One means to control costs included in the Affordable Care Act (ACA) took the form of a mechanism for publicly reviewing requests for rate increases by insurance companies. In Summer 2016, health insurance companies began requesting large increases in premiums.
A witness for one Pennsylvania health insurer observed that his company had about 250 clients who had signed up for coverage under the ACA, then received treatment worth about $100,000 each, and then had cancelled their policies immediately after receiving treatment. The cost of the care then had to be passed on to other clients. In Montana, ten individual customers consumed more than $4 million in care in the first six months of 2016, for an average of about $70,000 a month each. In this case, 1 percent of customers accounted for 30 percent of pharmacy bills. Making matters worse, in the first years of the ACA, a federal program helped insurers pay the cost of some of the most expensive claims. Now, according to a Department of Health and Human Services economist, that program is winding down.
What has been happening in Pennsylvania is not unique to the Keystone State. In Montana in 2015, one insurer reported that it had paid out $1.26 in claims for every $1.00 in premiums. Unable to sustain such losses, major insurance companies have had to choose between seeking much higher premiums and abandoning the health-insurance market places. In 20 states, insurers have asked to raise their premiums by at least 25 percent. In some other states, insurers seem to be abandoning the market places to more efficient or competitive insurers.
Who are the uninsured?
More than half of the uninsured live in the 20 states that refused to expand Medicaid, many of them populous Southern states like Texas and Florida. As a result, 39 percent of the uninsured have incomes below the federal poverty level.
In 2013, 28 percent of people between 19 and 34 years old were uninsured; today 18 percent are such “Millennials.” Still, that 18 percent accounts for almost half of the total uninsured.
In 2013, 50 percent of the uninsured were white; now 41 percent are white.
In 2013, 36 percent of the uninsured were American citizens of Hispanic descent; today 29 percent of the uninsured are American citizens of Hispanic descent.
In 2013, 13 percent of the uninsured were black; now 12 percent are black.
More than half (57 percent) of the working Americans without insurance work for small companies that were exempted from the requirement to provide insurance.
 It speaks volumes to the intellectual world inhabited by Democratic legislators that the NYT reporter Robert Pear can describe the process as intended to “shame” companies that requested increases. Apparently, Democrats believe that immense profits by health insurers and exorbitant pay for executives explain high health costs.
 Robert Pear, “Health Insurers Use Reviews, Intended to Constrain Rate Jumps, to Justify Them,” NYT, 15 August 2016.
 The chief executive of the federal insurance market-place optimistically portrayed the join-spend-quit pattern as a one-time “decline in pent-up demand for services.” In all likelihood, uninsured people will continue to pen-up their use of services, then join-spend-quit again. Robert Pear and Reed Abelson, “As Insurers Balk, U.S. Makes New Push for Health Care Law,” NYT, 18 August 2016.
 Abby Goodnough, “Still Uninsured, Even With the Health Law,” NYT, 18 August 2016.
 However, the ineligibility of illegal immigrants for coverage means that the total Hispanic share without insurance has risen from 29 percent to 40 percent.