Monday, November 25, 2013

When Dinosaurs Ruled the Earth

I’ve been feeling very fatalistic lately about the course ObamaCare will take and, more generally, about whether the juggernaut of Incredibly Huge Utterly Unresponsive Federal Government Bureaucracy is stoppable - or even slow-down-able. Kevin D. Williamson does nothing to change that:

Barack Obama’s administration is unmoored from the institutions that have long kept the imperial tendencies of the American presidency in check. That is partly the fault of Congress, which has punted too many of its legislative responsibilities to the president’s army of faceless regulators, but it is in no small part the result of an intentional strategy on the part of the administration. He has spent the past five years methodically testing the limits of what he can get away with, like one of those crafty velociraptors testing the electric fence in Jurassic Park.

As Williamson points out, "the American public accepts" this. That's not a hopeful sign, either.

Saturday, November 23, 2013

Access denied

Robert Laszewski’s newest post is, like all that have come before, worth reading in its entirety. Entitled “If You Like Your Doctor You Will Be Able to Keep Your Doctor, Period”, this piece explains why ObamaCare makes narrow networks an increasingly important way for insurers to control their premium pricing; hypothesizes that those low-cost, narrow network plans will strongly influence the subsidy amount; and points out that attempts to use legislation to force insurers to widen their networks will result in another round of rate shock.

One point Laszewski does not make clearly enough is that not only do the new insurance plans have restricted networks; many (my limited research indicates most) of them also do not have any out-of-network coverage other than emergency care. None. Zip, zilch, nada. Niente. So when Laszewski says (emphasis mine):

... some health plans are only offering narrow networks on the new health insurance exchanges. Health plans, figuring that a great many of the new exchange customers will be coming from the ranks of the uninsured have decided to craft plans that largely include providers located where many of these uninsured people live and where they are most likely to get their health care anyway––perhaps not as big a deal for these folks who, because they are uninsured, don't have a regular provider relationship. But it also means these people will not have access to some of the most respected centers of excellence if they have a serous illness. [snip]

People who might be accustomed to broader networks found in employer health plans will have to either buy-up to better plans or may find their choices limited on the exchange.

it isn’t just that people will have to buy a more expensive plan to get a broader network; it’s also that people will have to buy a more expensive plan to get any coverage for out-of-network treatment at major cancer centers, well-regarded children’s hospitals, specialty diagnostic facilities - all kinds of “respected centers of excellence”.

Do people without out-of-network coverage still have “access” to these facilities? Of course, if by access one means they can show up and ask to be treated. But if by “access” one means actually receiving treatment at these facilities without insurance coverage - well, if people could get expensive medical treatment without being able to pay for it, no one would need health insurance in the first place.

Thursday, November 21, 2013

Wait. What?

So I was looking for information about what income levels mean one is thrown into Medicaid and I found a website called “ObamaCare Facts”. I cannot figure out exactly who runs this site: the government, the insurance companies, concerned citizens? It appears to present an uniformly positive view of the Affordable Care Act. Anyhow.

On the page about subsidies, I found this:

A subsidy (cost assistance) lowers the amount you spend on your monthly premium (via advanced premium tax credits) or reduces your out-of-pocket costs for things like copays, coinsurance, deductibles and out-of-pocket maximum (cost sharing reduction).

Subsidies for out-of-pocket costs? Did I know that? A little later, the page says:

Those making less than 250% FPL can get subsidies to lower out-of-pocket costs.

And a little later:

In order to receive out-of-pocket assistance (AKA cost sharing reduction subsidies), you must buy a Silver plan from the state exchange and an individual or family must have incomes no more than 250 percent of the Federal Poverty Line.

Note that in order to receive “out-of-pocket assistance”, one must buy a Silver policy and one must buy if from a State exchange. Of course, this page also says that premium support subsidies are only available if one buys from a State exchange and the Administration is doing its best to make that restriction no longer operative.

I haven’t heard about this type of subsidy but I did find a Kaiser Health News write-up on it and apparently it’s for real for State exchanges.

You learn something new every day.

Belief, hidden information, lying, and do-overs

The Wall Street Journal piece in which Nicole Hopkins talks about her mother being forced into Medicaid by ObamaCare provides some insight into a number of issues.

Briefly Ms. Hopkin’s mother had been purchasing health insurance on the individual market in Washington State. Her current policy cost her $276 per month; making those premium payments every month was a stretch for her but she believed it was important to do so. She believes it is her responsibility to take care of herself; she also believes that taking government handouts is shameful.

Ms. Hopkin’s mother received one of the infamous cancellation letters from her insurer. It informed her of the usual: her current policy didn’t meet the ObamaCare standards and could not be renewed. In its place, her insurance company offered an ObamaCare-compliant policy with a premium of $415.20. There was no way Ms. Hopkin’s mother could afford the new premium so she used Washington’s State-run exchange to see what other coverage she could find. After entering all the required information, she was informed that Medicaid was her only option. Her daughter re-did her mother’s work on the exchange and achieved the same result. Hoping that hitting “Apply for Coverage” would reveal more options, they did so and found Ms. Hopkin’s mother was now enrolled in Medicaid.

This story illustrates some general points about the understanding and implementation of ObamaCare among those who are living with it:

1) Ms. Hopkin’s mother (and Ms. Hopkins herself) appear to believe that the Washington State exchange is the only way Ms.Hopkin’s mother can buy health insurance. This is not true. Ms. Hopkin’s mother can buy insurance directly from any of the insurance companies selling to individuals in the State. (Well, actually, in her county - how weird is this whole “available policies and/or rates vary by county” thing?)

If they do believe this, I can’t blame them. I spent a few very anxious weeks believing the same thing: I could only buy individual health insurance through the exchanges and the exchanges weren’t working and oh, no, what was I going to do? I don’t remember what finally clued me in that I could still buy directly from whatever insurance companies were selling individual policies but it was a great relief to me when I finally stopped panicking and realized I would be able to buy health insurance even if the exchanges never, ever worked.

Further, based on what I’m seeing written about the ObamaCare cancellations across the blogosphere, Ms. Hopkins, her mother, and I are not the only people confused about this. There are a lot of articles, posts, and comments of the form, “Their insurance was cancelled because of ObamaCare and the exchanges aren’t working and so there is no way for these poor people to buy insurance before their policy goes away and they are going to find themselves uninsured as of January 1.” Sometimes the context makes it clear this is shorthand for “there is no way for these poor people to buy insurance they can afford before their policy goes away.” In its expanded form, this statement may very well be true: if the policy in question was cheaper than the ObamaCare policies and the people who were cancelled cannot handle the premium increase on their own, then the only way to have any hope of getting a subsidy to make their insurance affordable is through the exchanges.

Often, however, the writer seems to believe that individual health insurance can truly only be purchased through the exchanges. That’s incorrect and given the extent to which people apparently believe this, I think the series of ads put together by Wellmark Blue Cross Blue Shield is an excellent idea. The fact that the ads are funny is an added bonus not just because we can all use a good laugh about now but also because it means the ads will likely be seen by people outside their target areas of Iowa and South Dakota, thus spreading the information that the exchanges can be bypassed if buyers can live without, or are not interested in, the subsidies.

2) The replacement policy offered to Ms. Hopkin’s mother is not the cheapest policy available to her. The Premara Blue Cross site tells me that a 51-year-old woman* living in Pierce Country (zip 98303) can buy health plans with premiums ranging from $343.39 to $541.50 per month. Even the cheapest of these plans is more than Ms. Hopkin’s mother’s current premium of $276 but it is less than the $415.20 premium quoted in her cancellation letter.

There may be other insurance carriers from whom Ms. Hopkin’s mother could buy insurance. The Washington State Office of the Insurance Commissioner lists all the plans potentially available to people in Pierce County. Unfortunately, some of the links seem to go to 2013 rate sheets so it’s not clear whether there is a better deal available.

Presumably the information that lower premiums were available is exactly what Ms. Hopkin’s mother hoped to find when she entered the Washington State exchange website. Because her income was so low, however, she was never shown these options and was instead shunted into Medicaid. This leads to the third point illustrated by this story:

3) If you want to see all your options, you may have to lie about your income when you’re shopping around in the exchanges - by reporting it as higher than it is. I’m not advocating lying about your income when it comes time to finally actually enroll through the exchanges (if you decide to go that route). However, if you want to see all available information and forestall the government deciding what you “should” see, you need to fool the system long enough to gather data.

As I understand it, the problem of incomplete information arises because if an applicant’s income is between 138% and 400% of the poverty level, he is eligible for a subsidy which can be applied to whatever policy he chooses. However, if the applicant’s income falls below 138% of the poverty line, he is not eligible for a subsidy and must either pay the entire cost of his insurance himself (and cannot buy it through the exchanges) or he must go into Medicaid.** I assume the system was designed this way to reduce the number of people getting subsidies (presumably Medicaid is cheaper than subsidies) but I really don’t like it. If someone who the government thinks is “too poor” to buy his own insurance wants to do so anyhow, I’d rather we help him than make him worse off than someone who makes just a few dollars more than he does.

A couple of the commenters over at the WSJ article are suggesting Ms. Hopkin’s mother lie to the exchange, reporting her income as high enough not to qualify for a subsidy, and that she do this as part of actually buying whatever policy she wants. There’s no need for this. She can report her income as high enough to see all her options on the exchange; pick the policy she wants; and buy it directly from the insurance company. So long as she does not want to try to get a subsidy, there is no need to buy her insurance through the exchange so there is no need to lie in a formal application.***

4) It sounds like the exchanges - Washington State’s, probably the Federal one and those of other States - need a better “are you sure you really want to do this” step and a relatively easy way to say “oops” if someone signs up without intending to or changes her mind or realizes she’s entered data incorrectly or her situation changes or whatever. This is particularly true if signing up erroneously affects someone’s ability to get insurance down the road, as I have seen claimed (although I can no longer find the source of that claim).

So was Ms. Hopkin’s mother “forced” into Medicaid. Sort of. There were other options available: she didn’t have to buy through the exchange; there was at least one plan that was cheaper than what her insurance company quoted her. However, by jacking up the price of health insurance to a level Ms. Hopkin’s mother could not afford; refusing to subsidize her purchase of this more-expensive insurance; and not making clear to her what other options she had, ObamaCare may have removed any other option. In that sense, yes, she was forced into Medicaid.

I find Ms. Hopkin’s mother’s story hits close to home. I admire her determination to take care of herself and find it terribly sad that her ability to do so has fallen victim to ObamaCare.



* Why are insurance sites (and this isn’t the only one) still asking about gender? I thought ObamaCare required that men and women be treated exactly the same.

** If your State did not expand Medicaid then if you make between 100% and 138% of the poverty level, you cannot go into Medicaid and your cannot get a subsidy. The technical term for this situation is "up the proverbial creek without the proverbial paddle".

*** If Ms. Hopkin’s mother lies on her actual application, reporting her income as higher than it is so she can get a subsidy rather than going into Medicaid, that’s fraud: she has received more than the law says she’s supposed to get. I have to admit that I planned to do exactly that at a point when I believed I would only be able to buy insurance through the exchanges; would not be able to afford to pay for an ObamaCare-compliant policy myself; and would have income low enough so that ObamaCare would throw me into Medicaid. (I have assets rather than income.) I figured I could get away with it because Obama had waived income verification for 2014.

According to this, I was wrong: it’s not true income verification has been waived. However, the guidelines for checking “suspect applications” apparently are all about looking for people who are reporting too little income, not people who are reporting too much. This seems to be yet another case where the people running ObamaCare don’t understand where the trap doors are.

Going back to whether lying on a formal application is fraud, if someone lies on a formal application through the exchanges, giving his income as higher than it is and high enough to not qualify for a subsidy, is that a crime? Fraud? Something? I suspect the government - Federal certainly, some States - would consider it so but the effect of the lie didn’t cost the government anything - may, in fact, have saved the government money if the applicant would have qualified for government help (either Medicaid or subsidies) if he had told the truth.

Here’s a more interesting example. Let’s say someone has been buying health insurance for himself all along. Now the ObamaCare policies are all that are available to him and they are all more expensive than what he’s been purchasing. His income is low enough that he would qualify for a subsidy that covers the entire cost of a policy roughly comparable to his old one. He does not like the idea of being subsidized but figures the only reason he needs the subsidy is because of ObamaCare. He decides to misrepresent his income, reporting it as higher than it is so the amount of the subsidy he receives is just enough to make his cost for the new insurance the same as his cost for his current insurance. Is this fraud? He has lied and he has received payment from the government but, once again, he has saved the government money.

(Apparently the whole issue of income and fraud is a tricky one as this piece points out.)

Monday, November 18, 2013

Moral calculus

Related to my previous post, JustOneMinute points out:

And do let's note - a standard lib talking point during the promotion of Obamacare was that access to health insurance saves lives. Dare we presume that failure to implement Obamacare thereby costs lives, eventually if not by this weekend? Ezra Klein was talking about 15,000 to 20,000 lives per year, which dwarfs the 1,833 who died at Katrina.

It’s an interesting moral question. If someone sees what they believe is a great wrong and attempts to fix it but instead makes the situation worse, is he more or less culpable than those who did nothing?

Sunday, November 17, 2013


The Washington Post is reporting that “[t]he Obama administration will consider the new federal insurance marketplace a success if 80 percent of users can buy health-care plans online.” A success for whom? For the Democrats? For the Obama Administration? For Obama's "legacy"? Not for the unlucky 20% who need health insurance and can’t buy it.

As JohnE over at Ace of Spades points out:

This, of course, includes the nearly 5 million people who have already been booted off their plans due to Obamacare. I suppose it's a success if 20% of them, or 1 million people, are unable to purchase insurance because the website is glitchy. Wait, wasn't this law passed in large part to "help those who were unable to purchase health insurance"? I seem to recall that being a thing.

Oh, well. Eggs and omelettes.

Today on Meet The Press, Nancy Pelosi insisted that the health insurance policies being cancelled were not because of the Affordable Care Act. You have to read her whole exchange with David Gregory to get a sense of how bizarre it is but here’s a snippet:

But that doesn't mean that there was anything in the law that said if you like what you had before 2010 you couldn't keep it.

Here’s what NBC said two days ago in an investigative report entitled “Insurers, state officials say cancellation of health care policies just as they predicted”:

In comments filed in August and December 2010, America’s Health Insurance Plans -- a trade group representing 1,300 insurance plans — urged the administration to “reconsider” grandfathering rules because they were too stringent to allow many to keep their policies.

In the first round of comments, AHIP stated that under the administration’s proposed regulations, “The percentage of individual market policies losing grandfathered status … will likely exceed the 40-67 percent range” and warned that could cause “disruptions” for those who wish to keep their policies.

When those proposed rules weren’t changed, AHIP again wrote in December, “We believe that more can and should be done to protect the interests of consumers who wish to maintain their existing coverage.”

That “first round of comments” happened in August of 2010. CNN reminds us that Republicans reacted to AHIP’s warnings shortly thereafter:

Senate Democrats voted unanimously three years ago to support the Obamacare rule that is largely responsible for some of the health insurance cancellation letters that are going out.

In September 2010, Senate Republicans brought a resolution to the floor to block implementation of the grandfather rule, warning that it would result in canceled policies and violate President Barack Obama’s promise that people could keep their insurance if they liked it.

In the round-table segment of Meet The Press, David Gregory said this:

And people will say this is like Katrina; I think it's more like Iraq. That was about life and death, this is not. That's not the comparison. The comparison is everybody looked at Bush through the prism of Iraq. Here, I think people are going to look at Obama through the implementation of Obamacare. He wants to talk about something else.

Gregory seems to be saying that Katrina was about life and death, but the Affordable Care Act is not.

That’s not what President Obama was claiming when he argued that we had to pass the Act. Speaking about a campaign supporter who died of breast cancer, he said:

She didn’t have insurance. She couldn’t afford it, so she had put off having the kind of exams that she needed. And she had fought a tough battle for four years. All through the campaign she was fighting it, but finally she succumbed to it.

It turns out Obama didn’t have his story straight but these kinds of anecdotes are exactly what sold people on ObamaCare: people who don’t have health insurance can’t get the health care they need and sometimes that means they die. And the Affordable Care Act was going to insure that didn’t happen any longer. That sounds like life and death to me.

The Administration that thinks leaving 20% of the people who need health insurance hanging is “a success”; the California Congresswoman who continues to lie about the damage done to those who are losing the health insurance she swears she wants everyone to have; the television pundit who sees health insurance as a political football rather than a matter of life and death. None of them seem to realize that the 20%; the cancelled policy-holders; the currently insured and currently uninsured whose only hope for insurance they can afford depends on getting through a broken website and praying there’s something on the other side they can afford - all these are human beings whose lives are being upended by the hubris, dishonesty, and incompetence of those who conceived, sold, and implemented ObamaCare.

I wonder if those responsible will understand the reality of what they’ve done if people start dying, or will that, also, be brushed aside as politics.

Saturday, November 16, 2013

The good, the bad, and the ugly

The Good:

It turns out I have some options. First, my current insurance carrier - Blue Cross Blue Shield of New Jersey - will allow me to do an early renewal on my current plan. This means I can re-up with a start date of, for example, December 15 and keep my current insurance for a year. Since I like my plan, it’s nice to know I can keep it, at least for a while longer.

Second, although I originally thought I would not be able to find an ObamaCare-compliant insurance plan (a metallic) with any out-of-network coverage, it turns out that’s not the case. AmeriHealth is offering metallics in New Jersey that have out-of-network coverage: one Silver, one Gold, and one Platinum. The Silver is roughly comparable to my current coverage and is only $85 more per month than my current plan will be in 2014. Given my past medical history, I need out-of-network coverage; I am unwilling to risk financial ruin in the (I hope) unlikely event I need treatment at one of the big specialty medical centers outside of New Jersey.

The Bad:

Every rose has its thorns, of course, First, if I want to renew my current plan to reset my start date to December of 2013, I have to go without insurance for one day. That is, I would have to cancel my plan as of end-of-day on December 13; be without insurance on December 14; and would regain coverage on December 15. This is not a problem with regard to deductibles re-setting since I’m nowhere near mine anyhow. It is a little scary to think of being without health insurance, even briefly - and even scarier since December 13 is a Friday.

Second, although I am hoping to avoid any extensive interactions with my doctors, there is one doctor who is the hands down favorite to be involved in any (I hope) unlikely expensive encounter during the next year. Unfortunately, that doctor is one of my three doctors who are in the Blue Cross network but are not in the the AmeriHealth network.

The Ugly:

My first reaction to President Obama’s decision to not prosecute insurance companies that “extend current plans that would otherwise be cancelled into 2014” (provided their State regulators agree) was that it might open up another option for me: Assuming the State of New Jersey and Blue Cross were amenable, I could simply keep my existing plan until the current anniversary date in Spring 2014, renew it then, and have it in place until Spring 2015. After sleeping on it, however, I realized that would be a very risky path.

Imagine that the website is working reasonably well by, say, January 31; alternatively - and more believably - imagine that by January 31 the White House figures out a way for people to buy policies directly from insurance companies and still qualify for the subsides. It wouldn’t surprise me if the President declared that there is no longer a reason to allow insurers to renew non-ObamaCare compliant policies going forward because those who are losing their insurance can now find affordable alternatives. He would declare his November 14 statement no longer operable and announce that, henceforth, he will prosecute any insurance company that renews a pre-ObamaCare policy. Poof! When my anniversary date arrives on May 1, I have to go into the exchanges. I’d have to be as dumb as a whole yard of grass to trust my health to whatever the President says is allowable today when I know there’s a good chance it will be disallowed tomorrow.*

So if I want to hold onto my current health insurance, my only viable option is to take the 24-hour break from it. If I decide to go that route, I’ll be spending December 13th and 14th locked in my room with a box of saltines, a jar of peanut butter, a jug of water, and a pile of books.



* If I were a Republican Congresswoman, I’d introduce a bill that does exactly what the President’s November 14th statement does: allow insurance companies to renew non-compliant policies through (or perhaps it’s “up to”) October 1, 2014, while requiring that they provide all the information outlined in the CMS November 14 letter (pdf) to Insurance Commissioners. If Obama vetoes that, or threatens to veto it, that would tell me all I need to know about whether he’s committed to his decision to forgo enforcement.

And, no, “October 1, 2014” is not a typo. The President’s change is generally reported as allowing non-compliant policies to be renewed “through 2014” or “in 2014” but the wording of the letter is:

... health insurance coverage in the individual or small group market that is renewed for a policy year starting between January 1, 2014, and October 1, 2014, and associated group health plans of small businesses, will not be considered to be out of compliance with the market reforms specified below under the conditions specified below.

Which means I’ll probably be having a conversation with Blue Cross in August of 2014 about doing another early renewal. Time to stock up on saltines and peanut butter.

Friday, November 1, 2013

Maybe he'll get a phone call

Some insurance companies that are having to cancel policies due to ObamaCare regulations are reported to be offering their current subscribers an opportunity to “re-up” for their current plans before the end of 2013. This has the effect of re-setting the start dates for those policies to the new enrollment date in late 2013 and thus resetting the anniversary date for those policies to late 2014. This allows the current subscribers to stay on their policies through most of next year: if they like their insurance they can keep it, at least for a little while longer.

After spending some time feeling resentful that my insurance company didn’t offer me that option, it finally occurred to me to just ask my Sales Representative at my insurer if there was any way I could do something like that. It turns out there is, although it’s not as straightforward as I’d like. I’d have to terminate my current policy, go without insurance for at least 24 hours, then pick up coverage again with a new policy. Also - and I need to talk to my Rep about this if I’m seriously considering doing it - I don’t know what happens if my new anniversary date is, say, December 15, 2014. Assuming ObamaCare survives, can I sign up during open enrollment for coverage that will start on that date or will I have to go uninsured from December 15 until my new insurance kicks in on January 1, 2015? I also don’t know yet how much the rates will go up next year on my current insurance. But at least it looks like I can hang onto my current policy for a little longer if that seems like the best option for me.

If I had inexpensive catastrophic health insurance, I’d almost certainly want to hang onto it as long as possible. However, since I live in New Jersey, catastrophic insurance has never been an option for me and so I already have a pretty pricey fairly comprehensive policy. I need to review the ObamaCare compliant offerings and see if there’s one that’s acceptable. Part of that is deciding how important it is to me to keep out-of-network coverage and part of deciding that is figuring out which doctors, hospital, and other care providers are and are not in the available networks. Once I’ve done that and gathered the rest of the information I need about renewals and rates if I do stick with what I have, I can decide what course is best.

I have to admit that even without running the numbers I'm very tempted to hang on to what I have. After all,who knows? Maybe by the end of 2014 everyone will have realized what a very bad idea ObamaCare really is and I can just avoid all those metals altogether.

And now I’m really, truly done blogging for at least a week.

(The title of this post is from the following baseball story:

One day, Jimmie Foxx came to bat with the bases loaded. Catcher Bill Dickey signaled for Lefty Gomez’ top pitch, a fastball. Gomez shook him off. So Dickey called for a curveball. Another shake off. So Bill went to the mound. "What do you want to throw this guy?" "Nothing," Lefty replied. "Let's wait a while. Maybe he'll get a phone call."

So maybe I'll wait a while.)