Covered California released an actuarial study on the premium changes for the ACA individual insurance market due to policy changes over the past six months. It is ugly. The premiums will vary greatly by state over the next three years according to this study. I just want to look at the worst states.
Senator Cassidy (R-LA) repeatedly brought up the story of one of his constituents last year. They were a family of four with total earnings in the the six figures. They did not qualify for premium tax credits even as they were spending $40,000 a year in total medical costs. One family member has a chronic, high cost medical condition. This person could never pass underwriting.
This family will face a choice of paying over half their income for premiums by 2021 under the current policy regime or aggressively finding ways to lose enough income to get under 400% FPL to qualify for a premium tax credit that caps their Silver premium expense at less than 10% of their income. Given the much higher premiums, the opportunity cost of financial engineering to qualify for a premium tax credit will go down. Having a family member with an expensive chronic condition under the current policy regime places a huge notch on earnings between 400% and 600% FPL where almost every additional dollar earned would go to either taxes or individual market premiums.
The critical question in any health financing system is how are the people with consistent and known high cost needs treated. Are they left on their own? Are they shunted aside? Are they consigned to a life of poverty? Or is there a system that counter-acts the bad luck that they have so the opportunity space is as broad and deep for them as it is for anyone else.
Right now the health policy proposals floating around Washington for the past year narrows opportunity space for many people
rikyrah
Mayhew,
Did you see this from Alabama?
https://www.cbpp.org/blog/alabamas-proposal-will-cost-thousands-their-medicaid-coverage-wont-encourage-work
WereBear
@rikyrah: It is working as designed. It’s not supposed to help citizens: it’s supposed to make them go away.
Feathers
Or you will see divorces/people with chronic illnesses not marrying, as you do among seniors for Medicare/social security/pension reasons. I know at least one person who got dumped because of their student loan debt, after discussion. I can see being able to handle the emotional and physical, but not financial costs of a chronic illness.
Would getting divorced, but remaining a couple solve this problem? That would be a good argument for coming up with a fix. Although having a decent healthcare system would, of cons be the best option.
debbie
I remember when the Bush administration brought out the Medicare prescription benefit and how many people complained that it would hurt, not help, them. We’re quickly becoming a nation of doughnut holes.
Patricia Kayden
What is Senator Cassidy doing to fix the ACA to help his constituents?
Betsy
This is so great and it is directly meaningful to my life.
I foresee a lot of people skewing their behavior strategically:
getting married,
avoiding getting married,
people with decent earning potential deliberately letting go of that and making the minimum necessary to live,
downsizing to enable living at a lower wage,
and something I bet even the Republicans haven’t thought of (sarcasm): people with *some* wealth deliberately leaving good paying jobs in order not to put their reserves at risk.
For example someone who has $200,000, or more, in the bank might take time off from paid,or work deliberately work at a lower income, in order to keep health costs from eliminating their capital reserves. This would include many wealthy people of course, but would also include middle earners who have been careful or fortunate with savings.
As more and more categories of people — white people, for God’s sake! – get caught in the Republican poverty trap, we need to beat this to death as an election issue
NorthLeft12
To Republicans/Libertarians/conservatives it is a fact that the US has the best health care system in the world. The fact that access to it is completely dependent upon your ability to pay for treatment is a part of that narrative.
EMedPA
@NorthLeft12: Except that if we look at access to care, money spent, and life expectancy, we don’t have the best system. And I pity any politician who ever says to me “anyone can get care by going to the Emergency Department.”
WereBear
I recently read about a woman who was in advanced pregnancy, on her way to a new job, and was hit by a drunk driver (who got away.) She was left paralyzed from the chest down, and the baby lived.
This new job was supposed to cover her, the coming baby, and the husband who worked for a small firm with no health insurance. But the timing sucked — the insurance hadn’t kicked in yet. So they weren’t covered, and the staggering costs pushed them onto Medicaid.
And a sentence of lifelong poverty; because they can’t make any money. Period. They can’t even accept relatives putting the baby through college when the time comes. To stay alive, they cannot better their circumstances. As long as she is alive and needs the medical care.
WereBear
@Betsy: Nomadland is a book about people smacked by high housing costs and the Great Recession taking to the roads in RVs, camper vans, or even a car; because that is what they can afford on the jumbled up options available to them.
RSA
@WereBear:
What a tragic story. Thousands (tens or hundreds of thousands, maybe?) of elderly Americans are in a similar boat. In general Medicare doesn’t cover long-term care, such as being in assisted living or in a nursing home, but under some conditions Medicaid does. It’s telling that the Medicaid Web site has a section titled “Spousal Impoverishment” to explain how much life is going to suck for some people, financially, toward the end.
Amir Khalid
It sounds like the Trump administration’s deliberate sabotage of Obamacare is working, at least partly. Making the best-case assumption about the midterm elections, how much of the damage do you think can be reversed or at least mitigated? And what would that take?
aimai
@WereBear: Is this the book, which i just read last year, written by a professor about the plight of her brother and sister in law in California? Can’t remember the name of the book but it was just jaw droppingly horrifying. The author is a professor of something related at MIT and tried to help them all she could but the conflicting california laws and the bizarre patchwork of services/not services left them in the most dire state no matter what they did. And all “because” for reasons having to do with their trying to better themselves she was attending nursing school on some kind of grant that did not have insurance coverage at the moment that she got hit by the car.
Yarrow
@Amir Khalid: I would like to hear David’s answer to this too. How much could be reversed right away? How much would take a Dem President? How much bad stuff can the current President do via signing statements, etc.?
In general, I’d think that if Dems can take one house of Congress then bills to undercut the ACA won’t get passed. For meaningful change to really happen we’d need a Dem President to sign bills into law.
WereBear
@aimai: Yes! That’s the one. Just heartbreaking and filled me with helpless rage.
David Anderson
@Yarrow: I think we bifurcate the health finance system into the lucky and unlucky.
A Democratic Trifecta as large as 2009 but with the 60th Senator seated in January might be able to do more, but anything that moves to the ACA insurance system without German style mandate penalties will make upper-middle class Americans worse off and they scream and are listened to.
I am not in an optimistic mood this morning.
Kristine
And this discussion was enough to spur me to elect the recent inflation adjustment on my LTC policy.
MomSense
I just saw a job posting for a wonderful not for profit. It would be such a fun job for me but then I saw the salary of $21,000. A little later I realized that I could actually qualify for Medicaid and probably end up with the same amount of disposable income. Like everyone I know, I was totally screwed over by the Republican games with the ACA. I pay twice as much as I did last year for a cost sharing silver and get a bronze plan that doesn’t touch any of our regular medical needs. Prescriptions, labs, routine visits – all completely out of pocket. The deductible is $6,000. I’m back where I was 25 years ago with the old next to useless catastrophic plans. Oh and dental care would be covered for my son. As it is now I pay for a plan that really only covers 40% of routine care.
I will never forgive the selfish people who voted for trump.
Yarrow
@MomSense: People will take jobs at large corporations, if they can get them, doing work they hate because they need the health insurance. Just like the bad old days.
Yutsano
@Yarrow: Honestly maybe people need this kick in the teeth to get motivated about this. Health care is hard and expensive, especially in the US. It’s time people started demanding better. Or, y’know, what the rest of the world gets.
WereBear
Just one of the reasons why big corporations don’t want Other People to have access to health care. They love the thought of employees shackled to their desks.
Yarrow
@WereBear: Exactly. Healthcare handcuffs. It gives them access to hire the very best employees because most people can’t afford to leave and get healthcare on the open market.
Mnemosyne
I can’t help but notice that all but two of the listed states voted for Trump in 2016. Way to shoot yourselves in the foot, guys! ?
Yarrow
@Mnemosyne: I asked David about this previously and he said that the health insurance premium rates will be out before the midterms so people will already be aware of just how much Republicans screwed them. May not influence too many votes but it could turn a few.
Radiumgirl
@Yarrow: Exactly this. A major reason why I continue to work where I do is the health insurance.
MomSense
@Yarrow:
There aren’t even large corporate jobs up here unless you want to work for a call center or build navy destroyers.
MomSense
@Patricia Kayden:
It depends on how you define his constituents.
Yarrow
@Radiumgirl: My term for it is “healthcare handcuffs.” It’s wrong in so many ways. It should be a big part of the discussion but for some reason, even during all the ACA discussions, it didn’t get a lot of play. In addition to the moral and ethical ways that it’s wrong, it also hurts our economy because people can’t leave their corporate job to go start a small business if they have any kind of healthcare risk.
I always thought, “Why do Republicans want to hurt our economy?” and “Why are Republicans anti-entrepreneur?” would be good lines of attack against all the Republican healthcare lies, but for some reason it just doesn’t get traction.
Yarrow
@MomSense: Yeah… It totally sucks. I’m so sorry.
MomSense
@Yarrow:
It’s just frustrating because things did get better so you miss it more when you lose it. This was a big hit to my budget and I really don’t have enough to absorb this extra expense.
Yarrow
@MomSense: Feel your pain. I wonder if Yutsy is right that having it and having it taken away is enough to wake people up. I doubt it. At least this time the Republicans own more of the healthcare issue.
MomSense
@Yarrow:
I suspect a lot of the people affected think this is the failing ObamaCare that the Republicans have been warming them about. Hell, LePage and the GOP cut tens of thousands of people off Medicaid by substantially tightening the eligibility requirements and made it sound like it was because of the ACA in the letters they sent out to enrollees.
We are dealing with sociopaths.
PhoenixRising
@Betsy: This is a good summary. The notion of young Boomers and Xers ‘getting good jobs with group benefits’ if we’ve been sick is a nasty joke that’s not funny, though.
My now-wife’s cancer DX was in 1994. We jumped off the income treadmill in 1995 and holed up in a low-cost, no-job, entrepreneurial paradise (Ohio) for 6 years, during which we started a business that let us buy an asset we also lived and worked in. Because she was uninsurable, our plan for a recurrence was that we kept all assets in my name, such that she was also indigent. Paid cash for required routine care.
My DX in fall 2011 got us under the ACA wire, but barely–my insurance company was required by law to offer me a policy renewal at a ZIP code rated premium for 2012. Once the exchanged rolled out, and we were legally married, we were able to buy a family policy, but we still aggressively manage our earnings through our LLCs to keep ourselves eligible for premium support.
The years I was sick in which my mom was also sick were…interesting (we had to pay tax and self-employment tax on more income than we actually earned, in that we left deductions on the table in order to fit into that gap).
Looks like I’m going to need to sell a seminar on how to work that under the new GOP policy framework of FYIGM.
Brachiator
The Republicans promised to repeal and replace Obamacare with something better. People should keep putting this question, and others, to them.
Ruckus
@Patricia Kayden:
Not one thing Katie.
Or as @MomSense: said, depends on who he sees as his constituents. The people that voted for him, or his owners.
BTW this is why they want slavery, they are willing to sell themselves, why shouldn’t everyone else be.
Ruckus
@MomSense:
No. These assholes make sociopaths look positively lovely. I have no idea what is below sociopath on the food chain, but they are below even that.
Really how many rich conservatives are there bank rolling politics to destroy the country and make them even wealthier? koch bros, mercers, devose family, how many others?
MoCA Ace
I’m moving this here from a previous dead thread because it highlights the terrible fucking choices facing those with expensive medical needs and those who love them. And I’m feeling selfish and need to rant!
So my son and his girlfriend are in college. She is a beautiful young woman and I fully expect her to be part of the family some day… She also lost the genetic lottery and her medical bills run $150,000.00 to $200,000.00 per year and will for the rest of her life.
So are my kids (I think of her that way already) wasting their time trying to become young professionals? Are they better off working at some retail job and keeping their total income under the ACA limit? I’m terrified for both of them. About the only thing that keeps me up at night is wondering about their future. I have already heard them talking about a life together and waiting until they graduate to get married.
Do I really have to council my son not to marry the woman he loves because they will be sentenced to a life of financial ruin? I honestly don’t think I can do that. Does any employer hire someone when a routine check will likely turn up the fact that she has this condition and will drive up their groups health insurance rates?
It’s soul crushing when i think about the fact that I, a fat, out-of-shape middle-aged guy, probably have a longer life expectancy that she does, yet I have never seen her bemoan her situation or even hint at the reality of her life. She is in every way a better person than any of these disgusting republican ghouls.
FUCK THEM ALL!
Ohio Mom
@MoCA Ace: Maybe your kids need to move to a blue state? Could that work? They are young enough not to be tied down and rooted to any particular place yet.
Hopefully they can find somewhere to live and work that has a major medical center with the needed specialists. I know, it is ridiculous that they have to consider emigrating like they are peasants from a war-torn, drought-stricken, third-world country.
On another note, sheltering money to remain eligible for Medicaid and Social Security has long been the name of the game for special needs families.
There are loopholes just for us, that I guess we should be thankful for. So thanks all you power-that-be for all the attorney bills and fine print and other hoops continually set before us.
Thanks too for the opportunities you provide for us to stay up nights worrying that we made mistakes with the paperwork and that as a result, our kid is going to end up living in a box after we’re gone (if he has the sense to obtain a box).
louc
@RSA: This is my family. My father suffered a stroke and a brain bleed a few years ago. Then while in care recuperating, he fell and hit his head and suffered another brain bleed that led to early and rapid onslaught of dementia. Now he’s in a nursing home because my stepmother can’t take care of him and after a year, yes, indeed, they spent all their savings on his care. So stepmom is living on his pension and his SS plus Medicaid is paying for his care. The hoops she has to jump through are excruciating. She can keep their current house though she’d like to downsize and move closer to the home. But if she does, half the sale proceeds would go to his care, which prices her out of buying anything reasonable.
She can’t save more than $2,000 — so God forbid the roof leaks or the house has some other major expense — or she gets seriously il herself, which at 79 is likelyl. She has to copy front and back of any check she writes and mail to the state. She is not allowed to use a credit card at all.
We can’t contribute anything or else the state will turn over all the expenses to us. So I can see the kids running out of their own retirement savings+ savings for grandkids’ college to pay for Dad if the Republicans get their way and cut Medicaid drastically and require families to pay for nursing home care.
This is what this country has devolved to.
MoCA Ace
@Ohio Mom: Until a few years ago I lived in a blue state (thanks economically insecure white guys!). I suppose moving to Cali or some other progressive state may be necessary for them. Right now she is still in college and on our state version of medicare. I don’t know all the details but I know her grandparents already shelter money for her because if its in her name the state will remove her benefits, that’s how she is able to afford college and lead an outwardly normal life. My question is how does she make this work after she graduates and starts earning a salary? From what David is reporting even living in a progressive state may not rescue her from a life of poverty.
As I see it there is only one alternative… vote these fuckers out of office and hope we can fix it before too many people die.
On that note, I am by no means a violent man, but if these fuckers visit that kind of evil on my family I will take it very personally.
WereBear
@MoCA Ace: What I learned from the book aimai and I were discussing above is that states vary widely in what they allow and don’t; and there can be surprises.
I really feel for your son and his girl: I have a genetic condition which can be managed, but not cured. On the one hand, I am not running up any health care bills because medical science is not much help. On the other hand… medical science is not much help.
I am looking at how to manage my work life moving forward, because this has changed my future.
Ohio Mom
The thing to do if you think you will have a need to shelter money so as to not run afoul of “the rules” is to consult with an elder care attorney. They are the experts on Medicaid, Medicare and Social Security eligibility, as well as trusts and other shelters.
It sounds like MoCa’s future mishpocha (that is a Yiddish word for very extended family, like your daughter-in-law’s grandparents; they aren’t really related to you but they are in your family’s circle nevertheless) have already consulted with an attorney.
Maybe that attorney can help them identify a good place to move to, since each state has different rules for Medicaid. If she is the right sort of disabled, she may be eligible for an ABLE account, which is a great way to shelter money.
@louc: My brother-in-law had a somewhat similar situation with his now-deceased mother (again, they were bailed out by an elder care attorney). In his case, the problem was that mom had given adult children lots of money to get them over some humps, and that these gifts had occurred during the infamous look-back period (my very well-to-do brother-in-law was not one of the adult children so helped).
I remarked that it is ridiculous that an older person can spend all their money on women, wine and song, come out broke and be immediately eligible for Medicaid, but if they had given the exact same amount of money to family members, say to help them buy a house, or send their kids to college, they are penalized.
I said I thought you ought to be able to give a certain amount of money to your family because we all benefit when families are able to build wealth. No said BIL, the government is doing you a favor (sic) by paying for a nursing home, why should they do you that favor if you have your own money?
Meanwhile, the ultra-wealthy can now pass ALL of their money down through every generation. They get to build wealth, we don’t.
MoCA Ace
@>Ohio Mom:
@>WereBear:
Thanks for the thoughts and advice. I’ve been long lurking but new to commenting. We live in a small town so I can’t really talk about this with most friends and acquaintances because I want to respect the privacy of my sons GF and her family. It really helps to talk about this and blow off some steam.
I will definitely consult an attorney if we get to the point where we are saving for them… right now its all we can do helping the kid with college.
Bob Hertz
It seems that most of the agony in these posts derives from means-tested benefit program, and their inevitable “cliffs” when benefits fall from decent to nothing.
This is not a god given necessity. For example, the ACA could stretch the eligibility for subsidies to all incomes, or to 600% of poverty. This would costs about an extra $6 billion a year, according to the Rand Corp. This is almost a rounding error in federal spending. It is the same kind of ‘correction’ that has been done in the history of Medicare numerous times.
However, this would be a federal solution costing tax dollars, and the right wing Republicans are determined not to let that happen. The angry and anguished families over 400% of poverty are a resource to Republicans, who would rather aggravate their anger than relieve their anger with federal spending.
Lenin would be proud.