Obamacare - practical discussion

Obamacare - practical discussion


Insurance has nothing to do with pre-existing conditions. Insurance is for the risk of potential expenses; Letting someone get insurance for $500/month when they have known expenses of $2k/month when signing up, violates the entire premise of insurance.

It’s no different then getting home insurance the morning after your house burns down.


The “protections” of the ACA apply to all individual policies (no preexisiting condition pricing, admin expense ratio caps, etc), as I’m sure you reminded us somewhere up thread. As such, off-exchange individual policies are basically the same as on-exchange in every market I’ve looked at. You certainly can’t buy a catastrophic policy with a $20k deductible (expense ratio rules effectively ban these), nor a platinium one that’s cheaper than the similar low deductible but very expensive ones on the exchange (since they have to worry about adverse selection of very sick people).

Yes, they took the bad “2/3 of BK are medical” stat from the Warren paper and multiplied it by a more recent number of total bankruptcies. Garbage in, garbage out.


Calling it “insurance” may be somewhat of a misnomer for the reason you said, but this just reflects that healthcare is largely not an area where normal market principles can produce fair results. The alternative is to let people suffer or die if they can’t afford the full cost of treating their preexisting condition(s). I – and I hope many others – find that completely unacceptable. Call it “insurance for random catastrophic risks that have not occurred + a subsidy plan where healthier people subsidize the less fortunate who do have known high expenses (and probably couldn’t afford to pay the full cost of treating them)” if you want.

One of the fundamental issues with our current system, I think, is that segregating risk pools in the way we do, by employers (often self-funded) and the “coverage of last resort” individual marketplace, is absurd.

  • On the employer side: Not only are participants generally healthier, employers with self-funded plans have a huge incentive to cherry-pick within that population by discriminating against workers likely to incur higher health costs. This results in behavior like discharging or failing to hire otherwise qualified older or disabled workers (who are statistically likely to incur higher health costs), as well as discharging employees who develop, or have a covered family member that develops, an expensive illness. The latter in particular could be called “dumping,” i.e. dumping known sicker participants off to other risk pools. While this behavior is illegal (under ERISA § 510 or federal or state anti-discrimination laws, depending on the circumstances), it is nonetheless extremely common and hard to prove in court (if court is even an option). It’s also a common practice for employers to quickly offer some minimal severance in exchange for a release (and arbitration agreement, if the employee hadn’t signed one already), knowing that many employees won’t be in a position to decline after suddenly losing their income and insurance, further foreclosing any ability for the employee to litigate the discrimination.
  • On the individual side: Adverse selection leads to a race to the bottom in plan quality, as we see with the Centene plans. Continuity of care is important to sicker people. They often have specialists they like already and don’t want to take the risk of switching to new ones, both due to the risk of not liking the new ones and the disruption in care. Narrow networks are effectively a backdoor way of weeding out preexisting conditions while still technically meeting network adequacy requirements (although, for Centene, there are some allegations that they do not). Healthier people are incentivized to pick the cheaper narrow-network plans, leaving the broader-network plans in a death spiral with only sicker participants.

Let’s just expand Medicare so we can have a single risk pool and be done with this nonsense.


In NY, the only options in the individual and small group market are HMOs and EPOs with no out-of-network coverage. For most types of routine care, even the current narrow network options are fine. For more complicated injuries and illnesses, the difference in quality of care between the top tier, which is not covered by ACA plans in NY, and the mid and lower tier of care could be substantial. To be clear, I am talking about rare, but very expensive types of care, that most of us won’t need. Still, it made sense for me to consider where I would want to be treated if I had cancer or a serious injury and to try to obtain coverage for the possibility of needing it at a reasonable cost

In order to mitigate this risk I have coverage from Liberty HealthShare, which can be used as a supplement to a catastrophic or bronze plan. For a full year, this plan currently costs $3,713 for two people with a $1K deductible but will increase by $50 per month for a $1,750 deductible. If we had added this coverage for roughly $4K per year to our existing coverage, our deductible would have dropped from @ $15K per couple in-network and unlimited out-of-network to $1K.

Although they have reimbursed us for a very expensive specialist that doesn’t take any insurance in addition to other lower cost providers, I am not assuming that the full cost of every type of care will be covered. Still, some coverage for what care that would not have been covered at all is better than none.

Since health sharing ministries are considered qualifying coverage, purchasers avoided penalties for a lack of coverage. Since there are significant difference between this type of coverage and ACA plans, I would be hesitant to recommend them as a replacement for any existing coverage. On the other hand, they could be a great option for someone who otherwise would have gone without coverage or someone who understands the limitations and believes the savings and expanded coverage outweigh the restrictions.


I’m considering dual coverage, hdhp and then a ppo ACA platinum plan.

Anyone know a good resource to read up on this kind of dual insurance?


Here’s what happens when sick patients become a cost center rather than people to be treated, the NHS edition.


In short, during the period between 1989 and 2000 at Gosport War Memorial Hospital, which appears to cover the start and end of the pattern of opioid prescribing of concern, the disclosed documents reveal that:

There was a disregard for human life and a culture of shortening the lives of a large number of patients.

There was an institutionalised regime of prescribing and administering “dangerous doses” of a hazardous combination of medication not clinically indicated or justified, with patients and relatives powerless in their relationship with professional staff.

When the relatives complained about the safety of patients and the appropriateness of their care, they were consistently let down by those in authority – both individuals and institutions.

The senior management of the hospital, healthcare organisations, Hampshire Constabulary, local politicians, the coronial system, the Crown Prosecution Service, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) all failed to act in ways that would have better protected patients and relatives, whose interests some subordinated to the reputation of the hospital and the professions involved.

Basically the hospital decided to kill off elderly costly patients by fast tracking them into an end-of-life opioid pain management track rather than actually treating them. And of course they covered it up and lied about and the officials in charge helped with that too. Sounds like stories out the VA here in the US… no accountability, bad incentives, and what do you get?


Sounds like everywhere across the USA.


This sort of thing can also happen here, and not involving the VA: https://www.dallasnews.com/news/frisco/2018/05/18/frisco-hospice-executive-admits-overdosing-patients-hasten-death-make-money.


Thanks. Here’s an ad-free version:

I guess if you go to a big hospital, they provide pretty much all services and you’re worth more alive than dead. If you go to a hospice center, like this case, they get paid for your end of life services and your risk is that they might decide they want to provide those early and get paid sooner and free up the bed for the next patient who needs another faked DNR…


Can you point to the bit where the report concludes that the unnecessary pain killer use was to save the hospital money??

“There is no suggestion Barton deliberately took the lives of her patients.”

Yet you’re declaring this was a intentional act to save money. Whats your basis for that??

Its a tragedy and an incompetent doctor. Lack of oversight too. But I’m just not seeing a profit motive involved as you claim.


Yep, everything depends on the compensation and accountability scheme regardless of whether the model is public-only (NHS, VA), private-only, or a combination (Medicare or other government payer paying a private provider).

CMS already does a lot of research into value-based compensation schemes, made possible by Medicare’s significant market power. It’s a hard problem. Pay-for-service obviously incentivizes overtreatment, and other schemes can incentivize undertreatment (where a service that probably should be performed is not because the provider won’t be paid anything extra for it) or cherry-picking (refusing to take on cases that appear more complex because the payment won’t be adjusted for the complexity). This is another reason I favor going full single-payer: a monopoly payer without a profit motive is, IMO, in the best position to research these models and force provider compliance, while balancing the providers’ interest of staying in business.

As in the hospice case, I think a monopoly payer is also in the best position to detect fraud. Healthcare fraud busts tend to involve Medicare, which might lead one to believe Medicare fraud is high compared to private payers, but that probably comes down to better detection capabilities than private payers (and also, the Medicare population is less healthy and probably more susceptible to fraud). It’s hard to find good data from private payers, and that’s ignoring Medicare’s inherent advantage of their fraud department being the DOJ.


The report deliberately did not attempt to assess the doctor’s motive. I think it was clear she was killing them if you read the numerous stories told by the family members, typically because either they were taking up space in the hospital they wanted for other patients or because they were troublesome to deal with.

The doctor managed to evade manslaughter charges and took and early retirement rather than getting various medical sanctions. Would you like your lack of care served up with a lack of justice?


You simply have no evidence of such methodology. You really need to refrain from concocting grandiose nonsense in a feeble attempt to support your unsubstantiated beliefs.


No, no evidence at all. It’s not like I read the Nerdwallet article you brought up.

Bankruptcy: We relied on a widely cited Harvard study published in 2009 [the Warren paper]… We also used official bankruptcy statistics, released this month through March 2013, from US Courts.

You really need to refrain from concocting grandiose nonsense in a feeble attempt to support your unsubstantiated beliefs.


That’s absolutely correct.

You ignored the word “ALSO”.

They did NOT state they “took the bad ‘2/3 of BK are medical’ stat from the Warren paper and multiplied it by a more recent number of total bankruptcies”.

They stated they “ALSO used official bankruptcy statistics, released this month through March 2013, from US Courts”.


You got nuthin’ but well-paid-for RightWing propaganda.


Look, I find it tiresome to keep serving balls you cannot return. For anyone else reading this, ask yourself who ya gonna trust, the paid-for RightWing propaganda xerty repeatedly links to, or the Department of Medicine, Cambridge Hospital, the Harvard Medical School, Cambridge, Mass, and the Department of Sociology, Ohio University ?

Do I gotta say “DUH” ?


You ignored my post #246 which seriously questioned the results of the American Journal of Medicine/Warren study. The study:

  1. Misrepresented the data to conclude that medical bankruptcies are more prevalent than they are
  2. Contradicted your assertion that the ACA could fix the problem even if it did exist.


Although not directly related to the ACA, an interesting read from ProPublica: https://www.propublica.org/article/health-insurers-are-vacuuming-up-details-about-you-and-it-could-raise-your-rates.

The ACA’s current preexisting condition provisions prevent insurers from using this data to price or decline to issue coverage at the individual level, but who knows what the future of those provisions will be. And, importantly:

This already happens, but usually in a much cruder form (age or disability discrimination). It may be legal for employers to cherry-pick applicants in this more advanced way, except to the extent the more advanced method is nothing more than a proxy for protected classes (40+ age, disability, or others) under federal and state anti-discrimination laws. Of course, even if it is illegal discrimination, it’s very difficult – near impossible – to prove unless the employer is a complete moron (like sending the applicant an email saying they’ve been passed up due to their 40+ age).

This is what happens when health risk pools are segregated in such an absurd way.


Too bad you got nuthin’ in that regard.


Your argument to the points I made in post 246 are “You got nuthin?”


It should be rather revealing to all that none of the peers of the Department of Medicine @ Cambridge Hospital have found fault with their data, and none of the peers of the Harvard Medical School @ Cambridge have found fault with their data, and none of the peers of the Department of Sociology @ Ohio University have found fault with their data. It’s only the paid-for propagandists that are mounting a phony dispute.