The Glade 4.0

One of the worst parts of the ACA is that the underwriters cannot adjust rates for such occurrences.

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But at the same time their combined ratios are hard-capped at .90 right?

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Pretty much; like DFK! and I keep saying ...

Obamacare simply forces us into a state where the US has to transition to a single payer system.

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So one by one the private insurers are phased out because of the inability to price adequately for risks.

In the meantime we as consumers become accustomed to paying more out of pocket (or accepting worse care) due to price-fixing.

But why prevent employers from dumping people into the exchanges? That would theoretically speed the cycle up.

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Hopwin:

They are going to retroactively fine the employers who already dumped their employees to the exchanges. This is a straight up money grab and indicative of this administration's continued hostility toward free enterprise.

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I didn't make any claim about gouging. Before the law change, insurers had to pay this amount. Now, they don't. They still can do so if they want. If market forces cause them not to pay, and this nonpayment drives providers out of business, then it was the government removing a restriction on insurers that caused the bankruptcies. You can't spin this any other way, regardless of what the rest of the ACA does.

Say that the ACA doesn't exist, and neither does this just removed requirement. Wouldnt insurers also not pay the difference in that case? What does the ACA do that makes it different? Medicare still exists either way. In either case, the providers aren't getting paid and are going out of business.

But, Xeq, it's the government's price fixing that's establishing what is considered "reasonable," not any market forces.

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"Aaaah! Emotions are weird!" - Amdee
"... Mirrorshades prevent the forces of normalcy from realizing that one is crazed and possibly dangerous. They are the symbol of the sun-staring visionary, the biker, the rocker, the policeman, and similar outlaws." - Bruce Sterling, preface to Mirrorshades

Its not price fixing if paying out at that price isn't mandatory. Insurers aren't required to conform to reference pricing. They can pay out more if they choose. In the absence of government rules, why wouldn't they pay out as little as possible? What in that case would suddenly cause them to pay out more?

They can "get away with" paying out less because there's this notion that they're paying a "reasonable" price.

If I told you I'd pay for the first $5 of your prescription eyeglass frames, but anything more than that was out of pocket because you were obviously getting "designer" brands, you wouldn't think much of my insurance and would reject it out of hand.

If the government had been perpetrating for years the notion that frames are really only worth $5 and the rest was greed-driven profiteering on the part of the manufacturers, and forcing those manufacturers to sell my glasses-for-the-poor programs those frames for $5, suddenly the ludicrous notion that they're only worth $5 is much easier to get the public to accept without backlash for the insurer, right?

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"Aaaah! Emotions are weird!" - Amdee
"... Mirrorshades prevent the forces of normalcy from realizing that one is crazed and possibly dangerous. They are the symbol of the sun-staring visionary, the biker, the rocker, the policeman, and similar outlaws." - Bruce Sterling, preface to Mirrorshades

But the thing is, even without the ACA, Medicare would still exist. And so would the reference price list. If it's all about psychology, why couldn't the insurers just match their payout to that list regardless and then insist the price is fair? All that was preventing them from doing so was the regulation that was just repealed. Logically, that means that at least some of the government regulation of health care must be having a positive effect.

No, no, no, no, no.

That's not how it works; that's not how it worked before the ACA.


Prior to the ACA

You go to a health care provider for some procedure, consult, diagnosis, lab work, or other legitimately medical purpose. They send you a bill. Let's say it was $200. It then gets filed with your insurance. Your insurance reviews it, looks at the current regional Medicare/Medicaid Reference Price formulary sheet for that bit of health care, determines how much to pay the service provider, and then sends you a letter.

If the Medicare/Medicaid Reference Price was $20, and you paid a $20 copay, your insurance tells the doctor to stuff it; he is legally prevented from collecting the rest of the money ($180 in this case), regardless of how much it cost your service provider to perform the procedure. If the Medicare/Medicaid Reference Price was $100 and you paid a $20 copay, the insurance company reimburses the provider $80 and tells him to stuff it on the remaining $100.

After the ACA

None of the above changes with respect to your insurances, except since the Exchanges are national, major metropolitan centers can now be referenced against rural West Virginia or low cost markets when determining what is "reasonable and customary." And, now, your doctor can turn around and tell you, "Well, your insurance only paid $0.00. Where's my other $180.00?"

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Right so the solution that presents itself is to get rid of medicare not to foster the same bad policies medicare has (and thus the bad consequences) but to remove other things we know are bad.

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"...but there exists also in the human heart a depraved taste for equality, which impels the weak to attempt to lower the powerful to their own level and reduces men to prefer equality in slavery to inequality with freedom." - De Tocqueville

Are you saying that Blue Cross, CIGNA, Kaiser, and the rest didn't each have their own price sheets and negotiated rates with major providers? That they all just looked up whatever Medicare paid and made the same payment? If that was the case, then why would "in-network" vs "out-of-network" matter?

In-network and out-of-network matter, because that tells you which physicians and institutions you can use under their plans. Out-of-network basically means that's not an approved service provider and they can rake you over the coals for violating your agreement with the insurance provider. And they might negotiate price sheets lower than Medicaid/Medicare for extremely large group plans, but they never pay more than Uncle Sam would for a procedure.

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Uhm, if this is the case, what is the original article even about? It says that "Obama just gave the go-ahead for reference pricing". Now you say they've been doing that all along? So what you're saying is that the only real difference between the health care here and the health care over in Europe is that over here the prices are fixed somewhat higher than they are over there?

Second, doesn't this only apply to providers that actually accept Medicare? I was under the impression that stuff like this was caused by Medicare's "equal pay for equal service" provisions that don't apply to doctors that don't accept it.

Also, if they've been doing this all along, how is the change going to drive providers out of business? It seems like providers being able to go after the patient for unpaid bills would net them a lot of money, especially if they're allowed to attempt to collect on the utterly absurd and fictional amounts they claim when they send you the first statement.