Obamacare: Is it working or not?

The Pediatric Insider

© 2016 Roy Benaroch, MD

‘Tis a season, fraught and shrill. Volume has replaced thoughtful discourse. I realize many of us have long-ago made up our minds about the Affordable Care Act – and if you already know whether it’s good or it’s bad, this really isn’t the post for you. But if you’re one of the people in the eerie, quiet middle, curious for some context and facts, here’s one doc’s take on the status of what’s typically called “Obamacare.”


What are the problems?

There are two big ones, the way I see it. First, the whole program is not sustainable with the current model. When the ACA kicked in, the whole idea was to provide uninsured people with a way to purchase insurance plans, similar to the ones offered by employers. This looked like a big bumper crop of new customers for insurance companies, who initially lined up with all sorts of plans at affordable rates. The costs for consumers, at first, looked especially appealing, because government subsidies made premiums pretty cheap. At first.

But: insurance companies ended up taking a bath on those ACA insurance products. The people who signed up for them turned out to need more health care – to spend more money – than expected. The “young invincibles” who don’t need much health care spending aren’t signing up for these plans, despite having to pay a penalty. (The penalty is still cheaper than the premiums, and they can always sign up later if they develop a health problem. They’re young and invincible, but they’re not stupid.) Insurance companies have had to raise their rates, this year by an average of 10%, and in some areas as much as 55%. Many have exited this part of the insurance market entirely. It’s estimated that when enrollment starts in November, about 20% of people looking for individual plans in the ACA insurance exchanges will have only one plan from which to “choose.” And, of course, areas with fewer plans are seeing the highest rate increases.

Insurance companies would like to hold down rates, but so far their solutions have been both unsuccessful and unpalatable. Smaller “in-network” groups of physicians, hospitals, imaging centers, and labs do reduce costs. But inevitably that means clients – I mean, patients – have to wait longer for services, or travel farther, or navigate endless administrative roadblocks. Another idea to contain insco costs: increased deductibles and copays, which share more of the health care costs with patients.

Which brings us to the second Big Problem: many people are finding that their ACA-compliant plan is costing them, big time, to actually use. Just having health insurance doesn’t guarantee access to affordable health care if you’ve got huge deductibles and out-of-pocket expenses.


Have any parts of Obamacare worked?

Yes. The ACA has brought insurance to about 20 million Americans who lacked it, including about 9 million via expansion of state Medicaid programs to low-income families (that number could be much higher, if some states hadn’t refused to participate.) The uninsured rate has fallen from about 16% to 9%. Though deductibles can be high on some plans, people with insurance are at least protected against truly catastrophic costs from a serious hospitalization or chronic illness, like cancer or a heart attack.

Though premiums on the exchanges are rising, they’re actually about $600 a year below what was projected for 2016. And, overall, the rise in national health care costs has been reduced to record-lows, in part from ACA-required hospital cost-control and quality improvement mandates. Overall, federal government spending on health care in 2015 was $2.6 trillion less than it was expected to be – and that’s even with the 20 million more covered people in the system.


You’re full of sh*t. Obamacare is (the greatest thing ever)/(a complete disaster for everyone) <–ß you choose!

Yeah, well, see, I was hoping to weed out the partisans with that flowery introductory paragraph. People on either side of this issue seem to have a hard time seeing this from the other point of view. The very idea that “the other side” may have something worth saying and listening to doesn’t seem to jibe with the world of Facebook, Twitter, and the current election cycle. Democracy can be hard, but (I think) it’s the best system out there. Let’s give it a try!


OK, Hippie, we’ll try it your way. What do you suggest?

More young people need to sign up. This can be encouraged by increasing subsidies and/or increasing the penalty for non-insurance. Though forbidding insurance from excluding pre-existing conditions is a common-sense provision that needs to be retained, the rules can be tightened. People shouldn’t be allowed to take advantage of this by dropping insurance when they’re well and restarting it only when they get sick.

More flexibility will allow more competition, so people have a choice and premiums can be kept in check. Insurance companies should be allowed to offer products in any state, and regulations requiring certain kinds of coverage for all plans can be relaxed. People should be allowed to choose the kind of coverage they’re willing to pay for.

There are other good suggestions to improve the Affordable Care Act, but it will take a bipartisan congress of adults actually listening to each other to get it done. Their focus needs to be on making quality health care accessible, rather than protecting the profits of the insurance industry.


You’ve made some good points! Will you be our next Surgeon General?

I’ll consider it, but I certainly wouldn’t accept that nomination if <REDACTED> wins.

Balance is possible

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2 Comments on “Obamacare: Is it working or not?”

  1. Great post Dr. Roy. We need to fix what’s wrong with ACA not start over. It’s a complicated program and we’ve made some progress so let’s not start all over and create another set of problems. Politicians make things sound too simplistic. It’s not that easy!


  2. wzrd1 Says:

    Regrettably, the employer provided pool will be going up soon.
    You see, my wife and I used our brand, shining new employer provided plan at the beginning of this calendar year.
    She was discovered to have both advanced osteoporosis and severe degenerative disc disease (globally, in the cervical spine), L5-S1 is a train wreck that’s causing falls now.
    I presented to a new doctor, newly in the region, with a BP of 200/100, pulse of 128. Yeah, hyperthyroid. I suspect that I blew a long bulging L4-L5 disc catching my wife after she had her gallbladder removed and a umbilical hernia repaired, secondary to a failing 32+ year old c-section scar.

    Yeah, we’re a pair of train wrecks.

    As for the young, healthy avoiders, the next one to brag about it to me *will* end up tripped with my cane.
    While you’re laying there stunned, don’t be surprised when my cane rests across your inguinal region, I kneel on it and your outstretched hand, administer a sternal rub while inquiring if you’re OK.
    Then apply another sternal rub under the guise of steadying you back.*

    *Never anger an old military medic, we learned early on how to subdue inebriated infantrymen in the rear of a far too small ambulance.** 😉

    **No infantrymen were harmed in the typing of this message, however, some will know precisely who I am. Or will they? I had to learn those tricks somewhere… 😛
    Hey, *I* never had to swear to the oath of hippocampus or even worse, the Oath of Hippocrates.***
    Sorry about that keyboard and monitor, those who were having a sip of liquid, but you really shouldn’t have liquids around electronic equipment.

    ***My A&P class was always to die for, while being highly educational for average soldiers. My IV class, memorable, to put it mildly (I took the most nervous student for the live stick and walked him or her through the steps, then taught a class on “fishing” when the vein was inevitably missed).
    My water petrification – erm, *purification* class, memorable, with a 100% pass rate and full retention. To give a hint to my actual identity, when speaking of water clarity, turbidity and sedimentation, “is it clear? Is anything, such as fish poop settling to the bottom? Are there sea monkeys in it?” was quoted back to me 20 years after the first class that I gave, with the accurate terms following.


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