[Kequc]

You are asking how fines are enforced?

Ideally you wouldn't have to pay for health insurance but this is what was able to be passed at this time. It has provided insurance to millions and largely reduced costs across the board. Everyone gets sick or at the very least eventually old. It isn't gambling, it isn't a risk, it's certain. You need to be insured. I'd just suggest it's better than what you had before.

[emidln]

    It isn't gambling, it isn't a risk, it's certain. You need to be insured.

Why? I have money to pay my family's medical expenses. I've done very well investing it. Giving it to an insurance company whose primary goal is to not pay my medical expenses while collecting premiums over versus investing it myself for future payment of services rendered seems like a really bad trade. I realize this isn't a trade that every person is in a position to make, but why do I need the insurance? If I don't need the insurance, then why do I have to pay a fine to opt out of taking it from an insurance company?

I don't know many who are making an argument against lowering health costs or enabling access to more people. Neither of those things necesitate compulsory purchase of an insurance product.

[joshontheweb]

This. I have enough to cover most things. Also I plan on doing any non-emergency procedures in another country where the prices are reasonable. Even if I do get hit with something catastrophic, I'd rather have them send me the bill and let me negotiate and pay it off myself. Insurance companies shouldn't be obligatory.

[aestra]

>Even if I do get hit with something catastrophic, I'd rather have them send me the bill and let me negotiate and pay it off myself.

You do realize medical bills can be in the millions of dollars, right? It isn't even vary hard to get into the hundreds of thousands. Requiring everyone to have insurance solves the "free rider problem," where some individuals pay less than others for the same thing. You can "negotiate" all you want, but that just means person A pays less than person B for the same thing. Especially if you get a $200,000 hospital bill and you had to declare bankruptcy. If there are a lot of Person As, it makes the costs for all the person Bs rise. If there is no incentive to be a Person B, then many people would be a Person A. Requiring insurance tries to eliminate the Person As.

Disclaimer: In the real world of US healthcare, prices are nuts and different for insured and uninsured.

> I realize this isn't a trade that every person is in a position to make, but why do I need the insurance?

Because most people can't deal with a $30,000 medical bill.

Also most people are, for lack of a better word, stupid. They don't make rational choices. My sister for example, thinks that she doesn't need health insurance because juice fasts can cure all diseases. How many of my sisters are out there vs people who are responsible with their money?

You may think you will be completely healthy, but really, we are all human and something terrible (and expensive) can happen to you tomorrow.

Do I think this is a good system or a good solution to the problem? No, I do not.

[joshontheweb]

A lot of my resistance is due to the fact that I've been burned in the past by the fine print and ended up having to pay 80% instead of the agreed upon 20%. If I truly trusted that the insurance company would be there for me when I need them, I would have a different approach. As it stands I paid monthly insurance premiums + deductible + most of the bill. No thanks. I'll take my chances on my own.

Edit: For clarity, the insurance company decided to pay 80% of what they claimed the procedure was worth, not what it actually cost. Apparently there was something in the fine print about that.

[aestra]

>If I truly trusted that the insurance company would be there for me

I don't believe they will be there for me either, and I've been burned before too. That's one of the reasons why I don't support the ACA. However, making others take on your risk is any sane solution. You are just shifting the burden to others.

> As it stands I paid monthly insurance premiums + deductible + most of the bill

You can appeal and appeal and appeal, then go to your state insurance board. This is a government required right. There wasn't any reason to just accept what the insurance company told you. You can even get an external review. Over 90 percent of insurance decisions are reversed on appeal.

Just several phone calls sometimes resolves the issue. I've been on the phone so many times I've practically gotten them on speeddial.

[couchand]

If I don't need the insurance, then why do I have to pay a fine to opt out of taking it from an insurance company?

One or both of these scenarios probably applies: you are young and healthy, so your purchase is necessary to spread risk over the population as a whole; or you're underestimating the odds of getting a major disease and the cost of paying out-of-pocket.

I'm not saying we shouldn't work to lower health care costs. What I'm saying is that insurance companies pay less than cash customers for health care and they spend a lot of time checking their risk calculations. Over the long term, over the population as a whole, you can't win that game.

Let's work to lower costs and fix that, but realistically, right now, in America, it's not a game you want to play.

[jamroom]

I think what we need for people who don't want insurance is some way to "opt out" of the health care insurance system - maybe a special card you carry that indicates to the emergency room or hospital (where maybe you have been admitted, unconscious and close to death from a car accident) that indicates any medical assistance provided will be 100% your responsibility - i.e. bill me or whatever. The only problem is that someone could then just claim bankruptcy and push the burden back onto the insured - so we'd need to make it so bankruptcy could not remove that outstanding debt.

[emidln]

    I think what we need for people who don't want insurance is some way to "opt out" of the health care insurance system - maybe a special card you carry that indicates to the emergency room or hospital (where maybe you have been admitted, unconscious and close to death from a car accident) that indicates any medical assistance provided will be 100% your responsibility - i.e. bill me or whatever. 

Why do I need to carry a card? What purpose does the card hold other than to tell the medical provider to treat me differently (as if I could either not pay (unfair to me, how do they know my assets) or could pay for better treatment (unfair to everyone else, why are some suffering through mere insurance while I have the good stuff that daddy greenbacks bring))? If you are differentiating for those without insurance, you surely must do the same for those with the comically legal 60/40 plans that have no practical out of pocket cap. 40% of a 100k bill is practically the same as being uninsured when looking at the effect of causing a bankruptcy to most of the country.

    The only problem is that someone could then just claim bankruptcy and push the burden back onto the insured - so we'd need to make it so bankruptcy could not remove that outstanding debt.

Would you prevent people who signed up for 60/40 co-insurance from Aetna or Blue Cross to file for bankruptcy when they cannot afford to pay their 40%? If not, why? They choose* to not pay for better plans that limit their out of pocket liability.

Making bankruptcy harder isn't the right solution. Complete nationalization is only solution that doesn't leave uninsured and underinsured individuals who need to take a bankruptcy after an illness or accident. If that is truly the goal, then that is what should be worked at.

[jamroom]

I don't disagree with you - I just believe there must be some way for someone to "opt out" if they want - but if they do that how do we prevent someone from gaming the system who doesn't have the money to actually pay for what they need? It's not that far fetched to be in a situation where medical expenses can be in the hundreds of thousands or even millions of dollars. Ultimately we need Medicare for everyone, but until that time (if it ever comes) is it possible to make the current law more palatable for everyone?

[Datsundere]

Uninsured person doesn't need a card. Doctors cannot deny treating a sick person in emergency care. Hospitals will however take all your assets away.

[panarky]

If you have the resources to self-insure, you don't need to pay an insurance company.

http://healthjournalism.org/resources-tips-details.php?id=65...

[ctdonath]

It has provided insurance to millions

It has cancelled the insurance of more millions. You're not just required to have insurance, you're required to have insurance meeting higher standards than many can afford and/or were living just fine without (ex.: not paying for birth control coverage when there is absolutely zero chance of pregnancy).

[aestra]

>not paying for birth control coverage when there is absolutely zero chance of pregnancy

The argument here is....

It is in our best interest as a society as a whole to have a society that controls its fertility. We have less children born that aren't wanted, less teen pregnancy. Les children in hardship. That's a plus for society.

It is also beneficial to society to have children who are born healthy. That's why we are all required to pay for maternity care.

It is also beneficial to society to have a well educated populace, that's why we are all required to pay for primary education (through property taxes) even if we have no children, and can't have children.

Educating the women in society and giving them access to birth control is one of the best ways to pull a society out of poverty.

[marknutter]

> It is in our best interest as a society as a whole to have a society that controls its fertility.

Conjures up images of other societies who have controlled their fertility..

[aestra]

http://www.prb.org/Publications/Datasheets/2012/world-popula...

[cujo]

It also gave a lot of us the ability to get insurance. Pre-existing conditions prevented an awful lot of people from getting insurance or changing jobs. This fixes that huge hole. No one is saying it's perfect, but it's going in the right direction.

[bmelton]

That's my biggest problem with the ACA, actually. I think it's great that insurance providers now have to accept pre-existing conditions, and while I'm against the ACA in general, I see that as the biggest good that it's doing.

My dislike for it is that one provision could have been its own separate law that would have been passed easily, with more bipartisan support, and would have fixed much of what ails the system. We could quibble all day over whether or not the ACA is the best way to get there (and I think very few would suggest that it is), but there are parts of it that I would support in isolation that didn't require the individual mandate, which I believe wholly violates the Constitution, regardless of what Justice Kennedy maintains.

[tzs]

> That's my biggest problem with the ACA, actually. I think it's great that insurance providers now have to accept pre-existing conditions, and while I'm against the ACA in general, I see that as the biggest good that it's doing

> My dislike for it is that one provision could have been its own separate law that would have been passed easily, with more bipartisan support, and would have fixed much of what ails the system

No, it would have destroyed the system.

This happened in Washington state in 1994. They passed a law in 1993 that required acceptance of people with pre-existing conditions, prevented charging sick subscribers more, and had an individual mandate to get health insurance. The mandate would start in a few years.

In 1994, Republicans got control of the state legislature, and repealed the individual mandate part of the law.

The result: people dropped insurance until they got sick, then got insurance. If their condition was not chronic, they would drop insurance after they got treatment. Insurance companies started bleeding money.

By 1998, 17 insurance companies that had provided individual health insurance in Washington no longer did so. By 1999, the last two companies that provided individual health insurance in the state stopped. You could essentially no longer buy individual health insurance in Washington.

In 2000, they modified the law so that people with pre-existing conditions had to wait nine months before insurance would be effective. I'm not sure why they picked nine months, but my guess is that it has something to do with how long pregnancy lasts in humans, because people buying insurance when they found out they were pregnant and dropping it when they brought the baby home was one of the biggest causes of losses to the insurance companies.

[hga]

There's a triad of things that must be done together to make one of these "no preexisting conditions", cover everyone grand schemes work:

Guaranteed issue are the words of art for not considering preexisting conditions.

Community rating (https://en.wikipedia.org/wiki/Community_rating), means charging everyone the same amount, although that's often "Adjusted"; for Obamacare, by smoking, and maybe somewhat by age.

Individual Mandate: everyone must be part of the system.

It's the latter two that are politically difficult. Community rating means the healthy young ("young invincibles" is the current phrase) must pay a lot more to cover the less healthy older folk, also men must pay more to cover women. And it's not hidden in taxes like a single payer system.

The mandate of course means you can't escape the game for the sorts of reasons you've noted. And it's political poison, e.g. presidential candidate Obama, unlike Hillary!, was against individual mandates. And as you've noted, it's relatively easy to zap and in due course kill the rest of such a system.

Three guesses what's going to happen in 3 years when the mandate ramps up....

Ah, another critical line of attack: "BAILOUTS FOR INSURERS!!!", the "risk corridors" that will prevent them from going under this year, and the next one or two, due to insufficient signups and more importantly payments.

"Official" enrollment figures for Healthcare.gov were those who've put a plan in their cart, as of a while ago not even those who then hit "sign me up", and the communications between it and insurers are horrible, and I doubt the government even knows who's "signed up" but never paid, or stopped paying, or didn't pay their first huge bill that started to satisfy the huge deductibles of lower grade plans.

[tptacek]

The Slate Political podcast last week (which included guest panelist Megan McArdle, who is no fan of the ACA) went into decent detail on the meaning of the signup statistics we have for ACA right now, including percentages of young signups and the "conversion" of site viewers to paying customers, and my understanding is that you've drastically oversimplified the situation w/r/t "official enrollment figures".

There will be attrition over the next several months, but I don't think it's accurate to say the official figures refer simply to people who "put a plan in their cart".

[bmelton]

Thank you for that insight. Yet another unintended consequence I hadn't considered.

I'm eager to see how many young, healthy people are signing up for health care under ACA, because if the registrations are primarily from sick people, the system can't work, right.. or at least, not without further raising rates for those who can afford it?

[hga]

Do you really have to ask???

There's a appalling lack of transparency in all this, but when the curtain is occasionally lifted (generally at a state site), or we otherwise hear stuff, there's nothing that indicates "young invincibles" are signing up in significant, let alone sufficient, numbers.

That may change as they get dinged for every higher penalties, but the political sustainability of those is highly questionable.

[cujo]

I agree that the ACA needs work, and has some questionable elements. The conflict I have is that I see as so much better than the previous non-system that it's hard to argue about it's crappy parts without someone jumping on the NObama train and killing any chance of discourse.

[bmelton]

The position I've maintained since before its enaction is that at best, the ACA is a temporary measure. This is just my theory, and it's very possibly wrong outright.

There are a variety of problems with medical coverage in the United States, in large part, because most of our medical coverage is handled by insurance. Insurance, at its core, is not good at complete coverage, and if we expect it to be, it's always going to be more and more expensive, especially as the payer is abstracted away from the true cost.

Medical insurance arose as a response to the wage freezes enacted by the government during the war. Wages were frozen to 'stabilize' the economy and money could be dedicated to fighting the war. The unintended consequence here was that businesses, leveraging 'benefits' to compete for top talent, petitioned the IRS to allow for medical coverage to be pre-taxable income. The result is that we have a system where largely, other people are footing the bill for medical costs. This was, IMO, the genesis of our failing health care system.

This got worse and worse and worse until the ACA. Now, the ACA appears to be fixing the problem with more of the same. More people abstracted further away from the actual cost of health care.

(Again, IMO) this is not a long-term fix, and I'll be very surprised if we don't see rates escalating dramatically in the next few years.

Before insurance became pervasive, insurance was for catastrophic purposes. E.g., cancer. For general health care needs, the flu, a cold, a pulled muscle, a broken wrist, etc., people should be paying for their medical expenses out of pocket, while paying into their insurance to buffer against bankruptcy from something like cancer, leukemia, etc.

If that were the case, we'd see the free market work. People wouldn't get three X-rays and two MRIs to determine whether or not a wrist had a very minor fracture or a very major sprain -- they'd just slap a cast on it and wait a few weeks until it was better. That cast costs a small fraction of the cost of an X-ray, or an MRI... but because the insured don't generally pay those costs out of pocket, they get all the X-rays that are needed, because they're free -- and then they're surprised at the cost of health care.

I have objections to the ACA on grounds of politics, and I have concerns with the ACA on grounds of pragmatism. I certainly don't begrudge those who have needed insurance but didn't have it until now, but if we really want to lower the cost of routine health care coverage, I find the current approach to be the least likely way to address it, and foresee rising health care costs in the future.

Again, just an opinion (though I think it's informed), and I could be proven completely wrong in a few years.

[panarky]

Please cite your source claiming more people cancelled insurance than obtained insurance.

A recent study from Rand Corp. debunks these claims:

  Researchers found that the share of adults ages 18 to 64 without
  health insurance has declined from 20.9% last fall to 16.6%
  as of March 22.

http://www.latimes.com/nation/la-na-obamacare-uninsured-nati...

[ctdonath]

Rand Corp. Their next study showed just 858,000 enrollees out of 7.1M were previously uninsured. Not sure yet what percentage of the difference were entirely voluntary transfer of services, but methinks most were signups due to cancellation of existing policies.

http://www.dailymail.co.uk/news/article-2594309/President-pl...

[panarky]

It is logically impossible for there to be more cancellations than enrollments, while the percentage of uninsured falls dramatically.

Methinks you've got your facts wrong.

[ctdonath]

Why the limiting of proffered statistics to ages 18-64? I'd expect those outside that range are most in need of coverage, yet are curiously excluded from statistics touting progress toward the goal of "health insurance for all".

[hga]

Errr, everyone over 64 years of age is automatically enrolled in Medicare.

[happyscrappy]

Not only that. Former arrangements when running multiple companies were deemed invalid, all employees having their healthcare through a holding company were dumped and forced to navigate the morass individually, leading to a three month lapse of coverage. Allegedly my family's healthcare restarts tomorrow. It is a little disconcerting that tomorrow is April Fool's Day.

[cgaudreau]

"Cancelled insurance" has mostly meant that you would lose your current plan and be automatically enrolled in a new plan by the same insurer, not that you would be uninsured. Some people did in fact lose their insurance or face higher premiums, but that number is now considerably smaller than the amount of people who have gained insurance.

[bmelton]

Citation?