Ask HN: Bootstrapped US founders, who do you use for health insurance? • Hacker News Board

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#111

Post by WillPostForFood » Wed, Jan 11, 2017, 9:01 PM UTC

tptacek wrote: post #108

WillPostForFood wrote: post #107

Earlier quoted context omitted.

In California, for an individual, the ACA is minimally 3 times as much, for substantially less coverage. Pre-ACA, we paid $400 a month for $2000 deductible PPO plan. We now pay $1200 a month for $12,000 deductible PPO, and had to switch doctors. Go check the numbers for a bronze plan (for 3) for yourself: http://www.coveredca.com/ It is ridiculous is to say a good solution to pre-existing conditions and "do-not-cover…

What year, how many people, and what provider? We insured California employees and I have some idea of how much we paid to do it. For instance: are you comparing individual market PPO premiums from 2009 to 2016 ACA individual market PPOs? That 2009 PPO didn't have guaranteed-issue, meaning that your insurer got to cherry pick you out of the population. Your number is a more accurate comparison if it's from the small…

2 adults, 1 child. In 2012 we bought Blue Cross PPO, $2,000 deductible, $400. As ACA approached it crept up a bit, but was still in the $400 range, deductible might have gone to $2500. First year of ACA it jumped to $800, and has gone up quickly since.

Besides the crazy rate hikes, and the massive deductible, it has been constant chaos in terms of plans and doctors. Under ACA we stayed with Blue Cross in year one, then had to switch doctors because they dropped Blue Cross, then Blue Cross dropped their ACA PPO, so we switched to Health Net, then Health Net dropped out of the CoveredCA. Every year december is a time of dread as we wait to see if our plan is changing, going up in price, if our doctors are still going to take insurance. We are thankfully all healthy, but it has created a huge stressor where there was none before.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#112

Post by WillPostForFood » Wed, Jan 11, 2017, 9:13 PM UTC

tptacek wrote: post #110

WillPostForFood wrote: post #109

Earlier quoted context omitted.

Look at the data then - ACA plans are going up 22% in just this year . And that doesn't account for the skyrocketing deductibles that effectively make the plans worthless except for catastrophic illness. It may have bailed out a some people with pre-existing conditions, but in totality, it isn't a money saver, it is crushing people that have to buy individual plans, and that's not an anecdote, it is clear from the da…

Non-ACA plans went up by a comparable amount in the years just prior to ACA; that was one of the reasons the ACA had the urgency it did at the time. Our Non-HDHP non-HSA-qualifying premiums today are more expensive, but not nearly twice as expensive, as the small group market was in 2009. But the trajectory we were on prior to the ACA was double-digit annual premium increases, so it's tough to say how much of that is…

2 points. First, yes, plans started to go up before ACA, in anticipation of ACA. Second, when a plan went up 20% in 2012, it might have been an $80 hike. Now in 2017 when it goes up 20% it is an extra $240 a month. So even if the rate of increase is similar, the pain it causes is not, especially contrasted with stagnant wages.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#113

Post by tptacek » Wed, Jan 11, 2017, 9:57 PM UTC

WillPostForFood wrote: post #112

tptacek wrote: post #110

Earlier quoted context omitted.

Non-ACA plans went up by a comparable amount in the years just prior to ACA; that was one of the reasons the ACA had the urgency it did at the time. Our Non-HDHP non-HSA-qualifying premiums today are more expensive, but not nearly twice as expensive, as the small group market was in 2009. But the trajectory we were on prior to the ACA was double-digit annual premium increases, so it's tough to say how much of that is…

2 points. First, yes, plans started to go up before ACA, in anticipation of ACA. Second, when a plan went up 20% in 2012, it might have been an $80 hike. Now in 2017 when it goes up 20% it is an extra $240 a month. So even if the rate of increase is similar, the pain it causes is not, especially contrasted with stagnant wages.

No, I'm sorry, but that's simply not true. Plans were going up for years. In almost a third of all years in the ten years prior to ACA, California saw double digit growth in its guaranteed-issue small group market.

Also, there's no mechanism by which plans go up by double digits "in anticipation of" the ACA.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#114

Post by tptacek » Wed, Jan 11, 2017, 10:01 PM UTC

WillPostForFood wrote: post #111

tptacek wrote: post #108

Earlier quoted context omitted.

What year, how many people, and what provider? We insured California employees and I have some idea of how much we paid to do it. For instance: are you comparing individual market PPO premiums from 2009 to 2016 ACA individual market PPOs? That 2009 PPO didn't have guaranteed-issue, meaning that your insurer got to cherry pick you out of the population. Your number is a more accurate comparison if it's from the small…

2 adults, 1 child. In 2012 we bought Blue Cross PPO, $2,000 deductible, $400. As ACA approached it crept up a bit, but was still in the $400 range, deductible might have gone to $2500. First year of ACA it jumped to $800, and has gone up quickly since. Besides the crazy rate hikes, and the massive deductible, it has been constant chaos in terms of plans and doctors. Under ACA we stayed with Blue Cross in year one, th…

Did you buy your Anthem PPO on the individual market, or through a small group insurer along with your peers in a startup? Again: the California individual PPO marketplace wasn't community-rated and didn't have guaranteed issue; you would be making an apples/oranges comparison to ACA. The small group market, on the other hand, had many (but not all) of ACA's regulatory changes already, and it had been seeing double digit premium growth for a decade.

It's not interesting to look at the individual marketplace pre-ACA, because insurers had so many tools to avoid providing benefits to claimants: they could not only simply refuse to provide insurance for anyone associated with a very long list of "conditions", but also had recission powers to retroactively refuse coverage, and had both annual and lifetime coverage caps to minimize their liability to consumers.

It's worth noting that in some states, my own state of Illinois included, the crappy pre-ACA individual market still exists: you can buy a non-ACA-compliant individual market plan, for less money than is offered on the exchange. Of course, you're subjecting yourself to 2009 insurance market norms by doing so.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#115

Post by WillPostForFood » Thu, Jan 12, 2017, 6:50 AM UTC

tptacek wrote: post #114

WillPostForFood wrote: post #111

Earlier quoted context omitted.

2 adults, 1 child. In 2012 we bought Blue Cross PPO, $2,000 deductible, $400. As ACA approached it crept up a bit, but was still in the $400 range, deductible might have gone to $2500. First year of ACA it jumped to $800, and has gone up quickly since. Besides the crazy rate hikes, and the massive deductible, it has been constant chaos in terms of plans and doctors. Under ACA we stayed with Blue Cross in year one, th…

Did you buy your Anthem PPO on the individual market, or through a small group insurer along with your peers in a startup? Again: the California individual PPO marketplace wasn't community-rated and didn't have guaranteed issue; you would be making an apples/oranges comparison to ACA. The small group market, on the other hand, had many (but not all) of ACA's regulatory changes already, and it had been seeing double d…

I disagree with almost every assertion you are making, and I'm not sure I have the time or energy to respond anymore. But let me just say this, the individual market pre-ACA had choice, offered real value, was cheaper, had lower deductibles, and had more doctor choice. So if 3x price increase and huge deductibles was somehow still a net in for you, congrats, but it came at a huge price for a lot of other people, and I'll celebrate the upcoming repeal of the ACA.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#116

Post by WillPostForFood » Thu, Jan 12, 2017, 7:00 AM UTC

tptacek wrote: post #113

WillPostForFood wrote: post #112

Earlier quoted context omitted.

2 points. First, yes, plans started to go up before ACA, in anticipation of ACA. Second, when a plan went up 20% in 2012, it might have been an $80 hike. Now in 2017 when it goes up 20% it is an extra $240 a month. So even if the rate of increase is similar, the pain it causes is not, especially contrasted with stagnant wages.

No, I'm sorry, but that's simply not true. Plans were going up for years. In almost a third of all years in the ten years prior to ACA, California saw double digit growth in its guaranteed-issue small group market. Also, there's no mechanism by which plans go up by double digits "in anticipation of" the ACA.

"Plans were going up for years" - yes, but not as much they went up after ACA.

"[a]cross all states, from before the reform to the first half of 2014, enrollment-weighted premiums in the individual health insurance market increased by 24.4 percent beyond what they would have had they simply followed state-level seasonally adjusted trends.”

And the rate increase is 49% if you don't weight enrollment, which is a better indicator of individual impact.

https://www.brookings.edu/wp-content/uploads/2016/07/Fall201...

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#117

Post by tptacek » Thu, Jan 12, 2017, 1:04 PM UTC

WillPostForFood wrote: post #116

tptacek wrote: post #113

Earlier quoted context omitted.

No, I'm sorry, but that's simply not true. Plans were going up for years. In almost a third of all years in the ten years prior to ACA, California saw double digit growth in its guaranteed-issue small group market. Also, there's no mechanism by which plans go up by double digits "in anticipation of" the ACA.

"Plans were going up for years" - yes, but not as much they went up after ACA. "[a]cross all states, from before the reform to the first half of 2014, enrollment-weighted premiums in the individual health insurance market increased by 24.4 percent beyond what they would have had they simply followed state-level seasonally adjusted trends.” And the rate increase is 49% if you don't weight enrollment, which is a better…

Again, you're comparing the pre-ACA California individual insurance market, in which insurers could (and actively did) simply refuse coverage to anyone they might have to provide services to, to the post-ACA California individual insurance market in which they couldn't.

The correct comparison is to the California small group market, which prior to the ACA also had guaranteed issue. The small group market covered companies with low single digit numbers of employees and approximates the ACA individual market (less the adverse selection of people without benefits-providing employers). In that market, the price trends before and after the ACA are broadly comparable.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#118

Post by tptacek » Thu, Jan 12, 2017, 1:11 PM UTC

WillPostForFood wrote: post #115

tptacek wrote: post #114

Earlier quoted context omitted.

Did you buy your Anthem PPO on the individual market, or through a small group insurer along with your peers in a startup? Again: the California individual PPO marketplace wasn't community-rated and didn't have guaranteed issue; you would be making an apples/oranges comparison to ACA. The small group market, on the other hand, had many (but not all) of ACA's regulatory changes already, and it had been seeing double d…

I disagree with almost every assertion you are making, and I'm not sure I have the time or energy to respond anymore. But let me just say this, the individual market pre-ACA had choice, offered real value, was cheaper, had lower deductibles, and had more doctor choice. So if 3x price increase and huge deductibles was somehow still a net in for you, congrats, but it came at a huge price for a lot of other people, and…

It did none of those things. It was cheaper and had lower deductibles for young families with practically no prior exposure to the health system. But if you were older, or were a woman who had ever seen a reproductive health specialist, or had at any point in your past had an unexplained seizure, or had reported any of a constellation of 10 different symptoms predictive of a future diabetic condition (and so and so forth), the California individual market provided literally no value at all, because you were locked out of it: insurance wasn't available to you outside the group market at any price.

It's easy for insurers to provide incredibly cheap premiums when they can exclude broad classes of customers on the suspicion that they will in the future make claims.

It's also easy for insurers to provide incredibly cheap premiums when they can quietly impose low annual and lifetime caps on coverage, which they could and did before the ACA.

It's also easy for insurers to provide those cheap premiums when they can re-evaluate your coverage and rescind it retroactively when you're diagnosed with a chronic condition, which they could and did before the ACA.

My point is simple: you're not comparing apples and oranges. You need to compare the small group market to the post-ACA individual market if you want to compare like with like. The system you're comparing it to now was exploiting consumers; you were a beneficiary of it, I agree, but your benefits came at others expense.

More importantly, though, outside the moral dimension: as soon as you got your company off the ground and had to begin providing for employees, you'd have found yourself in the same situation you are now: with annual double digit increases in premiums. Because that's where most of us were prior to the ACA.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#119

Post by hundt » Thu, Jan 12, 2017, 3:14 PM UTC

tptacek wrote: post #118

WillPostForFood wrote: post #115

Earlier quoted context omitted.

I disagree with almost every assertion you are making, and I'm not sure I have the time or energy to respond anymore. But let me just say this, the individual market pre-ACA had choice, offered real value, was cheaper, had lower deductibles, and had more doctor choice. So if 3x price increase and huge deductibles was somehow still a net in for you, congrats, but it came at a huge price for a lot of other people, and…

It did none of those things. It was cheaper and had lower deductibles for young families with practically no prior exposure to the health system. But if you were older, or were a woman who had ever seen a reproductive health specialist, or had at any point in your past had an unexplained seizure, or had reported any of a constellation of 10 different symptoms predictive of a future diabetic condition (and so and so f…

One thing I wonder about ACA: it seems like the young/healthy who bought their own insurance have had their premiums go way up compared to before (and also they are penalized if they don't buy insurance, so presumably more of them buy it now), and I haven't heard about any large groups of people whose premiums went down.

So, more money is going into the system than before. Where is the extra money going? Here are the possibilities I can think of:

- Better health outcomes for the previously uninsured or uninsurable. This would be the case if the previously uninsured just didn't get useful medical care before ACA, and now they do. In this case we might see longer life expectancy, increased happiness, or some other improved health care outcome.

- Less money out of the pockets of the previously uninsured. This would be the case if the previously uninsured used to get the medical care they needed anyway, but had to pay a lot for it. In this case we might see, for example, fewer medical bankruptcies.

- More profits for insurance companies or medical service providers. This could be the case if providers were directly or indirectly subsidizing the previously uninsured when they couldn't pay their bills. (If this is true I'm assuming they didn't simply pass the costs on to the previously insured, because that should have resulted in a lot of people's premiums going down after ACA, and apparently that didn't happen.)

Do you have a sense of whether these things have happened, or do you expect them to happen in the future? Or maybe I missed some other possibility.

Re: Ask HN: Bootstrapped US founders, who do you use for health insurance?

#120

Post by samaritan1 » Thu, Jan 12, 2017, 3:31 PM UTC

brianwawok wrote: post #96

vyrotek wrote: post #77

Earlier quoted context omitted.

This is definitely a starting to become a popular option. I had just commented over in another thread about it https://news.ycombinator.com/item?id=13356900 It's pretty affordable and the nicest part is most of these health shares are ACA exempt so you don't get hit by the fine of not having "normal" insurance. Do you use a Direct Primary Health provider to cover normal doctor visits and things? I'm a fan.

Are there ones not run by religion? The health sharing plans I have seen require such things as belonging to a certain church and not drinking any alcohol.

I think they're all Christian, but I don't know any that require belonging to a specific church or totally abstaining from alcohol. I think they do all ban smoking habitually and getting drunk, though. And they all have a broad statement of faith and require participating in some kind of regular church/spiritual community.