# 为什么ACA的个人强制要求ACA中最痛苦的部分，而ACA在没有ACA的情况下无法获得资助呢？

Sidney 08/21/2017. 12 answers, 4.732 views

“平价医疗法案”（ACA）是一项具有多个组成部分的分裂和复杂的立法。 在关于废除的讨论中，政治家们承诺保留其中的一部分并消除其他部分。 有一些受到广泛赞誉的做法（让孩子们长期继续保留父母的保险，强制保留原有条件），少数人接受（最低保障标准，限制老人可以被迫支付的费用）和少数几乎所有ACA的反对者都会嘲笑，比如个人的授权。

22 Mason Wheeler 07/29/2017

1 SoylentGray 08/01/2017

Brythan 07/28/2017.

1. 覆盖率增加（覆盖的人数）。
2. 增加保险范围（程序类型）。
3. 覆盖先前存在的条件。

1. 预算影响。
2. 增加税收。
3. 保费增加。

16 Segfault 07/28/2017
15亿美元是针对个人授权收取的税收处罚金额。 它并没有衡量有多少收入来自卫生保健提供者的健康个人谁没有得到充分利用的计划。
3 Andy 07/28/2017
@Segfault“OP在询问如何让”让孩子留在父母的保险上“可以得到资助，这是由保险公司承担的成本，而不是联邦政府的成本。” 它不是保险公司出生的成本; 它不能自由地遵守政策，你仍然必须支付家庭保险费率，以保持你的孩子。
1 Segfault 07/28/2017
@Andy这是一个离题，但让我反驳这一点：如果它不是比买他自己的计划便宜，它不会存在。 它降低了保险公司的利润率。
1 Segfault 07/28/2017
@Andy这个离题越来越长，哈哈。 我不想就此进行大讨论，因为这是我原来的评论中的一个小切点。 让我问一下，如果保险公司向5个成年人的团队出售家庭计划而不是5个个人计划，那么他们为什么不为那些30岁或以上的孩子做这件事？ 请回答这个问题，这不是修辞！
1 Andy 07/28/2017
@Segfault因为他们不仅仅向一组五个成人出售一个家庭计划，他们还出售了80个家庭计划，每个计划3-5人。 团体保险计划中的家庭计划（通过您的雇主）与您可以在交易所（个人市场）获得的家庭计划相比，保费较低。 通过这80个家庭计划，你有20个单人或保险+配偶计划，所有计划都有单点联系。 这就是我的小公司，有100名员工。 想象一下保险公司刚刚从GE那里得到多少计划。

PoloHoleSet 07/28/2017.

1. 整个社会的代价更高，对于受到医疗保健需求打击的个人而言更具灾难性，并试图在没有保险的情况下处理这些情况，从而导致个人破产，并将成本转嫁给其他人。

2. “我为什么要为别人付钱”的“我”观点？ 方便地忽略了这样的事实，即如果发生什么事情，决定不被保险意味着其他人将不得不为你支付（拖欠所有债务，除了学生贷款，不仅仅是医疗，破产时提交，成本转嫁到他人点＃ 1）

3. 虽然健康保险涵盖正常的，预期的和预防性的费用，但其目的是为了保障付款人免受意外和更高的possibilities

4. 没有人选择生病或绝症。 每个人最终死亡。 这意味着每个人都会违背自己的意愿，在他们的生活中需要医疗保健，除非他们完全健康并因某种瞬间事件而死亡。 这使得“选择”医疗保健的想法成为某种消费者选择的谬误。

5. 通用保险不是一个短期命题。 你一辈子都在买东西。 当你年轻/健康时，你可能比你付出的钱多。 当你年纪大了或者生病多了，你就会得到比现在更多的钱。这个想法是平衡的，再加上你为这种灾难性保护付出了代价。

6. 那些把它看作“我目前不使用x，y，z”或“我可能不会使用x，y或z”的人不理解保险的概念，这是集中的风险/使用。

7. 大部分的反对意见都是因为奥巴马提出的，而且是反思性的。 个人授权是医疗保健检修的必要组成部分，是由保守的遗产研究所在回应克林顿90年代失败的建议时提出的，并在共和党总统候选人米特罗姆尼成为马萨诸塞州州长时成功实施。 显然，个人授权与GOP或保守价值观根本相冲突，没有任何一个概念是一个概念。 除了基本的无知之外，反对派的很大一部分是“拍摄信使”的心态。

3 Tim 07/30/2017
The idea is that it balances...它不可能平衡。 根据定义，保险通常不值得; 平均而言，你会付出比你多的钱，否则保险公司不会获利。 这是NHS的另一个优势。 虽然很多人付出的钱比他们使用的多，但NHS平均不赚钱 - 目前他们亏本。
2 David Schwartz 07/30/2017
@Tim没有任何关于保险的概念要求它由公司发行或者这些公司获利。 您可以拥有保险公司发生的保险。 您可以购买支付超过其从客户收入但由政府补贴的公司发放的保险。 （这在美国实际上很常见于健康保险。）
1 Maciej Piechotka 07/31/2017

5 Wes Sayeed 07/31/2017
“这是一个普遍的主题，即不负责任的自私自利 - 自由遭到挫折......”-1，这是我见过的最具有争议性的答案。 问题是人们为什么不喜欢个人的任务，你的回答基本归结为“因为人们很愚蠢，这就是原因。” 这不是一个答案，那是一种自以为是的咆哮。
1 PoloHoleSet 07/31/2017
@MaciejPiechotka--是的，但如果我把它放在“他们的反对意见是基于误解和/或无知”，我会被问到我在说什么误解，所以我继续支持它。 对立部分真的很简单。 误解和无知的数量涵盖了一个非常广泛的区域或区域，这就是为什么答案如此结束的原因。

Cort Ammon 07/31/2017.

ACA对此的解决方案是个人授权。 它剥夺了您的“自由”来决定是否支付健康保险，而是要求您必须将自己置于其中一个池中。 无论保险公司认为您应该为医疗保健支付多少价格，您都需要为此付费。

ACA的很多部分都可以在没有个人授权的情况下进行调整和资助，但是原有的条件覆盖有一个自然的滚雪球效应，如果没有它，会破坏稳定。

MSalters 07/28/2017
“一家保险公司在未来5年内保证花费30万美元” - 这种情况并不罕见， 人寿保险就是这样工作的。 也许有点高，但不是保险公司会担心的。 而30万美元的待遇则不太确定 - 明天你可能会被汽车撞到。 它不会花费30万美元的保费。
3 Cort Ammon 07/28/2017
@MSalters就人寿保险而言，未知数是你付出多少钱（死前），所以还有一个有意义的未知数。 我可以调整措词以便与之交谈，但我认为这可能会稀释信息而不是帮助。 但是，根据您在未来5年内被汽车撞击的统计概率，保险代理机构可以为您提供保费的轻微折扣是正确的。
jamesqf 07/30/2017
@ MSalters：这不是人寿保险的工作方式。 在任何时期，死亡的概率都是已知的，这取决于年龄和健康等因素，因此保险公司可以相应调整其利率。 因此，25岁健康的人每年的保费要比80岁的癌症患者低得多。 这也是为什么通常排除自杀和战争死亡的原因。 OTOH对你的家属有利，如果你死了，应该超过你的成本 - 这就是为什么对没有家属的人毫无意义。 但是ACA根本就不能这样工作。
Izkata 07/31/2017
“这就像是问如果你反对战争，你如何反对杀人，更有趣的问题是有人争论说如果他们是为了战争而杀人。” - 这些都不矛盾，看起来至少有一个词是错的/缺失
Cort Ammon 07/31/2017
@Izkata好的间谍，第二个应该是“反对杀人”。 我会编辑

Deolater 07/28/2017.

Michael Richardson 07/28/2017.

Sam I am♦ 08/02/2017

coteyr 07/29/2017.

ACA的许多部分通常被认为是“好”的。 可见的是“没有预先存在的条件”，“孩子停留更长时间”以及HIPAA的变化/调整。

• 健康保险不起作用。 你得到较低的护理标准和较少的选择。 保险公司决定你的护理，而你的医生不会。 这是非常真实的。 许多医生会根据他们的经验和智力开处方，并根据规定的计划为保险公司支付费用。 这导致个人护理质量较低，但理论上使护理质量更好。
• 健康保险太贵了。 我发现这也是真实的。 今年我的家庭医疗保险费用约为9,000美元。 我们的医疗保健总成本只有2,300美元左右。 支付2,300美元，然后再支付9000美元，对我们来说更具经济意义。 事实上，通过这种成本差异，我们可以（并且确实）每年为储蓄账户节省约5,000美元的医疗需求。 我们实际上是在紧急情况下被覆盖的。
• 个人的任务减少了个人选择。 我们很高兴能够为急诊室，手术等提供“紧急”保险，我们不希望“全面覆盖”不幸的是，这些飞机已经停产。 因此，现在不是我们的首选设置：“我们将支付我们通常所有的医疗费用，并获得保险以涵盖紧急事件”。我们必须“全面覆盖”，费用太高，并且给我们的护理质量较低。
• ACA /个人的授权实际上会让医生变得更加昂贵。 有时令人无法接受。 例如，我的妻子看到一位专家。 专家访问，自己支付350美元。 通过保险的共同支付约为60美元。 60美元似乎较小，但为了符合这种共付的资格，她不得不频繁下注，并且每月支付750美元。
• 将个人授权卸给雇主会产生巨大的经济影响。 由于您不能选择不提供保险，所以没有业务成本上涨。 有些人需要付钱。 相反，薪酬冻结，工资降低或产品成本增加，某个地方需要弥补差异。
• 许多美国人首先不希望它。 事实是，很多很多美国人首先不想要ACA或个人任务。 他们觉得它要么做得不够，要么完全无效，要么实际上是有害的。
• 它没有解决健康保险的问题。 我听到的一个共同主题是，单个任务并没有解决问题，它只是迫使每个人都有同样的问题，使问题更容易接受和更难解决。 健康保险不能解决健康问题。

tj1000 07/29/2017.

2009年为什么没有这样做是超越我的。 为什么今天的repubs不这样做是超越我的。

3 jamesqf 07/29/2017

2 blip 07/29/2017
@ jamesqf如果你可以选择不拥有一个身体，那反驳论点可能是有道理的。 :)但是，是的，保险的作用方式是每个人都投入 - 甚至不太可能最终使用它。
1 jamesqf 07/30/2017
@blip：这不重要。 我可以选择不使用传统的医疗系统（比如说我是基督教科学家）; 我可以（的确如此）选择过一种健康的生活方式，这可以减少我需要医疗护理的几率。 然而，在ACA的支付下，我的付款方式和我的邻居完全一样，他们的运动想法是坐在电视机前重复做12盎司卷曲。
1 tj1000 07/30/2017
@blip：也不是那么简单。 如果你按照这个例子得出合乎逻辑的结论，那么医疗保健费用将决定你的生活。 你的所有活动都将根据他们的成本来判断。 告别攀岩，泛舟，在酒吧度过一个愉快的夜晚，快速的汽车，骑马，足球......所有有趣的事情都会让生活值得生活。 我们都会变得无聊，沉闷，毫无生气的自动贩卖机，过着我们的医疗保健成本的生活。 你确定你要走这个方向吗？
2 Magisch 07/31/2017
@jamesqf医疗保健是一个俘虏市场，历史先例和逻辑说，资本主义对俘虏市场的做法是行不通的。 这就是为什么全民医疗保健是only真正可行的解决方案，以及为什么绝大多数发达国家拥有这种或那种形式。

Segfault 07/31/2017.

3 Andy 07/28/2017

4 Segfault 07/28/2017
@是的，这是第三种选择，人们不应该生病或受伤。
4 WernerCD 07/29/2017

1 Segfault 07/29/2017
@WernerCD我的意思是说，正确的立场是医疗保健应该由私人资助，而且没有保险的人数可以接受。 你是对的，它有偏见，我会纠正这一点。
5 WernerCD 07/29/2017

user3753318 07/28/2017.

2 Andy 07/29/2017

1 blip 08/01/2017
@你需要解决'不断上涨的医疗保健费用'和'获得健康保险'的问题。 医疗保健费用一直在上涨，很可能会继续这样做。 ACA是关于确保人们有access健康保险。 随着时间的推移，ACA应该help控制成本（增加风险池），但本身并不会奇迹般地解决导致成本上涨的所有其他问题。

JimmyJames 07/31/2017.

The idea of the mandate is to create a gigantic pool of insured people so that insurance companies are willing to sell insurance. It's not simply about costs. Its about whether the market can function. Prior to the ACA, there really wasn't a significant individual market. Relatively few (healthy) people could afford it and most of them were already getting insurance through their employer. For this reason I find all the news about rising premiums to be so misleading. Compared to what? Most people could not even buy insurance on the individual market if they wanted to and it was unaffordable for many people who could get it.

The mandate is not something that was cooked up as part of Obamacare. For example Milton Friedman (the highly influential conservative economist) "advocated replacing Medicare and Medicaid "with a requirement that every US family unit have a major medical insurance policy." . The individual mandate is a core component of Romneycare .

While it's true that some conservatives have long opposed the individual mandate because it means the government must choose what insurance is acceptable (essential benefits), I think it's pretty obvious that when the ACA was passed, the Republicans latched onto this as the most unpopular piece of the law. Then, when they were not in power, they talked about the mandate as much as possible because it played well in the polls.

The problem now is that, despite the rhetoric, the ACA and the exchanges have been successful. There are a few places where the market is not doing well but these are also places where the state and local governments are politically antagonistic to the ACA. In addition, there ways that the current congress is damaging the current exchange system without a full repeal. The ACA is essentially a three-legged stool where the three legs are pre-existing conditions, subsidies, and the individual mandate. To remove the mandate, you need to replace that leg and those proposed so far are too short.

Everyone is congress knows this. There's an army of lobbyists representing the insurance companies telling them that if they remove the mandate without addressing the adverse selection issue the insurance companies will exit the market place and the individual market will basically vanish. That's why the Senate won't pass the 'repeal' without a realist replacement.

PS It's kind of orthogonal to the specific question at hand but one of the big misconceptions I see repeatedly is that people think that the rising cost of insurance (the rate of growth of which has actually slowed since the ACA) is caused by the 'insurance companies'. This is patently false. The 'skim' that health insurance companies take from what they get from premiums and what they pay for care and drugs has not changed. What costs more is care and drugs. For example, a course of treatment for Hep-C is about $90,000. This is something that didn't exist a few years ago. Every time a new test and a new treatment comes out, the rates need to increase to pay for the increase in costs. This misunderstanding makes it seem like it should be no big deal for insurance to cover pre-existing conditions. They think the insurance comapnies have huge vaults of gold coins and cash like Scrooge McDuck or something. This misconception also leads people to be outraged by being forced to carry insurance. It feels like being forced to pay tribute to Croesus. ##### 5 comments JimmyJames 07/31/2017 I'd love a comment from the downvoter. This is actually something I know quite a bit more about than the average person. If anyone wants to dispute the documented facts here, please don't be a coward. blip 07/31/2017 OK, I had to read this twice. It actually explains things quite well. Yes, the individual mandate and pre-existing coverage go hand in hand. The fact that Trump recently claimed you can buy health insurance for$12 a month shows that he really has no idea how the health insurance industry works. Sadly, a lot of supporters of his party's attempts at undoing the ACA seem to share that naiveté. +1 from me.
JimmyJames 07/31/2017
@blip I don't think is naivety. Nothing has passed because they know all this. You have the libertarian wing that doesn't care about this and the moderate wing that does. It's unfortunate because this is probably the only way that we don't end up with a single-payer system. If the ACA is repealed or allowed to fail (it needs some tweaks) 'Medicare for all' seems much more likely and that would be a little ironic.
blip 07/31/2017
Well, I was referring to the masses more than congress. I truly believe Trump doesn't have an understanding of Health Care. (Remember his infamous "who knew it would be this complicated?"). And I believe a lot of people that voted for him don't, either. Look at the polls showing the number of people that hate 'obamacare' but think 'the ACA' is good. All that said, yes, I think we're in complete agreement that, at the end of the day, a single payer system is the only real solution for both parties.
JimmyJames 07/31/2017
@blip You misunderstand. I am not a supporter of single-payer in the US. What I would like to see is a real market-based system where the customer (the insured) are choosing directly from the sellers (the insurance carriers). Having the employer involved really makes no sense. I don't get my home or auto insurance through my employer. They do offer life insurance as a perk but I am free to buy it on the open market. What we have now with self-funded, employer-based, federal medicare, state medicaid and all the rest is basically chaos. The mandate will allow for that market.

Peter Masiar 08/01/2017.

Mandate is not popular, because freeloaders are very vocal constituency , and mandate (or "no freeloaders") was a standard part of any conservative health care reform suggested by conservative think-tanks.

Using this very vocal constituency allows to politicians to attack ACA which they dislike for other reasons.

Mandate "refuseniks" are freeloaders because they want to pay (low low monthly fee) for insurance only during months they require (expensive) health services, paid by everyone else , gaming the system.

Even Mitt Romney, when he established individual mandate in Massachusetts in 2006, called such people "freeloaders".

It is made worse by the fact that hospitals are required to provide emergency services regardless of the ability to pay (so people are sure they can game the system , even if partially, and are used to be able to do it), even if hospital knows/suspects that person will not pay for provided services. This cost of emergency services is so high that (I read a research somewhere) for few homeless people it would be cheaper to provide them free housing (so they have less medical emergencies) than "free" emergency care they are getting now. Not all homeless, but few. But of course it would not work, because it would give such homeless perverse incentive to consume more emergency services to qualify for free housing.

If you don't want people without insurance dying on the street like in a 3rd world country, we need individual mandate.

Sidney 08/01/2017
I feel this could almost be a good answer if it were reasonably well fresh out without epithets.
Peter Masiar 08/01/2017
@Sidney OK I removed the rant part, even if I think was quite valid

Joel Rees 07/29/2017.

This is a bit long, but we can't answer the question without getting the full context in front of us.

First, let's start by asking what people did before there was insurance:

(1) They didn't get sick or have accidents.

(2) When they got sick or had accidents, they just died immediately and saved society the burden of caring for them.

(3) If they didn't have enough resources (including, but not limited to, savings) people who were close to them -- people in church, sodalities and fraternities, etc., friends, neighbors, relatives, sometimes even strangers would help them until they got back on their feet. And life went on.

(E) All of the above.

Second, let's ask what happened with insurance:

(1) Check. Lots of people were still not needing help. One point of difference, some of these people are voluntarily joining the strangers I mentioned above who help other people in need, by contributing to one of many independent companies that establish these pools that we talk about.

(2) Check. Lots of people were still getting sick or having accidents and dying. One point of difference is that some of those who died were covered by insurance and some weren't.

(3) Check. But with more insurance available, fewer neighbors and strangers feel the need to get involved, unless they get involved by buying insurance. And, with money going out in insurance premiums, there was less available for savings.

Overall result?

There was a new way of making a living called working for (or running) an insurance company. (I'm speaking loosely here, some of those weren't really companies in the legal sense. There were several legal categories besides company for insurers. I think some of those categories still exist.) This is not a strictly bad result -- has both pluses and minuses.

Also, it became easier for people without good neighbors, church or other abstract community, close relatives, etc. to get help. This contributes to alienation, but it also contributes to reintegration. Again, there are both pluses and minuses.

Unnoticed tertiary results?

Insurance companies start making rules that our government is Constitutionally forbidden from making. This is an essential bit of information here.

Third, let's ask what will happen with mandatory insurance.

(1) Will people stay healthy?

We should hope so. We aren't sure, however.

(2) Will people get seriously ill or have accidents and die?

How can we expect it to be otherwise?

(3) Will family, neighbors, friends, relatives, people in their abstract communities, and strangers still help?

Wait, let's back up to (2). Insurance companies are motivated to reduce risks, so they will be making even more rules to try for force people to be healthy and safe.

They will also escalate the social narrative about " responsible behavior " as if conformance to any arbitrary set of rules could really be called such.

Does letting the insurance companies get their fingers in every little aspect of individual lives actually make anyone healthier, safer, or more responsible?

I hate to be rude, but use your common sense --

When was the last time society was benefited by someone, or by some group, asserting they should be allowed to play God?

You say the rules aren't that bad, but I'll point to some examples. Flu shots are considered a moral requirement in Japan, in no small part due to the social narrative from the insurance companies.

Do they work? For some people, they seem to work, but there is a growing percentage of people who have bad reactions and end up becoming seriously ill, permanently disabled, or dying. The insurance companies started backpeddling on this recently.

Surely things are not that bad in the US?

Vaccinations.

I am thinking of the children. Most vaccinations were recommended not to be given before six months or so for very important biological and medical reasons. It was not that they were not recommended before six months, they were recommended against .

But the pharmaceuticals salescrew works on the insurance salescrew and the staffs at hospitals, and "Oh! Let's just get them done with and over before the parents forget!"

And the vaccinations don't work like they used to. They change children's biology, and the new generation is, no, not superhuman by some chemist's accident. The new generation is susceptible to a new class of diseases that are harder to deal with.

Vaccinations are not the only problems here.

And, finally we get to the question of mandatory premiums.

I've been sidelined from my original career path for more than fourteen years or so. I've been working entry-level/temporary jobs, just barely making a living. I haven't been making enough to send my kids to school, and that fact makes me something of a social pariah in Japan.

I just crossed an age line three years ago where it has become difficult both to renew the contract, and to get a different entry-level/temporary job. I paid about \$150 yesterday for August's mandatory insurance premium when I don't have money for August's rent or next week's food.

Fortunately, because I live in Japan and not the US, I don't have to pay an additional mandatory premium to the fatherland. (Fortunately, somebody who wrote the law realized we expatriates would have good cause for class-action suit against the government if they tried to double-down on us.)

(JFTR, I'm writing this while I wait for a friend to give me permission to use her as a reference on a job application.)

There are a lot of people in any country who are physically healthy, who, for reasons they really don't control, are one step away from being in the sort of situation I am in.

Now do you understand why the question of mandatory insurance, and the ACA that underlies it, is considered "nuanced".

blip 07/29/2017
"Insurance companies are motivated to reduce risks" = not necessarily. Most of the revenue from medical insurance companies comes from group plans. They price group plans as they need to to make a profit. Risks go up? 没什么大不了的。 They just raise their rates. As for the companies with the group plans...rates go up? No biggie, they just raise the employees contribution amount.
1 Philipp♦ 07/29/2017
Welcome to Politics.SE. Please note that we prefer it when answers illuminate a topic from a neutral point of view. The tone of this answer is very opinionated and polemic.
2 Stilez 07/30/2017
First part: add 4) They suffered inhumanely, often through no cause of their own, and ultimately often couldn't "get back on their feet" or needed long term help they couldn't afford. So their lives, the lives of others, the economic burden to society if one only respects money, all lost out, often by very great amounts. Someone who couldn't afford good treatment for an injury often couldn't work, and to support them others couldn't work as much. Not just "they died or got on their feet". (Cost to society of a larger-than-needed "have/have not" division, in all its impacts? Probably huge.)
1 GGMG 07/31/2017