[tptacek]

That's not the cost we're measuring! We're measuring cost on the macro scale, in terms of the percentage of the economy spent on health care and, in particular, the percentage of the federal budget spent on health care entitlements. That's the cost curve we're talking about bending, because the pre-ACA projections were literally prima facie untenable.

Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.

[0xbear]

You can measure whatever you like, but my costs have gone up nearly threefold and my plan is worse now than it used to be. I'm not interested in solving world peace here. I just want to understand why insuring a relatively healthy family of three under a very high deductible plan costs $1700/mo, and why is it now illegal to not go along with this ridiculous rip off.

[tptacek]

Your plan was already going up before the ACA was proposed, even if you were in medium or large group markets. (My firm offered health insurance to employees in California, New York, and Illinois from ~2006-2012.) Family health insurance on the group market was something like 1100-1200 pre-ACA.

If you're paying for your own insurance, you're in the individual market, which is significantly more expensive, and what you're seeing is, in part, the market absorbing the cost of guaranteed issue, something we decisively did not have before the ACA, when health insurers could lock people out of coverage on suspicion of a medical condition, and later rescind care. Pre-ACA and post-ACA insurance is for that reason also not an apples-apples comparison.

[yourapostasy]

> ...you're in the individual market...

Is the actuarial and outcomes data corpus of the health insurance industry so bad that it makes actuarial sense to segment the markets to individual, medium group, large group, etc.? I've always wondered what the explanation is for so many cohorts.

Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools, or co-marketing with life insurance companies that gather pretty detailed data on individuals before underwriting?

[morgante]

> Are state insurance regulations preventing medical insurance providers using more sophisticated risk modeling to create larger pools

Especially post-ACA, there are very strict limits on what factors can be used to set premiums. Risk-based assessments are basically outlawed except for a few defined variables like age and smoking habits.

[chrishynes]

Yep, prices were rising before ACA and continued to rise thereafter. I'm not sure on the rate of increase, but the absolute levels are getting to the impossible.

Regardless of the cause, it's extremely frustrating to be hit with such a large monthly bill for rather poor coverage. I'm not quite as bad off as 0xbear, but we're at $1550/mo for a family of three for much crappier coverage than we had a few years back.

Here in Phoenix we've seen double digit increases every year for years, and are down to a single provider on the individual market.

Paying $18k/yr before you even use a plan is insane. Use it at all and you're looking at $20 or 25k total, with coverage limits not really kicking in to stop the bleeding until you've shelled out 30k or so.

Somebody making $80k/yr just hits the subsidy payout and is spending 20-40% of income on health care. Unsustainable.

Argue the whys all you want, these sky high rates have to change.

[groby_b]

> Argue the whys all you want, these sky high rates have to change.

If you don't argue the whys, you're mostly providing a lot of noise that is convenient cover for the next attempt to bilk insured people.

Yes, premiums are way too high. They are not high "because ACA", though. In fact, they'll rise at a much faster rate if we get rid of ACA. (The latest bill had an annual rise of $11.4K for a single male adult >62 years, with an annual income of $12K.)

There's no question ACA is broken, and we need to fix it. But we need to know and understand what is broken to fix it. A repeal won't do that.

There's a good argument to be made that e.g. enforcing cost transparency would do that. (Right now, you have no idea what insane cost your provider will charge you - they make shit up as they go). Single payer is one possible way to do that. Not the only one.

There's another good argument to be made that we need to talk about the right to die. Numerous patients are kept alive at insane costs, even though they would rather live out the last few quiet moments at home, with their family.

There's another good argument that for a decent risk pool, everybody needs to be insured. (This is an argument that stands little chance until being insured is actually somewhat affordable)

There's a good argument to be made that Medicare should be allowed to actually get competitive bids. (Right now it's rejected to "pilot projects" and "test markets").

There's a good argument to be made we need to focus much harder on preventative care. Follow-up costs from acute episodes are much higher than a decent investment in preventative care.

There's a good argument to be made we should talk about our test and prescription obsession. The amount of stuff unnecessarily prescribed "just in case" is ludicrous.

None of these will immediately lower rates. But each day we spend wasting on the theatre that is the junk the current GOP tries to ram down everybody's throats is a day they rise. And should this pass, they'll rise tremendously.

If we don't all inform ourselves as to the why's and then hold our representatives feet to the fire using well-formed arguments, so they can't weasel out, we're stuck with a shitshow. So, while I understand the frustration - I've got health care bills too, after all - an attitude of demanding change without informing ourselves what change to ask for leads to an even worse disaster.

And that feet-to-the-fire thing applies to all parties, in case you were thinking I have a particular partisan view. But it needs to be an informed roasting, or we'll merely end up with the loudest guy making the good sounding promises.

[chrishynes]

Certainly, and I am in full agreement with you on pretty much everything you said.

I'm ranting against those who continually tell me "it's not that bad", "suck it up", "you're lucky you have insurance" or some variation of the above.

The first step in fixing the problem is to recognize the problem, and there's many I've talked with that reflexively reject the premise that there is a problem in the first place because of what that means for the ACA.

The foundational issue is that we're stuck in an uncanny valley between single payer and private insurance. Either single payer or private could be viable, but not the unholy menagerie we have now.

The high costs, over prescription and under prevention that are bloating the system all driven by that issue and could be solved with a single arbiter that gets the bill, whether that be the government or the citizen.

The best proposal I've seen is a two-tier system like Germany has, with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness, but really solves most of the problems because it gets universal coverage to spread the risk pool while accepting the natural impulse to want to pay for better care if you can rather than rejecting that option out of hand like some single payer systems do.

[groby_b]

> with public healthcare for all and private healthcare available for the rich. That tends to rub Americans the wrong way because fairness,

I lol'ed. Because... we already have private healthcare for the rich, we just don't have public healthcare for all. Because fairness ;)

And I'm very much enamored with the German system as well, but then, I'm biased. I'm from there. (And currently pondering going back there, because as much as I love what the US could be, I hate what it currently is)

[seanmcdirmid]

This is why Switzerland doesn't have a group market. Everyone is forced into the individual market, which makes individual polices cheaper (I.e. You can't get health insurance from your job).

[isostatic]

$1700 a month would be £5,440 a year per person.

The NHS costs about £3,500 a year per person.

[0xbear]

The costs don't end there, though. Other than preventative care, you're also covering the first $6k or so in costs, though the insurance company will negotiate them down for you from the initial insane levels to something merely causing headaches and indigestion. I've yet to pay more than $6k per year, so essentially I'm paying the remaining 20k for the benefit of others. Not even when I broke my ankle a few years ago did the (negotiated) bills total up to more than $10k or so.

[KekDemaga]

Unfortunately for the DNC, the costs many voters were measuring last November wasn't healthcare spending compared to GDP it was actual out of pocket costs that have risen dramatically for many working class Americans.

[tptacek]

Can you cite a source for that claim?

[KekDemaga]

You need a source for "people care more about their family budgets than percentages of GDP spent on healthcare"? Take a look on how the middle class voted last election.

As for the increase premiums are up 25% in 2017 alone. At the same time deductibles are also rising, its much more money for much less coverage if you are unlucky enough to make over 50k a year or so.

http://fortune.com/2016/10/25/obamacare-insurance-premiums-2...

[tptacek]

No, I need a source for "the rate of cost increase is steeper under the ACA than it was prior to the ACA".

[KekDemaga]

"enrollment-weighted premiums in the individual health insurance market increased by 24.4 percent beyond what they would have had they simply followed trends"

https://www.brookings.edu/wp-content/uploads/2016/07/Fall201...

[pcwalton]

The very next two sentences: "The observed premium increase reflects unsubsidized premiums. Insurers receive the full premiums each month, regardless of whether they are paid by the individual or the federal government (IRS 2014). Thus, although the data reflect premiums received by insurers, individuals likely faced smaller changes in premiums after taking the subsidy into account."

It's remarkable that premiums didn't rise more under the ACA, despite how many new previously-uninsurable people were covered.