The Patient Protection and Affordable Care Act

I wrote my last two columns about health insurance, but not at all about the Patient Protection and Affordable Care Act, commonly known as Obamacare.

In total, it’s 906 pages long, and creates and commands many organizations to write regulations which today may have already exceeded 40,000 standard pages, with much more to come. Then-Speaker of the House Nancy Pelosi famously said, “we have to pass the bill so that you can find out what is in it — away from the fog of the controversy.”

At the time of its passing, the CBO estimated it would cost $940 billion over 10 years. Two years later, the decade-long cost estimate was $1.76 trillion. This doubling is primarily a function of the act having almost no expenses in the early years, not an earlier misestimate.

The ACA is an incredibly intricate piece of legislation. It is written in such a way that it depends on many accurate predictions about human behavior. If even one of these assumptions does not prove to be accurate, then the ACA will likely cost substantially more money or provide coverage for far fewer people, among a number of possible adverse outcomes.

Here is a short subset of assumptions that the ACA depends upon.

— Hospitals will participate with the policies purchased on the exchanges and receive the lower reimbursements provided for in the law.

— Costs won’t exceed estimates.

— Insurance companies will continue to serve the communities they did before the ACA, maintaining a competitive marketplace of insurers.

— More Americans will have health insurance coverage.

— Penalties for hospitals with above average re-admittance rates won’t reduce care in those communities.

— Hospitals that primarly serve the poor will remain economically viable if the “disproportionate share” payments are discontinued because more patients they serve will have insurance.

— Job growth will result, or at least there will not be job loss in the private sector

— A three-month grace period before cancellation, in which an insured can stop making payments for three months but still receive full benefits, won’t be overly costly to insurance companies.

— A marriage penalty whereby the joint income of a married couple qualify for a lower subsidy than the joint income of two co-habitating people will be accepted as fair

— Medicaid expansion will result in fewer expensive visits to the emergency room.

— The “young invincibles” will comprise 40 percent or more of the pool of exchange policies

— The American people will accept the provision that private insurance companies can be “bailed out” for any losses they incur because of the ACA and that these costs won’t be significant.

At the time of this writing, polls indicate that 58 percent of Americans oppose the law’s requirement that everyone must purchase insurance or pay a penalty. Fifty-one percent believe the overall quality of health will decline because of the ACA. Other polls show that 19 percent believe that their health care will be better a year from now, and 24 percent of the uninsured view the law positively.

Clearly, these polling numbers are not what the proponents of this legislation intended. Some of the skepticism about the ACA stems from the fact that evidence is accumulating that each of the predictions of human behavior above, that underpin the ACA, are inaccurate. The most popular provision of the ACA seems to be allowing children up to age 26 to stay on their parents’ policies. The clear winners under this legislation are people who were unable to obtain insurance or only able to obtain extremely expensive insurance because of a pre-existing health condition.

All of the statements in this article, even when trillions of dollars are involved, sound very abstract. Next month I will write about the effect of the ACA in Robeson County. If you have been personally affected by the ACA and have information for this column, please email me at

Eric B. Dent, a Lumberton resident,is a business professor at Fayetteville State University.


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