Humana contemplating pullout of some markets next year

[easysurfer]

When the ACA was still being legislated there was some discussion about opening the Federal Employee Health Benefit program to areas where there was inadequate private insurance.

The problem is, these insurers - BCBS, Aetna, Humana, UHC, etc - all continue to participate in all these states, but are limiting themselves to group, Medicaid and Medicare. The individual markets are too granular, segments are too small.

For my situation, at least BCBS is sticking around for next year. They are asking for a huge premium hike though .

 

[NW-Bound]

Full circle. Before the ACA, if you had a pre-existing condition you might well find that no one wanted to insure you, but it kept rates lower for the well.

Now, pre-existing or not, people will be on the same footing: no healthcare.

I think I'd better surf the Web to understand more about getting major healthcare overseas, like in Thailand as a poster recently describes.

For sudden health problems, one has to live there as an expat. Darn. I do not want to do that.

 

[MichaelB]

Now, pre-existing or not, people will be on the same footing: no healthcare.

I think I'd better surf the Web to understand more about getting major healthcare overseas, like in Thailand as a poster recently describes.

For sudden health problems, one has to live there as an expat. Darn. I do not want to do that.

This is only individuals not eligible for healthcare from employers, Medicare, Medicaid, or TriCare. About 15% of US population.

If we could "self-insure" and pay health care providers the same rates the insurers get it would be different. Self-payers, however, are charged 10x - 15x more, for no good reason (other than unbridled greed) with no regulation or guardian angel to help.

 

[NW-Bound]

Besides that, nothing is really done about cost control. People only talk about shifting the cost around. They figure that as long someone else is picking up the tab, it's all honky-dory.

I'd better stop now before it raises my blood pressure.

 

[rodi]

This is only individuals not eligible for healthcare from employers, Medicare, Medicaid, or TriCare. About 15% of US population.

If we could "self-insure" and pay health care providers the same rates the insurers get it would be different. Self-payers, however, are charged 10x - 15x more, for no good reason (other than unbridled greed) with no regulation or guardian angel to help.

+1000

I am part of that 15% that needs access to non-employer healthcare and don't qualify for medicare, medicaid, VA, or tri-care.

I discovered with our HUGE medical bills last year, the difference between negotiated rates and non-negotiated rates. In effect I am self insuring by purchasing a (very) HDHP. $4500 deductible for individual, $9k for the family. Our medical bills came close to the $9k... with the 2 kids both approaching, but not exceeding the $4500. For this plan where I had almost $9k OOP for 3 of us (2 kids and myself) I paid $550/month... This year it's over $600 a month.

But - that premium gets me access to the negotiated rates. My son had a short hospitalization. It was $850 a day rather than $3k/day if we didn't have insurance. When he took a baseball to the face the ER would have been $7k all in (including x-rays etc...) we got out for about $1500 when it all settled out. Similar for the face bone specialists and for the ophthalmologist he had to see as follow up. And all of this was in a closed network, docs as employees, system.... Kaiser Permanente.

 

[Sunset]

Sounds like a game of chicken.
Perhaps since we have Medicare, the Medicare should be expanded and allowed to negotiate with drug companies on prices, so that folks without private insurance at X% of the poverty level cost can get insurance at some cost Y.

Sort of like our Northern Neighbors, who all have coverage whether employed or not.

 

[mpeirce]

If we could "self-insure" and pay health care providers the same rates the insurers get it would be different. Self-payers, however, are charged 10x - 15x more...

I was reviewing DF's bill from his recent hospitalization.

"Total cost: $151,244"

But there was a line item: "Calculated contractual adjustment: $140,547"

My goodness.

 

[NW-Bound]

... Sort of like our Northern Neighbors, who all have coverage whether employed or not.

But some of them cannot or have a heck of a time to find healthcare providers, like one of our friends with his aneurysm.

See: http://www.early-retirement.org/forums/f38/aneurysm-82778.html.

Nemo2 turned out OK, but 4 years ago when I was faced with a life threatening disease and time was of essence, I was seen by a specialist after 2 days, who set the extensive and intensive course of treatment and surgery going within a week.

 

[Souschef]

A long time ago, I read that the 3 goals of health insurance were to be : universal, accessible, and affordable.
No country has been able to meet more than 2 of those criteria, and Obamacare proves the point.

 

[MBSC]

If we could "self-insure" and pay health care providers the same rates the insurers get it would be different. Self-payers, however, are charged 10x - 15x more, for no good reason (other than unbridled greed) with no regulation or guardian angel to help.

I discovered with our HUGE medical bills last year, the difference between negotiated rates and non-negotiated rates.

But - that premium gets me access to the negotiated rates. My son had a short hospitalization. It was $850 a day rather than $3k/day if we didn't have insurance. When he took a baseball to the face the ER would have been $7k all in (including x-rays etc...) we got out for about $1500 when it all settled out.

The self-payer is also allowed to negotiate down the billed charge. While they will not be able to get the final price down to the insurance rate in the vast majority of cases, there are anecdotal cases of cash prices being lower.

When Nancy Surdoval, a retired lawyer, needed a knee X-ray last year, Boulder Community Hospital in Colorado said it would cost her $600, out of pocket, using her high-deductible insurance, or just $70 if she paid cash upfront. When she needed an MRI to investigate further, she was offered a similar choice—she could pay $1,100, out of pocket, using her insurance, or $600 if she self-paid in cash.

Many hospitals also offer discounts if patients pay in cash on the day of service, because it saves administrative work and collection hassles. Cash prices are officially aimed at the uninsured, but people with coverage aren’t legally required to use it.

Reference: How to Cut Your Health-Care Bill: Pay Cash - WSJ

 

[DrRoy]

On the news yesterday I heard that Aetna is exiting from ACA, as they lost too much money on individual plans. Last Sunday's newspaper said rates in Michigan will be up 17% next year.

 

[ShokWaveRider]

We will happily leave and move North if the ACA Goes Pear Shaped Next or the following year. But we have that option. The money we save will go into Raincoats and brollies.

 

[MichaelB]

On the news yesterday I heard that Aetna is exiting from ACA, as they lost too much money on individual plans. Last Sunday's newspaper said rates in Michigan will be up 17% next year.

Aetna announced it is cancelling its ACA expansion into new markets, but will continue in current markets. Health insurer Aetna backs off ACA expansion plans - Ap - Independent Tribune

 

[pb4uski]

...The problem is, these insurers - BCBS, Aetna, Humana, UHC, etc - all continue to participate in all these states, but are limiting themselves to group, Medicaid and Medicare. The individual markets are too granular, segments are too small.

What I don't get is why the individual market isn't the same as having one big, diverse group. The plus is that the insurer gets to adjust premiums for age (unlike group) with a corresponding minus that they need to bill and collect individually (somewhat unlike group). Perhaps we need to have the marketplaces do signup and premium billing and collections and reinsure the claim risk and claim administration to the health insurers, similar to how some large groups work.

From what I understand the crux of the problem is medical costs, and the medical cost problem in turn creates problems with health insurance... if insurers price it at expected claim costs plus 20% for overhead and profit the price exceeds what consumers are willing to pay... subsidies or not.

 

[ShokWaveRider]

What I don't get is why the individual market isn't the same as having one big, diverse group.

It is all about what the market can bear. We all need healthcare, why not capitalize on it an make the most they can? Look at their TOTAL profits, not just the ACA numbers.

Not to get Political this is just an example. Many People and Corporations in the US (and Other Countries too) maximize profits based on other's misfortunes (RE Companies like TE is a prime one), they even admit it. The problem with healthcare is people are often not in control of what ails them. I find that Insurance companies making obscene profits from people's misfortunes very similar and deplorable.

This is the main reason a "Single" payer system is the ONLY way to go. It would be Non Profit.

 

[pb4uski]

You're just plain wrong on that... the ACA included a protection against health insurers trying to gouge customers by requiring that 80% of premiums be paid out in claims.. with the remaining 20% available for overhead and profit. In fact, there are notable instances where the insurer's exceeded this threshold and (as required under the law) sent refunds for the excess.

So while it is easy for the uninformed to perceive that the problem is greedy health insurers, those protections ensure that doesn't happen. Sorry to disappoint you.

A basic financial measurement used in the Affordable Care Act to encourage health plans to provide value to enrollees. If an insurer uses 80 cents out of every premium dollar to pay its customers' medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80%. A medical loss ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions. The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws.

 

[MichaelB]

What I don't get is why the individual market isn't the same as having one big, diverse group. The plus is that the insurer gets to adjust premiums for age (unlike group) with a corresponding minus that they need to bill and collect individually (somewhat unlike group). Perhaps we need to have the marketplaces do signup and premium billing and collections and reinsure the claim risk and claim administration to the health insurers, similar to how some large groups work.

It is, sort of. Composed mostly of people who were denied insurance because they had health problems. When the ACA was passed there was a type of reinsurance to help insurers deal with too many claims, but that was retroactively de-funded after the fact. Now there is no reinsurance and each state individual market is separate from all other groups in the state and all other states. This is not really insurance (like life or homeowners), it is more like healthcare intermediation between users and providers.

This problem with ACA insurance coverage is not happening in California, Florida, downstate NY or upstate Illinois, where there are higher population densities and State Insurance commissions more active in dealing with the insurers. It is taking place across the country where populations are more spread out. In all the areas where insurers are withdrawing their ACA coverage they continue to provide policies for group, Medicare and Medicaid.

I don't think we have enough information to determine why this is happening, as there has been no public scrutiny at all on the insurers, and the last two announcements about ACA plans came after the insurers were denied permission to merge. There should be no doubt, though, that if an insurer is going to measure profitability just on individual plans in states like Montana, Wyoming, Alaska, etc., then coverage in those areas will be challenging.

More effort needs to be put into defining larger groups and dismantling the artificial barriers that separate inssured population into smaller insured groups. Otherwise people living in low density and rural areas will always be unfairly disadvantaged.

 

[ShokWaveRider]

You're just plain wrong on that... the ACA included a protection against health insurers trying to gouge customers by requiring that 80% of premiums be paid out in claims.. with the remaining 20% available for overhead and profit. In fact, there are notable instances where the insurer's exceeded this threshold and (as required under the law) sent refunds for the excess.

So while it is easy for the uninformed to perceive that the problem is greedy health insurers, those protections ensure that doesn't happen. Sorry to disappoint you.

Ouch!


I meant NON ACA Plans. The Individual Private NON Employee subsidized.


Without ACA I for one am insurable. I was Quoted a silly number when I tried for individual Non ACA Coverage.

 

[pb4uski]

Perhaps, but the MLR restrictions apply to all health insurance plans... even group (but 85% rather than 80%). if does not apply to employer self funded plans where the insurer provides claim administration for a fee along with stop-loss coverage.

Health insurers collect premiums from policyholders and use these funds to pay for enrollees’ health care claims, as well as administer coverage, market products, and earn profits for investors. The Medical Loss Ratio provision of the ACA requires most insurance companies that cover individuals and small businesses to spend at least 80% of their premium income on health care claims and quality improvement, leaving the remaining 20% for administration, marketing, and profit.1, 2 The MLR threshold is higher for large group plans, which must spend at least 85 percent of premium dollars on health care and quality improvement. .....

The MLR provision of the ACA applies to all types of licensed health insurers, including commercial health insurers, Blue Cross and Blue Shield plans and health maintenance organizations. The provisions apply to all of an insurer’s underwritten business (i.e. when risk is transferred to the insurer in exchange for premium), including plans that were grandfathered under the ACA. Health insurance provided by an insurer to an association or to members of an association is subject to the MLR provision.

 

[Silver]

Wendall Potter previously work for Cigna and has a blog that is sometimes reprinted in Huffington Post. He provides some data about insurance company profits, and describes some possible consequences of Anthem wanting to buy Cigna, and Aetna wanting to buy Humana.


It's Way Past Time For Us To Stop Deluding Ourselves About Private Health Insurers?


Having worked in health care for over 30 years I am very jaded about our health care system. Providers and researchers want to help people. They are most definitely at odds with pharmacy companies, insurance companies, and hospital systems who just want to make money. As a VP of a hospital, I worked in the no-man's land between providers and hospital administration for many years....it was no fun.

 

[ivinsfan]

This is only individuals not eligible for healthcare from employers, Medicare, Medicaid, or TriCare. About 15% of US population.

If we could "self-insure" and pay health care providers the same rates the insurers get it would be different. Self-payers, however, are charged 10x - 15x more, for no good reason (other than unbridled greed) with no regulation or guardian angel to help.

I see this number all the time, yet I wonder how they arrive at the stats. More then a few companies have such pricey plans that offer employees no options. My young nephew works for one of the largest privately owned companies in the US. He is a low management level employee he's only 25. He makes a decent wage compared to the front line retail helpers. Yet, the insurance offered him would have taken the equivalent of 30% of his paycheck. He opted out and went private pay,makes too much for ACA. So when hiring this company brags they have employee health care and yet that is not the whole story.

Believe me there are a huge amount of people who are paying more for less insurance thru their workplace.

 

[pb4uski]

I see this number all the time, yet I wonder how they arrive at the stats. More then a few companies have such pricey plans that offer employees no options. My young nephew works for one of the largest privately owned companies in the US. He is a low management level employee he's only 25. He makes a decent wage compared to the front line retail helpers. Yet, the insurance offered him would have taken the equivalent of 30% of his paycheck. He opted out and went private pay,makes too much for ACA. So when hiring this company brags they have employee health care and yet that is not the whole story.

Believe me there are a huge amount of people who are paying more for less insurance thru their workplace.

Even though he makes too much for ACA subsidies, since his insurance is unaffordable (more than 8.15% of his income) he would qualify to buy ACA catastrophic coverage through his exchange. In most cases, particularly at his age, catastrophic coverage is reasonably affordable and if he is in good health, a good fit for someone his age.

 

[explanade]

Aren't there still a lot of states which refused to set up exchanges?

A lot of these southern states sound like those which wouldn't have set up exchanges.

 

[MichaelB]

Aren't there still a lot of states which refused to set up exchanges?

A lot of these southern states sound like those which wouldn't have set up exchanges.

The Federal marketplace Exchange is used in any case a state chooses not to set up it's own exchange.

 

[NW-Bound]

You're just plain wrong on that... the ACA included a protection against health insurers trying to gouge customers by requiring that 80% of premiums be paid out in claims.. with the remaining 20% available for overhead and profit. In fact, there are notable instances where the insurer's exceeded this threshold and (as required under the law) sent refunds for the excess.

So while it is easy for the uninformed to perceive that the problem is greedy health insurers, those protections ensure that doesn't happen. Sorry to disappoint you.

+1

It's this HUGE misconception that focuses the public attention on the insurers and not the real problems that causes them to not get fixed.