What's the future of the ACA?

[FreeBear]

Much of the disapproval or disagreement with ACA is really an issue with the high cost to insure, and that will not change. This is one reason why it is so difficult to replace. I think this is not so much kicking the can down to road as it is completely ignoring the real underlying issues.

+1 Yep, ACA is just the tip of the iceberg, the high cost of medical care is the huge submerged mass.

Sometimes, you will hear people say just go back to the way things were before the ACA but not even the opponents of the ACA seem to be pushing this line of thinking that heavily.

The ACA may have conditioned people to think that govt. needs to try to ensure coverage is more broad or accessible to more people, rather than all individuals having to fend for themselves.

That change in mindset might be the legacy.

Personally, I see this as a good change, regardless of what the specific mechanism, ACA or "other".

- The Texas court ruling will be overturned
- The ACA will stay pretty much as it until the next election
- Premiums will rise less than many folks anticipate

I believe we aren't supposed to discuss politics, so I'll leave it at that.

If you are right, I can live with this until Medicare...

Still the rise in premium's and increasing OOP is still a problem. For now, our ACA subsidy takes most of the edge off, and I've heard that most on ACA receive some subsidy. Can't help but think the rapidly rising premiums (rack rate) is tied actual medical costs out of control. Also, this was an issue even when I was w*rking. The company was pushing High Deductible plans hard. I suspect Cadillac PPO will become the dodo bird at many companies.

 

[Aerides]

Mod reminder:

As with all things healthcare, we realize it's difficult to keep politics out but want to keep these threads open - as they are so important to many members here. However, if we can't keep things non-partisan, the conversation will come to a close.

Please keep this in mind as you continue your thoughtful contributions to this discussion.

 

[Gumby]

They spend more on marketing than R&D and they’re hiking prices on drugs developed decades ago.

They’re not even pretending that the hikes are to recoup R&D or for future R&D.

They’re practically saying “because we can.”

The other villains are the pharmacy benefit managers taking their own cuts.

In fact, they may be breaking the antitrust laws in a massive way.

The alleged collusion transformed a cutthroat, highly competitive business into one where sudden, coordinated price spikes on identical generic drugs became almost routine.

https://www.courant.com/nation-world/hc-pol-generic-drug-cartel-20181210-story.html

 

[explanade]

Hard to believe anyone is defending pharma these days.

Even politicians will criticize high drug prices while taking pharma lobby money while doing nothing about the prices.

But few if any will try to rationalize these price hikes.

 

[explanade]

That will be the mother of all fights get some popcorn ready..Pharma will not go down without a fight. I've seen my DH EOBs from Medicare and if the hospitals got that little amount of money from everyone they'd go broke.

I personally believe the Medicare Advantage plans will be the blueprint for Medicare for all and it's the reason the marketing for Advantage has been so aggressive.

Had a bad experience with trying to get second opinions for my father who was on an Advantage plan.

If you have any suspicion about the providers in an Advantage plan and want to go to an outside provider for that second opinion, you’re at the mercy of that Advantage insurer. They in effect control your Medicare funds. You apparently can’t go to an outside doctor who takes Medicare and be granted of being reimbursed.

Based on that we put our mother on a Medigap (F plan) which has higher monthly premiums but no deductibles or copays.

I plan to sign on for Medigap, not Advantage.

 

[gstillson]

In fact, they may be breaking the antitrust laws in a massive way.



https://www.courant.com/nation-world/hc-pol-generic-drug-cartel-20181210-story.html

That is about generics, not drugs that are progressing through clinical trials.

I guess it would be better if we could not slap the whole industry with one label. Just because you have a few bad eggs doesn't mean you have to throw out the whole henhouse.

If you drastically reduce the incentive to make money on developing a drug to treat a needed disease, you will lose investors. This is simple simple math. Aside from charity, none of you would put your retirement money in a company who had a 99% chance of losing it all with the only upside being a small gain. None of you.

 

[Gumby]

That is about generics, not drugs that are progressing through clinical trials.

I guess it would be better if we could not slap the whole industry with one label. Just because you have a few bad eggs doesn't mean you have to throw out the whole henhouse.

If you drastically reduce the incentive to make money on developing a drug to treat a needed disease, you will lose investors. This is simple simple math. Aside from charity, none of you would put your retirement money in a company who had a 99% chance of losing it all with the only upside being a small gain. None of you.

Oh, the branded drug companies also do their share of acts alleged to be in violation of the antitrust laws. Google "pharmaceutical product hopping". Here is one example.

https://www.cnn.com/2016/09/23/health/suboxone-lawsuit-antitrust/index.html


P.S. -- I try not to invest in companies that deliberately violate the law. (Yes, I know that these are for the present mere allegations in a lawsuit. At the end of the day, they may not actually be found liable.)

 

[gstillson]

Oh, the branded drug companies also do their share of acts alleged to be in violation of the antitrust laws. Google "pharmaceutical product hopping".

https://www.cnn.com/2016/09/23/health/suboxone-lawsuit-antitrust/index.html

And Wells Fargo employees set up fake accounts using real customer information. Do you still bank?

 

[Gumby]

And Wells Fargo employees set up fake accounts using real customer information. Do you still bank?

Not with Wells Fargo.

 

[pb4uski]

That's not what insurers here in New York thought when they filed their 2019 rate increases back in June. I posted this link to begin the long thread last year about 2019 rate increases.

https://www.dfs.ny.gov/about/press/pr1806011.htm

Insurers filed for a 24% increase overall, with half of that (12%) due to the repeal of the mandate and the other half (12%) separate from the repeal of the mandate.

Back in 2010-2011, before the ACA, I saw increases of 20% and 25% in those 2 years (50% overall) before I finally dropped that policy and opted for, temporarily, a bare-bones, hospital-only policy to get me to 2014 when the exchanges came in. My rate for a Silver plan dropped to less than what I was paying in 2009. The mandate surely dropped the rates because there were more healthier people like me (this was before I got sick in 2015) were back in the main insurance pool.

Sounds like NY insurers used the repeal of the mandate to take you for a ride. This link of a study by Kaiser Family Foundation suggests that most insurer adjustments for repeal of the mandate were modest... on average 6% and ranging from 0% to 14%.

https://www.kff.org/report-section/...d-plans-are-affecting-2019-premiums-appendix/

Among insurers that publicly specify the effect of these legislative and policy changes, we found that 2019 premiums will be an average of 6% higher, as a direct result of individual mandate penalty repeal and expansion of more loosely regulated plans, than would otherwise be the case.

 

[marko]

Slightly off topic but last week I went to the pharmacy to get a months supply of Simvastatin. Granted it is a generic and common drug.

I was three days early for my supply and BCBS couldn't cover it for another three days.

I told the pharmacist that I was leaving for Florida the next day and couldn't wait. He suggested I call BCBS and battle it out. Then...the guy standing in line next to me said "Why don't you ask how much it is if you pay out of pocket?"

I learned two things:
1) At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that?

2) My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

 

[joeea]

My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

Most drug plans have a web site where you can check the cost of a medication, and determine if it is covered or not.

I don't have BCBS, but I always check first.

At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that?

I believe this is an insurance contract issue (between the insurer and pharmacy) and not a law. And it's not limited to Massachusetts.

See: https://www.nytimes.com/2018/02/24/us/politics/pharmacy-benefit-managers-gag-clauses.html

 

[REWahoo]

I believe this is an insurance contract issue (between the insurer and pharmacy) and not a law. And it's not limited to Massachusetts.

See: https://www.nytimes.com/2018/02/24/us/politics/pharmacy-benefit-managers-gag-clauses.html

New Federal law in October should have invalidated such contract terms:

Insurers will no longer be able to bar pharmacists from telling consumers when paying cash would be cheaper than using insurance for their prescriptions, as a result of bipartisan legislation signed Wednesday ...

https://www.aarp.org/health/drugs-supplements/info-2018/gag-rules-pharmacists.html

 

[24601NoMore]

They spend more on marketing than R&D and they’re hiking prices on drugs developed decades ago.

They’re not even pretending that the hikes are to recoup R&D or for future R&D.

They’re practically saying “because we can.”

The other villains are the pharmacy benefit managers taking their own cuts.

Recent example of "because we can"..

I was prescribed a topical NSAID cream for some mysterious leg pains I've been having. Was told that because it was a "compound" drug that only specialty pharmacies could fill. Called CVS and was told they couldn't because it was a $3,000 (?!!) cream.

Got the cream (Pennsaid) and saw on my HC Portal that the Pharmacy charged over $5,000 (!!!) for ONE TUBE OF CREAM.

I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances..

Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

 

[jimbee]

Slightly off topic but last week I went to the pharmacy to get a months supply of Simvastatin. Granted it is a generic and common drug.

I was three days early for my supply and BCBS couldn't cover it for another three days.

I told the pharmacist that I was leaving for Florida the next day and couldn't wait. He suggested I call BCBS and battle it out. Then...the guy standing in line next to me said "Why don't you ask how much it is if you pay out of pocket?"

I learned two things:
1) At least in Mass, it is against the law for a pharmacist to offer the retail price unless you ask. That is why the pharmacist told me to call BCBS! If I asked he must tell me but he couldn't suggest that I pay out of pocket. Who benefits from a law like that?

2) My prescription cost (no insurance) was $6.95! WHAT? I was going to spend a half hour on hold with BCBS for seven bucks? I was always under the impression that even with a common generic like Simvastatin it was in the $50 range for a month's supply. Seven bucks?

I haven't used my medical insurance to buy prescription medication for years. It is always more expensive than goodrx.com or wellrx.com.

 

[fh2000]

Recent example of "because we can"..

I was prescribed a topical NSAID cream for some mysterious leg pains I've been having. Was told that because it was a "compound" drug that only specialty pharmacies could fill. Called CVS and was told they couldn't because it was a $3,000 (?!!) cream.

Got the cream (Pennsaid) and saw on my HC Portal that the Pharmacy charged over $5,000 (!!!) for ONE TUBE OF CREAM.

I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances..

Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

Is $5,000 the negotiated amount from your insurance company, or there is a lower amount that you do not see from your Portal?

 

[gstillson]

I can't fathom why one little container of topical cream would be $5K, even IF the drug company was "pretending" to recoup their R&D costs. Nope..they charge $3 -$5,000 per tube "because they can" by all appearances..

Oddly enough, the HC company covered the cost without even batting an eyelash. Yet, they made me jump through all sorts of hoops to cover a ~$1K MRI for the same issue..go figure.

How long did the MRI take? I had one done and it took all of 20 minutes.

$1000 for 20 minutes is also a pretty good scam, especially considering how old the MRI technology is now.

 

[24601NoMore]

Is $5,000 the negotiated amount from your insurance company, or there is a lower amount that you do not see from your Portal?

It was >$5K ($5,200-something IIRC) paid.

ETA - just checked the Portal. Paid > $5,300 (!). Crazy. If I had known, I would have never gotten the RX filled.

 

[Mulligan]

The reality of the situation is such that the underlying problem of the issue is not being addressed. And nothing near term will suggest otherwise that it will be. So in reality its a game of every man and woman for him/herself. Find a cost shifting angle to move the financial burden to someone else, or at least away from having to pay for others. Depending on ones needs that can be HSAs, short term insurance that is renewable, healthcare ministries, income management for ACA, PT employment that has health insurance, etc...I have found the best suitable plan for me. Longtime GF will be moving in with me and in a year I will cost shift onto Fortune 500 company using their domestic partner plan. After cafeteria plan tax reduction, I will pay $150 a month for a robust network, $200 annual deduction, with dental and vision all included in the $150 premium...I will ride this for 10 years right into Medicare, I hope!

 

[scrabbler1]

Sounds like NY insurers used the repeal of the mandate to take you for a ride. This link of a study by Kaiser Family Foundation suggests that most insurer adjustments for repeal of the mandate were modest... on average 6% and ranging from 0% to 14%.

https://www.kff.org/report-section/...d-plans-are-affecting-2019-premiums-appendix/

I can see why New York is at the top end of the 0-14% range. Not allowing age rating will increase the rates for younger people while lowering them for older ones. These rightly or wrongly inflated rates for younger people will more easily drive them out of the insurance market once the mandate has been repealed. And remember that more than half of the state's population lives in the downstate NYC-LI metro area where the rates are already higher than in the rest of the state.

I remember from my actuarial days when I was estimating the percentage of uninsured motorists. The higher-cost urban areas always had higher rates of uninsured drivers than the lower-cost suburban and rural areas. I see no difference between that and how those uninsured people are distributed in the HI market.

No, I'm not being taken for a ride as you suggest.

 

[gstillson]

Find a sugar momma. Best idea yet actually.

 

[youbet]

Had a bad experience with trying to get second opinions for my father who was on an Advantage plan.

.

My DW was able to get all the second opinions she wanted using her Advantage plan. And she also had access to any of the cancer centers she wished (as long as they accepted Medicare assignment). Your dad made a mistake when he selected his Advantage plan as many do. They assume all the plans are close to the same and they aren't. You need to understand the important differences.

I assume you got the second opinions regardless of insurance coverage. They usually aren't expensive as long as the required diagnostic test results are already available and can be carried to the second opinion doc.

 

[explanade]

My DW was able to get all the second opinions she wanted using her Advantage plan. And she also had access to any of the cancer centers she wished (as long as they accepted Medicare assignment). Your dad made a mistake when he selected his Advantage plan as many do. They assume all the plans are close to the same and they aren't. You need to understand the important differences.

I assume you got the second opinions regardless of insurance coverage. They usually aren't expensive as long as the required diagnostic test results are already available and can be carried to the second opinion doc.

It was Kaiser, which was one of the highest rated Advantage plans.

But if we wanted to go to UCSF, we’d have to pay for ambulance and hospitalization out of pocket.

They refused to release Medicare funds and the clerk at their claims office said they never do.

We took imaging to another doctor who had a complete different opinion, which we presented to the Kaiser doctors who all said nothing can be done.

We weren’t conv8nced that was a medical opinion as much as a financial one.

 

[youbet]

It was Kaiser, which was one of the highest rated Advantage plans.

That confirms that the "rating" doesn't account for the network or type (HMO vs PPO) of plan.

We took imaging to another doctor who had a complete different opinion, which we presented to the Kaiser doctors who all said nothing can be done.

There ya go. Although I wouldn't have gotten involved in an HMO style Advantage plan to begin with, given that your dad did, this was the way to go. How did the second opinion information factor into or change the course of treatment your dad was receiving?

In DW's case, her Advantage PPO plan covered second opinions to the same extent that traditional Medicare would have and the second opinions supported the original diagnosis and treatment recommendation so nothing changed. But we both felt better for having another independent source of analysis and opinion.

As was mentioned earlier in the thread, it does seem like progress towards universal coverage in the USA will likely involve some restrictions in flexibility such as those in Advantage HMO plans or the national plans of countries like Canada or the UK. We probably all need to practice living and dealing with those restrictions, although I don't look forward to them.

 

[Lisa99]

On a slightly different but related topic the ACA "cliff" of $60k has caused us to keep our withdrawals artificially low which isn't a bad thing.

So instead of withdrawing a little more than 5% per year until SS kicks in, we're below 4%.