Why are so many Americans against Obamacare?
I guess you could say I'm against Obamacare, but I think it's more fair to say that I'm mad at the system, of which the ACA is a part. I want to give you a lot of personal details, with the hope that 1) you don't see me as just talking about this stuff as abstract political argumentation, and 2) maybe I get to contribute something new/different to a familiar debate.
Back in 2009/2010 when reform was being discussed, I was generally in favor of ACA legislation and the opinion that there were problems that needed to be fixed. I was just entering the full-time workforce around then, and I worked for a company that was big enough to provide good health insurance. I think I had $130 taken out of my paycheck per month, and I had a $500 deductible and low co-pays. This set my expectations for what healthcare looked like as an adult with my own plan.
Health care costs on the exchange
In 2014 I changed jobs. My company is small enough that offering health insurance isn't really a financial gain for anyone, so I went on the exchange. I picked a Gold plan that had a monthly premium of $169/month. It had a $1,200 deductible, a $3,700 max out-of-pocket, and reasonable co-pays ($20 for primary care). This was a slight increase across the board but very much within reach of what I previously had (and the job gave me a raise as well), so I signed up and was generally happy with the plan.
For 2015, the premium went up to $192.58/month. Not unreasonable. The only other change here was that they split their network into two tiers: "Enhanced" and "Standard". But my local services were in the good tier, so no big deal.
2016 was a different game because I had a lot of life changes that made thing less cut-and-dry. I'll skip the details in an attempt at brevity.
In 2017, if I had purchased a Gold plan for myself, I'd probably have picked the plan that looks like this: $332.63/month premium, $1,000 deductible, $6,500 out-of-pocket maximum. Almost twice as expensive as 2014 for two of those three metrics.
But I have other family members in the mix now and I think it would have been too expensive for all of us to have that plan, so we dropped to a Bronze tier plan. Our plan now has three "in-network" tiers instead of two. Our health providers are in the middle one, so I'll use those figures for pricing.
We are paying just under $700/month in premiums for four humans. If it was just me, I'd be paying $225/month. What does our $8,400/year get us? $13,600 family deductible ($6,800 is the individual deductible, for comparison), $14,300 max out-of-pocket ($7,150 individual), and a whopping $130 co-pay just to get in the door at a primary care place (it'd be $90 if I was willing to go to the 'preferred' places that are farther away from me).
We don't qualify for financial assistance either, so that means that the architects of the current legislation think that we make enough money that this isn't a burdensome expense. And they may well be correct, in a sense. I don't think $700/month would be a terrible fee for healthcare, if it bought peace of mind that everything would be covered.
But it doesn't do that. A $130 copay means that when the kid is crying and you're thinking about going to the doctor, there's a 50/50 chance that you wasted the money because it was just a cold and not an ear infection. And even though you know you can get a free checkup every year, you don't go because you don't want to deal with turning down an extra test that might end up functionally being an out-of-pocket expense.
In 2023, a comparable Gold plan is $432.71/month premium, no deductible, $7500 out-of-pocket maximum, $20 copays. This is a PPO (as were my previous examples, I think); an EPO could get that down to $405.43/month.
If you drop to Bronze plans, the cheapest this provider offers is $278.15/month with an $8900 deductible AND out-of-pocket max; you're essentially paying your own way until you hit that number, while also paying over $3000 throughout the year as a hedge against a larger expense.
To compare with the 2017 Bronze plan for four humans, I could either do $975.92/month with $17,800 deductible/out-of-pocket max, or $1084.98/month with $65 copays, $7600 deductible, and a $18200 out-of-pocket max.
Why am I mad at the system?
If you think of buying health insurance like buying any other kind of insurance, you get maddeningly frustrated.
First, it's a boring product that you're forced to buy, so there's a similar level of interest as, say, buying a water heater. But even that's not a great analogy, because you could choose to not heat water in your home, or rent so you don't have to make that decision. While I fully understand (and don't necessarily disagree with) the notion that you need everyone to buy in to control costs for everyone else, the fact remains that being compelled to do something against your will doesn't jibe psychologically with humans . While I probably would never choose to go without health insurance unless I couldn't afford it, having the option means that I would have an actual choice.
Second, I have no control over costs. For car insurance (and most things that I buy, really), I have power to control my policy premium. I can tailor a plan to where I live, so an underwriter wouldn't factor in snow/salt damage to a car in southern California. I can install some device in my car so the insurer knows I'm a safe driver and lower my premium adjusted accordingly. If I don't get tickets or don't get in an accident, my premiums can go down. But for health insurance? I can be completely healthy and still have my premiums go up. I could theoretically rack up a bunch of expenses on injuries caused by reckless behavior, and no one's the wiser when it's time to pick a policy next year. I could live next door to the hospital, but I still have to buy a plan that covers ambulatory expenses. When those cost increases happen, there is nothing that I can do about it.
Third, it's a confusing place to do business. Every year you have to relearn what all the terms are and you have to figure out what the plans are actually offering. For example, I'm looking at plans available to me on the exchange right now. Two plans are from the same provider, both in the bronze tier, have the same deductibles and max out-of-pockets, but one costs $9.50 more per month. Presumably these plans both exist to serve different needs, but what are those needs? Time to read a bunch of documentation and learn how their networks operate. And even once you pick a plan, you have to watch out for gotchas, because if you don't know them you pay big time. For example, in 2016 my lack of understanding of my policy cost me $1,500 in unexpected expenses. Is that my fault? Ultimately, yes. But I'd like to think it could have been explained better to me.
Fourth, as a relative expense, it feels like a terrible value. $700/month is roughly equal to my mortgage, property taxes, homeowner insurance, and the electric bill. A roof over your head and the juice to power it, a tangible benefit that you get to enjoy every day. Compare this to health insurance: A product that you never want to use, and because the deductible is so high you only ever benefit from it when something catastrophic happens to you. Car insurance is similar, but we pay about $100/month for two people, which isn't a massive expense.
Fifth, the cost increases over four years of plans seem really crazy. Is that the ACA's fault? I don't know, but I know that (with few exceptions) I'm not allowed to shop anywhere other than the exchange. If I could only shop at Walmart and the prices are high at Walmart, it's certainly easier to be mad at Walmart than it is to be mad at someone further up the supply chain, even though it might not be correct to do so.
Sixth, the fact that employers offer insurance throws a few wrenches in the mix. First, I'm pretty confident that that $130/month I paid back in the day was subsidized, so I don't know the true cost of my plan. Second, I believe that was a pre-tax expense, so I saved money that way too. It'd be nice for contractors/consultants/small businesses to get the same benefits. Third, since a really high percentage of people get insurance like this through their work, they don't know what it's like to be on the exchange and often don't make good arguments about healthcare as a result.
Some discussion of these arguments
You could look at all of these complaints and contend that single-payer would address each one. I don't disagree. But when you go down that road you start to worry about what your government will choose to cover or not cover. Let's use euthanasia as an example (trying not to kick hornet nests in this post but I need something for this example) - some people want it, some people don't. I'm against it morally, but I know that the actuarial tables will make it look extremely tempting to an administration looking to reduce end-of-life healthcare costs.
So perhaps the fundamental flaws of the ACA are:
- It's trying to advance goals and ideology of universal healthcare through a system of purchasing a private insurance product. This creates cognitive dissonance.
- It's expensive! I've argued with my friends that if you surveyed every American and asked "Would you support universal healthcare if it cost you $20/month?" the results would be overwhelmingly in support. $20 for that random guy to have his cancer looked after? Absolutely! But when $8,400 a year disappears from my paycheck with only the vague promise that it'll keep me from bankruptcy if the unthinkable happens? It's harder to look past your family at that point.
- Lack of choice. If you view healthcare as a product similar to other types of insurance, then the restrictions of 1) being forced to buy something, 2) being more-or-less forced to buy it from one place, and 3) having limited buying options creates for a really unpleasant experience.