Steerpike

A visitor from UK was asking 'what is Obamacare'. Does the following capture the essence of it, would you say, in terms of key features / changes? Please don't turn this particular thread into another debate on US healthcare


This discussion only applies to those under 65; once you reach 65, you are eligible for ‘Medicare’ which is a different system.



Pre Obamacare

1. Group health plans, offered by companies to employees, could not exclude conditions from coverage (no ‘pre-existing conditions’ terms) and could not refuse coverage to anyone eligible for coverage. Lifetime caps of benefits were allowed (eg, $2 million max lifetime payout).
2. Individual health policies (used by self-employed, retired, those working for small companies not offering healthcare insurance, etc) could exclude ‘pre-existing conditions’ from coverage, and could refuse to offer a policy to anyone. Lifetime caps of benefits were allowed.
3. Individual health policies could be customized to cover and exclude various events. As a result, inexpensive plans were available that only covered a subset of events.
4. Rates were set entirely by the insurance companies.
5. No one was required (forced) to have any health insurance.

Post Obamacare

1. Minimum standards of coverage were implemented for all plans (group and individual) – ‘must cover basic items’ (including mental health).
2. Lifetime caps on payouts were outlawed (group and individual).
3. Group health plans otherwise remain largely unchanged.
4. Insurers cannot exclude ‘pre-existing conditions’. This brings ‘group’ and ‘individual’ coverages into alignment.
5. Insurers cannot refuse to insure anyone. This brings ‘group’ and ‘individual’ coverages into alignment.
6. Each insurance company can set the rates for Individual Health Plans as they see fit, subject to various rules: Rates can vary only based on age, location, and smoker/non-smoker designation. 4 coverage levels introduced – Bronze through Platinum. Bronze has lowest premium cost, highest deductible. Maximum ratios were set between youngest and oldest rates (that is, rates for a 64 year old could not be more than ‘x’ times the rate for a 25 year old).
7. Everyone must have insurance. This is a key requirement to spread the risk across young and old. Subsidies are available to those falling below income thresholds. Financial penalties (Fines) are the enforcement tool.
8. Profits are limited; insurers must demonstrate that they pay out some minimum percentage of revenue on actual ‘care delivery’ – 80-85%, based on various factors.

sir_eccles

Pre

- often a waiting period for pre existing conditions, or the condition would be excluded from coverage

- premium based on health, and anything they liked

- not only could they decide not to insure you, they could drop you like a hot potato for any reason

- many of the basis plans offered were effectively useless and would never be able to pay out to cover anything

Post

- large list of preventative care is now free (vaccinations, well checks, mammograms...)

- tax subsidy to help low income households pay the premiums

- dependents can stay on parental plan up to age 26

mrken30

From my personal experience group health plans went up, but individual, especially those with pre-existing conditions like past history of cancer went down. HDHP plans became more common in the work place. I'm not sure if that is an ACA thing.
I think birth control has to be made available to all.
Also a weird thing, breast pumps are now "free" to all new mothers.

BritishGuy36

Comments on the above (I only used a few and so the numbering of your points is different from mine above).

Since the Dems are completely running scared of getting found out if they allowed the unaffordable care act to be implemented fully (prices skyrocketing and coverage being cancelled), the above is just not true as to what companies are "forced" to provide. ACA is only half implemented and since companies aren't forced to do everything in your list, they offer policies that don't comply with everything in ACA.

Insurers are absolutely offering coverage that does not cover pre-existing conditions. This one item in itself makes a mockery of ACA. I was recently looking for a policy recently and it stated quite clearly that pre-existing conditions are not covered, and that the policy does not qualify one to "avoid a tax penalty under ACA/IRS rules".

I was also recently refused coverage.

Obviously the last statement is also not true, since anyone can opt to not have insurance, they just get a tax penalty.

Pulaski

Post #1 misses out the expansion of Medicaid - and how some states declined the federal incentives to expand Medicaid, leaving some people too poor to be allowed to enroll for ACA coverage and not eligible for Medicaid.

sir_eccles

Non-compliant plans are still offered but they are not "major medical insurance" plans and tend to be short term insurance, temporary plans and the like.

As a resident, I don't know why you would be looking at one instead of an ACA-compliant plan.

What was the reason for refusal, sounds very odd.

Steerpike

How did this work, in practice? If I had an individual plan, and developed Cancer, presumably they had to cover me for at least some part of that condition's care - discovered on their watch, as it were. There must have been some protocol for dropping a patient who developed a condition?

RoadWarriorFromLP

I would say that the OP is generally accurate, although I'm not sure whether platinum-level plans are always available.

They would find some reason to claim that you had lied or omitted relevant information on your application about a risk factor or pre-existing condition, which would give them the right to exclude coverage or dump you entirely.

Or they find some reason to justify the denial of a claim. The provider will not want to provide you with treatment if there is no opportunity to be paid, so you end up with a denial of service attack, if you will.

If you got to be expensive, insurers would look for reasons to stop doing business with you. There's no way that they can charge you enough to cover the risk and expense, which made them highly motivated to get rid of your account.

morpeth

I have heard millions have signed up for ACA, and in some instances a good deal, but I would be curious how many have lost insurance because of increases in premiums, or from companies cutting hours below 30 per week to avoid paying health insurance.

To give an example I am familiar with.

Pre ACA private policy covering family of 4, $300 per month (high deductible)
Better policy provided through employer cost the employer $900 a month and they required employee to pay $150 a month

Post ACA :
-first policy that cost $400 a month if bought privately now $900 per month,
-second policy through employer now costing $1300 a month but employee has to pay $400 a month
-After ACA premium bill would be $1,250 per month, original cost to employee was $150, but second year increased to $300 per month.

But if individual makes more the Medicaid threshold, but cant afford private policy or ACA policy, they are out of luck. and they would get penalized end of year.

sir_eccles

I know someone who was working with the local BCBS here in AZ. They had a couple of families who were running up $10m+ annual bills childhood cancer I think. Pre-ACA they wouldn't have had that problem.

Without knowing the level of coverage and reading all the fine print of both plans, the comparison is meaningless. It is quite likely as was borne out by much of the media coverage at the time, that people who were desperate to keep their pre-ACA plans were being conned. The plans were cheap for sure, but they would never have paid out, didn't cover anything.

morpeth

I completely agree the ACA was great for people with pre-existing conditions, and regardless of the faults of the ACA it has doubtless saved many families form bankruptcy, or even getting access to proper medical care.

The example I gave you were from the experience of someone I know and I looked at each of he policies referred to. I realize the experience may be different from state to state. Simply the same policy/coverage of a family buying direct pre and post ACA went up dramatically so it became unaffordable. The same person then worked for a company and had the same premium increase and cost I outlined below. And at same time another had the ACA experience I outlined over two year period.

That doesn't mean that ACA wasn't beneficial, but the experience of where I live was as I pointed out. And considering the extra benefits mandated by ACA, certainly normal to expect premiums to increase. But for many Americans premiums alone are unaffordable now.

sir_eccles

You make it sound like premiums never rose before the ACA came in. In fact premiums are rising at a lower rate.

Slower Premium Growth Under Obama

The truth about healthcare premiums: They'd be a lot higher without Obamacare - LA Times

BritishGuy36

1) I thought the entire point of ACA was that NO plan could refuse to cover pre-existing conditions? Otherwise the whole thing is a complete waste of time (not to mention money).

2) Because the unaffordable-care-act plans cost a fortune. The cheapest I can get is close to $400 a month.

3) I didn't comply with their height/weight "guidelines" for acceptance.

sir_eccles

Aca complaint plans cannot refuse coverage.

So you want to pay for a plan PLUS the tax penalty? If it really is unaffordable for you maybe you are eligible for a subsidy. You must go through the marketplace to get a subsidy.

Non-complant plans can refuse coverage.

Steerpike

Well regarding #1, one of the goals (not the whole point) of ACA was that no plan could refuse to cover pre-existing conditions. I believe any plan deemed 'ACA compliant' does have to meet that criteria. But due to the strong opposition to the ACA (from people who had the cheap non-compliant plans), the govt. relented, temporarily, and allowed some continuation of 'non-ACA-compliant' plans. I'm unsure of the details of this (are there time limits on how long these can be offered for, etc). I'd be happy to learn more about this aspect from others here, hopefully without too much political spin.


Regarding #2, how old are you? I'm 57 and the cheapest bronze plan I could get (and did get) was about $600. I was paying $620 for COBRA continuation of my prior (pre-ACA) health plan that I had through my former employer (I termed in 2013, used COBRA through 2015, and got ACA-compliant individual plan in 2015). The 'cobra' rate is a good guide to 'real cost' because the company simply passes on their cost to you (+ small % admin fee). Now, the deductible on the 'group' plan I continued through COBRA was lower, so my overall coverage 'benefit' went down as a result of switching to an ACA-compliant individual plan, but the differences are fairly moderate. Bottom line is, the ACA plan was not much different in terms of cost or content to the prior group plan.


I'm now in discussions with an employer to go back to full-time employment (currently I'm self-employed, hence using individual coverage). One of the big benefits is of course massive subsidy of the insurance premium; only $15 per paycheck. But I asked 'what would it cost if I were to leave and use COBRA?' - in other words, what is the cost TO YOU the company for my coverage?. The answer was $680. (this is for a silver-level plan).


So my conclusion is, the ACA compliant Individual plans are not that different from the costs of good-quality 'group plans', both before and after ACA.


If you had an 'individual plan' before ACA that was 'cheap', I'd be interested to know what exclusions it had.