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In 1994, Republicans got control of the state legislature, and repealed the individual mandate part of the law.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