Iowa asks to rewrite Affordable Care Act rules to prop up its insurance exchange

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Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  
That's the problem with healthcare though. Unless someone has insurance, when you ask the question: "What's a reasonable price to pay for x medical service?" The answer is simply approximately tree fiddy million. 

Basically, it's like people going into a car dealership wanting to buy cars and the car seller gets to pick what price they pay. Of course you're going to sell them a Toyota Camry for $60,000 because that's what THEY (the seller) perceive it to be worth (And I'm sure there's absolutely NO bias there). It's completely bass ackwards.

cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

Wouldn't a simpler solution be to move the 1 person costing $1mil a month to a neighboring state? Give his family $2million if they leave and go to Illinois?

Stubtify said:   Wouldn't a simpler solution be to move the 1 person costing $1mil a month to a neighboring state? Give his family $2million if they leave and go to Illinois?
  their condition is too critical to move them

JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

 Do you really think that the nation should pay that much for a single person? I don't think there is any way possible for that to work. 

cloose said:   
rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

 Do you really think that the nation should pay that much for a single person? I don't think there is any way possible for that to work. 

  you mean 4 cents a person a year?

rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

But it wouldn't be evenly distributed.  Only adults (> 26???) that can "afford" it would be obligated to pay.   

rufflesinc said:   
cloose said:   
rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

 Do you really think that the nation should pay that much for a single person? I don't think there is any way possible for that to work. 

  you mean 4 cents a person a year?

  
I get that this is a very touchy topic, but it's a discussion that every health care system (public, private, single payer, multiple payer, etc.) needs to have (except systems that are purely pay to play, with no insurance component.  Resources are finite, and the real question is "what ELSE could we do with $12M/year?"  The UK's NHS uses QALYs (Quality-Adjusted Life Years) to assess treatments (basically, number of years the treatment will extend life, times a multiplier of the quality of those years).  So, a drug that will allow a patient with terminal cancer to live another few weeks in the ICU would have a very low QALY score, while something like the measles vaccine would have an extremely high score.  Then, then look at cost per QALY, and decide "we'll pay for X, but we won't pay for Y."  Given that, by most metrics (risk premia for more dangerous jobs, for example), Americans value their lives at around $6M, does it really make sense to spend 2x that every year on a single individual?  Or should we spend it on (pulling stuff out of a hat) prenatal care, pap smears/cancer screening, childhood nutrition, etc. etc.

cestmoi123 said:   
rufflesinc said:   
cloose said:   
rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

 Do you really think that the nation should pay that much for a single person? I don't think there is any way possible for that to work. 

  you mean 4 cents a person a year?

  
I get that this is a very touchy topic, but it's a discussion that every health care system (public, private, single payer, multiple payer, etc.) needs to have (except systems that are purely pay to play, with no insurance component.  Resources are finite, and the real question is "what ELSE could we do with $12M/year?"  The UK's NHS uses QALYs (Quality-Adjusted Life Years) to assess treatments (basically, number of years the treatment will extend life, times a multiplier of the quality of those years).  So, a drug that will allow a patient with terminal cancer to live another few weeks in the ICU would have a very low QALY score, while something like the measles vaccine would have an extremely high score.  Then, then look at cost per QALY, and decide "we'll pay for X, but we won't pay for Y."  Given that, by most metrics (risk premia for more dangerous jobs, for example), Americans value their lives at around $6M, does it really make sense to spend 2x that every year on a single individual?  Or should we spend it on (pulling stuff out of a hat) prenatal care, pap smears/cancer screening, childhood nutrition, etc. etc.

  Well this person obviously isn't dead yet so ...

cestmoi123 said:   
rufflesinc said:   
cloose said:   
rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he... 

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

 Do you really think that the nation should pay that much for a single person? I don't think there is any way possible for that to work. 

  you mean 4 cents a person a year?

  
I get that this is a very touchy topic, but it's a discussion that every health care system (public, private, single payer, multiple payer, etc.) needs to have (except systems that are purely pay to play, with no insurance component.  Resources are finite, and the real question is "what ELSE could we do with $12M/year?"  The UK's NHS uses QALYs (Quality-Adjusted Life Years) to assess treatments (basically, number of years the treatment will extend life, times a multiplier of the quality of those years).  So, a drug that will allow a patient with terminal cancer to live another few weeks in the ICU would have a very low QALY score, while something like the measles vaccine would have an extremely high score.  Then, then look at cost per QALY, and decide "we'll pay for X, but we won't pay for Y."  Given that, by most metrics (risk premia for more dangerous jobs, for example), Americans value their lives at around $6M, does it really make sense to spend 2x that every year on a single individual?  Or should we spend it on (pulling stuff out of a hat) prenatal care, pap smears/cancer screening, childhood nutrition, etc. etc.

  
cloose said:   "Do you really think that the nation should pay that much for a single person?"

cestmoi123 said:   "Resources are finite, and the real question is "what ELSE could we do with $12M/year?"

Both of you are are really effing idiots advocating for death panels!!!   What if it was your child??? Going to pull the plug are you????????????????????????

Yes, the country should and resources are NOT finite!

What the both of you fail to grasp is that Øbamacare was designed to fail.






 

Removing risk corridors didn't help.

The plan was always to fix issues with the law as they came up. The problem is that the opponents don't agree to the basic argument that healthcare works best when everyone has coverage. Stalemate has ensued.

LOOPHOLE, there's a lot of sensible debate on this topic. But there's none about whether resources - of any kind - are finite or not.

rufflesinc said:   
JepJepJep said:   
cestmoi123 said:   Iowa's got the extra problem of a relatively small exchange pool, and one pool member whose bills are running $1 million. Per month.

http://www.desmoinesregister.com/story/news/health/2017/05/31/he...

  $12,000,000 a year / 30,000 person on the Iowa exchange = an extra $400 for each person.

  but only $0.04 per person if distributed across the whole country

But then there are supposed to be 20,000 hemophiliacs in the country.
My life is not worth $12 million a year.

LOOPHOLE said:   
  if he were my child, I'd say (to the insurer), "Give me $12M cash, right now, and I'll let him be euthanized.  He'll probably live another 5-7 years. So his early demise saves your company tens of millions of dollars, even after accounting for my incentive."

There's something wrong with this picture. Hemophilia is million a year, not a million a month.

LOOPHOLE said:   
Both of you are are really effing idiots advocating for death panels!!!   What if it was your child??? Going to pull the plug are you????????????????????????

Yes, the country should and resources are NOT finite!

What the both of you fail to grasp is that Øbamacare was designed to fail.

 

If it were my child, I'd want them to do whatever possible, to hell with the cost.  I'd also like to have around the clock police protection on my house, a team of tutors with Ivy League PhDs for my child in every subject, and so on.  I'm biased - I would hope every parent is.  

So you say resources aren't finite?  Great, good to know.  Kids are clearly safer in new vehicles with advanced safety systems, and properly installed carseats.  So, there's no reason we can't give a brand-new top of the line Volvo to every family with kids, and provide a certified carseat technician available 24/7 to ensure that the child is correctly strapped in before every trip.  Right?

The ACA was designed to fail?  How, pray tell?  Certainly, it's being actively sabotaged by the administration at the moment, who don't want it to succeed, and it's far from perfect, but who designed it to fail, and why?

scrouds said:   There's something wrong with this picture. Hemophilia is million a year, not a million a month.
  
Apparently, it varies a lot by patient, and this is an extreme case.  The speculation is that he's got serious factor resistance, and they're giving him massive doses in an effort to overcome that.  

woworanger said:   
LOOPHOLE said:   
 

  if he were my child, I'd say (to the insurer), "Give me $12M cash, right now, and I'll let him be euthanized.  He'll probably live another 5-7 years. So his early demise saves your company tens of millions of dollars, even after accounting for my incentive."

  did not see this coming

cestmoi123 said:   
 
So you say resources aren't finite?  Great, good to know.  Kids are clearly safer in new vehicles with advanced safety systems, and properly installed carseats.  So, there's no reason we can't give a brand-new top of the line Volvo to every family with kids, and provide a certified carseat technician available 24/7 to ensure that the child is correctly strapped in before every trip.  Right?

 

  or just have NIHTSA mandate those features in all new cars

rufflesinc said:   
cestmoi123 said:   
 
So you say resources aren't finite?  Great, good to know.  Kids are clearly safer in new vehicles with advanced safety systems, and properly installed carseats.  So, there's no reason we can't give a brand-new top of the line Volvo to every family with kids, and provide a certified carseat technician available 24/7 to ensure that the child is correctly strapped in before every trip.  Right?

 

  or just have NIHTSA mandate those features in all new cars

  Not sure if you're being serious.  If you are, then there's again a tradeoff - require the expensive safety features, and you make it harder for people to buy new cars.  Apart from the underlying "should people be required to have that level of safety," you'll end up with people keeping older cars (which are less safe) longer, so there's an unintended consequences issue.  NHTSA absolutely looks at the cost/benefit of requiring features when they set automobile standards.  

Like 123 said Iowa has a small population pool problem - but higher density areas don't. This problem need to be addressed.

I was once told you rack up 50% of your total lifetime medical cost in the last six months of your life.

Please. Let me die six months eailer and save me that 50%. I would have rather have spent six months in my 20s living on a boat in the Mediterranean Sea doing hookers and blow.

wilesmt said:   I was once told you rack up 50% of your total lifetime medical cost in the last six months of your life.

Please. Let me die six months eailer and save me that 50%. I would have rather have spent six months in my 20s living on a boat in the Mediterranean Sea doing hookers and blow.

  
This. Not so much in my 20's though. I hope to go quickly and in the least expensive and painful way. 

Why like 3 more months if it's living on a bed embarrassingly taking dumps that nurses have to clean up after, etc...? I'm the same way as far as my funeral. Nothing fancy, least expensive. No grave-site rentals or anything - cremation and put it in a solo cup for all I care.

scrouds said:   There's something wrong with this picture. Hemophilia is million a year, not a million a month.
  It's a rare case, I read some of the details on Bloomberg but the identity of the family is kept confidential for obvious reasons.

I see Loophole's rant above but at the same time, he offered absolutely zero solution.  As technology gets better, this scenario will become more prevalent and we need more rational discussion on it.  Everyone can simply declare that a live is priceless, until the price figure reaches a certain point, until they realized the opportunity cost is that other lives are threatened.  In essence, it's a "Runaway Trolley Problem"

wilesmt said:   I was once told you rack up 50% of your total lifetime medical cost in the last six months of your life.

Please. Let me die six months eailer and save me that 50%. I would have rather have spent six months in my 20s living on a boat in the Mediterranean Sea doing hookers and blow.

  
It's been suggested.  The general response is a very strong "ick."  Personally, I think it's a great idea.

http://freakonomics.com/podcast/are-you-ready-for-a-glorious-sun...

"A Stanford University study shows almost 90 percent of doctors would forgo resuscitation and aggressive treatment if facing a terminal illness."

http://www.npr.org/sections/health-shots/2015/07/06/413691959/kn...

cestmoi123 said:   
wilesmt said:   I was once told you rack up 50% of your total lifetime medical cost in the last six months of your life.

Please. Let me die six months eailer and save me that 50%. I would have rather have spent six months in my 20s living on a boat in the Mediterranean Sea doing hookers and blow.

  
It's been suggested.  The general response is a very strong "ick."  Personally, I think it's a great idea.

http://freakonomics.com/podcast/are-you-ready-for-a-glorious-sun...

  I guess the problem (in some cases anyways) is determining in advance that you really only have an extra six months with treatment.  It's much easier to see it after the fact.  It's like the nonsense phrase "that thing I lost is ALWAYS in the LAST place I look!".

Sure, if they can't figure out what's wrong and run out of tests or multiple treatments don't work, you'll die and be spending the most on medical care at the end vs the years you never even went in for an annual checkup.  Or maybe you went in and it was fully treatable and the first treatment (or second, etc) worked as well as possible, so the "costs" were not as high and you also don't die so they don't count in the equation to lower the average "costs in the last 6 months".

The discussion reminds me of the Star Trek TNG Episode "Half a Life" where a planet has a ritual euthanasia of all people when they turn 60 years old.

New medical discoveries are expensive, and yes, resources are not finite. The cost of these advances is driven down over time as long as the cost to create them is recouped. There is still private insurance in countries with single payer so I think there will always need to be private insurance here too.

Are there cures out there that unlimited money could find? I'm sure there are.

Is $1m a month too much to spend on a person's life? Everyone would answer "NO" if it was their own kid. So let's act as if it is our own kid. I honestly don't think it is fair to point to that one person as a failure of the system.

How many $1m a month patients are on group coverage through an employer? Oh that's not a political hot potato so we won't discuss that. Are we going to keep pointing to sick people and say that they're the problem and the reason insurance is so expensive?

Just a depressing morning of news so I had to vent.

Stubtify said:   Is $1m a month too much to spend on a person's life? Everyone would answer "NO" if it was their own kid. So let's act as if it is our own kid.

 

  
What about $1 billion a month?  What about $1 trillion?  The problem is, the anger towards people who think we should pull the plug on the $1 million a month kid is faux outrage.  Unless you are willing to spend a trillion dollars a month to save a single life, you're not taking a stand that every life should be saved no matter the cost.  Whether it is $1, $12, $25, or $100 million per year to save a life isn't the point, at some price EVERY SINGLE person is going to say pull the plug even if they won't admit to it - we're arguing money and utility, not ethics.

Realistically though, you could just as easily use the "your own kid" argument to justify $1 billion a month, which would obviously be both impossible and ridiculous to actually pay. In a society with finite resources, there is a level at which you must just say "Enough, I'm very sorry, but that's it."

wilesmt beat me to it, but we agree. A reasonable limit must be set.

Stubtify said:   
Is $1m a month too much to spend on a person's life? Everyone would answer "NO" if it was their own kid. So let's act as if it is our own kid. I honestly don't think it is fair to point to that one person as a failure of the system.

 

  What is the actual percent of people that would require $1m a month? If it is only 0.00001% or something, then by denying coverage that only costs 4 cents a year per person , you're basically killing them for losing the perverse lottery
 Whether it is $1, $12, $25, or $100 million per year to save a life isn't the point, at some price EVERY SINGLE person is going to say pull the plug even if they won't admit to it - we're arguing money and utility, not ethics.
What number do you think that is?

wilesmt said:   
Stubtify said:   Is $1m a month too much to spend on a person's life? Everyone would answer "NO" if it was their own kid. So let's act as if it is our own kid.

 

  
What about $1 billion a month?  What about $1 trillion?  

  what medical treatment costs $1T a month?

wilesmt said:   
Stubtify said:   Is $1m a month too much to spend on a person's life? Everyone would answer "NO" if it was their own kid. So let's act as if it is our own kid.

 

  
What about $1 billion a month?  What about $1 trillion?  The problem is, the anger towards people who think we should pull the plug on the $1 million a month kid is faux outrage.  Unless you are willing to spend a trillion dollars a month to save a single life, you're not taking a stand that every life should be saved no matter the cost.  Whether it is $1, $12, $25, or $100 million per year to save a life isn't the point, at some price EVERY SINGLE person is going to say pull the plug even if they won't admit to it - we're arguing money and utility, not ethics.

  
Agreed.  It's like that old joke:  Ugly man walks up to gorgeous woman in a bar, says "hello, will you sleep with me?"  She immediately says "no!"  He then asks "will you sleep with me for $1 million?"  She pauses, and then agrees.  He then asks "will you sleep with me for $20?"  She yells "what do you think I am?"  To which he responds "we've already established what you are, now we're just negotiating price."

People who say something is priceless, or you can't put a price on something, are either lying to themselves or to you.  

"How much is a life worth" is a false question.

When asking that question, you assume that the government, or the insurance company, has an unquestioned responsibility to pay for your healthcare irrespective of the cost - at par with other basic constitutional freedoms like free speech etc.

I don't think that is a valid, or even tenable position.

Any "insurance", or single payer setup is simply a contractual agreement governing payments received and payments paid out. There should be mathematical formula governing the outflow to the inflow - period! e.g. "you want QALY to be increased to 80k/year? Fantastic - petition for another 2% tax increase!". Or "medical cost inflation eats up 2% of the taxes now. Petition for 2% tax increase unless you are fine with a 20k QALY score decrease dictated by the formula."

"How much is a life worth" is suitable only for the person himself, or his loved ones to ponder upon, and action on! If a Forbes list person wants to spend 1 billion/month for someone's life - that should be his/her choice, but never an obligation!

See - it's not only the conservative ideology that is dangerous!
Liberal ideology (which can give rise to these kids of false questions in the first place) can be even more dangerous and mathematically untenable!!

LOOPHOLE said:   
Both of you are are really effing idiots advocating for death panels!!!   What if it was your child??? Going to pull the plug are you????????????????????????

Yes, the country should and resources are NOT finite!
 

Nobody can be objective with their kids or family members. You cannot base a serious discussion on stuff that's too close to home though. But there are many discussions to be had on what kind of healthcare we want and what are we ready to pay for it. Per capita, Americans spend roughly double that of any other country on healthcare per year. Yet our life expectancy is falling. There are probably multiple reasons why we're spending way more for less desirable outcomes, not all connected purely to healthcare, but discussions on the value proposition of paying millions for extending the life of terminally-ill patients by a few weeks is certainly one to be had.

all that aside, can I interest you into a small gofundme project to pay for my retirement, my house, my kids education, my medical bills going forward, and ongoing reasonable expenses, etc? Shouldn't be a problem if your resources are infinite but it'd help me a bunch (since mine sadly aren't). Thanks.  

puddonhead said:   
Any "insurance", or single payer setup is simply a contractual agreement governing payments received and payments paid out. There should be mathematical formula governing the outflow to the inflow - period! e.g. "you want QALY to be increased to 80k/year? Fantastic - petition for another 2% tax increase!". Or "medical cost inflation eats up 2% of the taxes now. Petition for 2% tax increase unless you are fine with a 20k QALY score decrease dictated by the formula."

 

  not everyone will have that same cost. Some people will never get sick, some people will draw the short stick and need $1M a month in care.  If only a few people in the whole country end up needing that level of care, then it is only a few pennies for each person

Skipping 20 Messages...
Health insurer Medica announced it will file with regulators to sell individual insurance statewide in Nebraska under the ACA.

Additionally, health insurer Centene announced it will enter Kansas, Missouri and Nevada in 2018, while expanding its presence in Florida, Georgia, Indiana, Ohio, Texas and Washington.

Oscar Health and Medica both announced they would join Centene in launching individual products in other states where other insurers have left public exchanges under the ACA. Perhaps Iowa?



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