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Life Health > Health Insurance

'The ACA exchanges are dead' is fun to holler

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My inbox is flooded with emails declaring the Affordable Care Act exchange system to be dead.

Related: State ACA exchange rate changes vary wildly for 2017

Most, of course, from the same people who’ve been declaring everything ACA-related to be satanic, dead, or satanic and dead since it was just something Barack Obama was talking about, at a time when he probably figured it was about as likely to come into actual existence as the real Santa Claus was to appear in his living room.

A few emails come from folks who are declaring that the exchange system is dying, and ought to be replaced with a public option program.

Some still come from dreamers singing about how everything is bright and sunny in ACA exchange land.

My general, instinctive bias is: Get a life.

“The ACA exchange system could be dead” story has been out there since at least August, when Aetna, one of the most loving ACA exchange system supporters, turned away from it. 

Related: 3 ways Aetna just shook the ACA’s foundations

Open enrollment will start Tuesday. We’ll find out what happened with that in a few weeks.

Maybe the exchange system is dead, but the ACA story has taken many weird turns. Maybe it will take new weird turns.

Maybe it will have a great fourth open enrollment period because President Trump will offer a free steak to every hundredth enrollee and that promotion will take off. You never know.

If Hillary Clinton takes office, maybe Harry Reid (one reason I avoid using the term ‘Obamacare’ is because, for good or for ill, the ACA is really, truly ‘Reidcare’) will figure out some way to make her fix the ACA system rather than replacing it.

No matter who’s in the Oval Office: It’s hard to see how any incoming president without at least 60 firm backers in the Senate can do anything more than work to improve the current system. 

Without 60 firm backers in the Senate, Trump would come in with a firm mandate to glare at the ACA and to draw rude cartoons on the home page.

Clinton would come in with a mandate to organize committees to study how wonderful Medicare-for-all would be, with report publication dates starting somewhere around Nov. 15, 2024.

I myself have written, bitterly, about how the Centers for Medicare & Medicaid Services (CMS), a part of the U.S. Department of Health and Human Services, has done a miserable job of communicating with insurers, exchange managers and other people about what’s going on with ACA programs, including the exchange programs. And I’m right. Really, I am.

But it seems likely that CMS and HHS have also had problems with communications in connection with the Medicare supplement insurance, Medicare Advantage and Medicare Part D prescription markets. All three of those markets are CMS-run markets that are similar to the ACA exchange system, and, at this point, everyone seems to be reasonably happy with those programs.

So, what can we learn from the problems the ACA exchange system is having, as the private Medicare product markets enjoy a moment of reputational bliss?

Continue reading …

ACA exchange system performance lessons

  • It’s hard to run a big, complicated health program well while members of a major political party are trying to tie you up and put you in a car trunk.

  • Everyone hates the health insurance companies. Because everyone always hates the health insurance companies. Insurance companies exist so everyone else can point to insurance companies and say, “Those are the folks who denied you coverage for a test that has a 99.999 percent chance of finding that you’re healthy and an 0.0001 chance of finding out that you’re dying. Hate those folks, not me!”

  • Most people want lots of the ordinary sick care associated with chronic conditions such as diabetes, high blood pressure and high cholesterol levels when they have those conditions, but, when they are paying the premiums out of their own pocket, they have little interest in paying much extra for ordinary sick care for other folks who have those chronic conditions. (Because that’s where most of our health care spending goes, not to preventive care, and not to end-of-life care.)

  • Many people who are paying the individual health insurance premiums out of their own pocket have little patience with the kinds of dedicated, independent doctors and high-quality hospitals that appear on TV shows.

What the successful ACA exchange plan issuers seem to be implying, in their earnings reports, is that, frankly, many people paying for their own coverage would just as soon go to a crowded, smelly, high-volume, low-cost clinic with faceless, salaried nurse practitioners or physician assistants, and an occasional weary medical doctor, rather than paying extra for the old-fashioned kinds of doctors who have their own offices, their own aquariums, and their own stacks of old magazines.

In theory, consumers should want great hospitals and classy, well-qualified, caring doctors who feel good about their lives. In theory, most consumers are nice people who wish they wanted that. But, in reality, many of the consumers who are buying individual coverage are broke. They are threadbare and stressed out. If they’re the ones paying the full premium for the coverage, or a large part of the net premium left over after ACA premium subsidies are netted out, they can only afford providers who are as threadbare and as stressed-out as themselves.

This is a depressing problem. The great thing about hollering, “The ACA exchange system is dying!” is that it’s a lot more abstract and victim-free than admitting to ourselves that, in the long run, after the bills come due, the only way to get a decent level of care for many people in the United States is to:

  • Support wellness, chronic disease management and medical research programs that may gradually reduce the size of the decent-care supply gap.
  • Scrape up even more money for health care, from somewhere.

  • Use either government-sanctioned coverage limits or a “shift to a free-market system” to limit the amount of care our system promises to provide.

  • Be even nastier to doctors and hospitals than we already are (through either mean government programs or a “shift to a free-market system” that gets the invisible hands of the free market to do the dirty work).

Or, get “Star Wars”-style automated health care provider technology. (As opposed to “Star Trek”-type health care technology, which seems to assume all people should be about 12 feet from a hospital at all times.)

Maybe we could get Apple to put Siri in charge of mobile app clinics. If Siri knows what restaurants we should try, maybe she can figure out what’s wrong with our gallbladders.

Allison Bell is a senior editor at


State ACA exchange rate changes vary wildly for 2017

ACA definitions: Federal executive branch agencies

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