# Explain the health insurance penalty to me. **URL:** \ **Category:** Factual Questions\ **Created:** [March 9, 2015, 7:55pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629 "2015-03-09T19:55:36Z")\ **Posts on this page:** 11\ **Page:** 3
**Author:** ![actualliberalnotoneofthose](https://avatars.discourse-cdn.com/v4/letter/a/e79b87/32.png) [@actualliberalnotoneofthose](https://boards.straightdope.com/u/actualliberalnotoneofthose)\ **Post date:** [March 14, 2015, 11:34pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/41 "2015-03-14T23:34:25Z")
> [@jtgain](#): > > Of course, with a bronze level plan, you have a $6k deductible which for most able-bodied adults means you never benefit from the insurance, but that is GD territory. You benefit from the reduced rates negotiated by the insurance companies. At least in my experience. I’ve seen the cash vs. insurance paid rates for plenty of types of visits and procedures before and after I had private individually purchased insurance. I think most people overlook this, though, and I suppose YMMV. And don’t these plans cover things like an annual physical (or something) without deductible? ---
**Author:** ![actualliberalnotoneofthose](https://avatars.discourse-cdn.com/v4/letter/a/e79b87/32.png) [@actualliberalnotoneofthose](https://boards.straightdope.com/u/actualliberalnotoneofthose)\ **Post date:** [March 14, 2015, 11:37pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/42 "2015-03-14T23:37:46Z")
> [@Si\_Amigo](#): > > I absolutely dread posting anything in this thread due to the political aspect of the topic but I believe that in the case you are describing would qualify you for free healthcare, all you need to do is sign up. Depends on where you live, if you have a disability, and/or if you have kids. ---
**Author:** ![Fear\_Itself](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/fear_itself/32/19637_2.png) [@Fear\_Itself](https://boards.straightdope.com/u/Fear_Itself)\ **Post date:** [March 14, 2015, 11:44pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/43 "2015-03-14T23:44:28Z")
> [@actualliberalnotoneofthose](#): > > And don’t these plans cover things like an annual physical (or something) without deductible? Yes. An annual physical, plus any preventative treatment, such as flu shots and colonoscopies. ---
**Author:** ![jasg](https://avatars.discourse-cdn.com/v4/letter/j/f0a364/32.png) [@jasg](https://boards.straightdope.com/u/jasg)\ **Post date:** [March 15, 2015, 12:55am UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/44 "2015-03-15T00:55:34Z")
> [@jtgain](#): > > Of course, with a bronze level plan, you have a $6k deductible which for most able-bodied adults means you never benefit from the insurance, but that is GD territory. Don’t forget that at low income levels, in addition to the premium subsidy, there is a cost sharing reduction that limits your OOP costs for copay+deductible to $2250. To many still a big number, but only if you have a serious medical issue - which, without insurance, could easily cost much more. ---
**Author:** ![Iggy](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iggy/32/3364_2.png) [@Iggy](https://boards.straightdope.com/u/Iggy)\ **Post date:** [March 15, 2015, 1:10am UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/45 "2015-03-15T01:10:01Z")
> [@md2000](#): > > ,… > > How much could a family of 4 conceivably be out of pocket in cash expenses each year for covered procedures, even if insured by a plan that meets ACA standards? Going to [the source](https://www.healthcare.gov/choose-a-plan/out-of-pocket-costs/) for this: > [@](#): > > The maximum out-of-pocket costs for any Marketplace plan for 2015 are $6,600 for an individual plan and **$13,200** for a family plan. This means when the amount you’ve paid in deductibles, copayments, and coinsurance reaches these limits, the insurance company pays 100% of your costs for covered care. Even if you choose a catastrophic coverage plan your out-of-pocket costs shouldn’t exceed this limit. (bolding is mine) ---
**Author:** ![md2000](https://avatars.discourse-cdn.com/v4/letter/m/73ab20/32.png) [@md2000](https://boards.straightdope.com/u/md2000)\ **Post date:** [March 16, 2015, 9:21pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/46 "2015-03-16T21:21:59Z")
Nobody has answered my other question. Apart from the “stop Obamacare at any cost” movement, I thought I had read that the ACA Medicare subsidies for the states to expand Medicare reduced and/or expired after 5(?) years; the principal objection from some states was that they would expand Medicare which would cost a lot more money, then the feds would pull the rug out from under them and the states would be on the hook for the heavily expanded costs. ---
**Author:** ![slash2k](https://avatars.discourse-cdn.com/v4/letter/s/439d5e/32.png) [@slash2k](https://boards.straightdope.com/u/slash2k)\ **Post date:** [March 16, 2015, 10:02pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/47 "2015-03-16T22:02:28Z")
> [@md2000](#): > > Nobody has answered my other question. > > Apart from the “stop Obamacare at any cost” movement, I thought I had read that the ACA Medicare subsidies for the states to expand Medicare reduced and/or expired after 5(?) years; the principal objection from some states was that they would expand Medicare which would cost a lot more money, then the feds would pull the rug out from under them and the states would be on the hook for the heavily expanded costs. The MedicAID subsidies for the states are not scheduled to expire; [they will dwindle from 100% to 90% by 2020](http://medicaid.gov/affordablecareact/provisions/financing.html), but are then planned to remain at 90% in perpetuity. It is of course possible for a future Congress to change the law and reduce or eliminate the subsidies, but this would require an affirmative act by the Congress to leave the states on the hook. (MedicARE is a wholly separate and almost entirely federal program. The ACA did not expand Medicare.) ---
**Author:** ![What\_the](https://avatars.discourse-cdn.com/v4/letter/w/f4b2a3/32.png) [@What\_the](https://boards.straightdope.com/u/What_the)\ **Post date:** [March 17, 2015, 3:15pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/48 "2015-03-17T15:15:46Z")
> [@Lord\_Feldon](#): > > That’s how your taxes always work, though. Maybe the subsidies involve a little more risk for an average taxpayer, but our tax system is based on paying as you go based on assumptions, then checking to see if they were correct when the year ends. I just deleted a longer post because I finally see your point… if you were over-subsidized you didn’t “pay as you go” so you have to pay more later. So it’s clearly a tax then I guess. ---
**Author:** ![wevets](https://avatars.discourse-cdn.com/v4/letter/w/e9a140/32.png) [@wevets](https://boards.straightdope.com/u/wevets)\ **Post date:** [March 17, 2015, 3:22pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/49 "2015-03-17T15:22:39Z")
> [@jtgain](#): > > But how many of those are childless and non-disabled adults who live in the 21 states that don’t offer Medicaid for those people? Not sure, but remember this is GQ, not GD - the Census Bureau has a number of reports like the one I linked to earlier. Feel free to browse their website to see if you can find the answer to your question. I’ll link you to another report that is up the alley of what you’re looking for, but I haven’t read it so I’m only guessing that it might answer your question: [Income, Poverty, and Health Insurance Coverage in the United States: 2012](https://www.census.gov/prod/2013pubs/p60-245.pdf) - as far as I can tell, the 2013 version of that report is not out yet. Table 3 might interest you since it breaks down poverty by people in families and those not in families, since you asked about “childless and non-disabled adults” and Table 7 breaks down poverty by region, although not by state. Edit: Actually, Table 7 is of uninsured people, not poverty - not as helpful for your question. ---
**Author:** ![Iggy](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/iggy/32/3364_2.png) [@Iggy](https://boards.straightdope.com/u/Iggy)\ **Post date:** [March 17, 2015, 4:47pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/50 "2015-03-17T16:47:45Z")
> [@slash2k](#): > > The MedicAID subsidies for the states are not scheduled to expire; [they will dwindle from 100% to 90% by 2020](http://medicaid.gov/affordablecareact/provisions/financing.html), but are then planned to remain at 90% in perpetuity. > > It is of course possible for a future Congress to change the law and reduce or eliminate the subsidies, but this would require an affirmative act by the Congress to leave the states on the hook. > > (MedicARE is a wholly separate and almost entirely federal program. The ACA did not expand Medicare.) The worry is not idle speculation. The federal government has lowered its Medicaid contribution percentage in the past, leaving the states to make up the shortfall. [Cite](http://www.cbpp.org/cms/?fa=view&id=722) It has to do with how the percentage that the federal government pays, called the Federal Medical Assistance Percentage (FMAP) is calculated. In essence, states with higher per-capita incomes generally get a lower percentage of their Medicaid covered by the feds. So as incomes rise in a state, the feds chip in less for Medicaid. And, of course, Congress can change the formula by which the FMAP is calculated at any time. [Some states receive](http://kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/) as little as about 50% federal funding for Medicaid (for those patients eligible pre-PPACA). On the other extreme, a state with low per-capita income and high poverty (Mississippi) received about 74% federal medicaid funding. ---
**Author:** ![slash2k](https://avatars.discourse-cdn.com/v4/letter/s/439d5e/32.png) [@slash2k](https://boards.straightdope.com/u/slash2k)\ **Post date:** [March 17, 2015, 5:41pm UTC](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629/51 "2015-03-17T17:41:34Z")
> [@Iggy](#): > > The worry is not idle speculation. The federal government has lowered its Medicaid contribution percentage in the past, leaving the states to make up the shortfall. Your cite, however, shows changes in how the formula applies to different states at different times, not changes in the formula itself. (That is, when they plug the per capita income numbers into the formula, it may yield a different result due to economic conditions in the state relative to the nation.) Are there any examples of the formula itself being changed to any state’s detriment? That is, has Congress ever taken an affirmative act to reduce a particular state’s percentage (or all states’ percentages)? [Previous page](https://boards.straightdope.com/t/explain-the-health-insurance-penalty-to-me/714629.md?page=2)