Monday, December 14, 2015

As the 2016 enrollment period ends.

Those without health in­sur­ance have a lot to con­sider.  Many chose not to insure as it's is costly, they are healthy and anticipate little in healthcare costs.

On one hand, the fine for re­main­ing un­in­sured steeply in­creases for next year. On the oth­er, the cost of the in­di­vidu­al man­date pen­alty is cheap­er than buy­ing the least ex­pens­ive in­sur­ance plan for 7.1 mil­lion of the nearly 11 mil­lion un­in­sured eli­gible to en­roll in health ex­changes, ac­cord­ing to a Kais­er Fam­ily Found­a­tion ana­lys­is re­leased Wed­nes­day.

The in­di­vidu­al man­date fee is a crux of the Af­ford­able Care Act, aim­ing to serve as a mo­tiv­at­or for Amer­ic­ans to sign up for health cov­er­age, par­tic­u­larly “young in­vin­cibles” ages 18 to 34. If they don’t, they’ll be faced with the total cost of their health bills. Yet, just how many people this will in­centiv­ize is un­clear.

About 12 mil­lion re­ceived ex­emp­tions from the in­di­vidu­al man­date due to hard­ships, fin­an­cial status, and life events.
Next year those who de­cided against en­rolling in a health plan will have to pay a much high­er tax for not hav­ing health in­sur­ance in 2016 which they will feel when they file their fed­er­al taxes due April 2017.   The cost: $695 per adult and $347.50 per child or 2.5 per­cent of a house­hold’s in­come.  the higher number rules.

Will people who cannot afford the deductible pay the tax or buy insurance they cannot use?  Will those that are healthy opt out and just pay the tax.

What's the future for the ACA?  The cost of healthcare will continue to rise as inflation does that to everything.  Doctors need to be paid, Max needs to be paid, hospitals need to be paid.  We all demand the latest and greatest, the best tests yet complain about the cost of healthcare.  Will the government issue larger subsidies to offset the higher costs?  Will taxes need to be raised to support higher subsidies or will enrollment begin to slip as premiums rise?


  1. Hey Lou,

    Your post to me kinda highlights the point that we really don't know what we want in this country. If we could reach a more or less consensus about what is important, we could start to work on solutions. Because of politics though, we can't even get that far. The ACA, IMO, had one primary goal, and that goal was to reduce the number of uninsured. As a nation, we can't even agree that this is an important goal because of politics.

    I can see the point of free market types, if we had a pure free market, IE not even allowing subsidies from employers, we would have a much much different looking system. That said, even the free market types believe the uninsured should be allowed ER treatment, which means they don't really support a free market solution. We are pretty much just debating the ACA at this point, which is politically expedient for all involved, but functionally useless. In the short term, you can't insure more people and expect it make healthcare cheaper. In the longer run, if people actually started to get healthy, in part through having healthcare access, we might start to reduce the overall cost of care. A subsidy is a subsidy. An employer subsidy is paid for through higher costs of goods and services, a government subsidy is paid for by higher taxes. Bottom line, we are all subsidizing each other and by default, are enabling bad behavior of the many many individuals who have their insurance subsidized who don't take good care of themselves.

    Now that Obama has gotten the ACA passed, the Democrats seem to just want to walk away and neither put in effort to improve it, nor put any political capital into defending it. The Republicans, here and there, have offered what, IMO, are less than comprehensive solutions. I'm not sure that maximizing the number of insured is a goal of theirs. Clearly, they don't like the ACA. Now that it's passed into law, it's kind of an enigma thing, neither party is going to do anything really to improve it and neither party is going to do anything genuine to repeal it because it has accomplished a goal of reducing the number of insured. Ideally, I'd like to see the discussion switch to, "What do we want from our system?", but I won't hold my breath for that.

    1. Actually, that sentence near the end should read the ACA has accomplished a goal of reducing the number of Uninsured

    2. What good is insurance if you cannot afford to pay the deductible?

      Reducing the number of insured was what it was all about, not more affordable healthcare. Want to really reduce the number of insured put a 10K tax on those that chose not to pay for insurance.

      The Dem's are still smarting from passing this piece of legislation losing both houses of congress. They will continue to ignore it and nothing will happen until it collapses under the weight of costs as people drop insurance unable to afford the cost.

    3. If you can't afford the deductible, then it's basically a catastrophic plan without access to basic care. This is still better than what we had before wherein people just went to the ER and stuck someone else with the bill, or wound up going bankrupt from an illness. And in reality, we need to be realistic, even with insurance, if someone gets sick and has a lengthy hospital stay, they are still going bankrupt. I feel bad for those who cannot get insurance through work. Insurance is expensive. Period. I have been lucky to have had employer subsidized insurance for my entire adult life. Many in my same situation, however, have never considered what their health care cost. From that perspective, it is very easy to say F off to those who work in low paying jobs with no benefits. If we had no employer subsidized health plans, the free market might actually work to lower costs because anyone who uses healthcare would be brutally charged and the vast majority of people would simply not be able to afford it. hence, we would use less healthcare and it would cost less.

      for discussion sake, I really don't believe that passing the ACA is what cost the Dems both houses. Historically, the party in control of the WH loses gobs of seats in mid term elections. Even more ironic, I think there are tons of people who got insurance through the ACA who still hate the uppity Obama. But, I agree they are going to ignore it and do nothing to fix it. I would further tend to think they are banking on the balance tipping toward universal coverage rather than wasting an ounce of capital to fix this one, and that is contemptible to me.

    4. ER visits are up since the ACA took effect.

      So instead of sticking the hospitals for the care we stick the doctors with the bill when people can't pay it.

      The ACA insures less than 10% of Americans. Universal coverage? Single payer? Only problem is no one wants to pay for it. The poor don;t want to pay anything. The middle class balks at any increase in taxes and there are not enough wealthy to pay for it.

    5. Well, you are hitting on one of my perpetual points, our entire system is built on cost shifting. It's not like hospitals absorbed the cost of the uninsured, they instead turned around that cost into the form of a 300 dollar ace bandage. our system as it stands, contains an enormous amount of middle men who do nothing but change money and take a "taste" as the money passes them. Doctors may be getting stiffed on a co pay now, but it's not like they are not getting anything from the insurance company. It's not good for doctors, but at the practice I was at this year, the abundance of new patients who came in through the ACA paid their bills. net net, my preceptor benefitted nicely from the ACA through picking up about 200 new patients. Your point is not without merit, but like the mirror image of my preceptor, neither tells the entire story.

      To your second para, again, I keep going back to thinking we need to ask the right question. Obviously there is not any solution that is going to make every person int he country happy. With than in mind, what's the best question to ask? Ultimately, I think we could take one of maybe two choices, one choice is to pick reasonable goals that will benefit a majority of people and then work on passing the things that have a majority consensus while accepting that those majorities who pass the legislation might be small despite the fact the legislation helps a larger majority. The other choice is to just do nothing at all while continuing to just blame left of right ideology for our cost. The latter choice is good for those who need a campaign issue to run on, but horrible for the rest of us. It is true that nobody wants to pay a dime towards anything that they don't feel immediately benefits them. I think this attitude is a little childish.

  2. Yet, Demand has been unprecedented, resulting in clogged government servers, again.

    1. What do you want for 677 million dollars with all exchange costs over 5 billion dollar and some still don't work??

      2014, approximately 600 bucks per enrolled person on the exchanges.

    2. Had we agree that reducing the number of insured was an important goal, I think we could have done a better job. But this was one of many areas of disagreement. It cost a lot of money and did not go smoothly at all. I suppose that's one thing to grab and beat to death. Doing so doesn't change anything, but I helps avoid both parties cooperating to fix it.

      If the current paradigm holds, I don't think this is going to get talked about much in the election run up. And that is a problem because the ACA does need some fixing. If they just keep doing stop gap tweaks, it will continue to be an albatross.

    3. There will be few if any tweaks, fixes.
      Bama would never allow changes that he didn't like and the Congress would never allow changes that solely benefits the Dems.

      In the end, the ACA will begin collating as the price of insurance continues to rise. Subsidies can only offset some of the increase. People will weight the cost/benefit something congress and this president never does and drop their coverage unless they are high users which will force costs higher.

      What was needed was a catastrophic plan. Want more, pay more. insurance was never intended to cover the everyday needs i.e. physicals, BC pills, immunizations etc.

    4. Have to say, I still don't get the BC thing and why that is so important. But, I agree with a catastrophic approach with small caveats. I don't think a subsidized yearly visit with basic labs is unreasonable, and I'm willing to cover things that have been shown, based on evidence, to save lives and save money, such as colonoscopies and mammograms and so on. These aren't yearly tests.

      On the drug front and with regard to immunizations, my views are again driven by what has been proven to provide societal benefit. There is no denying that immunizations work, and society clearly benefits from them. If giving a free pneumonia shot to a senior keeps them from an 50k ICU stay for pneumonia, that is money well spent. If we follow guidelines, we won't be doing this stuff every year. These things have been proven to save money. Checking cholesterol 3 times a year has not.

      With drugs, we have a multi tiered problem that isn't easy to fix. I get that people don't want to just pay money for a drug benefit they don't use, and further, they of course don't want to pay for the BC pills so some woman can whore around. It's not that simple though. Imagine an example of a kid with asthma who lives in a house where a parent smokes and where that parent refuses to smoke outside. It is likely this kid's asthma won't be well managed, and the kid is going to cost the system a lot of money. Now if the parents don't have much money to afford to pay for that medicine, the kid is simply going to have a lot of ER visits, which is going to cost the rest of us a lot of money. It can't be helped a kid is born with asthma, but what do we do in this case? Let the kid suffer because his parents are idiots? I fully understand the ramifications of stepping in, IE we are subsidizing the parents and enabling bad behavior. If we don't, the kid suffers and asthma medicine is brutally expensive. I think I'd rather everyone pay something extra for drug coverage and be thankful if they don't need it.

      Another problem, however, is inappropriate prescribing and I know I am going to be faced with this problem. There are very well established guidelines for treating hypertension, cholesterol, multiple other conditions. However, a lot of people want something and the provider is stuck being the gate keeper. Further, when people go to a "specialist" they are probably going to get medicine whether they need it or not, or will get a more expensive medicine because it is new and shiny. There is no easy fix here.

      I think we could still do a primarily catastrophic oriented plan that allows for minimal, evidence proven, interventions that would help with prevention of disease. I also think we could provide some subsidy with medication. Not to make it free, but to help offset the cost of it. I think we could do that at a reasonable cost, but if we do, I think we should take away employer provided insurance, especially the tax free benefit of it, and then let insurers create a secondary market to provide other benefits.

    5. The BC thing is an example of a monthly cost that's built into premiums.

      In the past if you had drug coverage it was built into that insurance option.

      Why should immunizations be covered? It should be part of the deductible like a Flu shot, now FREEE.

      It would be like oil changes built into auto insurance policies as well as brakes and tires.

      The more Free you add, the higher the premiums.

    6. "In the past if you had drug coverage it was built into that insurance option. "

      But the principle is the same today, it's risk pooling. IE collect premiums from everyone knowing that some will use the benefit, and others won't. In curiosity though, I"m not sure what you mean on the monthly cost. All drugs have a monthly cost to them like BP meds, cholesterol DM, asthma and so on. I think a lot of the resistance to BC is on a moral objection basis. Philosophically, I get the big picture thinking to that, but I think the emotion is far stronger than the logical basis when you compare it to other situations like the one I described above. It's not that I want to give shit away free, rather, I just think that for a small cost, if we all pay something, we can provided subsidized medicines and that by doing so, we save each other money in the long run.

      On immunizations, I guess I should qualify that a little. The flu shot is really kind of a hit or miss proposition, I think estimates are typically a reduction in risk of 11-20%. No doubt, a lot of people die every year from the flu, but I don't think you can show such a clear benefit to providing this "free" and on top of that, they would not be able to produce enough anyway. That said, immunizations for children should be a no brainer. Likewise with HPV and arguably, Hepatitis B. As for adults, I would agree that providing free flu shots to generally healthy adults is not a good use of pooled resources. A pneumonia shot for a senior though is a different story to me, especially those not in such good health. Setting aside moral objections for a minute, I think all of these have shown substantial return on investment for reducing or avoiding related medical care costs. The difference from that auto insurance policy is that you WILL eventually need brakes and tires. A flu shot is more like attending a safe driving course.

  3. The senate just passed the bill to defund Obamacare and the House will most likely go along. But, it is like a bluff in poker since the Republicans have no alternate plan and they dare not deprive those now covered of needed insurance. So they hope to force Obama to use the veto. But, in the final analysis they are holding a losing hand and this legislation will likely cost them votes in the end when they have to lay down their hand.

    1. Agreed. They know Obama will veto it and the votes are not there to override it, so it's ultimately no different than the house voting how ever many times when Reid controlled the senate and was assured to block any house measure from coming to vote in the senate. The strange thing to me is this, many people who dislike Obama have nonetheless benefitted from the ACA, but will continue to support the party who is telling them they want to take away insurance that they, the party, feels they should have been allowed to have to begin with.

      In fairness, Republicans are not without plans, but I don't really think there is true consensus among them as to what it should look like. They want the ACA repealed, but I don't think they really have a central goal to cover as many people as possible.

    2. Max, the ACA changes affect all of America. hence the rise in the cost of insurance.
      Why should the country subsidize people that insure their 20's children when they could easily insure themselves?
      Why should the country subsidize BC pills, immunizations, physicals, colonoscopies, mammograms etc when it should be covered as part of their insurance plan, not FREEEE?
      The list is long on the freebies that have forced the insurance cost higher.

      Had sad for this country that we now push out bills on our neighbors take government handouts for healthcare for people making up to 94K a year. People take subsidies that are not qualified for and are required to pay only a portion back.

      Reid still blocks legislation in the Senate. The old filibuster rule and all. Time to pull the dirty Harry trick and declare the nuclear option and pass all legislation by a simple majority only.

      But this is the results of one party control and the aftermath.

    3. This comment has been removed by the author.

    4. That didn't say what I wanted it to. If the least thing we could do correctly would be to have a national that does nothing more than ensure you won't go bankrupt by covering hospital bills, I guess that would be better than nothing. I think we would still leave many people in a spot where they could not afford health care, and hence, would not be able to afford provider visits, or medicines, that could keep them from going to the hospital. I'm genuinely not interested in increasing the power of government, and believe me, as someone just about to become a provider and bill for my services, I'm hesitant about the prospect of becoming a government employee. Still, I have an ongoing view, that no one here has ever addressed, which is that insurance companies do nothing more than shuffle money around and take a slice as it goes by. That annoys me and their management doesn't make healthcare cheaper.

      If we created the catastrophic plan, and then let everyone find an insurance company to help offset drug costs or several visits a year, I see nothing fundamentally different from having an insurance company run it, or a government agency. I can't speak for all providers, but my preceptor had much less grief dealing with medicare than he did the medicare supplemental plans run by large insurers who make him argue with uneducated people manning phone banks telling him to jump through ten hoops to get a pre-authorization.

      I don't know Lou, if all we can do correctly is catastrophic coverage, I guess that's better than nothing. Perhaps my world view is wrong because I see the entire thing as nothing more than risk pooling. IE, the payer collects premiums from thousands of people with the hope that they will only have to pay claims for relatively few, basically the healthy are subsidizing the sick. If this is the basic principle that will be operative in any system, then it seems to me the best solution is to pool as many people as possible.

  4. The senate just passed the bill to defund Obamacare and the House will most likely go along. But, it is like a bluff in poker since the Republicans have no alternate plan and they dare not deprive those now covered of needed insurance. So they hope to force Obama to use the veto. But, in the final analysis they are holding a losing hand and this legislation will likely cost them votes in the end when they have to lay down their hand.

  5. Hypertension and BP need not cost a bunch to manage. I take meds for both and the total bill is $14 a month. I think Max part of the solution is exactly the road you are on. Nurse practitioners can take care of a lot of health problems more cost effectively then a visit to a doctor. Target just turned all that over to CVS and any Target with a pharmacy will now be staffed with a nurse practitioner thru CVS minute clinic program.

    1. I agree with you Rick that it should not cost a lot of money to manage BP. Most of the front line medications are pretty cheap these days and will work for a majority of people.