6 Big Unanswered Questions About Obamacare
Whitehouse.govObamacare supporters are taking
a bit of a victory lap today after yesterday’s administration
announcement that six million people have signed up for private
plans under the law, equaling the revised projection put out by the
Congressional Budget Office after the botched launch of the
exchanges last October.
It’s a weak cause for celebration, given that success, according to Health and Human Services Secretary Kathleen Sebelius, was originally "at least" seven million people getting covered under the law by the end of March. And as an Obamacare factoid, the six million sign-ups figure just doesn’t tell us all that much about whether and how the law is working. There are still a lot of major unanswered questions about the law and its future.
1. How many people have actually enrolled? This is the big one. I’ve written about it a lot for a reason: The headline sign-up numbers are often described as enrollment numbers. They’re not. A significant portion of people who sign up for coverage aren’t paying their first month’s premium, and are therefore never enrolled. In California, it’s about 15 percent of sign-ups. In Wisconsin and Georgia, it’s closer to 20 percent. In Nevada and Vermont, it’s more than 30 percent. Until we know how many people have paid, we won’t know how many people got covered.
2. What percentage of those who are enrolled are between the ages of 18 and 34? After the launch of the exchanges last October, the White House repeatedly emphasized that they were less focused on the total number of enrollments and more concerned with the demographic mix—specifically, the number of young adults signing up. Young adults tend to be less expensive to insure, so their premiums are needed to balance out the costs of the older, more expensive enrollees. Early on the administration had been clear that it was aiming for 40 percent of enrollees to be in the youngest cohort. But so far, the administration’s reports have indicated that only about 25 percent of sign-ups are young adults.
3. Are the young people who are enrolling actually healthy? This one will be hard to answer, but it’s important. In the population as a whole, young adults tend to be healthier, and therefore less inclined to use lots of health care services, than their elders. But the characteristics of the 6 million or so folks who end up in the exchange population may not mirror the population as a whole. It’s entirely possible that the young adults who do end up signing up will be sicker, on average, than their peers. If so, that will complicate premium pricing down the road.
4. What are the sign-up totals, demographic breakdowns, and overall health of the individual state markets? The headline national numbers only tell part of the story. By the middle of this month, 13 states had exceeded initial enrollment projections, according to a count by Philip Klein of The Washington Examiner. But another 12 states were at less than half their projected sign-ups, and 24 were at less than two-thirds of sign-up expectations. What this means is that Obamacare is going to look very different depending on what state you live in. Some states will meet or beat enrollment expectations and presumably end up with viable insurance markets in the process. But others will have low enrollment totals and bad demographic mixes, and are likely to face higher premiums and fewer plan choices as a result.
5. How many of the people enrolled under the law were previously uninsured? And how many of them were previously among the long-term uninsured? Even once we find out how many of the people who have signed up for coverage have actually enrolled, we still won’t know the answer to another big question: How many of the enrollees were previously uninsured? Surveys and word from insurance industry insiders suggest that anywhere from a quarter to half of enrollments were previously uninsured—meaning it’s possible that the majority of enrollments are for people who were already covered before the law’s insurance expansion took effect. Moreover, when trying to figure this out, it’s worth thinking about who counts as previously uninsured: Many counts of the nation’s uninsured population count people who went without insurance for a few months, often while transitioning between jobs. But it’s the long-term uninsured—those who have gone years without coverage—we should be focusing on.
6. What will premiums look like next year? This matters both for the politics of the law and for its success as a policy mechanism. President Obama initially sold the health care overhaul as a way to reduce premiums, but recently the administration has trimmed back its promises, saying instead that premiums will still rise, just not as fast as prior to the law. But there are early rumbles from insurers suggesting that, when they set rates for next year, premiums could jump dramatically, with some warning that rates could double, or more. Because of the state-by-state nature of Obamacare’s insurance markets, those effects won’t be felt evenly. But if big hikes do appear in many markets, then you have to wonder: How many people will want to stay with their current plans? And what will this do to the already weak political support for the law?
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After it was obvious fiasco was on the horizon, the goal has been to come up with some number - any number - that will put some kind of shine on this turd. Six million whatevers is close enough for government work.
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Just move the goal posts enough and you will hit the kick eventually.
They were saying seven million was the minimum before this started. And they were assuming that no one who had insurance was going to lose it. Yet now, "six million looks like success".
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THE LAW ID SETTLED! TREASON!!! NO DELAYS!
*looks at reports of various unilateral O! waivers/exemptions/delays*
MINOR TECHNICAL ADJUSTMENTS MAY BE NECESSARY BECAUSE OF LIBERTARIAN/GOP/TEATHULGICAN OBSTINANCE!
/prog
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Ask the next 10 proggies you run across about all this shit. I would be willing to bet that 9 of them deny that these issues even exist. The tenth will blame Boosh.
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Gee, there is probably a middle ground between "tremendous success" and "disastrous failure" that will upset both TEAMS.
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We don't know what it is, because we're still in "Disastrous failure" grounds here.
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Gee, there is probably a middle ground between "tremendous success" and "disastrous failure" that will upset both TEAMS.
How will this impact your Obama Fellating Program Putins Buttplug?
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Young adults tend to be less expensive to insure, so their mandated excessive yet subsidized premiums are needed to balance out the costs of the older, more expensive enrollees.
I know you leave this out because it complicates the point. But it is the point. Without the young healthy sheep coming to the shearing, there will not be enough wool to cover the more expensive enrollees.
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I've Changed my mind, again.
I think we should consider a two system
A. A cash system in which doctors accept payments from the patient
and the patient only. No private health insurance or company
sponsored heath insurance.B. Medicare for all in which all 300,000,000 people are in one
pool and the risk is spread out. Effectively, a single
non-profit insurance company that must be either operated
by the Government (like today) or a Public Corporation with
Monopoly rights. The point is to have everyone in one pool.My eyes are squinting and I'm ready for the Tomatoes.
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The ONLY thing I like about ACA is the pre-existing condition thing. That's pretty much it.
I'd say get rid of the law and pay for people rejected by insurance companies and have Zero Income tax for insurance companies that do not reject or dump people for now.
But later on, single payer baby!
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The ONLY thing I like about ACA is the pre-existing condition thing
That's called Welfare Alice, not Insurance. If you want to provide Welfare for every living soul within the US borders, then make an argument for it. Might as well go for the whole globe while you're at though, cause it would be bigoted to leave all the poor yellow, brown, red, and black people living in poverty around the world out of your fantasy.
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Not exactly Welfare as with that you tax all and give benefits to a few.
Here, you collect medicare payroll taxes and capital gains taxes and everyone is universally covered. While, at the same time, leaving the cash options for those doctors that don't want to deal with government insurance and are confident that their patients will be able to pay them.
I'll even offer tax credit for going to the cash doctors if one chooses to never go to a Medicare DOctor.
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It may not be welfare but it certainly isn't insurance. Insurance basically by definition is to insure you against something that MIGHT happen in the future. Pre-existing is, I dunno, maybe a stipend?
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Whether you redistribute wealth by taxation and entitlement payments or by legal decree to 3rd parties (i.e., insurance companies) it's still fucking welfare.
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I agree a little more with Raven Nation above.
I keep going back-fourth on this one.
It is definitely a socialist insurance program as it is non-profit and there is only one of them. I just feel that if insurance is the way to go, one plan with all 300million people can't be beat.
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The net effect of forcing my insurance company to raise my premiums to cover un-insurable people is no different than the government raising my taxes to pay for the medical treatment of un-insurable people.
The mandate to cover pre-existing conditions is welfare by deception. That's why I insist on calling it welfare.
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I hear you.
But once everyone is covered by the plan, the concept of pre-existing condition as a criteria for coverage goes away.
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This is replacing insurance with mandatory welfare for all. Just fucking call it that.
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I agree. It is a socialistic welfare program.
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See my comments below regarding pre-existing conditions and insurance companies.
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If you are not allowed to charge the actuarial cost of insurance, it is not insurance.
It is, as kinnath notes, welfare.
A "pool" of 300 million is not "reducing insurance risk by expanding the pool". It is "welfare".
The only risk artificial pools or premium subsidies insure against is waking up in someone else's body.
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I must give in.
It's definitely a form of Welfare.
But I think it'll beat out Medicaid and will kick the shit out of the ACA. -
Good. We can now have rational and honest discussions about replacing or not replacing private for-profit insurance companies with state-supplied welfare for all.
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Agreed.
Someone below suggested that my Medicare plan should ONLY be Major Medical. That is, only cancer, hearth surgery and other expensive and emergencies would be covered by the welfare plan.
And, private insurance can cover routine and non life threatening matters.
What do u think?
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Agreed.
Someone below suggested that my Medicare plan should ONLY be Major Medical. That is, only cancer, hearth surgery and other expensive and emergencies would be covered by the welfare plan.
And, private insurance can cover routine and non life threatening matters.
What do u think?
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I don't think there is any reason for the government to be involved in any of what you just described. Dressing it up and trying to carve out all these exceptions and special rules to satisfy some preconceived notions of what insurance should and should not be, or to try and "nudge" people's behavior towards your desired outcomes, actually only makes it worse.
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Wish we could copy Switzerland's system: no employer provided insurance, an individual mandate for basic coverage that can't exclude pre-existing conditions, supplemental policies for those that want deluxe coverage (which is how the insurers make profits). Insurers have reinsurance pool that protects them on the guaranteed issue plans. Consumers have skin in the game, doctors in private practice, best health care in the world (but some measures).
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Or we could unshackle the market and see what a truly free market in insurance delivers.
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The free-market falls short when it comes to health insurance. Insure a wooden house in a remote area? You will pay more than the guy with a brick house in town, closer to the fire dept. and hydrants. Drive a Porsche, get speeding tickets? You decided on a sports car, you decided to keep breaking speed limits - so you'll pay a lot. Health insurance? There are life style choices: smoke, 50 lbs. overweight, don't take your blood pressure medicine - you deserve to pay more - right? But many people have pre-existing conditions that have nothing to do with lifestyle choices - they just had some bad luck. The Libertarian idea: risk pools for all those sick people (who need Welfare?). I think many would be surprised how difficult it was for individuals to obtain health insurance (pre-ACA). Health ins. companies didn't just turn town applicants with serious and/or chronic conditions like diabetes, cancer, heart disease, etc. I believe that a significant number of people, once in their 50's have some "condition" that(pre-ACA)would have made them uninsurable (or had certain conditions permanently excluded)if applying for an individual policy. Since most people under 65 have employer provided coverage, they have the protection of plans that don't exclude pre-existing conditions or decline new employees for due to medical history. I'd love to know how many Libertarian pundits (like all the writers at Reason) enjoy the security of employer provided health insurance.
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1) Just because something happens because of bad luck instead of bad choices doesn't suddenly mean the government can or should step in to make things "fair".
2) I suspect almost everyone here is in favor of putting employer and individual insurance on a level playing field, and removing other government incentives to for using insurance to pay for routine medical treatments. So that it becomes, you know, actual insurance.
3) It seems to me like the pre-existing conditions issue is really an issue of employer provided health coverage. Put individual on a level playing field, buy insurance that will follow you your whole life when you are healthy. Make sure the contract says you can't be dropped for getting sick. Problem solved.
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The part where you "make sure the contract says you can't be dropped" is where it all falls apart. Private Insurance (especially profit driven ones) weasel out of expensive claims, sit back, and say "take me to court".
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Then take them to court. If they breach their contract, sue the hell out of their asses. And shout to the world that they can't be trusted. Ruin their business. I'm all for that.
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I don't think Reason Magazine is big enough to be self-insured.
I agree that the free-market doesn't work for something as inelastic as life-saving medical service. Unlike food and water, which are abundant, I respectfully disagree with Libertarians and feel that Major Medical and Life threatening expensive medical care should be a welfare benefit paid for by all. In effect, Medicare.
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I'm glad you brought up food. Now, ask a very simple question. Why is it abundant?
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You're getting close.
Change A to completely free up private health care provisioning, including allowing any private insurance anyone wants. Make sure that tax law does not bias any supplier of insurance over any other, e.g., by making employer provided insurance tax free.
Change B to make the medical care covered explicitly worse than the private state of the art. Use the standard that government will pay for the least expensive standard private treatment of the last 30 years. Have death panels. Do not go through the expensive fiction of premiums and the necessary subsidies at all. Pay for it out of the general fund.
The point of this two-tiered system is that the 25 or 30% of people who can't afford private insurance won't die in the streets. But the 70-75% of people who can afford private insurance will be utterly unencumbered. This will drive prices down rapidly while also allowing critical R&D efforts to continue -- motions that would be killed by single-payer or other nationalization of health insurance.
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Why would R&D be killed by single-payer?
Big Pharma depends on patients to pay for their expensive drugs via Health Insurance. We'll keep paying it until generic solutions (10 years later) show up. Big Pharma still get their money. Only, instead of a bunch of Insurance companies you have one 300,000,000 pool.
Yes, the $1,000 aspirin will be gone.
But with the absence of profit-motive and the fact that everyone will have the same coverage, why not? -
Medical R&D costs are paid for almost entirely out of US health care expenditures because there are many payers competing to provide, and individuals paying to get, the best care. Most of the rest of the world gets these advances at cost, not at cost plus recoup.
Make the US single-payer, and the single-buyer will squeeze pharma for rock bottom prices -- just as, e.g., Canada does today. There will be greatly reduced incentive for anyone to spend money on uncertain innovations given the questionable ability to make money down the road. The capital will simply go somewhere more profitable.
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MikeP I like this debate.
I know that the reason single payer works everywhere else is because it was invented HERE in THE US and for Profit.
That is very very important. Many libertarians believe that us Progressives don't see this. We do.
We have to somehow preserve that in a single-payer model. Right now, private insurance has a limited grip on the squeeze on Big Pharma. We should keep that with Single payer. Perhaps legislate it in that or something.
I know the solution cannot be REVOLUTIONARY. It must be EVOLUTIONARY and in phases. Leave everything alone except have one insurance company (Medicare). And, get rid of Medicaid.
The real downside to my idea is that many people in private health insurance would lose their jobs.
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Alice Bowie:
I know that the reason single payer works everywhere else is because it was invented HERE in THE US and for Profit. That is very very important. Many libertarians believe that us Progressives don't see this. We do.
How do you progressives explain the success of the Singapore model, which isn't single pair, leaves pricing largely to the free market, is cheaper than the places progressives typically lump into "everywhere else", and produces health outcomes just as good or better, while proving everyone with access?
After all, I thought that was the objective.
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I'm open. If free market can do it even after I lose my job or go broke, I'm all for it.
Although I am not sure, I think Singapore doesn't really have as many poor people.
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How about that !
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Nah, they will freed of their jobs and able to become the next Elvis.
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I think you can have cash up front AND insurance if you want. I've had dental insurance for about 10 years. For a lot of that time, I went to a dentist who wouldn't accept any insurance. I paid her up front and the insurance company reimbursed me for the portion they would sign off on.
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Not such bad ideas at all. Most seniors on Medicare have a supplemental policy since Medicare doesn't pay for everything. With Medicare for all, the insurance companies could stick around and sell supplemental policies.
I especially like the notion of no employer provided health insurance. I believe that is the biggest reason our health insurance and health care costs are the highest in the world. Unfair tax treatment, job lock, not enough consumer skin in the game --- all sorts of problems. The ACA solves (though not neatly) the pre-existing condition problem -- which helps solve the job lock problem. Other than that, the ACA continues the worst parts of our screwed up, multi-tiered health insurance system.
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The ACA is horrible man.
You bring up an interesting idea of having private insurance around.
Perhaps, Medicare should only be major medical (Cancer, emergency, open heart) and private insurance can cover non life-threatening matters.
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Number 6 is the one I have been focusing on. All these O'Care disaster/ libertarian porn stories are great and all, but whether it will launch into a death spiral will not be fully known until next year's enrollment when insurance companies readjust their premiums rates based on the previous year's costs.
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Numbers 1,2,3,4,5,and 6 prove that this law needs to be thrown in the Toilet.
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I've been focusing on Number 6 for quite some time.
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Try smothering him with Rover.
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Next year's premiums are due to state regulators in April/May in most states. Some are made public at some point in the process. We'll know a good deal in the next two months, and have a really good idea by September.
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I'm going to go out on limb and guess that most of the the "6 million" enrollees are middle to upper middle class white Americans. The combined Latino and black enrollment will be less than 40%.
Which throws cold water at the notion that "white people don't like ACA because they hate Obama and they don't want to pay for the healthcare of poor and minorities".
ACA feels like one of those government schemes that wouldn't work if not for the contribution from the middle class and the wealthy. Totally unexpected.
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There are not 6 questions to answer there are two. The act was sold to the public on 2 premises - 1) There were approximately 42 million uninsured people running around the country. This is not only morally unacceptable in a rich nation like ours, but the second order effects are driving up healthcare costs for everyone. 2) Healthcare costs, including insurance costs, have been climbing at an unacceptable rate for far too many years and launching a big national program would "bend the cost curve down", resulting in big savings not just for Obamacare enrollees, but for everyone.
How many uninsured people are there today?
Have health care costs, including insurance premiums, gone down since passage?If the costs have gone up or if there is not a significant reduction in the number of uninsured, the program is a failure. Even if costs went down slightly and the number of uninsured decreased significantly, it doesn't mean the program was a success because the unintended consequences need to be considered (i.e., longer wait times, reduced access to treatment, uncertainty impacting the job market). But it cannot be judged a success if the first 2 objectives are not met.
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Actually, I take it back. The act was sold to the public on "You will have free healthcare and the evil one percenters Koch Brothers will pay for it."
If that hasn't happened, then the proponents lied.
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Yup, any deviation from this narrative is dishonest.
Obamacare was supposed to fix those two major things, the high number of uninsured and the high costs, period.
So far, it has failed miserably on those counts.
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We need to get rid of the ACA NOW!.
But, in fairness to Obama, he did propose, in his original version, the public option. This was in lieu of the stupid Exchange Idea. Also, people over 50 would be able to apply for Medicare.
Both were shot down by the stooges of the Private Insurance Industry by their men in COngress. One of them being Jerry Lieberman.
With what Obama originally offered, one would had been able to keep their private plans.
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So, what I'm trying to say it wasn't all lies.
