READ THIS ARTICLE below if you want to understand the degree to which this ruling is an important step for healthcare reform.
But as John C. Goodman points out, administrative ruling can only go so far without being codified by legislative action.
Some believe the Individual Market is too weak to revive, given the hit it took as as result of the ACA.
I am optimistic that this ruling to utilize HRA is this manner will be a “shot in the arm” and revitalize the market again.
This hopefully highlights the benefits, and spurs popularity, of a defined contribution approach as a means to purchase health insurance.
Anything that makes us less dependent on ESI and gives more portability & options, freeing the labor market from job-lock is a good thing. -Forum for Healthcare Freedom
A HUGE WIN FOR THE LABOR MARKET AND A STEP TOWARDS ENDING JOB-LOCK!
This is one of the most positive and substantive changes in healthcare policy to come out of Washington, D.C. in the past 40 years. It finally pierces the veil of separation between the Group Market & the Individual Market, helping to dissolve the perverse tax incentive which ties health insurance to employment. ~ Forum for Healthcare Freedom
“Starting on January 1, 2020, employers will be able to offer their workers HRAs to buy individual market coverage for themselves and their families. The administration’s new rule addresses a major inequity by, in effect, providing the same tax advantage that traditional employer-sponsored group plans receive — exclusion of premiums from federal income or payroll taxes — to coverage that workers in the individual market purchase from an HRA.
The rule will significantly expand worker options since 80% of firms that provide insurance currently offer only one type of plan. Now, workers will be able to use tax-advantaged money from their employers to buy coverage of their choosing. This new flexibility will allow people to maintain their coverage when they switch jobs.
In particular, this new rule should help small business workers by making it possible for employers to fund coverage with less hassle and cost than maintaining a traditional group health plan. Between 2010 and 2018, the proportion of workers at firms with three to 49 workers covered by an employer plan fell by more than 25%. This rule should help reverse that decline. The rule also makes it easier for small businesses to compete with larger businesses for talent.
It will take roughly five years for the full impact of the rule to hit — at which point, we expect 11 million workers and family members to use HRA funds to obtain individual coverage. The HRA rule may increase the size of the individual market by upwards of 50%, and should spur a more competitive market that drives insurers to deliver better options to consumers.”
~Enrollment in every other major type of coverage grew or held steady~
The subtitle in the article above is correct: Enrollment in every other major type of coverage grew or held steady.
But this should not surprise anyone.
“Why“ the other major types of coverage increased, is the more important question. And examining this also reveals that the real, or net, uninsured rate probably went up much less than 5%.
The CBO data, based on their own definition of “insurance”, was destined to over-state the number of uninsured based on these data…
“CBO includes only major medical insurance that meets ACA minimum essential coverage standards in that definition. It excludes people who belong to health care cost sharing ministries. It also excludes people who are using products such as short-term health insurance as alternatives to major medical coverage.”
Nor does the number of “uninsured” mean that those folks went without care, especially those who might have cash-friendly Primary Care providers, or a Direct Primary Care physician.
And, as premiums continue to rise in the individual market we will see a shift from Unsubsidized plans to subsidized plan; and just as the data indicates we’ve witnessed a 300,000 shift in that direction.
Let’s examine some recent history as a perspective.
The first two enrollment periods after implementation of ACA in late 2013 and 2014, which also corresponded to economic recovery (no cause and effect) showed that the largest portion of newly insured (following the nadir of the uninsured rate) came from the Employer group market as hiring increased; and the second largest portion came from Medicaid and the smallest percentage from the individual market in form of ACA exchanges.
When you measure the effects directly attributable to ACA, the largest percent gains in insured rate have come from new Medicaid, followed by subsidized ACA plans. This is a crowd-out phenomenon at work, catalyzed by subsidized coverage (Medicaid expansion) on one end and rising premium prices in the Individual market on the other.
This is horrible public policy as it doesn’t promote insurance to be more affordable or efficient, it simply shifts the burden to the public sector while making premiums more expensive. And those premium increases are a direct result of regulations placed on the Individual Market: Community Rating, guaranteed issue and compression of the age ratios to 3:1, in an attempt to force it to “behave” more like the group market.
So does it really make sense to purposefully, by design, cause the price of insurance to rise and then turn around and subsidize the same product to make it “affordable”? I guess we know how they justify the name… Affordable Care Act… but there certainly isn’t any buyer protection from soaring prices!
All of which goes to show, that the net effect of the ACA has been to make the individual market UNAFFORDABLE which effectively shunts the demand into gov’t sponsored and/or subsidized coverage!
This is NOT a sound healthcare policy. But it is a very effective form of legal plunder accomplished by using the law to benefit a few special interests at the expense of the many.
Using a similarly contorted legal and regulatory logic that went into the design and subsequent SCOTUS justification for the ACA, a Federal District Court in District of Columbia (Judge John C. Bates) has ruled to block the Labor Department’s final rule on the implementation of Association Health Plans as an “end-run” around the ACA.
So let’s all pretend it all worked out just peachy, as the flimsy arguments made by the Plaintiffs suggest, and remove yet another financial tool which might help small businesses and individuals obtain affordable, more portable coverage!
Ostensibly and officially, the goal of the ACA was to expand affordable health insurance coverage. Yet it has, arguably and predictably, expanded the Health Insurance Industrial complex by propping it up with tax-payer subsidized funds and making insurance MORE expensive.
And who cautions against the new AHP final Labor Department rules? Who else but the American Health Insurance Plans (AHIP).
“…we remain concerned that broadly expanding the use of AHPs may lead to higher premiums for consumers who depend on the individual or small group market for their coverage. Ultimately, the rule could result in fewer insured Americans and may put consumers at greater risk of fraudulent actors entering this market.”
Really? Higher premiums? Compared to what?
In the ACA individual market insurance exchanges, single coverage premiums (unsubsidized) increased by 62% and family coverage premiums increased by 75% just since implementation of ObamaCare!
The financial life support of the community rating standards in the ACA Individual Market was contingent on a “Young-Healthy” participation rate of roughly 40%. It never happened as predicted, thus the skyrocketing premiums in the Individual Market.
The only concern of opponents of AHPs and other market reforms is to ensure that our healthcare dollars keep flowing through the channels they control.
In the department of economy, an act, a habit, an institution, a law, gives birth not only to an effect, but to a series of effects. Of these effects, the first only is immediate; it manifests itself simultaneously with its cause—it is seen. The others unfold in succession—they are not seen: it is well for us, if they are foreseen. Between a good and a bad economist this constitutes the whole difference—the one takes account of the visible effect; the other takes account both of the effects which are seen, and also of those which it is necessary to foresee. Now this difference is enormous, for it almost always happens that when the immediate consequence is favorable, the ultimate consequences are fatal, and the converse. ~Frederic Bastiat
The results of the immediate/ intended effects (the seen) and the subsequent/ unintended effects (the unseen) of U.S. healthcare policy are clearly instantiated by examining the way we use, and misuse, health insurance.
Despite the ostensibly good intentions to improve access by expanding coverage for various medical services, the “ultimate consequences are fatal, and the converse.”
Our insurance-based third-party payer protocols have pernicious and nefarious economic consequences on our healthcare system. This manifests as rampant healthcare inflation catalyzed by the macro-economic market distortions of the 3rd party payer effect and perpetuated by the micro-economic price-obscuring distortions of the billing cycle.
As evidence for the negative consequence of misusing insurance as a pass-through system for virtually every healthcare expense, we can examine the employer-sponsored group market premiums. From 2007 – 2017 the average premium for family coverage increased by 55% and employee contribution rate as a share of premium cost increased by 74% over the same 10-year period; while median household income went up by only 3%.
To add financial injury to insult, the percentage of employees with an out-of-pocket maximum of greater than $3,000 doubled, going from 30% to 60% of employees.
“Eighty-one percent of covered workers have a general annual deductible for single coverage that must be met before most
services are paid for by the plan. Among covered workers with a general annual deductible, the average deductible amount for single coverage is $1,505. ~KFF.org
In the ACA individual market insurance exchanges, single coverage premiums (unsubsidized) increased by 62% and family coverage premiums increased by 75% just since the implementation of ObamaCare!
And between 2002 and 2016, medical costs for a family of four in an employer-sponsored PPO plan increased 180%!
Given that household income has barely budged in real dollars since 2002, these increases are clearly not sustainable. By contrast, the auto insurance market (a real indemnity product) increased by only 17% from 2007 – 2016, while deductible offering ranges remained stable, averaging $500.
The refusal of some to recognize the valid comparatives between the health insurance market & the auto insurance market (ostensibly because healthcare is SO different) is not an argument suitable to justify the dysfunction and high costs of Healthcare; nor does it explain why health insurance premiums have become an unwelcome surrogate for total healthcare costs! The irony being that a competitive cash market for all things related to driving and keeping a car in working order, which are not paid for at all by insurance, is exactly why the auto insurance market is affordable and sustainable! Based on data from 2014, auto insurance accounts for about 15% of the cost of ownership of a nicer car for an average safe driver. Stated differently, the cost of insurance adds about 18% to the cost of ownership compared to not having insurance.
Health insurance, on the other hand, adds about 50% to the cost of healthcare compared to no having insurance. Now consider that cost ratio in light of the NIHCM 2012 study on the concentration of healthcare spending.
“… mean annual spending for the bottom half of distribution was just $236 per person, totaling only $36 billion for the entire group of more than 150 million people… 15% of the population had no spending whatsoever in the year.”
So in any given year, 150 million of us spend less than $300 per person on actual medical care. Even more striking is the statistical likelihood that roughly 15% of the population (nearly 50 million) will have no personal health expenditures in a given year (we have no reason to believe the year in question was an aberration)!
The flip side to this story – and one that is often used to justify the way we use health insurance – is that about 81% of the spending comes from 20% of the population, which holds largely true in almost any given year. But this is the rule for almost any market and is not unique to healthcare. Most of the cars or new homes or new roofs or refrigerators or new tires or new windshields are purchased by a small percentage of the population each year; but it is not by the same people every year.
This is precisely why insurance is necessary and valuable; but also precisely why insuring too many things that are more affordable in a cash market is a horrible financial strategy! Yet we continue to commit to paying for all the small stuff, plus the unpredictable catastrophes, with this expensive proposition we call health “insurance”!
So maybe should re-frame how we look at healthcare and ask…”What have we done TO healthcare to make it behave the way it does?”
Instead of blaming “market failure” – or any of the usual suspect villains – for the high costs & low quality of healthcare, maybe we need to re-frame how we view the provision of healthcare. And when it comes to blaming the “free-market”, how do you blame something that is wholly absent? Because almost NONE of the factors which define a normally functioning free market system (discoverable, actionable prices and outcomes data with competition based on price & quality) are operational in healthcare today.
Rather than market failure, a more productive and accurate way to view healthcare would be as a massive, systemic, well orchestrated pricing failure…brought to us almost exclusively by the central planners in Washington DC, And the perverse incentives that are baked into the system.
“In every profession outside medicine – law, accounting,
engineering, architecture, etc. – providers are able to repackage and reprice what they offer to the market…Doctors by contrast are slaves to a third-party payer system that has been shaped and molded by government.
Many of the problems begin with Medicare, which pays doctors today the
same way it paid in the last century – long before there were emails or
iPhones. Most private insurers and most employers pay the same way. State governments pile on. Sometimes they make consultations with patients by phone or by email or by Skype illegal. In most places, doctors can’t freely practice across state lines.” – Dr. John C. Goodman
Collectively, these interventions add excessive costs of our healthcare system. It is important to remember that many of these cost over-runs are manifestations of the applied distortions, not intrinsic to healthcare itself.
One of most pernicious of these pricing failures can be traced to the bizarre way in which we utilize health insurance; which brings me to our featured “lie that won’t die”, and it goes like this…
“Health insurance is expensive because Healthcare is expensive.”
But like all effective fallacies, it contains just enough truth on the surface and enough logical coherency to be believable. Let’s explore why this commonly held doctrine in healthcare circles is not only wrong, but counterproductive to useful healthcare reform.
Insurance should be the financial fireman that protects us from the consequences of catastrophic events. But for insurance to work, these catastrophic events must be infrequent & unpredictable, thus spreading the risk of these infrequent events across a large population; so at any given time, only a few are affected.
When insurance becomes a funding source for the routine – the predictable – the affordable events, then we actually concentrate risk rather than spreading it! This model changes “insurance” into a perpetual payout fund, violating every tenet of insurance! And to compound the effect, the contractual obligations on both the demand side and supply side promote the incentive for everyone to utilize their health plan as often as possible.
It doesn’t take a Ph.D. in economics to predict that the costs of sustaining such a model are never satisfied, always being squeezed by patients who are chasing the benefits and providers who chase the billing codes for reimbursement.
So health insurance is definitely the Fireman or “lifeguard” when we have a costly health crisis; but when it becomes an expensive medical maintenance plan, insurance also becomes the arsonist.
We have taken a tool designed to pay out rare higher-priced claims on unpredictable events, and turned it into an inflation-prone product whose design promotes an incentive for everyone to use it as often as possible. That makes about as much sense as trying to buy insurance for a car that is regularly used in a demolition derby.
Our third-party payer system has created a dependency paradox; the same funding method (health insurance) that contributes to runaway costs also causes us to be more dependent on it for access.
The result is a healthcare system that costs way more than the sum of its parts. This is why playing the blame game does not solve the problem. American doctors could take a 50% pay cut and we could eliminate the spend equal to all care during last 12 months of life and we would still spend more per capita than any other country. You can go down the list of culprits and repeat the calculations, which I’ve done, but the math doesn’t add up; it doesn’t reconcile.
The introduction of DPC has deflated these cost escalations considerably. In the individual market, data from several sources bears this out. CovenantMD, a Direct Primary Care practice in Lancaster, PA illustrates the potential savings based on a typical family’s utilization.
They compared the total costs incurred using a Bronze ACA plan with $6K individual/$12K family deductibles without and with a DPC membership at CovenantMD. Pairing a Bronze Plan with a DPC membership resulted in an out-of-pocket savings of $7,267, even after the cost of the membership was counted. That is a 65% reduction in out-of-pocket costs!
Zenith Direct Care did a similar analysis for a typical family of five with an 80/20 plan with $3,000 deductible. They compared annual costs for this scenario with a Zenith Direct Care membership plus a Health Cost-share Plan (health-sharing member). Estimated out-of-pocket costs with the traditional insurance alone was $18,343 compared to $6,160 with the Zenith/HCS combination. A savings of 66%!
Core Family Practice, a DPC practice in Kennett Square, PA, compared a 90-day supply of four common primary care medications purchased through Aetna’s Mail-order supplier with the prices their members pay for same quantity. The annual cost for the Aetna mail-order came to $2,248.68 compared to only $850.80 for the same medications from Core’s generic supplier, which were dispensed in the office. That $1,397.88 savings equates to a 61% reduction in out-of-pocket costs for the married couple! They also looked at the costs of obtaining three sets of commonly ordered lab tests for the same couple. Out-of-pocket costs using their high-deductible plan (QHDHP) was $480 in lab test responsibility. The same tests drawn and paid at time of services to Core FP totaled $63.17 yielding an incredible 87% reduction.
All components of healthcare spending add to cost of care. But the overwhelming cost drivers for the U.S. healthcare system are embedded so deeply within the way we access and pay for medical services that we often overlook them, choosing instead to blame the symptoms for the disease rather than the disease for the symptoms.
So the next time you hear someone say or pen the words, “health insurance is expensive because healthcare is expensive”, please gently remind them of the facts. It is the unwise use of a pre-paid, highly regulated & gated access model, masquerading as insurance, that causes medical care to be more expensive than it needs to be; and the same payment model suppresses the market for more cost-effective alternative pathways to access healthcare.
“Wednesday’s rule reinstates and even expands the consumer protections Obama curtailed. It allows short-term plans to last 12 months, and allows insurers to offer them with renewal guarantees.
You read that right. Democrats curtailed consumer protections; Republicans are expanding them.
The policy change also promises more secure coverage for the sick. It frees consumers to avoid Obamacare’s price controls, which are eroding coverage for the sick. Instead, consumers can purchase consecutive short-term plans, tied together with renewal guarantees that protect them from medical underwriting when they fall ill.
Renewal guarantees can even protect some 200 million consumers with employer-based coverage, or no health insurance, from medical underwriting — for just one-tenth the cost of Obamacare plans.
When Congress passed Obamacare, insurers had just begun selling renewal guarantees as a standalone product. These policies gave purchasers the right to enroll in a health insurance plan whenever they wanted, at healthy-person premiums, no matter how sick they got in the meantime, and cost roughly 90 percent less than the average Obamacare premium. Twenty-five states approved this marvelous innovation for sale before Obama unilaterally banned it. Wednesday’s rule makes this and further innovations possible again.”
Alternatives to our current over-priced and dysfunctional health insurance market are often biased, and thus limited, by our current operational and regulatory structure. These structures are so entrenched in our healthcare psyche that it makes it difficult sometimes to set these aside in our minds while entertaining how another approach might work.
If we view all alternative plans to replace the Affordable Care Act from the vantage point of “what is”, then there is little room for anything other than attempts at further regulating the problems away. If one presupposes that the current regulatory framework remains unchanged, indeed the same framework has served to suppress the very market we wish create, then of course that market will not be created.
The dilemma facing alternative healthcare plans being considered to replace the ACA is particularly evident when it comes to the issue of selling health insurance across state lines. A brief on this subject published by the American Academy of Actuaries in February of 2017 speaks to the the main challenges facing the advent of a viable interstate market for the sale of health insurance.
Lots to like and consider here. We need more details about how tax equalization in the group market vs the individual market will be handled. The expansion of uses and benefits of HSAs is robust and will go along way to establishing more ways to self-insure and less reliance on networks and government programs; both are a good thing. The flexible, market-friendly Interstate Market for Health Insurance Cooperative Governing of Individual Health Insurance Coverage will be a welcome change. Again, devil is always in the details. Stay tuned for more details and insightful analysis here on the Sovereign Patient; we will post them as available.
Effective as of the date of enactment of this bill, the following provisions of Obamacare are repealed:
- Individual and employer mandates, community rating restrictions, rate review, essential health benefits requirement, medical loss ratio, and other insurance mandates.
Protecting Individuals with Pre-Existing Conditions:
- Provides a two-year open-enrollment period under which individuals with pre-existing conditions can obtain coverage.
- Restores HIPAA pre-existing conditions protections. Prior to Obamacare, HIPAA guaranteed those within the group market could obtain continuous health coverage regardless of preexisting conditions.
Equalize the Tax Treatment of Health Insurance:
- Individuals who receive health insurance through an employer are able to exclude the premium amount from their taxable income. However, this subsidy is unavailable for those that do not receive their insurance through an employer but instead shop for insurance on the individual market.
- Equalizes the tax treatment of the purchase of health insurance for individuals and employers. By providing a universal deduction on both income and payroll taxes regardless of how an individual obtains their health insurance, Americans will be empowered to purchase insurance independent of employment. Furthermore, this provision does not interfere with employer-provided coverage for Americans who prefer those plans.
Expansion of Health Savings Accounts:
- Tax Credit for HSA Contributions
- Provides individuals the option of a tax credit of up to $5,000 per taxpayer for contributions to an HSA. If an individual chooses not to accept the tax credit or contributes in excess of $5,000, those contributions are still tax-preferred.
- Maximum Contribution Limit to HSA. Removes the maximum allowable annual contribution, so that individuals may make unlimited contributions to an HSA.
- Eliminates the requirement that a participant in an HSA be enrolled in a high deductible health care plan. This section removes the HSA plan type requirement to allow individuals with all types of insurance to establish and use an HSA.
- This would also enable individuals who are eligible for Medicare, VA benefits, TRICARE, IHS, and members of health care sharing ministries to be eligible to establish an HSA.
- Allowance of Distributions for Prescription and OTC Drugs o Allows prescription and OTC drug costs to be treated as allowable expenses of HSAs.
- Purchase of Health Insurance from HSA Account o Currently, HSA funds may not be used to purchase insurance or cover the cost of premiums. Allowing the use of HSA funds for insurance premiums will help make health coverage more affordable for American families.
- Medical Expenses Incurred Prior to Account Establishment o Allows qualified expenses incurred prior to HSA establishment to be reimbursed from an HSA as long as the account is established prior to tax filing.
- Administrative Error Correction Before Due Date of Return o Amends current law by allowing for administrative or clerical error corrections on filings.
- Allowing HSA Rollover to Child or Parent of Account Holder o Allows an account holder’s HSA to rollover to a child, parent, or grandparent, in addition to a spouse.
- Equivalent Bankruptcy Protections for HSAs as Retirement Funds o Most tax-exempt retirement accounts are also fully exempt from bankruptcy by federal law. While some states have passed laws that exempt HSA funds from being seized in bankruptcy, there is no federal protection for HSA funds in bankruptcy.
- Certain Exercise Equipment and Physical Fitness Programs to be Treated as Medical Care. Expands allowable HSA expenses to include equipment for physical exercise or health coaching, including weight loss programs.
- Nutritional and Dietary Supplements to be Treated as Medical Care o Amends the definition of “medical care” to include dietary and nutritional supplements for the purposes of HSA expenditures.
- Certain Providers Fees to be Treated as Medical Care o Allows HSA funds to be used for periodic fees paid to medical practitioners for access to medical care.
- Capitated Primary Care Payments o HSAs can be used for pre-paid physician fees, which includes payments associated with “concierge” or “direct practice” medicine.
- Provisions Relating to Medicare o Allows Medicare enrollees to contribute their own money to the Medicare Medical Savings Accounts (MSAs).
Interstate Market for Health Insurance Cooperative Governing of Individual Health Insurance Coverage:
- Increases access to individual health coverage by allowing insurers licensed to sell policies in one state to offer them to residents of any other state.
- Exempts issuers from secondary state laws that would prohibit or regulate their operation in the secondary state. However, states may impose requirements such as consumer protections and applicable taxes, among others.
- Prohibits an issuer from offering, selling, or issuing individual health insurance coverage in a secondary state: If the state insurance commissioner does not use a risk-based capital formula for the determination of capital and surplus requirements for all issuers. Unless both the secondary and primary states have legislation or regulations in place establishing an independent review process for individuals who have individual health insurance coverage; or The issuer provides an acceptable mechanism under which the review is conducted by an independent medical reviewer or panel.
- Gives sole jurisdiction to the primary state to enforce the primary state’s covered laws in the primary state and any secondary state.
- Allows the secondary state to notify the primary state if the coverage offered in the secondary state fails to comply with the covered laws in the primary state.