I wonder, how is "obamacare" viewed after those years? Was it a success? Ist there partisan disagreement and a realistic chance that it might get repealed?
Win column: ending “preexisting condition” horror, and prices supposedly have not gone up as much as they were expected to otherwise. Marketplace plans are relatively easy to compare, which is welcome.
Loss column: Insurance rate increases still bonkers and unsustainable (IOW at some point, it’ll get high enough to force some kind of big shift or reform, with a lot of suffering and economic damage along the way). No public option. Not all plans are on the exchange (this varies state by state). Even “gold” plans are kinda shit and insurance still tends to cover less each year, even as prices increase. Fewer insurers offering individual plans at all, at least in some states. Healthcare spending in general still stupid-high and getting higher. Whole thing’s still very complicated, adding costs all over the economy and putting a significant time-burden on sick people and families of sick people, all for no reason whatsoever except protecting a bunch (a whole bunch) of middlemen’s jobs.
> Loss column: Insurance rate increases still bonkers and unsustainable. [...] Healthcare spending in general still stupid-high and getting higher.
Worse, nobody seems to have any idea how to fix that.
For the problem of high costs we can at least take a look at what other first world countries do for some idea. Most are spending well under 1/2 of what we spend.
For the problem of increasing costs though we can't look at others because they too have increasing costs comparable to the rate of increase of US costs.
For example, in 1980 the per capita health costs in the UK, France, and the US were (in USD) 385, 659, and 1036.
And here is what the costs were in those countries in 1990, 2000, 2010, and 2018, divided by that country's 1980 costs:
Year UK FR US
1990 2.0 2.2 2.6
2000 4.1 4.1 4.4
2010 7.5 6.1 7.7
2018 10.6 7.5 10.2
Here are a few countries and the ratio of their 2018 to 2000 costs:
2.1 Germany
1.8 France
2.0 Canada
1.7 Italy
2.6 Japan
2.6 UK
2.3 US
I used 2018 instead of 2020 because I did this calculation a few years ago, and 2018 was the latest data at the time. My source now has data through 2022.
If anyone wants to do this for other years, or for other countries, here's how to get the data:
2. Uncheck "latest data available". This enables the year range selector control.
3. Use the year range selector to expand the range to cover the years you are interested in. They have 1970-2022.
4. The chart will then show the total costs in US dollars/capita by year of health care in 50 countries. You can use the "Highlighted Countries" drop down to narrow that to select a "background" of OECD, EU, Euro Area, G7, or G20 if you want. You can then add individual countries using the list on the left of that dialog.
5. You can change what is shown from total to government/compulsory, voluntary, or out-of-pocket and you can change the measure from per capita to % of GDP.
This maps with my experience. I have one child with pre-ACA and one child with post-ACA non-marketplace plans. The post-ACA is expensive and not good, the pre-ACA is okay, but essentially neck and neck with the post-ACA on price.
The pre-existing condition coverage part is really important for us.
The problem with all health insurance is the opacity of actual costs. 80/20, deductible, out-of-pocket, these things are not trivial and they wander all over the place. Add to that the seemingly random prices charged by healthcare providers, which are even less understandable as "adjustments" are made.
Nobody has any idea what anything costs. Healthcare providers throw out a number, see how much they get back, and call that the price. It's absolutely insane. The only way you can get this level of brokenness is to combine government, big corporations, and a powerful middleman lobby and let them figure out how to run things.
The ACA increased costs far beyond what they otherwise would have been. It made the cost of good health insurance go up 25% overnight where I lived. The discontinuity in price increases before and after ACA were pretty stark, and not in a good way.
There are some charts of health insurance costs over time [1] here. These charts look the same pre-ACA and post-ACA. Costs continued to rise at about the same rate has they had before.
IMO, the #1 failure of Obamacare exchange markets is that employer-sponsored group plans remained legal under the ACA. Everyone should have been forced into the same free market.
I had a conversation with my neighbor, a staunch Republican, about eye exams after she had taken both of her kids to get checked and was dismayed over the cost of the exams. She seemed surprised when I mentioned that nearly all insurance plans are required to cover vision tests for children due to provisions in the ACA.
She didn't know what the ACA was, which kind of surprised me, but she definitely knew what "ObamaCare" was and changed the subject after realizing that she had wasted money on screenings because she assumed that she had no vision coverage.
It astounded me how many people hated "ObamaCare" but had positive views of the Affordable Care Act. Even today I think that it would be political suicide to repeal the ACA.
The GOP does many things that would be political suicide, but the Democrats never make them pay a price, never even try. How are the Dems using the Speaker of the House debacle? They should be all over the place talking about GOP incompetence, and here's what you'll get if you elect them.
I hate it just as much. "If you like your insurance you can keep it is true" - but I didn't like my insurance and I'm still forced to keep it. I've long said the big mistake is tying health insurance to employment is the problem (it isn't the only problem, but it is a big one). If I take anything else I turn away more than $1000 in subsidies that my employee currently it putting in, and that means as much as I don't like my insurance I cannot use anything else. Of course since the customer of health insurance isn't me but my employer that means they are not responsive to me and my needs.
I'm against socialize health insurance, but what we have today is just as bad though in different ways.
I've long said the big mistake is tying health insurance to employment is the problem (it isn't the only problem, but it is a big one)
Yes. This is one of those frustrating areas where economists and experts across the political spectrum are in near-unanimous agreement, but anybody who tries to move the system in a sane direction gets attacked for "taking away your insurance". The ACA doubled down on employer mandates, when it should have used the exchanges as an opportunity to get people off employer-based plans.
I'm against socialize health insurance, but what we have today is just as bad
As I've often said, we've managed to combine the worst aspects of both markets and central planning with the benefits of neither.
The ACA included a public option to remove that tie to employers, but it was removed due to the opposition of Joe Liberman and his insurance company backers.
$1000 would be on the low side. Employers on average are now subsidizing family coverage by about $17000 per year. Annual increases continue to exceed the rate of inflation. This is obviously unsustainable.
No you can't. Well if you work for a small company, or don't have a job you can. However anyone working for a company with any size has to come up with the $1000+ per month their employer throws into the company insurance plan that they don't get by going with ACA. So sure you can, but it is so move few can afford so we may as well say you cannot.
Unless the employer offers you the $1000+ per month to opt out and get your own insurance, which quite a few do. Or, as more companies have been doing, just subsidizing your choice of plan through the marketplace so they don't have to think about it.
Car and home insurance both have a socialized component. Check your policy for an “uninsured driver charge”. Similar concepts exist for home insurance. And we all pay for flood insurance as it’s heavily subsidized by tax dollars.
Uninsured driver protection is not socialized, everyone is just forced to pay for it, the state doesn’t pay it. And this requirement as well as minimum coverages will vary by state, for example, Florida doesn’t mandate it.
And honestly the fact about flood insurance even if it’s true is only an implementation detail.
The point stands: you can have strong insurance markets with multiple private options in a well regulated environment without being tied to your employer or just a public option.
> Uninsured driver protection is not socialized, everyone is just forced to pay for it, the state doesn’t pay it.
Being forced to pay for something to share the cost across a set of people is the definition of socialized. The implementation detail is that it’s shared by all purchasers of insurance as opposed to the population as a whole.
> The point stands: you can have strong insurance markets with multiple private options in a well regulated environment without being tied to your employer or just a public option.
There is no such market for flood insurance.
I don’t think it’s possible to fix the US medical insurance system without banning corporate health plans. It’s the only way to unify the risk pools. Not just removing the tax incentive for corporate plans, I mean banning the concept so that the pools are unified.
> Being forced to pay for something to share the cost across a set of people is the definition of socialized.
For some definition of socialized. I would argue that a transaction between two private entities in which there might be a minimum ceiling for some items is not “socialized”. Even if the minimum ceiling is enforced by the state.
We can argue all day about definitions but at the end of the day nothing is black and white: even if we agree that there’s some “socialized” extent in the private car/home insurance markets I think most would still not say that it is “socialized” in general.
Regarding flood insurance, yes, agreed, there’s no natural law that says that flood insurance must be a profitable business (hello global warming!) so the government steps in.
Well, the other option is to make it possible to affordably purchase insurance directly from carriers without your employer being involved at all. I've always been skeptical that having your employer negotiate for you in these cases is actually more beneficial than a true free market.
Personally, I'd rather we figure out how to have at least some real baseline of public healthcare, but what we have today feels like the worst of both options.
I had insurance purchased through the exchange for a few years after.
It was just for me, a healthy(ish) man in my 20s. The year was $200 a month. The next year was $300 a month. The next year was $450 a month.
It had some good in it, such as not denying people based on pre-existing conditions (along with the limited period you can get insurance). Capping how much insurance companies can make as a percentage of revenue was a real poison pill that only served to make costs balloon. They have no reason to be more efficient, or to try to clamp down on healthcare costs. The more we all pay, the more they make, and it's their only path to do so apart from taking marketshare from a competitor.
I think we'll probably end up with single-payer sometime, which will be a real mess and a huge amount of money will be wasted for decades. We could fix the insurance system, but it'd be politically unpopular:
Everyone's insurance is insurance again. By that, I mean it doesn't cover routine care (apart from a yearly physical, just to encourage that), medications, etc. It's all very high deductible, possibly with some sort of low income subsidy (that still shouldn't go too far).
Providers need to publicly list prices, or give good faith estimates for things that aren't routine.
Cap medication prices to an average of...Canada, UK, Germany, and Japan - or some other list. This wouldn't be needed for cheaper drugs but for the ridiculously expensive ones that'd normally eat up your high deductible in a month.
Bam. Done. There'd be a few years of pain, but you'd quickly see healthcare prices drop off a cliff as consumers would suddenly care that their clinic's sleep study costs $7,000 when the place an hour away only charges $1,500, or that they can do testosterone injections for $20 a month instead of taking a pill that costs $500 a month.
Or just copy the Swiss system (which is entirely privatized, more so than in the US) if you want to maintain a high degree of direct government involvement in healthcare which exists know you could also copy one of the functioning mixed public/private systems (like the one in the Netherlands). Why try and reinvent the wheel?
Just need price controls (at least limited ones, and the credible threat of more) plus a good public fall-back option, and strong standards for what health insurance has to cover. That seems to be the minimum (Singapore model). Those elements seem to be the common factors in basically all OECD healthcare systems outside the US. Taking it farther can work, and may even help, but those seem to be the things you have to have (though price controls can also be implicit, via monopsony). “Credible threat of more” for the price controls may not work in places less authoritarian than Singapore, so you may have to swing closer to the price-book model of places like Japan, if not just go single-payer.
Yup. The CBO have in the past even estimated a generic public option as being revenue positive due to replacing ACA subsidies for private insurance plans.
Single-payer is unlikely in the US for many reasons, if you're interested in the topic though the CBO did a thorough look at all of the different things that would be required for such a system:
The amount of pushback we'd see from doctors, nurses, pharmacists and the like if they got paid like they get paid in the rest of the world would be immense.
The Netherlands has a system very similar to the ACA and the Swiss system mandates insurers offer a not-for-profit plan with minimum requirements, as well as offering generous subsidies to those with lower incomes. Both have cost controls though, which the US lacks.
The argument for having insurers cover routine care is that prevention is cheaper. Ideally insurance companies would gladly pay for that since it would save them money in the long run.
The problem is that companies are penalized for long-term thinking. Why pay today when in the future it may be someone else's problem. That creates a sort of tragedy of commons among insurers. No one is insurer wants to pay today, but everyone would be better off if all insurers paid. That's a known market failure so some government intervention is necessary to improve market efficiency.
Unfortunately healthcare ticks a lot of other "market failure" boxes in its mode of operation. So it needs to either be heavily regulated or socialized to prevent market failures driving prices up and efficiency down. Don't believe me? Ask any economist that studies market failures.
Re the annual increases; in the startup world (both pre and post Aca), I saw the small company switch brokers (and available plans) each year for the teaser rates in 2011, 2012, 2013 to avoid nearly 100% increases yoy.
Still in startups, from 2016-2022, my company switched brokers with the exception of 2 years to get teaser rates. We're looking at a new broker this year to avoid a 9% increase.
This is a typical result in public-opinion poli sci research, at least in the US. The descriptions of what programs do are almost always more popular than programs by name, often by a wide margin.
This is how you get weird shit like Trump making vague promises at rallies that sure sound like a call for some kind of stronger ACA or even single-payer healthcare. Many aspects of those things are broadly popular—the propagandized-against labels for them, however, are unpopular in some circles, especially if promoted by a person with the wrong letter next to their name.
Romney got on board with the push for increasing healthcare coverage in MA and helped get the Medicare waiver required for MassHealth, but he didn't propose the system and vetoed significant parts of it, most of which was overridden by the state legislature. "Romneycare" was the name his GOP opponents gave it when he was running to be the Presidential nominee in 2012.
Poor? It is awesome, your healthcare might be ~$40/mo
Work for a huge company? you're indifferent to it.
Self-employed? It is terrible, your rates skyrocketed. Trash bronze plans can cost you >$500/mo and barely cover anything. Good plans will be closer to $1000.
Except for the first category, I believe it was the same thing before the obamacare. I paid $380/mo as self-employed plan, but it was like 10 years ago. And employers paid even more for their employees.
> I wonder, how is "obamacare" viewed after those years?
From 2020:
> As the Affordable Care Act, or Obamacare, turns 10 years old on Monday, the health care law is as popular as it has ever been, according to new numbers from the latest NBC News/Wall Street Journal national poll.[1]
> Forty-two percent of all registered voters believe the law is a good idea, compared to 35 percent who think it's a bad idea, while 23 percent don't have an opinion.
> Eighty percent of Democratic primary voters, as well as 72 percent of all registered voters who describe themselves as Democrats, say the Affordable Care Act is a good idea.
> That's compared to 72 percent of Republican voters in the poll who say it's a bad idea.
* Ibid.
2022:
> Public opinion of the Affordable Care Act (ACA) has been largely divided along partisan lines since the law was passed in 2010. Following Republican efforts to repeal the ACA in the summer of 2017, KFF Health Tracking Polls found a slight uptick in overall favorability towards the law, and since then a somewhat larger share has held a favorable than an unfavorable view. The most recent KFF Tracking Poll conducted in March 2022 found slightly more than half of the public (55%) hold a favorable opinion of the ACA while about four in ten (42%) hold a negative opinion of the law. Views of the ACA are still largely driven by partisanship: nearly nine in ten Democrats (87%) along with six in ten independents (58%) view the law favorably, while eight in ten Republicans (79%) hold unfavorable views. Explore more demographic breakdowns using our ACA interactive.
It succeeded in getting more people covered by health insurance. It did so by enriching the private insurers who basically run our health care system. Personally I don’t see that as a success, rather it simply made all our health care system problems worse. Access to insurance just isn’t the same as access to health care, because the insurance costs money, and insurers tend to be roadblocks to care. People who tend to need the most care were either already covered (Medicare/Medicaid) or the subsidies under ACA were paltry jokes compared to their needs.
There isn’t a realistic chance of repeal. Both of the main political parties here benefit from it too much: the democrats by claiming a health care win, which our latte liberal class eats up, and the republicans by having an additional hot button issue (like abortion and guns) to whip their lunatic fringe up with. Not to mention all the campaign and lobbying money from private insurers who are profiting immensely off of ACA.
Private insurers don't run our health care system; provider networks do. When you include fee/service ratios for younger cohorts in the Medicare math, the administrative overhead numbers look a lot less compelling; more importantly, you can zero out administrative overhead from insurers and still only get a grocery store discount on services. The immediate problem with American health care is that providers charge too much for services, and secondarily that Americans access too many services.
It's also important to remember --- though I don't think it changes any of the fundamentals of the issue --- that the ordinary "retail" care that we access on a year by year basis, including short hospital stays, isn't where all the cost in the system is.
However insurance companies have absolutely no incentives for pressuring the providers to reduce prices, the opposite in fact because they get to keep a share of the revenue..
Medicare also pays unacceptably high rates for services; the idea that Medicare would successfully and meaningfully reduce those rates is more aspirational than empirical. One of the most important bottlenecks in health care affordability (residency funding) is explicitly maintained by Medicare.
There are tons of middlemen / services directly in between the consumer and the medicine or doctor the consumer ultimately needs (including insurance). Almost all of those middlemen are trying to maximize their own profits. The industry is complex and our entire society and economic culture is to blame, you really can't single out a single entity
My belief is it was oversold in terms of its transformative impact, both by the advocates and detractors. The major change is no longer refusing insurance for pre-existing conditions, and the various lives that have changed due to having health insurance when in the counterfactual they would not have had it.
But there's a reason why all democrats are still running for federal office on a platform of healthcare reform. It won't be repealed after the supreme court upheld it and the republican congress under Trump gave up on trying to repeal it after McCain's no vote on repeal.
There is no realistic chance it will get repealed if the democrats control either branch of congress or the presidency. I think it was a success. It might not be as good for people who were getting excellent healthcare through work, but tens of millions of people have insurance who didn't before.
This is my understanding, as someone married to a healthcare professional and with sick parents I've followed it reasonably well.
Before the ACA went into effect, the main focus that everyone talked about was on the individual insurance market: in particular, trying to fix the adverse selection issues that had kept the individual insurance market in a continuous death spiral. ACA tried to fix that with the "Three Legged Stool": guaranteed issuance (no longer could a pre-existing health issue be denied coverage), government subsidies for people who couldn't afford it, and the individual mandate (everyone has to buy insurance or pay a fee) to make sure people didn't free-ride while healthy and only get insurance when they were sick. There was also a side project, which was this was that subsidies for really poor people turned out to be really expensive, so perhaps it would be easier to have everyone below a certain threshold just get Medicaid (government insurance for poor people that for complicated historical reasons is largely federal but partly each individual state funded- this is distinct from Medicare, which is entirely Federal and offers universal coverage to everyone over 65). So everyone can use the exchanges to get insurance, if they don't get insurance they have to pay a fee in their taxes at the end of the year, and Medicaid had expanded eligibility rules to cover more people. Health care wonks largely expected the exchanges to do most of the work, and some of them even envisioned a future where the link between jobs and health care were broken- your job pays you more money and you get insurance on your own through the exchange. But that was a future dream, for the ACA itself the focus was on just getting the exchanges to run. That is what healthcare.gov was all about, matching you to your local exchange and offering you the right plans and subsidy amounts- tying together insurance companies, the IRS for your tax returns, and state IT systems all together.
Then the conservative-controlled Supreme Court surprised many, and upheld the ACA exchanges on a 5-4 vote, though they added a random restriction never found before in any Supreme Court ruling that each state would have to accept the Medicaid changes on their own- a rewriting done by the Chief Justice's clerks in haste (after he apparently changed his vote late in the game to allow the rest of the law to stay, the liberal wing joined him immediately, no matter how weird it was, much better than losing the whole thing).
Now a decade on, the exchanges have proven to not be very popular- everyone who can still gets their insurance through their company because it is seen as a better deal than going through the exchange (because of corporate consolidation on both the insurance company and medical provider sides there is actually very little competition in the exchanges, so the prices didn't go down as expected). Far more people are covered by insurance than before, but it was almost entirely because of the Medicaid expansion- slowly over time even red states have gotten into it, and now only 10 states are still holding out, even as their rural hospitals are utterly devastated and many are forced to close because they can't get paid for their work (in order to balance the budget within the act, some of the US government programs that used to support poor people without insurance were ended- they'll all have Medicaid, so are unnecessary- except then the Supreme Court's rewriting meant that many poor people don't have Medicaid, and the GOP views even attempts to fix things for their own states as a step too far). The individual mandate- which had been viewed as essential to the success of the exchanges- was zeroed out by the Republicans when they took power, that is, the fee for not having insurance was set to 0. And it didn't really have much noticeable effect, because the exchanges didn't make much difference in the end, the power turned out to all be in the Medicaid expansion.
This in turn is what has driven the more liberal health care wonks towards single-payer and BernieCare and the like: if the exchanges didn't have much impact and Medicaid did, why not just make Medicaid-for-all?
> Now a decade on, the exchanges have proven to not be very popular- everyone who can still gets their insurance through their company because it is seen as a better deal than going through the exchange
This is a rather strange interpretation, because the marketplace was never intended to compete with or replace employer provided insurance. In fact, the ACA has an employer health insurance mandate for companies with at least 50 employees. The marketplace is primarily for people who aren't otherwise covered by employer health insurance or Medicaid, such as the self-employed, and I suspect that the marketplace is used by most of those people, especially because of the income-based subsidies.
Like I said, a lot of health care policy wonks in 2010 were definitely expecting the exchanges to be where the action was, and were talking about future changes that would allow employer subsidies onto the exchange or for higher wages in exchange for breaking the link totally (health care wonks have long hated the link between employment and health insurance- it's a weird legacy of WW2 that doesn't make sense). This is why Congress and their legislative staffers are the only people who do have employer subsidies on the exchange- the GOP offered a poison pill to force Congress to only be offered insurance through the DC exchange, but the Dems gladly accepted the pill because they thought it would mark the way to the future. This did require a lot of extra rule-making and pipe-fitting such that the (quite poorly paid) staffers didn't get screwed too badly on the deal, which took an extra year, but since 2015 Congress has only been offered health insurance through the DC Exchange, the same as anyone else who lives in DC. Because the GOP thought it would embarrass the Dem's and the Dems thought it would instead mark the way that everyone would go.
> a lot of health care policy wonks in 2010 were definitely expecting the exchanges to be where the action was, and were talking about future changes
Ok, but... how are the dreams of "policy wonks" relevant? What we got is what Congress passed, and what Congress passed preserved and enshrined the role of employers in providing health insurance. Thus, the fact that people who have employer-provided health insurance are not on the exchanges doesn't seem interesting, given the actual laws in place (as opposed to some imagined future alternative).
And I think you're underestimating the number of people who don't have employer-provided health care and who do use the exchanges, especially with the so-called "gig economy".
> This is why Congress and their legislative staffers are the only people who do have employer subsidies on the exchange
Congress granting itself an exception is just par for the course.
I have been a contractor for more than 30 years - well before Obamacare existed - and I always had insurance, why was it not possible for you before Obamacare?
