March 18, 2017
In the midst of wiretapping accusations, hysteria over ratings for “The Apprentice” and a revised immigration ban, you might have missed the House Ways and Means Committee’s quiet approval of a bill to repeal the Affordable Care Act (ACA) in the early hours of March 9th. After 17 hours of debate, the Committee formally began the process that has been the subject of Republican fever dreams for the past seven years. “Obamacare,” the controversial, sweeping legislation that had the nerve to dream up universal healthcare for all Americans, is now on the chopping block. Coinciding with this development was the public release of the American Health Care Act (AHCA,) the GOP’s replacement plan that I might call “Trumpcare” if only our president had had more of a role in crafting the bill beyond professing its complexity.
The AHCA is somewhat of a partisan measure aimed at undoing one of Barack Obama’s signature achievements as president. It also addresses some aspects of the law that have been deemed less than satisfactory by conservative lawmakers. It’s necessity, however, is questionable. Republicans, already staunch opponents of the law by virtue of its nickname, seem more concerned with getting rid of it than assessing its viability.
I believe in the Affordable Care Act. It has drastically reduced coverage gaps, largely eliminated discrimination in healthcare against those who need it most, and provided reasonable checks on insurance companies who previously were able to exclude the poor, old, and sick from their plans without penalty. True, it does have flaws (many of which, I would contend, can be traced back to Republican-controlled states’ refusal to comply with some of the law’s measures,) but I do not think these drawbacks necessitate abandoning the entire system.
What is interesting to note is that the AHCA actually maintains most of this existing system. It keeps the ACA’s pre-existing conditions stipulation, allows children to stay on their parents’ plan until the age of 26, and maintains the provision that insurance companies cannot put a cap on lifetime spending, meaning that no matter how much your treatment costs, insurers cannot put a ceiling on the amount they will cover.
For the purposes of this article, however, I do not want to focus on the relative strengths and weaknesses of each bill. Instead, let’s talk about an oft-overlooked aspect of this issue—the general apathy of young people when it comes to health insurance. The healthcare debate is arguably the most complex of all the current major national discussions, but that is not an excuse for college-aged students to ignore it. While the bombast and posturing surrounding the ACA can seem alienating to the average young person, it would be a mistake to allow healthcare to become a topic understood by only the experts and those who are immediately affected by changes in policy . It may be convenient for college-aged Americans to ignore the debate by virtue of their well-being, but it is important to remember that health is far from assured, no matter your age. Understanding the healthcare debate and how proposed policy stands to affect you in later years is crucial to leading a healthy life and helping maintain a stable system of care.
First, what has been the effect of youth apathy on the ACA? In short: damaging. Even though the Commonwealth Fund reports that the uninsured rate for US adults between the ages of 19 and 34 has dropped from 28% in 2011 to 18% in 2016 (thanks, Obamacare), healthy young adults are hurting the market through lack of participation, which in turn has driven up premium costs for the older and sicker groups. The Congressional Budget Office found that the “most significant factor behind [rising healthcare prices]” was the millions of young people who have not signed up for plans under the ACA. The structure of the law puts a greater financial burden on insurance companies by forbidding them from discriminating against those who will need the most support, such as the elderly and those with pre-existing conditions. Also, it prevents these companies from driving up costs as you get older, mandating a “3 to 1” ratio that essentially says older age groups cannot be charged more than three times their younger counterparts on insurance plans. To balance out the greater costs, the ACA created the individual mandate, which compels everyone to buy an insurance plan by levelling a tax penalty against those who choose to remain uninsured. That way, just as many healthy, young people would enter into the coverage pool as those who are likely to incur more costs, which theoretically balances out the entire system.
Unfortunately, this “coveted” 18-34 demographic has underwhelmed in their ACA enrollment during the law’s first few years. Modern Healthcare reports that between 2014 and 2016, this group made up just 28% of all enrollees, well short of the 40% level that experts say is needed to create a stable market. There are plenty of explanations for why it has been so difficult to entice young people to join the marketplace (look up “adverse selection” if you are interested,) but the overarching reality seems to be that younger, healthier Americans are willing to roll the dice on their coverage in order to avoid paying for an insurance plan. Even more troubling is the idea that this aversion is being caused by a simple lack of understanding around how to get insured. Doug Hough, a healthcare and behavioral economist at Johns Hopkins University, says, “It's one thing to buy a subscription to Pandora, but it's something else to figure out, 'I have to buy health insurance. Which plan am I going to buy?'” Young people need to start learning about healthcare, and even though it may not be as accessible as other policy issues, the benefits that can be gained from doing so outweigh the costs of any additional effort.
Then again, why listen to me? I am still on my parents’ plan and will not have to worry about getting insured for more than six years. I am guessing the same is true for many reading this article. Healthcare, like buying a house or starting retirement savings, is distant and lacks any feeling of urgency.
If you are thinking this, do not listen to me. Listen to Andy Slavitt. He is the former Acting Administrator of the Centers for Medicare and Medicaid Services. From 2015 to 2017, he led the organization that ran Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act marketplace. He was also a key figure in righting the Obamacare ship after its initial technological glitches. Not only is he among the most educated and experienced healthcare experts in the country, but he has also made it his mission to make healthcare accessible to the average American. When I asked him about the challenges of convincing young people to engage with the healthcare issue, he said that “getting people who are younger to think about healthcare was always going to be an uphill battle.” In his view, one of the main reasons for this apathy is short-term memory. He says, “Young people don’t remember that [before the ACA] healthcare used to be a primary cause of personal bankruptcy.” The aforementioned “lifetime cap” and pre-existing condition discrimination by insurers made healthcare unreasonably expensive. Now that the ACA has done away with those issues, healthcare can be taken for granted by those who do not immediately require it, which, in most cases, is true for young people. Slavitt emphasizes this point by comparing health insurance to fire insurance. “You don’t expect your house to burn down in a fire,” he says, “so it can be tempting to just not buy that insurance.” However, “in order to sleep soundly at night, you do so.”
Slavitt also tempers the notion that young people are solely responsible for rising premium prices. He explains that older people who are healthier but would have to pay more for their plans have gambled and held off on buying plans. Also, he says the risk pool turned out to be “sicker than people thought” and “employers didn’t kick people off their work plans as expected.” Even so, while America’s youth may not be uniquely culpable for issues in the insurance marketplace, added participation from this group would only benefit the country as a whole.
One of the main hurdles insurers face in attempting to attract this demographic group is a lack of knowledge about coverage options among young people. Slavitt says that many who are just beginning to think about getting insured are not asking the right questions. More often than not, they only look at what they willl pay per month on a plan. The better question, he says, is, “What will I pay over the course of the year?” This thinking better encapsulates the costs that can be hidden on a month-to-month basis, such as varying premium and deductible rates. Also, plans vary between genders. “If you’re a woman, you have to be aware that you could be charged for things men are not,” Slavitt says. “Pregnancy and contraceptive coverage need to be accounted for.” Learning about insurance coverage and the nuances of healthcare law will help young people make the best decisions for their plans, but these pursuits need to tackled sooner rather than later. In a constantly evolving market, awareness is key and apathy can be killer, perhaps literally.
Now, more than ever, young people need to start thinking about healthcare. The Republicans’ new proposal would have little to no effect on costs for the young, healthy, and rich, but could be disastrous for individuals who lack even one of those variables. “If you stay healthy, you don’t have to pay much,” says Slavitt, “but if you get sick, be ready to start paying more.”
Currently, the healthcare debate is dominated by partisan politics. In Slavitt’s words, “Healthcare makes a great political football unless you need it.” If you are a young person and wait until you desperately need healthcare to join the debate, it will be too late. The time to learn and participate is now, even if that does not necessarily involve buying insurance (yet).
Fortunately, there are many great—and underused—resources available with the specific aim of getting young people engaged in the issue. The first place to start? Slavitt’s Twitter account. Search for “@ASlavitt” and click follow. You will be able to learn about the subtle differences between the ACA and AHCA, as well as the fundamentals of American healthcare in the 21st century. It is accessible, engaging, and visually stimulating (and Mr. Slavitt will often reply if you ask him a question). Prefer to keep social media a meme-only zone? That is fine. Head over to health.younginvincibles.org. Young Invincibles is an organization dedicated to “representing the interests of 18 to 34 year-olds and making sure that our perspective is heard wherever decisions about our collective future are being made.” They focus specifically on the healthcare debate and have countless resources to help you learn about the issue, make your voice heard, and even select the best insurance plan. Additionally, Slavitt says that any state healthcare website has the basic information a young person needs to have as he or she begins to think about signing up for an insurance plan. “Most importantly,” he says, “stay tuned. Things can always change.”