thrilling. I really do miss the museums. I really do NOT miss the winter !!
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Old 06-06-2017, 10:17 PM   #35
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Actually a 21 year old in my state can buy a high-deductible ACA catastrophic plan for about $240 a month (no subsidy) so perhaps that suits your fancy better.
That seems high. My kid pays $251 for Kaiser plan in HCOL area in CA, non ACA plan. She loves Kaiser.
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Old 06-06-2017, 10:28 PM   #36
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Did anyone see that in NV they are proposing that you can buy into medicaid? While not the best care, (Ideally they would like to include exchange subsidies). Now this might mean healthcare ala the college clinic many of us recall from college days.
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Old 06-07-2017, 12:27 PM   #37
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And the cost of healthcare in NY may become even cheaper in the near future. Passed in the Assembly now on to the Senate where it only trails by one vote for passage.

"On Wednesday, May 27, the New York State Assembly passed the “New York Health Act” universal health care bill (A. 5062/S. 3525) by a vote of 92 to 52. New York Health would provide universal, comprehensive health care to all New Yorkers without premiums, co-pays, deductibles, or limited provider networks."

https://www.healthcare-now.org/blog/...e-legislation/

Link to the full bill: New York State Assembly | Bill Search and Legislative Information
That link (for the NY State Assembly Bill) does say May 27, but has no year. The accompanying comments are from 2015, and conclude by saying that NY State Senate did not pass the bill. So did all this happen in 2015 and is dead now?
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Old 06-07-2017, 12:43 PM   #38
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NY State did announce measures to address coverage in the individual market. Essential health benefits will be required and insurers must continue to offer exchange plans if they want to participate in the Medicaid marketplace.
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SYRACUSE, N.Y. -- Any insurers that leave New York's health insurance exchange will be banned from participating in the state's Medicaid program or contracting with any state agencies under regulations Gov. Andrew Cuomo announced today.

Cuomo also will make all insurers who do business on the state's exchange guarantee the 10 essential health benefits required by the federal Affordable Care Act, also known as Obamacare. Cuomo to ban companies from Medicaid if they leave NY health insurance exchange | NewYorkUpstate.com
Requiring insurers to offer individual policies if they want access to the Medicaid market is a smart move. Nevada is doing something similar. Perhaps this is something that other states will follow.
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Old 06-13-2017, 05:30 PM   #39
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I was reading this article about health coverage at the fivethirtyeight web-site:

https://fivethirtyeight.com/features...lth-care-bill/

The really interesting part from the point of view of most participants on this board is the map that shows how subsidies might be affected for a 60 year-old couple earning $50,000 on a county by county basis if we switch to the AHCA as it stands.

Amazingly upstate New York comes out pretty well! On the other hand, sadly, Alaska is screwed.

Noticing that the source was the Kaiser Family Foundation led me to this page:

Premiums and Tax Credits Under the Affordable Care Act vs. the American Health Care Act: Interactive Maps | The Henry J. Kaiser Family Foundation

which has a really useful interactive map that allows you to select age and income. You can then point at your specific county and get actual numbers.

Of course, since health care is a moving target the accuracy of these numbers is debatable, but I do think it might help people plan for the future especially those that are maybe thinking of moving when they retire.
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Old 06-17-2017, 10:52 AM   #40
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Since health care is a moving target right now there is very little info to help ERs plan for the future. All we can do is comment on current legislation and executive action until we see how the sausage has been made.

I find it interesting that all of this is happening behind closed doors right now, with no public input or hearings. I guess we'll see if an attempted ram-through of pork into sausage is the result.
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