In a recent article, health economist Uwe Reinhardt provided a comprehensive critique of the growing effort to depict the Affordable Care Act as a “War on the Young”. Because the ACA places limits on the ability of insurers to adjust premiums for the expected costs of a person seeking health insurance, there is a redistribution of resources from the young (who typically use less care) to the old (who use more). Younger people will pay higher premiums because their risks are pooled with older people, rather than rated and charged at their lower expected costs. It would be more accurate, of course, to say that this redistribution is from the healthy to the sick, but that’s not the way it has been presented by those who raise the issue.

While Reinhardt covers many important points, including the similar issues raised by age and gender (should women be charged more because of child bearing costs or should men share in the burden of that cost?) and the fact that this type of community rating is common in employer insurance, I want to emphasize the redistributive aspects described above.

Redistribution is a fundamental element of almost any type of insurance, and occurs in many forms. Viewed on a lifespan or lifecourse perspective, insurance redistributes income from good times to bad. Life insurance allows me to transfer income from when I’m alive to my surviving family members, if I die. Health insurance allows me to transfer income from when I’m working and healthy to periods of my life when I am sick, face higher than expected medical expenses and possibly must reduce or stop work.  Insurance is, effectively and literally, redistributive.

Even without government intervention, however, insurance not only allows individuals to transfer income across their lifespan, it redistributes income from one person to another. If I die after just a few premium payments, my life insurer has to use other peoples’ premiums and the returns they’ve earned on those to pay the death benefit. If I get sick soon after purchasing health insurance, my medical costs are paid by others. All insurance, private and public, pools funds and redistributes them. Few people get back exactly what they pay in–but we all get the security that if we get sick or if we die, there will be funds available to cushion that impact.

So, my perspective is that this notion that Obamacare is a “war on the young” fails to grapple with the essential redistributive aspect of all insurance. Transferring income, not only across your own lifespan, but also across people, is the very purpose of insurance. Theologian Francois Fenelon wrote: “All wars are civil wars, because all men are brothers.” That may be more true in the health insurance “war on the young” than in any other war.

And if Obamacare is a war on the young, we might want to remember that the biggest drop in being uninsured since the law was passed has been among young consumers, as more than 3 million are estimated to have gained coverage. If this is a war on the young, it may be one that ends up saving lots of young lives.

A chart created by Justin Wolfers and shared by Jonathan Cohn made the rounds this week identifying the 3 percent of Americans who would be “potential losers” under Obamacare. As with too many things we see in health policy and health journalism, the chart is far too simple. 

In particular, the portion of the chart labeled “80% unaffected” ignores that while the 80% might be unaffected in the short term, over a longer time period, some significant portion of those with employer plans will be affected.  One reason for this is described in Avik Roy’s recent article. A significant number of employer plans will lose “grandfather” status and have to be changed. 

While Roy estimates that this totals more than 93 million people, there are some important problems in his assessment.  For example, he appears to assume that because about 50 percent of plans will have to change, 50 percent of employees will be impacted.  But, plans vary in size. If there are two plans, one with 1,000 employees that does not meet the new ACA requirements and one with 10,000 employees that does, then 50 percent of plans having to change means only 9 percent of employees are affected. 

For another, (and this has not been well discussed with respect to the individual market either) people’s plans change all the time.  Few individual plans or employer plans stay the same over any 2 year period. To say people or employers will be “forced” to change their plans because of Obamacare without recognizing at the same time that they are often “forced” to change their plan regularly now because of cost, network, benefits, contracting and other changes is more than a little disingenuous.

But, even taking into account that some of that “80% unaffected” will truly be unaffected fails to consider one of the most important, yet lesser known, parts of the ACA—the “Cadillac” tax.  The “Cadillac” tax is a 40 percent excise tax that will fall on insurers or self-funded plan sponsors for health plans premiums that exceed an annual limit–$10,200 for individual coverage and $27,500 for self and spouse or family coverage.

While the “Cadillac” tax begins in 2018, its impacts are already affecting some of those in the “80% unaffected”.  As detailed last month in Health Affairs, about one-sixth of employer plans will be impacted by the tax in 2018, and many have already started adjusting their plans to make sure they fall under the premium level and avoid the tax. By 2028, some 75 percent of current employer plans could be impacted. Because it is large and generous health plans that are likely to be subject to the tax, it would not be surprising at all to see that this part of the ACA is the one that leads to the greatest number of people affected and the largest population of “potential losers”.

Some health policy experts, however, would argue that this element of ACA is the biggest “winner” in Obamacare. The generous subsidy that the current system provides to largely healthy employees at large employers and the fact that this subsidy gets larger as the employee’s income grows may be the most important change in health policy. The current regressive subsidy leads its relatively healthy, high income beneficiaries to overinsure in myriad ways, driving up costs throughout the health system.  By reducing this subsidy, ACA may reduce that incentive and provide some critical “skin in the game” for this important group of health care consumers, benefitting everyone by reducing cost pressures.

So, really, the only honest answer to the question of who is a “winner” and a “loser” under Obamacare is truly this: “It’s complicated.”