Depending on stability of ACA marketplace for next 8 years?

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curmudgeon
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Depending on stability of ACA marketplace for next 8 years?

Post by curmudgeon »

I know this can be a touchy subject that easily gets into politics, please try to stay on the narrow topic if possible (I'll understand if mods feel the need to lock the thread).

One of the big challenges for early retirement when you don't have a company retiree medical plan is figuring out what to do for medical insurance. On the surface, ACA is a great boon in this regard, removing a number of major issues around pre-existing conditions and medical underwriting. TANSTAAFL applies as always, of course, so there are a number of significant concerns around where rates are going, and what may happen over the next few years. The article linked below expresses some of my concerns fairly well; it puts more focus on the negative outcomes, but those are the ones I need to worry about.

http://www.bloomberg.com/view/articles/ ... -exchanges

In my current HCOL area, I expect the exchanges are reasonably viable, and though the costs may get ugly over the next few years I could personally probably manage our income in ER to keep enough subsidy to cushion the costs. The problem is that we are considering a move to a MCOL area which has less competition in healthcare and much less current availability in ACA plans; I really don't like the prospect of becoming hostage to a single provider if more insurers exit from the area.

I guess the question implicit in this is - If you have been using ACA (or tracking the plans closely), especially if you live away from a major metro area, what are the trends you are seeing in terms of provider networks, plan competition, and costs? Are there reasons why you think things will get better or worse in this regard over the next few years? Please try to stay away from the question of what congress or the next administration will do; stick to the law as it currently exists.
fpr4
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by fpr4 »

I wish we could just outlaw employer provided health insurance. People would scoff if someone suggested employers providing car or home insurance.
radiowave
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by radiowave »

The answer you are looking for depends on what you mean by "next few years." There is a lot of momentum in the ACA with planned changes over the next several years like value-based care and bundled payment (mostly this affects Medicare providers). If you are asking about the potential stability of US healthcare in the next few years, that's probably as hard to predict as the stock market. Costs will likely increase in the short term thus premiums will climb. The other thing to consider is there is a growing concern about potential provider shortages especially MDs and RNs that may make access to healthcare more difficult especially in more rural areas of the country and increase wait times for elective procedures. Some national healthcare insurers are considering backing out of the exchanges. So there is the very real potential of moving to a state that has an existing exchange, and the insurers pull out. That could leave a lot of people scrambling for coverage.
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celia
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by celia »

fpr4 wrote:I wish we could just outlaw employer provided health insurance. People would scoff if someone suggested employers providing car or home insurance.
The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
curmudgeon wrote:The problem is that we are considering a move to a MCOL area which has less competition in healthcare and much less current availability in ACA plans; I really don't like the prospect of becoming hostage to a single provider if more insurers exit from the area.
I believe this is also an issue for Medigap plans (since you are entering retirement).

OP, I believe ACA is only available to low income families who have "income" that is at least at poverty level. So depending on your income in "early retirement" you may or may not be eligible for ACA subsidies. Remember you can still buy medical insurance without using ACA.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by James1 »

celia wrote: OP, I believe ACA is only available to low income families who have "income" that is at least at poverty level. So depending on your income in "early retirement" you may or may not be eligible for ACA subsidies. Remember you can still buy medical insurance without using ACA.
[/quote]

The ACA is open to people of all income levels. Anyone can buy a plan through the exchange, but only certain people will qualify for the subsidy. We bought a plan through the exchange for myself and 2 children last year after comparing them to my husband's work plan. We were able to get cheaper and better insurance through the exchange than with my husband's employer, even without the subsidy. (And if you end up qualifing for the subsidy when you file your taxes, you can still get it).

We lived in a MCOL city and found that many well known insurance companies were starting "off-brand" insurance companies to use on the exchange. Our company was only 1 yr old, but it was owned by Blue Cross. I don't know what they will do in the future or how the plans compare to this year since we have moved out of the area.
fpr4
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by fpr4 »

celia wrote:
fpr4 wrote:I wish we could just outlaw employer provided health insurance. People would scoff if someone suggested employers providing car or home insurance.
The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
curmudgeon wrote:The problem is that we are considering a move to a MCOL area which has less competition in healthcare and much less current availability in ACA plans; I really don't like the prospect of becoming hostage to a single provider if more insurers exit from the area.
I believe this is also an issue for Medigap plans (since you are entering retirement).

OP, I believe ACA is only available to low income families who have "income" that is at least at poverty level. So depending on your income in "early retirement" you may or may not be eligible for ACA subsidies. Remember you can still buy medical insurance without using ACA.
The subsidies are fairly far reaching. I make many times more than poverty level income, yet purchased my family's health insurance for the past few years from the exchange and received a (minmal) subsidy.

I think one of the intents of the ACA was to make it where family's like mine, that don't have access to employer sponsored healthcare weren't punished for being outside a group plan. Before the ACA, I paid relatively high premiums for relatively crappy coverage. My daughter broke her arm and we were hit with a $11k doctor's bill. So our total OOP for that year was like 1/3 of our total income for the year. Not even remotely comparable to most people with employer sponsored plans. So I was essentially being arbitrarily handcuffed by the regulations of the system stacked against me, and stacked in favor of those that choose to be dependent on a large corporation for their personal welfare.
Big Dog
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Big Dog »

what are the trends you are seeing in terms of provider networks, plan competition, and costs?
Networks: more limited and shrinking each year

Competition: not much, really, since the plan design is dictated and not much flexibility allowed

Costs: increasing.

And, Services: will be decreasing slowly but surely as we move toward health care delivery based on outcomes.

But in reality, all of those "trends" were evident before ACA.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by nisiprius »

(Shrug) Nothing about medical insurance or medical practice has been stable over the previous few decades, why should it start being stable now? It's one of the great unknowns in personal financial planning.

As to why employers provide health insurance, this may not be logical or satisfying but it's the actual answer. In the 1920s and 1930s medicine had advanced to the point where doctors could actually be scientific and effective, and hospitals became transformed from, basically, lodging for sick people (the words "hotel" and "hospital" come from the same root) into technology centers with things like X-ray machines, EKG machines, and centrifuges, where patients were "worked up" with batteries of tests. This increased expenses. Doctor and hospitals wanted to get paid, and patients were having trouble paying, so, to avoid collection hassles the doctors invented Blue Cross and Blue Shield, which, because they were serving the doctors' interests, were motivated to pay for care rather than deny it.

In order to address the wartime and postwar inflation, the government instituted price controls and the Wage Stabilization Act froze wages.

During the war, companies were landing lucrative government contracts and having difficulty finding labor to fulfill them, so competition for labor was high. Unable to compete on salary, employers began competing by offering what there then called "fringe benefits." This was the origin of the "benefits" package we all expect as part of our work nowadays. Health insurance was popular at that time, partly because at that time it was cheap.
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stlutz
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by stlutz »

In my state the move is away from PPO and even traditional HMO plans and more toward arrangements where the insurer and the providers are one. Maybe not so much like Kaiser, but more where the provider and insurer share similar financial incentives.

There is also a trend toward more regulation of provider billing, particularly in the area of balance billing for hospital services. More states are adopting regulations of such practices.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by OnTrack »

celia wrote: The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
The reason that insurance companies charge less for employer group policies than individual policies is not just because they are selling in bulk, it is because on average people in those groups tend to be healthier than people who buy individual policies.
rguina
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by rguina »

I don’t have a warm and fuzzy feeling about the future of the ACA marketplace. That isn't to say it won't be around, or that it won't be a viable option. But you will need to be flexible with your provider, coverage, and other features.

I'm not a health insurance expert, so I can only speak as a layman. In layman's terms, I've seen nothing but change for the last 6 years, which is when I became self-employed and left the group health insurance world for the world of individual health care plans, and now plans from the ACA exchanges. I've had a new health insurance plan in each of the last 6 years (due to rising rates, changing coverage/networks, implementation of the ACA exchanges, etc.).

I live in northern Illinois. There is amazing health care in the general area. But the ACA marketplace has undergone major changes in every year we've participated. Our preferred doctors have pulled out of most plans found on the ACA marketplace. Several of the big insurance companies in our state have already announced plans to leave the marketplace, or they are publicly discussing the possibility.

Case in point: Until this year we had always been on Blue Cross Blue Shield (just different plans within BCBS due to the constant plan changes). We changed coverage to UnitedHealthcare this year after our children's pediatrician stopped accepting Blue Cross insurance plans found the ACA marketplace. My wife's doctor also stopped accepting BCBS plans from the exchanges. Unfortunately, UnitedHealthcare is leaving the Illinois exchanges next year, so we'll need to find our 7th health insurance plan in 7 years.

Actually, there is a laundry list of changes coming to our state - https://www.healthinsurance.org/illinoi ... -exchange/

I imagine our state is fairly normal in this regard.

To answer your questions:
curmudgeon wrote:I guess the question implicit in this is - If you have been using ACA (or tracking the plans closely), especially if you live away from a major metro area, what are the trends you are seeing in terms of provider networks, plan competition, and costs? Are there reasons why you think things will get better or worse in this regard over the next few years? Please try to stay away from the question of what congress or the next administration will do; stick to the law as it currently exists.
The provider networks have changed each year, with many of our preferred providers only opting to serve group health insurance plans or select ACA plans. I expect this to continue.

Plan competition is good on the surface, but the devil is in the details. It's more important than ever to research which networks and providers participate in each plan. Do not assume your preferred doctor will be in your network after the calendar turns to January, even if you have the same health insurance plan. That was an expensive lesson we learned last January (the admin in the doctor's office didn't even realize they were no longer in our network until after we had been billed, so we now make sure to ask every time).

Costs have risen each year. Most plans we have participated in have either been closed after one year, or the cost increase made the plan no longer viable.

As for non-metro areas, I don’t have a great answer. My guess is these situations are highly variable by state, network, and other factors. In general, I would assume fewer options unless the area has a large medical center, universities, etc.

My overall thoughts: I want the exchanges to work. It makes health insurance more accessible to those who don't have access to a group health care plan. And to a large degree, most people can make the plans on the exchanges work. But it takes a lot of flexibility and patience on the consumer's end. Much more than you may expect if you are used to being in a group health insurance environment.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Epsilon Delta »

rguina wrote:My overall thoughts: I want the exchanges to work. It makes health insurance more accessible to those who don't have access to a group health care plan. And to a large degree, most people can make the plans on the exchanges work. But it takes a lot of flexibility and patience on the consumer's end. Much more than you may expect if you are used to being in a group health insurance environment.
I think it depends on how large your employer was. I've worked for both large and small employers. My experience with the exchange plans is very similar to my experience with small employer plans going back to the 80's and quite different for my experience at large employers, particularly government employers. At small companies the plan I was offered kept changing, HMO, PPO, different networks, new primary doctor. big rate changes; sometimes more than once a year. The main differences from the ACA is the small employers rarely offered a choice but at the small employer I had more opportunity to share information with others in the plan.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by BruDude »

As a health insurance agent with 10 years in the business, I will say no, they will not remain stable. Id be surprised if they last another three years. Something has to change, the current market is not sustainable for insurance companies or unsubsidized consumers.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by mouses »

celia wrote: The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
Think how much money would be saved if everyone was on Medicare and Medicare was allowed to negotiate prices.
Tanelorn
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Tanelorn »

The current trends are clearly towards less doctor/network choice, higher premiums, and fewer remaining carriers. Longer appointment wait times are probably coming, but aren't as obvious yet since the networks are still shrinking as better doctors leave from inadequate compensation and the insurers try to cut costs further by negotiating exclusive contracts with fewer providers. If you want to plan for something definite 5-10 years down the road, budget for an ala carte or premium private doctor service - those will clearly still be around and in increasing demand if the quality of the ACA offerings continue to suffer. Or plan to look poor, take your subsidies, and pay the difference with your time and your health in terms of worse healthcare delivered more slowly ala the UK model.

Strong arming the insurance companies to continue their unprofitable ACA market participation in exchange for regulatory merger approval (there are two big ones proposed right now) will only go so far. Public shareholders won't tolerate large continuing losses like the ones we've seen in the past year or two - either the management will insist on the 50% premium hikes like we're seeing requested in some places for 2017 already, or they will pull out of the exchanges to stop the bleeding, or the shareholders will vote in new management who will.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by DetroitRick »

As most others are saying, I see a future in our state (Michigan) of fewer choices and massive premium increases.

Statewide in Michigan, according to the 2017 ACA premium submissions as recapped in The Detroit Free Press on 7/31/16 (expected to be approved by state regulators shortly), next years premiums will average a 17.3% increase. We have 14 insurers total (varies, with MANY state areas having fewer). Our own current carrier, Blue Cross Blue Shield, is expected to get an increase averaging 18.7%. The last few years have seen slightly smaller, but still large, increases.

The weird thing happening here is that for the last few years, the second lowest Silver plan insurer (the benchmark for premium tax credits) has been a minor player with an ungodly low premium (and limited network). Which significantly lowers the tax subsidy for most. They are now proposing a 30% increase for next year, which will provide a bit of shelter for some against full absorption of these increases (since the benchmark will be much higher).

Several ACA carriers have dropped out so far. And I notice that many carriers are Medicaid companies that have branched out into this arena since ACA was implemented. In many areas of the state, the number of insurers is VERY small and getting smaller.

We have not yet experienced network problems ourselves, as we know many others have - probably because of several unique features in our local market. Blue Cross Blue Shield has traditionally been the insurer of last resort here (pre ACA, per arrangement with the state) and have a massive market penetration in general. I can't imagine any Michigan physicians dumping BCBS and still having much patient base left - at least in the foreseeable future.

To sum up, I couldn't even begin to predict how this will work out over the next 8 years. But I am worried because of the developments I see. It is the "great unknown" in my personal financial plan.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Da5id »

DetroitRick wrote: To sum up, I couldn't even begin to predict how this will work out over the next 8 years. But I am worried because of the developments I see. It is the "great unknown" in my personal financial plan.
I totally agree. ACA has an murky political fate. But more than that, it is largely implemented by for-profit companies that are answerable to their shareholders. Those companies have been struggling to make ACA marketplace participation profitable. It very much seems like higher costs and worse networks are in the future for all without employer plans. Those getting subsidies will of course see the effects on costs mitigated to some degree.

I currently have coverage through a job, and the uncertainty of healthcare is one of the major things I worry about with early retirement. I'd be OK retiring today, but double digit health care costs until I'm on Medicare would really eat into the budget. While double digit increases can't go on forever (presumably medical costs won't consume 100% of the economy), hard to see where the current trend will be broken.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by dm200 »

I doubt the ACA marketplace will be "stable" overall over the next 8 years. BUT - who knows?

More narrowly, in addressing health care and insurance costs in early retirement (before Medicare eligibility), the "answer" may depend on where you live, your needs/desires and what choices are available.

My wife and I are now on Medicare, but she was only Medicare eligible in the last year. We faced very large costs until the ACA and she could get a plan.

We are in an area (Washington DC) where Kaiser has a large number of participants and where Kaiser has facilities and services over the entire area. We have been with Kaiser off and on (only left due to employment coverage) for 35 years and are very happy to be with Kaiser Medicare plan. Just my opinion (time will tell), but I believe that in areas, like this, where Kaiser is a strong presence, that Kaiser's HMO "model" is likely to be more "stable" over this period of time.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by michaeljc70 »

mouses wrote:
celia wrote: The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
Think how much money would be saved if everyone was on Medicare and Medicare was allowed to negotiate prices.

If only it were that simple. Medicare and Medicaid underpay providers and they charge insurance companies more because of that. Medicaid is far worse than Medicare. A doctor isn't going to go to school for 8 years and be hundreds of thousands in debt to see a patient for $20.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by rguina »

Epsilon Delta wrote:
rguina wrote:My overall thoughts: I want the exchanges to work. It makes health insurance more accessible to those who don't have access to a group health care plan. And to a large degree, most people can make the plans on the exchanges work. But it takes a lot of flexibility and patience on the consumer's end. Much more than you may expect if you are used to being in a group health insurance environment.
I think it depends on how large your employer was. I've worked for both large and small employers. My experience with the exchange plans is very similar to my experience with small employer plans going back to the 80's and quite different for my experience at large employers, particularly government employers. At small companies the plan I was offered kept changing, HMO, PPO, different networks, new primary doctor. big rate changes; sometimes more than once a year. The main differences from the ACA is the small employers rarely offered a choice but at the small employer I had more opportunity to share information with others in the plan.
Great point. I have limited experience. I was active duty military (TRICARE Prime), followed by working for two mega corps, then I went out on my own and into a series of individual health care plans and plans from the ACA marketplace.

I currently have access to TRICARE Reserve through my affiliation with the Air National Guard. TRICARE Reserve has very affordable monthly premiums, out of pocket expenses, and annual maximums. But it has limited health care options in our area. I use this plan for myself, but my wife and children use a plan from the ACA exchanges. Having separate plans is more expensive, but my wife values the flexibility and control this affords us. We're not sure what we will do next year - we haven't seen the available plans on the exchanges.

Overall, I'm not worried about us having access to health care - we will be fine. But I also understand everyone's situation is unique.

Health care is probably the biggest unknown any early retiree faces. The ACA makes it easier, but it introduces layers of complexity that likely won't be resolved any time soon. I'd recommend early retirees budget for fairly large annual increases to their current health care costs. It will cover you if expenses rise, and leave you with extra cash if you over-budget.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by soboggled »

Insurance rates are going up because of increased claims and participation and advances in expensive medical procedures. ACA cost stability will probably vary by locality.

Probably the best source on ACA is the Kaiser Family Foundation and their report:
http://kff.org/health-reform/issue-brie ... ketplaces/.

Their overall conclusion is:
"Recent reports of substantial increases from some insurers have led to concerns regarding the stability of the ACA’s marketplaces. There is reason to believe that premium increases in the ACA’s marketplaces will be higher in 2017 than in recent years. However, anecdotal examples of premium hikes or averages across insurers can provide a skewed picture of the increases marketplace enrollees will actually face. As noted above, about 8 in 10 marketplace enrollees are receiving government premium subsidies, and these enrollees are protected from an increase in premiums if they continue to be enrolled in a low-cost plan. Regardless of tax credit eligibility, most enrollees have multiple plans from which to choose and can often save money on their premium by switching to a lower-cost plan. Experience has shown that many enrollees are willing to switch plans to avoid a premium increase, even though this might mean changing insurers and potentially doctors as well.
Given this high rate of plan switching – and the jockeying by insurers to be one of the lower-cost options – it is instructive to look at how premiums for the two lowest-cost silver plans are changing. Our analysis of premiums in major cities in the 16 states and DC where more complete information is available finds that the premium changes for the two lowest-cost silver plans – which the bulk of enrollees tend to purchase – vary substantially across the country, ranging from a decrease of 14% to an increase of 27% for the lowest-cost silver plan. On average, proposed premiums for the second-lowest silver plan in these cities are increasing by 9%, up from 2% in 2016.
Another recent concern over the viability of the exchange market has stemmed from the news that UnitedHealth would exit all but a handful of the 34 states where it had participated. However, in earnings calls, other large insurers have expressed more confidence in the exchange markets, with some planning expansion into new markets. On average, across the 17 marketplaces where we analyzed premium data, insurer participation in 2017 will be lower than in 2016. Often the decrease in insurer participation in 2017 is resulting from the exit of UnitedHealth. In all of these states, there are multiple insurers continuing to offer coverage. A remaining question, though, is how insurer participation will vary geographically, and particularly in rural areas where a number of counties may be at risk of having just one insurer.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by randomguy »

celia wrote:
fpr4 wrote:I wish we could just outlaw employer provided health insurance. People would scoff if someone suggested employers providing car or home insurance.
The advantage of having employer coverage is that you are part of a group and the group can benefit from buying in "bulk" quantities, so to speak. The carrier only has to sell to one business instead of X individual families so that saves money for them which supposedly gets passed on to the company.
And wouldn't buying car insurance/home insurance/life insurance in "bulk" also have those advantages and they could pass the saving on?:) Just like in health care there would be winners and losers. Yes there are differences but those are more implementation details. You can look at how other countries do nonemployer based private insurance if you want to see how it could work out. It would be a tough switch to pull off after 70+ years of the current scheme

As a practical matter nobody can tell you much about the stability of ACA going forward. It seems like a total repeal is very,very unlikekly but how much costs go up (same 8% or so that health care has done for the past 30 years seems reasonable), availability (i.e. PPOs are dying in some area), cost sharing, and so on will be in constant flux. It isn't something I would worry about. If it happens, move. If the ~5-10k/yr difference in costs are the difference between made/break, you might want to work one more year.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Da5id »

soboggled wrote:Insurance rates are going up because of increased claims and participation and advances in expensive medical procedures. ACA cost stability will probably vary by locality.

Probably the best source on ACA is the Kaiser Family Foundation and their report:
http://kff.org/health-reform/issue-brie ... ketplaces/.

Their overall conclusion is:
"Recent reports of substantial increases from some insurers have led to concerns regarding the stability of the ACA’s marketplaces. There is reason to believe that premium increases in the ACA’s marketplaces will be higher in 2017 than in recent years. However, anecdotal examples of premium hikes or averages across insurers can provide a skewed picture of the increases marketplace enrollees will actually face. As noted above, about 8 in 10 marketplace enrollees are receiving government premium subsidies, and these enrollees are protected from an increase in premiums if they continue to be enrolled in a low-cost plan. Regardless of tax credit eligibility, most enrollees have multiple plans from which to choose and can often save money on their premium by switching to a lower-cost plan. Experience has shown that many enrollees are willing to switch plans to avoid a premium increase, even though this might mean changing insurers and potentially doctors as well.
Given this high rate of plan switching – and the jockeying by insurers to be one of the lower-cost options – it is instructive to look at how premiums for the two lowest-cost silver plans are changing. Our analysis of premiums in major cities in the 16 states and DC where more complete information is available finds that the premium changes for the two lowest-cost silver plans – which the bulk of enrollees tend to purchase – vary substantially across the country, ranging from a decrease of 14% to an increase of 27% for the lowest-cost silver plan. On average, proposed premiums for the second-lowest silver plan in these cities are increasing by 9%, up from 2% in 2016.
Another recent concern over the viability of the exchange market has stemmed from the news that UnitedHealth would exit all but a handful of the 34 states where it had participated. However, in earnings calls, other large insurers have expressed more confidence in the exchange markets, with some planning expansion into new markets. On average, across the 17 marketplaces where we analyzed premium data, insurer participation in 2017 will be lower than in 2016. Often the decrease in insurer participation in 2017 is resulting from the exit of UnitedHealth. In all of these states, there are multiple insurers continuing to offer coverage. A remaining question, though, is how insurer participation will vary geographically, and particularly in rural areas where a number of counties may be at risk of having just one insurer.
That seems a bit on the rosy side, considering that since that Kaiser report was published a few days ago Aetna and Humana also are having issues (e.g. http://www.bloomberg.com/news/articles/ ... health-law) that are making them revisit their future ACA plans. Limited networks and having to switch doctors is a big issue for many of us. I'd not want to switch my PCP, or my kids pediatrican myself. Having to switch providers seems to me likely to degrade care, as you lose both the relationship and the ability of your caregiver to notice changes due to loss of continuity. And losing access to top of the line care can be a big issue if you unexpected need services (surgery/cancer care/etc) where you'd like the best. Mind you, if you need such care you can switch at next open enrollment to a plan that gives you better access, but that can take quite a while.

Not saying it is all doom and gloom for ACA. Those getting high subsidies are still getting a very good deal for their money. And those without employer access need somewhere to go, and there will remain pressure for there to be a workable & affordable solution. But I do think OP is right to be concerned, particularly if their locale provides very limited choice in the ACA marketplace...
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curmudgeon
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by curmudgeon »

Da5id wrote:
soboggled wrote:Insurance rates are going up because of increased claims and participation and advances in expensive medical procedures. ACA cost stability will probably vary by locality.

Probably the best source on ACA is the Kaiser Family Foundation and their report:
http://kff.org/health-reform/issue-brie ... ketplaces/.

Their overall conclusion is:
"Recent reports of substantial increases from some insurers have led to concerns regarding the stability of the ACA’s marketplaces. There is reason to believe that premium increases in the ACA’s marketplaces will be higher in 2017 than in recent years. However, anecdotal examples of premium hikes or averages across insurers can provide a skewed picture of the increases marketplace enrollees will actually face. As noted above, about 8 in 10 marketplace enrollees are receiving government premium subsidies, and these enrollees are protected from an increase in premiums if they continue to be enrolled in a low-cost plan. Regardless of tax credit eligibility, most enrollees have multiple plans from which to choose and can often save money on their premium by switching to a lower-cost plan. Experience has shown that many enrollees are willing to switch plans to avoid a premium increase, even though this might mean changing insurers and potentially doctors as well.
Given this high rate of plan switching – and the jockeying by insurers to be one of the lower-cost options – it is instructive to look at how premiums for the two lowest-cost silver plans are changing. Our analysis of premiums in major cities in the 16 states and DC where more complete information is available finds that the premium changes for the two lowest-cost silver plans – which the bulk of enrollees tend to purchase – vary substantially across the country, ranging from a decrease of 14% to an increase of 27% for the lowest-cost silver plan. On average, proposed premiums for the second-lowest silver plan in these cities are increasing by 9%, up from 2% in 2016.
A remaining question, though, is how insurer participation will vary geographically, and particularly in rural areas where a number of counties may be at risk of having just one insurer.
That seems a bit on the rosy side, considering that since that Kaiser report was published a few days ago Aetna and Humana also are having issues (e.g. http://www.bloomberg.com/news/articles/ ... health-law) that are making them revisit their future ACA plans. Limited networks and having to switch doctors is a big issue for many of us. I'd not want to switch my PCP, or my kids pediatrican myself. Having to switch providers seems to me likely to degrade care, as you lose both the relationship and the ability of your caregiver to notice changes due to loss of continuity. And losing access to top of the line care can be a big issue if you unexpected need services (surgery/cancer care/etc) where you'd like the best. Mind you, if you need such care you can switch at next open enrollment to a plan that gives you better access, but that can take quite a while.

Not saying it is all doom and gloom for ACA. Those getting high subsidies are still getting a very good deal for their money. And those without employer access need somewhere to go, and there will remain pressure for there to be a workable & affordable solution. But I do think OP is right to be concerned, particularly if their locale provides very limited choice in the ACA marketplace...
This is one of my concerns; a "race to the bottom" to having Medicaid equivalent networks and service levels for any affordable ACA plan. We are not especially demanding about our medical providers, wanting specific doctors or such, but we do expect timely access and quality care. Over the years we have gone through a wide gamut of employer medical plans. The early ones had deductibles and then paid something like 80% until an OOP max; this worked OK for us because we were careful financially, but I know co-workers sometimes struggled with their portions of their medical bills. The shift to HMOs started out OK, but then went downhill with most of the HMOs having very poor service/networks. The only HMO that I've really been satisfied with was Kaiser; Kaiser had a bad rep for years (maybe like the British National Health), but when they lost their locked-in employer contracts and had to compete for customers they really turned around and built a system that we found quite satisfactory.

I have relatives with gold-plated Federal Employee health plans who go to the nationally known hospital in the area for all their major medical issues. I don't necessarily need or want to pay for that level of medical plan (though, of course, I do get to pay for it in my taxes). I'd be satisfied with Kaiser or a good equivalent, or a plan with high deductibles but a good network. What I'd really prefer is a catastrophic plan with access to negotiated rates where I would pay directly for all normal medical care, but ACA outlawed that for me :confused
soboggled
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by soboggled »

curmudgeon wrote:
Da5id wrote:
soboggled wrote:Insurance rates are going up because of increased claims and participation and advances in expensive medical procedures. ACA cost stability will probably vary by locality.

Probably the best source on ACA is the Kaiser Family Foundation and their report:
http://kff.org/health-reform/issue-brie ... ketplaces/.

Their overall conclusion is:
"Recent reports of substantial increases from some insurers have led to concerns regarding the stability of the ACA’s marketplaces. There is reason to believe that premium increases in the ACA’s marketplaces will be higher in 2017 than in recent years. However, anecdotal examples of premium hikes or averages across insurers can provide a skewed picture of the increases marketplace enrollees will actually face. As noted above, about 8 in 10 marketplace enrollees are receiving government premium subsidies, and these enrollees are protected from an increase in premiums if they continue to be enrolled in a low-cost plan. Regardless of tax credit eligibility, most enrollees have multiple plans from which to choose and can often save money on their premium by switching to a lower-cost plan. Experience has shown that many enrollees are willing to switch plans to avoid a premium increase, even though this might mean changing insurers and potentially doctors as well.
Given this high rate of plan switching – and the jockeying by insurers to be one of the lower-cost options – it is instructive to look at how premiums for the two lowest-cost silver plans are changing. Our analysis of premiums in major cities in the 16 states and DC where more complete information is available finds that the premium changes for the two lowest-cost silver plans – which the bulk of enrollees tend to purchase – vary substantially across the country, ranging from a decrease of 14% to an increase of 27% for the lowest-cost silver plan. On average, proposed premiums for the second-lowest silver plan in these cities are increasing by 9%, up from 2% in 2016.
A remaining question, though, is how insurer participation will vary geographically, and particularly in rural areas where a number of counties may be at risk of having just one insurer.
That seems a bit on the rosy side, considering that since that Kaiser report was published a few days ago Aetna and Humana also are having issues (e.g. http://www.bloomberg.com/news/articles/ ... health-law) that are making them revisit their future ACA plans. Limited networks and having to switch doctors is a big issue for many of us. I'd not want to switch my PCP, or my kids pediatrican myself. Having to switch providers seems to me likely to degrade care, as you lose both the relationship and the ability of your caregiver to notice changes due to loss of continuity. And losing access to top of the line care can be a big issue if you unexpected need services (surgery/cancer care/etc) where you'd like the best. Mind you, if you need such care you can switch at next open enrollment to a plan that gives you better access, but that can take quite a while.

Not saying it is all doom and gloom for ACA. Those getting high subsidies are still getting a very good deal for their money. And those without employer access need somewhere to go, and there will remain pressure for there to be a workable & affordable solution. But I do think OP is right to be concerned, particularly if their locale provides very limited choice in the ACA marketplace...
This is one of my concerns; a "race to the bottom" to having Medicaid equivalent networks and service levels for any affordable ACA plan. We are not especially demanding about our medical providers, wanting specific doctors or such, but we do expect timely access and quality care. Over the years we have gone through a wide gamut of employer medical plans. The early ones had deductibles and then paid something like 80% until an OOP max; this worked OK for us because we were careful financially, but I know co-workers sometimes struggled with their portions of their medical bills. The shift to HMOs started out OK, but then went downhill with most of the HMOs having very poor service/networks. The only HMO that I've really been satisfied with was Kaiser; Kaiser had a bad rep for years (maybe like the British National Health), but when they lost their locked-in employer contracts and had to compete for customers they really turned around and built a system that we found quite satisfactory.

I have relatives with gold-plated Federal Employee health plans who go to the nationally known hospital in the area for all their major medical issues. I don't necessarily need or want to pay for that level of medical plan (though, of course, I do get to pay for it in my taxes). I'd be satisfied with Kaiser or a good equivalent, or a plan with high deductibles but a good network. What I'd really prefer is a catastrophic plan with access to negotiated rates where I would pay directly for all normal medical care, but ACA outlawed that for me :confused
I didn't realize HSAs were "outlawed", confused curmud.
hicabob
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by hicabob »

It hasn't been stable yet so why should it start to be? My ACA rates have gone up between 10 and 20% each year. Being an unsubsidized ACA consumer I'm happy that Kaiser will be an option for me next year which, judging by close by communities where they are an option, should reduce premiums by about 33%.
jane1
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by jane1 »

This is a concern for a lot of us. I decided in worst case we would move. And if needed to MA.

I will post (edit) a more detailed response. I have done detailed analysis of raw public data of 3 years - premiums, providers, plans by age, lcation. Similar to kff study.
General trends I found
- urban areas typically saw increased participation
- rural (lower population density) saw opposite
- some states don't have age penalty I.e. are "better" for older adults since they don't pay as high premiums (compared to younger adults). 3x for 65yr compared to 21yr vs flat curve by age.
One thing I learnt in the process was that providers offer plans through other channels (that have to conform to ACA rules) but not through ACA marketplace (so they don't have to insure those with subsidies). More may be exiting the marketplace (media focus) but continuing to offer the plans. Example UHC. Look at your state insurance website, ehealthinsurance.
If you want to PM me your desired zip code, I can try to dig up your relevant data.
joebh
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by joebh »

curmudgeon wrote:I guess the question implicit in this is - If you have been using ACA (or tracking the plans closely), especially if you live away from a major metro area, what are the trends you are seeing in terms of provider networks, plan competition, and costs? Are there reasons why you think things will get better or worse in this regard over the next few years?
For me personally, the ACA has been terrific.

After retiring last year, we purchased a plan on the exchange this year that was less that what I used to pay when employed, with a far smaller deductible. Due to our lack of projected income this year, the plan is significantly subsidized.

I looked at the plans available the prior year as part of planning for retirement. While I noticed some of the names changed, there were plenty of plans covering our doctors, and the costs for many were very reasonable.

I live in a MA suburb, so it's close enough to a major metropolitan area I guess. Still, at least in MA, things look good health insurance-wise. Of course, we have had mandatory health insurance that predated the ACA. Lots of folks predicted disaster, but that simply hasn't happened.
Please try to stay away from the question of what congress or the next administration will do; stick to the law as it currently exists.
Right.

[OT comment removed by moderator prudent]
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curmudgeon
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by curmudgeon »

soboggled wrote:
curmudgeon wrote: What I'd really prefer is a catastrophic plan with access to negotiated rates where I would pay directly for all normal medical care, but ACA outlawed that for me :confused
I didn't realize HSAs were "outlawed", confused curmud.
HSAs are still allowed, (though they get attacked regularly); it is catastrophic plans that are outlawed by ACA unless you are under 30 (and even those are required to stuff in "free" services that pretty much break the concept).
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Hayden
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by Hayden »

I live in a smallish city. My plan has changed each year for almost the last 15 years (not by choice, the plans keep being discontinued). I don't have a lot of choices in plans. I always buy the plan with the largest network.

As to providers and networks, I've never had an issue, and i dont know anyone who has, either. Perhaps because there are so few insurers, all the doctors seem to take the insurance. Every year I carefully check that the providers I want are in network, and I've never run into a dr. who is not in network.

The problem I have had is service. Typically, I schedule an appointment with a specific dr. When I arrive, I am informed that my appointment is with the nurse, and I never actually talk to the Dr. Even getting an appointment to talk to the nurse is difficult.
jane1
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by jane1 »

For those who are interested in looking at some 2014, 2015 ACA premiums/Issuers/Plans, etc comparison by location (county), take a look at these graphics, by yours truly. Apologize I had not well labelled them for public interpretation. The US maps are color-coded to show competitiveness/cost. Data is ACA marketplace data (not off-exchange plans). Some states are missing since they operate their own exchanges.

Each workbook, then has multiple tabs (with additional graphs). You can zoom into the map and hover over an area to get more info. I have more analysis and YoY comparisons in R but not as easily shareable.
https://public.tableau.com/profile/r.a5815#!/

OP, you can probably look at your current as well as desired counties to compare.
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deanbrew
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by deanbrew »

This is one of my concerns; a "race to the bottom" to having Medicaid equivalent networks and service levels for any affordable ACA plan.
There are two major insurance companies active in my area. Both offer a bewildering array of plans that severely limit one's choice of doctors and hospitals as you move down the pricing ladder. To make matters worse, my county is pretty much the dividing line where one company is dominant to the east and the other is dominant to the west, and there are excellent medical centers in both directions for different maladies, so you have to gamble one way or the other. They also offer seemingly identical plans available on- and off- the ACA marketplace. The plans that you buy direct from the insurance company (non-ACA) are cheaper, with the same network, copays and deductibles. Since I'm self-employed and don't know what my income will be, it's a guessing game and gamble which will end up cheaper 14 months later (choose in December 2016 and pay taxes in April 2018) once you factor in possible subsidies. What a friggin' mess.
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fpr4
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by fpr4 »

joebh wrote:
curmudgeon wrote:I guess the question implicit in this is - If you have been using ACA (or tracking the plans closely), especially if you live away from a major metro area, what are the trends you are seeing in terms of provider networks, plan competition, and costs? Are there reasons why you think things will get better or worse in this regard over the next few years?
For me personally, the ACA has been terrific.

After retiring last year, we purchased a plan on the exchange this year that was less that what I used to pay when employed, with a far smaller deductible. Due to our lack of projected income this year, the plan is significantly subsidized.

I looked at the plans available the prior year as part of planning for retirement. While I noticed some of the names changed, there were plenty of plans covering our doctors, and the costs for many were very reasonable.

I live in a MA suburb, so it's close enough to a major metropolitan area I guess. Still, at least in MA, things look good health insurance-wise. Of course, we have had mandatory health insurance that predated the ACA. Lots of folks predicted disaster, but that simply hasn't happened.
Please try to stay away from the question of what congress or the next administration will do; stick to the law as it currently exists.
Right.

[OT comment removed by moderator prudent]
This is my problem with the ACA, I think. What counts as income towards your subsidy? I'm paying exorbitant amounts in premiums and still paying a lot in OOP costs towards care. This is handicapping my ability to plan for the future. Meanwhile high net worth retirees are receiving significsnt subsides. This isn't exactly how economic policy should be structured.

Delete if that's off topic, but it's the truth.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by dm200 »

I'm paying exorbitant amounts in premiums and still paying a lot in OOP costs towards care. This is handicapping my ability to plan for the future. Meanwhile high net worth retirees are receiving significsnt subsides.
.

What are the specifics (including age, if applicable to what you pay) of what you regard as "exorbitant amounts" in premiums? Are there factors involved that are causing you to choose a higher premium policy?
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by leonard »

fpr4 wrote:I wish we could just outlaw employer provided health insurance. People would scoff if someone suggested employers providing car or home insurance.
Exactly.

I was hoping my prior employer was going to get me a good deal on Pet Insurance. Or, a bulk discount on an extended fridge warranty.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by ace1400 »

Do be very cautious about the limited networks. In my area, the only Doctor in a rather significant specialty area that was in network for a popular ACA plan was someone I had never heard of, so I looked into it. His "office " was a mail drop. He didn't have a working telephone number. None of my colleagues in that field had ever heard of him. He didn't actually see patients from what I could determine. I can't imagine how frustrating it would be if this was my only option- especially since urgent issues are common in this field.

In contrast, most physicians accept all or nearly all employer sponsored plans. The ACA plans didn't even attempt to contract with most physicians.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by celia »

fpr4 wrote:What counts as income towards your subsidy? I'm paying exorbitant amounts in premiums and still paying a lot in OOP costs towards care. This is handicapping my ability to plan for the future. Meanwhile high net worth retirees are receiving significsnt subsides. This isn't exactly how economic policy should be structured.
Subsidies are determined by INCOME, not NET WORTH.

Retirees who are eligible for Medicare (age 65) are not eligible to use ACA for their insurance needs.
A dollar in Roth is worth more than a dollar in a taxable account. A dollar in taxable is worth more than a dollar in a tax-deferred account.
DetroitRick
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by DetroitRick »

fpr4:

One financial planning technique that can be used by your FIL (people that are drawing down net worth and do want to avoid being forced into Medicaid under ACA), is to create taxable income (which counts towards ACA MAGI) by selectively and partially converting regular IRA assets to Roth. All things being equal, just convert enough to bring income to ACA minimums. It can be done yearly as needed.

The net worth point was raised by Congress when all this was first implemented. It's an interesting dilemma. Congress was advised that to bring net worth into the equation (rather than just income) would basically have required the implementation of a whole parallel tax and enforcement system to report and audit net worth. Not to mention the complexity of determining an exact definition of net worth to be imposed. The expense to do so, at the IRS level, would be staggering. Apparently Congress listened to that advice.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by pshonore »

In Connecticut, the one "co-op" provider has just gone belly up and will not be writing policies next year. This seems fairly common nation wide with the co-ops and just shows that even health insurance is very complicated business which should never be turned over to amateurs. One of two remaining providers has just requested an 50% premium increase for next year. The other (Anthem) has announced large losses for their policies. CT has also reduced the maximum income limits for the Medicaid folks and several thousand have been booted off that part of ACA. Yes, things are very stable.

edited to correct Insuror name
Last edited by pshonore on Fri Aug 05, 2016 11:29 am, edited 1 time in total.
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celia
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by celia »

fpr4 wrote:But what about someone that retires earlier than age 65? My FIL is an example. Enough net worth to retire before age 65 but not enough income to qualify "out" of the subsidy. His gap insurance will be medicaid.
If they don't qualify for ACA, they should just buy an individual policy from an insurance company. Pre-existing conditions are no longer considered, so everyone should be "eligible" to buy their own insurance, provided they can afford it.

In California, which has its own ACA website, a young friend who is unemployed but has disability income and little assets didn't have enough income to qualify for ACA. Medicaid is the last thing you want here as few doctors accept it and the wait times are long. But he bought his own individual policy from Blue Cross for a little over $200/mo. I'm not sure if you have to wait for Open Enrollment season to get in, but a few phone calls to insurance companies in your state will answer that.
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Re: Depending on stability of ACA marketplace for next 8 years?

Post by LadyGeek »

This thread has run its course and is locked (not personal nor actionable). General comment threads are off topic in the forums with "Personal" in the title. See: A reminder that non-investing general comment threads are OT
- It must be personal. In other words, you must be asking about your own situation. You can also ask on behalf of someone specific, such as a family member.

- It must be actionable. You must be able to do something specific with the replies that will make a difference in your situation.
If you have a specific question, please ask directly and provide sufficient information for members to supply appropriate advice.

I also removed a few political comments, see: Politics and Religion

This thread is now in the Personal Finance (Not Investing) forum (insurance).
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