U.S. judge finds that Aetna misled the public about its reasons for quitting ACA | Hacker News Reader

U.S. judge finds that Aetna misled the public about its reasons for quitting ACA

latimes.com

181 pointszitterbewegung176 comments

I've said it before, we need a single payer system.

Insurance companies and Pharmaceutical companies can more or less dictate the prices they'll charge because if you're chronically ill, you can't just choose not to be treated (unless you're ok with dying.)

This behavior should not be surprising. Until the American people get pissed off enough, we'll continue to have these shenanigans.

Obama said that too, once. I think most Democrats in office have said that at one point, even if they don't want to say it in public anymore. The ACA was not passed because it was better than single payer, it was just the closest thing that could possibly get through Congress.

> The ACA was not passed because it was better than single payer, it was just the closest thing that could possibly get through Congress.

The ACA was deliberately modelled on Republican/Industry plans with the hope it would have been a bipartisan solution. This was, of course, a vain hope as we now know, but it was fundamental to why it had the shape it did.

I think this is the greatest obstacle to the "...and Replace" part of Repeal and Replace.

The ACA was already the workable compromise.

Except that it wasn't workable. It was never financially sound and was doomed without additional funding for which the public was never prepared politically. It was rammed through Congress without a single Republican vote using a procedural trick, so politically the best play for the GOP was to let it fail and then hang the failure on the Democrats.

I have no idea what Trump's plan is, but I hope whatever it is the Republicans don't play games with the GAO accounting and they also bring Democrats on board so both parties have a political stake in success.

> they also bring Democrats on board so both parties have a political stake in success.

Republicans and Democrats in government (not necessarily in the electorate) now (this was not as obviously the case before the ACA was proposed) have fundamentally opposed goals on healthcare. So a bipartisan compromise is improbable.

I disagree. The goals are actually quite similar. It's the vision of the framework that achieves those goals that's in conflict.

I'm not sure that's true. The GOP platform does not mention universal healthcare or anything like it, that's simply not a top priority. The healthcare-related planks are:

- Restoring Patient Control and Preserving Quality in Healthcare

- Protecting Individual Conscience in Healthcare

- Better Care and Lower Costs: Tort Reform

- Advancing Research and Development in Healthcare

- Putting Patients First: Reforming the FDA

Freedom of choice, high quality, affordability, and limited regulations are the goals. I don't think they're against universal coverage, but as a party it is not a main focus.

The Democratic platform healthcare section begins with "Securing Universal Health Care: Democrats believe that health care is a right, not a privilege". Their priorities are:

- Securing Universal Health Care

- Supporting Community Health Centers

- Reducing Prescription Drug Costs

- Enabling Cutting-Edge Medical Research

- Combating Drug and Alcohol Addiction

- Treating Mental Health

- Supporting Those Living with Autism and their Families

- Securing Reproductive Health, Rights, and Justice

- Ensuring Long-Term Care, Services, and Supports

- Protecting and Promoting Public Health

- Ending Violence Against Women

- Preventing Gun Violence

The main goals are universal coverage, public funding, affordability, opposing discrimination, and a couple specific areas of focus. Some of this overlaps with the Republican platform, but this is clearly a very different set of goals, and I think universal care is the most significant difference.

Oh, the Republicans don't want health care to be provided by the government, but that's not the same thing as saying they don't want everyone to have health care.

I understand, but it isn't a goal. Their goals are to get government out, get costs down, get quality up, and if universal care happens as a result of that, great. Priorities matter, and wanting something is not the same as making it a goal.

What procedural trick? It received 60 votes in the Senate and a majority in the House.

The final bill would not have survived a filibuster because the Democrats no longer had 60 votes.

From wikipedia:

"House Democrats had expected to be able to negotiate changes in a House-Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[165] They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.[166][169][170]

As per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations.[171][172] Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."[169]"

Despite the gloss the wiki authors put on it, this is highly irregular. It's within the letter of Senate rules, but if you're expecting to ever get cooperation from the opposition party this is not the sort of stunt you want to pull.

I saw a headline that said something along the lines that the Republicans plan to repeal the ACA using reconciliation, which would be poetic if true.

If I'm reading that right, both House and Senate approved almost the exact version that went into law, but some of them expected there to be more rounds of edits that didn't happen.

So they avoided filibuster by suddenly being more cooperative than expected and not having more rounds of edits? I might be deeply misunderstanding, but that trick seems okay. Don't pass a bill if you don't want the bill becoming a law...

The normal process is different bills pass different houses, then they go into a conference committee that produces a negotiated third version which then goes back to be voted on in each chamber.

What happened in this case, as I understand it, was the Democrats in the Senate took a bill that had already passed, a bill addressing some other matter entirely, and rewrote it completely while maintaining it was the "negotiated third version" above, i.e. it was a reconciliation of the bill that had been discarded.

I'm a bit fuzzy on the details, TBH, but that's the essence.

Exactly. Plus, it violated Article 1 Section 7, which requires that revenue bills originate in the House.

Then, the Democrat leadership argued that it wasn't actually a tax, so Clause 1 didn't apply.

Then, in the infamous Supreme Court case, they argued that it was a tax and therefore couldn't be challenged before collections actually begin due to the Pre-emption clause.

The process of taking a bill in progress and completely rewriting it (while retaining "credit" for those procedural steps the original bill completed) is commonly known as "gut-and-amend".

>What happened in this case, as I understand it, was the Democrats in the Senate took a bill that had already passed, a bill addressing some other matter entirely, and rewrote it completely while maintaining it was the "negotiated third version" above, i.e. it was a reconciliation of the bill that had been discarded.

That's not what the text around your quote says. In fact reading it in full context implies that nobody got tricked. First the senate broke the filibuster and passed the act. Then the house, realizing that breaking another filibuster was unlikely, decided to pass a version that was compatible with the senate version and only needed budget reconciliation. Then it passed without the ability to filibuster and became a law.

I don't see where a bill addressing something different comes into the picture. I don't see any deception. Am I missing something?

Read the whole wiki page. The part about the existing bill was further up.

And I used the word "trick", not deception. I'm not aware of any deception, just the abuse of a process.

Oh, I see. They replaced one bill with another long before they broke the filibuster. That replacement was to get around the "this bill must originate in the House" requirement. Getting past the filibuster was done completely legitimately.

They shouldn't have done that, ideally, but the rule of which house a bill starts in is pretty unimportant.

I don't see how reconciliation could be used to help repeal the act, because the reconciliation was not key to getting it passed, and neither was the trickery used to say the bill 'started' in the House.

You don't have to repeal anything. You use the budget process to cancel all individual and employee mandate penalties, eliminate the relevant taxes and subsidies, and roll back funding for the Medicaid expansion.

Then you just sit back and let it collapse on itself.

Using the term rammed through feels like a stretch given the description.

The bills were negotiated for over a year, and liberal features like the public option and coverage for abortion were removed due to Republican and independent opposition. The bill ultimately received a Supermajority in the Senate and a majority in the house in regular voting, and not through reconciliation. The Republicans are unlikely to pass the repeal through the senate with anything close to the same numbers.

You allude to the origination clause below, but that argument was rejected by the courts, and the Supreme Court declined to hear it. The first version of the bill was also introduced in the House, as was the original revenue bill that the senate bill was built onto.

The initial bill did have one Republican congressman voting in favor, the guy from Louisiana.

That may be true, but the final vote tally had every Republican voting against.

great plan except that it hasn't failed and hijinks like this are making it look like it is.

> The ACA was already the workable compromise.

At the time of Republican minority. Power has shifted to the Republicans and there can be a new "compromise"

Workable politically, practically it's been completely ineffective in reducing healthcare costs.

The ACA's goal was not to rein in healthcare spending (this potential shortcoming was discussed before it even passed).

While there is funding for experiments aimed at reducing costs, none of the bill's major facets deal with this issue.

Here's an article where one of the bill's intellectual architects talks about the topic: http://www.nejm.org/doi/full/10.1056/NEJMp1006571

This is factually wrong. I have been providing health care for my employees since 2001. Pre ACA, rates rose 20% per year. Post ACA we've seen 5% raises most years, one year we saw a decrease, and this year, we saw 9%.

Maybe on paper you're factually correct. My rates didn't go up this year ($1800/month) but my benefits went down costing me about $3,000 more than last year.

Actually, it has saved Americans trillions of dollars:

http://fortune.com/2016/06/21/us-health-care-costs/

Single payer would be ideal for most Americans, but those in power (both government and industry) seem to prefer the high deductible health plans with health savings accounts.

Unfortunately I don't see high deductible plans working for anyone unless healthcare providers and pharmacies are required to list all prices up-front. As it is there's no way for consumers to "shop around" because they can't get prices for most tests, procedures, or even medications until they bill through insurance (which can take weeks).

Exactly this. It's a falsehood to think that HSA/HD will cause you to be a better consumer because you can't be a better consumer when the sellers refuse to provide price information. We had our first child this year and the hospital coded some things to my wife and some to my daughter which caused us to pay two deductibles. I tried to get an itemized breakdown repeatedly from the hospital and was met with "we can't do that."

Never mind the fact that you can't exactly shop around for places to deliver when your OB/GYN only has admitting privileges at one hospital. I'm about as free market as they come but when the providers flat refuse to tell you what they are going to charge you. Try going to one of those corner ERs, you'll have to sign a form saying you are solely responsible for all charges but they sure won't tell you what those charges are until you sign it.

Does anyone claim that HD plans make people more savvy consumers? I've always thought it was a transparent way to make people of moderate means think twice about any care that could be considered elective. Whether it's a good idea or not, paying out of pocket for a $3000 procedure might make you question the need for a CAT scan.

High deductible plans definitely don't make anyone smarter consumers. The market is opaque and your options are limited to in-network in the best case.

> As it is there's no way for consumers to "shop around" because they can't get prices for most tests, procedures, or even medications until they bill through insurance (which can take weeks).

To complicate things further, some of these things will happen while people have passed out and taken to the emergency room. This might be the only sort of debt you can incur while both unconscious and without prior specific authorization. Many other medical decisions are made under duress - sickness and pain, with an occasional risk of death.

All of this nonsense is exactly because everyone expects insurance to pay for all medical care from hangnail to heart failure. Single payer would be even worse, because it's even more of a "not my money -- I don't care" situation for the individual.

Dentists, optometrists, physical therapists, etc. all have straightforward pricing for each procedure, and you can call and ask them what it is and it's not too hard to shop around. Only medicine has mystery prices hidden behind third party payers.

> Dentists, optometrists, physical therapists, etc. all have straightforward pricing for each procedure, and you can call and ask them what it is and it's not too hard to shop around.

Not IME. I've gotten different prices from what I was quoted, and some places have refused to quote me a price.

It is possible to get prices and negotiate - healthcare providers just aren't used to it. I was just listening to a good friend who doesn't carry insurance negotiate on price for an elective procedure he was thinking about having. They came down 20% right off the bat. After a callback, he had them down 50%. That was just for the physician. He had to make another call to the hospital, and the anesthesiologist, so I can't tell you the outcome. Point being, it isn't as hard as you might think.

My point though: Just because it may be easy for you doesn't work for everyone. I called 3 different hospitals for a procedure, and none of them had any idea how to go about quoting me anything. I got transfered around a lot because they honestly didn't have a procedure for quoting. And I honestly doubt that any of them gave me an correct quote, because if they don't even know how to quote, what are the chances that their quote is accurate?

As it turns out, we don't have to speculate about single-payer since most other advanced and some not-so-advanced nations use it, and it works great. Costs are vastly lower than the U.S.'s system.

When you are having a heart attack good luck shopping around for the cheapest hospital.

High-deductible plans are not the answer. They are a symptom of the problem. You assume risk up to say $10,000 (your high deductible) because you don't expect to need it unless you wind up in the hospital. If you have a chronic illness, high deductible plans don't do shit for you.

As long as we view this as a "not my problem, I'm not sick" issue, this will never be fixed.

Not even chronic illness - as you get older you expect a certain level of health complications or maintenance, and you adjust your deductible accordingly. A $10k/mo deductible is catastrophe insurance, and is only really useful for people < 30.

If we'd realize that we're all one unfortunate random event from a dire (medical and financial) situation, a single payer system would be a no-brainer for everyone.

> A $10k/mo deductible is catastrophe insurance, and is only really useful for people < 30

HDHPs quote their deductible as a maximum out of pocket per year. Paying $10k a year to manage a chronic illness doesn't sound ridiculous.

I pay $19,200/year for insurance and another $3000+ for medical supplies. My 5 year old didn't ask to get a lifelong illness (type 1 diabetes.)

I'm lucky to be able to afford it, but it's highway robbery.

$14,300/year is the max out of pocket for family ACA plans. What are you buying that's not insured?

Then you live in a bubble.

Most people I know don't have 10k a year sitting around, just those lucky enough to have relatively well-paying jobs - and having a chronic illness will only make finding such a job harder.

Uh, no. Max out of pocket != Deductible.

$10k max out of pocket is not that bad. $10k deductible is bad if you're single over 30.

  Single payer would be ideal for most Americans, but (opponents) seem to prefer the high deductible health plans

I think a single-payer system would be far more efficient, but the problem is: how do you just "shut down" a huge economic system (insurers, for-profit providers) and keep it Constitutional? They have equity in their current structures, but how do you fairly compute a "fair market value" for their market share and investments when you effectively use Eminent Domain (unless you could amend the Constitution accordingly) to dismantle an entire industry?

I can imagine how Britain's NHS could be created in a time of great national unity, scarce resources, and complete Labor control, but I can't picture the mechanism by which health care could be nationalized in the present-day USA, even if a popular mandate existed.

> Single payer would be ideal for most Americans

Not for Americans who care more about economic ideology than health. This is how many Americans appear to vote.

That would be true if all voting Americans were economic idealists.

The truth is that many don't even know that Obamacare and the Affordable Care Act are the same thing.

Well, I'm not saying the idealists understand what's going on, but it remains that people have a dogmatic attraction to the free market, regardless if it means they pay more for the same service and have reduced freedom in finding efficient health care.

Honest question. What chance do you think, or how would you propose we start this discussion with people who genuinely believe the market as it is now, with 'choice' is the best option for consumers?

I live in flyover country, and people legit believe that letting the market make choices is best, and single payer is a quick step to full on communism. I'm looking for positive arguments to counter that nonsense.

Ask them how many insurers they got to choose from when they got their most recent job.

I would bet a truckload of money that it's between zero and one.

What kind of choice is that?

Wouldn't they then refute with: "My employer chose between the insurer competition, not I" implying that there's still competition?

(for the record I am pro single payer)

While they wouldn't be wrong, I think one of the huge distortions in the US health insurance market is that most of us get our health insurance through our companies. It distorts & hides costs, and it prevents employees from leaving for fear of health coverage uncertainty.

I agree. Employers don't pay for a number of other insurances, why should health be different?

Yes that would be the standard reply. But the point is to shift the terms of the discussion away from choice vs non-choice and towards the realization that you're not making a choice at all. Someone is making a choice for you.

That's the kind of choice left when "You like your Doctor/Plan, you can keep them" comes to fruition. It's also hard to afford better plans when the $2500 a year in savings turns into $2500 a year more in premiums... and then you have to pay thousands in deductibles before you can even "use" your insurance.

Oh yeah... the Government Option is a real winner.

Wait... I know... lets go to the VA model where people aren't dying... while on waiting lists... and the administration spends millions on Bonuses, Art Work and Vacations.

Lack of choice? That's from lack of ACTUAL 'free market competition'.

Taking away more choice and removing more competition isn't the way to solve the problem caused by removing choice and competition.

The worst thing you can hear? I'm from the Government and I'm here to help.

Do you want a choice of health insurance or a choice of health care? If you actually want choice in health care, then single payer makes the most sense since you can just go to whichever doctor you want (since they will all be part of the single payer system).

I want the government involved as little as possible. Two things don't happen with the government: Affordable and easy access.

"Free" might sound affordable... until you have to pay the taxes that drive "free".

And government run anything? Yeah... how about a big ole glass of no. With a double dose of hell no. Look at all the cost overruns, crappy care and red tape surrounding the VA, Medicare, Medicaid...

It seems like we need a state or two to become an experiment (in the same nature as pot).

However I fear that any attempt to will result in companies suing the state for unfair competition or the like.

How about an inter-state compact where states can willingly join a group and adopt common set of laws/regulations. If California, New York, Illinois and Massachusetts join this group, you already have 75-80M population with more liberal states to follow. This group can also be used to advance other liberal agenda on issues pertaining to energy, climate or agriculture.

Of course, conservative states can do the same to advance conservative agenda to bypass gridlock in DC. But nothing wrong with that either. We will have some sort of real world A/B testing between the two groups and see which policies work better for a given problem.

The advantage of a compact of states is that it enables significant weight behind a proposal, which would be hard to ignore for the companies (eg. fuel efficiency standards might be ignored for MA alone, but will be hard to ignore for market controlling 30-40% of the population).

I learned recently that this is similar to what happened in Canada - it started with one province (I can't remember which) and spread from there.

Saskatchewan. Good ol' Tommy Douglas.

For those curious:

https://en.wikipedia.org/wiki/Healthcare_in_Canada#The_begin...

It's likely that providers would flee any smaller state that attempted to do single payer.

Not universally of course, but enough to have a big impact on availability of services.

California might be able to try it.

> California might be able to try it.

This. California democrats recently achieved a supermajority[1] making such an experiment possible. If California cannot push state legislators hard enough to give it a shot, the idea that a fractured national Congress will is fatally flawed. Voters rejected the idea in Vermont[2] (Bernie country[3]) -- so, can California be different? Granted, a California experiment must balance the fact the CMS money originates from federal sources, but that should not completely inhibit an experiment.

[1] http://www.latimes.com/politics/essential/la-pol-ca-essentia... [2] http://www.politico.com/story/2014/12/single-payer-vermont-1... [3] https://en.wikipedia.org/wiki/Vermont_Democratic_primary,_20...

Put the Surgeon General in charge of it and conscript all healthcare professionals into a uniformed US Health Service. Uniforms would make the best political cover.

> I live in flyover country, and people legit believe that letting the market make choices is best

There is a large segment of the population that worships the free market. They believe it will fix anything. Any flaws are because it's not a truly free market, but we can fix that and make it free and then it will work properly.

"Healthcare is not a market."

So obviously single payer is a system that is what most would strive for. But could it work in the US?

I am from Denmark originally where we have it and it's not without issues because suddenly you turn a profit center into a cost center which means you need to budget and you need to restrict who can get what, how much you can afford etc.

What about illegal immigration, do people who are here illegally get access too?

These are all questions that are very hard to answer IMO because the US after all is such an open society.

> I am from Denmark originally where we have it and it's not without issues because suddenly you turn a profit center into a cost center which means you need to budget and you need to restrict who can get what, how much you can afford etc.

Are the same decisions not still made when health care is for-profit? Except it becomes the insurance companies that get to decide who gets treatment and who is too expensive to treat so we'll just drop their coverage instead?

For all that is wrong with the US system it at least have access to almost any possible treatment in existence.

So yes the individual insurances are limited to various degrees but there are for some access to he best of the best.

In my world the major problem in the US is that you can "go bankrupt" by being too sick too long.

It should be so that everyone pay to go to the doctor for minor things but no one go broke if they happen to be sick.

Why this balance can't be found baffles my mind.

> It should be so that everyone pay to go to the doctor for minor things but no one go broke if they happen to be sick.

> Why this balance can't be found baffles my mind.

Because paying for a doctor visit for a minor infection is the cheap part of healthcare. "Being sick too long" is extremely expensive. Getting a shot of penicillin costs a couple hundred dollars. Treating cancer can cost tens of thousands.

Which is why you should pay for most of your less expensive visits to the doctor so we can pay for the really serious things.

I think you're not recognizing the magnitude of difference here. I could personally pay for the normal checkups and basic healthcare for my family and my immediate neighbors with no real hardship. However, just one of the people I provided care for was diagnosed with cancer or any of a number of severe, chronic diseases, it could wipe out my savings entirely. The cost of one severe illness could cover the cost of dozens if not hundreds of generally-healthy people's healthcare.

I don't strictly disagree with your assessment that people should cover their own basic healthcare needs. I just don't think that this actually does much to make coverage more affordable in general, because it's catastrophic coverage that costs so much.

I think you are missing the point of what I am trying to say.

In Denmark it's both free to go to the doctor and to go to the hospital.

This model is obviously great but it has it's limits with things like treatment opportunity.

What I am proposing is a model that mixes the US and the Danish system. We pay for our non-serious things but don't get bankrupted on serious illness.

The price of US hospitals are inflated, they aren't the real cost which any visit to a hospital anywhere else in the world will tell you.

I get your point. I just don't think it actually matters much. If you make people pay for basic care but cover the big stuff, you only cut a few percentage points off the cost of care carried by the state/insurers.

I don't see how this is at all related to the inflated costs of American hospitals.

It matters quite a lot because the source of the money creates very different dynamics. I have lived in both of them.

There is a reason why the us healthcare system can have inflated costs and thats because of the nature of the the way it gets funded. And because it gets funded differently it allows for a different kind of dynamics in the offering.

Go to Denmark the hospitals mostly look the same with a few notable differences and you have to wait til it's your turn.

Not really. In the US you have access to what your insurance company deems medically necessary. Not that different from other countries except that you don't get to vote on the people who ultimately decide what care you get.

and insurance companies give various access some to everything more or less some to very little. In a public healthcare system everyone have access to the same, but the same is less. So there is a tradeoff.

> For all that is wrong with the US system it at least have access to almost any possible treatment in existence.

Oh, not at all. The dialog goes like this:

A: I'd like a treatment, but I can't pay for it.

Hospital: Go away.

Most people in the U.S. have no access to care costing more than a few hundred dollars, because that's how much money they have.

Again I am not saying that the current system is good just that you can get access to that kind of treatment if you can afford being on the right healthcare plan. In a single payer system like the Danish you don't even have the potentially.

What medical care is available to the general public in the USA but not available in Denmark? I'm curious.

Various types of cancer treatment to begin with.

Which cancer treatment?

That's only correct for elective treatments. Have something life-threatening? Go to the ER and you will be treated. And then everyone else will pay for it indirectly through increased costs.

The vast majority of life-threatening conditions aren't required to be treated at any ER, and won't be, unless you can pay.

It is true that the US has a very large illegal immigrant population, but a very large portion of them are migrant agricultural workers, and previous analysis by the state of California has worked out that the state receives a net benefit from their labor, even including ER/medical care visits.

This may not hold for other forms of immigrant/refugee, but the agricultural laborers are a net boon to the state.

Agriculture employs only a tiny percentage of those here illegally. In fact, many agricultural workers come in legally on H2-A visas.

Ag work in general is only a few percent, sure, but look at the %/industry.

Here in California, for example, ~45% of ag workers are estimated to be here illegally. Similar percentages are in construction, and other manual labor jobs.

Also keep in mind that the job descriptions of this migrant population are fluid- who is counted as agricultural vs. construction, etc. changes by season and state.

I have no doubt, but how do you deal with it? Thats the question. How do you determine how is a net benefit for the country and who isn't?

It is not a question with an easy answer. In general, people that come here to work are a net benefit, as they provide cheap labor, and spend much of their income locally. But this is only speaking in broad swaths.

http://www.wsj.com/articles/immigration-does-more-good-than-...

For a good start on reading material.

"you need to budget and you need to restrict who can get what, how much you can afford etc."

The private insurers already do that.

It's not the same believe me.

A cost center literally puts a stop to how much you can spend, it doesn't have the flexibility of a profit center.

It's a very different world where it's possible (for some) to get the latest treatment because it exist vs. a world were it doesn't because there isn't money for it.

I am no fan of private insurers but it's very different.

Medical care is a cost center for insurers.

But they can remedy that cost by getting more insured into their fold.

Edit: Not sure why this comment warrant a downvote. Anyone care to elaborate?

I didn't (and can't) downvote you, but in general you're simply wrong. You cannot add more costs to "remedy" a cost center. If an insurer takes on more clients, they might make more profit, they might mitigate some risks, but their costs will definitely go up proportionally with their client base.

I'd also like to propose a thought exercise for you. Imagine a private insurer. They have, say, 50K clients. They make a couple million dollars a year in profit and make many millions of dollars in medical payments. Next year they double in size, which reduces their risk of failure and improves profit margin slightly. The better profit margin allows them to reduce costs a bit to attract more new clients. The next year they do the same, and the year after. Then they start merging with other insurers while continuing to grow. All along, as their client base grows, they improve profitability (and/or reduce costs) and their business becomes less risky.

Suppose eventually all Americans use this one enormous insurance company. They have the power to negotiate the best rates with doctors, drug companies, hospitals, etc. They have such a large client base that there is no risk, just extremely predictable income and expense. They can get costs as low as the medical industry will allow because they have such a large base.

Now suppose that this one enormous company is simply a part of the federal government. What changes to make single payer not work when it was working just fine before the words "federal government" were introduced?

An insurer is a business it can make money, that makes it a profit center, it does not mean that they will make a profit. A public healthcare system get a budget, they cant make a profit only manage their cost. So no i am not wrong i am fully inline with the very definition of those two terms in this context. Yes an insurer can have cost centers too but they are again in this context able to make money.

profit/cost centers as i understand them are internal parts of an organization.

its uncommon to say an entire organization is a cost/profit center; instead you would say x department is a cost/profit center.

FWIW, i believe most insurance companies make their money from investing the insurance premiums - i would say within an insurance company the finance department is likely the profit center, and whichever department handles payouts to healthcare providers would be seen as a cost center for the org.

oh it may be worth adding- most major US insurance companies are run as non-profit organizations.

Yes but in this context it's important to distinguish between something which is purely run at a cost with only budgets determined by politicians and then something which is turning a profit and can use that to invest.

Another way to put it is that companies have both cost and profit centers, public healthcare systems like the one in Denmark only have a cost center.

I am not sure what this seems so controversial.

This IS the big difference between a system which is purely run by tax money and don't take any revenue and then one which do.

Private insurers make their money by providing less care per dollar. They cannot raise rates arbitrarily (or if they can, it indicates they have no competition and there's no free market at play) and they cannot reduce the cost of care significantly. The best way for an insurance company to make more money is to simply make fewer payouts. i.e. Reduce the cost center.

Every dollar a private insurer makes (or invests) is a dollar they didn't spend on care for their clients. If you assume that insurers have, say, a 5 percent margin, the fastest way to cut the cost of care by 5% is to eliminate the profit.

An insurance company can get more companies as customers and there can be more companies created.

You are getting way to hung up on the internal details of how it works.

Insurance companies are one part of the healthcare package. There is a reason it's a business which can do well or not so well.

Thats very different than a public healthcare system where EVERYTHING is budgeted.

As unprepare pointed out, you're using these words incorrectly. Payouts for medical care cannot be anything except a cost center.

I also don't know why you think private corporations are excluded from having budgets. I assure you that Aetna and Kaiser and all the other insurers have budgets for the medical care that they pay for. They cannot print money to pay the bills. All they can do is raise rates or provide less coverage. On the other hand, the government can print money if they need to.

No I am not using them incorrectly you are simply just not taking this discussion in it's proper context.

We are talking about a healthcare system like the US version and comparing it to the Danish version.

The funding of those two systems are very different. The US healthcare system is run as a business with profits.

There is no such thing as profits in a public healthcare system like the danish and so everything is a cost.

In the US system thats not the case.

I frankly don't know why this is such a controversial discussion.

  What about illegal immigration, do people who are here illegally get access too?

In California, yes (paid for by CA taxpayers, and debt). Generally, no.

Let's not ignore the providers themselves. Excluding the middlemen, my wife had a bill for a lithrotripsy procedure (she was there for approximately 4 hours) of nearly $10,000, and most of that went to the hospital. That was before insurance negotiated their rate.

Lots of people have said it. Single payer has advantages and disadvantages, and we haven't decided, as a country, whether that makes sense.

> Pharmaceutical companies can more or less dictate the prices

This is a problem with overreaching intellectual property law, not with having a choice in health providers.

>>> Insurance companies and Pharmaceutical companies can more or less dictate the prices they'll charge because if you're chronically ill, you can't just choose not to be treated (unless you're ok with dying.)

How is this consistent with the pre-ACA availability of high deductible, low premium PPO plans in low-regulation states?

As an example, in 2008, a middle aged man could buy such a plan in Arizona for $70/month with a $10K deductible and $2 million lifetime coverage. This included free annual wellness visits, women's wellness checkups, etc. Keep $10K in the bank for emergencies, and you're good to go.

Millions of self-employed people and people working jobs that provided no group insurance benefits were able to take advantage of these products. I was able to insure my family of three for $330 a month at that time, and the coverage was quite good.

I don't fully understand the single payer concept, except that it essentially is a form of national health insurance similar to the British NHS. For a country as big and diverse as the U.S., it sounds expensive and unworkable.

I would propose as an alternative a hybrid of low-regulation plans such as we had prior to ACA, plus support for those who can't even afford one of these low price plans. Free or low fee clinics for the needy, less regulatory load on hospitals and small practices, e.g. remove or delay the electronic medical record requirement, attack the causes of high malpractice insurance, stop incentivizing physicians to "turf" challenging patients off to specialists and overprescription of tests to cover their liability.

There has to be a way that works, short of a national Medicare for all that I fear would lead to great mediocrity.

> As an example, in 2008, a middle aged man could buy such a plan in Arizona for $70/month with a $10K deductible and $2 million lifetime coverage. This included free annual wellness visits, women's wellness checkups, etc. Keep $10K in the bank for emergencies, and you're good to go.

1. Only if you were already in good health and had no pre-existing conditions. Otherwise you would be rejected.

2. $2 million lifetime limit is not great for certain illnesses that can become very expensive to treat (e.g. cancer).

3. The practice of recission meant that you had no idea whether or not that $70/month plan would actually pay out in the event that you needed it.

Insurance plans were great for insurance companies pre-ACA, you could reject everyone except those least likely to need health care, and then drop their coverage if it turned out they actually needed it, or if they got too expensive to treat. It was a win-win-win situation for the insurance companies.

You're going to the extreme case of catastrophic coverage. For the majority of common conditions such as appendicitis, broken bones, even some types of heart disease, this type of plan worked quite well.

It's true that a catastrophic case could blow through the lifetime cap, but then there was something else called catastrophic coverage for not that much more. I chose not to get it, but maybe should have.

I suspect it's not so much that the coverage was prohibitive but that people simply didn't, and don't, understand the economics. A lot of people were knowingly going "bare", i.e. foregoing coverage altogether. Even today, people are consciously choosing to pay the personal penalty.

Your claim that "you could reject everyone" pre-ACA is completely false. In fact, insurance companies were required to carry a certain percentage of high liability customers. It varied from state to state, though.

Finally it's also worth mentioning that even for people with no coverage whatsoever, hospitals were (and are) required to care for them. If you stumble into the ER with any condition, they are required to provide care, or at least transport you quickly to a place that can. The poorest among us will get excellent care albeit they may not have the wherewithal and knowledge to actually go seek out that care.

The ACA sought to rationalize this fragmented and confused system and deploy a universal system throughout the country. It will be a subject of debate for decades to come whether this law would have worked.

Of course I'm talking about catastrophic coverage: that's when you need insurance the most! (And the worst possible time for them to say "sorry, you're too expensive to treat, so you're on your own now.")

Besides, what good is a plan that will pay $ to treat a broken bone but refuses to pay $$$$$$ to treat leukemia?

> Your claim that "you could reject everyone" pre-ACA is completely false. In fact, insurance companies were required to carry a certain percentage of high liability customers. It varied from state to state, though.

What? Tell that to the millions of people that couldn't get coverage pre-ACA due to pre-existing conditions.

> Finally it's also worth mentioning that even for people with no coverage whatsoever, hospitals were (and are) required to care for them. If you stumble into the ER with any condition, they are required to provide care, or at least transport you quickly to a place that can.

Are you suggesting you can go into a emergency room with a non-emergency condition and they're legally obligated to treat you? Can you cite a source for this?

> I don't fully understand the single payer concept, except that it essentially is a form of national health insurance similar to the British NHS.

Here's why single payer works to keep costs in check everywhere it's implemented:

Providers and pharmaceutical companies have only 1 organization to negotiate with.

Another alternative that won't see the light of day is cost regulation for the entire industry. My sons type 1 diabetes supplies for a quarter bill my insurance plan $6000. There's not more than a couple of hundred dollars worth of materials there (and I'm being generous.)

A friend of mine takes Gleevec, a leukemia drug, costing his insurer $14,000 per month. Generics are now coming on the market for a much "cheaper" $38,000/year. That same generic in Canada is $8,800/year.

We're being systematically ripped off.

Not a rip-off, but a consequence of lower regulations in the U.S.

Through higher domestic prices you are subsidizing the lower prices in most other countries for American-developed drugs.

You are also subsidizing the R&D. A single drug can cost billions (with a "B") of dollars to develop, test, and manufacture. It takes years of experimentation and careful trials, and even after the chemical is approved by the FDA, there are hundreds of millions of dollars in liability insurance baked into the price against the almost inevitable class action suit should there be an unforeseen side effect.

For example, Roche has developed an MS drug, ocrelizumab, which attacks B cells exclusively and appears to slow the progression of the disease. It's in stage 3 tests and has cost well over $1 billion so far. There is a large market for this treatment, should it ever make it out of the lab. The problem is, a side effect may cause the FDA to deny approval, and there is no particular compensation. Maybe they can use the knowledge to develop a better drug, or maybe it will help some other research organization. Either way, it's a very expensive and risky gambit.

The way they recoup their costs is by charging a lot up front. Since Canada and other countries cap the prices they can charge, they can only do so in the domestic market.

I'm not saying I approve of this approach. Frankly if I had MS I'd not want to wait 5 years for the FDA to declare it perfectly safe. I used to volunteer in an MS clinic and I can tell you, people were often willing to take the risk. Tysabri was another one that was amazingly successful against MS, but it also activated a rare and fatal virus in the brain in a very small number of patients, so it was pulled off the market. I've read that it's being allowed in limited cases.

The key word you're looking for here is "high deductible."

$10k is a very high deductible; it essentially renders the medical plan useless for anything short of emergency or life-threatening care. Most people don't just have $10k lying around.

If said middle-age man had expensive chronic conditions to treat then that $70/mo policy would quickly become a $10840/yr policy. That might be workable for a high-earner but even for the average-income American it likely wouldn't be.

Yet, in the pre-Medicare days, this is exactly what families were faced with when someone got seriously sick: they had to pool their money to pay for treatment.

Today, people resent even paying the co-pay, and the notion of coming up with a few thousand dollars that might be a small fraction of the bills would be considered outrageous and unfair.

>I was able to insure my family of three for $330 a month at that time, and the coverage was quite good.

Whenever I see a like claim tossed around I always ask (and never get a straight answer): What was your deductible and out of pocket maximum for your family of 3 at $300/mo?

It was a high deductible plan, $7500 as I recall. We had enough savings that the tradeoff made sense.

For some conditions, the high deductible was waived. I don't remember now what they were.

Right, but what was your Max out of pocket? If you can't remember these details then how can you say it was a good plan?

On paper, none of the Star Wars movies ever made a cent of profit. On paper, Google and Facebook had not profits in America.

ACA insurance profit are loss are similar. With enough creative accounting the business could be made unprofitable to squeeze concessions from the Obama administration.

Look at all the major insurers stock price since Obamacare began. That will tell you all you need to know about this story. If you think they are making all that money because the non-ACA health insurance business suddenly got real good, I have a bridge to sell you.

The trade off that made the ACA possible was clear to everyone at the beginning: The mandate will bring the insurance companies more customers and that will help pay for the sicker customers they will have to cover. If it doesn't work out the federal government will be backstopping their losses.

Optimism around insurance stocks reflected in their stock prices was all about larger volumes making up for smaller margins and lower risk, there is no tricky misdirection going on here. That is "all you need to know about this story".

I've heard of these accounting shenanigens. If you are ever faced with a contract where you get "residuals"/net-profit, how do you protect yourself?

All of the Star Wars movies made profits for their distributor. The accounting loss was recorded only in the special-purpose holding company (SPHC) that was specifically set up to disburse profits to net-profit participants. To ensure that this type of entity has no profits, all production and distribution expenses of the studio and distributor are generally charged to this entity, usually in advance lump sums. The studio and distributor record and are taxed on their income.

In many cases, any licensing income is earned by a separate but related company that paid the SPHC for the rights to re-license the film (but usually the distributor also acquires licensing rights). The SPHC is generally a profit-participant in the licensing company, but its share of the licensing profits usually varies based on industry politics (i.e., leverage).

A-listers with sufficient leverage and competent representation can sometimes participate in the profits...of the distributor. It's not enough to get gross profits since gross profits take into account COGS/COSS. What you really want is "first-dollar gross", meaning "gross income" before distributor expenses.

For example, say, "Gravity 2" makes $100m at the box office. That $100m is first-dollar gross. If WarnerBro's COGS were $80m, gross profits were only $20m. If Sandra's share of profits was 1% of first-dollar gross, she's looking at $1m; but if she only had a gross-profits participation, she's looking at only $200k. If Sandra was a net profit participant, she wouldn't make anything at all since Gravity Special Purpose Movie-Making Entity has an $X million dollar loss related to production expenses for making the movie and the distribution expenses WarnerBros is expensing to it.

[source: I do this. But not for WarnerBros or Gravity, those are just examples that are easily Googled if you want to follow up with your own research.]

Actors with good negotiating position get big up front payments and a percentage of gross.

So I suppose one answer is to have good negotiating position.

You negotiate a percentage of the gross.

Am I misreading this, or are they forgoing profit purely out of spite? Or I guess the idea is they could make more profit in the long run if they generate enough bad publicity for the ACA. These quotes almost seem too on the nose to be real:

> “I just can’t make sense out of the Florida dec[ision],” the executive, Christopher Ciano, wrote to Jonathan Mayhew, the head of Aetna’s national exchange business. “Based on the latest run rate data . . . we are making money from the on-exchange business. Was Florida’s performance ever debated?” Mayhew told him to discuss the matter by phone, not email, “to avoid leaving a paper trail,” [the judge] found.

Aetna hoped to forego smaller profits from these exchanges to access larger profits with the acquisition of Humana. By withdrawing from those markets where Humana was competing with Aetna, Aetna could then claim that the merger would not reduce competition between insurance providers. Also, article claims that participation in ACA exchanges was privately used as a bargaining chip to pressure the DOJ into allowing the merger.

From article: "Aetna tried to leverage its participation in the exchanges for favorable treatment from DOJ regarding the proposed merger." — U.S. District Judge John D. Bates

"Aetna could then claim that the merger would not reduce competition between insurance providers."

But the merger did reduce competition, because of Aetna's withdrawal to (they thought) enable that very merger. "We'll just kill your chickens before we let our chicken hound run free. See? Our hound won't kill your chickens."

"The cynicism ... the cynicism ..."

I didn't mean to evaluate any particular claim, only to use my modest powers of reading comprehension to helpfully summarize the article :)

And I understood your comment exactly that way. I actually tried to think of how to make that obvious, but couldn't in the time I gave myself. Have a good day, citizen. :)

Not quite. Based on the article, they threatened to withdraw if the DoJ did not support their proposed merger with Humana. The DoJ did not support it, so they followed through on their earlier threat. So it's not spite, but part of a negotiating tactic.

> Am I misreading this, or are they forgoing profit purely out of spite?

Not spite: it's sacrificing short-term profit to help create a political context in which they expect more favorable general policy -- the entire idea was that if the Democratic administration wouldn't give them favorable anti-trustanalysis treatment, they'd do what they could to make the ACA look like a failure, knowing it would be a major election issue. Presumably, they expected a Republic administration to be friendlier, either for ideological reasons, or gratitude, or because Aetna successfully flexing it's political muscles would have proven that they must be deferred to (or a mix of all three.)

ACA was designed to drive consolidation. Because large companies are easier for the government to control.

Source - ACA author: http://www.wsj.com/articles/i-was-wrong-about-obamacare-1469... (How I Was Wrong About ObamaCare: The law’s drafters wanted consolidation)

Which why, all of a sudden, all the hospitals are buying each other, and insurance companies are buying each other.

It seems Aetna felt that the government didn't live up to its side of the bargain.

Ok, but on its own that doesn't make sense as a business decision. Assuming they are profit-driven businesspeople, they either they thought their best option was to try and sabotage the ACA, or they really thought this would work as a negotiation tactic, which seems absurd.

Why does it seem absurd as a negotiation tactic? They use what leverage they have against the government.

I don't know, does this kind of thing usually work? I don't really know anything about this, but it just seems sort of obvious that Aetna is in a much weaker position than the US government and can't possibly strongarm them that easily. But I guess if the prospect of making the ACA look like a failure is part of the leverage then it makes more sense.

Also they pulled out of areas with little competition to prevent the argument against their Humana merger being due to inadequate competition.

"Forgoing" profit now, in pursuit of greater profit when there's less competition after the merger. Always follow the money.

Am I misreading this, or are they forgoing profit purely out of spite?

I love how all the responses here are all "No no no, it's not spite, it's perfectly valid extortion. Well what else could they do?"

There are 2 simple things we can do to fix health care. First, make it like public school. If you want to pay for private school, go ahead, but health care should be socialist like school and sewage. 2nd, make it illegal for the AMA to limit the number of doctors admitted to med school. Its a cartel that reduces supply.

Unfortunately, a lot of doctors believe that to become a doctor, you need to practice on real patients. I believe there is artificial reduction in the number of doctors minted each year, but I also realize there are practical limits on that number as well(ie cadavers). Fortunately, we are working on the problem with use of technology.

Not an expert but I'm pretty sure the AMA gates the number of residency seats and then the schools take the hint and gate admissions numbers independently.

> First, make it like public school.

We can learn from our mistakes there and, if we really feel we need to make medicine socialized (as opposed to deregulated like the excellent private healthcare in Mexico or India), we can at least do it on a voucher-based system. Everyone gets $x tax money a year to spend on medicine, and you can choose where to spend it.

What if you need more than you're allowed?

What if you need more than the government is willing to spend on you in the "public school" scenario?

I had a longer, more detailed response, but I realized that what you asked isn't really a fair question. In the end, the answer is "you die", and by elaborating on that it made it sound like I agreed that this isn't an issue in socialized medical care.

I figured you'd want to say more about it because that obviously doesn't work. But.. OK.

TIP: If you're having trouble viewing the page because of the pop-up telling you to turn off your adblocker, Click the little 'i' by the address bar (Chrome only) and disable Javascript for the site.

And there is reader view for firefox users.

A company lying to further it's goals, well I never!

Note that both things can be true: that Aetna lost money in the individual marketplace (which would square with the experiences of other insurers in guaranteed-issue markets) and that their tolerance for loss was sharply influenced by support for their proposed merger.

"Bates found that this rationalization was largely untrue. In fact, he noted, Aetna pulled out of some states and counties that were actually profitable to make a point in its lawsuit defense — and then misled the public about its motivations."

It could be the case, but it seems that, in at least some of the markets, it was not. They were pulling out to try to invalidate the DOJs finding that the merger would produce insufficient competition.

Even if this was true, which the article states it is not, isn't that the point of insurance? To spread the risk and cost across a geographic or demographic populace while making a reasonable, but steady profit?

I want to be clear that I'm not saying Aetna should have left unprofitable markets; I think, for instance, that it would be reasonable to require that any insurer wishing to offer group coverage in a state also offer individual market coverage.

But the claim Aetna is making is that, at least in some of the markets it abandoned, it was making a net loss on insurance contracts.

This a million times over. Aetna makes huge money in the group business. By allowing insurers to take all the healthy people in group business, but absolving them from taking the sick people in a market, you essentially create smaller pools of "unprofitable" customers. But essentially it is a giant subsidy to the group insurance providers.

> Even if this was true, which the article states it is not,

Not really:

"As for Aetna’s claimed rationale for withdrawing from all but four states, Bates accepted that the company could credibly call it a “business decision,” since the overall exchange business was losing money;"

Again, both can be true...

Though, again, it clearly says in the article it's not and they pulled out of states where they were profitable.

It could have been but it doesn't sound like that's the case. The evidence indicates that they just wanted an anti-competitive merger enough to leave profitable, competitive markets.

But it wasn't true that they were losing money in all the markets they pulled out of.

Shameless misdeed by a greedy corporation.

That being said, I fail to understand one thing about those who propose a single payer system (and I mean this with all sincerity): If we cannot afford to pay for doctors, hospitals, and medications, how can we afford to pay for doctors, hospitals, medications, plus a bureaucracy to manage all of it?

To me, "negotiating" better deals doesn't work. As a single payer system, that's just a rephrasing of "price controls".

It seems game theory could be put to good use here, as life is effectively a single round game where many (most?) participants will spend everything they can for the game to not end (i.e. extend their lives and postpone their death). This one attribute seems destined to really challenge insurance of any kind (including single payer) given the large aging demographics in the US (aka "Baby Boomers").

> If we cannot afford to pay for doctors, hospitals, and medications, how can we afford to pay for doctors, hospitals, medications, plus a bureaucracy to manage all of it?

The same we are doing it now. Do you think the insurance companies are not bureaucracies? A regulated monopoly is the most efficient form of bureaucracy, because of efficiencies of scale.

Also, insurance companies still generate profits, profits that can directly go towards health care, instead of being used as an investment cushion or for god knows what.

Also, having every single person under 1 health care umbrella is a systematic reduction in risk, which further lowers costs.

I was pretty sure the news orgs I was following pointed this out at the time the merger was approaching its conclusion.

I'm glad a judge with access to more information that the average news consumer was able to make a judgement and reduce the uncertainty around the claims (both Aetna's and the news coverage).

Wake me up when charges are filed.

I don't think this is really illegal. What would it be, libel against the Obama administration or something?

I'm for universal healthcare but the ACA is collapsing in many states. I happened to ride back to Santa Fe with the CEO of Blue Cross of Omaha who told me that BC/BS of NM lost $100m on the ACA in 2015. That's a lot of money for anyone to lose. He believed there were a few relatively simple fixes that would go a long way to bring some sanity to the system. And let's face it, tax penalties are not the way to achieve health coverage for all Americans. Boo on Obama for not even bothering to try for Universal Healthcare...

> Boo on Obama for not even bothering to try for Universal Healthcare...

President Obama didn't create the ACA. Congress did. It was modeled after a system that works very well in Massachusetts and was developed by Republican, free-market think tanks.

And every Congress since has tried to sabotage it rather than fix it. Last I heard, the current Congress still doesn't have a great solution to solve the core issues. And that is after 40+ votes to dismantle it.

I think you mischaracterize the Democrats of 2009. There was a significant desire to push for "a single payer option" (a partial "universal healthcare"), but there was also severe resistance, even within the party. And Republicans largely didn't want to deal with any option the Democrats came up with.

I'm glad something was done, even if it was an imperfect law. It forced the issue to eventually be dealt with. I would have preferred that Republican Congress critters would have chosen to try and fix the law rather than sabotage it (they were largely waiting for Republican president that could get credit for fixing the flaws).

  Republicans largely didn't want to deal with any option the (2009) Democrats came up with.

No Republican was even allowed to read the final bill before the vote. Do be fair.

> Boo on Obama for not even bothering to try for Universal Healthcare...

You must have missed the entirety of 2009 that extensively debated the topic with Obama very much gunning for universal coverage and the GOP very much trying that no one got covered. The public option would solve much of the current issues, but was shot down by the Tea Party. Same for expanded Medicaid to cover the poor, Republican governors refused to expand.

The ACA is far from perfect, but not because Obama wanted it to cover less.

>Boo on Obama for not even bothering to try for Universal Healthcare...

He tried to include the public option but it only had 59 votes to the 60 required to pass it

How about you take it to a vote and see what happens? If you just cave up front, I guarantee you you're going to lose. That's my point.

You only need 51 votes. If Democrats really cared they could have just sit in the senate until the republican speakers collapsed. And it would have gotten to a vote.

It may have taken a couple of days but whatever.

Edit: Can anyone explain the downvotes please? A filibuster can be overcome by just siting and listening to the other side until they can no longer speak from exhaustion.

They can trade off speaking during the filibuster.

Say only 20 of the minority decide to be completely intransigent. How many weeks do you think it will take to exhaust them when they each only need to speak for ~9 hours a week to maintain the filibuster?

They don't have the right to leave the senate hall I think. So I do think they will have to make number one and two from time to time. The answer also is as much as needed.

The Senator that has the floor can't leave the Senate. They can leave if they aren't holding the floor.

So 52 weeks later, maybe you compromise to get some things done (or maybe sooner)?

"Boo on Obama for not even bothering to try for Universal Healthcare..."

How old were you when the ACA was passed? I ask not to be snarky, but to see if you remember the huge fight that erupted over the whole thing. Go back and read some of the coverage of the time, and ask yourself if you really think that he would have had the political capital to push the public option through.

> BC/BS of NM lost $100m on the ACA in 2015

And they would have broken even on Risk Corridors if it wasn't for Marco Rubio.

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