Here’s what happened to me before the ACA: I started grad school at ange 22 in a state where my parents’ coverage didn’t work, and therefore had to buy into the school plan through Blue Cross (may they forever burn in hell). For an entire year, I paid for all medical care out of pocket PLUS paid for an insurance plan, so that after a year Blue Cross would go “ok, I guess you paid enough to get on our plan for next year.” This is to say nothing of the ensuing years spent fighting tooth and fucking nail with Blue Cross over literally every medical decision my providers made. Absolutely nothing went without needing an appeal or a peer-to-peer due to “pre-existing condition.” The ACA made some of this easier, but Blue Cross figured out they could do stuff like drop drug coverage from their formulary to “pass on savings,” which brought back the need to do peer-to-peer on literally everything to get a high-copay “formulary exemption,” etc. It’s going to be a nightmare you can’t possibly imagine.