The Affordable Care Act: Who Was Helped Most

http://www.nytimes.com/interactive/2014/10/29/upshot/obamacare-who-was-helped-most.html?_r=0

by brandonb • 12 years ago

45 91 12 years ago

Seems like either a poor headline or the wrong metric.

I am insured now, but as someone who was rationally uninsured, I don't think I am better off. While I am only one person, the assumption that insurance necessarily makes someone better off seems a bit spurious.

Are there any metrics on whether the cost of insuring the same person has gone down? Wasn't that meant to be one of the benefits?

Edit: Did some digging and it looks like a more comprehensive review of the stats can be found here: www.nytimes.com/interactive/2014/10/27/us/is-the-affordable-care-act-working.html

As for my own question, it does look like the majority of the markets will see prices increases.

01Michael102• 12 years ago

Rationally uninsured? Care to explain your circumstances?

I don't think it was meant to reduce the cost of insuring someone but to reduce the rate of the increases. Remember how fast health insurance premiums were going up in the late Bush and early Obama years?

To answer the headline of the article I did not read... The health insurance companies?

BrianEatWorld2• 12 years ago

I have catastrophic insurance to cover unexpected circumstances and enough money in an account to handle normal, day-to-day healthcare. In setting up my finances in this way, I am able to cover myself and not have to fork over a premium every month. This has saved me thousands of dollars over the years, if I compare the current premium I am obligated to pay with my previous strategy of putting money into an account.

True insurance is a hedge against risk, I looked at my risks and made the rational decision that covering myself was the better decision.

Its not for everyone and so I don't want to generalize. I just offer it as anecdotal evidence that while increasing the percentage of the population that is insured, may be a nice easy metric to measure and affect, it is not necessarily an indication of improving situations for all Americans.

bluthru3• 12 years ago

but as someone who was rationally uninsured

It's not rational for anyone to be uninsured. Any healthy person could get in an accident.

sp3322• 12 years ago

And we should all play the lottery because we might win? If the expected value https://en.wikipedia.org/wiki/Expected_value is lower than the cost, then you rationally shouldn't buy it.

danielnaab• 12 years ago

As for my own question, it does look like the majority of the markets will see prices increases.

Health spending was growing at an average of 7.2% / year from 1990-2008, vs an estimated 3.6% in 2013. Certainly the slowdown is the result of more than just the ACA, but this is the relevant metric one should use when measuring its success at cost containment, not the fact that almost everything gets more expensive from one year to the next.

http://content.healthaffairs.org/content/early/2014/08/27/hl...

tptacek11• 12 years ago

Did you have $20,000 socked away to cover appendicitis? (If you've already had appendicitis, insert any of 100 other relatively common highly tractable medical emergencies you haven't had yet). If not: your policy of rationally forgoing insurance was being financed by everyone else in the market.

(The $20,000 figure comes from my friend, whose teenager had appendicitis a couple years back).

brightsize• 12 years ago

About five years ago my brother had appendicitis and, since he'd decided not to buy insurance (which he could have easily afforded), the $17K came out of his hide. So your $ number is about right. Fortunately he was wealthy enough to afford to pay up, but I have no idea what someone for whom $17K was a year's after-tax income would have done.

rdl4• 12 years ago

I mostly got burned by ACA -- I had $80-120/mo HSA+HDHP which was awesome, and then got forced into $280/mo inferior coverage (a "Bronze" plan) with fewer doctors. (I ended up canceling all coverage a month later, getting a $750k "insurance, temporary" plan for 364 days at $30-60/mo, and ended up having a job with employer care before that expired.)

Now I have employer-provided health care which is "free" but objectively the worst insurance I've ever had (in terms of number of doctors, etc.) HRA rather than HSA, so not very useful there, either.

I hate the idea of employer-provided healthcare. If I had "interesting" medical issues, I'd probably just pay for insurance out of pocket vs. sharing health data with an employer. I'm pretty sure my coverage costs employer more than $300/mo, too.

itbeho• 12 years ago

Similar experience for me. Had insurance I was happy with. Had the plan forcefully cancelled out from under me. Then found less benefits for more money. Now I can't see one of my doctors without paying cash [1]. Nothing affordable about this for me.

http://www.huffingtonpost.com/2014/04/10/obamacare-patients-...

tptacek11• 12 years ago

If you're young and relatively healthy and you're not paying out of pocket for at least most of your first year's worth of medical expenses, you're paying too much in insurance premiums. You want an HSA-qualifying high deductible plan, and you want to manage the pool of money that finances the deductible yourself, rather than signing it over to an insurer as a higher premium every month.

phkahler2• 12 years ago

> I hate the idea of employer-provided healthcare.

Yup. The most obvious problem is that when you change jobs, you change providers. That alone is undesirable and contributed to the problem of rejections due to pre-existing conditions.

The less talked about aspect is that large companies are self insured. Meaning they cover all the costs and just have an outside company manage the plan. The issue with self insured companies is that on average, working folks are healthier than non-working ones. That means it shifts the higher costs to the non-corporate plans - medicare/medicaid.

Just taking away the incentives for this and having people get their own plan would have gone some way toward a better system.

tptacek11• 12 years ago

All my reasonable Bronze options in Illinois as HSA/HDHP-qualifying, and they have the same doctor networks as the Silver or Vanadium or whatever plans.

rasz_pl2• 12 years ago

As an European

in terms of number of doctors

what does that even mean?

rdl4• 12 years ago

Out of the 2k doctors in SF (?), only 200 or so seem to take Cigna (my current insurer); 1500 would take Blue Cross/Blue Shield (previous).

If your doctor doesn't take your insurance, it's considered "out of network", and you end up paying ~50% of the cost, vs. 0-10%.

ethana• 12 years ago

Whenever a congressional law passes, just take the opposite view of the Act name and it shall be true. For example, there's nothing affordable about the ACA. My old healthcare plan was eliminated and replaced with a more expansive and less beneficial because of ACA regulations.

Then for people who are forced into ACA plans, they'll have their rates raised conveniently after the Nov 4 midterm elections...

hawkice• 12 years ago

So, I was going to make the point that this is only true for the controversial bills (a point worth making -- most laws are tremendously boring), but scrolling through the laws passed by this congress I found an example that makes your point perfectly:

Violence Against Women Reauthorization Act of 2013

It turns out this law doesn't authorize or reauthorize ANY violence against women. It seems to do the exact opposite of what it says -- it is primarily about _punishing_ violence against women.

That is all, continue being outraged. I'm sorry your insurance costs more, that does suck.

herge2• 12 years ago

more expansive and less beneficial

Really? Reporters and politicians have searched for these mysterious slighted people who have had their premiums go up for the exact same plan. You should call the O'Reilley factor, you could be a star!

A lot of people could not buy crippled insurance plans with insanely high deductibles and severe limits on coverage, because those were outlawed by the plan. Also, some people were bumped from subsidized plans to fend on the open market, but that's shitty employers taking advantage of their employees, and not the fault of the ACA.

Finally, with the heavy subsidies to your premiums, the same plan usually cost less under the ACA. You could however talk about the cost of insurance in 5 years when the subsidies start to wear off, but, hey, I imagine the republican leadership has plenty of ideas to help the common folk with that.

WarDekar• 12 years ago

I would imagine most/all young (under 35 - I'm 30, personally, and had same experience as GP), self-employed people making a decent amount of money (such that they don't get subsidies) have had this experience. The plans never match up fully, but I had a high deductible "catastrophic" plan pre-ACA and for the equivalent coverage I a.) had to apply for an exemption to even get the "catastrophic" plan through ACA and b.) it still cost significantly more for a higher deductible.

Now as you note I do get certain benefits with this plan I didn't get with my other one- namely a couple doctors visits a year when my other one was only one every 2- but I had a catastrophic plan for a reason and my premium more than doubled under the ACA. Beneficial to me (and likely the GP) is being able to pay only for coverage we actually want- not additional "benefits" that we don't plan on using and would rather pay out of pocket for.

anesmike• 12 years ago

My rates increased 40 percent for a HDHP+HSA bronze care plan with no preexisting. So, you can say I'm am one of the ones that really got screwed with ACA.

infinite8s3• 12 years ago

No you didn't. Just that your future risk was finally accurately priced into your premiums (whereas before you would likely have just been dropped if something drastic happened).

etrautmann• 12 years ago

I'm skeptical of the existing comments in this thread - they strike me as too on message to be four separate individuals with identical concerns.

defen2• 12 years ago

You think the person with 27,254 comment karma on a 2,304 day old account, with identifying info in his profile is posting anti-ACA comments as part of some conspiracy?

phkahler2• 12 years ago

I have not looked at this particular case, but if you have an agenda to push, it makes sense to take time to establish a solid looking reputation. Also, high "comment karma" means lots of activity. There have been times on HN when I noticed similar things and wondered...

forkandwait• 12 years ago

My wife and I want to start an astroturfing tracker website. Perhaps we have a few candidates? A ShowHN someday?

sunetos• 12 years ago

I agree with your observation, but in this case, it makes sense. As someone with a permanent preexisting condition, I am the only person I know that benefited from the ACA. Huge portions of my family and friends were impacted very negatively. Many of them had their rates go up 30-40% and ended up with worse insurance plans.

I am a bit bothered that the NYTimes chose to ignore a wealth of data for a major current societal problem, and just cherry-pick some category that ended up "better" to make a map and article.

bluthru3• 12 years ago

Compare this map to states that accepted or refused Medicaid expansion: http://i.huffpost.com/gen/1119617/thumbs/o-MEDICAID-EXPANSIO...

jordanpg3• 12 years ago

I don't know much about the politics or economics of the health insurance industry, but I'm pretty sure if you're posting on HN, you're not part of the group the law was enacted to help. It was never claimed that it would make healthcare cheaper or better for everyone. We have options.

Yes, I'm sure there are some true rags to riches stories around here; but we're talking about right now. I am grateful and lucky to have the background and skills to be able to take for granted that I can afford health insurance. Moreover, since it's not socialized, I'm happy to pay for it. I don't worry about finding bottom dollar on this particular thing.

logicalmind• 12 years ago

I don't really understand this comment. If you're posting on HN you probably care about startups. And generally, startups don't or can't provide health insurance to their early employees. Which leaves the startup game to the very young and very healthy. The ability for everyone else to have the opportunity to leave their existing job (aka healthcare source) and strike out on their own should surely increase due to this.

tptacek11• 12 years ago

Wow is this ever wrong. Guaranteed issue is an enormous win for entrepreneurs. When you work for your own tiny company, you obtain insurance on the individual private market. Prior to the ACA and its guaranteed issue rule, insurers routinely denied coverage to family members based on cryptic "DO NOT COVER" condition lists. Coverage denial didn't merely mean the insurer wouldn't cover a particular worrisome condition (which is bad enough) --- it was a blanket denial of any coverage at all.

Young male entrepreneurs didn't run into this problem because they were male, which conveniently dodges more than half of the "DO NOT COVER" list, and because they usually don't yet have families. But cross 30, get married, have a kid, time travel back to 2007 and try to insure your family. You'll see, like I did, how helpful the ACA is for startup founders.

humanrebar4• 12 years ago

And if you own or work for a startup, are under 27, and have middle-class-or-richer parents, you obviously benefit as well.

jordanpg3• 12 years ago

Fair enough. I was responding to commenters that I felt were being glibly dismissive of the ACA. I am a strong supporter of it for a number of reasons.

DennisP3• 12 years ago

Anyone who wants to work freelance or do a startup, rather than work for an employer, and who has any sort of preexisting condition, is definitely helped a lot.

People here are complaining that their insurance got pricier. The reason is that insurers aren't allowed to exclude sick people anymore. If you ever get chronically sick, you'll appreciate this change.

Someone12342• 12 years ago

It actually makes health insurance worth a damn now.

Before if you had minor medical stuff insurance was there. But as soon as you got legitimately sick (e.g. cancer) they quite literally went back through every form you ever filled out looking for an error, typo, or omission in order to cut you.

Worse still they actually designed forms to increase the chance of error for exactly this reason. Did you ever wonder why you have to sign it three different times on different pages? That is why.

Plus if you got laid off previously you were in deep trouble since your new employer's insurance company would reject you and you'd struggle to work while sick regardless.

Honestly Obamacare improved things decently. Only short-sighted greedy people are unhappy. Next challenge: Unlink health insurance completely from employment.

Health insurance from your employer is bad for everyone. It reduces consumer choice (e.g. you have the "choice" to either go with the company your employer picked or nothing), and it makes SMBs much less competitive than large corporation.

Startups in particular struggle to offer employees health insurance even if they can afford to offer a competitive income (as they pay disproportionately more for health insurance than a much larger company).

At least an argument can be made for why the "public option" (nationalised health care) is a bad idea, I've heard no good arguments for why unliking employment from health care is. Except "I get really good healthcare right now and I am too lazy to shop around for it."

The only organisation that should be allowed to offer their own health insurance/care is the US military, and that is more for practical reason.

jordanpg3• 12 years ago

Well put. Unfortunately, too many people can't get past "the government is taking my money".

It is a bizarre consequence of our modern politics that so many have become so enchanted with this mantra, as if there is "correct" portion of each dollar that should go to the government, and whatever is currently being taxed is too much, regardless of what needs to be or should be paid for.

hackbinary7• 12 years ago

Except the US spends $8,362 per person per year. The UK spends $3,480 per person per year. http://www.theguardian.com/news/datablog/2012/jun/30/healthc...

humanrebar4• 12 years ago

  Only short-sighted greedy people are unhappy.

The polling numbers disagree with you:

http://kff.org/interactive/health-tracking-poll-exploring-th...

incision2• 12 years ago

"Before if you had minor medical stuff insurance was there. But as soon as you got legitimately sick (e.g. cancer) they quite literally went back through every form you ever filled out looking for an error, typo, or omission in order to cut you."

This is pure truth in my experience [1].

Yes, all of it, but it's not just your forms - they'll scour phone calls too. Anything you've communicated can and will be used against you.

Problem is, it's the sort of thing that seems too unlikely or simply too far off until, out of blue, it hits you on the backside of a routine visit. More insidious is the way the scheme necessarily limits the number of people who survive to talk about it.

1: I spent years fighting this on behalf of a terminally-ill family member and I witnessed the lengths a company will go to in order to avoid making payouts first hand while working for an insurance company.

tracker1• 12 years ago

When you hit lifetime limits it's pretty harsh to... After 6 years, I'm finally under $10k owed to medical debt, and that's still quite a lot. I'd had to defer those collection companies that wouldn't negotiate, or wanted monthly payments that were disproportionately large, which are now all that is left. Though, my credit score now hovers around 600 as a result of the negative statements (all medical).

I think the biggest problem with Obamacare is the sheer number of exceptions for existing insurance plans... most of which still don't meet the minimum requirements for new plans. Also, I think that an NPO insurance organization is needed to provide a competitive baseline, which we also don't have.

I'm strongly against taxes for simply being alive... that said, there are definitely things that could/should have been done to make things more effective and less costly overall. Clearing import restrictions would go a long way... reducing the strength of derivative medical patents, and the terms of copyright on government funded research papers would as well.

tptacek11• 12 years ago

Or for that matter if you ever spontaneously change genders (statistically speaking), because getting health insurance prior to guaranteed issue was treacherous for women. We were routinely denied family coverage.

krupan2• 12 years ago

So post-menopausal women are now required to buy a more expensive plan that includes maternity coverage because, "insurers aren't allowed to exclude sick people anymore." Sure...that makes sense.

tptacek11• 12 years ago

The idea that a typical post-menopausal woman could easily obtain any kind of health insurance on the individual market prior to the ACA is laughable.

marknutter• 12 years ago

Didn't it really just increase the number of insured people primarily because of broad expansions of medicaid and medicare?

oldspiceman• 12 years ago

Have any states attempted to take control of medical care and negotiate doctor wages / drug prices? Works reasonably well for Canadian provinces. There's got to be a reason it hasn't been done in the states. What is it?

incision2• 12 years ago

If your rates went up, but your previous coverage was never actually put to the test in a serious way you might want to consider the very real possibility that the old plan never would have paid out [1].

"Since insurance companies now won’t be allowed to collect premiums while you’re healthy only to yank coverage when you get sick, they have no choice but to pre-emptively cancel plans that wouldn’t be financially beneficial to actually pay out."

1: http://www.slate.com/articles/business/moneybox/2013/11/obam...

alukima2• 12 years ago

Yep. My employer based insurance was cheap but they dropped me when I got cancer. They wouldn't have covered much anyway I later found out.

paul9290• 12 years ago

So as a freelancer I was paying $140 a month with a $500 deductible.

Now with Obamacare I am paying $260 for the same level of coverage.

How is that helpful to me? I'd love to hear some positive stories, because I'm just paying more and making less in my pocket, while people who don't work are getting health care for free.

tptacek11• 12 years ago

One way to think about it is that you're paying an extra $120/mo for protection against rescission.

Another way to think about it is that you're paying $120/mo for the guarantee that you'll be able to obtain coverage for your spouse and children in the future. That guarantee did not exist at any price prior to ACA.

I'm not sure how to respond to your last point, because people who don't work have always received health care for free. The backstop for health care financing has never been "no health care". The backstop is bankruptcy, which isn't an issue for the unemployed poor.

By extending health care to people who can't afford it, the ACA has probably lowered your costs over the long term. That's because the most expensive possible way to provide coverage is through emergency room visits, which is how the uninsured obtain coverage.

hackbinary7• 12 years ago

... the most expensive possible way to provide coverage is through emergency room visits, ...

By which time a generally very treatable condition has become acute, and then very expensive to treat no matter what.

humanrebar4• 12 years ago

  ...people who don't work are getting health care for free.

And some of them would love to work and pay for their own healthcare. But instead of focusing on economic development and employment, the government was debating the ACA. I don't think it's a coincidence that there is massive underemployment out there. The labor force participation rate hasn't been this low since women started leaving the home to work last century.

From the article:

  Critics of the Affordable Care Act have
  often warned that the program would be unfair
  to the young because it limits the ability of
  insurance companies to charge higher rates to
  older customers, who tend to be sicker. But
  young adults show the largest reductions in
  being uninsured of any age group.

...and the young have the highest unemployment rate.

alukima2• 12 years ago

About 5 years ago, at age 25, I found out I had a thyroid tumor for the second time in my life. My employer based coverage dropped me citing a surgery I received at 16.

Not only was I employed full time, I was restarting school. I lost everything. Tuition I paid, loan privileges, I had to sell everything, my credit sucks. Until the ACA went into affect I avoided doctors, even for big stuff because I was terrified of getting my family dropped.

I can go to the doctor and many people I know from cancer support groups can get insurance now, I'm not just talking about those who don't work, it was really hard to just get a company that would cover you when you've had cancer multiple times.

I know it sucks for some people but it's helping so many people who really needed the help.

tptacek11• 12 years ago

This is a story about rescission, which, thanks to the ACA, is now illegal across the entire US.

pyre• 12 years ago

How is that helpful to me? [...] while people who don't work are getting health care for free.

- Your phrasing of "people who don't work" implies to me that you feel disdain towards them, and that they could work, but are just lazy. (and now they can "freeload" health care too!) If this is not the case, then I would change the phrasing to something like "people that are unemployed."

- "What's in it for me?" isn't always the best measure of the value of something. For example, Bill Gates can afford to pay all his health costs out-of-pocket. Would you agree with him if he said that we should dismantle the entire health insurance industry because he doesn't need it?

- You haven't explained what level of coverage you think that the "non-working" people had before. Do you think that their level of coverage has improved or declined?

Now with Obamacare I am paying $260 for the same level of coverage. [...] How is that helpful to me?

Insurance companies now have to account for the risk that if you get sick in a chronic/expensive way that they can't find some technicality to drop you. Whether you see this as a benefit or not is probably correlated with your belief that those things "happen to other people."

dr_• 12 years ago

There's no guarantee, with your old plan, that they would have kept you had you gotten really sick with expensive medical bills. The Slate article above touches on some of this.

Some people are getting subsidized care but the only people getting it for free are those who are eligible to enroll in Medicaid. Not all states have agreed to increase their Medicaid rolls however. Plus, as a Medicaid patient, it is not that easy to find doctors, especially specialists, who are willing to see you. I had a Medicaid patient who had surgery for a wrist fracture a few weeks ago. The orthopedist who operated on her would only agree to see her in follow up in a separate clinic for 'caid patients, and that appointment would be in February. Fortunately we were able to encourage the surgeon to see them sooner. Im guessing that's not the kind of healthcare you want, even if it's free.

hackbinary7• 12 years ago

Young, healthy people will get screwed by any mandatory government healthcare system, but my view in general is that having strong government oversight of healthcare is just a good thing. With reference to this Guardian article, the US spends $8,362 (Private individuals, Government, and insurance combined) per person. Contrast that to the UK which spends $3480 per person. While I hate paying taxes just as much as the next person, I do think I get very good value for money for my National Health Service.

Universal healthcare is just a good thing.

http://www.theguardian.com/news/datablog/2012/jun/30/healthc...

deciplex2• 12 years ago

Please define "screwed". Paying more than you take out does not count, provided older people are paying less than they take out (I hope I don't need to remind you that young people eventually turn into old people).

I mean, it sounds like you're just pointing out that, if health insurance/coverage is mandatory, then you are getting 'screwed' if you don't use the healthcare system. That's like saying I'm getting 'screwed' by public transportation if I own a car.

hackbinary7• 12 years ago

Yes, exactly. Similarly old people get screwed by the public Education system. And publicly funded universities and colleges.

dmishe• 12 years ago

you're young and healthy until your first visit to ER without insurance

infinite8s3• 12 years ago

Eventually young and healthy people turn into old people. Also, you should qualify that with the gender. You maybe be a young and healthy female but you would have been hardpressed to get independent coverage once you hit 'motherhood' age.

schnable• 12 years ago

As the map clearly shows, the people who were helped most are all the new people who joined Medicaid when it was expanded.

sarciszewski• 12 years ago

I can tell you who it hasn't helped: Me.

Why? I couldn't afford insurance before, and I sure as heck can't now.

For the sake of fairness, it also hasn't hurt me any either.

So basically, before the ACA if I got sick, I was doomed. And now if I get sick, I'm equally doomed. But in the long run, things will supposedly get better. Here's hoping for the best.

trebuchette2• 12 years ago

I'll be the dick. On paper, it's helped me, yes (girl problems that would have run $16K by June just mainly for tests): I met an OOP early (yay! Didn't even know what OOP=out-of-pocket WAS!), so after that I didn't have to pay anything until next year! (Who's heard of such a thing?!)

But the hospitals/docs didn't file right, or didn't get preauths? Basically, providers aren't getting paid; and while AHCA says "ignore bills you've met your OOP!", I'm seeing bills from people I've never seen before because while a doc was "in coverage area", their test readers weren't, and I've actually been served a DEBT WARRANT (by the police!) now. So basically, I'm paying what AHCA said NOT to pay because I don't want to be sued (hire lawyer, get tripped up in legalese, ...it's just cheaper to PAYOLA); plus, I figure radiologists or labs did their job and should get paid (plus their phone calls are scary). I find the entire thing ridiculous, but the debt warrant is scary. NGL.

lawnchair_larry• 12 years ago

What is a debt warrant? Isn't this a civil matter?

trebuchette2• 12 years ago

I have no idea; IANAL. All I know is a "local" (not really) doc says I owe him money for some tests he ran on a sample, and nobody will pay him. I pay my bills, but I didn't take the sample, wouldn't have known who to send it to even if I had taken the sample, etc. I spent months faxing copies of bills to the doc who took the sample AND to my insurance, then finally the "claimant" had this debt warrant hand-delivered by the po-po to my home! I'm supposed to show up in court (albeit no time soon). I faxed copies to doc and insurance, and (though I wasn't going to, but I chickened out) I gave it to my lawyer.

The Affordable Care Act: Who Was Helped Most

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