I even messed up and said self-insured because it's just in the vernacular and I did find
I used to have the Kaiser family bar chart from 2019 and I mean it's 65% of all firms
are self-funded and if you're in a firm, if you work for an employer that has over
5,000 workers, 93% are self-funded.
I mean it's almost like we have to stop using insurance and start, I mean way more than
half of how people are accessing care is through a self-funded vehicle.
And yet we think, we still talk and think about insurance, right and so.
And do you, I'll probably ask you later if you have like numbers, exact numbers, or if
you can help me find Wisconsin, across the U.S., but that's interesting.
I mean, right, do you, I mean, you know, like, and it's just been going up and up.
Right, so that's the, I think that's the, one of the takeaways for me is, is this just
where care, coverage, if I can use that term?
Yeah, is going, yeah.
Does that concern you as an advocate?
Absolutely.
And don't get me wrong, it's not, you know, insurance companies also are challenging.
Their motive is also profit and I'm concerned when the employer or purchaser of that coverage
is no longer aligned with their employees, right.
So in an insurance situation, right, the employer wants to protect the employee, right, they
want to get the most for their money.
They've paid a fixed amount and they're sort of on the employee's side.
Hey, wait a minute, we bought that product.
We're expecting insurance to equal care, right.
Once we're in a self-funded situation, the employee is at odds with the employer.
The employer is wanting to not pay claims, right.
That is the, you know, direct savings opportunity.
And so, yeah, I think I'm, I'm deeply concerned when what was the original sort of partnership
or agreement, right, the reason we attached health insurance to employment was to have,
it was a benefit.
It's a benefit.
It was supposed to be a benefit for the employer because they got good workers, right, people
chose to work there and a benefit for the employee to access care.
And so we've, we've broken that partnership.
Oh, if the employer has the same insurance though, is there not motivation to have it
be good insurance because it covers them too?
So say, I'm sorry, ask that again.
So let's say the owner of the business buys insurance instead of self-funding.
Is that?
No.
If a, if a business is self-insured, wouldn't the owner of that company be under the same
insurance or be under the same?
So therefore, wouldn't they?
Maybe, but also maybe not.
So my wife runs a nonprofit that is trying to provide health insurance for, you know,
80 employees and they get their insurance through me because, right, access to the state
is better insurance than access through a small nonprofit.
So we can, you can ask it again and I can answer saying that like a owner, a CEO of
a company is going to have a lot more choice and options than, than the employees and also
probably the ability to pay for a lot more out of pocket themselves.
I can't see a few questions from you.
But right, right, you know, but yeah, I mean.
Of course, one would hope that they'd be covered by the same plan and therefore have
an incentive to have it be good and again, but not necessarily and, right, an opportunity
for savings doesn't mean that it's an opportunity that's realized.
And if you're the CEO of a company, I have a duty to my shareholders, right?
I have a duty of, of making money that is generally a goal of a company.
That's not an nefarious thing.
That is, you know, we're here to make and sell this product and a duty to my employees
and some, you know, and in this case that duty can potentially conflict.
So it's kind of, it can represent conflict of interest.
I think so.
Yeah.
Okay.
So.
Oh, the other thing that I thought of.
So you can't, as a consumer, buy health insurance on healthcare.gov if your employer is offering
you the minimum basic standard health insurance plan.
I think that is correct.
What I will say is we at the Center for Patient Partnerships partner with covering Wisconsin
quite a bit.
They are the entity in Wisconsin that helps people purchase insurance on the marketplace
and experts in all the rules of that.
But not surprisingly, it would make sense as a way to design things that you want people
to be accessing healthcare through their employer, if possible, right?
And then we also want to have a backup plan for people who can't.
So a previous job I had, they offered them their bare, bare, bare, bare minimum.
I don't know if it was self-funded or not.
But when I said, I really don't like this insurance and I tried to go on the marketplace
to buy something better myself, I wasn't allowed to because my employer was offering insurance.
Do you happen to know if self-funded plans fall under that category?
Qualify.
I don't off the top of my head, but that's something I will happily look up for you and
or talk to our colleagues in covering Wisconsin, right?
Yeah.
Right.
Like, could you opt out because it's not an insurance product?
So a couple things that I think about one is you'd have to be an incredibly sophisticated
consumer who knew that, right, who understood it was self-funded at the beginning, and
then also be aware of the marketplace, right?
And understandably, for many consumers, right, we're not thinking about the deep complexities
of how we're getting coverage and what's covered until we're in the middle of a health
crisis.
And then we're learning a whole bunch really, really, really fast, and we can help people
sort of plan for the next, right?
When they have open enrollment, it could potentially change, but it's human nature to not fully
understand something until you really, really need to understand it.
Yeah.
And then there's how much fine print, too, and it's just very, very difficult to understand
all of it.
And here's the challenge, right, and what the Affordable Care Act tried to do was to incentivize
everyone to buy in to a system, right, to buy into insurance or a self-funded plan because
we don't, you don't know what expenses you're going to have, right?
And for young people, they can, you know, call the invincibles, right?
You can sort of hope, oh, I won't, I'll be fine.
I won't need to use access care until, unfortunately, there is a diagnosis or an accident or, right?
Okay.
So moving on to maximizer accumulator portions, which is another layer of complication, right?
But it was good that we set the table, I think.
So this baseline are accumulator maximizer plans only possible under self-funded plan?
I don't think so.
So another sort of scaffolding we should add when we want to talk about accumulator maximizer
plans is that healthcare costs are just going up and up and up, right?
So many of the things that are designed, plan designed, whether it's insured or self-funded
is to keep costs down, right?
And part of denying claims arguably is to keep costs down.
So what an accumulator or maximizer plan does is it when you have a high deductible plan,
which has lower premiums because a patient has to pay, for example, $7,000 out of pocket
first before the insurance will pay for everything, right, or pay their percentage of the co-insurance.
But because for many people that $7,000 is too much, many, many consumers, people don't
have $7,000 in savings, these high deductible plans get coupled paired with a copay coupon,
right?
So the manufacturer wants to help people access the medication they need and so there's a
coupon that's equal to part of that deductible or the whole deductible.
So in a traditional manufacturer coupon, high deductible partnership, the patient then doesn't
have to pay any of that deductible.
So they're not out of $7,000 in pocket.
What an accumulator or maximizer plan does that's confusing for consumers is it actually
just delays when the patient starts to pay that deductible that they owe.
It doesn't apply to the deductible.
So for the first few months, the manufacturer will pay for the cost of the medication using
this coupon and then once the value of that coupon is done, the patient has to start to
pay their own deductible.
And it's in the fine print, right?
They get, they're deceptive and they're sold as if this is going to take care of that deductible
but it doesn't and patients don't learn that for months, you know, until they already have
the insurance, they already are using it and they hit the place where the coupon has been
exhausted.
Is it named inside of the plan as accumulator maximizer or is it other language and it's
just kind of generally referred to as?
My understanding is that there's multiple different terms that can be used and they're
not clearly defined necessarily, right?
So I will say, I didn't know what an accumulator or maximizer plan was, right?
It actually sounds like it's a good thing, maximizer, cumulate, right?
Like it sounds like it's, you know, it's something I'd want, right?
Oh, good, this coupon accumulates, right?
Like maximize my benefits, right?
So in that sense, even if it's named, it's named deceptively, it's not named in a way
that's highlighting, you know, consumers be wary of this thing, right?
And my understanding from my research and we haven't seen patients with these at the
Center for Patient Partnerships, my understanding is that, um, I lost my train of thought.
It's not just self-funded.
Yeah, but I was going to say that I was going to fly around.com.
I have no idea what that was going to say.
So it sounds like a good thing.
It sounds like, right.
And you haven't seen cases in the Center for Patient Partnerships?
Yep.
Have this problem.
I think the reason we haven't seen patients with these is I don't see a remedy for people.
An easy way that an advocate can help fix this.
So in Wisconsin.
So many states have recognized that these are deceptive practices and are outlawing them
in the state.
That has not happened yet in Wisconsin.
I hope it will.
There has recently been a federal court case that has said these should not, this loophole
that has allowed these shouldn't, should be closed, right?
This shouldn't, these, these plans should not exist.
You shouldn't be able to have a fake coupon, it's called a fake coupon.
The problem is there's no, no one is enforcing that court ruling right now.
That court ruling has been appealed and the federal agency, the Department of Health and
Human Services has said, we will issue new regulations about this, but we haven't done
that yet.
So for a patient right now who's faced with this, who has an accumulator plan in Wisconsin,
it's wrong, it feels wrong, it acts wrong, it has been identified as wrong by a court,
it has been identified as wrong by 19 states, but there's no way to stop it because there's
no enforcement.
Really quick, I must stop at least.