The discussion about the 80/20 rule is just miserable. Classic example of hiding behind industry lingo and scolding tone to shame others into shutting up.

The rule is supposedly that health insurance providers must pay a minimum percentage of their gross income in claims.

For all their smugness, this zb2929 is missing some obvious ways that this magic rule solves nearly nothing about the problems of ordinary customers.

All the rule does is enshrine a “legitimate” profit margin for insurers. It doesn’t do anything to protect people from inflated premiums or the delay, deny, depose tactics used to get these insurers to their “deserved” profit margins.

[–] SixthSunOfASixthSun@lemmy.ml 26 points 1 week ago* (last edited 1 week ago) (1 children)

All the rule does is enshrine a “legitimate” profit margin for insurers.

Ding ding ding.

It's almost as if the ACA was an insider bill that was accepted by the entire industry because it allowed them to reset the economics of the business without one insurer feeling like they were taking a loss.

The vast majority of the ACA is literally about risk portfolio balancing between private companies.

The regulations on profit essentially changed the game and is why most insurance companies are now vertically integrated with pharmacies, concierge medicine, or even entire medical systems. It's the only way you can charge more for insurance without having to rebate out is by capturing your own payouts which allows you to keep MLR.

Year 1: You pay $100 for insurance and insurance pays $80 for your meds to the insurance company pharmacy.
Year 2: You pay $105 for insurance and insurance pays $84 for your meds to the insurance company pharmacy.

Creative accounting. That's why every insurance company makes special pharamcy benefits rules for the in house pharmacy and spams you with "switch your prescription to Optum RX"

[–] quarrk@hexbear.net 15 points 1 week ago (1 children)

That comment on vertical integration is fascinating and would change the calculation quite a bit.

[–] SixthSunOfASixthSun@lemmy.ml 18 points 1 week ago* (last edited 1 week ago)

Yeah look up Kaiser Permenete, absolute leaders in the shit, they have contracts on a whole bunch of public employee health care too in Western States.

They also take from both ends, since they have some of the most overworked nurses and hospitals. They're unionized but almost every contract negotiation ends up in a strike.

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