Brett Davis (Washington state) The headline to this piece – “Health reform lives!” – makes me think of Frankenstein’s monster. Of course, ObamaCare is its own sort of government-created monster now raging out of control. Anyway, only in Paul Krugman’s head is ObamaCare – with its narrowing choices, insane coverage mandates and increased premiums – working out well for the masses. 23 HANK (Newark, DE) What I can’t figure out is why insurance companies are shocked over “unexpected high costs.” Many buying ACA policies were getting insurance for the first time, the older the more likely not to be in the best of health. Then there was the Republican Party’s wanton destruction of the insurance business paradigm with lies, disinformation and outright obstruction of the ACA’s vital mechanisms at state level. Further perplexing, why didn’t the authors of this bill foresee this? 9 Sylkirk (Long Island) When the flaws in the system cause bitter complaints, I hope the complainers will remember that tne Affordable Care Act is based on a REPUBLICAN plan. It originated in a REPUBLICAN think tank and was the only plan that the REPUBLICANS would allow to pass Congress before they tried to kill it or make it less effective. Why don't the repubs come up with their own plan? They can't. Because THIS IS THEIR PLAN. 24 Oiseau (San Francisco) Perhaps selling so of the UnitedHealth Group corporate jets would solve the problem! 5 Jimmy Harris (Chicago) What a joke! I just love it. The one word that should be outlawed in this country is "Affordable". Why, because, the ACA is not affordable for most people. I guess if they keep saying it enough, people will "buy" it. Having a system that's reasonable like other modern countries, is the way to go, because what's in place is just a guarantee that the insurance companies, big pharma, et al will get more customers, and unreasonable prices, that their commercials will keep calling affordable. 10 Lawyer/DJ (Planet Earth) Excellent piece. However, as always, the problem lies with the GOP and their intransigence.The GOP would rather people be harmed so Republicans can score political points, as opposed to working to find common sense solutions to our problems. 11 Jennifewriter (Orlando) As the public digested the study that came out recently showing increasing mortality rates for middle-aged whites in America, while the rates for that same group in all our peer nations are declining, I couldn't help but make a connection between our peer nations and their single-payer healthcare that covers all citizens from cradle to grave, while we leave huge groups of people to fend for themselves. Surely that is a factor in what we're seeing. And yet, we spend twice as much per-capita as those nations, leave millions uncovered and have worse health outcomes. I'm not a rocket scientist, but I don't think one needs to be to make a leap of logic... 17 John (Intellectual Wasteland, USA) Sadly, for those who only have fear to sell, everything must be scary, or they are out of business. Unfortunately those selling fear have a large audience willing to believe the marketing hype, and unwilling or unable to see beyond the hype. 6 Dee (Los Angeles, CA) The first year my premium was reasonable and I was pleased that I supported the plan. But this year it's gone up 20%. What I thought would be affordable health coverage is now turning out to be as expensive as my policy BEFORE Obamacare. 10 John (Michigan) While we applaud the goal of the ACA, we would much more prefer universal, single-payer coverage (Medicare for all). But more onerously, as a mom-and-pop business owner, we are paying $22,000 a year to cover ourselves and one employee through Health.gov's SHOP program. The young employee's coverage is inexpensive while ours is sky high. It seems age is only allowable discriminatory practice available.... 8 Joseph (albany) Well, at least there is one person who has written a column on Obamacare in the last month who believes the program is working and is sustainable long-term. 11 Jamie (NYC) Every American should receive the same healthcare benefits as those we employ, i.e., Congress. Period. 14 Independent (the South) I never understood why employers should take care of health insurance for most Americans. 9 George (Monterey) Americans can always be counted on to do the right thing… after they have exhausted all other possibilities. 6 Hoover (Union Square) My insurance was cancelled. Then, after 6 months of misery trying to deal with the government, I finally got coverage that cost about 60% more. I had to go to the hospital for emergency surgery and ended up paying $20k out of pocket. Paul, sincerely I ask you, are YOU on Obamacare? 20 g-nine (shangri la) The single biggest positive reform brought by the ACA is that insurance companies cannot deny coverage to everyday, average Americans and their families because they or one of their loved ones in their household had a preexisting medical condition or became sick or injured and no longer was profitable to the company. Prior to the ACA, and to what every Republican candidate wants return, the law of the land permitted the insurance industry to deny coverage to Americans with a preexisting medical condition which accounts for about 1/3 of America. That's about 110 million people! The law not only allowed it but the Insurance Companies hid behind that when they dropped coverage for people who had paid insurance premiums religiously for decades but once they inevitably became ill the company dropped them and their families from coverage because they no longer were profitable under the old system. If the Republicans repeal Obamacare as they all claim they will do then if you or a loved one in your household are sick of injured then you will no longer be eligible for any health insurance whatsoever and it will all be perfectly legal under the repeal of ACA. 7 Mike (Tampa) The mere fact that Dr. Krugman is so much as acknowledging problems (I mean "rough patches") with Obamacare must mean that it's in deep, deep trouble. 18 JT (AL) It's working great if you like high premium, high deductible insurance. 17 Robert (Out West) I am seeing a lot of numbers thrown around here that I simply don't trust at all. http://www.ncsl.org/research/health/health-insurance-premiums.aspxThere are probs with the PPACA, sure. But Krugman's basically right--and if you want your illusion of "choice," in a "competitive markeplace," this is about as good as it gets.I hasten to add that no, single-payer will not simply save you--and no, single-payer isn't what European countries use. They use a mix of public/private plans, in systems structured a lot like Obamacare. Moreover, they ain't free.Health care is incredibly expensive, and not just because of medical gouging. It's spensive because we're lazy, and often selfish, and we don't eat and exercise right at all. So two things: first, where this is going:1. Towards PPO plans with very, very restricted "out-of-network," access, and 80/20 co-insurance.2. Or to CDHP/HDHP/HSA PPOs, again with very restricted networks.3. Or to HMOs.By the way--all the Republican plans to "repeal and replace," also plan to treat at least half of any benefit you get feom an emloyer as taxable income, and tax you on it. You'll get a big, big $2000 voucher in return, says Ben Carson.Good luck. 5 boosterman (Space Coast) Krugman glosses over some recent troubling developments and ignores the impending doom of all the "mandates" Obama kicked down the road. And just wait for the tax increases to pay for all those subsidies. 14 DF (California) It's health care insurance reform, not "health reform." 6 nobrainer (New Jersey) Hilary tried to reform the system when she was Mrs President and found out how powerful it was. 3 Lou D (Florida) Mr. Krugman remembers that some Republicans warned about death panels. However, he conveniently forgets that President Obama said the ACA will lower premiums by $2500 and that if we liked our plans we could keep them. Why doesn't he ever concede that they were both lies? 12 DA (Michigan) Hooray! Paul is back to cheer on the affirmative action president! 7 HJ Cavanaugh (Alameda, CA) Medicare should be the base health insurance plan for all Americans. Fund it through payroll deductions as we do with Social Security. Yes, some people will make more use of medical insurance than others, but at least you know you have a base level to prevent insolvency, and enjoy the fact you don't need to use it too often. A bit like fire insurance on your home. This will eliminate the deserving vs, the undeserving mantra those against ACA are trumpeting. 5 Harlod Dichmon (Florida) Then how do you explain 50% of the co-ops failing? 8 hankfromthebank (florida) If ACA was the success that Paul Krugman claims it to be, his column that denies the frustration of the middle class on this issue would not be necessary. 9 The Old Netminder (chicago) This clearly was written by someone who doesn't find himself trying to find insurance that covers anything and that he can afford. 7 Jane (<br/>) If the only purpose of ACA/Obamacare was to insure the uninsured in the country, we have done well.But for that alone, we would not have needed "comprehensive healthcare reform" as ACA was touted to be."Reform" of a system that was becoming too expensive for patients, less remunerative for doctors (once the yoke of health insurance companies was laid upon them in the 1990s), would not mean higher deductibles, spiraling premium increases for the middle class. We had that already!We were sold on the fact that "reform" would mean govt control over the excesses of greedy health insurers. And okay, that would work because in exchange for those supposed restrictions on insurers, gov't money--i.e. our tax dollars--would subsidize health insure companies.But guess what? Nothing's changed. We're paying more for less, most every year, and now the PRIVATE for-profit health insurers receive money from us, and the PUBLIC funds from our govt.Paul Krugman, I am with you on just about everything, you helped get me through the Bush years. You have a blind spot on this subject. 7 Rain on a lib parade (Naples fl) As always, the professor is a liberal cheerleader first, economist second if at all, and omits and distorts facts he doesn't like.For example, that 10 of the lauded ACA co-ops have now failed, some spectacularly These were supposed to bypass the insurer's "profiteering"."excessive" executive salaries, etc.He dismisses United's losses as if irrelevant and isolated, ignoring the CEO's comments: "We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself,” adding that “we saw no indication of anything actually improving."The death spiral is happening, exactly as predicted."UnitedHealth reported one problem after another: An expensive risk pool that lacks the younger and healthier consumers who are supposed to buy overpriced plans to cross-subsidize everyone else. Enrollment growth continues to lag (behind projections). People join the exchanges before they incur large medical expenses—insurers are required under ObamaCare to cover anyone who applies—and then drop out after they receive care"http://www.zerohedge.com/news/2015-10-30/obamacare-disaster-co-op-insure....http://www.wsj.com/articles/unitedhealths-obamacare-reckoning-1448232440 10 Melvyn Polatchek (New Jersey) I am in favor of Obamacare. But Paul who criticizes right wing effort to exaggerate the problems has no trouble using his skill as a wordsmith to make it seem less so. I can o better get a handle on the truth than I can from National Review. 1 Independent (the South) I have never understood why my employer takes care of my health insurance. 9 A.G. Alias (St Louis, MO) "The number of uninsured Americans dropped sharply, roughly in line with projections, while costs came in well below expectations."ACA is an astounding achievement. It would have been far, far better, if the Republican obstructionism had been LESS, not absent! They opposed & obstructed at every step of the way. One can only hope, another president, sometime in future should be able to expose this Republican hypocrisy. It may well be Hillary Clinton. But I wouldn't be too sure about it.Having said that, what we face now is the growing menace of Daesh. Although Bush-Chaney created it, president Obama's inaction & blunders in off the cuff remarks made it grow to this level. It's now his responsibility to eliminate it.Daesh is the new Nazis, but Nazis came to power about how GW Bush was "appointed as president by the 5-4 majority of the US Supreme Court." Daesh used muscle & brutality to expand its hold on Sunni Muslims, as a direct result of Maliki's culpable discrimination oppression of the Sunni minority, which Obama passively permitted.Unfortunately such mistakes happen. But it's his responsibility to correct it. He is not doing that as yet. Democrats ought to criticize him, relentlessly by joining the Republicans, I think. 2 MrReasonable (Columbus, OH) If Krugman wants to cover his eyes and not see how Obamacare is imploding, that is his right. But to write a column saying everything is fine when he knows it isn't is just dishonest. All the co-ops are failing, insurers are dropping out, premiums are skyrocketing, ER visits are way up - all these things point to an unsustainable program that s soon to die under its own weight. It is sad when a famous columnist has to resort to dishonesty. 21 David (San Francisco, Calif.) America spends an outrageous amount on health care - both per capita dollars and as a % of GDP.Nearly every country in the world understands health care is a public good, like the police or fire department. Imagine if your home was burning to the ground and the fire department asked for payment before it would put the fire out. Or an assailant had a gun to your head and the police asked for payment before intervening.The same holds true for health care.The only reason I can imagine why it is treated differently in America is per statement one: the profits for health care are outrageous.Lobbyists fight tooth and nail to make health care for profit, but it is not sustainable. For instance, companies like Valeant purchase the rights to life saving drugs and increase the price to consumers 1000%. They don't innovate, they extort. The patent exemption in the Sherman Act was meant to encourage innovation, not extortion.Under the Sherman Act, companies using anti-competitive practices are guilty of a felony and their monopoly power in the market is nullified.Health care is not like other profit-based markets where there is transparency and substitutability. For profit health care makes illness a gun to the head requiring payment for intervention.Health care is a public good, and therefore should be paid for by taxes instead of multiple insurers and private companies. It would radically drive down costs and make it available to every citizen. 15 Tom Beeler (Wolfeboro NH) It's ironic that that despite the fact that the Affordable Care Act was created to protect the lock private health insurance carriers have on the market, insurers are merging to reduce competition and United HealthCare is complaining it isn't making money on the deal. So much for saving the fortunes of healthcare CEOs. Even when they got what they wanted it is never enough.Time for single payer. Reduce overhead and cut costs by 30%. Don't worry about the healthcare CEOs. They have already made enough to move to Switzerland or the Cayman Islands to be with their money. 14 Minnue (New York) Just read in The Guardian (online) that starting in 2016, there will be no PPO options available in the Obamacare exchanges for people in NY, NJ and Texas. The article featured a woman in Texas who, despite $1600 a month premiums, will no longer be able to continue her cancer care at MD Anderson. As insurers bail out, we'll be left with just another version of haves and have nots -- those who can buy decent coverage through their employers, and those with sub-par (and expensive) options on the exchanges. Is this the best we can do? 5 Bill (Des Moines) Paul - I purchase my health insurance as an individual. My premiums have skyrocketed over the past three years, the network of doctors I can see has shrunken, and I have limited choice of hospitals. This may be progress to you but not me. You probably get insurance provided by City College or the NYT so are not affected by these very real middle class problems. I'm glad other people have the opportunity to buy insurance - I'm just sorry I'm paying the bill. 15 Lawyer/DJ (Planet Earth) Yawn. Another GOP fraud comes out from under a rock to lie about "skyrocketing premiums."Bill in Des Moines = Bette in Spokane, a total phony. 4 Bart DePalma (Woodland Park, CO) Trying to put lipstick on a pig.Obamacare mandates have increased the average cost of individual market insurance by over half - 41% in 2014, 7% in 2015 and now 11% in 2016.The taxpayers are paying 85% of the roughly 9 million people who signed up for this insurance on the government exchanges.Over 30 million people who are generally healthy and/or do not qualify for subsidies are paying the Obamacare fine rather than sign up for this expensive government designed insurance.Of the people who do sign up, the healthy generally stop paying their premiums and bail out during the coverage year once they discover its high out of pocket costs like several thousand dollar deductibles. The fact that the insurance provides coverage for your yearly exam is pretty useless if you cannot afford the deductible before coverage kicks in to treat any problems they find during the checkup.The insurers stupid enough to take part in the Obamacare exchanges are losing billions. Obama illegally covered their losses from other appropriations in 2014 and 2015, but the GOP put a stop to that in the 2015 budget bill. Half of all co-ops are now out of business and the private insurers are getting ready to bail.This is what is meant by a death spiral. 13 BobR (Wyomissing) Such baloney from someone who makes a terrific salary, gets many Honoria, and has a fine employer health plan.His declamations about deductibles are nauseating, and reflect those of someone not in touch with the real world. I suggest he wander a few blocks from NYU, and find out what's really happening.Disclaimer: I was an MD in private practice for 40 years, and just retired. 14 Joseph (albany) A much better idea is to limit what insurance companies pay per beneficiary (I will make up number of $15,000, because only a small percentage of Americans under 65 have more than $15,000 in annual medical costs). Then, allow people to purchase insurance across states lines, and implement some real tort reform.Above $15,000 (or whatever the number is), then there could be "Medicare for all," funded by an increase in the payroll tax.Result? With insurance company liability limited, choices increased, and tort reform enacted, premiums would plummet, and most would be able to afford health insurance.And for those who want single-payer (where it is a crime for a doctor to take direct payment), the only two major western countries that provide that are Canada and Great Britain. Both are in big trouble. 3 David Michael (Eugene, Oregon) Canada and Great Britain's Health Plans in great trouble? Really? Seems like I have heard that pronouncement for decades. I have been treated in both countries with excellent results for about 10% of the costs in the USA. It's the USA that needs a complete overhaul to a Single Payer System or Medicare for all. 9 Dr. Lee, PhD (The Scripps Research Institute) So, 24 states already have medical tort reform. When are the effects of this magical tort reform going to be seen by the general populace? 2 Robert (Out West) They did the tort reform, Obamacae allows for insurance exchanges across state lines though that's blocked by refusals to build any exchange at all, and Canada and Britain's health systems are dong just fine, thanks. 3 Doug Terry (Maryland, DC area) Since Republicans in the states dominated by their party have made it clear that they hate anything the govt. can do to help ordinary citizens, Obamacare has, inadvertently, opened a window on changing American politics and govt. As it stands now, the right gets to denounce everything from Washington, DC, while their constituents eagerly use those benefits to survive, including those in low paying, Walmart type jobs. The Supreme Court ruled, however, that states can op out of Medicare expansion (possibly violating the 14th Amendment, "equal protection under the law" clause, but that's for legal scholars to fuss over).So, as a result of this ruling, the door is now open for future legislation allowing the backward looking states to op-out of every safety net program they don't like. Would that be a good deal? Well, it would make the reality of "two Americas" crystal clear to everyone and it would also take away the basis for some of the complaints from the right. The red states would find a shocking truth: they can't live without those federal benefits. People would either flee those states in great numbers or they would force politicians to realize there is good even in the "evil" of taxes. In other words, it might force us to grow up as a nation and stop fighting some of the old battles over and over. 8 Frank (Santa Monica, CA) As an admirer of Dr. Krugman, and as a Californian who "fell through the cracks," I respectfully submit that the so-called affordable premiums on our state's exchange are more than just a "slight disappointment." As a healthy 59-year-old who dutifully paid into the complex Rube Goldberg-esque US "system" for nearly 40 years, I really wish I could continue to afford the luxury of improving the risk pool for executives at UnitedHealth et al. Sadly, all of that changed in 2014, when my premiums and deductibles doubled. 13 Christopher Monell (White Plains, NY) Heath care should be publicly funded not publicly traded. I fail to see how health care will ever become truly affordable and universal in a shareholder-based health care system. They are two diametrically opposed concepts. 14 Ian Maitland (Wayzata) If you think health care is expensive now, wait till we have a single-payer system. 5 John Joseph Laffiteau MS in Econ (APS08) Dr. Krugman and Readers: Just four brief points, if I may.1) As the ACA helped to employ more uniformly the best current methods and practices among medical professionals and hospitals; it should be expected that medical costs would rise simply because the "easy savings" already have been implemented. The new marginal reductions in costs should be smaller, as medical organizations have now more uniformly instituted these best practices.2) "Adverse selection" is a medical insurance concept that, in succinct terms, states that as more sickly and costly patients are insured, rates will rise. The healthy will opt out of the system because the premiums, with the sick being the cost drivers, will force medical costs upward. The dissatisfaction among some policy holders from the rise in deductibles is simply concern aimed at a form of a medical insurance rate increase.3) The recent concentration of market shares in this sector may have increased the pricing power of hospitals and other larger medical organizations, which is probably contributing to the 11% average premium increase.4) Many of these merged entities face reduced overall income tax bills simply because many hospitals pay no income taxes as nonprofit entities; whereas pre-merger, many of these physician practices paid forms of corporate and individual income taxes. These tax savings, which result in reduced costs, do not appear to have been passed on to the consumers of medical services.[11/23/15 M 1:16p] 3 vishmael (madison, wi) As bored with adding my two-cents' worth as all are with reading such repetitious entreaties, nonetheless:Health insurance and Big Pharma companies ARE the death panels,making obvious that all citizens and congressional reps dedicated to the well-being of their constituents (That would include for this writer Ron Johnson, Tammy Baldwin. Ron Kind, Paul Ryan, et al., any reader encouraged to name and petition your own reps.) must work together toward immediate installation of a single-payer system like those which provide equal or better services at one-half the cost across an array of democracies more advanced, more civilized, more compassionate, more democratic than the USA.. . . Although trying to talk sense to the billionaires' concubines hasn't worked yet, the effort remains valid so long as time permits or requires. 7 Royce Street (Seattle) The fatal flaw in the AFA is that it is hemorrhaging money. When, as PK acknowledges, the "long term trend" in medical costs is a 5 - 10% increase per year -- and no relief in sight -- something's got to give.But as Stephen Brill points out in his book "America's Bitter Pill," the framers of the AFA early on made the decision to focus on increasing access to health "insurance," rather than on containing costs.Back in the '90's, under "managed care," the explosion of medical costs was contained. But that was abandoned due to pressure from consumers who thought they didn't get the benefits they were "entitled to." One area where the AFA did try to contain costs was by taxing "cadillac plans." Now that, too, is in danger of being repealed. As long as we depend on third-party "insurance" to fund the vast bulk of medical care through employer-sponsored insurance, Medicare, and Medicaid, the problem will only get worse.The solution is to restrict insurance to what it does best: spreading risk. Everyone should have true catastrophic insurance, meaning every penny of medical expense over, say, $35,000 should be covered -- no exclusions.Over a lifetime, the average -- the average -- person will spend $1,250,000 for health "insurance" or medical care. After paying for True Catastrophic, you'd still have around $850,000.So here's the choice: spend your own money, or go bankrupt having others spend it for you. 1 FCH (New York) No offense Mr. Krugman but I think you're looking at this the wrong way. Just focusing on the number of uninsured will not give you a comprehensive assessment of the success (or lack of) of the ACA. I am a strong proponent of universal healthcare but can perfectly understand why the ACA is not popular. You rightfully mention the shortcomings; an increase in premiums (by the way 11% is a lot of money for the lower end of middle class families), high deductibles, arcane sign-up procedures, etc. I would add approx. 3 million adults who fall into a “coverage gap” of having incomes above Medicaid eligibility limits but below the lower limit for Marketplace premium tax credits in states that opted out of Medicaid expansion. I think the President lost a once in a generation opportunity to come up with an ambitious plan to reform healthcare at the beginning of his mandate by wanting to play nice with the GOP and caving in to the pressure of various lobbies. Universal state sponsored healthcare works in most other advanced countries and would have worked here as well. 8 Kathryn Tominey (Benton City, Wa) Senator Baucus was a major player in dropping the single payer option. His Committee chr position allowed him to dump single payer in a vain attempt to get some republicans to buy in to ACA. He literally threw it away and his dishonest republican colleagues did not keep their word. Big surprise given the republucan party's decision to put racism ahead of the welfare of the nation at large. 5 Mary (Brooklyn) First of all, United Health Care is NOT losing money. It's just making a little less money because it actually had to provide more of the service that insurance is for, rather than just collecting premiums. This is due to a substantial jump in new enrollments of either people who never had insurance before and finally went to see a doctor or were unable to get insurance due to pre-existing conditions. So they picked up a number of new customers but were not able to profit as handsomely from them as they actually used health services. I would think that this use would level out as they became returning customers year to year, but the point is that insurance companies, which we have been suckered into paying huge sums of money to, are NOT in the business of providing health care. They are in the business of profiting from collecting premiums and not providing health care--hence the mounds of paperwork in the doctors office from rejections of coverage until they word the service in a way that may or may not ever get them paid. The doctors then cover their losses by hiking prices on everyone else. I for one, find it completely egregious that health insurance is a for profit business that answers first to it's investors and looks for any way to avoid the cost of actually providing the service for which it exists in the first place. This is the reason that health care is so outrageously expensive in this country compared to the rest of the world. Let's go single payer please. 7 Independent (the South) I have always paid for my own health insurance.Before the ACA, my premiums went up 20% to 30% a year. The insurance companies could never explain why when inflation was 3% a year.This year with the ACA, my premium actually went down!They told me this was not common but did happen for some policies. 6 MaryM (New Jersey) Our family of 4 has $1500/month insurance with a $2K per person deductible for the Silver plan.i hit the 2K deductible after a routine blood test showed microscopic blood in the urine. One cat scan and cystoscopy later, I had reached 2K in bills to find nothing wrong.The insurance only covers annual physicals and ob/gyn exams.Annual visits to a specialist for skin cancer count toward the annual deductible.Basically we would have to pay 18k / year for insurance and another 6K for the family deductible.It is really better to forgo insurance, especially for the young or healthy. 6 Robert (Out West) And I'm sure the rest of us would adore paying for your fanily's medical care.By the way, it'll silly to see a skin cancer specalos every year, unless you have some big risk factor. Your GP should easily be able to see if there's a problem. James Jordan (Falls Church, VA) In the evolving political experiment of a Republic, most would say the experiment has been a success. It had its ups and downs but this society has been successful in wealth creation & creation of a better standard of living for most of our people. An evaluation of our system of government reveals that we still have many challenges that our society must adapt to. Healthcare has not fully adapted to the realities of society & technology but we are getting there.One of the fundamentals is the disagreement over the fact that healthcare is a natural monopoly in which the free market does not perform as well. The monopoly nature of the industry has been overcome by a system of socialism that we have adapt to with Medicare, Medicaid health insurance & job related private health insurance plans.The hybrid has been successful but there are several populations that need more work: insurance is a good concept but it also has generated problems in cost control & providing healthcare to low & mid income people. We can overcome this problem. The ACA is a step forward. Everyone knows it would be better if we all had a single payer health insurance system from a simple axiom of insurance such as, the larger the "risk pool", the lower the cost to pool participants. But change has been slow in coming because some believe that the free market should determine how goods are distributed & it simply is not true for natural monopolies. This can be solved next election. Vote wisely. 6 Ian MacFarlane (Philadelphia, PA) This is a fight that should never have been fought with ringside commentary that should never be given.Society exists for the benefit of all or it doesn't exist.We are either an intelligent people who recognize and follow the precepts of society or we are a bunch of circus animals following the crack of the whip.With the freedom to vote and actually choose our representation there is no excuse for our nation to lead in utilizing the oppression of the military/police against others as well as ourselves.The economic model we tout and practice is only sustainable for those at the end of the Ponzi schemeWe have the wrong idea, if any, about our responsibilities as citizens and that ignorance will continue to haunt us until we educate our selves and vote en masse 3 optimist (Rock Hill SC) The basic problem is that the Health Care Consumer Price Index continues to rise faster than the CPI and wages year after year. As long as the underlying problem of health care inflation is not addressed, neither Obamacare or anything else will solve the problem of inadequate access to high quality, affordable health care. 8 JK (Orlando FL) I think you are completely off base, I am paying almost a 1k a month and i have a $6,000 deductible. I have 3 daughters in their teens that require all the doctors appointments and such that go along with that, please tell me how this is the "affordable" care act? I have a combined yearly income of $85,000 with three children, the monthly payment alone is breaking me I can barely keep my head above water. People like Paul Krugman drive me nuts, you do not have a clue what the average blue collar middle class wants or needs. This law is killing the average american and it will get worse next year. 14 rebecca1048 (Iowa) It's expensive, but what other options are there to guarantee all have access? Robert (Out West) The average family premium is over $16 grand a year, and your daighters are getting all their routne stuff done for free, actually. Dr. Lee, PhD (The Scripps Research Institute) If you have a family of 4 (you didn't say anything about a spouse), your premium would be $894 a month for a deductible of $900 and copays for doctor's visits. For a plan with a $6000 deductible, you'd be paying $654 and would also have copays for primary care. 1 Straight thinker (Sacramento, CA) Had to read this yo see how PK would spin this one.Clever piece. Classic trick of stating bad news in a positive or minimalist manner, thereby taking some if the thunder out if the opponent's statements. Sort of like a prosecutor calling a defense witness to the stand if possible to lessen the witness's impact.Even the "good" news is bad. The number of people covered is well below the expectations that prompted the legislation in the first place. Expectations, and the cost to add new people is astronomical on a per person basis. The real costs, as high as they are, are still not implemented. The worst us still to come if and when govt subsidies to insurance companies stop.Let's not forget the promises of lower premiums, keep your doctor, etc. Any positive news with regard to the ACA is actually horrible when compared to the promises.All that can be said in favor of the ACA and the underhanded way it was passed is that it will most likely lead to a single-payer system, which is the only way out of this mess. Single-payer would not have passed on its own - it needed this deceptive and, in my view fraudulent, legislation to make it viable. Now we have no choice. 8 Don (Washington, DC) It's lost to history, but surely there was somebody who was assuring passengers well into that terrible April night that they wouldn't be inconvenienced by that little nudge with the Ice berg. I had to laugh out loud at this passage: "But are we looking at the beginnings of a death spiral? Some people are indeed saying that, but as far as I can tell, they’re all people who have been predicting disaster every step of the way, and will still be predicting imminent collapse a decade from now."Is there any statement possible that more perfectly provides a mirror image of Paul Krugman? He has so far removed himself from being an honest analyst on this issue or any other relating to the Obama administration that there is no way anyone could take him seriously as anything but a shill. 12 Doug Terry (Maryland, DC area) Even if the Affordable Health Care Act is fully successful (and thank goodness for the many who are now insured who weren't before) it is nonetheless a kind of rolling disaster. First, it helped to install the Republicans in the House of Representatives, something that happened historically EVERY TIME the Democrats proposed major health insurance reform going back to FDR in the 1930s. Second, we got half a loaf and that loaf, while better than nothing, now serves as a blocking point to something truly workable and universal.The biggest blunder by the Obama team was the first one: standing back and allowing Congress to be the author of the plan. This created a months long period of loud debate (screaming) well before the legislation was ever written and formally considered. It set the stage for the downgrading of the Obama administration before they had really gotten going. While it probably was all but impossible to get the Republicans on board with anything that would be successful, greater efforts should have been made in that area, too.Unfortunately, the Democrats set the table for this disaster back during the Nixon administration when, for partisan reasons, they refused to back a similar plan proposed by the Republican president. They goofed. So, it was another generation before it could be considered again and, sadly, it will be yet another generation before real, substantial changes can be made to make health care universally available and affordable. 5 wsf (ann arbor michigan) Most of have some control of the cost of health care just by our lifestyle. It is certain that a catastrophic illness, serious accident or genetic disorder can strike even the seemingly very healthy individual. However, as modern medicine has established, we mostly receive serious and chronic diseases because of our lifestyle. Preventative medicine is where the most money should be spent in the health care system. 2 RaflW (Minnesota) A significant part of the problem with healthcare spending is demographics. OUr country is aging and in declining health, broadly speaking.What we need is a rise in the working age, healthy population to 1) create net pay-in to the system and 2) to widen the base of the triangle we've always had for Medicare as well as work-age insurance. Social Security would be strengthened as well.How can we grow our work-age population? Immigration comes to mind as a most direct route. But the nativists are in the process of slamming that door, and if Trump has his way, many millions of workers currently here would be booted out. We should instead document these folks, integrate them into the insurance system, and benefit legally from the work and pay they are already earning but that goes underground now. 2 FCT (South Jersey, NJ) I believe President Obama made a big mistake in agreeing to take the public option off the table, even though he was facing relentless opposition from Joe Lieberman and Grassley. Realistically the ACA is probably the best we could get at the time. I've looked at the plans for NJ and they are just a reminder of the crazily complexity of our healthcare delivery system whether it company-provided, from Medicare or via ACA. The key points from Prof. Krugman's column today are: 1) employer insurance is having similar increases this year; 2) ACA is still new but Repub opposition prevents any improvement; 3) there should be further support for non-profit plans; 4) a renewed push for single payer. 5 Ira Loewy (Miami) My wife and I are comfortable middle class, but hardly rich. Fortunately, I am now on medicare. For next year, my wife's Florida Blue policy will cost more than $1,200 per month, with a $3,200 deductible and it does not even cover Dexilant, a medication she needs for very bad Gird. This is the only policy which lets her keep her doctors. I don't mind the high deductible, which in essence makes this a catastrophic policy, but the premium is obscene. As usual, the rich can get what they want and the poor get subsidies or medicare, but those of us in the middle get screwed. 10 [email protected] (new york) The ACA is an imperfect program with too many working parts ...it needs to be streamlined one solution is more mandatory participation by carriers on both the exchanges and in the small group market too many companies are are picking and choosing where to play...not sure of the motivation for United making a splash about leaving the market their participation is minimal and their profits are driven by the commercial and Medicare supplement business, however when coops pull out people will look to brands that they are confident in to place coverage more choice by the consumer is always better. MattM (Marietta,GA) As long as health insurance companies have to pay seven and eight figure salaries to CEOs and return ever higher dividends to share holders how can we ever expect premiums to stabilize or fall 9 Nancy (Great Neck) Protecting our national healthcare insurance program, which is the Affordable Care Act, is essential but Paul Krugman in the shared wish to protect the ACA does not allow for enough consideration of the failings of the ACA which needs to be expanded to more residents and more more affordable by limiting out of pocket costs by in turn regulating insurers and providers. 2 Nelson (austin, tx) I hope Dr Krugman will write something about the bankruptcy rates related to health expenses soon. That was another shameful and sickening aspect of our healthcare "system," along with pre-exisiting conditions, that demanded meaningful change. In so many ways we have been like the frogs in the pot of water with the heat turning up gradually: medical insurance administrative waste and corporate profiteering. I have been watching these changes for the past 40 years, but the breadth and depth of the carnage seems shocking. We are at the boiling point and cannot implement Medicare for all fast enough. 6 DBrown_BioE (Pittsburgh) I think the best you can say about the ACA is that it's been a modest success that has been directly helpful to a limited number of Americans. It has yet to be seen if it can hold down health care costs, which is the real problem. And no, don't tell me about the slow rate of health care inflation in the past few years - the economy was in the tank and the pace of pricey new medical innovation was slow. The ACA came at the expense of President Obama's entire political capital and has dogged him ever since. Since 2010, legislation has pretty much ground to a halt. It makes me wonder if he'd do it all over again... 4 Stan (LA) Krugman is as delusional over Obamacare as Obama is delusional over ISIS. 13 Tony (Chicago) My example: I pay $20,000 just in premiums for a family high deductible health plan and then subsidize that same cost for my employees, and my family uses about $200 worth of health care per year. That sounds like the makings of a death spiral. 9 angbob (Hollis, NH) That sounds like justification for universal health-care financing. 2 Frank Dracman (NJ) I doubt this guy Krugman has ever run a business or purchased health insurance, he's just a professor type. I have purchased health insurance as an independent sales rep for 16 years, 3 years ago I was forced into the ACA as Horizon BC/BS cancelled all the non conforming plans. The ACA is basically a $12K tax to people who make over the minimum subsidy level of $95K, because that is the max outta pocket. Today a Silver PPO plan for a family of 4 is $1530/mo. through Horizon, with a $2k/person deductible, then 60/40 until you hit the $6K max, that is per person until you hit the total max of like $23.5K/family. prior to the ACA my premiums would go up like 3-5%/yr. and that has not changed under the ACA it still goes up the same, however I use to have a $0 deductible, and now my deductibles are huge!, The third thing this idiot doesn't mention is the narrow networks, if you sign up for the bronze HMO plan you won't be able to stray to far from a narrow network that the plan sets up for you. If you do and go outta that network, hold on for outta network fees. The ACA didn't do anything for middle class folks making between $95k - $250K, which is middle class in NJ now, only if you make less than that. If the basic premise with insurance is that the more people in it the less expensive why didn't Obama and Emanual drop health coverage for federal employees, give them a 5% raise and have them forced into the ACA which would have put more people into it? 7 David A. (Philadelphia) I wrote the same thing about two hours ago about how ACA is unaffordable for the middle class. Plain and simple. It works ok if you make 18,000 a year and it also works okay if you make 250,000 plus a year. But in Philly, for a couple in their 50s with one kid and household income of $81,000 (husband and wife each make $40,000 - solid middle class family), the Silver PPO for 2016 is 1825 a month. And there is a 2000 deductible per person capped at 4000 for the family. A family making 81,0000 or 100,000, can't afford to pay 25% or 20% of their pretax income on health insurance. There is no way the numbers work. Krugman has either never spent 10 minutes running the numbers for what the plans cost or he knows and he is just too partisan to care. Either way, he's a joke though the joke is really on the middle class who can't afford health insurance. 7 Robert (Out West) Government workers DO have to use the Exchanges, and if you bough a policy at those rates that's 60/40 in-network co-insurance, boy did YOU get hosed.You need to talk to somebody who knows what they're talking about before you renew. res (TN) Re: High Deductibles. Welcome to the real world! The so-called "Consumer Driven Health Plans" are becoming common place for those of us who are lucky enough to have medical insurance offered by our employers. The deductibles on those are in the thousands of dollars, which renders them no more than catastrophic coverage. 4 Richard Luettgen (New Jersey) Great news! You don’t have cancer! Isn’t that wonderful?! Bad news, I’m afraid, is that a small asteroid is about to hit the house you’re in, vaporizing all within.Insurers find that their risk pool is too sick and expensive than expected? Could that be because so many healthy young decided to pay the penalty of not obtaining insurance rather than pay for a policy with a deductible so high that they’re simply paying cash all year for services – and they can’t afford it? Fewer healthy, exploitable bods and what happens? Those remaining can’t support the ill within the pool.Pretty pricey policy only good as catastrophic insurance, FAR more expensive than they’d bought BEFORE the ACA, when they even bothered. And, of course, they’re paying out-of-pocket all year long for services. Did I mention that they’re paying out-of-pocket all year long for services?While Paul is desperately seeking players “sounding much more positive” than UnitedHealth, Aetna and Cigna also have flagged major challenges for the same reason – structural losses. Expect major league premium increases. The primary reason for the shortfall in enrollees isn’t that “surprisingly few employers are dropping coverage”, but that, other than the very poor who pay nothing, so many can’t afford the policies, even WITH subsidies. And the poor STILL are going to emergency rooms for care.But let’s honestly rejoice that you don’t have cancer. Just look out for that asteroid: it’s getting closer by the second. 5 DM (Dallas TX) "the average increase will be around 11 percent. That’s a slight disappointment, but it’s not shocking".Uh ... yes it is. 6 Grove (Santa Barbara, Ca) Health reform lives ! . . . For now. However, the Republicans will relentlessly persist in their fight against anything and everything that is designed to benefit non-rich Americans.Talk about a war on the poor.But hey, money is for rich people.Also, healt(don't)care companies are trying to morph into entities that can get around actually providing healthcare, and ultimately increase their profits.After all, their business model is to make money by NOT providing healthcare. Nevermind that their existence is mostly unnecessary. No one has figured that out yet. Our economic ststem is a silly game designed to enrich hucksters, fraudsters, banksters and other charlatans. It is virtually unusable as a means of creating and maintaining a stable country and world. 1 H. Torbet (San Francisco) I never understood why the Democrats never argued their espoused principles, and instead advocated for the Republican health care plan. The part about death panels was particularly incomprehensible, especially for anyone who has ever dealt with an insurance company.A typical story is the patient who shows up with a life threatening medical emergency. Under the rules, the doctor must get the insurance company's approval. This requires telephone calls and the submission of documents.Well enough. However, this is where the insurance company starts to earn its money. Whatever the doctor says will be rebuffed, and the documents will be "lost". The matter will have to be reviewed by a committee. All this takes time. Time the patient may not have.This is the time when the insurance company is hoping that the patient will die before it has to spend any money. There's some executive in Connecticut or Nebraska trying to up his Christmas bonus on this patient's life or death.You want to talk about death panels? What the heck do you think insurance companies are?I'd take an official at Medicare in this situation over someone in the employ of an insurance company any day, and twice on Sunday.The Democrats, the cowards that they are, refused to join the debate and fight for their principles. Thus, we have to ask, "Who do these Democrat politicians actually represent?" 8 Jim H (Orlando, Fl) If The Republicans win the general election next year, the ACA will be repealed, pure, plain and simple. And, let's not forget what an awful job the President did in negotiating this chimera of a health-care bill to begin with. The Democratic Party, led by Nebraska Senator Ben Nelson, forced concession after concession, weakening what could have been a simple, inexpensive single payer system. The Republicans gleefully watched the whole pathetic show and knew this President would roll over if pressured. We know what happened later: this President was ready to sell Social Security and Medicare down the river in what he called a Grand Bargain. Fortuitously, the Democrats pulled him back from the precipice.Republicans sneer at Democratic voters. They say we are lazy and not too bright. More often than not we fail to show up and vote and when we do vote and win we get a moderate Republican, not a strong Democrat. 3 jmc (Stamford) I had private insurance for decades, still do, but my primary insurance is Medicare. It is far better than anyone could expect, it eliminated complicated billing problems, clearly reduces cost. ACA is working. But our goal should be universal single payer. In effect from birth forward. There is an adjoining issue, which includes health concerns generally. Infant mortality is higher than in Cuba and that situation. In some states, Louisiana, Arkansas, Mississippi and Alabama, infant mortality is a multiple of Cuban numbers. Worse yet, we are very significantly higher than advanced countries which have very nearly eliminated infant mortality. 7 James (Flagstaff) Many comments here rip our much maligned president in two: too weak to have given us single-payer, too autocratic in forcing Obamacare (supposedly) down our throats. Funny thing, it's like this on everything: energy (not drilling everywhere and destroying coal; or relying too much on fracking); immigration (deporter in chief, or madman issuing executive orders and bringing hordes of refugees); national security (number one weakling or superspy using drones and surveillance). Is there a pattern here? On healthcare, as on many things, the president has skillfully steered a middle course. That's doesn't mean it's perfect, but it is a reasonable attempt to move forward in a polarized society. And, it is consistent with a central pillar of his campaign (laughable though it may seem in today's environment): getting beyond partisanship. In normal times, we'd see these policies as giving something to everyone. Sadly, in today's times, we only see them as pleasing no one. I don't think the problem there lies with the president. 7 elizafish6 (Portsmouth, NH) I have been supportive of Obamacare all along, even though I would have much preferred single payer or, at least, the inclusion of the Public Option. I continue to be supportive. But my two sons, both in the young, healthy, just-who-we-want-to-sign-up category, can't really afford insurance. The quotes run $100 to $200 a month for $6,000 deductible insurance. So yeah, they'd be covered in a catastrophe. But they are not covered in the evet of a sore throat that won't go away or a sinus infection. Around here, medical costs are such that out of pocket is too expensive. I think they figure they would do better to pocket the insurance premiums so they can afford to go to the doctor. I am deeply disappointed, because, God help us if they do have a catastrophe. We can't afford to pay for them. 6 MrReasonable (Columbus, OH) You have demonstrated exactly why Obamacare is in a death spiral and was always going to fail. Forcing young people to bu overpriced health insurance policies they don't need or want to cover older people's expenses was never going to work. We said this 4 years ago, too bad Democrats did not listen 2 Roger DeCoverley (NY) "I hope the Democrats take Krugman's advice and campaign on how amazing Obamacare is and how it's the best thing for our healthcare system!!!" Said no Democrat in 2015. I find it rather astonishing how the goal-posts for the ACA have been moved over and over again, and now it's "obvious" that premiums are going to have to go up, and "obvious" that it couldn't cover everyone, and the first two years of implementation went "remarkably well." Are we on the same planet?? 6 Kinnan O'Connell (Larchmont, New York) Many commenters complain about excessive copays and deductibles, but this is the case for health insurance outside of the ACA exchanges as well. It confirms what we have always known - the "for profit" health cares system does not work for anyone except the insurance companies. We need single payer, Medicare for all. 4 David (Little Rock) Not at all happy with the changes my employer made this year. Not only deductables must be paid up front before the insurance kicks in, but there is a 20% coinsurance fee. So a $20,000 total bill leaves me with a bill for $5,600 and that is the so called "gold" plan of the company. 2 DR (New York, NY) ACA exchanges are helpful to a very small percentage of the nation, about 2.5% of the population. So if the Republicans are right, which Krugman doesn't want to admit is possible, it's not that big of a deal one way or the other, except for the 8 million personally affected. ACA was always only a stopgap. Bill Birrell (Santa Monica) First, I'm a supporter of ACA. My comment is the following: The national average may be 11%, but that means those of us in an expensive market, who want excellent insurance have been handed a 29% increase in the Platinum plan. Sure, there are options, like downgrading coverage, or going to an HMO, but I for one am disappointed that the media has not zeroed in on this phenomenon and examined if this kind of increase is justified. As the customer, it feels outrageous. 1 LFA (Richmond, Ca) Yes Obamacare is a workable system. And that's both the least that can said for it, and the most. It is providing care to some of the previous uninsured. In some public sectors it has also forced low income workers from their previously adequate but affordable health care, into less affordable options on the exchanges.What Obamacare hasn't done is remediated the crisis in heath care and health in this country. It won't do that, and it can't do that. And this point Obamacare is not about healthcare anymore, its about politics, and giveb the promises associated with its introduction, the politics are not winning politics. Obamacare hasn't particularly helped health outcomes and it has set back the cause of quality affordable healthcare, like they have in every other advanced economy, a generation. Tina (California) Bernie Sanders said he was on the committee that wrote the ACA. I'm presuming that he proposed a public option then. If he wasn't able to persuade those writing it, how does he think it'll get done now? Even if Democrats are in favor (and many are), Republicans are not. There has be an element of realism here. Clinton's plan for tax credits will help with the deductibles, which do go up every year, even for those with employer-sponsored healthcare.I know exactly what single payer is and I support it, but I also know that the tax burden in countries that have it is quite high; hence, the reason Clinton said that taxes will increase significantly (and not just on the wealthy). Economists like Austan Goolsbee agree. That may be palatable to a lot of people, but it won't be for many. Sanders talks a lot about the benefits, but he needs to be up front about how much it will cost, who will pay and that goes for the rest of his agenda. It's fine to advocate for reallocation of resources, but if you want people to vote for you, treat them like adults and tell them the whole story. Stressing the benefits, while refusing to detail the costs is a political strategy, because everybody likes 'free' stuff. NoBigDeal (Washington DC) This article sure seemed like a "yeah but" argumetn was being made. At least Krugman addressed the issue instead of quietly walking away from something he pushed as cracks are appearing. Elena (home) I spend my days enrolling people in ACA insurance. Just to pick a plan, use it optimally, takes an average person about five hours or review with me. It is way too complicated. Having said that, many people don't want "to pay" for insurance. Many people have told me that they are willing to gamble that their health is ok and if not, many people I have met do believe that their health needs will be taken care of through charity. And for the most part, they are correct. Which every direction we decide to go as a country, please know that health-care is not free. We all are effected by the decisions that others make. If a young man decides not to have insurance, has a bad accident, and then goes to the public hospital, his medical care will be covered. It may not cost him anything, as he can choose not to pay, but taxpayers then will have to pay for his care. 4 Ruthmarie (New York) PK - "...some Americans who bought low-cost insurance plans have been unpleasantly surprised by high deductibles. This is a real issue, but it shouldn’t be exaggerated..."I usually love Paul Krugman, but this is the type of clueless misstatement that make conservatives do backflips. It sounds elitist, looks elitist and in fact IS elitist. Its like canon fodder for their cause, and this is why: A comment like this can only be made by someone who is all too comfortable financially to understand the implications for the average person. These deductibles are a devastating blow to those who are just scraping by. When the ACA was enacted, it was a blessed relief. Sadly, the relief lasted but one year. Right now Its tough enough for me to pull the premium for a silver plan out my hat each month, but with the deductibles I'm looking at this year, going to the doctor is going to be an unaffordable luxury. But sometimes seeking medical care is not an option.Decisions about whether we pay the mortgage or go to the doctor are being made every single day by middle class Americans who are tapped out. The young people upon which the health of the ACA depends have learned to either game avoid the system. What's next? Stiffer penalties for non-participation? Meanwhile, insurers are using this debacle to consolidate, which is going to make matters worse. We need to stop defending the ACA and start pushing HARD for a single-payer system. 5 Tuvw Xyz (Evanston, Illinois) Personally, I am outside of Obamacare, depending on the two Medicare plans and a Group Health Plan. But I could never understand how a country as rich as the US would not have affordable medical care for all.Perhaps Obamacare would be remembered as Obama's greatest achievement, and his other inadequacies will be forgotten -- his erroneous perception of world history, the causes of wars, and his pronunciation that is not always on the height expected of a Harvard J.D. Robert (Out West) A few notes from reality.1. No, every other industrialized country DOES NOT have a single-payer system. They typically have mixed systems, wih some exceptions such as Canada. What they do have is cheaper insurance, with better outcomes.2. No, Medicare premiums WILL NOT cover everything in a single-payer sustem. Medicare--like all insurance--relis on having many paying, and fewer taking out. The money for single-payer would have to come from someplace, so while I'm in favor, it ain't free.3. Obamacare has a whole passel of rules to cut costs, improve quality, and publish expenses.4. You might want to look at rates between 1998 and 2008. 10%+ annual increases, average family premims up to arond $15, 000 a year, no limits on overhead, insurers allowed to dump or refuse you, far fewer covered.5. Here's a typical state--Virginia--that refused the Exchanges.https://www.healthinsurance.org/virginia-state-health-insurance-exchange/ 1 JH (San Francisco) Judging by the comments here Obama "Care" is a failure/disaster for so many people.What explains Paul Krugman's disconnect from the terrible effect Obama "Care" is having lives of so many Americans?Paul Krugman used to pride himself on being part of the "reality based community".Here's the REALITY of so many Americans are having with Obama "Care" printed in here the comments section-and it's so different from what Krugman says its frightening the degree he's "out-of-touch" on what Obama "Cares" doing TO Americans not for them.When the insanity of Obama "Care" providing useless insurance to so many people is on the front page of the New York Times you have have to question-why is Paul Krugman so blind to what Obama "Care" is really doing TO Americans? 4 Nanj (washington) The problems with the outcomes from the ACA are (at the risk of repeating):1. The size of the deductibles really means that there is no insurance for the bulk of the buyers; if its not the deductibles then its the out of pocket maximums or very high premiums (unless one is in the lower income bracket).2. Now we also have narrow networks. Very limited group of providers and larger out of network costs and double out of pocket maximums for these services.3. Drug companies and their unconscionable prices - whether Turing or the other large Pharma with their exorbitant specialty drug prices. The "no negotiation for medicare drugs or no importing drugs from abroad" deal that Pharma has is a blatant form of crony-capitalism! Because the insurers or government programs pay, Pharma feels it can justify any prices.4. Annual premium increases (and out of pocket and therefore deductible), even if smaller than in the past, cause significant financial strain since the incomes don't increase as much. 4. Even with medical loss ratios of 80% (or 85%), the actual allowed expenses often exceed 20% since taxes. Imagine 20 to 25% of the premium is just an entry fee to insurance.Where has the advantage been?1. Through ACA many who would not have had insurance now do and that is something to feel good about, for sure.Its time to tighten up and improve ACA so that it is affordable and provides peace of mind without choking the financial resources of families. 1 Grnwayrob (Houston, TX) I generally support the ACA. However, Dr. Krugman, you're being dismissive when you shrug off an average premium increase this year of 11% as " a slight disappointment". Remember, real wage growth in this country has been averaging less than 2% annually for several years now. When your income increases by 2% and your health care goes up by 11%, the average person takes a financial hit.ACA has been good at getting more people insured, but has not addressed the issue of rising health care costs. Single payer would do that. 3 Kevin (New York NY) We need Medicare for all, from cradle to grave. 5 Michael (Baltimore) What would be great is if there could be some tinkering and tuning up of Obamacare. Any system this complicated -- mainly because of all the constituencies Obama had to please -- was bound to have a few clunky parts. But, as with the wording glitch that went all the way to the Supreme Court, Obamacare cannot be touched because the Republicans in Congress want it to fail and will consider not changes to it other than repeal. They would literally rather people get sick and/or go broke than taint themselves with this bill. What a country! What a political party! 43 Heysus (<br/>) Single payer. Cut out the middleman(insurance companies making huge profits). 4 manfred marcus (Bolivia) Yes, Obamacare is working, giving low-income folks the chance, for the first time in their lives, to have health insurance, removing the anguish of 'knowing' that if anything goes wrong, bankrupcy is a given. No more. And the republicans, in a most hypocritical stance, clain 'willful' ignorance of the facts; this, to spite Obama. Shameful you say? Indeed. obina (San Francisco) I have heard that "yes, the uninsured can get insurance, but it is sky hgih"Is this true? 1 taopraxis (nyc) When my private health insurance was cancelled and the offered replacement policy premium was neatly doubled, when I negotiated the new nightmare system to get insurance and then saw the effects of the deductibles and copays and exclusions would mean that the insurance was too often just a cruel illusion, I was attacked by the ACA defenders in this space. I was called a liar and worse.Now, reading the comments, I see that *hundreds* of people shared my negative experience. Nice to hear from you.I've got insurance that I never use because I do not trust the quality of care and because the system is unethical and unfair. Only a serious illness or injury will ever get me to a doctor.This system needs total reform, yesterday.The people need to take meaningful individual economic actions that do not require political action. Remain complicit and you will get nothing.The system is rotten to the core and it will bleed you to death if you allow it to do so. 3 Daniel A. Greenbum (New York, NY) If UnitedHealth makes good on its threat to withdraw won't it move the United States close to a single payer system? It will also make mergers among healthcare insurances that much harder to justify. 2 Larry (St. Louis, MO) Paul,If things are as rosy as you say, why do Americans still disapprove of ACA 52% to 44% according to the latest Gallup poll? This law has hurt more people than it has helped. Just because someone has signed up for insurance through an exchange does not mean they prefer that insurance over what they had before. 2 PAULIEV (OTTAWA) Inflation has been very low for several years now. How does the health-care industry get away with annually raising its rates by such large amounts? 1 RaflW (Minnesota) In part because the population is getting older and less well faster than the cost of food or rent is rising. Healthcare inflation is driven by very different causes than most commodity or labor-driven expenses. Demand is outstripping supply. 1 Kurfco (California) Healthcare is a giant game of whack-a-mole. We are probably heading toward some system that will attempt a form of price controls -- on doctors, hospitals, and pharma. When this happens, we will see a lot of doctors who decide they have had about as much of this nonsense as they care to endure. They will retire en masse. 1 Al (davis, ca) Right, nothing could be more terrible than doctors' income dropping to the low six figures. It can't happen soon enough. Perhaps then the "free market" mechanisms and global free trade can begin to work for health care "consumers" as it has for multinational corporations. Jay Savko (Baltimore) My premium is going up $119 in January or 29%. Of course that's just a slight disappointment, right? 1 John Townsend (Mexico) Re "Obamacare .... was supposed to be nationwide but has been rejected in many Republican-controlled states."Cruz asserts "the people to whom I believe I am accountable are the men and women in Texas”. Yeah sure! What a shameful and shameless purveyor of crass politics!!! His state is ranked first for the number of people with no healthcare coverage at all ... fully a third of its population ... a circumstance which he has deliberately precipitated by refusing provisions of the ACA. 1 Richard Head (Mill Valley Ca) Yes better then before but not as good as universal coverage will be. We will continue to stumble and fall and eventually find that this is the plan we needed all along. 1 WB (San Diego) It looks like Krugman has decided to go down with the ship...... 3 David (Homer, Alaska) I was not opposed to the ACA, but after experiencing it, I'm disgusted. Wife and I in the system for 6 months, premium increase for 2016...20%. Both of us marathoners, own our own business. Can't get in pool that rewards healthy behavior. Healthy behavior not even questioned. Only questions: "How old are you? Do you smoke?" Deductibles? Crazy. $6450 each...in network, $12900 out of network. Oh, and did they mention only 1/2 of what you pay out of network may go to deductible, so our "actual" out of network deductible is $25,800 each, or $50,000 as family. We pay $1322 a month, essentially $16,000 a year for that? It's killing us. We work in Alaska for 6 months, in Colorado for 6 months. We're out of network in one of the places. Cost was never addressed. It's insanity. Have checked other options and there essentially are none for us. 25% of our net income out the window every year. 5 Cheval (A Town Called Panic) My experience with United Healthcare is that for the past couple of years I've gotten a refund check because they didn't spend a high enough percentage of premiums on medical care. That doesn't indicate that they're particularly well managed. 1 Len Rothman (Norfolk, VA) ACA should just be considered a very first step in health care reform. Insurance companies merely reflect the cost of the health care industry. With both subsidies and regulations curtailing the insurance companies previous abuses, such as rescissions, pre-existing conditions, denials and dropped coverage, we have decreased the number of uninsured Americans. A good thing.Yet we are still stuck in the fee for service, outrageous drug prices, hospital billing that is undecipherable and over the top in cost, uncontrolled torts, medical devices that cost more here than anywhere else in the world and, finally, patients' destructive lifestyles.Until we can come to grips with any or all of those issues, insurance reforms will still be at the mercy of annual increases at multiples of inflation. And that is on top of premiums that are already about a third of the median income for a family of four. Trakker (Maryland) My premium for next year went down 7%. You won't hear this "horror story" on Fox News. 2 Louis Lieb (Denver, CO) The Republicans should be careful what they wish for. If the Republicans do in fact win the presidency, they’ll only be able to blame the Affordable Care Act for so long before they’ll have confront the same issues President Obama had to deal with in designing and implementing the Affordable Care Act. Designing a viable healthcare policy that covers most (if not all) American is incredibly complicated—it’s rarely a “black and white, no shades of gray” proposition. RaflW (Minnesota) There is very little evidence whatsoever that the Republican party wants to design "a viable healthcare policy that covers most (if not all) Americans." 1 Aurel (RI) Thank you Supreme Court for allowing states to opt out of expanded medicaid. North Carolina is one of them (surprise, surprise). The county in which I live, Buncombe, has an uninsured rate of 19%. Do the politicians in Raleigh care? Of course not, they are all Republicans who are doing their very best to keep government off our breaking backs. 43 DaveG (Manhattan) 1.“The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working.”This statement is not true. Consider the ACA’s “80/20 Rule”. If an insurance company spends less than 80% of premium on medical care, it must rebate the portion of premium that exceeded this limit.All well and good, but the incentive here is to increase the costs of medical care, in order to increase the 20% the insurance companies get. A greater 20% means greater profits; increased medical costs mean a greater 20%.2. “The long-term tendency of insurance premiums [is] to rise 5-10 percent a year.”Why? Annual inflation is at most 2%, and has been single-digit for years. Social Security goes up 0%. In contrast, medical costs have been double-digit for years. (My 2016 premium will go up 21%, though I have not used my insurance AT ALL in 2015.)3. The insurance companies said they underestimated “their risk pool” as being “somewhat sicker and hence more expensive than they expected”.Estimating “their risk pool” is what they do for a living, and have been doing for years! Yet premiums have been going up more than the annual rate of inflation, double-digit, year after year.The ACA is not “working”. It’s a shell game, where the insurance companies have a built-in incentive to increase health care costs.Instead of honest, quality health care, it seems to be more an instance of “racketeering and conspiracy”, with the Democrats and Republicans in tow. 1 E C (New York City) Low premiums and high deductibles are the fairest way to sell health insurance.You only pay the majority of the money when you actually use the healthcare. Ellen Liversidge (San Diego CA) Obamacare has helped many who would otherwise have had no coverage at all, and for that we can be thankful. But a single-payer system is in our future, should we elect our next president wisely. I believe that Bernie Sanders, after all his years in Congress, is the man to negotiate such a thing, because he speaks sensibly and people of all political stripes respond to him in turn. He attracts every demographic in Vermont, and here's hoping he gets to do so with our nation. 1 B (Minneapolis) As is true of the many issues the Professor chronicles, opponents of the ACA just keep changing their criticisms, rather than reconsidering their position, as old arguments are debunked. Now the criticisms are about increases in premiums and deductibles.To date, the exchanges are covering only private insurance plans. Critics dis-remember that prior to Obamacare private plans had much higher deductibles than group (e.g., employer sponsored) plans, and they either had much higher premiums for comprehensive coverage or they had very limited coverage (i.e., covered only $200 per day of hospitalization, covered only cancer, etc.). Only 17% of private plans were renewed - so you definitely didn't keep your coverage - either because you had high claims and the insurer dropped you, you couldn't afford to keep paying the premium or you got lucky and got group insurance.Critics re-write history to pine for the "good old days' that never existed. We now have databases that show what the "good old days" were really like.Even in the group insurance market premiums increased 50% and deductibles doubled from 2003 to 2010. http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief...Premiums in the individual market increased 9.9% in 2008, 10.8% in 2009 and 11.7% in 2010.So much for the "good old days"Critics, time to find other arguments. Independent (Maine) Health insurance for a couple (who commented on the NY Times article about the ACA costs going up) who lost 40% of their retirement to the Wall Street thieves, having the husband to need to take early retirement and the wife to be the main supporter of the couple with free lance work, with a $1000/month premium and a $5000 deductible, is not "health insurance". The ACA was a give away to the health insurance scammers. The only solution is single payer, and raising taxes and closing loopholes on the already too rich. And no, none of the POTUS candidates would move on that except Bernie Sanders. bern (La La Land) I was for this idea at first but have seen that it makes things much worse for many who were just getting along. Ed (Honolulu) I wonder what type of insurance coverage Krugman has. Cadillac no doubt paid for by his employer. But I'm glad he thinks Obamacare is such a wonderful success. 2 WKing (Florida) "Yes, Obamacare has hit a few rough patches lately."Here's another rough patch PK didn't mention: 10 of 23 "not for profit" coops created by Obamacare are folding because they are insolvent. 4 Brian (Syracuse, UT) Those of us in the middle class that Democrats tout supporting are none to happy with your glorious plan. We are getting far less coverage for higher prices, but as long as the poor continue to get discounted rates and better coverage, everything will be alright. It sad that the poor are getting gold plans, while those of us who are paying the subsidies can only afford the bronze plans, but who ever said that Obamacare was about being fair. By the time I pay for my premiums and my deductibles, my healthcare costs have skyrocketed. Keep putting the kool-aid out on the table. I think I will pass. I cannot afford the cost of becoming diabetic. 1 Cheekos (South Florida) The GOP has been acting like little kids who have been forced to eat their vegetables. I’m not gonna like this! Mommy, its too hot…then its too cold! OK, my eyes did sparkle, but my hair didn’t turn curly! Excuses, excuses, excuses.In Florida, a purple state, with a Republican Governor, and control of both houses of the Legislature, they have done their best to run it off the tracks. They wanted their own state exchange; but, then they decided they didn’t. They rejected Extended Medicaid, refused Government Navigators access to state building to help people sign-up for health care insurance, and they refused to enable the state insurance commissioner negotiate for better plan prices from the insurance companies. And all the while, the GOP has been castigating the ACA, even scaring people away from it. Sort of like telling ghost stories around a campfire on a moonless night. And on FOX “News”, there have been testimonials about small business owners having to lay-off workers. But, as it turned out, all three of these people were not even bound by ACA requirements since they employed less than 50 employees. And, of course those Koch Bros. deceitful TV adds.The Republican lying ways are only surpassed by their incompetence!http://thetruthoncommonsense.com 1 hm1342 (NC) "The GOP has been acting like little kids who have been forced to eat their vegetables."That's actually an apt comparison, except substitute "everyone" for the GOP and "buy health care coverage or pay a fine" instead of "eat their vegetables". Do you think the federal government has a right to compel you to buy anything? 1 A Mainer (Maine) These are indeed catastrophic plans and under the ACA, are not even eligible for health savings accounts, which might give a few dollars of relief to the working middle class. 1 Jonathan (NYC) It drives me crazy how partisan you are on this issue, Professor Krugman. I am a NYC liberal, but I have had to switch plans twice in the last two years because both the health insurance companies I was with shuttered, and will have to change plans again for January 1. If you think that most Americans perceive that as a hiccup, then you are sorely out of touch. I fear deeply that Obamacare could defeat the 2016 Democratic nominee, just as it led to huge congressional losses in 2010 and 2014. 1 Alan (Santa Cruz) As a staunch supporter of the President, and the ideology used to create ACA I have now become dismayed by the rate increases for 2016. The rates are closer to 24% than 11% . The whole system supports the creation of 1% CEO's, who take home over $10 million a year . I would like to see the chart of data accounting for the increases of Medical costs for the last two years. I posit the providers of Medical care account for less than the insurance companies' :cost" factors. Gregory (salem,MA) I have a top notch insurermy premiums continue to rise, my deductibles continue to rise, the tax savings from by FSA account goes down. 1 Richard Sorock (Evanston) Where is some or any bipartisan effort to improve ACA ?Correct mistakes in order to make the law function better. That is how government should work.Apparently not today or sadly beyond any foreseeable future given what the Republican Party has devolved into, taking the sane among us along for the ride.So, I recommend only blaming Republicans at this point, who have only worked at hobbling or killing ACA without any goal or policies beyond that. GodGutsGuns (Michigan) The Democrats rammed this through with ZERO GOP participation, why should they now bail them out. You wanted this bill, you got this bill, you didn't read this bill, now pay the consequences. 1 Pete Casale (Stroudsburg, PA) Increased enrollment in Medicaid is the result, high deductables are the result, increasing premiums are the result & the federal government exempts itself from the program. Elected officials should abide by the laws of the nation which they create, the president signs, and the supreme court considers constitutional. Great American (Florida) America, the only industrialized nation in the world where holding a health insurance card doesn't ensure access to quality affordable safe health care.The insurance industry is whining because they are unable to redistribute their usual % of funds away from health care and physicians and institutions into the pockets of their bureaucrats, executives, bondholders, shareholders and patron politiicans. 2 KK (WA) Fair point. The Affordable Care Act while not perfect has done a LOT to improve access to health care. Now then, instead of whining and grandstanding, perhaps the great party of "No" will go from "no ideas" (notice the GOP has yet so propose a viable alternative to ACA) to some useful action. A few suggestions:1. Concentrate on REDUCING COSTS of medical services.2. Eliminate the stranglehold of big pharma on our government and bring competition to our prescription drug market.3. Seriously look at a single payer system for universal health care.4. Provide patients with information about the costs of medical services, rather than the costs of insurance. Encourage smart consumerism of medical services. I know what prices I am being asked to pay for any other service I seek, why should medical service costs be hidden?I know that the GOP may have forgotten how to do anything other than blame Obama and say NO to everything, but now that they have both houses in congress perhaps they might begin to actually govern?? 2 John Townsend (Mexico) Re "now that they have both houses in congress perhaps they might begin to actually govern??"No way Jose! .... and it is very doubtful new house leader Ryan will ameliorate the persistent GOP dysfunction where largely through gerrymandering a GOP-dominated congress prevails precipitating a deliberate paralysis of government, where a rump is holding the whole place to ransom. It doesn't really jibe with the notion of the US as a global leader with a bunch of gleeful stalwart obstructionists holding court whose sole aim is to thwart Obama's governance with political impunity because their seats are safe. Ryan himself derives from such a gerrymandered district ensuring his own seat safety regardless his political record. This is an insidious form of plutocracy. It's a sinister development where elements of a ruinous anarchy are now emerging. 1 Robert (Out West) It wouldn't be that hard at all to do two things: agree to have every state expand Medicaid and open an Exchange, and allow Medicare to bargain drug costs with companies. And the Republicans could get some of the fixes they want--thogh I must say, I get tired of them yelling about how there need to be the "catastrophic," plans that are perfectly available (in fact, mandated!) by the PPACA, and then yelling more about high deductibles when high deductible cheap plans are what "cat," plans are. S Kennedy (Houston, TX) I am a big proponent of the HSA with a high deductible plan. Without going into every aspect, the key driver is that until you meet your deductible you see the true medical cost. Go to the doctor for a cold - you see exactly what the doctor receives in payment because you pay it. Beyond the $25 or $50 copay very few of us really know how much money a doctor receives. Need an X-ray or CT scan - you actually see the cost.How does knowing the cost help? Once you realize you could have gone elsewhere and paid $700 to $500 and the difference would have gone to your own bank account. You'll ask what's the cost before getting your next lab exam. If and your family are relatively healthy, there will be a number of years that you won't exceed the family deductible. The money saved will go to you and not the insurance.If something major happens then the insurance kicks in and begins paying, akin to a catastrophic plan. The plans I was covered under had a max out of pocket amount.The other thing we don't talk about is our health. Eating like crap and living a sedentary life. We need to be honest with ourselves and realize that medical care we get in our 50's could have been avoided if we did things different in our 20's and 30's. Working doc (Delray Beach, FL) Medical care is expensive. Insurance is insurance. Not a bill paying service. All insurance (Obamacare and traditional workplace-based plans) have high deductible. People need to be able to pay a few thousand dollars. The purpose of insurance is so that a catastrophic bill does not make them homeless. GodGutsGuns (Michigan) I agree. The problem is the costs of even minor treatments are absurd. M JimBob (California) Get insurance companies out of the health care business! Single payer! 3 GodGutsGuns (Michigan) Next time my English family members come here to get treatments they can't get or can't get timely, I'll have them tell you why this is a bad idea. Robert Cohen (Atlanta-Athens GA area) KNOCK-ON-WOOD.Many were/are still pro-single payer, and if these allegedly money-losing private guys are overall indeed costing approximately twenty-percent, isn't there a chance-- especially if United withdraws in 2017--for a coalition of adaptive GOPers and Dems to reform to single payer? In other words isn't there a plan B movement/contingency?SEMI-FANTASY: probably Hillary or DT will be the decision maker. and both parties, are miraculously shocked/struck by the "enlightening" rational compromise spirit of the traditional past and would be able to render something that could save up to twenty percent. "WORSER" FANTASY: Or we place many patients in off-shorehospitals for some tremendous savings. 1 Gangulee (Philadelphia) Yes, but a young man told me that his insurance with Aetna that cost him 46.00 this year went up to 70.00 for 2016. Unfortunately, his pay didn't rise by that percentage. I agree with PV. Cynthia Kegel (planet earth) Obamacare is not working. We should have universal single payer healthcare like other first world countries. High premiums, copays, and deductibles make Obamacare not insurance at all for many people or just catastrophe insurance. They cannot afford to use it. 1 littlemac12 (california) No, the problems with ACA didn't turn out to be death panels or a death spiral. A more real problem is that you don't have to make too much money and you subsidies go down (or away) and you are looking at paying some pretty big premiums with an already squeezed middle class income. The ACA has helped those at the bottom but not the lower-middle and middle. Can you say resentment of big government and the poor? Ravi (Dallas TX) My wife and I are 55. Our premiums are $10,000 per year for a BRONZE plan, deductible $12K per year. We don't have access to our preferred doctor. The ironly is that many families on subsidies will opt for a silver plan with bigger networks and fewer deductibles. So, we are indirectly subsidizing families who will then receive BETTER healthcare than us.What's wrong with this picture?Give us a single payer plan any day. Medicare for all, or for 50+ ages at the very least. 4 Amused Reader (SC) Another cheerleader waving his pompoms, what a surprise!!! Thanks for the rousing update to try and make everything better for poor little Obamacare.So far the unexpectedly good news has been because the government propped up the insurance companies. As was predicted, by 2017, when the government stops helping, insurance companies would start to see problems. It's just starting a little earlier as United Healthcare said, folks sign up who are sick, get services and then drop out after they are well. And the healthy folks aren't signing up in the droves that were expected.It must be hard to come up with something important to editorialize about when this is all you are left with to talk about. 3 Robert (Out West) Like, reality? What happens in 2017 (latr, actually, but what's a little accuracy) is that government starts cutting its support for Medicaid.All the way down to 90%. Which is where it stays.A tad bit of reality would be nice. KathyAnne (<br/>) SURPRISE SURPRISE! (...not...) It's a big success for insurance companies! ...regardless of what United Healthcare may be saying about its financial state. Only one travesty of this "Obamacare" is the proliferation of unaffordable high deductible plans that make a plan inherently unusable despite that one is paying (reasonable or not) premiums for it. The U.S. still needs to get to a single payer plan that offers universal coverage -- because healthcare for all is a right for all -- not a business that makes profits! 3 Lilo (Michigan) I respect Professor Krugman and probably share many of his political tendencies. But on this issue he's starting to sound like Baghdad Bob. The bottom line is that higher premiums and higher deductibles were not what most people thought they'd be getting from the PPACA.It was predicted though, mostly by people who have political POV 180 degrees different from Prof. Krugman. The aphorism about broken clocks comes to mind. Although it's still too early to emphatically say that the PPACA didn't work at all, it might be worth admitting that when the government forces companies to cover pre-existing conditions AND makes individuals pay for coverage they will never need, costs to insurance consumers will rise, not fall. 2 Ned Netterville (Lone Oak, Tennessee) "The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working." Perhaps, bot for those for whom it is not working. Among those who bought into it and found their premiums and/or their deductibles unaffordable, it isn't working.Obamacare made no improvements in the American healthcare system, which was neither intended nor possible. Quality cannot be legislated. What it did do is make it "affordable" for some at the expense of others. The subsidies and forced coverage are not freebies. They cost someone money. In large, the losers are the taxpayers and those whose cost of healthcare has risen to pay for the subsidies and mandated gratuitous coverage.When, oh when, will socialists and Keynesians admit that government cannot create "benefits" out of thin air, that someone will have to pay, and that the total cost will be higher because of the waste, fraud and corruption that plagues all government programs. Witness the VA. . 1 Pragmatist (Austin, TX) The real shocker is how well the program has done considering it has not been adjusted/amended since inception, because the GOP refuses to use anything approaching common sense in governing. While the program has flaws, any other legislation would be studied and adjusted as appropriate, but not Obamacare. The GOP has also refused to broaden the Medicaid component in red states, which in effect has been a form of negligent manslaughter. I wonder how these supposedly "moral" legislators can live with themselves given they must know people who could have been covered and are not have ultimately died because of late intervention of a medical problem? Why aren't we studying that - a good study of deaths caused by these actions would make an interesting headline. naive theorist (Chicago, IL) "The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working." A man jumps off the top of a very tall building. as he passes the 14th floor, he sees a man looking out the window and he yells out "so far, so good". 2 JH (San Francisco) The worst part is this is all TRUE.EVERY candidate running for President is running on the Repeal, Replacement or Repair of Obama "care".We still have a CRISIS in Healthcare where 30 MILLION people are UNINSURED.And we have a NEW crisis of UN-affordability of Health Care for the middle class who can't afford the premiums and can't see a doctor because of the $10,000 deductibles-see front page of the New York Times.And for some in the middle class this has turned into Death Insurance-not Health care insurance.Childhood friend of mine is dying because he couldn't afford the deductible but kept the insurance so when he has a medical crisis and dies his family won't be stuck with a huge bill of hundreds of thousands from his death.This is actually true.And for another poor person I know who's been paying out of his pocket for some excellent grandfathered health insurance-the ONLY thing good thing in his life has he takes care of 3 disabled people-gets NO insurance subsidies.Why? Because he has an EXCELLENT older plan so can't get a dime of help from the government unless he gives up his insurance.Then he gets a $9,000 deductible and worse insurance-this is insane-which costs more than the current plan-again this is insane!And for myself we just got repriced-42% increase!What a disaster-nobody we know who desperately needs help got it from Obama "Care".Come out and see what Obama "cares" is doing TO people not for them. 3 Ken (MT Vernon, NH) Krugman's cheerleading for the ACA shows a warped sense of reality.In his partisan zeal, he was too quick to declare success and now only looks more foolish as time reveals the actual results, and yet he continues to attempt his cheerleading.Krugman looks kind of funny as a cheerleader. 6 B (Los Alamos, NM) There is no possible way that the ACA debacle was NOT designed to force single payer. You couldn't come up with a worse system by random processes, coin flipping, or dart throwing. The ACA will converge into single payer by "Intelligent Design". There is a creator. The unified D's of 2009.Ok, I give up. You win. Single payer. Raise our taxes and let us figure out how to subsidize our own health care on top of the free government health care. Just do it already. Whats a few $100T in liability? Everyones doing it. It's the best. 1 Paz (NJ) Medicare/caid have the worst reimbursement rates, which is why doctors and facilities charge private insurance holders through the roof for health services. If you want rationing, then you want medicare for all or single payer. When 47% don't pay squat, the 53% of us are not going to have our lives inconvenienced, sorry.You cannot predict emergencies, but for all non-emergency care, you absolutely need competition. Competition guarantees fairness and innovation. 2 Terry Malouf (Boulder CO) I've been a Kaiser Permanente patient for 30 years. Perfect, no--what is?--but overall Henry J got it right from the beginning: Non-profit, where the doctors (and PA's, and nurses, etc.--they're all integral to the model) are able to concentrate on medicine rather than running a business.Coincidentally, last night we had dinner with a director of KPCO (Kaiser Colorado) who was lamenting that they were experiencing huge challenges in trying to meet the demands of far more ACA sign-ups initially than anticipated, at greater cost than anticipated, while facing the prospect of even more enrollees now that Colorado's one-and-only insurance cooperative was ceasing operations. The demise of several important non-profit coops nationwide is one of the less-reported yet noteworthy stories in the "not-great news about health reform."As usual, follow the money. This revealing article lays it all out: https://nonprofitquarterly.org/2015/10/15/why-5-new-nonprofit-health-ins...Our friend pointed out that KPCO is committed to serving ACA participants in spite of losses, but the only reason is that they're a large-enough nonprofit to absorb a few years of losses on that part of their business.I'm still feeling the Bern: Single Payer, which would pump about $1T/yr (6% GDP difference in HC costs between the US and EU countries) into the US economy. What could we do with $1T/year to spend elsewhere???? Montana Al (Bigfork, MT) I was a big supporter of Obamacare when it first came out but with a 15% increase in rates this year and now 25% increase for 2016 the model is NOT sustainable. Where is the 'Affordable' in the Affordable Care Act for those who don't get any subsidies? When the cheapest policy that a single person can buy - who falls just outside the subsidy limits making just a bit over $50K per year - is $432/month (with a $4500 deductible and $6,000 out-of-pocket max). I will not be able to afford health care insurance in 2017 with these kind of rate increases. At this rate pretty soon my monthly insurance premiums will be more than my mortgage!! 4 Walter Pewen (California) Anyone who is complaining and voted Republican even once during the last 35 years needs to can it. The ACA is just the logical continuation of the New Deal. Even Richard Nixon talked about a national health insurance plan. But no, Americans had to have their last fling and blow their wad with the magic marketplace at an unrestrained clip. Sorry, but did you honestly think those insurance companies who have gotten even richer since the 1980's were going to go home empty handed?Americans have wanted their cake since 1980, well, you can't have it. You get this for now, hopefully in a few years you get single payer if you are good and don't start complaining about how hemmed in you are by that nasty federal government. Cowboy Marine (Colorado Trails) The salary of the CEO of the "non-profit community hospital" in my town...population 100,000...is $2.7 million. They have purchased most of the medical practices in town and put the doctors on salaries averaging about 7% of the CEO's. As Americans we have to face the fact that socio-pathic greed is the main personality trait of the individuals and corporate boards who run our country and our lives. 3 Publicus (Seattle) Thank you; I was getting worried. Those deductibles should be addressed; and it must get simpler to use. Misterbianco (PA) Here's an easy way to evaluate ACA from a cost standpoint. If you live in the Northeast, where I live, and you're paying less than $25--30K annually to provide GOOD coverage for your family, you're way ahead of the game. Pre-ACA, that's what comprehensive family health coverage cost. And by "good" coverage I do not mean the cheap "mini-meds" that ACA abolished. They were fraudulent junk designed to hoodwink an ignorant public offering them little or no benefit, regardless of price. I spent eight years in the insurance business and learned a few tricks from that experience. JD (Ohio) Krugman apparently doesn't use this joke of a program, which can't even be called insurance. My cost has about doubled or tripled depending on how you view it. My premiums are $818 per month for the highest possible deductible of $12,000 a year. This roughly means I have to spend $20,000 out of pocket to get substantial benefits from the program. I am healthy and have 2 healthy children. What a disgrace that it is in place and that Krugman defends it.JD 4 Robert (Out West) In 2010, just as Obamacare was kicking in, the national average premium for a family climbed over $15, 000 a year.You're paying $818? Maybe do the math. By the way, you DO know that you're not supposed to be paying anything for checkups, regular tests, and vaccines, yes? And, your costs are capped at about 9% of annual income?So why are you spending so much? Tom P (Milwaukee, WI) I have been a firm supporter of ACA. If it were not for ACA, medical care for my 2 sisters would have bankrupted my retirement savings. But there are some deep flaws. Speaker Ryan said several years ago that ACA will collapse under its own weight and he is probably right. Supporters of ACA are in denial. Our denial may not be as large as the denial Republicans carry on climate change but it is still denial. 1 Stan Jacobs (Ann Arbor, MI) Will the defects of the Affordable Care Act be remedied if the Republicans succeed in repealing it? To ask the question is to answer it. If the ACA is repealed we'll return to the status quo ante with, perhaps, small subsidies to encourage states to establish high risk pools and individuals to buy health insurance on their own. We'll again see a refusal by insurance companies to cover pre-existing conditions and a return to annual and lifetime caps on coverage. And we'll see a big jump in the number of uninsured people, particularly if Medicaid expansion is cancelled in states like Kentucky and West Virginia. The Affordable Care Act has defects, but it's better than nothing. And nothing, or next to nothing, is what the Republicans are offering. TM (Minneapolis) The problems with the ACA are, as you say two or three times in this article, due to the "complexity" of the law. I would suggest that this complexity is not accidental, it is designed. When the proponents of health care reform immediately threw single payer - and even the public option - under the bus, they voted for the exact problems you have described. These problems are due to one single thing: the need for private businesses to earn a profit. So, I will continue to support Bernie Sanders and his proposal for a single payer system. Talk about simple - you get sick, you go to the doctor, you get the treatment you need, and you go home. Your tax dollars pay for it all, and there are dedicated professionals in the entire system whose job it is to make the whole thing cost effective. Of course, if you're among those who feel that there is no way that government can get anything right - while trusting your life to air traffic controllers every time you step into an airplane, or road builders every time you drive somewhere, or meat inspectors every time you cook dinner, etc. - then maybe you think this is nothing but a pie-in-the-sky liberal fantasy. Except that it is working quite well in a lot of countries around the world. 89 Robert (Out West) Except that in reality, very few countries around the world actually have single-payer systems--Canada does, France doesn't, for xample--and that no, the current levels of Medicare premims would NOT cover everybody's costs.I'd prefer single-payer, but i also prefer reality. 1 Rhea Goldman (Sylmar, CA) 'Health Reform Lives'. You bet it does! While the rest of us slowly sink into the quicksand of ever increasing medical and pharmaceutical costs. As the number of health care providers shrink and Medicare pays less and less toward care we find the Pollyanna-ish attitudes of Paul Krugman (and Ezekial Emanual ) to be more than tiresome and disgustingly dis-ingenuous!Mr. K claims that Obamacare is working. For whom? While the Health/Pharma industries endlessly merge (thanks to a weak oversight agency and as our premiums and co-pays soar, the above two 'bright-boys' have offered only a 'suck-it-up' solution for Americans that are struggling. A ground-swell for single payer Health Care is building and hopefully our next President will take heed. 2 Misterbianco (PA) Put the blame where it belongs, on Obama's kowtowing to republicans for the fact we don't have single-payer. One day, after the coming GOP meltdown, common sense will prevail and we'll join the rest of the world in providing decent, affordable health care for all. David A. (Philadelphia) There was a typo in my last post:should have read, "household income of $80,000 or $100,000..." and not $1,000,000. Sorry. Willy E (Texas) So sad that United and others are dropping out of markets because they cannot earn big enough PROFITS. Hello, this is why we must get rid of insurance companies. Medicare's administrative costs are around 3%, while most insurance companies' administrative costs are 15%. This includes their profits, which Medicare does not have. Enough said. 91 R M Gopa1 (Hartford, CT) Get rid of insurance companies? Yes, and here's why:Insurance is a risk-free business in that, as long as the laws of statistics hold, virtually the only way an insurance company can lose money is through embezzlement by its officers. Insurance companies, therefore, cannot advance the rationale that they are risking their capital, an act that lends a fig leaf to their profiting from the pain and suffering of fellow human beings. Another way to see the absurdity of the societal tolerance of profit-making health insurance companies is hidden in statements like "the insurance company pays for my MRI scan." Think for a moment. The insurance company is structured in such a way as to never pay a penny for subscriber healthcare needs. Instead, what the insurance company does is to collect premiums from participants, skim off a healthy chunk of it for profit and then distribute what is left to healthcare providers.Let insurance companies bet on the probability of piano players losing fingers and museums losing artwork. In the meantime let us have the government provide health insurance through a corporation funded by a dedicated tax. Richard (Wynnewood PA) Interesting that United Healthcare, which says it's considering dropping out of Obamacare because it's a losing line of business, also says that Medicare continues to be a big profit generator. So which is good news and which is bad news? Blaise Adams (San Francisco, CA) Unfortunately, a death panel DOES exist.It is called the US Department of Health and Human Services. It has formed the United States Preventive Services Task Force. According to Wikipedia (but you can also check their own website):"The United States Preventive Services Task Force recommends against screening using the PSA testing, due to the risk of over-diagnosis and over-treatment as most cancer diagnosed would remain asymptomatic."But this isn't exactly true. In 2012, 27,000 American men died of prostate cancer. And many of those deaths could have been prevented by the simple PSA test.Caught early enough with a PSA test, prostate cancer is usually curable. Ben Carson is an example. His prostate cancer was discovered in 2002 and he is STILL ALIVE!The American Cancer Society recommends instead DISCUSSION OF OPTIONS, but many HMO doctors follow the recommendations of the Department of Health and Human Services.This saves HMO's money. And the pressure to save costs has become even more severe with Obamacare.Consider what HMO's offer for yearly physicals---the five minute physical. A blood panel is taken. The doctor takes blood pressure, performs a digital prostate exam, looks at the blood panel and declares it OK unless the patient need immediate emergency room care.Even when the patient has BPH, no PSA test. That would sometimes show positive readings and doctors to actually THINK, leading to exams longer than five minutes.Obamacare KILLS! 3 Robert (Out West) Except I had my routine physical at an HMO this kast week, and they ran a PSA. And that the PSA turns out to not be a great diagnostic tool. And that the guidelines have to do with not running in there are doing surgery that may be unnecessary, and is often debilitating. Chris (Arlington, VA) Pre-ACA I had one of those questionable insurance plans because I was self-employed and there were very few options. Everything about that plan improved under the ACA. But early 2015, they moved out of my state (VA) and would no longer offer insurance (I suspect due to their increased costs required by the ACA). I then switched to one of the basic PPO plans in the Bronze range of the Health Exchange. There were only 12 options in the Bronze range and all were much more expensive than my previous plan (which was also a PPO plan). My monthly premium (myself and husband) went from $480 to $740. Quite an increase (over 50%) for coverage that was fairly the same. Now that insurance company (BCBS) has decided to DROP that plan completely. The only PPO they offer in the Bronze range now has a monthly premium of $890 - that's a 20% increase. As far as I can tell, the big winner in the ACA is the insurance companies. I am all for health care for all, but letting the insurance companies dictate the plans was wrong. 7 Dean H Hewitt (Sarasota, FL) Just to clear something up, UnitedHealth has always been a slimy insurance company. They are one that tries to push providers to cut them special deals and guess what, the providers aren't doing it. So now UH is saying they are taking their ball and going home. Good riddance to bad rubbish.One thing that's happening now that makes the future brighter is we can develop a better structure for costs and future plans because of experience. People are learning about health ins and coverage when before they weren't even in the game. Most insurance companies are seeing the positive impact of the ACA and helping develop the future. This is so much more positive then what was happening in 2008. Dick Richards (North Wales, PA) One only needs to look at all the democrat politicians that originally crammed this law down the throats of American citizens who have been thrown out of office by an angry electorate to see how out of touch Krugman is on the issue. The people didn't like the law when it was passed, with congressional tricks and deception, and they like it less now. That simple fact, combined with the fact that it was passed on a purely party line vote, means nothing will be done to fix ACA's many problems. United's decision to withdraw due to unsustainable markets is telling and is further proof that the death spiral has indeed begun. 3 Steve (Los Angeles) One problem not addressed, healthcare providers are charging substantial more for individuals than they do for people on a group plan usually arranged through an employer. 2 dbl06 (Blanchard, OK) All the more reason for Medicare for everyone and all the more reason to choose Bernie over HRC. 2 Chuck Mella (Mellaville) As mush as I admire and respect Paul Krugman, the only answer here is single-payer universal health care. I don't care how you parse it, insurance is utter crap and only the affluent don't seem to see it that way. Deductibles, co-pays, the completely rapacious profit-taking is unconscionable and has to end. 5 Adirondax (mid-state New York) What is absolutely stunning is that Americans will put up with being treated as second class citizens when it comes to health care. Historians will marvel at how long it took the country to adopt single payer - the standard in every other single western civilized country.Welcome to the power of propaganda.Which is why I say again, Dr. Krugman, please use the legislation's actual name, or if you prefer, the ACA acronym. To call the president's health care legislation "Obamacare," a made-up right wing word, is simply to be tone deaf. This word implies that the health care legislation is about a man of color in the White House giving away health care to people of color. Facts be damned.But that is the beauty of propaganda. The facts are irrelevant.To pretend that we don't live in a society in which a propaganda war is being waged 24/7 is to believe that the health care fairy will deliver single payer to all needy Americans tomorrow night.So why is there no single payer? Because large companies make money off these "insurance" policies, and the .1% knows their taxes will have to go up to pay for it.But what about the Americans who are literally dying because they can't get access to health care?These folks - the insurance companies and the .1%, they couldn't give a toss. They are in fact the living and breathing death panels that the right so frighteningly speak of.They're hiding right there in plain sight. 4 keith k (ny) The glaring issue at hand is the slow acceleration of the penalty phase for healthy uninsured built into Obamacare. The poor, old, sick, are the main beneficiaries here of Obamacare, but without the healthy & young to balance out the cash flow, things will get worse before they get better. 2 John Townsend (Mexico) Just what does the GOP expect if they get rid of Obamacare? The health care system it is replacing was a disaster. It had been hijacked and turned it into a giant ATM for Wall Street, providing healthcare coverage only to a select group who can afford it and who accept certain exclusionary conditions. All others go without.Cruz's buddy UnitedHealth CEO William McGuire sets the example with his $125 million bonus, $5 million annual pension for life, and $1.1 billion golden parachute. How does it make sense to invite middlemen of this ilk into health care who add a huge and unnecessary cost. Industry profits increased 428% from 2000-2007. In addition to profit, an obscene portion of premium dollars are scalped off for sales, marketing, and of course quite effectively lobbying Congress which we're now witnessing. 2 JoeB (Sacramento, Calif.) This was a big start and deserves to be refined and continued. Bernie Sanders has suggested Medicare for all, and that might be the direction to head in. A single payer health care system that kept you with your doctor for as long as you wanted would be an improvement on a system that often makes you change your care when you start Medicare at or after age 65. Hillary is also right that this may not be the program that can get passed. A step in that direction would be to lower the eligibility age of Medicare to 60, then 55 and eventually 50. The costs of creating that change could be charged to the user; it would create a savings, as it would be less than existing insurance. 40 MGL (Baltimore, MD) An overwhelming number of Americans are trapped in poor health, no question about that. I am truly sympathetic. Some diseases are the bad luck of the draw. Others, like high blood pressure, diabetes, addiction to tobacco, obesity, etc. respond to an individual’s recognition of his role in controlling the outcome. Unfortunately today, Americans from birth are inundated with advertising that lures them into thinking they can’t live without commercially prepared dinners, soft drinks, sweets, high calorie fast food, an endless array of tempting offerings. This is one of the glories of unregulated capitalism: enjoy today – don’t think about tomorrow. Other countries somehow do better in educating their citizens to live more responsibly. But not here. Of course we have multitudes of people who need care that they can’t personally afford. We’ve helped create that problem. Now we must pay the bills. 1 Robert (Brattleboro) This column is an excellent example of the liberal elite's utter disdain for the intelligence of the average working American. Obamacare is a burden on the middle class and no amount of cheerleading is going to change this fact. The reality is that we will most probably have a Republican President in 2017. Obamacare will be scrapped and replaced with another health insurance plan which is more favorable for working Americans. And Krugman will most likely end up in a straight jacket. 2 Diana (Centennial, Colorado) As a grateful recipient of Medicare, I want all citizens in this country to benefit from such a system. The high deductibles of many policies are a real problem. You have to pay out of pocket for the deductible before the insurance begins to kick in. Many still lack health care because they cannot afford thousands of dollars for doctors visits in addition to whatever insurance premium they are paying. My cousin's insurance just increased $100/month, no small increase for him. I do agree many are benefitting from at least having a modicum of insurance, and catastrophic coverage is certainly preferable to no coverage at all.Hopefully, if Democrats are elected in 2016 single payer insurance will begin to replace Obamacare. If Republicans are elected even Obamacare will disappear. Poor62 (NY) Whatever happened to the 50 million uninsured that were waiting for the implementation of Obamacare back in 2009 and 2010? Where did they all go? The best number I've been able to find says that a total of 17 million have signed up for Obamacare or have been placed onto Medicaid. So where are the remaining 33 million now 5 years later? Then again, Pelosi said "This bill...will create 4 million jobs, 400,000 almost immediately." Where are all of theses extra jobs that never happened? 1 Kurfco (California) Many of the young and/or healthy have rightly decided that they are better off paying the penalty and going without insurance. If you have a $5,000 deductible, you are essentially uninsured for the first $5,000 of expense. It's pretty rational to choose not to buy this "product", priced as high as it is. Eric (Fenton, MO) Oh yeah, it put a lot of people on Medicaid-- which is the cruelest joke, if the "clients" in that program are led to believe they're going to be able to get reliably decent health care-- or on "private" insurance plans with deductibles so high they would've been better off uninsured. It made government much bigger, and much more expensive; it's certainly "working" if that's your thing-- you know, destroying western civilization with ostensibly wonderful intentions. 1 Christopher Walker (Denver) Destroying western civilization? You don't think that's a tad bit hysterical? Eric (Fenton, MO) No. Just a conclusion drawn from observing current events. Obama voters will disagree. johnny (poughkeepsie) Krugman consistently mixes up access to health care and access to health insurance. These are two separate things. Having Obama insurance does not equal access to health care so please stop using those terms interchangeably. If health care was cheap, say like groceries, we would not need health insurance (leave out food stamps for now). Krugman is always banging the drum about how great it is to be insured and pay at least $400 a month for bronze care (NY state) and in the end have a piece a paper telling me how much I have to pay (co-pay/ DEDUCTIBLES!!)if I get sick. Perversely one could make the case that it is cost effective to not have Obamacare because if you do need a doctor you would not have wasted your money on the "insurance".Krugman I have a task for you: You and your interns create dummy accounts and get quotes from the NY exchange (various incomes) and then publish your results. 1 Apple Jack (Oregon Cascades) Having spoken to many Canadians & Western Europeans about their health care systems, I never met even one dissatisfied with the blanket coverage offered to their people. I did, however, meet many right wing zealots parroting the denigration of those systems by the bloviators on talk radio & Fox news; how long will these savages hold sway? 4 chip (new york) I remember death panels, and they are here! Whenever a group of experts decides that a test is unnecessary, based on cost effectiveness, they are in effect condemning some people to death. For instance in limiting access to mammograms for patients under 45 years old, cancers will be missed and women will die. The same can be said of prostate cancer screening and colon cancer screening. That is a fact!Another fact, is that we have limited health care dollars to spend, and we have to choose the most effective ways to spend them. Screening for breast cancer is not as effective as other ways to spend health care dollars. It would be more productive if we could have an open and honest discussion about health care spending instead of denying that these death panels exist.Here is another fact: you can't insure 20 million people for nothing. Is that a surprise? Nonetheless, Mr. Krugman and his cronies in the liberal press, actually claimed that we would save money by insuring more people, a claim which is utterly preposterous on its face. So, it is no surprise that ACA costs more than some thought it would.It would have been, and still would be productive to have discussions based on facts. The facts are:we have limited resources to spend on health care, we will have to make hard decisions on how best to spend these resources, and insuring people, especially sick people, will cost money. That doesn't mean the ACA isn't worth the cost; obfuscating the issue doesn't help. Kat (GA) The US is virtually alone among developed nations who do not provide universal health care. Why? Well, hyper capitalism and hyper militarism explain a lot. 1 No Spin 128 (Wall, NJ) Mr. Krugman, if Obamacare is so great why haven’t you enrolled in it, otherwise you cannot intelligently speak about it. I had to enroll my daughter and the premium costs and deductibles for one year on the platinum plan would have exceeded $10,000 for single coverage. Even the NY Times had a piece last week finally speaking the truth about how the deductibles and co-pays that must be paid first, even if you have free subsidized premiums that are paid for by us taxpayers, many still cannot afford access to health care. So who is benefiting? It seems to me that the insurance companies are getting paid premiums for 10 million new subscribers. How many of them are now able to go to the doctor for a persistent cough, the flu, an ingrown toenail, etc.? If the insureds can’t afford to access health care, they don’t file claims and the insurance companies win. We have to stop painting this rosy picture and truthfully have a conversation about what works and what doesn’t work. Otherwise, your words are meaningless and biased. 55 Bruce Williams (Maryland) You don't qualify for subsidies at Krugman's income level. He couldn't enroll if he wanted to. You misunderstand the ACA. No Spin 128 (Wall, NJ) Bruce - You need to read ACA again until you understand it. Anyone can enroll regardless of their income level. You also misunderstood the whole point. Obamacare is even worse for those who don't qualify for the subsidy! Most of those enrolled do not qualify for the subsidy, including my daughter. It is unfortunate that a lot of misinformation makes it to these opinion pages, because so many of the writers are uninformed or haven't done their research. Further, the mandate requires everyone without health insurance to enroll or pay a penalty. Where have you been? 1 Ray (Texas) You have to hand it to Krugman, he stays on-message. Premiums rising 11%? That's normal. Unaffordable deductibles? At least preventative services are free. A major player is pulling out of the system? They weren't really that big. The systems is in a death spiral? Actually, it's getting better, not worse. It kind of reminds me of Kevin Bacon's character in Animal House - All is well! 1 Mike (Arlington, Va.) "Health Insurance" has always been a fraud. You can't insure peoples' health. Everybody gets sick and dies. This costs a lot of money. I remember when the only health insurance company was Mutual of Omaha. Do they even sell health insurance anymore? Today so-called health insurance companies are simply highly-paid intermediaries between businesses and the government (which pay for peoples' health care) and health care providers (who deliver the care). There is little or no control over costs (which go up without cease) and the whole system is sucking the life out of the American economy. Obamacare is either nothing more than a way station on the road to universal, taxpayer provided health care; or, if it fails, a way station on the road to total privatization of the health care system and the end of "health care" for the poorest twenty or so per cent of the population. The decision is up to the people. By the way, most people on Medicaid don't even bother to vote, so my guess is many of them will die before they could graduate to Medicare. (On last point, see article on Kentucky governor's election in Week in Review section of Nov. 22, 2015 NYT.) Reality Based (Flyover Country) Republicans for decades have their enormous propaganda operation selling the Big Lie of private sector "efficiency" and have utterly brainwashed most of the public in this regard. It is self-evidently true from every comparative statistic that US health care is by far the most expensive, and least efficient, of all advanced countries. Having protected and promoted this monstrosity for decades, they now of course blame it all on the handy scapegoat they derisively call "Obamacare. " Lies on top of lies, with a huge helping of hypocrisy on top.And their illiterate, ignorant base, forty percent of whom believe Obama is a Muslim, lap it up like a thirsty Golden Retriever. Pathetic. ExPeter C (Bear Territory) This sounds like a briefing from Saddam's PR man. 1 Bruce Rozenblit (Kansas City) It's alive and its killing me.My old policy shot up from $573 to $916 a month. Absolutely unaffordable. Going on the marketplace, the cheapest policy I can find costs $503/month. It has a deducible of $6800!!! That policy covers nothing except an annual wellness exam and associated labs. If I get sick, or injured, or the doctor wants to go fishing for suspected problems, or I need a prescription, those costs all come out of my deductible. My annual costs with this plan will be $12,836 before it does anything. I can lower the deductible by paying more in premiums but the net costs are the same. A plan with premiums of say $700 will lower my deductible by about $2500, but I still end up paying just as much if I get sick. I'm only buying down the deductible. So the only way to save money is to not get sick.The competition issue between insurers is a farce. The plans between insurers all cost about the same because they all have the same operating costs. The difference is in the mix of options.United Healthcare has just announced that it will drop out of the Marketplace in 2017. So many very sick people have signed up, that they are losing money. Meanwhile, the healthcare cabal now has 100,000 new insurance codes is can use to bill the insurers of every dime they can. Forbes reports that costs for 2014 exceeded $3.8 trillion. Healthcare reform is the parasite that is sucking the life out of everything else. 51 Brian P (Austin, TX) Dr. Krugman is an apologist who, when he says and 11 percent increase isn't so bad, is playing us for stupid -- that eleven percent will compound every year, which an economist is very well aware of. No, this whole exercise is a flagrant example of how the people at the top -- of corporations, academia, politics, and government -- have NO CLUE how people live these days. You are isolated and you need to sit down. What's the definition of a liberal? A person who doesn't care what the solution is, as long as it is mandatory. Congratulations, Dr., you are King of the Coercive Liberals.As it stands, I will be required to pay over $3000 in cash to buy a policy that grants me exactly back nothing in benefits and services. I do not have that kind of free cash flow -- guess what, CL, NO ONE DOES ANYMORE. So I will not get the policy because I am not stupid. Sorry about that. 5 leslied3 (Virginia) The ACA is a not-so-bad step toward universal health insurance, aka Medicare for All. There is no reason, and actually a negative reason, that profits should be taken out of the relationship between insurer and insuree to satisfy share holders. None whatsoever. Robert Salzberg (Bradenton) Repealing Obamacare would more than triple the estimated 27,000 deaths due to Republican obstruction of Medicaid expansion. Apparently, All Lives Don't Matter to most Republican politicians. 1 JL (Durham, NC) Please stop putting lipstick on the ACA pig, Paul. Premiums are jumping and plans are being dropped. 3 Robert Demko (Crestone Colorado) Republicans always site costs and socialism as the reasons for avoiding single payer and indeed the ACA. They would rather see each other die rather than accept the possibility that there are better ways of doing things. For them ideology always trumps better healthcare never mind that a Republican proposed our current system.Single Payer would definitely bring down costs as we would have better control of big Pharma rip offs and allow the whole US population to mitigate health care costs. Behind the scenes opposing this are the big corporations who do not care about ideology or fair health care for all but only for their profits. If we are to have true health care reform we must make health care a right to which all are entitled, a system not held hostage to profits and careless corporations. Republican ideology will not cure disease only increase it as modern medicine passes them by in their search for correctness. 2 DocHoliday (Palm Springs, CA) I am always amazed at the coddling Obamacare gets from the professor. He certainly has no problem calling out the crazy about the Republican's economic plans. However, when it comes to health care, he has, IMHO, too high a tolerance for a sick system. Obamacare perpetuates the sickness by rewarding insurance companies whose business model is to make money by either denying care or shifting the cost onto the consumer. High deductibles are another way to deny care; however, they get the consumer to do it themselves. It's brilliant really. It is also really bad care that causes untold anxiety to working families with health issues. Single payer is the only sane approach. Why are we not hearing more about that (and Bernie Sanders!)? 7 Constance Underfoot (Seymour, CT) "Now, just a couple of years after the Affordable Care Act (ACA) was implemented, 12 out of 23 co-ops have failed, costing taxpayers $1.2 billion in defaulted loan repayments"I realize Nobel Prize winning economist Dr. Krugman's article is in the opinion pages, but given the aforementioned facts, maybe the NYT wants to exercise a little editorial review before posting such tripe? 1 VV (Boston) The real question is why we can't have socialized medicine in this country as in other developed countries. Answer: the ideology of a minority of our fellow citizens. 3 Dennis (New York) You are correct, Professor Krugman. The PPACA is alive and well, and flourishing, and though far from perfect, more importantly, it has finally established a permanent foothold in the American psyche. Republicans continue to deride it using the "Obamacare" reference, and will do so until, like Social Security and Medicare whose embryonic stages are unrecognizable today, it becomes secunda natura.Republicans have already begun their retreat. From repeal to reform, they have changed the subject, pivoting from claiming that the US already had the best health care in the world not requiring any tinkering to a reassessment which acknowledges that some adjustments are needed. Like they did when FDR's Social Security began to take hold, Republicans claimed they did not want to abolish SS they just wanted to "help make it better" FDR, campaigning for reelection, mocked Republicans incessantly for their offer of "help" and their feeble attempts at trying to take credit for Social Security. So it has begun with the PPACA. Republicans have dampened down their rhetoric against "Obamacare" after voting fifty times to repeal it failed. They have pivoted and offer "alternatives" to President Obama's "Folly". The worm has turned and once again hypocritical Republicans find themselves fighting an uphill battle. They were behind the arc of history in the 1930's with FDR's New Deal. They continue that Grand Old Party tradition in the Twenty-First Century.DDManhattan katalina (austin) I think reader Salzburg has stated an important point about the state legislatures and their refusal of Medicaid expansion. I live in one of the xx states that will continue to rail against the federal government and some of the help it makes available as part of the original contract between states and the federal government. These anti-gum'mt folk may not take expansion for the poor for medical care, but when a natural disaster strikes, their pride goes out the window and their hands go out for dollars from Uncle Sam. 1 Xlt (Boston, MA) Where's my $2,500 savings promised? My premiums went up by $1,765 this year. Is it because of the maternity coverage I am required to keep even though I'm a man and can't have kids? Obamacare, like obama is a fraud and big time failure. JW (Tallahassee) So what do you propose Mr. Dallas? Do you have a perfect plan? The GOP hasn't even tried to formulate one. 1 Gene (Atlanta) Come on Paul. Stop this absurd manipulation.Obamacare was passed promising to insure the 50 million uninsured at a cost of $1 trillion over 10 years. The reality is that there are still 36 million, or more, and annual cost was over $200 Billion.Obamacare counts everying who signed up through the exchange as newly insured. The reality is that half of those who signed up already had insurance.Meeting espectations? When and who set them. (It is like miving the goal posts to the 50 yard line and counting field goals kicked from the 20 yard line as touchdowns!)Sharp drop in uninsured? 50 million to 36 million, half under Medicaid, 90% of the rest subsidized.11% average increase in premium?. Paul mentions United Healthcare but ignores those already bankrupt or dropped out.High deductible? You bet, up to $5,000. Paul mentions no specific numbers for a reason.Preventative services covered? What preventative services?Fewer employers dropping out? Paul failed to mention the increase in employee portion of premiums of those who stayed in. He also failed to mention the employer 50 person mandate has been delayed indefinitely.The reality is that healthier people who would actually have to pay for it, have not signed up for Obamacare. They never will unless the penalty for nit signing is greater than the cost of the insurance. it is like trying to sell saving for retirement. Everyone agrees that it is a good thing to do but very few do it. 1 jb (weston ct) "Health reform lives!" Perhaps. But only because waivers and extensions have protected 95% of Americans from the actual costs and burdens of Obamacare. At some point the bill must be paid. 1 Thomas OMalley (New Jersey) The so called “Public Option” that was not allowed to be part of the Affordable Care Act was, and in my opinion still is, the only way to counteract the bottom line, for profit private insurance companies, who are supposed to believe in the free market system and competition.If a single payer system was in place to compete with the private companies such as United Health Care, Obamacare as it’s called would be in a much stronger position today. That may be why the health care reform opponents during the debate, along with the likes of that true Democrat, Senator Joe Lieberman of Connecticut, fought so hard to defeat it. 2 Larry Jacobs (Houston, Texas) He's totally wrong. At least for me. My current carrier is leaving Texas at least for individual plans. I have had a PPO plan for years. Here's the Reader's Digest version of what I am learning as I look for new insurance. There are no PPO plans being offered in Houston. So far I haven't had a plan that will allow me to keep my doctors and hospitals of choice. I'm deciding whether I should be more concerned about cardiovascular issues or cancer because I can't have access to the two best hospitals for those diseases on the same plan.I don't know what the prescription benefits will be since I haven't been able to find a plan. so contrary to what the President said, it appears I can't keep my plan, my doctors or my hospitals of choice. mike green (boston) you would think someone with Krugman's supposed economic credentials would understand this: Obamacare did nothing to introduct competition or market forces into the health care industry; all it did was continue the false route of shifting the question of WHO pays ever escalating costs instead of discussing WHY costs are so high. we have been playing ashell game for decades now, shifting the bill from the cnsumer to the health care provider to the health insurer to finally the federal government. health care is one of onyl two major market sectors in our economy that get to ignoire both of the twin horns of the bull we use to control costs - market competition or government price controls (such as for electricity). instead the players in the industry price their products and services with complete disregard for the abitlity of their customers to pay. and expact "someone else" to cover the gap. riduculous and ruinous. $700 pills and $100,000 operations, giant hospital groups buying each other up and operating e facto monopolies are all the nrom, every dollar billed as health care is sacrosant and above question. ANY industry that can operate withour true competition and can get someone else to pay will turn into a fedding frenzy at the pig trough. since it is health care and so important the numbers just explode. 1 The Ancient (Pennsylvania) Krugman is always wrong except to those who have so little knowledge or intelligence to actually analyze events and issues and come to their own independent conclusions. Costs are going up dramatically, big insurers are losing money and some backing out already, and only half the number of participants have signed up with most being on Medicaid or old and sick. With these facts Krugman concludes its working. I would note that its working about as well as our current foreign policy and economy, which Krugman also thinks are going so well. Al (davis, ca) That's great news! For as you'll recall our foreign policy and economy was headed over a cliff until just before the 2008 presidential election. You do recall that, don't you? Activist Bill (Mount Vernon, NY) The so-called Affordable Care Act is Affordable ONLY for the insurance companies, because they pay very little, if anything, for the health care services for which people are paying sky-high premiums. This is why most of the insurance companies were all in support of the ACA - they knew the so-called health care reforms were being legislated in their favor and not for the people who would be forced to buy insurance. 1 Bob Burns (Oregon's Willamette Valley) Medicare for all. Pretty simple, really. Private (Cadillac) plan is optional but you pay into Medicare just the same. 2 C. V. Danes (New York) If there is a death spiral, it is in the red states that have fought against protecting their populations tooth and nail. It is a matter of principle, you see, based on Christian values of punishing the lazy poor and banishing one's brother out onto the street. 70 John (Lafayette, Louisiana) "The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working."Maybe so, but Medicare for All would be a much less imperfect system and would work far better. 3 jacrane (Davison, Mi.) Keep lying to yourself and the public with your articles. Obamacare is killing the middle class. I'm beginning to thing that was exactly what this administration wanted it to do. Medication I paid $7.50 for a 3 month supply is now $79.00 per month. Co-pays are up and the cost of the policy itself is up. Thanks for nothing but please quit lying and saying it's good. It STINKS 2 jrd (NY) Better than nothing, yes, but ignored here are the issues that only those familiar with Obamacare could appreciate. The problem is the quality of insurance, and the quality of the insurance companies, not so much Obamacare itself, so neither the proponents nor the detractors pay it any attention.NYS, for example, is forcing all lower-income New Yorkers into HMO "Essential Plans". These plans cost the consumer nothing, or very little, but there's a reason why. United Health Care, for example, is one of those insurance companies offering them.Search for a NYC dermatologist in United's local network -- say, within 20 miles of Manhattan -- and you'll find hundreds. Unfortunately, only one is still taking patients, somewhere in the Bronx. This is not unusual, for specialists in the network. You may also have to go to a Medicaid clinic for your primary doctor, to get that referral, to go the Bronx. If he's still taking patients by then.Not many people would choose this kind of insurance. Lower income New Yorkers aren't even allowed to "shop" now. 42 Billy (up in the woods down by the river) paying health insurance premiums of $15k annually on $45k annual income plus another $5k in deductibles if one requires any actual care. this is not an annoyance, it's a death spiral. and it's become the norm. Dr. Krugman should read today's comments. The evidence is in and he's ignoring it and therefore wildly out of touch. cheerleaders start to look pretty silly when their team is behind 63-0 and they behave like we still have a chance. We don't. 4 Sean (Portland) Waiting to look silly, it'll be a while. dpr (California) I once asked my sister, who considers herself to be a pro-business, moderate independent voter, whether it was okay with her that people die because they can't afford health insurance. She told me she didn't know and would have to think about it. I still can't wrap my head around the idea that any American would be okay with that idea. But they are out there, obviously, and some are very close to home. Until there is a real consensus among Americans that every person should have access to healthcare regardless of financial status, we will continue to suffer with a system badly in need of improvements but that we refuse to improve. I don't know how we would get a consensus, given all the hysterical ranting by conservatives. And to be fair, I have very liberal friends who were among those hit hard by the initial costs of ACA policies, and they are grumble about the law, too.Is the ACA in a death spiral? Probably not. But that doesn't mean that it is doing what we need it to do. We need either a public option or a single payer system, and we need to regulate prices. Doctors who consider themselves to be entrepreneurs won't be happy, but those are probably doctors you should stay away from, anyway. 86 Geoff stephens (Bozeman, MT) Critics of the ACA never propose any credible alternative. Are they suggesting we would be better off going back to the way things were? It's particularly ironic to hear United Healthcare complaining. After recovering from a major illness, the only insurance I could get was an individual plan with United Healthcare (grandfathered from previous employer). Knowing that I had no alternatives and a preexisting condition, United Healthcare proceeded to shamelessly gouge me; reducing reimbursements with a complex and everchanging formula for what was covered, and dramatically raising my premiums. The ACA has allowed me to get decent coverage and gone a long way towards controlling costs. If opponents would focus on helping to fix the ACA instead of spending vast amounts to destroy it, we might be able to address its problems. Eric Glen (Hopkinton NH) I work everyday with people at the low end of the pay scale, most of whom did not have health insurance before, and most of whom do not have it now. The reason has remained that they cannot afford it, despite the passage of the Orwellian named affordable care act. We were told by our President we could keep our plan, our doctor, and that costs would decrease on average $2500. These statements are demonstrably false. The fact the administration has been able to cobble together two years worth of statistics to fool a representative of the Woodrow Wilson school hardly justifies this misguided program. Sean (Portland) I think we'll go with your anecdotes and ignore the statistics. Christine McMorrow (Waltham, MA, 02452) I see a little difference between the premium increases projected in the ACA for 2016 and the terrible system we had before of private health insurance plans. In fact because the ACA limits premium increases, under Obamacare they are likely lower then in the private market place.The same goes for deductibles. All those people who loved their catastrophic coverage because the premiums were low were in for sticker shock when they actually got sick and realized how much they had to pay out-of-pocket in return for low premium's.There there is no free lunch in healthcare. You are always going to pay somewhere somehow. The only way to spread the costs across all Americans and actually lower their aggregate healthcare expenses is to adopt a single-payer system. When everyone is insured, the healthy subsidize the sick and when the sick get better, they subsidize those who benefited from them.Single-payer would allow the government to set price controls just like it does in Medicare. Seniors love Medicare and I suspect most Americans would love Medicare for All as well. Risk is is evenly divided, not put on the shoulders of the of those least able to pay. And contrary to the naysayers. The total cost would actually be less than the Darwinian survival of the richest system the GOP wants to reinstate. 4 Robert Wagner (New York) Like any new law there will be imperfections that become evident. Republicans have enumerated a few as well as Democrats. One large issue is restricting the sale of insurance within state boundaries as opposed to allowing interstate competition. There seems to be no bipartisan support to fine tune the program so the playing field can be equalized between the consumers and insurers. A friend of mine is self employed with annual taxable income of $30,000. The person resides in Virginia and has been chronically ill for some time. I helped this person find an ACA plan that would provide comprehensive coverage without high deductibles and coinsurance. I found a plan with a monthly premium of about $500 after a Federal subsidy. The coinsurance and deductibles were in the range of six to ten thousand dollars. At a $30,000 a year income level the plan is not affordable. Virginia has a relatively large and prosperous population. There are a variety of plans to chose from. Take a less populous state such as Montana or Wyoming and there may be only one or two plans offered which amounts to no competition. Residents there should be able to shop nationwide in an open competitive environment. Under its current structure the Affordable Care Act is not affordable for segments of the population it was designed to serve. Insurance companies in general don't seem to be affected as their profits have risen and multi-billion dollar mergers are in the works which will further stifle competition. arbitrot (Paris) That's the Good and the Bad.But now is the time to start beating the drums for taking on the really Ugly and doing something about it.The Ugly?The way Big PhRMA continues to gouge the entire US health care system with outrageously overpriced prescription drugs, and does so with impunity.The statistics are just a Google away for anyone who still feels she needs documented proof of this. But I can tell you on an anecdotal basis that I can get my roughly $3,200 worth of annual maintenance Rx drugs in the US from Part D Medicare for the abovementioned $3,200 - which is to say WITH insurance.Or I can buy them in Paris at my local Pharmacie with NO insurance for about $1,700.Notice: in France not only are my Rxs about half of what they are in the US in terms of MY costs, in France the $1,700 is the FULL cost. The government isn't chipping in a nickel.But in the US, my $3,200 cost is only part of the cost. PhRMA has not finished by gouging just me. They then turn around and gouge Medicare - which is to say you, the taxpayer - for even more than they're charging me.What is it abut the "lazy" French which allows them - and many other "socialist" countries to keep a lid on PhRMA?It's called single payer, with big gummint being the guy with the wallet, and the means to protect it better from the PhRMA pirates.Who, by the way, ripped off many of "their" drugs from the taxpayers who supported the basic research to develop them in the first place.Seize the time! 177 Ian Maitland (Wayzata) Oh come on, Arbitrot. There is no secret why drug prices in France are lower in France than in the US. Do a little Googling. The French steal. They don’t pay the economic price for the drugs they use. They let US consumers and taxpayers fund their drugs. The same policies that explain why the French and other Europeans pay less for drugs than we do also explain why Europe has been replaced by the US as the pharmacy of the world. Just look at Golec and Vernon (2006). http://papers.ssrn.com/sol3/papers.cfm?abstract_id=932989Golec & Vernon analyzed what would happen to drug development if the US adopted EU-type price regulation gradually over 19 years starting in 2005. They found that R&D would be $427 billion lower (in 2004 dollars) and that 974 new medicines would be NOT be developed. They conclude (p. 32) that “these [French and EU] policies essentially trade off the health ... opportunities of future generations for cost savings for current pharmaceutical consumers.” Next time you buy your Rxs, keep in mind that you are stealing from your children. 1 jmc (Stamford) No question about your statements on drugs in France. In fact there are some drugs that are prescription only in the US but Not in the EU or France. In those instances, the same drug can cost a fraction of the US cost, in one case the US version cost 10 times that in France The company that markets a Hepatitis drug that can cure Hepatitis for $97,000 in the US while company has negotiated a deal with the Egyptian government to provide that same course of treatment for less than $400 and confidently project enormous profits in Egypt alone. 1 David Appell (Salem, OR) Calvin Coolidge said "the business of America is business." He didn't say it was people. 1 Sherry Jones (Washington) There is a problem beyond unaffordable deductibles: premiums and subsidies under the ACA are based on 5% of income so everything patients pay above that is, by definition, unaffordable. Regardless of this, patients are being punished by robotic and indifferent billing and collection systems for being unable to afford those deductibles. The current culture in billing and collection is require payment of the entire amount due within a very short period of time; worse, the newest trend is to require payment of unaffordable deductibles up front. On top of this, patients who fall behind are sent to collection, where they are harassed by agents, sued, their modest wages are garnished, and their reputation (for getting credit, housing, even employment) is ruined. In my county of 30,000, 1,300 people were sent to collection last year even though they were insured, and their insurance paid the bulk of their bills. And since hospital bills typically exceed actual cost by 600 percent, and insurance pays the bulk of that, patients are actually being sued for the hospital's lost profit. For Congress to allow punitive collection practices to continue is outrageous and unconscionable.Sending ACA patients to collection should be illegal. Requiring payment up front should be illegal. And patients should be given all the time they need to pay their high deductibles. 2 tom carney (manhattan Beach) "...UnitedHealth Group made a splash by announcing that it is losing money on the policies it sells on the Obamacare exchanges, and is considering withdrawing from the market after next year."The really sad and untalked about, even unthought of issue here is that the health of the people is a profit making business.. that individuals should make profits, not just a reasonably good life support wage, but huge, in the Billions of dollars over and above what it costs to deliver the services. (check out the pay for the ''CEO's of these insurance businesses)The insurance business should be governed by the Agriculture Department.. It,s a lot more like cultivating people for profit than healing because health is a Human Right.It is not something reserved for the wealthy. Morally and ethically and commonsenseically it should be a totally run government service to the people, paid for by the people's taxes. 6 NJB (Seattle) The main point to remember is that there is no viable alternative if we still wish to open meaningful health insurance to all. The Republicans have not presented a detailed plan even after 7 years of the Obama administration. And the few ideas sketched out by a few GOP politicians and conservative think tanks will all restrict and reduce coverage while raising out of pocket costs to those who currently benefit from or are eligible for ACA coverage. If you think the ACA has flaws, wait until you see what the Republicans would (maybe) replace it with.Rather than trying to destroy it, conservative would do better to work with Democrats to make improvements. 3 Urizen (Cortex, California) Let's face it - when you stay within the dreadful confines of a private health insurance system, your choices lie between dumb and dumber. 1 Glenn Wright (Austin, TX) Last decade, you always were criticizing GOP health care plans, i.e. Bushcare, by pointing to their chief defects, higher deductibles and higher co-pays meant to burden or "discipline" consumers in a market-driven program. Nevertheless, when it became evident that all three contenders for the 2008 Democratic presidential nomination were adopting Romneycare variants, you explained that this was a necessary compromise, since a truly effective and fair plan, a universal one-payer plan, was not politically realistic.Now, as the failures of Obamacare mount up, in precisely the way you predicted would happen in a market-driven program—high costs to consumers both inflicting poorer health (as consumers deny themselves health care because they can't afford it), as well as lowering the incentive to participate in the program at all, you are sounding like the Pentagon repeatedly assuring Americans that the Afghanistan project will be a brilliant success—in another six months.Maybe now you can sympathize with the generals, and their habitual need to paint rosy scenarios so divorced from the reality on the ground. You should pull back from advertising for a failed program, and start dealing with the facts and their very harmful effects on so many Americans. Old lawyer (Tifton, GA) Health care is a basic necessity of people since a lack of it leads to suffering and death. Government is the only institution that can effectively provide universal health care. Most First World governments, the ones Republicans like to mock, recognize this and do something about it. It's just another bottom-line deal with the Republicans. 3 Dennis Byron (Cape Cod) There are many implicit and explicit comments on this comments thread in favor of "Medicare for All" or allowing buy in to Medicare earlier than the current age 65 or similar statements. Spend a minute looking at how United States Medicare works before you wish Medicare for All on anyone. On the Obamacare insurance Bronze-Platinum spectrum, United States Medicare is a Tin Plan. If you look at its four Parts of Medicare in the same way as the typical set of options you get through employer sponsored insurance, this is the result:1 Least expensive option: High deductibles and lifetime and per-incident limits on hospitalization only; no coverage of medical services (even most doctors needed in the hospital) or drugs2. Second least expensive option: Choice 1 plus medical services coverage with unlimited (no annual out of pocket spend limit) very high co-pays and/or co-insurance and limits on the types of medical services covered.3. Most expensive option: Choice 3 combines the first two choices with about 75% coverage of self-administered drugs and some additional medical services (typically an annual physical not included in Choice 2) with co-pays and deductibles more like employer sponsored insurance.As a result of these three unattractive options, almost all people on Medicare who are not also on Medicaid or who can only afford public Option 3, arrange additional costly private policies (mostly as a benefit of former employment) to cover as many of the gaps as possible hm1342 (NC) "The reality is that Obamacare is an imperfect system, but it’s workable — and it’s working."The reality is that the previous health care system was imperfect, but workable. But you weren't forced to get health care coverage or pay a fine. And if we liked our health care provider, we could actually keep it - and our doctor. We were also told that the average family's health care cost would go down $2500 a year, with no mention of changes in deductible increases. Can we say the same thing now, Professor Krugman? 1 hawk (New England) Krugman the funny man. This is like saying the NY Jets are a good football team. No Paul, Mediaid works very well. it would have been a lot easier to just phase out the ESI tax exclusion and expand Mediaid. But then again, Krugman has never heard of Jonathan Gruber. Ross W. Johnson (Anaheim) Health reform lives as a result of the Great Recession. A perfect storm of economic, social, and political upheaval opened a brief door for reform that otherwise would have remained shut for at least another generation. Moreover, Democrat control of two houses of the Congress enabled enabled barely enough votes to bring the legislation to Pres. Obama's desk to sign (Note that the Great Depression and Democrat control of the Congress also enabled FDR to pass similar social legislation). Pres. Obama's crowning achievement is the ACA. Its passage is a result of coalition building, political will, and historical events. Like all great legislation, its detractors will continue to demonize its very existence. Eventually health care may be accepted as a public good and government program too important to lose. In the meantime, content vigilance is needed to insure that its provisions are defended for subsequent generations. hm1342 (NC) " In the meantime, content vigilance is needed to insure that its provisions are defended for subsequent generations."How much of your own paycheck are you willing to spend to ensure that the ACA lives in perpetuity? 1 dougk (Indiana) High deductibles are a problem but don't forget that having any insurance means you pay the ALLOWED COST, NOT THE BILLED COST. This is a huge advantage since the allowed is often 15-20% of the billed. Of course, if you have multiple medical expenses, you will still have to pay up to your deductible but if you only have one or two, this helps a great deal. Panos E (Western PA) The bad news include the implosion of many coops and exchanges. Unfortunately, if the next President is not Democrat OC may face its own death panel. Doug (Minnesota) High deductibles and co-pays/co-insurance make the insurance unusable. You pay a high premium and then keep on paying. We should resolve the root of problem of health care being too expensive. The problem is not fee for service - Canada and other countries have fee-for-service and lower costs. The problem is too many organizations (including non-profit provider organizations) sticking their fingers in the money flow and the lack of a global budget, a single payer, and less opportunity to grab the money (not much different than bankers). Lets solve the problem correctly and reduce costs through system redesign. 3 fran soyer (ny) The articles last week about United Healthcare's threat to pull out of ACA exchanges were an interesting read.The interesting part of these articles was not that UNH is considering pulling out of the exchanges, but that these articles were very careful not to mention that United Healthcare is expected to make $6 billion this year.If you read the stories, they were very forthright in explaining how the losses tied to the ACA were a "staggering" $600 million. That number was front and center of every article I read. What was not in any of these articles was a mention of the $6600 million they made from everything else they did. 2 Professor David (West Lafayette, IN) Implementing any complicated system will unveil unexpected problems In a different legislative climate, it would have been easy for Congress to teak the law here and there with amendments which would have solved many of these problems (for example, having the subsidies apply to state exchanges explicitly, rather than dragging things through the courts, maybe modifying subsidies, etc.). It is obvious which party is culpable in this. Timmy (Providence, RI) "that's the problem with a fairly complex system."It's a ridiculously, needlessly, complex system. American citizens are made to try to navigate an absurdly complex and inefficient system not because it makes any sense, whatsoever, but simply because our once-democratic nation has been hijacked by corporate power. In order to appease our corporate masters, and assure their profits, citizens are forced to navigate a maze of confusing options with daunting deductibles to find a plan. And, after doing so, they are then expected to determine if there are any programs available that might subsidize them adequately to permit them and their family members to actually receive healthcare. All of this to appease the corporations who own our politicians. When I lived in Canada the government gave me a health card. When I got sick I went to the doctor and showed them the card. When I left the doctor's office I stopped at the desk and asked what I owed. They laughed and said, "You must be American." The card in my wallet meant I had healthcare; it was that simple. Why can't we have that here? 7 shend (NJ) Regarding an 11% premium increase. Its bad, really bad. Especially in light of the fact that general inflation is less than 2% with wage increases in line with inflation, an 11% increase is a budget buster for a lot of families, and extremely worrisome for following years. When average annual premium increases were 7.5% as you have noted, remember, general inflation and wage increases were around 3-4%, and that was troubling. I think your column discounts just how devastating an 11% premium increase is to many families. 4 Larry Roth (upstate NY) The Death Spiral is still out there, but it applies more to the GOP obsession with destroying Obamacare, the failure of Democrats to defend it, and the media bias in playing up the bad news while ignoring the good. Republicans will continue to scream Obamacare is a disaster, the Mighty Wurlitzer of right wing media will amplify the message with more lies, distortions and selective reporting, and the increasing grip of GOP governance at the state level will be used to sabotage it wherever possible.Will Democrats run on the successes of Obamacare in 2016 and call out Republicans for putting political gain over the health of millions? Will the media support them if they do? 30+ years of GOP conditioning of both says no.And we will still have billionaires out there determined to keep the American people from finding out that government can actually make their lives better. 1 Big John (North Carolina) I was self insured for many years and paid on average $10,000 a year for an HSA if I had to use my $3000 deductible which happened the last three years. I currently have been on medicare for one year and it is not hard to figure out the insurance industry takes advantage of many seniors and make huge profits selling policies that only cover the 20% medicare does not pay. I get anywhere from one to three pieces of mail a day, phone calls and watch ads plastered over the TV on these plans proving they are spending huge amounts on advertising and marketing. The ads all claim that medicare supplements are difficult to understand and they are more than willing to help (cheat) us into picking a policy that is just right for us. Why should it be difficult to understand and why so may plans?It is a shame you are forced to deal with healthcare insurance companies your whole life in this country knowing the whole system operates on greed and corruption. It is past time Americans should insist that Washington stop the madness and look for examples of other countries who have good healthcare programs without involving insurance companies who only care about their stock prices. Many countries take care of all their citizens and the USA cannot even take care of it's elderly and veterans. How sad, disgusting and shameful. 5 E (Chicago) Krugman's articles prove extremely smart and intelligent people can be blinded by ideology just like the rest of us. Anyone that thinks this is a good law is fooling themselves the numbers don't bear it out. 2 DJ Stone (NY) If you believe the lies that you’re telling, is that the same thing as telling the truth? Mr. Krugman believes, "The number of uninsured Americans dropped sharply, roughly in line with projections, while costs came in well below expectations.”…but, this doesn’t fit the facts.1) Originally only 10-12 million Americans were considered to be in need of health insurance nationally, and would be the target of the Obamacare State marketplaces.2) But, according to the CBO, in 2016 there will be 6 million Americans opting to take the penalty rather than paying for Obamacare insurance premiums.3) Many of the insured who qualified for Medicaid in 2015 will be ineligible in 2016, due to stricter State guidelines.4) If the costs of Obamacare have come in “well below expectations”, it’s because the cost has been off-loaded onto people who have been mandated to buy expensive, high deductible, high co-pay policies from health insurers who will be raising 2016 premiums 7.5% (per the U.S. government), but revealed to be as high as 50% on some State marketplace exchanges.It's shameful that Mr. Krugman should make light of "unpleasantly" surprising high deductibles, which can cost families up to $10,000 in out-of-pocket costs before the insurance company begins to payout...this doesn't even count the historically high co-pays that are part and parcel of Obamacare marketplace plans.Sometimes, even a Nobel Prize winning economist should just admit that, "I was wrong, I'm very sorry". 4 Common Sense (New York City) Correct me if I'm wrong, but....1) The vast majority of the newly covered are those being covered by the expansion of Medicaid - which happened to have been rolled into Obamacare and could just as easily have been pushed through separately. It's a great thing, but it's not an Obamacare win. It's a Medicaid win.2) Stop measuring affordability by looking at premiums. HC companies are slowing the growth of premiums to feed the misnomer that plans are affordable - and then slamming anyone who wants to actually use their insurance with large out of pocket costs, running into the several thousands of dollars. 4 jb (weston ct) More dissembling from Krugman on Obamacare. The basic fact is this:The burden of initial Obamacare implementation fell almost exclusively on the 5 million Americans who held individual policies. Their individual policies were deemed non-compliant and they were forced to buy new policies, often with long-time doctors out-of-network. Deductibles higher. Premiums higher. Remember "like your policy, keep your policy"? A big lie. Why individual policy holders? Because the insurance companies didn't want to set up- and try to price- an entirely new class of previously uninsured people. Existing individual policy holders were therefore added to the Obamacare pool, a proven actuarial base to protect insurance companies.Why individual policy holders? Because they had no political clout. Mostly self-employed they were not unionized (hello, union waivers!), they were not employers (hello, employer waivers!), and they did not already have comprehensive group plan policies through employers (hello, Cadillac tax repeal efforts!). "Health reform lives!" indeed. Only because waivers and extensions have protected 95% of Americans from the actual costs and burdens of Obamacare. 3 Bob F. (Charleston, SC) ". . . .first two years went remarkably well" If fewer poor people being covered than before, and the dwindling middle class being slammed with higher premiums and higher co-pays looks like "remarkably well" to you I might suggest that whatever Kool-Aid you have been drinking has worked remarkably well. By the way, how heavy is the water you have to carry for this inept administration? 1 James (Houston) Krugman just can't bring himself to admit that the ACA is a failure and is in its death spiral. It will take some time for him to finally admit it, but eventually he will. 2 Cleetus (Knoxville, TN) I am sorry, but I just cannot stand this nonsense anymore. When Obamacare was rammed down our throats (since the majority if Americans did not want it and it was passed on a Democrat only vote using gimmicks) we have been treated to one absurdity after another.>Case 1 is when we were told that if we like our doctor...., health care would cost $2500/year less, and so forth, but when we found out we could not keep our doctor, that costs were rising faster than ever we were then told that things are still better than they could have been. This is a cheap and stupid tactic because you can never prove in a case like this how it is still better because it is all based on you assumptions and you drive your assumptions.>Case 2 is that we were originally that Obamacare would eventually cover the vast majority of those currently uninsured. Projections showed that at this time there would be around 25 million participants and yet today we barely see 10 million. For a program that gives subsidies to over 85%, that results in a fine if you do not participate, and that has been hawked constantly, , only having 10 million participate speaks volumes of how badly people dislike the program. These people are voting with their feet.>Case 3 is how insurance companies are telling us how the entire program, in agreement with previous critics, is unworkable. United Healthcare is looking to loos half a billion dollars so they are leaving. This is a success? 3 Eugene Patrick Devany (Massapequa Park, NY) Obamacare economics requires $130 billion a year in penalties for business. These penalties, and the job losses that will occur, have been delayed by presidential executive order until after the presidential campaign. An "imperfect system" indeed; and one that is now designed to fall apart as soon as Mr. Obama leaves office. 3 Thomas Huffer M.D. (Green Bay, Wisconsin) As a political independent, I would expect Republicans to favor the private insurance market, and I would expect Democrats to favor a single payor insurance market. So can someone explain to me why Republicans are trying to destroy the exchanges, when they are one of the last hopes for the private insurance market? If the exchanges go away, there is a real risk that the private insurance market would collapse, and, so far, they have presented no other options to the American public. If this were to play out, there might be no option other than single payor. In other words, collapse of the exchanges brings us closer to single payor.In this light, also, why are Democrats fighting so hard for Obamacare to survive? It would be in their interest to allow the private insurance markets to collapse, and then single payor would be the only option left. From the center, it seems like we live in an Alice in Wonderland political world. 68 Bruceb (Sequim, WA) "So can someone explain to me why Republicans are trying to destroy the exchanges, when they are one of the last hopes for the private insurance market?"It's the "Obama" part of Obamacare.Next question? 1 Peter Czipott (San Diego) Democrats don't want the chaos that would result from the collapse of private insurance markets without an alternative in place. Hence, Obamacare as the only politically feasible choice, given the political and social character of the U.S. body politic. JoAnn Vargas (85706) I think in the case of the democrats Obamacare is still fairly new and the idea of a single payer is unknown by many or they have lost enough hope in the political system they don't see it becoming reality. 1 Kurfco (California) My son has run into a perverse result of the Medicaid expansion. Under the law, anyone eligible for Medicaid must take it (it's free) in lieu of getting covered on an exchange policy (paying, but getting a subsidy). The law assumes "free" is better, right? But many doctors don't take Medicaid patients, so getting it for free is of limited benefit.One would think that enrolling for Obamacare, as a family of four, would be treated as a family of four enrolling for Obamacare. But, no. My son and his wife can get Obamacare, with a subsidy, but the kids must be on Medicaid because the income threshold for a family of four is $63,000 (!!) thanks to expanded eligibility. The state website helpfully points out that it is common for different family members of the same family to be covered differently. Tim (Florida) Mr. Krugman, you continue to support Obamacare even as the evidence mounts that it is not working. I live in south Florida. This will be the third year in a row we have had to change providers, as companies have stopped writing policies in Florida; Assurant for 2016. Only one plan on the exchange for 2016 covers my wife's and my primary physician and two key specialists. Our monthly premium has jumped from $1,200 per month before Obamacare to $1,600 in 2015, to 1,995 for 2016 as our deductible has risen from $1,500 each to $2,500 to $3,000 each. We are healthy people and have yet to reach the deductible levels, thus pay ridiculous premiums and get few benefits. Moreover, mega-mergers are coming that will further deteriorate the already diminishing choice, reliability and service of health insurance companies. Let's face it, Obamacare is a failure and the consequences of this half-baked legislation will have increasingly dire consequences for Americans as the full impact becomes apparent over time. 4 Alex D (Indianapolis) All I can say is SINGLE PAYER NOW. It's still insanity to have our healthcare decisions made by profit-seeking insurance companies. 5 GBrown (Rochester Hills, MI) When Democrats make excuses for the failure of programs they created, they are just as guilty as Republicans for clinging to ideology and denying reality. There is nothing about Obamacare that is affordable, especially for families that are barely middle class. How is it affordable for the average family that earns 50k a year to pay insurance premiums of 12k a year plus annual deductibles up to 12k a year. Have you ever done the math Mr. Krugman? 1 DP (atlanta) An initial strong supporter of the ACA, I have been troubled by the double-down stance of both the conservative opposition and its liberal supporters. It makes the necessary improvements and changes impossible to enact and, I believe, to survive the ACA needs both.It's important to re-state what Congress and President Obama originally promised the ACA would do: provide affordable health insurance for all Americans.Not just cover some of the uninsured (those with the lowest incomes as the Urban Institute and RWJ Foundation found). Not just make it possible for low income Americans to buy affordable coverage and get premium and cost sharing discounts. High premiums and high deductibles, poor provider networks and the preponderance of new restrictive HMO and Medicaid managed care type plans are the new troubling reality of the ACA. That may be fine if your coverage is heavily subsidized but not if you actually pay the full or nearly full price and get so little in return.The much touted new benefits best serve only a portion of those in the individual market and add big costs to the policies. The most costly, of course, is childbirth and care for newborns and toddlers up to age 5. Many of the people who are blind to the ACA's failings get coverage from an employer. I'm waiting for the Cadillac Tax and other provisions to hit their healthcare insurance and access to care. Maybe then we will have a serious discussion. 2 Old lawyer (Tifton, GA) The basic and insurmountable problem with Obamacare is that it leaves the private insurance companies in the loop. They are not in it out of concern for the welfare of the people. They are in it for profit. In a perfect world, welfare would come before profit. 4 Dougl1000 (NV) Health insurance is Balkanized. Donald Trump said he would open the insurance market across state lines, meaning everyone could shop for the best plans in the country. This would create competition, which the insurance industry would oppose. But short of single payer, it is a good idea. I'm puzzled why more Republican aren't proposing this as an alternative to the ACA. 1 nancy (michigan) Obama Care has been a huge success. Tell that to my friend who has a wife and two children and earns $65,000.00 per year and cannot afford health insurance because the price keeps increasing. Not my definition of a success. Obama who said he would advocate a single payer system certainly did an about face on that one. 4 pieceofcake (konstanz germany) Thanks Obama America got a Health Reform and now this reform has to be reformed until it is comparable to Health Care in Countries where the people pay half of the US rates for their insurance with no deductibles.If the US doesn't manage to do this in the coming years Health Reform might die - which for sure will NOT be the fault of Obama or 'Democrats'. It will be the fault of 'Animals Spirits' who are under the illussion that Health Care is just another money making scheme. Jane (New Jersey) How is this working? The premiums for small businesses are so high that it is stifling the growth of start-ups which create new jobs. Private medical practices are small businesses which have closed or sold out to hospitals. With reduced reimbursements & increased government interference your doctor cannot afford to stay afloat, let alone afford insurance for his own family! Obamacare has destroyed primary care in this country. So what good is insurance if we have few doctors available to now treat us? 1 mj (<br/>) Perhaps you could supply us with some supporting links, Jane? Otherwise there is a danger your comment may be taken as Right-wing hyperbole. poslug (cambridge, ma) Negotiating drug prices should be the push back for all those who complain. Since science research has already been cut to disastrous levels and drug companies are raking in profits, lets start using our market power to get world class prices, i.e. lower ones like the rest of the first, second and third world. 3 stalkinghorse (Rome, NY) The fact that we pay full fare is what allows the R&D. If everybody did there would be no new drugs. Janis (Ridgewood, NJ) The premiums will continue to increase due to : Obamacare and insuring the masses, the aging baby-boomer generation with a need for cancer, cardiac, psychiatric, geriatric and other specialty physicians, and designer drugs so that we can all live longer. If new system is so great why do people complain they cannot make the $3,000 family deductible and are not having necessary tests? Also, why is United Healthcare going bankrupt and considering dropping the Aarp supplemental many Americans use secondary to Medicare? 1 mj (<br/>) Again, Jane, how about some reference as to where you get your information that it contradicts a columnist in the New York Times. Thank you! James Lee (Arlington, Texas) The controversy over the ACA and the healthcare system suffers from the way we frame the issue. Liberals tend to focus on the needs and rights of the individual patient, which simply provokes a question from conservatives as to why the taxpayer should help pay for something that benefits only the patient.In fact, however, as advocates of universal healthcare in any other industrialized nation would stress, the community reaps major benefits from the good health of its members. The enhanced productivity of workers strengthens the economy, while universally available preventive care helps to contain overall medical costs. Additionally, a government that sets a high priority on the physical well-being of its citizens strengthens the bonds uniting the community, because this attitude assures each individual that everyone else regards her as a valuable member of the group.Everyone knows all this, and occasionally supporters of national healthcare will stress some part of this argument. But the individualist bias of our culture deflects attention away from the community interest in extending basic healthcare to everyone. Placing undue emphasis on individual rights raises the uncomfortable issue of individual responsibility. If we shifted the focus to the needs of the community, conservatives might see the wisdom of a comprehensive system or at least face a greater challenge in justifying opposition to it. A new approach could not fare worse than the current one. 80 John D. (Out West) Anyone who asks "why the taxpayer should help pay for something that benefits only the patient" does not understand the basic concept of insurance. DL (Monroe, ct) As a major supporter of the Affordable Care Act overall, I must diverge from Krugman's sunny portrayal of the plans' affordablility for people who are neither poor nor wealthy. Here in CT, the lowest priced plan, both on and off the exchange, for an aging but not Medicare age male is just under $600 a month, for a policy that will only cover one checkup and a colonoscopy (not an annual event) until the've paid over $6,000 out of pocket. These are people who make too much for subsidies but are by no means rich. What's more, the policies don't even cover doctor visits until the deductible has been met. Get sick at the end of the year? Tough luck. It starts all over again - $6,000 please before coverage. These are in essence high-priced catastrophic policies. 127 johnny (poughkeepsie) The point you made is the main one that is seemingly ignored by Krugman and the supporters of the ACA. The example you made with $600/month and $6000 per annum deductible is not isolated. Perversely one could draw the conclusion that if they did not buy insurance and did get sick at least they would have an extra $600 a month to spend on medical bills. 1 George S. (Michigan) Had Obamacare not been in existence, what would the cost of that exact same policy be today? Since you're talking about older Americans, what would that cost or even availability be if you have a pre-existing condition? You can't just look at it in isolation. You have to compare it to something. 1 DM (Dallas TX) Krugman never ventures into what it now costs the middle class, those without the subsidies. There, as the above writer notes, it has been a sharp increase in costs - NACA, Not Affordable Care Act. Frankly, even those earning less and eligible for subsidies would generally be much better off putting their money in an IRA. Sam08943 (Chicago) Once again Krugman is trying desperately to defend his messiah Obama. 12 out of the 23 exchanges have failed and gone bankrupt. United health care is pulling out due to a 425 million loss. Healthy people "are not signing up". But watch Democrats try to save this disaster by secretly placing a bill in legislation just before the end of the year in congress for a taxpayer bailout to United Healthcare. It will be the Democrats undoing if Obamas signature piece fails, but then again it was doomed from the beginning. I told republicans to wait, that O-care would implode all by itself ! Dumb liberals ! bruce (Saratoga Springs, NY) Well Paul, the apology for the ACA is technically correct, but we can now see the games played by all involved (those for whom improving the entire population's health isn't uppermost in their hearts). This seems like a good time to plug for some process improvements. I would start with reintroducing the public option - it would keep the other payors honest. As for "health systems," we have a long way to go to get to real, population-based healthcare operational. 2 Pat King (Buffalo Grove, IL) Seems to me that one reason for the reasonably high premium increases is the failure of Congress to fund the risk corridor payments to insurers at the levels called for in the ACA. This program was supposed to be a backstop against the risk profiles of people insured through the exchanges being worse than expected. Without that protection, insurers are going to be cautious about pricing too low. 1 Dick Richards (North Wales, PA) Without bipartisan support of the ACA in the first place, you cannot expect it now. This is what happens when one party crams bad law down the throats of all Americans. John D. (Out West) My extreme right-wing in-laws used to rant and rave about the disaster of the ACA (aka Romneycare, but they've never acknowledged that inconvenient fact) -- but last year, all the raving stopped on a dime, and shifted to other high-priority topics, like the "War on Christmas." Turns out they are now insured under the ACA. Odd how the red-faced, bared-teeth shouting stopped after they signed up. 181 Tom (California) I had the same experience with a friend who is a veteran when i pointed out to him the he was receiving "socialist government health care" at the VA. He too suddenly stopped ranting about the ACA. 2 Support Occupy Wall Street (Manhattan, N.Y.) Professor Krugman, you are minimizing the huge problem of exploding deductibles. Middle income people can barely cover the premium, then they have a huge deductible to cover before the insurance pays a dime. As many of us feared, this is having a piece of paper called insurance but being unable to use it. In New York Every plan on the Exchange offer ONLY a so-called "narrow network". There is not a single plan which has Memorial Sloan Kettering in the network, hence, people buying from the Exchange are excluded from Memorial if they need cancer care.As you know better than anyone, the Affordable Care Act was written by the health insurance lobby. The actuaries knew full well going into this, exactly what numbers (deductibles), would keep people from being able to access health care. So we have the specter of people paying for insurance under a law laughingly called the Affordable Care Act, which they cannot afford to use. This is a huge problem. We need Medicare for All Americans and we need it today! 2 Jim K (San Jose, CA) When United Healthcare announces that it is loosing money on policies sold through the Obamacare exchanges, that probably means it is impossible for them to make a profit while simultaneously funding outrageous executive compensation packages and a huge advertising budget. Call me unsympathetic on this issue. Single payer anyone?The insurance companies do not like Obamacare. Expect them to do everything they can in order to make it fail, to raise its costs, and to hyper-publicize anything that could be construed as a negative. 2 mike bergs (palm beach) And then there are some who want Obamacare to end because they want a single payer system, The threat of which, should scare the Bejesus out of the insurance companies, 1 William Trainor (Rock Hall,MD) High deductible policies, as we find out, are expensive for those who have lower income. When that individual has to pay for a less than catastrophic event, say a new CPAP machine, it costs thousands out of pocket, and Health Insurance costs end up increasing for him. Of course that would means that there is a market effect driving costs, so one would hope that costs would come in line with benefits, which would be the Holy Grail of heath economics. Unfortunately, this could lead to poor Blood Pressure control, or poor Diabetes control at the doctor's office level because the individual would rather buy a new TV to watch the Superbowl, and the actual health effect could suffer (unless each person negotiated with his/her doctor about the cost of care and vouchsafed the most expensive new treatments).However, the policy would cover the major Heart Attack or Stroke. This deal does more for Hospitals, Pharmaceutical firms and Doctors than Insurance carriers and individuals. This all seems like making rope out of spaghetti. We either have to use a Single Payer system or treat Health Care as a Utility. 1 babel (new jersey) "First, premiums are going up for next year, because insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected."Which is another way of saying young people have once again disappointed Democrats with their lack of participation in a plan which not only benefits the poorer people in this country but gives them health care protection also. For a generation that is pro ported to have such a large social conscience they have time and time again proven to be a very selfish lot. They can't even spend an hour or less every two years showing up to vote. Their laziness is probably one of the least reported stories by the press and is a major reason that Republicans continue to control many of the levers of power in this country. They are the antithesis of the 60s generation. 2 Nancy R Ohio (<br/>) Now with the specter of Pfizer merging and moving off-shore.. and loss of tax revenue from an American company. Time for the Justice Department and our Congressmen to say NO to that merger. 3 chickenlover (Massachusetts) To some, especially those on the hard right, that every American must have access to healthcare is not as obvious an axiom as every American - including young children - must have access to a gun. 2 Josh (Grand Rapids, MI) Lots of comments blaming the GOP, when on paper, and now in reality, the math never really added up. It was only going to work long enough for those that voted for it (and Obama) to be reelected. 1 Grey (James Island, SC) Rates are up " because insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected." No..rates are going up because that what insurers do. Another example of the need for single payer health care..Medicare for all. 6 Michael Anthony (Brooklyn, New York) When reading a report on primary employer/economic driver for each Metro District throughout the US, I was surprised to discover that once you are outside of the big twenty cities, the primary employer is usually involved with the Hospital or Health Care Provider in that district.Health Care is obviously one of the most important parts of our society, however, it should not be one of the most important parts of our economy. As more people rely on Healthcare for their income, the cost of Healthcare will increase.It is great that our nation has finally taken the first step towards a single payer healthcare system but the elephant in the room is that the healthcare system (single payer or otherwise) can never be viable until we are able to control healthcare costs. 1 taylor (ky) The Republicans should think of the country and sit down with the Democrats and make ObamaCare even better, if they ever want a shot at the Presidency again. 1 hquain (new jersey) Isn't the real health care news to be found in the Pfizer-Allergan merger, which the Times lede tells us "would create a huge new pharmaceutical giant and could potentially help Pfizer lower its American tax rate." For the ever-burgeoning transnationals, Obamare seems to be little more than a diversion. Of their future, we may be confident. 3 Michael Livingston (Cheltenham PA) I don't think Krugman lives in the real world. In the real world. one hears constant stories overly expensive policies, absurdly high deductibles, an so on. it's possible these are being made up, but I doubt it. 2 A Mainer (Maine) I wonder what Dr. krugman's total healthcare costs are. Add up premiums, deductibles, copays, and co insurance. Under ACA, my healthcare costs amount to about 25 percent of my adjusted gross income.I find it hard to agree that "Health reform is still a huge success story." 1 Patrick, aka Y.B.Normal (Long Island NY) You've got to be crazy if you don't have health insurance to take care of yourself.If you're crazy, you need health insurance.Go figure! Get health insurance. 1 ACW (New Jersey) It's official: Krugman has gone completely off the deep end.Every single thing I predicted would go wrong with this awful law now has, and the news section of the NYT has faithfully documented it; most recently, an article on people whose high-deductible insurance - the only kind they can afford - is pretty much useless. Meanwhile, costs continue to ratchet up, both for premiums and for services; consumers who must scramble to ditch an unaffordable plan every year have no continuity of service and no guarantees their providers will take the replacement plan; small businesses resist expanding, and large ones continue to lay off and outsource. And on and on.Krugman, of course, sticks fingers in ears and sings la la la, because, in his cosy sinecure in Princeton and at the NYT, he hasn't experienced the real world in ages. Nor have many of his readers in his amen corner.Health insurance is not health care. And we have yet more evidence that having a 'Nobel Prize' (Hayek and Friedman also got the economics prize) is no guarantee of intellectual honesty or even of common sense.This is the last Krugman column I will bother with. 4 R M Gopa1 (Hartford, CT) "Health reform is still a huge success story."Just imagine what a historic success Obamacare would have been had it received a modicum of support from the Republicans. 2 Harold (Winter Park, FL) I worked for a company for several years that had two health care plans: 1) with a high deductible, and 2) with a very high deductible. The top execs thought it was a wonderful choice either way. So, if I am on the market for a plan and faced with a high deductible, I can view it as better than going bankrupt if I, or anyone in my family, have a life threatening disease. Before ACA, a friend who was self employed, had a wife and two children. His plan cost him $2,000 a month. Life was difficult for him. Complaints about ACA fall on deaf ears for those of us who live in the real world. 1 True Freedom (Grand Haven, MI) Obamacare is a total failure as it does not reduce the cost of health care anywhere as the insurance carriers as well as those who provide the services are the real money makers. Take out the insurance costs and the service provider profits (including the drug company profits) and at the time eliminate all of those legal fees which are paid for by the consumers in this nation and then you can start to create a real national health care system (for basic issues only). Until this approach is taken this nation will always have a top on the line health care system when it comes to costs but close the bottom of the line when it comes to effective services. 1 Alan (Santa Cruz) I'm so glad to knocking on the door to Medicare. KarlosTJ (Bostonia) Dr Krugman neglects to point out that time must pass before the full meaning of the PPACA comes alive. How much time? He doesn't know, but like the scare tactics, he is cheering before the results are in. The "Death Panels" are still in place - the administrators of The Plan (PPACA) have the authority to deny paying for services at their whim. That means appointed bureaucrats you have no contact with, who do not answer to you, are going to make decisions about your healthcare. But Dr Krugman neglects to point that out. 1 Bookmanjb (Munich) As an American who moved to Germany 10 years ago to start a now-thriving small business, I would like to comment on the issue of deductibles. Despite making no claims for years, my US health insurance premiums kept going up 50% - 100% per year. Consequently, I kept raising the deductible to minimise the cost of the policy. By the time I moved in 2005, the cost of insuring myself and my family plus the outlay due to the deductible was financially crippling. In Germany, I insured myself and my child privately (yes, Virginia, here they have a "private option") while my wife qualified for public insurance. I was amazed when I finally understood that there are no deductibles required. Doctors and insurance execs make upper middle-class incomes and a few become rich. The quality of care is, for the most part, superior to what I had experienced in the US. And the system is financially sound. There is no need for high deductibles in a public system, as America will discover if she ever manages to institute one. It will be sad that doctors and insurance & medical supply company execs will be able to afford only one house, two cars, and one boat, but that's how it goes. 385 Tom (California) We were on vacation in Berlin last year and one of our friends fell and took a hard blow to the head. The ambulance and being checked out by three specialists was a grand total of 1,200 dollars without any use of insurance. they are doing something right. 5 jhamje (Philadelphia) How can it be a bad thing that premiums are increasing because more people are being treated for being sick? Isn't there a flip-side savings in visits to hospital emergency rooms that have to be absorded because patients could not previously pay?I also didn't see an analysis that shows that premiums would have increased whether or not ACA was in place.Finally, there has to be an economic benefit arising from the fact that families do not have to hedge their bets on facing large medical bills and can invest their nestegg more aggressively.In sum, the whole picture has to be viewed as isolated metrics can distort the picture and I would expected that you would have done that. Prometheus (NJ) >This system is doomed, no small part because it was and is a GOP devised plan. As anyone with some intelligence knows, the core of the ACA was devised in the 1990s by Republicans, Jack Kemp being one, to save the health insurance industry. The ACA was their escape hatch to flee the inevitable Single Payer system bearing down on them, which/like most of the other modern industrial countries maintain.There is a reason why most other countries don't have something similar to the ACA, it generally is recognized as a doomed schemata.Even if it was working, America's over abundance of stupid people could still easily be convinced of its failure and that it is against their self interest.N.b., as a rule premiums generally go up, ACA or no ACA.Sent from iPad 3 M.I. Estner (Wayland, MA) Let's tell the truth. Obamacare is just a whipping boy. The only reason Republicans continue to complain about Obamacare is that they are determined to criticize everything done by Obama or by Democrats generally. It's just part of their Big Lie strategy, which is that all Democrats and all Democratic supported ideas are bad and all Republicans and all Republican supported ideas are good. They've made it nice and simple. The hateful diatribes and pronouncements of the Republican candidates for President predominate headlines simply because there are so many of these candidates making them. Their hateful, divisive messages and their Big Lie are repeated with enough regularity that too many Americans are believing them and falling into line. Democratic candidates need to stand up and challenge first this underlying Big Lie approach by calling out these liars at least as often as the lies are told. Anything less permits the lies to be believed. Repetition is the soul of learning. Tell people the same thing enough times and they will believe it. In truth, none of us actually knows all that much with certainty. At best, we just believe what we think we know. The lies must not be left unchallenged. 125 Brendan (New York, NY) In London right now, so Churchill comes quicker to mind now than normal. But clearly, clearly, this is another instance of Americans always doing the right thing after they have tried everything else.Universal health care with cadillac plans for those rich enough to buy them, and to also pay the taxes into the pool for everyone else to have health care is the answer.And those states refusing Medicaid expansion! Criminal!How many have died because a governor was too beholden to some false ideology to take care of the people?Time for good people to get an edge, organize, and fight for our future. Health care is a right. 171 Bill Gilwood (San Dimas, CA) "How many have died because a governor was too beholden to some false ideology..."How about beholden to their donors in the health insurance industry? 1 Patrick, aka Y.B.Normal (Long Island NY) For the same reason that Republicans have always beat the war drums to sacrifice their followers, the Republicans have been trying to destroy Obamacare since it's inception. Of course they know they will never destroy the program after passing legislation 50 times or so, but think of how many of their followers now think the program is "evil". Isn't it remarkable how the Real "Republican "Death Panels" in Congress have sabotaged the program, all the while sacrificing their followers for their selfish idiotlogical reasons? 1 jerry (The Blue Planet) With an economy growing far less than 5-10% a year how is an 11% increase sustainable? How is an average annual rise of 5-10% sustainable!?Maybe this year, but if it doesn't break sharply downward in the next year or two, won't it be fair to say health care reform failed on one of its most basic goals? 1 Carolyn (Saint Augustine, Florida) When I have written about the ACA in this column in the past, I was critical of it; often I wasn't published. Still, I persist. Dr. Krugman is a very smart man that should finally recognize that good, even adequate healthcare through the ACA is a myth. Thanks to the ACA, we will no longer be insured next year. The deductibles are enormous, so enormous that most don't dare go to the doctor. Only a few can afford the ridiculous premiums plus the huge deductibles in the course of a year. And of course, we can depend on premiums rising by at least 25 percent every six months to a year. The program is a failure. The savings it has achieved in the industry are achieved because consumers are opting out of seeing a doctor altogether, if they haven't bee forced to drop the insurance, which is the next step. And fining Americans for not having insurance when it's nothing but slavery under a parasitic industry is an American disgrace. Dr. Krugman should be fighting for single payer instead of continually defending an indefensible program. And yes, the ACA as it stands will collapse. Dr. Krugman, because the American people can either afford to support each other OR support the insurance companies. We can't do both. The insurance companies are parasites draining the resources of Americans that are in desperate need of those resources. 142 joel (oakland) Actually, your comments probably *are* being published, but the problematic way comments often display means you won't see it unless you search several (different) times, and maybe start from oldest rather than newest (or vice versa).It's not unusual for one of my comments to disappear when I check back to see if it's raised any replies, only to reappear when I check later. From time to time the earliest comments are simply not accessible - a lot of them. And they stay that way when I check back.You may have noticed also that it's not unusual for new comments to suddenly appear when you click Read More Comments or Read All Replies. Comments you've previously read will show up again with additional replies or new comments appear among ones you're already read.Don't take it personally. I've only had one comment actually rejected of god only knows how many, and I knew I was pushing the NYT boundaries on that one. And there are plenty of trolls whose absurd comments show up. 1 Alan (Santa Cruz) Imagine the net boost to our economy when a single payer health care program is enacted. Lots of cash now going to insurance companies would become discretionary income for millions of families, who could then fix homes, support their college age children, fix cars, donate to charity.........and so on. 1 Beorn Borg (Florida) Was your insurance plan was canceled because it didn't meet the requirements? From what I understand those plans became illegal, because they were "junk". When people actually needed them they didn't cover them.http://www.motherjones.com/politics/2013/11/obamacare-canceled-health-in...And that's why they were cheap, and only worked if you stayed healthy. Consumer groups were complaining, and lawsuits were being filed. How much did your insurance go up that you can't afford it? If you're that tight for money you'd probably qualify for a subsidy. 1 taopraxis (nyc) A characteristic symptom of sociopaths caught in a lie is that they fail to adjust their approach in the face of failure. They just keep lying, ever more openly and obviously, utterly indifferent to the fact that they've been caught in the lie and that their credibility is gone. One might almost admire them for their tenacity. They seem to feel that if they lie persistently enough, reality will adjust itself to suit them. Eventually, the targets of their lies grow quiet and simply stare into the space between their ears.At that point, it's over... 2 Len Charlap (Princeton, NJ) The Heliocentric Theory of Health Care ReformBefore Copernicus and Kepler, people generally believed the sun and the planets revolved around the earth, but as we got more data it became increasing hard to reconcile this basic idea with the observed facts. People thought up the Ptolemaic system in which the heavenly bodies didn't just revolve around the earth, but they revolved in small circles called epicycles as they went around the earth. That eventually turned out not to be sufficient, so they hypothesized epicycles within the epicycles. The last iteration of the Ptolemaic system was an incredible complicated mess that was almost beautiful in it's complexity.That's what we are doing today with health care reform. We wanted a "uniquely American solution." We wanted to keep the private insurance industry. We wanted the sun to go around the earth.So we talk about mandates, exchanges, reference pricing, death spirals, etc. The problem of adverse selection is an example. We need some more epicycles. We wound up with a bill with thousands of pages whose result is unknown. HR676 (improved Medicare for All) had 70 pages.If Kepler were alive, I am sure he would say, "If you simply give everyone Medicare, you wouldn't need all this complication, and I'll bet it would be cheaper, too." 3 njglea (Seattle) No part of OUR health care system should be a market-based commodity. Costs are going up because providers and manufacturers, in cooperation with insurance companies, are pushing them up as fast as they can for profit, not paying taxes on the profits and using the profits to kill competition and create huge wealth centers for the already wealthiest. It is NOT acceptable. Americans must DEMAND Universal Medicare for all with stringent and well-policed price controls at every level. My life matters and so does yours. They should not be held hostage to socially unconscious profit-seekers. 1 Fred (Up North) Just 8 days ago the NYT published a piece saying that huge deductibles are a problem for many. Somebody needs to be fact-checked.Fortunately, I don't need the ACA but it was and remains a kludge. 1 Jeff (California) Those people who chose policies with the lowest monthly premiums have the highest deductibles. They chose to gamble that they would never need health care. Now they are bitterly complaining. My mother used to call this "wanting to have their cake and eat it too." The point is that theses same complainers didn't have insurance before the ACA. Historically, people who didn't have insurance went to the ER for everything, knowing that in the end, we taxpayers would foot the bill. 1 Fred (Up North) It is called the Affordable Care Act. If people can not afford to buy insurance or use it when they do buy it it is not affordable.My mother used to call this "bait-and-switch". PV (PA) Not surprising that the Administration's cheerleading economist sees everything with rose glasses. He neglects a few important details:-The massive failure of taxpayer financed co-ops that brought very low and unsustainable pricing to ACA markets to the delight of consumers and Administration officials (until the party ended).- The huge price increases for 2016, @ 11% according to the NYT….almost 10X the CPI, due not only to risk pool issues, but also end of government subsidies to co-ops and the entire insurance industry to cover underwriting losses the first few years-Failure to address the underlying health cost drivers--- oligarchies in both insurer and provider markets…. A failed economic paradigm. No competition and no utility-like regulatory mechanism to control hospital costs/pricing (except in Maryland).- Failure to enforce antitrust provisions that have permitted massive consolidation in provider and insurer markets…… Perhaps that is the Administration's grand design--- oligarchies to finance Democratic PACs. Yes, coverage has increased due to massive taxpayers subsidies-- to expand Medicaid and ACA coverage (more than 80% of ACA insureds are taxpayer subsidized) plus huge subsidies to insurers as described above. If this is success, I wonder what failure looks like.I think that the good economist is smelling the roses a bit too much rather than studying the facts. 5 JustThinkin (Texas) It would be nice if we could see the insurance companies' books, and have more information all around concerning health care. On the one hand premiums were never cheap and are going up, while most policies have high deductibles -- meaning after paying the premiums patients are still paying a lot out of pocket. On the other hand, insurance companies say they are not making money. So, either someone is not telling the full story or -- and I think this is the answer -- many of the uninsured have in fact been very ill and are finally getting appropriate health care. That is, the ACA is beginning to cost more because more Americans are getting treated (maybe even cured) for their health problems. A great health care success that needs more reporting. And this leads me to two likely conclusions -- 1) over time as the ACA gets fully implemented and more people sign up when young, everyone will be treated earlier for diseases (which usually has more efficacy and is cheaper) leading to lowered costs in the long run, and 2) we really need to reduce the cost of health care -- more competition not mergers of pharmaceutical companies, for instance, (unless they are all merged in a government run system), and the use of best practices, transparent pricing, and more humane end of life care, to begin with. 110 Dr. James (scottsdale, az) It's a good point that excluding a large portion of the population from anything but emergency dept care keeps costs down. Now that we are letting a large portion of the uninsured into the system costs are bound to go up. But it is inhumane to continue to exclude a fifth of the population from health care. In AZ the Medicaid expansion went through largely because health care is such a big driver of employment here, I expect it's similar in a lot of the other red States and find it hard to believe they refuse to sign up. JoAnn Vargas (85706) You are right, someone is not telling the full story, Gail Boudreaux, CEO of UnitedHealthcare: $8.5 million, down 22 percent. Larry Renfro, CEO of Optum: $8.62 million, down 19 percent. Lori Sweere, executive vice president of human capital: $4.47 million (first year salary reported to SEC) Anthony Welters, executive vice president: $7.41 million, down 6 percent. and here they are. Abin Sur (Ungara) Just a couple of minor points; first, the newly elected governor of Kentucky has vowed to reject the Medicaid subsidy depriving nearly 4000, 000 of their insurance. He claims it is holding back employment. Secondly, every Republican candidate for President has vowed vehemently to repeal it, and with majorities in the house and Senate, it is a real possibility. It is extremely important to keep in mind, that these people ran on a platform to repeal it. And those who voted them into office may have done so be pause they were disgusted with the rising cost, high deductibles and bureaucratic snafus they had to deal with. Yes the macro picture may be bright, but on street level their is dissatisfaction. Add that to the group that believes low cost insurance which covers little if any costs if people get sick is preferable and you get a rising consensus against the law. Let's face it, the greatest flaw in the law was not its intent or implementation, but the resistance of those who hate the idea of joining a group they didn't choose to join. 2 Lindah (TX) I'm always a little suspicious of "averages". In this case, I'd like to know the range. Most critically, I'd like to know if state populations are part of the calculation. If New York's average premium increase is 14% and Wyoming's is 2% (both hypothetical numbers), would you say that the average increase is 8%? Perhaps that is a valid measurement, but it should be stated. 1 gerald (Albany,NY) When Government or business do not want us to understand what they are doing, they devise a 'fairly complex system,' a term that Dr. Krugman uses twice in this article. If Government wanted Americans to understand the health care system or the tax system each would be a ONE PAGE document.My solution? Fire any one in Government who can't write a law in one page...At least we would then know what the laws mean that we are expected to follow. 2 Elizabeth (New York, NY) I recently had an eye injury that required a trip to an emergency center. Before being treated, I was required to sign a "financial responsibility" form stating that I agreed to pay any charges my [very good, private] insurance declined. How much might that be? $100? $1000? $10,000? More? I have no idea. Since the emergency center doesn't tell you what its treatment will cost, and the insurance company doesn't tell you what it will cover, that "financial responsibility" form amounts to writing a blank check. A civilized country would provide its citizens actual health CARE, not just the opportunity to purchase health insurance, the adequacy of which is unknowable until *after* you try to use it. Medicare for all. 8 carla van rijk (virginia beach, va) There is something inherently defective in a health care system that provides the poor with free & abundant access to the most advanced medical treatments available, while the working class are forced to forego seeking care due to high deductibles & unaffordable out of pocket costs. If there is financial aid for struggling families who don't qualify for Medicaid yet are unable to afford health care then there should be a mechanism in the government health care website to allow them to access this.I don't blame this problem on President Obama or the Democratic politicians that helped push this historic legislation into law but rather on the legislative process that allowed for big business including Pharma, Commercial Health Insurance Companies & an uptick in out-patient emergency facilities cropping up around the country. It seems that the big health insurance companies that helped underwrite the legislation turned around after the fact & started to undermine it. Even Jeb Bush who claims that Obamacare is anathema to American values, profited greatly from the law since he sold his stock in Tenet Healthcare in 2013 for a capital gains of $556,283 thus doubling his investment. I'm betting that Wall St. profited the most from Obamacare while the small businesses & hourly workers in Red States hurt the most until the law can be improved hopefully in the near future.http://www.theguardian.com/us-news/2015/nov/22/obamacare-ppo-plan-texas-... 6 Greg (Vermont) Deductibles are a much bigger problem than acknowledged here. Anyone who sees a specialist pays out of pocket. These expenses accrue as debt year-to-year for most families who need subsidies. It is my understanding that the "Affordability Clause" within this law, says that a employer must specifically state that it will not make insurance available to family members in order for spouses and children to qualify for subsidies on the exchange. This quirk in the law means a husband/wife is stuck paying full price regardless of whether their policy is provided through work or the exchange. There was a time when problems like this were addressed with subsequent tweaks to the law. What now? 5 GH (MN) In year one I saved alot of money from the ACA in that I was able to separate out my insurance as a single parent and get a separate policy for my child, something not previously provided by the insurance company. This year my child's premium increased 50%. I receive no federal subsidies - nada. What concerned me was the corporate insurance correspondence that came before the increase - noting that there might be other adjustments taken in the future - one of which was the potential elimination of stand alone children's policies. This is a big insurer and some adjustment was bound to happen as they seek to adjust their bottom line, but I was surprised by the increase and it is an issue and I'm not exaggerating. 1 Barbyr (Northern Illinois) Concerning high deductibles, Paul says, "Furthermore, additional financial aid is available to lower-income families to help cover such gaps."Care to expand on that, sir? Sounds like pie in the sky to me. Fact is, someone who faces a $5,000 deductible still cannot afford to go to the doctor or ER because a debt of that size will sink them financially. I know - 2 years in a row, it happened to me, and I will be paying those debts for 10 years or more. So what's the point? This is not insurance, it's a boon to our immoral and unsustainable health insurance industry.I never thought I'd see Professor Krugman shilling for predatory capitalism. 6 mjb (Tucson) we need a single payer plan. period. cut the insurance companies out of the profit business. In fact, get medicine out of the profit-making business, period. 11 Woof (NY) Sara Rosenbaum, a professor of health law and policy at George Washington University who supports the health law, said the rising deductibles were part of a trend that she described as the “degradation of health insurance.”Insurers, she said, “designed plans with a hefty use of deductibles and cost-sharing in order to hold down premiums” for low- and moderate-income consumers shopping in the public marketplaces. (NY Times, 11/14/2015)Many people on these plans have stopped going to see a doctor,But not this columnist, who undoubtedly on a first class health care plan, having worked for some of the richest Universities on the planet. 3 Pdxtran (Minneapolis) I qualified for Medicare this year, and it was a huge relief. The ACA (crafted in closed-door meetings with the insurance companies, may I remind you) specifically allows insurers to price-gouge people over 50.As an employee of a university, Professor Krugman, you may be somewhat shielded from this reality.As a self-employed person, age 64, I was paying a nearly insupportable premium for a policy with a deductible of $5,000, which meant that I could never afford to actually receive medical care. Sure, preventive care was free, but I paid out of pocket for any actual care for illness or injury. It felt as if the insurance company had a license to print money at my expense.Now, as a Medicare enrollee, I have the most expensive supplement plan available in my state. I'm still saving $300 a month over what I paid last year, and I have (glory, hallelujah!) no deductibles!Supposedly the high cost of health insurance for us over-50 types is part of what is driving age discrimination in the corporate world.Why not gradually lower the age of Medicare eligibility to age 50 (taking away the cohort that the insurance companies don't want anyway), which will bring younger, healthier people into the system, paying premiums, but in most cases, not using the most expensive services.Better yet, gradually lower the age of eligibility to zero, using the existing bureaucracy?The insurance companies will have only themselves to blame. 15 Fleming (Pickering) Thank all of us for your healthcare. My family is having to suffer because of your great benefits. Mathew Carniol (New York) "Second, some Americans who bought low-cost insurance plans have been unpleasantly surprised by high deductibles. This is a real issue, but it shouldn’t be exaggerated. All allowed plans cover preventive services without a deductible, and many plans cover other health services as well. Furthermore, additional financial aid is available to lower-income families to help cover such gaps."This is the type of thinking that's destroying the middle class. 3 Mike Schumann (St. Paul, MN) I don't know where the 11% increase numbers are coming from. My personal experience is vastly different.Both my wife and I have individual policies with Blue Cross / Blue Shield MN. In 2016, my wife's premium is going up 47% over 2015 for identical coverage. My premium is going up 68% in just this one year.This is a direct result of two "features" of the ACA:1. The elimination of annual coverage limits. With the dramatic advances in health care technology, we are rapidly entering an environment where if you spend enough money, you can keep anyone on life support indefinitely. Not having any financial caps on insurance coverage is going to bankrupt the country.2. The ability to change or get new coverage every year makes it increasingly attractive for healthy people to drop their coverage, knowing that if they get seriously ill, they can sign up for new coverage at the end of the year. As a result fewer and fewer healthy people are participating in the individual insurance market forcing rates even higher, which makes the problem even worse.All of this was 100% predictable. Something needs to be done in a hurry to fix this, or the individual insurance market is going to collapse. 2 Fleming (Pickering) You assume that democrats no not want the "individual insurance market to collapse". A lot of people would argue that this was the desired outcome when the PPACA was forced through on Christmas eve. DJ (Tulsa) The ACA may work in certain states but it doesn't in many more. Here in Oklahoma, we are left with only two providers, Blue Cross and United Health and both offer only high deductible (average $5 to $6,000/year for an individual and $12,000 for family) and a very limited doctor / hospital network. Out of network services are not covered at all, and have no yearly out of pocket nor lifetime limits. Blue Cross's network doesn't even include the two largest hospitals in Tulsa and United health announced they may be out of the state by 2017. In short, both providers offer only catastrophic coverage and very limited network of providers. Most people I know cannot find their doctor in the in-network list of providers offered by these companies. And the costs are not cheap either, with the average silver plan in excess of $400/month - an increase of 40% since last year. Forget Medicaid. Our state, in its infinite Republican wisdom, has declined to participate. The ACA is not working in small population states. We need a public (federal) option, and fast, and force the private sector out of the health insurance market. It shouldn't be difficult, as it appears they are slowly doing it on their own. 11 citizen vox (San Francisco) This is my first opportunity to hear first hand observations of health care in a staunchly conservative state. Apparently the private insurance plans are woefully inadequate and the state government only works to impede ACA.So if the populace is poorly served by government, why am I not reading about mass demonstrations to have government work for the people?Here in California, in any given week, I can participate in multiple grass roots actions/demonstrations. I can't say our efforts are anywhere near equivalent to moneyed interests, but we do win a few battles over decades of activism.We do have a less corporate friendly state government than OK and we have Covered California, our active version of ACA.So Oklahomans, stand up for your interests. 1 Tom Norris (Florida) The ACA's opponents, through Fox News and the cadre of conservative radio talk show hosts, will incessantly proclaim the failure of Obamacare. No amount of good news will ever convince them otherwise. The core of their position is their fury over the fact that poor people (in some states anyway) will get free health care. That many of these people are minorities upsets them even more. This is why many states have refused to take federal Medicaid funding. Here in Florida, when a state official was asked why the legislature and governor refused those federal funds, his reply was that poor people in Florida deserved something better. What that might be remains to be seen. 8 Fleming (Pickering) No our problem with this law is all the LIES we were told during the debate and passage. Until democrats understand this simple fact we are going to disagree. cjm (VA) While I agree the ACA has helped many - especially those with preexisting conditions - it fails when it penalizes those who do not have insurance. My son, unfortunately, lives in Texas, a state that rejected the Medicaid funds. He works for a small office that offers no insurance benefit. Yes, he gets a very small stipend that is supposed to be used for insurance, but with a wife and two small children, a mortgage, etc., his pay is barely enough to survive, and the additional money he receives helps purchase food.So, when he files his income tax return he has a penalty to pay, which then forces him to pay additional penalties because he has to work out a "payment plan" with the IRS. THIS is one of the examples of how this country continues to punish the low and working class people. I do not agree with the penalty imposed, and would work to remove that from the ACA. 6 Andy (Salt Lake City, UT) I'd prefer single-payer but I'll take what I can get. I've know friends and family that rely on the ACA for health coverage. Some use the ACA temporarily as a stopgap. Others use it habitually due to self-employment, unplanned retirement, or woefully inadequate/non-existent employment packages. I also appreciate that young adults have a more generous time buffer in providing their own health insurance.The system is still a clunky, flawed, unjust, and expensive mess but it's a slightly better mess than before. That's worth some amount of praise. 11 mlg56 (Vermont) It's embarrassing to have a Nobel prize-winning economist defending a system which leaves intact insurance companies' obscene profits from illness and misfortune. We need Medicare for all ages. Simple as that. 12 Jeff (Evanston, IL) Yes, you're right. Please outline your course of action for convincing the Republican Congress to pass a Medicare-for-All Bill. Obamacare is the best we could get, and it's a lot better than what came before. 2 Bob (Chappaqua, N.Y.) Anyone who sees their doctor must know how the medical system has fallen.15 minute visits, little to no follow up from their doctors because the doctors are being forced to see too many patients because of concern over the "bottom line." I do not blame them. I blame the poor job the President has done in "reforming" the system.There is no real doctor patient relationship now. No one I know who remembers the old patient doctor relationship is satisfied with what occurs today.It seems to me the President Obama is all too satisfied with a degraded health care system and it seems that so too is Prof. Krugman. 6 Sam Kirshenbaum (Chicago, IL) I generally like Paul Krugman's columns and agree when he challenges the rationale of the powers that be, but in this case he's the one who is pretty clueless. I really think he is minimizing the impact of the dramatic increase in premium costs and the substantial increases in co-pays, out-of-pockets, and deductibles. As a small business owner, I experience these things first hand -- for myself and my employees. The burden of the rising premiums is substantial on my business and hurts my employees -- especially older ones. And, everyone was shocked by the rise in deductibles, etc. Frankly, I'm glad more people have access to healthcare, but without putting in some price controls, the ACA is a disaster for many of us. And, I suspect, with no effective governor on costs, it's only going to get worse. 8 John F. McBride (Seattle) Social Security has been around for 80 years and "Without question, the run of unexpectedly good news" for it came to an end a long time ago. Yet despite repeated attempts by Conservatives to sabotage it, tinkering that hasn't made it the better system it can be, and constant threats to end it or reduce it (Ross Douthat vaguely referred to it yesterday) Social Security is still with us. My 99 year old father needs every dime he can collect. I intend to start collecting it soon.Obamacare is an imperfect system, but our society includes a lot of people who desperately need it, unlike the Conservatives in Congress, running for office, and paying the campaign bills. The imperfections are easily fixed; acknowledge that health care works in every other Western peer nation, including our neighbors Canada and Mexico, and make it as good and better as theirs.The problem isn't Affordable Care, the problem is a political party that never ceases proclaiming its patriotism, its virtue, its religiosity and its values, but applies them to a mere 1% of the population and denies them to all others.They'll pay Trillions for wars but not a dime toward building a great nation and fair, equitable, healthy society.They're not a political party, they're a madhouse named Republican in which only the neurotic and psychotic are welcome.. 30 Cogito (State of Mind) I'll add briefly to that, recalling something my H.S. track coach (Nathan Krinsky) said to me, when as a callow youth he heard me echoing certain sentiments against people coming from other states due to easier welfare in NY (was it true? I don't actually know). But he said, "Don't kick a man when he's down." I've come to the conclusion that kicking people when they're down is part and parcel of the Republican creed, even among "moderate" Republicans (such as Charlie Baker here in Massachusetts who felt compelled to join the motley crew of governors inveighing against admitting Syrian refugees.) Got to appeal the Republican base, no matter how base the appeal. 1 HenryC (Birmingham, Al) Obamacare lives, but should it? The same results could have been achieved by a simple expansion Medicaid. Single payer makes sense as health care is not price sensitive. People pay whatever is needed. Obamacare combines bad aspects of private insurance with bad aspects of public heath care with little of the good aspects of either. Dr. Krugman's arguments are straw men making false analogies. 9 AMW (Santa Cruz, CA) While I am a big fan of Mr. Krugman, I think he is minimizing the impact of premiums and deductibles on those of in the middle class. Our family of four now pays as much in annual premiums as we do on our mortgage payment, and we live in coastal California, which is saying something. Our deductibles are terrifying and I have stopped going to the doctor out of fear of the bills which are sometimes large and seemingly unpredictable. Huge premium increases have thrown my employees into crisis this year and we are scrambling to find raises for everyone...but I suspect at least some will need to leave this non-profit job for something more lucrative to pay insurers and doctors. It is demoralizing. 13 Diane Kropelnitski (Grand Blanc, MI) AMW,I couldn't agree more. In my community, for the poor we have excellent healthcare through Medicaid, and there is still a huge need for a free medical clinic. Why? Coolhunter (New Jersey) Paul, you must have missed United Health Care's conference call last week. Implode it will, all parts except the Medicaid part. It was the way it was designed from the start. After all, with the government paying, given its endless ability to print money, no end would be in sight. I am working hard to lower my income to qualify. Almost there. 2 David A. (Philadelphia) A very foolish column written by someone who obviously has not spent 10 minutes investigating the cost of plans under ACA which is unaffordable for the middle class. If he had spend a little time actually going to site to sign up and looking at the prices, he would see that the numbers just don't work for the middle class. Example: in the Philadelphia area, a family of three with a household income of $80,000 which means no subsidy (husband and wife each make $40,000 and the kid makes no money -solidly middle class at best in a East Coast city), the monthly premium for the Silver PPO, the second to lowest tier, was $1725 a month in 2015 and going up to 1825 a month in 2016. There is no way a family making 80,000 or 1000,000, who have housing costs and other expenses relating to raising a kid, can afford 25% or 20% of the pre tax income for health insurance. The numbers just don't work. I will say that ACA is pretty good is for someone on the low end of the salaries and who is eligible for a subsidy - I know people making $18000 a year paying about $120 a month for a good plan -and ACA is also pretty good for people making a lot of money, say $200,000 and up, who pay the same amount as someone making, in the example above, $80,000. But the middle class, it's a joke and Krugman is a joke for purposively not addressing this issue. 22 Dink Singer (Hartford, CT) A family of three with an income of $80,000 without access to an employer provided plan was eligible for a subsidy in 2015, with their premium for the second lowest priced silver plan capped at 9.5% of income. ($80,000 was just above the cutoff for subsidies in 2014.) Because Pennsylvania allows age rating, whether or not the family actually receives a subsidy depends on the age of the parents. If each is age 30, the 2016 monthly premium for the second lowest price silver plan is $628 so there is no subsidy. If each is age 40, the full premium for the plan is $690, but there is a $45 subsidy, bringing the cost down to $645. If each is age 60 the subsidized premium is still $645 but the subsidy is $665 bringing the full premium to $1,310. If the couple is making $85,000 they are not eligible for a subsidy and the premiums are 8.9% of income at age 30, 9.7% at age 40 and 18.5% at age 50. David A. (Philadelphia) Husband 57, Wife 59, Child 21 with household income of 81,000 pays full freight - no subsidy - in 2016 with a monthly premium of $1839 for Silver PPO or 27% of pre-tax income. Unaffordable in any universe. If both spouses are 35 and their kid is 10, with the same annual income household income of 81,000, the monthly premium in 938 a month for Silver PPO, or just under 14% of pre-tax income. Still unaffordable even if the numbers are better than the older couple. Bella (The City Different) People with healthcare have much less stress in their lives than those without it. This alone makes the ACA somewhat successful. Could it be better? Should we expect a better program? If we had a political system geared to giving the best results to the American people, we would have a healthcare system that mirrored every other developed nation instead of what we have ended up with. A healthy nation is good for everyone both physically and productively. The results could be amazing. 7 jennifer.butson.in0l (Mill Valley, CA) I was jettisoned from my company's healthcare program because of ACA and the stress that it causes me and the personal expense as a middle-class individual in my 50's is palpable. The deductibles are so high I never use the HMO policy I was forced to buy. While you can't be declined for pre-existing conditions I pay a fortune for other individuals poor health due to bad eating habits and lack of exercise and it is ageist to make me pay more in my 50s than someone in their 30s. 2 Mark Datema Lipscomb (Chicago) I always enjoy Mr. Krugman. I support our moves toward Affordable Health Care. But Mr. Krugman needs to dig more deeply into this issue. I recently quit teaching. I worked half a year & began self-insuring in Illinois through Blue Cross Blue Shield. My premium for health & dental = $490. I have had no doctor visits. I have had only one 90 day refill of a 3 generic prescriptions (gastritus & blood pressure). As open enrollment came around (2 months after my coverage began), I was informed that BCBSIL would no longer offer my plan. In fact they simply renumbered my plan, made a couple of cosmetic changes & raised my premium to $700 with Dental included.As I say, the average hike may well be 11%. But given that I haven't needed to see a doctor for anything not already in my health profile when I got the insurance and the fact that my premium is now (for this plan) unaffordable, I would encourage Mr. Krugman to drill down on the numbers. His voice & acumen are sorely needed. 11 NSB (New York, NY) It is rare that I disagree with Mr. Krugman but on Obamacare I'm afraid we must part ways. Yes -- not being discriminated against because of pre-existing conditions is great. Expanding Medicaid is another positive. However beneath the surface of expanded coverage is a disastrous mess. Coops going out of business. $300 monthly premiums with $6000 deductibles. Lack of coverage of preventative services like physical therapy: why pay $75 for 20 weeks when one can spend $150000 for hip replacements?! And the biggest disaster of all: narrow networks and formularies that make treatment and continuity of care a dream not a reality. And here's bonus -- you can't change insurance plans but once a year but your hospital or doctor can drop your plan at anytime. So you sign up for a plan because you find decent doctors in it. Then in April you find out that doctor hates the plan so much he/she has dropped out. So much for research & planning -- which takes a lot of time and effort by the way because no one's web site is accurate. And forget about lowering costs. Since we don't want to interfere with the free market system hospitals can charge whatever they want and the insurance companies don't seem to do much negotiating. How can they? No one will give you a price going into a procedure -- even a standard one. I've seen the bills mu insurer pays. They are outrageous. Time to start over again. 13 Jon (Buffalo) But what you are describing is the very nature of health insurance in America. You may see this on the exchanges, but it is the same thing with the employer based programs. I find it hard to hear people complain about the exchanges, since the costs are similar through one's employer. And no, the employer plans are not going up because of Obamacare. Sure they are required to cover some more preventive care items, as well as sons/daughters up to 26 rather than 21. But those costs are not great (typically, people in their 20s need little medical care). Costs go up because medical treatment costs continue to go up as new drugs and procedures are developed. Unless someone wants to touch the third rail of "rationing", then this will always be the case. 2 Nancy (<br/>) I'm afraid Obamacare is in big trouble. Here in IL our health insurance premium has rise some say 17% some say 25%. That means insurance for my husband and me is now $12,600/yr with out of pocket (which excludes premium) of $13,700 for a grand total of $26,300. That's for two people ages 63 and 58. We can manage one year of this two years will be financially devastating. A huge portion of our after tax income is going to this, which jeopardizes expenditures on travel, home renovation, charitable contributions. Is that good for the economy? All I'm doing is transferring money to overpaid doctors, insurance companies and hospital administrators.Healthcare is over 17% of GDP in the US, no other developed country is more than 11.5%! If we had the next highest burden $1 trillion would flow into the rest of the economy. Single payer can't happen fast enough. 25 David Henry (Walden) Because of the GOP, Obamacare is all you have. Sharon (<br/>) http://www.denverpost.com/opinion/ci_12523427Many of the negative comments I see are related to aspects of the Obamacare system that was the result of a grisly bargain fomented by the well financed greed heads of the medical industry, big pharma, the medical insurance industry and the Republicans ( their paid lackeys).In America 31% of the premiums go to the paperwork and CEO's profits as opposed to the 1% overhead of the Canadian system. America spends 17.4% of its GDP on healthcare as opposed to Canada's 11.4% ( 2012 Washington Post figures) with a marginal Canadian higher tax bite. Our drug prices cannot be lowered by law because of legislation sponsored by big pharma ( ie. Republicans) -as a result our costs are the highest in the world.Of the 11 wealthiest nations we are first in costs per capita and dead last in results. Britian is the highest.As to the snipe about "death squads" some of us today call that "hospice care". I saw my uncle pass away with dignity and serenity surrounded by his family and the caring staff of a splendid hospice care facility in Connecticut.It is indeed a miracle it has worked so well with the Republican Party, big pharma and many in the insurance industry dedicated like religious zealots to eviscerating it. 25 KS (Centennial Colorado) ???No Republican in either the House or Senate voted for this plan. It is the sole property of Democrats.Please let me clarify the death panels. These are to be appointed government people who will decide what procedures will be paid and which will not. It is called rationing. There will be, according to the bill, a fixed amount of Medicare money. Those unelected bcrats will then decide what gets spent where. Has nothing to do with hospice care...except the panel may decide that after age X, for instance, certain procedures/interventions will not be covered.We may be first in costs, but we provide superior care. I don't argue that it has been a disjointed system. But we cover more rehabilitative care than other counties, and don't have their waiting lines. Further...and I don't know where you obtained your information...we have better results..even 25-40% better survival rates for breast and prostate cancer.Further... I believe Britain only counts the NHS expenditure figure...private care is not included in their figures, which obviously would add to their published health care expenditures.As for your approval of Canada and its costs: In 2006, in a ruling re. the two year wait a patient expected for surgery, an Ontario judge opined: The Canadian system does not guarantee care. It only guarantees a place in line. Sharon (<br/>) http://www.aarp.org/politics-society/government-elections/info-03-2012/m... "1966, Canada implemented a single-payer health care system, which is also known as Medicare. Since then, as a country, Canadians have made a conscious decision to hold down costs. One of the ways they do that is by limiting supply, mostly for elective things, which can create wait times. Their outcomes are otherwise comparable to ours.Please understand, the wait times could be overcome. Canadians could spend more. They don’t want to. We can choose to dislike wait times in principle, but they are a byproduct of Canada’s choice to be fiscally conservative.Yes, they chose this. In a rational world, those who are concerned about health care costs and what they mean to the economy might respect that course of action. But instead, they attack the system."In the beginning there was the conflating of "death squads with the end of life care that is hospice.There is a limit to how many rebuttals that one can cut and paste paste to your many erroneous assertions.Putting an "I believe" vis-a-vis the British NHS expenditures does not make it sooth. 1 Sharon (<br/>) @KS Furthermore- I don't know where you get your figures from but the World Health Organization's ranking of the planets health system ranks us 37th, Canada 30th and France 1st. You may have your own figures. In terms of breast cancer- ( not the only plague on the planet) has Belgium followed by Denmark, then France as having the best outcomes on breast cancer after 5 years. 1 rkh (binghamton, ny) While overall costs may not have increased it is because those costs have been shifted to employers and and employees which equates to wage suppression and ironically makes it more difficult to get ahead or even stay at the same level. We need a single payer system that is consumer focused,not insurer and provider focused. Such a system would allow for the sufficient clout to negotiate fairer rates with, pharmacy, insurers and hospitals. 13 FreddyB (Brookville, IN) I really wish the Democrats would not force non-Democrats into their super jeenyus programs. I really don't want the same people in charge of eradicating marijuana in charge of my healthcare and retirement. If the Democrats want ACA or even single payer I have no objection as long as it's self funded and all the participants are voluntary. All I ask is that the grown ups be allowed to find their own solutions that do not depend on the economic equivqalent of a perpetual motion machine. (To those who would reply that free market health care doesn't work in the real world, please understand that the highly regulated and cronyized mess that we had before was not anything close to a free market.) 6 uofcenglish (wilmette) It is just too expensive for people to buy insurance. The cost of all policies need to be governmentally regulated. Insurance companies need to pay to play! People are getting angry and it is the insurance companies who we will be ooming after. 9 Cogito (State of Mind) Without campaign finance reform, we will never see health care reform (or other reforms such as breaking up the big banks and limiting media concentration), because both parties are bought and paid for. James (Flagstaff) I hope that reforms and adjustments move in the direction of enrolling more people in Medicaid (wider income groups) and Medicare (more flexible age limit), with appropriate changes to those systems to ensure that the widest possible number of doctors and institutions accept patients. A marketplace for health care is inevitably very complex, and beyond what most Americans can usefully spend their time figuring out. It sounds great to free market ideologues to "shop around" for plans, but this isn't like buying a house or car, planning a vacation, or purchasing consumer items. The key about health care is that most of us do not know exactly what larger problems and expenses we may face -- we normally know what we're looking for when we purchase other items. Comparing plans doesn't do a lot of good, if you can't anticipate your needs. Shore up Medicaid and Medicare, make them effective for larger numbers of Americans, and use them as levers to keep prices down in the private market. That's my prescription. 9 alprufrock (Portland, Oregon) My wife has a pre-existing condition, so up until 2014 she was more or less trapped with her current coverage, fortunate to have it insurers would probably say. We have ample resources to obtain coverage without going through the exchanges. However, she was sent a letter by her current health insurer announcing without explanation that her premiums in 2016 would increase 30%. She dropped that coverage and found coverage with another insurer at about the same rate she has been paying (which is probably also dripping with unreasonable profits for the top management but nonetheless). She fired her insurer! This is something she has never been able to do before. She went to this magical free market the Right is always touting and shopped around. For those who have gotten a similar letter, throw off the yoke and shop around. Health insurers no longer control every corner the health care market and they are chaffing under the competition. 25 Tim C (Hartford, CT) I add my voice to those who heartily agree the "Obamacare is an imperfect system." The president should have held out and forced the U.S. into the 21st century with a single-payer system. Now we'll have this hybrid mess for the next few decades.The bias in the U.S. for a fee-for-service approach is rooted in a market-based philosophy and assumes the existence of a free and informed consumer. And, clearly, no one purchases health care like they do cars or iphones. Let's give up the "exceptionalism" and join the rest of the intelligent world. 9 stalkinghorse (Rome, NY) That is a 19th century system (with predictable results). 2 Urizen (Cortex, California) Not all criticism of ACA comes from the right - the left offers criticism of the rational variety, which is why Krugman, a self-appointed cheerleader for ACA, avoids or downplays the left's critiques.The high deductibles are a serious problem. Health care insurance does not equal access.The subsidies Krugman mentions are only available to those earning less than $41K/year - not much help for a sinking middle class (another topic Krugman studiously avoids) and even for the poor, after the subsidies, they are still paying more for care than they can afford.The figure of 29 million uninsured should concern a liberal with a conscience. At the very least that liberal should stop calling ACA "universal health care" - there is only one system that can make that a reality, single payer, but Krugman, also a self-proclaimed guardian of the permissible boundaries of left thought, doesn't say much about it.Finally, the group that will most whole-heartedly proclaim "Health Reform Lives" is, of course, the private insurance sector. Not only did ACA save the sweet deal they enjoy with US health care delivery, a relationship that's analogous to that of a leach and its host, it increased their profitability so that next time a real challenge to their scam appears, as it did in 2009, they will have even more lobbying might to fend off challenges. 33 rs (california) Urizen,I think in earlier columns Krugman has made it clear that he would prefer single payer. His support for the ACA is because it is certainly an improvement over what we had before. 1 witm1991 (Chicago, IL) Urizen, even though i may agree with everything you say, messy as it is, the ACA is for the moment, much better than nothing. Of course the FDA decision not to label GMO salmon is another threat to the system down the road. The average American diet is its nemesis. Kodali (VA) The Republican arguments are similar to Dollar debasing, inflation spiral out of control and now health care costs goes out of control. The Republicans hope these things happen so that they can get elected. The hope for republicans in the absence of good policies is promote fear and it worked last mid-term elections. May be it works again by creating the fear of refugees. I hope not. 13 Domer76 (St. Petersburg) The ACA works very well for those whose incomes don't exceed 250% of the poverty level. They receive credits that reduce their premiums to a fraction of the actual cost, and most importantly they are eligible for cost sharing reductions which significantly reduce the deductible, coinsurance and copayments.For everyone else, including the middle-class they are forced to buy more insurance than most want at very high prices. The cost of employer-provided insurance for my daughter, son-in-law and two children for a plan with a $10,000 deductible is $18,000 a year of which the employer pays $4,500. When my son, an amputee, needed a new prosthesis for $15,000, insurance didn't cover any of the cost because they maintain he is entitled to one prosthesis in his lifetime. (His leg was amputated at the age of 7 months.) 14 Mark (Boston) Not that it stands the remotest chance of passing either the House or the Senate, but a national risk pool that spread costs among insurance companies according to the relative sickness/health of their enrollees would make a lot of sense. 8 efazz (Fort Wayne) And a national healthcare system that spread the cost across a universal pool and disposed of insurance companies altogether would make even more sense. 10 Frank Correnti (Pittsburgh) I know I'm not the only one who has spent a lifetime witnessing the consequences of a society willing to allow some to fall off the curb without the benefit of regular work, ability to provide for family and little encouragement to face the new day except a faith in the Lord. I call these state executive and legislative bodies chicken hawk also because I can't bring to mind anyone in my experience and knowledge who has served the people as a conscript or volunteer or a supporter of the common good day to day in the military or social services. So many, a generation or more were not included in Social Security and that was called alright, and when Medicare survived opposition and negativity it was not sufficient for all. And in the modern times of Medicaid, which includes those elderly and disabled otherwise left behind, we see these some inconsequential in the cosmic judgment, states blatantly posting not in my back yard on the issue of providing for the common good and the general welfare. Don't deny that these unwholesome products of our way of life are also today infiltrated in the national halls of government. Thanks to others who speak against these 'intransigentes'. 3 Bos (Boston) The current ACA is the beginning. If Congress is sincere, it should work with the next POTUS to refine it 21 Nick (Guilford, CT) People complain that ACA has raised costs, and that is superficially true but: Before ACA, the yearly and lifetime caps on policies had made sure that over 50% of the personal bankruptcies in the US were to people who had health insurance but still lost everything when a large expense hit. Caps of $100K were common, and made the policies worthless. Comparing a worthless policy to a modern one is a fool's errand.Additionally, high deductibles are the norm, my gold-plated work policy from an aerospace giant requires $4000 annual pay-in and then a $6000 before it pays 100%. This is not ACA speaking, it is our absurd medical system.Philo is right, a single payer method is best, but until he un-elects republicans, welcome to reality. 37 Adam (Scales) A couple of these points are questionable. Lifetime caps (eliminated by the ACA) were not a widespread problem. I teach insurance law, and have never seen a case involving a $100,000 lifetime cap, though I'm sure it existed somewhere. A Price Waterhouse study in 2009 estimated that about 1% of employer-sponsored policies (where most people get their coverage) were subject to caps of less than $1,000,000. So, while eliminating lifetime caps was a good idea, it did not materially improve the quality of insurance the vast majority of people were getting.Second, the "medical bankruptcy" phenomenon, illuminated most brightly by then-Professor Elizabeth Warren, is more complicated than this comment suggests. Lifetime caps, for reasons above, certainly are not a significant driver of medical bankruptcy. Moreover, those with truly catastrophic injuries (who will have the highest medical expenses) are sent into bankruptcy because they can no longer work, and have inadequate disability coverage. Significant uninsured health expenses are just one of several factors, acting concurrently, that send uninsured people into bankruptcy.Finally, your "gold-plated" plan has very high out-of-pocket costs, unless it's a family plan (and even then, it's well above the national average for employer-sponsored plans). By contrast, there are many ACA exchange policies with $6,000 per person deductibles - which is over five times the national average of employer-sponsored plans. 1 Frank Dracman (NJ) You work for a company which provides health insurance so how do you know what the caps were? I agree that is one benefit of the ACA is that it clarified coverage a little better however I bought plans for 16 years now and never saw one with less than a $1Million benefit, so your statement about $100K cap is not true. I'm sure that type of policy existed but you would be a fool to buy it. loveman0 (SF) When expansion of medicaid is paid for entirely by the federal government, why isn't it the law of the land in all 50 states? The answer is because a majority on the supreme court is blatantly racist. 11 Philo (Scarsdale NY) I have been and still am a supporter of the ACA, but Mr. Krugman , who I am a fan of, is being to flip and disingenuous in this column today,I am self employed and have paid for my own insurance for nearly 30 years. I have been fortunate in my success, so ably to afford it, each year because i am a 'small group' ( just family) my insurance plan changed, premiums went up and coverage became less, nothing to do with the ACA; that just became an excuse for the insurance companies to accelerate these things using the ACA as an excuse. I expected that, and am willing to bear this burden to help move forward health care in the US. But please Mr. Krugman, dont try to paint what is happening now as some wonderful accomplishment, Its is a burden for many people out there - I hear this all the time from friends, family and associates who are extremely burdened by high deductibles , cost of insurance etc. Yes , it is catastrophic coverage ( thats how my insurance assured me that my 5 figure premium with a huge deductible is still a 'bargain') and that is important. But we as a nation need to move to single payer care, and not being under the influence of the insurance companies and now the medical industry, something not addressed in your column.The consolidation of medical practices into corporate conglomerates is as dangerous to our national health as the instance industry. You cant paint that as a rose. 52 H (Boston) He supports single payer care. My question to you is the ACA better than what we have before? Philo (Scarsdale NY) Yes, I think its better ( for the nation , not me personally) than what we had before. and I think its a step towards single payer Historian (North Carolina) I am sure that Krugman's comments are correct for the nation as a whole. But there are real problems in states, such as North Carolina, which has been captured by really far-right Republicans, thanks to about the worst gerrymandering in the nation. Our daughter lost her job, which had health insurance, in July 2014. She signed up for a plan through the ACA for 2015 that was reasonable, and I paid her premiums. She has not yet found a job. She has now been informed that her plan's cost will rise 43% for 2016 and with a higher deductible. North Carolina has rejected the federal Medicaid program, and Blue Cross of North Carolina, her insurer, can do practically whatever it pleases, because the Republicans in the General Assembly prevent the state insurance commissioner from doing his job, which is to regulate the health insurance companies. The newspapers say that the average premium increase for ACA-insured people in North Carolina is 33%. And some have been hit with 50% increases. 25 Michael Richter (Ridgefield, CT) While Obamacare may be working and is far preferable to the "system" in place before it was instituted, nevertheless Obamacare is far inferior to a Medicare system of medical coverage for all----to insure that sick people can get adequate, appropriate medical treatment and to keep costs down.Every advanced Western nation has some sort of federal, universal unipayer system of health care for all----except the United States.When is America going to do the obvious and join them? ****A Connecticut physician 34 Vincent Maloney (New Haven CT) The answer,Doctor, is when America elects Bernie Sanders president. stalkinghorse (Rome, NY) It would never work here. Americans pay the freight so that others may ride for free. carolinajoe (North Carolina) "When is America....?"Never, if Democrats don't vote in midterms..... 1 Jennifer (NYC) Funny, when I was laid off during cancer treatments and found work a couple years later as a contract worker so I could finally resume treatment, I was again laid off after finally qualifying for benefits, again, because I maxed out at the hourly rate (don't worry, I was called back to work for $7 less an hour but without the benefits). Obamacare was not affordable. The employer plan would have given me access to my former doctors. On a wing and a prayer, many, many people with cancer diagnoses, formerly with full benefits, still cannot get access to the care they need. So, please, stop with the hurrahs. It works for slices of society, and particularly the insurance companies, but certainly not everyone. 11 H (Boston) Who said everyone?. If the ACA were repealed would we be better off? Gets grip people. NM (NY) That so-called "death spiral" is precisely why healthcare works with a universal coverage basis - everyone is covered and at all times, not only when they become ill. If only those with grave conditions got covered, or if others enrolled only at the moment they became sick, then costs would skyrocket. Everyone being insured, at all times, keeps us out of that "death spiral." 4 skip1515 (philadelphia) As an employer who's offered health insurance (though basic) for 20 years in an industry that did not have a tradition of offering it (hospitality, non-union), my wife/partner and I are all for the ACA. Dealing with it, however, shows how flawed the program is. Forget the plans' costs, deductibles, out-of-pocket number, etc., the overwhelming complexity of employer management is enough to turn a high percentage of employers against it. Of course this is a function of it's not being single payer: the complexity is needed to eliminate loopholes of every sort that single payer would avoid via universal, direct payroll deduction. Still, large companies are devoting resources to entire departments to manage their use of loopholes that still exist and thereby minimize their costs.It is hard to see how the ACA can continue to be successful, or more specifically as successful as possible, without a move to a single payer system that cuts down the profit motive of insurers and tangential health care industries. Socialism? Maybe, certainly more than what it is now. But in this case protecting a purer definition of capitalism is damaging our national health. 30 Bob Hylas (Allendale, NJ) Please do an article about how Onamacare all along was supposed to be the conservatives' preferred plan for near universal health coverage as an alternative to Medicare for all. And despite conservative opposition to an approach that was originally their idea ala Romneycare, that if the conservative's so called market base approach is only working okay then maybe it's time to go to the only viable so lution left. Medicaire for all. And oh by the way there are and were all along a lot of good reasons why that was and is the best solution.and in fact in reality the only actually good solution compared to any other kluge "market based" solution. 14 Grin83 (EvanstonIL) Funny to see Prof. Krugman's defense of an expensive but functioning ACA next to a piece about Ben Carson's God complex in the OR. He chose to perform controversial--and yes, extraordinarily expensive--surgeries when colleagues had doubts. We seek Tesla healthcare on a chevy budget, and we are naive and short-sighted if we think we'll improve that circumstance overnight. There is no economic, political or cultural silver bullet for improving our healthcare system. Patience, people. 4 stephen (Orlando Florida) I support the health care reform. But for quite a while it will be politically vulnerable. Just like Social Security and Medicare was. The same old crowd are out to kill this reform in it's infancy if they can. I will watch Kentucky and it's Tea Nut incoming governor closely to see if he can and does kill health care reform in his state. It would be telling if he can considering it is a very bright example of the reforms success. 6 Sheldon Bunin (Jackson Heights, NY) The Republican party agrees that Obamacare must be repealed, root and branch if they take the White House. Millions insured would be suddenlyuninsured. Policies would be cancelled or payments declined because of preexisting and un-insurable conditions. They would privatize SS and advance the eligibility age to 70 or 72. They would voucherize Medicare and block grant Medicaid to the states to use as they see fit. They would, if they could turn the calendar back to 1900 before we had Workers Compensation.Yet these people get elected to high office. Why? If we were a nation of multi-millionaires fine, but we are not. Why aren’t these people booed and given the raspberry? Is it hate or selfishness or anger that leads some to cut off their noses to spite their faces? I think that it is malicious disinformation drummend in by those internal enemies, presently calling themselves, Conservatives, but who are something far more dangerous to our country, ignorance and garden varity stupidity which no education can overcome.Worse we have an over supply of non-voting boobs whose non-votes are votes for their own demise. In the Republican debates these presidential wannabees are preaching to their quire. The rest of us have to get out there and beat the drum to bring America into the 21st century and maybe some expert writer, if not already in the works, should publish “Obamacare for Dummies” so non-experts can read about all of the benefits that the GOP would repeal. 11 KS (Centennial Colorado) I don't know whether to characterize Krugman's column as "alternate universe" or simply "denial of facts and reality."You bet there are death panels, Paul. Ready to go into effect for your sunset years.Commonwealth Fund's published study showed that there are 31 million Americans so underinsured that they might as well have no insurance at all, because of the high deductibles. What good is it to count a person as "insured" if his policy is close to worthless except for catastrophic coverage?Millions of people lost their doctors and their insurance plans because of Obamacare. Millions have seen their premiums skyrocket. Why didn't you mention the current requests by insurance companies in many states for raising the 2016 premiums another 25-50%...and the fact that in the first year or so of Obamacare many saw their premiums rise even 100-200%, often with poorer coverage?And then there are the "narrow networks"...a result of Obamacare...where Medicaid reimbursement to doctors is so low that many people have to travel long distances to find a physician who is willing to see patients at reimbursement which is often below overhead.Obamacare is the promise of something for nothing, or close too it. It is, and always was , a false promise. And, contrary to this column, it is not working. 11 tekon7 (Sarasota, Florida) The problem of high deductibles is more serious than indicated. For working and middle class families the deductible are so steep that folks will avoid seeking health care because they can't afford the out of pocket expense on top of the monthly premiums. I fear many will start dropping out because they will realize they are paying premiums on an insurance benefit they can't access because they can't afford to get to the end of $5000 out of pocket. Token freebies don't really assuage this problem.What all of this points out is that we need a single payer Medicare for all. Private health insurance pays little over 50% for actual patient care compared to the government run program which pays over 90% of all dollars taken in for actual patient care. All those ads on television, executive compensation, etc. make private, commercial health insurance an incredibly wasteful alternative. Health care is a sector of the economy that is run best by the public system. No one will ever select their cardiologist on price like they do a tv at Best Buy. Single payer, efficiency, a true non profit is the only way for health care for the people. 17 stalkinghorse (Rome, NY) No friction, no efficiency. It's expensive any way you slice it. MKB (Sleepy Eye, MN) Like so many who discuss this topic, Dr. Krugman equates access to medical insurance with human health (real "health reform" would mean outlawing fast food and soft drinks). The ACA perpetuates a parasitic, profit-driven industry which extorts money from the 99% who would be ruined by serious illness, Medical costs are so high because most people are "covered," and thus can "afford" treatment.Imagine the cost savings if Americans were provided with actual health care, kicking the insurance industry to the curb. A serious economic analysis of this alternative would be a far greater service than another dose of Krugman's political blame game. 5 David Stevens (Utah) The problem with the ACA is that it helps in dramatic ways with access to health care but people think it should provide health care itself - two very different things. Until individuals start taking responsibility for their own health through eating right, exercising, not smoking, not drinking excessively, and demanding a healthy environment in which to live, insurance companies will take their money and offer little in return. True health care would eliminate this middle man. I guess some people either don't want to be healthy (or at least don't care), or don't understand that personal responsibility is key to being healthy. Injuries happen, environmental toxins are around (that's something we can control as a society), genetics happen - the system should serve those so afflicted. The rest of us, chicken soup and a couple of sick days should do the trick. 2 famj (Olympia) Something else I believe that is lost in the discussion of the Health Care Act is that we forget what it was like before that. Between 2000 and 2010 health care premiums increased by 130%. What worries me is that health care costs themselves aren't being reigned in. An example, talked to a friend last week who needed to buy an anti-fungal cream. She paid $174 beyond the $400 her insurer paid, and this was for a one-month supply. In focusing on the Health Care Act I fear we sometimes miss the forest for the tree. 11 Rick (Charleston SC) One real problem with health insurance companies is that they refuse to group all their healthcare polices into one statistical group for measure of performance. Rather they box in just ACA policies which will have higher rates of use. Then then say "see we cannot afford these type of policies" when they fail to show that their other plans have far lower costs. This "playing" with statistics is the same when I ran a small consulting service and had to pay individual or direct insurance for me and my family. The rates were really high because they said direct payers were a small group and therefore cost more. If I had the chance to join a group or large my rates would have been lower. 4 PointerToVoid (Zeros & Ones) Dress it up how ever you want Krugman, the simple fact is that the US health care system is still an expensive, bloated, mess designed for nothing more than profit taking off the backs of sick people. I would rather have the old system, not because it was better but because it would have collapsed much faster. Now those of us who wanted correct health policy will need to wait another 70 years before this monstrosity collapses under the fact that it can't control costs either and the profit motive from physicians, hospitals and insurance companies remains the only incentive.Churchill was right, we really will try absolutely everything before we do the right thing.P.S. No this is not making the perfect the enemy of the good. There are correct answers to the question of how to provide quality health care (NOT "coverage") to one's people and incorrect answers (Spoiler Alert: All the correct answers involve treating quality health care like what it is--an end in itself and a fundamental human right). 12 NYT reader (Connecticut) "insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected"It is possible that this is a backlog effect. Specifically, during the first two years of the ACA program people who were sick but had not previously had insurance were finally able to get coverage and medical treatment. Also, having not been able to get treatment before the ACA could have made their medical condition more grave and made treatment more expensive once they did have coverage. This effect while expensive is part of the start up cost of the ACA rather than a long term cost, with people who get sick after the ACA was introduced being able to get treatment before their condition might deteriorate. 7 c kaufman (Hoboken, NJ) Forget the demagoguery and political distraction game Washington plays. There is a major problem if annual increases of 11%, 10%, or even 5% for premiums continue while American families wages stagnate. 6 david g sutliff (st. joseph, mi) Mr. Krugman, like most liberal writers, carefully avoids the matter of money and the longer term costs of social programs. While getting medical care to all is undoubtedly a great goal for any society, i wonder still if we can afford it over time? A few successes and a few failures are not the real issue, and any serious economist would skip over those, and focus on the impact big new programs will have on life and liberty down the road. 3 Paul (Nevada) What is your alternative? Should we let the citizens die in the streets. "So sorry sir, you have a treatable cancer, but gee, we don't have the money this year we have to balance the budget." The issue is profit, as long as a private sector operation calls the shots the US consumer will get gouged. 2 taopraxis (nyc) The headline on this article is almost Orwellian...The denial of reality is so pervasive and so extreme, I'm starting to feel that there is no real point in reading or participating in the conversation.If there were a democratic system that was responsive to the needs of the people, such blatant propaganda would be unnecessary.In fact, I do not think the basic assumptions that underpin public discourse and political elections are valid, anymore. The people's voice has not been silenced but it is being assiduously ignored.Meanwhile, the views of the public are reflected by a press hall of mirrors.Not helpful, to say the least... 8 John boyer (Atlanta) It's still too bad that we don't have universal health care in this country. An 11% hike in the premiums so the mega insurance companies can maintain their profit margins is exactly the effect that national health insurance was supposed to provide.It says something about the power of the insurance lobby that they could spend $300 Million in 2009-10 to kill the "public option", then complain a few short years after the initiation of the law, while they have reaped the profits of insuring another 30 Million people.Those Republicans who scream at the top of their lungs about Obamacare were in the pocket of the insurance industry then, defending it to the hilt, when it was clear that the systems long in effect in Europe and Canada provide a much healthier citizenry overall. Besides, they have no plan - just go back to the old system, which would cost average Americans much more. If people only realized that the supposed increases in the longevity index in this country, once the upper stratosphere of wealthy citizens is subtracted, is the same as what it was 40 years ago, maybe we could get something worthwhile done on this issue. For now, we have to console ourselves with the fact that millions of people who were shut out of the former system entirely now have a chance to live less painful lives than before. 4 r (undefined) Krugman is dreaming. All this act did was double the amount of money the insurance companies are making. I was a supporter because I thought it was a step in the right direction. But after paying lots of money and the government kicking in, I realized I am getting nothing for my money. Out of pocket expense is very high as is the deductible. I think Pres. Obama's intent was right but it ended up all wrong. And people are basically forced to buy it now. Forget it..... We have one chance and that's if Bernie Saunders gets elected and makes single payer a top priority. Hillary Clinton might do something, she did try right off when she was First Lady. But now when she speaks of it she says that whole experience basically soured her on trying. 6 richie (nj) Just one point. Even if Bernie gets elected there is no way he can implement a single payer system without the cooperation from Congress. Since the House will likely remain in Republican hands for a while, there is nothing Bernie (or Hillary for that matter) can do.The President is not a King - but 1/3 of three equal parts of the government. 5 Sleater (New York) Professor Krugman, I'll take your word for it, but believe me, based on all the news I've seen, Obamacare/ACA is in serious trouble. Not that the "news" is a reliable arbiter, but you're swimming against the current on this one. You have the Nobel Prize, though, and can disarticulate and understand data, so my bet is on your appraisal this go round. 5 Paul (White Plains) This opinion piece is nothing but a cheer leading effort for Obamacare. Krugman fails to mention the daily documented cases from real people who are seeing massive premium increases. He fails to accept that the sky high deductibles for most Obamacare health plans prevent many Americans from purchasing insurance, much less ever reaching the deductible limit. The paperwork required to qualify for Obamacare is a nightmare that many Americans just can't fathom. We already knew that Krugman was a shill for the Obama administration; we just didn't realize that his grasp of reality was likewise compromised. 15 richie (nj) OK then, what do you suggest as a solution? 1 Barb (wisconsin) High deductibles,, soaring premium prices.... we've been living with these things long before Obamacare. Now I hear comments like; "Why should I pay for smokers, or obese, or maybe even pregnant patients?" Insurance only works if we all contribute to the pool. None of us can afford to pay the bills for our own health disasters. If he insurance market becomes a game to opt out of not only will individual bankruptcies rise again, but also the whole insurance market will fall like a house of cards.Sure, Insurance companies are profit driven, but at least under Obamacare they are mandated to spend all but a small reasonable percentage of premium dollars on health care, not stock buy backs or CEO benefits.Will Obamacare fail? Maybe, but if it does the Romney, Obama, Republican health care plan's failure will see the end of private insurance and your tax dollars will be spreading the risk pool.mark wi 6 Purplepatriot (Denver) I have United Healthcare insurance through my job. While the premiums haven't changed much I have noticed that deductibles and copayments have increased significantly. Now United is making noises about withdrawing from the exchanges and individual market. That's disappointing but not very surprising. I fully expected private insurers to try to circumvent and undermine Obamacare in order to maximize their profits once again, and I assumed they would do it incrementally by transferring costs to the customer while limiting premium increases. If that becomes a trend, we will need to revive the discussion about a public option. That's the only way to keep the private insurers honest. 15 jrfromdallas (dallas) This column is proof that you are no longer an economist, but a liberal hack that under no circumstance or evidence can you see that this law is about to go under and has had the complete opposite effect that was intended. The deductibles and the premiums are so high that it has become easier to pay the fine and go without insurance. The employer mandate has been illegally suspended until who knows when and the insurers (I know the EVIL insurers) are dropping out because they are losing money. Every part of this law has had an adverse effect on the touch points but no worry, because a former renowned Economist will explain that it's still here and succeeding..You sir, are a disgrace! 14 Edward B. (Philadelphia, PA) As self-employed, I have been responsible for my own health insurance for the past thirty years. Three years ago before the ACA became active, the best policy I could afford carried a 7000.00 deductible with co-insurance to 12,000. Thankfully, I'm fairly healthy, but I still ended up with a few thousand in bills.The exchange policy I carry today has zero deductible with out of pocket expenses capped at 1000., at a lower premium than before using tax credits I'm qualified for. It is the best health insurance I have had for 25 years, and I am at an age where I am starting to use it.Yes, my co-pays and deductible, along with my premium, will rise about 10% for my renewal next year, but those costs to me have always risen every year, it is what they have always done, every year, till the point where I couldn't afford to get sick any longer. The health industry is a free market, for profit system, run by "Evil" corporations, it's how it works. The ACA (or ObamaCare) tries to control costs along with tax breaks working with the system we have in place. The controls work best when states work with it rather than against. Texas is an example of a state that fights Obamacare irrationally, and seems to want it purposely to fail. I really believe we should have called the ACA, "Americare" or the "Health Care Freedom Act", and it wouldn't have half the problems in acceptance has. 2 entprof (Minneapolis) Facts be damned you know you just know that it can't be working because well because. Right Junior? Millions covered, healthcare inflation well below expectations, but you know just know that it's failing because Roger Ailes told you so. famj (Olympia) Data please. How high are those deductibles? For what procedures with what plans? How do those compare to plans before the health care act? What percent of people are willing paying the fine? What are their costs like when they have to see a medical professional? The insurers - who besides UnitedHealth Care and are they the insurers who had a bigger stake in this business? I find your post long on vitriol, but short on data and fear it may be anecdotal. Also, we know Dr. Krugman is a liberal and has long supported health care. Are you a conservative who has always opposed it? I like to know the value of a source, but also its limitations. 1 Robert Stewart (Chantilly, Virginia) The "gap created" in the state where I reside, Virginia, has been created by the Republican-controlled legislature via "Medicaid rejection." Although Virginia taxpayers have already paid for the coverage, the Republicans rejected Medicaid expansion, a program that would have covered 400,000 working poor Virginians, because it was part of "Obamacare."So, as a result, Virginia has lost millions of dollars and left 400,000 of its poor without medical coverage. But Virginia Republicans in Virginia House and Senate are proud of the fact that they are not math smart (refusing to accept millions of federal dollars to fund the program) and their heartless ideology have left thousands uncovered. Of course, they have no ideas for covering the uninsured.Health reform may be alive, but that success is not due to states such as Virginia and other former slave-owning states that are so proud of their ignorance of math and their heartless ideology, an ideology that keeps so many of the working poor uninsured. 16 strongmind (Chicago) nice that the middle class in Virginia should pay higher premiums for their own health insurance and higher taxes for the insurance premiums of their subsidized neighbors. Fred P (Los Angeles) The official name for Obamacare is the "Affordable Care Act," but although the claim that the ACA has reduced the rate of increase of medical costs may be true, the actual costs for medical care continue to take a larger and larger percent of GDP and unless drastic steps are taken these costs will cause unprecedented economic problems. In 2014, total US medical costs were $3.8 trillion and US GDP was $17.4 trillion, so America spent 21.8% of GDP on health care; historically the percent of GDP spent on medical care has risen every year for the last decade, and there is no reason to believe that this upward trend will not continue, yet not one presidential candidate has addressed this problem. How much longer can we continue to bury our heads in the sand? 15 skeptonomist (Tennessee) Sanders has pledged to enact a universal single-payer system (like Medicare). In other countries which have such a system costs are about half those in the US. 2 famj (Olympia) As long as we get upset about a health insurer dropping out of the plan due to declining profits (note, they're still making a profit), but don't mention that the CEO of that firm took home over $28M in compensation in 2013. Diana Moses (Arlington, Mass.) I don't think the cost increases are trivial. It was clear to me much earlier that the focus on premium price during the early days of signing up for policies on the exchange was missing the mark, that high deductibles would be an issue. I wish someone would take a harder look at how this system is shaking out: are we subsidizing catastrophic plans that cover more scenarios than the catastrophic plans that were no longer allowed to be sold under Obamacare, but are still basically plans which only make economic sense for subscribers to make use of for a medical event that produces huge bills?Where I personally experience negative fall-out from the orientation of Obamacare is in "preventive" medicine. Our physicals are now virtually required, in order to be a patient in good standing, and they turn out to cost us co-pays regularly, because apparently the discussion of any medical condition during the exam results in a billing for a concurrent medical visit with a co-pay, even if it is the doctor who raises an old issue that is not presenting at the time. Similarly, if the doctor orders a different set of blood tests, the exam produces a co-pay as a medical visit. I conclude that the physical without co-pay has been artificially narrowed. The other effect I see with the emphasis on preventive care is my being phoned at dinner time, as if by a telemarketer, by the doctor's office, trying to pressure me into making appointments for preventive care I don't want. 7 dave (mountain west) Until such time as single payer becomes law, health care will not be affordable for most but the wealthy. For example, my medicare Part D drug costs skyrocketed more than 40% for 2016 as well as a $250 deductible added on that wasn't there before.The ACA was written by insurance industry lobbyists. Now even they are griping that they can't make enough money. That's a real good definition of greed. 22 strongmind (Chicago) it's not a definition of "Greed," it's a great example of how the obama administration paid off the health insurance companies with guaranteed profits for five years so they would not oppose the ACA. Skyrocketing costs for your Medicare Part D drug costs? What about the fact that the president looked into the tv cameras several times and told us our insurance premiums would go down an average of $2,500.00? Oh that's right, nothing more than a big fat lie to take over the health care system. And single payer will do nothing to stop rising costs, once you pay for another 30 million people's insurance costs. Sage (California) Single Payer is the only way out of this unsustainable mess. I often agree with Paul Krugman, but high deductables and rising rates of premiums are NO trivial matter! There will be a backlash with fewer Americans able to afford healthcare. 71 Xlt (Boston, MA) They have single payor in North Korea. Everyone is guaranteed health insurance, but not healthcare!! Brian (New York) As someone who's been navigating the individual health insurance market since before the health care law I've been a long-time supporter of the legislation. Pre-reform the market for health insurance was a booby-trap laden disaster.Having said that, it's hard not to fear that the market has in fact started the dreaded death spiral - especially for those of us who earn a bit too much to qualify for subsidies. Since the law has passed I've seen my health premiums go up about 20% per year. Over five years that has resulted in a roughly 300% increase in my premium for a policy with a $10,000 per person deductible. My premium this year in TX is approaching what I would have paid prior to reform in states like NJ or NY that had guarantee issue laws with no individual mandate. Judging from that it looks like the ACA insurance risk pools aren't much younger or healthier than those where adverse selection was basically unchecked.Meanwhile, the choice of insurance products keeps shrinking. This year Blue Cross Blue Shield dropped all PPO insurance plans in Texas. Other states have experienced similar withdrawals.Perhaps the pool of people receiving subsidies is large enough to keep the whole thing afloat. But for those too rich for subsidies and too poor to be considered rich, our reformed health insurance market is starting to spiral out of reach. 17 Paul (Westbrook. CT) Lying underneath all the rhetoric is the basic philosophic difference between political points of view. On the one hand there are those of us who care about our fellow citizens' well being, and on the other hand we have those who don't. Some of these notions are served up under the guise of moral argument. Some are served up as fiscal ideas. But for all the nonsense surrounding and engulfing the difference between those who do and don't care, the issue is still relatively simple. If one cares, one tries to do something to help. If one doesn't, one simply negates any attempt to help. So warts and all Obamacare is trying to help. What has the opposition offered to help? And remember to end Obamacare isn't an approach to solving the problem of affordable health care for all. Let's not lose sight of the problem. When the do nothing folks offer to do something, I will listen! Until then, I will put my vote in with the doers and let the chips fall. 24 strongmind (Chicago) so you're putting your chips in with the "doers who created obamacare." Isn't that special. You will bankrupt all of us. Government does not manage anything well which is why 307,000 veterans died while waiting for services. Is that the kind of program you want? You like the rest of the government control people are complaining about the cost of health care insurance...... isn't your life worth that?We have 30 million uninsured because they don't feel the need to pay for their insurance. It's that simple. Nothing is going to change that unless you give them 100% subsidized insurance.... paid for by taxpayers who already see their insurance premiums going up, up, up. Sure, I'll pay higher taxes to insure the non-responsible. And they can come over and shovel that foot of snow out of my driveway. Paul (Nevada) Beautifully stated. stalkinghorse (Rome, NY) Asking the state to pay for the health care of others is not the same as paying for it out of your own pocket. It's just moral preening. blackmamba (IL) For me health reform meant that I could not use either the doctors nor the hospitals that I preferred nor could I follow my medical professionals recommended health care nor effectively control costs. My health care options were very limited and costly. Having chronic health conditions in my twilight years by definition limits practical options. The transition from one very expensive individual option to "health reform" was more marginal economically and medically effective than I imagined and believed. 7 sdw (Cleveland) While Paul Krugman may have a glass-half-full optimism about Obamacare, his analysis is honest and accurate, pointing out that recent setbacks have been largely self-inflicted by Republican-dominated states which have declined to take advantage of available subsidies for political reasons.The real problem, as we enter a national election year, is the ease with which conservative opponents of Obamacare can use recent setbacks to skew the true picture and gain traction with voters who are understandably susceptible to such distortions. If someone is fed the same fiction again and again, it becomes an accepted fact – even though it really isn’t.It is up to those who realize what is happening to mount a campaign to defuse the unrelenting opposition to more universal coverage. We cannot expect help from insurance companies, even though they benefit from a broader risk pool.Providers like hospital systems and physician groups are also conflicted because medical cost control is less palatable when utilization narrows to a less healthy patient base. Other providers like medical device vendors and the pharmaceutical industry have been consistent opponents.Selling the success of the Affordable Care Act cannot be left to the administrators of the Act, because they tend to be obtuse and, even when explaining things well, they are now distrusted after the G.O.P. campaign. There must be better reporting by the press, in general, and a massive ad campaign financed by progressives. 9 Michael Benefiel (Kensington, MD) I want to see daily congressional hearings on how Obamacare and the alternatives are working out in the lives of American voters. strongmind (Chicago) and who, pray tell, is paying for those "subsidies?" sdw (Cleveland) If you are unwilling or unable, strongmind, to educate yourself about Medicaid and the Affordable Care Act (ACA), that’s your choice or your problem. In case others, however, are sincerely interested, I’ll give a thumbnail sketch.Since 1965 Medicaid has been a means-tested program for providing medical care to low-income people whose incomes are compared to Federal Poverty Guidelines. Medicaid is jointly funded by each state and the federal government, but it is administered and managed by the state. The portion paid by the federal government is the subsidy.Under the ACA, states were allowed, but not forced, to expand their Medicaid programs and effectively receive higher subsidies from the federal government.Persons of limited means, who are not covered under Medicaid or other form of insurance, typically receive no regular medical care and obtain care only through hospital Emergency Rooms, which is the most expensive care. You and I actually pay for that expensive care, because hospitals figure those very high costs into their overall charges for hospital care.The alternative, favored by some Republicans and Libertarians, is to let the acutely sick poor folks die in the street. 1 Joseph Huben (Upstate NY) The flaw in the ACA is that it does not have a public option. A public option would allow individuals to "buy into" a Government Insurance plan. Medicare would be a great public option. Everyone know what it is! It would require some numbers crunching to arrive at individual "rates" but the CBO analysis in 2009 concluded that those rates would be lower than private insurance. Problem: the estimate was that 20 million people would shift to the public option 12 million of whom would shift from private insurance.Here's the big reveal (as in a magic act): Congress rejected providing 20 Million citizens a less expensive, non deductible, insurance plan in favor of the profitability of private insurance companies. Wow! What a surprise! 99 Michael Benefiel (Kensington, MD) Sadly, I believe that it would have been impossible to pass Obamacare without some support from health insurance company investors and senior executives. I share your faith that Obamacare was our less desirable option but I don't think Medicare for all was a politically possible outcome given the strong opposition of many malefactors of great wealth. 9 Tom (Midwest) There is also one other issue that few people seem to grasp (particularly those getting insurance for the first time). The federal government does not set the rates or the deductible level. Your state insurance commissioner or other officer is responsible for approving rates and rate increases as well as which insurers can operate in the state. As to the "some people may not know about these mitigating factors", I would posit most people on the exchanges and with private insurance have this problem. The amount of erroneous, derogatory and just plain lies by people exaggerating their issues is incredible. Third, a large number of people who were on private insurance prior to ACA had no clue how bad their coverage really was until the basic minimums were defined in the ACA. Fourth, as most of my conservative friends were saying prior to the ACA passage, they almost thought higher deductibles to ensure that individuals had "skin in the game" to keep them from going to the ER for every sniffle and would make them more personally responsible for their health care needs. Now they have changed their minds. 19 Matthew Carnicelli (Brooklyn, New York) Paul, the Affordable Care Act represented the best legislation that could be passed by that coalition of the bribed that we call Congress - but was in no way an ideal long-term solution to the problem of ever-escalating health care costs.The co-ops, which were substituted for a public option as a mechanism for keeping costs under control, are either going under or struggling.Paul, as in every other advanced industrialized nation, it is only by leveraging the immense power of a people's union that a government obtains the ability to keep health care costs under control.Paul, we tried the Republican-lite solution to health care reform - and it's flying like a bird with a broken wing. It's time to stop carrying water for the ACA, and instead take up the fight for a truly nationalistic solution to health care reform. 105 Michael Benefiel (Kensington, MD) I share your hope that a fairer and more inclusive national health insurance system will evolve. Since the right wing has decided falsely to claim failure for the compromise system we are living with, where do you see the national coalition in favor of a better system will come from? 1 Joe Yohka (New York) So first the facts, health care inflation continues, the underlying cost drivers were not addressed by ObamaKare. 11% on average, again? Ouch. I've read that only 15 of the original 23 co-ops are still providing coverage, despite the federal government doling out a reported $2.4 billion in loans to help start Obamacare insurance cooperatives around the country. Was the only purpose of the initiative to insure more people? Including those who didn't want to pay for insurance, young and healthy, then yes it is a success. Yet cost of care keep going up up up and the Obamacare Act did very little to address this. Shifting burdens of paying for the cost is not fixing. 8 Almighty Dollar (Michigan) Neither is letting the uninsured flood emergency rooms. Bush and Reagan had 20 years combined and offered nothing, zero, zilch. KKKeep blaming Obama if it makes you feel healthier and more clever. 2 Leonard Mark (Fairfax, Virginia) In the past when Congress passed major legislation, they would also (quietly) pass additional legislation months, even years, afterward to remedy shortcomings in the original legislation. Because the Congress has been so dysfunctional, these followup bills have not been passed and the original legislation has had to stand on its own without corrections, revisions or legislation designed to close loopholes and address unintended consequences. I wonder how much more effective the ACA would be if Congress were able to revisit the ACA and make changes that would increase its effectiveness based on the feedback from the initial period. 19 sallyb (<br/>) That's what would happen in a congress where our elected representatives were interested in making life better for the American population. But seeing as how the Repub-controlled congress would like nothing more than to see ACA fail completely, one cannot expect them to lift a finger to improve it. 1 Steve C (Bowie, MD) Paul, it is important that the "rough patches" be addressed quickly because they are truly painful. I have read about them in the Times. Perhaps the 11% rise in premium costs is not excessive, but if they continue to rise at 11% +/- each year more pain is inflicted. Add to that the refusal of Republican states to take advantage of Medicaid funding and the situation grows worse.I am very supportive of the ACA and want more than anything to see it work as intended. Right now, the problem with high deductibles is big. What it points out is that the insurance companies can in reality, pretty much do as they choose and assurances that these costs will drop over time doesn't help the person facing them now.Given the ACA's status as a "brand-new system," it must still continue to move forward and meet its projected goals. Another 50 Congressional attempts to reject it will just cloud the questionable future of the ACA and Congress. 129 marsha (denver) The Achille's Heel in the Massachusetts plan was the cost containment of the insurance companies. This is the same issue with Obamacare. The bill would never have passed in either MA. or the U.S. if the legislation had included cost containment. Finger is back pointing to the initial culprit. Onward to single payer. 1 Tom Connor (Chicopee) I suspect more bad news is yet to come. The insurance/hospital industry need to make money. As with any corporation, obscene CEO profit and shareholder value is paramount , yet antithetical to good health outcomes because it leads to de facto rationing. AHCA's opponents have tried to burn the bridge to a single payer system many times. I am afraid this hobbled bridge is emblematic of our crumbling infrastructure. A strong one isn't necessary for those who jet around town and country above it all, but is pretty important to folks who get around town lower to the ground. And, somehow this originally conservative plan for healthcare became contaminated once President Obama touched it. I wonder why that happened? 6 taopraxis (nyc) Nobody ever expected Obamacare to cover all the uninsured? Reminds me of someone who told me nobody ever expected Obama to stop the wars...I have insurance under ACA but it has so far gone unused. I stay away from doctors in solidarity with those who lack insurance and out of contempt for the poor quality of care available today. The system is in dire need of reform. 9 Jordan Davies (Huntington, Vermont) Without reading any comments here before I post my own, I am sure that there are many, many complaints about high deductibles, huge! increases in premiums, etc. Firstly, the insurance companies are in this to make MONEY! If they can't they will raise premiums. I would like our legislators to draft an addenda to the ACA to make this price gouging end. As you say, premiums go up by 5 to 10% annually as a rule anyway, before the ACA was law. If this was a single-payer plan, this wouldn't happen, but that issue is another story. What about some real help for the non-profit insurers? And how about going back to trying to implement the public option portion of the original bill? "The public health insurance option, also known as the public insurance option or the public option, was a proposal to create a government-run health insurance agency which would compete with other health insurance companies within the United States. The public option is not the same as publicly funded health care, but was proposed as an alternative health insurance plan offered by the government. The proposal was initially part of the debates surrounding the Patient Protection and Affordable Care Act, but was not passed in the final reconciled bill." See: https://en.wikipedia.org/wiki/Public_health_insurance_optionor other sites for more information. 72 herje (ft. lauderdale) not passed because of Sen. Joe Lieberman! 2 Doug (Minnesota) Non-profit? Really? They behave like for-profits. hawk (New England) Oh Vermont! I've got news for Vermont, the rest of the people have no stomach for nationalizing the healthcare insurance companies. And yes single payer prices go up just as fast, it's all taxes. Walter Rhett (Charleston, SC) What happens at a building site when contractors are stealing all the goods and refusing new deliveries or redirecting supplies to other sites--or simply failing to order? The site will be disrupted, costs will go up, work flow will be bottlenecked and forward progress will slow. Is that reason to abandon the project? Doesn't solving the problems make more sense? Every immediate problem is not a sign of impending doom. Every stumble or revision doesn't offer incontrovertible proof the project is flawed. New changes shouldn't paralyze the project. Yet doom and paralysis are the Republican claim on the issues of life and death seen in healthcare.Bullets aside, the protections of health for citizens of a country should be a part of the national character and an honest accounting--not dependent on preconceived notions or well practiced cynicism--not seen as gifts of isolated charity but the imperative of a just society. By acknowledging the pain and loss of others, we respect the traditions and ways of life that make up America and continue its original moral choice to change. 48 Richard Luettgen (New Jersey) If that many things are going wrong at a building site, Walter, fixing them may cost more than shutting it down.But I have a lot of sympathy for the notion that we should have some form of single-payer as WELL as subsidized purchased insurance, so long as we get rid of everything else -- Medicare, Medicaid, ObamaCare, EVERYTHING ELSE.My problem with the whole thing is this blithe assumption by liberals that society has this ENDLESS obligation to satisfy your sense of the "imperatives of a just society", regardless of our ability to pay for it while NOT destroying all incentives. Certainly, Europe has tried it, supported by our defense subsidy; and as we pull back, the world sees that they can't defend themselves effectively against ISIS, against Russia, against their own internal contradictions and frictions, against destructive labor-protection laws. Yet, this is the model many point to as the one we should adopt.We won't be adopting that model, Walter. We'll need to come up with something that actually works. 2 Ron Cohen (Waltham, MA) PK is Pollyanna-ish about Obamacare, and has been all along. The confounding difficulty of shopping the exchanges and changing insurers every year, which folks must do to keep their costs down, the patchwork of costs, benefits and delivery systems, the unequal access to care between red states and blue, between rural and urban areas, the inadequate coverage of catastrophic care, the rising premiums and co-pays – all tell a different story: the ACA is a Rube Goldberg monstrosity. And it lives beside another such monstrosity, employer-sponsored heath insurance. But the central weakness and vulnerability of Obamacare is not programmatic; it is political. As a means-tested program, it takes from some and gives to others. Recently, The Times published an eye-opener, "Who Turned My Blue State Red," analyzing why working-class whites have been leaving the Democratic Party in droves. They are reacting against government handouts to people they feel are able-bodied and should be working, when they, themselves, have sacrificed and worked hard to get ahead. http://tinyurl.com/ogfgfmd The Republicans have perfect pitch when it comes to such reactionary social attitudes, and exploit them deftly. While the self-absorbed Democrats remain tone-deaf.As a result, half of all Americans now live in states under total GOP control. And the Republican takeovers continue, with Kentucky only the latest state to fall. See Washington Post: http://tinyurl.com/oq4yk59 But liberals don't get it. 38 mike bergs (palm beach) Does government hand-outs apply to corporate America or the tax breaks for the extremely wealthy bother you, I didm't see it in your post. And a far more recent example of an election return would have been to mention republican Vitter's Saturday loss in Jindal country. 2 Lennerd (Ho Chi Minh City, Vietnam) Mr. Ron Cohen, Liberals do get it: they want single-payer. But we liberals can't get it in this country even though we liberals have got it in almost every other western democracy. Working class whites may be deserting the Democrats in Dixie, but non-whites, Dixie or North, are not: they get that the Republicans are tone-deaf to the needs and wants of the general population. When was the last piece of Republican-driven, promote-the-general-welfare piece of Federal legislation written? During the Reagan administration? Or maybe Nixon's?And as goes California, so goes the country. Non-whites are a majority in California, though no single ethnic group is larger than the population of European-ancestry whites - yet. And there's the tone-deaf part: the country won't be majority-white forever, hard as the GOPers try, as much as they want to take back "our" country, there's no going back - unless of course they want to fight the Civil War all over again. Wait a sec, apparently quite a few do.How 'bout you Mr. Cohen? You game for that? The dividing lines now are pretty much where they were in 1861, too.Oh, and the Republican contribution to Obamacare? They wrote the first draft over there at the Heritage Foundation and they also wrote the second draft - Romneycare - and implemented it in your own state of MA. It seems like a case of "we like this health care deal. But now that the Democrats like it, and it was signed in by a Dem., too, we don't like it any more." Pshaw. 2 awmarch (Phoenix) The unpopular parts of Obamacare are the conservative parts; the complexity of multiple private insurance companies with multiple plans and deductibles and copayments with restricted doctor/hospital panels and constant changes. This is how businesses "compete". The popular parts are the liberal aspects: near universal coverage, support for those with low income, children can stay on parents' plans up to 26, no health care underwriting, no annual or lifetime caps, free preventative care and even taxing the wealthy and minimum "loss ratios" for insurers. It is ironic that Republicans blame President Obama for the parts they would support in a conservative plan. 2 Anne-Marie Hislop (Chicago) In right-wing-world, Obamacare is "known" to be an utter disaster and a complete failure. Other folks do seem satisfied. As to the horror over premium rises - my Medicare supplement premium purchased through my self-insured employer (I am retired) will go up 15% next year. Health care cost rise. That should not be a surprise. What is both sad and outrageous is that the right-wing and the GOP politicians who are so vociferously calling for the dismantling of the ACA have no real plan with which to replace it. They'd turn Medicaid into block grants to the states, then merely shrug at all the folks not poor enough to get care yet again not covered. 30 ACW (New Jersey) Anne Marie needs to visit the real world and meet some of those people who are not satisfied. Of course, she is comfortably retired and can afford to write off a 15% hike.She might also note that it is not only the Republicans who are now calling for the dismantling of Obamacare. Replacing Obamacare is a key plank of Sanders' platform, such as that gassy mass of glittering generalities is. However, the Democrats don't even have the honesty to admit the law was badly planned, clumsily implemented, and does exactly one of the things it was promised to do - and that one thing is to siphon off dollars to underwrite care for illegal immigrants.Yeah, I know. I'll save you the trouble, and call myself a racist, because heaven knows that could be the only reason anyone had any criticisms of Obamacare.Sometimes I read the news section, then repair to the op-ed and the comments, and wonder why some people's heads don't explode from cognitive dissonance. Then I realize: compartmentalisation. if you don't let anything from the news section into your head, the dogma from the editorials can just placidly slosh around in there unroiled by reality. 2 Paul Cohen (Hartford CT) Paul, in the closing days of the Congressional battle over passing ACA you blogged something to the effect that although ACA is not perfect, once the law is on the books it can be tweaked over time to its ultimate perfection. Even those companies that continue to provide health insurance to its employees I believe it will eventually end. Each year more of the total cost to the company is passed along to the employee as well as higher self-insured retentions. There was a time when multiple choices between Insurance Companies were made available to employees and gradually that was paired down to one. Recently, a greedy Wall Street hedge fund manager purchased ownership of a generic drug and turned it into an investment vehicle jacked the price of out of the stratosphere. The merger of Insurance competitors is a bad sign. Betsy Imholz, a director for Consumer Reports said:““History has generally taught us when there’s greater concentration of health insurers, premiums are higher. Companies say there are greater efficiencies, but I’ve never seen that passed along to consumers… We really do need the regulators to be watching out for consumers in this because there’s not too much consumers can do” about it.”http://www.marketwatch.com/story/how-the-big-health-insurer-mergers-will...Given the state of affairs in Congress combined with the weight of big money buying clout, I’m not optimistic about the long-term success of ACA. 20 Michael (North Carolina) As others have already commented, the primary benefit of Obamacare overall is in highlighting just how out of step with the rest of the developed countries the US health care system is. My wife's company is, like most other large US based companies, currently implementing its annual medical benefits enrollment, and the plans offered in her case average 20% premium increases. This has nothing to do with Obamacare, and everything to do with the continuing upward spiral of health care costs in the US, far above the level of economic growth overall. By definition, that is unsustainable. Obamacare is simply not large enough to effectively offset the pricing power of big medicine. Medicare is to some extent, and would be even more effective if it were combined with Obamacare in a well designed single payer plan. It's time, and the templates are out there. Ultimately, inevitably, that's where we're headed, but we're wasting valuable time and resources in the meantime. And the world is not standing around waiting for us. Quite the contrary. 133 Jim Kardas (Manchester, Vt) Exactly. It would have been so simple to implement a Medicare 64 Plan where everyone through the age of 64 was covered until Medicare kicked in. Why wasn't this done? Why do solutions to problems have to be so complex when there is an obvious and easier approach? 3 Fred (Georgia) 8 years ago, I was without work covered health insurance, so I had to go to the open market. I found a catastrophic plan with a very high deductible ($10,000). At the end of the first year, with no claims at all, I was informed that my cost would double. Fortunately, I found a job. When I canceled that policy, I was told that they would have dropped me after the second year.So now I wonder how much that policy would cost me now without ACA? Talk about gloom and doom! 55 fran soyer (ny) Two things:Most importantly, without the ACA, your would have had no insurance, zero.Was that a better outcome for you ? For anyone ?You are much more likely to keep your job under a Democratic President than a Republican ( www.bls.gov, see for yourself ). Don't get fooled into voting against your self interest. 3 Look Ahead (WA) US health care has a cost problem, which is why it will soon consume 20% of GDP, while remaining under 10% in other developed countries. It would be even larger, except that Medicare and Medicaid regulate prices for for a large part of the health care sector. We regulate virtually 100% of utility prices in the US without controversy. Converting overnight to "Medicare for all" sounds appealing but would be very disruptive to life and death services we all eventually need.A logical step in that direction would be allowing buy-in to Medicare at age 50, when private premiums really start to climb. Another logical step would be expanding use of reference pricing in the employer market. 38 Karen L. (Illinois) I would also like to see Medicare cover more than 80%. Unless you purchase a supplemental plan, that 20% can still bankrupt an elderly person. I've seen it firsthand. And the supplemental plan premiums, great because they pick up that 20% meaning no out-of-pocket for an event, are rising exponentially as well. The premiums for my husband and me for supplemental insurance, Rx (big pharma giveaway) insurance, and our Medicare contribution now exceed my combined monthly teacher pension (albeit small) and social security check. That leaves his check and our savings/investments (not all that much as we've been self-employed most of our lives), to pay the rest of our bills. And we're only in our mid-60s. And yes, I'm still working (self-employed). Add to that no COLA for 2016 (though our supplemental premium going up 12%--don't get me started on the price of food), we lose ground every year. If we live into our 80s, we will probably be destitute. And we have been solidly middle class all of our adult lives. Of course, thanks big banks for destroying most of the equity in our house which was supposed to give us a nice little nest egg someday. Thank God we have 2 successful kids who will probably have to support us. Wasn't supposed to be this way. 8 Cathy (Hopewell Junction NY) In a way, getting people insured, making sure that healthcare is not denied to people who are sick because they cannot get insurance, was the easy part.Making the hard decisions about allocating health care so that it doesn't bankrupt the nation is the hard part, and we have barely begun that. Anyone signing up for private insurance sees the whole cost of the program and it is staggering. Either premiums are expensive or the deductible is high. If the ACA has done nothing else, it has rendered the incredible cost of health care obvious. For many of us, the full cost is hidden by an unknown amount that our employers are picking up: we are probably paying similar prices, but we are paying for it as lost wage increases, not out of pocket.The next step is to cut actual costs. Cut the amount providers are charging for drugs, for hospitals, for tests, fro services. And we will have to determine what health care uses are necessary, paid for and which are less so, and not fully covered.If we thought that getting the ACA into place was hard, we haven't seen anything yet. 40 Socrates (Verona, N.J.) The Death Panels are still around, but only in GOP states for the working poor, where Republicans have made sure that hard work is penalized by generally refusing to expand Medicaid for the working poor.Let's also remember American history.Democratic President Obama's ACA is almost identical to Republican President Nixon's 1974 healthcare proposal, and the Supreme Court of the 1970's never would have come up with the radical, misanthropic 2012 decision that allowed today's GOP state Death Panels to flourish.So 2015 America has almost caught up to Nixon's 1974 America...after 40 years of tacking harshly to the right.That's how bad it is in right-wing America.The reason Nixon's ACA didn't pass in 1974 is that liberal Democrats were holding out for the more civilized single-payer system, which is of course the health care gold standard of civilized societies.America still spends a disgraceful 17% of its GDP on healthcare as all other first world countries do better for the masses spending just 10% to 12% of GDP, the main difference being that those other countries outlaw or regulate medical extortion, insurance middlemen hellbent on profit, and are less corrupt at their core.President Obama and the Democrats deserve high praise for standing up to the radical right and passing the ACA, a 1974 idea.But the better, more civilized and more economical idea is single-payer.Unlike Nixon in 1974, only the Republicans are holding America back from basic human decency. 634 Meredith (NYC) Socrates.....What’s inexplicable is why our nobel prize economist, who proclaims his liberal conscience, concerned with economic inequality, doesn’t write about our disgraceful 17 % of GDP health care spending? He downplays this, but he should be the one to contrast the positive role models of dozens of nations who cover all at less cost. And their rw parties don’t aim to dismantle h/c for all as our radical Gop does. That’s a stunning contrast.The big difference is as you say regulation of corporate profits. Here, instead of being regulated by the govt we elect, for our benefit, they are subsidized---by us taxpayers, for the h/c industry’s benefit. But this is hardly discussed because regulation is now portrayed as un-American govt intrusion into business profits---which must be satisfied before we have access to medical care. Finally, it’s all related to campaign finance—and efforts to reform this are also kept dark. Just label it all too Left Wing and even the liberals in the mainstream media know what side to take. 1 John T (NY) Obamacare isn't working because it's Romneycare. As everyone who doesn't watch Fox News knows, Obamacare was thought up by the right-wing, conservative Heritage Foundation. They saw that the private health insurance market was about to implode, and Romney-Obamacare is government mandated life-support for private health insurance companies.There is no reason why Medicare cannot be extended to all citizens. It works for senior citizens; it can work for all citizens. In fact, it would work better if it covered all citizens, not just the sickest and most expensive. 263 Paz (NJ) Absolute nonsense. The MA law was actually negotiated between then-governor Romney and the Democratic majority state legislature. Still, it has been a failure. Never let Democrats get anywhere near something that involves the private sector.As for Medicare, I find it laughable that people keep talking about Medicare for all. The reimbursement rates are horrible, which is why those of us on private plans from Aetna, United, Cigna, etc are billed at insane rates.More people (especially illegal aliens) are using the ER rather than regular health services. 1 Bill (Des Moines) I didn't realize that Republicans voted in the Affordable Care Act. Lets stick to the facts. The ACA is a creation of the Democratic House and Senate and signed by a Democratic President without a single GOP vote. So if there are problems, they weren't caused by the Heritage Foundation or any other collection of right wingers. 1 robert garcia (Reston, VA) United Health losing money? United Health would rather have people get sick and die rather than lose money. Sounds similar to something said by Alan Grayson regarding the Republican health care plan. 34 ReaganAnd30YearsOfWrong (Somewhere) Democrats continue acting as if they did something wrong. It's no wonder people who have neither the time nor inclination to follow the details accept the lying bellowing of the GOP and the tenor of the irresponsible, ignorant press. Democrats are easily brow-beaten cowards. 18 A (Bangkok) The sad fact of health insurance in the US, with a majority of the population overweight or obese, is that no health insurance system is viable.It is as if you had a national home insurance program trying to insure a majority of American households that were smoldering in low-burning fires.It is not sustainable. The sooner we recognize this as a society the sooner we will confront a solution. Though I'm not sure what that solution is. 10 John Mann (Alstead, NH) Maybe do something about the junk food industry. Make Coke cans have a black band painted around them to show how much is sugar(s). 1 Len Charlap (Princeton, NJ) "Australia's obesity levels are now on par with the United States, but slightly less than New Zealand."http://www.abc.net.au/news/2014-05-29/australian-obesity-rates-climbing-...And yet health care costs in Australia and New Zealand are less than half of what we pay, and they get better results. It's because their system is more efficient.http://www.oecd.org/els/health-systems/oecd-health-statistics-2014-frequ... 4 Bob F. (Charleston, SC) So, it's "You are heavy, and you ain't my brother!" for you. 2 Howard Larkin (Oak Park, IL) The ACA was never the ideal solution, it was a compromise that was politically possible at the time it was passed. Many of the gaps now becoming apparent were deliberately built in to reduce the sticker price of premiums -- designing Bronze plans to cover 70% of projected costs with the rest coming out of pocket as deductibles and co-pays is a prime example. Other problems, including technical difficulties with exchanges, lack of competition in many markets and the willful refusal to participate in Medicaid expansion are inevitable unintended consequences of launching a huge and hugely complex program. These problems are compounded by the impossibility of passing needed corrective legislation in the current deadlocked Congress. But the problems are real problems that leave real people physically and financially vulnerable. The solution is not to discount them, but to work toward correcting them. This will require voting in people willing to honestly address the issues. I'd like to think that can happen but it probably won't be soon. In the meantime, half a loaf is better than nothing, but we need to keep working toward a better solution. 21 DavidF (NYC) Being self-employed I've bought my own health insurance since 1992. There are always trade-offs, it's important to understand your real needs. When I was married with children I ponied-up for full coverage. When the kids left and I was only responsible for myself, I only had hospitalization and catastrophic care insurance and paid as I went for routine medical care, figuring between premiums and deductibles it was a a wash at best and I didn't need to deal with the paperwork.I think this is something missing from the exchanges, where it appears people are guided to policies that seem affordable, but don't really meet their needs, so many are buying policies insufficient for their actual needs.The real issue is there really aren't any cheerleaders for Obamacare the way there are legions of bashers out there supporting the notion that the ACA is a failure. I don't understand why the retort to claims of "government run" healthcare is that previously there were indeed "death panels" at private insurance companies which made life and death decision about whether or not they would pay for the course of treatment prescribed by your doctor, and if they denied it and you couldn't afford it, too bad for you! So there is indeed a major problem with perception, as exhibited by the fact that people are buying private health insurance from private companies seeing private doctors and yet the system is branded as "Government Run!" We need to hear success stories but who would fund that? 21 sjs (Bridgeport, ct) I know, from talking to friends, that for some the Affordable Care set them free. In one case he was able to leave a job he hated (and was making him sick) because now he could get health insurance. For many, many people this insurance freed them from job lock. 27 LindaP` (Boston, MA) "First, premiums are going up for next year, because insurers are finding that their risk pool is somewhat sicker and hence more expensive than they expected."Surprise, surprise. Those of us not in think tanks or with Nobel Prizes could have told the insurers that. When you have NO health care and pass on basic medical treatment and exams for decades, what to you expect? It is the clear end result of health care being a privilege, not a human right in this county. The real question is why that was notion was ever allowed to take hold, never mind be implemented, in this nation in the first place? This column is a huge disappointment as it slices the health care baloney i a way that continues to provide cover for insurance companies calling the shots. These corporate entities sit with us at our kitchen tables as we make decisions about what to do when coverage or prescriptions are denied. These corporate entities call the shots at our hospital bedsides. It's immoral and wrong. Single payer. 83 SF (New York) Helped me.During years before Obamacare the premium was going up in a proportion I never understood taking more and more of my income away.With the first year of Obama care my health cost dropped 30%.Now with the exchange I have a new drop in my health cost coverage.I would like to stress that the same Company I was enrolled before Obamacare is outside of this plan offering a new policy with the same price as three years ago when I left them for a 30% reduction.Clear conclusion is: Obamacare is working for me.The competition in the market place is forcing them to drop the prices and of course they cannot be very happy. 16 sallyb (<br/>) Additonally, you cannot be dropped from ACA, which is HUGE improvement over any other plan. Jon Harrison (Poultney, VT) Clearly, Janus presides over the health care debate. The author criticizes opponents of Obamacare for doubling down on their criticisms and hyping every bit of bad news -- fair enough. But he in turn minimizes the problems that have arisen, and doubles down on his advocacy of an unwieldy, overly bureaucratic, and increasingly expensive system.Every citizen should have a right to medical care. Covering the uninsured could have been done by simply expanding Medicaid, with a dedicated tax to pay for it. At the same time, provisions such as no discrimination against those with a pre-existing condition could have been written into law, and on a half-dozen or so sheets of paper. Instead, of course, we got a massive, Rube Goldberg-like "reform." Lovers of government just can't resist creating a Frankenstein monster when a few simple changes would suffice. And just as the opponents of big government exaggerate and kindle fear, the lovers of Obamacare downplay and gloss over the flaws. They are mirror images of one another; both paint a picture that reflects only their chosen view of reality. 4 John Mann (Alstead, NH) The risk was that a single payer system would have met too much resistance. Step 1 have a plan. Step 2 once that idea settles in make a better plan. Karen L. (Illinois) Could be solved with one bill-one issue legislation. Instead we get (or used to get, before current Congress refused to legislate anything) you can have "this" (watered down version of some item) if I can have "that" (equally watered down version of a totally unrelated item). They call it compromise; I call it dodging the real issues.I can see it coming in 2016: We get to put boots on the ground in Syria and we will give you a few dollars to repair 50 bridges in PA. Doesn't that sound fair? Let's vote. JABarry (Maryland) " — remember death panels? —" Obamacare did in fact herald death panels. Every Republican governor who chose to oppose implementing expanded Medicaid coverage under Obamacare, chose to deprive citizens in that state of healthcare--each Republican governor was in fact a death panel, making choices about who lives and who dies. 19 tdom (Battle Creek) I get that because the opposition was so overboard with their predictions and descriptions of the ACA, that it's fun to take them down, but don't you feel a little uneasy defending this massive give-away to the Insurance industry? Today, insurance companies control both ends of the health services payment equation with the differences all going to the consumer. Insurance companies agree to pay a certain percentage of the costs the consumer incurs, but then base that on what they determine is "permissible". So a consumer that thinks she has coverage for 60% of her costs ends up with only 40% covered because the insurance companies are paying 60% on a smaller number which they decide. Meanwhile, erstwhile champions of the masses such as commentators and politicos are too busy patting themselves on the back for clearing a subterranean bar set by the right, that no one is standing up for consumer. Meanwhile, the insurance industry can't believe that they got to write a bill that is so good to them and got the left to champion it. Unbelievable but true! 32 ted (portland) A couple of things I would like to point out: the right to healthcare for everyone "regardless of pre existing conditions," which as far as I can see is the biggest benefit of the ACA, could have been written on one page, the other hundreds of pages were written for the benefit of the insurance and pharmaceutical cartels, this should be quite evident by the rise of stock prices in both big pharma and health care stocks since the ACA was enacted, the fact that the c.e.o.s are still walking away with hundreds of millions in pay packages while raising premimiums, forcing many Medicare recipients to use a shrinking network of participating physicians at much higher deductibles and reclassifying many very effective drugs (in particular mild pain prescriptions) so as to either make them difficult to obtain and forcing the patient into new often less effective,always more expensive, non generic medicines. I feel our President did what he could but perhaps was initially attempting to work together with the Republicans, if he had it to do over when there were the votes to pass a single payer system I am confident he would have been less conciliatory now that he knows what he is dealing with on the other side of the aisle. Oh and one more thing, Bernie was always for a single payer system, Bernie 2016! 28 Michael Hutchinson (NY) The high deductible plans are somewhat more of a problem than you think. They keep patients away from specialists and from testing. The insurance industry loves them because the patient pays his or her premium (which is usually not "low cost"), then when they get truly sick they end up paying for their own healthcare. It was an enormous concession made by Obama and represents upwards of 25% of premiums. Depressingly, Hillary Clinton says that she is OK with $3,000/ year deductibles, another example of her ties to Wall Street.Insurance industry = Wall Street = Clinton. 17 bill b (new york) The virulent GOP opposition to the ACA is in reality a form ofvoter suppression. If they are dead, they can't vote. If we've learned anything it's that facts have precious little to dowith the repeated efforts to take health care away from millions. 15 Joe Yohka (New York) can you name some specific GOP people that you know want others dead? I am curious. 3 Robert Salzberg (Bradenton) The real death panels created by Obamacare are the Republican state legislatures and Republican governors that have rejected Medicaid expansion. It has been estimated that the rejection of Medicaid expansion will lead to the deaths of 27,000 Americans due to lack of health insurance. That's equivalent to the death toll from the Paris attacks every week for 4 years. Negligent homicide is defined as the killing of another person through gross negligence or without malice. So are Republican politicians not aware of the deaths they are causing by not expanding Medicaid or are they purposefully and willfully legislating death? 865 Princeton 2015 (Princeton, NJ) " So are Republican politicians not aware of the deaths they are causing by not expanding Medicaid or are they purposefully and willfully legislating death?" That's pretty inflammatory and plain wrong. Are Republicans also responsible when people die from malnourishment or homelessness or any other deficiencies ? There is nothing magic about redistribution. It is a choice that people make ... and have already made. In eight states today (including NY), benefits exceed $40,000/yr or twice the poverty rate. So many people do not work. And of course, taxes are high. In other states like TX, benefits are lower than min wage so, of course, people work. Taxes are low.Read the 10th amendment. These basic decisions like the extent of redistribution (and taxes to pay for it) are supposed to be made at the state level. People in different parts of this country think very differently about the appropriate level of government services. Diversity is about different ways of thinking - moreso than skin color.Instead, Obamacare was forced on all of us - including many who did not want it. If States want universal healthcare, let them have it. But when even liberal states like VT saw the price tag for such government expansion (9% sales tax and 11% income tax), they rejected it. That should be a lesson for liberals out there. Europe may be a nice place to visit. But many of us don't want to live there. 3 mmp (Ohio) Most Republicans will do whatever they can to destroy Obama. 4 sallyb (<br/>) Even worse than death is a long, untreated illness, which can sap a family's wealth. 6 Reality Based (Flyover Country) America had a sixty vote Democratic Senate majority for only about sixty days early in the Obama administration. It was never veto-proof because one of them was one Joseph Lieberman, who opposed any universal system, as did every Republican.It is the height of foolishness that many "progressives" are still blaming Obama for the lack of a universal system. And electing Bernie Sanders without a Democratic, veto-proof Congress will accomplish exactly nothing. A Democratic congress. is virtually impossible due to the Republican gerrymandered congressional districts. They have replaced the power of the ballot with the power of money. Thank you, Republican Supreme Court. 324 sallyb (<br/>) Reality Based – sadly, what you say is true. But we of the more progressive persuasion must not stop trying to change things.And electing a Dem president will at least possibly keep things from getting much, much worse – e.g., the Supreme Court. 2 JMM. (Ballston Lake, NY) Thanks for reminding me that Lieberman - CT senator from the land of insurance companies - stopped that train dead in its tracks. Had forgotten all about that. 2 RichWa (Banks, OR) As a progressive I don't blame Obama for our not having universal health care rather I blame Obama for not even trying to get universal health care -- starting with the secret deals he/his administration made with those that control big pHARMa. It's one thing to try and fail, it's something else to give up without trying -- and that is what Obama did! 2 Paul (Nevada) I will not address the somewhat whistling by the graveyard stand by Paul K in this piece. At least there is one mainstream commentator who is willing to point out the good aspects. Lord knows it would be nice if a few Democrats would step up to the mic and say the same things. I will leave criticism to the rest of the crew because I know some will. What I will say in the programs defense, what was the alternative? Which GOP caucus had a better idea except to do nothing? In other words Obamacare is far superior to Nobamacare of the GOP field. They have control, come up with a better plan and pass the bill. 16 thomas (Washington DC) Obamacare is a deficient structure. Medicare For All is what we need.If anyone wants to supplement that with private insurance paid out of their own pocket, or their company's, fine. 15 An American Anthropogist in Germany (Goettingen) As a regular commenter, and longtime Krugman fan, I'm deeply disappointed by his blasé dismissal of high deductibles. Insurance that is too expensive to use is useless. Literally. Here in Germany where I live the deductibles are, get this, ZERO. Same in the UK where I lived previously. I understand Krugman's urge to "put things in perspective," but why not just be honest? This isn't simply a "Rube Goldberg machine" whose complications are necessary to keep for-profit health insurance in the black. It is a corporate boondoggle. A scam. And Obama, by inexplicable and idiotically taking a single payer option off the table, has painted himself into a corner. Or rather, he's painted others into a corner. Because, like members of Congress, this is a problem he'll never have to face. 220 Mike (New York) I never could understand why the US didn't look more towards the German system when they were planning this. I lived under their system for 20 years, and it seemed to work.I guess we're just to proud to ask someone else for help. Now we are all forced to buy "coverage" we can't afford to use.I ran the numbers for me: One year of Obama's healthcare "coverage," if I actually spend enough for it to kick in, cost me more than I've had to pay for healthcare the last ten years... 4 An American Anthropogist in Germany (Goettingen) why didn't the US look more towards the German system? because our president was a milquetoast who was committed to keeping guaranteeing profits for our for-profit health care system. he refused to fight, and rule out a single payer option before even coming to the negotiating table. that was the best chance we had in generations, with Obama's commanding electoral victory. now we've got a discredited system that is just "good enough" in policy makers eyes to be worth preserving, while we fight a rear guard battle against a right wing party that is bent on taking way what small gains we made. 10 jmc (Montauban, France) Ditto in France - no deductible. In fact, if you have a chronic illness, say diabetes for example, all expenses for the long term illness is paid at 100%. If someone with a chronic illness doesn't have to outlay funds, they will stay in care, and in the end cost the system less (reduced complications and hospitalizations). Drug prices are negotiated and "me too" drugs are not put on formulary if they can't show any medical benefit beyond that of existing drugs. Generics are mandated. No insurance company 'owns' provider networks; I can go see any doctor I want or may need. Most insurance companies in the US reimburse providers on established Medicare reimbursement rates. Why are Americans paying an additional 20% to insurance companies? Where did people think people with chronic illness, previously uninsured or insured in state run high risk pools would go? Of course the exchanges are spending more than they envisioned. Having a high deductible Obama care policy that limits your choice of providers is leaving many people under insured and staying out of routine health care. That the Professor doesn't get this baffles me. He knows that we'd be better off financially and in health outcomes if we had Medicare for all. That's the reality. 12 Stephen Powers (Upstate) If only we considered a system of universal health care the war we look at our military, an institution that ptroects the general welfare of its citizens, then we'd all have no problem imrpoving when and where needed. 12 Ralph Averill (New Preston, Ct) If UnitedHealth Group really is loosing money under ACA rules, and not blowing smoke, it is an indication that the "free" market can profitably provide reasonable health care for only the healthy and wealthy. The poor and the sick can either curl up and die or be covered by government programs. (Private charities could never, ever come close.) But don't even think about raising taxes to pay for that very expensive government care. And don't let government programs negotiate cheaper drug prices.Are we inching toward universal, single-payer health care? One dares hope. 14 Midway (Midwest) Wait until the Cadillac tax kicks in, Mr. Krugman. Certainly you expect that incentive to employers will change things? How will comfortably ensured employees react? That's when you should be writing up your conclusions...To me, the saddest thing is the lack of choice for healthy people who have their own needs and who do not want to subsidize the medical plans and healthneeds of wealthier others. (If you have money and poor health, why should you get subsidized healthcare and not have to sacrifice vacations, vehicles or luxury pleasures that others are still working for? Why should my good health transfer my money into your pockets when I am not wealthy and would otherwise not be paying in?)Luckily, there is no penalty, only a "tax" if you choose not to enroll. 5 Tim Kane (Mesa, Az) A 2nd class something is better than a 1st class nothing.Still single payer would be cheaper & everyone covered.Nonetheless some studies show the best bang for the buck is the East Asian model (Japan, Korea & especially Taiwan).The main difference between them & us are:1) A Price Setting Commission for all medical procedures2) A centralized service that processes all claims for all healthcare providers AND all insurance companies.These two components make the system function much like a single payer for users, drives down cost & red tape for all, makes predicting costs & returns far easier.Given its advantages I see no significant entrenched interest hostile to implementing these 2 agencies in the US.The price setting commission contains reps of health care providers bargaining with reps of insurance companies & consumer groups w/ the government as an arbitrator. This agency makes predicting future cost much easier for all parties.Once you have set fees, you can implement a Centralized Processor for all claims, radically reducing admin costs.I go to my doctor, pay $5 copay, he sets my broken leg, the set price is $100, he files a claim w/ the CP. The CP debits $95 from the insurance company & credits it to the doctor. In this scenario Insurance Cos have no admin cost, they function like banks & their future revenues & costs are highly predictable (as are the doctors).If we can't get single payer, lets at least do this! There's nothing stopping us. 156 Tim Kane (Mesa, Az) I forgot to mention: another benefit of this system is that everyone has access to all healthcare providers. There is no restriction on who you can see, and there is no restriction on who a doctor can provide service to. But if everyone wants to visit the same doctor, then you are going to have to schedule ahead of time to get an appointment. 6 Ron Cohen (Waltham, MA) Tim Kane,Nice idea! Thoughtful comment.Do think this would be simpler and cheaper than the Medicare model? 3 jlalbrecht (Vienna, Austria) @Tim: I always like your posts, but this time I think you are woefully naive. "I see no significant entrenched interest hostile to implementing these 2 agencies in the US." Uh, how about the insurance companies? Right now they have far greater rein to do and charge what they want. "Reduced admin costs"? Why would they want that when they have a captive clientele now?I fully agree that this would be a great next step. Let's elect Bernie Sanders, someone who knows how to negotiate and get legislation passed. He'll propose and push single payer. After negotiations we'll get your (East Asian) plan. It will be a step up from ACA and a step closer to single payer. 8 HealedByGod (San Diego) Can you explain to me why the number of ER visits have gone up since ObamaCare has been implemented?How do you explain the fact that they are only have way to their projected number of 20 million signed up? isn't it true that there are still 31 million that are uninsured?Isn't it true that premiums are going up drastically as evidenced by Robert Pear's July 5th Column? Blue Cross and Blue Shield requested increases of 23% in Illinois, 51% in New Mexico, 25% in North Carolina, 31% in Oklahoma, 36% in Tennessee, and 54% in Minnesota?How many people will drop out as a result of these increases? And isn't it true that the rising costs are due in large measure to the disproportionate amount of services used by our elderly? Don't they average significantly higher number of visits, more prescriptions, more ancillary services? And who pays for this? The people who are least able to afford it. Is this how the system was designed?The back end of the federal website is still not finished, the one dealing with billing? How do they determine reimbursements when it's still not finished?What is your response to the fact that Cover Oregon spent $300 million on their website and did not sign up one person?Bernie Sanders wants Medicare for all. How nice. Another giveaway. Just tell me how you will pay for it? The dreaded tax on the 1%? Do you honestly think you will raise enough revenue to cover 320 million? The free market should determine cost, not the control everything Democrats 17 Paul (Nevada) This sounds like an episode of Perry Mason. Furthermore, isn't it true if you leave mayonnaise in the sun it will spoil? One easy item to debunk, elderly are not part of ACA they are on medicare. Just because they ask for an increase doesn't mean they get it. And I don't think Oklahoma is on the federal system. And with regards to Bernie Sanders idea, the only way national healthcare will work is if we have full blown national healthcare for all of us. It is true this Rube Goldberg System has flaws. But what was the alternative except real national health care? Sounds to me like this is an audition for a midnight slot on AM talk radio. Get in line, beaucoup people want that job. 45 Tim Kane (Mesa, Az) HealdbyGod: How to pay for it? Actually we already are. Currently we have single payer for some (Vets, Retirees, the very poor, Government employees). Turns out, SINGLE PAYER FOR SOME IS MORE EXPENSIVE THAN SINGLE PAYER FOR ALL !So if you could cross out "over 65" from the medicare legislation Government outlays would go down! And everyone would be covered! (Out existing system is that inefficient).Can you say Tax Cut!(This is why some people think our system is really welfare for Insurance executives - they get to make millions of dollars for not providing any value, but instead, stealing value). Under Single Payer- for-some our government already pays out more per head NOW than any other country and we still have people without health care insurance.Its just ridiculous system that also kills people who are uncovered. One thing about the atrocities in Paris, just about everyone was assured immediate care of high quality and no doctor asked "do you have insurance?" 30 Len Charlap (Princeton, NJ) 1. Every other developed country except possibly Germany (which has had a universal, government run system since the 19th century) had a free market health care system, an NONE of them could get it to work. 2. Here are the basic figures with references:All other industrialized countries have some form of universal government run health care, mostly single payor. They get better care as measured by all 16 of the bottom line public health statistics, and they do it at 40% of the cost per person on average. If our system were as efficient, we would save over $1.5 TRILLION each year.www.pnhp.org & www.oecd.org, especiallyhttp://www.oecd.org/els/health-systems/oecd-health-statistics-2014-frequ...I ask you HbG, which would you prefer, paying $12,000 a year for private health insurance or paying $4800 a year more in taxes for better health care? The question is not how would we pay for an improved Medicare for All. The question is what would we do with all the money we saved. 15 R. Law (Texas) Going forward, a key question in the success of the ACA will be whether costs are driven further up due to the lack of competition from providers; DOJ should stop the continuing merging/buyout of health insurance companies on the grounds they are anti-competitive. 28 F. T. (Oakland, CA) I'm a supporter of the ACA, but I also think there's more work to be done. It's great to make insurance possible for millions of uninsured. It's great that insurers cannot deny coverage based on pre-existing conditions. It's great to have a focus on the shortcomings of health insurance in our country.However, there are also millions with chronic diseases, who have paid for insurance all these years, and are still caught unaided by the ACA. Folks with chronic disease often pay high copays every year; even with minimum copays, 10% of a couple of hospital stays is a lot of money. My cost for premiums and copays is half my income every year. (For 16 years.) As with other benefit programs (Medical, low-income housing, disability etc), the ACA doesn't take those expenses into account when the subsidy is calculated. So even with the ACA, half my income goes to health care.In addition, in California, my ACA rates have gone up 70% in 2 years. I cannot afford it for next year. I have to care for my disease, and I have to have insurance. So I have to move somewhere with lower insurance costs.Millions of chronically ill face the same challenges. I'm sure there are many, many others whose situations also "fall through the cracks" of the ACA.So yes, let's laud the program for what it has done. That is essential. But I also hope that politicians and voters at some point can look into ways of improving it. To make sure that all Americans truly can have health care. 312 Kodali (VA) It is a good point, that the cost of premiums and copayment(s) must be taken into consideration in providing subsidy for the premiums. Paul Krugman wasn't saying there is no room for improvement, but simply stating that the Republicans are not even admitting that ACA is a successful program. Instead of accepting the success and propose improvements, they want to kill it and behaving like sour losers. 3 Brud1 (La Mirada, CA) Since you live in California, you may have access to Kaiser where rates are reasonable and where medical care is first rate. You should check out Kaiser before the open enrollment period ends. My son pays $289 for a Silver policy, and a Gold policy would only be a few dollars more and well worth it for someone with chronic diseases. I've been a Kaiser member for over 50 years and swear by them after three bouts with two different cancers, throat and bladder. Go for it, you'll be glad you did. 1 memotech (Denver) Would you clarify your numbers?.For everybody, as far as I understand, the worst case scenario is the total amount of your premiums, which for example, for a man in his 50s' is about $400x12=$4,800 per year, plus a maximum out of pocket of $6,500. In this example, is this $11,300 amount what you are talking about? Or is there something else for chronic diseases?Thanks 1 David Henry (Walden) After having done everything possible to subvert Obama's attempt at health reform, the GOP then has the gall to complain that Obama hasn't done enough.In effect, Obamacare has become just another phony rhetorical game, like Benghazi, to attack Obama.History will record that the Republicans, aided and abetted by their ideological pals on the Supreme Court, have denied people medical care. Is there anything more immoral than that? 424 Meredith (NYC) Strange.....In other democracies they expect h/c to cover everybody.Too bad, Americans haven't got much bargaining power in our 2 party system financed by big corporations. So what will Hillary do? The irony is that in 08 Hillary was to the Left of Obama re Health Care. Now she’s to the Right of Bernie Sanders.It’s interesting to read the excellent Krugman column 2/4/08.... “Clinton, Obama, Insurance.” He compares the 2 candidates on their plans....that the “difference between the plans could well be the difference between achieving universal health coverage — a key progressive goal — and falling far short.”Says Clinton’s plan promises to limit insurance costs as % of family income, and seems to include more subsidies. “But the big difference is mandates: the Clinton plan requires that everyone have insurance; the Obama plan doesn’t.”That was then. Now he tells us to be thankful for Obamacare and maybe someday its shortcomings might be corrected,( to reach some parity with dozens of other nations.) So we do have mandates, but also with uncontrolled rising costs, and with regulation taken off the table. So corporate profits are protected, but the right of all to care is not. Regulation is the crucial element enabling dozens of nations to give all citizens h/c since generations ago. Now Clinton is up against a Gop that wants to destroy Obamacare. We await our fates. With Gop political ‘terrorism’ at our throats, we’ll be thankful for anything we can get. 10 Fran Kubelik (NY) There is nothing wrong with high deductibles if you see insurance primarily as a way to avoid catastrophic costs due to cancer or other life-threatening health problems.I've been self-employed for almost 30 years and have always purchased high-deductible policies. Here's the way I see it: I don't mind paying for routine maintenance and repairs on my car, so why should I object to paying for routine maintenance and repairs on myself?That said, I think we need a single-payer system. One-third of the U.S. workforce now consists of "contract" employees like me who receive no employer-provided benefits. I've put off receiving all but absolutely necessary healthcare until 2017, when I will be covered by Medicare.I've been fortunate to have had a successful freelance career and no major illnesses or injuries.The Affordable Care Act has helped me buy better coverage at a lower price, for which I am grateful. But I won't really have full access to the healthcare system until I finally turn 65. In a country as wealthy as ours, this is a disgrace. Medicare should be an option for self-insured, self-employed workers of all ages. Now. 1141 Naomi (New England) What you said, Fran! That was the huge downside of quitting a job that was going offshore,, returning to school, then being self-employed. I lost the best health coverage possible, the kind you get working at a Fortune 100 company. The ACA helped, but it's a messy fix. It's crazy to have a system that switches you back and forth between two completely different systems with different doctors if your income fluctuates year to year, above or below the Medicaid cutoff. I loved working for myself, even making substantially less money than at my corporate job, but it would all make much more sense with Medicare for all. Why should US businesses have this burden that foreign businesses don't, and why should self-employed workers and contractors be penalized for going out on their own? 15 alan (CT) i've never heard anyone say ACA is coverage at a lower price, unless you are getting a subsidy. The higher coverage requirements have made ACA more expensive than high deductible plans before ACA. 4 SH (Brooklyn) @Fran.. "There is nothing wrong with high deductibles if you see insurance as a way primarily to avoid catastrophic costs"Fran.... That would be fine if these plans didn't have high monthly premiums (subsidy included) and people weren't being forced to buy them. A public option is the only way. 6 Stuart (<br/>) So when Paul Ryan says Obamacare is a disaster and still needs to be repealed, how come nobody bothers to ask a follow up question? 462 Lynn (Greenville, SC) "So when Paul Ryan says Obamacare is a disaster and still needs to be repealed, how come nobody bothers to ask a follow up question?"Maybe it's because they're sick of hearing Republicans whine about gotcha questions. (Guess the Republicans failed to notice Hillary wasn't whining after 11 hours of snarky questions.) 6 Michael (Indiana) There are no follow up questions because the press is owned by the American public not billion dollar corporations and has no interest in soaking up money from the bribed politicians (wink wink snicker snicker). 4 Meredith (NYC) This column is full of rationalizations. Anything would be an improvement over the past with it’s millions of medical bankruptcies found only in USA. Plus excess deaths/disability. But other countries would be marching in the streets to protest a system that still leaves millions out, with their taxes forced to subsidize huge insurance/drug profits. Instead of making excuses for our 2nd rate ACA, Krugman the liberal economist concerned with inequality, should explain how dozens of nations have financed and used universal h/c for generations at fraction of our cost. What about their ‘risk pools’, which include every citizen? Or their regulation of insurance/drug prices? That was kept off the table here as the price for passing ACA, by a congress tethered to big money lobbying by the medical industry. Why should we have to put up with the world’s costliest care, saying it could be much worse if the Gop wins? The threats of the Right have pushed the center of politics, keeping liberals on the back foot. No way is ACA a ‘huge success’. It’s more an insult. Costs are below expectations? But the NYT editorial recently wrote that people are dropping out due to raises in premiums. An article told of doctors not being in networks as listed, and patients outraged by huge unexpected bills. 30 million uninsured? This doesn’t happen abroad. Why does Krugman keep international positive role models dark? 83 Rima Regas (Mission Viejo, CA) "This doesn’t happen abroad. Why does Krugman keep international positive role models dark?"Because doing so, a bit further down the line, will get in the way of supporting Hillary Clinton's platform of tweaking Obamacare, rather than supporting Sanders' more rational approach of implementing universal healthcare and stopping the bleeding at the neoliberal source: Big Pharma and Big Insurance.Professor Krugman has avoided writing about both Clinton and Sanders because writing about either or both puts him in the pesky and impossible position of justifying the unjustifiable positions of a now questionably presumptive nominee.One only need to give the last Democratic debate a second viewing to see how much sharper the contrast is between Hillary Clinton and Bernie Sanders on all issues, including health.http://www.rimaregas.com/2015/11/the-democratic-primary-voters-left-to-f...Sanders hit a home run with the speech he wrote himself and gave at Georgetown University:http://www.rimaregas.com/2015/11/bernie-sanders-on-democraticsocialism-a...Eventually, op-ed writers in the Times will have to turn their attention to the left side of the election. The more they wait, the more ridiculous the waiting appears. 35 Skip Montanaro (Evanston, IL) Alas, a President Clinton or President Sanders would, in all likelihood, still need to deal with a Republican Congress putting up road blocks at every turn. I imagine Obamacare would look better had more been possible in the face of continuous undercutting and opposition. 23 Janet Camp (Milwaukee, Wisconsin) Unless you change the Congress, a Prez Bernie would be utterly ineffective at anything, let alone health care. 4 FF (Baltimore) Of course none of these would be problems in a Medicare for all system. When President Obama gave up on the public option he threw a lot of people under the bus. I guess you reap what you sow. 18 David Henry (Walden) As if the public option or Medicare for all could have passed congress. 15 Len Charlap (Princeton, NJ) Well, you may be right David, but consider that Obama had a filibuster proof majority briefly when first elected. Furthermore Medicare is one of the world's best loved brands. There was tremendous public support even if the media barely covered."Between 2003 to 2009, 17 opinion polls showed public support for a single-payer system. These polls are from sources such as CNN, AP-Yahoo, Quinnipiac, New York Times/CBS News Poll, Washington Post/ABC News Poll,  Kaiser Family Foundation and the Civil Society Institute. In October 2003, a Washington Post poll found that 62% supported "a universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers."A poll of practicing physicians in Massachusetts published by the American Medical Association (AMA) found that 55.7% of AMA members and 66.8% of non-members preferred "single payer" as a basis for reform over the other alternatives offered of "managed care" and "fee for service". Overall support for single payer was 63.5% compared to 25.8% for fee for service and 10.7% for managed care."From WikipediaA well financed campaign would have put great pressure on the senators on the fence like Collins and Snow.The point is that if you never try, you never know if you could have succeeded. 10 Lisa (Charlottesville) If you think that Medicare for all had a snowball's chance in Hades of passing... 1 Spence (Malvern, PA) Reality-wise Obamacare is working. Perception-wise the GOP are still using it as a punching bag just not lately.We are in the midst of a Presidential campaign so Xenophobia, ISIS and the traveling GOP circus suck all the air out of the room and take all the headlines. With Paul Ryan as Majority leader, he will selectively use Obamacare when needed to blackmail, um, press his GOP agenda. Next month, Planned Parenthood is back on the table. Will the GOP shut the government down – again over government funding?Defense recently got an $112B boost last month, but the GOP want more. As the war rhetoric ratchets up and the GOP goes on the war path, all domestic programs are again on the chopping block. It seems $600B we spend on Defense just isn’t enough.Of course, Bernie says otherwise, but he has to deal with Hillary, the war hawk, who like the GOP will not back down. What’s sad is that Congress hasn’t done anything since 2010 for the people and now all they want to do rev up the war machine. Both sides are beating the drums. Once the fear mongering, hysteria reaches a pitch, anything is possible.Enjoy your healthcare today because unless Bernie is elected no one will defend it after the elections. 21 Andrew Dashiell (Boulder, Colorado) Obamacare is probably the worst health insurance system this country could have. Except for the one it replaced. 177 Joel (Cotignac) What's missing here and in other articles is an analysis of average cost increases for private coverage in past years, as well as the percentage of policies that insurers simply refused to renew. I suspect increases considerably higher since the companies could do as they wish, but I would really like to know for sure. Apart from Mr Krugman, there are precious few articles that look logically at the results of ACA, and very many negative ones. 8 Abhijit Dutta (Delhi, India) I'm afraid Professor K, you're on the defensive today for no good reason.It's important to remember why we do things : The objective Obamacare was to cover the uninsured, as a matter of good policy and social practice. In principle, if the uncovered were generally sicker, there was no way that costs - and therefore premiums and the number of people happy with the new benefits of increased coverage - would stay down. That's just plain mathematics.These were EXPECTED results of Obamacare. That doesn't mean it's a (good or) bad thing. Theoretically, depending on how sick the newly covered population is and the ability of the covering organizations to negotiate rates, the premiums could rise further. Is that unexpected ? No !As a government, America has done the right thing by giving people a chance to live (more) secure lives with a better chance of advancement. More needs to be done of course, but the path is right. As coverage is adjusted for bad lifestyle choices etc., rates will adjust accordingly. Nobody should be surprised. As the number covered s higher, the general actuarial risk should decline.But let us not forget why this was done. And let us not be defensive for the wrong reasons. It is our job as providers to give people a chance to do better for themselves. Some will take it and some will not. As consumers, it is our job to take the chances for advancement.At least we can't blame the cruel "system" for being unjust. 6 Larry Eisenberg (New York City) Now Dr K makes it quite plainObamacare works in the main,But hope we may dareOne day Single PayerMay be voted in by the Sane.And may I add with a fierce frown,Let's end the myth of "trickle down"Upward Wealth does strayAnd to this very dayThe tenth percent's wearing the crown! 106 Meredith (NYC) Re single payer....seems every country that covers all citizens at lower cost doesn't necessarily have single payer, Some use insurance companies and have 2 tiers. But all their govts seem to negotiate prices with insurance and drugs companies.Seems their right wing parties accept this, while the dominant US rw made sure that price regulation is politically impossible. So our candidates don't even mention it this crucial factor. Thus we stay backward. 24 Rima Regas (Mission Viejo, CA) Given a choice of Obamacare or nothing, I would much rather have Obamacare. Given a choice of covering every single American citizen in the nation versus what we have now, thanks to States' Rights, I would rather have a mandate that extends healthcare to all Americans through Medicare and abolishes Obamacare. The cost of Obamacare premiums in California is rising. For many among us, it is a huge blow, especially when you add copays ($10 for PCP and $50 for specialists), coinsurance, and deductibles. My Obamacare plan has a deductible for prescriptions, as well as deductibles for all other services. We scaled down to a middle tier as the platinum was just too expensive. I met my prescription deductible when I replaced my Epipen, to the tune of $289.I just received rebate checks from our insurer as, under Obamacare, they must give the insured money back when they do not utilize 80% of premiums toward the care of the insured. The rebates are a drop in the bucket. To say that Obamacare is imperfect is an understatement. Big Insurance profits have soared as workers dropped, if they have any work at all.Bernie Sanders is proposing universal healthcare. Obamacare, as far as I'm concerned, serves as a bridge to healthcare for all. Big Insurance and Big Pharma are squeezing the middle class with increases that are unjustifiable and our rotten political system is allowing it. Bernie is right. Healthcare should be a right. Voters need to make it so.---www.rimaregas.com 359 loveman0 (SF) 20% overhead/profit is too high. 15% maximum with incentives to bring it down to 10% or less. Single payer would be about 5%.Where generics have increased in price 15% in any 3 year period, put in new suppliers have tax free profit access to the market for 5 years in exchange for substantial price reduction. Make the incentives for low prices. Same for solar panels/installation. 6 Doug Broome (Vancouver) Private health insurance in the U.S. ran on 30 per cent overhead expenses for items like non-health-professionals second guessing doctors, profits, and multi-million salaries. Public health insurance in Canada ran on three per cent overhead.Obamacare allows 20 per cent overhead which is way too much and specifically sold out to Big Pharma parasites.The entire private health insurance industry needs to be abolished for true cost control. 8 Rima Regas (Mission Viejo, CA) Doug,Right on. I completely agree. The coming year is going to be one of the most ruinous for me between major surgery and gobs and gobs of lab testing and CT scans. 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