Bob Laszlewski on the ACA exchanges

Based upon my survey of a large number of health plans accounting for substantial market share in the 36 states the federal insurance exchange is operating in, not more than about 5,000 individuals and families signed-up for health insurance in the 36 states run by the Obama administration through Monday.

It is not uncommon for a major health insurer with a large market share to report less than 100 enrollments in the first week.

Reports today say the enrollments continue to trickle in at about the same rate.

Worse, the backroom connection between the insurance companies and the federal government is a disaster. Things are worse behind the curtain than in front of it.

Here is one example from a carrier–and I have received numerous reports from many other carriers with exactly the same problem. One carrier exec told me that yesterday they got 7 transactions for 1 person – 4 enrollments and 3 cancellations.

For some reason the system is enrolling, unenrolling, enrolling again, and so forth the same person. This has been going on for a few days for many of the enrollments being sent to the health plans. It has got on to the point that the health plans worry some of these very few enrollments really don’t exist.

The reconciliation system, that reconciles enrollment between the feds and the health plans, is not working and hasn’t even been tested yet.

When health plans call the special health plan “help desk” they are lucky to get through. When they finally get through, the feds are creating a “help desk ticket” to be researched.

Now, if we are enrolling 20 to 50 people per day per health plan per state through the federal exchange, that might be sort of manageable. But if this thing ever ramps up to thousands of enrollments a day…

In summary, big market share health plans are getting maybe 50 enrollments per day per state from the feds and that little bit of new business is a mess.

The link is here, hat tip goes to virtually everyone in my Twitter feed.


Is this a surprise?

No one comments on "through Monday" and how that affects data vs perceptions. It cuts the live time in half, doesn't it?

That's the discouraging part. It appears we have a significant portion of the population who are immune from facts and experience. The government fails at every project it takes on, yet these folks maintain total faith in the state to pull off the next bit of social engineering. There's no reasoning with fanatics, but that leads to the question as to what to do with them.

'The government fails at every project it takes on'

The people who experienced Fat Man and Little Boy at ground zero aren't around to disagree with you, and the idea that Americans actually walked on the moon is simply laughable, right? Just like the idea of a telescope in space, or mobile robotic probes exploring Mars.

But as you noted, 'It appears we have a significant portion of the population who are immune from facts and experience.'

I agree. Things run better when Germans are in charge.

Well, that is actually worse.

If the government consistently failed at everything, it wouldn't be trusted anymore. The situation is such that the government finishes successfully some projects (though you'd better not ask for the price tag - that includes the Moon landings), and it can wave them around loudly, thus masking a long line of bureaucratic failures.

You'd better take into account both sides of the coin.

Using the Mnahattan project and the Moon program as evidence that the government can get things done well is absurd. They have no relevance to ordinary government activities -not to mention that they were done with little or no concern for costs.

Next time, just get Amazon to host your ACA policy. I bet they would have done it for a nominal transaction fee.

Amazon was a great idea until that first Christmas holiday season and their computer systems went down. I had coworkers working the problems as consultant from software vendors, and they just could not get the systems working right even after months of trying.

Amazon just went bankrupt as a result....

HHS gets no sympathy from me for this screw-up, but this was precisely the intended effect of the state opt-outs.

" 'The more states that opt out of the state-based exchanges, the harder it will be for the federal government to fully implement Obamacare and the more likely it will be that we can turn back the clock and reframe the health care debate,' Tea Party Patriots wrote to supporters ahead of the deadline for states to decide whether they would operate an exchange."

Yep, look at the states that set up their own plans. NYT article about it today.

Horseshit. Even most of the states are reporting a range of zero policies sold to numbers less than 1000. And, note, there is no clarity what constitutes a policy sold in states like Kentucky that reports thousands of "completed applications". Add into that the obfuscation about who "applies" and is sent instead to apply for Medicaid. There were numbers coming out anonymously last night from HHS that the federal exchange reported 51,000 applications, but having tried to deal with that site for 10 days, I bet one of those 51,000 is my "application" in which I finally created a userid and password to an account that I cannot even access now, nor can I delete. In any case, I followed the advice that seems to have been given by HHS to create a second account, and have not been able to even accomplish that in 5 tries.

I understand your frustration. I think the situation is more that most states don't have data or haven't released it. You might have to hold your fire on the states for a couple weeks here. Also, this article, says that Kentucky actually enrolled more than 18,000. That aside, I think it is great if this facilitates people enrolling in Medicaid--maybe people who didn't know they were eligible.

Again, "horseshit!" is my initial reaction, Jan. Again, I point out the inability to even distinguish between people who have created accounts, actually applied for policies, and have had those "completed applications" processed. The numbers coming out of Kentucky don't do this. Based on the numbers from KY, I would bet that 18,000 includes more than 10,000 Medicaid recipients. The Medicaid recipients may well have been enrolled (after all, KY has been doing that for almost 50 years), but I doubt even that- my guess they have simply been redirected to apply for Medicaid. I think the states break down into three groups- those that are honest about the numbers, those that are silent about the numbers, and those that are lying through their teeth.

By the way, I have tried every single on of the state sites at least once (and some multiple times out of curiousity), and I was only able to get into one with ease (CT).

The article I linked said over 18,000 in KY had enrolled, whereas other state statistics specifically say X have created accounts. It seems to me most states are clearly are making distinctions between enrolled/completed application/queried/just don't know yet, at least as it is reported in the media.

I admire your perseverance for trying every single state exchange website. Would you expect that they would let someone from out of state create an account? Do you live in CT?

No, Jan, Kentucky isn't making this clear- they don't define what "enroll" actually means, and, really, the other states don't define these terms either. Kentucky's numbers could just as easily be interpreted as 18,000 people entered the site and set up accounts with all the information required to buy a policy or apply for Medicaid. There is no reason to believe it means people have actually selected a plan and a payment method. Every single state seems to be deliberately leaving these terms up for interpretation, and media is seemingly too incurious to pin it down.

Enrolled is a pretty unambiguous term to me.

Yancey, my state is doing just fine, according to an HMO VP neighbor. The state set up its own site.

Yeah, Bill, I believe anything you write. I have checked Covered California 10 times since Tuesday before last, and only on the first day and today was it even possible to hit the "apply button". On other days, the site either timed out, or the button was grayed out.

Just crazy that states and individuals are allowed to opt out of this.

The collective needs to obey unquestioningly.

If one thinks that Obamacare is bad, then opting out in hope of limiting the extent of its implementation is a logical course. There is nothing devious about that.

If participation is voluntary, but necessary for success, then low participation rates are a failure of the law, as it did not offer strong enough incentives for participation. Even if you think the opting out is purely political, that was a known part of the environment for which the law was written. If the success of your law depends on the opposition happily getting on board then, again, that is a failure of the law.

It doesn't necessarily make this law better to assume the worst about states and remove their ability to market and manage its implementation. Lots of states did accept the challenge to create their own exchanges and did a great job -- you don't sacrifice that flexibility because some states refuse to help. These govnuhs are failing their residents.

The "accepted the challenge."

Is that what they did?

Or did they stumble blindly - with ideological blinkers - into a costly, unpopular, badly conceived and poorly implemented mess?

Ok, you don't really have a response for that.

The issue remains -- many states wanted that flexibility and took advantage of it to make their own exchanges. I wouldn't say that is stumbling blindly. It is trying to make the program as good as it can be for their particular situation. The other states just sort of whined and moaned and said they hope it fails, and even though they know it isn't going away, they won't assist their residents. That sucks.

But what is the end game dan? The US health care system was in crisis in 2008 that was dwarfed only by the prospects of the trillions in losses by tens of millions of individuals if the shadow and FDIC banks were allowed to fail without Congress stepping in.

In 2005 or 2006, the biggest problem small businesses reported was health care costs followed by too little demand, finding qualified workers, getting credit, etc. Obviously the lack of demand and credit problems became top problems quickly.

But the cost of insurance to employers and cost of self insurance had doubled over the 7-8 years up to 2006 with no end in sight.

The conservatives in attacking Obamacare have made employers not providing health benefits the conservative ideal which is effectively the Republican talking point. Republicans are not behind expanding the role of employer health benefits but are largely the voice of forcing individual to pay for their health care. Republican/conservative businesses are thus focused on not providing health benefits. And the job market gives them the power to do that as long as they don't need the group market to insure their family.

Meanwhile, the medical providers and the insurers have been changing their businesses in response to the health care crisis shaped by Obamacare. It is thus impossible to get back to 2008 by "repealing Obamacare".

"Obamacare failing" is chaos so the entire sector will do everything they can to make it succeed.

If the system collapses like they did in England during WWII, maybe the US creates the NHS??

All the argument come down to single payer as the solution.

Employers should not be mandated to provide health insurance.

Individuals should not be mandated to buy from for profit corporations'

No one needs insurance because everyone is guaranteed health care for free if you don't have money or insurance.

I haven;t followed the precise set-up of the exchanges so this may be a silly question but is there any reason to think that the companies that can't wait to sale very expensive, heavily subsidized insurance, won't essentially cut out the exchange and figure out how to work with their customers directly? Given the incentives in play, I would think there is an exec at ABC Ins Co. who stands to gain a hell of lot more from working out a system of delivering this insurance than any government employee will.

I would presume that the existing state (again, this is a guess) of the law doesn't not allow for such, but given the extraordinary incompetence displayed in the last week, I would think tweaking the exchange system is suddenly a lot more attractive to lots of people on the port side of the aisle.

Anyone with some background in the insurance industry who understands how that industry is looking at this last week would probably have a much better sense for this issue. I just can't see (another guess) the industry waiting around for this mess to work itself out- particularly since there is no reasonable means of insuring such will actually occur.

The exchanges are supposed to be places where the consumer can compare the options, so going through the exchanges is probably the only way that the insurers can receive the government subsidies on the policies they sell. However, I'd guess some states might be open to industry cooperating to design and manage a better version of the exchange. At the federal level, I don't see it happening.

I haven;t followed the precise set-up of the exchanges so this may be a silly question but is there any reason to think that the companies that can’t wait to sale very expensive, heavily subsidized insurance, won’t essentially cut out the exchange and figure out how to work with their customers directly?

A big part of the exchanges is that they provide a way to integrate the government side (verifying income and subsidies) with the provider side (verifying premiums based on location/age). I'm sure the insurers could find some direct to customer way to do it, but it would inevitably be buggier because the government side wouldn't be looped into the process to begin with: they'd have to "estimate" your subsidy, and then you'd have to send income verification documents, they'd have to contact HHS, etc.

It seems to me that they should definitely have KISSed this and just had folks apply directly to the companies and bring in vouchers of some sort.

You can still put info out there without entangling what is essentially a double application process (one for subsidies, one for insurance) and sometimes a triple process (Medicaid).

I think, in the end, they will regret trying to make this process "easier".

In starting our process, one thing I found that I didn't know about before is that your subsidy is actually a payback -- if you buy a plan from the exchange, you pay the premiums, and if you qualify for a subsidy you will get that money on your tax return the next year in a lump sum. That's our state, at least.

If you need to have the subsidy pre-applied, you have to apply for Medicaid first. Since I have to think that most of the people going to the exchanges qualify for a subsidy (people with wealth would be more likely to have already budgeted for insurance, since health insurance is asset protection more than anything else and they'd have the most to lose), and if you need a subsidy you probably can't afford to pay the premiums in full and get "paid back" at the end of the year, I have to think there will be a huge slow down as everyone figures out they have to apply to Medicaid first. We applied to Medicaid over a month ago and have not heard an answer, so unless there's a streamlined process this is going to be slow, maybe impossible.

Yes, this is going to come as a big surprise to many people. I have actually encountered very few people (almost you only), who understood this is a tax credit applied at tax return time.

I've never seen it in one news story, although the question, "How will the insurance companies get the subsidy" seems a pretty 101 question.

I was surprised, and I'm pretty downregulated for surprise these days.

So, will we start to see Markets in Everything, subsidy edition? "Get your sudsidy, now!" "Instant subsidy service"

Just sign on the dotted line ...

I had a similar thought- like a payday loan.

If I were a Republican politician looking for party advantage, why would I try to get the introduction of Obamacare postponed for a year? Wouldn't it be better for me to let this dégringolade run on and on and on?

Republican politicians are evidently more afraid that Obamacare will work than that it won't work.

No, their fear is that even failure won't lead to its demise, and history suggests they are right to feel that way.

True. The NHS in the UK is dreadful but popular. Canada's single payer system has 18 month waits for surgery but take away their 'free' healthcare at your peril.

History shows that government healthcare is almost impossible to dismantle once in place, because it's so easy sow fear about privatization.

I suspect Obama knows exactly what he's doing and it doesn't matter if the rollout is messy. Once people accept the govt role there's no going back.

The idea that Obama and Democrats want to grow government and increase regulation just for its own sake is naive. You're so blind to their true motivations that your -- and Republicans' -- opposition stands virtually no chance of working. That also means it will make it 10 times harder to fix the things that could be improved.

"Dreadful but popular." Yeah, those dumb citizens. You tell 'em they better hate that healthcare system!

Also, that story about 18 month waiting times for surgery in Canada isn't relevant, because 1) what we are doing here is nothing, nothing like the Canadian system, 2) that little stat applies to only a couple mostly elective (e.g. bariatric) types of surgeries, and 3) the US has more surgeons per capita already than Canada.

I'm actually very nervous, getting on here, complaining about the ACA when I'll be completely dependent upon it next year. Like, serious life and death dependent. I figure no one cares what my opinion is so I'm pretty safe, but I'd never talk like I do about ACA in a group of strangers who knew who I was. I've seen the same attitude in friends on Medicaid.

When you use commercial insurance, you can call them all sorts of names (my favorite line on HMOs is from "As Good As It Gets"), you can be an Aetna customer and still stand host the Aetna sucks Web site. Because the checks and balances of law say they can't ding you for that. But when the ones who execute the laws are the ones insuring you, which is essentially what happens here, you tend to say you love your insurers. And then you internalize that, very Sovietly.

This is part of why it was bad that the federal government encouraged businesses to provide benefits, it tied a life essential to your employer, and made you inclined to take things from him and fake a love for him you might not otherwise take and love. For years reform advocates have been using the idea that someone will be a slave to an employer if he gets a pre-existing condition during employment. This is the same phenomenon, you'll have millions that are slaves to the government and don't dare speak against it.

I see what you're saying, but I don't think that most lawmakers view the ACA as a "we gave you this great thing -- now you have to shut up and take it!" proposition. In fact, about half of Congress would be with you criticizing just about any aspect of it. But this is one reason why I think that the "most horrible, America-destroying law ever" rhetoric doesn't help. If instead of the all or nothing attitude about the ACA, people (citizens and lawmakers alike) took a constructive approach and actually tried to improve the law, this would be going much better.

The history of employer sponsored insurance is actually very interesting. In WWII, due to concerns about economy killing inflation (like that which was seen in Germany), there were restrictions on wage increases here. Employers got around this by offering health coverage instead of higher pay. Roosevelt had opted to forgo a national health plan and so in the 50's health care was basically privatized by enacting the employer tax deduction for insurance contributions. But remember, the tax deduction applies to individuals who buy their own insurance as well employers.

One of the main problems with the employer model was that an individual who had preexisting conditions probably couldn't buy health insurance, or at least not at an affordable rate. One good thing about the law is that it enables people to buy their own policies if they need to. For example, if you have health insurance now at your employer, but need to leave to care for a sick family member, you can do that now without fear of being denied coverage. Or, if you want to take a great job at a small employer that doesn't offer health coverage, you can take the job and be confident that you'll be able to purchase an individual policy. Remember, you'll be buying the insurance from a private company -- not the government itself -- so you're not beholden to anyone.

People with pre-existing conditions were able to buy insurance before ACA.

Nope -- my sister was categorically denied insurance by most carriers in Michigan; one offered her coverage for something ridiculous like $3,000 a month. Only a handful of states had caps on how much more insurers could could charge sick people versus healthy ones.

I don't know much about Michigan's high risk pool, but I believe she should have been able to be insured with this program. If it's like ours, it prorates for lower incomes. It will, like ours go away in 2014.

Thirty six or 38 states have high risk pools, I can't remember which.

Of course, there's also COBRA for awhile; many states allowed you to start your own business and buy group insurance, where pre-existing couldn't be denied or charged more for; or, of course, getting a job with another insuring employer since group plans don't ding for pre-existing (although Michigan, if I'm remembering properly, allowed insurers more leeway on group policies). And children in poverty, of course, had Medicaid and CHP.

There's also accident insurance, which does not exclude for pre-existing because it's irrelevant in the case of accident (slip and fall to auto crash).

We've been self-insured with an expensive pre-existing for almost four years, unsubsidized premium of under $300 a month, $1000 deductible, probably $250 in out of pocket monthly, but that's because it is expensive.

Sorry your sister got stuck. The biggest pre-existing condition problem, in my experience, was that people didn't know about the systems in place. We have used our state's high risk pool but have now applied for two forms of welfare, in both situations the social workers handling the application had never heard of the high risk pool program. Their own state's program for helping those without insurance, totally ignorant.

There was also the direct solution for the portability problem, federally -- the same solution our state uses. To have portability, you have to have had continuity of coverage. So, for example, you lose your job, you can sign on to the pool and buy insurance from day one. You move up in income and come off Medicaid, still can sign on and be good. But if you have not had insurance and try to buy into the pool, there is a six month wait just for that condition -- you have to pay the bills yourself for anything related to the pre-existing. This means people who don't bother to insure until they get sick still risk bankruptcy, but folks trying to transition don't. This could have been a one page federal fix, it's the kind of "get together and work it out in the places we agree on" thing that would have been really helpful to the country.

Yeah, it seems like there are lots of holes but easy fixes left on the table. Terrible that people don't even know about these programs. My sister actually did apply for the high risk pool, but didn't qualify--don't know if it was because of her particular condition or because she did have some income; she lost that fight. Last I checked Michigan had only enrolled like 250 people in the plan. Anyway, she is actually on COBRA now after working at a firm with good benefits for almost a year. That costs about $400. I guess she'll be looking into Medicaid soon, but Michigan only accepted the Medicaid expansion with some restrictions that we'll have to figure out.

Last I looked into it, Michigan really had a crummy system. I think they are bad, also, for regulating in state with group insurance plans.

The federal high risk pool stopped taking new applicants, don't know about the Michigan plan but I'd believe it's not as good as what other states do. In our state it doesn't matter what your income is or what the condition is, if you are denied coverage you qualify.

Glad she got some relief, COBRA is awfully high, you are paying the higher group rate the company paid so it's no fun. Hope she comes through all this with really good options and things turn up for her.

I have thought the same. You would think the Republicans could just let the wreck happen and then swoop in later like vote looters.

Still, human beings do tend to follow power, and the power to destroy is still power, so that might backfire.

Maybe it is because they are interested in actually helping Americans, and doing what's right for the country.

Seriously, a completely nonfunctional healthcare system is in nobody's interest.

Yancey Ward's answer is probably the more common one among the blogosphere, political class, media, etc. That your answer is less common is quite revealing about the way such people attribute motives to Republicans. If Republicans want to delay the individual mandate, it can't be because they want to provide relief to the uninsured, the very people that Obamacare was supposed to help. Nor is it possible that Republicans are concerned that many people's premiums seem to be dramatically increasing this year or that people are being shifted from full-time to part-time work. No, because Republicans can't possibly be motivated by concern for people, we can only interpret their motives in terms of what might lead to future party advantage.

I have not heard anyone ask why Democrats don't delay Obamacare to build support among voters that would surely grow more frustrated with our existing system and, thus, more impatient for Obamacare's rollout. Nor do I recall such questions in the immediate aftermath of Scott Brown's election to become the 41st Senator specifically to stop Obamacare. Rather than ensuring themselves future electoral triumph by tabling Obamacare, Democrats decided to override the election by passing Obamacare using extraordinary means. (Aside: while Scott Brown's election was the result of a single-issue campaign, effectively a referendum on Obamacare, I seem to recall other issues during Obama's reelection campaign: "binders full of women" and the Republicans' purported desire to outlaw contraception come to mind. Yet, somehow, Obamacare's supporters now claim a clear mandate from Obama's reelection.) Why do Democrats resist Social Security privatization and Medicare vouchers? They must really fear how well these reforms would work!

The republicans have had years to solve this problem--incentives, tax policy, subsidized clinics etc. A delay will not lead republicans to fix the ACA or educate people, it will be to try to dismantle it. They will continue to try to undermine the effort. How do republicans propose to help people with few resources obtain life's necessities? Layout a vision for us that supports people in the efforts to climb out of poverty over the next 3 or 4 generations. I don't think you can.

You do realize that Bush's 2007 health reform plan was scored by the CBO as reducing the number of uninsured by a greater amount than they evaluated Ocare? If what Dems really cared about was reducing the # of uninsured, then why didn't they back his plan?

"The Good Intentions Paving Company - It's the thought that counts!"

No, they'd rather drive down their approval rating to its lowest level ever by shutting down our government and sacrificing our credit rating again. Fine with me.

Most observers, even (or especially) Democrats, would agree that the shutdown is hurting Republicans politically. Equivalently, but rarely phrased this way, Democrats have the most to gain politically from a shutdown and, thus, have the least incentive to end it. However, since we can never attribute political motives to Democrats, we can't blame them for the shutdown, their blocking of (clean) funding for cancer patients, the FAA, etc. notwithstanding.

No, the Dems aren't going to prolong this fight and do government by piecemeal CRs into eternity. That has never been the way government was funded and it is the most inefficient way to do it. Of course there are political motives on both sides. The Dems have the most to gain politically right now precisely because the public realizes that Republicans have been obstructing to obstruct and haven't offered any reasonable way out of this. If realistic proposals, maybe even a big idea, were on the table the public would understand that and poll numbers would rebound.

"since we can never attribute political motives to Democrats": I do all the time - i view them as a vile bunch of slimeballs. I'm old enough to remember them as the party of segregation, the party of the Kennedy bothers and the party of the Clintons, and I'm not old enough to remember the presidency of Truman. I do think that the decent Carter gets treated a bit harshly though.

Since most such threads eventually get infested with OFA volunteers lying about success on the Federal Exchange, I will just post the normal comment to save them the time:

"I opened the newly fixed today, and it filled out all the information for me in 3.653 nanoseconds. I got a quote for a health insurance policy that costs me 27 cents/yr (or just 0.0737704919 cents/day during a leap year!) with no co-pays or deductibles. With the tax credit, my costs fall to a minus $4,999.73/yr which a helpful navigator used to auto-booked me on a trip to Cancun this January. In addition, my new policy covers massage therapy with happy ending at my local Asian Healthcare Spa, and I can add my pets to the policy for free."

Edit: however the spa has a no pet policy.

Dude, you're trying way too hard. Relax and enjoy your Friday evening.

Is trolling a pre existing condition?

Pre-emptive reverse trolling -- I like it!

I would be willing to bet that if the 5000 number is even close to being correct for the federal exchange, not a single one comes solely from the online exchange, but is, instead, a paper application taken by a navigator at some point.

Yancey, I bet you a million billion dollars. Also, what do I get when this is all working just fine a month from now?

I would want to know how 5000 people managed to buy anything in a system I am literally zero for fifty in even entering in a functional way, and I have tried every single bit of help offered on the site's front page. I guarantee, any policies bought on the federal exchange (if actually any at all) by-passed the online site at some level. But, obviously, you haven't even looked at any of the sites based on your comments- all your information seems to have come from promoters of the sites and not from any personal experience in trying to actually use them.

"Also, what do I get when this is all working just fine a month from now?"

That won't happen. You would be correct to say that these are the type of things that can be fixed and, at some point in the future, they almost certainly will be fixed. A month, however, is way, way too optimistic. HHS has been working on these problems for more than three years, if they could be fixed in a month they would have delayed the program for a month to fix them. The refusal to delay the program for a year, even when doing so would have prevented a government shut-down and debt crisis, means that Obama believes the problems will persist and that the best way forward will be for people just to get used to the "glitches" and lousy service. You are used to lousy service at the DMV but you have stopped complaining about it. You still don't like having to deal with the DMV but you figure there is nothing you can do to change it. At some point, you even forget that there might be other ways of accomplishing the same goals. At that point, the program becomes a success.

In any case, the problems so far have all been problems with the easy stuff. The hard stuff will be the actual program itself. A small number of people will surely benefit from the program, most others will suffer financially as a result of it. If you sister (assuming you have a sister) no longer has to pay $3,000 a month because of her pre-existing condition, that just means that other people have to pay the $3,000 for her. Great for her, tough for them. Tough for everyone if people can opt out of the program by paying a $95 tax penalty and still opt back in when they acquire a pre-existing condition. But that, of course, is just where the problems start.

Having read your contributions above, you strike me as someone who believes that as long as a program was designed with good intentions by people with good hearts, the problems will all be solved in the long run. I believe this is a commonly held opinion among people who don't actually have jobs in which they try to solve difficult problems.

you need a hobby.

Yes, I need a hobby to keep me from telling people that all these claims about successful exchanges are total bullshit for the most part. Just shut up and take it, I suppose.

"Also, what do I get when this is all working just fine a month from now?"

I don't know, but I know what 'you' get 20 years from now, when this whole thing is a complete debacle--like just about every other government-run get screwed up the poop chute.

Thanks, DBrooks. I appreciate your contribution. Since roughly half of our elected officials see anything the government does as problematic and, according to commenters here, people are just going to get screwed by the ACA, it should only take a year or so to dismantle the whole thing. Right? That would follow logic, amirite?

If no one signs up for it, then how is it going to become a debacle? In that case 20 years from now most people would be insured from Medicare if they are old, Medicaid if they are poor, or their employer is they have a halfway decent job and a minority of people will either be buying private insurance or going without coverage. In other words, the pre-ACA status quo. On the other hand if huge numbers of people sign up for insurance...well the pace is going to be a bit more than 500 per day isn't it?

The advantage of the ACA that most commentators refuse to address is that it actually is remarkably flexible. It locks in almost nothing.

If literally no one signs up for it then it will be a failure as a program but, arguably, not a debacle for the Country. But that won't happen. People with very expensive expected future health care costs (such as Jan's alleged sister) will certainly sign up. People who receive subsidies sufficient to cover the the increased premimums caused by the fact that Jan's sister will sign up will also sign up. A big part of the program will also be extending medicaide to many people who didn't know they were already eligible. Once the employer mandate is in place, people who lose their employment related coverage because their hours are cut to part-time will also sign up.

For the program to be successful, however, millions of people, especially young and healthy people, must voluntarily pay thousands of dollars for medical care they won't use. If they choose to pay the tax/penalty instead (only $95, much less than even one month on most ACA-approved plans). If that happens, the insurance companies will cancell their programs or be forced to raise premiums. As premiums increase, the law requires that any subsidies increase on a dollar for dollar basis. Eventually, nearly all of the costs are born by the taxpayers. But the government cannot shut the program down or reduce costs in any way because those that are in the program have a vested property right to their medical coverage. At that point, its a debacle.

Rather disjointed here and you miss logically unavoidable consquences.

For example, say no one signs up except people who are sick. Are those sick people today being denied care? No. That means someone, somehow is paying for it. If those sick people get paid for via subsidies on the exchange, then that means the costs to cover them elsewhere drop (whether that's on employer provided insurance, unreimbursed hospital ER visits, Medicaid or whatnot). So if costs elsewhere drop wouldn't that make employers less inclined to drop coverage?

Or if people with jobs (such people tend to be at least somewhat healthy) lose coverage by employers dropping it, well that would seem to either increase fees collected from not following the mandate or put more people into the exchange to buy coverage. More healthier people in the exchange would lead premiums to drop. More employers paying taxes and fines for not having health coverage and more people paying the mandate penalty means more funds for subsidies.

I supposed Medicaid expansion might drive up costs...except Medicaid is probably the lowest cost health insurance coverage out there. Granted the doctors who take it are limited and it has a well deserved rep. for being stingy but we again come upon the question of what do these people who are right near the poverty line currently doing for healthcare? If they get it then someone is paying for it somehow so Medicaid coverage will reduce costs for whoever that someone is. If they don't get health care then we have a real humanitarian problem with the current system

For the program to be successful, however, millions of people, especially young and healthy people, must voluntarily pay thousands of dollars for medical care they won’t use. If they choose to pay the tax/penalty instead (only $95, much less than even one month on most ACA-approved plans).

Most younger people:

1. Work full time often beyond 40 hours, which would make it tricky for companies to turn them all into part time workers without benefits.

2. The period of being relatively confident you don't need to worry about thousands of dollars of medical bills is actually very brief. I'd say once you go beyond your mid-20's you start thinking more and more about medical risks (or if you're very active under 25 you also think about medical risks since sports injuries can be very expensive). If you have a family the worries begin even sooner. The idea that a huge portion of the population can be comfortably confident they will have no more than minor medical expenses until about 50 years old doesn't really pan out imo.

3. It would seem if this was a problem then employer provided insurance would be a failure too. Big employers provide coverage by having employees chip in a portion of their pay and they put in the rest. Since every employee is charged the same you have an environment very much like the ACA's exchanges (even more so since the ACA does allow premiums to vary by age!). Even if the cost was only $100 per paycheck, one would think younger workers would balk leaving the only ones in the pool the older workers who consume much more than $100 per check. Yet employer provided insurance is a highly sought after benefit, there's not much evidence that it's collapsing as 20 and 30 somethings refuse to sign up for even trivial payroll deductions because they are so healthy they don't feel they need it!

These are not logical or unavoidable consequences, they are just wishful thinking.

No, sick people are not denied care and do consume health care right now. In fact, people like Jan's alleged sister contribute a lot of money for the health care they receive. In my opinion, this is appropriate because, after all, they are the ones receiving the health care. From now on, however, those people will pay much less if they sign up for ACA programs. So they will. Ultimately, the taxpayers will pick up these costs.

The ACA works if, and only if, young healthy people, especially those who are currently uninsured, sign up for ACA coverages. But they won't. Only a few commited liberals will be that stupid. And this is where is gets really expensive. Some people currently pay for health insurance even though they are not currently sick because they don't want to be caught without health insurance when they do get sick. Now, that they can't be required to pay extra or be denied coverage for a pre-existing condition. Although some might remain concerned about the possiblity that they might critically ill between open enrollement periods, this is actually a very rare event. The taxpayers will pick up the additional costs.

In addition to sick people, less sick but more responsible people buy cheap health insurance which does not provide coverage for many things which the ACA mandates. Now that those people are required to have access to coverage which they don't really want, some of them will use it (why not, they're paying for it) and drive up costs. The taxpayers will pick up these additional costs.

You have evidently forgotten that many employers (actually the vast majority of employers) can avoid the ACA altogether by reducing hours below 30 per week and/or reducing the number of full time employees below 50. Employers who take this approach will not pay any additional fines or taxes and, if fact, will avoid health care costs they are currently paying. Employers who fail to take this approach will be at a competative disadvantage. Over time, all or nearly all employers will be forced to drop coverage to deal with the competative pressures. The former employees or former full-time employees will go on the exchanges but few people will be able to pay the ACA prices without subsidies working part time or unemployed. The taxpayers will pick up these costs.

Employer provided coverage exists because in the past it has received advantegous tax treatment compared to wages and therefore was a way to attract employees. Marginal employers could always provide low cost health plans and some valuable employees would prefer health insurance to extra pay. Obviously, however, many employers could not afford that even with the tax advantages. Now, employees (especially low cost employees where this issue matters most) have less interest in health insurance (they get subsidies) and the cheap health insurance provided by marginal employers is now forbidden by law. These marginal employers will drop their plans, the taxpayers will pay.

And it was a few days ago we had a post that the ACA was doomed because it offered insane subsidies to those seeking to buy insurance. Remember? The idea was that if you got a subsidy, it didn't matter what the price of the plan was since the gov't was picking it up so go ahead and buy the $15,000 plan rather than the $8000. And, of course, health care inflation was around the corner because the best way to compete in such a market is to add more and more generous coverage to patients......

So on one hand we are being told today that hardly anyone is signing up for it, but on the other hand the program offers such insane subsidies that one would think the insurance companies themselves would be buying servers and programmers to help get the website working..

See, the two can't both be true at the same time. Either Obamacare doesn't give enough subsidy, or it doesn't. Either no one will want to buy insurance or everyone will want it but at the same time you can't claim both are true. Yet listening to ACA critics for over a year now one gets the sense that the only people who haven't thought the matter through as much as those who created the ACA are those who bash it.


Would help if you knew a bit about how the ACA actually works...
1. The scenario you describe - "might as well sign up for the $15,000 plan" does not work - the subsidies are FIXED amounts based on a specific plan one is eligible for - if you go for the more expensive plan you are stuck picking up the difference - in the case you describe the FULL $7,000

2. The problems many of us see with the ACA are outside of the marketplaces/exchanges. The structural changes that the Act has made and will continue to make in health care are very significant - not very beneficial - very expensive and will be very very hard to undo. These include, but are not limited to...
- no copays for a range of screenings that will likely mean we end up doing a lot of these - with no data to say they do much - if any good.
- compelling all plans to cover birth control, maternity benefits, abortions etc
- limiting the ability of insurance - and insurers to offer plans that work well with Health Savings Accounts
- putting in place plans with very high deductible and out of pocket expenses [trading this for lower premiums] that will, I predict lead to a lot of angry people when the start drawing down their savings when faced with a year or two of medical need.
- in the end we will still have a LARGE number of uninsured - in some segments we may actually see the number of uninsured INCREASE.
- BUT worst of all we will have locked ourselves into a system that makes medical professionals, hospitals, drug companies and insurance companies a lot happier, the rest of us a lot poorer, and very few of us any healthier. Warren Buffet correctly pointed out that we should have first attacked the cost problems - gotten the costs under control - THEN done the reform.

The ACA actually takes a radically different view of abortion, actually requiring a patient to essentially buy their own stand alone policy to cover abortion! In contrast, if you get coverage from your employer you probably enjoy full coverage for abortion and that coverage is not part of your taxable income. In other words the ACA is actually more pro-life than the status quo policy.

AS for covering screenings, there's a good argument that this is part of the cost problem, getting at problems when they are small rather than waiting for them to become larger. But I understand your objection, screenings like mammograms run the risk of false positives and in some cases may cause more problems than they prevent. On the other hand, it's hard to see that as a major cost driver. Almost all screening procedures I'm aware of are pretty unpleasent in their own right. In other words "free colonoscopties!" isn't exactly a sign that's going to get thousands of people banging on your door. Even if unlimited 'screening' was mandated as a practical matter that can only increase demand so much.

"BUT worst of all we will have locked ourselves into a system that makes medical professionals, hospitals, drug companies and insurance companies a lot happier, the rest of us a lot poorer, and very few of us any healthier. "

Keep in mind we are talking about maybe 7 million people getting health insurance. Medicare and employer provided insurance as well as insurance that is sold off the exchanges will cover the supermajority of people as it did before the ACA. The ACA hasn't 'locked us' into anything as almost any policy you think is the magic bullet is still open as an option.

Think single payer is the end all? Just advocate expanding Medicare. Think high deductible plans are the way to go? Easy increase the cadillac tax and lower the subsidies. The only plans no hurt by that would be the ones with higher deductibles.

Warren Buffet correctly pointed out that we should have first attacked the cost problems – gotten the costs under control – THEN done the reform.

I think this is incorrect. Health care costs have grown higher than inflation mainly because of 'cost disease' IMO. If that's true then it's the result of productivity growth, despite being positive, being less in the health care sector than in other sectors. That means you will never 'control' the costs unless productivity in other sectors slow down dramatically or an unexpected series of breakthrus happen in health care. While it's great that we try to tackle the huge amount of waste and inefficiency in the system, making a mantra out of 'getting costs under control' is spitting into the wind.

limiting the ability of insurance – and insurers to offer plans that work well with Health Savings Accounts
- putting in place plans with very high deductible and out of pocket expenses [trading this for lower premiums] that will, I predict lead to a lot of angry people when the start drawing down their savings when faced with a year or two of medical need

Errr this is exactly what a Health Savings Account is. You get a high deductible plan with lower premiums and save money so you can meet the out of pocket costs. Of course if you get sick(er) you're going to draw down your savings. That's the idea! You seem to be saying the ACA trashes the 'good' HSA type policy only to replace them with a 'bad' high deductible/low premium policy!

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