From the comments

by on April 17, 2014 at 2:17 pm in Current Affairs, Law, Medicine | Permalink

This is from John B. Chilton:

For those who don’t click through this is what Tyler wrote:

“6. The exchanges will be mostly working by March 2014, but by then the risk pool will be dysfunctional. In the meantime, real net prices will creep up, if only through implicit rationing and restrictions on provider networks. The Obama administration will attempt to address this problem — unsuccessfully — through additional regulation.”

The simple answer to Christian’s query (“I’m curious how you stand now given current enrollment numbers and your previous prediction about a dysfunctional exchange.”) is that it’s not the enrollment numbers that matter, it’s the risk pool.

The jury’s out on the risk pool — lots of opinions out there on whether exchange premiums will go up for 2015.

Here is Ross Douthat on how will we know if Obamacare is working?  It is the best post on this debate so far.  He closes with this:

I’ll lay down this marker for the future: If, in 2023, the uninsured rate is where the C.B.O. currently projects or lower, health inflation’s five-year average is running below the post-World War II norm, and the trend in the age-adjusted mortality rate shows a positive alteration starting right about now, I will write a post (or send out a Singularity-wide transmission, maybe) entitled “I Was Wrong About Obamacare” — or, if he prefers, just “Ezra Klein Was Right.”

joan April 17, 2014 at 2:26 pm

Age adjusted mortality rate is not a good marker since the increasing number of fat people will have a greater effect on that than the medical care people receive.

Jan April 17, 2014 at 6:10 pm

Props to Ross for laying something out there, though I agree obesity trends could determine a lot wrt mortality.

For example, this CBO report on long-term care cost projections basically said that spending on long-term care could either almost triple by 2050 (>3% of GPD) or less than double, all depending on whether people get more or less obese. http://www.cbo.gov/sites/default/files/cbofiles/attachments/44363-LTC.pdf

Marie April 17, 2014 at 9:14 pm

I don’t see why obesity should be exempted. I thought the argument was that people are generally healthier with insurance (or Medicaid). So if having insurance gives me some protection against cancer, against car accident injuries, against mumps, then why shouldn’t it give me the same kind of protection against the diseases “linked” to obesity?

Sure, those diseases are today’s cross to bear, but yesterday’s cross to bear was infectious disease, and before that diseases of malnutrition, right? What kind of health care improvement plan would it have been in the Middle Ages if we’d said it’s a success if deaths go down — except infant mortality and plague deaths?

It kind of points out the bizarre nature of the claim, that having insurance makes you more likely to stay healthier and die later. Seems to me that having, I don’t know, vaccines and good food and medicine and quality doctors — that sort of thing — would make you healthier and help you live longer. But if that’s the claim, I don’t see why our modern maladies should be exempted since we live in modern times.

Jan April 17, 2014 at 10:43 pm

Obesity isn’t being exempted. I am saying it is bizarre that Douthat would judge success–well, one of his three criteria for success–of the law on health outcomes that are determined by many factors, only one of which is access to health care. If obesity increases significantly, especially among older people, health outcomes aren’t going to be as good as they otherwise would have been.

Insurance isn’t an anti-obesity measure, so if some other external factors cause it to rise and kill more people, it would be stupid to conclude the ACA is a failure based on that. Insurance of course can help mitigate the impact of related disease, but it isn’t a cure-all.

I’d note that the same logic would apply to increased smoking, reductions in exercise, more drug use, etc., but obesity is the biggest threat right now.

Jan April 17, 2014 at 10:52 pm

To be clear, I would say the same thing about your other examples. I do not claim that more health insurance would guarantee that the mortality rate would decrease despite some significant increase in cancer rates or long-term growth in serious car accidents.

And I am not sure why Douthat is choosing that criteria. Did I miss Obama talking about decreased mortality when he touted the health law in 2010? I’m not saying nobody made that claim, but I don’t remember hearing it.

Joe Smith April 17, 2014 at 2:49 pm

The US apparently has the highest medical spending in the G7 and the worst outcomes.

ObamaCare is the last hope for a private sector medical system in the US. If it fails then some version of single payer will be the alternative.

Ad Nauseum April 17, 2014 at 3:53 pm

Adjust for homicide, suicide, and other factors that medical care has no power over. Then, look at the numbers.

Joe Smith April 17, 2014 at 4:49 pm

Medical care can have a big impact on homicide rates. I know of one city where the homicide went down from one year to the next and when it was investigated it turned out the improvement was just a consequence of the major urban hospital getting better at dealing with stab wounds.

Ad Nauseum April 17, 2014 at 4:58 pm
Jon April 17, 2014 at 5:07 pm

That piece is fatally flawed. The most obvious example is prostate cancer; most prostate cancers never kill anyone. Diagnosing more of those will increase the five year survival rate. Similar issues apply to other cancers.

Also, as Joe Smith pointed out, outcomes of accidents and assaults do depend on the quality of medical care.

Another challenge– the relative life expectancy performance in the US improves when the age exceeds 65 (I don’t have the source handy). But that is the group we treat most like other countries do.

andrew' April 17, 2014 at 5:25 pm

How does aca affect accident and violence outcomes?

You are assuming stabbing victims are being denied care? That has nothing to do with treatment outcomes.

Joe is wrong. US is ahead on many outcomes.

The point about gross life expectancy is that it is a bad indicator. Certainly for not controlling obvious factors and probably after some arbitrary age that also conflates accidents and violence affects differences based on age. The same traumas that decrease with age also make life expectancy after age x increase.

Ad Nauseum April 17, 2014 at 5:47 pm

Jon, outcomes of accidents and assaults depend only if the person/people involved are lucky enough not to have fatal wounds. If you have a higher rate of accidents and attempted homicides, you will have a higher death rate. And did you seriously just claim that cancer, including prostate cancer, doesn’t kill anyone? Wow! Then why treat it?

As for your other challenge, why cherry pick the U.S only? And why compare the 65+ population to the entire population in other nations? Apples to apples would be preferable. What is the life expectancy of those 65+ in the “other countries” that you speak of? (I believe it’s lower in most cases) Why is that?

Errorr April 17, 2014 at 10:41 pm

Every single male will eventually have prostate cancer if they live long enough. By age 100 it to is basically 100% so using cancer survival statistics are terrible. Many rates of sicknesses should go up as they are caught in people with health care now.

Cliff April 17, 2014 at 11:55 pm

Yeah, that’s a good rule of thumb when comparing health care systems- IGNORE CANCER. Lets see how much we have to contort to get our preferred result that America sucks. Should we ignore heart disease as well?

Ad Nauseum April 17, 2014 at 5:01 pm

You obviously didn’t adjust for those numbers. The data is there, you just have to pay attention to it.

jon April 17, 2014 at 5:40 pm

Andrew and Ad Nauseum: The outcome numbers were not cited to prove the aca is working–they are cited as part of the debate on how efficient our health care system is.

Accident and violence outcomes depend on the quality of the immediate care, and the quality of followup care.

More importantly, strip out the deaths from accidents, and let us assume the higher health expectancy numbers that Avik Roy cites are correct and entirely due to our health care system. How much are we paying for the additional few months of life expectancy? Can you do the calculation and report back what you find?

Ad Nauseum April 17, 2014 at 5:56 pm

Jon, I was replying to Joe Smith’s assertion that “The US apparently has the highest medical spending in the G7 and the worst outcomes.” That argument has been repeated ad nauseum since the beginning of the ACA debate, and is misleading. Outcomes in the U.S are not “the worst” after adjusting for appropriate factors. That is why I cited that article.

Quality of immediate care can only go so far for accidents and violence. That is one reason why we rocket to the top after adjusting for those factors. Haven’t you heard of a driver being “dead at the scene of an accident”? If resurrection was a health procedure, you’d have a better argument.

Dealing with our higher cost is a different argument with many factors, and many possible solutions.

David Wright April 17, 2014 at 4:13 pm

Lots of countries have much better outcome/spending levels and are not single-payer.

Take Germany. Most doctors are in private practice, most hospitals are private non-profits; very few are employed by the government. There are “public option” insurers (AOK) but they are government-sponsored enterprises (like Fanny Mae), not government agencies; their premiums must cover their costs. There are also plenty of private insurance companies that they compete with. Different insurance packages do offer different levels of coverage. (Birth control coverage, though, is pretty much unheard of.) As with Obamacare, there is an employer mandate, an individual mandate, and premium subsidies for those with low income.

I gather than Japan is similar, although their “public option” insurers are branch of government — local government though, not national. Switzerland is also not single-payer. Nor is Singapore.

Canada and Britain are often called “single-payer”, although “single-supplier” would be a better term: most hospitals are directly run by the government and most doctors are government employees. There is no “insurance company” layer at all, at least for covered services, because the government pays for these facilities and services directly out of general tax revenue.

The most concrete “single payer” proposal from the left in the US, the one for which the term was invented, was that providers would continue to be private but the government would run a big insurance company from which everyone would be required to buy a policy. There would still be bills from providers and premiums from customers, subsidized by income in a fashion similar to Obamacare. I actually don’t know any other country that follows a model like this, although the French system (which I don’t know as well as the others I’ve mentioned) might be close.

Joe Smith April 17, 2014 at 4:47 pm

In Canada, most doctors are independent but bill the government on a fee for service basis and most of their revenue comes from the government medical plan.

Thomas April 17, 2014 at 6:32 pm

Joe, you can’t seem to run fast enough away from your false assertions regarding health outcomes.

Errorr April 17, 2014 at 10:43 pm

German politics has always had a very strong catholic element amongst certain groups which is why birth control isn’t universal there.

Jim April 18, 2014 at 4:47 pm

Actually I don’t think there is a country with better outcomes from medical care than the US. Spending levels are another matter.

andrew' April 17, 2014 at 5:14 pm

How does aca improve stabbing outcomes exactly?

How does the panoply of public versus private spending worldwide improve their stabbing outcomes versus ours?

jon April 17, 2014 at 8:14 pm

Ad nauseam: The article you cite is an opinion piece by a partisan, not a reproduced scrutinized or peer reviewed analysis. It is far from the final word

Dan Lavatan April 17, 2014 at 8:32 pm

There are a lot of alternatives, however you bring up a good point – the uninsured rate doesn’t matter at all, only disability-adjusted longevity and health spending as a percentage of GDP. Spending would need to be under 4% of GDP to be considered a success – I don’t consider this very likely. Nothing can probably be done to move longevity higher in the next few years, and spending would have to be cut even further for it to go down.

Buford Puser April 17, 2014 at 2:50 pm

Douhat: “If, in 2023…”
So the smartest thing anyone has said about the success or failure of Obamacare is that we can’t possibly know if it’s is working until 2023?
“Holy moving the goalposts, Batman!” Or “Golly, that jury is gonna be out for a long time, Peabody!” (Bullwinkle reference for you kids)

Julian April 17, 2014 at 3:03 pm

So Obamacare can’t be declared a success until 2023? Then it shouldn’t be declared a failure before the same deadline either.

Willitts April 17, 2014 at 5:59 pm

I can’t declare an airplane trip a success until it lands.

I can declare it a failure the moment the plane explodes.

dead serious April 17, 2014 at 6:22 pm

Which it hasn’t, so back to the analogy bookstacks with ya.

David C April 18, 2014 at 12:32 am

Everybody’s a critic; even post-mortem.

Michael April 17, 2014 at 3:16 pm

And to think people used to make fun of Friedman for always insisting that we needed another 6 months to evaluate the Iraq war. Maybe we can one day add the “Douthat Unit” along side the “Friedman Unit” in the NY Times Pundit Metric System.

http://en.wikipedia.org/wiki/Friedman_Unit

Ad Nauseum April 17, 2014 at 3:55 pm

Well, it took a few decades to find out that the faults in our Social Security system were real…..

jon April 18, 2014 at 6:59 am

A few…it has been around now for about 80 years and is still highly popular…no doubt it will change, but for most people the faults of not having one would be far more intolerable.

Roy April 17, 2014 at 4:32 pm

Douthat said that he would declare it a success then, if it met his metric, he didn’t say you had to, and he said nothing about not being able to know if it was working before then. Douthat is actually on the right as that is generally understood, and opposed Obamacare

Beefcake the Mighty April 18, 2014 at 12:12 am

Tyler = tool

Matt April 17, 2014 at 2:55 pm

A point perhaps similar to Bufords- it seems very unlikely that “Obamacare” will not have been modified in quite a number of ways, making it difficult, if not impossible, to say how much any changes in the things that Douthat mentions are due to any particular part of the current plan. I’d like to think he must know this, but I’m not sure. What interpretation is better for treating him as being honest, I don’t know, but none of them seem very flattering to him.

Buford Puser April 17, 2014 at 3:24 pm

It seems equally unlikely anyone will still care about Douhat’s opinion in 2023.

Willitts April 17, 2014 at 6:08 pm

I think it is a more honest opinion than people on either side are making about whether it is a success right now. He at least laid out measurable criteria and a time horizon. He didnt set benchmarks that were unreasonable.

Will anyone care about Ross’ opinion in nine years? Probably not. But he sets a good example here and now.

Beefcake the Mighty April 18, 2014 at 12:13 am

I don’t give two shits about it now.

pcm4 April 17, 2014 at 2:58 pm

Why does health inflation matter? The primary goal of the bill was to reduce the population of uninsured. I haven’t read a credible argument as to why health inflation would increase as a result of the bill and frankly given how watered down the cost control measures are I’d find it hard to attribute any significant decrease to the bill either.

Michael April 17, 2014 at 3:09 pm

And most people probably don’t look past their own premiums. Pre-ACA, premiums for employer-sponsored plans usually increased by 5 or 6% per year, outpacing wage growth and inflation (and much higher than the series Douthat links to). That’ll be the cost metric most families will probably notice. Although, talk to some people these days, and they act like their premiums never used to see annual increases.

Marie April 17, 2014 at 5:11 pm

No, they’ll certainly note that health insurance was too costly and increased stupidly.

6% a year is dumb.

After ACA started getting out the door, we saw 15 to 20% each year on our policies.

January last year, saw a 100% increase in our premiums.

Lots of folks, I’ll grant you, were perfectly happy with the previous status quo, and I agree that was a narrow view — the previous system was also a mess.

Far more were imperfectly happy, and would have been glad to see a good reform, they just don’t think this is one.

dead serious April 17, 2014 at 6:27 pm

Pre-ACA my premia were rising a good 10%+ per year and with diminishing coverage each and every year in the form of larger co-pays, higher co-insurance, less coverage of actual treatment, and so on.

I’ve worked for some pretty large companies and have reason to doubt that my experience is the outlier.

Marie April 17, 2014 at 7:03 pm

@dead serious,
Not shocked if that was the case, but were you paying the premiums or a portion of the premiums? Are you sure the employers didn’t just make you cover the extra costs plus a little of the old costs each year? Seems like a good way to effectively cut worker pay during a depression while making it look like the insurance company’s bad.

I was seeing the full premium costs and calculating off that, although I took the 6% from Michael.

dead serious April 17, 2014 at 7:53 pm

I guess that’s a fair question, and one I hadn’t even considered. The effects were felt company-wide from MDs down to the plebes, though – and these were (are) Wall Street companies – so I don’t think this was a way to cut worker pay. I’m talking about a decade+ long trend, through great years and past the meltdown, where my costs went up a good 10+ % a year and coverage waned YoY.

byomtov April 17, 2014 at 9:05 pm

Of course he was paying th premiums. If your employer cuts your pay to let the comapny met the higher premium then you are paying it, regardless of who writes the check.

Marie April 17, 2014 at 9:17 pm

@dead serious,
I can see it being fully premium increases, it’s definitely possible.

JWatts April 17, 2014 at 9:30 pm

According to Kaiser, from 1991-2009 average healthcare increases averaged 5.3% for the US.

http://kff.org/other/state-ind…..er-capita/

“Government data show that the growth in premiums has tracked directly with the growth in underlying medical costs. Thus, as health care costs increase, so do premiums.”

http://www.ahip.org/Issues/Ris…..Costs.aspx
reply to this

JWatts April 17, 2014 at 9:31 pm
Marie April 17, 2014 at 9:33 pm

@byomtov,

You might reread my comment.

dead serious April 17, 2014 at 6:29 pm

Also, not a fan of Obamacare but am a fan of bringing down healthcare costs through the use of more nurse practitioners, overhaul of licensing schemes, and elimination of middlemen.

Marie April 17, 2014 at 7:04 pm

You’ll get my vote when you run for office. Totally with you there.

Jeff April 17, 2014 at 3:12 pm

Was all that talk about “bending the cost curve” back in 2009 just a bunch of hot air?

pcm4 April 17, 2014 at 3:23 pm

A slight oversimplification, but for all intents and purposes yes. Why? Because you can’t pass a healthcare related bill in this country without waxing poetic about slowing down cost growth. I think best case scenario the cost containment measures in the ACA have a mild effect on cost growth, but certainly nothing to write home about because they are so limited. At the end of the day the meat of the bill (expanding Medicaid, individual mandate and the exchanges) are all about expanding coverage.

Thomas April 17, 2014 at 6:39 pm

It would be pretty foolish to sell a policy which is supposed to reduce the number of people who **can’t afford** insurance by imposing an individual mandate to purchase it. Your “waxing poetic” is more accurately described as intentional deceit.

ThomasH April 18, 2014 at 3:21 pm

Not exactly. It would be foolish to try to correct the problems in a market with adverse section without an individual mandate and subsidies for those who with low incomes. Fortunately the designers ACA was not foolish, at least in that way.

Marie April 19, 2014 at 12:34 pm

ThomasH,
I’ve pointed out before, about 36 states had already solved the problem of pre-existing without mandate, so I hope the designers of ACA were foolish (or ill-informed) since they sold the mandate as a necessity when it was already demonstrated that it was not.

Willitts April 17, 2014 at 6:05 pm

I have yet to hear anyone explain what “bending the cost curve” means.

Jan April 17, 2014 at 8:10 pm

Assuming you’re not being sarcastic, I think a picture might be the easiest way to explain it.

http://www.whitehouse.gov/sites/default/files/omb/assets/blog/curve.gif

When health care spending grows more slowly than it is expected to, based on historic trends and other factors like demographics, then you have bent the cost curve.

AndrewL April 17, 2014 at 3:19 pm

To meet Douthat’s conditions is very simple:
1) make not having insurance a felony, and only count law-abiding citizens in your insured statistics.
2) Impose cost controls and rationing to explicitly bring down health costs (a procedure can’t *cost* more if you don’t even have the option to pay for it).
3) re-define age-adjusted-death rate or 2 outta 3 ain’t bad!

andrew' April 17, 2014 at 5:04 pm

Yeah. He gave away really bad terms.

Success is whether it is cost effective relative to alternatives and consistent with some broad principles if liberty and due process. It has a long way to go.

ThomasH April 18, 2014 at 3:23 pm

Unfortunately, the party that does not agree with ACA has not advanced those alternatives.

rayward April 17, 2014 at 3:57 pm

Obamacare will never get off the ground. Obamacare won’t survive 2014. Obamacare won’t survive 2015. Obamacare won’t survive five years. Obamacare won’t survive 2023. How many times do opponents of Obamacare get to move the goalposts. This is ridiculous, and embarrassing for the opponents of Obamacare. Fundamental changes are occurring in the health care industry (consolidation ind clinical integration included), and opponents of Obamacare engage in wishful thinking. It’s those changes outside the Washington political bubble that economists (and policy makers) should focus on.

AndrewL April 17, 2014 at 4:24 pm

Of course Obamacare can’t fail if you’re allowed to just make it up as you go along. (employer mandate delayed, last day to sing up is November, March, okay if you just say you tried to sign up you can get another delay. We need 14 million insured by march to be a success, okay 7 million insured, okay 7 million enrolled, okay 7 million website visitors, SUCCESS! )

andrew' April 17, 2014 at 5:04 pm

Funny. I don’t feel embarrassed.

derek April 17, 2014 at 6:50 pm

Obamacare has not survived as written. Already. How many mandates and special exclusions have been done by Executive order so far?

Jan April 17, 2014 at 8:15 pm

So it’s done then, right? Ok, you win. Now everyone can start to contribute to making the law better in bipartisan ways, which has finally started to happen: http://news.yahoo.com/gop-seeks-coverage-choices-health-law-hate-120338136.html

Ryan Allen April 17, 2014 at 10:55 pm

No, Obama’s law making by fiat is not over yet. And why is it the GOP’s job to try to make the sh** stink better?

Jan April 17, 2014 at 11:12 pm

Continue to hurt their constituents, that’s the way the GOP can really show ‘em?

Watch how many more states expand Medicaid after this next election.

ThomasH April 18, 2014 at 3:26 pm

It’s still “Obamacare” as long as the GOP want to repeal it. :)

Cliff April 18, 2014 at 12:02 am

Did Russ Douthat say any of those things? If not your comment is a complete non sequitor. If different people had different predictions about the success of Obamacare, that is much to be expected.

Just Some Commenter April 17, 2014 at 4:09 pm

I’d bet the mortality aspectb is largely about population health effects of increased imprisonment:
http://www.yale.edu/ciqle/CIQLEPAPERS/Wildeman%28Crossnational%29.pdf

Scott April 17, 2014 at 4:30 pm

I’ll provide a little first hand experience. I purchased a policy through the exchange. In October, the site never worked. Couldn’t even create a user namel. Beginning of November, I could get logged in and even start to fill out information, but it would crash repeatedly and all my data would be lost so I would have to start over. End of November, I was finally able to complete an application but there was a bug in the system that tried to send me to medicaid (which I don’t qualify for on multiple counts). When I talked to Healthcare.gov, they told me that they couldn’t do anything and that it had to be resolved through the state medicaid office. So I called the medicaid office and they said they can’t do anything cause the system is broken and they never get anything from the exchange. So I called HC.gov again and they said they don’t have any answers, try starting all over. Finally, in mid December, the site functioned well enough to get to the marketplace and select a policy. I did some crunching of numbers to see what plans might be best for my family and narrowed it down to a couple. I spoke with a rep from Anthem who explained some basic info to me, and I made sure our doctors were covered. A few days later, I logged on, finished registration, and then contacted Anthem to pay my first premium.

Fast forward, I didn’t get an insurance card from them until late February, I have repeatedly tried calling them and contacting them through email and have never received a response, they have routinely denied coverage which we discovered (from our drs, not Anthem) that they in fact do not cover our doctors. I am now in the process of filing a grievance with the marketplace and with our state insurance commissioner and praying that this all gets fixed because so far, this has been nothing less than a nightmare. So, there may have been 8 million signed up on the marketplace, but that in no way to me signifies success. From what both my attorney, the marketplace, and the insurance commissioner have all told me, my situation is not particularly unique.

Marie April 17, 2014 at 5:21 pm

Was watching for your story, saw you were one of the few folks on here that seemed to have first hand experience with the exchanges.

Similar story here, lots of work with Medicaid and the exchanges with a ton of confusion. Finally got a good rep from the exchanges and a good rep from Medicaid to sort it out on March 14th. We started the application process in September, 2013. We still don’t have the final result in writing, but I’m thankful that it seems sure we’re settled now until the end of the year.

Yancey Ward April 17, 2014 at 6:08 pm

You can’t rely on the exchanges and insurers to know what the extent of the network is- at least not before buying a policy, and then I suspect a lot of people are in Scott’s shoes- only finding out by having the coverage denied.

On three occasions since October, while considering purchasing a policy, I checked with my usual primary care physician to see if what the insurer was telling me about coverage with that provider was true, and in every case the insurer was telling me something different from what the provider was telling me. It is hard to explain these things- are the insurers just lying in order to get you to buy? You can’t even blame this on the exchanges- the bad information is coming from the companies themselves.

JOhn April 17, 2014 at 6:49 pm

Scott –

Were you previously ensured? If so, how were you covered between October and today? Was your existing plan cancelled?

Just wondering, as it seems from my reading that most ACA applications are either from plans cancelled under ACA or Medicaid enrollees. Of course, who the applicants are is the big unknown.

Marie April 17, 2014 at 9:38 pm

“it seems from my reading that most ACA applications are either from plans cancelled under ACA or Medicaid enrollees”

Many are both.

Our pediatrician office tells me they have had tons of patients move to CHP+ (Medicaid light) after their high risk pool insurance was cancelled. Remember that if you qualify for Medicaid, you are not allowed to get a subsidized ACA plan.

Jan April 17, 2014 at 11:10 pm

I don’t know how expensive high risk pool insurance generally was/is, but I thought CHP was generally a very good deal for parents. CHP has strict caps on how much the state can require in out of pocket spending towards premiums and copays. In many states the copay for a doctor visit is $5 or less.

Marie April 19, 2014 at 8:59 am

Of course CHP will cost parents less than buying insurance. The high risk pools were just regular insurance and they were more costly since it was a pool with higher costs. The state would pay part of the premium if you were lower income, many of these folks may have only paid part of the premium, some may have paid all.

CHP, the state (with federal) pays most of the costs. So, yes, it’s a “good deal” for the parents if someone else is paying.

But my understanding is that the bars for Medicaid and CHP for kids have not changed — Medicaid expansion changed the bar for adults, not kids. So that means that all these folks who are on CHP now could have been on CHP before if they had applied.

So before they could have had CHP or insurance, and they chose insurance. They must have had reasons, don’t you think? Now they can only have CHP.

Scott April 18, 2014 at 8:31 am

I was enrolled in a private health plan before, but because I bought the plan in 2012, it wasn’t grandfathered and thus I would have to pay the fine if I kept it. It wasn’t a huge issue as we were planning on purchasing a different plan anyway, but the exchange turned out to be much worse than what we had anticipated. And it is true that most insurers seem to be saying they cover doctors despite knowing they won’t. I assumed asking the insurer was sufficient but have learned to talk to my doctor’s billing dept instead. They are the only ones that have given me straight answers.

I wonder if the idea is to get as many people to sign up for these trash insurance policies as they can, knowing that a fraction, say 20%, will be upset and take action while the rest will sit back and take it. But if they can keep that 80%, that would be a huge win for both the insurance companies and the proponents of the exchanges.

Adam G. April 17, 2014 at 7:23 pm
Marie April 19, 2014 at 10:52 pm

Very interesting post.
Doubt it’s atypical.
Don’t think anyone cares on either side, much.

andrew' April 17, 2014 at 4:59 pm

It hasn’t worked well enough to have failed yet.

Willitts April 17, 2014 at 6:02 pm

Ross’ challenge is quite bold considering we could meet all of those benchmarks without Obamacare being the “but for” cause.

Typically, the burden of proof for success is on the proponents of a policy.

Thomas April 17, 2014 at 6:43 pm

For most proponents, success was achieved instantaneously when the bill was passed because: regulation is gud.

David C April 17, 2014 at 10:54 pm

Well, when you look at some of the goals, that’s pretty much true. It made it illegal to charge women more than men, for example. So that goal was accomplished by just signing the law. As was making it illegal to deny coverage for pre-existing conditions.

It has achieved the goal of getting more people on insurance too. Even before 2014, there was an uptick from the provision that allowed kids to stay on their parents insurance until they were 25. Now one could argue that having health insurance doesn’t in anyway improve one’s health, but I don’t hear that argument often, and when I do, it isn’t from someone who has decided to forego health insurance.

There are lots of reasons to suspect that all of Douthat’s goals will be met.

Yancey Ward April 17, 2014 at 6:11 pm

One of the things I am looking for in the next two months is for HHS to give numbers of actual purchases of policies on the exchanges. If that data is not forthcoming, then you really can’t trust the 8 million number. I am guessing HHS will claim to not have this information until Hell freezes over.

David C April 17, 2014 at 10:56 pm

And if they don’t, and they produce the number of policies that were purchased, will you concede that sign-ups were higher than you expected?

Jay April 18, 2014 at 1:46 pm

I think the number of previously uninsured from that number would be important as well remembering that 6 million got cancelled due to its provisions. How many are receiving subsidies would also be worth mentioning depending on how important you think the bill to taxpayers is.

Really it depends on what your expectations were. While the law was being passed the 40 million uninsured number was thrown around by supporters. Should we be happy that only 20% of this number, 8 million, signed up for something they’re REQUIRED by law to sign up for?

David C April 19, 2014 at 10:32 pm

No one really knows how many people had their insurance cancelled, but politifact says it’s nowhere near 6 million. They say there were 4.7 million cancellations. Half of those were restored when Obama administratively allowed canceled plans to continue for another year. Many others were moved to new plans, either through their insurance company or by purchasing a new policy on the marketplaces set up for Obamacare.

So the number of people who signed up on Obamacare because their policies were cancelled is less than 2.35 million. Probably much less than that.

How many are receiving subsidies is kind of irrelevant to this discussion unless you’re trying to make a cost-benefit argument about Obamacare. And if that is the case, then that is a real victory for Obamacare. That means it has gone from Death Panels to Government Takeover to Socialism to Trainwreck to “the benefits don’t match the costs.” Which means that there are benefits to the law. A cost-benefit argument is one Obama would be glad to have.

The 40 million number was for 2019. And there is no reason to think it won’t be met. 8 million people got insurance off the Obamacare exchanges, but that is but one way that people can get insurance. They can also get insurance on the off-exhcange market, from Medicaid/CHIP expansion or from their employers. According to acasignups.net, the number of additional people who will have insurance in 2014 because of Obamacare is between 14.4 million and 23.5 million.

txslr April 17, 2014 at 6:37 pm

All we know so far is that the administration has claimed that 7 or 8 million people have done something. We don’t know what they’ve done or who they are; or if the claim is true regardless. The debate is over!

Jay April 18, 2014 at 1:51 pm

In the months leading up to the deadline the HHS sent letters to “potential” sign ups saying they’ve automatically had an application started for them and to log on to the website to complete the sign up. I haven’t heard a followup on whether these auto-enrollies are counted in the number, but if they were that seems pretty insidious.

Chip April 17, 2014 at 7:24 pm

And my prediction is even if it is a failure, the ACA like most entitlements will be almost impossible to revoke.

The question is whether it becomes a national treasure like the UK’s awful NHS or just another govt program hemoraging money without ever solving the initial problem.

Benjamin Cole April 17, 2014 at 8:14 pm

Remember:
ACA=bad
VA=good
The VA is communism in action, curiously enough.

Marie April 17, 2014 at 9:41 pm

I’m sorry, but you must be a young person.
The VA has one of the worst reputations of anything the government has ever done. The horror stories from after Vietnam to about mid-eighties were legend. Only thing with a worse rep, I think, is the BIA. Post office is way down the line from them.
To be fair, I think it has been reformed. Now there is Tricare competing, I don’t know how it fares.

Jan April 17, 2014 at 10:59 pm

The VA Health Administration is very commonly cited as a leader in the health care world. They are probably the most innovative, best-integrated system in the country. They also produce good outcomes and provide care at a fraction of the cost of most providers while handling a pretty sick cross section of the population.

Outside of health care? Yeah, the VA has got a pretty bad reputation in general.

Beefcake the Mighty April 18, 2014 at 12:21 am

By whom?

Jan April 18, 2014 at 6:47 am

There are lots of articles if you search major medical journals, like JAMA or NEJM.

Here is one summary from RAND that focuses on quality of care: http://www.rand.org/blog/2012/08/socialized-or-not-we-can-learn-from-the-va.html

Boonton April 17, 2014 at 8:26 pm

The jury’s out on the risk pool

What would be a ‘bad risk pool’? Lots of sick people in the exchanges? OK if there’s lots of sick people in the exchanges then there’d have to be fewer sick people in employer based (as well as non-exchange based) health plans. The cost of providing subsidies to the exchanges would go up, but the cost of employers covering employees would go down.

Again this is what makes the ACA pretty interesting IMO. There’s multiple ways it can work. In the # of possible universes where Obamacare has worked, the range of possible end games span from a rather libertarian case of many individual health insurance consumers buying health care privately using gov’t subsidies to help (essentially VoucherCare) to ones that are highly single payer based with provision for those who wish to buy private insurance either to get more generous coverage.

andrew' April 17, 2014 at 9:18 pm

” we have to pass it to find out what’s in it.”
-FA Hayek

Boonton April 18, 2014 at 6:10 am

Market based reforms would be definition not be very predictable ahead of time.

Wheelchair Fred April 18, 2014 at 12:07 am

butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug butt plug

tt April 18, 2014 at 12:20 pm

interesting… so if i understand correctly: butt plug. is that right ?

David C April 18, 2014 at 12:42 am

So Ross Douthat feels that 3 separate improvements have to occur and by a large enough margin in order for the law to be a success? He can’t just acknowledge that the law has increased enrollment and lowered costs? I always felt the metric should always be relative to the old status quo. If it’s better, good job, and if not, fix it. I don’t see why the bar has to be any higher than that.

Scott April 18, 2014 at 8:47 am

David, as someone who had a private policy and then went to the exchange, I had high hopes. I really wanted to see this law work because the current system is terrible. What I’ve found, though, is that the exchanges are not more affordable. For example, I priced a policy out before going to the exchange through a private provider. It would have covered everything I wanted, for about $600/mo for my family. A similar policy on the exchange that has a much smaller network and much higher deductible runs about $900. Now, the exchange policy covers pre-existing conditions (which I don’t have), colonoscopies and prostate exams (which I don’t need), etc etc that drive those costs up. Essentially they have to charge me as if I’m at a median risk level, despite the fact that I’m young, healthy, have no family history of cancer or heart disease, exercise regularly, and don’t have any high risk behaviors (I don’t drink, smoke, do drugs, etc).

I don’t understand cheering a law that isn’t working well. If you want health insurance markets to function better in the US, this isn’t solving the problem. From my standpoint, the ACA gives insurers near monopolistic powers right now as in my state there are only 3 companies to choose from, and none of them are particularly great. For example, my current plan covers the hospital closest to my home, but none of the doctor groups that work there that are not hospital employees. So, if I go to the emergency room, I’m covered. If I schedule an appointment for a physical with my doctor at that same hospital, I’m not because that doctor is not covered under this plan. I would have to go to a doctor in a different network in a hospital 45 min away (and that hospital is not covered, so I can’t use their other facilities, just this doctor). The closest pediatrician covered is an hour away. This is just as confusing and nightmarish in real life as you might imagine. There are some very serious problems with the exchanges and insurance regulation. Blindly celebrating passage of the ACA will not fix them.

Boonton April 18, 2014 at 11:37 am

The problem here is your analysis by definition includes its opposite. If you’re being charged today as if you were ‘medium risk’ then before you were being charged as ‘low risk’. The average person in the US, of course, has to be ‘medium risk’. So today you’re paying more the day before someone else was paying more. Your loss is offset by their gain. That sounds tough but there’s really no other alternative. If you’re going to cover everyone, the average person is going to pay the average cost more or less. This is a fact with ALL other schemes (for example, some Republican plans would create ‘high risk pools’ subsidized with tax dollars..your premiums may be lower but then you’re taxes will be higher so you’re still in the wash)

This is just as confusing and nightmarish in real life as you might imagine

In not clear why. From what you wrote it sounds like you maybe have one doctors appointment per year and that’s just a standard check up. So all you really need from your insurance is to cover you in case of a drastic emergancy. Why not just go with the one that covers the nearest hospital and forget about whether or not the doctor is ‘in network’? If you’re only going for a checkup periodically just pay out of pocket once a year for an appointment (what are you talking about, $100?, possibly less if you’re willing to engage in a bit of haggling with their billing department)

A more creative option might be to simply pay the mandate penalty and buy a non-exchange plan that covers catastrophic care. With the savings you could afford to pay both the penalty and out of pocket for your few doctors visits

As for competition I agree there should be more competition in the market. But the lack of competition IMO is not so much due to the ACA as it is to the fact that few people are in the market of buying insurance individually. Most people who aren’t old or very poor would rather get it from their employer.

T. Shaw April 18, 2014 at 8:18 am

Because Obama . . .

Everything these people touch goes to Hell.

In 1964, they passed “war on poverty.” In the 50 intervening years they spent $20 trillion to reduce poverty. The result more poverty.

Past performance is not a predicter of future . . .

Or, fool me once shame on you. Fool me twice shame on me.

Millions cancelled private policies.

Death panels.

All of a sudden cancer screening is no no.

My advice: Drink. Drink heavily. And, legalize weed!!!

Obama worshiping imbeciles . . . lotus eaters unite! You have nothing to lose.

Boonton April 18, 2014 at 9:09 am

The US has more poverty in 2014 than 1964? I don’t think so

My advice: Drink. Drink heavily. And, legalize weed!!!

Hasn’t hurt your ability to operate a computer well enough to post comments here it seems.

ThomasH April 18, 2014 at 2:45 pm

The effort to reform US health care has had since at least 1992 two goals: improve access and control costs (in the sense of better matching cost with the value of the outcome of the service). The way this was supposed to work was that one political party would push harder for access and less for cost control and another one would push harder for cost control and less for access. Unfortunately one party did not play it’s role (basically no role at all) so ACA does not have enough cost control features. This means that we can only judge ACA by access standards. We’ll have to wait for some future time when a new political constellation will focus efforts on cost control. Thus for Mr. Douthart to set a cost-based metric for ACA success is a bit disingenuous.

Boonton April 18, 2014 at 4:20 pm

Exactly what cost control features is the ACA missing? I recall a certain party running against Obama on the grounds that it cut Medicare too much. I recall lowering the tax subsidies that are given to higher end employer provided coverage (so-called Cadillac plans). The exchanges are set up mostly so that individual consumers are the ones who decide whether or not they want to write a check each month for the premiums for coverage.

Let’s contrast this with the last major health care reform. That would be Medicare Part D under George Bush which last I checked was premised on no funding, essentially an entitlement for seniors (granted there’s some market aspects to it as seniors actually have to shop for plans and pay more for ones that are more expensive).

Be real here, the GOP is not a party of ‘cost control’ It’s a party of upper class tax cuts and if it can ‘buy’ that by letting costs run wild it will.

Comments on this entry are closed.

Previous post:

Next post: