A Question…

At the risk of receiving a public flogging during my next Whole Foods visit, I must ask…

On the radio, I’ve heard many people talk about how they are going to save money now that the ACA is in (almost) full effect and the exchanges are open.  If this is true, and all these people are going to save money, then who are going to be the people who lose money?  I mean, it only stands to reason that if less money is being spent on something, then there is less money available to those who typically receive the funds.  Perhaps this is a fundamental misunderstanding of how it all works, but it seems like a reasonable question to ask.

I should also make clear that just because some people are going to lose money doesn’t mean the law is a bad one.  Maybe some of those people SHOULD lose money.  But I’m curious to know who they are.

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62 thoughts on “A Question…

  1. a) people who didn’t already have health insurance and are now forced to buy it
    b) the government–often it’s a case of sticker price going up but subsidies and tax credits more than covering the difference.
    c) crappy insurers. Lack of transparency in the insurance market means that some companies can get away with charging a whole bunch for not very many services. That’s largely going to stop

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    • b) the government–often it’s a case of sticker price going up but subsidies and tax credits more than covering the difference.

      Except the government does not have its own money, so ultimately the citizens pay, one way or another.

      Healthy people whose premiums could increase because of community ratings could pay more.

      Also, people who got moved to part time because their employers could/would not pay for the increased insurance costs.

      Employers who pay increased premiums because they are unwilling/unable to shift their employees to part time.

      People who were relying on HSAa and high deductible insurance, but can longer purchase those plans because of the mandate.

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      • Patrick,
        I’m skeptical of that chart. Why would employers start cutting people’s hours right after PPACA passed, before its implementation date? I’d say any data prior to the past month is baseline, not data points.

        And however widespread it does or does not end up being, it is happening. At least in colleges, where adjuncts are having their courseloads creduced. This I know factually.

        I don’t know how big the subsidies are supposed to be, but I hope they’re big enough to offset the combination of an extra required expense and a pay reduction.

        I haven’t seen liberals addressing this issue much. I’m curious what their take is.

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      • I haven’t spoken much on the issue in general, but I’ll say that I fully expect some employers who employ people full time but do not typically offer benefits will cut back hours.

        It won’t be the norm, but I’m sure it will happen. I mean, it’s simple logic. If employing someone to work 35 hours incurs an additional $5K/year in benefit costs but cutting them back to 34 hours does not, well, 34 hours it will be for businesses that can get by with the reduced human power. And I do think it is an issue.

        Yet another reason to decouple insurance and employment. Problem is, the PPACA seems to double down on it.

        So, count me among the liberals willing to talk about it and criticize this portion of the law.

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      • “Why would employers start cutting people’s hours right after PPACA passed, before its implementation date? ”

        Because PPACA declares that you don’t simply say “I have fewer than 50 employees who work more than 30 hours a week”; it goes by a complex formula that takes into account aggregate employee work over the previous calendar year.

        Which means, basically, that if you want to say someone is part-time in October 2013, they have to have been part-time since the beginning of October 2012.

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  2. I don’t think we know yet who is saving money, and who is going to lose money.

    That was the nub of Jaybird’s comment on the shutdown thread… there’s not much sense in fighting the ACA on the illusion of free healthcare… better to fight it on the crushed hopes of free healthcare.

    Of course, Rose’s observation is that Republicans don’t have confidence in their rhetoric above… hence the Sugar fight.

    Avik Roy, Ezra Klein, Krugman, Maddow, Tyler Cowen, and Megan McArdle have been hemming and hawing over the hypothetical impact of the Exchanges.

    Since the Exchanges are only Live(-ish) yesterday, I’m not sure that anyone knows for certain whether they will really save money… or even if person X does save money, will person Y in another state have their insurance tripled (per some early estimates)… and, will 27 somethings even buy insurance at all.

    We have to be able to log in to find out.

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    • Individuals won’t know whether they save money or not until they buy a policy (but then, if your employer picks up part of your tab, you probably don’t know your actual current cost either) but the costs of the plans on the exchange were under the OMB’s projections by a sizable amount.

      The OMB’s original projections were lower than the current prices — except for the more useless of the mini-meds, IIRC.Certainly they were lower for anyone with a pre-existing condition.

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      • Well, that’s pretty much what the Roy/Klein argument was about… predictions vs. the actual rates insurance companies were going to put up on the exchanges. Early analyses in June we’re suggesting that the actual costs were going to be higher than what were currently available on the open market… quite likely owing to the requirement to insure pre-existing conditions (among other things).

        Cowen basically called Jump Ball and wanted to wait on the actual exchanges to assess. Which is where we are today.

        McArdle has an interesting post today looking at the math behind paying the (un-enforcable) penalty vs. paying for health costs out-of-pocket for the “Young Invincibles.”

        For certain we will see the penalty turned into a real Tax… but that’s ok, its just on the Milennials, they can afford it.

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      • For certain we will see the penalty turned into a real Tax… but that’s ok, its just on the Milennials, they can afford it.

        Given the actual law — not the ACA, the pre-existing law governing ERs and critical condition patients — a better term for “young invicibles” might be “free riders”.

        Everyone without insurance is basically being provided, by society, a free catastrophic care policy. It’s amazing how suddenly moral hazard and free rider problems drop out of the conservative conversation when Health Care is the topic.

        If I’m 24 and uninsured, I am running a non-zero risk of piling up medical bills I will never be able to pay. It might be quite pragmatic, from a personal viewpoint, to do so — to impose that cost on society instead of myself — but then society is quite right in taxing me back to cover the costs.

        There’s also the fact that health-care is a lifelong proposition, and while I realize it blows some people’s minds — if I overpay as a 20-something and underpay as a 50-something, I’m pretty sure that evens out and I’ve not got a lot of room to complain at 25.

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      • All employers with more than 250 employees are required to show both individual and employer contributions to health care on (at least) the W-2, as of 2013.

        Many seem to be showing this information on each pay-stub as well (though I don’t see that as required on the IRS site).

        I’ve known the cost of my (very expensive) health care since the day I started… it is, ironically, a source of concern since COBRA isn’t like a guaranteed exchange – it is simply the legal right to pick-up the very expensive cost of the insurance my employer selected for us… inconveniently at the very moment my employer will have elected not to pay me at all.

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      • ,
        if I overpay as a 20-something and underpay as a 50-something, I’m pretty sure that evens out

        Maybe, but it’s not as simple as that. First, 50 somethings mostly have more money than 20 somethings, so we’re asking the less well off to support the more well off. Second, there’s the time value of money. If I have to overpay now, that’s money I can’t invest so that I can have more money later.

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  3. 1) Free Riders — of which, basically, every uninsured person in America is. (And many of them would rather not be free riders, but plenty are). A car accident, a bad fall, sudden cancer — and one person just added hundreds of thousands of dollars in costs everyone else pays for.

    2) Insurance companies — they’re facing actual competition AND a requirement to spend a certain % of their premiums on actual health care. While not a big problem for their big clients –Lockheed Martin is big enough to hire experts to parse plans and make apple-to-apple comparisons, and to get large insureres to compete with each other on prices — Bob buying an individual policy is, bluntly, screwed. Bob also doesn’t have an HR department and lawyers in case his insurance company wants to retroactively yank his coverage.

    We actually HAVE universal health care here in America. We pay for everyone who shows up needing it. We just pay for it in the least efficient way possible. That’s not even debatable (a quick glance at every other first world country on earth spells that out in black and white). Some of it’s flat-out waste, some of it’s bloated profits, some of it’s shifted costs, some of it’s just horrible inefficiency (treating at an ER what could be treated by a PA — or spending a week in ICU what could have been treated three weeks ago with 40 bucks of antibiotics and an injection).

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  4. At present, outside of the margins, we don’t really know who is going to save money. I could cite Avik Roy’s extensive evaluation of it all, but no evaluation is perfect and his critics think they have found holes or maybe have.

    We won’t know who is right for quite some time. But the people who are obviously going to be paying more are some percentage of the healthy uninsured. People who have catastrophic plans that won’t be available. Some physicians and providers are going to lose money, depending on how they do business. Others are going to have to pay more for the equipment and will be passing that on to consumers.

    I believe that most people are going to end up paying more, in the end. But even if that ends up true, supporters can argue that it will save for the most vulnerable. Those with pre-existing conditions, for example. The aging. It looks like it will save money for people in states that already have a lot of the regulations that will drive up costs elsewhere.

    And I could be wrong and it could end up saving just about everybody money.

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    • ” Those with pre-existing conditions, for example”
      … you mean like women with a C-section?
      … you mean like anyone ever diagnosed with depression?

      I think the list of folks with a preexisting condition is
      “anyone the insurance companies can possibly put in that category”

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      • Not all pre-existing conditions result in insurance hikes. My understanding is that it’s roughly 1 in 4 who either have to pay higher rates or cannot presently get insurance due to pre-existing conditions.

        But let’s say that you are right. All that means is that the goalposts shift to people who not only have pre-existing conditions, but have more pre-existing conditions to the next guy or gal. If almost everybody has to pay extra for pre-existing conditions, then that is going to be baked into the premiums offered in the exchanges.

        I really hope that what I say above about most people having to pay more turns out to be wrong. I was initially optimistic or at least hopeful. But the numbers I saw, and the responses I saw when the analyses were made, have deflated my optimism. People without group plans may indeed be getting more from PPACA, but it seems very likely that they will be paying more (whether they wanted the “getting more” part or not).

        Let’s say that everybody has pre-existing conditions that result in having to pay higher premiums. Well, then, many people with pre-existing conditions will end up paying more simply by virtue of the fact that they have less pre-existing conditions than the next guy or girl because the pool will include everyone who has pre-existing conditions that result in higher rates

        So change my verbiage to “more extensive pre-existing conditions” and proceed.

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      • Will,
        I believe you mistake what I’m saying. In the old system, anyone (including over 50) who had a C-section (even twenty years ago) could be credibly denied individual insurance for a “preexisting condition”.

        My point is that most “preexisting conditions” are fucking bullshit. I noted two egregious examples, which are basically the “red cars pay higher insurance rates” (I kid you not, I know someone who wrote that into the code)… except here they’re flagging “people likely to go to the doctor for problems”

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  5. My law firm passed out the mandatory PPACA advice forms to the employees yesterday. Today, my paralegal came into my office and asked me, “What is this shit, Burt?”

    “It’s Obamacare, Paralegal. Exchanges opened yesterday.”

    “But this is expensive!”

    “So don’t buy it.”

    “Then I have to pay a penalty! 1% of my annual income!”

    “Is that more or less than the cost of the insurance, Paralegal?”

    “…The penalty is less. Insurance is really expensive, and I don’t want to pay for it!”

    “So pay the penalty.”

    “What? But it’s a penalty!” She seemed shocked at the notion. “Will this… this… penalty be a new line item on my paycheck for withholding?”

    “No, but your income tax withholding might go up a little bit if you choose. I don’t really know for sure how that’s going to play out. I don’t know if anyone does.”

    “Oh, well, if the income tax withholding goes up a little bit, I don’t really care. But I don’t want an extra kind of withholding!”

    I was confused. “Huh? Paralegal, doesn’t the amount withheld matter to you more than the number of items they use to withhold it?”

    “I just hate seeing all those line items! I’d rather they just withheld everything in one item.”

    Took me a second to process this before I decided to just leave it alone. “So are you going to buy the insurance or not?”

    “If it’s cheaper for me to pay the penalty, I’ll do that!” Paralegal laughed at her own devil-may-care attitude, threw the memo in the trash, and went back about her regular business.

    And that, folks, is the reaction to Obamacare of what I presume to be a pretty typical specimen from the body politic. I guess labels matter. So maybe Ted Cruz shouldn’t have called it “sugar.” People like sugar.

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      • Basic actuarial concepts says the exchanges should be cheaper than individual policies. (Individual policies have to charge more because the risks are more variable, whereas with a large pool you can forecast quite closely what your actual costs will be).

        Which is why, in general, the same policy from my large company costs me far less (counting the employer’s contribution) than a similar individual policy would.

        In practice, insurance companies have handled the individual market by basically either offering sub-par plans OR (in effect) only offering policies to individuals who won’t need it. (Basically cherry-picking out the young and healthy).

        As such, individuals who could get affordable individual policies will probably see their costs rise, as they’re not longer cherry picked based on age, current health, risk-profile, and how lucky they were in the genetic lottery.

        On the one hand, it sucks to be them now as they face a hike in prices (if not a large one). On the other hand, those people would quickly get priced out of the market as they aged, or as soon as they got unlucky. So longer term, they’re better off.

        What I find most interesting will be the death of policies that are, basically, scams. There’s a lot of policies on the individual market (or rather, were) that were ‘affordable’ but only because the coverage they offered was illusory. These were the ones that most frequently used recission, and whose actual coverage tended to be…well, fraudulent is probably too strong a word. Perhaps…predatory with a lot of obfuscated numbers is better.

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      • , my insurance for the maximum deductible under ACA will cost less and pay more benefits then the $15,000 deductible plan we previously had. For states that didn’t allow insurers to cherry pick and required some basic coverage in all plans (sort of like what ACA does, isn’t it?) costs will drop significantly.

        I also think that insurers used the unpredictability argument to jack prices for individual plans, they knew those markets spread out over the larger group every bit as much as they know them under the exchanges already. The difference is that they’ll be getting premiums from people who wouldn’t have bothered to purchase a plan without an expensive motivator — an illness, accident, or child.

        Those companies know the individual risk markets particularly well in a state like mine, where there were only two companies selling individual plans, and one state-run program, which was set up for high-cost people, originally, so that the private companies would bother to offer a plan at all here.

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      • (Individual policies have to charge more because the risks are more variable, whereas with a large pool you can forecast quite closely what your actual costs will be).

        Again, this doesn’t stand up to mathematical scrutiny. If you sell many individual policies, you have a large risk pool. You only earn a risk premium for risk that can’t be diversified away, and selling many policies diversifies away the risk. All else being equal, the mean and variance of medical expenses for 10,000 people covered under individual policies is exactly equal to the mean and variance of medical expenses for 10,000 people covered under a group policy.

        There are reasons to expect individual policies to cost more, but this isn’t one of them.

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      • “There are reasons to expect individual policies to cost more, but this isn’t one of them.”
        Can you elaborate on what those reasons might be?

        I assumed it had more to do with a guaranteed client base. Insurer X agrees to offer my employer a lower rate in exchange for having a relatively captive audience of consumers. I imagine they’d rather sell 50 guaranteed plans at $5000/year than have to wrangle up 25 individuals at $10000/year (or whatever the numbers are).

        I also assume that they use the “risk” as an excuse to jack up prices. “Oh, you’re 50 and smoke? Yea, you have to pay more. But you? You’re 25 and healthy? Well, we won’t lower your price. We just won’t charge more.”

        Companies charge what they can afford to charge, by and large.

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      • Again, this doesn’t stand up to mathematical scrutiny. If you sell many individual policies, you have a large risk pool

        Actually you don’t. People seeking individual policies are not, shall we say, a random sampling of the population. They’re not even a sampling of their local community — by and large, they tend to sicker and more in need of health care.

        As noted in this thread — a rather healthy paralegal has never bothered to seek health insurance, free-riding on the rest of us. Whereas if she was, say, genetically at risk for expensive conditions, partook in dangerous sports, or had other risk factors she was aware of — she’d most likely have sought health insurance.

        Whereas, say, the pool generated by a large company? If insurance is part of your benefits package, then the entire company is entered into the pool — healthy and sick alike. (Although you get into fun numbers there, because that gets self-selected into coverage levels and deductibles….someone seeking a low-deductible, high-coverage plan is generally someone a lot more likely to be expensively sick than someone looking for minimal coverage with high deductibles).

        This is like…bare basics of health insurance in the US. Employer provided stuff only works because the pools generated by an employer tend to be fairly representative of the whole, whereas the pools generated by bundling individuals is…not so representative.

        A few seconds thought about who seeks individual coverage and how it’s obtained should make that clear.

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      • Again, this doesn’t stand up to mathematical scrutiny. If you sell many individual policies, you have a large risk pool.

        That is in fact the case. But that’s not how it’s priced. Here’s the essence of the scam. A large insurance firm has internal probability data for its entire pool of lives. But when it comes to pricing policies, they grin like shit eating dogs and say the pool of lives is only as large as your pool of employees.

        The insurance firms do know the real numbers. They aren’t reflected in actual prices.

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      • While Brandon’s median argument makes superficial sense regarding prices that isn’t the way insurance companies operate. They don’t want to take an individual who will cost them money so if you are individual with pre-exsisting conditions or likely to have high costs they will either charge you a massive amount or deny coverage. It is only through group policies that give some bargaining power to the buyer that many people who would otherwise be uninsurable have been able to buy coverage. If the insurance company wants to contract with a group they have to take all the people they would avoid if they had the choice.

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      • They don’t want to take an individual who will cost them money so if you are individual with pre-exsisting conditions or likely to have high costs they will either charge you a massive amount or deny coverage.

        Oh the insurance companies loooove those individual policies. They jack up the rates as much as 10x over a policy for a larger pool of lives.

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      • People seeking individual policies are not, shall we say, a random sampling of the population. They’re not even a sampling of their local community — by and large, they tend to sicker and more in need of health care.

        Or they’re apt to be 1) self-employed or 2) working for an employer who doesn’t offer insurance as a benefit.

        Again, we get to the scamming of it all, because there are a lot of people who are self employed; artists, musicians, carpenters, plumbers, electricians, independent consultants, and on and on. They’re no more or less likely to be sick then the next guy.

        (In fact, I’d wonder if they’re less likely to be sick then most people on an employer’s plan because they have long felt the direct costs due to their high-deductible policies and risks of losing coverage due to the tendency of insurers in many states to drop people once they’re sick. So better life style choices to minimize a lot of what ails us.)

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      • They’re no more or less likely to be sick then the next guy.

        But they are less likely to buy insurance. That’s the point. The pool of people seeking individual policies? It tilts heavily towards the sickly and expensive, because those people have serious motivation to get coverage.

        Especially when they see how dang expensive the policies are for real coverage. That’s the logjam the exchanges were created to destroy — and the reason the mandate (and associated tax/penalty/whatever) is required — to make the pool of applicants for individual coverage reflect the community at large, rather than be shifted towards the sickly.

        That’s not even getting into profit motives. Flat out, simple, basic facts here: The individual market is tilted towards expensive people to insurance, because healthy people don’t really buy health insurance.

        (We, again, have a perfect example in this thread. Do you think the famous paralegal here would be so blase about it if she had, say, diabetes? Family history of breast cancer? Was still paying off 30k in hospital bills from a car accident?)

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      • Actually, I was thinking of individual insurance vs. subsidized group insurance. Morat’s talking about the exchanges, where people still buy insurance as individuals, so I have no idea what he’s talking about. There’s no question that individual Obamacare policies will be more expensive on average than pre-Obamacare individual policies. One of the key selling points of Obamacare was that it would bring the sickest individuals into the risk pools. There’s no way that’s not going to raise costs. Especially with a combination of overpriced insurance and underpriced penalties pushing the healthiest consumers out.

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      • They’re no more or less likely to be sick then the next guy.. Let’s sharpen the pencil and put that in proper statistical terms:

        They’re as likely to be sick as anyone else in the pool of lives.

        See, once we can view one guy in the context of millions of lives, his odds of getting sick are easily derived. A million people, we have people getting sick all the time — but most of them aren’t. But it’s not the Next Guy. It’s all the guys.

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      • Again, this doesn’t stand up to mathematical scrutiny. If you sell many individual policies, you have a large risk pool.

        And here I thought Libertarianism 1A was to think about effects at the margin.

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      • There’s no way that’s not going to raise costs. Especially with a combination of overpriced insurance and underpriced penalties pushing the healthiest consumers out.

        Absolutely wrong. Here’s the deal, Brandon, those exchanges will create large life pools. To compete on those exchanges, the insurers will be obliged to use their entire life pool numbers. Fact is, it will take several years to get this market running effectively. This will be the first time pricing will be run on the basis of meaningful statistics.

        Who is telling you this will push out the healthiest consumers? If everyone either joins the pool or pays the penalty, that puts everyone in the life pools. Doesn’t matter if they’re insured or not. They become part of the picture, statistically. I know stats and prob get sorta non-intuitive, but believe me, it’s rather like a high resolution picture: the more individual pixels you have, the better the resolution of the image.

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      • The ACA is aimed at brining everyone into the risk pools not just the really sick. The really sick, once they health gets crappy enough, could usually get some form of gov health care since they could get disability or just get mediocre care at an ER without being able to pay.

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      • And here I thought Libertarianism 1A was to think about effects at the margin.

        Libertarianism lacks a socially acceptable solution to the health care problem. You can’t have a functioning free market in health care if you’re not allowed to, effectively, run a credit check before treatment.

        Americans, by and large, won’t stand for that. Which basically screws a pure free-market approach.

        You can’t do it with insurance, either — because, as shown, sick people get priced out and healthy people don’t bother to buy, free-riding on everyone else.

        While there is, no doubt, plenty of room for market forces to drive down costs, increase efficiencies, and the like — the basic insurance/health-care/customer interaction is simply unworkable without the ability to deny care from lack of funds.

        Anyways, that’s why the GOP pushed the ACA (well, effectively) back in 1994. It keeps most of the market, it just makes sure you (1) have to buy insurance and (2) subsidizes the price so that the poor can afford it. That creates an actual, large risk pool with predictable prices while still leaving insurers to compete and try to use market forces to drive down costs and improve efficiency.

        Sadly, a Democrat enacted it and Socialism happened. Which led to such hilarious comments — from Republicans — like “We don’t need universal care, you can just go to the ER” wherein, apparently, it’s absolutely free and incurs no costs to anyone, anywhere.

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    • Does Paralegal get paid enough that she wouldn’t get a tax credit/subsidy for her insurance?

      And I mean, it might be expensive, but I’m assuming she’s young enough that insurance coverage is currently not a concern for her. Since ACA would cap her annual premiums at something like 9.5%, then it might actually still make sense to pay the 1% fee instead.

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      • She’s close to my age (early 40’s) and in good health so far as I know. In her case, it seems paying the 1% penalty/tax/fee/whatever is a reasonable choice for the immediate future.

        She’s got a teenage daughter who’s active in athletics, though, which is a scenario ripe for injury. The father is perpetually unemployed. So in her shoes, I’d look for actual coverage, perhaps through the exchange — but I can’t make those choices for her and as you might infer from the illustration of her reasoning process, my giving advice to her is sometimes of necessity an indirect endeavor with a low success rate.

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      • So, in essence: She’s a free rider, offloading her risk of catastrophe* onto society at large?

        Sounds like exactly the reason for the tax/penalty/whatever in the first place.

        *getting cancer, major accident, what-have-you that generates medical bills she will be unable to pay?

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      • Morat,

        That may be true, but I think you’re missing Burt’s point. This is–in the real workd, whether we like it or not–how a great many people likely will respond to PPACA. And if they do–regardless of whether they should–what will that do to the risk-pools and financing of the older folks’ insurance?

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    • What I like about your paralegal anecdote is that it’s a reminder to those of us who have been paying attention (on some level) to the controversy over the ACA for a couple years might be outliers, and that other, presumably intelligent and functional adults, might only now be getting to know about its main features.

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    • “Oh, well, if the income tax withholding goes up a little bit, I don’t really care. But I don’t want an extra kind of withholding!”

      I was confused. “Huh? Paralegal, doesn’t the amount withheld matter to you more than the number of items they use to withhold it?”

      “I just hate seeing all those line items! I’d rather they just withheld everything in one item.”

      It other people were not around, I think I would be screaming at the computer right now. I cannot comprehend that line of thought.

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    • Whether Paralegal knows it or not, Obamacare is going to help her. Right now, as Morat points out, she is a free rider, enjoying free catastrophic insurance for herself and her family.
      Yet at her age, her health is going to begin a slow decline and she is at enormous risk of being wiped out financially by non-catastrophic illness.
      Paying for health insurance, although inconvenient, is much, much less than the wage garnishment she will experience after the bankruptcy.
      Furhter, having her pay for insurance is much better for all of us than spreading the cost of her catastrophic visit to the ER.

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  6. Thanks for all the responses. It seems there are a number of factors at play:

    1.) Maybe of the people citing savings are comparing expenses they never incurred because they were priced out of the insurance market to expenses they actually will pay.
    2.) For some people, costs might actually be down.
    3.) For some people, costs might rise.
    4.) Other parties (doctors, medical facilities, insurers) might see loses, which may or may not be disproportionately felt among the worser members of these groups.
    5.) Ultimately, we don’t really know what is going to happen.

    All that said, my feelings on the PPACA remain as they were: Huh? Actually, I’d say they are more muddled than anything. Though, on a personal level, they are very fortuitous to our family because a little known provision requiring hospitals meet new standards for digital data collection, record keeping, and the like has been a boon to my wife’s industry and will open up many professional opportunities for her.

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  7. As one of the dwindling middle class I expect to pay the majority of the impact-or at least be a the group that is the lagest contributor, other than the bond holders who buy gov’t debt. They will be the largest group. No one’s actually “paid” for much in the last 30 years or so, we’ve just borred it from others. That’s going to do us well in the future with this great recovery we’ve got for the last few years…..

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  8. I just saw this, Kaz. I haven’t read the comments, so this may already have been answered, but the answer is that the people who “lose” are those that will now be paying premium who were not prior. Insurance and healthcare costs at this point will not fluctuate; there will simply be more people dividing up the liability costs, so the share for people currently paying premium will go down.

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  9. The answer to “who’s going to lose money” is “the providers, on paper”.

    Just for those who don’t know: If you have insurance, look at the bill next time. You’ll see something like “provider’s billed cost” and “insurance authorized cost”. That second number is what you actually get charged even if you pay with cash.

    One of the big benefits of health insurance coverage is not the actual coverage; it’s the negotiations that the insurer engages in with the providers. The negotiation being “if you want any of our customers to go to you, Mister Doctor, then you’ll charge what we tell you”. And the insurer has an incentive to do this, because after you’ve filled in your deductible, it’s the insurer’s money that’s paying for your treatment.

    So, with ACA, there will be a lot more people who have a negotiating organization behind them setting prices for treatment. And the doctors will say “ah bloo-bloo-bloo, we’re losing all this money, it used to be we got ten thousand dollars for poppin’ a zit and now we only get five bucks”, and they won’t mention that they never actually got that ten thousand dollars, they just charged it, and the insurance company told them to piss up a rope.

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