It took just a few minutes for the Affordable Care Act to feature in Sunday’s presidential debate between Democratic nominee Hillary Clinton and Republican nominee Donald Trump as Trump quickly blamed the legislation for the rising cost of health care.
“When I watch what’s happening with some horrible things like Obamacare where your health insurance and health care is going up by numbers that are astronomical,” Trump said, adding that costs have gone up as much as 71 percent.
The Trump campaign has not said where he obtained his figures. But even though premiums are rising, the effect is concentrated on plans sold on the individual market — not those that are provided through an employer.
Rising premiums on Healthcare.gov capped by subsidies
The 12.7 million people who enrolled in coverage on Healthcare.gov last year make up a small portion of the population, but their insurance costs seem to be the most in flux.
“That simply may be that health insurers don’t know how to price policies yet," said Sidney Watson, a health law specialist at Saint Louis University. "They don’t really understand the risk pool; they are learning trial by error.”
Her research shows that the premium changes vary widely from city to city. In Missouri, last year pre-subsidy premiums for the benchmark plans rose by more than 20 percent in some areas, but declined in Hannibal, Missouri. Because the state did not have a rate review law until this year, the expected costs of plans on the exchanges won't be available until they are released later this month.
In Illinois, this year’s rate increases are expected be particularly high, averaging 43 percent for the benchmark silver plans. Blue Cross Blue Shield, the state’s most popular insurer, has proposed a rate increase of 51.3 percent for individual plans. (Rates affect premiums, but the two are not the same thing).
The amount of competition in each market also is becoming tough to predict. UnitedHealthcare, Aetna and Coventry have signaled their plans to exit the exchanges in several states, citing losses. In Illinois, the situation is particularly dramatic: while the state had nine insurance carriers in 2016, only five will remain for the coming year.
The Obama administration has argued that income-based subsidies will protect most consumers from the rising costs of premiums on the exchanges. But Dr. David Hyman, a health law professor at the University of Illinois, said that line is misleading.
“Even if the individual that’s purchasing care is subsidized, so they don’t see the full increase, the taxpayers are," Hyman said. "So we are collectively bearing the dramatically increased costs, relative to what they were in the prior year, which might have been lower than they should have been.”
Premiums for employer-based coverage rise slowly, but deductibles skyrocket
Despite the increases in premiums on the exchanges, the challenge isn't as dire as it appears, said Wendy Netter Epstein, director of the Jaharis Health Law Institute at DePaul University.
“Because across sectors — including the employer based insurance and public insurance — health care costs are actually increasing at a much lower clip than they were increasing prior to 2010 with the passage of the Affordable Care Act,” she said.
Though plans on the exchanges get the most attention, employer-based insurance covers more than half of U.S. residents.
Average premium costs for employer-sponsored family health plans have risen 3 percent since 2015, according to an analysis by the Kaiser Family Foundation. Premiums have risen 20 percent since 2011, the first full year of the Affordable Care Act’s implementation.
One way employers have avoided raising premium costs is by adding higher deductibles to the plans they offer, which ask employees to pay a certain amount of money towards their care before the plan will cover any medical expenses. A 2015 Kaiser Family Foundation survey cited by NPR’s fact-checkers showed that the average worker has to pay $1,077 before their health plan chips in; an increase of 67 percent since 2010.
Trump, Clinton differ on strategies forward
Both Clinton and Trump have released proposals for the health care system if they are elected: Clinton said during the debate that she would “save what works” about the Affordable Care Act and expand it, while Trump favors repealing the law and replacing it with a block grant system. (A side-by-side comparison of the two candidates’ health policies can be found here).
Click here for a full transcript of last night’s debate, and fact-checks from NPR reporters and editors.
The Healthcare.gov exchanges open to sell individual and family plans for 2017 on Nov. 1. The third presidential debate will take place on Oct. 19.
Follow Durrie on Twitter: @durrieB.