I'm Jon Cohn, a senior editor at The New Republic and I know LOTS about Obamacare. AMA!

Non-American here, how is Obamacare even an issue that causes an entire country to shutdown? Seriously, the rest of the first world just doesn't understand how any person who has emotions, empathy for others or a soul could say affordable healthcare is a bad thing.

I get this question every time I go overseas.

I wish I knew the answer.

I'm a student at Penn State. In light of the ACA, the university issued a new rule that no student could work over 20 hours/week and could no longer hold 2 jobs in the university. Some of my friends rely on working more to pay for rent, tuition, etc and are now worried about money. Do you think that many people will be affected in a similar manner?

I hear you and would like to hear more about your situation. Tweet me at @citizencohn

As I've said elsewhere, I think this problem isn't as prevalent as media accounts of suggest, but it's obviously happening and something that, ideally, the parties could get together and figure out a way to fix.

All reforms have come with tradeoffs -- when they introduced minimum wage and child labor laws, for example, some companies laid off workers because complying meant paying more. The goal is to maximize the upside and minimize the downside, and in this case I think the upside -- more widely available insurance, including for part-timers -- is huge. But, as I've said, that doesn't mean a lot if you were counting on that extra money and can't get it. This is why ACA, like all laws, will need refinement and improvement.

Hope that's helpful (and honest).

Several companies have announced that they are dropping workers' hours to get below the 30 hour a week threshold that requires them to offer health insurance. Is there any possibility that this threshold will be tinkered with to allow more workers to use exchanges and to prevent companies from targeting it like this? What was the point of this threshold in the first place? Why not just allow everyone to use exchanges?

This is a really interesting and important question, one I addressed at some length in an article I wrote a few weeks ago.

Quick version: Most of the experts I have consulted think this isn't happening much. The aggregate data just don't show a major change in hours worked, particularly in the context of such a large economy with so many other larger forces pushing on it in different directions. That said, it's a big country. Something that affects only a minor portion of the population might not be enough to register on national economic statistics, but it can still make a difference to thousands or tens of thousands of people. I've seen enough anecdotes to think that may be happening here.

The employer requirement has never been popular with the policy wonks. But it does generate a decent chunk of revenue, to offset the law's costs. Get rid of it, and you have to find a substitute -- or tolerate higher deficits or give less help to people.

In a less dysfunctional political environment, this is precisely the sort of thing lawmakers could fix easily. But for that to happen, both sides have to be willing to talk. Obama and the Democrats have made clear they are willing to do so, but first Republicans must give up their attempts to undermine the law (and shutting down the government if they don't get their way.)

Should the law include a provision for the employers to pay a penalty proportional to the number of work hours a week for every employee to demotivate this part time tactic?

I've heard that suggestion, haven't spent enough time on it to know whether it would work.

Do you have any critiques about Obamacare? After reading through this, your answers, while incredibly informative, only tell one side of the "story." Obviously, you're in support of Obamacare, but, just as obviously, tons of people aren't. Can you lay out some critiques of Obamacare that are accurate without the positive spin? To truly understand something, we need positives and negatives.

Thanks for the AMA!

5 things I don't like about Obamacare

1. It won't insure everybody and even those people getting insurance will, in many cases, have higher out of pocket costs than I would prefer.

2. It's awfully complicated, which is one reason it's so hard to get the technology right.

3. It relies a lot on market forces to cut costs -- and I don't always trust the way that will work out.

4. I think government can do a lot of good, but sometimes government really is wasteful -- and I'm sure we'll see examples of that as we go forward

5. I've grown more skeptical of the employer requirement and would be up for junking or modifying it, as long as the replacement restores the revenue and doesn't cause more harm.

What is your best guess as to where this government shutdown mess goes from here?

My crystal ball on politics is notoriously bad, so I hesitate to make any predictions. My gut tells me the Republicans will have to concede on Obamacare and not get much in return. But it might be a while.

What exactly does the government shutdown mean? Sorry if this is off topic but I'm just curious to find out from someone who is well-informed

There are no stupid questions. My colleague Mimi Dwyer has the answers for you.

I don't know much about the ACA, but I was in class earlier and another student criticized it as foolish because the government "has no money." What is the relationship between the ACA on one hand, our current levels of government spending, and our national debt? (I guess that makes three hands). Also, I see you are from Ann Arbor..Go Green!

Another excellent question. According to Washington's official scorekeeper, the Congressional Budget Office, the Affordable Care Act will reduce the deficit.

Here's why:

Under the law, the government must spend more money. Most of that money will help people get health insurance, either by giving them Medicaid coverage or providing them with tax credits to help them buy private insurance. (There's also some extra money for seniors, so they can get more help paying for prescription drugs.)

But the law also reduces what the government spends, mostly by reducing what Medicare pays for goods and services. It also raises some new funds, primarily from a new tax on very wealthy Americans.

Think of it as a ledger. There's money on the negative side (new spending) and money on the positive side (spending cuts and new taxes). The positive side is bigger than the negative side. Hence, the deficit comes down.

1. I work at a high school and have great, really affordable health insurance through the school district. Will my healthcare be changed at all by this law?

2. Are members of Congress ACTUALLY exempt from this law, or is that just a taking piece for the GOP?

Thanks so much! I was hoping I would find something similar to this on Reddit

[deleted]

Glad you asked, because this question gives me a chance to make a very critical point...

Did you mean will Obamacare change employer-based health plans? If so, then my answer is not really. At least in the short term, I don't expect the law to cause many visible changes to employer coverage. There will be some new protections -- no lifetime limits, ability for parents to enroll their young adult children -- and some small, frequently one-time costs associated with those. . But it's minor stuff financially.

But that's not what you actually asked. You asked me whether current employer-based health plans are going to change. The answer is most definitely yes -- because they were already changing.

I can't emphasize this enough. Our health care system was changing long before Obamacare came along -- and many of those changes are going to continue to take place. When you read about a company making this or that cut -- for example, companies changing options for retirees -- it may have nothing to do with the new law. (That's true even if the companies say ACA is the reason for the change; they may be using it as an excuse.)

Hi Jon! Thanks for agreeing to do this AMA.

As best I can understand it, the long-term success of the ACA is contingent on convincing young Americans to sign up. However, some recent research suggests that more than 3 million Americans ages 18-34 will be at least $1000 better off today by paying the penalty, and that the lifetime cost of Obamacare is higher than under market-driven premium rates.

http://www.nationalcenter.org/NPA652.html

Can this adverse incentive be fixed? Is it possible for Obamacare to be reformed in the long run such that it is a cheaper alternative for young people than the current market? How could this be done?

I think young people are going to be a lot more enthusiastic about Obamacare than the critics expect. Thanks to the subsidies, it's a really good deal for many. And it's not like they need to get huge numbers to sign up right away. It's all about the ratio. Projections suggest about 7 to 8 million people will sign up for the exchanges in the first year, which means they probably need about 2.5 million young people to sign up, just to keep the actuarial balance stable. But those aren't hard numbers and if they are higher or lower at the end of the year it's not that big a deal, as long as over time they get young people into the pool. For more details, see (Six Reasons Hipsters Will Bite on Obamacare)[http://www.newrepublic.com/article/114103/obamacare-and-hipsters-6-reasons-theyll-proabably-enroll] -- an article I wrote over the summer.

But how is this going to be a good deal? As a young, healthy male, my annual medical expenses total in the "dozens of dollars" range. At the cheapest 'bronze level' of coverage offered, that's going to be $840 worth of insurance I'm going to have to purchase annually, and my expenses won't even touch the deductible. So I'm being asked to pay hundreds of dollars and receive essentially no benefit?

Edit: thank you for the gold, kindly stranger. I don't feel my comment was especially insightful, but hopefully it garnered some good discussion.

With all due respect, I would say you get a benefit for those $840 -- a very substantial and important benefit. It's the knowledge that, should something happen to you, you won't have to face tens of thousands of dollars in medical bills. I certainly hope that doesn't happen and, given your age and health, it probably won't. But anybody can get sick and anybody can have an accident.

Do you think a single-payer system could be passed within the next 50 years?

50 years is a long time and I'd like to say yes, because I'm a single-payer fan and wish we had one here.

But it will always be tough in our political system. I suspect the best hope is that some states use the law's flexibility to try scaled-down/modified versions of their own. That's sorta what Vermont hopes to do.

BTW, I'm surprised conservatives haven't thought about this more. The same flexibility that allows liberals to dream of trying out single payer on a state level ought to allow conservatives to dream of trying out their plans on a state level. If I were on the right, I'd be working up proposals for that now.

Reposting my question!

Could you explain more about payment models (fee for service, capitation, bundled payment), how it exists in the pre-ACA healthcare world, and what, if anything ACA does to [possibly] change this arrangement?

Thanks for asking and I'm sorry it took me so long to get to your question, which is really important.

For the sake of readers who might not be familiar with the issue and terminology, traditionally the dominant way of paying for medical care in this country has been "fee for service." And it's just like the term sounds. Insurers -- whether public (like Medicare) or private (like Cigna, Aetna, Blue Cross, etc.) -- would pay more or less whatever the providers of medical care charged. This was very much by design. The original insurance plans in this country were started in the 1920s and 1930s by hospitals, in order to make sure patients could pay their bills. The architects of these plans didn't want anybody scrutinizing the bills. And that model stuck around for a long time.

But from the beginning there were attempts to make payments in different ways -- in effect, by giving the providers lump sums of money, for each patient, and then letting providers figure out the best way to spend that money. Early attempts at this trace as far back to the 1920s and 1930s too, and eventually evolved into the "group practice" plans you find today in places like Seattle (Group Health Cooperative of Puget Sound) and California (Kaiser Pemanente).

While not everybody loves these places -- Kaiser certainly has its critics -- most experts believe they really do a great job. They tend to be cheaper, since they don't have incentive to perform more and more procedures and tests. They also tend to provide better care, since they do a really good job of keeping track of people, focusing on prevention, and making sure patients are under the care of teams of providers (not just doctors, but nurses, medical assistants, rehab specialists, etc) who communicate with each other constantly.

For a while now, there's been a push to get more people into plans like these. But it's been difficult to do, for a whole bunch of reasons. Obamacare is trying to make this transition happen -- by , among other things, changing the way Medicare pays for treatments. The hope is that the changes in payment will reward both providers and plans that develop and use these models -- and that, over time, patients will gravitate towards these plans becuase they really are cheaper and better.

But this is going to take some time. It took decades for the system to get so wasteful and expensive and dysfunctional. It's going to take at least a few years, probably many years, to unravel the mess.

Why do you and Avik Roy disagree so much?

He's a smart guy and he knows a lot more than I do about some things, particularly when it comes to drug industry. I respect that. We also have some philosophical differences. I respect that too. I thought some of his analysis left out important details and I said so, but I've also learned from him, as I do from many people on the right.

He's a graduate of the University of Michigan. I live in Ann Arbor and my wife is on the faculty, so I've adopted the school. So we agree on one thing, at least: Go Blue!

BTW, Avik and I are going to be having a live, one-on-one debate at UM in November. I am hoping the New Republic can carry a webcast. Should be fun!

Hi Jon,

I think what might help most people is a quick rundown of what Obamacare is. On reddit, people sometimes add a summary of a post using a term "TL;DR" meaning, "Too Long, Didn't Read." It ends up being a couple sentences making broad summarizations. Many people don't have a ton of time to devote to understanding everything and these small summarizations are what the majority of people learn about a subject. If you could summarize what Obamacare in a TL;DR, what would it be?

Obamacare in two sentences:

1) It will make sure almost every American can decent, affordable health insurance -- primarily by expanding Medicaid and setting up marketplaces for people who don't get insurance from employers

2) It will start to change the way we pay for medical care, so that it delivers better quality for not quite such high a price

Obviously that simplifies a great deal -- it describes the goals, but not the mechanisms for achieving them. And conservatives would insist the law will accomplish neither of those things. But that's the gist.

Thanks for coming here! Is there much actual evidence that companies are significantly reducing hours because of the 30-hour definition of full-time employees? If so, is that necessarily a bad thing? Trader Joe's released their data showing that many employees will be better off (after the $500 bonus and subsidies). Would you support changing the requirement to units of 30 or 40 man-hours, rather than a per-person requirement?

I think there's some evidence that it's happening, less than the media hype suggests -- more in this article

To have it out there, The New Republic is a left-leaning magazine, roughly analogous to Der Spiegel. So this will be from the perspective of someone who is a fan of the ACA.

Totally fair. My support for universal health care generally, and ACA specifically, is well-known. That said, I try very hard to be candid and report the facts. I have no problem writing about ACA's deficiencies and problems, for example -- or acknowledging that some conservative arguments are correct.

Have you looked at other countries health care and what the US can do to improve its system? When ever a health care debate comes up, I mention three countries - Norway where everything is covered - so the system is over burdened with unnecessary scans and tests. The US where if insurance doesn't cover it you won't get tests or scans and lastly Australia. A mixture of both. Australia I recently learnt only passed its new healthcare reforms in the 80s.

Thanks for the question. Yes, I've spent a lot of time studying other countries. And that includes time abroad studying some of these systems up close -- in particular, the Dutch and French systems, which I frequently praise. I wrote about the Dutch system for the Commonwealth Fund, which sent me there to study it, if you want to learn more. But other countries have good models too.

Of course, nobody's system is perfect. And if you talk to people in those countries, you'll hear plenty of complaints -- many of them similar to the ones you hear in the U.S. But looking at the data, and comparing the stories, I think it's a slam-dunk that they are doing better overall than we are.

You're an awesome dude, uh...economic question, economic question...fuck it.

Favorite sandwich at Zingerman's?

I'm partial to Dave's Open Road, hold the Ranch, and Big Al's Saturday night. Professor Mrs. Citizen Cohn is more of a traditionalist - she goes for Lisa's Boisterous Brisket.

I remember reading somewhere that ACA has a lot of initiatives aimed at bending the cost curve of health care beyond simply paying for less and different treatments. Can you elaborate on what some of these measures are? Do you think these efforts will bend the curve down to a sustainable level?

There are a ton and it's hard to list them. That's sort of the point. There are lots of ideas out there -- ACA's architects figured they'd try as many as possible, in quasi-experimental form, and then double-down on the ones that work. Like throwing a bunch of stuff at the wall and seeing what sticks.

An easy one to explain is the new penalties for in-hospital infections. Hospitals should be able to reduce in-hospital infections through relatively simple steps. That should make people healthier and save money. The hospitals that do the worst on this will get a small reduction in what they receive from Medicare. That threat, hopefully, provides incentive for less safety-conscious hospitals to clean up their acts. Literally.

Do you think that Obamacare will have a positive impact in southern states like Texas?

Definitely. But it would have a much bigger effect if Rick Perry and his allies endorsed the Medicaid expansion.

No question, just want to say that I've been reading you for years, and consider your writing on ACA and in general completely indispensable.

Very kind of you to say. I'll pass along your thanks to the rest of the staff here, from my superb editors to the tireless production folks to the incredibly diligent factcheckers. They do amazing work and get far too little credit for it.

Hello Jon Cohn, thank you for doing this AMA.

I believe I am a candidate that Obamacare was intended to help, but everything I have seen shows that I am about to get screwed next year. Could you please help me out?

I am 33 years old living with my parents while I go back to school in the down economy and get an education. I have made approximately $0 per year for the last three+ years. I am fully dependent on my parents right now.

Both parents are small business owners, and they have a lot of income. Both parents are small business owners and have a lot of expenses. Their incomes are high but their final take home dollar amount is not high. Every website calculator I have looked at indicates that I do not qualify for an exemption or major discounts, and that I will still have to pay a significant amount ($3,000 to $5,000 more or less) for coverage through Obama care, or pay a fine.

Am I missing something? Am I totally going to get screwed? Is there another option I could utilize that will save me money a significant amount of money, or better yet, is there an option where I pay nothing?

To give you an idea of how much financial hardship we're experiencing, this semester we had to choose between buying car insurance or me going to school; we chose me going to school. An extra few thousand could mean the difference between me going to school or not (community college.)

Thank you for your time.

Edit:

A lot of replies to this comment are saying effectively "That doesn't sound right." I AGREE! This seems really wrong to me. That's why I asked this question.

I don't make any money, but every website calculator I've used says I'm going to be forced to pay many thousands of dollars for health care or be fined for not buying healthcare due to the household I live in. Saying "This seems wrong" doesn't help me at all. I already know this seems wrong. I agree with everyone who says "this seems wrong." I'm not here to argue the politics, or say "This is a bad move for everybody" or be a figurehead in any political movement. My main concern is finding the most affordable way to survive next year while still continuing my education.

If you have legitimate information that can help me, I'll be all ears. But if all you can say is "This doesn't seem right, so you must be lying" (Note: Nobody explicitly said this) then you aren't being helpful. And while I can't keep you from replying, just realize that such comments will now fall upon deaf ears.

I'm looking for help, not to scream and shout and say this is why we can't have nice things. I need help, and very few people are providing anything close to help in a thread, I thought, was supposed to be helpful.

I'm not an accountant, but I was always under the impression that income for small businesses is not how much money they take in, but the amount of money left over after business expenses. Which would mean your parents don't have much income if their business isn't profitable at the moment.

Without knowing more about your situation, I can't say for sure what choices you have, etc. But in general, if you're not making much (or any) income then you should qualify either for generous subsidies or you should be eligible for Medicaid.

The exception would be if you live in a state that has decided not to expand Medicaid. As we've been discussing elsewhere on this thread, in states like Florida and Texas, Republican officials are rejecting the expansion, which means people with low incomes -- below the 133 percent of the poverty line, or about $15,000 for a single person -- can't get public insurance in those states.

One thing to remember: People who don't have affordable coverage available to them aren't subject to the penalty. That includes low-income people living in states that haven't expanded Medicaid. Of course, it would be better still if they could actually get insurance.

What is your opinion of Politico's latest review of Obamacare? link to download pdf

Haven't read. But Politico has some really good health care writers -- I read and learn from Jen Haberkorn and Jason Millman all the time.

Serious question:

I am 28 and in good health. I start a full time job with benefits in September. Is it worth it to buy the insurance or should I just pay the 1% penalty for the months I do not have the required insurance?

Just because you are young does not mean you are immune from disease. At that same age a friend of mine at work was diagnosed with liver cancer,and a friend from high school was hospitalized for a bowel obstruction. Not to mention the possibility of getting into a car accident.

What maxthurst said.

Not a question about Obamacare, but about TNR. Were you working there at the same time as Stephen Glass? If so, what was he like?

Is Stephen Glass still a relevant persona at TNR?

Steve who?

Glass, he, well, shattered the much of the newspaper's credibility a while ago.

^{It's ok, I got the door...}

There was a movie about that, right? With the guy who ended up playing Anakin Skywalker, I think...

My wife and I are self employed and we pay for our own insurance. So far we've been lucky to find a plan that's affordable. I've heard self-employed people might be the ones getting hit on this. Any thoughts?

Totally depends on your situation. This article will help give you a sense of the different factors and the Kaiser Family Foundation subsidy calculator can give you more information about your specific situation.

But really you'll have to check the marketplace in your state to see exactly what's available, what kind of federal assistance (if any) for which you qualify, etc.

What's the Day One reaction to the administrative process so far? How long are the telephone wait times, any glitches in healthcare.gov, any reported attempts at Denial of Service attacks from anti-Obamacare hackers? Anything? Recognizing that the day is still early, I'm surprised we are not getting inundated with "it's so easy" / "it's a total disaster" messages yet.

I'm not sure because I've been on reddit! :)

But it seems like the sites are having plenty of glitches, as all of us expected. I'm not worried. Yet.

Do you think that the decision most States made to not take the money from the federal government to expand Medicaid will work out? I can see both sides I suppose. I can see how States would worry about how they would pay for extended coverage down the line when the subsidies end, but I also think it is irresponsible to deny coverage to poor people, especially when it is "free" for the first couple of years.

I think most states will come in eventually, just like most states eventually joined the original Medicaid program. They need the money, their residents need the insurance, and it's a fundamentally good deal. Also, states are under enormous pressure from business and hospital industries to sign on. I expect many will do what Michigan did, and add a few wrinkles that make the program conform more to conservative ideals of insurance. They'll also do everything they can to disassociate it from Obamacare and Medicaid. But they'll come in. Of course, it will take time -- and I fear it will be long, long time for a few of them.

What do you think about Boston's chances this year?

No jinxing here. Every team in the playoffs is good and Detroit, the team I hear about most locally, is downright scary. Two good hitter and a top-notch rotation is more than enough to win a title. I think Boston is good enough to make a run but, honestly, I'm just grateful for October baseball again.

Hi, thanks for doing this! Can you tell me more about the constitutional implications of Obamacare? If memory serves, the only way it was found to be constitutional is by calling it a tax. Can you expand on the constitutional issues with Obamacare?

I'm not a constitutional lawyer, obviously, but I did my best impression in 2011 and 2012, leading up to the Supreme Court case. You can read my broad take here.

And, boy, am I glad that episode is done.

First of all, I really love your work for TNR, it's consistently great.

Which part of the ACA implementation are you most worried about (or think will lead to perceptions of "problems")?

I'm neurotic so I worry about everything. As it happens, I have a new piece up on which glitches worry me and which ones don't -- it's here. Short term, I'd say, I worry about the IT component. It's really complicated stuff and I'll be pleasantly surprised if they work out the kinks even within the first two weeks. (Sites have been down this morning, for example.) Long term, though, I think they'll get those issues straightened out. My big worry is whether the big gaps in the system remain -- ie., whether reformers can improve affordability protections, since some people still won't be getting the help they need, and get states like FL and TX to expand Medicaid along with the rest of the country. Both of those will require winning over conservative Republicans, which is not something I see happening in the immediate future.

Hello Jon, first I'd like to point out that as an A² resident, your support of the Boston Red Sox is disgusting.
Moving on.

If a part time employee has access to their employers coverage, but only during an enrollment period (which has since passed and will not begin again before March 2014), is that employee able to participate in the health insurance exchanges?

Thanks a lot! Go Tigers!

Honestly, I'm not sure how the rules work if you're a part-timer with an offer of insurance. You'd have to check with your employer or try healthcare.gov (once it's glitch free -- I'd wait a little while).

FWIW, I like the Tigers! Big Verlander fan and not just because he's a union guy.

But I lived in Boston for 12 years. The Red Sox remain first in my heart.

Ann Arbor resident, huh? Be honest. Are you a BTB guy or a Panchero's guy?

Sorry to admit but I end up going to Moe's because it's what my kids like. Real local favorites, though, are Jerusalem Garden and Casey's. For coffee, it's Sweetwater on Ashley. I wrote half my book there.

What is the strongest argument against Obamacare? What's the strongest argument for it?

Strongest argument against it: The cure is worse than the disease. Strongest argument for it: The disease is really bad and there's every reason to think the cure will help.