Please explain the ACA to me

Triggered by this articletrending on Twitter/Facebook in the last day or so:

My questions:

  1. Both parents are working. Why wouldn’t they have coverage from one of their employers?

  2. In a related Snopesarticle, we learn of a Doug Hoffman that had a family policy for his family of 3 (two parents, one 22yr old dependent) from BCBS for $675/month. How the hell did the Kinders get Individual BCBS for a family of four on $380 a month? Is that $380 per person, or $1540/month?

  3. Would ADHD medication cost $400 a month?

Based only on their family blog, the Kinders seem like a lovely family; I’m just left feeling like I’m missing something.

The article actually seems to be more about the wife’s frustration with dealing with healthcare.gov (although some things seem really weird - calling in at 9pm on a Friday??), but perhaps the saddest part of all this - the nasty comments being left on the various places this has been republished. Typical comments start off referencing Hitler and how Obama only cares about destroying ‘middle-class (i.e., ‘white’) America’ and go down-hill from there…

  1. Thats employer specific. And some employers (like WalMart) might be better to get coverage through the exchange.

  2. You get rate subsidies based on income and number of family. Plus the amount the snopes guy could have been a better plan or less subsidy.

I cant answer 3, unfortunately.

Because a lot of employers don’t offer health insurance, and many that do only offer it to some employees and not others - I worked for a place 10 years that fell into the latter category. According to reporting by the census bureau as of 2010 68% of working adults between 18 and 64 had employer-based health insurance or were covered by someone else’s employer-based plan. The total likelihood of being able to be covered by insurance offered by employers is only 56.5% (a significant decline from 1997 when it was 64.4%), and only 71% of employers offer health insurance to any of their employees. So…it’s quite possible that they both work somewhere that doesn’t offer coverage.

As for #3 isn’t the cost of $400 inclusive of the kid’s medication and $55 co-pays for office visits for therapy related to the condition?

Txs for the answers so far. I’m particularly curious about point two - Individual BCBS for four people, including dental, for $380/month just sounds waaaay too low.

Odds are, they are getting a lotof subsidy. We need wage information to know for sure.

The thing about all these anecdotes is that we never hear the precise details of the old insurance plans, making apples to apples comparisons impossible.

What has happened is that there has been a sharp increase in insurance premiums for employer-based plans, coupled with a decrease in benefits (often in the form of a raised deductible). I don’t know to what extent this is because of ACA, or is part of what has been a general trend for some time. But it does seem like the massive cosmic shift in the market is probably playing some role.

So, before, some family member (the one with an employer who was offering insurance) was able to cover the whole family for $380/month. The employer was probably paying more on top of that.

So, employer’s provider jumps premiums by $400/month. Employer doesn’t increase their own contribution, and so all that gets passed on. Family sees rates double.

This is where ACA is really screwed up. You are only eligible for subsidies if you either don’t have employer-provided insurance or if your employer-provided insurance is “unaffordable” or really awful. “Unaffordable” is defined as “more than 8% of your gross income”. However, that only looks at what it costs to insure the person who works there. The dependent costs aren’t considered at all.

The reason why this sucks is that lots of places pay a huge chunk of the employee’s premium and nothing toward dependent/spouse care. That’s my case: my employer pays just enough that my own premiums are negligible, but to cover my kid and my husband is now close to $10K a year–which is well over 15% of my gross income. If we weren’t offered insurance at all, we could buy on the exchanges and be subsidized to that 8%, saving me about $4K a year. If I actually made what I take home after paying for health insurance, my kid would be eligible for CHIP, and I wouldn’t need to buy him insurance. And this huge rise in premiums comes with a doubling of my deductible–to $2400/person, so we also have to increase our savings rate to cover the actual cost if one of us gets sick. In a year in which no one goes to the doctor except for well-visits, health care would still be our biggest expense. This was not true ten or even five years ago: it’s a real shift.

Anyway, I suspect that the lady in Alabama is in the same sort of situation we are in: it’s ACA-related, but really also part of the larger trend of health insurance growing more and more expensive as health care costs balloon out of control combined with the stupid family glitch.

While I’m sure there have been many nasty comments, it’s a plain fact that the ACA does harm typical middle-class Americans. Five years ago the Democrats set out to pass health care reform. Millions of people were unable to get insurance, either because they didn’t have the money or they had pre-existing conditions that caused insurance companies top reject them. The Democrats wanted to guarantee health insurance to all of these people. Great, but that costs money. How did they intend to pay for it?

Well, they raised taxes on the rich and on certain companies involved in health care, but only a little bit. So where’s the majority of the money going to come from.

Answer: it’s going to come from middle class Americans. The ACA forces premiums to soar upwards. A typical, healthy middle-class person will pay a lot more for health insurance, while in return getting less. (Higher deductibles, higher copays, more restricted networks of doctors and hospitals, &c…) Those near poverty line either get Medicaid for free or get a large subsidy. The middle class gets little or no subsidies. Except for those with pre-existing conditions, we end up with a lot less money.

Rereading it, I see they did have individual coverage. My guess would still be that that was subsidized somehow.

As to ADHD medication costs… yes, some of those meds are costly. A $400 monthly script is not out of the range of realistic.

Anecdotally some parents of kids with ADHD claim that there is a noticeable difference in name brand vs generic medication. Though the FDA requires bioequivalence, the FDA allows a generic to provide blood levels of a medication in arange of 80 to 125 percent of what the name brand drug produces.

I have a question about the bolded part- I hear a lot of people blaming those issues and others on the ACA, but they happened even before the ACA. There were employers that required all employees to take health coverage unless they could prove other coverage - because the insurance company offered a lower rate with such a requirement. And the insurance company offered those lower rates because that meant the healthy 22 year olds who might have gone without insurance would subsidize the not-so-healthy 50 year olds working for the same company. Doctor have always been free to decide which networks they want to participate in and insurance companies have always been free to drop doctors from networks and it’s not at all clear to me how the ACA causes restricted networks rather than doctors and insurance companies .( Pre-ACA, people blamed the insurance companies for that, even if it was the doctor’s decision) I’ve had coverage from two different companies while at the same job- I switched about 10 years ago when my share of premiums doubled- and under each policy my copays increased. The current policy covers out-of-network care and there were deductible increases pre-ACA. I’m not sure how much the ACA itself is to blame - and how much is that the ACA gives the insurance industry a convenient excuse.
I really question that $380 a month individual insurance including dental that covers a therapist and $400/month in medication for one member of the family - especially since Alabama allowed underwriting. I can barely understand a policy that costs under $4000 a year- but I can’t understand an insurance company writing an individual policy for $380 a month when they know there will be a therapist visit every month and a doctor visit every other month and prescription costs just for the ADHD. A group policy with no underwriting- then I can see it. But not this situation. Unless the old plan didn’t cover the $400 in prescriptions , but then the cost under the old plan was $780 (premiums + prescriptions) not $380.

The ACA exacerbated the available processes by basically mandating everything but dropping doctors from networks. Before, if you wanted A++ insurance, you paid for it. You could get any health configuration you wished. Now, you MUST have X insurance. On top of this, you had extra requirements to cover. Things like preexisting condition coverage, while a great thing, is costly.

So, you can no longer compete on price by varying services. So, really, the only things left to tinker with are the deductible amount and the number of doctors in the network. So to restrict costs to a function that netted them profit, they increased the deductibles, in most cases, to the maximum allowable and cut the more expensive doctors from the plans.

Note - Numbers selected for easy math. So, now, you have, say, 10 people on an insurance plan. Each premium is $500 per month. Half of the people get subsidies, but that doesn’t matter to you as the insurance company. You will get your $5,000/month income. Now, each person has a $6,000 deductible. So you get $60,000 off of these people, and you potentially don’t have to make any payments outside of the mandates (free preventative care items, etc). They pay for just under the average cost per person per year (~$8,000) and you make off with $40,000 having to only outlay an estimated $20,000. Plus, the payment split, in the Silver range, is 80/20 - so even after your deductible is met, you will still be paying 20% of your medical bills.

This is the BASIC way it works - The actual equations are far more complex and scaled up to thousands of users. There is also cap on how much an insurance company can take as “profit” from the insurance pool, which is 20%. If they actually had $40,000 in the above example, they’d have to refund $28,000 to the ten plan members. Note that this is for premium income to the insurance company and not deductibles.

That’s why. Everyone is carrying everyone else.

Odds are their actual premium isn’t $380 from subsidies and such (thought it could be if it’s a lower-level Silver or Bronze plan), plus it depends heavily where you are. Rural areas, for example, are way more expensive because you don’t have as many potential people doing that cost sharing.

I think I hit the basics effectively. Anyone please let me know if I got something wrong.

Health insurance company worker here, you are correct. Maternity coverage is another example of a mandated benefit that isn’t inexpensive to provide, before ACA we gave subscribers the option of buying individual policies without it if they weren’t going to have kids.

Cutting expensive doctors (provider tiering) was actually started a few years ago in the response to the failure of managed care to control costs and member backlash against it, as well as all the overhead required to administer it, but of course it continued under the ACA.

Having experienced universal healthcare for 50 years, I have no idea what the above means.

Is it too late to try Plan B: Feel ill > go to hospital (take ID) >> get treated>> go home

No, it’s probably way too late. Instead of poking the bubble of the insurance industry and letting it out when it had the chance, we instead tied it inextricably with government.

In America once the government is in your business, your industry is boned. If something goes right, they take credit and mess with the working model until it breaks. If something goes wrong, they blame the other political party and mess with what works until it breaks even more.

I’m dubious we’ll get UHC anytime soon. :frowning:

I get why the premiums went up.

But if I’m understanding you correctly, the ACA didn’t mandate the $6000 deductible. The insurance companies could have made the deductible $4000 , paid out about $40,000 and kept $20,000, right? Or am I missing something?

It was the insurance that ended 12/31 that had a $380 premium and presumably didn’t have a subsidy.The Silver plan was over $700
[/QUOTE]

The ACA mandates the MAX deductible. But the deductible is one of only a few things that an insurance company can change to affect price. The lower the deductibe, the higher the premium because you’ll hit the payout time quicker.

A lot of the older plans didn’t have things like Pre-existing coverage, prostate exam coverage, or maternity care. If you were a family without any pre-existing conditions, this was fine for you. if the wife/mother of the household had, say, a hysterectomy or had her tubes tied at her last birth, and the husband/father of the household lost his prostate to a tragic rhinoceros incident, then these weren’t losses for you, either. But now, you must pay for those.

Depending on your needs, you could get good coverage on the individual market for fairly cheap. Anecdotally, in my early 20s I had $50 copays for all services (Except ER, which was $150) and drugs on my own dime for a premium of $184/month for my wife and myself.

But this pricing depends on so many factors that we need a policy statement to go off of what he had and why it was set at that price for his family. Did he have disaster coverage only? Did he lack maternity? Was he required to visit the Mayo Moon Clinic (estimated open date: 2466)? And so forth.

I know that’s what the insurance company is going to do.What I’m asking is whether something in the ACA prevents the insurance company from doing this :

10 people on an insurance plan. Each premium is $500 per month. You will get your $5,000/month income. Now, each person has a $4,000 deductible. So you get $40,000 off of these people, and you potentially don’t have to make any payments outside of the mandates (free preventative care items, etc). They pay for half the average cost per person per year (~$8,000) and you make off with $20,000 having to only outlay an estimated $40,000.

And again, I know the insurance company won’t do it. But I don’t think the ACA prohibits it.

And although the $380 still doesn’t make sense to me given the fact that the kid has a known medical issue, here’s an update

Nothing is stopping them. In fact, you can find exchange plans with deductibles as low as $2,000 on my state’s exchange. Not all of them are pegged at the 100% maximum.

As for the response, that’s great that they have care!

But it’s incredibly annoying to me that we have so many programs that no one can coordinate. Why did he have to get uppity in the press just to get attention by the HHS so that they could reveal his options? Additionally, did that grease the wheel of getting into the All Kids program?

I guess I don’t really understand your question. But based on my experience if you have 10 random subscribers at least 1 of them is going to file a substantial number of claims. And if you have 10 young healthy subscribers they’re supposed to balance out the older and unhealthy subscribers we’re now obligated to insure.