If insurance companies have to take all comers, that makes the system easy to game: don't get insurance until you're sick, and then jump onto the system. This would essentially destroy insurance markets.
What's the obvious solution? Mandate everyone sign up for insurance, at risk of facing penalty fees. Then you're always paying into the insurance industry, and insurance companies can survive and provide value to the healthy and the sick.
But this is tough: not everyone can afford health insurance. So, you provide subsidies to those who can't.
So, if you start from the 2008 status quo and want to add protections for pre-existing conditions, that game plan is pretty much set in stone. But the issue is that that essentially is the ACA. There are other aspects, but that's the core mechanic.
It's pretty much impossible to build a system from 2008 to cover pre-existing conditions without re-implementing the ACA. You can play with how high fees should be and how high subsidies should be, but that's pretty much it. And most of the Republican "alternatives" (insofar as they exist at all) work by putting a ton of loopholes in the pre-existing conditions protections, a strategy widely regarded as revolting and that only works because people are being bamboozled about what protections they would actually receive.
For example, one of my good friends is a lawyer with a very simple single-member law practice. He has no employees and is self-employed.
As I understand it, BY LAW, he cannot apply for coverage or subsidies for himself or his family (wife and single child) and the only way they can provide for their health care is to purchase it via the New York exchange.
Every year, their chosen coverage provider has closed up shop to be replaced by a new provider with worse insurance terms involving premium increases and higher deductibles.
The plan they had before ACA (essentially catastrophic coverage) was deemed illegal by NY state and is no longer offered as it didn't meet the guidelines for suitable coverage for a family.
SO...by his words:
"I had a hospitalization plan I liked that was $175/month. Covered only catastrophic shit. I loved that since I do a lot to be healthy and no deductible. ACA banned that. First ACA plan was 300 a month or so - w 2500 deductible. Then that company went out of business. New company HealthConnect - price 350 a month - but 6500 deductible for bronze plan. They went bankrupt. Now i have CareConnect - 450 a month - 10,000 deductible $80 co-pay"
So, if your good coverage went from $175/month to $450/month and covered less and less with each passing year and you had no choice to go elsewhere because as a "business owner" you were deemed ineligible for any subsidies or other assistance from the government that was pushing these changes down your throat, you'd probably think it was a shitty deal.
The part that people don't seem to get is that these deductibles are HUGE for the kinds of people that ACA is supposed to help.
If you're paying $450/month and don't even get a single dollar of benefit until your family needs more than $10K of healthcare, would you feel like the government made your situation better or worse?
The reasoning is that, if you allow bare bone plans, then someone could offer plans that let you pay a nominal fee but cover nothing. That, of course, is pretty much nixing the mandate, and you run into the same issues with pre-existing condition protections destroying the insurance market.
Neither of us really know enough about your attorney friend's exact situation to know what went on, but that $450/month plan certainly covers a lot more than the $175/month one. Before, he was essentially self-insuring for the less costly situations, and now that insurance is required to be externalized.
Not perfect, and I'd like if Republicans came up with a solution to ease your friend's situation. But if it comes to a tradeoff between people dying and an attorney being forced to purchase a more comprehensive health insurance plan, it's really not a hard decision.
The main political/democratic value codified into the law is that no one should have to go bankrupt from treatment costs. That means outlawing those practices, which meant a lot of plans no longer qualified. That was the moral argument part that Republicans generally disagreed with. We're all paying a little more so that a family we don't know doesn't go bankrupt from a family member getting cancer. (And we're all also paying a little less due to other parts of the ACA.)
Big Fortune 500 companies that used to offer 'PPO' plans (i.e. you paid your rate and then had $10-$20 copays) now only offer catastrophic plans.
So we are paying the same (and higher) for the plans as we used to, but now we don't actually get anything for them until we reach the deductible, which is higher and higher every year.
I pay the same as a few years ago every month, but get absolutely nothing until I hit $2K or so.
These are the situations the ACA is trying to avoid and it was clear from the beginning that these types of plans (a nominal fee for virtually no care) would not be allowed.
Even if plans like this were allowed, we'd be in a situation where the healthy essential chose the equivalent of no insurance for the smallest amount possible. That's nearly the same as not having insurance at all.
There's a moral question at the heart of this, the answer to which defines the solution space: do we, as a society, think it is important that all sick people receive care? If yes, there are a bunch of potential solutions, but they all involve healthy people subsidizing care for sick people. If no, there are, of course, a lot more options.
The thing that frustrates me about the current Republican approach is that they seem to want to answer "yes" to this question, while telling voters they will not have to subsidize care for the sick in any way.
Depending on your point of view, either the best feature, or the biggest failure, of the ACA was that it made this subsidy for the sick visible to anybody buying their own insurance, rather than hiding it behind taxes or complicated dynamics between governments, insurers, employers, and hospitals.
A little more succinctly: either we decide to let emergency rooms turn sick people away, or somebody will be paying for their care. There's no magical solution.
The way to make care available is to drive down costs. We haven't done a single thing with the ACA to improve the affordability of care, we've just made the un-affordability a problem borne by the people who were already doing a good job of taking care of themselves. That's not a scalable solution.
The ACA got us a lot of short-term benefit for a small group of people but set in motion a chain of events that will only drive UP costs while driving affordability down.
And I'd like to argue that until we do something to improve the market dynamics of healthcare we are very likely to see this sort of thing continue to get worse until it's so unsustainable that it's like trying to legislate away the force of gravity.
One thing I'd like to see in any future version of ACA reform is RIGOROUS price transparency by healthcare providers. It should be absolutely illegal for any healthcare provider to conceal, obfuscate, or otherwise obstruct the price discovery mechanism of the market.
Even if you argue that consumers aren't the best people to decide what services are necessary or needed, they can rely on the advice of trusted advisors and popular understanding to shop for healthcare at providers known for offering good value.
SO MUCH of health care isn't of the "emergent" kind but the kind that is for chronic issues that are the result of unhealthy living or plain bad genetic luck. We need to redouble our efforts to drive those costs of care down and start paying for results and not treatment. Paying for treatment encourages overconsumption. Paying for outcomes encourages optimizing for cures.
Democrats don't just come out and admit that they want a wealth redistribution program that they can use to show voters how compassionate they are with other people's money.
They're politicians. They just aren't honest and voters aren't perceptive or concerned enough to call them on it.
Here is a nice summary: http://www.newsmax.com/Newsfront/wsj-nyc-insurance-market/20...
There is no way he had any kind of health plan for $175/month, not in New York pre-ACA.
Edit: It looks like you need to be enrolled in a plan to be eligible for a HSA
But that's not the case, because that $175/month insurance didn't meet current standards of "good." While the ACA made it happen a lot faster for health insurance, this is kind of like me bitching about how high my car payments are because they keep adding on stupid useless things like bumpers, seatbelts, airbags and antilock brakes and I don't need ANY of those because "I don't get into accidents and if I do I have enough savings to cover it."
As for the question of him not being able to get subsidies for himself as a matter of law, I'm 99% positive that the way you become ineligible for subsidies is by making too much money to qualify. It has nothing to do with owning your own business, and if he's telling you it does then he's blowing smoke up somewhere.
As for the amount you're paying before you get benefits, yeah, there are plans in there like that, and they tend to be cheaper. You might almost consider them catastrophic care plans, except they cost more than $175/month and cover things beyond hospitalization. They're the ones with "20% coinsurance after deductible" for regular doctor's office visits, while what you're probably looking for are the ones with a "$40/75 copay" for primary care/specialist visits. That coinsurance/copay bit is one of the things insurance companies can still do to game the system.
The thing that those plans all have in common though is a maximum out of pocket number. That means if your friend the lawyer has a heart attack, is hospitalized, needs a couple of stents put in immediately or god forbid a bypass and doesn't have the time to shop around for other hospitals that might be cheaper, he's not going to be leaving the hospital with $250,000+ in medical bills that he's personally responsible for. Sure, $10-15k is a lot of money to take on as unexpected debt, but for an awful lot of people that's not bankruptcy money it's "payment plans for a few years that are going to kind of suck" money.
https://nystateofhealth.ny.gov/
Let's start with how much money you need to make to see your subsidies completely extinguished: $50,000. That's the limit no matter if you live in Buffalo or Westchester.
Let's then get into the regulations associated with ownership of a company. Did you know that as the owner of a company no matter the size or organization, you're NOT considered an employee of your own company? Nor is your wife?
From the NY state website:
"Under 29 CFR 2510.3-3, an employee would not include a sole proprietor or the sole proprietor's spouse. The definition for Common Law employee can be found here.
The structure of the business does not matter. For example, the business could be a corporation, LLC or d/b/a.
Employees (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership.
Specifically, 29 CFR 2510.3�3 states the following: (c) Employees. For purposes of this section: (1) An individual and his or her spouse shall not be deemed to be employees with respect to a trade or business, whether incorporated or unincorporated, which is wholly owned by the individual or by the individual and his or her spouse, and (2) A partner in a partnership and his or her spouse shall not be deemed to be employees with respect to the partnership."
So it does matter that the self-employed seem to get screwed a bit harder than the popular opinion acknowledges.
So, tell me again, which part of shifting costs from people who didn't go to law school and dropped out to work at McDonalds to those who finished school and did sounds like a fair deal to you?
Does shifting costs to those more conscientious sound like a great plan for national unity? How do you feel when your co-workers play hookey, sleep in, and write bad code? Do you think those folks deserve the same promotion opportunities you do? Do you think that any society that punishes achievers is one that is set up for success?
Let's discuss facts and not opinions. Show me the costs for insurance and where the subsidies end and tell me if you think it sounds like a good deal to you in a county where the property taxes for a small condo run about $25K per year.
Then they're not insurance companies any more.
Yes this is what both sides of the aisles won't admit. You can't have 20% of the people use 80% of the services and make things fair without forcing the users to eat the costs.
Same things with:
1. The US (like most Western countries) has a huge post WWII baby boom now approaching old age. The younger generations will have to pay for this.
2. The US refuses to allow chronically sick and dying patients to let death takes it course, managed only with pain killers. Instead, vast amounts of money (some say 80% - there's that number again) are spent on the last year of a person's life carrying out procedures that only prolong a few more painful months, with no chance for recovery.
The costs could be reduced by taking away some of the huge profits of the medical and pharmaceutical industries. But in the end, there will need to be societal changes.
