A Brief History of Health Insurance

00:01.79
Jay Moore MD
All right everybody hello and welcome to our first episode of the Explanation of Benefits podcast. My name is Jay Moore, I'm the chief clinical officer at Paytient, and I'm joined by my friend and colleague JR Clark. JR, how you doing?

00:16.30
J_R
Doing great, Jay! How you doing today?

00:20.88
Jay Moore MD
I'm going to tell you something JR. Like this is the first time I've ever done a recorded podcast and so I'm a little I feel a little rusty here a little bit nervous I'm not exactly sure what to expect I'm just hopeful. That someone out in the world will find this interesting or useful in some way.

00:41.41
J_R_
Yeah, we're in the same boat together Jay feeling the same way as you but I think there'll be enough interesting topics in this to at least find 1 or 2 folks that will be enjoying this.

00:53.50
Jay Moore MD
We've got some big goals here to find 1 or 2 people on the planet who will enjoy listening to the 2 of us talk and you know we talked about this when we first got started and we were like you know we have all these conversations just the 2 of us and we've done this for years because we've been working together for a long time in different companies and. Now coming together at Paytient and we have time where we just get on the phone together or Zoom call or whatever and just chat about various topics and brainstorm ideas and think about how this crazy world of healthcare works and somewhere along the way. Somebody said you know I wish that you guys would record some of these conversations and. Let us just listen in like a fly on the wall and I said well not sure how exciting that will be for you. But hey if that sounds interesting and cool to you then we're happy to do it. So I think that's my goal for this. What about what about you J R.

01:43.30
J_R_
I'd say the same you know I think you having the clinical background that you have have certain perspectives on Healthcare and the whole health system you've seen firsthand how you know how the doctor interacts with the patient and then how the hospital interacts with the doctors that work for It. You know I come from the actuarial side of things I'm very numbers-oriented so you know the way I perceive things or view things Maybe a little bit different than yours. So some things we're going to have great conversation on that. We agree about and some things we may completely disagree about but hopefully it's educational for the folks listening.

02:14.30
Jay Moore MD
Yeah I think sometimes when we disagree. That's when the conversation really becomes most interesting um because it it makes me think about things a little differently. Hopefully it does for you too. I mean you are definitely the brains of the operation. Um with your actuarial background and. I Always appreciate your perspective and you know I come up with these crazy ideas people who know me know this and I can run them by you and you can say Jay you know come On. That's ah maybe think about that a little more and I think that's ah, that's great. It's really foundational to our relationship. So. So thanks First of all.

02:46.52
J_R_
Yeah I think real quick to interject here. We should probably let the listeners know that the initial thought on what we would call this was Sizzle and Steak with you being the sizzle and me being the steak.

02:59.52
Jay Moore MD
Yeah, yeah, ah right I'm the you know, ah you're actually the meat of the podcast that people come and they might learn something from you. But maybe I can tell a joke or 2 and and get them to um smile through the through the podcast right.

03:14.39
J_R_
Right? right.

03:16.91
Jay Moore MD
So anyway I think that our first topic. Ah today is going to actually be talking a little bit about the history of health insurance and how we came to the place that we are now and the reason we're doing that is because I think that. Sometimes people look at our health care system and you know we work at a company where we have some folks that are not from the United States and they look at the U.S. health care system and they just say this is this is a little bit crazy the way that the United States does health care. Why do you do this who would come up with such a system. And I think that the answer is well. It's an evolution. We've been doing health care in the Us for a long time and this insurance system that we find ourselves in is is about a hundred years old at this point and hundred years is a long time to lay a lot of track and. Create some things that are very interesting I guess is one way to put it and so we talked about this and thought that it would just be fun to dive in a little bit to the to the history of insurance and and how we got to where we got today and maybe that would help us is set a foundation for future episodes as well.

04:23.68
J_R_
Yeah, it sounds good. And Jay, yeah I'm thinking about this, you know we could even go back much further than a hundred years ago go into the eighteen hundreds at the start of things when really there was this concept that was kind of like health-ish insurance right? It was. Basically like accident insurance that said hey we'll cover some health things if they're related to accident and that really kicked off what we think of as health insurance today.

04:48.24
Jay Moore MD
Yeah, and and honestly in the 1800s and really well into the 20th century, medicine did not look like it does now I mean if you think about it. World war two was really the advent of a lot of our modern medical techniques with advanced surgical practices and antibiotics and medicines. I I don't remember the the number but I know that when I was in medical school and some of the doctors who had been around for a long time but tell us it's just much harder now because when I was in practice back in the 40 s and 50 s you know there were maybe 20 medications that we would use total in all of healthcare and really before the advent of antibiotics. Hospitals you know the the origin of a hospital was really some place that a very sick person would go to die peacefully that was that was how hospitals got the same root word as hospice right? It's like ah a place that that people can go to convalesce and not necessarily people would go for treatment and doctors you know. Modern medicine really didn't begin again until the the 20th century doctors who knew what you would get if you went to see your local doctor. The guy who was giving you the medicine to take care of your snake bite was also pulling your teeth and maybe cutting your hair so it was ah. I mean it was literally the wild west in terms of medicine prior to the Twentieth century.

06:01.76
J_R_
Right? And then you fast forward now to all of the kind of conditions that are out there that we didn't even know were conditions back you know 40 or 50 years ago and because there's a need to treat those conditions. There's a need to create businesses pharmaceuticals. You know.

06:09.90
Jay Moore MD
Right.

06:19.96
J_R_
Treatment centers to take take care of folks who have those conditions so vastly different approach to healthcare now.

06:24.77
Jay Moore MD
Yeah, for sure. So let's let's kind of move ahead from the 1800s you know the days of um cattle drives and gunfights and the ok corral and all that stuff. Ah and move on into the twentieth century and really I think our first touch point is the year Nineteen Twenty nine and the reason that's important is because that's when the first modern health plan really came into being and it was the blue cross plan and blue cross and blue shield were both plans that started kind of coincidentally around the same time late 1920 s early nineteen thirty s as a way for people to get hospital care jr how like is this new to you like how much do you know about the the ancient history of blue cross and blue shield and how those came to be.

07:08.28
J_R_
So I know just enough to know that you know the whole idea behind it was was in a Baylor hospital that basically came out and said hey look we can sell prepaid hospital services here for folks and.

07:17.18
Jay Moore MD
Yeah.

07:23.49
J_R_
And basically in doing that it essentially set up what was like a health insurance structure that that turned into the blue cross system.

07:26.31
Jay Moore MD
Right? right? and it was insanely cheap at that point. Also it was ah it would guarantee the first blue cross plan would guarantee teachers Twenty one days of hospital care for the very large total of $6 per year. And that was the first health insurance plan. So you'd pay in your six bucks you know $6 per teacher per year and if that teacher needed to go into the hospital. It was already paid for and they could stay up to twenty one days to get the care that they needed and hospital could do whatever it was the hospital needed to do.

08:01.72
J_R_
And and I guess you add to that even kind of moving forward from that plan you saw a lot of expansion because at that point in time you had a whole lot of industrial workers and and with industrial workers came a lot of essentially injuries with their work.

08:16.79
Jay Moore MD
Ah.

08:18.80
J_R_
And they needed places to get care for those injuries and so you saw an expansion of the whole process to say hey look if you have if you have workers that are working for your company and they're getting injured at your company you need as an employer to provide some benefit for them to care for the injuries they sustained while working for you.

08:35.74
Jay Moore MD
Right? right? Yeah, and then you know like we move into the 1940 s and world war 2 happened and the baby boomers all came back from war and started putting together. Um families and in the.

08:37.78
J_R_
Which allowed for that to expand.

08:53.96
Jay Moore MD
You know, mid to late 1940 s the United States was in a bit of a labor expansion because there was so much industry that was really growing at that time and the salaries began to inflate tremendously. Ah because people were competing to get workers to come into their companies. And at that time congress passed a law that actually put some salary caps in place and would not let salaries increase by more than a certain percentage each year and it became very difficult for companies to compete for workers and so they started looking for fringe benefits that they could offer to workers that didn't count as wages. So other sorts of employer sponsored benefits that could attract workers to come and work for them and health insurance was one of those that you know it became something that was offered by employers right.

09:43.81
J_R_
Yeah, that's right because the labored board at that point in time had decided that that was not considered part of your salary. So obviously it became a huge attractant for employers to offer to potential employees or to retain their own employees with.

09:58.26
Jay Moore MD
Yeah I I just think that's such a fascinating story. You know that we we sometimes wonder like why in the United States how can we have this crazy market where it's employers that are providing health insurance for the vast majority of people in the United States and it all goes back to that labor expansion and you know world war ii and I just think that's very interesting prior to that employers just didn't do this and now like every employer does this. It's a major part of a compensation package right.

10:23.63
J_R_
Yeah, absolutely and it was really through those employers that we started to see the huge expansion of health insurance in general and and there's ah no, there's a lot to talk about historically. But I think prior to the war. There was something like. 20000000 folks or so that fell under some form of a health insurance or a health coverage. You know, but then when you think about it over the course of wartime and this kind of change in in employer benefits that happened in effectively. There was like a sevenfold increase in the number of folks that were insured. Under health plans.

10:57.68
Jay Moore MD
Yeah, that's that's insanity that there was such a huge expansion and in Health care and naturally with an expansion and people who were covered costs started to go up as well and it became increasingly difficult for people to afford Health care if they didn't have some sort of insurance and then the sixty s came.

11:07.10
J_R_
Right.

11:16.33
Jay Moore MD
And what happened in the 1960 s well you know it been another twenty years another generation had gone by the first you know people who had been in world war two and were part of that labor expansion began to retire and as they retired and they would lose their employer health coverage. They didn't have a way to pay for health expense and of course you know. They were getting older and so they needed more and more hospital care and more care from doctors. So what happened then what happened to 1965 j r I'm leading I'm leading the witness here. But.

11:41.74
J_R_
Look at you. Yes, we had the introduction of Medicare and medicaid at that point in time so that could provide coverage for senior citizens and also for folks who are lower income. So yeah, great introduction there and and brought a whole bunch of folks into the insured book.

11:57.94
Jay Moore MD
Yeah, so now the government becomes a buyer of health care as well. In addition to private employers. So again, we have now the vast majority of the country is no longer paying for their own health care either. Their employer is paying for it or the government is paying for it and the market.

12:13.61
J_R_
Yeah, yeah, exactly and it bumped it up I think at that point in time was three out of every 4 americans then were covered under a health insurance plan either through and their employers or through you know, government assisted health care.

12:16.44
Jay Moore MD
Becomes decoupled right.

12:28.20
Jay Moore MD
Yeah, yeah, and that's really the the genesis of where we're getting to in modern times. So I'm a doctor as you know, um and I know a lot of doctors and I know a lot of hospital people and in the sixty s. Cost control was not necessarily a thing for Medicare. So the way that it was paid the hospital would generate a bill and they would send it to whoever the payer was and payer would just see the bill and say okay, well that's what it costs to take care of this person. So I guess I'll pay that and you know what happens in this sort of. Scenario like the hospital begins to increase their expenses and they start thinking. Maybe we should build a new wing. We need a few more dollars to put into the the kitty to be able to enhance services or buy an mri machine or a ct scanner which was you know first introduced in the late 70 s early 80 s and so costs. Began to increase and the hospital solution for this was just to you know increase the charge so it used to be you know a hundred dollars for a day of hospital care. Maybe we could charge 12525 isn't quite dating maybe 200 and there was just nothing in place that would stop that expansion of expense. Until 1983 and in 1983 the big law that was passed was medicare payment reform and that's a reform law that's very near and dear to my heart because it really forms the basis for a lot of the work that I've done in my career and also for the way that we price things and and understand how. Expensive health care is going to be so tell me what you know about that payment reform law in 1983 JR.

14:05.14
J_R_
So in terms of the law itself I mean I think you covered the the bulk of it but 1 other thing I wanted to add to that is that you know as folks got used to the idea of consuming health care in a different manner than what they had you know over this period of 1940 through 1980 or or so like. Expectations for what they received as care increase I remember stories like my grandma talking about you know when she when she had her children and literally they would go in the hospital and they'd be in a room with 9 other people with just maybe curtains in between or just some form of of a blockade and you have this.

14:39.44
Jay Moore MD
Yeah, yeah, the old words. Yeah.

14:44.53
J_R_
Yeah, exactly like full wards full of care happening as opposed to like the expectation of hey I should only have maybe 1 other person in this room with me or even nowadays where we look at it and we say everything needs to be private healthcare and but so those expectations of care increase. So.

14:52.44
Jay Moore MD
No bright right.

15:00.71
J_R_
It wasn't just the you know build a new wing of a hospital or I need to you know grow my number of of physicians or nurses working here for better care. It really was the expectation. The consumer was increasing with the time as well.

15:12.28
Jay Moore MD
Yeah, for sure and you know to be clear many of those changes were good I think that you know I'm I'm married you're married I think that when our wives had babies I think they were pretty grateful that they had a private room.

15:16.18
J_R_
Um.

15:25.12
J_R_
Yes, well and we were as well when we were sleeping overnight on the couch in that room and.

15:27.23
Jay Moore MD
And that they weren't sharing with 8 other people right? Um, that's right? Yeah yeah, um, so yeah, these changes weren't necessarily bad and arguably lead to better care. But in some cases they can get to be you know a little much and certainly cost more. And over time that increases the cost platform for a hospital and so the costs continue to ratchet up so in in 84 what the federal government did is they came up with a payment system where they started setting a specific rate that they would pay for a given procedure or a day of hospitalization or what have you. And we introduced this wonderful bureaucratic world of coding so CPT codes which are current procedure terminology I think is what it stands for CPT and ah the ICD codebook the international classification of diseases. And that is how the government started to say you know if you go in and you have a a gallbladder surgery this is the code number for a gallbladder surgery. So. That's what you will submit and then we will take that and we'll pay you X number of dollars if you go in for a brain tumor. And you have an imaging for a brain tumor then this is the code that you'll submit and we'll pay you Y number of dollars and so we started to have this state where now things cost a set given amount depending on the procedure that was done and that really forms the basis for modern. Claims platforms and how insurance really works today.

16:58.99
J_R_
And ja quick question on that because it's something I I don't know much about on specifically for what those reimbursements were for services but would the number be different in say New York than it would be in Kansas for you know, ah a brain tumor under the structure.

17:15.40
Jay Moore MD
Yeah, so there is a yeah, there's a geographical difference that's applied. It's a modifier that gets applied but you know just in terms of like the magnitude of the expense. It's still the same a brain tumor being taken out is a lot more expensive than your appendix getting taken out. For example.

17:17.80
J_R_
Is it 1

17:30.71
J_R_
Right.

17:32.70
Jay Moore MD
It will be paid a little bit more in New York compared to in St Louis where we are or in California you know some place where costs are just more expensive in general. So yes, there is a geographic modifier and there are other modifiers. It's a really complicated system so there are other ways that that medicare that CMS. Will adjust payments for particular things based on geography the type of patient you're seeing comorbidities that the patient has like there. There's a whole world that we can get into someday of how all of this coding stuff. Works.

17:59.69
J_R_
Yeah, and it's probably worth adding too that just because you know the federal government set specific rates for services for what they were going to reimburse. It didn't mean that all insurance still met had to meet that same amount. So for example, if a service cost $1000 under medicare or reimbursement under medicare. It didn't mean that your commercial insurance was going to have that same thousand dollar structure to it but it did set a basis to work off of and again probably something we could give it into a lot of detail on downstream.

18:24.96
Jay Moore MD
Right? Yeah we'll put that down for like episode 5 or something um, payments and networks and how that's all set by insurance companies and where CMS comes in for all of that. But yes, it's a great point and cost continue to increase though. Ah, because there were more treatments available and you know just more people that needed more care and as you stated before more health conditions were being identified. So then we get into the wonderful world of the 1990 s and really the dominance of the HMO the health maintenance organization and Jr this is really your bread and butter. So tell me about an HMO and how that's different than a traditional insurance plan and why those came to be popular in the 90 s and and even on into the present day.

19:11.91
J_R_
Yeah, so the idea behind an HMO really is that you have 1 centralized primary care physician who is almost quarterbacking all of the care that happens for a person. So let's say that you were you felt you know you had a pain in your side under an hmo your first. Point is to go to this specific primary care doctor who would then you know, check you out look at your your side and say hey you know what I think you should go see a specialist and then they would refer you to a specialist. Um and what that meant was if you had a pain in your side. You couldn't just go straight to see ah a. Specialist or else. It wouldn't be covered under the insurance plan and the idea behind it was you gave up a little bit of your flexibility and then you had an expert doctor who was quarterbacking your care and in in doing that you could effectively help curb the costs by by eliminating some of the waste from the system of a person jumping.

20:05.26
Jay Moore MD
Right? right? and you know it works to an extent the costs in an hmo are frequently lower than the costs in more open access networks. But there's a drawback which is what you mentioned that the.

20:07.30
J_R_
You know to get parent places that wasn't referred.

20:21.42
Jay Moore MD
Number of hoops that someone has to jump through to get to see a specialist or to get a procedure done can sometimes be overwhelming and without some controls in place that can be really frustrating to the patient and so there was a blowback against hmos that happened. Like you know in the mid to late 90 s and I remember did you ever see that movie as good as it gets the one with Jack Nicholson do you do you ever remember that movie and you know for for viewers or listeners I guess who haven't seen that like you can go back and you can find this scene where they just have a rant against h of os that you know for its day it kind of became viral.

20:41.14
J_R_
Um.

20:57.35
Jay Moore MD
You know, like people were talking about this and saying yeah, that's how I feel about an hmo and to me I remember that because I was in I don't know maybe medical school at that time and the ah just the the blowback against Hmos really seemed to be captured in that moment and we really saw a shrinking of the number of hmos that. We're out there and you know new plan designs and options that started to propagate in the early 2000 s.

21:18.80
J_R_
And and to put it in context Jay for what you're what you're kind of leading to in terms of numbers. It's like if we look back at like 1960 s I think our healthcare spend as a nation was something like $30 billion per year and you know as health insurance and the idea of benefits increase substantial. You get into this. This point in the 1980 s where we're up to like $450 billion so you know a huge huge increase 15 times the amount of healthcare spend over that period of time. So there was a need to really start finding ways to curb those costs and hmos were were the proposed solution and did do a pretty good job.

If you think about like kind of the for lack of error words I'll say the glory days of the HMO would have been between the mid 80s and the mid 90 s maybe even a little bit into the later portion of it. Healthcare  went from about you know, $500 billion a year mark to $1 trillion which much better cost trend when it comes down to it for just a double over a 10 year period as opposed to what we saw from the 1960 s to the 1980 s and I think yeah I've looked at some numbers year by year. There were even years in the time of HMOs where like medical costs were increasing 0%, 1%, or 2% per year which is really really low. You know, just lower than general inflation.

You know when you talked about the "As Good as It Gets" movie, you know, a big portion of things that people didn't like about hmos were that they were finding that they didn't have the choice that they wanted to and who their providers were you know if somebody went to go see a specialist. They had a lot of kind of for like by words I'll say red tape to go through before getting to see a specialist and that emerged into the idea of the preferred provider organization that really took hold in the you know late 1990 s early 2000.

And what that basically meant under a PPO, you didn't have to have a primary care gatekeeper that was prohibiting you from seeing whoever you wanted to see for services and you know we think about choice choice is obviously a good thing but typically with expanded choice comes expanded costs. And we saw that in the United States in the 2000 you know 2010 timeframe and I think that those you know if you look at the trend numbers jumping up over that time we talked about with HMOs, it was 0%, 1%, 2% per year well costs were increasing by like you know double digits. 10%, 11%, 12% per year over that period.

24:47.26
Jay Moore MD
Yes, and you know by 2010, healthcare was something like 17%, 18% of the entire gross national product in the United States which is just ah, such a huge amount. It's hard to comprehend.

25:04.43
J_R_
 That caused and you know health insurers employers you know lots of folks who were paying for those costs to have to rethink how they were going to keep those costs lower. And that's when you started seeing things like you know insurance companies that were either not willing to offer coverage to folks who had health conditions that were very expensive you know or you started seeing which had a whole lot of lot whole lot of blowback to it understandably. So so you saw people that you know effectively were uninsured.

25:12.20
Jay Moore MD
Oh yeah, yeah.

25:23.60
J_R_
But needed to be insured and you know that really was a cost curbing mechanism so that that kind of led into the Patient Protection and Affordable Care Act. And and why that you know really got its traction and.

25:34.77
Jay Moore MD
Yeah, so so you mentioned the Patient Protection and Affordable Care Act. You know we know that is the ACA signed into law in 2010 and a big touch point and probably the most recent sea change in terms of healthcare delivery in the United States. Really driven by a lot of the things that you just described: the increasing costs of health care and reactions from the insurance industry to try to push some of that cost down and we really have seen a big change in the way health care is delivered so in in your mind as an actuary and you know with your illustrious career. What sorts of things. Do you think are the biggest in terms of the the changes that ACA has brought over the last 10 or so years to the healthcare industry.

26:16.97
J_R_
So I'll give a handful of good things and a handful of bad things in terms of costs. So right.

26:21.25
Jay Moore MD
And and by the way I want to say neither of us are really politically motivated here like we're not saying that it was a good thing or a bad thing or what have you like we're just saying this is what the law did and here's some of the consequences and to your point like there were good things and there were not so good things that happened so just want to caveat that and get it out of the way because you know. A lot of people that are listening and and people have different ideas on the best way to handle health care in the U.S. So with that out of the way, please go ahead.

26:46.54
J_R_
Yeah, so so number one obviously was the idea that a person who formerly could not get insurance was able to get insurance. You know their health condition didn't prohibit their ability to get insurance.

27:01.27
Jay Moore MD
That's called Guaranteed issue right? Yeah, yeah I learned a couple things.

27:05.91
J_R_
Well so so effectively what that meant was you know formerly before before the ACA, a health insurance company would underwrite people and say either you can be insured or you can't. And by saying you can't be insured because you had a health condition meant that you could curb costs. Obviously and that meant after the ACA that mechanism for health insurance companies was pulled away so great for the consumer to be able to get health insurance kind of bad from a financial perspective for a health insurer who's trying to figure out how to kind of blend all these costs together. Now there was an offset to that in that because you had more folks that were able to be insured, you made your your pool be able to expand, which helped kind of make costs a little bit more predictable. But in general under under the Affordable Care Act, I mean to be completely blunt on it, costs went up substantially for individuals because folks were entering the pool that had formerly not been in the pool.

So that was one one change that was pretty substantial. You know because it changed just the general mentality of how you approached business as an insurer but it also changed the way that you thought about health insurance as a consumer because you no longer had the fear of, "Oh my goodness. What if I can't get insurance?"

28:21.29
Jay Moore MD
Right? And let me tell you like I worked in a hospital at the time and it was a big deal for hospitals because hospitals of course are morally and legally obligated to take care of anybody who comes through the doors and if that person had no insurance because they weren't able to get it from an insurance company then that was just free care that was provided by the hospital to the patient. So with the advent of the ACA, that problem disappeared to an extent.

28:43.61
J_R_
Yeah, yeah, good point I think the second thing that this is one that you know I was excited and not excited about the same time when it kicked in so there used to be annual and lifetime max, and those annual lifetime and maximums meant that effectively there were some cap with which the insurance company would not pay for a benefit beyond. So in doing that like just as an example in a lot of states, you may have had a $1 million lifetime maximum. And what that meant was that if your care ever exceeded a million bucks well it wasn't going to be covered by the insurance company that seems bad. But there's actually a reason for that to be in place because um, you know, effectively what that maximum does is it caps the ability for a bunch of services or excess services to be piled onto a person when they need true care. 

So for example, we've all heard the news stories of a person that was near end of life that. All of a sudden got a gallbladder surgery and got all these things these services piled on that increased the cost when those annual lifetime max were removed maximums were removed it opened the door for costs to go up but at the same time. It also allowed for the creation of a lot of new medicines and introduction of a lot of new procedures like you know J you you can probably name 5 or 10 things off off the cuff but like there are new medicines now that treat things that would have never been created if there was a cost cap attached to them.

30:09.13
Jay Moore MD
Right? Because there's an incentive now to actually do that and you know again as a physician I got to say like the idea of a maximum amount of dollars that we're willing to spend on a person to try to take care of them over their life like that has always struck me as Wrong. Um. Because you're right. There is some abuse that happens but there are for every case of abuse I think there are cases of people that are um, you know that that still have a lot of life to live and continue to need treatment. But if they've come up against ah a lifetime limit then. You know that's really a bad place for a person to be so again from a from a patient point of view from a doctor point of view from a hospital point of view the lifting of those lifetime limits while they certainly had financial implications was really you know a good thing overall to me and I think really affected I mean I've I've seen people who would not have been able to get their care paid for under the old rules. But now they can and they're continuing to be able to live. But to your point, it also means that that expensive medication they're on, there's no reason for the cost to go down because the drug manufacturer or the doctor or whatever like they know there's no limit. They can keep giving it and charging as much as they need to for as long as they need to.

31:24.78
J_R_
Yeah, and I think that kind of bleeds well into the third thing is that you know it introduced when when the ACA came into play and all these mechanics were part of this that changed the dynamic of the structure this is when we started seeing that more costs were being shifted to individuals to pay for their care outside of their insurance plan. So when we talk about deductible, we talk about coinsurance, and out-of-pocket maximums, we started seeing those raise substantially over the last 10 years or so in order to try and offset the health insurer's portion of things or the costs associated with it. So you know, you typically call it 10 or 15 years ago you would see deductibles that were $500 or $1,000 and now it's not uncommon to see a deductible sitting at $6,000 or $7,000 I mean very very high.

32:11.84
Jay Moore MD
Right? And and we are definitely going to get into that in another episode where we talk about plan design and how deductibles work and why they are what they are and again just understanding some of this history and where we've come from and where we're getting to and. Where things are going it really lays the groundwork to be able to understand some of these other topics as we move forward and I'm looking at the time and you know like we were going to try to keep this to 20 or 25 minutes and and we're at about half an hour now so I think probably even though I know you and I could literally do this all day. Um, we should probably wrap up and so any any final thoughts on on the history of healthcare, JR? What are your takeaways here? Like, what do you want listeners to come away with?

32:54.62
J_R_
Ah, again, sidestepping your question here to say that I think that there have been several things that have come up in this conversation today that are very evident that we have a lot of future topics to get into in more detail and and on that note you know for sure we you know we would like to totally talk about anything that is valuable to our listeners and so my my takeaway from it is not specifically about the history but more so the takeaway is, "Wow, there's a lot to healthcare and there is a lot to talk about." So many many weeks of this to come.

33:26.72
Jay Moore MD
I think so too and this is really fun I'm excited and I think we're going to have a great time doing this in the future and and moving ahead with this podcast. 

So how about I'll take it out um to the um I don't know what do you call it in the professional world. The outro. Ah, so you know cue the groovy music that comes from some royalty free site and we'll just remind you guys to subscribe to this feed. We will have additional episodes in the future, and we'd love to have conversations with you. Also I think there will be a way for you to communicate back to us and talk to us about the episode and what you liked about it and maybe other topics that you'd like to hear about, so we'll get to look at that information up on the website as well so that you can come and find that.

So, thanks everybody for joining. JR, thank you. This has been a lot of fun. Thanks for getting on with me and talking about one of my favorite topics which is the history of healthcare. And where we are today and the ACA, and all of this fun stuff I just find it fascinating. So thanks a lot. Any final words?

35:06.35
J_R_
Well thank you Jay! I'm looking forward to the next one.

35:14.11
Jay Moore MD
All right! Thanks everybody. We'll see you next time on the Explanation of Benefits podcast with JR and Jay. Sizzle and Steak!