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Comment by mrosett | Hacker News Reader

You can argue that the ACA improved the healthcare system overall. But it's been tough for people who were already covered by employer insurance.

I think people fail to appreciate that prior to the ACA, when the healthcare system worked, it actually worked really well. I got very sick at the age of 20 while I was still on my parents very modest insurance (pre-ACA). Within 48 hours I had an appointment at the best oncology hospital within 500 miles, and I was able to get scans, tests, etc on a very short turnarounds. Ultimately I had two major surgeries in 4 months, and the whole thing probably cost the insurance company a couple hundred thousand dollars. Since my parents had already hit their out-of-pocket maximum, the marginal cost to us was 0.

Now, the "when it worked" caveat is a big one. The story would be very different if my parents didn't have insurance at all or if I hadn't been eligible to be on it. But the same story today on my insurance would cost me a lot more money out of pocket due to a much higher deductible and a higher out-of-pocket maximum.

My perspective is that the ACA made things significantly better for a small group and modestly worse for most people. I'm open to moral arguments that the tradeoff was worth it (although that's not what I believe.) But I dislike rhetoric that pretends there's no tradeoff at all.

Edit: Added substance to a one-liner.

View on HN

Pre ACA, pre-existing conditions could disqualify you from insurance. People with pre-existing conditions are the people that need health care coverage the most. We can't under-weigh the moral obligation we have to this previously marginalized group, when considering service may be slightly worse for people who have employer coverage.

How I see it: if you were in the pre-ACA pre-existing condition pool, your perspective would be vastly biased in a different direction. And nobody wants to end up in that pool. Nobody chooses that. That's why it's a net win overall.

People died because they don't have coverage (unfortunately, still happens, but substantially decreased by ACA). If things are slightly worse for people who already had access, It's such a small price to pay.

My favorite one was pregnancy being a pre-existing condition so if your husband got fired (noone would ever fire a pregnant woman for no reason), you couldn't get insurance when you needed it the most.

Though (if both spouses were working & had access to employer sponsored insurance), wouldn't the husband being fired result in a qualifying change for the woman, allowing her to enroll on her employer's insurance plan, thus covering the pregnancy?

Or COBRA, unless you expect your pregnancy to last longer than 18 months.

COBRA these days ends up being way too expensive for most people to afford. Perhaps at one time it was a useful regulation. Now it is pretty unaffordable.

If it was useful, it was a very long time ago. I remember my parents being in between jobs in the late 90’s and early aughts and complaining that COBRA was extremely expensive. The only reason the law seems to exist anymore is for people who somehow have some expensive debilitating condition yet can still work (or are a worker covering a family member with such condition). And that’s a pretty small subset of all health insurance buyers.

Data seems to agree: in 2007 the usage of COBRA was 10%: http://www.cnn.com/2009/HEALTH/01/23/cobra.health.insurance/

I thought COBRA was exceedingly expensive in 2000. Now, the cheapest HMO Bronze plan is 300% more, adjusting for inflation.

Unless her employer's insurance plan excluded her based on the pre-existing condition of being pregnant. (which it certainly could have)

The point of trying to get on an employer's insurance plans were that people were not excluded for pre-existing conditions because the employer plans were less selective (and also correspondingly more expensive, though the employer contributions hid the additional expense from the employees).

Why would you expect people to want to open their own wallet to pay for your pregnancy-related medical expenses in exchange for premiums that are much smaller than the expenses you already know you're going to incur?

"noone would ever fire a pregnant woman for no reason"

Companies do this all the time. My sister worked at a major oil company that laid off all the pregnant women and new moms out on maternity leave within her department. (To be fair, they also laid off about 1/3 of the rest of the company as well.) It's totally illegal, but if you've just been laid off and have a new baby on the way are you really going to have the money or energy to fight a lawsuit? And even if 10% of people affected did, it's cheaper for the company to settle for $500K or so than to pay the salaries of all the people they fired.

I do believe that was unmarked sarcasm, so hazardous in these times.

AFAIK, preexisting conditions weren't a disqualifier for any employer-provided health insurance (which is why group policies are so expensive).

That's a slightly maddening thing about many these comments. If you were getting your healthcare through an employer, you had a lot more security both on the pre-existing conditions end and on the keeping coverage end.

I remember several stories in the news before the ACA about employees being pressured to find private insurance or even getting fired because they were raising the group plan's costs. Are you sure it's so cut and dry that it's something you should be maddened about?

Is there any legal basis for that or is that something negotiated by employers with the plan provider?

I don't know the details but my understanding is that it is partly covered by tax law - if the employer kicks employees who get sick off the insurance, they (and all the other employees) lose some or all tax deductions for health care premiums. The employer can, however, still fire people to get around that.

Your employer could fire you, though, if you all of a sudden developed an expensive medical condition. HIPAA would say that's illegal to do, but it'd be incredibly difficult to prove that was the reason you were fired.

Was the ACA the best to address the problem of pre-existing conditions?

https://www.theatlantic.com/business/archive/2011/06/why-has...

"There were supposed to be millions of people who were uninsurable because of pre-existing conditions. We heard lengthy testimony about their terrible plight. I don't think it's too strong to say that this fear--that you could get sick and no one would insure you, that's right, you, Mr. & Mrs. Middle-Class Voter--was one of the main reasons offered for the health care overhaul. It was estimated by Medicare's Chief Actuary that around 400,000 would sign up (the CBO estimated 200,000, but only because they assumed that HHS would use its authority to limit enrollment in order to stay within the $5 billion budgeted for the program). So where are all the uninsurable people?"

So if this is accurate, that is the size of risk pool isn't that large. Wouldn't be better to create a special program for people who fall into this category?

> Wouldn't be better to create a special program for people who fall into this category?

Why? The only difference between "people who have already been diagnosed with cancer" and "people who are going to be diagnosed with cancer" is that you know who the first group is. The second group is hidden among the "healthy" people.

But both groups will need the same treatment.

You didn't understand what I wrote. I am talking about the group of people that were uninsurable because of preexisting conditions. This group of people was used as a reason for the ACA. However when a pilot program was run before the ACA went into effect, the size of said group appeared to vastly over-estimated.

So the reason for a special program would be to help the people that need it and not mess with the entire country insurance.

I don't like the entire concept of "pre-existing conditions". It goes against the entire concept of caring for sick people.

We are all people. We all get sick sometimes. Sicknesses can last a long time, or a short time. Sick people need help. Help the sick people. Pay what you can (a reasonable amount) into a common pool and take what you need (only as much as you need)

Or turn it around and make it equally burdensome to both insurer and patient. If you acquire a malady while insured by a particular company, all medical expenses that are tied to that diagnosis must be forevermore paid by that insurer, even after the policy lapses, is cancelled, or the patient switches insurers.

If that sounds unfair to an insurer, that's great--now they know how we feel about it.

Insurers want to deny pre-existing conditions because they don't want to add already-sick people to their risk pool. They wouldn't have to, if the previous insurer was still on the hook for that diagnosis. But they'd never agree to that, because it exposes them to some of the same insolvency risk due to medical bankruptcy that some patients have to face.

> Pay what you can

Surely "what you can" should be relative to both your income and your need. We'd need to supervise the system to make sure people aren't taking advantage or else the whole system goes broke.

> into a common pool

We could also invest the money in the pool to make some extra cash and reduce what people need to pay in, we'd have to have an organization do that too.

> (only as much as you need)

How can we know what people need? We'd have to charge a token amount for office visits and medication so that people aren't frivolous with their medical visits, while perhaps guaranteeing an out of pocket limit in case of extreme illness. We'd also need some kind of system to verify that people are only taking what they need.

I think you just invented health insurance.

They’re describing health insurance, except for the part where you pay what you can and get what you need and people are all in one pool.

We probably have different ideas of "paying what you can". How do you judge whether someone is only paying what they can, or they are taking advantage? Not a rhetorical question.

One way is like we do today -- highly-paid positions often come with high-quality insurance, which is (ime) fairly expensive and low-paid positions have less expensive insurance that is a bit worse (all this on average, I'm sure there are outliers).

We are in different pools today but I don't see how that's meaningfully different than everyone being in one pool if the individual pools are large enough and you can't discriminate the population of the pools.

There are cases where it’s hard to tell if someone is truly paying what they can, but there are also cases where it’s easy: when it costs more than they can pay. Health insurance trivially fails the “paying what you can” criterion for sufficiently poor people.

> I don't like the entire concept of "pre-existing conditions".

If you have an elective health insurance system where people choose whether or not and when to participate, it implies this restriction.

Say you have private health insurance companies but don't allow them to prohibit members based on pre-existing conditions. Everyone will simply not get health insurance to avoid paying the premiums until the day they need it. That would make health insurance companies completely unviable financially.

This is why Obamacare both eliminated the pre-existing condition restriction and mandated people get health coverage. You can't have one without the other or you get the free-rider problem.

This is another reason why healthcare should just be universal. It doesn't work at all like an actual efficient market product.

Would a wait limit, like with hurricane insurance, help to mitigate this problem? You can't wait until the NWS declares a Category 4 storm is barreling towards you to buy coverage. I mean you can, but the coverage doesn't kick in until 30 days later.

True but we could have had preexisting without all the other garbage included. Some of it sure but overall I have yet to see any compelling data to say the tradeoff was efficient.

  pre-existing conditions could disqualify you from insurance

Only if you chose no insurance before diagnosis.

Under Obamacare, people can go with no coverage at all and, once diagnosed, then get care paid for without penalty. It's like letting people drive without insurance, then making insurance companies write retroactive policies for them after an at-fault collision.

I'm not seeing the connection to the ACA in your argument. If your argument is that the ACA raised the price of health insurance, that's incorrect: health insurance premiums had been skyrocketing prior to the ACA (that crisis was what generated the political capital to pass the bill), and the ACA in fact reduced the rate of growth in health care costs.

In my previous career, I was an accountant, and I worked for a health insurance company, you are straight up uniformed if you do not think that ACA raised the the cost of insurance.

With that said, as a type 1 diabetic, without ACA it would be impossible for me to get insurance outside of employment, so i think there is some good in it, just needs to be actually thought through, unlike what the administration did that put it in place.

>> just needs to be actually thought through,

It's impossible because you both political parties want exclusively mutual results

You can't have cheap insurance without making it mandatory since only the sick will get it

You can't have easily accessible insurance without forcing healthcare companies to comply with new regulations forcing them to increase costs

You can't have good insurance if you aren't willing to pay the market price which happens to be very inflated in the US

You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts

Overall, it's a shitshow that will keep being patchworked every time the administration changes between parties.

> You cant lower costs in the US without having a more aggressive regulatory body which 50% of political bodies strongly oppose alongside lobbying efforts

Here is the fundamental problem from my point of view. Compare human medical costs to veterinary costs. Yes, people expect a slightly higher standard for themselves than they do their animals, but you can get a major knee surgery for your dog for a small fraction of what they charge for humans. The process is performed in a sterile environment by professionals in either case. We're smarter than animals on average, but our bodies and medical needs aren't vastly different.

The problem is price gouging because the providers and insurance companies know we have no real ability to shop around. They conspire with each other to publish false rates when the true costs are much lower after you agree to them.

You could maybe solve this with regulation on prices (a socialist approach), but you could also solve it by mandating they advertise true prices and re-enable competition (a capitalist approach). Either way could fix this, and the problem is corruption (lobbying) not party ideology.

You don't even have to go all the way to veterinary medicine. This is an old article, but compare the $100,000 cost for a joint replacement in the USA vs. $13,000 for that same procedure in Belgium. https://www.nytimes.com/2013/08/04/health/for-medical-touris...

They do have to publish prices, right? See: https://www.google.com/search?q=doctors+and+hospitals+must+p...

Maybe these aren't the "true prices"? I certainly wouldn't know where to look to find how much a "knee surgery" would cost, and I'd probably need to know some obscure medical code I don't have access to, as well as the intricacies of the knee surgery to know exactly what price to look up. I don't know how publishing "true prices" would work.

What kind of knee surgery am I having? Will I have to pay extra for the anesthesiologist? What kind of anesthesia will they be using? What about surgery preparation? What costs do I need to include for that? What about post surgery? There's probably a dozen cost items to add to the total for post surgery. The nurse brought me a glass of water. I'm not sure if that comes with a charge or not? Presumably someone has to pay for the plastic cup. Etc.

>Maybe these aren't the "true prices"? I certainly wouldn't know where to look to find how much a "knee surgery" would cost, and I'd probably need to know some obscure medical code I don't have access to, as well as the intricacies of the knee surgery to know exactly what price to look up. I don't know how publishing "true prices" would work.

This is exactly the problem. They publish "prices" but those prices don't mean anything.

Published medical prices are not real because most procedures are paid by collective programs like private insurance or Medicare, which use their bargaining power to pay less--sometimes MUCH less--than the public "list price".

You're right that the complexity of medical billing also makes it difficult to anticipate and compare prices. However, that might be more of a side effect of how the billing is done, rather than an unavoidable attribute of medical care.

Arguably, medical providers have the information and capability to package procedures and publish what it actually costs to do them. But they have no incentive to do so, and many incentives to not do so.

Many many years ago, auto mechanics would gouge customers after fixing their cars. This resulted in laws in all US states requiring written estimates in advance.

We should expect hospitals to meet the minimum ethical standards of auto mechanics.

> you can get a major knee surgery for your dog for a small fraction of what they charge for humans.

I mean you can't really compare vet bills to surgery bills. Veterinarians have actual price constraints where the owner is willing to put their foot down once it gets beyond a certain point. They love their pets but they aren't willing to go financially insolvent for them.

No such constraint exists for American healthcare. You pay what they tell you until you are destitute and on Medicaid.

> by mandating they advertise true prices

I think most Americans want this to be the solution and it still won't work unless there is pressure on the entire system. Doctors, hospitals, surgery theaters, radiology, and diagnostics have such complex billing that even if you could price compare are you even capable of understanding what those options do?

Well, the start would be mandating that the cost must be same to all patients. Which means that uninsured/underinsured patients will face bills no greater than the payout the medical professionals get from large health insurance companies. Part of the problem is that no only are the prices not transparent (for comparison shopping), they are also different for different buyers.

  It's impossible because you both political parties want exclusively mutual results

You can't blame ACA's flaws on party disputes -- Republicans were allowed no input to the process, and it passed on Democrat votes alone. Republicans and rank-and-file Democrats* weren't even given the final bill to read before the vote*.

lol, You might want to take in account who you are replying to. tptacek is one of the more prolific commenters on HN. And just to be clear, he was talking about 'rate of growth` in costs, not absolute costs.

Being a "prolific commenter" does not preclude one being uninformed on a topic. Quantity != quality.

> you are straight up uniformed if you do not think that ACA raised the the cost of insurance.

The post you replied to said:

> the ACA in fact reduced the rate of growth in health care costs.

Meaning the RATE of increase slowed. The Department of health & Human Services estimates that the ACA saved $2.3T up through 2017 ($650B in 2017 alone). Premiums haven't gone down, and they weren't estimated to.

Anecdote, but the two years pre ACA my premiums went up about 9% each year. After ACA it was about 6% each year. Pre ACA my employer said "Sorry. Premiums went up from insurance companies." Post ACA employer said "Blame Obamacare."

Employees being people bought the "Obamacare made my premiums go up!"

You're laying the blame at the administration's feet but you're ignoring the complete shit show in the legislature that resulted in what we have today. They compromised and compromised and finally surrendered major concessions to someone in their own party to get it passed. I'm shocked it did any good at all.

I signed up for the ACA the year it came online. Over the years I went from a sub-$100 plan that actually covered things to paying $300+ per month for the "hit by a bus" plan that was so expensive, one year I said fuck it and paid the penalty instead. I understand well what could have been had something truly happened, but I ended up saving money paying the penalty while still having a few minor doc-in-a-box visits out-of-pocket. I also say a number of insurers go out of businesses such that now your only option in my state is the BCBS.

Say what you will about the ACA, but requiring folks to purchase a product while doing not curbing the rampant greed in the industry screams of corporate welfare to me.

It is corporate welfare, I remember lots of libertarian arguments to that very point. But to solve health care in the US you would eventually have to start questioning the for-profit underpinnings of the whole enterprise. That was far too much to expect from the generally pro-market Democrats in office at the time.

Even after Bernie Sanders, the "Very Serious Democrats" talk more of protecting the Health Insurance Industry than anything else. Best case, we'll see a timid proposal of a expensive Medicare Buy-In added to the ACA exchange that will never get past the Senate.

As I once heard it put: the US doesn't have a left and a right party, it has two parties to the left and right of capital.

I heard it once said that America is a one-party system, but in typical American excess we have two.

Both in service of capital.

I used to dabble in enjoying quips like this. They're simple and fun and sound insightful and knowing. But when I look around me I see no truth to them. We have two parties with very distinct philosophies making very different arguments for how the future of our culture and economy should function. "Capital" influences both of them, in different, sometimes overlapping, ways. But they have many differences across many axes.

The "above it all" smugness of quips like that is tiresome.

If you're saying the ACA didn't completely fix the US healthcare system, I strongly agree.

If you're saying the ACA harmed the health care system, strong disagree. Again: the cost increases you're talking about were a fact of life before the ACA. There is no evidence that your costs would have leveled off without the ACA, and substantial evidence that the opposite would have happened.

The increase in costs were most certainly driven in part by the ACA changes. No longer allowed to deny based on pre-existing conditions? Insurers need higher rates to cover those costs. Require a bunch of things be added to mandatory preventive visits? Those have to be paid for as well.

That said, I agree the costs would have continued to go up, but to say there is no evidence that the ACA contributed to it is just ignoring the math.

I had the same experience where as a sole proprietor health insurance for a family of 5 is now $2,000/month. $24k/year not for great healthcare, but for the privilege of paying a "discounted rate" on "select services" when you actually need healthcare.

We haven't needed the coverage for two years but when we did, what we needed wasn't covered so we paid full price anyway including $80 for a bottle of Ibuprofen that was casually offered to us. The markups are almost criminal.

For a $1M home you can find insurance for $1,500 per year. It's exponentially less expensive.

ACA was the worst possible compromise to a serious problem. A public option, universal healthcare or deregulation all would have been better options.

It'd be much nicer to be able pay a doctor to make house calls as needed and waive your right to a malpractice lawsuit than to pay to support this insurance/legal/government system we have now.

My companies insurance premiums were going up 10-15% a year for years before the ACA.

Ours were going up sharply before too, at Matasano (2005-) and before we started Matasano, our health insurance at my previous employer also got slashed (2001-).

> No longer allowed to deny based on pre-existing conditions? Insurers need higher rates to cover those costs.

Is there any alternative though? We're going to pay those costs one way or another: either the government pays for all the unprofitable patients' healthcare (the wet dream of health insurers), or we tell those people to go fuck themselves.

And now we have the worst of both worlds:

Those patients have no coverage so get Emergency treatment for acute symptoms of their issues that rarely fix the underlying problem, and beyond that we also tell them to go fuck themselves.

The government subsidizes ACA plans for many participants. That was partly meant to soften the impact of requiring coverage for pre-existing conditions. And then there is/was the individual mandate, to get everyone to contribute even if they were currently healthy. The ACA also imposed a tax on high earners (IIRC, >=200K, not sure if it is inflation adjusted) to fund the subsidies, and it cut spending on Medicare Advantage, which costs the government more than the other medicare plans.

That being said, I'm not disagreeing that costs went up after the ACA more than they would have, but, IMO that was just insurers/providers raising prices because they could.

There's no evidence that costs went up after the ACA more than they would have, and, in particular, costs grew significantly faster under Bush than they have at any point after the ACA. I'm not sure I understand why we're supposed to give credence to HN-style first-principles analysis of why insurance costs should have increased; in particular, most employer-provided health plans already complied with the ACA's coverage requirements. The data simply doesn't back these arguments up.

You are "most certain" about something that empirical data refutes. Health care costs grew more slowly after the ACA than before it and, in particular, at no point subsequent to the passage of the ACA have health costs grown more than they did during the Bush era.

There are all sorts of things that should have (and perhaps even did) impact prices after the ACA. Not just coverage requirements (which, again: most employer-provided health plans --- which is what we're talking about here --- already complied with), but, more importantly: unprecedented instability in the insurance markets during the almost decade-long concerted effort by the GOP to hamstring and ultimately repeal the bill. And yet, the numbers are right there: health care costs are growing, but they are not growing more than they were prior to the ACA.

I think we’re arguing different things.

Sure, costs went up less after ACA.

However, the ACA directly added costs to insurance that weren’t there previously.

I don't understand this argument. The ACA changed a bunch of things about the health care system. It reduced some costs and increased others. The point is to reduce the total cost (or, in this case, the total rate of increase in health care costs).

It reduced some costs

What were those?

P4P, bundled care, reference pricing, the IPAB-based spending controls, reduced hospital readmissions, the premium rate review process.

Can you help me understand the argument you were trying to make above? I continue not to grok the point you were trying to make.

> If you're saying the ACA harmed the health care system, strong disagree.

The system? No. Corporate welfare is great for "the system." But the consumers? Absolutely harmed!

> Again: the cost increases you're talking about were a fact of life before the ACA.

I've been working for over a decade now. 100% increases, year-over-year have never been even close to a thing with employer plans I've held. Not even close. Typically something in the realm of $20 per year at worst for a quality plan.

Here is another fun anecdote. I recently lost a job, and my firm was too small, with only 4 insured, to qualify for the COBRA. Total premium for the plan was roughly $150, roughly $75 per party as my employer paid 50%. Comparable coverage through the same insurer through the marketplace would have cost me nearly 4x as much.

The reality is the ACA allows insurance firms to sell obscenely over-priced plans to consumers. A sane system would have seen price controls in conjunction with the requirement for insurance. Instead I am forced to pay an insurer, pay the government, or prison. I would happily pay taxes for a fully nationalized system, but the ACA is obscene.

Again, consumers have absolutely been harmed by the skyrocketing cost of health care. But every bit of evidence shows that the ACA slowed that growth.

The only connection you’re making here is that your own costs went up after the ACA. It’s a post hoc fallacy.

> The only connection you’re making here is that your own costs went up after the ACA.

The connection is that the ACA rates, and rate-increases are out-of-touch with the employer-offered system, even when those firms are tiny and not nearing some kind of "scale" cost-savings.

I have been hollering about this issue for years, and I've yet to have someone say "Ya know, I actually experienced something radically different." So where is all this evidence you claim but can't be bothered to provide?

I'm having trouble parsing what your argument here is. Are you saying that rates on the individual market are more expensive than the large group market is? Yes, that's true, and always has been (the small group market is effectively a facsimile of the individual market, for the obvious reason that there's not much actuarial benefit to pooling 10-20 random people).

There also isn't one "employer offered" system. In addition to the aformentioned small-group marketplace, there are also large group plans that cover big companies, and very big companies often self-insure, using health insurance companies solely to administer benefits but financing the care themselves. Can you be specific about which of these kinds of health care financing have been impacted by the ACA, and how?

The ACA is a bandaid on a wart

> The reality is the ACA allows insurance firms to sell obscenely over-priced plans to consumers.

As far as I am aware, the ACA actually introduced limits on how much mark-up health insurance can have, where 80% of the cost must go to actual medical expenses, and administration, marketing, etc must be no more than 20% total. So how is the ACA the cause of insurance mark-up?

I think the actual root of the problem is not mark-up but that health care in the US is quite expensive (and always increasing). The ACA in some cases shifts who pays for it (young healthy people pay more), but it doesn't appear to change much the overall cost. It sucks temporarily for those younger people, but considering they will most likely become older, less-healthy people over time it doesn't seem that unfair overall.

> A sane system would have seen price controls in conjunction with the requirement for insurance.

If you are paying 4x more though, it sounds like the marketplace may be breaking down in your location with a "death spiral", where the price goes up, all the healthier people leave, causing the remaining insurance pool to be even sicker and the price going up even more. The whole purpose of the mandate was to prevent this, but it looks like it's been repealed. Price controls in that situation is hard since the pool is actually expensive to insure, I don't think the government can force the companies to sell at a loss. To reverse it maybe they could re-instate the mandate, or change it to a tax, or add a public option. Or, of course, give up on insuring pre-existing conditions.

> I would happily pay taxes for a fully nationalized system

Keep in mind, there are other countries like Germany and France that have private insurance markets and much cheaper care. I think it is fully possible for the US to implement a nationalized system that does not achieve the cost-effectiveness that we want. The VA system might be an example of how that might go.

> As far as I am aware, the ACA actually introduced limits on how much mark-up health insurance can have, where 80% of the cost must go to actual medical expenses, and administration, marketing, etc must be no more than 20% total. So how is the ACA the cause of insurance mark-up?

One of the issues (and I like the ACA generally), is that that limit removes an incentive for the insurance companies to control costs and the 20% markup becomes a floor, not a ceiling. If they get 20% of revenue as non-medical costs, and they want to increase their profit, the best way to do that is to allow medical costs to increase. Then their 20% is larger because the pie of costs is larger.

Presumably they could pass along the savings and increase revenue by expanding their market share, or lose revenue to a company that controls costs. I see your point though, and in a given year it might be easier to increase medical expenses by 5% than to grow market share by the same amount.

One thing I wonder though, is that even without the 20% rule, if the company can get away with raising rates by 5%, wouldn't it make sense for them to do so? If they started with a 20% margin that would increase their profits by a whole 25%, instead of a measly 5% with the cap, so you'd think the incentives would be even stronger. It seems like adequate competition is the most important thing in a for-profit insurance model rather than having a 20% margin rule or not.

In a healthy, actually competitive market, I think that would work, but there are so few insurance operators in each market, it's really easy for them to quietly collude with each other rather than compete. Additionally, everyone else in the industry wants higher prices and more profit. They are not limited to a 20% cost margin. The insurance companies are supposed to be the downward drivers on price. However, here, it's just easier to not fight the price increases, take your 20% of the increase, and move on, rather than fight hard to push prices down, and gain market share.

I think many economists would say that while you had an employee-based plan your costs were actually going up significantly, you just didn't see it because those increases were coming out of (what would have been) your yearly salary raises.

I don't think ACA plans are much more expensive that what we are _really_ paying for employer insurance. I recently became unemployed and when I priced it out, an ACA plan that offered benefits similar to what I would get with a COBRA plan were pretty much the same price - both ridiculously expensive, so I went with a cheaper silver HMO ACA plan. And my old employer charged a 4% "fee" on COBRA premiums as well - I guess the benefits companies want some of the action.

When I look at what my insurance company actually covers for all of my doctor bills, I'd probably be better off just paying the penalty. At least I'd have a few hundred more every pay check to cover that 11 extra dollars that my insurance company could dare to part with for a $300 X-Ray.

The penalty has been more or less hamstrung by the GOP, so if that's your only consideration, then, yes, you're better off not paying for health insurance.

Additionally: you can (you shouldn't have to, but you can) shop around for cheaper medical imaging. Imaging in particular has wildly varying prices, and if you stay on the "happy path" your PCP and hospital puts you on, you're going to pay the higher end of the range of prices.

You are not, as a general matter of life advice, better off going without health insurance. Rather, find the least expensive HSA-qualified HDHP, fund the HSA with the savings, and pay for routine care (effectively) out-of-pocket. The point of insurance isn't to make your annual checkup cheaper, but rather to avoid going bankrupt if you get hit by a car or your appendix bursts.

From the way you write, your appendix presumably hasn't burst yet. That's great! Neither has mine! My house has also not caught fire† and I have not managed to crash my car into a fully occupied city bus. But I am insured against both of those things, too.

† since we bought it, i mean

I should probably specify the level of "tongue-in-cheek" in which my dismissive comment was made. I'm well aware of the function of medical (as well as other) insurance. Having a family, I'd be a fool to "go it alone". But you're correct, it's my responsibility, especially as one who chose a HDHP this year, to shop for the best deals.

And nope, still on my original appendix... I change the oil regularly.

While the growth rates for healthcare have been lower over the past decade I would be hesitant to attribute it to the ACA. Most of the higher rates over the previous 30 years were due to landmark legislation increasing demand for services. If you take a look at numbers you might be less convinced.

year | growth rate

2005 | 6.7% (Bankruptcy act passed making it harder to discharge medical debt)

2006 | 6.5%

2007 | 6.5%

2008 | 4.5% (Great Recession)

2009 | 4.0%

2010 | 4.1% (ACA Signed)

2011 | 3.5%

2012 | 4.0%

2013 | 2.9% (ACA Taxes)

2014 | 5.1% (Exchanges Open)

2015 | 5.8%

2016 | 4.3%

2017 | 3.9%

There are also a couple of timing advantages that people give credit to the ACA that would have happened otherwise.

There were a lot more prescription drugs created after the Orphan Drug Act and the Hatch-Waxman bills of the early 80's. So the timeline for that is 83-84 laws passed => research => 1990-1999 prescription drug explosion => 2010 - 2019 patents expire. This lead to a dramatic increase in costs over this period, but this is good since people now have access to drugs that wouldn't otherwise exist. The patents expire and the costs decrease, and they won't likely increase further due to the nature of those bills.

You could also make the point that from 2001-2006 you should see higher healthcare costs due to war.

A lot of the calculated savings are based on government projections of future spending. We can go off on a tangent on how good the CBO is at its job, but I think we could agree that predicting the future is hard and people are frequently wrong about their predictions.

Furthermore, lower costs aren't necessarily a positive thing. To put it simply if you are buying a BMW and I am buying a Kia, they are both cars but you aren't unhappy to pay the higher price.

Percentage increases also get harder to maintain as time goes on.

The numbers here are quite helpful. The parentheticals are harder to understand and, for that matter, so is "higher healthcare costs due to war" (we have a nationalized health care system for war veterans).

I wouldn't expect it to be clear unless you've studied the area for awhile but all of those are external shocks to the marketplace.

Healthcare expenses increase during wartime since you have to treat newly injured veterans. That statement basically can be interpreted as "people get injured on battlefields and it costs money to treat them".

First, once again: we have a nationalized health care system for injured veterans. They not only have a separate payer system but also a separate provider system.

Second: I have followed health policy for quite awhile, and it's not clear to me at all what impact you believe your parenthetical callouts had on health costs.

First: I know you're not stupid so I have no idea what you aren't understanding when it comes to veteran care costs increase during wartime. Of course they have a separate payer and provider system. That system is included in the growth rate statistics. It should be fairly obvious that people being regularly shot at have higher healthcare costs.

Bankruptcy Law: In 2005 there were 2,000,000 bankruptcy filings, in 2006 there were 600,000. This was a result of the passing of the BAPCPA in 2005. At that point in time 46% of bankruptcies were due to medical bills. This change increased the expected value of delinquent accounts which in turn should lead to lower costs for medical services.

Great Recession: People put off non-essential medical expenses, or delay usage of medical services. Someone who might get braces doesn't, someone might take care of a parent themselves instead of hiring an in-home nurse, etc.

ACA Signed: Marker for before and after growth rates.

ACA Taxes + Exchanges Open: The two main policies of the ACA intended to curb healthcare costs go into effect. I would classify these two years as overestimation of savings and regression to the mean. Most insurance companies had to backtrack after their financial projections did not materialize.

No, I do not believe veteran health care is included in the statistics you are citing, and I am similarly dubious of your explanations for how each of those other 4 events impacted health care costs, because everything I've read suggests that the impacts are way more complicated than they look (for instance, much of the health cost impact from the "Great Recession" wasn't felt until years after).

Here's the dataset that I'm referencing.[0] From the summary documents, "DOD spending in the NHEA excludes spending that occurs outside of the United States." I'm not certain whether this does or does not include forward operating bases. (Post offices count those as being in the United States so I believe they are included; but I could be wrong) Nevertheless it does include domestic spending on veterans.

Also, many veterans get care outside the VA. From my own experience working with these people, they cite long waiting times or broken relationships with the government for not wanting to take part in that system.

I'm not trying to downplay the complexity of the healthcare market, it's really complex. However, it I were to pick the things the government had control over and impacted the marketplace the most over the last 15 years, I still would pick the same things I did. I could fill several books with other changes that impacted the cost of American healthcare. (switching to e-prescriptions, subsidies for electronic medical records, medicare part D, certificate of need laws, FSA changes, HSA changes, consolidation of pharmacy benefit managers, health system consolidation, the opioid epidemic, the rise of the physicians's assistant, the expanding role of nurse practitioners, etc.)

I'd rather spend my time continuing fixing the things I know I can make better.

[0]: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

Can you give me a deeper link to the specific data from which you drew the table you posted above? There's a lot of stuff hanging off the link you just posted.

Here are some more links, since I can't nest further.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

https://www.chcf.org/publication/us-health-care-spending-who...

The main one you might be interested in is this one though, https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

I've excerpted this from page 34 for your convenience.

"Other public programs include health insurance coverage provided by the Department of Veterans Affairs (VA) and the Department of Defense (DOD). Enrollment for other public programs for 1987-2011 was estimated using the levels from the enhanced CPS (SHADAC) and for 2012, 2013, and 2014 estimates were extrapolated using the CPS. "

None of these appear to contain the table you posted at the root of the thread, the table you now claim also includes the increased cost of veteran care due to the wars in Afghanistan and Iraq. Can you just tell me how you made that table, so I can look at the source and evaluate your claim that it incorporates increased costs in the VA along with private health care?

The raw data comes from the following sublink from the first link in that group "NHE Summary including share of GDP, CY 1960-2017 [ZIP, 27KB]"[0] I computed the table by hand. You can recompute it if you like.

[0]: https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

Oh, for God's sake. The Kaiser foundation just tracks the stat we're actually talking about directly. Here's the numbers for employees covered by group insurance provided by their employers:

    1999  2196 
    2000  2471 12.52%
    2001  2689 8.82%
    2002  3083 14.65%
    2003  3383 9.73%
    2004  3695 9.22%
    2005  4025 8.93%
    2006  4242 5.39%
    2007  4479 5.59%
    2008  4704 5.02%
    2009  4824 2.55%
    2010  5049 4.66%
    2011  5429 7.53%
    2012  5615 3.43%
    2013  5884 4.79%
    2014  6025 2.40%
    2015  6251 3.75%
    2016  6435 2.94%
    2017  6690 3.96%
    2018  6896 3.08%

Can you provide a reference for this data, I'm not 100% sure what I'm looking at. I deleted a previous comment on why I think the data I used is better for analysis but I want to confirm that this is what I think it is before I comment further.

It's the chart data from:

https://www.kff.org/interactive/premiums-and-worker-contribu...

I'm sorry for getting snippy, I just couldn't untangle your numbers from your source even after you pointed to the raw XLS you got it from.

If we just stay focused on commercial health care, we don't have to litigate whether the Iraq War (materially) impacted health care costs prior to the ACA. And: this thread is about whether employer shifts to HDHPs and (more broadly) the ACA has impacted those specific costs, not the total government cost of providing all health care services.

When all else fails, go up one derivative.

How so?

The choice of covering crappy plans is the employer's choice... and crappy plans are what have been pushed AFTER the ACA was passed. Largely by the GoP...

Is that what the ACA was, or what someone(s) who want it to fail want?

There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall.

The parent comment is exaggerated, but I think the point is that prior to ACA, employer-provided plans tended to be cheaper and have lower deductibles largely because insurance companies were able to drop or deny coverage whenever they felt like it for individual plans to keep their margins up. While logically true, this is roughly equivalent to hearing from an old coworker that South Africa was a great place to be white under apartheid...

I think it's also worth exploring how much of the difference in financial cost of health insurance plans is due to time + annual overall increases in healthcare cost in the US. ACA was passed 9 years ago. Even under the previous 9 year annual percentage increase averages, you would expect healthcare costs to be at least 20% more expensive than they were in 2010, regardless of ACA.

It's more extreme than your example. The parent is ignoring the fact his great healthcare experience is predicated on them being able to drop him the moment they could, when his illness became too expensive.

Ending pre-existing conditions was the game changer in the AMA. Treating people is obviously more expensive than not treating them.

That's just not how it worked with employer insurance. Perhaps they could drop your whole company, but the insurer couldn't unilaterally cancel a single employee's plan.

No, but sick individuals, or those with sick family members are lousy employees... wink... wink..

https://www.chicagobusiness.com/article/20140918/NEWS03/1409...

I know someone who pre-ACA had employer insurance who was dropped by that insurance after they got skin cancer. The official reason was lying during the application process (10+ years earlier).

They forgot to list childhood Asthma on their application form ten years earlier.

Would the ACA prevent that kind of scam? I genuinely don't know.

The incentive is gone, since preexisting conditions are no longer a disqualification.

The incentive is still very much there. You just can't use a preexisting condition as your excuse anymore.

I would argue that the incentive was implicit and fundamental to the nature of the business, because it provided agents with a method to pick and choose their clients.

By inducing lapses in insurance coverage, insurance companies were able to convert illnesses under active treatment into preexisting conditions.

You aren't required to complete an application form when you sign up anymore, so they don't even ask you medical questions.

There were plenty of cases where they would raise an employer's premiums and let them know why, and sick people lost their jobs and their insurance.

Witness all sorts of horrible behavior, like employers saying "Sorry, all, no raises this year, because one of your coworkers was using so much of our health insurance pool that they raised our rates!"

Yes: if you go back in time, health care costs go down, because they've been rising rapidly over the past 20 years. But the only thing that happens at the point in time when the ACA passed is that the rate of growth in cost falls.

That's not really true, though. Costs as a % of GDP went down from '05-06 and went up slightly from '06-07.

In real numbers, in 2008-2009, the increase in overall cost per year was actually lower than in 2014-2015, when the exchanges opened.

You're right that the rate of growth in Medicare cost fell after the ACA passed, but that's much more specific than overall cost delta.

Something very relevant happened in 2008-2009.

It also impacted prices all the way into 2012, by moving people out of full-time employment and onto COBRA, and by reducing the number of young people on health insurance plans.

> There's a weird narrative where any event is tied to the ACA while they ignore what the healthcare system is in the US overall.

The ACA fundamentally shifted the landscape for the whole healthcare system with minimum coverage mandates (including employer plans), guaranteed issue, etc. It's also led to higher demand for medical services (ie because more people are covered - a good thing) at a time when the number of doctors has stayed fixed. The net result is that health coverage is simply more expensive. One way that could have played out would be employers eating the higher premiums themselves (which is essentially giving everyone a raise.) Anecdotally, it seems the way it's played out is that employers have kept paying roughly the same amount while employees have either paid higher premiums or received higher deductibles.

The trend of higher and higher medical costs, employer plans trending down as far as benefits and up as far as costs was established long before the ACA.

My employers have been complaining about skyrocketing health insurance costs since my first job in 1998. This all predates the ACA by at least 20 years.

The cost to employers of very good plans massively increased after ACA went into effect. When this changeover happened, I was running a company where we paid 100% for one of the best healthcare plans available in the state for both the employees and their families -- people really appreciated this benefit. This was the polar opposite of a "crappy plan", and it wasn't inexpensive to begin with.

After the ACA, this plan became so expensive so quickly that continuing this plan became nearly untenable financially and now these types of plans have become increasingly unavailable in any case due to that cost escalation. If you were formerly on one of these plans, of course the post-ACA environment seems like a big step backward. This happened in one of the deepest of blue states; the Republicans can't be blamed for the destruction of health insurance benefits here because they were never involved. The cost of healthcare here has not risen nearly as fast as the cost of providing top-tier healthcare benefits did.

What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps.

Even with the ACA, employers have the best of both worlds. Expensive older people are covered by the government, and anyone who gets to expensive can be shuffled off with a little cover and the joy of "at-will" employment.

The lifetime max was multiple millions, I don't remember the exact number. As I stated, it was just about the best policy available for any amount of money. There is no credible way to spin this as actually being worse for those employees. I like to hire "expensive older" engineers, so dialing healthcare benefits up to eleven was intended to attract that kind of employee.

All insurance policies have implicit lifetime maximums, unless the laws of economics and finance have been repealed.

> What was the lifetime max on this plan? It probably would have left people out in the cold when they most needed it. I don't think it's wrong to expect insurance to cover people when they most need it, which was largely not true with million dollar lifetime caps.

Note that lifetime caps are a lot more generous than what they have in say the UK, where you don’t get treatment if it costs more than $50-75k per year of extended life. (So to blow through a million dollars, the treatment would have to be expected to produce 15-20 years of extra healthy life. Most treatments offered when people “need it the most” can’t make that sort of promise).

> Note that lifetime caps are a lot more generous than what they have in say the UK, where you don’t get treatment if it costs more than $50-75k per year of extended life

Do you have any data for that? Sounds odd.

https://www.bbc.co.uk/news/health-28983924. It’s not odd at all. It’s a basic thing that makes the UK’s health system work. US insurers (in the past) would piss away a half a million or a million on uncertain treatments. (And then the family would go out of pocket, go broke, and there would be an article on medical bankruptcies.) The UK doesn’t do that. Instead, it’s very aggressive about justifying costs with expected outcomes.

This happened with my employer as well. And this is/was before the "Cadillac tax" came into effect (I believe it's been pushed back to 2020 now).

This is exactly the point I was trying to make in my original comment. Really good healthcare plans (with minimal deductibles and great coverage) used to be a benefit that employers could reasonably provide. Employees/family members who got sick would get good coverage without going broke. Now the cost is of providing that kind of coverage is completely untenable.

I don’t see what the purpose of pointing out the fact of health insurance being cheaper when it doesn’t have to provide coverage for people who actually used healthcare. Goal is to provide all of society with healthcare, problem is voters didn’t want to pay with their tax dollars. Now they get to pay with their insurance premium dollars. There never was a free lunch, only people who were unable to get health insurance.

This happened to me. I had what is considered a "Cadillac plan" which my employer offered generously as a benefit. After ACA, the government began to tax that plan and our public company could not justify that while other companies in our market were offering much lower quality plans. Thus my medical spending rose by thousands of dollars per year (also thanks to an unfortunate @$3000 hospital stay but that would have cost me $250 on my old plan). The old plan did of course come with a lifetime max but obviously was not a factor at my age yet.

I think the ACA does good things for people who needed it. And generally I've been against repealing it, but only because there has not been an adequate replacement as part of the repeal, only "trust us, we'll do something great".

The increase in high-deductible health plans (HDHP) enrollment predates the ACA by many years. You can look at the trend here: https://www.cdc.gov/nchs/products/databriefs/db317.htm

Their role is to protect against very high bill of $5,000 and up due to major surgeries, illness, pregnancy, and so on. They should definitely be completed by a health savings account (HSA) for day-to-day coverage.

That's interesting data. Thanks for sharing it. In the 2017 snapshot, I'm surprised to see that HDHP plans are slightly more common for high-income families. I didn't expect that.

There's a missing variable here: What are the premiums? HDHPs are attractive to insurers (and by extension employers) because they increase employee sensitivity to healthcare costs and may lead to less wasteful spending. Advocates emphasized that the savings on premiums could be passed on employees as HSA contributions [1]. But as that chart shows, a quarter of Americans have an HDHP without an HSA, and at every point most HDHPs haven't come with an HSA. Are employers just keeping the premium savings? Or have rising healthcare costs meant that the savings haven't materialized?

[1]: https://www.wsj.com/articles/SB10001424052970204251404574342...

I imagine it's because it provides a way to sock away $7k each year in a retirement fund that can be invested in index funds and won't get taxed after 65 on qualified medical expenses making it more valuable than either traditional or Roth IRAs that get taxed on withdrawal and when you put the money in respectively. High-income families have the spare cash to do that, so for them it's a valuable investment vehicle.

My wife's employer covers our family under an HDHP. Our out of pocket cost is 0. Our plan requires us to have an HSA, though I don't thinkone is required to contribute to it. We contribute the max $ to our HSA each year.

A more traditional plan would run us about $4-5 thousand annually in payroll deductions. Most years we spend far less than our HSA contributions and can roll that money over year to year and even invest it. The one year she needed major surgery, we hit out OOP max and probably spent about $10,000 total from our HSA.

Probably our biggest risk exposure would be if one of us needed to take an expensive prescription since I don't think there is any annual limit on those costs.

High deductible plans started becoming popular due to the Medicare Modernization Act[1], not the ACA.

[1] https://en.wikipedia.org/wiki/Medicare_Prescription_Drug,_Im...

But it's been tough for people who were already covered by employer insurance.

Yes. The only word I disagree with in the headline is "start." The squeeze started years ago. One way to look at the problem is this way: http://seliger.com/2018/11/11/health-insurance-security-fqhc...:

In Northern Virginia, for example, the cheapest 2019 Obamacare individual market Silver plan for a family of four (mom and dad age-40) making a subsidy eligible $65,000 a year costs $4,514. That plan has a $6,500 deductible meaning the family would have to spend $11,014 on eligible health care costs before collecting other than nominal first dollar benefits.

I am not a fan of the word "unsustainable," but it seems to apply here.

That's not necessarily true, the discounts that insurance companies negotiate can be huge, but it's hard to include that since prices are so inflated to begin with.

At least that premium is totally reasonable. In Germany, the health insurance tax is 15%, half paid by the employer and half by the employer (and it’s not progressive like the ACA subsidy). $4,500 per year is 7% of income, lower than what the employer-side tax alone would be in Germany.

Now do the math when you include total out-of-pocket. My napkin says: "Considerably more than 15%". (Unless I misremember, and the 15% German tax doesn't cover the vast majority of cost.) Not to dismiss your point completely, but I could sell you insurance for $1/year, but your total out-of-pocket cost is going to be considerably more than $1.

The out-of-pocket max is something you’re likely to hit only if you get sick. The 15% is something you have to pay every year.

The ACA barely touched employer-based insurance. It definitely did not make things "modestly worse for most people". You are blaming the ACA for problems that existed in the health care system before the law went into effect. Any degradation of care for "most people" is because of crazy year-over-year cost increases that were already happening.

And the people who had pre-existing conditions before the ACA were well and truly screwed. That didn't mean insurance was expensive for them - it meant insurers wouldn't sell them insurance at any price.

My personal anecdote: Pre-ACA, I was denied insurance by Aetna at age 35 because I had "acid reflux" and I had injured my neck in my 20s (even though I had no problems with it at the time). Then all the other insurers denied me, because the first question on any application was, have you ever been denied for health insurance? The annoying thing was the ACA had already been passed, but had not gone into effect yet - so until that happened, I guess it was just business as usual for the insurers.

My family went bankrupt because the insurance companies decided my mother having a stroke and falling down the stairs constituted a pre-existing condition.

I don't think people understand how pervasive the usage of pre-existing condition bullshit was used to deny payment.

Oh yes. One of my "favorite" stories of this was:

"You didn't know you had X. It had never been diagnosed. But looking at your history, your treatment for 'unknown ailments' and such were actually symptoms of X, in other words you had X, though you didn't know it. And when you signed up for insurance, you 'failed to disclose' this condition [that you didn't know you had], therefore, we are voiding your coverage effective immediately [and should consider yourself lucky if we don't try to 'recover costs'...]".

You're right. Know why you're caveating this and tip toeing? Cuz ACA had a huge propaganda/rhetoric element to it. Even after it was an abysmal failure for most, politicians behind it kept pushing it like it was just a matter of time before it improved. It had a few good components but for the tradeoffs it wasn't worth it. (No Preexisting conditions should have always been a thing).

This is the world we live in. People have to apologize while expressing perfectly reasonable objections.

All of us with pre-existing conditions that couldn't buy insurance no matter the cost feel different of course, but you acknowledge that.

I'm interested in why you think ACA itself has made anything worse. Surely premiums have gotten worse, but it's not clear to me how it is nec linked to the ACA. (And it should be said that the insurance industry basically wrote large portions of the ACA, and arguably its weakest parts or because of that!)

ACA requires insurers to cover pre-existing conditions. That's a cost that needs to be recovered, and most of that additional coverage comes by increasing premiums. Ergo, ACA increases premiums.

That's excellent, and really contributed to your quality of life.

I on the other hand had "excellent" employer-provided healthcare. But when a routine kidney stone (my first) ended up having (pre-existing, not as a result of procedures) infection and I had three procedures for it, two in the OR, the bill ended up being the best part of $100,000, which I had to come up with co-pays and others to the tune of nearly $8,000.

For a kidney stone. Something that (touch wood) I might not have again, but could also have dozens through my life.

My sense is that your experience is becoming more and more common. As far as I can tell, co-pays, deductibles, etc have been going up dramatically over the last few years (as the original article points out.)

Not in the least. Just to name a few of the ways the ACA changed things in the right direction for most "normal" ESI:

- ACA threw out lifetime nor annual limits [0]

- Essential benefits ensuring you have a more comprehensive plan that covers actual health insurance [1]

- Ability to stay on a parent's insurance until you're 26 [2]

- For every $1.00 your insurance company takes in from premiums, $0.80 has to be spent on patient care [3]

- There's a max of a 3:1 ratio of age rating for health insurance premiums, irrespective of your health. It used to be that insurance companies would raise your premium or even cancel your policy if you got a costly disease like cancer [4].

The problem with your secular analysis is that there is not positive control for the "what if?" without these sort of policies. Most healthcare economists suspect it would have been even worse without the (somewhat modest) regulations that were imposed by the ACA. Again, this is high level policy analysis that requires dedicated study, and there's lots of evidence that the market has highly benefited consumers across most socioeconomic strata.

[0]. https://www.hhs.gov/healthcare/about-the-aca/benefit-limits/...

[1]. https://www.healthcare.gov/glossary/essential-health-benefit...

[2]. https://www.healthcare.gov/young-adults/children-under-26/

[3]. https://www.healthcare.gov/glossary/medical-loss-ratio-mlr/

[4]. http://us.milliman.com/uploadedFiles/insight/2017/MillimanAC...

I agree. The pre-ACA healthcare system worked well ( maybe not great but well ) for 80% of the population and not so well for 20% of the population. We paid less premium for far less co-pay, deductible, etc overall. Feels like the ACA made things worse for the 80% in order to make things better for the 20%.

COBRA is cheaper for me than ACA.

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