ChrisWeigant.com

Patiently Crunching Obamacare's Numbers

[ Posted Monday, April 7th, 2014 – 17:29 PDT ]

We are in the midst of a political battle over the Obamacare numbers right now, so it seemed like a good time to examine what they all mean, in an attempt to interject some clarity into a very confusing debate. The numbers will change over time, as will (no doubt) the claims made from both sides of the debate; but without a little context the numbers by themselves don't actually say much. And as time goes by, one particular number will become the most important of all the data -- and this number just got better today (more on this at the end).

 

Obama's big number

The first thing worth pointing out is that the big number everyone's currently arguing about -- the 7.1 million signups on the Obamacare exchanges -- is a tough number to put together, but it would have been even tougher to aggregate if Obamacare had worked as originally designed. One of the big complaints from the anti-Obamacare camp is that the signup numbers aren't complete (in various ways), and haven't been sufficiently broken down into subgroups for full analysis. This contradicts one of their own talking points about Obamacare (that it was a "big government takeover" of the health insurance marketplace), since the very reason the numbers aren't complete is that data must be accumulated from all the insurance companies participating in the exchanges. The Obamacare website doesn't measure who has yet paid for their insurance, for instance, because it is up to the insurance companies themselves to collect the money, and not the government. But the real irony is that the 7.1 million figure would have been a lot harder to add up (and would have taken much more time to release) if we currently had 50 state exchanges, as was intended by the law's authors.

The original plan was for each and every state to run their own exchange. But not many actually did -- most of them punted this responsibility to the federal government. This is why the federal Obamacare website got so big, after all. Because of this, however, it became a lot easier to compile data, because if all 50 states had separate exchanges some of them would have done a good job of collecting data and some would have done (to be polite) a not-so-good job. As it stands, we are still waiting for final data from some of the states with their own exchanges.

This is the first reason the 7.1 million figure is not exactly carved in stone -- it will change, as better data arrives. The second reason it will soon change is that President Obama left some wiggle room in the deadline for signups, until the middle of this month. Check the box that indicates "I tried to sign up previously" and you can still go onto the website and sign up for an insurance plan (no verification necessary). So there will be an adjustment upwards at some point during this month for that 7.1 million figure. After even this extended signup period is over, there will still be a trickle of people using the exchanges all year (until the next open enrollment period), since people will still be able to sign up for new insurance after life-changing events (moving from state to state, getting a new job, etc.). By the time next year's open enrollment period begins, the number is almost guaranteed to be different than the 7.1 million everyone is pointing to right now.

There are plenty of existing questions about the makeup of the 7.1 million, and so far no real hard data to answer these questions (which is why we're in a window of time where there's a lot of confusion out there). There is only one thing to advise, at this point: patience. The breakdowns will appear soon, one expects, as the numbers are fully crunched. Once again, these numbers are streaming in from the state exchanges which do exist, the national Obamacare website, and the insurance companies themselves.

 

Patiently breaking down Obama's number

The questions over Obama's main number are valid, and deserve answers. Because it is not just the total number of signups so far which is important, but also the mix of who has signed up. If the mix isn't right, the insurance companies will hike their premiums next year so much that the marketplace could enter what is known as a "death spiral." This would happen if most of the new people with insurance are sick and need lots of expensive care. This would result in rising premiums, which would drive away healthy people next year, making the pool of people insured even more sick and expensive, and the whole thing could thus spiral out of control. This is why there is so much attention paid to the question of how many young and healthy people have signed up.

So far, the insurance companies haven't begun to panic, at least from anecdotal evidence. The target for young people was initially set at 40 percent of new signups. The first few months that the Obamacare website actually worked (December, January, February), this number was low -- more like 24 or 25 percent. But young people are indeed known for waiting until the last minute, and the insurers have indicated that the last-minute surge had a large portion of young people within it (exactly what was expected, in fact), and is now somewhere in the range of 1-in-3 (still not 40 percent, but a lot better than 25 percent, to put it another way). But again, we'll have to wait a few weeks to see what this percentage actually turns out to be -- and whether it'll be high enough to avoid that death spiral. So far, as I said, the insurers don't seem to be panicking, yet.

The next big question is how many of the 7.1 million were previously insured. There is no solid data on this yet, although some estimates do exist. Part of figuring this number will hinge on what "previously insured" and "newly insured" mean to different people. If you had a job that ended halfway through 2013 (just for example), and then had no insurance for a few months, but were able to sign up on the exchanges, then were you "previously insured" or are you now "newly insured"? Or does "newly insured" only mean people who have never had health insurance in their lives? As you can see, there is a moving-target quality to sorting this data. The whole purpose of Obamacare was to provide affordable insurance so that America could reduce the number of uninsured people, so it is important to figure out who among the 7.1 million were just shuffled from one plan to another versus those who were able to sign up for insurance that wasn't previously available (or affordable) to them. Again, the only thing to advise here is "patience," until we get a better breakdown of the data.

More patience is needed for the number who signed up who have actually paid their first bill and now have (instead of just "have signed up for") health insurance. So far, most estimates have been putting this number in the 80-85 percent range (or, 15-20 percent who haven't paid yet). But there's a lag time built in to collecting this data, since it takes time to mail in a check and get a policy in the mail in return for a lot of folks. So we'll be able to see in roughly a month a much better number for how many have actually paid up. Patience, people, patience.

 

The number of cancellations

There are two further arguments over numbers -- one from each side of the debate -- which deserve mentioning here as well. From the anti-Obamacare side, their biggest argument has been deflated somewhat by the release of the 7.1 million figure. Their argument (before the 7.1 figure was announced) was, in essence: more people would be harmed by Obamacare than helped. This argument hinged on the number of people who received cancellation notices in the mail from their insurance companies. I've seen various figures used by people making this argument, from about 4.5 million to 5.4 million, and even up to 6 million.

The pro-Obamacare folks argue that this number (whatever it actually is) is misleading, for a number of reasons: it is in no way an official count, merely an estimate; it does not separate out insurance plans that were not acceptable to Obamacare's standards from insurance plans that were (a number of insurance plans are cancelled every year by insurance companies, which has been going on long before Obamacare arrived); and most of these estimates were made before taking into account the fact that Obama allowed for extensions when the initial stories appeared in the media. These are minor quibbles, though. The antis have a point, at the core of this argument: some people will indeed be harmed by Obamacare. This is a tough thing for the pro-Obamacare folks to admit, but it is indeed true. There are always winners and losers in any sweeping changes to such a large marketplace, and ignoring the losers and pretending they just don't exist weakens your overall argument. But the Obamacare supporters have a valid point here, too: you can't just compare the two numbers directly, and say something like: "6 million lost their insurance, 7.1 million signed up, therefore only 1.1 million were actually new signups." Of course, right up until the 7.1 million announcement, the antis were arguing that "more people lost insurance than gained it," but this talking point simply doesn't work for them anymore (since even a third-grader could tell you 7.1 is bigger than 6).

But Obamacare supporters have a bigger point about the people who got cancellation notices: just because they got a notice in the mail does not mean they are not now insured. This is the breakdown that the antis conveniently forget about in making their point. Because the group which did get cancellation notices now has choices that they didn't have last year. Some of the people who got such notices just signed up with their old insurance company again on a different plan, for instance. Importantly, these people are not counted in the 7.1 million. If they didn't use the exchanges and communicated directly with their private insurers, they are not counted at all in the total number of signups through the exchanges, to put this another way. Some of the people who received cancellations may have been newly eligible for Medicaid, which would also mean they are not counted in the 7.1 million. And quite a few of them were indeed able to go to the Obamacare exchanges and sign up for different insurance plans. What this all means is that even if the highest (6 million) figure is used, nobody has any idea how many of those people who were previously insured (in some fashion or another) are now uninsured. The antis try to equate the 6 million with people who "lost their insurance," but that doesn't mean the same thing as "are now not insured."

Of course, this doesn't take into account two major things: what type of insurance these people had before, and how much they are paying for insurance. Obamacare supporters like to write off these folks as "having substandard insurance," and state that therefore they are now getting better health insurance (or "Qualified Health Plans") for cheaper, but with no actual numbers to back this claim up. Anti-Obamacare folks like to state that these people are now "paying insanely higher premiums," but again, without offering anything more than anecdotal evidence to back such statements up. The only sure thing right now is that there were indeed losers in the grand shuffle of Obamacare, but we don't yet know how many or what categories they fall into.

 

In addition to the 7.1 million

But the pro-Obamacare people have a point to make of their own, outside of the 7.1 million. Because the 7.1 million number doesn't take into account a lot of other people who have been helped by Obamacare. There are a number of groups who are seeing more benefits under Obamacare, some of whom are pretty all-encompassing. For instance, all women are now not charged more than men for health insurance. Nobody faces lifetime caps anymore. Pre-existing conditions cannot be taken into account when purchasing health insurance. All seniors are seeing the "donut hole" in their Medicare prescription drug benefit shrink year by year, until it will disappear entirely. Everyone who has health insurance can now get preventative care for free, as well.

There are several other groups now getting even more direct benefits from Obamacare who are not counted in the 7.1 million number. People who are newly eligible for Medicaid, for instance (roughly 4 million of them, to date). This group could have been even larger (perhaps even doubled), it is worth pointing out, if all the states had opted in to the Medicare expansion. States run by Republicans have resisted this, meaning that millions of people are now denied Medicaid when just across the border in a neighboring state they would be eligible. Young adults who are still covered on their parents' insurance (which wouldn't have been possible without Obamacare) number around 3 million. Add just those two groups to the exchange signup figure, and you get 14 million people with health insurance directly due to Obamacare -- double the 7.1 million figure (although, again, the 3 million and 4 million numbers aren't very firm at this time and could become more accurate in the near future).

 

Today's good news -- a number really worth watching

Which brings us to our final point. The nationwide healthcare marketplace -- something like 16 or 17 percent of the total American economy, remember -- is always going to present a moving target. Absent a real "takeover" of the insurance marketplace by the government (such as "single payer," for instance), it is always going to be tough to exactly quantify how everyone is affected across the whole country at any given time. This confusion is going to give rise to people on both sides of the argument tossing estimates and anecdotes around with abandon, of course (it is, after all, an election year), as the politicians exploit the vagueness in the public mind of what's really going on.

But there is one measurement that more and more people are going to start paying attention to, especially after today's announcement of new data. This is the percentage of the American public which has no health insurance. When you examine the basic motivations behind the Obamacare law, there were two main problems which it tried to solve. The first was that nobody should go bankrupt to pay for health care if they are paying for health insurance. The second was that the rate of uninsured Americans is too high, and must come down somehow. The latter is the number that was just released today.

The Gallup organization polls intensively (using a much bigger data sample than a normal nationwide poll, with over 43,000 interviews) on this question. They just announced some good news today: the percent of uninsured Americans has now drastically dropped, to its lowest point since 2008. Since the Obamacare exchanges got up and running, this percentage has steadily gone down, from 18.0 percent in the third quarter of 2013 to 15.6 percent in the first quarter of this year. Take a look at the chart to see the magnitude of this drop. The analysis gets even better when individual months are examined: 16.2 percent in January, 15.6 percent in February, and 15.0 percent in March. Even within the month of March, the first half showed 15.5 percent, which fell to 14.5 percent by the end of the month. The trendline is pretty easy to see, in other words, and very good news for Obamacare fans.

My guess is that this is the number that will be closely watched, over time. The bickering about the 7.1 million signed up (or the 6 million cancellation notices) is going to fade, as both the public and the politicians step back to look at the bigger picture. Granted, the number is from a polling organization rather than official data from the government or the insurance companies, but it has the benefit of being one simple number which, over time, will show the success or failure of Obamacare to insure more Americans. And with such a massive sample (with a miniscule margin of error of only plus-or-minus 1 percent), it is a number that can be trusted much more than the average public opinion poll (which normally have error margins in the 3-to-5 percent range).

Obamacare supporters are cheering the good news today, as well they should. Such a sharp drop is hard to argue with, to put this another way. But much more work needs to be done. Even 14.5 percent is still way too high. Massachusetts (birthplace of Romneycare), after all, insures all but 2 or 3 percent of its citizens. That's a goal that Obamacare may never actually reach. Even softening this goal to something reasonable like only 5 percent uninsured, though, is going to take a lot more effort in the second and third year of the ongoing Obamacare rollout. Whether the program is successful at achieving anything like this goal still remains to be seen (Massachusetts didn't hit such fantastic numbers in its first year, either, it's worth pointing out). A lot of Americans won't find out what their fine is for not having health insurance until this time next year (when they do their 2014 taxes), which will be after the second open enrollment period ends -- so it is going to take a full three years to judge ultimate failure or success.

Which leads us back to our main point, throughout this article. We're all going to need to be patient for a while to see how well Obamacare works. That is going to be tough to do in the midst of an election where one party has dedicated its entire campaign effort into proving Obamacare is irredeemably broken, to be sure. For now, please just remember that we simply don't have enough data right now to answer all the questions being raised. Some of this data will appear in the next few weeks. Some will take months. But the final numbers won't really be in for years. Which is going to require a lot more patience on everyone's part.

 

[Full Disclosure: Although it has no bearing whatsoever on what I write, I am actually currently in a polling group for Gallup, which means that my own personal data is one tiny shred of whatever aggregate numbers Gallup comes up with for health insurance. To put it another way, I am one of the 43,562 adults in their survey. As I said, this does not influence my writing in any way; but to be absolutely scrupulous, I feel duty-bound to point it out, should anyone care.]

-- Chris Weigant

 

Cross-posted at The Huffington Post

Follow Chris on Twitter: @ChrisWeigant

 

25 Comments on “Patiently Crunching Obamacare's Numbers”

  1. [1] 
    YoYoTheAssyrian wrote:

    Not enough data, null program.

    Which means we can get back to the fun!

    Michale I call you out, you're wrong! About everything!

    I welcome your data and statistic based rebuttal. But I'm obviously unassailable here.

    :-P

  2. [2] 
    Elizabeth Miller wrote:

    Chris,

    Their argument (before the 7.1 figure was announced) was, in essence: more people would be harmed by Obamacare than helped. This argument hinged on the number of people who received cancellation notices in the mail from their insurance companies.

    Okay, this is where mine eyes begin to glaze over ...

    I mean, it seems to me that this is an argument with absolutely no basis. In fact, it's better than that, it's an argument that makes the other side's case!

    IF I'm understanding this correctly, insurance companies can cancel policies that pre-date Obama, if they so choose ... for any reason? or only if these policies don't measure up to the new Obamacare standard?

    In any case, is it correct to say that insurance policies under the new Affordable Care Act cannot be canceled by the insurance companies?

    And, if this is the case, then this is, to be polite, an extremely spurious argument against Obamacare, is it not?

  3. [3] 
    YoYoTheAssyrian wrote:

    Not really, the devil is in the details. But yes one can try and blame insurance companies, but ultimately the biggest disruption in the healthcare market has been Obamacare. So people freak out when that happens, but ultimately it's about whether the disruption was worth it. I think it is, especially considering the horror of the previous status quo, but people are free to defend that situation if they like.

  4. [4] 
    YoYoTheAssyrian wrote:

    And really you should pay attention to this stuff liz, you never know when something like the upheaval in the ukraine will come to the fore and you'll still be focused on what is going at sochi.

  5. [5] 
    Elizabeth Miller wrote:

    Not really, what?

    Where did I go wrong - and, my point was not to blame the insurance companies but to understand what they could do before Obamacare versus what they can do now, with respect to canceling policies ...

  6. [6] 
    Elizabeth Miller wrote:

    Sigh.

    Only 'blame' was to be italicized.

    [Ed: Fixed. -CW]

  7. [7] 
    YoYoTheAssyrian wrote:

    Obamacare gets the blame, fair or not, because regardless of the insurance companies, Obamacare is still the thing causing the most disruption. As Chris mentioned, insurance companies cancelled tons of plans before the healthcare law was implemented. Unfortunately, because it tried a incremental fix, Obamacare gets blamed for all the problems of the previous status quo, the disruption it causes, and any downsides of the new status quo.

    Really we should have gone with a statistically proven single payer system, but the blue dogs put an end to that. And really I can't see how that would have changed the debate or dynamic at all, going with the heritage foundation plan didn't win any Republicans over.

  8. [8] 
    Elizabeth Miller wrote:

    Surprisingly enough, I get that.

    But, my question remains unanswered.

  9. [9] 
    YoYoTheAssyrian wrote:

    Which is the point of the article, many paragraphs of, "I dunno, and neither does anyone else."

    :-P @chris

  10. [10] 
    YoYoTheAssyrian wrote:

    Someone could make an interesting bit about how long term shake-ups are fundamentally unsuited to an media culture which is based on now, Now, NOW! and tie it in to how both sides of the political debate are using mutually exclusive fact sets, but I have work in the morning.

  11. [11] 
    Elizabeth Miller wrote:

    You have been completely unhelpful. Good-night.

  12. [12] 
    Mopshell wrote:

    Hi Liz,

    IF I'm understanding this correctly, insurance companies can cancel policies that pre-date Obama, if they so choose ... for any reason? or only if these policies don't measure up to the new Obamacare standard?

    In any case, is it correct to say that insurance policies under the new Affordable Care Act cannot be canceled by the insurance companies?

    Firstly, your questions are very valid ones and I'm going to do my best to answer them for you.

    Insurance companies could only cancel plans which were not ACA-compliant. That some of them cheated in this respect is now the subject of at least two court cases that I know of:

    Anthem Blue Cross tricked tens of thousands of Calfornia policyholders into giving up health insurance plans from which they could not be dropped and pushing them into policies that Anthem knew would be cancelled, according to two lawsuits filed in Los Angeles.

    Since March 23, 2010, "Blue Cross successfully enticed tens of thousands of its individual policyholders to switch out of their grandfathered health plans and forever lose their protected grandfathered status," the lawsuits state. "Blue Cross concealed information about the consequences of switching plans and intentionally misled its policyholders to encourage the replacement of grandfathered policies."

    Anthem played up the possibility, even likelihood, that premiums of grandfathered plans could go up sharply and failed to mention the possible consequences of replacing a grandfathered plan.

    Further, the insurer misrepresented that certain Obamacare-required benefits like no pre-existing condition limits for dependent children would be available only in non-grandfathered health plans, when in fact such benefits must be incorporated into grandfathered and non-grandfathered plans.

    From: The International Business Times

    http://www.ibtimes.com/anthem-blue-cross-wellpoint-wlp-unit-sued-allegedly-tricking-tens-thousands-dropping-grandfathered

    So that is the answer to your first question - they could only cancel policies if they didn't measure up to the new Obamacare standard.

    Secondly: yes, it is correct to say that insurance policies under the new Affordable Care Act cannot be canceled by the insurance companies. As far as I'm aware, the only exception to this is the non-payment of premiums in a timely manner.

    As for those who received cancellation notices (including the tens of thousands embroiled in these two lawsuits), there is some information coming through from the insurance companies which estimates how many there were (close to 5.8 million is the most likely figure) and what happened to them:

    Fewer than a million people who had health plans in 2013 are now uninsured because their plans were canceled for not meeting new standards set by the law, the Rand survey indicates.

    Republican critics of the law have suggested that the cancellations last fall have led to a net reduction in coverage.

    That is not supported by survey data or insurance companies, many of which report they have retained the vast majority of their 2013 customers by renewing old policies, which is permitted in about half the states, or by moving customers to new plans.

    From: The LA Times

    To put this in perspective: 5.8 million received cancellation notices; 4.8+ million of those were re-covered by their insurance companies either through policy renewals (thanks to a delay in scrapping non-compliant plans) or signing up to alternate plans offered by their insurance companies.

    This leaves under a million people with cancelled plans. We do know what happened to the majority of them:

    # some qualified for Medicaid under existing rules or the new ACA Medicaid expansion and either registered at their local Medicaid office or via the ACA exchanges.

    # some chose to seek out better deals via the ACA exchanges rather than sign up to alternate plans offered by their insurance companies.

    # some were small businesses which chose to wait for better deals in 2014 on the ACA exchanges.

    As Chris noted, it will be some time before we know the exact figures for people in each of these three groups and how many of these one million people chose to remain uninsured for whatever reason. It seems likely (but cannot be verified as yet) that the remaining uninsured from the original group of 5.8 million is a very small figure indeed and that at least some of them chose this voluntarily rather than for indigent reasons. But, at this stage, it's impossible to be sure.

    I hope this is helpful. :-)

  13. [13] 
    Elizabeth Miller wrote:

    That was extremely helpful, Michelle. Thank-you!

    Now, I can get some rest. :)

  14. [14] 
    Chris Weigant wrote:

    OK, let's see what we've got. To tell you all the truth, this column was inspired by Michale and his obsession with "facts." I thought to myself, well, what are the facts. The more I thought about it, the more uncertains arose. Again and again, the answer seemed to be "wait, until the data is in." I didn't really think it'd be all that interesting an article, but I thought I better sum up everything I had been thinking. That's what was behind it, now let me get on to answering comments...

    LizM [2] -

    OK, you really need to go back and re-read that whole section, because it makes the argument, and then deconstructs it a bit. Not to the level that you point out, but still... it is acknowledging that the other side is making an argument, and then attempting to see if there is any data to back it up.

    Cancellations happen. They happened before Obamacare, and they will happen after Obamacare. I don't know if this really applies, but allow me to try to use a metaphor. It's like banks and checking accounts. They offer certain terms, and sign you up for "ExtraMegaChecking" and you get certain benefits for a while. But then they decide to change their whole system around and they tell you EMC is no longer available, and you have to choose between new plans.

    This happens all the time in insurance. How much of it was "due to Obamacare" is an open question, but it's not like it didn't happen previously to some out there every year. So it's a pretty vague thing all around.

    Don't know if that fully answers your question, but it might be enough to clarify things a bit.

    YoYo [3] -

    The whole ball game is (politically) whether more people are harmed than helped, you're right. But we really won't be able to definitively say that until better data comes in. I'd bet on it being a net positive, personally.

    But then I'm an incurable optimist, at times. Hey, I wonder whether Obamacare treats that? Heh. Sorry...

    LizM [5] -

    I'm not sure of the exact rules. Pre-Ocare, they could do pretty much anything they wanted. But post-Ocare, they may be able to do the same.

    Two points: they will not be able to cancel a certain individual's policy BECAUSE HE GOT SICK. That is verboten, now (used to happen all the time). Secondly: insurance companies cancel policies that don't make money for them (maybe not enough people sign up). But that doesn't mean they won't come up with a plan to replace it, for most of their customers. To put it another way, it's not as brutal as it sounds just to "cancel a policy."

    YoYo [7] -

    Exactly right.

    [10] -

    Obama himself hates this the most about Washington: the absolute inability of anyone to see past the 24-hour news cycle. In such an atmosphere, long-term planning is almost impossible. I wrote this article mostly as a "benchmark" type of article I could refer to in future writing, to update figures and provide better data, and see how certain predictions panned out.

    Mopshell -

    OK, I have to admit, you answered LizM a lot better than I did! Well done! The big problem with the concept of "grandfathering" in plans was that the grandfathering date was set very early (2010?) while the full implementation of Obamacare waited until 2014. This was written into the law to satisfy both the insurance companies and the Blue Dog Dems. But this 4-yr gap caught a lot of folks unawares -- many of them in that "6 million cancellations" figure. This, though, will be a one-time problem which will work its way out one way or another. Obamacare, however, is an ongoing thing, so eventually all these people should be (theoretically) helped in one way or another.

    Whew! OK, that's it for now.

    -CW

  15. [15] 
    Elizabeth Miller wrote:

    LizM [2] - OK, you really need to go back and re-read that whole section ...

    Not necessary. Thanks for the edit.

  16. [16] 
    Chris Weigant wrote:

    LizM -

    Wow, you're up late!

    :-)

    I think what you were trying to address was the grandfather thing, which Mopshell spoke to. I left it out of this article, I admit, because I didn't want to get "too far into the weeds," but maybe I should have mentioned it.

    -CW

  17. [17] 
    LewDan wrote:

    The 4.5 - 6 million policies "cancelled" is a meaningless number. Comparing it to the number of sign-ups, or anything else, is misleading. NO policies were cancelled. Policy LINES may be cancelled by insurers at their discretion when policies expire.

    No active unexpired policy may be cancelled for ANY reason other than policyholders failing to meet their contractual obligations under the policy, such as failing to make premium payments. Exactly when, and how, policy lines may be cancelled depend on the individual terms of the policy. No policies were cancelled because of PPACA. NO policies were cancelled without the prior written consent of the policyholders. Any such cancellations would be contractual violations and illegal.

    Policyholders whose policies were nonrenewable due to cancellation of the policy line are offered alternatives as a matter of course by insurers, and as a matter of law under the PPACA.

    The only ones who might experience immediate short-term "harm" are those who have unrenewable policies for which all available alternatives offer less value for the money. VERY few, if ANY, policyholders fall in that category. Reducing premium costs, eliminating lifetime caps, prohibiting rejection due to "preconditions", and requiring everyone to pay for their healthcare, instead of passing costs on to others through unpaid emergency room visits, benefit EVERYONE.

    The ONLY ones who MAY suffer true "harm" are providers' profits. EVERYONE else benefits. The only question is "how much?" Some will benefit more than others, but their ARE NO "winners and losers." Only "winners" and "bigger winners."

    The rightwing misinformation promulgated to sabotage the PPACA is so pervasive, and so accepted by the media as the baseline for beginning discussion that nearly ALL "comparisons" are misleading.--I've a radical suggestion, why don't we talk about the "accuracy" of Obama's numbers and the comparisons to the number of people "harmed" when someone has actually produced an "accurate" number for people who've actually proven to have BEEN "harmed!"

    Even the claim that young healthy people are harmed is untrue. They won't be young and healthy forever. The small increase in costs they may experience now will pay dividends for them later.--Which is the whole point of insurance. Its not about gambling on whether you'll need it, (with the public underwriting your bet through emergency rooms,) its about managing your risks, and costs, by participating in a pool.

    Being young and healthy certainly doesn't guarantee you'll never need care. And neither does it guarantee you've a right to care at everyone elses expense should you need it. Requiring the young healthy to carry insurance too isn't "harming" them, its requiring them, like everyone else, to support themselves instead of taking advantage of the rest of us. We're willing to help those who need help, not provide for those simply unwilling to pay their own expenses.

  18. [18] 
    LewDan wrote:

    BTW, as an example of just how surreal the debate over ACA is, thanks to the irrational propaganda from the Right, I offer the continuing "debate" over the number of sign-ups.

    Carrying health insurance is NOW THE LAW. It is NOT optional. It is the law. And yet, the "no amnesty to lawbreakers" crowd take it as a given that everyone will break the law and refuse to sign-up for ACA. Which is why Obama's numbers COULDN'T be right!

    Because NOW, suddenly, breaking the law is every persons "right," if you disagree with it.--Which, of course, is news to Mexicans who immigrated illegally, blacks who smoke pot, women who want abortions, or gays who want to marry.

    Apparently the law applies to everyone--except old white folks.

    Then there's the outrage over being forced to carry adequate health insurance, while forcing poor people to drug test, prove they're seeking work, or do community service work is just fine. Old white folks having a right to be a "burden on society" no one else enjoys.

    And if the policy proposals Conservatives created are truly such socialistic unconstitutional democracy destroying assaults on the forth amendment then why did Conservatives propose them in the first place?--And why is no one asking them that question?

    How is the ACA not bipartisan because Conservatives created its provisions but didn't vote for it? You create the parts of a bomb but have no responsibility because someone else put them together and pushed the button?

    Call me crazy, but I just don't see why we should care about the "accuracy" of Obama's numbers when we don't care about the "accuracy," logical consistency, or even the rationality of the claims from the Right. Carrying health insurance is the law. Of course almost everyone is going to sign-up!--Aren't they?!

  19. [19] 
    Elizabeth Miller wrote:

    Wow, you're up late!

    Just one of those nights.

    I wasn't trying to address anything, really, just ask a simple question.

    To be perfectly blunt, I find the whole discussion on Obamacare incredibly tedious.

    I will say one more thing about it, though ... if this new healthcare law isn't just the first step toward single-payer, in the final analysis, then I wish y'all a lot of luck with it 'cause I think you're gonna need it.

  20. [20] 
    Elizabeth Miller wrote:

    LewDan,

    You win the prize for the best comment on this subject I have ever had the pleasure of reading - here or anywhere else ... not that I read comments in many other places, you understand, just to be clear.

    Bravo!

  21. [21] 
    TheStig wrote:

    Nice job CW -

    Just to get down into the weeds a bit...

    ..."it is not just the total number of signups so far which is important, but also the mix of who has signed up. If the mix isn't right, the insurance companies will hike their premiums next year so much that the marketplace could enter what is known as a "death spiral."

    The ACA incorporates a number of mechanisms to ward off THE DREADED DEATH SPIRAL. Among them are:

    Risk Adjustments, to redistribute funds between insurance plans with higher and lower risk enrollees.

    Reinsurance, which basically subsidizes high risk pools for the first 3 years.

    Risk Corridors, which limit potential profits and potential losses, also for the first three years.

    This is conventional insurance risk mitigation stuff, even if Flo, Maxwell and the Gecko don't mention it.

    The Kaiser Family Foundation site has a helpful chart on this subject:

    http://kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/

    You might want to down a couple of NoDOz before you wade in.

  22. [22] 
    TheStig wrote:

    Dept. of One Link Per Post:

    Wonk Blog had a good piece on THE DEATH SPIRAL back in November:

    http://www.washingtonpost.com/blogs/wonkblog/wp/2013/11/07/wonkbook-seven-reasons-obamacare-isnt-facing-a-death-spiral/

    On the Individual Mandate:

    "There's a lot of confusion over the actual costs of the individual mandate, so here's a reminder: In 2014, it's $95 or 1 percent of adjusted income (which is income minus the tax filing threshold, which is $10,000 for individuals and $20,000 for families), whichever is greater. In 2015, it's $325, or 2 percent of adjusted income, whichever is greater. In 2016, it's $695 or 2.5 percent of adjusted income, whichever is greater.

    The reason I keep italicizing "whichever is greater" is because it's the part that really matters. A lot of people believe the mandate's penalty in year one is $95. It isn't. Almost everyone who faces the mandate makes more than $9,500. So imagine someone making $53,000. For them, the mandate's cost in year one is $430. By year three, it's $1,075. That's a lot of money."

  23. [23] 
    goode trickle wrote:

    Well, finally a couple of hours to participate before I head back to the land of non-participation. Pesky Jobs.

    I just wanted to chime in that the perspective of patience on the numbers is worthwhile and great job on breaking down some of the arguments, however it also is somewhat disappointing that the ACA discussion has come down to just numbers and is in general ignoring some of the larger issues and problems that plague the legislation as it now stands. I would have preferred to see something getting us little more into the "weeds" as the longer we avoid the weeds and allow both parties and the HC industry to dictate that the big numbers are the only ones that matter the longer major issues will not be addressed. I prefer the stance of patience while the numbers are collected but continue to hold both parties feet to the fire to provide accurate information and pointing out often that both sides are doing a sucky job of protecting the interests of the many and how we can be making the ACA better.

    To LEW - I have to disagree on your stance that there are no losers. I am most definitely a loser in this transition. As a person who makes his living predominantly outside of the US I really never carried a qualifying ACA "traditional" style insurance policy as it made no sense for me to do so. For me it is cheaper to purchase travel insurance and pay out of pocket for my traditional preventative care. What I did have however was a very, very, good catastrophic policy, as that is really what I needed to prevent "bankruptcy". The current legislation makes no allowance for someone like me who is in and out of the country frequently it only makes an allowance for people who spend large consolidated blocks of time out of the country, so as a result I now have to carry insurance that for the most part I cannot use. Being forced to have "more" insurance is not so bad per se', however the price tag is, I happen to be fortunate enough to be able to provide for myself but this has come at a price in that I make just enough to be disqualified from receiving any subsidies and I live in one of the more expensive area's of the US. My old policy which limited my out of pocket at $10k max and covered a host of the side expenses only cost me $2500, now for a bronze policy which has a $12k cap (once you factor deductibles and other exp.) is going to cost me $6300 per annum. Now if the threshold for subsidies had been indexed for the cost of living as set by the census for the region my insurance premiums would have been closer to a more palatable $3k per annum. Yes I realize that by paying premiums we are subsidizing the pool and that is how this whole thing works, but how exactly am I winning by just having all of the years I've already put into the pool just tossed? Perhaps some of my view might have something to do with the fact that I have had to receive a tendon repair surgery while trying to find a replacement policy that works for my unique circumstance costs 14k and running.... Perhaps if they had thought things out better I still would of had my old policy that would have covered this. While my story is certainly not the norm, it is also not Fox news bait.

    I will agree with most that there are lot's of people benefiting from the ACA I have friends that now have insurance and will not have to worry about treatment for long term problems. I also know people who will now be forced to purchase insurance they don't really need, to subsidize a risk pool held by a private corporation because of the way the ACA was written to keep the monied corporate interests happy. So in my opinion yes there are winners and losers.

    Which, as CW said "leads us back to our main point" that as long as we allow both the right and the left in concert with the big monied interests to drive the discussion and determine the data sets used and we as citizens or well meaning pundits do not demand and make known our expectations, we can have all of the patience in the world but, the discussion will never change from the current form of poor math and general data sets driving the "it does or doesn't work" 24 hour news cycle discussion we have now. Unless we demand the data sets that contain something meaningful for the middle the only thing, no matter how long we wait, that is certain is any "fixes" will only benefit the top and the bottom and the middle will just be left to muddle along and pay the freight.

    Since we can't trust Washington to look out for our interests it is up to us to be demanding the fixes that need to be made now while the numbers argument has yet to be solved. The smart people should be stating loudly ACA is here to stay, and while we are waiting for this information lets plan to analyze and use it to improve and fix the system for all. Unfortunately that call to action is missing from the mantra of patience as it sits.

    Since I my soap box is to big for carry on, I'll leave it behind for you to kick around...time to fly. Remember way back when congress used to come together and compromise for the betterment of all once the discussion was over and a battle had been won?

  24. [24] 
    LewDan wrote:

    GT[23],

    I don't quite follow. First I think your missing quite a few points. In no particular order, participating in insurance pools one year have no effect on other years' pools. That's why policies expire annually, insurers earn "excess" profits, and one of the things PPACA takes baby-steps toward reforming. Ideally, insurance pools are supposed to spread risks and costs over the life of the pool, not fiscal years, but currently they don't.

    Also, typically policies are still in effect outside the country. Catastrophic coverage still burdens the public with your risks. I understand that you expect to be able to cover your own costs at need without relying on public assistance. But we the people have a right to a little more in the way of surety, hence the requirement of insurance.

    Sounds like your surgical costs are due to your indecision not ACA. Its my understanding your insurer would have offered you alternatives and any new policy from anyone would provide coverage since preconditions are no longer barred. A 10K max against a 14K surgery on a policy that costs 2500/year saves you just 1500. If, as was typical before ACA, your policy is cancelled with rates increased as soon as you actually make a major claim it may not only not have saved you money it might actually have cost you more.

    I don't know your details and I'm not arguing with you. I'm simply saying that your situation, though atypical, is like most other stories of "harm" in that the harm done to you may very well be more perceived than real. One reason those cheap policies are unacceptable, and WERE so cheap, is that most offered no real value, or actual coverage, at all.

    As to your actual point... Full disclosure time. IMHO concentrating on the data is a red-herring. The basic problems with our system is that third party insurers are inherently expensive and wasteful. We, as a nation, are fully capable of self-insuring, eliminating both the middleman and the middleman's cut for his profit.

    Additionally, when it comes to insurance, the larger and more diverse the pool, the more likely it is to remain solvent and the cheaper it is to finance it. So anything short of single-payer is a band-aid. I'll grant that it isn't politically or economically feasible to just chuck the insurance industry and enroll everyone in Medicare, so PPACA is better than nothing and moving in the right direction.--But not a WHOLE lot better.

    What I like about ACA is that it at least starts to move us back to the idea of insurance, and insurance pools, instead of short-term gambles over whether claims can or will be filed this quarter, or this year. And away from the idea that "insurance" is about taking in any funds in the pool not expended in a year, so that preventing payouts on claims increases profits.

    Insurers are SUPPOSED to be about earning fees for managing insurance pools. And insurance pools are supposed to be solely for the purpose of covering the claims of the insured.

  25. [25] 
    goode trickle wrote:

    @Lew,

    I doubt this gets read but that's what happens when work interferes...

    typically policies are still in effect outside the country. Catastrophic coverage still burdens the public with your risks. I understand that you expect to be able to cover your own costs at need without relying on public assistance. But we the people have a right to a little more in the way of surety, hence the requirement of insurance.

    You are correct to a point, My previous policy was very good, had my injury happened outside of the country the insurance would have covered not only the surgery but my housing, and if required flight back to the US to finish receiving treatment. Post ACA policy coverage is limited to "emergency treatment" only. The definition for "emergency Treatment" is so narrow that my new post ACA policy, that I am forced to pay more for, would still have soaked me for about $12 to 13k in out of pocket expenses because the nature of the injury requires 2 procedures, 1 to stabilize and 1 to repair. The repair process must be performed within 48 hours to ensure a positive outcome so really under the new ACA standards I actually am paying more for less. I still have to purchase travelers insurance to cover what a "regular" policy doesn't and due to the ACA and the state in which I reside the choices have gotten smaller and more expensive yet really do nothing more. All to satisfy a talking point driven by the right of surety.

    I'm simply saying that your situation, though atypical, is like most other stories of "harm" in that the harm done to you may very well be more perceived than real.

    I consider the harm to be real in that I am paying more for less all in order to subsidize a larger pool of beneficiaries. While that is how this whole "game" works, the added monies I now have to pay into the system comes at the expense of monies spent elsewhere in the economy at the expense of my comfort and to an extent others comfort as well as now more of my dollars will go straight to the top vs taking a small detour through a couple of other pockets on the way to the top.

    As long as we allow the right to frame the argument in such a manner that causes us to have to fall back on the "well it's a start", we will never get the system to move forward with meaningful reform that benefits the major plurality vs the way it is now of benefiting the rich or the very poor. Now is the time for us to be making the forceful arguments that it is not "good enough", it is here to stay and it is time for fixes. Mark my words if the right gains control of the senate and retains the house they will defund the ACA and retain the mandate, and they will use the "well it's a start" arguments to do it. Then we will see everyone who is not at the top get hurt for real, and it will all be due to us not arguing loudly for proper reform that benefits the middle.

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