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You can argue that the ACA improved the healthcare system overall. But it's been tough for people who were already covered by employer insurance. I think peopl

You can argue that the ACA improved the healthcare system overall. But it's been tough for people who were already covered by employer insurance. I think people fail to appreciate that prior to the ACA, when the healthcare system worked, it actually worked really well. I got very sick at the age of 20 while I was still on my parents very modest insurance (pre-ACA). Within 48 hours I had an appointment at the best oncology hospital within 500 miles, and I was able to get scans, tests, etc on a very short turnarounds. Ultimately I had two major surgeries in 4 months, and the whole thing probably cost the insurance company a couple hundred thousand dollars. Since my parents had already hit their out-of-pocket maximum, the marginal cost to us was 0. Now, the "when it worked" caveat is a big one. The story would be very different if my parents didn't have insurance at all or if I hadn't been eligible to be on it. But the same story today on my insurance would cost me a lot more money out of pocket due to a much higher deductible and a higher out-of-pocket maximum. My perspective is that the ACA made things significantly better for a small group and modestly worse for most people. I'm open to moral arguments that the tradeoff was worth it (although that's not what I believe.) But I dislike rhetoric that pretends there's no tradeoff at all. Edit: Added substance to a one-liner.

duxup 7y ago
How so? The choice of covering crappy plans is the employer's choice... and crappy plans are what have been pushed AFTER the ACA was passed. Largely by the GoP... Is that what the ACA was, or what someone(s) who want it to fail want? There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall.
- mdorazio 7y ago
  The parent comment is exaggerated, but I think the point is that prior to ACA, employer-provided plans tended to be cheaper and have lower deductibles largely because insurance companies were able to drop or deny coverage whenever they felt like it for individual plans to keep their margins up. While logically true, this is roughly equivalent to hearing from an old coworker that South Africa was a great place to be white under apartheid... I think it's also worth exploring how much of the difference in financial cost of health insurance plans is due to time + annual overall increases in healthcare cost in the US. ACA was passed 9 years ago. Even under the previous 9 year annual percentage increase averages, you would expect healthcare costs to be at least 20% more expensive than they were in 2010, regardless of ACA.
  - WalterSear 7y ago
    It's more extreme than your example. The parent is ignoring the fact his great healthcare experience is predicated on them being able to drop him the moment they could, when his illness became too expensive. Ending pre-existing conditions was the game changer in the AMA. Treating people is obviously more expensive than not treating them.
    - mrosett 7y ago
      That's just not how it worked with employer insurance. Perhaps they could drop your whole company, but the insurer couldn't unilaterally cancel a single employee's plan.
      - pnutjam 7y ago
        No, but sick individuals, or those with sick family members are lousy employees... wink... wink..
      - WalterSear 7y ago
        https://www.chicagobusiness.com/article/20140918/NEWS03/140919814/centegra-sued-after-firing-employees-with-high-health-care-bills https://www.chicagobusiness.com/article/20140918/NEWS03/1409...
      - Someone1234 7y ago
        I know someone who pre-ACA had employer insurance who was dropped by that insurance after they got skin cancer. The official reason was lying during the application process (10+ years earlier). They forgot to list childhood Asthma on their application form ten years earlier.
        mrosett 7y ago
        Would the ACA prevent that kind of scam? I genuinely don't know.
        7y ago
- mrosett 7y ago
  > There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall. The ACA fundamentally shifted the landscape for the whole healthcare system with minimum coverage mandates (including employer plans), guaranteed issue, etc. It's also led to higher demand for medical services (ie because more people are covered - a good thing) at a time when the number of doctors has stayed fixed. The net result is that health coverage is simply more expensive. One way that could have played out would be employers eating the higher premiums themselves (which is essentially giving everyone a raise.) Anecdotally, it seems the way it's played out is that employers have kept paying roughly the same amount while employees have either paid higher premiums or received higher deductibles.
  - duxup 7y ago
    The trend of higher and higher medical costs, employer plans trending down as far as benefits and up as far as costs was established long before the ACA.
  - deleted 7y ago
    [deleted]
  - jeffal 7y ago
    My employers have been complaining about skyrocketing health insurance costs since my first job in 1998. This all predates the ACA by at least 20 years.
- jandrewrogers 7y ago
  The cost to employers of very good plans massively increased after ACA went into effect. When this changeover happened, I was running a company where we paid 100% for one of the best healthcare plans available in the state for both the employees and their families -- people really appreciated this benefit. This was the polar opposite of a "crappy plan", and it wasn't inexpensive to begin with. After the ACA, this plan became so expensive so quickly that continuing this plan became nearly untenable financially and now these types of plans have become increasingly unavailable in any case due to that cost escalation. If you were formerly on one of these plans, of course the post-ACA environment seems like a big step backward. This happened in one of the deepest of blue states; the Republicans can't be blamed for the destruction of health insurance benefits here because they were never involved. The cost of healthcare here has not risen nearly as fast as the cost of providing top-tier healthcare benefits did.
  - pnutjam 7y ago
    What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps. Even with the ACA, employers have the best of both worlds. Expensive older people are covered by the government, and anyone who gets to expensive can be shuffled off with a little cover and the joy of "at-will" employment.
    - jandrewrogers 7y ago
      The lifetime max was multiple millions, I don't remember the exact number. As I stated, it was just about the best policy available for any amount of money. There is no credible way to spin this as actually being worse for those employees. I like to hire "expensive older" engineers, so dialing healthcare benefits up to eleven was intended to attract that kind of employee. All insurance policies have implicit lifetime maximums, unless the laws of economics and finance have been repealed.
    - rayiner 7y ago
      > What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps. Note that lifetime caps are a lot more generous than what they have in say the UK, where you don’t get treatment if it costs more than $50-75k per year of extended life. (So to blow through a million dollars, the treatment would have to be expected to produce 15-20 years of extra healthy life. Most treatments offered when people “need it the most” can’t make that sort of promise).
deleted 7y ago
[deleted]
tptacek 7y ago
I'm not seeing the connection to the ACA in your argument. If your argument is that the ACA raised the price of health insurance, that's incorrect: health insurance premiums had been skyrocketing prior to the ACA (that crisis was what generated the political capital to pass the bill), and the ACA in fact reduced the rate of growth in health care costs.
- sithlord 7y ago
  In my previous career, I was an accountant, and I worked for a health insurance company, you are straight up uniformed if you do not think that ACA raised the the cost of insurance. With that said, as a type 1 diabetic, without ACA it would be impossible for me to get insurance outside of employment, so i think there is some good in it, just needs to be actually thought through, unlike what the administration did that put it in place.
  - bliblah 7y ago
    >> just needs to be actually thought through, It's impossible because you both political parties want exclusively mutual results You can't have cheap insurance without making it mandatory since only the sick will get it You can't have easily accessible insurance without forcing healthcare companies to comply with new regulations forcing them to increase costs You can't have good insurance if you aren't willing to pay the market price which happens to be very inflated in the US You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts Overall, it's a shitshow that will keep being patchworked every time the administration changes between parties.
    - civility 7y ago
      > You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts Here is the fundamental problem from my point of view. Compare human medical costs to veterinary costs. Yes, people expect a slightly higher standard for themselves than they do their animals, but you can get a major knee surgery for your dog for a small fraction of what they charge for humans. The process is performed in a sterile environment by professionals in either case. We're smarter than animals on average, but our bodies and medical needs aren't vastly different. The problem is price gouging because the providers and insurance companies know we have no real ability to shop around. They conspire with each other to publish false rates when the true costs are much lower after you agree to them. You could maybe solve this with regulation on prices (a socialist approach), but you could also solve it by mandating they advertise true prices and re-enable competition (a capitalist approach). Either way could fix this, and the problem is corruption (lobbying) not party ideology.
qqqwerty 7y ago
High deductible plans started becoming popular due to the Medicare Modernization Act[1], not the ACA. [1] https://en.wikipedia.org/wiki/Medicare_Prescription_Drug,_Improvement,_and_Modernization_Act https://en.wikipedia.org/wiki/Medicare_Prescription_Drug,_Im...
rockinghigh 7y ago
The increase in high-deductible health plans (HDHP) enrollment predates the ACA by many years. You can look at the trend here: https://www.cdc.gov/nchs/products/databriefs/db317.htm https://www.cdc.gov/nchs/products/databriefs/db317.htm Their role is to protect against very high bill of $5,000 and up due to major surgeries, illness, pregnancy, and so on. They should definitely be completed by a health savings account (HSA) for day-to-day coverage.
- mrosett 7y ago
  That's interesting data. Thanks for sharing it. In the 2017 snapshot, I'm surprised to see that HDHP plans are slightly more common for high-income families. I didn't expect that. There's a missing variable here: What are the premiums? HDHPs are attractive to insurers (and by extension employers) because they increase employee sensitivity to healthcare costs and may lead to less wasteful spending. Advocates emphasized that the savings on premiums could be passed on employees as HSA contributions [1]. But as that chart shows, a quarter of Americans have an HDHP without an HSA, and at every point most HDHPs haven't come with an HSA. Are employers just keeping the premium savings? Or have rising healthcare costs meant that the savings haven't materialized? [1]: https://www.wsj.com/articles/SB10001424052970204251404574342170072865070 https://www.wsj.com/articles/SB10001424052970204251404574342...
  - ctchocula 7y ago
    I imagine it's because it provides a way to sock away $7k each year in a retirement fund that can be invested in index funds and won't get taxed after 65 on qualified medical expenses making it more valuable than either traditional or Roth IRAs that get taxed on withdrawal and when you put the money in respectively. High-income families have the spare cash to do that, so for them it's a valuable investment vehicle.
  - brewdad 7y ago
    My wife's employer covers our family under an HDHP. Our out of pocket cost is 0. Our plan requires us to have an HSA, though I don't thinkone is required to contribute to it. We contribute the max $ to our HSA each year. A more traditional plan would run us about $4-5 thousand annually in payroll deductions. Most years we spend far less than our HSA contributions and can roll that money over year to year and even invest it. The one year she needed major surgery, we hit out OOP max and probably spent about $10,000 total from our HSA. Probably our biggest risk exposure would be if one of us needed to take an expensive prescription since I don't think there is any annual limit on those costs.
jseliger 7y ago
But it's been tough for people who were already covered by employer insurance. Yes. The only word I disagree with in the headline is "start." The squeeze started years ago. One way to look at the problem is this way: http://seliger.com/2018/11/11/health-insurance-security-fqhcs/ http://seliger.com/2018/11/11/health-insurance-security-fqhc...: In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits. I am not a fan of the word "unsustainable," but it seems to apply here.
- pnutjam 7y ago
  That's not necessarily true, the discounts that insurance companies negotiate can be huge, but it's hard to include that since prices are so inflated to begin with.
- rayiner 7y ago
  At least that premium is totally reasonable. In Germany, the health insurance tax is 15%, half paid by the employer and half by the employer (and it’s not progressive like the ACA subsidy). $4,500 per year is 7% of income, lower than what the employer-side tax alone would be in Germany.
  - mikestew 7y ago
    Now do the math when you include total out-of-pocket. My napkin says: "Considerably more than 15%". (Unless I misremember, and the 15% German tax doesn't cover the vast majority of cost.) Not to dismiss your point completely, but I could sell you insurance for $1/year, but your total out-of-pocket cost is going to be considerably more than $1.
    - rayiner 7y ago
      The out-of-pocket max is something you’re likely to hit only if you get sick. The 15% is something you have to pay every year.
JMTQp8lwXL 7y ago
Pre ACA, pre-existing conditions could disqualify you from insurance. People with pre-existing conditions are the people that need health care coverage the most. We can't under-weigh the moral obligation we have to this previously marginalized group, when considering service may be slightly worse for people who have employer coverage. How I see it: if you were in the pre-ACA pre-existing condition pool, your perspective would be vastly biased in a different direction. And nobody wants to end up in that pool. Nobody chooses that. That's why it's a net win overall. People died because they don't have coverage (unfortunately, still happens, but substantially decreased by ACA). If things are slightly worse for people who already had access, It's such a small price to pay.
- WrtCdEvrydy 7y ago
  My favorite one was pregnancy being a pre-existing condition so if your husband got fired (noone would ever fire a pregnant woman for no reason), you couldn't get insurance when you needed it the most.
  - frenchman_in_ny 7y ago
    Though (if both spouses were working & had access to employer sponsored insurance), wouldn't the husband being fired result in a qualifying change for the woman, allowing her to enroll on her employer's insurance plan, thus covering the pregnancy?
    - mikestew 7y ago
      Or COBRA, unless you expect your pregnancy to last longer than 18 months.
      - golover721 7y ago
        COBRA these days ends up being way too expensive for most people to afford. Perhaps at one time it was a useful regulation. Now it is pretty unaffordable.
fzeroracer 7y ago
My family went bankrupt because the insurance companies decided my mother having a stroke and falling down the stairs constituted a pre-existing condition. I don't think people understand how pervasive the usage of pre-existing condition bullshit was used to deny payment.
- FireBeyond 7y ago
  Oh yes. One of my "favorite" stories of this was: "You didn't know you had X. It had never been diagnosed. But looking at your history, your treatment for 'unknown ailments' and such were actually symptoms of X, in other words you had X, though you didn't know it. And when you signed up for insurance, you 'failed to disclose' this condition [that you didn't know you had], therefore, we are voiding your coverage effective immediately [and should consider yourself lucky if we don't try to 'recover costs'...]".
basetop 7y ago
I agree. The pre-ACA healthcare system worked well ( maybe not great but well ) for 80% of the population and not so well for 20% of the population. We paid less premium for far less co-pay, deductible, etc overall. Feels like the ACA made things worse for the 80% in order to make things better for the 20%.
llamataboot 7y ago
All of us with pre-existing conditions that couldn't buy insurance no matter the cost feel different of course, but you acknowledge that. I'm interested in why you think ACA itself has made anything worse. Surely premiums have gotten worse, but it's not clear to me how it is nec linked to the ACA. (And it should be said that the insurance industry basically wrote large portions of the ACA, and arguably its weakest parts or because of that!)
- weberc2 7y ago
  ACA requires insurers to cover pre-existing conditions. That's a cost that needs to be recovered, and most of that additional coverage comes by increasing premiums. Ergo, ACA increases premiums.
dominotw 7y ago
COBRA is cheaper for me than ACA.
- jowiar 7y ago
  If your previous employer had a cheaper risk pool than the general public, it makes sense that this could be the case. Fair warning: if you’re doing this while self-employed, there are tax issues that may make getting a plan on the exchange cheaper.
FireBeyond 7y ago
That's excellent, and really contributed to your quality of life. I on the other hand had "excellent" employer-provided healthcare. But when a routine kidney stone (my first) ended up having (pre-existing, not as a result of procedures) infection and I had three procedures for it, two in the OR, the bill ended up being the best part of $100,000, which I had to come up with co-pays and others to the tune of nearly $8,000. For a kidney stone. Something that (touch wood) I might not have again, but could also have dozens through my life.
- mrosett 7y ago
  My sense is that your experience is becoming more and more common. As far as I can tell, co-pays, deductibles, etc have been going up dramatically over the last few years (as the original article points out.)
trashface 7y ago
The ACA barely touched employer-based insurance. It definitely did not make things "modestly worse for most people". You are blaming the ACA for problems that existed in the health care system before the law went into effect. Any degradation of care for "most people" is because of crazy year-over-year cost increases that were already happening. And the people who had pre-existing conditions before the ACA were well and truly screwed. That didn't mean insurance was expensive for them - it meant insurers wouldn't sell them insurance at any price. My personal anecdote: Pre-ACA, I was denied insurance by Aetna at age 35 because I had "acid reflux" and I had injured my neck in my 20s (even though I had no problems with it at the time). Then all the other insurers denied me, because the first question on any application was, have you ever been denied for health insurance? The annoying thing was the ACA had already been passed, but had not gone into effect yet - so until that happened, I guess it was just business as usual for the insurers.
skwb 7y ago
Not in the least. Just to name a few of the ways the ACA changed things in the right direction for most "normal" ESI: - ACA threw out lifetime nor annual limits [0] - Essential benefits ensuring you have a more comprehensive plan that covers actual health insurance [1] - Ability to stay on a parent's insurance until you're 26 [2] - For every $1.00 your insurance company takes in from premiums, $0.80 has to be spent on patient care [3] - There's a max of a 3:1 ratio of age rating for health insurance premiums, irrespective of your health. It used to be that insurance companies would raise your premium or even cancel your policy if you got a costly disease like cancer [4]. The problem with your secular analysis is that there is not positive control for the "what if?" without these sort of policies. Most healthcare economists suspect it would have been even worse without the (somewhat modest) regulations that were imposed by the ACA. Again, this is high level policy analysis that requires dedicated study, and there's lots of evidence that the market has highly benefited consumers across most socioeconomic strata. [0]. https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/index.html https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/... [1]. https://www.healthcare.gov/glossary/essential-health-benefits/ https://www.healthcare.gov/glossary/essential-health-benefit... [2]. https://www.healthcare.gov/young-adults/children-under-26/ https://www.healthcare.gov/young-adults/children-under-26/ [3]. https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/ https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/ [4]. http://us.milliman.com/uploadedFiles/insight/2017/MillimanACAAgeBands_0131_Final.pdf http://us.milliman.com/uploadedFiles/insight/2017/MillimanAC...
thatoneuser 7y ago
You're right. Know why you're caveating this and tip toeing? Cuz ACA had a huge propaganda/rhetoric element to it. Even after it was an abysmal failure for most, politicians behind it kept pushing it like it was just a matter of time before it improved. It had a few good components but for the tradeoffs it wasn't worth it. (No Preexisting conditions should have always been a thing). This is the world we live in. People have to apologize while expressing perfectly reasonable objections.

duxup 7y ago

How so? The choice of covering crappy plans is the employer's choice... and crappy plans are what have been pushed AFTER the ACA was passed. Largely by the GoP... Is that what the ACA was, or what someone(s) who want it to fail want? There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall.

mdorazio 7y ago
The parent comment is exaggerated, but I think the point is that prior to ACA, employer-provided plans tended to be cheaper and have lower deductibles largely because insurance companies were able to drop or deny coverage whenever they felt like it for individual plans to keep their margins up. While logically true, this is roughly equivalent to hearing from an old coworker that South Africa was a great place to be white under apartheid... I think it's also worth exploring how much of the difference in financial cost of health insurance plans is due to time + annual overall increases in healthcare cost in the US. ACA was passed 9 years ago. Even under the previous 9 year annual percentage increase averages, you would expect healthcare costs to be at least 20% more expensive than they were in 2010, regardless of ACA.
- WalterSear 7y ago
  It's more extreme than your example. The parent is ignoring the fact his great healthcare experience is predicated on them being able to drop him the moment they could, when his illness became too expensive. Ending pre-existing conditions was the game changer in the AMA. Treating people is obviously more expensive than not treating them.
  - mrosett 7y ago
    That's just not how it worked with employer insurance. Perhaps they could drop your whole company, but the insurer couldn't unilaterally cancel a single employee's plan.
    - pnutjam 7y ago
      No, but sick individuals, or those with sick family members are lousy employees... wink... wink..
    - WalterSear 7y ago
      https://www.chicagobusiness.com/article/20140918/NEWS03/140919814/centegra-sued-after-firing-employees-with-high-health-care-bills https://www.chicagobusiness.com/article/20140918/NEWS03/1409...
    - Someone1234 7y ago
      I know someone who pre-ACA had employer insurance who was dropped by that insurance after they got skin cancer. The official reason was lying during the application process (10+ years earlier). They forgot to list childhood Asthma on their application form ten years earlier.
      - mrosett 7y ago
        Would the ACA prevent that kind of scam? I genuinely don't know.
        7y ago
mrosett 7y ago
> There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall. The ACA fundamentally shifted the landscape for the whole healthcare system with minimum coverage mandates (including employer plans), guaranteed issue, etc. It's also led to higher demand for medical services (ie because more people are covered - a good thing) at a time when the number of doctors has stayed fixed. The net result is that health coverage is simply more expensive. One way that could have played out would be employers eating the higher premiums themselves (which is essentially giving everyone a raise.) Anecdotally, it seems the way it's played out is that employers have kept paying roughly the same amount while employees have either paid higher premiums or received higher deductibles.
- duxup 7y ago
  The trend of higher and higher medical costs, employer plans trending down as far as benefits and up as far as costs was established long before the ACA.
- deleted 7y ago
  [deleted]
- jeffal 7y ago
  My employers have been complaining about skyrocketing health insurance costs since my first job in 1998. This all predates the ACA by at least 20 years.
jandrewrogers 7y ago
The cost to employers of very good plans massively increased after ACA went into effect. When this changeover happened, I was running a company where we paid 100% for one of the best healthcare plans available in the state for both the employees and their families -- people really appreciated this benefit. This was the polar opposite of a "crappy plan", and it wasn't inexpensive to begin with. After the ACA, this plan became so expensive so quickly that continuing this plan became nearly untenable financially and now these types of plans have become increasingly unavailable in any case due to that cost escalation. If you were formerly on one of these plans, of course the post-ACA environment seems like a big step backward. This happened in one of the deepest of blue states; the Republicans can't be blamed for the destruction of health insurance benefits here because they were never involved. The cost of healthcare here has not risen nearly as fast as the cost of providing top-tier healthcare benefits did.
- pnutjam 7y ago
  What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps. Even with the ACA, employers have the best of both worlds. Expensive older people are covered by the government, and anyone who gets to expensive can be shuffled off with a little cover and the joy of "at-will" employment.
  - jandrewrogers 7y ago
    The lifetime max was multiple millions, I don't remember the exact number. As I stated, it was just about the best policy available for any amount of money. There is no credible way to spin this as actually being worse for those employees. I like to hire "expensive older" engineers, so dialing healthcare benefits up to eleven was intended to attract that kind of employee. All insurance policies have implicit lifetime maximums, unless the laws of economics and finance have been repealed.
  - rayiner 7y ago
    > What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps. Note that lifetime caps are a lot more generous than what they have in say the UK, where you don’t get treatment if it costs more than $50-75k per year of extended life. (So to blow through a million dollars, the treatment would have to be expected to produce 15-20 years of extra healthy life. Most treatments offered when people “need it the most” can’t make that sort of promise).

deleted 7y ago

[deleted]

tptacek 7y ago

I'm not seeing the connection to the ACA in your argument. If your argument is that the ACA raised the price of health insurance, that's incorrect: health insurance premiums had been skyrocketing prior to the ACA (that crisis was what generated the political capital to pass the bill), and the ACA in fact reduced the rate of growth in health care costs.

sithlord 7y ago
In my previous career, I was an accountant, and I worked for a health insurance company, you are straight up uniformed if you do not think that ACA raised the the cost of insurance. With that said, as a type 1 diabetic, without ACA it would be impossible for me to get insurance outside of employment, so i think there is some good in it, just needs to be actually thought through, unlike what the administration did that put it in place.
- bliblah 7y ago
  >> just needs to be actually thought through, It's impossible because you both political parties want exclusively mutual results You can't have cheap insurance without making it mandatory since only the sick will get it You can't have easily accessible insurance without forcing healthcare companies to comply with new regulations forcing them to increase costs You can't have good insurance if you aren't willing to pay the market price which happens to be very inflated in the US You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts Overall, it's a shitshow that will keep being patchworked every time the administration changes between parties.
  - civility 7y ago
    > You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts Here is the fundamental problem from my point of view. Compare human medical costs to veterinary costs. Yes, people expect a slightly higher standard for themselves than they do their animals, but you can get a major knee surgery for your dog for a small fraction of what they charge for humans. The process is performed in a sterile environment by professionals in either case. We're smarter than animals on average, but our bodies and medical needs aren't vastly different. The problem is price gouging because the providers and insurance companies know we have no real ability to shop around. They conspire with each other to publish false rates when the true costs are much lower after you agree to them. You could maybe solve this with regulation on prices (a socialist approach), but you could also solve it by mandating they advertise true prices and re-enable competition (a capitalist approach). Either way could fix this, and the problem is corruption (lobbying) not party ideology.

qqqwerty 7y ago

High deductible plans started becoming popular due to the Medicare Modernization Act[1], not the ACA. [1] https://en.wikipedia.org/wiki/Medicare_Prescription_Drug,_Improvement,_and_Modernization_Act https://en.wikipedia.org/wiki/Medicare_Prescription_Drug,_Im...

rockinghigh 7y ago

The increase in high-deductible health plans (HDHP) enrollment predates the ACA by many years. You can look at the trend here: https://www.cdc.gov/nchs/products/databriefs/db317.htm https://www.cdc.gov/nchs/products/databriefs/db317.htm Their role is to protect against very high bill of $5,000 and up due to major surgeries, illness, pregnancy, and so on. They should definitely be completed by a health savings account (HSA) for day-to-day coverage.

mrosett 7y ago
That's interesting data. Thanks for sharing it. In the 2017 snapshot, I'm surprised to see that HDHP plans are slightly more common for high-income families. I didn't expect that. There's a missing variable here: What are the premiums? HDHPs are attractive to insurers (and by extension employers) because they increase employee sensitivity to healthcare costs and may lead to less wasteful spending. Advocates emphasized that the savings on premiums could be passed on employees as HSA contributions [1]. But as that chart shows, a quarter of Americans have an HDHP without an HSA, and at every point most HDHPs haven't come with an HSA. Are employers just keeping the premium savings? Or have rising healthcare costs meant that the savings haven't materialized? [1]: https://www.wsj.com/articles/SB10001424052970204251404574342170072865070 https://www.wsj.com/articles/SB10001424052970204251404574342...
- ctchocula 7y ago
  I imagine it's because it provides a way to sock away $7k each year in a retirement fund that can be invested in index funds and won't get taxed after 65 on qualified medical expenses making it more valuable than either traditional or Roth IRAs that get taxed on withdrawal and when you put the money in respectively. High-income families have the spare cash to do that, so for them it's a valuable investment vehicle.
- brewdad 7y ago
  My wife's employer covers our family under an HDHP. Our out of pocket cost is 0. Our plan requires us to have an HSA, though I don't thinkone is required to contribute to it. We contribute the max $ to our HSA each year. A more traditional plan would run us about $4-5 thousand annually in payroll deductions. Most years we spend far less than our HSA contributions and can roll that money over year to year and even invest it. The one year she needed major surgery, we hit out OOP max and probably spent about $10,000 total from our HSA. Probably our biggest risk exposure would be if one of us needed to take an expensive prescription since I don't think there is any annual limit on those costs.

jseliger 7y ago

But it's been tough for people who were already covered by employer insurance. Yes. The only word I disagree with in the headline is "start." The squeeze started years ago. One way to look at the problem is this way: http://seliger.com/2018/11/11/health-insurance-security-fqhcs/ http://seliger.com/2018/11/11/health-insurance-security-fqhc...: In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits. I am not a fan of the word "unsustainable," but it seems to apply here.

pnutjam 7y ago
That's not necessarily true, the discounts that insurance companies negotiate can be huge, but it's hard to include that since prices are so inflated to begin with.
rayiner 7y ago
At least that premium is totally reasonable. In Germany, the health insurance tax is 15%, half paid by the employer and half by the employer (and it’s not progressive like the ACA subsidy). $4,500 per year is 7% of income, lower than what the employer-side tax alone would be in Germany.
- mikestew 7y ago
  Now do the math when you include total out-of-pocket. My napkin says: "Considerably more than 15%". (Unless I misremember, and the 15% German tax doesn't cover the vast majority of cost.) Not to dismiss your point completely, but I could sell you insurance for $1/year, but your total out-of-pocket cost is going to be considerably more than $1.
  - rayiner 7y ago
    The out-of-pocket max is something you’re likely to hit only if you get sick. The 15% is something you have to pay every year.

JMTQp8lwXL 7y ago

Pre ACA, pre-existing conditions could disqualify you from insurance. People with pre-existing conditions are the people that need health care coverage the most. We can't under-weigh the moral obligation we have to this previously marginalized group, when considering service may be slightly worse for people who have employer coverage. How I see it: if you were in the pre-ACA pre-existing condition pool, your perspective would be vastly biased in a different direction. And nobody wants to end up in that pool. Nobody chooses that. That's why it's a net win overall. People died because they don't have coverage (unfortunately, still happens, but substantially decreased by ACA). If things are slightly worse for people who already had access, It's such a small price to pay.

WrtCdEvrydy 7y ago
My favorite one was pregnancy being a pre-existing condition so if your husband got fired (noone would ever fire a pregnant woman for no reason), you couldn't get insurance when you needed it the most.
- frenchman_in_ny 7y ago
  Though (if both spouses were working & had access to employer sponsored insurance), wouldn't the husband being fired result in a qualifying change for the woman, allowing her to enroll on her employer's insurance plan, thus covering the pregnancy?
  - mikestew 7y ago
    Or COBRA, unless you expect your pregnancy to last longer than 18 months.
    - golover721 7y ago
      COBRA these days ends up being way too expensive for most people to afford. Perhaps at one time it was a useful regulation. Now it is pretty unaffordable.

fzeroracer 7y ago

My family went bankrupt because the insurance companies decided my mother having a stroke and falling down the stairs constituted a pre-existing condition. I don't think people understand how pervasive the usage of pre-existing condition bullshit was used to deny payment.

FireBeyond 7y ago
Oh yes. One of my "favorite" stories of this was: "You didn't know you had X. It had never been diagnosed. But looking at your history, your treatment for 'unknown ailments' and such were actually symptoms of X, in other words you had X, though you didn't know it. And when you signed up for insurance, you 'failed to disclose' this condition [that you didn't know you had], therefore, we are voiding your coverage effective immediately [and should consider yourself lucky if we don't try to 'recover costs'...]".

basetop 7y ago

I agree. The pre-ACA healthcare system worked well ( maybe not great but well ) for 80% of the population and not so well for 20% of the population. We paid less premium for far less co-pay, deductible, etc overall. Feels like the ACA made things worse for the 80% in order to make things better for the 20%.

llamataboot 7y ago

All of us with pre-existing conditions that couldn't buy insurance no matter the cost feel different of course, but you acknowledge that. I'm interested in why you think ACA itself has made anything worse. Surely premiums have gotten worse, but it's not clear to me how it is nec linked to the ACA. (And it should be said that the insurance industry basically wrote large portions of the ACA, and arguably its weakest parts or because of that!)

weberc2 7y ago
ACA requires insurers to cover pre-existing conditions. That's a cost that needs to be recovered, and most of that additional coverage comes by increasing premiums. Ergo, ACA increases premiums.

dominotw 7y ago

COBRA is cheaper for me than ACA.

jowiar 7y ago
If your previous employer had a cheaper risk pool than the general public, it makes sense that this could be the case. Fair warning: if you’re doing this while self-employed, there are tax issues that may make getting a plan on the exchange cheaper.

FireBeyond 7y ago

That's excellent, and really contributed to your quality of life. I on the other hand had "excellent" employer-provided healthcare. But when a routine kidney stone (my first) ended up having (pre-existing, not as a result of procedures) infection and I had three procedures for it, two in the OR, the bill ended up being the best part of $100,000, which I had to come up with co-pays and others to the tune of nearly $8,000. For a kidney stone. Something that (touch wood) I might not have again, but could also have dozens through my life.

mrosett 7y ago
My sense is that your experience is becoming more and more common. As far as I can tell, co-pays, deductibles, etc have been going up dramatically over the last few years (as the original article points out.)

trashface 7y ago

The ACA barely touched employer-based insurance. It definitely did not make things "modestly worse for most people". You are blaming the ACA for problems that existed in the health care system before the law went into effect. Any degradation of care for "most people" is because of crazy year-over-year cost increases that were already happening. And the people who had pre-existing conditions before the ACA were well and truly screwed. That didn't mean insurance was expensive for them - it meant insurers wouldn't sell them insurance at any price. My personal anecdote: Pre-ACA, I was denied insurance by Aetna at age 35 because I had "acid reflux" and I had injured my neck in my 20s (even though I had no problems with it at the time). Then all the other insurers denied me, because the first question on any application was, have you ever been denied for health insurance? The annoying thing was the ACA had already been passed, but had not gone into effect yet - so until that happened, I guess it was just business as usual for the insurers.

skwb 7y ago

Not in the least. Just to name a few of the ways the ACA changed things in the right direction for most "normal" ESI: - ACA threw out lifetime nor annual limits [0] - Essential benefits ensuring you have a more comprehensive plan that covers actual health insurance [1] - Ability to stay on a parent's insurance until you're 26 [2] - For every $1.00 your insurance company takes in from premiums, $0.80 has to be spent on patient care [3] - There's a max of a 3:1 ratio of age rating for health insurance premiums, irrespective of your health. It used to be that insurance companies would raise your premium or even cancel your policy if you got a costly disease like cancer [4]. The problem with your secular analysis is that there is not positive control for the "what if?" without these sort of policies. Most healthcare economists suspect it would have been even worse without the (somewhat modest) regulations that were imposed by the ACA. Again, this is high level policy analysis that requires dedicated study, and there's lots of evidence that the market has highly benefited consumers across most socioeconomic strata. [0]. https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/index.html https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/... [1]. https://www.healthcare.gov/glossary/essential-health-benefits/ https://www.healthcare.gov/glossary/essential-health-benefit... [2]. https://www.healthcare.gov/young-adults/children-under-26/ https://www.healthcare.gov/young-adults/children-under-26/ [3]. https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/ https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/ [4]. http://us.milliman.com/uploadedFiles/insight/2017/MillimanACAAgeBands_0131_Final.pdf http://us.milliman.com/uploadedFiles/insight/2017/MillimanAC...

thatoneuser 7y ago

You're right. Know why you're caveating this and tip toeing? Cuz ACA had a huge propaganda/rhetoric element to it. Even after it was an abysmal failure for most, politicians behind it kept pushing it like it was just a matter of time before it improved. It had a few good components but for the tradeoffs it wasn't worth it. (No Preexisting conditions should have always been a thing). This is the world we live in. People have to apologize while expressing perfectly reasonable objections.