Paul Krugman asks whether health insurance is purely parasitical; doesn't quite answer

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Paul Krugman, noting that most U.S. healthcare spending is filtered through private insurers, takes aim (in his new post-NYT retirement Substack) at private health insurance in the U.S.:

Let me offer a somewhat, but only somewhat, caricatured view of U.S. health care: It’s a system in which taxpayers bear the cost of major medical care, but this taxpayer money flows through private companies that take a cut, spend a lot on administration, and do their best to deny care to people who need it.

His argument as to whether private insurers add value is sketched in lightly, and focused entirely on Medicare Advantage:

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What service do private insurers provide in return for the tolls they in effect collect on a largely taxpayer-financed system? Medicare Advantage plans generally offer more extensive coverage than traditional Medicare. But there doesn’t seem to be any clear evidence that this is because private insurers provide efficiency gains the public sector doesn’t. What happens instead is that Medicare Advantage plans appear to be able to game the system sufficiently that they receive more taxpayer funding per enrollee than traditional Medicare spends on recipients in equivalent health…So you could make the case that at this point private health insurance is, in large part, a parasitical racket.

You could make that case, but leading with “you could” is a pretty equivocal way to make it. My take on the evidence (adapted from my comment on Krugman’s post) is below. The first point is a footnote to Krugman’s overview of private insurance’s share of U.S. healthcare spending.

1) Most Medicaid coverage is now also administered through private insurance companies (MCOs). Per KFF, 74% of Medicaid enrollees are in MCOs.

2) According to a KFF literature review, including a review of enrollee satisfaction surveys, Medicare Advantage enrollees are about as satisfied as traditional Medicare enrollees. By all accounts, problems in MA tend to come when you need serious care (especially post-acute care) — and denials appear to be on the increase. According to a Senate investigative report (inspired by reporting from STAT’s Bob Herman and Casey Ross), coverage denials from UnitedHealthcare MA plans for acute care more than doubled between 2020 and 2022 after the company adopted an AI tool (owned by UHC subsidiary NaviHealth, and also used by Humana and CVS Aetna) to assess claims.

3) Insurers "save" healthcare spending by denying not only needed but unneeded care -- and it's difficult to parse out the proportions of each. Surveys indicate that MA plans do encourage people to get screenings and so may prevent more acute care down the road. According to the KFF literature review, “The analyses consistently found that Medicare Advantage enrollees had higher utilization of preventive services and lower utilization of post-acute care and home health services.”

4) Some healthcare economists (e.g., Austin Frakt) find evidence that Medicare Advantage treatment protocols "spill over' into traditional Medicare and so save money there.

5) Private companies (MACs) also administer traditional Medicare, but with a very broad coverage grant and few coverage denials. MACs have no incentive to deny coverage.

6) In countries that deliver universal healthcare through private insurers, such as Germany and Japan, major medical insurers must be nonprofit. Germans can opt out of the nonprofit Statutory Health Insurance system into private plans, as 11% of the population did in 2019. But the government sets provider payment rates for private plans and limits premium increases. In Japan, as in many countries that deliver universal coverage through private plans, supplemental insurance can be for-profit.

7) In the U.S. whatever money insurers save by managing (denying) care is swamped by overpaying providers, which happens because we have no uniform payment rates, so providers divide and conquer. In the case of Medicare Advantage, where providers are paid Medicare rates or less, the savings are negated by payment formulas that overpay MA plans on a capitated basis, via a) a ridiculous risk adjustment system that incentivizes massive gaming, b) over-generous payment benchmarks, and c) bonus payments based on quality ratings that don't measure quality effectively.

8) Private insurers probably do have the capacity or potential to add administrative and care management value. But in the U.S., profit skews the incentives. In fact, it skews incentives for providers as much as for insurers. Almost all participants (e.g., those owned by giant insurers or private equity) are geared toward revenue maximization ("nonprofit" or not).

P.S. My own two-part assessment of Medicare Advantage (from 2022) starts here.

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Should the U.S. ditch private insurance?

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Elizabeth Warren has gotten tight with Ady Barkan, a brave ALS patient and advocate for Medicare for All. In the July 30 debate, she told his tale:

The guy who has ALS, this isn’t this is somebody who has health insurance and dying. Every month he has about $9,000 in medical bills that his insurance company won’t cover. His wife Rachel is on the phone for hours and hours and hours begging the insurance company please cover what the doctors say he needs.

Barkan, in his turn, tweeted during the next night's debate: 

Every candidate on stage who doesn’t want to get rid of private insurance should have to explain what a company like Aetna adds to our health care system. How do they make patients’ lives better? #DemDebate

— Ady Barkan🔥🌹 (@AdyBarkan) August 1, 2019

Fair enough. Whether to preserve private insurance, and how to reform it if so, are the questions that divide Democratic candidates' approaches to healthcare reform, at least theoretically (what each of them would truly aim to accomplish via legislation introduced in 2021, and how they would balance their healthcare goals with other priorities, are questions they should be asked). 

In any case, let's look at the rap sheet against insurance companies -- and set it against their claims to add value to our healthcare system.

The raps

• Divided and conquered: All but uniquely among wealthy countries, the U.S. leaves private insurers to each separately negotiate payment rates with healthcare providers. The fragmented payer universe gives providers outsized bargaining leverage, particularly in areas with dominant hospital systems or provider shortages.  Accordingly, commercial insurers pay hospitals about 189% of Medicare rates, according to a Congressional Budget Office estimate, and 241% Medicare according to a more recent RAND study. Commercial rates for doctors are about 128% Medicare, according to MEDPAC. 

Supporting the biggest decision for ACA marketplace shoppers

People make poor decisions when buying health insurance. So demonstrates health economist Austin Frakt in a review of studies probing Americans' health insurance decisions and knowledge base. Frakt cites studies finding that:

• most people choose wrong when faced with relatively small tradeoffs between premium and deductible; 
• Americans have a poor grasp of core insurance terms like "coinsurance; 
• low income people will choose a plan labeled "gold" over one labeled "bronze" even if the "gold" plan is manifestly inferior (researchers swapped the labels to test comprehension); and
• when given an estimate of our yearly medical costs, a typical ACA marketplace shopper can't determine which plan would cost them least.

The upshot: When choosing among Medicare plans, employer-sponsored plans, or private plans on offer in the Affordable Care Act marketplace, we all need help.

But what kind of help? That depends, in part, on the menu of choices. And the ACA marketplace is unique -- different in at least one vital way from the markets for Medicare or employer-sponsored plans.

Addled by the metal level

Austin Frakt has a series of posts (1,2,3) reviewing research that highlights what a hard time most people have making good choices among insurance plans -- mainly in balancing premium against deductibles and copays. One such study, by a team led by Peter Ubel, highlights (to my mind) a defect in ACA marketplace design:

...two of us recruited a convenience sample of participants from public buses in Durham, North Carolina, and asked them which category of plans they would look at first if they were shopping for health insurance. To half the people, we described the gold plans as having higher monthly premiums and lower out-of-pocket costs — the language used by many exchanges. For the other half, we switched the gold and bronze plans, describing the gold plans as having lower monthly premiums and higher out-of-pocket costs.

...among participants who were below the median in mathematical ability, the majority said they preferred gold plans over bronze plans, regardless of which plan was labeled as gold.

In real life, of course, labeling skimpier plans "gold" would be deceptive marketing, and labeling superior plans with a less-valuable metal would be just plain stupid. But for about two thirds of marketplace customers, that latter mislabeling is pretty much what the marketplace does.

Narrow networks: a painful of tourniquet on a bleeding healthcare system

Stories of bad buyer experiences with ACA exchange plans often induce me to push back a bit. I can't do that with Elisabeth Rosenthal's laser strike on patients' troubles with ACA plans' narrow networks and mazes of separate copays and coninsurance for different procedures.  Rosenthal is too nuanced, too thorough with context, and too precise in her accounts of buyers' experiences to quibble with. A sampling:

Alison Chavez, 36, who is self-employed, signed up for a marketplace plan in October 2013 that she hoped would be an improvement on her previous plan. She had recently been given a diagnosis of breast cancer and was just beginning therapy, so she was careful to choose a policy on the Covered California marketplace that included her physicians.

But in March, while in the middle of treatment, she was notified that several of her doctors and the hospital were leaving the plan’s network. She was forced to postpone a surgery as she scrambled to buy a new commercial policy that included her doctors. “I’ve been through hell and back, but I came out alive and kicking (just broke),” she wrote in an email

Rational choice in the ACA marketplace

Here's another piece of the puzzle in my quest to figure out why ACA private plan buyers bought low-premium, high-deductible bronze plans in much higher proportions in some states than in others (8% of Mississippi plan buyers selected bronze; 41% of Hawaiian shoppers did). A good predictor is each state's public health profile. (Thanks to Brad G. for putting me on the trail.)

Bronze plans, in which deductibles average over $5,000 per person, are bad deals for people who are likely to make heavy use of medical services. They're also bad deals for low-income buyers, who can access generous Cost Sharing Reduction subsidies that reduce deductibles and co-pays (radically for those with incomes under 200% of the Federal Poverty Level) -- but only if the buyer chooses a silver plan. Low income buyers are often in poor health, and know it. Most ACA buyers have been uninsured and so may have pent-up healthcare needs.

I have previously noted that a very high percentage of buyers eligible for CSR did in fact choose silver plans, and that lower income states did have lower percentages of bronze buyers -- though there are notable exceptions up and down the scale. The same is true for measures of public health in each state. Wealthier states tend to have healthier residents -- though wealth disparities within states can complicate the picture.

In the chart below, I have tabulated three public health measures drawn from the Kaiser Family Foundation's State Health Facts: life expectancy, incidence of  Diabetes, and obesity -- for the ten states with the lowest and highest takeup of bronze plans. The average bronze takeup states in the former group is 14.25% of all plan buyers, and in the latter group, 31.1%.  In all three health measures, the low-bronze-takeup states as a group significantly underperform the high-bronze-takeup group. The income disparity between the two groups is also stark.*

More choice is coming to ACA exchanges. How much is too much?

Hooray! Based on the first state reports, more health insurers will enter more ACA state exchanges in 2015 than in 2014. In Illinois, for example, as Peter Frost reports in the Chicago Tribune, six insurers offered a total of 120 health plans in the state in 2014, whereas in 2015, eight companies (with ten brand names) will offer 306 plans.

That's good, right? Well, more competition should mean better prices, and perhaps force constructive creativity in plan design. From a consumer shopping standpoint, though, how much choice is too much? What will a state marketplace with 300 plans look like?

The first thing to recognize is that the market is different in each county, and no county will offer 306 plans. This year, with 120 plans sold in the state as a whole, Cook County, home of Chicago, had 65 plans on offer.* Other Illinois counties that I tested at random had between 36 and 51 plans.  (That's a lot. By my count, Los Angeles, CA had 36 plans on offer this year.) Extrapolating, Cook County may have 160+ plans posted next year, sorted into the four metal tiers plus catastrophic. 

When "choice" is a euphemism for "wealth"

I am a little surprised that two leading healthcare economists, Austin Frakt and Amitabh Chandra, write approvingly in The Upshot of this proposal for a new kind of health insurance:

If plans could compete on the basis of the therapies they cover, consumers could decide what they wish to pay for. This sounds complicated, but it need not be.

Health plans could define themselves at least in part by the value of technologies they cover, an idea proposed* by Professor Russell Korobkin of the U.C.L.A. School of Law. For example, a bronze plan could cover hospitalizations and visits to doctors for emergencies and accidents; genetic diseases; and prescription drugs that keep people out of hospitals. A silver plan could cover what bronze plans do but also include treatments a large majority of physicians find useful. A gold plan could be more inclusive still, adding coverage, for instance, for every cancer therapy shown to improve patient outcomes (no matter the cost) as long as it was delivered at a leading cancer center. Finally, a platinum plan could cover experimental and unproven cancer therapies, including, for example, that proton beam.

This way, nothing would be concealed or withheld from consumers. Someone who wanted proton-beam cancer treatment coverage could have it by selecting a platinum policy and paying its higher premiums. Someone who did not want to pay higher premiums for lower-value care, in turn, could choose a bronze or silver plan

The author of the proposal, Russell Korobkin, implicitly admits that it's a bit utopian, or at least a distant prospect, in that "there is very little solid information demonstrating the basic effectiveness of the majority of medical treatments recommended by physicians and other providers every day" and "where there is more than one plausible intervention, there is even less information available concerning the comparative effectiveness of possibilities."  His plan depends on creating a uniform scale of "relative value ratings" based on an existing measure, quality-adjusted life-years, "routinely used by health service researchers to compare the benefits of dissimilar interventions."

How to choose a health plan? Even Austin Frakt needed help

If you were shopping for a new health insurance plan, how much extra would you be wiling to pay for a plan that included your current doctor or doctors, or a nearby hospital you think well of, or a top cancer center that you don't need now --as far as you know?  How much more deductible and co-insurance would you take on to lower your monthly premium?

These questions are not easy to answer. Not for a 27 year-old transitioning off a parent's health plan. Not for a 35 year-old fast-food worker. Not for a 48 year-old self-employed consultant. Not even for a health economist.

Austin Frakt, a health economist at the U.S. Department of Veterans Affairs and Boston University and co-Editor-in-Chief of The Incidental Economist blog, has had a personal taste of the complex decisions facing shoppers on the health insurance exchanges established by the Affordable Care Act. In many states, buyers are confronted with dozens of plan options -- though for most, price will probably narrow the feasible choice to a handful. As a federal employee, Frakt has for some time chosen his family's insurance on a yearly basis  from a precursor of the exchanges, the Federal Employee Health Benefits Program, which in Massachusetts offers more than a dozen options. He has long chosen Blue Cross Blue Shield plan for his family that has a low deductible and is "accepted pretty much everywhere" -- that is, by every doctor and hospital the Frakt family has had cause to access.

Frakt has more than once considered the possibility that higher deductible plan with a lower premium might save his family money. He tells me, though, that when he considered switching to a high deductible plan without any form of decision support,  the utility of doing so was "very hard to assess. You have to know a good deal of detail about your own plan,  the plan you're comparing it to, and your own utilization pattern. Also, the deductibles and copays for everything. You would want to know if the doctors you currently use are in the other plan's network. It's a very complicated comparison. I was overwhelmed, couldn't compare them meaningfully."

What if the (Republican) dog catches the Obamacar(e)?

Healthcare economists Austin Frakt, Donald Taylor and Yevgeniy Feyman on the future of healthcare reform

If Republicans win both houses of Congress and the presidency by 2017, what will they do to the Affordable Care Act?

The first substantive "repeal and replace" legislative proposal offered by Republicans since the ACA passed, unveiled in outline on January 27 by Republican Sens. Tom Coburn (OK), Richard Burr (NC), and Orrin Hatch (UT), purports to settle that question by making repeal of the ACA its first provision.  The Coburn-Burr-Hatch proposal (CBH*) has led healthcare wonks on the left and right, however, to conclude the opposite: "Repeal ACA, RIP," as Donald Taylor of Duke titled his analysis.

That's because after the "repeal" provision come the come the "replace" provisions, and to greater or lesser degree most are cousins of their counterparts in the ACA. CBH subsidizes insurance for people whose earnings fall between 100% and 300% of the Federal Poverty Level (FPL); provides a functional if more porous equivalent of the individual mandate and guaranteed issue; allows adults up to age 26 to stay on their parents' plans; bars lifetime coverage caps and  policy cancellations for reasons other than fraud; semi-privatizes Medicaid; taxes employer-sponsored insurance more heavily than the ACA does; and leaves the ACA's Medicare payment reforms and cuts untouched.

CBH thus clarifies that we are in a healthcare world remade by the ACA, and any conservative proposal that purports to cover as many people as the ACA, or close to it, must retain its basic infrastructure: subsidized private insurance, with some mechanism for minimizing medical underwriting and luring almost everyone into the risk pool. In short, the first relatively fleshed-out "repeal and replace" proposal demonstrates that "replace" effectively erases "repeal."

If repeal is all but off the table, how would a GOP-controlled federal government alter the ACA? I asked three healthcare economists to consider that question: progressives Donald Taylor of Duke and Austin Frakt of the U.S. Department of Veterans Affairs and Boston University, and conservative Yevgeniy Feyman of the Manhattan Institute. There was substantial consensus among them that repeal is dead -- but also that conservative alterations of the ACA are likely. Feyman is  eager to open the individual market to a greater variety of plans than the ACA allows on its exchanges.  Frakt and Taylor have long urged compromise that could win Republican acceptance and deploy "conservative designs for progressive ends," as Frakt put it (as the ACA itself does). Both Taylor and Frakt find some provisions of CBH palatable and even desirable on the merits. (Frakt, Taylor and Feyman all blog extensively on healthcare reform: Frakt at the healthcare policy blog The Incidental Economist, where he is co-editor in chief; Taylor on his personal blog; and Feyman at Forbes.)

If Republicans win it all, what will they do to the ACA?

I want to make a foray into reporting and ask some healthcare wonks what they think Republicans will do to the Affordable Care Act if they win both houses of Congress and the presidency by 2016.

While Republicans gleefully anticipate the ACA's implosion, ACA supporters assure themselves that repeal is a dead dream, as the ACA has already provided insurance to millions and rewritten coverage rules (e.g., guaranteed issue) in ways that will be impossible to take away. That may be true. But it does seem to me that Republicans in control of Congress and the presidency could ruin the law without repealing it outright.  They could do so out of a combination of antipathy to a law that (colloquially) bears Obama's name and sincere belief in principles such as consumer choice and deregulation.

Facto or factoid?

Austin Frakt has started a Twitter string, partly prompted by an exchange with me, that has me troubled about the name of my blog, which was a casual accident.

The substantive discussion was about whether policy outcomes eventually settle policy debates (Frakt is skeptical). The Twitter shorthand is "fact or factoid?"  That brought me back to what I thought I was doing in naming this blog.

I opened a space on Blogspot called xpostfactoid in 2004 and put up a handlful of entries about the Kerry campaign. It sat fallow until 2007, when Obama appeared on the horizon. The name was, I think one of those spontaneous puns that please the finder and then aren't given much thought.  But it did later take on a significance to me that I'm now thinking was founded on a double error.

A country struggling to share too-high healthcare costs

Jonathan Cohn today posted a roundup of eight health care experts' prognoses for the Affordable Care Act. Among them is Sean Parnell, author of the book and blog The Self-Pay Patient, information sources for those forced to pay all or most or a good portion of their medical expenses out of pocket. Regardless of whether the ACA "succeeds" or "fails," this part of Parnell's forecast is a near-certainty and worth noting:

There will be more Americans who pay directly for more of their health care. The ACA is projected by the Congressional Budget Office to leave 30 million people uninsured, and tens of millions more will get high-deductible plans through exchanges or their employers. These self-pay patients will demand price transparency and discounts for paying in full at the time of treatment, and innovative entrepreneurs will step up to cater to them while ignoring the traditional third-party payment system.

Many have pointed out the irony of Republicans excoriating the ACA for offering high-deductible plans, which conservatives have long touted as a means to promote patient responsibility and cost control. Some reforms intended to make patients weigh costs could be effective if they include the information required to make an informed choice -- e.g., incentives to choose providers with high performance ratings and transparent pricing -- or reference pricing, where the use of a plan-preferred specialist is fully covered, while patients pay the difference if they want a more expensive provider. 

Red states' ACA exchanges: lab or slab?

Austin Frakt has launched a multi-post-and-tweet campaign arguing that the Affordable Care Act is an essentially conservative chassis amenable to conservative reform, and that conservative healthcare wonks should be aiming to mend it, not end it. (Subtext: they'd be doing just that  if they were not playing for Team GOP.)

The penultimate post in the series dangles conservative wonk-bait via a list of potential reforms in ascending order of disruptiveness to the current ACA structure, e.g., paring back essential benefits and allowing more catastrophic plans on the exchanges (not so disruptive) and creating high risk pools or universal zero- or low-premium catastrophic insurance (very disruptive).  But how to move GOP lawmakers and their think tank supporters off their "repeal and replace" schtick and onto a "revise and reform" track?

Frakt's most recent post suggests an answer by misdirection:

My conclusion is that the ACA is far more amenable to more conservative reforms than to more liberal ones. Of course, this could change. A public option could be added, for example. But, having had that political fight recently, I doubt it will. The most likely pathway leftward (in the sense of toward single payer) would be if the ACA failed in a sense that could be interpreted as market failure.

In fact, I do expect the ACA to fail in some states, but not in the ones that are most likely to adopt a state-level single payer program. Exchanges may fail where support for and enrollment into them is discouraged by political leaders and other institutions. Ironically, this is more likely to happen in states whose leaders are more ideologically supportive of market-based approaches.

If some state exchanges fail, and Republicans do not at that time control presidency, Senate and House, then what? Looking back at GOP state governments' refusal to run their own ACA exchanges, Jonathan Bernstein offers a might-have-been that's also, it seems to me, a may-be-yet:

Imagine if, right now, there were only a handful of states in the federal exchange, and some of the more aggressive and innovative conservative governors were running their own exchanges...suppose that several Republican governors had pushed for a deal in which they would implement Obamacare, including setting up exchanges in their states, if and only if they were given waivers and allowed to try some conservative policy ideas. The pressure would have been intense on the administration to allow at least some of them. After all, the administration never wanted to build all those different state exchanges in the first place. And certainly the president didn’t want obstruction verging on sabotage from Republicans across the board, as is de rigueur now. In order to get some Republican buy-in, there’s a very good chance Obama would have been extremely willing to cut deals, even if liberals would have been appalled at the results for the affected states.

Recall also that back in 2011 Obama supported legislation that would have moved the starting line for state waivers enabling alternative means of reaching near-universal coverage from 2017 to 2014 -- and further, that the administration has proven receptive to rather radical, privatized variations of the Medicaid expansion.

In short, O'Barkis is willing.  Too bad Republican governors and legislatures are more interested in sabotage than in genuine conservative policy innovation.  If and when, however, they're stuck with the corpse of a state exchange (or one on life support), and the ACA is still the law of the land, Republican governors may cook up some fetching Frankenstein monsters of their own. 

The ACA as a framework for (further) conservative healthcare reform

Austin Frakt does AEI's James Capretta the honor of seriously considering* elements of Capretta's attempt (with Douglas Holtz-Eakin) to fill in the long-empty "replace" blank in Republicans' purported "repeal and replace" program for the Affordable Care Act. After spotlighting various lacunae as well as potentially workable elements in Capretta's "decentralized, market-diven alternative to the PPACA," Frakt comes to a core point, implicitly questioning whether conservative healthcare wonks are acting in good faith:

6...Democrats are well aware of the limitations and problems with the Affordable Care Act. Some are so troubling that the administration is considering some interesting proposals that would require Congress to act. Point being, there is leverage for some negotiation on some aspects of the law. And, crucially, some of the things Capretta has proposed fit within the structure of the ACA, such as allowing Medicaid enrollees to buy exchange plans (see Arkansas), capping the employer-sponsored insurance tax subsidy (see the Cadillac tax), or making exchange plans more catastrophic. But that brings me to …

"What if Obamacare works?" -- What Ross Douthat leaves out

Ross Douthat "fairly fairly" describes the differences between the cheapest health insurance plans available on the ACA exchanges and the cheapest plans currently available on the individual market, most of which will be phased out because they don't comply with ACA minimum coverage requirements.  But he leaves some important facts out.

Douthat acknowledges that the ACA's premium subsidies will offset the price increase for many who buy on the exchanges, and he fairly if too briefly presents the limitations of a cheap plan currently available on the individual market ("a $5,000 deductible, an annual out-of-pocket limit of $12,500, and all kinds of copays and coverage restrictions"). He then frames the ACA's political prospects like this:

With some grandfathered exceptions, Obamacare makes those kinds of plans illegal. The out-of-pocket limit for individuals is capped at $6,500 a year, preventive services are fully covered, and various “essential benefits” as well. 

If we ever get beyond the follies of HealthCare.gov, the politics of the rollout will probably be defined by how (and how vocally) middle-class Americans just above the subsidy threshold react to this “pay more, get more, subsidize other people” deal.

True, perhaps -- though the politics will also be defined by the reactions of those eligible for the subsidies, and those shut out of the current market by preexisting conditions or age (the ACA limits age-related price differentials to 3-to-1; currently they're as high as 6-to-1), or, to a lesser extent, by those newly eligible for Medicaid (who are less likely to be politically vocal and perhaps less likely to recognize that their new benefits are a product of the ACA).

It's Douthat's presentation of the likely long-term consequences of a successful ACA rollout that tilts our view of past and future playing fields:

The price of dealing with an extremist opposition?

There is a meme gathering steam on the left -- whether triggered by Ezra Klein or by multiple people in the know or making the same deduction -- that Obama will accede to raising the Medicare eligibility age as the price for pretty much getting his way on taxes (and stimulus)?  Here's how Don Taylor compressed the logic in a tweet: 

it is only thing Rs have on health. Inevitable & some D political advantages per ACA even tho bad policy

My first thought in response was, "since Republicans always toss in "means-testing" when they talk up entitlement "reform," why not "means-test" the eligibility age? As Paul Krugman has pointed out repeatedly, "Gains in life expectancy have been very strongly correlated with income and class; those with lower incomes and lower status...have seen very small gains in life expectancy." So perhaps eligibility could be tied to income or assets. That might create some marginally perverse incentives, but that only underscores what a dumb idea raising the eligibility age is in any case (it will raise total healthcare spending, as Sarah Kliff has demonstrated).