• Refusing people with pre-existing conditions
  
• Limiting, or even denying payments (the small print in your policy..)
  

• The market left tens of millions uninsured, often the most vulnerable people with the lowest means and/or the biggest health problems. That is, the market outcome left a huge demand for medical needs unmet.
  
• People were afraid to change jobs, reduce the amount of hours worked (for instance to take care of children or sick relatives), or start their own companies out of fear of losing health coverage.
  
• Medical debts are the single biggest source of personal bankruptcies
  
• The uninsured draw on emergency care (Medicaid). Apart from serious health consequences (earlier visit to a doctor often prevent things getting much worse), this is very inefficient as the cost to society are higher than if they would have been insured.
  

• End discrimination on the basis of pre-existing condition
  
• Personal mandate; people have to get insurance to avoid the adverse selection, that is only the sickest taking up insurance.
  
• Subsidies for those that cannot pay the premiums.
  

• Blaming ACA for a market failure from people who waged war on ACA as big government is incredibly disingenuous.
  
• A part of insurance companies leaving is simply the outcome of the normal competitive process of the exchanges, which are markets. Markets weed out profitable from non profitable business model, and the exchanges are not really different in kind.
  
• The ideological war waged by the right on ACA can itself be blamed for at least part of the problems, as it's likely it kept many young and healthy from signing up, worsening the risk pool (that is, adverse selection).
  

Quote:The main challenge, however, has been political. It is hard to implement a law when opponents want it obliterated.

Quote:The furore over Obamacare is baffling to the rest of the world. Most rich countries have universal coverage; developing countries are trying to introduce it. Yet in America, home to the world's biggest health system, the fight over insurance is vicious enough to bring government to a halt.

Quote:On the campaign trail on Monday, former President Bill Clinton called parts of the law the "craziest thing in the world" because of a gap in subsidies that leaves many middle-income families without support. Obamacare currently provides subsidies for a family of four that makes less than roughly $100,000 combined to receive health insurance through the ACA's public marketplaces if they do not have insurance through their jobs or government programs like Medicare or Medicaid.

This leaves families making above that threshold without access to subsidies, but still requires them to get health insurance because of the law's mandate. Given the increasing costs of health insurance premiums and the problems facing the ACA exchanges, Bill Clinton bemoaned the squeezing of middle-class families. "It doesn't make any sense," Bill Clinton said at a campaign stop for Hillary Clinton. "The [health] insurance model doesn't work here. It's not like life insurance. It's not like causality. It's not like predicting flood. It doesn't work."

Bill did, however, say that the system before the ACA was even worse. He touted Hillary's plan to expand Medicaid and Medicare to catch those people missing out on subsidies.

• 20M newly insured people
  
• Healthcare inflation curve bended
  
• Premiums are still more than $600 below their initial forecast and 10% lower than employer sponsored healthcare premiums..
  
• The probability of a death spiral is fairly remote
  
• Most of the problems are caused by Republican sabotage
  
• Fixing Obamacare is easy and cheap
  
• Fixing Obamacare is politically impossible
  

Quote:When a party, or even more broadly, a political tendency, is so plainly befuddled by what it repeatedly has vowed to be its first policy priority, something very fundamental must be very wrong. And that “something” is fundamental indeed: It is the conservative belief that markets can fix any problem and address any need.

If ever there were evidence that markets can’t do that, it’s the Republicans’ inability to provide universal, or even substantial, health coverage through a more pure market system. So long as they advanced the idea that the market could handle Americans’ health-care needs at the purely abstract level, in the realm of faith, as a truth validated by incantation, conservatives convinced themselves that all would be well. Confronted now by the rude reality that any market-based replacement for Obamacare, stripped of the regulations and tax-provided funds that make it work, will lead to millions of Americans losing their coverage, a sudden weakening of Republican resolve is evident.

And what does this say of the vaunted conservative think tanks—of Cato, the American Enterprise Institute, and Heritage? They’ve had seven years to ponder a workable Obamacare replacement. Where is it?

In fact, back in 1989, the Heritage vice president for domestic and economic policy, Stuart Butler, did indeed come up with a plan of sorts. But it wasn’t really an alternative to the ideas that became Obamacare. If anything, it was their source—a mix of government and market that proposed to establish an individual mandate and impose some employer obligations that would increase coverage. In various forms, this model was passed down as the Republicans’ 1993 alternative proposal to Hillarycare, and then as the Massachusetts insurance program enacted under Republican Governor Mitt Romney, which served as a partial model for Obamacare itself....

The problem is, devising a replacement plan that still insures everyone covered by Obamacare—as the GOP has repeatedly promised it would—yet adhering to the deregulatory, subsidy-withdrawing market models to which the party fervently clings simply cannot be done.

This week, the most senior Senate Republican, Utah’s Orrin Hatch, as much as acknowledged that. According to an account in the January 18 Washington Post, Hatch “told reporters that it is difficult to commit to providing universal health coverage in any upcoming GOP replacement. ‘It would be wonderful if we could do that,’ Hatch said Tuesday of universal coverage. ‘We’ve never been able to do that before.’”

The Post noted that in 2012, Hatch had “said it was a ‘disgrace’ that so many Americans were uninsured, ‘but we cannot succumb to the pressure to argue on the left’s terms.’” In other words, universal coverage is out of reach because it requires “the left’s terms”—that is, regulation, taxation, and subsidies. It is out of reach because it goes against American conservative ideology.

Even the coverage provided by Obamacare—which falls short of universal, but which has moved the nation in that direction—is out of reach because it goes against conservative ideology. That’s why the Republicans have spent seven years without coming up with a replacement. That’s why they don’t have a plausible one yet. That’s why, so long as they remain market zealots, they never will.

Quote:Obamacare is not imploding. Nor is it collapsing. Nor is it a “ticking time bomb” that Obama ordered B613 to set to go off the moment he left office and he and Michelle arrived in New York City looking younger than you.

Don’t believe me? Ask the nonpartisan Congressional Budget Office, which concluded in its report on the Trump-Ryan replacement plan that the “non-group” market, the individual insurance market in which people sign up on state or federal exchanges, “would probably be stable in most areas under either current law or the legislation.”  In other words, it can survive whether or not Republicans “repeal and replace” Obamacare, because even when premiums spike, as they did in 2016, in large part because of Republicans in Congress and 19 states actively sabotaging the law, those increases are offset by the federal subsidies people get under Obamacare, which rise as premiums rise, according to people’s incomes. In fact, of the new signups this year, 84 percent were eligible for subsidies which covered 73 percent of the price of their premiums.

So while Republicans really want Obamacare to collapse, and indeed they’ve tried very hard to make it collapse so they could have an excuse to repeal it; the law is not, in fact, collapsing.

Nor is it in a “death spiral” – which actually has a specific meaning, which Politifact defines as “… a cycle where shrinking enrollment leads to a deteriorating risk pool (that is, healthy people leave the plan due to the cost). That leads to higher premiums, which causes enrollment to shrink even further, continuing the cycle." Well, that’s not happening, either.  

According to The Centers for Medicare and Medicaid Services, the federal government agency that keeps track of these things, 12.2 million people enrolled in health plans during this year’s open enrollment period. That’s less than the 13.8 million people the Department of Health and Human Services projected, but by definition, if millions of people are still signing up for insurance under the ACA, rather than dropping it, Obamacare cannot be in a death spiral.

On the contrary, thanks to Obamacare, roughly 22 million people have gained insurance, between the exchanges and subsidies, the Medicaid expansion, and those remaining on their parents’ plans. As a result, the uninsured rate is at a record low of below 11 percent. It would be even lower, and the CBO would not have been so wrong in its estimate of how many people would be covered by now, had 28 Republican-led states  refused to set up their own exchanges, and had 19 Republican-led states not refused to accept the Medicaid expansion. You’ll recall, they went all the way to the Supreme Court in 2012 to establish the fact that they could keep  millions of their own people from accessing Medicaid through Obamacare. Roughly half of those who are uninsured by Republican fiat live in just two states: Texas and Florida.

Ryan himself bragged about the Republican-led congress withholding money from Obamacare’s risk pools in order to help elect a Republican president and cripple the law. When the Trump administration took over, they went so far as to cancel the TV commercials urging people to sign up.

It’s no secret that lots of insurance companies hate Obamacare, even though some of them have made quite a bit of money on it. Obamacare prevents them from excluding sick people from coverage; or cutting off the checks when their customer is in mid-treatment because she’s reached her lifetime cap; or charging older people much more than younger ones. Insurers did like the idea of potentially getting a flood of new, young, healthy customers who were required to buy insurance due to the mandate, and many are unhappy that they haven’t gotten more. Meanwhile, the law also made the junk policies they used to sell those younger, healthier customers illegal.

Republicans’ “repeal and replace” plan is a giant gift to those insurers, letting them bring back some of those awful – but profitable – practices; specifically, allowing them to charge older people five times more than younger customers, and restarting the junk policy machine, while also scrapping Obamacare’s limit on how much of their extravagant CEO pay packages insurers can write off on their taxes. As a bonus, Trumpcare would swap out the individual mandate that makes people pay a fine to the IRS if they go uninsured for a fine they pay directly to the insurance company when they do choose to sign up. Ka-ching!

Quote:It's hard to decide which would be the more politically damaging outcome for Republican politicians: passing the American Health Care Act, and therefore owning the premium increases and coverage losses it would cause; or not passing the bill, and therefore failing to do anything that can be framed as "repealing Obamacare."

Each option is a political nightmare for Republicans for the same reason: Each would amount to an admission that Republicans cannot deliver what they have promised for years on healthcare.

For years, Republicans promised lower premiums, lower deductibles, lower co-payments, lower taxes, lower government expenditure, more choice, the restoration of the $700 billion that President Barack Obama heartlessly cut out of Medicare because he hated old people, and (in the particular case of the Republican who recently became president) "insurance for everybody" that is "much less expensive and much better" than what they have today.

They were lying. Over and over and over and over, Republicans lied to the American public about healthcare. It was impossible to do all of the things they were promising together, and they knew it.

Then they unexpectedly won an election and had to face the question of whether they would break all of their promises — or only some of them.
If the AHCA passes, Republicans will have delivered on a couple of promises: lower taxes (mostly for people who make over $200,000 a year) and lower public expenditure (mostly because of Medicaid cuts, the main reason the bill could leave 24 million more Americans uninsured). All the rest of the promises will be broken.

And if they don't pass the AHCA, well, then they'll have broken all of the promises.

Quote:If it passes, the American Health Care Act will be Donald Trump and Paul Ryan's Iraq War. It's been sold with lies. It's been pushed forward with a shock-and-awe legislative strategy. And its architects are woefully unprepared for the chaos it would unleash upon passage.

There is an honest argument that could have been made for the AHCA. Conservatives believe it is not the government’s responsibility to ensure the poor can afford decent health insurance. They argue that if taxpayers are pitching in for someone’s coverage, that coverage should be lean; a high-deductible plan that protects against catastrophic medical expenses is plenty for charity care. Under this view, the basic structure of Obamacare — which taxes the rich to purchase reasonably generous coverage for the poor — is ill-conceived and should be reversed. The core philosophical disagreement here is real and worth hashing out. Whereas liberals see access to health care as a right, conservatives see it as more akin to transportation — important, and perhaps worth subsidizing at low levels, but if someone can’t afford a car, it’s not the government’s responsibility to buy them one, much less buy them a nice one.

This is the viewpoint the AHCA reflects. It is not the viewpoint elected Republicans are selling. Instead, their rhetoric fits the sort of plan that Sen. Bernie Sanders might offer. Donald Trump won the 2016 election promising to protect Medicaid from cuts and ensure coverage for all. After the election, he reiterated the vow, telling the Washington Post “we’re going to have insurance for everybody” with “much lower deductibles.”