Kansas State University


Issues in Health Reform

Category: ACA premiums and out of pocket costs

Variation in 2015 Marketplace Plan Selection Rates by Income

Open enrollment in the federal and state Health Insurance Marketplaces is over for the 2016 insurance year but we’re still learning from prior years’ experiences.  The focus of the following issue brief written by RWJ and the Urban Institute  http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2015/rwjf424382 presents March 2015 data (end of Open Enrollment 2) showing:

  • how many estimated people who were eligible for Marketplace coverage actually signed up, and of those,
  • how many were eligible and applied for assistance in paying for premiums, and
  • how many of those in total “effectuated” coverage, that is paid premiums and filled out all necessary paperwork to start the policy coverage.

The data are presented by state, with some data on how people of different income levels behaved in these markets.

The general picture shows that there are many people in all states who are likely missing out on using the Marketplaces for affordable health insurance coverage.  The selection rates…number of people eligible for financial assistance paying for Marketplace plan divided by the total number of people estimated eligible…are still lower than might be expected.  There is also large variation between states as to how many are enrolled, and whether or not it was a state-based exchange, or a state with a Medicaid Expansion, were not necessarily the defining factors.

Some key findings:

  • 24.1 million people were eligible for Marketplace tax credits
  • 10 million, 41%, selected plans but only 8.6 million “effectuated” their coverage for a more accurate enrollment rate of estimated eligibles of 35%.
  • the 13 state based marketplace states had more variation between each other in effectuated plan rates (5-50%) than those in the 37 states using healthcare.gov (18-57%).
    • Florida’s high effectuation rate (57%), the highest of all states, skews the non Medicaid expansion states’ rates when combined.
    • Rates in Minnesota and DC were impacted by special programs they have that cover individuals under 200%FPL.  Over 200%FPL, Minnesota and DC look much as the other states.
  • the higher the income, the less use of the Marketplace. This was true for all states. That is, even with tax credits, out of pocket premium costs for those with higher incomes get increasingly more expensive and appear to be discouraging Marketplace enrollment.  (Some of the drop off may be due to under estimated alternative insurance options like employer based insurance.)

Report conclusions:

  • The relatively low effectuation rate could be improved by additional outreach efforts, especially in states with very low rates.
  • Premium tax credits, cost sharing reductions, and premium criteria are the same across all states so Marketplace enrollment data provide insights into people’s willingness to pay for insurance given some level of financial assistance.
  • The limits of a willingness to pay more of the premium costs could hold back significant decreases in the number of people uninsured.  While the fines for remaining uninsured may weigh into families’ decisions as those fines become increasingly expensive, it may be that without a policy change to improve affordability overall insurance costs may remain a barrier to fuller insurance levels.



What Does Open Enrollment 2016 look like? Part 1

The latest numbers say that more than 1 million consumers have already selected plans through healthcare.gov. More than 2 million have submitted applications. Still, shopping for health insurance is not for the light of heart. It is serious business. To make an informed and reasonable choice requires an understanding of how health insurance works and what different policies cover, matched to an individual’s projected health care expenses for the coming year. At its base, it is a contract and only what is in the contract is covered.

Americans who are either without health insurance or had purchased a plan through one of the Exchanges are in the middle of another open enrollment period. It’s the third time for many through this process. This open enrollment period began November 15 and runs through January 31, 2016. For a plan to be effective on January 1, 2016 however, that plan must be purchased by December 15.

Because of significant changes in premium and out of pocket costs most are suggesting that people shop around rather than simply renew a policy they’ve already had. Benefits covered and the network of health care providers covered in different plans are also subject to change from year to year. This too suggests a careful review of plan details.

As insurers vie for more customers, and more healthy customers, this volatility of prices and benefits is likely going to be part of the fabric of this new insurance market. The good news is that less expensive plans can be found. A new Kaiser Family Foundation (KFF) analysis found that in 73% of counties, healthcare.gov enrollees could lower their silver level premiums by shopping around

For a more personal side to this with real life stories, see the NY Times article on the “…New Seasonal Stress.”

Will health insurance cost me more this year?


Health insurance premium costs in the US have been rising every year since number crunchers have been watching this.  In the past some of those numbers have been very high, double digits for years.  The Affordable Care Act (ACA) is working to keep the rate of those increases down to a minimum, below where they have been in previous years.

However, for Kansas there is a report showing that we are not doing as well as other states. Perhaps not surprisingly given the political nature of evaluating the success of the ACA, there is disagreement by analysts over the accuracy and the relevance of those numbers.

The national report singling out premium increases in Kansas as being higher than all but Alaska came from PricewaterhouseCoopers (PwC) (http://www.pwc.com/us/en/health-industries/health-research-institute/aca-state-exchanges.jhtml).  That report projected Kansas’ health insurance premiums overall up more than 15 percent this year compared to about a 5 percent average increase nationwide. As reported in the NY Times, these reports, however, are misleading on several levels. http://www.nytimes.com/2014/11/19/upshot/how-much-did-health-insurance-rates-go-up-its-complicated.html?_r=1&abt=0002&abg=1

For one, if you are concerned with what consumers are really paying, these national analyses muddy the waters by including premiums for all plans offered in each state as opposed to only using data for those plans people are actually enrolling in. In reality most consumers purchased one of the lower cost bronze or silver plans.

To correct this bias, they commissioned an analysis looking at the costs of those bronze and silver plans for all federally facilitated marketplace states, including the one in Kansas.  For Kansas, the cost increase for an average lowest bronze plan for a 50 year old non smoker was 8 percent, compared to 3 percent increase nationally, but the average lowest silver plan for the same person went down 6 percent in Kansas compared to a 4 percent increase nationally. http://avalere.com/expertise/life-sciences/insights/avalere-analysis-2015-exchange-premium-file

A more detailed analysis of the Kansas marketplace is provided by the Kansas Health Institute (KHI) (http://www.khi.org/news/2014/nov/15/kansas-marketplace-opens-year-two/).  Their report said that the average premium for all plans offered in the marketplace increased just 0.1 percent from 2014 to 2015, while acknowledging that individual Kansans could see a wide range of price changes for specific level plans. As an example, premiums for some silver plans are anywhere from 11.6 percent more to 13 percent less in 2015 compared to 2014.

When considering what these premium increases really mean for consumers we also have to remember that last year the Kansas marketplace was ranked as having the 5th lowest premium costs of all states. Even an 8 percent increase of a smaller starting amount will likely yield an affordable premium compared to others.  So, coupled with the lower starting point, these reports provide evidence that Kansas premium increases are at minimum comparable to other states, in some cases better, and that the actual premium costs still provide value at a good cost to Kansas consumers.  It is surprising and encouraging that even as Kansas has a small number of insurance companies offering plans in the marketplace, those insurers seem to be offering affordable products to Kansans.  We might expect with less competition prices could be higher.

As time goes on we would expect insurers to adjust their premiums based on the collected health care expense experiences of all insureds in those plans.  According to the Henry J. Kaiser Family Foundation (http://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population/#table), this past year only 19 percent of Kansans expected to be eligible for enrollment in the Kansas marketplace actually signed up.  This was less than the 28 percent national average. Still Kansas had a good number of the valued younger (under 35) adults enroll, 38 percent, helping to ensure a workable mix for insurance rates overall.  All states are expected to see growth in their enrolled populations for 2015.

Tax Subsidies

This year it is likely to be the change in the tax subsidies rather than premium increases that have the potential to make health insurance more expensive. Over 80 percent of families nationwide and in Kansas are using these subsidies to help pay for insurance. This financial assistance to pay for premiums is based on the premium of the second lowest cost silver plan offered.  So, if there are plans that have lower premiums in that tier compared to last year…and there are…then the subsidy will be based on the cost of those new plans resulting in a smaller subsidy. Re-enrolling in the same silver plan may cost more even if the premium hasn’t changed because the subsidy one gets to pay for that premium is now based on a different plan. This difference is one of the important reasons why people need to consider plans carefully this year.  It could be that an individual finds the higher price she has to pay worth it but one needs to be aware and make this decision with full knowledge.  The reason there are less expensive plans in the same tier is that some of the plans offered for the first time this year have larger restrictions on network providers than those plans offered last year.  Restricted networks vs paying a higher portion of the premium is the choice many Kansas families may have to make.


The cost-sharing arrangements constitute a major part of the cost of health insurance.  These are payments you make outside of the monthly premium.  They include deductibles and actual copayments or coinsurance.  They are cost-sharing mechanisms when you actually use care and receive a bill.  Even those payments schedules may change within the insurance policies being offered so this is another feature people have to pay attention to when choosing a plan for this coming calendar year.  The bottom line is to be careful to see if you may be paying more for the types of health care services you may usually receive.


When one considers the overall costs of insurance she should also consider the cost of not being insured.  Besides the real risk of financial consequences if one has an unexpected major illness (one hospitalization can wipe out personal finances for those uninsured), there is also the tax penalty.  Kansans who fall under 138 percent of the federal poverty level (FPL) won’t incur a tax penalty for being uninsured.  With a few other exceptions everyone else who’s uninsured will face a penalty much higher for 2015 than in 2014. People who obtain health insurance through their employers, Medicare, TRICARE, Veteran’s Affairs, or KanCare, Kansas’ Medicaid program, are considered insured and will not face penalties.  Tax penalties will continue to go up every year. For 2014, you will face a tax penalty when you file in April 2015 of $95 per person or 1 percent of annual household income above the tax-filing threshold (about $10,000 for an individual), whichever is greater. You will face a penalty every year that you continue to be uninsured, and that penalty will increase every year.  If you choose not to enroll in 2015, you will face a tax penalty when you file in April 2016 of $325 per person or $975 a family or 2 percent of annual household income above the tax-filing threshold (about $10,000 for an individual), whichever is greater.

How to get insured

Open enrollment in the marketplace began Nov. 15 and goes through Dec. 15 to be covered beginning Jan. 1. People have until Feb. 15 to sign up for health insurance next year, though, for coverage to begin March 1. Whether or not a person buys in the Health Insurance Marketplace, as long as the coverage by some qualifying insurance plan starts by April 1, that person is meeting the federal mandate and will not be subject to penalties.

If obtaining insurance through the marketplace, log on to www.healthcare.gov. To learn more about how to enroll in the marketplace or KanCare, Kansas’ Medicaid program, call the marketplace, available 24/7, at 800-318-2596.

ACA Tax Credits may be taken away by courts

We will all be hearing lots on the news in the next days and weeks about some conflicting rulings regarding one important aspect of the Affordable Care Act…the premium tax credits and tax subsidies that help low income families afford their new health insurance policies.  It is expected that the Supreme Court will be the ultimate arbiter of this, especially since there are conflicting lower court rulings.  The NY Times piece covers the issue well.

In a nutshell….

1.  some states have federally facilitated Exchanges/Marketplaces (including Kansas), and others went ahead and fully designed their own Exchanges.
2.  The plaintiffs have argued (now successfully in at least one ruling) that the original law was written to allow tax credits to consumers purchasing insurance policies through state Exchanges, not through federally facilitated state Exchanges.
3.  The nuance being argued is whether or not Exchanges that were set up by the feds BUT IN STATES and with insurance policies sold in those states are the same as state Exchanges.  One court says yes, another says no.  Most pundits say the law was ambigious on this regard so it is up to the administrative body, in this case, the IRS, to interpret  and put into operation the law.  Others had said in the past that the writers were really trying to push the states to setting up their own Exchanges and hence, denying consumers the tax credit in those states that relied on the feds to set up the Exchange, ergo a presumed incentive to go with the state Exchange.  When fewer than half of the states felt ready to design their own Exchanges (and some chose not to for seemingly political reasons), then the administration asked that this aspect be interpreted more fully to include all Exchanges.  This will certainly be an interesting court battle to watch…but one with severe consequences for many Kansans and other Americans.

IF the Supreme Court holds that consumers are eligible for tax credits and subsidy cost sharing only Exchanges set up by the states this will negate tax credits for those in 36 states, including Kansas.

57,000 Kansans signed up for policies in the Kansas Marketplace.  National figures show over 80% of those consumers have been eligible for tax credits.  Some are only paying $20/month for policies that would otherwise cost approximately between $200-$600 month.  One can quickly see how the current rulings negating the ability of the IRS to implement tax credits would result in having those lower income families once again unable to afford insurance.

Note:  people may qualify for subsidies if they have incomes of up to $45,960 for individuals and up to $94,200 for a family of four.  The Congressional Budget Office estimates that subsidies this year will average $4,400 for each person who receives a subsidy.

How do I get health insurance before the next open enrollment period starting Nov 15, 2014?




Everyone with few exceptions (see https://www.healthcare.gov/exemptions) must have health insurance or may have to pay a penalty. Medicare Tri-Care, VA and Indian Health Service all remain the main insurance for those eligible for those programs. Because these programs qualify as insurance beneficiaries are not subject to penalties for being uninsured.

 Here are health insurance options for you to consider.

Your Job

 •   Your insurance stays the same unless your employer decides to make changes. If this work-based insurance is not affordable (costs more than 9.5% of your household income for a single policy) you may be eligible for financial help if purchasing a policy in the Marketplace.

 The Marketplace at healthcare.gov

 •   The Marketplace refers to a place for specific kinds of insurance policies that have been approved by the federal government to offer policies in Kansas.  Most think of it as the website where those policies can be found but it exists regardless of the website.  People can enroll via phone, mail, in person, or yes at the website.  The website offers an easy way to view and compare plans for providers, services and price. Anyone can shop in the Marketplace however, open enrollment is closed for 2014.

  •   Open enrollment for 2014 ended March 31. Only people with special circumstances can purchase in the Marketplace now   marketplace.cms.gov/help-us/enroll-limited-circumstances.pdf

  On November 15, 2014 the Marketplace will reopen for everyone else. KHN has a good story about those circumstances http://www.kaiserhealthnews.org/Stories/2014/May/09/Andrew-reader-question-on-insurance-between-open-enrollments .aspx?utm_campaign=KHN%3A+Daily+Health+Policy+Report&utm_source=hs_email &utm_medium=email&utm_contnt=12736814&hsenc+p2ANqtz-8xGUxlk04t5iCJ8D7Y8Jwxuv9SS7HSFMuLR4B3eRiCwWSwqRzCZzABM9aYnlvSyRfYLombN4pnWb0OtxE6FVYARW2m7A&_hsmi=12736814

  •   U.S. citizens, nationals and lawfully present immigrants living in the United States and not in prison can enroll in health insurance in the Marketplace.

  •   If you purchase in the Marketplace AND your household income is less than 400% of the federal poverty level (FPL), you may get tax credits to reduce the cost of the premium.  If it is less than 250% of FPL, you may also get help paying for out-of-pocket costs. This is not true for those who have work-based insurance that is considered adequate and affordable. Adequate means that the plan pays on average 60% of all your medical costs in a given year. Affordable is considered less than 9.5% of your annual household income. If work based insurance meets those criteria than you are not eligible for tax credits.

 KanCare at http://www.kancare.ks.gov/

 •   KanCare is the Kansas Medicaid program for U.S. citizens and lawfully present immigrants of low income who are over 65, under 18, or disabled.

 •   Children and pregnant women may be eligible with household incomes less than 225% FPL.

  •      Those over 65 have both income and asset limits, depending on the specific program.

  •   Check eligibility at http://www.kancare.ks.gov/ or the Marketplace healthcare.gov

  Additional options for young adults

  •   Stay on parents’ policies until age 26.

  •   Buy a catastrophic plan (for those under age 30 or with special financial circumstances).

  •   For higher education students, ask about student health insurance.

  Buy a private plan from an agent or broker.

  To get help or learn more to enroll in the Marketplace or KanCare

 •   Call the National Help Center at 1-800-318-2596 available 24/7.


Marketplace Eligibility Monthly Income

Marketplace Eligibility Monthly Income

Group Size

Up to 250% FPL Help with out-of-pocket costs

Up to 400% FPL Income limit for Tax Credits










For each additional person add

For each additional person add




Resources for the Kansas Exchange: Health insurance premiums and other options

There are several excellent resources available for consumers trying to make sense of what the Marketplace/Exchange in Kansas looks like.

The Kansas Insurance Department has a consumer friendly site that helps individuals and families understand the new Marketplace and offers some resources for support in making decisions.

Our colleagues at the Kansas Health Institute have a very informative map on their home page that shows what the ranges of prices for health insurance premiums through the Exchange are in Kansas.  HHS reports that the average monthly premium for a middle of the road plan in Kansas is $260/month, less than the US average of $328/month, the fifth lowest rates in the nation.

The Kansas Health Institute also has an issue brief on the Marketplace.  The brief includes

  • a summary of the 65 types of plans being offered to individuals and
  • tables showing examples of costs depending on region of state, age, and income level including the range of monthly savings for those receiving tax credits (between $100 and $1000/month depending on age and income level).


Delay in employer mandate may not impact number of people insured nor costs

NEW STUDY by Rand verifies basic findings from Urban Institute report original July 18 posting as below, THOUGH it does point to a significant loss of federal income due to expected penalties not being collected.

“In July 2013, the Obama administration announced a one-year delay in enforcement of the Affordable Care Act’s (ACA) penalty on large employers that do not offer affordable health insurance coverage. To help policymakers understand the implications of this decision, RAND analysts employed the COMPARE microsimulation model to gauge the impact of the one-year delay of the so-called employer mandate. They found that the delay will not have a large impact on insurance coverage: Because relatively few firms and employees are affected, only 300,000 fewer people, or 0.2% of the population, will have access to insurance from their employer, and nearly all of these will get insurance from another source. However, a one-year delay in implementation of the mandate will result in $11 billion dollars less in federal inflows from employer penalties for that year. A full repeal of the employer mandate would cause revenue to fall by $149 billion over the next ten years (10% of the ACA’s spending offsets), providing substantially less money to pay for other components of the law. The bottom line: The one-year delay in the employer mandate will have relatively few consequences, primarily resulting in a relatively small one-year drop in revenue; however, a complete elimination of the mandate would have a large cumulative net cost, potentially removing a nontrivial revenue source that in turn funds the coverage provisions in the ACA.”

A report issued by the Urban Institute states that “The one-year delay in ObamaCare’s employer mandate won’t have much effect on the law’s costs nor the number of people it covers.”  The report summarizes though that a change in the individual mandate will have a significant impact.  Having a parallel delay in the implementation of the individual mandate is something currently being considered by Congressional Republications, though like their attempts at full repeal of the law, it is not destined for any traction.

The analysis in the report predicts a decline from 19% to only 15% without the individual mandate, down to 10% with the individual mandate.  Without the employer mandate this model predicts the number of uninsured to go to 10.2% uninsured rather than 10.1% with the mandate. That is, the difference with or without the employer mandate is pretty insignificant in terms of impacting the numbers of newly insured.


New report finds competition lowers premiums by nearly 20 percent in the Health Insurance Marketplace

An important new press release from the Department of Health and Human Services reports that health insurance premiums are much less than had even been anticipated given changes to hold down those costs by ACA.  The report is available at: http://aspe.hhs.gov/health/reports/2013/MarketCompetitionPremiums/rb_premiums.pdf

“Today’s report shows that the Affordable Care Act is working to increase transparency and competition among health insurance plans and drive premiums down,” said Secretary Sebelius.  “The reforms in the health care law ensure consumers will have access to better coverage at a lower cost in 2014.”

How will ACA affect insurance premiums?

How ACA will affect insurance premiums has been a matter of debate for a while.  The evidence from the first state to set up an Exchange and post rates, California, paints a mixed picture.  A report in Forbes is showing rates for young people as increasing by 100-123%.  Rates for families seem more affordable.  The take away points from my perspective:

Many have predicted that premium rates under ACA would rise.  It really depends upon where you were in the market.  Someone with a pre-existing condition if she was fortunate enough to get health insurance will see her rates fall.  Rates could go up in general because:

  1. The law mandates not only that almost all must be insured but that all insurers must take all comers.  That is, there can be no denial of coverage for any reason.  Further, it mandates that there can be no rate differences between healthy consumers and the sickest or some of those most likely to use a lot of health care, the riskiest (including farmers and others in high risk occupations).  There remain rate differences for smokers, some age based differences, and differences based on prevailing costs of health care delivery in different regions of the country.
  2. The law mandates all non-grandfathered plans to include preventive benefits.  So now insurers will factor in the cost of screening exams that previously some may not have used or paid high prices for out of pocket.  (Grandfathered plans are those that were in existence before the law and have not changed anything since then.  Once they make a change they are no longer exempt.)
  3. The law mandates all non-grandfathered plans to include some coverage from a list of 10 essential benefits.

On the surface having increased premiums seems like a bad thing but note:

1.      Premiums before ACA had been rising so much that without some way to get insurers to control costs, insurance had already become unaffordable for many and was quickly heading that way for many more.  That is, premiums were going up without any real control.  Now we may at least know some of what the costs are for.

2.      Most specifically, if the premiums are really out of line with what the true cost of covering all of those people, sick and healthy, then the insurance companies have to give back.  That is the 80/20 rule where the insurance companies have to use 80% of monies collected for direct health care costs.  This year alone 67,000+ Kansans with private insurance received more than $4 million in rebates from insurance companies because the insurance companies made more profit than allowed by ACA. 

3.      There are some significant benefits we get from having all insured even if it costs more in premiums

    • The most important part of ACA from a consumer protection perspective is that no one who tries to purchase insurance can be denied coverage, or be thrown off when they get sick.  Previously one major illness often led to being uninsurable.  There are also no lifetime limits, and soon to be no annual limits, on your coverage.
    • A favorite of middle class consumers is being able to keep their young adult children up to age 26 on their family plans.
    • People who live in communities when more people are insured have better quality health care and better health outcomes.  So it matters not just that you or your family are insured but that your neighbors and co-workers are as well.
    • And a little discussed fact is that job lock will be over.  That is, because group like premiums are now not only to be found with your employer but also in the marketplace, and because pre-existing condition exclusions are gone from all plans, individuals can choose the jobs they want to work at and not just stay because of health insurance.  They will be able to purchase on their own on the Exchange.  There have even been predictions of more entrepreneurial undertakings.  This is detailed in a new report from the Robert Wood Johnson Foundation, the Urban Institute and Georgetown University’s Health Policy Institute. The number of self-employed people is expected to rise by 1.5 million — a relative increase of more than 11 percent — as a direct result of the health care overhaul.
  1. So better plans, and more secure plans.  For some it will cost more.  For some it will cost much less.  And for many it will some type of plan, better than none at all.   

The goal of ACA was to get as many Americans insured as possible.  It is well established that people who are insured, and securely insured, are healthier, and use the health care system more appropriately, holding down costs for all.  It matters to the economy of any nation that it has a healthy workforce. The choice with ACA was to build upon the current health insurance market.  This meant paying premiums to private insurers and having those insurers negotiate with the health care providers while bearing the risk.  To do that they needed to have healthy people in the risk pool.  That is the reason for the mandate to strongly encourage that enrollment.  In the past premiums were rated based on one’s health status and predicted risk factors.  That’s why younger people had less expensive plans.  By blending all in the same risk pool it was known that premiums would rise for some but significantly decrease for others and actually be available for some who had been locked out of insurance altogether.  To lessen the impact of the premium increases ACA tried to make insurance as affordable as possible by allowing for tax credits.  That is, the feds will help individuals and families under certain income maximums pay for those premiums.  The insured gets a premium discount and the feds pay the insurance company the balance.  (Qualifying incomes are up to $45,960 for single, $94,200 for a family of four, maximize consumer premium contributions between 2-9.5% of income, on a sliding scale.)

So, mandates that we are all in game and that more pieces on the game-board are covered leads to likely increased costs for premiums for those who were lucky before.  The reason for the mandate is to get healthy people into the pool paying premiums to help minimize the costs for the non-healthy.  The youngest, under 30s, are allowed to purchase catastrophic plans to minimize the costs to that young population that is trying to get established economically. AND there are tax credits to help many pay for those premiums. So to talk about increased premiums without noted that the feds are going to be picking up a significant portion of those increased costs seems disingenuous at best.

ACA had also intended states to put their poorest individuals and families into their states’ Medicaid programs and to have the feds pick up that bill for 3 years.  The Supreme Court negated the penalty that was to be placed upon states that did not comply so as of June 2013 only 26 states (not Kansas) are participating with the result that many of states’ neediest populations will continue to be uninsured and use safety net providers, something that costs all of us when we balance out in other ways the uncompensated care provided to this population that is often very sick. 

There were alternative health reform plans floated for years, most prominent among these was to expand the very popular Medicare program to all US citizens.  That would have made the feds the direct payer of care for all and not just those over 65.  Money collected would have gone to health care providers and not to insurance companies for insurance policies.  It matters not if that would have been less expensive as many predicted.  It is not the plan that passed. 

And of course, we could have continued on the path we were on with no reform.  That would have meant that many Americans would have continued to worry about how they were going to meet the medical care needs of themselves and their family members and potentially go bankrupt.  And it would have meant that millions were at risk of being thrown off their insurance policies.  Even today before ACA goes into full effect as of January 1, 2014, there remain Americans who are one major illness away from being uninsured and uninsurable.  That American could be you, your neighbor, your co-worker or your loved one.  Only when it happens close to home do people realize how devastating that reality has been for many.  That reality goes away for most by January 1, 2014. 

I’ve also been reminded recently that when Medicare first passed in the mid 1960s it took many years and tweaking to improve it.  ACA likely needs improvement.  And there are many who would like to start over.  When Medicare got improved that was a time when Congress seemed to be capable of bipartisan crafting of our laws. 

Is ACA going to cost us?  Yes?  Will it be worth it?  Perhaps.  Could some other kind of health reform have been passed?  Perhaps.  Would we have been better off doing nothing?  It probably depends on whom you ask.