How many people would lose insurance, again?

My Facebook feed is clogged with hysterical warnings that tens of Americans will lose their health insurance if the Republicans repeal Obamacare. I don't like to dismiss this warning, as I know to my cost just how awful that threat feels. Part of me says, "You can't very well threaten me with whatever you've already done to me," but if there really are a lot of people who finally managed to get insured under the ACA when they never could pull it off before, I want to know how many of them there are, what's in store for them, and what it might cost to figure out a way to protect them. The Daily Signal reports:
The Obama administration estimated that the average monthly effectuated enrollment in the exchanges was 10.4 million people in 2016. This is significantly below original projections from the Congressional Budget Office, which estimated that 21 million people would be getting their coverage through the law’s government-run exchanges in 2016.
According to the IRS, in 2015, 12.7 million taxpayers claimed one or more exemptions from Obamacare’s mandate to purchase coverage and another 6.5 million taxpayers paid the penalty rather than sign up for coverage.
So 11.4 million signed up, but 19.2 million were eligible and declined. I've also read that a previous Heritage Foundation estimate of 14 million new insureds included 11.8 million who were shunted into Medicaid, leaving only 2.2 million who'd signed up in the post-ACA private individual insurance market. This article quotes an AP estimate that 4.7 million pre-ACA insurance policies (in the individual market?) were cancelled upon implementation of the ACA. Again, I'm not feeling the vibe that the repeal will be worse than the implementation.

Still, there are definitely people out there, like myself, who bought Obamacare policies and are wondering how they'll replace them, now that they've lost the protection from pre-existing conditions that they previously enjoyed under their longstanding pre-ACA guaranteed-reissue plans. I've been hearing that the Republicans had some kind of protection in mind for people with pre-existing conditions, and of course Trump says he does without explaining how it would work. It appears that all four Republican plans currently circulating include proposals for some kind of one-time opt-in for people who have maintained their coverage, much as was the case under the late-1990s HIPAA law.


Anonymous said...

I crossed my fingers and got a mutual-assurance plan. It does not cover pre-existing conditions, but I've never had that coverage. I still pay out of pocket for exams, but I've had to do that since I first got insurance *mumble* years ago. But it is far less expensive than either of the other options, one of which is not accepted by anyone here except for the ERs, and is now no-longer penalty-inducing.

I think the old state-risk-pool plans for pre-existing, chronic, and serious medical condition insurance. Or allow people like me to buy into the now-vanished cancer pools, for example.


Grim said...

I could use a better option, still. Since my grandfathered plan was finally canceled as an option by BCBS, I've been making do with a pretty garbage option that is really more of a discount plan than insurance. It qualifies for the ACA mandate, but it's completely useless (but, of course, somewhat expensive).

jaed said...

There were three groups of potential winners under the ACA:

1. Non-disabled poor adults (in states that expanded Medicaid) who were now eligible for Medicaid. Medicaid is, well, Medicaid, but it is arguably better than nothing.

2. People who had preëxisting conditions and hadn't gotten/maintained continuous coverage. Not sure how big this group is. (Possible to exit this group by getting a job that offered insurance and keeping it at least long enough to get creditable coverage under HIPAA.) If Group 2 has bought insurance, presumably they will be able to take advantage of whatever continuous-coverage exemption there's going to be.

3. People below 2x poverty level but not eligible for Medicaid. This is the sweet spot where you get not only a large premium subsidy but cost-sharing subsidies for out-of-pocket expenses, so your deductible goes from $4K to $500, your copays go from $75 to $5, etc. People in this category can get an insurance policy they can afford to use, due to the additional cost-sharing subsidy.

On the other hand, the third group is also dealing with the ever-narrowing networks and, in much of the country, the limited choice of insurers. To get a subsidy, you must buy from the exchange, and the exchange policies at this point are about equivalent to Medicaid. So it's basically Medicaid that you have to pay something for.

I worry most about people in Group 2—preëxisting conditions—who are just above the subsidy threshold, who haven't been able to afford the large Obamacare premiums, or concluded it didn't make sense given that they wouldn't be able to afford to use the coverage if they did get sick, and therefore have been going commando for part or all of the Obamacare era.

(It should be noted also that the category "preëxisting conditions" expanded a lot during the 2000s. It was very difficult to get an individual policy if your BMI was over 30—for any reason—for example, and that's a lot of people. Usually no limited lookback period, either, so some condition diagnosed 20 years ago and that hadn't caused any problems since could make it impossible to get new insurance. This wasn't true in 1995 but it was largely true 15 years later, and it was a genuine problem and something that contributed to the sense of panic that resulted in Obamacare.)

Finally, has anyone seen a state high-risk pool that wasn't awful? I looked at a few of them at one point and they all seemed bad. High premiums, high deductibles, many exclusions, very low caps, and dangerous provisions like having to go without insurance for six months before you could join. I don't think that's much of a solution. If we need to subsidize people, better to have them buy ordinary insurance, have the insurer price the added financial risk versus the pool, and subsidize that amount. (This also goes for Medicaid and Medicare. I don't like segregated insurance programs for targeted populations, especially when they result in hidden cross-subsidies from other customers. Adding them to the general market for medical care, and subsidizing as necessary, cuts back on admin costs and also makes the subsidies more transparent.)

Sorry about the novel-writing. ;-)

douglas said...

Making enough to not get subsidies, but not enough to be able to afford a ridiculously expensive plan with massive deductibles and being able to get insurance if something really went wrong with no penalty, the only logical thing to do was not have insurance and pay for doctor visits and prescriptions out of pocket. The regular asthma meds are a little pricey, but that's way, way cheaper than the insurance. Plus, it's a kind of protest that I won't be part of this unconstitutional (in my opinion)and certainly oppressive policy.

And the media and beltway left still don't seem to get why over 70% of the American public doesn't approve of O-care.

Hopefully, sometime in the next year I'll be able to get insurance again.

Texan99 said...

I agree with all of the above. It's long seemed to me that health insurance is a very odd product to try to price and buy and renew annually; more rationally it would be a lifetime purchase, more like whole life, I guess: priced up front and guaranteed long-term, though it usually would be paid for over time. I think it also would be nice if we would limit the socialization of the risk to very high lifetime aggregate bills, and give people a lot more freedom to decide how to deal with the risk up to that amount. Finally, we ought to face squarely the fact that the problem will be solved for some people only through out-and-out charity, so we can quit pretending it's something else.

Eric Blair said...

Jaed, you forgot the 4th group of winners: The insurance companies. Oh, some are whining, and dropping their participation in the ACA exchanges, but the real money is being made in the medicaid expansion.

(Nobody here thought that the Federal and state government adjudicated those claims themselves did you? It's all farmed out to various insurance companies.)

jaed said...

Right, and particularly the insurance companies that run Medicaid HMO programs. These are bringing the same cut-rate practices to their exchange policies (it's no coincidence that the exchange policies resemble Medicaid in their networks).

Basically I'd like to see a lot less one-size-MUST-fit-all thinking about medical insurance. Some people might want lifetime coverage, some might want a comprehensive all-paid-for plan (like old-school Kaiser was - your premium covers all your medical care, period), some might want very-high-deductible plans with no insurance involvement unless your costs go above $XXXXX, some might want per-incident or per-diagnosis indemnity insurance with a cash payout, some might want to combine these.

And keep the policy wonks—at least the sort who delight in controlling what proles are allowed to do—OUT of the room when laws are being drafted!