nosuchreality
Well-known member
R2DS, you on Medicare yet? If not, if not for ACA, would you even be able to get insurance yet (outside of an employer plan)?
Obamacare on Life Support article
- Thread starter eyephone
- Start date
Perspective said:
Obamacare screwed me over from day one
- I got dumped from my plan because of Obamacare.
- The new plan coverage is the same, but my costs have gone up for a lot of things. Also, my premiums went up 30% right away.
- My son was born right after Obamacare passed, it took 6 months to get him insurance due to flaws with obamacare that they had to iron out. That was a bunch of stress and more effort than it should have been.
Our price increases have outpaced inflation.
Let's face it. Obamacare failed to meet it's key selling points. Why is this? It was a rush job. False premises were attacked. Dishonest promises were made.
morekaos
Well-known member
Coming apart at the seams...
Inside the Affordable Care Act?s Arizona Meltdown
Nearly every county in the state now has only one insurer selling plans through the health-care law?s exchange, and premiums are soaring
When Affordable Care Act insurance marketplaces launched in fall 2013, Arizona seemed like a success. Eight insurers competed to sign up consumers, offering a wide variety of plans and some of the lowest premiums in the country.
Today, with ACA enrollment starting Nov. 1, Arizonans will find in most counties only one insurer selling exchange plans for 2017. Premiums for some plans will be more than double this year, some of the biggest increases in the nation. Only last-minute maneuvering prevented one Arizona county from becoming the first in the nation to have no exchange insurers at all.
That left only one county in Arizona, Pima, with more than one exchange insurer?it has two. There will be a few more options sold outside the exchange, to people who don?t get federal subsidies.
Premium increases are steep, though the effect will be blunted for those who get subsidies. Blue Cross?s rates are up by an average of 51% from this year, Centene?s Health Net unit?s, by nearly 75%.
Mr. Walton, the consumer who benefited from lower premiums at the start of the exchange, worries he won?t be able to find a plan that includes his primary-care physician and his cardiologist. ?I don?t know what?s going to happen come November,? he says.
http://www.wsj.com/articles/inside-the-affordable-care-acts-arizona-meltdown-1477925051
Inside the Affordable Care Act?s Arizona Meltdown
Nearly every county in the state now has only one insurer selling plans through the health-care law?s exchange, and premiums are soaring
When Affordable Care Act insurance marketplaces launched in fall 2013, Arizona seemed like a success. Eight insurers competed to sign up consumers, offering a wide variety of plans and some of the lowest premiums in the country.
Today, with ACA enrollment starting Nov. 1, Arizonans will find in most counties only one insurer selling exchange plans for 2017. Premiums for some plans will be more than double this year, some of the biggest increases in the nation. Only last-minute maneuvering prevented one Arizona county from becoming the first in the nation to have no exchange insurers at all.
That left only one county in Arizona, Pima, with more than one exchange insurer?it has two. There will be a few more options sold outside the exchange, to people who don?t get federal subsidies.
Premium increases are steep, though the effect will be blunted for those who get subsidies. Blue Cross?s rates are up by an average of 51% from this year, Centene?s Health Net unit?s, by nearly 75%.
Mr. Walton, the consumer who benefited from lower premiums at the start of the exchange, worries he won?t be able to find a plan that includes his primary-care physician and his cardiologist. ?I don?t know what?s going to happen come November,? he says.
http://www.wsj.com/articles/inside-the-affordable-care-acts-arizona-meltdown-1477925051
irvinehomeowner
Well-known member
Perspective said:
But (in my opinion) gov't involvement slows down the process and increases the costs.
When insurance is private, competition keeps prices controlled and makes companies improve their servicing, now that it gets "tax" funding, that impetus (impeti?) aren't as influential.
I find it interesting that we get taxed more to pay for ACA and then we also pay more for our own plans/premiums.
What?
Perspective
Well-known member
irvinehomeowner said:
Agreed. The best political decision would be to not touch this area and just ignore the tens of millions of folks who aren't broke enough for Medicaid and/or ineligible for health coverage due to pre-existing conditions. Healthcare delivery is just too complex, you can't fix all issues, and it won't be perfect.
Perspective
Well-known member
morekaos said:
We can exchange hyperbolic rhetoric, or we can discuss the issue in real terms.
morekaos
Well-known member
I don't think that's hyperbolic. There are several real examples (myself included) that this is exactly what happened. ACA is a real world application of why not to let big government bureaucracies run these massive social programs. All the end results were not only predictable but were predicted. As i said before that the road to ruin is paved with good intentions. Now they scream "we can fix it". Pardon my skepticism.
Harambe for President!!
Harambe for President!!
irvinehomeowner
Well-known member
Perspective said:
So under ACA, are these "tens of millions" no longer ignored?
I remember back when ACA was being pushed, they kept saying there were so many who could not seek medical attention but from what I understood, it's the law that no one could be denied it, regardless of ability to pay.
The best political decision would be to litigate such that private companies were required to provide coverage to everyone, but by keeping gov't out of the funding aspect, that would still let the market define costs and promote efficiency.
Or put it at the city/state level. If you don't like the coverage in your state, move.
Perspective
Well-known member
irvinehomeowner said:Perspective said:
So under ACA, are these "tens of millions" no longer ignored?
I remember back when ACA was being pushed, they kept saying there were so many who could not seek medical attention but from what I understood, it's the law that no one could be denied it, regardless of ability to pay.
The best political decision would be to litigate such that private companies were required to provide coverage to everyone, but by keeping gov't out of the funding aspect, that would still let the market define costs and promote efficiency.
Or put it at the city/state level. If you don't like the coverage in your state, move.
I believe nobody can be denied emergency care, which is why emergency rooms have long waits. If you have a condition that requires regular treatment (diabetes, cancer, etc.), you either pay out-of-pocket, through private insurance, or public care (Medicare/Medicaid).
That's the issue ACA is attempting to solve - require healthcare providers to accept all applicants, pre-existing conditions and all, and create a funding mechanism so that healthcare providers can do this without going broke. This is why there's a mandate to either obtain healthcare insurance or pay a fine/tax.
You can reasonably oppose this approach. You cannot reasonably argue that the healthcare delivery system pre-ACA was great. Healthcare insurance premiums were rising well above inflation for years prior to ACA.
Winners post-ACA: lower-to-middle income families, families with kids in their early 20s, and folks with pre-existing conditions.
Losers post-ACA: higher-income families who pay the additional Medicare tax and/or the net investment income tax, families with high-deductible lower-coverage insurance plans, and religious folks who don't want to cover any healthcare that violates their beliefs.
No, that is just "an issue" that the ACA attempted to solve. Had that simply been "the issue", it would not have gotten the support it got.Perspective said:
The issue was the costs and the unsustainable price increases. People were getting fed up, and quite frankly, they still are.
The ACA failed to meet it's goals on all it's selling point promises.
Economics might have fixed that. People got to the point where they wanted to rush this junk law in. It is quite possible and probable that price increases would have slowed down. The ACA increased costs, lowered supply and increased demand with mandates. Those things generally lead to higher prices (econ 101).Perspective said:
Perspective
Well-known member
ACA has bent the cost curve for my healthcare insurance. Anecdotally, my premium is increasing 2.6% for 2017. Annual increases were much higher than that pre-ACA at my employer.
irvinehomeowner
Well-known member
What was the time range for those "much higher" increases?Perspective said:
From what I remember, insurance carriers were already bumping up rates a few years prior to ACA to prepare for the increased usage.
All I know is that anything the gov't gets involved with financially ends up being very inefficent cost-wise. Isn't that why we have that running joke of the military spending $640 on toilet seats?
Gov't fiscal inefficiency is also why people are worried about Social Security.
Perspective
Well-known member
spootieho said:
That's a vital political point. With any change and its accompanying promises, it's very difficult to prove the alternative scenario, much less the cause-and-effects of the change itself. We rely on economists for this.
To be very clear again, I am only defending ACA against hyperbole. I thought it was a very poor political decision at the time, and is proving such. I think it's fair to give ACA a few years before we fully analyse and determine whether the cost curve bending promised, occurs.
Will Obamacare cut costs?
The growth in America?s health-care spending is slowing
Mar 7th 2015 | CHICAGO | From the print edition
http://www.economist.com/news/unite...are-spending-slowing-will-obamacare-cut-costs
BACK in 1980, when Jimmy Carter was president and leg warmers were cool, America spent 9% of GDP on health care. Now it spends a whopping 17%?far more than any other rich country. In absolute terms it spends more than twice as much per head as Britain. And for what? American figures for diabetes, infant mortality and life expectancy are worse than the median for the OECD, a club of rich countries.
For decades health spending has grown faster than the economy as a whole. The soaring cost of health insurance provided by employers has left little or nothing in the pot for pay rises. Out-of-control public-health programmes such as Medicare and Medicaid have threatened to crowd out everything else that Uncle Sam pays for.
Yet something appears to have changed. America is experiencing its slowest growth in health spending in five decades. In 2013 the share of GDP devoted to health care was the same as it was in 2009. Some of this is due to the recession and its aftermath?when Americans lose their jobs, they often lose their health insurance, too. But the Affordable Care Act of 2010, better known as Obamacare, may also have helped to curb costs. As the Supreme Court considers whether to strike down a crucial pillar of that law (see next article), economists are furiously debating how big that effect has been. By one estimate the economic downturn accounted for 77% of the dip in health-care inflation; by another, it was only 37%.
Obamacare sought to fix two problems: coverage and cost. To extend coverage, the law made it compulsory for Americans to have health insurance, on pain of a fine. It also offers subsidies for those who cannot afford it and bars insurance firms from charging people more if they have ?pre-existing conditions?; ie, they are already ill. Before the exchanges arrived in 2013 some 41.3m Americans lacked health insurance. That has fallen to 30m (of whom 48% are eligible for assistance).
Curbing costs is more complicated. Traditional American health care is inefficient and wasteful. Costs vary enormously from provider to provider?sometimes by an order of magnitude?and until recently were largely opaque. Medical bills were long paid by third parties, such as insurers, so patients neither knew nor cared whether one option was cheaper than another. Under the ?fee-for-service? system every blood test, bandage or X-ray triggers a payment. Doctors are tempted to order lots of unnecessary procedures to pay for a new yacht or their children?s education.
Obamacare introduced (or encouraged the adoption of) various tools to restrain all this. For example, health-care providers receive financial rewards for cutting costs and penalties for bad care, such as when patients have to be readmitted to hospital after they have been discharged or when they catch nasty infections in a clinic. Between January 2012 and December 2013 there have been 150,000 fewer readmissions among Medicare patients?an 8% decline. The law also requires greater price transparency.
Doctors and hospitals are encouraged by the law to club together in Accountable Care Organisations. Instead of charging fees for everything they do, most ACOs try to keep people healthy. Obamacare rewards them for keeping costs below a set limit per person covered. Not everyone is convinced that ACOs?which strongly resemble the unpopular Health-Maintenance Organisations of the 1990s?will work: Regina Herzlinger of Harvard Business School calls them a ?fantasy? because they are so difficult to manage.
Stop shovelling cash out of the door
The health law encourages the use of ?bundled payments?, where a hip replacement or a heart bypass generates a single fee, no matter how many tests are performed or how many complications arise. These bundles may also help to cut spending on drugs, says Paul Keckley of Navigant, a consultancy. When hospitals cannot simply charge extra for each pill, they are more likely to haggle for discounts with the drug firms that supply them.
On January 26th Sylvia Burwell, the health secretary, said she hoped that by the end of 2016, 85% of Medicare?s payments would have some link to value and quality (as opposed to simply shovelling money out of the door willy-nilly), and almost a third will be via ACOs or bundles. Private insurers such as Anthem, Aetna and United HealthCare are following suit.
The amount that Medicare spends on each beneficiary has actually declined in real terms, from $12,000 in 2011 to $11,200 in 2014. If this is sustained, it could make a huge difference. Medicare has long been the most frightening part of the federal budget. Falling Medicare spending could be driven by falling demand?lots of baby-boomers have just turned 65, and they are healthier than their elders. But it could also be because hospitals and doctors are working more efficiently. A paper by the Congressional Budget Office suggests that over the previous decade providers were trimming costs, for example by treating beneficiaries at lower-cost clinics, adopting more efficient procedures and introducing new technology more slowly.
Much of the American health-care system still clings to fee-for-service. But towards the end of the past decade doctors, hospitals and other providers surely saw Obamacare on the horizon. Anticipating changes in the way hospital payments are updated each year, they realised they would have to shape up. Anecdotally, they have been preparing for years. New evidence from the journal Health Affairs suggests that hospitals grew more productive between 2002 and 2011?particularly after 2009 (see chart). Chapin White of the RAND Corporation says that the fall in Medicare spending in hospitals last year was worth $98 billion, for which Obamacare can take some credit.
Overall the CBO projects that, if the law is unchanged, net federal spending for the government?s main health-care programmes in 2039 will be 8% of GDP, about 15% less than had been projected in 2010. Projections for Medicare and Medicaid spending between 2011-2020 have been revised downwards by $1.1 trillion. The government also claims that since 2011 some 50,000 fewer patients died in hospitals as a result of Obamacare.
Far from bankrupting the nation, as its critics predicted, Obamacare may be making medicine thriftier. Even so, health-care spending as a share of GDP is likely to rise over the next decade as Americans age. With the economy recovering this year, the total health-care bill is projected to grow by 6%. Hold the champagne, then, and not just because it is bad for you.
Perspective
Well-known member
irvinehomeowner said:
The government was heavily "involved" in healthcare delivery prior to ACA. It's not a simple "free market" ideal vs. ACA question.
Perspective
Well-known member
The Affordable Care Act
Encumbered exchange
Obamacare?s future is not yet secure
Sep 10th 2016 | WASHINGTON DC AND NEW YORK | From the print edition
Timekeeper
http://www.economist.com/news/unite...res-future-not-yet-secure-encumbered-exchange
?WE HAVE to pass the bill so that you can find out what is in it, away from the fog of controversy,? said Nancy Pelosi, then Speaker of the House, of the Affordable Care Act (ACA), Barack Obama?s health-care reform, in March 2010. More than six years later, that fog has yet to recede fully. Nearly half of Americans say they oppose the law, despite large majorities in favor of most of its contents when these are polled separately. Donald Trump calls the act an ?incredible economic burden?, to be replaced, under his presidency, with ?something much better?. And critics continue to insist that the ACA is heading towards an inevitable failure, a charge fueled by recent headlines about soaring premiums and struggling insurers. Democrats, meanwhile, largely celebrate the law as a defining success of Mr. Obama?s presidency. Who is right?
Under Obamacare, the percentage of Americans without health insurance has fallen from 16% in 2010 to 9% in 2015. The law achieved this in three ways. First, it expanded Medicaid, government-provided insurance for the poor, to cover all those with incomes of less than 138% of the federal poverty line. Only 31 states have gone along with the expansion, because the Supreme Court ruled in 2012 that it was optional. Nonetheless, together Medicaid and the Children?s Health Insurance Program now cover 23% of the population, up from 18% in 2013.
Second, the law established government-run insurance marketplaces, or ?exchanges?. These offer federally funded subsidies to help those with incomes beneath 400% of the poverty line?$97,200 for a family of four in 2016?to buy insurance. Seventeen states run their own exchanges; the federally run fallback option, healthcare.gov, does the job everywhere else. About 12m Americans now buy health coverage on an exchange, 10m of them with subsidies.
The third mechanism was the most subtle. Insurance markets always redistribute from the lucky to unlucky: everybody?s premiums pay for care for those who fall victim to, say, cancer or a car crash. But a thicket of regulations in Obamacare has made this redistribution more dramatic.
Before the law, insurers selling new policies to individuals could vary what they charged based on customers? sex, medical history, occupation and most other factors that correlate with health spending. Obamacare drastically limited this practice. Premiums now vary only with age, smoking habits, family size and where customers live. Discrimination is limited: for example, the old can be charged at most three times as much as the young. Insurers must accept all applicants, regardless of their health. And policies must offer ?essential? coverage, which includes some things, like mammograms, which many buyers will never need.
That has made plans cheaper for the riskiest customers, at the cost of higher premiums for the healthy and young. Poorer folk, who receive subsidies, do not particularly notice. But those who are healthy and too well-off to receive subsidies are paying more for insurance. Since 2010 households with incomes over $50,000 have reported the greatest increase in spending on premiums, despite the fact that coverage expanded most among poorer people (see charts).
The regulations do more than just redistribute, argues Jonathan Gruber, one of Obamacare?s architects. A ban on lifetime limits on coverage gives everyone peace of mind. And a worker with medical problems knows that if she loses her job, and with it her employer-provided plan, she can buy new coverage.
Still, concentrated increases in premiums help to explain some of the antipathy towards Obamacare. Before the law, Brian Anderson, a 30-something orthodontist from Nashville, paid $80 a month for insurance that came with a $5,000 deductible. In 2014 his insurer cancelled the plan, as it did not now comply with the law. His new plan, from healthcare.gov, provides, in his view, essentially the same coverage?the deductible is in fact higher?but costs fully $201 per month. Mr. Anderson says he is glad many more people now have insurance. But the estimated 2.6m others whose plans were cancelled that year may not all be as understanding.
Yet on average, marketplace plans have proved surprisingly cheap. A recent analysis by Loren Adler and Paul Ginsburg of the Brookings Institution, a think-tank, found that premiums were initially 10-21% lower on the exchanges than in the pre-existing market. More competition on the exchanges may have brought premiums down a bit. But insurers also set their prices low because they failed to predict buyers? poor health.
Three things caught them out. First, it was thought that many small employers would withdraw their plans once their staff could get to the exchanges. But this has not happened much: Obamacare has killed off perhaps 2m employer plans, compared with a forecast of 6m. Second, more people than expected continue to buy plans directly from insurers. About 9m Americans are covered this way, almost as many as use the exchanges. Third, more people than expected chose to remain uninsured. Thanks to the ACA, doing so incurs a fine, though those who cannot afford coverage are exempt.
The poorer people are, the bigger the subsidy they get, and the keener they are to enroll (see chart). Poorer folk tend to be in worse health. By contrast, those who stay on their old insurance or pay a fine probably do so because they are healthy. The result is that average claims have been bigger than expected. ?We have seen higher-than-expected cost from membership with chronic conditions,? John Gallina, the chief financial officer for Anthem, one insurer, told investors in July.
Those who designed the ACA knew that insurers would struggle to predict the health of those enrolled. For that reason, it promised at first to redistribute cash from profitable insurers to loss-making ones. If everyone did badly?ie, if the industry accidentally underpriced insurance en masse?the taxpayer would make up losses. Similarly, if profits were excessive, the government would take most of them. This was not a new idea: a similar ?risk corridor? operates as part of Medicare, government-provided health insurance for over-65s. But congressional Republicans gutted this provision in 2015.
As a result, insurers have suffered from mispricing their plans. In 2014 only 30% made a profit from the exchanges, according to McKinsey, a consultancy. Premiums have risen from their initial low base, but the early evidence suggests that even fewer insurers?perhaps one in four?profited from the exchanges in 2015. And losses seem to have grown. Profit margins are now about minus 10%, so prices are rising further. The average planned premium increase for 2017 is around 25%, according to Charles Gaba of acasignups.net, a number-crunching website.
Spiraling down
Critics have long claimed that Obamacare would face a ?death spiral?, in which price rises would drive away the healthiest consumers, forcing prices higher still. On the exchanges this is unlikely, because the government will bear the extra cost for those it subsidizes. Price rises are inconvenient, because buyers may need to switch plans to avoid paying more (possibly disrupting their care). And it is possible that a death-spiral could affect the pricier ?gold? and ?platinum? options. But government support should keep the exchange market for other plans standing.
The same cannot be said of plans bought directly from insurers, without subsidies. These are also getting pricier. The only safeguard against healthy people abandoning those plans is the fact that they would be fined if they went without insurance. For a single adult, the fine is currently $695 or 2.5% of gross income, whichever is higher, up to a maximum. That may not be enough, given that even plans with big deductibles typically cost several thousand dollars a year.
The biggest threat to the exchanges is insurers leaving them. In April UnitedHealth Group, America?s largest insurer, announced it was pulling out from most exchanges. It will sell in only three next year. In August Aetna, another large insurer, said it would withdraw from 11 of 15 states, citing losses of over $400m. This year one in 50 potential exchange customers lived in a county with just one carrier, according to McKinsey. Next year, thanks to insurer withdrawals, as many as one in six people will. Some entire states will be served by only one insurer; Pinal County, in Arizona, is set to have an empty exchange.
Some insurers are faring better than others. Health-maintenance organizations, in which a general practitioner oversees patients? care within a limited network of specialists and hospitals, are performing relatively well. One example is Kaiser Permanente, a not-for-profit outfit. Its insurance covers treatment at its own hospitals, tracks patients? health and tries to keep them well. But this example does not offer a quick fix. Kaiser Permanente?s model requires owning hospitals and clinics, making it difficult to expand quickly.
Molina, a Californian insurer, is in one sense another success story. The company, an experienced Medicaid contractor, entered the exchanges slowly. ?We did not jump in with both feet,? says Mario Molina, its chief executive. It would have made a slim profit last year, thanks to its low administrative costs and pre-existing small networks of doctors. But rules requiring healthy plans to pay struggling ones meant Molina made a modest loss.
Exchanges can survive with just one insurer. It is odd to worry about monopolies when the main problem is firms? losses, especially as regulators can already limit price rises (indeed, the threat of overzealous price regulation may be helping to scare insurers away). If monopolists start to make juicy profits, there is nothing stopping others from entering, or re-entering, the market. Yet clearly it would be better to have more insurers involved. Obamacare came with a promise of a choice between different plans. In any case, every county needs at least one insurer.
The more the merrier
The law would work better with more people?especially healthy people?on the exchanges. The ideal way to achieve that would be to nudge Americans away from employer-provided health insurance. More than half of America?s under-65s get coverage through their job, although this arrangement serves no good purpose.
The culprit is the long-standing tax exemption for employer-provided health-care benefits. This costs taxpayers about $250 billion a year, and incentivises employers to ramp up health coverage rather than raise wages. That, in turns, inflates costs. The ACA?s ?Cadillac tax? on lavish plans will mitigate this eventually (it was recently delayed until 2020). It would be better to abolish the deduction completely.
The same goes for the part of Obamacare requiring firms with over 50 staff to offer insurance to their employees. This burdens firms with administrative costs and creates an unwelcome incentive for them to stay small. It has cosmetic appeal to some, because it appears to make firms foot the bill for keeping their staff healthy. But most economists agree that wages eventually fall to offset such perks.
Fewer employer-provided plans would mean more people on the exchanges. To the same end, the government could require all individually purchased plans to be bought and sold on the exchanges, as Washington, DC does. That would not improve the overall pool of risks, but it would stop insurers withdrawing from the exchanges and continuing to sell directly to wealthier?and probably healthier?customers. Finally, the fine for not buying insurance could be raised.
Unfortunately, these ideas are not politically appealing. In fact, any change requiring bipartisan co-operation will be difficult. Most Republicans want the law to fail, so that they can relax regulations and replace income-linked subsidies with a tax credit linked to age. Democrats, meanwhile, talk most about starting a publicly run insurer to compete on the exchanges, an idea Republicans hate.
The administration can tweak some rules. For instance, it is proposing to do more to prevent people from signing up only when they become ill. Insurers want the health department to improve a formula under which firms with disproportionately healthy members pay those with unusually sick ones. Marilyn Tavenner, who oversaw the launch of healthcare.gov for the administration but now heads the main insurance lobby group, says she is keen to see such changes happen before Mr. Obama leaves office in January.
The exchanges may look wobbly, but they are only one part of the reform. Even if the market shrinks and many more people opt to pay the fine, it will be hard for any politician to roll back the expansion of Medicaid. And other, less flashy parts of the law seem to be making dents in America?s biggest long-term health-policy challenge: rising costs. For instance, almost one in three dollars spent on Medicare now flows through one of several promising cost-reduction programs.
Cost-control must become the priority in the private market, too. Private health-insurance spending (including employer-provided plans) is forecast to grow by 5.6% a year over the next decade, fueled by spending on drugs. Overall spending on health care will rise to an absurd 20.1% of GDP by 2025. If Obamacare?s redistribution mechanisms survive, these rising costs will be felt more broadly. It will be easy for critical politicians to blame the ACA for the underlying trend. America will be better off if they avoid such a misdiagnosis, and search hastily for a cure.
Encumbered exchange
Obamacare?s future is not yet secure
Sep 10th 2016 | WASHINGTON DC AND NEW YORK | From the print edition
Timekeeper
http://www.economist.com/news/unite...res-future-not-yet-secure-encumbered-exchange
?WE HAVE to pass the bill so that you can find out what is in it, away from the fog of controversy,? said Nancy Pelosi, then Speaker of the House, of the Affordable Care Act (ACA), Barack Obama?s health-care reform, in March 2010. More than six years later, that fog has yet to recede fully. Nearly half of Americans say they oppose the law, despite large majorities in favor of most of its contents when these are polled separately. Donald Trump calls the act an ?incredible economic burden?, to be replaced, under his presidency, with ?something much better?. And critics continue to insist that the ACA is heading towards an inevitable failure, a charge fueled by recent headlines about soaring premiums and struggling insurers. Democrats, meanwhile, largely celebrate the law as a defining success of Mr. Obama?s presidency. Who is right?
Under Obamacare, the percentage of Americans without health insurance has fallen from 16% in 2010 to 9% in 2015. The law achieved this in three ways. First, it expanded Medicaid, government-provided insurance for the poor, to cover all those with incomes of less than 138% of the federal poverty line. Only 31 states have gone along with the expansion, because the Supreme Court ruled in 2012 that it was optional. Nonetheless, together Medicaid and the Children?s Health Insurance Program now cover 23% of the population, up from 18% in 2013.
Second, the law established government-run insurance marketplaces, or ?exchanges?. These offer federally funded subsidies to help those with incomes beneath 400% of the poverty line?$97,200 for a family of four in 2016?to buy insurance. Seventeen states run their own exchanges; the federally run fallback option, healthcare.gov, does the job everywhere else. About 12m Americans now buy health coverage on an exchange, 10m of them with subsidies.
The third mechanism was the most subtle. Insurance markets always redistribute from the lucky to unlucky: everybody?s premiums pay for care for those who fall victim to, say, cancer or a car crash. But a thicket of regulations in Obamacare has made this redistribution more dramatic.
Before the law, insurers selling new policies to individuals could vary what they charged based on customers? sex, medical history, occupation and most other factors that correlate with health spending. Obamacare drastically limited this practice. Premiums now vary only with age, smoking habits, family size and where customers live. Discrimination is limited: for example, the old can be charged at most three times as much as the young. Insurers must accept all applicants, regardless of their health. And policies must offer ?essential? coverage, which includes some things, like mammograms, which many buyers will never need.
That has made plans cheaper for the riskiest customers, at the cost of higher premiums for the healthy and young. Poorer folk, who receive subsidies, do not particularly notice. But those who are healthy and too well-off to receive subsidies are paying more for insurance. Since 2010 households with incomes over $50,000 have reported the greatest increase in spending on premiums, despite the fact that coverage expanded most among poorer people (see charts).
The regulations do more than just redistribute, argues Jonathan Gruber, one of Obamacare?s architects. A ban on lifetime limits on coverage gives everyone peace of mind. And a worker with medical problems knows that if she loses her job, and with it her employer-provided plan, she can buy new coverage.
Still, concentrated increases in premiums help to explain some of the antipathy towards Obamacare. Before the law, Brian Anderson, a 30-something orthodontist from Nashville, paid $80 a month for insurance that came with a $5,000 deductible. In 2014 his insurer cancelled the plan, as it did not now comply with the law. His new plan, from healthcare.gov, provides, in his view, essentially the same coverage?the deductible is in fact higher?but costs fully $201 per month. Mr. Anderson says he is glad many more people now have insurance. But the estimated 2.6m others whose plans were cancelled that year may not all be as understanding.
Yet on average, marketplace plans have proved surprisingly cheap. A recent analysis by Loren Adler and Paul Ginsburg of the Brookings Institution, a think-tank, found that premiums were initially 10-21% lower on the exchanges than in the pre-existing market. More competition on the exchanges may have brought premiums down a bit. But insurers also set their prices low because they failed to predict buyers? poor health.
Three things caught them out. First, it was thought that many small employers would withdraw their plans once their staff could get to the exchanges. But this has not happened much: Obamacare has killed off perhaps 2m employer plans, compared with a forecast of 6m. Second, more people than expected continue to buy plans directly from insurers. About 9m Americans are covered this way, almost as many as use the exchanges. Third, more people than expected chose to remain uninsured. Thanks to the ACA, doing so incurs a fine, though those who cannot afford coverage are exempt.
The poorer people are, the bigger the subsidy they get, and the keener they are to enroll (see chart). Poorer folk tend to be in worse health. By contrast, those who stay on their old insurance or pay a fine probably do so because they are healthy. The result is that average claims have been bigger than expected. ?We have seen higher-than-expected cost from membership with chronic conditions,? John Gallina, the chief financial officer for Anthem, one insurer, told investors in July.
Those who designed the ACA knew that insurers would struggle to predict the health of those enrolled. For that reason, it promised at first to redistribute cash from profitable insurers to loss-making ones. If everyone did badly?ie, if the industry accidentally underpriced insurance en masse?the taxpayer would make up losses. Similarly, if profits were excessive, the government would take most of them. This was not a new idea: a similar ?risk corridor? operates as part of Medicare, government-provided health insurance for over-65s. But congressional Republicans gutted this provision in 2015.
As a result, insurers have suffered from mispricing their plans. In 2014 only 30% made a profit from the exchanges, according to McKinsey, a consultancy. Premiums have risen from their initial low base, but the early evidence suggests that even fewer insurers?perhaps one in four?profited from the exchanges in 2015. And losses seem to have grown. Profit margins are now about minus 10%, so prices are rising further. The average planned premium increase for 2017 is around 25%, according to Charles Gaba of acasignups.net, a number-crunching website.
Spiraling down
Critics have long claimed that Obamacare would face a ?death spiral?, in which price rises would drive away the healthiest consumers, forcing prices higher still. On the exchanges this is unlikely, because the government will bear the extra cost for those it subsidizes. Price rises are inconvenient, because buyers may need to switch plans to avoid paying more (possibly disrupting their care). And it is possible that a death-spiral could affect the pricier ?gold? and ?platinum? options. But government support should keep the exchange market for other plans standing.
The same cannot be said of plans bought directly from insurers, without subsidies. These are also getting pricier. The only safeguard against healthy people abandoning those plans is the fact that they would be fined if they went without insurance. For a single adult, the fine is currently $695 or 2.5% of gross income, whichever is higher, up to a maximum. That may not be enough, given that even plans with big deductibles typically cost several thousand dollars a year.
The biggest threat to the exchanges is insurers leaving them. In April UnitedHealth Group, America?s largest insurer, announced it was pulling out from most exchanges. It will sell in only three next year. In August Aetna, another large insurer, said it would withdraw from 11 of 15 states, citing losses of over $400m. This year one in 50 potential exchange customers lived in a county with just one carrier, according to McKinsey. Next year, thanks to insurer withdrawals, as many as one in six people will. Some entire states will be served by only one insurer; Pinal County, in Arizona, is set to have an empty exchange.
Some insurers are faring better than others. Health-maintenance organizations, in which a general practitioner oversees patients? care within a limited network of specialists and hospitals, are performing relatively well. One example is Kaiser Permanente, a not-for-profit outfit. Its insurance covers treatment at its own hospitals, tracks patients? health and tries to keep them well. But this example does not offer a quick fix. Kaiser Permanente?s model requires owning hospitals and clinics, making it difficult to expand quickly.
Molina, a Californian insurer, is in one sense another success story. The company, an experienced Medicaid contractor, entered the exchanges slowly. ?We did not jump in with both feet,? says Mario Molina, its chief executive. It would have made a slim profit last year, thanks to its low administrative costs and pre-existing small networks of doctors. But rules requiring healthy plans to pay struggling ones meant Molina made a modest loss.
Exchanges can survive with just one insurer. It is odd to worry about monopolies when the main problem is firms? losses, especially as regulators can already limit price rises (indeed, the threat of overzealous price regulation may be helping to scare insurers away). If monopolists start to make juicy profits, there is nothing stopping others from entering, or re-entering, the market. Yet clearly it would be better to have more insurers involved. Obamacare came with a promise of a choice between different plans. In any case, every county needs at least one insurer.
The more the merrier
The law would work better with more people?especially healthy people?on the exchanges. The ideal way to achieve that would be to nudge Americans away from employer-provided health insurance. More than half of America?s under-65s get coverage through their job, although this arrangement serves no good purpose.
The culprit is the long-standing tax exemption for employer-provided health-care benefits. This costs taxpayers about $250 billion a year, and incentivises employers to ramp up health coverage rather than raise wages. That, in turns, inflates costs. The ACA?s ?Cadillac tax? on lavish plans will mitigate this eventually (it was recently delayed until 2020). It would be better to abolish the deduction completely.
The same goes for the part of Obamacare requiring firms with over 50 staff to offer insurance to their employees. This burdens firms with administrative costs and creates an unwelcome incentive for them to stay small. It has cosmetic appeal to some, because it appears to make firms foot the bill for keeping their staff healthy. But most economists agree that wages eventually fall to offset such perks.
Fewer employer-provided plans would mean more people on the exchanges. To the same end, the government could require all individually purchased plans to be bought and sold on the exchanges, as Washington, DC does. That would not improve the overall pool of risks, but it would stop insurers withdrawing from the exchanges and continuing to sell directly to wealthier?and probably healthier?customers. Finally, the fine for not buying insurance could be raised.
Unfortunately, these ideas are not politically appealing. In fact, any change requiring bipartisan co-operation will be difficult. Most Republicans want the law to fail, so that they can relax regulations and replace income-linked subsidies with a tax credit linked to age. Democrats, meanwhile, talk most about starting a publicly run insurer to compete on the exchanges, an idea Republicans hate.
The administration can tweak some rules. For instance, it is proposing to do more to prevent people from signing up only when they become ill. Insurers want the health department to improve a formula under which firms with disproportionately healthy members pay those with unusually sick ones. Marilyn Tavenner, who oversaw the launch of healthcare.gov for the administration but now heads the main insurance lobby group, says she is keen to see such changes happen before Mr. Obama leaves office in January.
The exchanges may look wobbly, but they are only one part of the reform. Even if the market shrinks and many more people opt to pay the fine, it will be hard for any politician to roll back the expansion of Medicaid. And other, less flashy parts of the law seem to be making dents in America?s biggest long-term health-policy challenge: rising costs. For instance, almost one in three dollars spent on Medicare now flows through one of several promising cost-reduction programs.
Cost-control must become the priority in the private market, too. Private health-insurance spending (including employer-provided plans) is forecast to grow by 5.6% a year over the next decade, fueled by spending on drugs. Overall spending on health care will rise to an absurd 20.1% of GDP by 2025. If Obamacare?s redistribution mechanisms survive, these rising costs will be felt more broadly. It will be easy for critical politicians to blame the ACA for the underlying trend. America will be better off if they avoid such a misdiagnosis, and search hastily for a cure.
At the time when Obamacare was getting passed, quite a few people were skeptical. The consensus at the time was that they were offering a program that is so bad that people will eventually support and demand UHC as a replacement. Once Obamacare was passed, the ball began rolling. There's no stopping it. There's no going back. Either we keep Obamacare or we replace it with UHC.
There's going to be more and more support for UHC. There's going to be a lot more people demanding it. I would be very happy with a basic level of UHC. Not sure how all the doctors in Irvine feel about UHC, though...
There's going to be more and more support for UHC. There's going to be a lot more people demanding it. I would be very happy with a basic level of UHC. Not sure how all the doctors in Irvine feel about UHC, though...
morekaos
Well-known member
As i said from the very start, it was designed to fail to bring about UHC...it is succeeding in that goal. Problem is doctors do hate it and all our healthcare now will suffer as fewer and fewer are choosing the profession, also predictable and predicted. So, once again this has been a lose lose exercise for most of us to insure just a few. Don't make it better, just make it equally worse. By that standard it is a wild success.
morekaos
Well-known member
Get your forks ready...to stick in it.
ObamaCare repeal ? don?t fall for the myths
1. Approximately 20 million to 22 million people will lose coverage
No way. Sixteen million of those who gained coverage are enrolled in Medicaid, the public program for low-income residents. ObamaCare allowed states to expand who could sign up for Medicaid, with the federal government covering the tab. Repeal could result in less federal funding. But no one is pushing to abolish the nation?s health safety net. And states that just expanded Medicaid are unlikely to do a 180 and shrink it. The 16 million are likely safe.
President-elect Donald Trump and other Republicans do propose giving states more flexibility in how Medicaid is run and who?s eligible, which is needed. Federal Medicaid spending has shot up 40 percent in the last three years under the ACA, and research shows all that extra spending is not improving the health of Medicaid patients.
What about the other five million or so newly insured? They?re in ObamaCare plans, along with 6 million other people who already had insurance, and all of them are having a tough time. Technically they?re ?covered? but many can?t come up with the cash to see a doctor. It?s true that four out of every five enrollees are getting taxpayer subsidies, but they?re still struggling with exorbitant deductibles ? $6,000 per person for the typical bronze plan ? and ever rising premiums.
In short, about five million previously uninsured people ? not the bogus 20 million ? may need help when the law is repealed and replaced. But they may actually benefit from what?s ahead. The individual insurance market has for years been dysfunctional and unaffordable in many states, and Trump is proposing market reforms to lower costs and increase choices for consumers stuck in this market
http://thehill.com/blogs/pundits-blog/healthcare/306788-obamacare-repeal-dont-fall-for-the-myths
ObamaCare repeal ? don?t fall for the myths
1. Approximately 20 million to 22 million people will lose coverage
No way. Sixteen million of those who gained coverage are enrolled in Medicaid, the public program for low-income residents. ObamaCare allowed states to expand who could sign up for Medicaid, with the federal government covering the tab. Repeal could result in less federal funding. But no one is pushing to abolish the nation?s health safety net. And states that just expanded Medicaid are unlikely to do a 180 and shrink it. The 16 million are likely safe.
President-elect Donald Trump and other Republicans do propose giving states more flexibility in how Medicaid is run and who?s eligible, which is needed. Federal Medicaid spending has shot up 40 percent in the last three years under the ACA, and research shows all that extra spending is not improving the health of Medicaid patients.
What about the other five million or so newly insured? They?re in ObamaCare plans, along with 6 million other people who already had insurance, and all of them are having a tough time. Technically they?re ?covered? but many can?t come up with the cash to see a doctor. It?s true that four out of every five enrollees are getting taxpayer subsidies, but they?re still struggling with exorbitant deductibles ? $6,000 per person for the typical bronze plan ? and ever rising premiums.
In short, about five million previously uninsured people ? not the bogus 20 million ? may need help when the law is repealed and replaced. But they may actually benefit from what?s ahead. The individual insurance market has for years been dysfunctional and unaffordable in many states, and Trump is proposing market reforms to lower costs and increase choices for consumers stuck in this market
http://thehill.com/blogs/pundits-blog/healthcare/306788-obamacare-repeal-dont-fall-for-the-myths