“This Is How Obamacare Works”: Listen Up Dipsticks, You Can’t Fix Health Insurance Without Changing Health Insurance
Bill Clinton has been one of Obamacare’s most effective advocates—the “Secretary of Explaining Things,” as President Obama famously called him. But in a new interview already getting attention and sure to get more, Clinton didn’t explain things very well. He made a statement that’s likely to create some misimpressions about the possibilities of health care reform, while giving the administration and its allies yet another political headache. But maybe it’s also an opportunity to have a serious conversation about the law’s tradeoffs—the one that should have happened a while ago.
In the interview, with Ozy Media, the former president fielded a question about the health care law. “The big lesson,” he said, “is that we’re better off with this law without it.” He went on to put the technological problems of healthcare.gov into some perspective: Medicare Part D had similar problems, he noted, “and they fixed it.” And he made a plea with Republican lawmakers to stop blocking the expansion of Medicaid. Fine, fine, and fine.
But then Clinton made news. He said that some young people facing higher premiums under the new system should have the right to keep their old plans, even if it requires a change in the law. Clinton framed it carefully: He said specifically he had in mind only those young people whose incomes were higher than four times the poverty line, making them ineligible for subsidies. (That’s about $45,000 for a single adult.) But he also suggested it was a matter of principle, because those people had heard the vow that they could keep their plans: “I personally believe, even if it takes a change to the law, the president should honor the commitment the federal government made to those people and let them keep what they got.”
Clinton’s statement makes it seem as if there is some simple way to let people keep their current plans—to avoid any disruption in the existing non-group market while still delivering the law’s benefits. As readers of this space know, no such magic solution exists. Broadly speaking, the Affordable Care Act seeks to make two sets of changes to what’s called the “non-group” market. It establishes a minimum set of benefits, which means everything from covering “essential” services to eliminating annual or lifetime limits on payments. At the same time, the law prohibits insurers from discriminating among customers: They can’t charge higher prices, withhold benefits, or deny coverage altogether to people who represent medical risks. They have to take everybody, varying price only for age (within a three-to-one ratio) and for tobacco use.
If you buy your own insurance now, it probably doesn’t live up to these standards. For starters, it probably isn’t as comprehensive as you think. It may not cover prescription drugs, for example, or it might leave out rehabilitative services and mental health. It might expose you to out-of-pocket expenses greater than $6,350 (if you have a single person’s policy) or a $12,700 (if you have a family policy). Until three years ago, when Obamacare’s first regulations went into effect, it was even possible the insurer could yank it retroactively—a process known as “rescission”—if you got sick and the carrier scrubbed your medical records for some previous sign of illness, maybe even one you didn’t know you had.
In addition, unless you live in a handful of states, the premiums you are paying come from insurers who knew, going in, they wouldn’t have to cover people who represent high medical risks. If the policy is affordable, that’s because the insurer figured you were pretty healthy and unlikely to have big medical bills. If you’ve had the policy for a while, and prices haven’t gone way up, that’s because the insurer is still making money from this arrangement—which means, overall, the people in this plan aren’t very sick. Until now, insurers have been able to hike premiums on plans that start to lose healthy customers, and they keep doing so until they become unaffordable—leaving those remaining subscribers unable to find new policies at affordable rates.
The Affordable Care Act includes a so-called grandfather clause. That allows insurers to keep renewing plans, without changes or benefits and prices, as long as they were available before March 2010, when the Affordable Care Act became law. But the non-group market is volatile: Very few people stay on plans for more than two years anyway. And the grandfather clause is narrow, by design: If insurers made even modest changes, the protection goes away. Those plans are subject to the new regulations that take effect in January. As a result, the majority of people who buy insurance on their own are learning they can’t have what they had before, even though Obama promised everybody they could. Either their premiums are going up, as insurers accommodate the new regulations, or the plans are disappearing altogether. In those cases, people have to find new plans. And the sticker price of what they’ll find is higher than what they pay now.
This is not a glitch or an accident. This is the way health care reform is supposed to work. And it’s important to put these changes into context. For one thing, it’s a small number of people relative to the population as a whole. The vast majority of Americans get coverage through employers or a large government program like Medicare. These changes don’t really affect them. The law also anticipates these changes by, among other things, offering tax credits that discount the premiums—in many cases, by thousands of dollars. (Other provisions of the law, like a limit on insurance company profits and overhead, should restrain prices more.) As a result, many people buying coverage on their own will be paying less money for benefits that are as good, if not better, than what they have now.
But there are real people who must pay more and, in some cases, put up with less. Some of them are people walking around with junk insurance, the kind are practically worthless because they pay out so little. Some of them are young people, particularly young men, whom insurers have coveted and wooed with absurdly low premiums—and make too much money to qualify for substantial subsidies. And some of them are reasonably affluent, healthy people with generous, open-ended policies that are hard to find even through employers. Insurers kept selling them because they could restrict enrollment to healthy people. Absent that ability, insurers are canceling them or raising premiums so high only the truly rich can pay for them.
Those people are the ones everybody is hearing about now, partly because they are a compelling, sometimes well-connected group—and partly because, absent a well-functioning website, stories of people benefitting from the law’s changes aren’t competing for attention. It’s impossible to know how big this group is. The data on existing coverage just isn’t that good. The anecdotes are frequently, although not always, more complicated than they seem at first blush. It’s probably one to two percent of the population, which doesn’t sound like much—except that, in a country of 300 million, that’s 3 to 6 million people. Most experts I trust think they represent a minority of people buying coverage on their own, but nobody can say with certainty.
Is that a worthwhile tradeoff for reform? Obviously that’s a matter of opinion. The fact that some people—even a small, relatively affluent group—are giving up something they had makes their plight (genuinely) more sympathetic. They are right to feel burned, since Obama did not make clear his promise might not apply to them. And there’s a principled argument about whether people should be responsible for services they’re unlikely to use presently, whether it’s fifty-something year olds paying for maternity care or twenty-something year olds paying for cardiac stress tests.
But the principle of broad-risk sharing—of the healthy subsidizing the sick, of the young subsidizing the old, and everybody paying for services like pediatrics and maternity care—is one built into the insurance most Americans already have. Employers, after all, don’t charge employees different premiums because of their age or gender. What’s more, the people with good, affordable coverage in the old non-group market were the beneficiaries of a system that marginalized many more. They were paying relatively cheap rates for insurance only because insurers trusted they were unlikely to get sick. Of course, some of them did get sick. And when it happened, many made an unpleasant discovery: The policies they carried left them exposed to huge bills. Giving up these plans isn’t merely an act of altruism. It’s also an act of enlightened self-interest.
Oddly, Clinton himself recognized this: In his soliloquy, he mentioned that a young man he met was upset at having to pay more for a plan—even though the young man knew it would help him more if he got sick. As Clinton surely knows, the whole point of reform—not just the pricing and benefit requirements, but also the individual mandate, which Clinton has repeatedly endorsed—is that people need to take steps to protect themselves against future hardship.
Rhetorically, Clinton’s statement actually isn’t that different from what Obama said in his interview with NBC’s Chuck Todd the other night—that he’d like to find a way to let more people keep their coverage. But it wouldn’t be easy to do. Attempting to rewrite the grandfather clause, so that it applies to more existing plans, could cause insurers to raise prices in 2014 for 2015. It’s also not clear that insurers could or would quickly renew existing policies at existing prices. Clinton mentioned specifically that something should be done only for those people facing higher prices—another echo of Obama’s statement. But distinguishing between groups wouldn’t be easy.
Maybe there’s some muddled, half-solution that will ease the transition without causing real damage. Or maybe there’s some brilliant administrative or legislative fix the experts can’t see. But absent an infusion of extra money—say, to create some kind of transitional assistance fund—any effort to slow changes to the non-group market might not just stop the bad things from happening. It might also stop the good. The latter might outweigh the former, by quite a lot.
You wouldn’t know it from all the press, but Obamacare actually disrupts very little relative to what it accomplishes. The problem is that eliminating disruption altogether simply isn’t possible. You can’t fix health insurance without changing health insurance. And there are bound to be some people for whom that change isn’t good. Those trade-offs should be clear. Maybe now they are.
By: Jonathan Cohn, The New Republic, November 12, 2013
“No Health Insurance, Just Drink”: Koch Brothers Generation Opportunity Campaign Against Obamacare Is Insanely Irresponsible
This is the strangest P.R. campaign yet against the Affordable Care Act. Generation Opportunity, the Koch-funded group behind the Creepy Uncle Sam ads, is throwing tailgate parties to “educate” young people about the exchanges. Read: To convince young people to forgo health insurance.
The group’s communication director, David Pasch, wrote an email to The Tampa Bay Times describing a drunken event at Saturday’s University of Miami-Virginia Tech football game:
“We rolled in with a fleet of Hummers, F-150’s and Suburbans, each vehicle equipped with an 8’ high balloon bouquet floating overhead. We hired a popular student DJ from UMiami (DJ Joey), set up OptOut cornhole sets, beer pong tables, bought 75 pizzas, and hired 8 ‘brand ambassadors’ aka models with bullhorns to help out.”
Mr. Pasch specified that “student activists,” rather than anyone employed directly by Generation Opportunity, “brought (lots of) beer and liquor for consumption by those 21 and over.”
As a sort of afterthought, he added, “Oh yeah, and we educated students about their healthcare options outside the expensive and creepy Obamacare exchanges.”
According to Think Progress, this isn’t a one-time thing: “The group is touring 20 different campuses this fall in a $750,000 effort to convince college students that they’re better off being uninsured than getting health coverage through Obamacare.”
That’s a lot of money for a campaign that’s not only insanely irresponsible, but also insanely dumb. Generation Opportunity is the old guy at a house party, convinced he can win the cool kids’ respect with booze.
By: Juliet Lapidos, Editors Blog, The New York Times, November 11, 2013
“Obamacare Expansion In The Offing?”: Republicans Crying About People Losing Junk Insurance Should Expand The ACA
Every few days, a new poster child for the horror of Obamacare comes along, the person who just loves their insurance plan but has been told it’s being cancelled. Pretty much every time, their story turns out to be full of holes—the plan they’re on is junk insurance, they’d be able to get better and cheaper coverage through the exchanges, and so on (here’s the latest). But without a doubt, this small group of people (and not, say, the millions who are getting free or low-cost coverage for the first time) have become the momentary face of the Affordable Care Act, at least in the mainstream news media’s eyes.
So now the administration is scrambling to deal with this political problem, and here’s the latest twist:
The most popular idea for a fix on the Hill is legislation that would entitle someone who purchases health insurance coverage through the end of this year to keep that coverage. Other legislative responses may include extending the health exchange enrollment deadline or or delaying the penalty for not purchasing coverage.
Obama is also considering a different approach.
According to the administration source, the White House is “looking at an administrative fix for the population of people in the individual market who may have an increase in premiums, but don’t get subsidies.”
Such a fix would address the issue of “sticker shock” that has been popping up across the country, as individuals are losing their coverage and finding only higher-cost alternatives. Under the ACA, there are tax subsidies to help individuals and families with income between 133 percent and 400 percent above the poverty level purchase insurance. Those with incomes higher than 400 percent above poverty get no such assistance. The proposed administrative fix would address this group.
Allowing the junk insurance plans to continue is a terrible idea, no less terrible because it’s being pushed by some Democrats. But giving more subsidies? That’s got some promise. As a big-government liberal, I’m all for the government helping as many people as possible afford coverage. I’m also very skeptical that the administration can just take this move administratively without an act of Congress, but let’s talk about it. Since for the first time in history Republicans are suddenly so very concerned about people not being able to afford health insurance, perhaps they can be pressured into signing on with something that puts their money where their mouths are.
Fat chance, I know. But as long as we’re going to start proposing fixes, how about we let everyone who got a threatening letter from an insurance company buy in to Medicare? If Republicans are going to take the opportunity to demagogue the issue, why not take the opportunity to expand our extremely popular socialized medicine program?
By: Paul Waldman, Contributing Editor, The American Prospect, November 8, 2013
“A Market Of Systematic Discrimination”: President Obama Shouldn’t Apologize For Blowing Up The Terrible Individual Market
Last night, NBC’s Chuck Todd asked President Obama about the people losing their health insurance despite his promise that “anyone who likes their plan can keep it.” (See the video and read the transcript here.)
“I am sorry that they are finding themselves in this situation based on assurances they got from me,” Obama replied.
The answer is a bit of a dodge. People aren’t finding themselves in this situation based on the president’s promises. They’re finding themselves in this situation based on his policy. And Obama isn’t apologizing for the policy.
“Before the law was passed, a lot of these plans, people thought they had insurance coverage,” he said. “And then they’d find out that they had huge out of pocket expenses. Or women were being charged more than men. If you had preexisting conditions, you just couldn’t get it at all.”
Obama was wrong to promise that everyone who liked their insurance could keep it. For a small minority of Americans, that flatly isn’t true. But the real sin would’ve been leaving the individual insurance market alone.
The individual market — which serves five percent of the population, and which is where the disruptions are happening — is a horror show. It’s a market where healthy people benefit from systematic discrimination against the sick, where young people benefit from systematic discrimination against the old, where men benefit from systematic discrimination against women, and where insurers benefit from systematic discrimination against the uninformed.
The result, all too often, is a market where the people who need insurance most can’t get it, and the people who do get insurance find it doesn’t cover them when it’s most necessary. All that is why the individual market shows much lower levels of satisfaction than, well, every other insurance market:
(Graph by Jon Cohn)
Those numbers, of course, don’t include the people who couldn’t get insurance because they were deemed too sick. Consumer Reports put it unusually bluntly:
Individual insurance is a nightmare for consumers: more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell plans with ‘affordable’ premiums whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.
Jonathan Cohn puts a human face on it:
One from my files was about a South Floridian mother of two named Jacqueline Reuss. She had what she thought was a comprehensive policy, but it didn’t cover the tests her doctors ordered when they found a growth and feared it was ovarian cancer. The reason? Her insurer decided, belatedly, that a previous episode of “dysfunctional uterine bleeding”—basically, an irregular menstrual period—was a pre-existing condition that disqualified her from coverage for future gynecological problems. She was fine medically. The growth was benign. But she had a $15,000 bill (on top of her other medical expenses) and no way to get new insurance.
This is a market that desperately needs to be fixed. And Obamacare goes a way toward fixing it. It basically makes the individual market more like the group markets. That means that the sick don’t get charged more than the well, and the old aren’t charged more than three times as much as the young, and women aren’t charged more than men, and insurance plans that don’t actually cover you when you get sick no longer exist. But the transition disrupts today’s arrangements.
(Interestingly, recent Republican plans have focused on disrupting the employer market by ending, limiting, or restructuring the tax exclusion for employer-based plans. There’s an extremely good case to be made that that needs to be done, but it means much more disruption for a much larger number of people. Obamacare’s focus on disrupting the individual market — and only the individual market — is a more modest approach to health-care reform.)
There’s been an outpouring of sympathy for the people in the individual market who will see their plans changed. As well there should be. Some of them will be better off, but some won’t be.
But, worryingly, the impassioned defense of the beneficiaries of the status quo isn’t leavened with sympathy for the people suffering now. The people who can’t buy health insurance for any price, or can’t get it at a price they can afford, or do get it only to find themselves bankrupted by medical expenses anyway have been left out of the sudden outpouring of concern.
If people have a better way to fix the individual market — one that has no losers — then it’s time for them to propose it. But it’s very strange to sympathize with the people who’ve benefited from the noxious practices of the individual market while dismissing the sick people who’ve been victimized by it.
Obama is rightly taking flack for making a promise he wasn’t going to keep, and he’s right to apologize for it. But he shouldn’t apologize for blowing up the individual market. It needed to be done.
By: Ezra Klein and Evan Soltas, WonkBook, The Washington Post, November
“Bringing Actual Facts To Bear”: The Truth Is, Obamacare Is Working
The Obamacare website might still not be working, but journalists are. All across the country, as Republicans try to highlight tragic tales of Americans losing their current health insurance and allegedly stuck with more expensive options, journalists are coming to the rescue. In case after case, journalists investigated these stories and called the policyholders and combed the insurance exchange websites to bring actual facts to bear in our public debate about Obamacare.
Here are just some of the mythical stories journalists have helped dispel — and the lessons we can learn from them about the reality of the Affordable Care Act:
Deborah Cavallaro was making the rounds on television complaining about how her current insurance plan was canceled under Obamacare. So Los Angeles Times columnist Michael Hiltzik talked to her. Her current plan cost $293 per month but had a deductible of $5,000 per year and out-of-pocket annual limits of $8,500. Also, the current plan covered just two doctor’s visits per year.
But in the California insurance exchange, which Hiltzik helped Cavallaro check, she could get a “silver” plan for $333 per month — $40 more than she’s currently paying. But the new plan has only a $2,000 deductible and maximum out-of-pocket expenses at $6,350. Plus all doctor visits would be covered. Hiltzik writes, “Is that better than her current plan? Yes, by a mile.”
Dianne Barrette also popped up on television on a CBS news report in which she lamented that her $54-per-month insurance plan had been canceled under Obamacare. But Nancy Metcalf at Consumer Reports investigated Barrette’s story and found that her current policy was a “textbook example of a junk plan that isn’t real health insurance at all.” According to Metcalf, if Barrette had ever tried to use her insurance for anything more than a sporadic doctor’s visit, “she would have ended up with tens or hundreds of thousands of dollars of medical debt.”
The plan, for instance, only pays for hospitalization in cases of “complications of pregnancy.” Instead, Metcalf found that Barrette could get a “silver” plan in the state insurance exchange for $165 per month that would actually cover Barrette in the case of any sort of serious or even moderate illness. Which is the very definition of insurance, isn’t it?
Edie Littlefield Sundby, a stage-four gallbladder cancer survivor, published an op-ed in the Wall Street Journal blaming the Affordable Care Act for her canceled insurance policy. In her essay, Littlefield wrote that because of Obamacare, “I have been forced to give up a world-class health plan.” But, according to Igor Volsky of Think Progress, Sundby’s insurer, United Healthcare, “dropped her coverage because they’ve struggled to compete in California’s individual health care market for years and didn’t want to pay for sicker patients like Sundby.”
Earlier this year, United, which has publicly supported the Affordable Care Act, announced that it would pull out of the individual market in California. A company representative said it withdrew because its individual plans have never had a huge presence in the state. According to United, and in compliance with state law, the company won’t be able to re-enter the California individual market until 2017.
By then though, competitors will get stuck with sicker patients like Sundby signing up in the first wave of Obamacare. This means that companies like United can cover cheaper patients if it decides to go back to the California individual insurance market.
According to a report by Dylan Scott at Talking Points Memo, a Seattle woman named Donna received a cancellation letter from her insurance company regarding her current plan. The letter steered Donna and her family into a more expensive option and said, “If you’re happy with this plan, do nothing.” The letter made no mention of the Washington State insurance exchange, where Donna could find plenty of other more affordable choices, because the company wanted a convenient excuse to jack up Donna’s rates.
Had Donna “done nothing,” she would have ended up spending about $1,000 more per month on insurance than the cost of insurance she ultimately chose through the Obamacare exchange. In fact, the practice of trying to mislead customers has become so widespread that Washington state regulators issued a consumer alert to customers.
This is just the tip of the iceberg. Republicans who have been desperate from the very beginning to destroy Obamacare at any cost, regardless of facts or the urgent health care crisis facing America, will continue to dig up stories of people supposedly harmed by the law. And journalists will hopefully continue to investigate these allegations, helping us all sort fact from fiction.
In the meantime, there’s a side benefit to all this: If you are one of the small fraction of Americans who currently relies on the individual insurance market and has seen your current policy canceled, call a journalist — like one of those in the stories above. Reporters all across the country are hungry for real-life stories about how Obamacare is working.
Plus, most reporters have access to high-speed Internet. If you can’t get through to the Obamacare exchange site, there’s a journalist standing by willing to help you navigate the exchange options and explore your pros and cons in terms of costs and benefits. The website might still be glitchy, but old-fashioned shoe-leather reporting is as reliable as ever.
By: Sally Kohn, Special To CNN, November 8, 2013
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