Obamacare’s proponents claimed that the American health-care system could and should be transformed from a fee-for-service model to one based on “value.” To make this transition, the law would promote the formation of accountable-care organizations, or ACOs—groups of health-care providers that assume responsibility and financial risk for the quality and costs of care for a defined group of patients. These groups would presumably yield superior care coordination, enhanced quality, and ultimately lower costs.
When Obamacare was enacted, commentators noted that the proposed ACOs looked like the integrated-delivery networks tried in the 1990s and the Medicare Coordinated Care Demonstration projects funded in 2002, both of which failed to lower costs and improve quality. But the health-policy community insisted that it knew better. A recent publication from the Congressional Budget Office (CBO) suggests that, as usual, they were wrong.
In a 2022 book, Seemed Like a Good Idea , health economist Mark Pauly and his University of Pennsylvania coauthors describe how health-care policymakers “often rely on hope or conjecture, not rigorous evidence of effectiveness” when proposing and implementing new programs. Even when those programs fail, as they usually do, the authors argue that policymakers often persist in supporting them.
It’s really funny. They wanted Medicare for all but they had to compromise down to Obama care. Everyone wants Medicare, can’t wait to get on Medicare, yet they vote for people exactly on the opposite side of their interests.
Everyone wants Medicare because current beneficiaries only have to pay a fraction of what it costs in premiums. Medicare’s premiums only cover about 15% of payouts. The rest is paid out of payroll taxes and general fund monies. Paying 15 cents for a dollar of benefits makes for a very popular program…but not one that can be offered to “all” on the same terms that seniors get it.
Plus, if you had to pay full price, Medicare’s a mediocre policy. It has an actuarial value of about 84%, compared to a typical employer-based plan of just over 90% (higher for HMO’s). Which is why so many end up supplementing the plans - and why efforts to provide single-payer at the state level always end up foundering on the shoals of trying to pay for them.
That said, the headline of this thread is inaccurate. The ACA wasn’t doomed to failure because it hasn’t failed. The ACA as passed was almost entirely about the federal government picking up the tab for lower-income folks’ health insurance - Medicaid expansion and heavily subsidized private market policies. And it’s succeeded amazingly well at doing that, save for a few holdout states
Massachusetts leads the nation with only 2.5% of it’s population without health insurance. State leaders have accomplished this by making it seamless when someone moves from the ACA to Medicaid when their income changes.
Contrast that with our nation’s craphole states where racism, ignorance and innumeracy informs public policy. Texas leads the way with 17% of it’s population uninsured.
The ACA wasn’t doomed to failure because it hasn’t failed. The ACA as passed was almost entirely about the federal government picking up the tab for lower-income folks’ health insurance - Medicaid expansion and heavily subsidized private market policies.
I think the monicker of “Affordable Care Act” was a bit misleading at the time. How soon the public forgets… My recollection of that time was not that ACA as originally proposed and certainly as it was finally enacted was ever going to:
lower premiums for everyone
eliminate the cumbersome claims processes
simplify prescription drug plans
Instead, one of the biggest risk facing average Americans (even upper middle class Americans) was not the risk of merely finding it difficult to afford (say) a $9000 health plan (or $18,000 for a family) and having to give up other things (new car, college tuition, family vacation) to cover health insurance but managing to get it. The problem was risking LOSING insurance by
having a pre-existing condition
losing employer-provided coverage due to a layoff / firing / etc.
being unable to obtain new individual coverage due to pre-existing conditions while unemployed
In that circumstance, being hit with a catastrophic health issue (extended ER / ICU hospitalization, surgery, etc) that rang up a $160,000 bill during a period of no coverage was a guarantee of bankruptcy or not getting treatments for things like cancer, etc. that resulted in death.
I know of dozens of collegues who stuck with jobs and employers they hated in those days because they feared any stint of unemployment and the inability to find new coverage – either because they might have an emergency during that gap or they already faced recurring, astronomic costs for drugs and treatments that would bankrupt them in a matter of months.
The ACA nominally eliminated the ability of insurance companies to NOT sell insurance policies to all individuals due to prior conditions. That didn’t require them to sell deee-luxe insurance coverage for $200/month but it also required all providers to offer “bronze” plans that were capped for yearly premiums and also capped the maximum yearly out of pocket that could keep someone from being hit with a $160,000 bill. The ACA also mandated a minimum set of routine care visits and routine preventative care that raised the basic level of care for ALL insured patients for cancer screenings, etc.
The same people who scream that ACA was / is a colossal failure are likely the same people that scream that ACA limited their choice of doctor. Those same people likely fail to realize how much of their doctor selection is pre-filtered by a) their employer’s choices of plans to offer each year, b) which networks are part of which plans, c) which doctors have negotiated contracts to swap paperwork with which plans. If you haven’t been forced to change doctors over the last 10 years, it could be because your local community is already dominated by 2 or 3 top “systems” that own all of the hospitals and those doctors are eating the cost of being in all 2-3 systems so they don’t see patients churn in and out of their practice every year.
I wouldn’t call Medicare a mediocre policy. It has pretty significant protections against price gouging and out-of-network billing. I was delighted once I turned age 65 and had the opportunity to dump my for-profit health insurer like a steaming bag of dog poo.
Instead, workers, management, and stakeholders are paying more for the private insurance admin costs.
In other words, the system was structured so you can not see the savings with the alternative.
Andy, I have only seen it mentioned once but the law manages or controls a profit margin in the offing for the private insurers to come into the market with advantage plans. It is vague to me now. Just got wind of that once.
When you select Medicare Advantage, CMS pays the insurer the actuarial value of your Medicare Benefit about $12,000/yr.
Your insurer is then allowed to siphon off up to 15% of the $12,000 to admin costs, though heavy competition in urban areas might drop that to 12%-13%. That’s about $1,500/yr – around 10 times the admin costs in traditional Medicare.
And it doesn’t stop there. Medicare Advantage insurers can cheat you a second time by forcing you to do business with a related or captive company they profit from. To get a medical or drug expense to count towards your deductible, you must do business with an in-network doctor or hospital, and your insurer’s captive pharamacy benefit manager (PBM). The reason your Medicare Advantage Plan is offering you a “free” Part D drug benefit, is because they’re charging you double or triple the price on generic drugs. That overcharge goes directly to parent company’s profit and excessive Executive Compensation, and doesn’t count towards the 15% limit on overhead & profit for the insurance company since the drugs are a medical expense to the insurance plan itself.
Lots of ways to cheat you and the Gov’t with Medicare Advantage.
Affordable Care did increase access but it did not lower costs which the experts claimed it would do. A fail.
But if medicare for all had been pushed for; all would have access.
I only know my personal situation. Once ACA passed by insurance premiums doubled. And yeah I shopped around for other carriers. But the next year I was eligible for Medicare and thus climbed on the wagon that taxpayers pull.
Part A of Medicare is funded 89% by payroll taxes. Part B is 25% by beneficiaries and 75% by general revenues eg taxpayer money. https://www.valuepenguin.com/medicare-funding
2024 part B premium is $174.70 times 4=$698.80/month or $8385.60/year with a Part A deductible of $1632 and part B deductible of $240 and coverage for 80% of medical bill. A very good deal that I suspect holders of Affordable Care policy owners would kill to have.
And in my case tack on an additional ~$8500 for medigap policy that covers the 20% Medicare does not cover and include gym membership, coverage for part A deductible and minor dental coverage-2 cleanings and an annual exam.
 average Obamacare cost by age for a 60 year old for a ACA plan=$994/month.
average Obamacare cost for gold plan=$1225 for 60 year old.
An ACA gold plan covers 80% of medical cost and has an a $500 deductible. Affordable Care Act Deductibles - HealthCareInsider.com
But that uncovered 20% could be significant coin. It varies by ACA policy. I look at Gold plans in my region. The maximum out of pocket could run $5300 to $9500.
Depends on what you mean by “costs”. If you mean premiums that is because the opposition in Congress reduced catastrophic cost subsidies to the insurers. The sickest patients initially were going to pass the costs form the insurers to the government. That got nixed quickly. Then the premiums screamed upward.