The Affordable Care Act of 2010 has failed its name. As most could’ve predicted, anything to do with healthcare ends up being about the “payors,” or the insurance companies and not the patients. It’s maddening and out of control.
Millions of Americans purchase health insurance through the Affordable Care Act Marketplace that has promised coverage for essential care. This number has risen as employer-based insurance plans are becoming less frequently offered by small and medium-sized businesses as employee benefits.
Why are health insurance benefits becoming out of reach for both employers and individuals who have access to the ACA Marketplace?
Participation in ACA increased, especially around the years following COVID and the simultaneous trend to offer no healthcare benefits in jobs or only very high deductible plans. These high deductible plans essentially mean the average patient pays cash for care unless they have a catastrophic surgery or illness that costs $10,000 or more.
According to the Centers for Medicaid Services (CMS), those who enrolled and paid for their ACA plans numbered:
• 10.4 million in 2016
• 11.7 million in 2021
• 22.1 million in 2025
• 19.2 million in 2026
The downward trend in the last year is due to premium increases of about 15%, the same amount premiums are expected to rise for the 2027 enrollment year.
Two years of double-digit premium increases for insurance companies is not affordable care with an increase in price of more than one-third in just 24 months.
Employer-based insurance plans have risen 24,8% for individual coverage and 26.5% for family coverage from 2020 through 2026, according to the Kaiser Family Foundation.
There is no affordable care anywhere! Health insurance companies claim the rising costs of hospital care, physician reimbursement rates, and pharmaceuticals justify the costs.
One of the fastest-growing spending areas in healthcare are the specialty drugs, like the GLP-1 drugs and “biologics” used for chronic diseases and illnesses.
Clearly, these premium increases far outpace wage increases that often just don’t exist in the world of part-time, side-hustle work that cause a person to work more than one job.
One key failure of health insurance premiums, whether ACA Marketplace or employer-based insurance, is paying only to manage treatment of injury, illness, and disease.
Prevention coverage has improved over time, sadly, as a result of mandated policies forcing some routine care coverage.
Chronic obesity, for instance, accounts for up to 70% of chronic disease spending as the underlying cause of disease and illness. Yet, health insurance plans must be battled for coverage and payment when healthcare providers attempt to address the underlying issue.
U.S. healthcare spending reached $5.3 trillion in 2024 which averages $15,474 per person and makes up almost 20% of the American economy.
Healthcare is big business with lots of “intermediaries” between a patient and their treating physicians and healthcare team. These intermediaries are adding a great deal of costs, along with the facts that pricing is still not transparent and competitive with hidden contracts.
Who benefits? Not patients.