IAmA RAND analyst who studies the impact of the Affordable Care Act (AKA "Obamacare") on people, businesses, and governments. Ask me anything.

So, can I keep my health insurance?

It depends on how you get your insurance. If you get it from your employer, the law won't change that (though your employer might). If you get it on the individual market, you will have access to new types of plans and your existing plan might not be allowed (for example, if you have a very high deductible plan)

Is it fair to say, then, that Obama's initial promise when selling the bill ("If you like your insurance, you can keep it") was, although spoken with honest intentions, a bit misleading?

Those statements certainly did not capture all of the nuances of the law, but for most people with insurance, there won't be an impact.

Which talking point against the ACA is the least truthful/meritorious? And which has the most merit?

There are no death panels in the law.

You won't necessarily be able to keep your exact insurance.

What do you think today of the RAND Health Insurance Experiment conducted in the 1970s? The study, I believe, determined that cost sharing reduced overutilization, but also reduced appropriate/needed care. Is Rand planning a revised study with ACA data and Oregan data, and include the analysis on healthcare outcomes and the uninsured missing in the previous report?

How much savings if any would the US receive if an NHS model or even a Canadian-single payer model was implemented? Would drug price negotiation, non-employment-based insurance or something else help?

Why is the US so embattled over domestic issues while so apparently lax on military spending? A single aircraft carrier is $9B-$14B (why so expensive?) and in comparison, medicaid cuts in many populous states amount less than that.

Is there a wall of Nobel prize winners? Is A Beautiful Mind mandatory watching? Would you be burned at the stake if you said that you thought game theory was bunk?

Great questions,

The US is on a path to spending 20% of our GDP on health care. Most other developed countries spend less than 10%. So in is certainly possible that a different model could result in much lower costs. I haven't done the same level of analysis on applying these alternate systems to the U.S. and can't really answer that in detail.

I'm not sure if there is a wall of Nobel prize winners, though the wikipedia page has a wall of them. I suspect most people here have seen the movie but it is not mandatory (maybe recommended).

Thanks for commenting everyone, I appreciate your questions. You can follow me on twitter: @CarterCPrice and see my recent studies here: http://www.rand.org/pubs/authors/p/price_carter_c.html

I'm going to sign off now.

So in your professional opinion will the ACA have a net positive or net negative effect on employment?

It will vary substantially state to state.

Researchers at the Urban Institute found that it would reduce "job-lock" where people are locked into jobs because of the insurance only.

How does the ACA make hospitals more efficient? Are there any parts of the ACA informed by contemporary operations research?

The ACA has some parts that are designed to reduce re-admissions to increase efficiency.

I strongly think that operations research should be applied to health care systems (I wrote my dissertation in that area), but the law does not promote that directly.

Can you explain to me in a nutshell how anyone sees this act as unconstitutional? And since it was passed by our government why are they shutting down now? It just seems so childish to me the way the way the Republicans are acting, but I'm not very well informed on politics so I don't know. Thanks for taking the time to do this!

There were concerns that the individual mandate was not constitutional because it compelled people to buy a product, though SCOTUS ruled that it was OK. They did strike down the Medicaid expansion piece of the law as it was written because it was coercive to states (http://www.rand.org/pubs/research_briefs/RB9706.html).

I can't comment on their motives for shutting everything down.

What would you say to small business owners who are worried about the effects of this law? Are there certain small businesses that would end up shutting down or become unprofitable because they have to provide health insurance?

Small businesses are not subject to the employer mandate and will have access to insurance exchanges. This could reduce the volatility in their premiums if they offer coverage.

It is unlikely that small businesses will shut down because of this law, because they are not required to provide insurance (only firms with more than 50 full time workers are required to provide insurance)

How does the obamacare act compare to the healthcare legislation seen in Europe. Take for instance the Netherlands, a country that was known for affordable healthcare. Where do they differ and where are they comparable.

berendho, This is a little outside of my area of expertise (I know a lot more about the U.S. health care market than that in other countries).
Most of those countries have a single payer system which removes some of the business costs related to health care delivery.

What is the likelihood that any large employers will terminate employer-provided insurance coverage entirely, in favor of a defined contribution model (either through a private or public exchange)?

Some may do this. Though, because health insurance is tax advantaged we don't expect many firms to do this. http://www.rand.org/pubs/research_reports/RR411.html

http://www.rand.org/topics/employer-sponsored-health-insurance.html

What about non-profits with thousands of employees that may not see a tax advantage to continuing to provide health insurance? Do you expect these types of employers to drop insurance benefits?

This is a really good question.

Non-profits won't get the same kind of tax advantage that a for-profit firm gets (though their workers will get the tax advantage). Additionally, non-profits still compete for workers and if they stopped offering insurance they would be at a disadvantage for good workers (though the competitive mechanisms would be different than for-profit firms).

We haven't looked specifically at non-profits firms propensity to drop under the ACA but it is likely that the impact would be more a function of the demographics for their work force than for other reasons. This would certainly be an interesting research question.

I know this is supposed to revolve around Obamacare but I am curious to hear from a mathematician..

What are your feelings toward an undergraduate degree in Analytics/Statistics?

Thanks for asking, I think it is generally a great idea. Those majors provide a broad set of skills that can be applied to many fields.

On that note, are there any ways for an undergraduate working toward an applied math degree can get involved with RAND Corporation? In particular any relevant internship or entry level positions that do interesting analytical work?

RAND has a summer associate program for graduate students, but I don't think there is one for undergraduates (you may want to check the job website). I suspect that other organizations have programs for undergraduates you may want to look into.

Hello Mr. Price, My question is I am a 24 year old male living in New Jersey and I currently purchase insurance for ~$200 a month, I also only make <$11,000 a year. I am fortunate enough to live with my parents so I do not have rent to pay. If I am eligible for the expanded Medicaid program will i have to give up my health insurance, or will I be able to keep it and receive a federal subsidy?

Thank you

If you're eligible for Medicaid, you'll have the option to go with that. You aren't eligible for a federal subsidy on the marketplace, nor could one be applied to your existing plan.

This is also true

If you make less than <$11,000 you are likely eligible for Medicaid but that might depend on if your parents count you as a dependent--you may want to talk to a navigator for your specific situation. Alternatively, since you are under 26 you should also be eligible to stay on your parents' insurance if they have insurance (that part of the law has been in effect for a while).

How is the ACA likely to affect insurance companies' profits? What about the availability of doctors? Are there estimates for the number of people who will choose to remain uninsured in favor of paying the penalty?

Insurance companies will have many new customers but have a cap on their profits, so it isn't clear what the net effect on there profits will be.

There will be an increase in the number of people covered but most of these people won't use a lot of more coverage. My colleague David Auerbach just wrote about this: http://www.rand.org/blog/2013/09/will-aca-implementation-lead-to-a-spike-in-demand-for.html

There will be somewhere around 20M people without insurance even with the ACA, but many of them will be undocumented immigrants. There will also be a lot of low income people in states that don't expand Medicaid that remain uninsured (~4M). http://www.rand.org/pubs/research_briefs/RB9706.html

Is it more cost effective for each state to expand medicaid or to push the poor, who qualify for fed subsidies, into the exchanges.

We have looked at this for several state. It is generally in the states best interest to expand Medicaid. There is a cost to the state, but the state will "pay" (They can opt out of Medicaid but not the taxes, fees, etc. that pay for the ACA) for Medicaid regardless of whether or not they expand.

Hi, Dr. Price. If I live in a state where the federal government will be putting the health exchange in place, will I see fewer benefits than if the state had done it?

Also, do you have any sense of the uptake on the exchanges, i.e., how many people will enroll and get covered? Some news reports seem to suggest people do plan to enroll rather than paying the penalty. If so, have you looked at whether the added expense will be manageable for most American households? Obviously, catastrophes are expensive, too, but is there some truth to the idea that insurance coverage is simply unaffordable for some, or maybe even, many families?

Finally, Republicans are asking the president to delay the individual mandate for a year in order to get the gov't funded. Even if it doesn't happen this time, they may bring back that demand during debt ceiling negotiations. If they were to delay the mandate a year, what would the likely effect be on the number of insured, or, failing numbers, would there be a substantial reduction in the number of people enrolling in the exchanges, in your opinion?

You won't see fewer benefits because the federal government is running it, though states that run there own will be able to make some changes that might better fit there state (e.g. how the individual market relates to the small group market).

Our estimate is that around 20M people will eventually enroll on the individual exchanges, though it is really hard to guess how many will show up in the first year.

We looked at eliminating the individual mandate a while ago and didn't find it having a huge effect (http://www.rand.org/pubs/technical_reports/TR1221.html). Mostly because the penalty is not actually that high.

What does RAND think of a universal single payer system?

I don't think we have done much work in that area.

Listening to NPr the other day I could not help but think obamacare is a scam where middle men make money. The coveredCA.com site sounds like a broker only that will present plans that if you do not purchase one - you get a tax penalty. Further, many kaiser users called in and stated their premiums went up as much as 91%.

Also, if you're going to fine people who don't get coverage why not just tax them the cost of the coverage and provide actual coverage.

This whole thing is totally shady.

The law caps insurance company spending for costs other than reimbursement which should reduce the cut of middle men.

Does the ACA make individual purchases of insurance tax-advantaged like employer plans are?

No, that is not part of the ACA

I hope it's not too late to participate, but I was wondering if you had any advice on actually becoming a policy researcher.

Currently, I am an undergraduate with the hopes of being able to immediately advance into a PhD program. The opportunities at my university to ground myself in statistics have been limited, so I have been doing extracurricular research with a professor for the past year. With his help, I am currently working on dynamic models such as instrumental variable analysis as well as Stata programming. Still, I recognize that most of the foundations I need to comprehend the logic associated with models is lacking.

What can I do or read to supplement a master's degree for PhD candidacy? What are some avenues I should take to hopefully secure a paid research assistant position before then?

I would recommend following policy debates closely, particularly in the policy areas that interest you most.
Most think tanks have internship programs (I was a summer associate at RAND one summer in graduate school) that can help you learn about policy research.
You also may want to read through some of the reports form whichever organization(s) you think would be the best fit for you to get a feel for the types of research they do and the methods they use. Good Luck!

1. Do you think the lower medicare reimbursement rates are going to stick? If not, how much is that going to cost?
   
2. What do you read to stay informed about what's going on with ACA? Are there good health care policy-focused blogs?
   

Good questions, 1. I'm not sure if they will stick, but the change in reimbursement is the biggest part of the spending offsets in the law. If they went back to pre-ACA rates it could be several 10s of billions of dollars.

1. I follow a lot of good folks on twitter: @onceuponA @sarahkliff or me @CarterCPrice You can go to http://www.rand.org/topics/patient-protection-and-affordable-care-act.html for RAND work on the subject. You can also go to http://thehealthcareblog.com/

The RAND HIE is still the best randomized experiment of its kind and the only real source for information about how people will respond to changes in their spending. We have factored in the information from the Oregon data into our current modeling on the ACA.

First, you should reply to the person asking the question so that we know what answer goes with what question and they can both be up or down voted on together.

2nd, What is RAND's pony in this show? How is the RAND corporation relevant to our lives nowadays?

ScannerBrightly, RAND is nonpartisan but you can see our work on the RAND website.

How is RAND relevant: http://www.rand.org/about/glance.html