What's the future of the ACA?

[ivinsfan]

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.

All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

 

[youbet]

All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

Sorry, nothing "blithe" about it. If he wanted flexibility in providers and network, then choosing an HMO-style Advantage plan was indeed the wrong choice. If only HMO-style Advantage plans were being offered in his area and he wanted wide network and provider flexibility, IMHO he should have then gone with traditional Medicare + supplement. He did have options and he picked one that was in-congruent with his coverage desires. Happens all the time.

The reason I keep beating the drum on the subject of Advantage plans not all being the same is for just this reason. Some folks keep discussing them as if they are all the same and they aren't. You need to know what you want and then compare that against the features of the various types of Advantage plans available to you and against traditional Medicare + supplement.

In our household, DW went Advantage and I went traditional Medicare +supplement. So far, we're both satisfied with our choices almost 7 years in. Although, I haven't needed any extensive coverage to test my situation whereas DW, unfortunately, has used hers a lot.

 

[ivinsfan]

Sorry, nothing "blithe" about it. If he wanted flexibility in providers and network, then choosing an HMO-style Advantage plan was indeed the wrong choice. If only HMO-style Advantage plans were being offered in his area and he wanted wide network and provider flexibility, IMHO he should have then gone with traditional Medicare + supplement. He did have options and he picked one that was in-congruent with his coverage desires. Happens all the time.

The reason I keep beating the drum on the subject of Advantage plans not all being the same is for just this reason. Some folks keep discussing them as if they are all the same and they aren't. You need to know what you want and then compare that against the features of the various types of Advantage plans available to you and against traditional Medicare + supplement.

In our household, DW went Advantage and I went traditional Medicare +supplement. So far, we're both satisfied with our choices almost 7 years in. Although, I haven't needed any extensive coverage to test my situation whereas DW, unfortunately, has used hers a lot.

You know it's unfortunate that Medicare coverage has gotten to this point...in fact Advantage plans can change their coverage and perhaps the plan you pick now will morph into an entirely different plan 5 years from now. Medicare recipients don't have the same freedom of movement between plans and coverage that others do, it would be nice to see that change.

 

[youbet]

All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

Help me, will ya? You say that I said "He picked the wrong plan" with quotes indicating not a paraphrase but the exact words I used. In going back to my posts, I don't see that. Can you point me to it please?

 

[youbet]

.in fact Advantage plans can change their coverage and perhaps the plan you pick now will morph into an entirely different plan 5 years from now. Medicare recipients don't have the same freedom of movement between plans and coverage that others do, it would be nice to see that change.

This is my main concern with DW's Advantage plan, that it will change. My research so far has indicated that if it changes to the extent that it "morph(ed) into an entirely different plan," that would be a "qualifying event" and she would have guaranteed access to change to traditional Medicare and purchase a supplement without underwriting. I haven't completely figured out to what extent they could make small changes without triggering a "qualifying event." But, thankfully, so far, so good. Provider accessibility, coverage, cost and customer service have all been very good. In fact, compared to Medicare, customer service is outstanding. Get this........ she calls with a question and someone promptly answers the phone and either knows the answer or calls her back in a reasonable amount of time. I've never had that kind of experience with traditional Medicare.

 

[ivinsfan]

All advantage plans are different and that's the problem...just because you were able to buy this plan in your home area, doesn't mean the poster's Dad had that option. It's not as simple as blithely saying "He picked the wrong plan"

So youbet you will see here I didn't use the words.. you saying "he picked the wrong plan".. I meant that lots of people get swept up in the Advantages of an Advantage plan without a hard look at the disadvantages of the same.

Lots of people will say, well he just picked the wrong plan and he screwed up, which is correct. I just signed up for my plan 3 months ago and believe me I have sympathy for someone trying to make a lifetime decision about healthcare when they are getting bombarded with info from all directions.


As a country we need to try and make this stuff more uniform and easier to understand IMO...

 

[daylatedollarshort]

Our new governor in California is taking steps to keep an individual mandate in California, have the state negotiate on drug prices, move towards single payer and increase the state income caps up to 600% (instead of 400%) of federal poverty level for ACA coverage.

 

[explanade]

Our new governor in California is taking steps to keep an individual mandate in California, have the state negotiate on drug prices, move towards single payer and increase the state income caps up to 600% (instead of 400%) of federal poverty level for ACA coverage.

New Jersey reportedly passed a mandate law and NY is said to be looking at doing something similar to CA with singlepayer.

 

[pb4uski]

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



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

WTF? They actually did something good? Who'd have thunk it.

 

[pb4uski]

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.

I think your logic that prohibiting age rating is the cause is flawed. Your neighbors in Vermont also prohibit age rating and their increases for 2019 were very modest.

 

[pb4uski]

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%.

But what about the tax torpedo once SS and RMDs start?

 

[scrabbler1]

I think your logic that prohibiting age rating is the cause is flawed. Your neighbors in Vermont also prohibit age rating and their increases for 2019 were very modest.

But Vermont lacks any large, high-cost urban areas (unlike in downstate NY), so people in that state aren't being priced out of the market to begin with, with or without age rating.

 

[pb4uski]

It seems to me that the modest cost of the penalty wasn't much of a disincentive to buy health insurance for those young people and that they probably went uninsured and paid the penalty... they'll remain uninsured but just won't have to pay the penalty any longer.

Perhaps there was a subset of people who bought health insurance rather than paid the penalty but given the annual cost of health insurance in relation to the modest penalty, I suspect that population was fairly small so the real impact of eliminating the penalty will be modest.

Given that open enrollment is over, I suspect that we are close to having an answer by now.

ETA... I see that it has been extended to the end of January 2019 in NY, but it looks like enrollments are actually up:

... Nationwide, CBS News reports that enrollment through the federal website healthcare.gov is down so far this year by about 11%, compared to last year. That decrease comes as federal funding for navigators has decreased, and the individual mandate that fined those without insurance has been eliminated.

The opposite trend has happened in New York. The State said Tuesday that enrollment is up over last year by about 60,000 people so far.

“In the last nine days alone, over 35,000 people have enrolled,” said Donna Frescatore, New York State of Health Executive Director. ...

https://cbs6albany.com/news/local/health-insurance-deadline-nears-new-york-state-of-health

 

[Luck_Club]

The solutions are simple:

Transparency in pricing:

Recently went shopping for family solution for the next 15 years before medicare. Doctors visit=$80-90. Which isn't bad when you think about it.
Walk in same price range.
Broken arm according to HSA sites is about $2500.
Colonoscopy self pay procedure, under general anesthesia no less, under $1200 might have been $500, if I recall correctly. It was excessively low in my opinion, and could have explained the short visit before and after procedure. Think assembly line type of throughput.
Stroke screening, pink flyer in your paper $350-$500 for EKG, ECG, Ultrasound of major arteries, maybe even an MRI.

So basic medical costs are in all sense reasonable, and not justifiable to the $14K+ per year with a $6,000 deductible under the Affordable (not) Care Act. Given the relative small risk of major medical issues like cancer etc. (roughly 12.7 million out of 5500 million) The premiums are way out of wack to the costs.

Stats:
5. United States
> Cancer diagnosis rate: 352.2 new cases per 100,000 residents

Morbidly obese, according to my daughter, are hospital patients at rate higher than cancer...Premiums triple, quadruple, no you can't have your diabetes medication subsidized?

No premium subsidies until truly poor. Means test all the way through your 401k & IRA, gifts and trusts. Lets all feel the pain vs minimizing our realized income so we don't fall off the cliff....

Tort reform--saw the my lawyer got me $1.4 million billboard today, with a smiling young healthy looking girl.

 

[scrabbler1]

It seems to me that the modest cost of the penalty wasn't much of a disincentive to buy health insurance for those young people and that they probably went uninsured and paid the penalty... they'll remain uninsured but just won't have to pay the penalty any longer.

Perhaps there was a subset of people who bought health insurance rather than paid the penalty but given the annual cost of health insurance in relation to the modest penalty, I suspect that population was fairly small so the real impact of eliminating the penalty will be modest.

Given that open enrollment is over, I suspect that we are close to having an answer by now.

ETA... I see that it has been extended to the end of January 2019 in NY, but it looks like enrollments are actually up:


https://cbs6albany.com/news/local/health-insurance-deadline-nears-new-york-state-of-health

I disagree that the penalty was "modest" before being eliminated. It should be higher, much higher, in order to discourage people from opting out of buying insurance. Before 2019, it is 2.5% of income, or $1,000 per $40,000 of income, and the person is still uninsured.

As for enrollments being up in New York, the article doesn't break that down by age. If the extra people buying insurance tend to be older (and, perhaps, sicker), then we have more adverse selection which only hurts the risk pool, the same way having younger, healthier people opting out also hurts the risk pool.

 

[pb4uski]

For someone who is young and healthy with earnings of $40,000, I'm guessing paying a $1,000 penalty vs $12,000 or more for health insurance might not have been a particularly tough decision.

 

[scrabbler1]

For someone who is young and healthy with earnings of $40,000, I'm guessing paying a $1,000 penalty vs $12,000 or more for health insurance might not have been a particularly tough decision.

A single person with $40k income can buy a Silver plan policy for about $7k per year, not including any subsidy. With a subsidy and that income, that $7k drops to $6k. A Bronze plan would be cheaper. And this is in a HCOL area such as Long Island. I am that person, and I have investigated Silver and Bronze plans. (When I have avoided going over the ACA cliff, I keep the subsidy.)

A young, healthy single person paying $1k a month for HI is way, way too high. Now the decision between paying a $1k penalty and remaining uninsured versus paying $5k or $6k and being insured is not a slam-dunk either way. But paying zero penalty and being uninsured will tilt the choice toward being uninsured. I wish that penalty were higher, at least doubled, to keep those young, healthy people buying insurance.

 

[gstillson]

A single person with $40k income can buy a Silver plan policy for about $7k per year, not including any subsidy. With a subsidy and that income, that $7k drops to $6k. A Bronze plan would be cheaper. And this is in a HCOL area such as Long Island. I am that person, and I have investigated Silver and Bronze plans. (When I have avoided going over the ACA cliff, I keep the subsidy.)

A young, healthy single person paying $1k a month for HI is way, way too high. Now the decision between paying a $1k penalty and remaining uninsured versus paying $5k or $6k and being insured is not a slam-dunk either way. But paying zero penalty and being uninsured will tilt the choice toward being uninsured. I wish that penalty were higher, at least doubled, to keep those young, healthy people buying insurance.

$6k is still way too much. $40k income is what, $35k after SS and taxes?

$6k/$35k is 17% of your net income just for insurance, which still has a high deductible. And this does not cover dental.

 

[USGrant1962]

...

So basic medical costs are in all sense reasonable, and not justifiable to the $14K+ per year with a $6,000 deductible under the Affordable (not) Care Act. Given the relative small risk of major medical issues like cancer etc. (roughly 12.7 million out of 5500 million) The premiums are way out of wack to the costs.

...

One fundamental problem with PPACA is that it is neither health insurance, nor health care. It is prepaid preventive care cobbled together with high deductible catastrophic health insurance, and with very limited risk rating.

If car insurance was regulated under PPACA, you would be paying Allstate/State Farm/Geico to pay for your gas, oil changes, routine maintenance and car washes, but your comprehensive/collision deductible would be half the cost of your car. And no good driving discounts for you.

As far as premiums being "way out of wack", the insurers are required to pay out 80% or 85% of premiums (depending on the program) under Medical Loss Ratio rules , so the premiums are mostly are actual costs.

 

[daylatedollarshort]

$6k is still way too much. $40k income is what, $35k after SS and taxes?

$6k/$35k is 17% of your net income just for insurance, which still has a high deductible. And this does not cover dental.

Cost sharing does help on that front. One of our kids has a paid internship without any benefits, and has an ACA silver cost sharing plan with $1 a month premiums and a $2.6K out of pocket max. But the cost sharing ends at $48,560 so with rent in a HCOL area, premiums, uncovered dental care and a $6K out of pocket max that still wouldn't leave much leftover for other necessities.

 

[bingybear]

Cost sharing does help on that front. One of our kids has a paid internship without any benefits, and has an ACA silver cost sharing plan with $1 a month premiums and a $2.6K out of pocket max. But the cost sharing ends at $48,560 so with rent in a HCOL area, premiums, uncovered dental care and a $6K out of pocket max that still wouldn't leave much leftover for other necessities.

I thought for a single that PTC/subsides end above 48560 and cost sharing started about 30350 and below.

 

[Dtail]

I thought for a single that PTC/subsides end above 48560 and cost sharing started about 30350 and below.

Doesn't the FPL change depending on whether that state has medicaid expansion?

 

[bingybear]

I thought medicaid expansion allowed people with higher % of FPL to qualify for medicaid insurance. But I really have not studied the medicaid insurance options.

 

[Dtail]

I thought medicaid expansion allowed people with higher % of FPL to qualify for medicaid insurance. But I really have not studied the medicaid insurance options.

Whether a single qualifies for Obamacare at 12k or 16k is dependent on the medicaid expansion in that state and thus the upper limits of 4x FPL follows suit.
If the state doesn't have Medicaid expansion, then if one is under the 1x FPL, one can have serious affordability issues.

 

[SecondCor521]

Doesn't the FPL change depending on whether that state has medicaid expansion?

No. FPL depends on where you live and your family size. And it increases each year by inflation.

So FPL for me for 2019, living in Idaho and having two dependent kids and thus a family size of 3, is $20,780:

https://thefinancebuff.com/federal-poverty-levels-for-obamacare.html

This is my FPL whether my state expanded Medicaid or not. (My particular state hasn't yet but there was a ballot measure that passed in the most recent election requiring the state to expand it. There is a lawsuit. Stay tuned.)

The cost sharing reductions are at 150%, 200%, and 250% of FPL.

Premium tax credits end at 400% of FPL.

Whether a person qualifies for Medicaid depends on their income relative to their FPL and whether the state they live in has expanded Medicaid.