With all the focus on Transparency mandates and HRA executive orders, much of the ACA remains in force (unfortunately). Even though the individual mandate penalty (uh…tax) will not be enforced beyond 2018, the employer mandate is still in effect, with all the coverage provisions!
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 article below highlights the benefits 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
Avek Roy
“Last week, the White House finalized a rule that allows employers to fund health reimbursement arrangements (HRAs) that can be used by workers to buy their own coverage on the individual market. This subtle, technical tweak has the potential to revolutionize the private health insurance market…
…The council found an elegant way to give employers the opportunity to voluntarily convert their health benefits from a defined benefit into a defined contribution. For example, an employer could fund an HRA for each worker and their family, which they could then use to shop for a plan that best suits their needs.”
~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.
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%.
“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
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.
Dr. John Goodman, economist and healthcare policy expert, has this to say about the consequences of this [“pricing failure”].
“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.”
NOT!
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.
Hats off to John C. Goodman again! His work in leading the effort for market-based healthcare reform over the past 4 decades, and highlighting the government’s role in the dysfunctional mess we labor in, is second to none.
This Forbes article lays out a most concise and accurate rendering of what healthcare has become and why…and what to do about it.
If you’re tired of the hearing healthcare pundits wax feverishly about their favorite villains and how more regulations are the answer; or if you’re just a novice starting to explore the Healthcare conundrum, Dr. Goodman’s work is required reading. I recommend starting here and then circling back to some of his earlier work. The book “PRICELESS” is a recommended next step!
…a recent review of the academic literature on the subject finds a mixed bag, but with the strongest link between coverage and health outcomes in cases where health insurance coverage improves access to care, “particularly among people with lower incomes and chronic conditions.”
That makes sense. Having health insurance makes less of a difference to people with higher incomes who can afford to pay for more of their medical care directly.
That leads us to the crucial, practical question that this academic debate largely misses: Who are the people that would no longer have health insurance if the mandate penalty were repealed?
Notice what CBO is not saying. CBO is not saying that those Americans will “lose” coverage. Rather, CBO is saying is that—absent the mandate penalties—those Americans, will voluntarily forego enrolling in health coverage. CBO is explicit on this point…
That explains CBO’s somewhat counterintuitive projection that, without a mandate penalty, millions of poor people will turn down the offer of free Medicaid coverage. The reason is that they don’t think they need it (because they are healthy) and if they become ill and seek care at a hospital, they know the hospital will enroll them in Medicaid to get paid. Indeed, it is also why, long before Obamacare came along, that there was a persistent and notable gap between the number of people eligible for Medicaid and the number of people enrolled in the program.
It also explains CBO’s other counterintuitive projection: that eliminating the mandate penalty will generate higher tax revenues. While not collecting mandate penalties brings in less revenue, CBO projects that there will be new revenues coming from the healthy people who decide to turn down tax-free employer health insurance in exchange for higher (taxable) cash wages. Presumably, CBO thinks that being healthy and very much alive are basic prerequisites for expecting those folks to generate additional tax revenues.
Repeal of the Obamacare mandate will not result in social catastrophe. Supporters of the mandate would have a more compelling argument if millions of poor and sick persons would be thrown out of their existing coverage, struggling with potentially fatal chronic illnesses and unable to get insurance to maintain continuous access to regular care. But that is not what CBO is projecting. Their argument is hardly compelling, to say the least, when the cohort of the future uninsured are healthy people who simply choose not to buy Obamacare coverage because they believe they don’t need it or want it.
Dr. Goodman’s article is a fantastic foray into the dark history organized medicine, culminating with a brutally honest assessment of the cartel that resulted. He gives a great preview of the good stuff in Greg Scandlen’s new book, Myth Busters: Why Health Reform Always Goes Awry, summarizing the oft-repeated myths we hear about healthcare economics thrown around like dogma.
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.
Our Rights come from God, not government. Physician/ Patient/ Survivor/ Wife/ Mother of 4 daughters/ Small biz owner/ Limited Government/ No Socialized Medicine/ Texan/ President www.AAPSonline.org
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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.
