[bduerst]

Which is why ACA also instituted marketplaces and insurance standards, so that competition across substitute services keeps premiums competitive.

E.g. Anthem is more than free to double the premium on their bronze plan to increase net profits, but then customers are free to swap in bronze plans from Cigna, Kaiser, or any number of competitors that didn't.

[ddingus]

Not really. Networks complicate all of that severely.

This massive price escalation was called out as a definite outcome by progressives seeking a public option at the time.

The percent cap was touted as the fix.

Insurers bought facilities and raising dollar amounts kept revenue near expectations.

[bduerst]

How exactly does networks complicate that?

Insurers had to scale (i.e. increase costs) after ACA was implemented because number of uninsured Americans went from 18 to 11%.

[hakfoo]

Networks complicate things by reducing demand elasticity.

For example, look at Maricopa County, Arizona. It's like 100km across and includes both a major capital city (Phoenix) and several suburbs with 6-figure populations (Mesa, Chandler, Glendale).

Many of the marketplace health plans* would have networks which focused around central Phoenix. If you wanted to see an in-network doctor or urgent care and lived at the fringes of the county, it was a 30-minute drive or more.

This meant people in the fringes had to pick the few plans that covered nearby facilities, even if there was a significant price difference.

* This was during the first few years of the marketplace. By 2017 or so they were basically down to a single insurer, so even that degree of consumer leverage was gone.

[ddingus]

Have you ever tried a policy change?

[bduerst]

Yes. I have actually bought my own insurance through one of the state-run exchanges in the past.

[ddingus]

For anyone with complications, medical history that is non trivial, networks become very important, and do costs.

Networks take people in and out of the chain of care providers, and costs swing dramatically.

The whole affair adds zero value when compared to simpler Medicare For All type plans.

People in my life got sick, and the financial carnage has gone on for decades.

This pretty much rules out any favorable view on markets and private insurers I may have. And I am by no means a unique, or even uncommon case.

If it were not for family, I would have picked up and left this cruel system a decade ago.

[tptacek]

Networks are very important with all kinds of insurance. The thing you notice when you switch from employer-covered insurance to ACA market insurance is all the fiddly choices your employer was making for you. You can say that having to make these choices is a process failure of the ACA, or you can say that having the freedom to make those choices yourself is a benefit of the ACA.

I'm not sure what M4A has to do with this, and, in particular, to relate this story back to the thread, you should be aware that Medicare drug benefit administration is also privatized, and that somewhere between 1/3 to 1/2 of Medicare recipients also get Medicare Advantage, a private insurance rider to Medicare that is largely defined by network restrictions.