Get a Real Job (or Take This HMO)!
November 24, 2015 10:37 AM   Subscribe

Blue Cross and Blue Shield of Illinois (BCBSIL), the largest health insurance company in the state, announced in October that it is discontinuing it’s popular Blue PPO provider plans for individuals. BCBSIL says the move was made to keep affordable plan options for all individual plans, citing “applicable laws” requiring plan rates to be based on total medical cost of all members. This move affects only self-insured individuals, while those in group plans continue to have access to the traditional broad PPO network of doctors, hospitals, and pharmacies.

The cancelled network plans were so popular, that despite being the most expensive single-state plans they offer, two out of every five individual BCBSIL customers choose them. Customers in the Blue PPO network have seen their plans discontinued at the end of 2015 and auto-enrolled in a more limited network plan without the choice to stay in the broad PPO even at a higher price. The discontinued broad plan’s network included every hospital in Illinois, more than 200 facilities, whereas the new "Preferred PPO" network covers 78.

The premier teaching hospitals in the Chicagoland area (including Northwestern, University of Chicago) have begun notifying their patients of the impending changes to self-insured individuals for 2016. Customers shopping to replace their policies will find 40% fewer PPO plans offered on the ACA Marketplace nationwide for 2016. With only a few small insurers left on the individual market in Illinois, patients find themselves weighing the benefits of sticking with BCBSIL and losing their doctors and hospitals or paying 100% cost up front, or choosing a new smaller insurance company which is accepted by more doctors but may have no cap on out of network fees.

Blue Cross Blue Shield has not limited the changes to Illinois. Self-insured Texans are now limited to BCBS HMOs, and BCBS is pulling completely out of the New Mexico individual market. In both instances financial losses were cited. This nationwide trend is not limited to BCBS, four major insurers (Aetna, BCBS, Cigna, and Meritus) have pulled all PPO plans from Arizona's individual market. Meanwhile, in California BCBS has been stripped of it’s non-profit tax exempt status after an audit uncovered $4.2 billion in financial reserves.
posted by Bunglegirl (101 comments total) 13 users marked this as a favorite
 
Well crap.
posted by phunniemee at 10:39 AM on November 24, 2015


Yeah, I'm in that contingent. (If yr in the Land of Lincoln & want to see a surprisingly good plan I found, DM me.)
posted by listen, lady at 10:40 AM on November 24, 2015


Forget bullshit jobs, health insurance is an entire bullshit industry.
posted by Steely-eyed Missile Man at 10:41 AM on November 24, 2015 [41 favorites]


The Naked Capitalism blog, which I will admit I do not always understand, has been predicting this as a consequence of ACA for a couple of years.
posted by wittgenstein at 10:42 AM on November 24, 2015 [6 favorites]


I'm certain that single-payer insurance would have jumpstarted the American economy, offering a recovery for a broader section of the country. Imagine an entrepreneur working for a large employer and wanting to instead start a small business, but not being able to because of the expense of self-insuring with high-deductable plans. Imagine also allowing out-of-state insurance companies to compete for customers, and the downward pressure that would put on non-health-related healthcare expenses. The per-state monopolies that the ACA enables inevitably lead these sorts of abuses. We truly missed a once-in-a-lifetime chance in 2008 to actually reform the healthcare system into something that could have matched what other industrialized nations offer, a system that actually benefits people instead of enriching insurance company shareholders and executives.
posted by a lungful of dragon at 10:50 AM on November 24, 2015 [37 favorites]


The cancelled network plans were so popular

Well, duh. We're not making as much money, so we're going to cancel it. Guess they're on to us.

Employees at my company were asking for better vision insurance, so they offered a supplemental plan that wasn't useful at all (by the time you paid the extra premiums, you weren't saving any money). Then they got mad at us: but you said you wanted extra vision insurance! And we went through all this trouble to offer it to you! And now you don't want it!

People can add and subtract, you know.
posted by Melismata at 10:50 AM on November 24, 2015 [13 favorites]


My premiums have gone up by about 20% every year since the first year they were available on the ACA Marketplace.

After the first year, my doctor (who I really liked) left the HMO and started accepting cash-only patients.

The ACA was supposed to:

1) Expand access
2) Reduce the cost of healthcare
3) Make Americans healthier

I supported the ACA (and still do, I suppose) but I think it's possible that Obama may have oversold the plan.

In retrospect, it's possible that Goals 1 & 2 are fundamentally opposed, and simply cannot be reconciled. Goal #3 may simply be beyond the purview of the government to comprehensively fix.
posted by Tyrant King Porn Dragon at 10:54 AM on November 24, 2015 [1 favorite]


Imagine also enabling out-of-state insurance companies being able to compete for customers, and the downward pressure that would put on non-health-related healthcare expenses.

Because that worked so well with the credit card industry.
posted by NoxAeternum at 10:55 AM on November 24, 2015 [5 favorites]


I am already reading about people who are saying that it's cheaper to pay the fine for not doing ACA than it is to pay the high deductibles.
posted by Melismata at 10:56 AM on November 24, 2015 [1 favorite]


ACA actually made my companies' premiums go down the last two years. They went up this year, I assume because our not-that-great insurer found a way to make them do so.

However, I am under no illusions that, sans ACA, I would not be facing the same kind of rise in costs. ACA is not strong enough to stop it. Pretty sure single-payer is the only real solution. Haha sob.

Also I used to work for BCBSIL/TX and individual plans were always their red-headed stepchild; not enough money there. They prized big juicy corporate contracts.
posted by emjaybee at 10:59 AM on November 24, 2015


Melismata, those people might not realize that the maximum fine in 2016 is more than $2000. (It was about half that in 2015.)
posted by paper chromatographologist at 11:01 AM on November 24, 2015 [2 favorites]


And the deductibles are higher than that, from what I've read.
posted by Melismata at 11:02 AM on November 24, 2015


Here's the thing that everyone seems to ignore, though - health insurers are only one part of this particular equation. But since they're both highly visible and relatively distant, they're the easiest to blame. For example, when a doctor leaves a coverage network, is the issue with the insurer, or is it with the provider being unwilling to accept the insurer's reimbursement schedule?
posted by NoxAeternum at 11:04 AM on November 24, 2015 [2 favorites]


Well, if you're expecting to pay the deductible, then you're expecting to need medical care. Paying a $2000 fine, plus 100% of costs is by far the worse situation.
posted by paper chromatographologist at 11:04 AM on November 24, 2015 [13 favorites]


I am already reading about people who are saying that it's cheaper to pay the fine for not doing ACA than it is to pay the high deductibles.

That's not wrong, but the thing that anyone making that decision should consider is the negotiating power of insurers. Insured people don't get the same bills as uninsured people -- uninsured people generally see the full list price (the completely ridiculous one.) Sometimes you can talk the providers down from those prices or negotiate payments, but that's mostly for emergent problems, not for regular visits, imaging, or tests.

My premiums, copays, and deductibles are all going up this year with changes to the plan I've been on since the ACA went into effect. I've got to do some math to figure out where to go from here.
posted by asperity at 11:08 AM on November 24, 2015 [2 favorites]


Paying a $2000 fine, plus 100% of costs is by far the worse situation.

And since a poor person doesn't have anywhere near that kind of money, ever, then what? What are they going to do, when everyone declares bankruptcy? Take everyone's primary residence? You can't fail the whole class...
posted by Melismata at 11:08 AM on November 24, 2015 [9 favorites]


My premiums have gone up by about 20% every year since the first year they were available on the ACA Marketplace.

As opposed to the ten years before that, when your premiums (when you could get insurance, which is to say exclusively through your employer) stayed flat or maybe decreased a little bit because of the largesse of the largely-unregulated insurance behemoths, yes?
posted by Mayor West at 11:09 AM on November 24, 2015 [17 favorites]


ACA lowered our premiums for this year by a small amount, on our less-than-stellar HRA plan.

I'm currently waiting for the outcome of a fight between my doctor and Anthem BCBS about which SGLT2 inhibitor she can prescribe for me, and whether that will have to change in two months when they switch from the 2015 formulary to the 2016 formulary. Because a giant faceless corporation who has never talked to me and doesn't have my full chart thinks it knows my needs better than the doctor I've been going to every 3 months for the past decade.

Bring on Medicare For All / single-payer / commie pinko medicine / whatever.
posted by Foosnark at 11:11 AM on November 24, 2015 [12 favorites]


They're getting sued for misrepresenting their PPO network coverage. We almost got hoodwinked by this when searching for new coverage this year after our existing insurer quit the business. The in-network facilities we were seeing on Healthcare.gov did not match what we saw on the provider's web site.
posted by RobotVoodooPower at 11:11 AM on November 24, 2015 [5 favorites]


A single-payer option that truly would improve access and service? Socialism! So we kowtow to whiners and end up with this. It's not Obama's fault.
posted by witchen at 11:00 AM on November 24 [1 favorite +] [!]


I wouldn't be opposed to single-payer, but doesn't it stand to reason that under a similar plan, healthcare would have to be rationed somehow?

Demand for healthcare is extremely high, and with no "pricetag" for consumers there would be an incentive for everyone to use as much healthcare as possible.

HMO's are basically the private sector's version of rationed healthcare (You have to ask your doctor pretty please before you get any healthcare, and the insurance company must approve it).

So...do we want to put everybody in America on a SuperHMO, where access to care is carefully regulated and managed to ensure nation-wide solvency?
posted by Tyrant King Porn Dragon at 11:13 AM on November 24, 2015 [1 favorite]


That's what other developed countries do and it works well.
posted by LobsterMitten at 11:15 AM on November 24, 2015 [28 favorites]


Mine have gone down two years in a row as well. Cheaper copays too. Maybe because I live in a blue state. Can't say.
posted by fungible at 11:15 AM on November 24, 2015 [1 favorite]


I've been receiving the letters for a while now and put off checking into it until yesterday. Usually I can just suck it up and pay a little more monthly and stay in a network which doctors actually accept. I wonder about all of the people who won't do their research and only realize what limiting insurance they have midway through next year.

Seems like BCBSIL is keen on creating ACOs with the suburban hospital networks. I'd be okay-ish with choosing a plan that was limited to Northwestern in downtown Chicago, for example, but there is no such thing available to us city dwellers. In fact, with the limited network BCBSIL wants me to take I'm not sure what hospital in Chicago would even be in-network anymore.

Ultimately, I knew that the ACA was far far far from perfect, but I naively thought that the self-employed/insured would now no longer be second class citizens in options. Back before it passed we all said "nobody cares enough because so many people still receive group policies though work." Far more people are self-insuring these days but we're still seen as second class to the insurers. I've gone from being denied coverage before ACA and paying all out of pocket, to being able to pay for the coverage I want on it, to not even having a choice anymore. For real, at this point is the only solution available to me is to close my business and take a job with a group policy? I thought we were past this.
posted by Bunglegirl at 11:16 AM on November 24, 2015 [4 favorites]


As opposed to the ten years before that, when your premiums (when you could get insurance, which is to say exclusively through your employer) stayed flat or maybe decreased a little bit because of the largesse of the largely-unregulated insurance behemoths, yes?

Ahh, yes, the pervasive myth that we should be grateful for what we have because the Bad Old Days were worse.
posted by listen, lady at 11:17 AM on November 24, 2015 [1 favorite]


Having been a BCBSIL individual PPO plan customer, it is not in any universe what I would call "affordable." I think it's the most widely-accepted in the Chicago area and that's why so many people just default to BCBS when picking an individual plan (especially if they've rolled off of a corporate insurance situation and are picking an individual plan). But seriously can't tell you how much happier I am with not-BCBS. (I even went from BCBSIL PPO to an HMO with my new insurer, and my network is basically the same size, I kept all my doctors, billing is simpler and faster, and my cost is lower.)

(However every July when the formulary switches over, my insurer's computers have a hiccup with my pharmacy's computers and I have to pay full price and wait for a refund check. Sole complaint.)

Tyrant King Porn Dragon: "healthcare would have to be rationed somehow?"

It's rationed now. It's just that instead of being rationed by need or reasonable cost/benefit ratio, it's rationed by "If I can afford this, I can buy all the stupid health care I want and suck up provider hours getting unnecessary procedures that don't have to meet any kind of standards for benefit-to-patients." There's not really any defensible reason we should currently be "rationing" health care such that poor people can't get diabetes care but rich people have their chiropraxy and homeopathy paid for.
posted by Eyebrows McGee at 11:17 AM on November 24, 2015 [52 favorites]


That's what other developed countries do and it works well.
posted by LobsterMitten at 11:15 AM on November 24 [+] [!]


If "National Government SuperHMO" works well why does "Private HMO" not work well?
posted by Tyrant King Porn Dragon at 11:17 AM on November 24, 2015 [1 favorite]


My premiums have gone up by about 20% every year since the first year they were available on the ACA Marketplace.

My ACA-plan premiums went up a little over 5%, which is less than the 10%+ they went up each and every year like clockwork (when on an employer's plan) before the ACA went into effect. The ACA has NOTHING to do with healthcare increases. The health industry is a huge, sucking maw draining the blood straight from our nation's heartplug.
posted by Steely-eyed Missile Man at 11:18 AM on November 24, 2015 [4 favorites]


Tyrant King Porn Dragon: "If "National Government SuperHMO" works well why does "Private HMO" not work well?"

Dude, because cherry-picking. That is like health insurance economics 101. Use the googles.
posted by Eyebrows McGee at 11:19 AM on November 24, 2015 [16 favorites]


The main problem with all of this is that health care is a for-profit industry. So long as that is the case the powers that be will be working against the interests of non-rich patients.
posted by grumpybear69 at 11:23 AM on November 24, 2015 [17 favorites]


Melismata, those people might not realize that the maximum fine in 2016 is more than $2000.

That's kind of misleading. The maximum fine of $2000 is for a family. For an individual adult the maximum is $695.

Since my monthly premium is about $500 that's not even 6 weeks of coverage.

The fact that the penalty for not insuring is so much less than the cost of insuring is it any wonder that the risk pools are skewing sicker and thus more expensive than anticipated? The penalties for not insuring needed to be at least as high as the cost of a bronze plan.

I am afraid of a premium death spiral because of the low (relatively speaking) fines and lack of enforcement.
posted by Justinian at 11:24 AM on November 24, 2015 [8 favorites]


Oh, for what its worth my premium on the California exchange went up a full 25% from last year to this year. 25%.
posted by Justinian at 11:25 AM on November 24, 2015 [1 favorite]


I'm a freelancer and honestly, if everyone had to deal with this bullshit we would have single payer overnight in the US.

Melismata, those people might not realize that the maximum fine in 2016 is more than $2000. (It was about half that in 2015.)

I'll be honest, I paid the fine last year ($700 for individuals). That would be like 2 months worth of the worst plan offered on my exchange. A plan where everything is completely out of pocket unless you go over $10k+ deductible. Why even bother? If I'm going to pay full cost for everything anyways, why not just put the money I would spend on a premium in savings instead? That $700 fine is tax deductible if you own a business, peanuts in the grand scheme of expenses.

I did sign up for a plan for 2016 so I can open an HSA. So for the cost of around $5k/year in premiums, I can contribute a max ~$3500 year to a tax advantaged account. It will take me 3 years to be able to legally save enough in my HSA account to cover the damn deductible on my plan that covers nothing! And for this privilege I will pay $15k in premiums over 3 years, assuming it won't go up, which we all know it will.

I mean I own a business, like someone said above, I know how to add and subtract.
posted by bradbane at 11:35 AM on November 24, 2015 [15 favorites]


I wouldn't be opposed to single-payer, but doesn't it stand to reason that under a similar plan, healthcare would have to be rationed somehow?

Correct me if I'm wrong, but don't you give all your Old People (voters!) free healthcare through Medicare? (Medicaid is the one for poor people?)

The vast majority of healthcare cost is for people in the last two years of their lives. Which is, happily, old people in the USA.

So you have already unrationed free healthcare for all the expensive people. Sure, it's costing you a lot of money - far more than the rest of the world - but you also have very good healthcare (especially in things that people value, like televisions in your rooms and prompt appointments, that aren't actually anything to do with health).

Expanding this to your uninsured people - who tend to be young, healthy people - wouldn't suddenly bring in problems of rationing you don't already have. You already have free unrationed healthcare for old, sick people. You would be adding unrationed healthcare for... healthy young people.

Or I've completely misunderstood your Byzantine system, in which case do tell me to go back to my Socialist healthcare! Smile.
posted by alasdair at 11:35 AM on November 24, 2015 [34 favorites]


I'm certain that single-payer insurance would have jumpstarted the American economy, offering a recovery for a broader section of the country.

I do not think you realize how much of the American economy is wrapped up in moving money around different financial institutions. Not just the companies with no desire to actually pay the physicians for work they did on you, their patient. But, the 401K money invested in the health insurers. The insurance and banking moneys wrapped up in layers of obfuscation at the Healthcare Insurance providers themselves. That's before we touch on the shady-as-fuck DME vendors selling you 'supplies' on a cycle that makes Gilette jealous, the pharmaceutical industry, the for-profit education ring turning out 'medical professionals' paid for with banking industry backed school loans.

Single Payer would only benefit sick people, and people who may one day get sick. It does nothing for shareholders!
posted by DigDoug at 11:37 AM on November 24, 2015 [8 favorites]


For example, when a doctor leaves a coverage network, is the issue with the insurer, or is it with the provider being unwilling to accept the insurer's reimbursement schedule?

To the extent that insurers are beating financial indexes and have record-high share prices, I would begin to investigate how much they are (or, more specifically, are not) paying providers for services, before placing too much blame on providers.

More coverage = higher revenue and profits. UnitedHealth has outperformed the broader stock market by a wide margin since the Affordable Care Act, or Obamacare, was signed into law in March 2010.

The stock also beat the market last year as most of the provisions of the ACA went into effect and consumers started to receive coverage...

The other four members of the so-called Big Five health insurers -- Aetna (AET), Cigna (CI), Humana (HUM), and Anthem (ANTM) (formerly WellPoint) -- have all beaten the S&P 500 over the past five years or so as well...

The Health Care Select Sector SPDR (XLV) exchange-traded fund, which owns most of the big insurers but also holds drug giants like Pfizer (PFE), Merck (MRK) and Bristol-Myers Squibb (BMY), beat the market last year. It is up so far in 2015 while the S&P 500 is down.

posted by a lungful of dragon at 11:40 AM on November 24, 2015 [4 favorites]


Why even bother?

I have my plan in case of a catastrophic event only.
posted by Steely-eyed Missile Man at 11:43 AM on November 24, 2015 [2 favorites]


Looks like at least IL's health co-op is still stumbling along. A lot of people in other states have been hit hard by the string of co-op failures. The co-ops got only a tiny fraction of the federal reimbursements for their services that they'd been expecting this year, and that's that, I guess. I feel bad for the people I know who're stuck looking for new coverage, again.
posted by asperity at 11:44 AM on November 24, 2015 [2 favorites]


Yeah, the risk corridors not paying what was expected really hurt the co-ops.
posted by NoxAeternum at 11:47 AM on November 24, 2015 [1 favorite]


I wouldn't be opposed to single-payer, but doesn't it stand to reason that under a similar plan, healthcare would have to be rationed somehow?

Healthcare is rationed under any system, it's simply a matter of how it is rationed. Right now we ration health care by wealth. Rich people get more or less unlimited health care and poor people get virtually none. Since there are a lot more poor people than rich people this is not a good way to do it.

Note that rich people can get almost unlimited health care under most ways of doing it since they have the money to go outside the system if they so choose, so what we're doing now is like the worst of all worlds.
posted by Justinian at 11:49 AM on November 24, 2015 [16 favorites]


my excellent but horrifically priced oxford PPO coverage will run out on 12/31/16 and i have spent the past few months looking over my options on the state exchange and hearing the horror stories of my friends who have dealt with exchange plans in 2015 and basically my plan for when my COBRA runs out on 01/01/17 is to just die i guess

oh or move to panama
posted by poffin boffin at 11:50 AM on November 24, 2015 [2 favorites]


To the extent that insurers are beating financial indexes and have record-high share prices, I would begin to investigate how much they are (or, more specifically, are not) paying providers for services, before placing too much blame on providers.


Except that not all insurers are for profit. In fact, the insurer this thread is centered on is a not for profit insurer. Also, as your piece points out, it's not just the insurers seeing profit, but medical care businesses across the board.

If you want to bend the cost curve, you need to curve it across the board.
posted by NoxAeternum at 11:55 AM on November 24, 2015


Healthcare is rationed under any system, it's simply a matter of how it is rationed. Right now we ration health care by wealth.

To the mind steeped in neoliberal economics (which, as an aside, is treated these days as synonymous with economics when there is any acknowledgement of other approaches at all), rationing is any method of choosing who gets what except for price rationing. Don't you know that price rationing is just natural? It's just how the world works.
posted by Steely-eyed Missile Man at 11:58 AM on November 24, 2015 [8 favorites]


I guess. Price rationing works wonderfully for anything which isn't a necessity. It works less well for something which you have to buy or you die since you have no leverage and no choice.
posted by Justinian at 12:00 PM on November 24, 2015 [9 favorites]


The point is they don't see it as rationing and often aren't even capable of conceptualizing it as such.
posted by Steely-eyed Missile Man at 12:04 PM on November 24, 2015 [5 favorites]


Correct me if I'm wrong, but don't you give all your Old People (voters!) free healthcare through Medicare?

Medicare is not free.

And 65 and over does not equal "Old".
posted by still_wears_a_hat at 12:05 PM on November 24, 2015 [3 favorites]


Hell, we have a BCBS PPO plan through BCBS of MA. We just got notice that the formulary won't be covering nasally administered steroids anymore because a couple of them went OTC. So my wife's Qnasl? Gone. And this is a god damn Cadillac plan. The company (and us) pay an arm and a leg for it.

Fuck BCBS.
posted by Talez at 12:06 PM on November 24, 2015 [4 favorites]


Except that not all insurers are for profit. In fact, the insurer this thread is centered on is a not for profit insurer.

From the FPP:

Meanwhile, in California BCBS has been stripped of it’s non-profit tax exempt status after an audit uncovered $4.2 billion in financial reserves.
posted by grumpybear69 at 12:07 PM on November 24, 2015 [11 favorites]


In my personal experience there is sadly nothing about non-profits that prevents them from being money-grubbing fucksticks. It probably has something to do with paying enormous administrative salaries.
posted by Steely-eyed Missile Man at 12:09 PM on November 24, 2015 [7 favorites]


So...do we want to put everybody in America on a SuperHMO, where access to care is carefully regulated and managed to ensure nation-wide solvency?

... yes?

Anyway the premiums on the options through my smallish employer are down substantially this year, with the not-so-sneaky tradeoff being that there is now a percentage co-insurance after deductible even on the fanciest plan.
posted by atoxyl at 12:11 PM on November 24, 2015 [2 favorites]


[insert standard seditious talk here.]
posted by You Can't Tip a Buick at 12:11 PM on November 24, 2015 [6 favorites]


Meanwhile, in California BCBS has been stripped of it’s non-profit tax exempt status after an audit uncovered $4.2 billion in financial reserves.

BCBSCA (Anthem) is not the same as BCBSIL (HCSC). There are about 25-30 Blues across the US, some being for profit, others not for profit.

And frankly, fuck Anthem. I lost a week to dealing with the fallout from their data breech earlier this year.
posted by NoxAeternum at 12:15 PM on November 24, 2015 [1 favorite]


What happens if Obamacare completely shits the bed but stays on the books and all the health insurers leave the exchanges? Does everyone currently on individual plans just go on Medicaid?
posted by Justinian at 12:16 PM on November 24, 2015 [1 favorite]


. That's kind of misleading. The maximum fine of $2000 is for a family. For an individual adult the maximum is $695.

That's not the maximum, that's the base. The maximum is about $2000 for a single adult* which is the base fine plus 2.5% of any income above ~$10,000.

*this is calculated as the average premium cost for a bronze level plan.
posted by the agents of KAOS at 12:18 PM on November 24, 2015 [1 favorite]


A lot of people in other states have been hit hard by the string of co-op failures

Like the sudden failure of New York's Health Republic. Facilities and providers are owed tens of millions of dollars, and patients have to scramble to find 12/1 coverage. Who the hell was in charge of this fiasco? Nobody with a grasp of grade-school mathematics saw this coming? For shame.
posted by ThePinkSuperhero at 12:19 PM on November 24, 2015 [2 favorites]


Yep. I'm one of the ones who had the most expensive PPO plan, plus dental, with BCBSIL, and I'm now screwed. My doctors don't participate in Blue Choice. So now, I have to hie myself to the goddamn Obamacare exchange and see if I can find coverage they do accept.

I chose my insurance when I went freelance in 2008, and even though I now have a full time job, I don't like the insurance they offer.

Fuck the ACA in the ear. Fuck health insurance in general. Fuck single-payer. I want no insurance mechanism. I want fee-based healthcare.
posted by gsh at 12:25 PM on November 24, 2015 [3 favorites]


How do poor people get healthcare under fee-based health systems?
posted by Justinian at 12:27 PM on November 24, 2015 [7 favorites]


That's not the maximum, that's the base. The maximum is about $2000 for a single adult* which is the base fine plus 2.5% of any income above ~$10,000.

Looks like you're right! Still, the people who are not signing up for insurance are not likely the people who would pay a $2000 per person fine based on their income.
posted by Justinian at 12:29 PM on November 24, 2015


I feel like this is something that was predicted at the time - that the ACA would help some, notably the most sick with chronic illnesses, and hurt some, notably people who already had good healthcare.
posted by corb at 12:30 PM on November 24, 2015 [2 favorites]


Employees at my company were asking for better vision insurance, so they offered a supplemental plan that wasn't useful at all (by the time you paid the extra premiums, you weren't saving any money). Then they got mad at us: but you said you wanted extra vision insurance! And we went through all this trouble to offer it to you! And now you don't want it!

It is a peculiarity of US employer paid insurance that people treat insurance as a discounting system, rather than a buffer against unacceptably large individual losses.
posted by pwnguin at 12:31 PM on November 24, 2015 [3 favorites]


It is a peculiarity of US employer paid insurance that people treat insurance as a discounting system, rather than a buffer against unacceptably large individual losses.

Which is how it should be. We're all going to get sick and die. It should really not be considered insurance in the traditional sense. Not with the prices the way they are, anyway (that's really the crux of the problem, and like people in this thread, I'm baffled as to why that isn't being addressed more).
posted by Melismata at 12:50 PM on November 24, 2015 [4 favorites]


How do poor people get healthcare under fee-based health systems?

They don't. That's the whole point of for-profit healthcare.
posted by Pope Guilty at 1:10 PM on November 24, 2015 [14 favorites]


Medicaid exists, if you're poor enough.
posted by paper chromatographologist at 1:12 PM on November 24, 2015


Fuck the ACA in the ear. Fuck health insurance in general. Fuck single-payer. I want no insurance mechanism. I want fee-based healthcare.

You can have that through the simple expedient of just not hieing yourself to the Obamacare exchanges.
posted by ROU_Xenophobe at 1:16 PM on November 24, 2015 [5 favorites]


Mine have gone down two years in a row as well. Cheaper copays too. Maybe because I live in a blue state. Can't say.

I'm a New York resident and our "gold" Empire Blue Cross family plan is going from $1600 this year to $1850 in January.
posted by Combustible Edison Lighthouse at 1:21 PM on November 24, 2015 [1 favorite]


Medicaid exists, if you're poor enough.

This is half true. For adults, the income requirements for Medicaid are brutal. But for children? I was recently gobsmacked and pleased as hell to learn that in my state, the income cap for children-only Medicaid eligibility for a family of four is now just shy of $77K per year. ($76,872, to be exact.) We discovered this when our application for insurance on the exchange suddenly signed our kids up for Medicaid. One of the Medicaid plans includes our current HMO, which lowered premiums for everyone this year. This means that our children get to stay with their doctors and get access to no-copay no-deductible coverage for $30 a month each.

Combine that with the fact that we're moving away from our HORRIFYINGLY AWFUL employer provided plan($5K deductible each, covers 50% after deductible is hit, would cost our family of four $980 a month) to a halfway reasonable private plan ($1500 deductible, covers 80% after the deductible is hit, first 6 visits are deductible-waived, costs me and the husband $547 per month) and we are going to save thousands and thousands of dollars on health care costs this year. Thanks, Gov. Inslee! You're a pal!
posted by KathrynT at 1:24 PM on November 24, 2015 [4 favorites]


They don't. That's the whole point of for-profit healthcare.

My question for gsh was more in the nature of a Socratic dialogue.
posted by Justinian at 1:25 PM on November 24, 2015


In other words, if your state participated in the Medicaid expansion and you have kids, FOR THE LOVE OF GOD CALL YOUR STATE'S HEALTH CARE AUTHORITY ELIGIBILITY PEOPLE! We only found out about this by accident!
posted by KathrynT at 1:26 PM on November 24, 2015 [5 favorites]


Soc. But what of poor people, Euthyphro? How are they to obtain healthcare in a fee-based environment?

Euth. Fuck poor people, Socrates.
posted by Steely-eyed Missile Man at 1:34 PM on November 24, 2015 [19 favorites]


. Per HealthCare.gov, it's the higher of two different methods,

You're right, I misread it. But you'd go over $695 at about $40k of total income I think, although now I don't trust my calculations. 2.5% of $27800 = $695, you'd hit the $2000 cap right around an income of $90k.
posted by the agents of KAOS at 1:34 PM on November 24, 2015


Our insurance is almost $1,000 a month for three people, with a $5,000 deductible per person, and a $15,000 deductible per family. So, we can be out almost $30,000 before insurance really kicks in. That's madness, as I discovered this year, after needing a series of MRIs, billed at 7,000 a pop, insurance negotiated down to 3,500 each, which I now have to figure out how to pay...and that's before I've even been actually treated for anything. I'm $13k in the hole, not counting the premiums I've paid, in November, and come January, all the deductibles reset.

There is no winning in healthcare billing for Americans.
posted by SecretAgentSockpuppet at 2:29 PM on November 24, 2015 [5 favorites]


Fuck the ACA in the ear. Fuck health insurance in general. Fuck single-payer. I want no insurance mechanism. I want fee-based healthcare.

On average, I'm paying about $8,300 a year for insurance premium, deductible, and copays on the two kinds of insulin I take -- not counting needles, test strips, lancets, doctor visits, oral medications, dental care, or any illness or injury that might need to be treated.

With no insurance I'd be paying $19,825 a year for the insulin. That's more than twice my mortgage on a 2000 square foot house. Until the last 3-4 years or so I would not have been able to afford that; I probably would have had to go on emergency room visits at the expense of people with insurance, to treat conditions that could have been prevented. I might not have my sight or all my limbs, or I might simply be dead.

In most European countries I'd be paying about $3000-$3500 a year, total.

A box of 5 Novolog Flexpens in the US costs $450 to the uninsured. In the UK, the NHS pays 42 GBP for the same box ($63 USD).

That's why we need single-payer.
posted by Foosnark at 2:30 PM on November 24, 2015 [14 favorites]


I should add: my numbers above do not even include the amount I pay into taxes for Medicare/Medicaid/etc., so it's actually worse than that.
posted by Foosnark at 2:32 PM on November 24, 2015 [5 favorites]


My premiums have gone up by about 20% every year since the first year they were available on the ACA Marketplace.

This more-or-less matches my experience on the private market before ACA, too, though. Frankly, the ACA, hasn't made any real difference in my insurance cost, while it has introduced a few nice things like the annual wellness check. Mostly, though, it's been a wash.

This enrollment period, though, it's looking like my options are either pay over $100/mo. more for the same UHC silver-level plan, or downgrade to something more restricted that I can actually afford.
posted by Thorzdad at 2:44 PM on November 24, 2015


I'm interested in how Colorado's initiative 20 turns out. I expect it to fail, but find it interesting that it made it to the ballot with >100k signatures.
posted by underflow at 2:58 PM on November 24, 2015 [1 favorite]


There's really no good reason that we don't have generic insulin or generic albuterol inhalers anymore in the U.S. Well, no reason besides profits.
posted by RobotVoodooPower at 3:00 PM on November 24, 2015 [4 favorites]


If "National Government SuperHMO" works well why does "Private HMO" not work well?

Because rent-seeking? If a government department started skimming off x% off the intake and depositing it in the pocket private individuals while putting a reduced (100-x)% towards public services, you'd be completely fucking incandescent but set matters up so that a for-profit corporation does the exact same thing and all the conservatives line up and salute the fucking shareholders.
posted by sebastienbailard at 3:02 PM on November 24, 2015 [12 favorites]


I'm always fascinated by the idea that having somebody to skim profit off the top of an endeavor such that it has less money to work with necessarily makes it more effective and efficient.
posted by Pope Guilty at 3:16 PM on November 24, 2015 [7 favorites]


I just spent 5 hours making a spreadsheet of plan cost vs network availability of my doctors. I usually only go to the doctor a few times a year—makes me think I should say "fuck it" and get the cheapest Bronze plan that will cover something if I get hit by a bus and then know I will be paying for those few visits out of pocket.

As someone who travels a lot though, I worry about the out of network costs if something does happen though. I guess they would send me back home to an in-network hospital if it was that bad? I also worry that if I go with Illinois' co-op (Land of Lincoln) I'm going to be SOL when it folds like all the rest.
posted by Bunglegirl at 4:44 PM on November 24, 2015


Bunglegirl, you should doublecheck, of course, but many plans don't penalize you for being out of network if you're traveling in an area where there's no access to in-network providers, or in an emergency.
posted by jaguar at 5:14 PM on November 24, 2015 [1 favorite]


Our insurance is almost $1,000 a month for three people, with a $5,000 deductible per person, and a $15,000 deductible per family. So, we can be out almost $30,000 before insurance really kicks in. That's madness, as I discovered this year, after needing a series of MRIs, billed at 7,000 a pop, insurance negotiated down to 3,500 each, which I now have to figure out how to pay

My health insurance premiums last year for a single person was 13k. If I'm reading you correctly, your premiums are a third of that, in a high deductible health plan.

The entire point of high deductible plans is to motivate patients to price shop and find a fair price. MRIs are expensive, and notoriously varied in price. Obviously there comes a time where you absolutely need an MRI this minute, and are not well enough to price shop. But I know there's a multitude of alternative anecdotes where this is not true; my father has gone through a number of MRIs and CT scans that were not at all urgent, exactly the situation where price shopping can bring the cost down.

The other bit is, that you're expected to be allocating the premium savings to a Health Savings Account. That's where you get the money to pay the deductibles. When I had one, I aimed at keeping 1 years' deductible in the HSA. Obviously the first year bootstrapping is hard, and any year you have a major adverse event will see you revisit that pain. The upshot is they roll over from year to year, and if you accumulate a surplus, the money is available for spending in retirement.
posted by pwnguin at 5:55 PM on November 24, 2015


This stuff gives me nightmares. Right now we have fairly good insurance through my partner's employer. For her to ever quit her job (to freelance, say), I'd have to find a different job with comparable benefits to what she gets now -- the costs of insurance and medications are just too high otherwise, and if the GOP ever succeeds in overturning the ACA's preexisting conditions clause we'd be totally fucked.

Some version of a single payer system would be a life saver and would reduce my long term stress, instead of this needlessly shitty system we have right now.
posted by Dip Flash at 6:01 PM on November 24, 2015 [2 favorites]


Can anyone explain to me how there is any benefit to a "family" plan vs two individual plans, assuming a 2 person couple family? The deductible on our individual plans is $6500 each, while the deductible per "family" is $13000- (the premium per 2 person family is 2x the individual. Since we are generally healthy people, it is very unlikely we will both have significant health problems in the same year so that it seem that if one of us has something catastrophic happen we have to meet a double deductible?? Is there ANY benefit to a "family" plan if you don't have kids?
posted by morchella at 9:38 PM on November 24, 2015


There's really no good reason that we don't have generic insulin or generic albuterol inhalers anymore in the U.S. Well, no reason besides profits.
posted by RobotVoodooPower at 6:00 PM on November 24 [4 favorites +] [!]


We do have generic insulin in the United States, at least. I bought a couple bottles last week for $50.
posted by mcrandello at 9:39 PM on November 24, 2015


Every time I want to go back to America, I read about the healthcare system and my opinions change. It barely makes any sense; the Australian healthcare system is explicitly not run on a profit, and when they wanted to charge $7 for doctors visits there was basically a revolt. It's so freeing knowing that even without a job, if you're sick you can get help.
posted by Charlemagne In Sweatpants at 2:25 AM on November 25, 2015 [2 favorites]


I have BCBS in NM, and I'm not happy about changing again. Last time around they were the only option that worked for my needs. I haven't yet checked the exchange, which I'm dreading...

The other bit is, that you're expected to be allocating the premium savings to a Health Savings Account. That's where you get the money to pay the deductibles. When I had one, I aimed at keeping 1 years' deductible in the HSA.

I require regular visits with mental health providers. The co-pay only kicks in when you meet the deductible. Until then, you pay full price for visits, which I need weekly. This is the case with my current plan with BCBS, a "gold" plan, and the only low-dedictible option available in NM as of this year.
posted by krinklyfig at 2:42 AM on November 25, 2015


Something everyone should be aware of is that for those who are under 250% of the Federal Poverty Line, subsidies are available not just for premiums for ACA plans but also for other out of pocket costs like the deductible and co-pays, but only if you buy a Silver or Gold Plan. Kevin Drum explains here.

Of course that still leaves a lot of people out, since a $6000 deductible could only be considered affordable for very high income families (so well over 250% FPL), but I think even for people who don't qualify for Cost Sharing Reduction it usually makes more sense to pay a little extra for a Silver Plan unless you are fairly confident you won't actually use your insurance and just want to have catastrophic coverage / avoid the tax penalty.
posted by Asparagus at 6:48 AM on November 25, 2015 [1 favorite]


First, we have to bend the cost curve down. When medical care costs go down we can have all the shiny things we want.
posted by Ironmouth at 7:21 AM on November 25, 2015


when it's near-impossible to plan for costs ahead of time, much less shop around for competitive rates, the onus is not on the patient to make it right

Well, it should not be, but it is, because they have the money, so they make the rules.
posted by Steely-eyed Missile Man at 8:40 AM on November 25, 2015


When providers are transparent with costs before the procedure takes place

Seriously. They often won't tell you before the invoice, which is the opposite of useful for anyone trying to figure out how to budget for care, whether they're insured or not.

The only regular exceptions I've found are for care that ordinarily has nothing to do with health insurance: optometry and dentistry. You can pretty much always get costs up front with those, making vision and dental insurance something that's relatively easy to skip while still getting care.
posted by asperity at 8:54 AM on November 25, 2015 [2 favorites]


Texan here. My BCBS Blue PPO was discontinued (as were all individual BCBS individual PPO plans in Texas), so I'm having to shop for new insurance. There are now *zero* PPO options remaining on the private healthcare exchange I use (through the State Bar of Texas). There is a new category, an "EPO," which is apparently identical to an HMO except for its deceptively-close-to-PPO-so-don't-think-its-an-HMO name.

I signed up for the BCBS Blue PPO plan at the beginning of 2014, after my prior insurance plan (Aetna PPO) sufficiently peed off my doctor and* my kids' pediatricians that they stopped accepting Aetna insurance.

Well, that's not exactly correct. I *first* signed up under United Healthcare at the beginning of 2014, but United has posted incorrect listings of in-network doctors, which I only discovered when my kids' providers sent me a letter requesting payment of all services, meaning that I paid three months of premiums with zero coverage. OK, so then it was BCBS PPO Blue.

Each year my premiums have gone up 10% or more, and it is really a pain in the ass to searchy for new coverage and figure out provider coverage (which is often inaccurately listed on the insurer side and can change with little notice on the provider side).

I'm in support of healthcare reform, but I'm starting to think that the right wing was right when they said that the ACA was the precursor for single payer (which can't come soon enough -- I've learned my lesson). Only upside is that I still get to deduct my premiums.

Thanks for indulging (or skipping over) my grousing. I was just pleased to see that my private grumblings are shared by others.
posted by seventyfour at 9:35 AM on November 25, 2015 [3 favorites]


There is a new category, an "EPO," which is apparently identical to an HMO except for its deceptively-close-to-PPO-so-don't-think-its-an-HMO name.

PPO is not a mark of quality
PPOs are not an indicator of whether or not a plan is a good plan.  It is merely an indicator of how out of network expenses are paid and if a primary care provider (PCP) is needed to authorize high end care. That is it.

As I’ve shown fairly recently, most of the top plans as rated by NCQA are either HMO or Point of Service (POS) plans (yes, please chuckle at the acronym as I do that every day). Of the bottom twenty rated plans in the country, the majority are PPO plan designs.

[...]

Furthermore, PPO is not a guarantee that a network is broad. The incentive is for a broad network to be created as the insurer does not want to eat out of network charges, but it is not a guarantee. In my region, there are several broad network HMOs with 80% of more of the docs, and 85% of the hospitals within 100 miles of Center City in the respective networks. There is also a PPO plan on Exchange whose base network is 25% of the doctors and 20% of the hospitals. (Yes, there are HMOs on Exchange with similar super skinny networks).
I quote this not to dismiss any of your complaints about the quality of the plans available to you, but simply to note that there's a lot of belief out there that PPO > HMO, and it's not nearly that simple.
posted by tonycpsu at 9:51 AM on November 25, 2015 [2 favorites]


The entire point of high deductible plans is to motivate patients to price shop and find a fair price.

The other problem with this line of thinking, aside from the issues cited above that making shopping for health care a lot different from shopping for a car, is that even if there were price transparency and you could find the best deal on an MRI, paying $1000 say instead of $3000 is still more than many can afford, so people will forgo needed care. In the long run this increases costs because this leads to poor management of chronic conditions.

The idea of the insured having some "skin in the game" makes sense when you're talking about a $25 copay for a visit to the doctor's office -- that will dissuade those who enjoy going to the doctor for fun (but as mentioned above, really?) from doing so, but when you make the insured pay for 100% of the care for the the first few thousands of dollars, that skin in the game becomes a pound of flesh and a lot of people will just go without health care.
posted by Asparagus at 10:09 AM on November 25, 2015 [5 favorites]


Oh and the other reason high deductibles are a terrible way to address overutilization is that for the highest cost patients, once they blow through their deductible, they have no incentive to price compare or avoid wasteful care.

There's also, in my mind, a perversity in that the deductible applies to each calendar year. So no one gets any special dispensation if they already met their deductible in the previous year. Which means that someone who requires $5000 of medical care in December 2015 and another $5000 in January 2016, will pay more than someone who requires $30,000 of care in January 2016.
posted by Asparagus at 10:16 AM on November 25, 2015 [6 favorites]


tonycpsu : Thanks -- I agree (and that was a good article, thanks). The PPOs I've had certainly had in-network coverage that was as narrow (or narrower) than the HMO/EPO I'm now considering -- that was a problem I ran into with both of my prior PPO plans.

The difference in my mind is that I could, at least hypothetically, get services out-of-network and still seek reimbursement, whereas the HMO/EMO provides zero reimbursement for out-of-network services. However, this was probably truer ten years ago, when the the PPOs I had via group coverage had terms that made out-of-network services plausible -- the trend I've seen is that my PPOs have increased the co-insurance amounts enough that the penalty for going out of network, along with a high deductible, effectively keeps you in the network. Given that shift, I don't particularly pine for the PPO (although I still think it the "EPO" designation is goofy).

With that said, I am baffled that the new insurance I'm looking at ("EPO") requires that meet the entire deductible for walk-in clinic visits. My current insurance incentivizes use of walk-in clinics by actually charging no co-pay at all for an appointment (although certain services -- like pulling a bit of carrot out of your son's nose -- are still subject to the deductible).
posted by seventyfour at 11:14 AM on November 25, 2015 [1 favorite]


The idea of the insured having some "skin in the game" makes sense when you're talking about a $25 copay for a visit to the doctor's office -- that will dissuade those who enjoy going to the doctor for fun (but as mentioned above, really?) from doing so, but when you make the insured pay for 100% of the care for the the first few thousands of dollars, that skin in the game becomes a pound of flesh and a lot of people will just go without health care.

The size of your deductible absolutely is a tradeoff. It sounds like people are picking bronze plans because they're the cheapest up front, without doing the "add and subtract" thing. Your Kevin Drum article sums up the situation eloquently:
Bronze is basically catastrophic insurance for 20-something kids who are certain they'll never use it. Silver is modestly more expensive, but the benefits are worth it, even if you have to scrimp to afford it.

The US system is broken in a lot of ways; clinics refuse to discuss price until the service is rendered, pharmas issuing coupons to cover your copay, generics suddenly skyrocketing in price, doctors setting up clinics to siphon patients away from hospitals without contributing to emergency care costs, and medical school debts that pretty much force doctor's hands on maximizing revenue.

I've never actually priced out insurance on the exchange, as I have one of those Real Jobs the post title refers to. So I ran the numbers on healthcare.gov, and honestly, I'm surprised at how cheap things are. For what my coverage costs right now, I could get a platinum plan and fully fund an HSA (were I allowed to). I suppose this means our coverage will be on the negotiating table next contract round. Or it could just mean I'm still on the cheap end of the spectrum as an insurable risk, compared to my coworkers.
posted by pwnguin at 11:27 AM on November 25, 2015


Agreed that a lot of people make the wrong decision on the premium/deductible tradeoff.

I think the options available to you via Obamacare depend a lot on the variables of your age, your income, and where you live. If your income is low enough that you qualify for Medicaid (in states that expanded it) or generous subsidies, the law helps you a lot. If you're young, most of the plans on healthcare.gov are reasonably affordable even if you have to pay full price. Folks who are older and have relatively high income are put in a really difficult spot though, especially if they have an expensive chronic health condition.

I also have job-provided insurance but I browsed on healthcare.gov out of curiosity. A 55 year old woman in Pennsylvania making $45,000 (too much to qualify for any subsidies) could find Silver PPO plans with a premium in the $300-400/month range and a deductible somewhere between $0 and $3000. That might not sound too bad, but the copays are really high ($70-100 for a specialty doctor visit!), so if she got sick and really needed to use a lot of healthcare, the costs would add up really fast. All of the plans have an out-of-pocket maximum of around $5000-6000, but that doesn't even include the premium, so total yearly costs can easily be over $10,000, or 22% of income. I have no idea how someone is supposed to afford that.
posted by Asparagus at 12:03 PM on November 25, 2015 [1 favorite]


total yearly costs can easily be over $10,000

Which is still less than what my employer and I pay in premiums alone. Turns out, health care is expensive.
posted by pwnguin at 3:00 PM on November 25, 2015


Yeah, I guess that's just the way it is everywhere and not just in the US or anything!
posted by Steely-eyed Missile Man at 5:57 PM on November 25, 2015 [4 favorites]


The idea of the insured having some "skin in the game" makes sense when you're talking about a $25 copay for a visit to the doctor's office -- that will dissuade those who enjoy going to the doctor for fun (but as mentioned above, really?) from doing so, but when you make the insured pay for 100% of the care for the the first few thousands of dollars, that skin in the game becomes a pound of flesh and a lot of people will just go without health care.

One of the frustrating things also is how this stuff is often very binary. Either you have a set of $25 copays (which isn't nothing, but is on the scale of "drinks with friends") or you are facing charges in the thousands, and it can instantly jump from one to the other. And you don't necessarily know which you dealing with until after you get the care and the bill arrives.

Or it could just mean I'm still on the cheap end of the spectrum as an insurable risk, compared to my coworkers.

At my spouse's last job, one year two people got rare-but-expensive forms of cancer. Those two people getting sick forced a redo of the math and of all the costs for the entire place -- it takes a big pool to be able to spread costs like that.
posted by Dip Flash at 12:11 AM on November 26, 2015


Does all state employees in Oregon count as a big pool?
posted by pwnguin at 1:32 AM on November 26, 2015


Medicare is not free.

Ah! Thank-you for the link, I stand corrected. So it seems to say that most people with Medicare will pay $100pcm, and when you're sick you pay $150 maximum per year plus 20% of the cost of treatment? And if you stay in hospital you pay $1000+ per year. That might indeed run to thousands of dollars over a year.

Is this enough to act as a disincentive to healthcare use? Anyone know?

And 65 and over does not equal "Old".

Forgive me, I've annoyed you. Healthcare costs are higher for very small children, pregnant people, and people in the last two years of life. Happily, people in the last two years of their life in the USA tend to be over 65, which corresponds to getting free subsidised healthcare because of age. I mean no offence by using the label, and I did not mean it as a criticism.

posted by alasdair at 4:29 AM on November 26, 2015 [1 favorite]


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