Even with insurance, millions of Americans with serious illnesses are trapped in a cycle of deductibles, debt collectors and annually resetting medical bills.
Moving from the corporate healthcare work world to that of non-profits working with the homeless provided a stunning revelation of how many people are homeless due to one big medical bill. My first thought was always wondering if that bill was even accurate. On top of that, many dual eligible people on the street who are covered don’t know they are. They are often victims of ever shifting health homes due to brokers who offer to “help” them sign up for a new plan.
In WA state I help patients navigate this incredibly complex maze and learn how to reclaim what they are due. Such a broken system (understatement) and one that punishes all of us. Not to mention, Medicare Advantage (DISadvantage) only serves to make it all worse. Thank you for profiling.
I keep telling people that Cuban isn't the kinder, gentler billionaire. And he proved it by joining Ramblethinskin on stage slapping him on the back. He raked me over it on LinkedIn earlier this year because I called him out allowing Trump to use his "open algorithm" for "TrumpRx." Join a table with roaches and you're a roach. These band-aids are part of the problem. Electeds say, see people can get medicine less expensively. The goal should be single payer, end of. If you don't think Cuban is making bank on CostPlus, I have a bridge that connects Manhattan and Brooklyn for sale.
It’s time to turn the healthcare system upside down. Instead of tinkering with reforms from the top down, we need to rebuild it from the bottom up — from the kitchen tables of middle-class families that are struggling to keep up.
Let's start with a simple idea, like limiting the cost of insurance to ‘X’ percent of annual HH income and capping a family’s total out-of-pocket expenses at ‘Y’ percent each year.
If the policymakers in Washington can justify putting a cap on earnings that are subject to the FICA tax, they can certainly put a cap on the amount of money a working-class family has to pay for health care each year?
BIG insurance is going to bitch and moan because they’ve gotten fat on their cost-shifting model of payment. They have failed to do what they have promised for the last 30 year—deliver high quality care for less money. Making health care affordable is what insurance companies are supposed to do. Not make a billion dollars in profit and leave American families destitute.
"There is a philosophical argument, still advanced in insurance industry testimony and in certain policy circles, that requiring patients to pay something for care makes them more cost-conscious consumers."
Even for non-urgent problems, cost-consciousness can't work without price transparency, which is sorely lacking in our system.
I just shopped around for an MRI – one marked "urgent" – because BigHospCorp (the local "nonprofit" system that's gobbled up the other hospital systems in my area) couldn't fulfill its own internal policy of getting urgent MRIs scheduled within a week. Not every outfit eager to publish its cheaper imaging prices is shoddily run, but enough are that I'd want more time to investigate before going that route (scam pricing can be exact but not transparent – it's not transparent if you can't be reasonably sure what you'll get for the price you pay). So, to address what BigHospCorp diagnosed, but won't treat as, urgent, I'll be paying more to expedite services at a reputable legacy institution – a tradeoff I'd be more OK with if it weren't a result of BigHospCorp's own policy failure.
I'm not alone in having ongoing medical needs that typically aren't urgent, that I could shop around for more if pricing were more transparent. But it isn't.
Midge - my US House representative (R-IN) recently had a telephone town hall during which she repeatedly touted "price transparency" as THE solution to controlling health care costs. Maddening, because of what you explain (and Norm Spier expanded). I'll add some more: in rural areas of Indiana (and elsewhere), the public may have only one provider facility within an hour's drive. So price decisions must include transportation & time lost from work (including own gig like farming, own small biz etc). Plus, how to evaluate "best choice" between the facility 50 miles north versus the one 75 east of you, neither of which you know much about? ...which you're supposedly researching with only your education from an under-resourced rural school & without high quality internet. And after having already waited 5 weeks to see the doctor who just informed you of the need for the additional testing. And depending whether one, both, or neither of those provider facilities is in your insurance company network.
So yeah, let's shop around for the "best" deal? ...which we all know, American consumers do every day, carefully analyzing each spending decision as we make them (yes, that last is satirical)
Simply saying "price transparency!" doesn't work. Still, price transparency – that patients can actually use – is important to controlling costs and letting patients plan their care. It's important in the better-functioning "universal" systems, too.
France, for example, doesn't just have basic universal health benefits, but an extensive provider system beyond that, with 95% of French patients enrolled in private mutuelle coverage to manage additional provider fees.
Medical pricing in France has three sectors. Sector One contracts providers to charge only what the state will reimburse. Sector Two contracts providers to charge more than what the state will reimburse while still accepting state reimbursement, reducing patients' out-of-pocket costs by at least that much – more if the patient's mutuelle kicks in. (Most medical specialists in France are Sector 2.) Sector 3 pricing gives providers even more liberty to set their fees, and is little-used. Providers in all three sectors are required to follow strict disclosure rules enforcing price transparency that patients can actually use.
In particular (translated from French), you, the provider, "are required to display, in a visible and readable manner in your waiting room or, failing that, in your place of practice, the rates (or ranges of rates) of the fees you pay and their reimbursement rate by the Health Insurance."
Sector-1 and -2 providers must also provide additional patient-usable information, while Sector-3 providers must additionally provide fair warning to patients that state reimbursement may not apply.
How different from "somewhere, BigHospCorp posts a machine-readable file unusable to ordinary humans to technically comply with transparency mandates that don't, in fact, inform actual patients"!
I certainly agree that accessible pricing data would be helpful. Necessary but certainly not sufficient - it’s a key part of the puzzle. Not by itself a solution because our problems have too many other moving parts. That’s my frustration with my rep - that she says this one component is all we need, then everyone will be fine… and then we can get rid of that horrible Obamacare and socialist, fraud filled Medicaid
As part of Trump I, hospitals are required to post certain prices: not only the list price, but the price paid by the larger insurers. The requirement was not retracted by Biden, and is still in effect, with modifications over time.
It's actually kind of funny how that worked out.
You can find the files for one hospital system here:
The one for Mass General Hospital, for instance, decompresses to 61 million bytes, and the entries have terms like: "CUFF URINARY 4.0CM SPHINCTER INHIBIZONE OCCLUSIVE COATED". (You need a spreadsheet program to open it.)
The thing is, the requirements for these files have been greatly reduced.
Last year, when I tried to access the same files, they may have been 50 times as large, and, in fact, I was unable to open it on my computer.
The files, I believe, are useless to people. Possibly, insurance companies, with the capacity to analyze and understand the data, do get some use out of them, to negotiate prices.
Whether that results in lower costs I do not know.
Yeah, my local BigHospCorp's prices are similarly posted, technically as text, but practically as not human-readable unless imported into programs it's not reasonable to expect ordinary shoppers to use.
Of course, even as I complain how different attempts at medical shopping are from, say, grocery shopping, my local grocery has innovated app-only coupons that are such a hassle to use I can't help suspecting that their point is to grab customers' eye with a desirable price in large print, then get customers who can't stand the hassle to pay the much less desirable price in fine print (which is the price I use to judge whether the item's still worth it). So maybe instead of price transparency in medicine, we'll get price opacity all round, stymieing our agency in all sorts of transactions.
Pure greed! It’s pure American! Forget the prophet and go for the profit! Health (should be Death) insurance should not exist in its current form. Why do you think nobody wants to come to America anymore?
The Medicare for all acts House bill 3069 with over 100 sponsors and Senate bill 1506 with 15 co-sponsors were introduced in Congress April 29 last year.
Demand the highest quality healthcare at the lowest cost by eliminating all profit and all unnecessary administrative layers. traditional Medicare’s administration cost our less than 2% while part c plans (which are
actually publicly funded private commercial plans) have administration costs of about 18%. accountable care organizations (ACOs)and other commercial health insurance companies can have administration cost as high 30% due to exorbitant CEO salaries and bonuses, lobbying, advertising and investor profits!
As promised in my other comment today, I will reference the latest data on the damage from the Republicans making the ACA expanded subsidies expire on 1/1/26.
I will do it saving space, as some of the info is in prior places.
Basically, it looks like around 3 million or more of 24 million who had coverage last year will be losing coverage, with many others downswitching (increasing deductibles and out-of-pocket maxes), as well.
There is something brand new: a KFF report of just today, so here it is:
(I have only skimmed of it so far. Much of the info is redundant with say Charles Gaba's reporting (accessible from https://charlesgaba.substack.com/ ), as well as what I have seen in one recent NY Times story.)
For the rest of the stuff, let me just link:
1) Prior to the KFF report, the latest information is outlined here:
2) A New York Times story with the terms "Paragon Health Institute" and Dr. Oz in the same sentence, has led me to think I see a coming propaganda attempt by the administration, based on calling large ACA on-exchange coverage drops, which we know from leaked information that the CMS is seeing, is due mainly to the administration's cracking down on ACA fraud.
3) Note that the scope of the damage does not include that from most of the One Big Beautiful
Changes, which are mainly to the other half of the ACA: expanded Medicaid, and have been timed to not go into effect until the beginning of next year. (After the midterms.)
Since your post mentions the Affordable Care Act and a serious inadequacy of it
("The Affordable Care Act limits the amount of money Americans with commercial insurance have to pay out of pocket, but the cap was unreasonably high from the start, it increases every year – and it resets every year. This year the out-of-pocket maximum is $10,600 for an individual and $21,200 for a family.")
let me indicate it has other defects, as well, and the whole set of defects has long been a focus of mine. (One has been repaired. Another was repaired as part of the expanded subsidies, but was just unrepaired when the Republicans forced the lapsing of those expanded subsidies on Jan 1, 2026.)
Note: I have a separate comment on the damage from the lapsed expanded subsidies, as much data is now starting to accumulate. But this comment will focus on other defects, including those excessive o.o.p. maxes, and one or two which the Democrats, at the national level, have not attempted to fix, and one of which is heavily structural to the ACA within our hyper-complex system.
--
History of me with this:
In about 2019, aware of a bunch of the defects, I actually stuck in a Problems section into the ACA article in Wikipedia.
The content was in the article for a month or two, but then, two other Wikipedia "editors" voted against me to remove all the content. (I don't know if they were honest folks trying to keep what they thought was content falsely besmirching the ACA out, or themselves trying to politically manipulate by controlling content. I do know that it was apparent that neither of them understood a thing about the mechanisms around the ACA, and, as well, no one ever found an error in anything in the content.)
Anyway, the 5 issues that I had inserted in 2019 boil down to:
1) “subsidy cliff” (returned start of 2026 with the lapse of the expanded subsidies; people dealing with the returned "subsidy cliff" are those who experience the truly humongo premium jumps--like of $35,000 a year for a couple with an income of $88,000 a year in some cases).
2) Often-unaffordable copays (a Wendell Potter issue of today)
3) “Family glitch” (fixed administratively by Biden for as long as another president doesn’t reverse it. So far it is in place.)
4) Medicaid estate recovery on the expanded Medicaid part of the ACA. (It depends on the state. Some states still have it. Massachusetts just fixed it in 2024). A person age 55 or older with ACA expanded Medicaid, in certain states, may not have insurance at all, but only a loan, until death, for whatever medical expenses occur.
5) These “coordination between the agencies problems” that I figured had to be happening, in a different way in each of the 50 states + DC. (In my state, I was thrashed up and down between the expanded Medicaid and on-exchange parts with little notice mid-year a few times.)
(1) and (2) are in focus, either in the wonky coverage these days (for (1)), of in the current Potter post today (for (2)).
(It has enough internet links that you can verify the assertions from that reference without having to trust me.)
The other problem, really a problem-group, classified under (5) will vary by state, and, in particular, many will exist because of that division of ACA coverage at 138% of FPL between ACA expanded Medicaid, and subsidized on exchange coverage.
Back when I used the ACA in my state (Massachusetts; before aging into my Medicare-for-Me plus a Medigap), I had determined that the state had a core principle: find out as quickly as possible when an income change switched the person up or down between expanded Medicaid and subsidized on-exchange coverage, and switch them as quickly as possible. (Don't worry about the complete change of provider network each time, and changing of autopays, etc.!)
My feeling was nothing would stop the state from thrashing a person up and down 26 times a year, with a provider network change each time!
(Note: The new OBBB requirements of at least twice annual expanded Medicaid eligibility checks, up from once a year, will undoubtedly cause thrashing up and down at least twice a year, even in states that technically manage things as well as possible given the new law.)
Moving from the corporate healthcare work world to that of non-profits working with the homeless provided a stunning revelation of how many people are homeless due to one big medical bill. My first thought was always wondering if that bill was even accurate. On top of that, many dual eligible people on the street who are covered don’t know they are. They are often victims of ever shifting health homes due to brokers who offer to “help” them sign up for a new plan.
Another truth bomb. Thank you Wendell!!
In WA state I help patients navigate this incredibly complex maze and learn how to reclaim what they are due. Such a broken system (understatement) and one that punishes all of us. Not to mention, Medicare Advantage (DISadvantage) only serves to make it all worse. Thank you for profiling.
All so true. Thankfully I'm healthy, but I buy my meds from CostPlusDrugs because they are cheaper than copays.
I keep telling people that Cuban isn't the kinder, gentler billionaire. And he proved it by joining Ramblethinskin on stage slapping him on the back. He raked me over it on LinkedIn earlier this year because I called him out allowing Trump to use his "open algorithm" for "TrumpRx." Join a table with roaches and you're a roach. These band-aids are part of the problem. Electeds say, see people can get medicine less expensively. The goal should be single payer, end of. If you don't think Cuban is making bank on CostPlus, I have a bridge that connects Manhattan and Brooklyn for sale.
Man o man do you have some derangement. If Cuban sells them cheaper, why would I pay more.to use my insurance?
I mean really, get your head out of the sand.
Noooooooooo
To Cost plus….corporate welfare greed
Whyso?
IMO these rx.coms are enriching themselves. Similar to how The Sackler Family contributed to opioid crisis while paving the way for fentanyl crisis.
Medicare for ALL Acts cover prescriptions and paid for with a progressive tax.
Well if the cost to me is cheaper than using my insurance (witch I've paid for), then isn't the insurance company ripping me off more than cost plus?
This is infuriating!
Ditto!
It’s time to turn the healthcare system upside down. Instead of tinkering with reforms from the top down, we need to rebuild it from the bottom up — from the kitchen tables of middle-class families that are struggling to keep up.
Let's start with a simple idea, like limiting the cost of insurance to ‘X’ percent of annual HH income and capping a family’s total out-of-pocket expenses at ‘Y’ percent each year.
If the policymakers in Washington can justify putting a cap on earnings that are subject to the FICA tax, they can certainly put a cap on the amount of money a working-class family has to pay for health care each year?
BIG insurance is going to bitch and moan because they’ve gotten fat on their cost-shifting model of payment. They have failed to do what they have promised for the last 30 year—deliver high quality care for less money. Making health care affordable is what insurance companies are supposed to do. Not make a billion dollars in profit and leave American families destitute.
"There is a philosophical argument, still advanced in insurance industry testimony and in certain policy circles, that requiring patients to pay something for care makes them more cost-conscious consumers."
Even for non-urgent problems, cost-consciousness can't work without price transparency, which is sorely lacking in our system.
I just shopped around for an MRI – one marked "urgent" – because BigHospCorp (the local "nonprofit" system that's gobbled up the other hospital systems in my area) couldn't fulfill its own internal policy of getting urgent MRIs scheduled within a week. Not every outfit eager to publish its cheaper imaging prices is shoddily run, but enough are that I'd want more time to investigate before going that route (scam pricing can be exact but not transparent – it's not transparent if you can't be reasonably sure what you'll get for the price you pay). So, to address what BigHospCorp diagnosed, but won't treat as, urgent, I'll be paying more to expedite services at a reputable legacy institution – a tradeoff I'd be more OK with if it weren't a result of BigHospCorp's own policy failure.
I'm not alone in having ongoing medical needs that typically aren't urgent, that I could shop around for more if pricing were more transparent. But it isn't.
Midge - my US House representative (R-IN) recently had a telephone town hall during which she repeatedly touted "price transparency" as THE solution to controlling health care costs. Maddening, because of what you explain (and Norm Spier expanded). I'll add some more: in rural areas of Indiana (and elsewhere), the public may have only one provider facility within an hour's drive. So price decisions must include transportation & time lost from work (including own gig like farming, own small biz etc). Plus, how to evaluate "best choice" between the facility 50 miles north versus the one 75 east of you, neither of which you know much about? ...which you're supposedly researching with only your education from an under-resourced rural school & without high quality internet. And after having already waited 5 weeks to see the doctor who just informed you of the need for the additional testing. And depending whether one, both, or neither of those provider facilities is in your insurance company network.
So yeah, let's shop around for the "best" deal? ...which we all know, American consumers do every day, carefully analyzing each spending decision as we make them (yes, that last is satirical)
Simply saying "price transparency!" doesn't work. Still, price transparency – that patients can actually use – is important to controlling costs and letting patients plan their care. It's important in the better-functioning "universal" systems, too.
France, for example, doesn't just have basic universal health benefits, but an extensive provider system beyond that, with 95% of French patients enrolled in private mutuelle coverage to manage additional provider fees.
Medical pricing in France has three sectors. Sector One contracts providers to charge only what the state will reimburse. Sector Two contracts providers to charge more than what the state will reimburse while still accepting state reimbursement, reducing patients' out-of-pocket costs by at least that much – more if the patient's mutuelle kicks in. (Most medical specialists in France are Sector 2.) Sector 3 pricing gives providers even more liberty to set their fees, and is little-used. Providers in all three sectors are required to follow strict disclosure rules enforcing price transparency that patients can actually use.
In particular (translated from French), you, the provider, "are required to display, in a visible and readable manner in your waiting room or, failing that, in your place of practice, the rates (or ranges of rates) of the fees you pay and their reimbursement rate by the Health Insurance."
https://www.csmf.org/tarifs/vos-obligations-legales-daffichage/
Sector-1 and -2 providers must also provide additional patient-usable information, while Sector-3 providers must additionally provide fair warning to patients that state reimbursement may not apply.
https://france-assos-sante.org/66-millions-dimpatients/patients-vous-avez-des-droits/le-droit-a-linformation-du-patient-sur-les-couts/
How different from "somewhere, BigHospCorp posts a machine-readable file unusable to ordinary humans to technically comply with transparency mandates that don't, in fact, inform actual patients"!
I certainly agree that accessible pricing data would be helpful. Necessary but certainly not sufficient - it’s a key part of the puzzle. Not by itself a solution because our problems have too many other moving parts. That’s my frustration with my rep - that she says this one component is all we need, then everyone will be fine… and then we can get rid of that horrible Obamacare and socialist, fraud filled Medicaid
As part of Trump I, hospitals are required to post certain prices: not only the list price, but the price paid by the larger insurers. The requirement was not retracted by Biden, and is still in effect, with modifications over time.
It's actually kind of funny how that worked out.
You can find the files for one hospital system here:
https://www.massgeneralbrigham.org/en/patient-care/patient-visitor-information/billing/cms-required-hospital-charge-data
and, they are pretty incomprehensible.
The one for Mass General Hospital, for instance, decompresses to 61 million bytes, and the entries have terms like: "CUFF URINARY 4.0CM SPHINCTER INHIBIZONE OCCLUSIVE COATED". (You need a spreadsheet program to open it.)
The thing is, the requirements for these files have been greatly reduced.
Last year, when I tried to access the same files, they may have been 50 times as large, and, in fact, I was unable to open it on my computer.
The files, I believe, are useless to people. Possibly, insurance companies, with the capacity to analyze and understand the data, do get some use out of them, to negotiate prices.
Whether that results in lower costs I do not know.
Yeah, my local BigHospCorp's prices are similarly posted, technically as text, but practically as not human-readable unless imported into programs it's not reasonable to expect ordinary shoppers to use.
Of course, even as I complain how different attempts at medical shopping are from, say, grocery shopping, my local grocery has innovated app-only coupons that are such a hassle to use I can't help suspecting that their point is to grab customers' eye with a desirable price in large print, then get customers who can't stand the hassle to pay the much less desirable price in fine print (which is the price I use to judge whether the item's still worth it). So maybe instead of price transparency in medicine, we'll get price opacity all round, stymieing our agency in all sorts of transactions.
Pure greed! It’s pure American! Forget the prophet and go for the profit! Health (should be Death) insurance should not exist in its current form. Why do you think nobody wants to come to America anymore?
The profit never ends.
The Medicare for all acts House bill 3069 with over 100 sponsors and Senate bill 1506 with 15 co-sponsors were introduced in Congress April 29 last year.
Demand the highest quality healthcare at the lowest cost by eliminating all profit and all unnecessary administrative layers. traditional Medicare’s administration cost our less than 2% while part c plans (which are
actually publicly funded private commercial plans) have administration costs of about 18%. accountable care organizations (ACOs)and other commercial health insurance companies can have administration cost as high 30% due to exorbitant CEO salaries and bonuses, lobbying, advertising and investor profits!
Contact Congress at 202 224-3121
Demand they Co-sponsor Medicare for ALL acts now.
Rico’d ON.
The private for-profit, commercial health insurance industry creates problems and then create another scam.
Care solutions are not this industries’s concern.
As promised in my other comment today, I will reference the latest data on the damage from the Republicans making the ACA expanded subsidies expire on 1/1/26.
I will do it saving space, as some of the info is in prior places.
Basically, it looks like around 3 million or more of 24 million who had coverage last year will be losing coverage, with many others downswitching (increasing deductibles and out-of-pocket maxes), as well.
There is something brand new: a KFF report of just today, so here it is:
https://www.kff.org/affordable-care-act/what-we-know-so-far-about-2026-aca-marketplace-enrollment-premiums-and-deductibles/
(I have only skimmed of it so far. Much of the info is redundant with say Charles Gaba's reporting (accessible from https://charlesgaba.substack.com/ ), as well as what I have seen in one recent NY Times story.)
For the rest of the stuff, let me just link:
1) Prior to the KFF report, the latest information is outlined here:
https://substack.com/@normspier828307/note/c-257979791
2) A New York Times story with the terms "Paragon Health Institute" and Dr. Oz in the same sentence, has led me to think I see a coming propaganda attempt by the administration, based on calling large ACA on-exchange coverage drops, which we know from leaked information that the CMS is seeing, is due mainly to the administration's cracking down on ACA fraud.
That's here:
https://healthcareuncovered.substack.com/p/canada-guarantees-care-and-america/comment/259106299
3) Note that the scope of the damage does not include that from most of the One Big Beautiful
Changes, which are mainly to the other half of the ACA: expanded Medicaid, and have been timed to not go into effect until the beginning of next year. (After the midterms.)
Since your post mentions the Affordable Care Act and a serious inadequacy of it
("The Affordable Care Act limits the amount of money Americans with commercial insurance have to pay out of pocket, but the cap was unreasonably high from the start, it increases every year – and it resets every year. This year the out-of-pocket maximum is $10,600 for an individual and $21,200 for a family.")
let me indicate it has other defects, as well, and the whole set of defects has long been a focus of mine. (One has been repaired. Another was repaired as part of the expanded subsidies, but was just unrepaired when the Republicans forced the lapsing of those expanded subsidies on Jan 1, 2026.)
Note: I have a separate comment on the damage from the lapsed expanded subsidies, as much data is now starting to accumulate. But this comment will focus on other defects, including those excessive o.o.p. maxes, and one or two which the Democrats, at the national level, have not attempted to fix, and one of which is heavily structural to the ACA within our hyper-complex system.
--
History of me with this:
In about 2019, aware of a bunch of the defects, I actually stuck in a Problems section into the ACA article in Wikipedia.
(https://web.archive.org/web/20190829095943/https://en.wikipedia.org/wiki/Patient_Protection_and_Affordable_Care_Act#Problems )
The content was in the article for a month or two, but then, two other Wikipedia "editors" voted against me to remove all the content. (I don't know if they were honest folks trying to keep what they thought was content falsely besmirching the ACA out, or themselves trying to politically manipulate by controlling content. I do know that it was apparent that neither of them understood a thing about the mechanisms around the ACA, and, as well, no one ever found an error in anything in the content.)
Anyway, the 5 issues that I had inserted in 2019 boil down to:
1) “subsidy cliff” (returned start of 2026 with the lapse of the expanded subsidies; people dealing with the returned "subsidy cliff" are those who experience the truly humongo premium jumps--like of $35,000 a year for a couple with an income of $88,000 a year in some cases).
2) Often-unaffordable copays (a Wendell Potter issue of today)
3) “Family glitch” (fixed administratively by Biden for as long as another president doesn’t reverse it. So far it is in place.)
4) Medicaid estate recovery on the expanded Medicaid part of the ACA. (It depends on the state. Some states still have it. Massachusetts just fixed it in 2024). A person age 55 or older with ACA expanded Medicaid, in certain states, may not have insurance at all, but only a loan, until death, for whatever medical expenses occur.
5) These “coordination between the agencies problems” that I figured had to be happening, in a different way in each of the 50 states + DC. (In my state, I was thrashed up and down between the expanded Medicaid and on-exchange parts with little notice mid-year a few times.)
(1) and (2) are in focus, either in the wonky coverage these days (for (1)), of in the current Potter post today (for (2)).
(3) seems to have been fixed.
So let me give a reference on (4):
https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing
(It has enough internet links that you can verify the assertions from that reference without having to trust me.)
The other problem, really a problem-group, classified under (5) will vary by state, and, in particular, many will exist because of that division of ACA coverage at 138% of FPL between ACA expanded Medicaid, and subsidized on exchange coverage.
Back when I used the ACA in my state (Massachusetts; before aging into my Medicare-for-Me plus a Medigap), I had determined that the state had a core principle: find out as quickly as possible when an income change switched the person up or down between expanded Medicaid and subsidized on-exchange coverage, and switch them as quickly as possible. (Don't worry about the complete change of provider network each time, and changing of autopays, etc.!)
My feeling was nothing would stop the state from thrashing a person up and down 26 times a year, with a provider network change each time!
(Note: The new OBBB requirements of at least twice annual expanded Medicaid eligibility checks, up from once a year, will undoubtedly cause thrashing up and down at least twice a year, even in states that technically manage things as well as possible given the new law.)