Group items tagged

"Fine. A big group, we can understand the overall risk. We can model that. We're happy. But individuals, we're not so sure, and that's why the individual insurance market, which is a market where Americans who don't get insurance from their employer or the government have to turn, that's why that market is so screwed up all around the country and why we needed the Affordable Care Act.

First, it was not primarily intended to push people to obtain protection for their own good, but to protect others. Like auto damage liability insurance required in most states, our requirement focused on "catastrophic" costs -- so hospitals and taxpayers would not have to foot the bill for the expensive illness or accident of someone who did not buy insurance.

But insurers underestimated how fast medical costs would rise, and how many seniors would actually use the benefits. And they underpriced the insurance premiums. Making matters worse, some insurers that were "hungry for market share" charged too little at first and planned to increase premiums later, says Joseph M. Belth, editor of the Insurance Forum newsletter and professor emeritus of insurance at Indiana University.

Several hospital chains are driving the boom – including HCA Inc., which will open its seventh ER later this year in Florida, and Wake Med Health and Hospitals, which will add its fourth next month in the Raleigh, N.C., metro area. They regard the facilities as a way to expand into new markets, generate admissions to their hospital and reduce crowding at their hospital-based ERs.

reater Houston has 150 emergency rooms — twice the number as greater Miami -- even though its population is only slightly bigger, according to a KHN analysis.

While the ERs charge insurers double or triple the amount per patient as an urgent care center or doctor's office, patients use them for routine care that could be provided in less costly settings, Ho says. That is the case with standard ERs as well. Yet, insured patients have little incentive to drive past the more expensive, freestanding ERs because their co-payment is only $50 or $100, just modestly more than what it might cost for a visit to an urgent care center or doctor’s office. Their insurers pay the balance generally.

A: That’s true. Or that’s a prediction that I believe will be proven true, I should say. Here’s the explanation. The standard theory on making insurance markets is that you want its competition to be continuous. The way to do that is to see that the risk pool of covered lives is a large, stable and ideally relatively health population. I cannot think of a larger, more stable and relatively healthy population, in proportion to the rest of the exchange population, than the Medicaid expansion population. They are systemically younger than the rest of the population. That’s one of the reasons that they're poorer. Our program design is also going to pull out the highest-risk people from the private option and treat them in the traditional Medicaid program because we would have had to supplement for many of their services. (Editor's note: Federal law requires Medicaid premium assistance to 'wraparound' to make sure recipients get the same amount of coverage through private insurance as they would in Medicaid). That’s very hard to do. It’s both care and administratively burdensome. Those individuals, the highest five to 10 percent costly individuals, would be better served in a single program, and by definition that would have to be the traditional Medicaid program.

Medicare covers all those treatment options. By law, it can't consider price when making coverage decisions. Nor can it insist that a new technology be significantly better than existing ones or encourage doctors or patients to seek less-costly alternatives. And once Medicare starts writing checks, private health plans generally follow, distorting the usual market mechanisms, says Arthur Kellermann, a physician and senior policy analyst at Rand Corp.

Another big driver of health-care costs is technology. In almost every other industry, innovation generally makes things more efficient and less costly. But in health care, it often brings higher costs with little added value.

About 7 million people are expected to buy insurance through the marketplaces in the first year. But it's more important to watch who signs up rather than how many. For these new insurance markets to thrive, they'll need to take in more in premiums then they spend on health care, so they need more healthy buyers than sick, economists say.

Even fewer were able to actually apply for coverage. Federal officials declined to provide those figures.

The large number of plans in some places masks the fact that there aren’t that many insurers actually competing. In Miami-Dade County in Florida there are nine insurers selling 137 plans; Florida Blue alone offers 52 of them. Few markets are as competitive as is Miami. Nationwide, 18 percent of counties have only one insurer offering plans and 33 percent of counties have only two insurers competing, the KHN analysis found.

including deductibles, co-payments and which doctors and hospitals are in their networks.