Monday, November 16, 2015

A month of "yes buts"

For some reason, in the past month or so I've found myself pushing back against, or at least qualifying, assertions about the ACA by people with deep expertise in healthcare, or economics, or healthcare economics. They all know a good deal more than I do, but touched on areas that I've been preoccupied with.

These posts aim to put a corrective lens on...not myths, but partial truths that in some cases leave a misleading impression. Specifically:
  1. Silver plans sold in the ACA marketplace offer skimpier coverage than most employer-sponsored plans.  True for some, but not for two thirds of silver plans sold in the marketplace.

  2. Most people choose unwisely when selecting a health plan.  Perhaps most buyers don't choose the plan that best suits their needs. But in the ACA marketplace, it seems that most buyers get the most important decision right.

  3. The ACA is not as egalitarian as it seems because it leaves many moderate-income buyers in the lurch. It's true that the program does not offer great options to many uninsured people with incomes over 250% of the Federal Poverty Level.  But about two thirds of the uninsured are below that income level.

  4. The ACA leaves many people with deductibles so high they forgo needed care. True, but how many is many? 21% of marketplace customers are enrolled in bronze plans. Another 12% are in silver plans unenhanced by Cost Sharing Reduction subsidies. Not all of this third are dissatisfied; surveys (Kaiser, Commonwealth) generally peg enrollee satisfaction at about 75%.
Collectively, these posts are far from suggesting that the ACA is an ideal or complete response to the country's problems with healthcare access and cost. It's provided vital resources to perhaps 20 million lower income people. It's helped more than it's harmed, though it's harmed some, at least in the short term. It would be a decent foundation to build on if our political system were capable of building on it. That is, if Republicans would work to improve rather than sabotage it.


  1. Another take on the same topic:

  2. Another take on the issue:

  3. Here are several reforms that would cure many of the ACA's problems:

    -- extend subsidies to all incomes, so middle class couples who earn more than $64K are not cut off

    - base subsidies on the cost of a gold plan, with more modest deductibles and decent drug coverage

    - use 80% of AGI for subsidies (since that is what a person really has to spend after taxes

    - allow persons over 55 to buy into Medicare at cost, using their subsidies to help pay what would be an $850 monthly premium

    Bob Hertz, The Health Care Crusade