>they can't just jack up premiums and thus increase their profits. They'd have to also increase benefit payouts if they're near the cap.

Maybe I'm missing something here, but other things being equal, just increasing premiums allows for a larger opex/profit pool.

20% of $100 is $20 and 20% of $200 is $40. Yes, they'd still need to spend (using my made-up numbers) $160 instead of $80 on care/benefits, but the profit pool still increases -- a perverse incentive to raise premiums.

>One could point out though, it kind of incentivizes them to no longer negotiate prices as hard. This makes benefits more expensive, growing the total size of their 20%.

Absolutely. That points up the perverse incentive to raise premiums and highlights the lack of incentive to reduce costs.

>But on the other hand, pointing out the idea of holistic health outcomes, increasing benefit payouts to those kind of processes is something incentivized by this rule. Adding a lot of these more "fringe" holistic health benefits, like telehealth nutritionists gym membership subsidies and what not, also grows the benefit payout side and then lets them take more total profit. But there's no free lunch here, those benefits are largely coming from the premiums being collected.

I guess I should have been more specific when using the word "holistic." I meant it in the sense of treating the whole person (with a focus on the outcome of such treatment) rather than just specific symptoms. I wasn't talking (or even thinking) about nutritionists and gym memberships and stuff like that. Those aren't bad ideas, but are geared toward healthy people.

Those with specific conditions (e.g., vascular disease, cancer, hepatitis, HIV, etc.) manifest with other issues that, while they are exacerbated by a specific condition, aren't successfully treated by addressing that condition(s). Addressing ancillary issues (which may be at least as, if not more, debilitating than the condition one may be treated for by any particular specialist) along with the "primary" issue in a holistic (rather than specific treatment for specific issues while ignoring other issues -- which is one of the perverse incentives of paying by the procedure rather than the outcome) fashion.

I won't get into details here, but recent events in my own life have pointed up how fractured medical care is and how difficult it is to navigate (especially when your GP is allotted 15-20 minutes with you every six months or so) side-effects of various treatments/procedures/drugs that have specialists shrugging their shoulders and saying, "that's not my specialty. I did my job. If you're not recovering/getting healthy, that's not my problem. Go see someone else."

There are no incentives for medical practices to provide comprehensive management of health issues because the only person who is (theoretically) paid to do so, isn't given the time or the resources to do so. Everyone else just wants to do their specialist thing and walk away.

That's the wrong way to do medicine.

My apologies if I wasn't clear about that in my previous comment.

>Also, a lot of these insurers don't even end up getting any of that 20% some years. The first few years after the ACA pretty much every insurance company had some big losses. It has been a while since I looked at the industry, but they're not always making massive money margin-wise.

That's absolutely correct. In fact, most insurers (at least in my area, a large, dense, urban area) have left the ACA market and those that are left struggle to maintain their viability -- mostly by screwing over their customers.

So yeah. I mostly agree with you. But that doesn't help me or the million of others who pay exorbitant premiums for mediocre medical care.

I'm pretty angry about it, but short of moving somewhere with universal health care, I'm not sure how to address that.