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Old 11-19-2015, 03:37 PM
Fotheringay-Phipps Fotheringay-Phipps is offline
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UnitedHealth warns it may exit Obamacare plans

UnitedHealth warns it may exit Obamacare plans

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The nation's largest health insurance provider, UnitedHealth Group, dealt a blow to the Affordable Care Act on Thursday when it warned it may stop offering coverage to individuals through public exchanges after taking a big hit to the bottom line from disappointing enrollment and the law's unexpected effects.
Quote:
People who purchase insurance through the public exchanges are typically heavy users of their plans, draining insurers' profits, analysts say.

In a sharp reversal of its previously optimistic projections, UnitedHealth suspended marketing of its Obamacare exchange plans for 2016 — which the company has already committed to offer — to limit its exposure to additional losses.

“We see no data pointing to improvement" in the financial performance of public-exchange plans, UnitedHealth CEO Stephen Hemsley said on a conference call, though he added that "we remain hopeful" the market will recover.

The move comes amid indications that insurers are absorbing steeper costs than they expected from plans offered to individuals through the public exchanges, which are purchased online.
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Even though UnitedHealth wasn’t a major player yet on the ACA exchanges, the fact that it priced plans conservatively and entered cautiously made its statements more significant, said Katherine Hempstead, who heads the insurance coverage team at the Robert Wood Johnson Foundation.

“If they can’t make money on the exchanges, it seems it would be hard for anyone,” Hempstead said.
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While UnitedHealth’s statement is significant, Kaiser Family Foundation Senior Vice President Larry Levitt said it "matters more for what it says about what industry as a whole thinks about Obamacare."

"If they exited (the exchanges), it wouldn’t matter that much to the functioning of the ACA, but it would show why increasing enrollment is so important," Levitt said. "This market is not yet profitable for insurers, but it could become profitable if enrollment grows."
Per the article, UHC is not a major player on the ACA exchanges, but they are one of the 4 big national health insurers (the others being Cigna, Aetna, and the Blues). So it's not like this is some two-bit insurer which doesn't know what they're doing.

It goes without saying that this does not mean that the roof is falling in and that the exchanges will fail. But it's an ominous sign.

As I've noted in other threads, there are risk-sharing measures in place for the first few years of the exchanges, and there is a school of thought which believes that once these are removed, the roof will indeed fall in. I would guess this possibility is a factor in UHC's thinking.

And this could snowball. Because one thing that keeps rates lower than they otherwise would be in new markets is companies buying market share at the expense of current profits, thinking that they'll recoup their money down the road when things stabilize. But if companies start thinking this is going to be a tough market at best, they'll be reluctant to take an upfront hit in order to get their feet in this particular door.

But again, the jury is still out. Time will tell.
  #2  
Old 11-19-2015, 04:02 PM
Trinopus Trinopus is offline
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If they overplay their hand, they'll alienate a lot of voters.
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Old 11-19-2015, 04:43 PM
Diceman Diceman is offline
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Originally Posted by Trinopus View Post
If they overplay their hand, they'll alienate a lot of voters.
It's an insurance company. It's not like they get a lot of love to begin with. But as the OP notes, there's only 3 other big players in the health insurance industry these days. If the rest follow suit, then the public exchanges will be left to a bunch of small-time companies with low-quality service (offering some combination of really high rates, really crappy coverage, and a tendency to go broke and leave their customers in the lurch).

Actually, haven't several of the exchanges already gone broke? Maybe UnitedHealth just sees the cliff approaching.
  #4  
Old 11-19-2015, 05:27 PM
Fotheringay-Phipps Fotheringay-Phipps is offline
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But as the OP notes, there's only 3 other big players in the health insurance industry these days. If the rest follow suit, then the public exchanges will be left to a bunch of small-time companies with low-quality service (offering some combination of really high rates, really crappy coverage, and a tendency to go broke and leave their customers in the lurch).
It's not as simple as that, though. These are the 4 national carriers, but there are other carriers which are pretty big locally, e.g. Kaiser in CA or Harvard Pilgrim in NE.

That said, it seems that a lot of the rates in the exchange plans are supported by either "skinny networks" (which are becoming something of an issue) or underpricing. These might not last.
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Old 11-19-2015, 05:42 PM
Trinopus Trinopus is offline
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Why didn't they bail out of Medicare decades and decades ago?

This sounds like more anti-Obamacare hogwash from Fox News, rather than any kind of meaningful economic commentary.
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Old 11-19-2015, 06:08 PM
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Why didn't they bail out of Medicare decades and decades ago?

This sounds like more anti-Obamacare hogwash from Fox News, rather than any kind of meaningful economic commentary.
Does Medicare pay insurance companies? Or does it pay health care providers?
  #7  
Old 11-19-2015, 06:18 PM
Jonathan Chance Jonathan Chance is online now
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From a tactical position please let them pull out. From a political standpoint the idea of the ACA using private insurers was a sop to get the damn thing passed. If the majors pull out maybe we can transition to a proper single-payer plan and the large carriers can begin phasing out health insurance from their books. There's more money in Life/Accident/Home, anyway.
  #8  
Old 11-19-2015, 06:25 PM
Fotheringay-Phipps Fotheringay-Phipps is offline
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From a political standpoint the idea of the ACA using private insurers was a sop to get the damn thing passed. If the majors pull out maybe we can transition to a proper single-payer plan and the large carriers can begin phasing out health insurance from their books.
Even with that "sop", the only way it got passed was because the Democrats controlled the presidency, the House, and had 60 votes in the Senate. That's a pretty rare circumstance, and they're certainly far from it now.

[Actually you could make the opposite argument - that this is the ideal scenario for ACA opponents. If it got struck down by court ruling it would produce enormous disruption, such that a political response of some sort would be called for. If it slowly crumbles it might just die. Though of course, the ACA is a lot more than just the exchanges.]
  #9  
Old 11-19-2015, 06:31 PM
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From a tactical position please let them pull out. From a political standpoint the idea of the ACA using private insurers was a sop to get the damn thing passed. If the majors pull out maybe we can transition to a proper single-payer plan and the large carriers can begin phasing out health insurance from their books. There's more money in Life/Accident/Home, anyway.
How much political will exists for single payer? You think that a forced single payer would survive court scrutiny? There's a greater chance for Obamacare to just crumble over the next decade than for the US to have single payer.
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Old 11-19-2015, 06:55 PM
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Originally Posted by Fotheringay-Phipps View Post

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"If they exited (the exchanges), it wouldn’t matter that much to the functioning of the ACA, but it would show why increasing enrollment is so important," Levitt said. "This market is not yet profitable for insurers, but it could become profitable if enrollment grows."
I love it. 'You wonder how we make a profit if we lose money on every transaction. Simple, volume!' - First Citywide Change Bank (SNL)

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If they overplay their hand, they'll alienate a lot of voters.
Which voters are those and which hand is being overplayed? UnitedHealth is saying that it may not be worthwhile to participate in the exchanges.
  #11  
Old 11-19-2015, 07:09 PM
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How much political will exists for single payer? You think that a forced single payer would survive court scrutiny? There's a greater chance for Obamacare to just crumble over the next decade than for the US to have single payer.
I think that an expansion of Medicaid or Medicare can pass, depending on the funding levels necessary, but everyone's going to demand to keep what they have.

As for United Health, everyone knows I'm very pessimistic about ACA, but I don't see this as particularly dangerous news. The exchange business model will work for some insurers, for others it won't. An insurer has to recognize what kind of pool they are insuring and set rates appropriately. United Health was one of the companies that was probably setting rates too low.
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Old 11-19-2015, 08:22 PM
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United is disingenuous.

As provider we see the other majors working on developing systems that incentivize cost effective care, as the ACA was designed to incentivize; United not so much so. No question if you do not try you do not succeed.

Then there is this play that they are making ... Harken Health.

Harken is an "independent" subsidary of United that gives every appearence of being specifically designed to cherry pick young White not poor (very likely healthier) members.

Yes, while United is making noise about getting out of the market that they never really entered or committed to, they have created a subsidary that allows them to cover only the lowest utilizers.

The trick is to make a product that is attractive but accessible only to those who are unlikely to cost you much. Others had tried similar things with Medicare HMO products ... having a product with attractive rates and networks with sign up in a building that required walking up two flights of stairs. (no cite for that, so leave it "as the story goes.") Harken's giimmick is that you can only access the otherwise overall attractive product using their staff model primary care providers who just happen to only be located in neighborhoods that are mostly populated with young White adults making significantly above a living wage. The article is wrong in that this is not an integrated model at all. It is brazen cherry picking.
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Old 11-19-2015, 09:57 PM
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What kind of rep do they have in the industry? Relative to others, how are they considered as to profit and service? In those scandals about insurance companies pulling legal shenanigans to screw people out of their coverage when they needed it most....how did they "stack up"?

Last edited by elucidator; 11-19-2015 at 09:58 PM.
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Old 11-19-2015, 11:10 PM
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. . . You think that a forced single payer would survive court scrutiny? . . .
Like Medicare and the Veterans Administration? The courts have certainly been eager to break up those monopolies, haven't they?
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Old 11-19-2015, 11:15 PM
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Maybe not quite the perspective you are looking for 'luci but from my side of the fence they are not thought of well.
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About 42 percent of hospital leaders said UnitedHealthcare was the worst at dealing with hospitals. ... Most trustworthy payers ...UnitedHealthcare scored the worst in this category as well. ... UnitedHealthcare was ranked as the worst for paying hospital claims promptly ... In terms of the worst reputation for honesty in contract negotiations, UnitedHealthcare again took the prize ... New initiatives. Commercial payers have started to partner more with hospitals on new initiatives, like accountable care organizations and patient-centered medical homes. About 37 percent of hospital executives said Blue Cross Blue Shield was the best for these projects. UnitedHealthcare ranked as the worst. ...
That last bit is most on point for this thread. Those new initiatives are the essential ingredient of making products that can cut it in the exchange environment. If a payor is not partnering to develop them then they are not really playing in that game, they just want business as usual.

In my region at least their reputation for customer service is not great. Below Humana even.

Interesting bit to compare and contrast ... in the Chicago area University of Chicago Hospitals has been the main academic center anchored in the South side surrounded by poverty. For decades the have been struggling as a result and often trying to dodge the responsibility of care to the populations that surround them. They dropped out of being an adult trauma center for years as they stated they were losing too much money on taking care of adult gunshot victims. Now they are, in a partnership with Sinai Health system, setting up a new adult trauma center at a hospital near Chicago's epicenter of gun violence. And merging with Ingall's Hospital in south suburban Harvey, a town whose median household income is $31K and a hospital whose admissions are mostly Medicare and Medicaid. The only conclusion I can come to is that they have decided that the ACA has made actually caring for the poorer (if not the poorest) fiscally feasible (as part of a plan that also includes working collaboratively with more solidly middle class suburban hospitals and physician groups).

Interesting times. Not all perfect to be sure but no roof falling in. One insurer who was really not at all committed to competing in the space not doing well in it, albeit simultaneously trying to do a scummy end run into it for only the healthiest subpopulation. Not so ominous a sign.
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Old 11-19-2015, 11:49 PM
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Like Medicare and the Veterans Administration? The courts have certainly been eager to break up those monopolies, haven't they?
Since private health care still exists I'm not seeing the monopoly or the single payer.
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Old 11-20-2015, 12:55 AM
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Looked for how we physician groups rate them and found this:
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For the fourth year in a row, Medicare Part B has received the highest overall satisfaction score from group practice professionals and UnitedHealthcare has received the lowest score, according to the latest survey on third-party payers conducted by the Medical Group Management Association (MGMA). ... The MGMA survey is not the only one in which UnitedHealthcare has received poor grades from physician practices. When Medscape asked physicians last year what payer they considered the worst, the biggest vote-getter — at 14% — was UnitedHealthcare. It also topped the list for the highest frequency of claims denial.
And yes they have had more than their share of legal issues.
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Old 11-20-2015, 12:57 AM
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Since private health care still exists I'm not seeing the monopoly or the single payer.
Exactly. You can do single payer on top of the existing system but you can't REPLACE private health insurance with single payer.
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Old 11-20-2015, 01:26 AM
elucidator elucidator is offline
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Maybe not quite the perspective you are looking for 'luci but from my side of the fence....
Precisely the perspective, actually. Kinda probing in the direction of asking why they need to make so much money that they can't "compete"? Because of the burden of their investor's expectations? What sticks out in my memory is reading how upset some of them were about a rule that means they have to pay out at least 80% of their premiums as benefits. A twenty percent margin is a problem?

I'm wondering if its a ploy. If they got really lucky, maybe they start a panic, Obamacare collapses and they go back to the good old days. Or, more likely, set up for negotiations, see if they can't get the rules tweaked a bit so that more cashflow stops with them.

Seems to me, if dire straits were the usual thing with health insurance, and none of them were capable of coping with the situation, then they would have all joined the chorus as soon as one of the big boys broke the ice. Which makes me think that some of them have counted their beans, and figure that if they are smart, they can make a modest but secure profit pretty much guaranteed. Maybe if you don't need your own building with a marble plaza and huge crappy modern sculpture. Maybe your CEO is frugal and modest, and can squeek by on ten times what the President makes.

Of course, just because you are not actively bitching doesn't mean you're happy. But I'm wondering if they've simply looked it over from a leaner perspective and figured, yeah, this can work.
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Old 11-20-2015, 01:37 AM
Trinopus Trinopus is offline
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Exactly. You can do single payer on top of the existing system but you can't REPLACE private health insurance with single payer.
Why not? Governments are immune from anti-trust rules.

(You don't see any competition to form private armies to reduce Pentagon costs.)

The argument that a single-payer system would be dismantled by the courts is contrary to reality, as the V.A. demonstrates.
  #21  
Old 11-20-2015, 01:41 AM
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Nothing about the VA prevents veterans from paying for private health insurance. Ditto for Medicare.
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Old 11-20-2015, 01:41 AM
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Just as an aside, how many times --- rough average --- is an American expected to change health insurance over a lifetime [ let's optimistically call that 80 years ] ?
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Old 11-20-2015, 02:31 AM
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Nothing about the VA prevents veterans from paying for private health insurance. Ditto for Medicare.
Nor does single-payer. It's relatively common in countries that have a government-mandated single-payer HC system for the middle class and up to have both government health insurance and a private one on top, typically covering quality-of-life medical costs the national healthcare system doesn't (glasses and dental, home care, elective surgeries etc...).
  #24  
Old 11-20-2015, 03:49 AM
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Obamacare was intended to be mandatory. If the mandate is not enforced, of course unhealthy people are more likely to get insurance than healthy people. Insurance companies can't thrive charging normal-health premiums for mostly bad-health patients. I'm surprised it took so long for the problem with not enforcing the mandate to appear.
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Old 11-20-2015, 03:53 AM
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That was foolish though, because mandatory health insurance is unconstitutional, and a constitutional law professor would at least be aware that such an idea was pushing the envelope and risky.
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Old 11-20-2015, 04:42 AM
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I thought SCOTUS approved the mandate; which is being deferred for other reasons. No?

But it all goes to reinforce how much better single-payer, or at least some public option, would be. Especially infuriating are all the right-wingers -- you can find them right here at SDMB -- braying that single-payer would be better than ACA. Where were you when it was clear that healthcare reform would be passed and the right-wing could have produced a grand single-payer compromise?
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Old 11-20-2015, 04:54 AM
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I thought SCOTUS approved the mandate; which is being deferred for other reasons. No?
It was approved as a tax, but rejected as a commerce clause power. So Congress can't make you get health insurance by putting you in jail if you don't, they can only charge you a tax.

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But it all goes to reinforce how much better single-payer, or at least some public option, would be. Especially infuriating are all the right-wingers -- you can find them right here at SDMB -- braying that single-payer would be better than ACA. Where were you when it was clear that healthcare reform would be passed and the right-wing could have produced a grand single-payer compromise?
There's too much of a gap between what we want and what the left wants. I'd take a single payer system that paid catastrophic costs only, along with the Medicaid expansion for the poor. Liberals want comprehensive care for all.

Last edited by adaher; 11-20-2015 at 04:54 AM.
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Old 11-20-2015, 09:01 AM
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Why didn't they bail out of Medicare decades and decades ago?

This sounds like more anti-Obamacare hogwash from Fox News, rather than any kind of meaningful economic commentary.
Which is what I said in a Facebook argument.

UHC's profits in Q1 sound pretty good:

Quote:
Profit jumped almost 29% year over year in the first quarter, totaling more than $1.4 billion. UnitedHealth's revenue increased 13% to $35.8 billion.
Maybe they expanded too quickly?

Quote:
UnitedHealthcare, the company's insurance subsidiary, expanded its presence on the Affordable Care Act's insurance exchanges this year from four to 23 states. Executives said there was a “positive market response” to the company's individual public-exchange products.
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Old 11-20-2015, 09:07 AM
Fotheringay-Phipps Fotheringay-Phipps is offline
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I love it. 'You wonder how we make a profit if we lose money on every transaction. Simple, volume!' - First Citywide Change Bank (SNL)
That's not as silly as may seem. The idea is that the sickest people would be the first to run out and buy insurance, but that if the market expanded to healthier people it would become more profitable.
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As for United Health, everyone knows I'm very pessimistic about ACA, but I don't see this as particularly dangerous news. The exchange business model will work for some insurers, for others it won't. An insurer has to recognize what kind of pool they are insuring and set rates appropriately. United Health was one of the companies that was probably setting rates too low.
I'm not sure if you read the OP, but it quoted an analyst who said the exact opposite. (See the third quotebox.)
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Old 11-20-2015, 09:41 AM
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A lot of ACA boosters in this thread have reacted by trashing UHC, and trying to suggest this is a UHC-specific issue. It's worth noting a couple of things:
  • A lot of the major carriers are losing money on the exchanges. In aggregate, the carriers lost $2.5B in 2014. The main difference between UHC and the others appears to be that UHC is less tolerant of these short term losses, and perhaps less optimistic about future prospects.
  • None of the professional industry analysts I've seen have taken this line. And perhaps more importantly, the stock market - reflecting the collective wisdom of people who have actual money on the line - doesn't buy it either. Stocks in all major insurers tanked yesterday - Aetna and Anthem more than UHC - as did stocks of hospitals (who are thought to gain from increased of levels of private insurance).
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Old 11-20-2015, 09:44 AM
Really Not All That Bright Really Not All That Bright is offline
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I don't think this should really be a surprise to anyone; it stands to reason that 10 million people buying health insurance for the first time in years (or ever) will have more health issues than others. By the same token, it stands to reason that exchange customers will gradually match the general insured population more and more over time. Unless other major players start pulling out, I don't think this is news.
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You think that a forced single payer would survive court scrutiny?
Of course. It's a valid exercise of Congress' taxing power, just like Social Security. See Helvering v. Davis, for example.
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Just as an aside, how many times --- rough average --- is an American expected to change health insurance over a lifetime [ let's optimistically call that 80 years ] ?
Well, most of us get our health insurance through our employers, and employer's don't change plans that often. I've been with my employer for eight years and we've changed plan offerings once (in 2009 or so) and carriers once (in 2010 and 2015). Of course, the cost-sharing always differs slightly from year to year.

Last edited by Really Not All That Bright; 11-20-2015 at 09:47 AM.
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Old 11-20-2015, 10:13 AM
JcWoman JcWoman is offline
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Well, most of us get our health insurance through our employers, and employer's don't change plans that often. I've been with my employer for eight years and we've changed plan offerings once (in 2009 or so) and carriers once (in 2010 and 2015). Of course, the cost-sharing always differs slightly from year to year.
With a 30-year career I'm closer to the question than a young turk like you. I've changed employers about 8 times and a couple of them changed insurance on us a few times. So a rough guess for how many times I've changed insurance in 30 years is about 13 or 14 times.
  #33  
Old 11-20-2015, 10:35 AM
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United is disingenuous.

As provider we see the other majors working on developing systems that incentivize cost effective care, as the ACA was designed to incentivize; United not so much so. No question if you do not try you do not succeed.

Then there is this play that they are making ... Harken Health.

Harken is an "independent" subsidary of United that gives every appearence of being specifically designed to cherry pick young White not poor (very likely healthier) members.

Yes, while United is making noise about getting out of the market that they never really entered or committed to, they have created a subsidary that allows them to cover only the lowest utilizers.

The trick is to make a product that is attractive but accessible only to those who are unlikely to cost you much. Others had tried similar things with Medicare HMO products ... having a product with attractive rates and networks with sign up in a building that required walking up two flights of stairs. (no cite for that, so leave it "as the story goes.") Harken's giimmick is that you can only access the otherwise overall attractive product using their staff model primary care providers who just happen to only be located in neighborhoods that are mostly populated with young White adults making significantly above a living wage. The article is wrong in that this is not an integrated model at all. It is brazen cherry picking.
I had no idea about Harken. I'm exactly the person they're looking for. Seeing as how my current plan is being canceled (two years in a row!), I'm in the market for something exactly like they describe. Awesome!
  #34  
Old 11-20-2015, 11:12 AM
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That's not as silly as may seem. The idea is that the sickest people would be the first to run out and buy insurance, but that if the market expanded to healthier people it would become more profitable.
Of course - the example is mostly joking. But why would we expect healthy people to disproportionately go to the exchanges? Healthy people already have insurance. Healthy people who don't have insurance have little incentive to get it.

As an aside, thus far I've averaged switching insurance every 2.5 years. Either there is a better offering, or I switch jobs. I just switched again for 2016 since my company had to increase the cost of my previous plan significantly in response to the tax penalty they would have to pay since it was previously a "cadillac" plan. I am now paying more, and getting less. I'm switching to an HSA type plan and I think it's a poor replacement.
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Old 11-20-2015, 11:15 AM
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Originally Posted by Fotheringay-Phipps View Post
A lot of ACA boosters in this thread have reacted by trashing UHC, and trying to suggest this is a UHC-specific issue. It's worth noting a couple of things:
  • A lot of the major carriers are losing money on the exchanges. In aggregate, the carriers lost $2.5B in 2014. The main difference between UHC and the others appears to be that UHC is less tolerant of these short term losses, and perhaps less optimistic about future prospects.
  • None of the professional industry analysts I've seen have taken this line. And perhaps more importantly, the stock market - reflecting the collective wisdom of people who have actual money on the line - doesn't buy it either. Stocks in all major insurers tanked yesterday - Aetna and Anthem more than UHC - as did stocks of hospitals (who are thought to gain from increased of levels of private insurance).

Meh.

And their stock is already back up 3% today, half of yesterday's loss. Over the year the stock had gone from a low of 95 and trading in the 50s before ACA (into 2013) to trading in the low 110s to 120s over the past half a year ... yup, enthusiasm had it increasing by 120% plus. A one day correction for a disappointing report? Bupkiss.

Aetna is back up 4% today so far, higher than it was a week ago, and more than 300% higher than were it was in 2011. And Anthem's correction began in May ... and is also up today.

And I won't check every hospital stock but the first one I looked for, Tenet, is back up today, but has been in a decline since July. Why any investor would think hospitals are a good investment right now is beyond me. Census is down and the trajectory is crap for them.

Last edited by DSeid; 11-20-2015 at 11:17 AM.
  #36  
Old 11-20-2015, 11:24 AM
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I had no idea about Harken. I'm exactly the person they're looking for. Seeing as how my current plan is being canceled (two years in a row!), I'm in the market for something exactly like they describe. Awesome!
Yup. You are may be who they want to cherry pick. And if you live where they have placed their staff model primary care offices it is a pretty sweet deal that they can easily afford to offer if they get that prime demographic. From the young White consumer on the Exchange in those neighborhoods POV it is a decent plan. Can't say what the quality of those staff model primary docs are ... and they do directly work for the insurer ... but in concept if they can score the healthy demographic by limiting access they can afford to pay for decent primary care office based care. Outside of that it is a traditional high deductible PPO with a reasonable selection of hospitals for a city dweller (better than Blue Choice's for example).
  #37  
Old 11-20-2015, 11:49 AM
Really Not All That Bright Really Not All That Bright is offline
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Of course - the example is mostly joking. But why would we expect healthy people to disproportionately go to the exchanges?
We don't need healthy people to disproportionately go to the exchanges. Healthy people vastly outnumber unhealthy people,* so we only need them to sign up proportionately. Something like 80% of health spending goes towards 10% of patients.

*There are an awful lot of people out there with uncontrolled hypertension and/or hyperlipidemia, of course, but as long as those people aren't seeking treatment they don't cost insurers anything.

Last edited by Really Not All That Bright; 11-20-2015 at 11:49 AM.
  #38  
Old 11-20-2015, 12:00 PM
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We don't need healthy people to disproportionately go to the exchanges. Healthy people vastly outnumber unhealthy people,* so we only need them to sign up proportionately. Something like 80% of health spending goes towards 10% of patients.
My previous post was ill-phrased. I was referring to the proportion of people that need to sign up going forward as compared to the group of people that have already signed up. In other words, for the viability to turn around, UnitedHealth is saying that the new signups need to be healthier than those who have already signed up. I'm not seeing how that is a reasonable expectation.
  #39  
Old 11-20-2015, 12:03 PM
Fotheringay-Phipps Fotheringay-Phipps is offline
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It's not completely far-fetched. Individual Mandate penalties are going to be increasing going forward.
  #40  
Old 11-20-2015, 03:53 PM
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. . . mandatory health insurance is unconstitutional . . .
The Supreme Court said otherwise. What's your cite?

(The constitution permits military conscription, which is a whole hell of a lot more intrusive than a tax to pay for health care.)
  #41  
Old 11-20-2015, 04:16 PM
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Obamacare was intended to be mandatory. If the mandate is not enforced, of course unhealthy people are more likely to get insurance than healthy people. Insurance companies can't thrive charging normal-health premiums for mostly bad-health patients. I'm surprised it took so long for the problem with not enforcing the mandate to appear.
Of course healthy people are going to skip coverage. The penalty is, what, 2% of your income? My health insurance premiums cost me far more than that, and I get insurance thru work, so I'm not even paying the full cost. The penalty is cheaper, by at least an order of magnitude, than even the most basic plan.

Last edited by Diceman; 11-20-2015 at 04:16 PM.
  #42  
Old 11-20-2015, 09:51 PM
GrumpyBunny GrumpyBunny is offline
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I think that an expansion of Medicaid or Medicare can pass, depending on the funding levels necessary, but everyone's going to demand to keep what they have.

As for United Health, everyone knows I'm very pessimistic about ACA, but I don't see this as particularly dangerous news. The exchange business model will work for some insurers, for others it won't. An insurer has to recognize what kind of pool they are insuring and set rates appropriately. United Health was one of the companies that was probably setting rates too low.
I would be very happy to expand Medicare for all, and allow private health insurance companies to work on top of that, as happens in many, other countries.

What I'm not happy about is the continuing work these companies are doing to make an extra buck on the backs of their sickest members, because IT DOESN'T MAKE SENSE. If you make a working-class parent pay the top tier price of $45 for a child's preventative asthma inhaler and she can't afford that, she won't buy it. Then the kid will end up in the ER or inpatient, and any corporate "savings" on that inhaler are moot. This has been demonstrated again and again, but insurance companies still do it, as if their members can will themselves out of asthma, diabetes, or heart disease.

I have said, and will say again, that until these companies smarten up and give a damn about their members' health beyond nagging them with phone calls and emails, they need to go commit self-love up their jacksie with a small thermonuclear device.
  #43  
Old 11-20-2015, 10:05 PM
GrumpyBunny GrumpyBunny is offline
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We don't need healthy people to disproportionately go to the exchanges. Healthy people vastly outnumber unhealthy people,* so we only need them to sign up proportionately. Something like 80% of health spending goes towards 10% of patients.
Your stats are pretty much correct.

The top 5% are the incrediably sick patients -- those with ESRD or major cancers, or "million dollar babies" born prematurely. Sometimes major, major traumas. We are able to control those costs by following evidence-based medicine protocols, applying appropriate preventatives (so grandma doesn't get pneumonia on top of cancer, for example), and by keeping costs within the member network. Also, finding out from the patients what they want, so we don't perform major interventions on a patient if that intervention doesn't provide much benefit.

The second 5% or so is generally patients with multiple major clinical problems that aren't well-controlled. Asthma with diabetes and hypertension, for example. The goal is to keep these people from moving into a sicker category, and to get their gaps in care under control so they can perhaps move into the "well-managed multiple clinical conditions (MCC)" cohort. CMS is working on improving care for MCC patients.

The bottom 80% or so range from perfectly healthy to well-managed chronic conditions.

What's interesting, is that people don't stay in one cohort. Someone in the second 5% can move into the bottom 80% by obtaining good medical care and following through on everything they need to do. This means, for example, that an uncontrolled diabetic receives counseling from a nurse and learns that he has to do some things to keep from getting sicker. So s/he measures his/her insulin daily and uses an app to track insulin levels; takes diabetes meds as prescribed; takes prescribed blood pressure and cholesterol medications to avoid cardiovascular side effects; works on his/her diet; takes exercise; gets lab tests as directed by his/her physician. This costs money up front, but saves it in the long run. THAT is what's difficult to get insurance -- and patients -- to understand.

[/lecture mode]

Quote:
*There are an awful lot of people out there with uncontrolled hypertension and/or hyperlipidemia, of course, but as long as those people aren't seeking treatment they don't cost insurers anything.
Yup, and that explains why our healthcare system has a problem. We have a sick-care system in that way. We're not willing to pay a little to treat a problem when it's fairly small, and to work with patients to keep them healthy or to prevent them from getting worse.

I used to point to the fact that obesity counseling or treatment was always totally non-covered under insurance, but now they seem to be catching on that maybe that's a false savings. Or maybe it's just a hot topic right now.
  #44  
Old 11-20-2015, 10:46 PM
DinoR DinoR is offline
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What sticks out in my memory is reading how upset some of them were about a rule that means they have to pay out at least 80% of their premiums as benefits. A twenty percent margin is a problem?
That's not a 20% margin though. 80% is what gets paid to providers. All the other costs have to come out of the other 20% before we know what the margin is.
  #45  
Old 11-20-2015, 10:48 PM
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I would be very happy to expand Medicare for all, and allow private health insurance companies to work on top of that, as happens in many, other countries.

.
Not on top of the single payer system, but in competition with it.
  #46  
Old 11-20-2015, 10:56 PM
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Not on top of the single payer system, but in competition with it.
That's simply not true. Private insurance plans in Australia, for instance, provide upgrades for "nicer" service -- private rooms instead of shared rooms -- but this is not "competition." You're completely wrong here.
  #47  
Old 11-20-2015, 11:02 PM
adaher adaher is offline
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What I meant is that this is how it should work, and how it does work in Germany. You can pay for the public insurance or you can opt out and get private insurance instead. About 11% of the population, mostly the well off, choose to opt out:

https://en.wikipedia.org/wiki/Healthcare_in_Germany

What we could do is keep Medicare and the VA, but change Medicaid into the new single payer health insurance. People could opt in if they wanted to, but everyone else could just keep what they have.

Last edited by adaher; 11-20-2015 at 11:03 PM.
  #48  
Old 11-20-2015, 11:53 PM
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Grumpy,

That is why the incentive systems now are transitioning away from the old ways and into population health metrics.

Don't get me wrong, I recognize that it is a work in progress and that not all get it yet. But overall medicine is not a solo event now; we work in systems. The evolution is to create the processes to identify those who are sickest and intervene with intensive outpatient care before they need lengthy admissions and re-admissions; to have fewer in that top group and have that healthier group be larger than 80%. That out of control diabetic with multiple co-morbidities? They have tons of resources being thrown at them, phone calls, care coordination, whatever it takes.

Many insurance companies do get it and quite a few medical groups do. I do not get the sense that UHC does but many do.

Since you used it as an example, asthma care in particular is often well incentivized. We as a medical group have significant dollars at risk based on our meeting or not meeting various quality of care metrics for preventative asthma care: documenting that patients are in a good clinical place, having asthma action plans reviewed, flu shots given, monitoring that there is not an excessive ration of rescue inhalers being used relative to preventative medicines prescribed, even documenting that depression has been screened for if control is more difficult to achieve.

Anecdotally we have at least as many children in our practice with asthma now as ever but kids needing to be admitted? Rare as hens teeth as they say. Usually a no-doc showing up in the ED when we are on ED call.

Remember that movie "As Good As It Gets" with Helen Hunt and Jack Nicholson in which her child had asthma and they portrayed the HMO as refusing to give him care? The irony is that it was the HMOs in real life who were spearheading incentivized disease management models that got kids better preventative care so that they needed admissions, ED visits, and even rescue inhalers less often.

The buzzword phrase in the industry is "value-based health care" and catalyzing the transition is more than anything else the biggest achievement of the ACA, of much bigger import than the exchanges.
  #49  
Old 11-21-2015, 11:02 AM
GrumpyBunny GrumpyBunny is offline
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What I meant is that this is how it should work, and how it does work in Germany. You can pay for the public insurance or you can opt out and get private insurance instead. About 11% of the population, mostly the well off, choose to opt out:

https://en.wikipedia.org/wiki/Healthcare_in_Germany

What we could do is keep Medicare and the VA, but change Medicaid into the new single payer health insurance. People could opt in if they wanted to, but everyone else could just keep what they have.
That would be kind of a PITA, since Medicaid is administered by the states and as far as I know, does not have any kind of central repository of member information. It would cost money to set it up so it would be an effective option nationally.

Medicare is already set up with a centralized member database (through Social Security) and can access and share that claims and member information across state lines if needed. There would be no need to change from one plan to another when you move or if you receive services somewhere else. No need to get different states' claims systems to be able to "talk" to each other, since that already exists with the Common Working File.

To get Medicare for all up and running, you really would only have to send out Medicare cards to everyone and upload the SSN information for every American into the Medicare eligibility file. Wham, ready to go.

Medicaid would have to be handled on the state level, which would be a logistical nightmare.
  #50  
Old 11-21-2015, 11:05 AM
GrumpyBunny GrumpyBunny is offline
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Grumpy,

That is why the incentive systems now are transitioning away from the old ways and into population health metrics.

Don't get me wrong, I recognize that it is a work in progress and that not all get it yet. But overall medicine is not a solo event now; we work in systems. The evolution is to create the processes to identify those who are sickest and intervene with intensive outpatient care before they need lengthy admissions and re-admissions; to have fewer in that top group and have that healthier group be larger than 80%. That out of control diabetic with multiple co-morbidities? They have tons of resources being thrown at them, phone calls, care coordination, whatever it takes.

Many insurance companies do get it and quite a few medical groups do. I do not get the sense that UHC does but many do.

Since you used it as an example, asthma care in particular is often well incentivized. We as a medical group have significant dollars at risk based on our meeting or not meeting various quality of care metrics for preventative asthma care: documenting that patients are in a good clinical place, having asthma action plans reviewed, flu shots given, monitoring that there is not an excessive ration of rescue inhalers being used relative to preventative medicines prescribed, even documenting that depression has been screened for if control is more difficult to achieve.

Anecdotally we have at least as many children in our practice with asthma now as ever but kids needing to be admitted? Rare as hens teeth as they say. Usually a no-doc showing up in the ED when we are on ED call.

Remember that movie "As Good As It Gets" with Helen Hunt and Jack Nicholson in which her child had asthma and they portrayed the HMO as refusing to give him care? The irony is that it was the HMOs in real life who were spearheading incentivized disease management models that got kids better preventative care so that they needed admissions, ED visits, and even rescue inhalers less often.

The buzzword phrase in the industry is "value-based health care" and catalyzing the transition is more than anything else the biggest achievement of the ACA, of much bigger import than the exchanges.
I work in population health, DSeid.

And unfortunately, we do still see plans that have those false savings, and have high levels of ED and inpatient claims. Maybe not with children, but we see it with adults a lot.
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