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> The worst piece of legislation ever to be passed in the United States of America.

I don't think it competes with, just for two obvious, off-the-top-of-my-head examples, either the Indian Removal Act or the Alien and Sedition Acts.

> I have seen many patients lose their doctors because the doctors were not contracted with Covered California.

Covered California is the California state health insurance exchange, it does not contract with doctors at all. The individual health insurance plans offered by private companies on the exchange contract with doctors.

> The reason the doctors do not contract with Covered California is because at face value the plan appears to be just like the usual say PPO plan.

Covered California is not a plan, PPO or otherwise. It is the exchange on which plans are offered. A number of different plans, PPO and otherwise, are offered on the exchange.

> The problem with the government effectively taking over Health IT by way of forcing Electronic Health Records to abide by bureaucrats definitions for "meaningful use" is a completely different disaster that has resulted in marked decreases in productivity and worse care for patients.

"Meaningful use" of EHRs is voluntary; the government involvement is providing incentives for meaningful use within the Medicare and Medicaid programs, not penalties outside those programs.

(EDIT: clarification of the meaningful use comments)

> I don't think it competes with, just for two obvious, off-the-top-of-my-head examples, either the Indian Removal Act or the Alien and Sedition Acts.

Those legislation mainly affected people who weren't US citizens, though. Obamacare does, which makes it way worse for US citizens.

Prohibition or the Japanese internments(if executive orders count) are maybe a better example.

We're diving into the semantics, but the post complained of the "worst legislation", not "worst for American citizens".

> Those legislation mainly affected people who weren't US citizens, though.

Then what about Samuel Worcester?

> Those legislation mainly affected people who weren't US citizens, though.

Certainly the Sedition Act's repression of free speech was not restricted to, nor primarily targeting, non-citizens; it principally targeted domestic dissent. (The first prosecution under that act -- or any of the Alien and Sedition Acts -- was of an opposition-party Congressman for writings critical of the administration.)

Not that "worst for American citizens" was the original claim, anyway.

The government reduces Medicare payouts by a fixed percentage, starting at 1% in 2014 going up until it reaches 9% in 2022, to any participant who doesn't meet meaningful use requirements. The only way to opt out of the requirement is to completely opt out of medicare. That rather sounds like a nonvoluntary penalty carrying program to me.

IMHO, that's a feature, not a bug. Though it is unfortunate that some doctors have to be dragged kicking and screaming into the 21st century; I'd be really suprised if such doctors were better, by any reasonable metric, than one that had needed no prodding for EHR.

ACA is the best legislation in my lifetime. It has allowed me the luxury of being able to purchase individual insurance as a cancer survivor, allowing me to spend more time with my young family instead of being chained to a 8-5 corporate job.

See, I can anecdote too.

I think this is the real win here. Like most legislation ACA is a complex combination of good and pad parts, but the fact that people with pre-existing conditions or terminal illnesses can still get health insurance for treatment is a huge step forward for our society as a whole.

Like the report said, there's still progress to be made.

I still contend that the availability/unavailability of health insurance was not the problem that needed solving. Instead, it's one of many symptoms that can be attributed to the unreasonable cost of healthcare, which has escalated in part because of the disassociation between the actual billing and payment. Insurance is similar in concept to chips as a casino in this -- by creating distance from the actual cash transaction, people are less likely to question the cost of something because it doesn't have a direct impact on their wallet.

It also allows us to pool money and average it in case unknown and expensive procedures are required. We also want to encourage people to get cheaper preventative care instead of avoiding it due to short-term costs. Insurance programs benefit from incentivizing that behavior as much as ordinary people do.

> I still contend that the availability/unavailability of health insurance was not the problem that needed solving. Instead, it's one of many symptoms that can be attributed to the unreasonable cost of healthcare, which has escalated in part because of the disassociation between the actual billing and payment.

The rate of increase in per-capita costs has decreased under the ACA. So, while it perhaps hasn't yet solved the problem, its certainly hard to argue that its been thing worse than the system in place before it was adopted.

We need a period of time that isn't coincident with a huge recession before we celebrate this too much.

> We need a period of time that isn't coincident with a huge recession before we celebrate this too much.

The most recent recession ended the same year the ACA was passed, the annual average cost growth rates, for private insurance and both major public programs, after the ACA are lower than the 5 year period containing that recession and the passage of the ACA, and even moreso lower than the 5 year period before that (during which there was no "huge recession".) [0]

[0] Figure 4 in TFA.

"People are less likely to question..." seems to be placing the blame at least one notch too far down. Try asking how much something will cost and no-one can tell you—insurance or provider. Medical billing at all levels is batshit insane, and it's not the fault of "consumers" (patients) that they can't figure it out. Even trying is mostly pointless.

Which is why insurance, unlike casino chips, has cash deductibles.

The uninsured rate has decreased from 16% to 9%, so there are now a significant more number of people insured that were not before.

The good parts and the bad parts are related. The ACA effectively forces rates to go up for people who can afford it to increase or extend benefits to people who can.

There was a slight increase in 2010, but (overall) not a significant change to the growth in premium contributions made by single workers and families between 2005 and 2015 - http://i.imgur.com/KCiwoEJ.png

Same here, my parents were in the "make too much to receive government assistance but not enough to pay for private insurance healthcare" group, now with the ACA they finally have health insurance after nearly a decade of going without it.

And in response to the parent, are there problems with the ACA? Of course, but let's iterate on it, instead of dismissing it completely because you happen to be one of the few who doesn't benefit from it.

Prior to the ACA, many states offered High Risk Pools to cover people in your situation. Were these not applicable in your case?

The only way to get into the pool in my state was to be without insurance for 6 months and provide proof of denial or exclusion of a condition. That was untenable when I was going to follow up visits every 3 months and CT scans every six months.

> It has allowed me the luxury of being able to purchase individual insurance

You could do that before ACA.

> instead of being chained to a 8-5 corporate job

What does this lifestyle choice have to do with ACA? ACA doesn't somehow give you free time or extra money. Unless you are getting your insurance for free (which was possible before ACA, mind you). ACA often does not offer the cheapest plans either...

The entire point is that healthcare is no longer coupled to a specific employer.

> The entire point is that healthcare is no longer coupled to a specific employer.

It never was. You could always get an individual plan.

> You could do that before ACA.

The GP said he was a cancer survivor. I've talked with several people with serious past or pre-existing conditions, including past occurrences of cancer, who could not find anyone willing to sell them an individual health insurance plan at any price prior to the ACA -- the only way they could get insurance was to be in a job where a group plan was offered.

> What does this lifestyle choice have to do with ACA?

It creates health insurance exchanges on which people can by individual insurance without being denied for pre-existing conditions, meaning they don't need to be in a job offering a group plan in order to get insurance.

> ACA often does not offer the cheapest plans either...

ACA has made it possible for people to buy individual plans who were not able to buy them, at any price, before (the rules that do that, such as the rule against pre-existing condition exclusions, are the reason for the cost increases for individual insurance for people who were insurable prior to the ACA.)

> It creates health insurance exchanges on which people can by individual insurance without being denied for pre-existing conditions

One could (and can) do this without the exchanges.

Yes, before ACA some pre-existing conditions would deny access to some policies from some insurers. This was to prevent a career smoker at age 75 from signing up for a new very large policy, and immediately get the benefits they haven't paid for.

We didn't need all of the baggage that came with ACA to accomplish this.

> meaning they don't need to be in a job offering a group plan in order to get insurance

> ACA has made it possible for people to buy individual plans who were not able to buy them

Before ACA, you did not need to belong to a group plan to get insurance. And to that endeavor, private individual insurance policies are about the same price now as they were then...

~~~~

Meanwhile... ACA didn't touch pharmaceutical companies - the true reason healthcare is so expensive ($700 salt water IV's anyone?).

> private individual insurance policies are about the same price

Not for `zrail: pre-ACA, insurers charged high-risk buyers like him/her much higher-than-average premiums based on their medical history. Now that's not allowed.

You say that like the ACA was the only way to get that outcome...that somehow more insurance was the solution rather than the problem. The fact of the matter was that with a democratic president and the largest democratic majority in generations, voted in on a platform of "just fucking fix healthcare already", we still couldn't even see a single payer proposal make it to the floor for a vote.

Not only did we not get the healthcare that we voted for, we got mandated insurance based healthcare at even higher prices, with even more bureaucracy, and huge tech boondoggles as the icing on the cake. Sold to the public as not a tax, but then justified at the Supreme Court as a tax. 5% of the population comes out ahead and everybody else behind.

The 111th congress will go down in history as the most cowardly and counter effective we will ever see. That Obama is whitewashing and patting himself on the back like this is bordering on insanity.

> we still couldn't even see a single payer proposal make it to the floor for a vote.

> Not only did we not get the healthcare that we voted for

Three of the Democratic candidates in that election campaigned on something very similar to what the ACA delivered, including both of the top two -- Clinton and Obama.

None of them campaigned on single payer, so its not surprising that what was delivered looked like what was successfully campaigned on. Inasmuch as anything can be said to be the "healthcare we voted for", the ACA is more like that than single-payer would have been.

I'm all for reasonable hyperbole, but you're doing your argument a disservice by claiming it's the worst piece of legislation ever passed in the United States. Just to start, we can all agree that the Fugitive Slave Act of 1850 was a worse piece of legislation that the PPACA.

Aside from that, do you have any suggestions for how to improve it? It sounds like you have a useful perspective.

Hey there! Long term Obama supporter (no longer) and healthcare consumer in the US. I agree with you mostly.

Monthly premiums for my wife and I are ~$700/month (both healthy, early 30s, Blue Cross Blue Shield). When our daughter arrives shortly, that will increase to $1000/month. That's a high deductible plan where we're out of pocket for everything for the first $6000/year.

I work remotely, so we're looking at moving to Central America (Panama or Belize, wherever its cheaper to dock a 40' catamaran); if you live outside the US more than 330 days/year, you're not obligated to carry insurance. I can obtain expat insurance, that covers my entire family in every country in the world except the US, for $3000/year. $9000/year after-tax savings is nothing to sneeze at.

The ACA was a sham; it measures the insured rate, not the ability of citizens to receive the care they need. On that metric, its failing terribly. But health insurance companies are doing well at least.

EDIT: I have no problem with universal healthcare. I believe greatly in it. I despise that the federal government didn't eliminate health insurance companies entirely and move to single payer through Medicare.

I'm pretty happy to have moved back to the US from Italy for a number of reasons, but the health care system isn't one of them. It's way, way too expensive for what it delivers: just look at costs as a percentage of GDP. It was pretty bad before, and hasn't improved a lot with this reform.

Indeed. The US has the highest cost of healthcare as a percentage of GDP, with worse outcomes compared to most other first world countries.

http://www.commonwealthfund.org/publications/issue-briefs/20...

Several large insurers are planning to withdraw from the marketplaces because they are losing money on the plans they offer there.

You're correct. They are losing money, and they are withdrawing from those markets in question.

Its important to note that the backstop payments those insurers were to receive from the federal government are being tied up by Congress, to stick a wrench in the ACA.

http://www.thefiscaltimes.com/2015/12/17/Congress-Weakens-Ob...

The elephant in the room is: How do we spend less on healthcare for everyone when so many people have vested interests in the status quo? Change must come from the outside, and must be applied with force.

I guess. Congress preventing Fed Gov from reimbursing insurance companies for their huge losses isn't really evidence that those companies are doing well though.

Why are we going to end up with single payer? I didn't follow that part of your argument.

I removed that part of my comment, as I thought it was not relevant to the specific point.

As the US population ages, more and more people will be on Medicare [1]. This increases its power, and removes almost entirely the likelihood it would be scaled back.

We will eventually have no choice but to move to single payer, as the cracks in the current model (dictated by the ACA) are already forming.

[1] https://www.census.gov/prod/2014pubs/p25-1140.pdf (warning: pdf)

> The ACA was a sham; it measures the insured rate, not the ability of citizens to receive the care they need. On that metric, its failing terribly.

Can you elaborate on this? Not because I think you're wrong, but because I haven't been able to find any data one way or the other about health outcomes and the ACA.

It simply mandates everyone buys insurance. It does not mandate affordable care. Does it matter if you buy insurance if your deductible is $6000 and you never seek medical help until its too late (because you can't afford the copay(s))?

Right, but are there any studies or statistics on how the ACA has affected actual care provided, or hospital visitation rates, or something? What makes you say the ACA is failing terribly on this metric?

> It simply mandates everyone buys insurance.

It mandates everyone buys insurance meeting minimum standards.

> Does it matter if you buy insurance if your deductible is $6000 and you never seek medical help until its too late (because you can't afford the copay(s))?

By definition, with "too late" as part of the premise, no; but more meaningfully, it definitely makes a difference if you buy a high-deductible plan and only use it to cover catastrophic costs.

(Of course, to meet the minimum standards under the ACA, plans must cover certain, mostly preventive, services at no cost to the covered individual, regardless of what co-pay and/or deductible they have for other services, so that also makes a difference.)

> I despise that the federal government didn't eliminate health insurance companies entirely and move to single payer through Medicare.

Medicare isn't single payer. Its actually very similar to the ACA exchange system, only with a public option alongside private options (all of which must offer at least as much coverage as the public option, and which are partially publicly subsidized for people choosing them instead of the public option.)

(And, in the case of prescription drugs, with a big hole in the public option, for which, if you want coverage, you either have to reject the public option or purchase a publicly-subsized private plan to cover that hole on top of the public plan.)

Medicare was a single payer system, back before most of the people posting on HN were alive.

Yeah the millions of Americans who gained health insurance are going to be real mad that a doctor had to pay a little more money for his health insurance.

I completely agree with you about how terrible obamacare has been. I've been screwed by it in every way imagineable. so much so that, they've prevented me from being able to file my 2015 taxes and will most likely have to pay late fees and penalties because of their incompetence. At one point, they had my family of 4 in 2 separate groups and assigned 6 separate insurance plans (true story).

however, I was always under the impression that Electronic Health Records would result in a meaningful improvement care and record keeping. Can you elaborate on what problems will come from this?

Thanks for calling out what it is but you might get down voted here.

11 thousand pages of new regulations can not be called reform. It is unbelievable how this new giant piece of regulation is even termed as "reform".

The reform in US healthcare could have been destroying the monopoly of AMA over supply of doctors, getting rid of complex procedures for prescription medicine, downsizing FDA and giving more flexibility to doctors to determine quality of service for day to day medical care.

I do not agree with "crony capitalism" part however. The Obama Labyrinth of Healthcare Mess is soviet style big government in action. It does not do good to pharma-companies, insurance companies, doctors or patients. All big insurance companies had to exit in few years from the government insurance exchanges.

> 11 thousand pages of new regulations can not be called reform.

Why not? Now, if you were complaining about someone, hypothetically, calling it "simplification", I can at least comprehend the objection, but what does the number of pages of regulation have anything to do with whether or not it can be called reform?

Higher the number of pages in a regulation harder it is for the representatives to read and study. The compliance cost goes significantly higher for all the stakeholders making entire healthcare more expensive all people and since IRS is roped in this cost is also passed on to entire population of United States including those who are not residing in USA and have never made a visit to a doctor in a given financial year.

Reform generally means government gives up control in favor of market so people can get what they want, forcing people to buy insurance is not reform it is tyranny.

There is a good reason why US constitution is just 4 pages and not 400 thousand.

> Higher the number of pages in a regulation harder it is for the representatives to read and study.

Representatives don't read and study most regulations, since regulations are issued by appointed regulatory bodies to implement legislation, not elected legislative bodies.

> Reform generally means government gives up control in favor of market so people can get what they want

No, that's what "privatization" means. Privatization can be a reform, but it is not what reform means generally.

So it's the worst legislation ever because a person with a very high income has to pay a few hundred bucks more so that healthcare is affordable to all?

Can't think why the Occupy movement caught on in the US.

In what ways do you think the Occupy movement caught on?