The uninsured, which along with those with existing conditions, would seem to be the clearest beneficiaries of Obamacare, and were thus assumed by many to favor it. But a new poll shows that on the whole far more distrustful that the Administration likely expected.
The New York Times gives the results of a new poll:
Fifty-three percent of the uninsured disapprove of the law, the poll found, compared with 51 percent of those who have health coverage. A third of the uninsured say the law will help them personally, but about the same number think it will hurt them, with cost a leading concern.
Ouch.
Mind you, disliking the law is not necessarily the same as not signing up:
Still, nearly six in 10 uninsured said having insurance would make their own health better. And 56 percent said they were more likely than not to get insurance by March 31, the deadline to enroll in coverage or face a tax penalty under the law. Thirty-five percent said they were more likely to pay the penalty….. And nearly six in 10 said they had not researched insurance on the online marketplace, even though, based on the demographics of the sample, many probably qualify for free or subsidized coverage.
I have to tell you, having done lots of marketing surveys, asking people whether they will or won’t buy a product is a highly unreliable way of gauging purchase intent. First, with polls in general, subtle differences in wording produce large differences in results. Second, and more important, consumer questionnaires and polls generally produce statements of willingness/intention to buy that are much higher than what actually happens. Survey respondents seem to have a a bias to please the interviewer by signaling willingness to make a purchase (that may not be operative here) and impress the interviewer with their economic status (as in saying they’d buy is a marker of being better off). So it’s reasonable to assume that actual results are more likely to be worse than what this poll finds rather than better.
Cost was the big reasons for expecting not to sign up; nearly half of the ones who gave negative signals cited it as the reason. And across all uninsured, only 10% expected Obamacare to make insurance cheaper (notice the confusion of insurance with health care, since the ACA almost assuredly will give them access to lower-cost insurance. But the question remains whether their all in health care costs are lower or not, given the typical high deductibles with low premium plans). Mind you, some of the people who are finding they can’t afford the plans are distraught. Michael Olenick provided this Facebook posting from a friend in her 50s, Roxanne:
Broke down crying during conversation with insurance agent, who confirmed my situation… as I un-enrolled in the only hope, a plan that I cannot afford… wondering what the hell I’m going to do if I get sick, how to get my prescription for Metropolol filled… feeling extremely small and insignificant… I couldn’t hold back tears. The poor guy couldn’t wait to hang up. The house was so big and quiet then. When you feel so low, it’s like even the walls are strangers… I am not alone, though. There’s many others with less, I know that for sure….
I don’t know, I guess I just fucked up, and now can’t afford insurance. It’s not like I committed a crime! Maybe it won’t be that bad. If I have to go to the doctor, I will pay them when I can. And if I get too sick and die? It has to happen someday anyway! Look at all the joy and love I have in my life. Maybe if I share my story others will calm down about it, too. We are so much more than this messed up system. How’s that song go… “Those not busy being born are busy dying.” I choose the former. . . So, as I head into the next chapter, I will go with a strong heart, knowing we’re all only here a short time anyway.
The uninsured also overwhelmingly resent being required to buy insurance, with 77% disapproving (and this resentment being the reason nearly 30% of the time for expecting not to sign up). And the poll restricted the range of focus to health insurance, not health care. For instance:
In addition, 64 percent of the uninsured and 54 percent of the general public said they thought providing access to affordable health care coverage for all Americans was the responsibility of the federal government.
At the same time, only 37 percent of the general public and 33 percent of the uninsured said the law was so flawed that it should be repealed.
But another factor that is clearly important, but apparently not included in the survey questions, is the complexity:
Mr. [David] Bishop, who is caring for his four children while his wife works, said he had looked at New York’s online insurance marketplace but found it difficult to use and did not get the information he needed. He did say, however, that he planned to get insurance through the marketplace, or exchange, before the March deadline.
This matters due to the fact that the uninsured skew less educated, and one would also assume that many have limited access to the Internet (2011 Census data shows that members of households with $25,000 to $49,999 in income, only 64% have access to the Internet from “some location”). Given the time it takes to shop for plans, that’s going to be a significant obstacle for quite a few (the Administration perversely is trying to discourage paper-based signups).
And the uninsured may have picked up on the narrow networks issue:
In one of the poll’s more striking findings, 44 percent of the uninsured said the new law would have no effect on the quality of the health care they receive. Thirty percent went so far as to say it would result in them getting worse quality of care, while less than a quarter predicted their care would improve.
And the poll findings are consistent with enrollment data: so far, fewer people eligible for subsidies than expected have signed up, although the ratio was higher in November than October.
When I read the lack of enthusiasm overall from one of its intended beneficiary groups, I can’t help thinking of one of the early Obamacare promotional videos (I’ve looked but there are so many I can’t locate it). It showed a flat cutout figure of a woman, with the entire segment in bright flat colors, the sort you see in children’s books. The video described how shopping for healthcare would be easy, and showed the cartoon woman scurrying with a cart through a store, putting different products in it, and then showed her shopping for insurance in the same manner (as in picking a policy off a shelf and putting it in her cart).
I found the imagery horrifying. Citizens aren’t just reduced to “consumers”: they were depicted in an infantilized manner, imaged as obedient puppets scurrying through the Administration’s shopping “experience.” If this is what the Administration really thinks of voters (and women), one might wonder if its target audience is picking up on its not-too-well-formulated marketing messages, as well as the defects in the product itself.
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If you want to see the future of Obamacare, just look at HAMP, another program that did the exact opposite of what it was supposed to do (unless you’re really cynical and believe that HAMP was a cover to increase foreclosures and fees for the big banks). Heck, BAC actually had a subcontractor set up to LOSE applications over and over again for years until the owner gave up and foreclosure began.
Fast forward to Obamacare. How many millions of applications will be “lost” by the insurance companies or the website. Imagine waiting months, even after having premiums deducted from your bank account, and still not getting proof of insurance?. Remember, the banks cashed the checks under HAMP, lost the applications, and took the houses anyway. Nobody went to jail, or even got a stern talking too.
Excellent points. Do you happen to remember the name of the subcontractor used by BAC?
Ah yes, HAMP. Putting it that way, Obamacare was probably the regime’s attempt to foam the runway for insurers with the bodies of American citizens. You know, since private insurance was getting to be so unaffordable that people were increasingly making the rational choice to opt out of it altogether anyway. But with Obamacare the insurers ostensibly got a reprieve.
As yet unaddressed, is how many people will pay their premium bills, on time and in full, once they sign up? The poor and very poor are not the issue here, but the more slightly well off who will have a premium to pay where there wasn’t one before. Premium collections will become the next major headache since many will consider health insurance a luxury item if they don’t need it and don’t use it immediately. It will become the last bill they pay, if at all.
Companies have already announced extensions for the first payment. It won’t get any easier to collect going forward since most Americans are already living pay check to paycheck.
I assume there will be a short lag period between the time where a premium due isn’t paid and the policy is cancelled, perhaps a month where you still have coverage even though you haven’t paid.
Should be a niche market for an up and coming collection agency.
90 days.
The main reason a ‘working poor’ family won’t be able to pay their monthly insurance premium will be because someone in the household saw a doctor that month, and the premium money went toward their deductible and co-pay and a prescription or two. Plus, income was likely lost that month because of the medical event, whether it was time off work for the flu or for a broken ankle. Less income that month, more expenses, and the premium goes unpaid.
Debts that cannot be paid will not be paid.
For Americans on tight budgets, Obamacare only works on paper. That insurance card is handsome, yes, but if you pull it out you have to be able to pay the deductibles and co-pays. Households that can’t will default on their premiums out of the necessity of choosing groceries, gas, rent and actual medicine in place of the empty promise of medicine, which is what Obamacare actually is for low income people. They will have no choice but to default, and return to using cash or the emergency room for medical needs rather than for purchasing insurance plans they can’t afford to use.
Health insurance is not health care.
But what about the dreaded tax penalty for not buying health insurance? It’s only $95 this year, but it goes up every year until 2016, when it can be over $600 for an individual, and more for a family.
Don’t give it a second thought. If you are on such a tight budget, living paycheck to paycheck, you are likely one of those 47% of Americans who pay no income tax. Simply enter one less exemption on your W-2 than you actually will be claiming on your 1040. It is not illegal to do so. At year’s end you will have no refund due. You might owe a little bit, but as long as it’s only around $1,000 or so the IRS will not penalize you. If you set that money aside during the year, you simply pay your tax bill if you have one. If you didn’t, just set up a monthly payment plan over the phone. The IRS will probably advise you to add one number to your W-2 form next year, but you are in no way required to do so.
You want to avoid having a refund due to you at tax time. You see, according to the US Tax Code, the IRS is not authorized to collect the “no insurance” Obamacare tax penalty from you by any means other than withholding it from your tax refund. If you have arranged to have no tax refund, they cannot bill you, garnish your wages, put a lien on your property or any of the other usual means they are authorized to pursue for collecting taxes owed. The Supreme Court was very careful, when they called Obamacare constitutional, to NOT say this penalty was a fine. It is only constitutional as a tax, and current tax law does not permit the IRS to assess it or collect it, only withhold it from a refund already due to you.
As it becomes clear in the next two years how very many American families can’t afford to buy handsome insurance cards that they can’t afford to actually use, Congress may find it necessary to rewrite this portion of the tax code so as to allow the IRS to actually assess this “no insurance” penalty and collect it, although this will definitely result in some very nasty and extended legal battles over the Commerce Clause that will most likely bring the question once again before the Supreme Court.
In any case, as those who live in the real world know, debts that cannot be paid will not be paid, and assessing and collecting tax penalties (with interest) from working poor families who don’t have the money to pay them will not lead to political popularity for the political party that approves the practice.
Yes, “health insurance is not health care” … please keep that meme going … if you want to defeat evil, you have to play evil’s game of repeating the truth that matters for our side as often as they repeat the lies for theirs.
The 2008 financial crisis and subsequent crises such as the BP well blowout and aftermath, Sandy, Government Programs supposedly designed to help homeowners plus the NSA revelations, and the overall inability of Congress, the Executive Branch and Judicial Branch to do anything at all for the majority of US Citizens, has served to dramatically increase the lack of trust in governments’ ability to do anything beneficial. Trust is required in every relationship.
Having personal experience of many hours on the Federal Health Exchange, I can report that it is over-obvious that the Insurance Companies are the predominant beneficiaries of this business plan to increase profits.
The “affordable” premiums belie cost prohibitive deductibles and poor provider choices which are based upon the county you live in.
I think most Americans in need of health insurance have a healthy “wait and see” attitude. Perhaps genuine success stories next year will turn the tide.
‘The uninsured also overwhelmingly resent being required to buy insurance, with 77% disapproving.’
You bet your ass they do. For the first time, the U.S. effectively has a poll tax: a tax on the right to exist. Margaret Thatcher tried that sh*t in 1989. Wikipedia records the results:
————
In some areas, 30% of former ratepayers defaulted. While owner-occupiers were easy to tax, those who regularly changed accommodation were almost impossible to pursue if they chose not to pay. The cost of collecting the tax rose steeply while the returns from it fell.
Enforcement measures became increasingly draconian, and unrest grew and culminated in a number of Poll Tax Riots. The most serious was in a protest at Trafalgar Square, London, on 31 March 1990, of more than 200,000 protesters. A Labour MP, Terry Fields, was jailed for 60 days for refusing to pay his poll tax.
This unrest was instrumental in toppling Margaret Thatcher in 1990.
http://en.wikipedia.org/wiki/Tax_per_head
————
It appears that Obama’s noxious tax will only be collected from those owed tax refunds (i.e., the less financially savvy who view being over-withheld as a kind of zero-interest savings discipline).
But it would be sweet justice if the smoldering resentment of millions of refuseniks stoked a rising level of tax noncompliance. Don’t feed the fedgov trolls!
I’ve heard different things on how the tax will be collected. Your “it appears” suggests you’re not positive either.
***
Yves writes about “lack of enthusiasm overall from one of its intended beneficiary groups” — since when do “beneficiary groups” need to be mandated to do something that will benefit them? This is probably one reason the uninsured are skeptical about the salutary effects of Obamacare, whether they’ve studied the law or not — they can just logically infer that since somebody is mandating they do it, it probably sucks.
Radio talk show host Rush Limbaugh [told] listeners: “The only way that they can collect the penalty or the fine is by taking money from your refund. If you are not owed a refund, they cannot get money from you.”
Mark Luscombe, principal analyst at CCH Tax & Accounting North America, [said] Limbaugh is essentially right. If you don’t get a refund next year, the “IRS could carry over the sum due and apply it against any refunds in future years. On a joint return, the penalty of one joint filer could be applied against the refund due to the other joint filer.”
“If you don’t pay it, all they can do is wait until they owe you some money and take that. Or probably just send you a letter every now and then reminding you that you owe money to the IRS,” says Timothy Jost, a professor at the Washington and Lee University School of Law and coauthor of the casebook “Health Law.”
http://finance.yahoo.com/news/does-the-obamacare-penalty-actually-have-teeth–144740030.html
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Clear enough … except under Obama, who selectively enforces laws and changes rules on a whim.
‘If you like your refund, you can keep your refund!’ ;-)
Soon you will see simple iPhone and Android apps for keeping a very accurate running estimate of your annual income tax. It isn’t even hard to do on the back of an envelope. The two key things to do are to avoid having a refund due (take one fewer exemption than usual), and avoid owing more than 10% of your tax bill at filing time (send in some money during the year if necessary).
The IRS may add up your health insurance penalties due for years, and the interest on them as well, but even this has a ten year statute of limitations on it. Until you actually are owed a refund, they cannot do a damn thing about it. You may put your thumb under your nose and wiggle your fingers at them.
Congress could change the ACA law to put teeth in the collection process, and health insurance lobbyists will pressure and cajole them to do so with real money, but getting draconian about it will likely spark a tax rebellion from coast to coast. College graduates with six-figure tuition debts, no job but a McJob, no hope of ever being employed in their field, and along comes a letter from the IRS threatening to put a lien on their bicycle or garnish their McWages — that strikes me as an explosive mixture.
A possibility to be sure. And with the noise from the insurance industry insisting the mandate be enforced (another subsidy BTW) makes it a strong one.
But the mandate has been tried twice before at the state level, with disastrous results. In both cases, the mandate was simply not enforced for fear of electoral reprisals or even a court challenge. In both cases, the mandate did not reduce costs and its simply not practical to force some one to buy something they can not afford. Ether way, Obamacare fails.
Better than nothing is next too nothing.
I have a theory that when the response to a yes or no question about something complicated is near 50/50, it’s a sign that nobody understands it and picks a choice at random- there being two choices, the result is expected.
Maybe it’s my geographic perspective or something — but my understanding of it is that we will have to wait until 2017 (January 20th, precisely) to do anything real in the American political sphere, because that’s when the Obots wake up to find out that their Favorite President has turned America into Hell on Earth for large numbers of people. So until then, we cope with our Favorite President’s crappy health insurance law, just like we cope with his crappy education, defense, jobs, and austerity policies.
I have a theory that very large corporations (most visibly banks) have captured the government to loot the whole of the population via contracts (preferably no-bid, no-oversight), legal monopolies, and selective enforcement of laws. Let’s see how this fits with some large examples:
Iraq, and the war on terror: check.
Spying: check
Banking: (blank) check
Medicines and drugs: check
The ACA is just the latest looting scheme. In my view, the intent of this and the previous administrations/congresses since at least Clinton has been to do things that sound good or may appeal to public opinion but are actually built to transfer wealth from the general population through corporations into the pockets of their top-tier owners.
This might not be news to most people on this site, but I have yet to see anyone articulate it this way.
“The Uninsured” are hardly homogenous, in fact being far more polarized than any other group. Good survey design would have ferreted this out if they wanted to. The media often refers to The Uninsured as if they were homogenous group that are uninsured due to systemic neglect and poverty. Many however are uninsured by choice, and in the context of the US Healthcare system entirely rational in their thought process and decision-making process. They are rational since actuarially, they are overpaying – whether through taxation or cherry picking by insurers. This is balkanization of the risk-pool is what characterizes the US Healthcare system, with the potential gains (of paying the right price) rarely passed on to the insured, captured as they are by the (cleverer) insurers and so privatized, leaving the poor risks to be socialized. So they (they healthy uninsured who can afford out-of-pocket and have an generally accurate idea of risk) “wing it”, rather than pay premiums (or be forced to pay a social insurance tax to fund the same). Rational individually, perhaps, but in the context of the possible or a single-payer alternative, simply free-riding.
The nearest optimal approach is single-payer (France), or some competitive private schemes that mandate universal pools to includes all ages, and pre-conditions, and forces participation of those free-riders that would otherwise (sensibly in the short-term) opt-out (Swiss model). Single payer has obvious advantages (monopsony cost control, view of the entire risk-pool, administration scale, etc.) where public administration is efficient and supported, but it is not essential. Insurers then, with more or less identical risk-pools, become mere TPAs (third party-administrators) with margins reflected as such. Philosophically this averages cost not just amongst the healthy and sick (one never knows of course how one might be stricken) and smoothes cost gnerationally as well which prevents the most predatory forms of privatization of profits and socialization of costs. That’s my view anyway, and observers should be careful when assuming the uninsured’s interests are aligned with progressive policy objectives. A reasonably large portion are diametrically opposed and will need to be dragged into the risk-pool to avoid the free-riding described above.
The problem isn’t hard to identify. A high deductible policy is a benefit at the prices on offer (both subsidized and unsubsidized) to those with assets to protect from catastrophic sized bills. The poor and the young simply have a lot fewer of those. Unless the subsidy the covers close to 100% of the premium, a poor person is going to have a hard time consistently paying a premium of even 30-40 dollars a month. These people aren’t stupid, and they will likely not even try to. And a poor person who has high health costs is in a bad spot- he/she really needs to buy the platinum plan, but the subsidy won’t pay the full freight.
Catastrophic policies were designed for relatively affluent and healthy insurance beneficiaries.
Period.
Their design does not easily satisfy the needs of lower-income individuals of any age, because of the (in some cases) astronomical co-pays, OOP, and deductible(s).
OTOH, many well-paid professionals [or just financially affluent people] who can readily meet their everyday OOP medical expenses for very basic care–routine physicals, doctor’s visits, lab work, etc., find the catastrophic coverage ideal to indemnify them against major financial loss, if and when they suffer a very serious, or chronic, medical illness, which can clearly never be predicted (especially due to “accidents”).
That catastrophic plans are “supposed to be” the type of plans that the lowest income Americans are thrown into, demonstrate what a “joke” this entire exercise is–that is, if obtaining good health “care” for all Americans, is truly the objective of the ACA.
I have a neighbor, age 51, who just finished being treated for one of the less-nice forms of breast cancer. She used to be all in favor of Obama and Obamacare. Now she says that she is far more scared re losing her health insurance than she was before Obamacare, because of what she is reading about the ACA. Her husband’s gigantic employer is self-insured, so along with the delay of the employer mandate, the employer is at least for now exempt from various Obamacare requirements; I could see that exemption going away. Until last month, she didn’t even know how much was taken out of her husband’s paycheck each month for insurance (!)(it wasn’t much, I can tell you). I’ve told her that the most sensible thing to do is to be thriftier (she could be) and save money for the higher premiums and copays they will likely face. Oh – just a month ago, she asked me if I thought that perhaps the computer programmers weren’t maybe subconsciously doing a bad job on the Obamacare website, due to racism. I told her no, I didn’t really think that was the issue. That I thought it was corrupt no-bid contract crony capitalism. There’s a learning curve here, I guess.
I’m not scared (yet), but I am embarrassed because I am giving up a principle. I have Kaiser Northern California, although through my husband’s job we could have something fancier, because on principle I’ve seen it as a good solid non-fancy way for people to get care. Well you know what, after 17 years of the place, I can tell you that the studies are a lie, and they suck. GP after GP after GP gets the same utterly simple thing wrong (you rarely get the same GP twice). But here’s my favorite:
About 14 months ago, I went in for my female exam. The doctor’s assistant took my blood pressure and it was 158/88. Horrible but true (I was on an SSRI that I’ve since quit; SSRIs make my blood pressure really high). I said to the doctor’s assistant, “wow, that’s not good.” She told me not to worry, that she could get me a “better” reading. She had me hold my arm up high, like a Nazi salute, while she took another reading. Voila!!! A much better reading!!! I mentioned this to the doctor when she came in, and she looked embarrassed, but I noted that she did not change the nice new reading that had been put down on the screen.
So Kaiser sucks, and I could tell you horror stories re people I know who have used it for e.g. cancer. But the reason I am giving up my principles and getting something fancier is because many more people will be going there due to Obamacare; Kaiser I am sure will be a big destination. And it is hard enough now to see a specialist through Kaiser; I have no reason to think that they will be hiring an adequate number of new specialists. A source of medical care that was crappy to begin with, is going to be a madhouse.
Oh, I quit the SSRI on my own. Soonest you can get a psychiatrist appointment at Kaiser is in two months, and their GPs are not allowed to deal with psychiatric med issues. Blood pressure is great now; I take it on my own, with my arm level to the table.
From a policy perspective, it is more optimal to separate the pricing and insurance element from the ability to pay. The former is a straightforward exercise which most of America’s peers have achieved, and serves as the primary force for cost containment (again resulting from the combination of regulation and monopsony power). The latter is a public policy decision. In Switzerland, the Cantons effectively cover the premiums of their citizens who cannot afford to pay via means-testing, but everyone by law must buy coverage. In France, social levies of ~12% of income are assessed at source to a fund single-payor (which libertarians will be pleased to know, cap out), making sure low income earners contribute even if they have no income tax obligation compensating for heavily regressive VAT). Those with no income apply for membership in a separate single payor, but everyone is covered. Again libertarians take note: everyone is free to purchase additional “gold-plated” insurance coverage, which can cover cosmetic dental, designer eyeware, private rooms, and premium rates charged by premium specialists. The paperwork and administration in France is universally simple and so straightforward it would make Americans cry. It is not perfect, but it truly strikes an optimal balance between the efficiency and logic of mandatory participation, with a single-payor, with a single risk-pool, with the benefits of full freedom of choice for patients to go anywhere they wish, for doctors and service providers (labs pharma etc.) to be competitive and private, for the better-off to have the freedom to purchase additional coverage if they so desire, all the while covering the entire population with an extremely high quality and quantity of care.
The concept and benefits of a high-deductible policy are red-herrings in a world where there are no efficiency gains vs. single payor in administration. High deductible policies (MSA etc) are mere smoke and mirrors to rally support for continued fracture of the risk-pool by handing out goodies (tax incentives, lower prems to the young), rather than pragmatically tackling the issues that cause the USA to spend >18% of GDP on healthcare perpetuating a flawed structure.
Working class people don’t need a “reason”. All they need is Rushbo or the Duck guys. My tenant says he didn’t apply for the expanded Medicaid because he didn’t “want a chip implanted”. He can’t pay the rent, but he can afford illegal oxy and doesn’t want “obamacare”. When he begins to use logic, I will listen – never happen. (I’m in Ky, by the way – our “Democrat” gov has made the exchange work quite well.) My co-worker’s construction trade ex-husband can afford a Harley, but not to pay his way via Obamacare. I guess I pay FOR him by paying increased EMR fees and taxes. This is the way it’s been for 40 years. Time for single-payer.
It’s not just working class people that don’t get it. My sister-in-law is over here in England for Christmas. She is insured through her husband’s employer but I asked her what she thought of Obamacare. Apparently most of the people she knows don’t like it but she sort of does.
When I said I thought it was going to be a disaster and that Single Payer was the only sane way to go her response was: “But we [meaning the US] can’t afford it”. I countered that the US can’t afford NOT to have it, that other countries in the developed world achieve comparable outcomes at little more than half the cost of the US approach but she couldn’t get past that one thought: “We can’t afford it”.
And this is a highly intelligent woman with two degrees from top universities. It’s a big hill to climb.
“From a policy perspective, it is more optimal to separate the pricing and insurance element from the ability to pay.”
Absolutely, these should kept separate. For ex. in the Swiss system, as pointed out, if not in those terms, the premiums are one thing, are separate from tax (all kinds of taxes), any penalties, or income, wealth, employment, health status, etc.
Those who cannot pay the premiums fall to social aid, in the same way as they do for housing, food, transport, etc., i.e. the premiums or ‘contributions’ are considered mandatory expenses, part of the (failing) household budget.
Means tested, the premiums are paid for in part or a whole by social aid. (At present in CH 3% of the population receives some sort of social aid.)
However, while this is a good policy decision (it was much debated in CH at the time), at the very upper levels the question arises:
How much of GDP (or other measure, whatever) is to be shunted to health care? While the system supposedly ‘works’ (ppl are happy with it as a whole, say), what are the consequences of the ‘health – service – industry’ eating up so much of the household budget? How to stop the rising costs and implement some kind of rationing? Or not? Why? etc.
This problem is brewing in CH. At present, Insurances Cos. occasionally refuse to pay. In principle they should not, as all is calculated for them to ‘break even‘ (they are heavily controlled, in fact public-private partnership, and can be bailed out by the Gvmt if they fail.)
However it does happen, say in the case of experimental cancer treatment, rare diseases, etc. e.g. patients who cost 400,000 a year for treatment that may prolong life for one year.
These cases go speedily to the Supreme Court, and the Supreme Court so far has come out on the side of Insurers, somewhat gingerly so. Their long opinion-s in fact state that this is not their problem, and the Gvmt., the Insurers, the Patients, all the parties, have to negotiate, figure it out, it is not their mandate to decide if Mrs. Z deserves special meds, if she should die this year or next for a cost of X. Very scathing, they are clearly furious.
So what is lacking is considerations about rationing, which nobody wants to take on.
I have been following the issue of the uninsured for 20 years. In addition I was in a high risk pool myself for six years.
At any rate, there is one element in common in virtually sagas of the uninsured — and that is, no employer help.
The defeat of any employer mandate in 1994 has somewhat laid a pallor over all reforms in this area ever since.
The ACA subsidies are a clumsy attempt to be something like a surrogate for a generous employer, at least for modest salaries.
The angry persons right now are those who are forced to buy an insurance product with all the protections of group coverage — but no employer to help them pay for it!
One small item: The comment in Yves’s piece from the woman who was afraid that without insurance, she could not afford her Metropolol prescription………..I take that little drug and it has always cost me less than $30 a month. (It costs me $4 a month now that I have Medicare Part D.) Something does not click in that paragraph.