Through the insurance exchanges, employers and individuals will be able to choose among plans that have a federally determined essential-benefits package. While the exact details of this benefits package have yet to be specified, health plans in the insurance exchanges must have an “actuarial value” of at least 60 percent; that is, for the typical population, the insurance plan must cover, on average, 60 percent of the cost of insurance..

In addition, the out-of-pocket limit for enrollee spending cannot exceed the regulated level for health savings accounts (roughly $6,000). [. . .]

(Emphasis supplied.) Consider this "affordability" argument. If you qualify for the minimum subsidy under ACA, you have to cover 40% of the cost of insurance premiums PLUS $6,000 in out of pocket costs. What is 400% of FPL (the level at which subsidies are permitted)? For an individual it is around $53,000.00. Do the math. This is affordable?

Gruber continues:

A major feature of the Affordable Care Act is assistance for low-income individuals purchasing insurance through the exchanges. Those with incomes from 133 percent to 399 percent of FPL are eligible for income-based tax credits to help defray the cost of purchasing insurance in the state exchanges. These families will pay the percentage of income specified in Exhibit 1 for the second-lowest-cost silver plan available in their area, and the government will pay any remaining costs above that level. [. . .]

(Emphasis supplied.) This is debatable, as the current GOP House and state governments like Florida will attest. It seems an act of misguided faith. Gruber asserts that:

The vast majority of America’s poorer families can afford health insurance premiums and typical out-of-pocket health care costs under the schedules specified by the Affordable Care Act.

Perhaps on paper. In the real world, governments will cuts their expenses at the expense of the most vulnerable. What will happen is that private actors will do what private actors do, cut their costs as much as permitted - which means less health care for the most vulnerable.

The ACA's exchange system is a Rube Goldberg contraption destined for failure. Some say that even this is better than nothing. I do not agree because ACA's exchange system occupies reform space that should be taken by the reform that can actually work in the United States - expansion of single payer public insurance.

The best reform proposal that was discussed during the health bill debate happened by accident - expansion of Medicare to persons 55 and older. Joe Lieberman blocked it at the time (though it could have been approved through reconciliation.) I would have traded that for the entire exchange contraption. Medicare is the best system for delivery of meaningful health insurance the United States has ever tried. It should be the model for all health reform in the United States. Let me again quote Paul Krugman:

What is Medicare? It’s single-payer coverage for the elderly. Other countries have single-payer systems that are much cheaper than ours — and also much cheaper than private insurance in America. So there’s nothing about the form that makes Medicare unsustainable, unless you think that health care itself is unsustainable.

What is true is that the U.S. Medicare is expensive compared with, say, Canadian Medicare (yes, that’s what they call their system) or the French health care system (which is complicated, but largely single-payer in its essentials); that’s because Medicare American-style is very open-ended, reluctant to say no to paying for medically dubious procedures, and also fails to make use of its pricing power over drugs and other items.

So Medicare will have to start saying no; it will have to provide incentives to move away from fee for service, and so on and so forth. But such changes would not mean a fundamental change in the way Medicare works. [. . .] So this business about Medicare in its present form being unsustainable sounds wise but is actually a stupid slogan. The solution to the future of Medicare is Medicare — smarter, less open-ended, but recognizably the same program.

(Emphasis supplied.) If this is true, and I think it is, then surely it extends to health insurance and care reform in general. RyanCare is LIKE ObamaCare in its structure, minus the affordability concerns.

Krugman argues, rightly in my view, that Medicare as is is the right approach. ACA's reforms go down the wrong path (indeed the Ryan path frankly.) Kruigman tries to square a circle here. The critiques of RyanCare can be applied to ObamaCare. They are similar attempts at reform (even though ObamaCare is more concerned with affordability.)

They both head down the wrong path of reform. If Medicare is worth defending, then ACA reform is the wrong reform.

Krugman is unable to accept this obvious conclusion.

Speaking for me only