So how are those health care exchanges coming along?

[Richard_Parker]

@Fotheringay-Phipps

What does appear to have happened is that the big players in the health insurance market - who have the best provider networks - have largely chosen to sit out the exchanges, at least for the initial year. I’ve not followed the prices issue, but it appears that there are fewer choices of carrier, and within the carriers, smaller networks of providers than are typical for major-carrier plans.

A lot of big insurers have never sold non-employer plans in most states. So it’s a little misleading to say they’re “sitting out” unless there’s some indication that they were expected to get in in the first place. IIRC, Cigna for example was never really expected to participate in the Exchanges. Blue Cross bid for some of them.
According to the ASPE report, on average, individuals and families will have 53 qualified health plans to choose from in their rating area, from 8 different carriers. That seems like a reasonable variety, although they could be systematically inferior, as you suggest (though obviously not along any of the variables that are regulated by the exchanges).

As for the provider networks, I’ve seen that claim made anecdotally, but I’ve not seen any comprehensive comparison. It certainly wouldn’t shock me if the plans have smaller networks on average. Of course, in order to reach the conclusion that they are “products that are also worse than expected,” one would have to examine more than that aspect of the insurance policies.

[Farin]

@Fotheringay-Phipps

[FWIW, I don’t think the average of increases over the past decade is a valid estimator of the next couple of years, as medical inflation has come down a lot over the past few years. Some of that is due to the recession, but it’s hard to predict the extent to which things might pick up in the next couple of years.]

I like the decadal average simply because it encompasses both “bubble” and “horrifically bad” years, currently. The estimate from the last couple of years is primarily a down turn, which makes it very low. If we continue to have the slow recovery it’ll go beyond the last few years average fairly easily. The 5.5% from the CBO is based on “bad years” plus anticipated cost additions from ACA mandates.

@Richard_Parker

As for the provider networks, I’ve seen that claim made anecdotally, but I’ve not seen any comprehensive comparison. It certainly wouldn’t shock me if the plans have smaller networks on average. Of course, in order to reach the conclusion that they are “products that are also worse than expected,” one would have to examine more than that aspect of the insurance policies.

I’ve also heard this. I would also like to see data on it, though I doubt anyone will be forthcoming to highlight the plans’ shortcomings.

[Fotheringay-Phipps]

@Richard_Parker

A lot of big insurers have never sold non-employer plans in most states. So it’s a little misleading to say they’re “sitting out” unless there’s some indication that they were expected to get in in the first place. IIRC, Cigna for example was never really expected to participate in the Exchanges. Blue Cross bid for some of them.
According to the ASPE report, on average, individuals and families will have 53 qualified health plans to choose from in their rating area, from 8 different carriers. That seems like a reasonable variety, although they could be systematically inferior, as you suggest (though obviously not along any of the variables that are regulated by the exchanges).

My impression is that they are worse than expected. See e.g.: USA TODAY

I don’t think you can measure them against what individual coverage was being offered previously, since the whole idea of the exchanges was to significantly improve the individual market, and if they fail to do that then it’s a failure.

And the significant point about health insurance is that it needs healthier people in the mix to be viable. The worse the product offered (or the higher the rates, or the more difficult it is to enroll) then the more the population which elects it will be skewed towards those who are most motivated to elect it, i.e. the sickest.

I certainly don’t think the verdict is in yet by any stretch, but I don’t see anything that says it’s going well, at this point.

[Bryan_Ekers]

@Lightnin

And if the fire truck doesn’t get there in the next hour, you fix the problem with 911. You don’t throw your hands in the air, proclaim the 911 system to be a failure, and pull the plug.

What if you just demand the resignation of everyone who works in 911 call centers?

[jasg]

Nm

[magellan01]

@Left_Hand_of_Dorkness

Huh. Now that I read over that, it’s a terrible dang analogy. Let’s scrap it altogether and move on.

In all seriousness, good on you for doing this. Too often analogies get offered, altered, twisted, contorted, re-altered and the discussion is lost.

[pohjonen]

Personally I could not get past the name and address pages of the Washington application website. I understand they use Equifax to verify initial identity, and if one is a credit ghost as I (and I’m sure I am not all alone here) am, that’s as far as the website can go. Calling the help line I was told to wait a couple of days, which I did to no avail. So I downloaded a paper application and mailed it in. We shall see how that goes.

I found it especially amusing since I applied online for and was granted SS without ever having to submit a single document.

[elucidator]

So, this Robert Lasewzki fellow, who’s expert testimony is cited. Beyond the fact that he has a website and a couple of endorsements, who is he? He is very big over at Health Policy and Strategy Associates, LLC, apparently. Best I can tell, he is the embodiment thereof.

But, all right, beware the Death Sprial. Damn right I will!

And I sincerely hope that our various insurance companies are also aware of the dread menace of the death spiral. Must be kinda sneaky, since “many insurance companies have had death spirals”. Heavens! A menace so insidious, even after other insurance companies have already fallen prey, others don’t catch on, they just stumble blindly into the Death Spiral Tar Pit, their bones mingle with the stegosauri.

(Perhaps the Death Spiral is the source influence on the heath insurance industry responding with an innovative and creative approach to their customes. Offering them the opportunity to play Wheel of Coverage. Insurance is a lot more exciting that way, so I suppose some folks would think of that as an improvement, the one’s who don’t spin to “Yer Boned!”)

Nonetheless, I am confident that the Obama admin has some expertise at hand. I know the subject of universal health coverage is one that has been talked about in academic circles for some time, hopefully the Obama admin has some contacts at local community colleges. As well, there is a smattering of real life experiences to refer to, being just about the entire industrialized world. Got to be some helpful hints in that.

We could gain a lot by studying those universal systems that crashed and burned into total disaster for all concerned. Hell, can’t even count the citizens of Canuckistan who come to the boards begging to be sponsored for American citizenship, so they can escape the horrors of socialized medicine! Haven’t really tried to count them, of course, but I’m willing to guess it climbs into the middle single digits!

[Strassia]

From everything I have read their are two big issues: The way healthcare.gov was contracted out and implemented (Slate is reporting that the site employes over 500 million lines of code and is estimated by some to need corrections in 5 million lines of code) and that the large numbers of states that have opted out of creating their own exchanges has put more pressure on it. The state exchanges are doing better, but they still have issues (California’s had to take down a provider network tool that didn’t work right).

Government’s aren’t tech companies. This needs to get fixed, but it doesn’t really address the law itself.

Of more concern, is the idea that the same tendencies that formerly kept young healthy people from getting insurance in the first place will tilt the market in a way that pushes everyone into the cheapest plans instead.

[QUOTE=Slate]
The ACA itself is designed to solve the problem of adverse selection. If only sick people buy insurance plans, then insurance plans have to be expensive, so there’s even more reason that only sick people will buy them, so they get even more expensive. Hence the individual mandate. What Handel, Handel, and Whinston are saying is that the exact same adverse-selection spiral is going to repeat itself inside the exchanges. Instead of unraveling all the way down to a state of noninsurance, it will unravel all the way down to the regulatory minimum of the bronze plan.
[/QUOTE]

[elucidator]

Yes, but if it works for us as well as it does for just about everybody else, why wouldn’t we plow some of that into improving the bronze plan? After all, its not like we’re out to make a profit.

[Richard_Parker]

@Fotheringay-Phipps

I don’t think you can measure them against what individual coverage was being offered previously, since the whole idea of the exchanges was to significantly improve the individual market, and if they fail to do that then it’s a failure.

The baseline not only should, but must be the individual coverage being offered previously.

But I agree that if the plans on the exchange fail beat that baseline for a substantial majority of people, then it is a failure. You have a lot of different people in different situations. Indisputably, some people are hugely benefited by the exchanges already. Equally indisputably, some people are harmed. Obviously, the million dollar question is the proportions of the two. From what I’ve read, the former group seems vastly larger than the latter.

But even if we had perfect knowledge, these claims about success would still be debateable because you must compare inherently subjective qualities (fewer providers, say, versus no co-pay for prevantative coverage; or coverage for dependents up to 26 versus a higher deductible for medical devices; or lower premiums vs. the inability to have the policy rescinded after a certain period, etc.).

What we can measure in all of that are things like average premiums vs. the predictions (and even better, versus the individual market before exchanges). Since the vast majority of people using the exchange will be choosing it over no insurance at all, price is the paramount consideration. AFAIK, on that measure the exchanges are a success so far. As you say, that’s not guaranteed to last, and could be a byproduct of offering plans that are less valuable to the average consumer, both those are both speculative rebuttals to objective data.

[Fotheringay-Phipps]

@Richard_Parker

The baseline not only should, but must be the individual coverage being offered previously.

I disagree. Because nothing is cost free. And the question about any loss or policy is whether it’s worth it.

But I agree that if the plans on the exchange fail beat that baseline for a substantial majority of people, then it is a failure. You have a lot of different people in different situations. Indisputably, some people are hugely benefited by the exchanges already. Equally indisputably, some people are harmed. Obviously, the million dollar question is the proportions of the two.

That’s not the only million dollar question. Because insurance is different. As my learned colleague elucidator expounded earlier, there’s this death spiral issue. If the exchanges benefit all sorts of people in the short run, but the mix of people is skewed to the unhealthy side, which pushes up the rates, which skews the mix further, and so on, then they will ultimately fail.

From what I’ve read, the former group seems vastly larger than the latter.

What have you read?

But even if we had perfect knowledge, these claims about success would still be debateable because you must compare inherently subjective qualities (fewer providers, say, versus no co-pay for prevantative coverage; or coverage for dependents up to 26 versus a higher deductible for medical devices; or lower premiums vs. the inability to have the policy rescinded after a certain period, etc.).

The way you boil down all these subjective qualities is by looking at who signs up and whether the rates are sustainable with this mix.

What we can measure in all of that are things like average premiums vs. the predictions (and even better, versus the individual market before exchanges). Since the vast majority of people using the exchange will be choosing it over no insurance at all, price is the paramount consideration. AFAIK, on that measure the exchanges are a success so far.

Problem is that the exchanges are offering a product that the people signing up are not familiar with. Even if a lot of people think the price is good - and it’s not clear how many do - these people don’t yet know what they’re getting for their money, and could conceivably change their minds when they begin using the product. So using price as the only measuring stick is looking at half the picture.

Yugos are no longer sold in this country, and they couldn’t be beat on price.

I’m not saying the exchanges are comparable to Yugos. That’s unlikely, and it’s far to early to tell at any rate. But my point is that you can’t just ignore evidence that the product might not be up to par and assert that price is the only yardstick we should be looking at.

As you say, that’s not guaranteed to last, and could be a byproduct of offering plans that are less valuable to the average consumer, both those are both speculative rebuttals to objective data.

It’s speculative if we call things that are not solidly established as speculative. If speculative means speculating about possibilities with no evidence, then no, there’s just a bit more to it than that at this point.

[Bryan_Ekers]

@elucidator

We could gain a lot by studying those universal systems that crashed and burned into total disaster for all concerned. Hell, can’t even count the citizens of Canuckistan who come to the boards begging to be sponsored for American citizenship, so they can escape the horrors of socialized medicine! Haven’t really tried to count them, of course, but I’m willing to guess it climbs into the middle single digits!

Heh, well… in all seriousness, some Canadians (a significant number, probably) do travel to the U.S. (or elsewhere) for medical treatments that are either not available in Canada or have prohibitive waiting lists, and there are any number of Canadians willing to move to the U.S. (and forego the single-payer system) because they can or feel they can make more money and pay lower taxes.

Just saying.

[elucidator]

So, how come you put up with it? Do mounties break down the doors of dissidents? You guys can’t vote, or aren’t smart enough to see how badly screwed you are? You didn’t have time to link to all those polls showing how totally fed up Canadians are with their socialized medicine eh?

If its no damned good, why do you still have it? Too polite to hurt its feelings?

[QuickSilver]

@Bryan_Ekers

Heh, well… in all seriousness, some Canadians (a significant number, probably) do travel to the U.S. (or elsewhere) for medical treatments that are either not available in Canada or have prohibitive waiting lists, and there are any number of Canadians willing to move to the U.S. (and forego the single-payer system) because they can or feel they can make more money and pay lower taxes.

Just saying.

I will tell you that a very large proportion of Canadians who choose to travel to the US for medical treatment do so because they can afford it and more often than not it’s either elective stuff or stuff that is simply not a critical health condition. That’s not to say that these will not be addressed by the Canadian healthcare system - just not in a cut to the front of the line fashion.

Also, I’d like to get ahead of the scare mongering many anti-social healthcare advocates tend to spread about long waiting periods for this or that. How many of you have to wait for doctors’ appointments? How often do you get to see you doctor same day or next day, unless it’s an emergency? Even a simple dental appointment often takes weeks with a good doctor. (Somehow, quacks always have time on their calendar. Go figure.) Canada is no different. Nobody goes untreated. Patiends are not dying on gurnies in waiting rooms of hospitals.

Finally, Canadian that choose to move to the US for financial reason are also choosing to forgo the socialized medical system they value. It’s a choice but also a risk. If you’re in otherwise good health and a professional that stands to make a good income in the US and can find health insurance for a reasonable price, there is little reason not to come to the US to work and live. It’s a good country to some/most. But I’ve yet to meet a fellow Canadian that is not wistful for socialized healthcare. Coming here is an economics choice and healthcare is only one of the many trade-offs considered in the decision. No Canadian I know leaves Canada to get away from their healthcare system.

[Cheesesteak]

@Bryan_Ekers

Heh, well… in all seriousness, some Canadians (a significant number, probably) do travel to the U.S. (or elsewhere) for medical treatments that are either not available in Canada or have prohibitive waiting lists, and there are any number of Canadians willing to move to the U.S. (and forego the single-payer system) because they can or feel they can make more money and pay lower taxes.

By “some” do you mean a random collection of Canadians from all walks of life, or do these folks have something particular in common? Something like wealth?

I don’t think anyone would dispute that the wealthy get great medical care in the States. It’s top notch, world class medical care, if you have money, or a good job. Providing good service to the wealthy is not our problem, and never has been.

[Budget_Player_Cadet]

@Cheesesteak

Nobody’s house is burning down because the opening of this website, 3 months before insurance coverage actually begins, is glitchy. They actually have many weeks to get the kinks ironed out before it can even charitably be considered a failure to provide the services it’s supposed to.

Just like any glitch ridden rollout, in 6 months, when it works the way it supposed to, the problems will be a footnote to a footnote.

Here’s hoping you’re right. The problem is, though, that Obamacare is simultaneously not very popular (yes, I know, people like what’s in it, but when faced with Obamacare as a whole, they don’t like what they imagine it to be), and that first impressions matter. If people try for a few weeks to go on the website and can’t get anywhere, how many do you think are going to keep trying a month later? It’s a fiasco, and I think it will at least in the short term have some effect (and we all know how important a midterm can be).

I heard somewhere that part of the problem was that the software (as usual) didn’t meet the deadline, but the deadline was forcibly kept anyways, meaning that a whole mess of bugs got thrown in. When the fuck will the government finally get a goddamn clue about the most important part of the modern world? We saw this shit with SOPA and PIPA and the DMCA and ACTA and basically every other copyright or internet-related law recently, and it’s really bad for us as a nation.

[Cheesesteak]

I think the website is more like an iPhone, if you can’t get it the day of release, you don’t walk away and buy a Droid, you wait for the supply to catch up to demand. People aren’t going to give up on the concept of low cost health care because the website isn’t working for a few weeks.

I have health insurance through my job, but I know that if I didn’t, I’d be on these exchanges like white on rice. If it doesn’t work now, I’ll keep tabs on the topic, and when things seem to clear up, I’m going on. Or… I find another way to tap into the resource, my understanding is that the website is not the only way to buy ACA health care.

[steronz]

@Cheesesteak

Nobody’s house is burning down because the opening of this website, 3 months before insurance coverage actually begins, is glitchy. They actually have many weeks to get the kinks ironed out before it can even charitably be considered a failure to provide the services it’s supposed to.

From other threads I’ve learned that big companies like Blue Cross are sending out notices to hundreds of thousands of their customers saying that their premiums are going up, in some cases by a lot, in order to comply with ACA standards. The response has typically been that they should go shop on the exchanges. It’s kinda hard to to do that if the exchanges don’t work. We’re 3 weeks into this and the system is still crappy. If the rate increases take effect 1 January, and people are expected to have a policy purchased by 15 December, then we’re looking at somewhere between 7 and 8 weeks before people need to start taking hard look at their budgets.

I’m lucky enough not to be in this situation, but I can imagine that it’s incredibly stressful for those who are. I don’t think you can call these glitches harmless, because that stress is real for those people.

Furthermore, from what I’ve read from neutral IT related sources, these aren’t “opening day rush” problems that can be solved by waiting a few weeks for demand to die down or by throwing servers at the problem. There are serious issues with the entire system, and I’m not sure that they’re going to be fixed by 15 December. I don’t think it’s time for panic, but I also don’t think it’s time for blind optimism.

[Farin]

@Cheesesteak

I think the website is more like an iPhone, if you can’t get it the day of release, you don’t walk away and buy a Droid, you wait for the supply to catch up to demand. People aren’t going to give up on the concept of low cost health care because the website isn’t working for a few weeks.

I have health insurance through my job, but I know that if I didn’t, I’d be on these exchanges like white on rice. If it doesn’t work now, I’ll keep tabs on the topic, and when things seem to clear up, I’m going on. Or… I find another way to tap into the resource, my understanding is that the website is not the only way to buy ACA health care.

The problem is that the exchanges aren’t “low cost health care” by any stretch of the imagination. You can play with the plan rates here. You’ll see that it’s hard to find “low cost” plans for a lot of situations. In fact, with my HSA contribution included, I’m paying half the cost each month through work than I can find on the exchanges.

As I was saying around GD in another thread:

$147 (After-subsidy) cost for a single 27 year old making $25,000 a year is a huge expense. So, if money is tight, what are you going to select? If you are making $25,000 a year and your bring home is roughly $21,250 (15% tax rate) you are working with $1700 a month. Basics of Rent (750), Gas/Electricity(50), Water(50), Car insurance(100), and a cheap car payment(200) brings you to $500 a month. Add in a cell phone(70), internet service(75), and food(200) and you have $155 a month left over, which would probably get used for fuel and small impulse purchases.

This is fairly average. Some places you can get by with paying less, some places you have to squeeze by with paying more. But none of these rates are outrageous. It also neglects anything like credit cards or student loans or anything else that might be afflicting 27 year olds.

So, now, that $155 left over each month has to go for health care. No more driving to work for you! What would you choose if you are 27 and healthy? $1,764/year (plus deductible) for health insurance? Or $250 a year in fines? If you are sick, you’ll pay out. If you are healthy, you won’t. As has been mentioned, the healthy are probably going to drag their asses quite a bit on this just based on cost by itself.