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Comment by mieseratte | Hacker News Reader

I signed up for the ACA the year it came online. Over the years I went from a sub-$100 plan that actually covered things to paying $300+ per month for the "hit by a bus" plan that was so expensive, one year I said fuck it and paid the penalty instead. I understand well what could have been had something truly happened, but I ended up saving money paying the penalty while still having a few minor doc-in-a-box visits out-of-pocket. I also say a number of insurers go out of businesses such that now your only option in my state is the BCBS.

Say what you will about the ACA, but requiring folks to purchase a product while doing not curbing the rampant greed in the industry screams of corporate welfare to me.

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If you're saying the ACA didn't completely fix the US healthcare system, I strongly agree.

If you're saying the ACA harmed the health care system, strong disagree. Again: the cost increases you're talking about were a fact of life before the ACA. There is no evidence that your costs would have leveled off without the ACA, and substantial evidence that the opposite would have happened.

The increase in costs were most certainly driven in part by the ACA changes. No longer allowed to deny based on pre-existing conditions? Insurers need higher rates to cover those costs. Require a bunch of things be added to mandatory preventive visits? Those have to be paid for as well.

That said, I agree the costs would have continued to go up, but to say there is no evidence that the ACA contributed to it is just ignoring the math.

I had the same experience where as a sole proprietor health insurance for a family of 5 is now $2,000/month. $24k/year not for great healthcare, but for the privilege of paying a "discounted rate" on "select services" when you actually need healthcare.

We haven't needed the coverage for two years but when we did, what we needed wasn't covered so we paid full price anyway including $80 for a bottle of Ibuprofen that was casually offered to us. The markups are almost criminal.

For a $1M home you can find insurance for $1,500 per year. It's exponentially less expensive.

ACA was the worst possible compromise to a serious problem. A public option, universal healthcare or deregulation all would have been better options.

It'd be much nicer to be able pay a doctor to make house calls as needed and waive your right to a malpractice lawsuit than to pay to support this insurance/legal/government system we have now.

My companies insurance premiums were going up 10-15% a year for years before the ACA.

Ours were going up sharply before too, at Matasano (2005-) and before we started Matasano, our health insurance at my previous employer also got slashed (2001-).

> No longer allowed to deny based on pre-existing conditions? Insurers need higher rates to cover those costs.

Is there any alternative though? We're going to pay those costs one way or another: either the government pays for all the unprofitable patients' healthcare (the wet dream of health insurers), or we tell those people to go fuck themselves.

And now we have the worst of both worlds:

Those patients have no coverage so get Emergency treatment for acute symptoms of their issues that rarely fix the underlying problem, and beyond that we also tell them to go fuck themselves.

The government subsidizes ACA plans for many participants. That was partly meant to soften the impact of requiring coverage for pre-existing conditions. And then there is/was the individual mandate, to get everyone to contribute even if they were currently healthy. The ACA also imposed a tax on high earners (IIRC, >=200K, not sure if it is inflation adjusted) to fund the subsidies, and it cut spending on Medicare Advantage, which costs the government more than the other medicare plans.

That being said, I'm not disagreeing that costs went up after the ACA more than they would have, but, IMO that was just insurers/providers raising prices because they could.

There's no evidence that costs went up after the ACA more than they would have, and, in particular, costs grew significantly faster under Bush than they have at any point after the ACA. I'm not sure I understand why we're supposed to give credence to HN-style first-principles analysis of why insurance costs should have increased; in particular, most employer-provided health plans already complied with the ACA's coverage requirements. The data simply doesn't back these arguments up.

You are "most certain" about something that empirical data refutes. Health care costs grew more slowly after the ACA than before it and, in particular, at no point subsequent to the passage of the ACA have health costs grown more than they did during the Bush era.

There are all sorts of things that should have (and perhaps even did) impact prices after the ACA. Not just coverage requirements (which, again: most employer-provided health plans --- which is what we're talking about here --- already complied with), but, more importantly: unprecedented instability in the insurance markets during the almost decade-long concerted effort by the GOP to hamstring and ultimately repeal the bill. And yet, the numbers are right there: health care costs are growing, but they are not growing more than they were prior to the ACA.

I think we’re arguing different things.

Sure, costs went up less after ACA.

However, the ACA directly added costs to insurance that weren’t there previously.

I don't understand this argument. The ACA changed a bunch of things about the health care system. It reduced some costs and increased others. The point is to reduce the total cost (or, in this case, the total rate of increase in health care costs).

It reduced some costs

What were those?

P4P, bundled care, reference pricing, the IPAB-based spending controls, reduced hospital readmissions, the premium rate review process.

Can you help me understand the argument you were trying to make above? I continue not to grok the point you were trying to make.

> If you're saying the ACA harmed the health care system, strong disagree.

The system? No. Corporate welfare is great for "the system." But the consumers? Absolutely harmed!

> Again: the cost increases you're talking about were a fact of life before the ACA.

I've been working for over a decade now. 100% increases, year-over-year have never been even close to a thing with employer plans I've held. Not even close. Typically something in the realm of $20 per year at worst for a quality plan.

Here is another fun anecdote. I recently lost a job, and my firm was too small, with only 4 insured, to qualify for the COBRA. Total premium for the plan was roughly $150, roughly $75 per party as my employer paid 50%. Comparable coverage through the same insurer through the marketplace would have cost me nearly 4x as much.

The reality is the ACA allows insurance firms to sell obscenely over-priced plans to consumers. A sane system would have seen price controls in conjunction with the requirement for insurance. Instead I am forced to pay an insurer, pay the government, or prison. I would happily pay taxes for a fully nationalized system, but the ACA is obscene.

Again, consumers have absolutely been harmed by the skyrocketing cost of health care. But every bit of evidence shows that the ACA slowed that growth.

The only connection you’re making here is that your own costs went up after the ACA. It’s a post hoc fallacy.

> The only connection you’re making here is that your own costs went up after the ACA.

The connection is that the ACA rates, and rate-increases are out-of-touch with the employer-offered system, even when those firms are tiny and not nearing some kind of "scale" cost-savings.

I have been hollering about this issue for years, and I've yet to have someone say "Ya know, I actually experienced something radically different." So where is all this evidence you claim but can't be bothered to provide?

I'm having trouble parsing what your argument here is. Are you saying that rates on the individual market are more expensive than the large group market is? Yes, that's true, and always has been (the small group market is effectively a facsimile of the individual market, for the obvious reason that there's not much actuarial benefit to pooling 10-20 random people).

There also isn't one "employer offered" system. In addition to the aformentioned small-group marketplace, there are also large group plans that cover big companies, and very big companies often self-insure, using health insurance companies solely to administer benefits but financing the care themselves. Can you be specific about which of these kinds of health care financing have been impacted by the ACA, and how?

The ACA is a bandaid on a wart

> The reality is the ACA allows insurance firms to sell obscenely over-priced plans to consumers.

As far as I am aware, the ACA actually introduced limits on how much mark-up health insurance can have, where 80% of the cost must go to actual medical expenses, and administration, marketing, etc must be no more than 20% total. So how is the ACA the cause of insurance mark-up?

I think the actual root of the problem is not mark-up but that health care in the US is quite expensive (and always increasing). The ACA in some cases shifts who pays for it (young healthy people pay more), but it doesn't appear to change much the overall cost. It sucks temporarily for those younger people, but considering they will most likely become older, less-healthy people over time it doesn't seem that unfair overall.

> A sane system would have seen price controls in conjunction with the requirement for insurance.

If you are paying 4x more though, it sounds like the marketplace may be breaking down in your location with a "death spiral", where the price goes up, all the healthier people leave, causing the remaining insurance pool to be even sicker and the price going up even more. The whole purpose of the mandate was to prevent this, but it looks like it's been repealed. Price controls in that situation is hard since the pool is actually expensive to insure, I don't think the government can force the companies to sell at a loss. To reverse it maybe they could re-instate the mandate, or change it to a tax, or add a public option. Or, of course, give up on insuring pre-existing conditions.

> I would happily pay taxes for a fully nationalized system

Keep in mind, there are other countries like Germany and France that have private insurance markets and much cheaper care. I think it is fully possible for the US to implement a nationalized system that does not achieve the cost-effectiveness that we want. The VA system might be an example of how that might go.

> As far as I am aware, the ACA actually introduced limits on how much mark-up health insurance can have, where 80% of the cost must go to actual medical expenses, and administration, marketing, etc must be no more than 20% total. So how is the ACA the cause of insurance mark-up?

One of the issues (and I like the ACA generally), is that that limit removes an incentive for the insurance companies to control costs and the 20% markup becomes a floor, not a ceiling. If they get 20% of revenue as non-medical costs, and they want to increase their profit, the best way to do that is to allow medical costs to increase. Then their 20% is larger because the pie of costs is larger.

Presumably they could pass along the savings and increase revenue by expanding their market share, or lose revenue to a company that controls costs. I see your point though, and in a given year it might be easier to increase medical expenses by 5% than to grow market share by the same amount.

One thing I wonder though, is that even without the 20% rule, if the company can get away with raising rates by 5%, wouldn't it make sense for them to do so? If they started with a 20% margin that would increase their profits by a whole 25%, instead of a measly 5% with the cap, so you'd think the incentives would be even stronger. It seems like adequate competition is the most important thing in a for-profit insurance model rather than having a 20% margin rule or not.

In a healthy, actually competitive market, I think that would work, but there are so few insurance operators in each market, it's really easy for them to quietly collude with each other rather than compete. Additionally, everyone else in the industry wants higher prices and more profit. They are not limited to a 20% cost margin. The insurance companies are supposed to be the downward drivers on price. However, here, it's just easier to not fight the price increases, take your 20% of the increase, and move on, rather than fight hard to push prices down, and gain market share.

I think many economists would say that while you had an employee-based plan your costs were actually going up significantly, you just didn't see it because those increases were coming out of (what would have been) your yearly salary raises.

I don't think ACA plans are much more expensive that what we are _really_ paying for employer insurance. I recently became unemployed and when I priced it out, an ACA plan that offered benefits similar to what I would get with a COBRA plan were pretty much the same price - both ridiculously expensive, so I went with a cheaper silver HMO ACA plan. And my old employer charged a 4% "fee" on COBRA premiums as well - I guess the benefits companies want some of the action.

When I look at what my insurance company actually covers for all of my doctor bills, I'd probably be better off just paying the penalty. At least I'd have a few hundred more every pay check to cover that 11 extra dollars that my insurance company could dare to part with for a $300 X-Ray.

The penalty has been more or less hamstrung by the GOP, so if that's your only consideration, then, yes, you're better off not paying for health insurance.

Additionally: you can (you shouldn't have to, but you can) shop around for cheaper medical imaging. Imaging in particular has wildly varying prices, and if you stay on the "happy path" your PCP and hospital puts you on, you're going to pay the higher end of the range of prices.

You are not, as a general matter of life advice, better off going without health insurance. Rather, find the least expensive HSA-qualified HDHP, fund the HSA with the savings, and pay for routine care (effectively) out-of-pocket. The point of insurance isn't to make your annual checkup cheaper, but rather to avoid going bankrupt if you get hit by a car or your appendix bursts.

From the way you write, your appendix presumably hasn't burst yet. That's great! Neither has mine! My house has also not caught fire† and I have not managed to crash my car into a fully occupied city bus. But I am insured against both of those things, too.

† since we bought it, i mean

I should probably specify the level of "tongue-in-cheek" in which my dismissive comment was made. I'm well aware of the function of medical (as well as other) insurance. Having a family, I'd be a fool to "go it alone". But you're correct, it's my responsibility, especially as one who chose a HDHP this year, to shop for the best deals.

And nope, still on my original appendix... I change the oil regularly.

It is corporate welfare, I remember lots of libertarian arguments to that very point. But to solve health care in the US you would eventually have to start questioning the for-profit underpinnings of the whole enterprise. That was far too much to expect from the generally pro-market Democrats in office at the time.

Even after Bernie Sanders, the "Very Serious Democrats" talk more of protecting the Health Insurance Industry than anything else. Best case, we'll see a timid proposal of a expensive Medicare Buy-In added to the ACA exchange that will never get past the Senate.

As I once heard it put: the US doesn't have a left and a right party, it has two parties to the left and right of capital.

I heard it once said that America is a one-party system, but in typical American excess we have two.

Both in service of capital.

I used to dabble in enjoying quips like this. They're simple and fun and sound insightful and knowing. But when I look around me I see no truth to them. We have two parties with very distinct philosophies making very different arguments for how the future of our culture and economy should function. "Capital" influences both of them, in different, sometimes overlapping, ways. But they have many differences across many axes.

The "above it all" smugness of quips like that is tiresome.

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