The Republicans' ACA shell game

The most credible rap against the Affordable Care Act is that it raises the cost of insurance bought in the individual market for people who have no preexisting conditions and earn too much to qualify for subsidies.

That is true. Hence all the "rate shock" stories bruited by the GOP last fall.  Most of those stories did not survive scrutiny, because the GOP went for dramatic hardship cases, and most true hardship cases qualify for subsidized coverage.  Those truly dinged by the law were more like a couple with two children profiled by the New York Times earning about $100,000 per year and a single 50-something man earning just under $50,000 profiled in the same article -- folks on the wrong side of the subsidy cliff.*

Somewhere between one and five million people suffered at least short-term financial harm of this sort. Their numbers are now dwarfed by the 6-7 million people getting subsidized private plan coverage, the 7 million-odd added to the Medicaid rolls, and the 2-3 million under age 26 who gained coverage on their parents' plans.

The law as a whole remains unpopular -- because Republicans have been relentlessly smearing it for five years, because the individual mandate has always been an unpopular concept, because healthcare.gov dysfunction imprinted "train wreck" perceptions before the problems were patched and signups surged, and because astounding numbers of the still-uninsured still don't know that they qualify for subsidized coverage.

Nevertheless, reality has seeped in enough to sap the strength of the Republican attack.  And as the intensity of that attack has diminished, its policy core has shrunk to a simple line that masks a core evasion. Here's one iteration, as expressed to Talking Points Memo's Sahil Kapur:

"Ensuring that people with preexisting conditions have access to coverage has long been a popular policy, and one where there is bipartisan agreement. It's the the entirety of ObamaCare that remains EXTREMELY unpopular," Brad Dayspring, a spokesman for the Senate GOP's campaign arm, told TPM in an email.

Buying unsubsidized insurance in the ACA universe: A preview

A few days ago, I noted that less than 20% of those who had completed applications on ACA exchanges and been found ineligible for subsidies had actually enrolled in plans through the exchanges.  I added an invitation to people who were shopping for insurance without a subsidy to share their experience with me.

I have since spoken to several people who have bought insurance off-exchange. I will report on their fascinating experiences in a few days: first, I want also to speak to brokers and perhaps others who can overview the off-exchange individual market (if you can help, please let me know). Here, I'd just like to overview a few patterns and general observations. Some are obvious but perhaps still not widely recognized. Here goes:

1) If you are subsidy-ineligible, there is no reason to complete the transaction through Healthcare.gov or a state ACA exchange.  Why add an extra layer of bureaucracy and send you application through the shaky "834" tunnel? (An 834 transmission is a reporting tool that brokers, and now the exchanges, sue to send completed applications to insurers.) Also, why not get a sense of how responsive competing insurers are? [Update, 2/17: a reader provides a reason to buy on the exchange: "future income is never guaranteed and if I end up unemployed or with a lower than expected income in 2014, I can get the subsidies later when I file my taxes if I’m eligible. "]

2) Price aside, the individual market is much easier to navigate than it used to be -- first, because the ACA exchanges offer a quick lay of the land and price benchmark, and second, because medical history is no longer relevant.  Two people told me that all you need is a credit card -- the insurers don't even ask for a driver's license.  And if you come to a broker quoting an exchange plan in your price range and asking if they can beat it, you are shopping with the benefit of solid price discovery.