Ezra Klein makes a good point about next week and Obamacare implementation — the mechanics are going to be messy:
Jan. 1 isn’t likely to be a glitch-free day for Obamacare. There will be people who try to use their insurance and find they can’t, or it’s not the plan they meant to buy, or it’s not a plan that covers their doctor. But those problems will, eventually, be solved.
Here are some of the glitches that I think will pop up quickly in the first two or three weeks until they get repaired.
- Late enrollees won’t have their ID cards
Individuals who enrolled in their plans by mid-December should be seeing their ID cards by now. However people who enrolled in their plans in the last few days probably won’t get their plastic ID cards by Jan. 1. This is purely a matter of timing. Enrollment on Dec. 24 leaves four business days and five mailing days for cards to be generated and shipped. Some insurance companies generate cards in-house and might be able to meet that time frame. Other companies outsource their ID cards to vendors and the turnaround time is between five to ten business days between enrollment verification and cards in members hands.
- Network directories are fuzzy
The networks have yet to stabilize. Significant groups of doctors are still moving into and out of networks as the promise of membership may or may not be fulfilled. Directories lag actual movement so it is quite probable that a provider will be non-par in a network but listed in the directory as a par provider.
- Narrow networks
For insurance companies that used to operate on a paradigm of big, broad networks with nearly unlimited access, the change to narrow networks will produce hiccups. For instance a provider can work at multiple groups. Provider Group A and Provider Group B are both in the par general network that most employer groups use. Provider Group A may be in the narrow network, while Provider Group B may be excluded from the narrow network. Previously, the insurance company would not have cared where a member saw the par provider. Now, an Exchange member showing up to see Dr. Bob at 4 Privet Drive will pay significantly different cost-sharing than if the Exchange member saw Dr. Bob at 123 Sesame Street. This will be confusing and ties into the network directory problem above.
- 834 Errors
From what I’ve been hearing, the error rate on 834 enrollment files is down to acceptable levels. However an acceptable level of errors will still produce people who thought they have coverage not have coverage. Angry calls to healthcare.gov, the insurance company and the local newspaper will resolve these problems noisily and quickly.
There will be other common errors of implementation that will be noisy, public and a pain in the ass to fix quickly but they will be fixed quickly. These errors happen all the time for the group insurance side but they tend to get intermediated by either the HR department or the broker. For most Exchange covered individuals, there is no intermediate problem solving/problem dealing layer.
burnspbesq
If our cards don’t show up in today’s mail, I will be on the phone first thing Monday morning. As long as I can download a pdf image of the card, I’m cool with the physical card not showing up for a while.
Richard Mayhew
@burnspbesq: That will be the most common work-around — PDF or a letter stating that such and such company is covering the BurnspBesq family effective Jan 1 with the following co-pays etc.
The other work-around is for the provider to call the insurance company once you show up at the office and get a verbal confirmation.
Richard Mayhew
PS: What is the over/under for comments before we get McLaren’s rant that I’m a DINO and apologist for the insurance industry — I’ll start the bidding at 18.5
muricafukyea
I think it’s real cute Ball Juice has their very own accidental Obamacare troll. I guess trying to spin everything negative is reserved for odd days.
Btw, depending on how you present the numbers and what you include between 5 and 10million people have signed up. Funny that Mr. Obamacare troll doesn’t say anything about that. Doesn’t fit his “nobody is signing up and we are all gonna die” narrative I guess.
aimai
@Richard Mayhew: I just want to thank you again for all your hard work and thoughtful posts on this subject. I continue to learn so much from you and it comes in handy when talking to people who are really confused by what is going on. I don’ tunderstand why we don’t move to a bar coded, downloadable, system instead of insurance cards, anyway. For several years our insurance company only gave us paper cards, anyway, and they were useless and crappy.
ranchandsyrup
the only question now is: INPEACH v. Superinpeach
The Red Pen
I’d still like a good answer to the wingnut attack vector about “doctors hate Obamacare.” The result, they say, is that doctors won’t take patients and that people who buy insurance on the exchanges will not be able to get the treatment that they signed up for, even though it’s now covered.
My answer had been that the provider networks were settled prior to the plans going live, but it sounds like doctors can, in fact, go in an out on a whim. Time will tell if the “can’t find a doctor” problem is real or not (I’m betting on “not”), but it would be nice to have a solid answer to this.
Butch
I’ve been appalled at the Nightly News insistence on ferreting out every little negative thing possible on Obamacare – a few nights ago on Pelley it was a woman fretting about receiving her insurance card with, as far as I could tell, absolutely no basis whatever. They’re going to throw a parade with these new, predictable “glitches.”
Mike in NC
We were emailed temporary Blue Cross Blue Shield ID cards with a note that the permanent ones would be in a membership package arriving in about two weeks.
dmsilev
@Richard Mayhew: Looks like you got the other troll instead. I guess mclaren is on the night shift.
Richard Mayhew
@aimai: Problem is getting all providers (docs, hospitals, pharmacies etc) to agree on the code that is embedded into the scanner strip.
It is “easier” right now for people to read the damn card instead of mandating a common data language plus mandating the purchase of a reliable data/card scanning system.
The Red Pen
@Richard Mayhew:
I assume that’s quatloos.
Chyron HR
@muricafukyea:
Yeah, yeah, and the employment numbers look much better if we pretend that receiving unemployment benefits counts as having a job.
karen
I found out yesterday because I have no income (EUC runs out on 12/28) and I’m disabled with Rheumatoid Arthritis and Fibromyalgia, after I enrolled I am on Medicaid effective 1/1/14. But they said that I’d get the package after 1/1. I’m assuming that glitch is because of the ACA? I enrolled through Maryland Health Connections.
shelly
Even if you don’t have your physical ID cards, in a pinch, can’t you call the insurer to get your ID number?
schrodingers's cat
Ezra Klein has been the cheerleader of concern trolls about the ACA website in the media, why do we have to take him seriously on this issue?
Davis X. Machina
@shelly: Or they can just scan the RFID chip that’s embedded in the neck of every Obamacare ‘client’….
Villago Delenda Est
@Richard Mayhew:
Just learn to ignore her. The rants are so silly sometimes.
Richard Mayhew
@schrodingers’s cat: Because he usually knows the mechanics better than 95% of the people who get paid a living wage to write about healthcare for a general audience. His interpretation of those mechanics and the implementation thereof may be concern trollery in your mind, but he actually has a decent clue as to how things work, and that is valuable.
Richard Mayhew
@shelly: For most insurance companies, a phone call and verbal confirmation will work.
Richard Mayhew
@karen: If circumstances changed significantly, (such as loss of income), your plans change. I would not characterize this as a “glitch” it is how PPACA was designed to work. This is a case of “churn” as income changes change the array of plans/options available to you. And if those changes were only detected recently (such as loss of extended unemployment), it is just a matter of turn around time. Prepping a package and mailing it to you takes a couple of business days.
maximiliano furtive, formerly known as dr. bloor
@shelly: If you’re in the insurer’s system, most doctor’s offices can access membership info on line in real time. They’ll want to see some sort of ID to make sure that you are really you before rendering services, of course.
Tommy
Of course there are going to be glitches. I expect them. And the Republicans will scream and holler about it.
Heck I spent Christmas day at the family my brother married into. Folks are freaking “birthers.” They know I am a liberal and my brother’s wife’s father started in on me before I got my coat off about Obamacare.
Now much of what he ranted about didn’t make sense, but it went something like this.
They use Medicare, but also have an insurance policy to cover any expenses it doesn’t cover. He said he didn’t get a notice from Blue Cross Blue Shield that his policy was canceled, but he had to provide them with more documentation, including some tax related materials.
Had to get them from his CPA, and it took him like two plus hours.
He bitched and bitched. All Obama’s fault.
Now I should note at this point that he and his wife have major health issues. His wife has diabetes and she recently got this oxygen machine that looks like something out of Star Trek. He has major hip problems.
After he ranted at me for like 30 minutes I said, “can I ask something of a personal question, how much are you pay out-of-pocket for care?”
Now wait for it, not a SINGLE FREAKING PENNY! We ALL should be so lucky.
I wanted to say the world’s small violin is playing for you ….. but I tried to be polite.
Cacti
@muricafukyea:
The last numbers were 3.1 million young adults who qualified for dependent coverage on their parents’ policies, 3.9 million who qualified for the Medicaid expansion, and 1 million who had signed up for new insurance polices.
So, that’s at least 8 million, and that was two weeks ago.
Villago Delenda Est
Totally OT, but get your popcorn early for this one, from Noisemax:
Chamber of Commerce Launches $50 Million War on Tea Party
Villago Delenda Est
Richard, quick, call DPM and have him mutter an incantation over a keyboard or something because the comments went wacky right around you at 21.
Tommy
@Cacti: Correct me if I am wrong here, but I thought the goal of the ACA was to get more individuals insurance. That could be done via a number of ways. The Exchange, young adults staying on their parents insurance, and yes Medicaid expansion. Clearly this program is about way more then just the Exchanges, which is something Republicans don’t want to talk about (for obvious reasons).
Ash Can
Well, I hope the BJ server has its insurance ID number by now, because it looks from this end like Steve sat on the sucker and ironed it flat.
Cacti
@Tommy:
You’re quite correct. The goal was to expand health insurance coverage, and there were a number of mechanisms for doing that.
The GOPers know this, and that’s why so many red-states refused the Medicaid expansion. They’d rather screw their own citizens than contribute to the success of the program. My own state of AZ was a surprising exception.
Imagine how many more new Medicaid enrollees there would be if Texas (highest number of uninsured in the nation) hadn’t refused it?
Tommy
@aimai: How about it. My Gold Gym’s card is this little tag I put on my keychain with a barcode (I am sure most folks here have dozens of them). Heck I went to Wal-Greens to buy like $300 in gift cards the other day and my mom hands me her Wal-Greens card to have scanned. But I guess baby steps or something ….
Tommy
@Cacti: As you might guess I can’t stand Jan Brewer, but on Medicaid expansion she showed she isn’t as dumb, cold hearted, or as stupid as I thought. I mean you have to be a pretty cool hearted person not to take FREE money from the Federal government to expand healthcare to those that need it most.
ranchandsyrup
@Tommy: There are apps for yr phone where you input your various membership cards so you have them all in one location. https://itunes.apple.com/us/app/key-ring-reward-cards/id372547556?mt=8
Tommy
@ranchandsyrup: I did’nt know that and I am a tech nerd :). As I often say there is an app for that. Just downloaded the Android version. My mom and dad have a very basic, non-smart phone. Mom wants a smart phone to text and do other things. My father is like, “what else would I do with it?” I am like I don’t know dad, cause I don’t know what you want to do. I do things with my smart phone I never thought I would, until I said to myself, “I wonder if it can do this.” 95% of the time it can.
BTW: Thanks for the tip, I’ll be using this darn thing 24/7.
ranchandsyrup
@Tommy: I hear ya re: the parents. It was a long slog to get my mom to upgrade. Got her the windows phone based on a lot of feedback from the olds that it was easy to use.
Villago Delenda Est
Ah, DPM or someone fixed the problem…the comment format is back as it’s supposed to be.
Let us all now give a small desire of thanks.
TR
@Tommy:
Christ, what an asshole.
Emerald
@shelly:
Yes. I did that. I filled out my application on the California exchange in the middle of the night on Oct 3rd. I took three weeks to decide, then enrolled in Kaiser (which is using their full network). It took them five weeks to get the paperwork to me so I could pay (there’s your major problem, right there). I paid on Nov. 29th. The payment was posted in my bank account on Dec. 4th. A week later I called Kaiser to see if I was enrolled. They said indeed I was enrolled and gave me my Medical I.D. number. Said I was insured as of Jan 1st even if I didn’t get my card by then.
Then, on Christmas Eve, my card arrived! I intend to spend the next five days in bed with the covers pulled over my head until I’m truly insured. Not taking any chances.
And that’s California, where things are running smoothly.
Yatsuno
And Richard has his first brokered the blog. I think it only took Freddie like two threads to accomplish that, or something.
FlipYrWhig
@The Red Pen:
How would the doctor know how you got your insurance? How distinctive are the exchanges’ policies?
Tommy
@TR: I wanted to say you don’t work, retired (with a government pension I might add). You are pretty well off (went private sector after working for the military). So two hours, what else were you going to do?
What really got me was him saying, “I had to call my CPA.” Dude, a lot of folks don’t have a CPA to call. They would have had to dig through their records themselves and try to figure out things. Isn’t this like something you pay him for?
Villago Delenda Est
@FlipYrWhig:
“You have the stink of the near sheriff on you! Begone, peasant!”
ranchandsyrup
@Yatsuno: Hope yr recovery is proceeding well. Been sending good thoughts.
FlipYrWhig
@FlipYrWhig: I mean, have you ever heard of a doctor turning away a patient because she bought a policy over the phone instead of from a person? How much could the method of purchase possibly matter?
The Red Pen
@FlipYrWhig:
I assume that policies available on the exchanges are unique to the exchanges. I’m also assuming that some of these have distinctive fee schedules which are lower than non-exchange policies.
Really, I don’t know, which is why I keep asking. This is my third attempt to get an answer. The first two times, I just assumed I missed the “active thread” window, but now I’m pretty sure that there isn’t a good answer for this.
Gene108
Richard, the ACA puts a lot of emphasis on employer based coverage.
Any stats on if employees insured through their employers has gone up?
It had been trending down the last ten years, due to higher medical costs.
cckids
I know I’m late to this thread, but we’re having a minor issue signing up; our 21-year old son goes to college in-state, but 500 miles away from our address (which is his “permanent” address). When we asked the navigator about the networks, or out-of-network charges for him, she didn’t know about it. We were asking about specific plans at that point.
Any ideas? It seems like a pretty straightforward, not uncommon problem, I was surprized she was so thrown by it.
We’re in Nevada, BTW. Haven’t had insurance (or doctor’s visits) for years, so we really don’t care about which doctors are in the networks, etc. Just being covered will be fabulous.
catclub
@ranchandsyrup: There is also a device that will consolidate your credit cards into one device. As a Non-user, I am a little afraid of a waiter with one of these. It is an easy creditcard copier. Chip and Pin, we need you!
Citizen_X
@muricafukyea:
Richard is our “Obamacare troll?” Jesus Hussein Christ.
Congratulations. You’ve convinced me that you’re even stupider than I thought previously.
catclub
@FlipYrWhig: “How distinctive are the exchanges’ policies?”
Well, in Mississippi they are pretty distinctive, because BCBS is not on the exchanges. I think it is the biggest insurer in MS, so the others will be notable.
FlipYrWhig
@The Red Pen: hmm. That hadn’t been my guess, but I suppose I don’t know either. I figured (based on what, I don’t know) that companies would be generally phasing out non-exchange-compliant policies, which would mean that the product on the exchanges would be the same as the product offered anywhere else.
FlipYrWhig
@catclub: ah, hadn’t thought of that.
MomSense
I understand why the focus is on the exchanges but I do think it is important to remind people that people with insurance have been benefiting from the ACA for some time now. Yes, keeping “kids” on their parents plan, closing the donut hole, and lots of patient protections and improvements. The solvency of Medicare has already been extended, medical costs are rising at the lowest rate in 50 years, and things like the end of lifetime caps which have prevented many people from going bankrupt or having to discontinue treatment because of inability to pay.
The Red Pen
@FlipYrWhig:
All policies have to be compliant with the same rules, but they can vary in the payouts and the network etc.
So, let’s say I stayed with my corporate plan and switched my wife to an exchange plan. We see the same doctor, but he might get a different deal for seeing my wife. If he decides that he doesn’t like the deal he gets from my wife’s plan, he could drop it — or so it seems.
So, it looks like a mass movement of wingnut doctors could contribute to sabotaging the ACA. I don’t think that mass movement exists, however, because the “surveys” that support this claim are all non-scientific self-selected surveys. So, I’m not really worried.
In the mean time, I’ve been telling wingnuts that providers are locked into contracts and can’t simply blow those off. It seems that I was wrong about that, so I was looking for a replacement argument that was similarly simple.
Richard Mayhew
@The Red Pen: I’ll get a post up on this question this weekend.
The Red Pen
@Richard Mayhew: Thanks! I really look forward to it!
Fred
@Tommy: Yeah, but two freakin hours, fer cripe sake. Oh the humanity! An’ it’s all Obama’s fault too! He’s probably spent six hours bitchin about it to anybody he can corner. But then that’s fun time so…
Bob Mulder
There are many shortcomings in the Affordable Care Act (ACA), but there are shortcomings in the American public as well.
In the ACA one major problem is the income cutoff above which we do not qualify for a subsidy. If I project a family income of less than the $62,040 cutoff amount for 2014 the plan for my wife and I might choose costs about $360 per month. If we were to make $1.00 over the cutoff income of $62,040 our monthly premium would increase to $1,140. Our annual premium would rise from $4,308 per year to $13,680 per year, an increase of $9,372, just for earning one extra dollar. So should I make less than $62,040? If I make more than that I will have to find a way to increase my income by much more than $10,000 because not only will I have to pay the higher premium, but I’ll have to pay taxes on the extra income. Our health policy would become unaffordable. Yet, arbitrarily self-restricting our income might adversely affect our ability to meet some of our other financial obligations. For us, earning more doesn’t mean a bigger car, but rather an extra mortgage payment or more in savings—earning less therefore restricts our ability to save for the future. I’m self-employed in a service industry—my annual income varies and is not something I can control, and I pay twice the Social Security and Medicare taxes than someone in a salaried job. If I have a good year any additional profits I make may very well result in a higher healthcare premium and a profit wipe out. Where is my incentive? Our current Blue Cross Blue Shield Plan costs us $298/month. We each have a $10,000 deductible and we are happy with the plan because it covers generic prescriptions and preventive procedures. We are therefore not likely to be blasé about our health.
The American public—including our elected representatives—don’t make much sense on healthcare reform. Most Americans have no clue how much their prescriptions or medical care actually costs; all they do is fork over a modest co-pay and go on their way. Furthermore, the system where medical providers charge excessive fees for medical procedures and drugs and then get beaten down by the insurance companies is quite frankly, a totally stupid and wasteful game. Over the past few decades insurance companies have added more types of coverages some of which may not be necessary, but create extra costs for insurance companies and businesses that provide coverage that are eventually passed on to policyholders.
Anyone who gets sick or is in an accident but lacks insurance can go to a hospital emergency room and get medical care. If a hospital provides $100,000 worth of care for an injured uninsured patient, the hospital is out $100,000. The taxpayer and those who have insurance, or are otherwise able to pay for their own care, get billed extra to cover the uninsured. One hospital in the Triangle area charges a $220 fee just to walk in the door; they are shifting costs to patients who can afford to pay. If, on the other hand, people were required to get at least a basic policy for example, with a $10,000 deductible, the hospital would potentially be out only $10,000 and any government subsidies could be less or not needed for such a policy. A basic policy in which patients pay a reasonable co-pay for the basics but are covered for major problems over $10,000 will instill a greater appreciation for how much healthcare costs, and underscore the personal need to stay healthy and spend as little of that $10,000 deductible as possible.
Many Americans do not do a good job maintaining their physical health. You can’t stay healthy sitting on the couch with one hand on the TV remote and the other hand on the refrigerator door, and then expect the insurance companies or the government to cover the costs for medical problems that could have been avoided.
I know that there are some Americans who even under the best of circumstances may not be able to afford healthcare insurance and they do need assistance. However, there are many Americans who can afford some level of healthcare insurance. It’s not enough for the latter to feel entitled to healthcare. Everyone needs to have some measure of personal financial investment in their health care costs or the system will break down.
The most recent insult is that while we can now keep our current policy for one more year, it comes with a 23.6% premium increase that will make it more expensive than a subsidized policy under the ACA. This is our dilemma: do we keep our current policy with fewer benefits, or risk an unaffordable increase with the ACA if we make more than the subsidy cutoff?
Mnemosyne (iPhone)
@karen:
IIRC, Maryland is one of the states who got screwed by the PPACA contractor (I think Kay linked to a story yesterday about the DOJ and the states that used them getting ready to sue). So it may be a Maryland problem and not technically a PPACA problem.
Stella B
@The Red Pen: well, polls show that the majority of doctors (a big majority of primary care doctors) favor the ACA. I certainly do as did my colleagues before I retired. The very large group of doctors that my spouse and I use for our medical needs sent out a letter in October listing which ACA insurance plans they were accepting. The other giant group in our city also takes multiple ACA insurance plans as well as running their own insurance HMO which is available through CoveredCA. The same threats that doctors wouldn’t take the insurance plan were also used when the Medicare plan was being debated, but currently just over 90% of docs take Medicare and there is a slow upward trend on that number.
I retired because of the ACA. My husband had some financial good luck and we were able to retire comfortably, once we knew that we were assured of being able to buy medical insurance. So you can add me to the column of docs who retired because of the ACA, but in a good kind of way. I’ve seen a lot of people forced to continue working after retirement age because they have to insure a younger spouse. Guess what? They’re retiring in droves.
We signed up in November. After missing multiple phone calls from BS, we paid our first month on 12/14 and received our cards and welcome packet on 12/26.
Stella B
@The Red Pen: Contracts between providers and insurance companies are renegotiated every 2-3 years. An individual doctor or a group are obligated to continue taking a specific insurance plan for the duration of the contract, otherwise they risk a law suit.
Stella B
@Bob Mulder: if you find yourself going $1 over the income limit for a subsidy, then you just slap $2 into an IRA and you are home free. If, however, your adjusted gross income is too large to qualify for a subsidy despite a maximum contribution to IRAs, then mazel tov!
In a perfect world, the other party would allow some adjustments to be made to the law that would further feather out that transition. That’s not going to happen any time soon.
aimai
@The Red Pen:
Whatever decision the doctor made to join/not join an insurance network happens long before a patient calls up and asks to be seen. So: if the doctor or his/her hospital or partnership accepts the insurance that means they are satisfied with the payment schedule. How could it be otherwise? Are you thinking that they accept the insurance, see the patient, and then short shrift them because they “know” that patients with one kind of plan won’t pay them much for the test or whatever? If this happens it would already be happening–you do know that insurance companies routinely offer multiple plans that cover different procedures and treatments and doctors, don’t you? The exchange plans aren’t some kind of substandard fake plans–they are simply real plans that the insurance company brokered with the same providers (or new ones) that htey always worked with. Because you bought an Aetna plan on the exchange doens’t mean you are a second class citizen w/r/t the doctors you are going to see.
aimai
@Bob Mulder:
So: your current insurance company is gouging you by raising your premiums (a practice over which you have no control) and giving you “fewer benefits” and in addition, having paid in for the entire year you have no guarantee that they wouldn’t drop coverage of you and your wife entirely if you got sick or tried to use the benefits and you are complaining because hypothetically if you made 1 dollar more than you make this year you might have to pay more for your insurance on the exchanges? Have I got that right?
On the exchanges you have, for the first time, guaranteed issue, no lifetime caps on coverage, easy comparison of plans, plan competition, and subsidies. And you are complaining because you think someone else, somewhere, is getting a better deal than they deserve because they are lazy and sit on the couch while you–what? Do you seriously think you are never going to need to use this health insurance or that you shouldn’t have to pay into the pool to gamble that you get the coverage you need when you need it?
NineJean
@The Red Pen:
So I’m a pretty old person… but I remember that this was the line of attack that was used against Medicare when it first became law. My own family doc had signs – big ones, all over the waiting room, and in all the exam rooms – that said that he would not, NOT accept Medicare as payment.
ACA is different in that it isn’t a distinct program, and they can’t just say “I won’t take […]”. But, hey, if it worked for Medicare, maybe it’ll work here. [Note: the docs got over it, eventually. Even my own, old family doc.]
aimai
@NineJean: Same trade off, really–you can either choose to get paid a little bit for your services to a lot of people, or you can choose to try to get paid a lot for services to a few people. Most elderly people couldn’t begin to afford any of the treatments they now access through medicare–not if they were paying for themselves. Ditto Medicaid, of course. If doctors don’t want to accept the negotiated payments for services rendered they can try to find an entirely self paying, rich, clientele who won’t default on the payments when the cure isn’t forthcoming. Good luck with that.
Kathleen
Some of the glitches Richard outlined happen under current employer based insurance plans. A friend of mine who worked for a contracting company who changed medical providers. The transition was very rocky; he did not have his medical card on the magic transition date. Also,a change to COBRA coverage can also be a nightmare (which I experienced 4 years ago) because one side of the insurance company doesn’t talk to the other side. It took months and massive intervention from an angel to finally get my insurance company to acknowledge that I was insured. Also, too, Richard, thank you so much for your posts. You are one of the few bloggers who have the expertise to understand and communicate how these systems and processes work.
FlipYrWhig
@aimai: I’m tempted to say that this is in fact an advantage of the exchanges and the use of private insurers: there’s no easy way to say “we don’t take Obamacare” because there’s no Obamacare entity that can be visibly stigmatized. The card of someone who bought insurance via “Obamacare” looks no different from anyone else’s card with the same insurer — as far as I’ve heard, and I’m not claiming to be an expert. I just don’t see how the doctor would know to rule out the “Obamacare” policies without also ruling out the same policy purchased through the pre-Obamacare status quo methods. I look forward to Richard’s writeup on the subject.
Bob Mulder
@aimai:
Why should I be penalized for making more money? You’re missing the point about my comment about people who are couch potatoes. You’ve taken it out of context. Reread and think about it some more.
Bob Mulder
Before the ACA anyone who had insurance or who paid cash for healthcare also paid for uninsured people who used the healthcare system. I would think that if the ACA had been properly structured, those of us of pay for our own insurance would either pay the same or somewhat less.
aimai
@Bob Mulder: You aren’t being “penalized for making more money.” The country isn’t subsidizing someone who makes a lot of money, in order to subsidize someone who doesn’t make enough money. The country decided that in order to get everyone covered somehow the poorest people would get medicaid, the oldest people would get medicare, and everyone else would have to purchase affordable care through the exchanges. What is affordable was set a certain way with subsidies for people at the lowest income levels. Naturally, these subsidies decrease as you move up in income. I’m not eligible to go on the exchanges AT ALL because we have employer sponsored health care and because we make too much. I’m not being punished. Thats just the way the cookie crumbles.
Also: what on earth was the point of the bizarre attack on people and their remotes? While unhealthy people with unhealthy lifestyles may need more health care up until the ACA they didn’t necessarily get it–rich people who can see their doctors when they want can be as unhealthy as poor people. People get cancer without being lazy. That was such a nonsequiteur I feel I was doing you a favor by even trying to figure out where it belonged in your complaint. I can assure you that you and your spouse can blow through that 9,000 dollars of your 10,000 dollar deductible in a flash, regardless of how virtuous you are with your health and lifestyle issues. But we can’t afford to let you go underinsured for all of that. In fact one of the things the ACA benefits are meant to encourage is seeing a doctor and getting vaccinations and taking good basic care of one’s health. Lots of benefits aimed at promoting wellness are included in the new plans because people mistakenly thought they could buy catastrophic, high deductible plans and then cheaper out on everyday, maintenance, kind of care and checkups because these weren’t covered.
aimai
@Bob Mulder: One of your problems is that you think that you are subsidizing other people. Thats probably not true. Everyone else is subsidizing you. Creating enormous pools is a favor which the ACA is doing for the entire country. Previous to the ACA people like yourself, who bought on the individual market, were at the mercy of the calculations of the insurance companies–they gave you what seemed like a good rate, sure, but they were gambling that you wouldn’t ask them for much of a payout or, if you did, they could throw you and your wife off the plan for “fraud” or for failing to notify them of a pre-existing condition.
One of the hidden benefits of the ACA is that recission now can’t happen. Now the insurance company can’t create tiny little bantustans for “healthy” people in which they cream off your premiums while planning to throw you off if you need the health care. This is a favor that the rest of us are doing for you. We are all paying into much bigger pools so that you and your wife can have coverage that is dependable and not mere junk.
You are welcome.
FlipYrWhig
@aimai: I think it’s useful to think about the ACA as guaranteeing that insurance companies profit _by providing insurance_. Which is a step in the right direction because pre-ACA there was a diabolical business model that amounted to taking your money and _not_ providing insurance, particularly through, as you point out, their infamous practices of rescission. So when people talk about it as a giveaway to insurance companies, they’re not entirely wrong, but to me it also amounts to a massive regulatory effort to cajole insurance companies into insuring rather than siphoning money out of our pockets for nothing. And that’s pretty huge.
Monala
@FlipYrWhig: Good point! I had a procedure done this summer, and prior to, I asked the doctor what it would cost out of pocket. The doc didn’t know, and told me to call billing. Billing quoted me a figure, that turned out to be much higher when I was actually billed.
When I called to complain, billing told me that they can only give estimates, since they don’t know in advance the full scale of what the doctor is going to do. They added that the doctors have no idea what plan you are on and how much is covered/not covered, so they have no way to give you even an estimated quote.
So short answer: the doctors have no clue about the billing/insurance plan side of things.
Bob Mulder
@aimai:
In a normal insurance situation it is true that sometimes you get more out of your policy than you’ve paid in. That’s the way insurance works. But in the ACA you are penalized if you make over a certain amount of money. That did not happen before the ACA. So now, I’m being asked to increase my subsidy to others simply because through my work I may make more than the subsidy cutoff amount. It is inequitable.
Two friends of mine are in the healthcare business and every day see people–sometimes the same people–who never lift a finger to take care of themselves. Should they be rewarded for that?
You are certainly being very cavalier about my money and the time I put in to earn it.
Monala
@Bob Mulder: aimai’s tone was probably snarkier than it needed to be, but s/he has a point. Being slightly over a cutoff level (whether it’s a cutoff to get Medicaid, a cutoff for a higher tax bracket, or a cutoff to qualify for subsidies) isn’t a punishment or penalty – it’s just the way the system was set up. And aimai is also right that although right now you and your wife are subsidizing other people, there may come a point when your health changes and other people end up subsidizing you, even with you paying higher premiums.
It sucks that your rates are going up. It sucks that my husband doesn’t qualify for a subsidy because I am covered through employer-provided insurance. But I am still thankful that he now has insurance again thanks to the ACA, since he has pre-existing conditions.
And while you’re right that most Americans could do more to take care of their health, I think aimai was set off partly because a) the ACA has a lot of policies and incentives built in to support wellness and prevention so hopefully the American public will improve in this regard; and b) even with the most diligent of caring for one’s health, anyone can be affected by accidents, cancer or a number of ailments beyond their control. I’ll add a third factor: people dealing with poverty and stress and lack of resources have a much harder time doing the good things needed to care for their health. There’s a reason why chronic ailments are often correlated with lower incomes, and it’s not laziness.
Betsy
I would like to understand if Bob Mulder’s understanding is entirely correct — and if it is, (I think no one has said that it is incorrect) why is it set up that way? Why would the subsidy cut-off point just end and then the policybuyer is suddenly out so much cash? You would think the subsidy would be smoothed somehow so that extra dollar doesn’t hit the worker so hard on the policy costs.
In Bob’s situation where it’s hard to anticipate whether income will be x or y this year, that seems like a very unfortunate glitch / flaw / shortcoming of the law.
It’s also especially hard on people who may make $30K one year and $65K the next. An awful lot of subcontractors and S corp folks are in that position. ( I used to be in that position, so I guess it seems particularly harsh to me!) For tax purposes, one year you’re “rich” and the next year you’re practically exempt from taxes.
The tax code tried some decades (?) ago an experiment in smoothing out incomes that vary from year to year, to remedy this very problem (not related then to health insurance of course) but I think that was done away with. Too complicated?
Stella B
@Bob Mulder: Prior to the ACA everybody who got insurance through an employer got a government subsidy and no one in the individual market got a government subsidy. Now some people in the individual market do get a subsidy and some people — like you and me — don’t. It’s a step in the right direction. It would be nice to get the subsidy, too, but at least you and I are guaranteed access to health insurance, now. We don’t have to worry that using insurance one year will result in rescission or jacked-up premiums the next year.
caune
What’s funny is, when all these glitches happen to these newly covered by insurance folks, they’ll be just like the rest of us already insured people, frustrated as hell with their insurance companies.
And that’s a good thing. Hopefully it will bring about positive change in the insurance industry….. or single payer!
Monala
@Betsy: That is a good question, because the subsidies phase out the higher the income. Our household income is about 358% of poverty, which is approaching the 400% subsidy cutoff. But because of another quirk of the law, the fact that I have affordable employer insurance means that we couldn’t get subsidized insurance for my husband, period (ETA: we can now get him insurance, but unsubsidized).
But the difference between the the subsidy we would get at 358% of poverty, and not getting a subsidy at all (as though we were a family making $1 over the cutoff) is about $30 a month. I’m not sure why it’s such a huge difference for Bob’s family – although maybe it has something to do with the size of his family. If my family had more members needing insurance, that $30 could multiply quickly.
Monala
@Monala: Now that I think about it, the number of family members is likely the issue. The ACA subsidies determine what you can pay as a family (the 9.5% of income, I think), and then subsidize you above that.
So at my family’s income, $490 per month is what we’d need to pay. Without a subsidy, we’re paying $520 for just my husband. But if I needed insurance too, we’d still be paying only $490, and the subsidy would be higher. But at just over the subsidy limit, suddenly we’d owe the $520 for both him and me, or $1040.
Comrade Mary
@aimai:
This needs to go up in big blinking letters all over the place.
Bob Mulder
@Stella B:
Before the ACA we did not get a subsidy from anyone since we pay for the entire policy ourselves. Without a subsidy our premium will be $1,140 per month ($13,680/year); for us this is unaffordable, If we artificially restrict our income to below $62,040 our monthly premium would be about $360. If we go over the $62,040 subsidy cap our premium rises to $1,140. Penalizing anyone for making more money makes absolutely no sense whatsoever.
For example, let’s use car insurance to make the point. Let’s say that right now your annual car insurance policy premium is $800 per year. Your auto insurer sends you a notice telling you that if your annual gross adjusted income exceeds $35,000 your annual premium will rise 216% (by $1,728) for a total of $2,528. Would anyone be happy with this kind of situation?
Bob Mulder
Ok, so here is yet another kick in the pants. Under the ACA my prescription costs will go from approximately $120 (total copay) per year to $4,400. So even with a subsidy, my basic annual policy costs will go from about $4,400 to about $8,800. The more I look into the ACA the less I like it.