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The Affordable Care Act One Year Later

The New York Times has a very distilled summary of the Affordable Care Act one year after coming into effect. The salient points:

1. The percentage of uninsured people has been significantly reduced – more so for states that elected to expand Medicaid. Overall sixteen million Americans have health insurance now who did not have it before the ACA went into effect. 8.7 million of these are from the expansion of Medicaid. 7.3 million purchased new private insurance.

2. Premiums have fallen for most people, but some people have seen premiums rise. This appears to be a function of supply and demand – that is, states with more insurance options have seen premiums fall; states with more oligopolistic health insurance markets have seen premiums rise.

3. It is too early to tell if health outcomes have improved as a result of the Affordable Care Act. Nevertheless, there are some clear positive indications of improving outcomes, such as increased rates of colorectal cancer screenings for those who should be getting them and improved access to care for nineteen-to-twenty-five-year-olds.

4. The health care industry appears to be booming. The S&P 500 health care index grew twenty-four percent over the last year, outpacing the growth of the rest of the stock market. This is also despite greater levels of competition being reported by insurance companies. Newly insured Americans has also meant that hospitals have had to eat fewer costs of treating the uninsured and that pharmaceutical companies have found more customers.

5. 86% of new Medicaid users have come from states that expanded Medicaid.

ACA_Medicaid_expansion_by_state.svg

States that have expanded Medicaid are highlighted. Image from Wikipedia.

Medicaid expansion was a cornerstone of the original Affordable Care Act that passed Congress that was to account for the majority of newly-insured Americans. Nevertheless, when the Affordable Care Act went before the scrutiny of the Supreme Court, Medicaid expansion was shot down. SCOTUS decided states could opt out of Medicaid expansion. Many states chose to expand Medicaid anyways, in order to provide more individuals with coverage as designed by the original law that passed Congress. Plus, the Federal government will pay all costs associated with Medicaid expansion through 2016 and more than ninety percent of costs after that (as opposed to roughly seventy-five percent of Medicaid costs the federal government paid before the Affordable Care Act).

Nevertheless, many states chose not to expand Medicaid. This is a double-edged sword for those states, since, with the presumed expansion of Medicaid on the federal dime as part of the pre-SCOTUS ACA, many extant sources of funding for hospitals that would have been redundant with funding associated with Medicaid expansion were cut anyways. Accordingly, hospitals in these states have been scrambling for new sources of funding to replace those that were unintentionally lost. Also, many people in states that chose not to expand Medicaid actually lost their insurance coverage as a result of the new law. Again, insurance coverage was lost for these people because, under the Affordable Care Act, Medicaid expansion was supposed to replace their prior insurance. It is estimated that this unintended coverage gap in states that did not expand Medicaid contains as many as 6.5 million Americans.

Despite that these two problems – loss of hospital funding and loss of insurance for individuals – have occurred overwhelmingly in states with Republican-controlled legislatures and due to the decision not to expand Medicaid, they have actually become Republican talking points. This is either: the political equivalent of taking someone’s hand, slapping them in the face with their own hand, and then saying, “stop hitting yourself.”; or, it is the result of Republican ignorance that obstructionism from their own party is responsible for the coverage gap that exists in their own states. And if such failure to understand the consequences of legislation is what is at the root of the problem, one wonders whether the Republican Party is at-all qualified to participate in policy-making.

6. Health care spending has slowed, but it is difficult to attribute this slowdown to the Affordable Care Act. Reduced health care spending is an international trend, and health care economists believe multiple factors are contributing. One proposed explanation is the growth of the accountable care model worldwide, with its emphasis on reduced rates of readmissions as its primary outcome for quality improvement. An increase in funding for preventative care may also be contributing. Nevertheless, one would expect sustained drops in spending from these or any other explanations, and it is too early to tell if the present trend will last.

In summary: the Affordable Care Act has resulted in marginal improvements, but it is not perfect, nor is it necessarily even a good piece of legislation. The United States has the best medical care system in the world, hands down. We have the best training for specialists, doctors from across the world come here for fellowships and training in advanced techniques, and innovations and new medical technologies disproportionately come from the United States, even across the developed world. Yet, when it comes to delivering care to our citizens, we pale in comparison to France, or Japan, or Greece, or Saudi Arabia, or Colombia, or Portugal, or 100 other nations.

We’ve had to really work hard to create such a pronounced ineptitude at health care delivery in this nation, where politics prevents medical services from getting to those who need them. The most recent and most apparent manifestation of this is in states that have declined to expand Medicaid. With the Affordable Care Act, we really had nowhere to go but up, but we still have a long way to go if we want to get to the top or even to a marginally acceptable, lukewarm standard of health care.

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120 thoughts on “The Affordable Care Act One Year Later

  1. “This is either: the political equivalent of taking someone’s hand, slapping them in the face with their own hand, and then saying, “stop hitting yourself.”; or, it is the result of Republican ignorance that obstructionism from their own party is responsible for the coverage gap that exists in their own states. ”

    It’s called ‘lying’.

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  2. Premiums have fallen for most people, but some people have seen premiums rise.

    The cheapest option I was able to find in the state in which I lived in prior to ACA is now double what I paid then, with worse coverage.

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    • Are you comparing buying as an individual versus buying as part of a group? Group prices vary from group to group based on size and the specifics of the negotiation, but are generally lower than buying as an individual.

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      • Nope. Individual before, and individual after. Same state, less than two years apart.

        I should note that I didn’t actually try to buy the insurance post-ACA, since I no longer live there. But I got the price quote from ehealthinsurance.com, the same web site where I purchased my pre-ACA insurance. The quote was accurate back then, and I doubt they’d quote me a price that’s higher than I’d actually have to pay. I also added two to my birth year when getting the post-ACA quote, to make sure that the difference wasn’t due to me being older.

        This shouldn’t really be surprising. It’s no secret that the ACA was explicitly designed to force young, healthy people to cross-subsidize the elderly and chronically ill.

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      • This shouldn’t really be surprising. It’s no secret that the ACA was explicitly designed to force young, healthy people to cross-subsidize the elderly and chronically ill.

        That’s called “insurance” in general. And cheer up, Brandon. One day you’ll be old and chronically ill, so you can view higher premiums now as basically a subsidy to yourself.

        (Also, I’d be a bit leery of comparing individual policies pre and post ACA — the individual market before the ACA was eight kinds of screwed up, and also about 80% scam. Cheap insurance, so long as you never used it, was pretty much the way it worked. If you wanted health insurance that actually covered you if you got sick, it was much more expensive. A policy build on rescission and claim-denial and less-than-bronze coverage WOULD cost a lot less, no doubt. But you got what you paid for)

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      • Interesting.

        At my work, I know the rates went up, but they go up every year and since I don’t take advantage of the plan, I don’t know how it compared to prior years. My wife’s insurer changed though we maintained access to all of the same doctors and our share of the premiums remained the same.

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      • Young, healthy people have been subsidizing the health care expenditures of the elderly and infirm for quite some time, or at least as long as Medicare has been around, and especially so after Bush II’s prescription drug legislation. The main difference now is that at least these same young people get insurance for themselves as part of the deal.

        Also, I certainly don’t mean to belittle the increased costs faced primarily by those who are self-employed and/or unrepresented by lobbyists; but, anecdotally yours or my insurance premium may have increased. When we look at everyone nationwide, there are some winners and some losers, but mostly winners.

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      • That’s called “insurance” in general.

        No, it isn’t. In a normal insurance market, without forced cross-subsidies, your premium is based on expected cost of coverage, and your payout is actual cost of coverage. There’s pooling of risk, but you don’t have, for example, young people paying inflated subsidies in order to subsidize the elderly.

        You’re confusing the ex post subsidies inherent in insurance (e.g., if I get cancer, my care is covered by other people’s premiums, because they didn’t get cancer and consumed less in health care than they paid in premiums, but we all paid the same premiums because we all had the same expected costs) with the ex ante subsidies mandated by Obamacare and similar programs (e..g, if I have type II diabetes and you don’t, my expected health care costs are more than yours, but our premiums are the same because the government mandates community rating).

        In a normal insurance market sans mandates, if company A tries to implement community rating, company B can easily lure away the low-risk customers by charging them a premium commensurate with their risk.

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      • Young, healthy people have been subsidizing the health care expenditures of the elderly and infirm for quite some time, or at least as long as Medicare has been around, and especially so after Bush II’s prescription drug legislation. The main difference now is that at least these same young people get insurance for themselves as part of the deal.

        Pre-ACA we subsidized the over-65 elderly. We continue to do that. The main difference is that now we subsidize the under-65 elderly. And we’ve always been able to get insurance. As I said, I was buying it on the individual market pre-ACA for about half what it would cost me now.

        When we look at everyone nationwide, there are some winners and some losers, but mostly winners.

        Contrary to the hype, Obama isn’t actually Jesus. He can’t multiply fishes and loaves, much less heart surgeons. The ACA didn’t increase the supply of medical care out of thin air. It forced some people to subsidize other people’s health care. It’s possible that in terms of individual headcount the winners outnumber the losers, but if so it’s only because the losers are losing bigger than the winners are winning. In dollar terms, the costs are at least as great as the benefits, and probably greater due to deadweight loss.

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      • To clarify my second paragraph, this is simply the nature of transfer programs. When the government robs Peter to pay Paul, it can only give Paul as much as it took from Peter. If there are ten Pauls and a hundred Peters, it must, on average, take ten times as much from each Paul as it gives to each Peter. Plus the extra tax burden may cause deadweight loss, so mathematically the costs must be greater than the benefits.

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      • Oh, and I meant ten Peters and a hundred Pauls, not the other way around. I’m strongly tempted to write a bunch of guest posts just to get comment-editing privileges.

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      • Every policy change is going to have winners and losers. Again, a relatively small percentage of people lost. I’m not thrilled. It’s always the independent, working, middle class, without any significant lobbying presence that loses with sweeping legislation.

        As I said in the article, I’m not enamored with the ACA. It did neatly solve several problems that existed and that everyone acknowledged existed in a clever, thoughtful way. There have been some major hiccups, particularly with SCOTUS and the roll-out, but it should – when regressed to the mean – have a net benefit to society.

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      • No, it isn’t. In a normal insurance market, without forced cross-subsidies, your premium is based on expected cost of coverage, and your payout is actual cost of coverage. There’s pooling of risk, but you don’t have, for example, young people paying inflated subsidies in order to subsidize the elderly
        Well then, cheer up. NOW if you get old and sick (but not old enough for Medicare), you can get insurance!

        Which you couldn’t before.

        That being the root of the problem, as you should know. If you were an unlucky ducky, young or old, there WERE no insurance policies for you on the individual market.

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      • In a normal insurance market, without forced cross-subsidies, your premium is based on expected cost of coverage, and your payout is actual cost of coverage.

        That’s true, but it’s the “expected cost of coverage” of whatever statistical/demographic pool you’re in, not really your personal expected cost of coverage. It’s all a question of bin size. Age 20-40? Age 20-29 and 30-40? 20-25,26-30,31-35,36-40? You could grow the bins until one bin covers everybody over a full lifecycle and still call it insurance at least as meaningfully as you could shrink the bins until you’re the only person in the pool and still call it insurance. Universal coverage simply does the former.

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      • To clarify my second paragraph, this is simply the nature of transfer programs. When the government robs Peter to pay Paul, it can only give Paul as much as it took from Peter.

        Except the ACA is not a transfer program, because it requires the subsidy to be spent on a specific kind of product and also includes thousands of new regulations. The whole point of this ACA discussion is whether these changes will lead to a more efficient market or not. Claiming that, by the laws of Peter and Paul, the market *has* to be less efficient (and ignoring any evidence to the contrary) doesn’t actually contribute to the discussion at hand.

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      • You’re confusing the ex post subsidies inherent in insurance (e.g., if I get cancer, my care is covered by other people’s premiums, because they didn’t get cancer and consumed less in health care than they paid in premiums, but we all paid the same premiums because we all had the same expected costs) with the ex ante subsidies mandated by Obamacare and similar programs (e..g, if I have type II diabetes and you don’t, my expected health care costs are more than yours, but our premiums are the same because the government mandates community rating).

        I don’t think this is a confusion.

        As I mentioned before when we were talking about this the last time (or the time before that, I forget precisely), you can amortize risk two ways, across a pool or across time.

        Individual insurance was risk amortized across time. Group insurance was risk amortized across a pool.

        Now you have an insurance mandate, so you can amortize risk across both a pool and across time.

        That isn’t a “subsidy of the elderly by the youth”, necessarily, because presumably the same product will be available when you’re elderly and your risk will be amortized across both the pool and time, still.

        Yes, it’s a different game, but it’s still insurance. It’s just insurance amortizing risk in a different way.

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      • And we’ve always been able to get insurance. As I said, I was buying it on the individual market pre-ACA for about half what it would cost me now.

        Who’s this ‘we’? I wasn’t able to get insurance. I’m young, or at least was young at the start of this, and fairly healthy…I just had a pre-existing condition.

        Saying ‘The people who were able to get insurance were able to get insurance’ is a tautology.

        The ACA didn’t increase the supply of medical care out of thin air. It forced some people to subsidize other people’s health care.

        The ACA didn’t increase the *supply* of medical care, but that has very little to do with who is paying for it or how. Your assertion may be *correct*, but those two sentences have nothing to do with each other.

        Moreover, I feel I must point out that *everyone* has been subsiding *everyone* in health care. The taxpayers subsidized the uninsured who didn’t pay their bills. Everyone subsidized the elderly. Etc.

        Trying to pretend you, as a young person, existed in some sort of magical universe where no one was subsidizing *you* is nonsense. I assert, right here and now, *I* was subsidizing you, because your insurance was lower because your hospital bill was lower than mine, because your insurance company threw their weight around negotiating their costs lower, which *made mine higher*. Your costs were *offset onto me*.

        And, on top of that, insurance completely destroyed the free market in medicine, making it utterly impossible for those of us that insurance companies would not allow to buy insurance to comparison show or save money or not be charged insane amounts of money. The way insurance has operated for decades has resulted in *complete nonsense* in medical billing and excessive costs for those of us who were blocked from the insurance market, but were still willing and able to pay our bills.

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  3. I’ll repeat this again.

    We’re all talking about the same thing now. The comparisons of prices here vs. prices there are all apples. We’re not discussing 50 different kinds of products due to 50 different sets of state regs. Until Obamacare, your insurance in your state and mine in my state had very little to do with one another.

    This simplification of rules means, finally, we can actually begin having a national discussion about health care without constant confusion because we’re comparing Maine to Nebraska to Texas to California, and most of us only knew about our state’s rules and problems.

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    • This is true for a relatively small percentage of the population.

      Most people still get their insurance either through Medicare, Medicaid – which varies very significantly from state to state in terms of level and type of coverage – or their employer. This is not likely to change anytime soon.

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    • Actually, you are wrong in your assessment. The standardization of state rules was removed from the legislation. The only ease of administration comes from the 13-15 (average) plans that each carrier offers. That is way down from over 100+. Sadly they removed most affordable plans and reduced networks by close to 50%, to reduce pricing.

      Each state still decides what type of licensing each provider must meet. Naturopaths in Montana are a licensed MD, while in Georgia they only need to read a book and take a test.

      Plans between carriers are significantly different from one another as well.
      I usually spend at least 2-3 hours with each potential client going through their current doctors, prescriptions and ongoing claims before recommending plans.
      Modeling costs even within “silver plans”, depending upon how someone accesses care, can be significant!

      It is no less complex than it was pre-ACA, and it is definitely not cheaper.

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      • I’m not referring to medical standards, I’m referring to insurance standards.

        Before Obamacare became law, much of the discussion about it was people talking past each other, speaking based on the health-insurance market problems and concerns in their state as if it equalled the concerns in another.

        There is now a minimum standard of what should be insured, people cannot be discriminated against because of their health in any state, and there are consistent methods of appealing insurance decisions nationwide.

        That is a huge step forward in the conversation.

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  4. By the healthcare index, do you mean this?

    http://us.spindices.com/indices/equity/sp-north-american-health-care-sector-index

    The reason I bring this up is because I’m not necessarily sure I completely agree with item (4).

    The reason is that it won’t include the not-for-profit hospital systems, many of which are desperately scrambling to adjust to the realities of the post ACA world. They aren’t sucking wind as an industry as a whole but there’s significant downward pressure on operating margins and they’re going to need to get their expenses under control to get through it.

    The margins are important because the anticipated increase in demand for healthcare services is going to require hospitals to spend a lot of capital in order to meet that demand, especially for facilities and services located off their hospital campuses (i.e. ambulatory/specialty facilities, free-standing ERs, perhaps urgent care facilities going into retail centers). More time is needed before we know how well the not-for-profits are adjusting.

    Some sectors are doing well as the number show but it’s not representative of the sector as a whole given the amount of healthcare providers that are not-for-profit entities.

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    • They aren’t sucking wind as an industry as a whole but there’s significant downward pressure on operating margins and they’re going to need to get their expenses under control to get through it.

      Absent other details, this sounds like great news. In healthy industries that are doing a good job serving customers, most companies spend most of their time worried about margins and trimming expenses in order to avoid being squeezed out of existence. None of the companies I’ve ever worked for has had the opportunity to cover a budget shortfall by adding a $15,000 bottle of aspirin to a few customer invoices to get back into the black.

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      • “In healthy industries that are doing a good job serving customers, most companies spend most of their time worried about margins and trimming expenses in order to avoid being squeezed out of existence. ”

        One man’s “trimming expenses” is another man’s “we’re closing the clinic on the edge of town because it costs us two hundred thousand dollars a month and we only serve maybe three patients a day, kind of sucks for the people who have to drive an extra forty-five minutes each way to the doctor, but the money has to come from somewhere. Oh, and we’re cutting back our Saturday hours as well.”

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      • I’m going to go out on a limb and suggest that if you’re averaging $2,200 in costs per visit, that’s probably not good for a clinic on the edge of town and we’d be better off just handing $2K to each of those 90 people, donating the rest to the “starving doctors and insurance executives of America” fund and calling it a day.

        But of course, since medicine isn’t government, we know with 100% certainty that there’s no possible waste in the system and anything that squeezes margins even slightly will result in catastrophic collapse instead of a partial rejiggering of the internal workings of the system. Those $15,000 bottles of aspirin couldn’t possibly be an indication of something very wrong in the day to day financial operations of medical providers. “Starve the beast” only results in belt-tightening when we do it to government bureaucrats.

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      • I’ve heard that there’s a somewhat reasonable explanation for the notorious $600 hammers the Pentagon bought, which is that there was some overhead that couldn’t be itemized for some reason and was just divided evenly among all the line items in the invoice. Which is to say, lousy accounting, but not actually waste or corruption. Granted, lousy accounting can conceal waste corruption, so they’re not entirely off thoffe hook, but it’s not as bad as it sounded.

        I think there’s something similar going on with ridiculous line items in medical bills.

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      • this is exactly right. It cost $x to keep a given hospital or health center open and functioning at it’s basic community-needs level. All care that’s not insured and covered and paid for out-of-pocket gets distributed through all line items to meet those basic operating costs.

        One of the keys to ACA was that insuring most people would radically reduce uninsured care that get’s redistributed throughout the system, and so the cost of the $16 tylenol.

        This is also the reason why the same procedure can have wildly different costs at different facilities, I recall circumcisions in Alaska ranging from a neighborhood of $300 to $2,000; it’s the part of the distribution formula for how hospitals cover their total costs.

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      • Brandon,
        there were two things going on:
        1) In order to prevent “higher ups” (think congressional busybodies) from removing small, but critical expenditures piecemeal, the accounting dept. would simply average the total cost over all the items. So the $600 hammers would balance out with $600 missiles. Stupid? sure, but just a bit of paperwork trickery.
        2) Actual mechanical constraints. A paperweight for a submarine can’t break, shouldn’t make a huge sound if it falls, etc. (or you have the two ergonomic keyboard issue, where you’re spending $10 for normal ones, but the ergonomic ones cost $600 apiece)

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      • Yes, I think that analogy is spot-on.

        The fundamental problem is that the medical industry has intentionally made its costs and billing practices a complete black box. When you get a bill that bills $750 for a one doctor’s time, $90,000 for another doctor’s time, $15,000 for a bottle of aspirin and then insurance pays $7,000 and you’re on the hook for $1,500, there’s clearly a bunch of nonsense going on. Something is very wrong somewhere and there aren’t really many good ways to get to the root of the problem. Given how limited our black box analysis capabilities are, I’m perfectly willing to start squeezing the box and see who screams.

        If there was some real transparency and a meaningful way to analyze the data, I’d be all for a soft touch and nuanced analysis. But since all we have is a black box, it’s reasonable to assume that none of these numbers is real and the only way to see what’s actually real is to put pressure on the system and see which parts cut their costs while remaining active and which parts actually start to break. Then maybe we can get somewhere. Right now, if you say, “Hey, why the $600 hammer?” the $600 hammer disappears and is replaced by two $300 pairs of pliers.

        The medical industry really has only itself to blame for this situation. They’ve benefited from years of black budget billing and managed to dodge questions about which components are really causing total costs to go up so high, so they can’t really be shocked when the customers as a whole say, “OK, we don’t really give a fish which pieces are driving these costs anymore. We’re just going to start paying you less and you can figure it out.”

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      • One of the keys to ACA was that insuring most people would radically reduce uninsured care that get’s redistributed throughout the system, and so the cost of the $16 tylenol.

        This is a false economy, though. Sure, if you give people free insurance, hospitals give out less free care to uninsured patients. But all those savings are cancelled out by the cost of giving those patients free insurance.

        I could be wrong about this, and I welcome evidence to the contrary, but my understanding is that the available evidence strongly suggests that expanding health insurance coverage results in more consumption of health care, not less. Yes, I know, preventive care, but it’s not clear a priori whether the present value of long-run cost savings are greater than the up-front cost of providing the preventive care. I’ve definitely seen studies that failed to find the hoped-for savings.

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      • I could be wrong about this, and I welcome evidence to the contrary, but my understanding is that the available evidence strongly suggests that expanding health insurance coverage results in more consumption of health care, not less. Yes, I know, preventive care, but it’s not clear a priori whether the present value of long-run cost savings are greater than the up-front cost of providing the preventive care.

        ‘Preventive care’ is what you call it when people go to the doctor where there is not any problem.

        That might, or might not, save a lot of money in health care, but what will certainly save money is people who go to the doctor *when a problem first appears*.

        That’s not ‘preventive care’, it’s ‘care when a person first has trouble breathing, not when they start coughing up blood and collapse on the sidewalk’. (Preventive care would have been a checkup three months earlier that would have noticed a slight wheeze in the chest and gotten an x-ray.)

        People without insurance delay until they cannot possibly not go to the doctor. This is really *really* expensive. (And they often go to the ER, which is even more expensive.)

        What’s the difference between treating appendicitis and treating peritonitis from a burst appendix? A lot of money, and a person that waited two days to see if they ‘got better’ before going to the doctor.

        I’ve definitely seen studies that failed to find the hoped-for savings.

        Some of the problem there is time. People, who spent all their lives delaying medical care until the absolute last minute because it was too expensive, now have to learn how it’s suppose to work. They have to learn when, exactly, you’re supposed to see a doctor. (And this might work both ways. Some of them still wait too late, and some of them possibly, maybe, go too soon? Although I’ve seen little evidence for that.)

        The only thing that will fix that problem is possessing insurance for an amount of time, and learning how the system is supposed to work.

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      • “People without insurance delay until they cannot possibly not go to the doctor. ”

        A single mother working two part-time jobs can get 100% subsidized medical care for absolutely everything, but she still won’t have a spare four hours to wait in the doctor’s office for a Z-pack prescription. The issue is not “is care available”, the issue is getting it to the people who need it. People don’t go to the ER because that’s their choice or their necessity, they go there because it’s open.

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      • A single mother working two part-time jobs can get 100% subsidized medical care for absolutely everything, but she still won’t have a spare four hours to wait in the doctor’s office for a Z-pack prescription. The issue is not “is care available”, the issue is getting it to the people who need it. People don’t go to the ER because that’s their choice or their necessity, they go there because it’s open.

        Yes, there is *also* the issue of time, which adds onto the other issue, and obviously merely having insurance will not cause time to suddenly appear. For that we’d need something like mandatory paid sick leave.

        A poor, busy person without insurance will almost always end up at the emergency room. A poor, busy person with insurance has at least a small chance of going to see a doctor earlier than that.

        And, of course, there were a lot of *non*-poor people without insurance, like I was, who despite not being poor didn’t often go to see a doctor, because *medical care is often really expensive*, and the entire system was so impossibly opaque that I would have no idea what anything costs. (1)

        My point is that there are a lot of people who have been trained to never go to the doctor except under absolutely dire circumstances, and just handing them insurance is not going to make them magically relearn how it is supposed to work. That takes work. You are correct in that a lot of those people also have fairly serious time constraints that *also* make them unlikely to be able to get to a doctor even if they wanted to, but that’s a different issue…first, we have to make sure they *do* want to go, we can worry about inability later.

        1) In fact, the last real time I was at a hospital, it was to remove a pyogenic granuloma. I walked in, learned the cost, canceled the appointment, and called the doctor that was going to do it and had him reschedule it at his own office. I wasn’t paying six thousand extra dollars to have it done at a hospital.

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      • I’m not sure that the savings from preventative care will outweigh the overall costs of having more people covered. I mean, sure it’s cheaper to treat an injury before it’s infected and you go to the emergency room. But you know what’s a bigger savings? Not bothering to treat somebody’s serious chronic illness because he doesn’t have insurance. That takes a big cost load off of the system. I wouldn’t argue that those savings are a good thing, but those are some serious offsetting costs that we’d have to nickel and dime back with preventative care.

        If we do see total net cost reduction, I’d expect it to come from the fact that more uniformly comparable insurance products are available on open exchanges. Buying insurance was a crapshoot before that (if you could get it)–people thought they had decent insurance but you never really know until you really test it out. That’s why I have a hard time crediting vague “before/after” stories without a decent amount of information about the policies. At least now, consumers have a better idea of what they’re buying and can comparison shop.

        It’s not ideal, but I’m willing to overlook a lot of flaws to see how this goes. Anything that moves us in a step away from being 100% dependent on our employers and buying everything through a long line of intermediaries with opaque policies is good.

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      • When I said “evidence,” I meant actual studies, not speculation. It doesn’t have to work out the way you say. Many times I have gone to the doctor when a problem first came up, and it turned out to be a complete waste of money (with the benefit of hindsight). Sometimes mine, sometimes the insurers, though from a public policy perspective it doesn’t really matter. The point is that usually “the first sign of a problem” is nothing of the sort, just a minor thing that will go away on its own.

        You can’t simply assert, a priori, that the savings from the cases where early intervention actually helps necessarily outweighs the costs of unnecessary treatment when it doesn’t. And sometimes medical care is wholly unnecessary and does more harm than good, e.g., slow-growing prostate tumors in the elderly.

        “Giving people free health insurance will save money” looks an awful lot to me like a left-wing version of “Cutting taxes will raise revenues.”

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      • That’s why I have a hard time crediting vague “before/after” stories without a decent amount of information about the policies.

        This, times infinity.

        There was a story out there the GOP was pushing about a women who had some really cheap plan that was being cancelled under the ACA, and she was being forced to move to plan that was about ten times more expensive. Upon close examination, the way her original plan worked was something like this, although I’ve forgotten the exact numbers:

        It would pay up to 50 dollars worth of a doctor’s visit, up to 4 times a year.
        It would pay up to 50 dollars worth of a prescription, up to 4 times a year.
        It didn’t include hospital stays at all.
        For all that, people paid $20 a month.

        That…is not health insurance. At all. It might be something that is, personally, useful to you, and could in theory save you some money (Almost certainly you wouldn’t, but hypothetically could.), but it’s not health insurance.

        Not bothering to treat somebody’s serious chronic illness because he doesn’t have insurance. That takes a big cost load off of the system.

        Sometimes. Other times they ended up back in the system and now cost *even more*.

        And, just as importantly, people forget how large ‘the system’ is. Someone who doesn’t have insurance, can’t get treatment for a broken leg, and ends up disabled is now *getting disability*. And other people are getting unemployment. And that homeless guy that has TB is infecting others.

        And that’s not even getting into loss of productivity and the decrease in GDP and taxes.

        It’s very easy to draw clear circles around ‘health care spending’, but ‘health care spending’ is *not* the only place that sick people are costing society.

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      • Many times I have gone to the doctor when a problem first came up, and it turned out to be a complete waste of money (with the benefit of hindsight).

        *Doctor’s appointments are cheap*. It’s *everything else* that’s expensive in health care.

        If you go to the doctor for no reason every single month in a year, and eleven of those times nothing happened, and that last time they caught something that would have resulted in you spending a single night in the hospital if you hadn’t gone in, money was saved. The average cost of a one night hospital stay is *$1700*, and the average cost of a doctor’s appointment is $200.

        Here’s one study claiming insurance saves money for exactly that reason:
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742317/

        Here’s an interesting study: http://www.imshealth.com/deployedfiles/imshealth/Global/Content/Corporate/IMS%20Institute/RUOM-2013/IHII_Responsible_Use_Medicines_2013.pdf

        It claims ‘Delayed evidenced-based treatment practice’ costs the US almost 40 billion a year in avoidable costs

        That’s just *medications*, not hospital stays or surgery. 40 billion dollars in avoidable costs because *people do not start taking medications early enough*. (Although admittedly that’s not only when people do not go to the doctor, it’s also when the doctor screws up and fails to diagnosis them in a timely manner.)

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      • A systematic review of the cost-effectiveness literature sheds light on these issues. We analyzed the contents of the Tufts–New England Medical Center Cost-Effectiveness Analysis Registry (www.tufts-nemc.org/cearegistry), which consists of detailed abstracted information on published cost-effectiveness studies through 2005. Each registry article estimates the cost-effectiveness of one or more interventions as the incremental costs (converted here to 2006 U.S. dollars) divided by the incremental health benefits quantified in terms of quality-adjusted life-years (QALYs). Low cost-effectiveness ratios are “favorable” because they indicate that incremental QALYs can be accrued inexpensively. An intervention is “cost-saving” if it reduces costs while improving health. Poorly performing interventions can both increase costs and worsen health. {…}

        Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not. Careful analysis of the costs and benefits of specific interventions, rather than broad generalizations, is critical.New England Journal of Medicine.

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      • Will,
        a simple phone call intervention that makes certain that someone who has left the hospital makes an appt with his PCP (as recommended in his exit instructions) dramatically decreases readmits.

        While the literature may not (with good reason) want to call this preventative care… I’m pretty sure that’s what Obama meant, as it’s the policy he has implemented (rewarding “wellness” by paying less for readmits).

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      • Absent other details, this sounds like great news. In healthy industries that are doing a good job serving customers, most companies spend most of their time worried about margins and trimming expenses in order to avoid being squeezed out of existence.

        While your statement may be correct on a very abstract Business 101 level, the details do matter and they go far beyond $15,000 bottles of aspirin.

        I should have been more clear when I said “get their expenses under control”. I did not mean to suggest that hospitals have not made any effort to reduce their expenses. Clearly, this is not true. Hospitals have been addressing this issue, even prior to the ACA being signed into law. My boss was at a healthcare real estate conference and the keynote speaker was the CEO of a major West Coast based healthcare system. He openly admitted that their business model was unsustainable in the upcoming environment and have attempted to take measures. It’s one reason why we see so many physicians practices being acquired by hospitals, especially for the high dollar services (oncology, cardiology for example).

        It’s not necessarily an issue of hospitals cutting costs but how much they need to cut costs. This is the unknown because the pressure on operating margins comes just as much if not more from the revenue side of the equation. While there may be some degree of predictability to revenues with respect to the revenue cuts, declining patient volumes poses significant challenges.

        Downward pressure on operating margins affects the key operating metrics that the ratings agencies look at in order to determine the health of the hospitals. In the worst case scenario, a hospital can have its credit rating downgraded (which no hospital wants because it pushes up borrowing costs). For the hospitals that are challenged and trying desperately to maintain an investment grade rating, being downgraded to a sub-investment grade rating is almost the kiss of death because they’ll no longer have access to the municipal bond markets for capital (and borrowing costs soar).

        With hospitals seeing a need to devote substantial amounts of capital to meet increases in demand for healthcare services, negative pressure on operating margins means potentially less cash from operations to invest in capital projects, potentially a drain on cash reserves if the operating margins move into the negative and the possibility of increased borrowing costs due to ratings agency downgrades.

        You say that most companies spend their time worrying about the bottom line. Fair point. However, hospitals are not companies (for-profits excluded), at least they don’t behave like them. They are not-for-profit entities with the singular goal of fulfilling the objectives it sets out to do – provide care. The institutional mindset is very bureaucratic and, in my experience, it takes substantial time and energy to get a hospital to move off the ball and do something.

        If you’re implying that it’s a good thing to get hospitals to change their mindsets, I would agree with you in theory. In practice, good luck with that.

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  5. Well, I was an unenthusiastic supporter of the ACA before and I’m a relatively relieved but unenthusiastic supporter of the ACA now. Still, I don’t think the Dems have any reason to be ashamed of it and that’s no small thing. If the admin hadn’t fished up the rollout it could conceivably have been a lift for this cycle.

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      • This about sums it up. The ACA was the most comprehensive plan that was politically possible to put into law under the given conditions at the time. It made some of the worst abuses of the health insurance companies illegeal, expanded Medicaid to cover more people, and made it possible for people to get health insurance through their parents longer.

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      • Not covering people with pre-existing conditions is not an abuse. You don’t buy fire insurance after your house burns down. You don’t buy car insurance after the accident (not if you want it to cover the accident), you don’t buy travel insurance after you lose your luggage

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      • That analogy works better if it’s easy to maintain continuous coverage starting from birth. In our system, it’s not. “You should have thought of that before your serious childhood illness,” or, “Well, you shouldn’t have lost your job,” aren’t the most convincing of rebukes.

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      • , the difference is that many of these pre-existing conditions are things that existed from birth or childhood and that people have little control over. When you go on trip, you know the possibility of losing baggage is possible. Homeowners and renters usually understand that a fire could destroy their home. Pre-existing conditions, which tend to be very broadly defined by health insurance companies, are much more difficult to avoid.

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      • Murali:

        I agree it’s not an “abuse.” Insurance, as I understand, is based on risk assessment and charging according to risk. But it is an outcome that is non-preferred by most (or if not by most, then by me!) because I don’t like to see people who get sick when they happen to not be insured to thereby forgo the possibility of ever affording treatment.. Forcing insurance companies to cover them might not be the best way to solve the problem, but it does seem to me to be the best way to solve it in the short term, given the political possibilities. Whether it will work in the longer term is another issue, and while I’ve supported the ACA ever since it was the Baucus Plan, I realize it might eventually end up harming some of those it means to help and that there’s a possibility it might not work.

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      • I read “abuse” in that case to refer to something more like this which was a real problem before the ACA tightened up the rules. TLDR: if you got too expensive, insurance companies would find a pre-existing condition that you didn’t report to them and use it as a pretext for canceling their contract with you in order to avoid paying out on things that have nothing to do with that condition. That’s pretty clearly abuse.

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    • Mostly fixed the pre-existing conditions problem in the individual market, most likely. Beyond that, if the cost growth slowdown that we’ve seen persists, and it turns out to be substantially caused by the cost control measures in the ACA, that will be a pretty enormous accomplishment. Certainly we don’t know yet whether this will be the case, but it’s a definite possibility.

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    • A lot.

      Basic preventive care requirements, including women’s reproductive health care, are now covered;

      Systems in place to better coordinate patient care amongst a patient’s providers;

      A system for comparing insurance plans now exists;

      Pre-existing condition coverage denials no longer exist;

      Coverage can no longer be rescinded if you get sick;

      Lifetime limits no longer exist;

      An appeals process is in place for care your insurance company denies;

      Medicare donut hole closed;

      Treatment efficacy evaluation programs established;

      Substantial increases in rural health care;

      Hospital standards established to decrease re-admissions.

      I could go on, but: the important thing to understand here is that much of this change was what happened before open enrollment began; changes to the way health care is delivered. It is baked into our health care system, now.

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      • I think the treatment efficacy evaluation program is going to be the biggest cost saver in the long term. And that is a good idea independently of the other stuff, but people call them death panels.

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      • “Substantial increases in rural health care”
        Shortages in rural areas is mainly due to centralization/regulation. I have serious doubts the ACA will find a sustainable solution to this without it looking like a subsidy. As has been a repeating theme, will create friction between rural and urban centers.

        Eventually the corners cut to produce savings will create a more expensive service that is lower in quality. Line of sight issues will persist and the thing on whole will become “To Big to Heal”.

        That outside of the obvious. As the industrial military complex has perpetuated endless conflict, the health/welfare complex will perpetuate endless endemics.

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      • Shortages in rural areas is mainly due to centralization/regulation. I have serious doubts the ACA will find a sustainable solution to this without it looking like a subsidy.

        You want to say more about your thoughts on this? The rural area that I pay the most attention to is the Great Plains, where the fundamental problem is that the population has been shrinking for 80 years. I also doubt that the ACA will find a solution for that region, even with subsidies. I might even say especially if what they try is subsidies. The states involved have been wrestling with the problem for decades, including various forms of subsidization, and it hasn’t work.

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      • Hospital standards to reduce readmits isn’t Obamacare. it’s an executive ruling on medicare payments.

        From the Center for Medicare and Medicaid Services web site:
        Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012.

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      • I am also curious what means about rural care.

        With regard to subsidies, I should say that the ones we’ve seen to recruit rural family physicians have been either (a) SF o conditional as to be unreliable, (b) inadequate compared to immediately available alternatives, or (c) both.

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      • Michael
        The bigger problem likely started in 1913. There probably is no other resolution than to let the ideologies run their course.

        I would say it would be important to legalize plant derived medicines, to not make criminals of the elderly and sick(in the meantime).

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      • @citizen: … As the industrial military complex has perpetuated endless conflict, the health/welfare complex will perpetuate endless endemics.

        Wow. There’s a lot of hard-core cynicism packed into that comment. Seems pretty lazy to just blanketly equate war with healthcare. Reading downthread, tho, looks like your Big solution is to just legalize pot. Hey, I’m all for legalizing pot too, but it’s hardly a panacea for what ails our healthcare system.

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      • Count me in as being skeptical of ‘s explanation of rural health care as well. If regulations explain the issue for medicine, do they also explain it for the lack of any other high-cost business/service that needs to cover fixed costs? I mean, rural areas look rural not because of the lack of hospitals. It’s the lack of just about any big buildings running businesses that aren’t related to farming. Is that a government conspiracy or just an economic side effect of not having a lot of customers out there to recoup your investment?

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      • , it’s both; Obamacare funds efforts to study the problem and identify best practices that hospitals can implement.

        rural health care means a lot of things; not just a big hospital within a 1/2 hour drive. It’s often small clinics; visiting nurses, facilities that are movable. It’s also finding ways to make it worth a doctor’s while to practice in a rural area, and encouraging more doctors to go into primary care instead of specialized medicine. It’s transportation for patients who need it. And dental care. This is actually one area where my state leads the nation; our proximity to Boston yet the sparse populations have made a good testing ground for delivering rural medical care.

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      • Legalizing pot is no solution. Just a alternative to the “checks in the mail liberalism”

        TF, rural areas had physicians at one time, even without the bright shiny big buildings.

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      • Let’s see the data. It’s not enough to say “rural areas had X at one time” and leave it at that. Rural populations had nearly the entire population of the US at one time. What has changed, how much, and why? What makes you think that government regulation is the driving factor as opposed to all of the other economic forces that are pushing the trend of everything moving toward urban centers?

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      • Actually, even though I suspect he is, Citizen may not be entirely wrong. If we consider “payment mechanisms” a part of regulation. Which is to say, Medicare has had an extraordinary and extraordinarily profound effect on how doctors are paid. It is actually quite reasonable to believe that while government funding may be disproportionately going to rural health care, the incentives provided make working in the city or suburbs even more lucrative, playing a role in more health care professionals setting up shop there had the changes not been instituted.

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      • TF
        Roy spent 4 months in a local community college getting his $4000 medical degree. After purchasing his $10 license he is now ready to see patience and apply medicine he developed at home. His going rate is $3.50/hour.

        what parts of that make you recoil, and why?

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      • So, no data, just a semi-related thought experiment. Am I getting that right?

        I’d try to address this, but I get a feeling there’s a huge asymmetry in the amount of effort being put into this discussion and I just don’t have the energy to tease out a fully formed position from you. If you’re going to make a claim, go ahead and do it clearly and without question marks.

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      • Maybe I’m falling short of the glory of number runners, but I find few data sets that accurately define the reality of the last 101 years.

        I tried to push the dots close together but will agree that unpacking the issues is more effort than the sum of our wills.

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  6. This is either: the political equivalent of taking someone’s hand, slapping them in the face with their own hand, and then saying, “stop hitting yourself.”

    As it’s hurting ‘their’ states, it’s more the equivalent of grabbing someone’s hand, hitting yourself with it, and saying “stop hitting me”.

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    • Well, if we’re going to nitpick analogies, the people doing the slapping almost always personally have insurance, and they had to fight to get to this point, its not what the other person wants. So…

      It’s the equivalent of them leaping on their enemy, wrestling them to submission, ending up in control of their enemy’s hand, and running around slapping their friends and family with it, and saying ‘Look at him hit you! I told you he couldn’t be trusted! I should be in charge!’. All while their enemy says ‘Stop hitting them with my hand!’

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  7. Nevertheless, when the Affordable Care Act went before the scrutiny of the Supreme Court, Medicaid expansion was shot down. SCOTUS decided states could opt out of Medicaid expansion.

    On my cynical days, I say, “Of course,” to this. CJ Roberts decided that the ACA should stand. So he sliced and diced the legal issues in such a way that he could assemble a majority for each of the little pieces (even though there’s no majority for the decision as a whole). He needed a sop to throw the conservatives and Medicaid expansion was it. He didn’t mind because he knew that within a very few years all of the states would succumb to pressure from the hospital chains and associations and pass expansion. This is the same thing that happened to regulation of CO2 from stationary sources (Scalia delivered the opinion, but it has Roberts’ fingerprints all over it).

    On my really cynical days, I also claim that Roberts could be predicted on this — it’s an enormous benefit to large corporate America. The health insurance, hospitals, and pharmaceutical companies all get a large number of new paying customers. In the longer run, there’s an escape hatch for companies to get out of the group health insurance business.

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    • We’ve had this discussion before elsewhere, but again, notably absent from this complaint is a comparison to what they had before the ACA was passed. Bad is still a step up from terrible.

      What is the use of being forced to purchase insurance if you don’t or can’t pay the deductible?

      Well, for one thing, if you’re in a car accident, you can end up with a debt of, say, $6,000 that you may eventually be able to pay off instead of a debt of, say, $100,000 that you may never pay off. That’s the critical feature about insurance. You’re not usually *happy* when you use it. You’re just happier than you’d have been without it.

      The fact that we in the US use insurance as a prepaid medical all-you-can-eat buffet often causes us to forget what insurance really is. If your house burns down, you’re probably going to be out a significant (perhaps devastating) amount of cash even after insurance. That doesn’t mean that you’d have been better off without insurance.

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    • “What is the use of being forced to purchase insurance if you don’t or can’t pay the deductible?”

      Glad you asked!
      You know what the liberal answer to this is, don’t you?

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  8. “In summary: the Affordable Care Act has resulted in marginal improvements, but it is not perfect, nor is it necessarily even a good piece of legislation.”

    Marginal improvements. For what cost, both financial and personal? That’s the real question.

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  9. This was a nicely balanced and useful article, right up to the penultimate paragraph where you claimed that the “United States has the best medical care system in the world, hands down.” This is simply false, on almost every metric that has been studied. A pity you felt you had to indulge in that kind of irrelevant exceptionalism….

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      • Well, if so, you’re making that final point very badly. The two statements “The United States has the best medical care system in the world, hands down.” and “when it comes to delivering care to our citizens, we pale in comparison to France, or Japan, or Greece, or Saudi Arabia, or Colombia, or Portugal, or 100 other nations.” are simply contradictory. A medical care system is the complete, end-to-end system, and it’s this system which is so badly broken in the US. Perhaps you meant that “The United States has the best medical technology” in the world. Possibly true, but irrelevant. Or perhaps you mean “best medical practice” (by doctors and nurses at the point of delivery). Sorry, even that is false; not only is practice distorted by billing systems and malpractice, but US practice is not keeping up. (See The Checklist Manifesto for one example.)

        If you were agreeing with me, that’s great – but I wish you’d done so more directly.

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      • You make some good points here. I should have been more explicit in differentiating medical care and health care. The term “medical care”, as used, refers to treatment for illness or injury by medical professionals, such as would occur in a hospital, a disproportionate number of the best of which are contained in the United States. Perhaps it is because we do not see the complete systems-based picture that the overall effect is so underwhelming.

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      • Ah, I get what you’re saying now (I was like Geoff, a little confused by the statement that the U.S. has the best medical care system in the world, because it obviously doesn’t). Ebola is a pretty good example. If I had some horrible, acute disease or condition like ebola, there are probably no hospitals that I’d rather be in the world than the top 5 or 6 in the U.S. (the top hospitals in France or China, say, would be equal, but we’re talking 1 or 2 hospitals in those countries, and 5 or 6 here).

        On the other hand, if I wanted to be healthier more generally, and increase both the length and quality of my life, the medical care systems of several other countries will do me much better.

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      • If I get cancer, there’s a handful of hospitals — pretty much all US — I’d like to get treated at, over practically every other hospital in the US.

        Those are world-class, top-of-the-line, best care anywhere.

        I’ll probably just get treated locally, wherein I will get first world health care — if I have insurance. Which leaves out a lot of people. Which is, frankly, a more third world sort of system.

        Our best is best in the world. Our average is..average. Our access is crap.

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    • ” A medical care system is the complete, end-to-end system, and it’s this system which is so badly broken in the US.”

      You can get really good statistics when you don’t count dead babies or resident-but-not-citizen-immigrants in your statistics.

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    • The two statements “The United States has the best medical care system in the world, hands down.” and “when it comes to delivering care to our citizens, we pale in comparison to France, or Japan, or Greece, or Saudi Arabia, or Colombia, or Portugal, or 100 other nations.” are simply contradictory.

      Those statement can, and often do, mean lots of different things.

      If Bob says to Jim, “Ferrari makes the best cars in the world,” and Jim replies, “No, Honda makes the best cars in the world because they build safe, reliable cars with good gas mileage that lots of people can afford to drive,” then it should be fairly obvious that Bob and Jim are having two slightly different conversations.

      On the other hand, if I wanted to be healthier more generally, and increase both the length and quality of my life, the medical care systems of several other countries will do me much better.

      This depends to what extent we believe that a country’s medical care system is directly related to individuals’ likely health outcomes. If you moved from America to another country you might improve your health outcomes because you end up eating a healthier diet or because you walk more or because you end up someplace with labor-leisure preferences tilted more towards the leisure. The only way, however, you could say anything meaningful about the effect of medical systems is if you found your lifestyle/statistical doppelganger in one of those other countries.

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      • “The only way, however, you could say anything meaningful about the effect of medical systems is if you found your lifestyle/statistical doppelganger in one of those other countries.”

        This is, of course, an absurd standard. If you were to follow it rigorously, you would be unable to make any comparisons between anything. Is your world totally devoid of shades of grey? Are all your correlation coefficients strictly 1.0, 0.0, or -1.0?

        Try again, please.

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      • [Gets out regression textbook.]

        Oh, it reading here about how regression modeling works, it looks like I don’t have to do a long-lost-Italian-twin study to come up with reasonable estimates of the effects of a health care system on longevity and quality of life.

        That’s a relief, too, ’cause I was all set to start cloning myself and sending clone me’s to the far corners of the Earth (I was going to take either Iceland, Italy, or Corsica).

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      • Oh, it reading here about how regression modeling works, it looks like I don’t have to do a long-lost-Italian-twin study to come up with reasonable estimates of the effects of a health care system on longevity and quality of life.

        That is a weird statement, because providing a ceribus paribus coefficient estimate is exactly what regression modelling does. So the question becomes: what do you think that coefficient looks like?

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      • How does that make what I said a “weird statement?” What you said makes it weird is basically the point I was making: you don’t need to do a controlled study with a matched-pairs sample to get a reasonable estimate, because we have statistical tools that can get us such estimates with existing data. You seemed to be implying that we need a controlled experiment. Controlled experiments would be better, since we want to make causal inferences, but are not possible on this scale or ethical for that matter.

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      • “you don’t need to do a controlled study with a matched-pairs sample to get a reasonable estimate, because we have statistical tools that can get us such estimates with existing data. ”

        But you do need to be aware of whether the numbers you’re looking at are controlled to show the comparison you want to make.

        Death by violence tends to occur far earlier in life than death by complications of ill health. If you just lump together all age-at-time-of-death statistics, then countries with higher rates of death by violence will appear to have a lower life expectancy than others. If you just use the flat number to draw conclusions about a country’s healthcare system then you’re doing it wrong.

        And hey ho, the USA has a higher rate of death by violence than those enlightened European countries that are supposedly kicking our medical butts.

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      • You are right that there may be studies out there that give us a good estimate of the effects of the US health care system holding all of the personal and lifestyle factors constant. And if your statement is based on that, then I am wrong.

        All of the comparative studies that I see being used as proof of the inferiority of the US health care system, however, rely on descriptive statistics. Descriptive statistics are not unimportant in a policy conversation, but they don’t do all that much work in making claims about one individual’s potential outcome.

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  10. Between

    A pity you felt you had to indulge in that kind of irrelevant exceptionalism….

    and

    Try again, please.

    I have to ask: should I know you? I don’t recognize your name, but maybe you are some remarkable person with a body of notable accomplishments to your credit and that’s what gives you that attitude. Or maybe it’s just run of the mill, unearned internet snark.

    Anyway, I guess it’s pretty easy to criticize someone else’s statements when you pull individual sentences out of context. Of course you can make comparisons between health care systems. What you can’t do is take those broad comparisons (mostly based on descriptive statistics) and extrapolate them to make meaningful predictive claims.

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  11. “What you can’t do is take those broad comparisons (mostly based on descriptive statistics) and extrapolate them to make meaningful predictive claims.”

    I’ll be happy to give up on “predictive claims” if you’ll accept “rational, evidential bases for choosing between alternative policies”. Without that, you’re left with fact-free ideology, which strikes me as a very bad alternative.

    And yes, I know that foundational principles like there is no role for government in health care or universal health care is a fundamental right are ideological axioms (or can be derived from such axioms). But when it comes to debating policies that are intended to achieve agreed-upon ends, it seems perverse to ignore relevant experiences elsewhere. Any claim that the USA is sui generis needs to be justified.

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    • But when it comes to debating policies that are intended to achieve agreed-upon ends, it seems perverse to ignore relevant experiences elsewhere. Any claim that the USA is sui generis needs to be justified.

      The I guess it is a good thing that no one is saying that. You’re tilting at windmills.

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    • Colorado has approved all of the rate changes for 2015. They range from -19% to +23%, with an average increase of 2.0% and a median increase of 2.1%. Economists for the legislature and the Governor’s Office are using an estimate of 2014 CPI inflation of about 2.8% for building the next budget. OTOH, my private sector retiree coverage went up >20%. If the company would drop its retiree group plan and just send me a check for what it contributes, I could go to the exchange and get a much better price. But then they would lose their lovely tax break…

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  12. Before this falls down, McKinsey’s study on insurance 2015 is out.

    Participation by insurers in the exchanges? Up 26%. And rates are up for 65%, but only 4%. When’s the last time your rates only went up 4% a year?

    #whodathunkit.

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  13. Just read this post, CC. Well done. My only contribution is a response to this claim:

    We’ve had to really work hard to create such a pronounced ineptitude at health care delivery in this nation, where politics prevents medical services from getting to those who need them.

    See, I don’t look at it that way. The gargantuan levels of ineptitude resulted from the complete absence of effort to do anything at all other than grease wheels that get really squeaky from time to time.

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