The Dark Side of the “Good Old Days”

The cost of health care is hitting Americans hard. 

Premiums may be reasonable (or not depending on where you live*)- but the out-of-pocket expense for most people before they meet the high deductible of their insurance plan is new,
onerous, and maddening. (We will get back to those high-deductible plans in a future Fontenotes… promise).

It would be so easy to think warmly of healthcare before the ACA. Nostalgia for those “good old days” is the message behind attacks on the law, the President, and changes
throughout the health care delivery system- and our dissatisfaction is increasingly being fed by talking heads and politicians in this election season.

So I think it behooves us all to take a look- I mean a real look- at those sweet memories of life not so long ago when healthcare was easy to obtain for a mere pittance of a copay.


Other than the obvious fact that those good times did not exist for wide swaths of our population- like the uninsured working poor, the unemployed, or people who were sick- I question if they were ever actually as rosy as we think; as perfect as detractors from health care reform want us to believe.

Do those sound like fighting words to you?

In previous Fontenotes I reviewed a number of components that are included under “Insurance Reform” in the Affordable Care Act (ACA)- including the availability of insurance at no increased cost to people with preexisting conditions, access to preventive care at no personal expense, and the requirement that insurance companies invest at least 80% of premium dollars back into care of their patients (“Medical Loss Ratio”). [If you missed any of these they are all available on my website:]

You and I could argue if all those reforms were good for our country and/or you personally- I would fall on my sword to say they were on both counts.

But something much, much bigger happened with the ACA- and I defy any of you to argue against it: The insurance you pay for will now be there when you need it. That may sound like a little thing. It is not. 

We Were Never as Safe as We Thought

Prior to the ACA, Americans had been deluded for more than five decades into thinking that the insurance coverage that they purchased (or gained through employment) offered them protection from financial ruin resulting from a medical disaster.** This was always an illusion at best and a lie in hundreds of thousands of cases.

Insurance was a really great deal in a pre-ACA world- as long as you and your loved ones remained healthy. But the security of coverage often vanished if disaster struck. 

This was for two reasons. The first was that sick people often found out that their insurance coverage could be denied because the company could wiggle out of it under the terms of the contract. The second was that even if the company did pay the bills- their liability was limited under a lifetime cap. Either way people were left on their own under the worst of circumstances.

Let me explain how both were possible.

Because pre-existing exclusions were allowed before the ACA- if you ever got sick the goal of your insurance company was to see if coverage for a condition could be denied because it could be traced back into your past. This was not evil- this was good business. The net effect- however- is that when you got sick your old medical records were scoured for any proof that what was presenting now was actually a problem long before you were insured- and therefore not the company’s responsibility.

The result was people battling disease were simultaneously battling their insurance plans for assistance. 

Unbelievably for those of us (myself included) who were ever in that situation- that battle is over. Now that you can (and must) be insured regardless of your past health- your insurance company cannot use your history to deny you. It would be hard to describe the relief that brings to so many of us.

But again- in the pre-ACA days there was a second problem: Caps on coverage.

Even if an insurance policy did cover the cost of care- even if there was no way to deny payment based on your past medical history-  prior to the ACA most private insurance policies contained a lifetime cap on what the policy would cover.

The caps didn’t sound so bad when you signed up. A million dollars? That looked like a good risk to the average healthy and intelligent person. It was hard to know how rapidly that limit would approach when you needed coverage the most.

Having paid premiums year after year (whether directly or through their employment benefit package), an untold number of people fell off that insurance cliff. Families confronted with a disabled child, patients with significant head or neurologic injuries, and cancer survivors requiring years of costly intervention are all examples of patients who met their insurance cap in the middle of treatment. On the breath of a diagnosis or in a split-second accident the specter of running out of coverage was a reality for far too many people.

The ACA now prohibits two of the most significant risks of the old insurance system. The only reason all Americans do not celebrate this victory is most had not encountered [yet] these significant gaps in coverage that left others in despair- and financial ruin.

Under the ACA we are now truly insured.

In a post-ACA world we are actually secure in our insurance. We aren’t going to be dropped- not because of a comment in our records years ago-not because the needs of our family are catastrophic and huge. We are now- for the first time- actually protected.

So- am I going to reminisce about “the good old days” with so many of my colleagues and friends? Am I going to turn a blind eye as people argue we should repeal the ACA and get back to good times that never were?  No.

What Does This Mean?

* For more on the question is premiums are skyrocketing– See Fontenotes Number 10: Are Insurance Premiums Skyrocketing?

** What do I mean that insured people could still experience “medical disaster” prior to the ACA? Unpaid medical bills were the number-one cause of bankruptcies in this country prior to the ACA. I am not saying the law was a panacea- in fact the impact of the ACA is debated– but a study by the Commonwealth Fund in January of this year showed a decrease in the number of Americans reporting difficulty paying medical debt down from 41% of Americans (in 2012) to 35% (in 2015).