Ross Douthat on the burden and incidence of ACA

As Angus has pointed out, Ross has been on a real roll lately, here is yet another good bit:

Now an effective levy of several thousand dollars on the small fraction of middle class Americans who buy on the individual market is not history’s great injustice. But neither does it seem like the soundest or most politically stable public policy arrangement. And to dig back into the position where I do strong disagree with Cohn’s perspective, what makes this setup potentially more perverse is that it raises rates most sharply on precisely those Americans who up until now were doing roughly what we should want more health insurance purchasers to do: Economizing, comparison shopping, avoiding paying for coverage they don’t need, and buying a level of insurance that covers them in the event of a true disaster while giving them a reason not to overspend on everyday health expenses.

If we want health inflation to stay low and health care costs to be less of an anchor on advancement, we should want more Americans making $50,000 or $60,000 or $70,000 to spend less upfront on health insurance, rather than using regulatory pressure to induce them to spend more. And seen in that light, the potential problem with Obamacare’s regulation-driven “rate shock” isn’t that it doesn’t let everyone keep their pre-existing plans. It’s that it cancels plans, and raises rates, for people who were doing their part to keep all of our costs low.

The full post is here.


"Now an effective levy of several thousand dollars on the small fraction of middle class Americans who buy on the individual market is not history’s great injustice."

So 50% - 75% of 14,000,000 is no big deal. Sure, Ross, sure. The little people - omelets, eggs.

Pretty sure something can be not not a big deal without being worse than a major genocide.

The annoying thing is that such a statement would even be made. I mean, what is the point? It makes it seem like there are two options: Holocaust, or No Big Deal.

"Ross has been on a real roll lately" <--- I do not think that means quite what you think it means...

I think Tyler needs to develop a bit of skepticism re the commentary of Ross, Matt, Ezra, et al.

“It’s that it cancels plans, and raises rates, for people who were doing their part to keep all of our costs low.”


Hence those health insurance consumers that are price-premium sensitive, those consumers that take the time to discover health-care price and shop around, those consumers that buy a plan with a high deductible and pay through HSA type of arrangements at the point of sale, and otherwise attempt to efficiently utilize an otherwise inefficient system….have their good deed punished.


The primary guiding principle of our government seems to be to reward those who do the wrong thing,or do nothing,or who fail ,while punishing those who do the right thing ,work hard ,and succeed .

it's no accident.

Just out of curiosity when do you think this principle was first enacted?

A reasonable guess would be the onset of the New Deal.

The 1960's.

The New Deal is somewhat exaggerated. America was still recognizably a republic through the Eisenhower years, despite the creation of the national security state under Truman.

The regulatory and entitlement state was only really created in the 60's. Kennedy was too politically inept to make it happen, so it waited until his assassination.

You mean like the conservatives telling people to not sign up for health insurance because the fine is cheaper and no one goes without health care if they don't have money or insurance?

... because the government mandates health care be provided without providing any means to force anyone to pay for their care so it is free.

The Ants have to provide for the needs of the Grasshoppers. Duh.

I don't see why the ACA couldn't also have required doctors, clinics and other healthcare institutions to post their prices for all procedures. You know, transparency. It seems that many of the plans being offered require high copayments. Why not help cost-conscious people seek out the best values for non-emergency care?

There has been a public debate about how to say to granny and her request for a new hip going back at least two decades. I recall these debates in the 80's, but I they were not they were more on the fringe. Regardless, two decades is a long to time to have a public discussion and still have the majority of chattering skulls not understand how insurance works. It really is shocking to see so may on the Left, for example, talk about insurance like a natural resource. They compare it to clean drinking water and sanitation systems. If only we can kill the monster guarding it, we can indulge to excess. The fact that it is not ten times worse is a miracle, given the lunatics we see debating the issue.

On the "Left", it's more about the millions of people who don't have insurance and therefore get substandard care when they can get it. On the "Right", it's about those folks who can afford it being forced to subsidize others/not being able to spend for what they want.

Or at least that's what these sides say its about.

You'll note that in neither case do they mention granny's hip replacement that granny can't afford. No one is seriously talking about doing anything other than making sure that is paid for by the Federal government, and if anyone THINKS of saying otherwise, it's a death panel.

" . . . otherwise, it’s a death panel."

You're parroting the 2012 memo wherein you were instructed to think that "death panels" are a figment of crazy Sarah Palin's imagination.

You need to open the 2013 memo which states, “Hey, death panels are good for you!”

In 2006, 80% of America was satisfied with health care and 20% dissatisfaied. By 2016, it will be 16% satisfied and 80% dissatisfied. The 4% shortfall (doesn't add up to 100%) are grannies that didn't survive the dp's.

2013: "Canada Has Death Panels And that’s a good thing."

It is much more than hip replacements. Thanks to ACA, I now have coverage for fertility treatments, acupuncture, chiropractors, in-patient drug abuse treatment. Basically a grab bag of expensive or completely unnecessary procedures. It is very very difficult to see how this will end well for American consumers.

Wow is it true that acupuncture is covered!

Funny, those things you listed probably on a dollar-for-dollar basis provide much more value to consumers than a lot of medical care.

Hookers and blow should be on there, too.

You're really scheming now, Yancey!! But how would that policy interact with state drug testing requirements to qualify for welfare or unemployment?

Maybe. Do you have a randomized control study showing the efficacy of hookers and blow?

Seriously? Have you looked at the recidivism rates for inpatient drug rehab programs? Any clue what the daily costs are? Chiropractors and accupuncture are mostly junk science, and fertility treatments are a medically risky and insanely expensive luxury. If you really want a child, and don't have $30k in cash burning a hole in your pocket, there's a half million children currently in foster care that would love a caring home. There's no reason I should be forced to subsidize other people's desire for genetic progeny.

"Have you looked at the recidivism rates for inpatient drug rehab programs?"

Are you talking about the prison treatment plan for drug use or the insurance paid drug treatment plan?

When the money runs out, things will change. The old line about bankruptcy (slowly at first then all of a sudden) is playing out in front of us. Unmentioned is the slow decline in the economy this year. Retail took a header in September. A year from now we could look back at 2013 as the good old days. At some point, they will not be able top keep all the plates spinning and they whole things comes to pieces.

ZeroHedge has a post on HR 3292 - Debt Limit Reform Act.

A fun drinking debate is to come up with amendments that will result from the great collapse. The banning of public debt, outside of war, is my favorite. Government should always be cash and carry.

"A fun drinking debate is to come up with amendments that will result from the great collapse. The banning of public debt, outside of war, is my favorite."

A few years back George Will made a good observation about a balanced budget amendment. Congress will find a friendly little country like Iceland, declare a nominal state of war, and let the deficits flow.

Not only does the ACA require that insurance sold on exchanges cover substance abuse counseling, but also counseling for other mental health problems. While I'm happy that those with legitimate problems get effective help they need, this expansion is bound to be a real boon to psychiatrists and psychologists --much more so, I'm afraid, than to their patients. I predict that there will be a huge increase in these types of services and that much of it will be attributable to ineffective and unnecessary services as well as to fraud. It will very likely be a major contributor to the cost of insurance, as well as the cost of expanded Medicaid, which also covers these services. Unfortunately, there is really no effective way to police this and it therefore will be subject to massive abuse. The only other thing that might add more expense, and I wouldn't doubt it will eventually be part of the "package", is tattoo removal. Compared to the expansion of mental health services, acupuncture will be a tiny prick in the budget.

Many insurers already offer coverage for these services but the reimbursement rates are so low that providers do not take patients who can only afford to pay with insurance. Unless there is some new rule that insurers must offer mental health coverage at reimbursement rates providers will accept (whatever that would be), I doubt there will be much change in the number of people seeking actual mental health care. Fraud may be more of a problem though.

Blame the National Rifle Association for this one, I imagine.

Are we comparing the privately supervised, by insurers, drug treatment plans to the legislatively supervised public government run drug treatment in prisons and parole?

Ditto for mental health?

On chronic pain management, we have yet another round of pain drugs being effectively criminalized by being moved from class 3 to class 2. Alternative treatments like acupuncture and such work for some people better than opiates which has been made effectively illegal for such patients.

A quick and easy way to lower US health care costs is to allow Americans to go on medical tourism trips. Last I checked, which is a few seconds ago on Google*, it was illegal.

Here in the Philippines you can get care for about one-tenth the price of US care, and it's about 80-90% as good. If you don't need brain surgery, come here, but you'll have to pay out of your own pocket.

* Under the Original Medicare Plan, you are not covered for medical services if you travel outside the United States (or its territories). There are a few rare exceptions such as certain emergency hospital services received in Mexico and Canada, or territorial waters, though.

That's what a HELOC is for.

Doctors and hospitals in the Philippines would, of course, never, ever think of padding the bills they send to Medicare were this to become an option. Everyone complains about "waste, fraud and abuse" in the Medicare system now -- it's not too difficult to imagine the problem getting orders of magnitude worse once you bring in doctors and hospitals who are not subject to U.S. jurisdiction and have crooked and ineffective legal systems. In fact, we already have some evidence on this -- there was a huge scandal in the Philippines several years ago surrounding medical care there for U.S. military veterans.

There might be a way to make this sort of coverage practical but it's not as if the rule against reimbursement for foreign treatment is completely irrational.

ACA isn't about providing health care for everybody, or about reducing expenses.

It''s about seizing control of everybody's health care.

No, its the doctor and hospital payment assurance plan.

Conservatives have been saying you don't need money or health insurance to get the medical care, but they don't say the doctors and hospitals have no way to collect for the treatment they must provide.

What is your solution to those people without money or insurance in need of health care? Euthanasia? Add in organ harvesting and that becomes creative destruction of failure to provide payments for needed medical care.

Yes, let's assure that they get paid less. Great plan!

Yep. You got it. They hate our freedom.

No, they don't hate Freedom. They just value it less than Security.

It’s that it cancels plans, and raises rates, for people who were doing their part to keep all of our costs low


Well, that was where a good part of the money to fund this had to come from. You couldn't really depend on the mandate to wrestle the non-insured but frugal people, so it had to come from people who were in the habit of buying insurance. Now doing so is not such a good habit.

these canceled policies have low payout for illness, and thus holders pay more out of pocket, and may statistically bankrupt more frequently. Is then "cost of premium" the total cost? I mean, I recognize that a wealthy family, with a stocked checking account, may run a high deductible and never fall upon socials services, nor become a bad debt, but not everyone with a cheap policy, is rich.

+1 Nuts, I can't get that cancer insurance which doesn't cover hospitalization and which has a $10k lifetime cap.

This is why Rs have been trying to push HSAs for years. It is the Dems that have neutered these policies for purely political and ideological reasons.

If you look at how much people pay for prepaid medical services (it's not insurance), buying a high deductible insurance plan would seldom result in bankruptcy. A $10,000 deductible is easily covered if instead of spending $3,000 a year on prepaid medical services, you spend $800 and put $2200 aside. They key issue, which libertarian leaning people will disagree with, is that the government probably does need to set limits for how much people must put aside in an HSA.

The biggest scam of the ACA is that unlike the catastrophic plans, the ACA plans don't cover all of your expenses. The low level is just 70%, and even that isn't the real figure because the insurance companies need to cover 70% of the expenses in the group, not each individual. There are going to be people under the ACA who buy the high deductible cheaper plan and assume their cost is that high deductible, and they're going to get a $100k+ illness and then find out they owe $30,000.

There's a max family out of pocket of $12,600.

Get rid of HSAs in general! It's obnoxious paperwork, and there's no reason not to just deduct medical expenses after the fact.

The real scam? No, pre-ACA there were tons of policies that covered <70% of the bill, plus a high deductible. Part of the problem was that in many states without decent insurance regulation there was virtually no standardization of plans and lots of them had really high out of pocket requirement, while excluding coverage for lots of services.

Obama's job was to pass ACA. The only way to do it, thanks to congress, was to let the insurance lobby write the law (causing people to overpurchase insurance). Now it's time to fix it. There was no way to fix it first AND have congress pass it. Obama knew what he was doing and it was a smart thing to have done. He'll get the blame over the next few years, but the do-nothing alternative would have been worse.

And he did it with: Lies. Lies. All lies.

Here was the starting point. In 2006, 80% of America was satisfied with health care, and 20% dissatisfied.

Not: "Everyone misses the point: the health care market was broken."

You people don't know what the hell you're writing about.

I am not surprised. None of you geniuses saw what was coming in 2007.

T.Shaw: None of you geniuses saw what was coming in 2007.

I don't think I was alone, ruefully accepting the ACA as better than status quo. For me the ACA still passes that low bar. If you'd like to move now to a leaner, cheaper, national health, I'm with you.

Obama's words during 2009 were that the problem with health care was the size of our bill: 1/6 of our GDP was going into it.

Obamacare, as passed, wasn't about controlling spending. You can blame the Republicans for refusing to participate at all, and you should. But the Democrats didn't have to respond with "Something Must Be Done, This Is Something, Therefore It Must Be Done."

Umm...other than to bash the other party, what reason is there that the R's can be blamed? The D's could have passed whatever they wanted without them and they did.

You are assuming two things:

1. It is the government's duty to provide you with health care, and everything else, for that matter.

2. That the government can do anything correctly.

I disagree with both assumptions. We have solid proof for #2.

And, from today's WSJ editorial:

: “ . . . Once customers are herded into the exchanges, HHS has the power to further standardize benefits, further limit choices by barring certain insurers from selling through selective contracting, and generally police the insurers to behave like the government franchises they now are. The state-run exchanges in Vermont and the District of Columbia have already barred individual coverage outside their exchanges.

“None of this is an accident. It is the deliberate result of the liberal demand that everyone have essentially the same coverage and that government must dictate what that coverage is and how much it costs. Such political control is the central nervous system of the Affordable Care Act, and it is why so many people can't keep the insurance they like.”

*You are assuming two things:...2. That the government can do anything correctly.*

The old P.J. O'Rourke joke: "Republicans say that government doesn't work, and then they get elected and prove it."

I like the new system better. Tough luck if you don't. The culture wars are over and guess what? The bums lost. Get used to it.

Ah yes, the smug asshole "WE ARE THE 53 PERCENT" approach. Nothing better to convince your political opponents that you're governing in good faith than to tell them they are un-people.

This from the man who calls other Americans "muds".

This has been the centerpiece of the Republican party's approach to politics for quite some time. Not to call them un-people, but "not real Americans". So not a very persuasive argument.

Once again, the politician's syllogism used seriously to explain why this wasn't a terrible idea.

Logic: you're failing at it.

Fortunately, the previously corrupt and unreliable congress has been replaced with honest, intelligent people working hard to make the world a better place. Otherwise, it might be just as impossible to get a good system retrofitted onto the bad system as it was to pass a good system in the first place.

Everyone misses the point: the health care market was broken. The Democrats were the only ones trying to fix it. And to do it, they took the plans of a conservative group.

Now, this is not an anti-Adam Smith rant. The market was and had been horribly regulated. Many people were collecting rents (i think I used the term correctly).

I am still waiting for a Republican idea (other than the current ACA) that would repair the market. for that matter, I think I am also waiting for a Democrat idea -- no wait, they have one: single payer.

Then why didn't they enact it in 2009, Allan? It isn't like you had to pass the ACA to get some Republicans on board.

+1. When you pass a bill without any Republican votes, then it follows that you didn't need any Republican votes. Thus, whether or not the ACA has its provenance in some Heritage study, or resembles RomneyCare is irrelevant. I would understand it if you bastardized a good concept to get Republican votes, but you didn't.

Arlen Specter was elected to the Senate and served as a Republican, switching parties only to escape his party caucus punishing him for supporting and voting for laws based on what is good for his State and the US instead of kowtowing to dictator Mitch McConnell.

And in the House, a Republican voted for the House bill in 2009, but he didn't last as a Republican in Congress.

The Senate bill included many kludges suggested by Republicans involved in drafting it. Republicans had ten times the influence what was in the Obamacare law as Bernie Sanders did.

The reason no Republicans voted for Obamacare or anything else was simply pure obstructionism because there was absolutely nothing Republicans would vote for because that would give Obama and Democrats a win. Or it would be so horrid they would never want to be blamed for it. On health care laws, Republicans couldn't pass anything even if they were to magically have 70 Senate seats and 300 House seats.

So, a bill with no Republican votes is the fault of Republicans. You give stupidity an entire new meaning, Mulp.

Actually, McCain's idea was fairly close to remedying some of these defects
1. Encourage, rather than outlaw cheap catastrophic plans + HSAs.
2. Replace the employer tax break with an individual credit.

If these had been linked up with the more popular elements of Obamacare (no maximum coverages, pre-existing conditions don't make you uninsurable)... and the unpopular mandate on the other side of it...the result would have been at least a somewhat workable outcome.

So, given Obamacare allows insurers to offer high deductible insurance with HSAs, Obamacare includes McCain's virtuous proposal, doesn't it?

What was McCain's answer to the free health care everyone got if they didn't have money or insurance, as conservatives keep pointing out "no one was denied health care if they didn't have money or insurance"? Other than the mandate, of course.


Don't be silly. The health care market was far from broken. It worked just fine for the vast majority of Americans. It was not a major issue in the '08 campaign. Reasonable alternatives could have been considered to address the problems of those directly affected. Not a surprise that ACA is not what Mr and Mrs America wants or needs.

That the vast majority of Americans are healthy is an under appreciated cause for most of them being satisfied with their health care. You actually do want to talk to someone who lost a job, picked up a pre-existing condition, and then applied for coverage.

I mean, seriously, health care for healthy people is pretty easy. Trivial.

How many people is that John? If it is a relatively small number (which I certainly think it is), massive intervention is in sallied for. One might characterize the problem as trivial.

I know that insurance companies aggressively test loopholes. When my COBRA expired I was told that one visit to ask about a sore shoulder made me uninsurable, and that I should inquire with my state's high risk pool. I tried another company and was turned down for similar silly reasons. I pushed back in writing, and they surrendered and gave me coverage. Certainly with someone with less navigational skills (or less silly preexisting conditions) would have been stuck though. People who just go job to job, and coverage to coverage, don't know.

Most people with employer-provided care really are happy with it, especially compared to a great unknown.

They might be nervous about losing it, they might grumble about the cost on their paychecks, but they like it right now, thankyouverymuch.

There's a reason "if you like your current insurance you can keep it" was such a mantra. Even a majority of Democrats would have rebelled against a plan saying "no, you really don't like your employer-provided insurance, we'll replace it with single-payer, trust us."

The fact that so much of the health care market is employer-provided insurance is a big problem, and I think that it would have been a great step for Obama to take, even making single-payer easier in the future. But McCain was for weakening the link between employment and insurance in 2008, so Obama had to attack it. Such is politics.

"It was not a major issue in the ’08 campaign."

What planet were you living on? Health care had been an issue in every campaign since 1993. Bush carved out health reform for the solid Republican base, those over 65. Clinton pushed on SCHIP before him.

The chamber of commerce made health insurance costs for its members the top priority. Romney did health reform in Mass to satisfy business lobbyists - too many small businesses were complaining about insurance costs. He figured Romneycare was his ticket to the White House.

There must be something weird with the matrix because I'm agreeing with a lot of mulp's comments on this page.

Health care was obviously a big issue during the 2008 election. You can hate Obamacare and think it's a stupid idea, but there's no way that this snuck in the side door without anyone noticing.

Quit perpetuating this false myth that the Repubs never had a plan. They've pushed quite a few plans over the years. W's plan in 2007 was even scored by the CBO as reducing # of uninsured by more than they scored O-care!

Can you please outline the similarities and differences between the ACA and the Heritiage plan? My sneaking suspicion is that you're parroting a common talking point that is rarely substantiated. This is besides the fact that any glancing similarity to the Heritage plan is irrelevant as the D's could and did pass the exact bill they wanted without R's in the process at any point.

The R's have plenty of alternatives, they're even linked to from the WH site. Because you disagree with them doesn't mean you get to say you're still waiting for them.

I'm sympathetic to this line of reasoning, but the fact is that if your goal is to allow people with existing conditions to get healthcare then you need a mandate, and if you need a mandate then you need to set a floor on what satisfies the mandate. I would like the floor to be lower, but I understand the need for the existence of the floor.

Michael - why not directly address this problem with subsidized high risk pools for those with pre-existing conditions? Why the need for the complex scheme?

There is money to be made in that complex scheme.

Subsidizing high risk pools - or creating true portability [allowing me to continue my plan after I leave work at a fair price] and some form of Cadillac tax to help pay for these would have been a sensible first step.

Creating a single payer catastrophic care plan might have been workable too - not a favorite of many Libertarians or Conservatives - but capping the OPC for the truly unfortunate would have also taken these folks
out of the general risk pool - and potentially saved a TON of paperwork and admin expense - have you ever seen the bill for a 100 day hospital stay?

But the progressives saw the opportunity to go for it - get the first step down the road for their single payer holy grail and went for it...

Now we shall see if they will pay in 2014 and 2016 for this over reach - or will the GOP be hammered for the shut down - it will be interesting.

The neat trick might be to put people insurance companies don't want onto Medicare ... until insurance companies find themselves with a thinning available market.

Just make any citizen who wants to apply eligible for Medicaid. That's fairly low-cost coverage, and I gather there are a lot of doctors who don't take it because it doesn't pay them well, but it does mean that you get rid of the problem of uninsured people being unable to get any kind of care. You could phase that in slowly over several years, and since the system already exists, it would presumably be much smoother than what we have now.

So, with tax funded subsidies to high risk pool insurance, no one needs by any insurance until they have a pre-existing condition. I just had a skiing accident, so I'll buy a high risk preX insurance policy. Ok, not that its healed, I'll drop it...

Sounds like single payer....

But previous law already required that insurance companies couldn't deny people for preexisting conditions, all you had to do was make sure that you had previously had insurance sometime in the past three months. A pretty low bar.

And mind you, the original sign up rates for the high risk pools designed specifically to address this problem was well south of 10% of the expected rate. Maybe this wasn't such a big problem after all.

But most States did not cap the premium - your COBRA runs out at $250 a month after you leave because of illness, so an individual policy for $2000 a month satisfies the Federal requirement that your State meet the requirement in insurance regulation.

Do you have a link to back up that $2k/mo assertion?

My COBRA was just over $750 a month in 2007 when my job ended.

"for people who were doing their part to keep all of our costs low"

Exactly who were these people and what were they doing?

I didn't like the phrasing Douthat used in this part because it covered up the essential point- these were the people who were buying insurance, but were little utilizing the services. In other words, they really were treating it like true insurance. The money they were saving was their own, this is the honey pot that the ACA creators decided to raid. I am guessing a lot of these people, if they don't get subsidies to cover the increases in their premiums, will become the new uninsured- their frugality hasn't disappeared.

I am a business owner. While receiving the news of my rate increase from my health insurance provider this morning, I realized an interesting, and I believe, overlooked part of this debate. If we believe that providing choice to health insurance consumers is the best way to foster competition and reduce costs, then employer-based plans are a disaster. Even in my state of New Hampshire, which has only one provider working in the Exchange, those customers in the Exchange have much more choice than my 75 employees. if you work for a company that provides insurance, it is very unlikely that you have much choice, if any. As such, employer-based healthcare is a dis-incentive to competition and cost control.

"While receiving the news of my rate increase from my health insurance provider this morning..."

Living in NH, I ask, "when in the past did you get news from your insurer of rate decreases?"

Actually, for us they do it every year.

True, however, the employer theoretically is handling the shopping for the employees each year. Starting next year, my employer announced they will be offering multiple insurance options for employees to choose from, with varying employee cost sharing on premiums, depending on what option you choose. I thought it was an interesting approach, though may not be feasible for smaller companies.

For us (75 employees) we are too small to offer options.

Douthat is just saying in a round about manner that he disagrees with the terms of the plans that are to be subsidized on the exchanges. Fair enough, but you have to actually argue that position, not presume it. Is a high deductable plan one that reduces health care spending in the long run? Which porceedures save costs in the long run and need to be cross-subsidized?

Quoting Ross:

"If we want health inflation to stay low and health care costs to be less of an anchor on advancement, we should want more Americans making $50,000 or $60,000 or $70,000 to spend less upfront on health insurance,

***rather than using regulatory pressure to induce them to spend more.*** -

Ross avoids the point of this exercise in re-distribution
This is redistribution by cost allocations,

The regulatory pressure is to require some to bear the increased costs of others (cost spreading) ***not*** to get some to "spend more" on themselves.

Exactly. Why couldn't Douthat just write that? Why try to dress it up like such people were doing something altruistic when, in fact, they were just being smart with their own money- money that will now be redirected to benefit someone else, should they still pony up the dough for the less beneficial insurance product?

This assumes these people will still have zero demand for medical services. Given that treatments like acupuncture are covered, there are going to be healthy people who will decide to go for monthly treatments. Costs are going climb.

Yes, it does depend on them, if they actually buy, still not utilizing the services available.

I don't think "covered" equals "free."

There must be legions of healthy people with all sorts of free time who like to and are able to pay $35 or whatever per acupuncture treatment.

Umm, sorta...

You are referring to the goal of Obamacare, while Ross is referring to the reality Of Obamacare.

One of the many flaws in the implementation is that the standards are simply way too high.

NO! Too Broad!

Agree with sentiment here. I hope a catastrophic version of ACA w/ large deductible becomes an option. Catastrophic protection is what I think many people want. The rest is just groceries or utility bill to me.

$6000 for under 30, and $2500 or so for over 30.

The law requires insurers to ensure doctors and hospitals don't suffer losses from unpaid deductibles, HHS is required to monitor unpaid medical expenses and thus change the rules on high deductible plans if they are merely a way to get free medical treatment.

If under 30s with $6000 deductible pay every bill promptly, HHS could raise the deductible to $10,000, or $100,000, if everyone buying such policies kept paying promptly all their medical bills.

I was thinking about this last night. I wonder if a high deductible plan would be available only to those who put down a "deposit" or could show "liquidity" or sufficient assets/resources? Car insurance in some states can be opted out like this.

In reality, however, requiring something like "deposits" or "proof-of-ability-to-pay" would probably kill the option in practical terms as it would not scale sufficiently.

"it [the ACA] cancels plans, and raises rates, for people who were doing their part to keep all of our costs low."

I think that's true, and that's the problem. What we do to "keep our costs lows" is place bets on our health -- bets that can be utterly wrong and can end up costing plenty. Sometimes inadequate coverage under cheapo plans can translate into uncovered medical bills of hundreds of thousands of dollars.

There is also considerable pressure on many to take the cheapest thing offered, period. Twice in the past day I have seen people on the internet say they had a wonderful plan -- for under $100 a month. In one instance that was coverage for a couple, the other was for mom and three kids. With family coverage averaging $16,000 a year, clearly no family of two or four has a great plan for under $100.

In the US, we are asked to predict next year's medical costs.
But such a prediction is subject to change that can be utterly unpredictable. All we can do is to make our best guess, based on our age, our current health, etc. But when we make such guesses and our plans do not have a reasonably low maximum for co-pays and deductibles, we can be liable for hundreds of thousands of co-pays.

I feel bad for the people who will be paying much more and didn't realize how much more. More should have been done to make the situation and costs clear. But the ACA does us a favor by identifying some downplayed faults in our current system.

One of these is the inability of anybody to predict their future health with any real assurance. Costly and devastating diseases and accidents can happen to anybody. The fact that they only happen to a relatively small percentage of us each year gives people a false sense of assurance that they won't happen to them in the future because they didn't happen in the past.

"Costly and devastating diseases and accidents can happen to anybody. The fact that they only happen to a relatively small percentage of us each year gives people a false sense of assurance..."

No, not a false sense of assurance, but a real definition of insurance!

The fact that costly diseases can happen to anyone, but in fact happen only to a small percentage of people each year, is exactly what true insurance is for. Those are the textbook conditions for an efficient insurance market, where insurance exists to pool the risk of catastrophic losses. When people buy a catastrophic, high-deductible policy, they're not "placing bets on their health." They're doing the exact opposite: they are hedging against risks to their health, and paying for routine expenses out of pocket, which is of course the efficient thing to do.

Richard, you echo my sentiments. I very much would like to see a high deductible/catastrophic plan made available. I emailed a couple of congressmen to this effect, but have no idea if that matters or not.

I will be purchasing my plan through the ACA.

You are writing about "Insurance" which is the transfer of risks (which are then spread by insurers).

At issue are healthcare contracts which are now converted into redistribution instruments and insurers serve as enforced cost spreaders and allocators.

But liberals believe auto insurance should cover oil changes and tire rotations. They just haven't gotten to it yet. That is the "Progressive's" regressive understanding of "insurance".

If we call don't call it "insurance" anymore, would that have any effect on your objections?

Not all the cheapi plans are catastrophic plans.

Some concentrate on paying for the small things and pay little or nothing for the bigger things.

Note: all that confirms the concept that the "know betters" should be making all the choices - and- nudging the choices remaining in their chosen direction.

We should not forget that because we pay so much more, per person, on heatlhcare than any other nation in the world makes financing heatlhcare in the US a uniquely heavy burden.

I would also say it's an unnecessary burden that we've accepted too long. At this point, between the costs of this, coupled with paying for healthcare and nursing home costs for the Baby Boomer generation, we are at the end of our ability to keep paying so much more than Western Europe, Australia, Canda, etc, for the same thing.

We will have to stop kidding ourselves that there's a net advantage to robbing ourselves in other areas to keep an unsustainable system going.

It is not being left to "us" to make those decisions

They are being made for "us."

This is the critique of the "mass man" who feels inadequate or fearful to make choices as identified many years ago by Michael Oakeshott.

I think it is time to undo the decisions, made many years ago, that have led us to grossly overpay for healthcare.

It seems you would prefer to be charged $200 for what our peer nations around the world might pay $100, $50 or even less than $20 for. i do wonder if you actually pay the $200 or does Medicare, the VA or other insurance pay the bulk of the price?

I find it hard to believe you'd be so eager to keep being overcharged if you were paying for the overchage.

To hell with Obama. To hell with the Democrats. And to hell with anyone who votes for them.

I had a "premium" PPO insurance plan on the individual market. I got it years before Obamacare became law. I was not grandfathered in. My plan was cancelled.

There is no equivalent plan under Obamacare. My premium will go up 82% and my deductible will be doubled. Worse I'm being forced into an HMO and out of the the PPO that had chosen.

Worse still is that my low co-pays for specialists are now being replaced with full fees that count towards my deductible.

I calculate I am now being forced to spend about $5k more annually for worse care and fewer options.

Are you being "forced" into what you describe because that's the replacement plan offered by your insurance company?

Or are you saying that's the closest equivalent to your prior plan that is available in your state -- through the exchanges or otherwise?

Shop for plans. There are options that are much better than that.

Alas, no. plans will not tell you before you sign up which doctors and institutions are part of the plans being offered. I'd like to know which hospitals in my state and which of the doctors I've consulted are participating in any insurance plan I buy.

That is as much a problem of the insurance companies as anybody. The exchanges get that info from the insurance company. Apparently those lists are inaccurate and improperly maintained.

The liberal fascist scum are saying it's just catastrophic plans being cancelled. They are lying maggots. My plan was as comprehensive as the insurer offered. I paid a premium for a premium plan. And still Obama and the weasel Democrats have killed my plan. And now they lie like dogs they are.

Hoyer has come out and admitted that it was obvious to him that millions wouldn't be able to keep their plans.

It sounds like your plan actually meets all the requirements of the ACA (i.e. it is premium and comprehensive). I think it is simply your insurer who is changing their business model, rather than updating this plan to meet the ACA standards. Do you know what specifically about your plan did not jibe with ACA? If not, I think your anger (e.g. maggots, dogs) may be misdirected.

All the commenters here should move to their Ayn Rand libertarian island of choice or just fuck off. You are losers in this. Expect to keep losing. Leave the country if that bothers you.

No. We will remain as the "Remnant" cited in A J Nock's "Isaiah's Job".

The concept that some few (and considered their demonstrated limitations) can and do decide what is "best" for all (except, of course a politically determined group) is not just "flawed" it is **false** as has been proven again and again.

This time, on this issue, the "fuse" is shorter.

Who are you to tell any American to leave America?

it is not a crime to disagree or to express an opinion. That is one of our precious rights that you are trying to eliminate for others -- but obviously not for yourself.

And to think it used to be the Republicans using this line. My, how the tables have turned.

They know they're losing. Their jobs, an impartial bureaucracy, their health insurance and any prospect for a future not drowning in debt.

You're subject to all of these things too.

But you think you're winning.

Doesn't get any sadder than that.

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