Since I’ve been self-employed almost as long as the Affordable Care Act has been law, I’ve had lots of opportunities to learn the finer points of the law. At its best, the ACA works as the gentlest possible nudge for folks who rely on employer-provided health insurance to start their own businesses, knowing they’ll have access to affordable, comprehensive health insurance, without exclusions for pre-existing conditions.
In the past I’ve written about triggering “special enrollment periods” by moving to a different zip code. In Wisconsin, which under Scott Walker refused to expand Medicaid, I paid $0.12 per month in premiums for a Silver plan with no co-pays or deductibles.
The District of Columbia has what I call “Super Medicaid,” which covers adults earning up to 233% of the federal poverty line, far higher even than in other Medicaid expansion states. Enrolling was a bit of a hassle, but after harassing them on Twitter about their terrible IT, I was eventually enrolled and received my insurance card in the mail a few days later.
Besides a couple of teeth cleanings, I never used my insurance, but knowing I was insured meant I knew an accident, injury or illness wouldn’t bankrupt me. Since it’s Medicaid, it wouldn’t even cost me anything.
I lost my insurance — 6 months ago
At the beginning of the year we all receive a slew of tax documents. At a minimum we expect W-2’s for wage income, 1099’s for interest, dividend, and miscellaneous payments, and health insurance verification documents to prove we were insured the entire preceding year.
Imagine my surprise when, a few weeks ago, I received my health insurance verification document from DC and the little black X’s abruptly stopped in July. I’d been uninsured for the last 6 months and no one had told me.
After some research, I eventually started to piece together what had happened. Like most states, the ACA is administered in DC through two separate programs, the “ACA (or Obamacare) exchanges,” which we call “DC Health Link,” and Medicaid, which we call “DC Healthy Families.” I was enrolled in Medicaid — DC Health Families. But since I had started my enrollment — all the way back in 2016 — through DC Health Link, my renewal material was being sent to that website, instead of to the Medicaid website. Since I wasn’t enrolled in an exchange health plan, I never logged into that site, and never got the renewal notification. Since I never completed the renewal application, my insurance was cancelled, and the notification of that was also sent to the DC Health Link website — again, a site I have not used since August, 2016.
Enrolling again was easy
Fortunately, since I know how the law works, it wasn’t a big deal to complete another application. Since I’m earning a bit more these days, and in order to avoid this mayhem in the future, I decided to enroll in an exchange plan this time, estimated my income at the level to maximize the possible subsidy, and selected a plan for coverage to begin March 1. I’d still rather be on Medicaid, but private coverage won’t be the end of the world, and it might get me into a better hospital if something serious happens to me.
Then I got sick. Then I got sicker.
About three weeks ago I started to develop a pretty unpleasant cough. It wasn’t horrible, but it was certainly annoying. I started warning people on the phone that I might have to go on mute if I had a particular nasty fit. It would come and go, I tried to stay hydrated, drank a little Robitussin here and there to see if I could bring up whatever was irritating my lungs.
Then it started keeping my partner up at night. I thought as long as I felt fine, and it was just a cough, it would have to clear up eventually. I promised I’d go to the doctor as soon as my insurance kicked in on March 1.
Then it started keeping me up at night. I couldn’t sleep for more than a few hours without waking up trying to cough up something I couldn’t cough up. I couldn’t sleep at night and I was useless during the day.
And on Wednesday, something finally clicked. I didn’t “have a cough,” I was sick. I knew I needed medical care. But where on Earth was I going to get it? I don’t have insurance, I don’t have money, and I didn’t know what the hell I’d contracted. I (half-) jokingly started praying it was coronavirus so the National Guard would quarantine me and treat me for free.
So, like any right-thinking millennial, I started Googling free health clinics.
There are no free health clinics in DC
My mom volunteers at a couple of free health clinics, and my brother runs a network of community health centers, so I had vaguely assumed in a large, diverse, working-class city like DC there would be 20-30 walk-in clinics around town and I just needed to find which ones were open on Wednesday mornings. I knew I’d be waiting around for a few hours, but since my body was rapidly shutting down, I figured I didn’t have anything better to do.
It turns out, there are no free walk-in clinics in DC (or if there are, they keep a pretty low profile). This is partly a consequence of how successful Medicaid expansion has been: since all low-income people are covered by Medicaid, and all high-income people are covered by exchange plans or their employers, there are relatively few uninsured people in the District.
I just happened to be one of them.
So I went and stole some healthcare
My mom has always told fond stories about living in DC and working at the Columbia Road Health Services clinic, which was a Christian mission attached to the nearby Potter’s House and Christ House. The clinic now belongs to a big health insurance chain, but since it’s just down the street, I thought I’d try my luck. I walked in, said I was sick, and asked if they could help me.
As it turned out, they took really good care of me. It’s not “fun” seeing a doctor, but they took my vitals, listened to my chest, listened to me describe my symptoms, gave me something called “breathing therapy” (not highly recommended) and diagnosed me with “community-acquired pneumonia.” The doctor called in a prescription for antibiotics and gave me a “GoodRx” discount card (I ended up paying $17 for a five-day supply at the CVS down the street).
Then I walked out of the clinic. They didn’t ask for money and I didn’t offer.
Interlude: “Walking Pneumonia”
In September, 2016, there was a brief round of news coverage when Hillary Clinton had to be helped into her vehicle after attending a memorial service at Ground Zero. She was later diagnosed with pneumonia; she had simply continued to campaign until she was finally sidelined by it for a few days.
This almost exactly mirrors my own experience. I kept working for the last few weeks through a “nasty cough” until the moment when it clicked for me that I needed help. And at that moment, it was inescapable.
I realized the real issue was giving myself “permission to be sick.” It’s a funny way to describe the feeling, since obviously most people don’t want to be sick — why would they give themselves permission to feel bad? But the second I acknowledged I was really sick, I realized I wasn’t “just coughing.” My body hurt, my head hurt, I was sweating and freezing, and I was exhausted. Basically, once I gave myself permission to be sick, I finally started putting myself in a position to recover (the drugs helped).
What’s next?
I’m a bit curious about this myself. I assume eventually the clinic is going to send me a bill, but since healthcare prices are completely imaginary, I simply have no way of guessing how much it’s going to be: $200 or $10,000?
Besides the obvious (money is expensive), one reason it’s relevant is that Medicaid allows retroactive coverage for medical expenses up to 3 months before enrollment. That means if I can manipulate my income sufficiently, I could apply for Medicaid once I get the bill and have them cover the expense “as if” I were insured when I received treatment. That would be exceptionally annoying since I just completed my ACA exchange enrollment, but it’s one option.
Another option is simply declaring bankruptcy in order to discharge the medical bill. Financially speaking this wouldn’t be a big problem since virtually all my assets are in retirement accounts that are protected in bankruptcy, but it would obviously be a big inconvenience, if for no other reason than that I earn a lot of rewards with my credit cards, which would presumably be closed after a bankruptcy filing.
Conclusion: Medicaid for All
The Affordable Care Act was a remarkable achievement in a country that has given up on remarkable achievements: it virtually eliminated uninsurance among low-income people in Medicaid-expansion states (and would have eliminated it entirely if not for the Supreme Court’s intervention); it gave entrepreneurs and sole proprietors access, for the first time, to affordable comprehensive health insurance; and it provided important guarantees of care to workers covered by employer-provided insurance (guarantees that would be even more valuable if the Supreme Court hadn’t proceeded to undermine them).
But the fact is, despite knowing every nook and cranny of the law, the ACA left cracks big enough for even me to fall through. The law has provisions for people who earn more money to transition from Medicaid to the exchanges. It has provisions for people who earn less money to transition from the exchanges to Medicaid. But it has no provisions for someone unknowingly disenrolled from Medicaid, who enrolls in an exchange plan, and needs medical care in the intervening 20 days. How could it?
The answer, the next step, has always been as simple and obvious as it sounds: Medicaid for All. No premiums, no deductibles, no co-pays. No retroactive enrollment, no prospective enrollment, no income verification, no residence verification, just Medicaid. For. All.
Couple comments from Mom. Everybody should have a good RX card. I get some of my Medicare covered meds cheaper that way.
If you get a bill, go talk to them. Brother Jonah made an $1100 ER bill go away. They have navigators to get you back on Medicaid easier than you can. It is a FQHC like Caleb runs, sees uninsured.
The reason my free clinic exists despite insurance availability is “undocumented “ persons, and those with insurance but too high deductible for reasonable people to pay.
Why do I often here demands for “no copay?” That makes no sense. Even a $5 copay is a disincentive to waste and is needed in any plan, except maybe for preventative measures like a physical or shots.
Nun,
How many people do you think is the “right” number for me to infect before getting treated in order to avoid a $5 copay? 10? 50? 100?
—Indy
I also wonder about this. Have heard that argument before and wonder if this is really a problem that needs to be solved: people seeking medical care who don’t actually need it. Do we even need to figure out how to disincentivized people from going to the doctor unnecessarily? If medical care was truly scarce and we didn’t have enough doctors and or nurses to see the gravely ill, then I suppose it would be a good idea for the people with the sinus infections to just try to fight it off. But other than that scenario, which I don’t think we are in, I don’t see another reason to convince people not to go to the doctor. It’s inconvenient enough to go to the doctor so I imagine if anything we really want to be doing the opposite and encouraging people who are sick to actually go.
Elderly tend to use medical care that they don’t need for a variety of reasons. Some are accustumed (addicted?) to a daily life that happens in doctor’s offices and hospitals and don’t want to miss that. Some even enjoy such a daily life because they have nothing more enjoyable to do.
A similar problem exists for some patients with acute diseases (who are not necessarily elderly).
As a 35-year veteran of the US healthcare system providing services on a daily basis, I can assure you that the “recreational” user of medical services exists but is an exceedingly rare bird. A far greater problem is the number of patients who fail to seek healthcare until a minor problem has grown into a health crisis. I can name all four of my patients over that three and a half decade that came in for every hiccup. I cannot name the hundreds and hundreds that I saw that should have come in a month, two months, two years before. BTW, 60-70% of my caseload in the last 12 years was elderly.
I just signed up for ACA seven months ago since quitting my job and being self employed. It surprised me that the refill for my high BP medication was cheaper for my ACA plan with very high deductible than in my former employer plan with no deductible. It was actually as cheap as paying with GoodRx.
Besides Medicaid for All, another option is for you to be more financially responsible and maintain an emergency fund so you can afford a $500 doctor’s visit rather than sheltering “all my assets are in retirement accounts that are protected in bankruptcy.” Medicaid is not free for taxpayers.
And, are you seriously such a selfish human being that you would get all of your loved ones and coworkers sick just to avoid a $5 copay? I’m concerned about your ability to make logical decisions.
UP VOTE
SC Parent,
As other commenters have observed, the point of charging for health care at the point of use is to discourage people from seeking care. As this post makes clear, that system works very well: if you charge people for health care at the point of use, people will avoid seeking care, which is good for you in the sense that your wait time at the doctor, and your taxes, will be lower, but bad for you in the sense that people avoiding care may expose the people they encounter in the community, including you, to infectious diseases. If you have employees, you may also be concerned about untreated diseases leading to more days of work lost.
It’s perfectly reasonable for different people to weigh those concerns differently. Personally, I think visiting health care providers is so unpleasant that people need relatively little additional discouragement in the form of cost sharing. You may think the risk of infectious diseases is so low we should tolerate relatively high levels of untreated disease.
But in neither case is “financial responsibility” or “selfishness” the relevant issue. When people avoid seeking care due to cost-sharing, the system is working as designed. The question is whether we should design a different system.
—Indy
“Personally, I think visiting health care providers is so unpleasant that people need relatively little additional discouragement in the form of cost sharing.”
THIS! And you know what? As a retired provider myself — I HATE visiting the doctor.
Agree that healthcare is unpleasant and that we should build a better mousetrap. Completely disagree about what that means. While we might be the sort of folk to like gaming the byzantine rules (in the form of finance or miles&points fine print), this is fundamentally inefficient AND not best replaced by a one-size-fits-all solution managed by govies.
Consider instead if your hypothetical $500 out of pocket visit were not so expensive, didn’t require any pre-existing plan, enrollments or insurance to get a reasonable price, was clearly priced before you entered the building, and/or allowed for an efficient telemedicine call, AND came with points-back for your routine visits. I have a feeling you’re saying that’s something like what medicaid for all would provide.
The problem is that care is dictated by insurance companies, diagnostic codes, and starts with a false premise that all care is the same (violating differential pay for differential service). Outside of that there is opaque pricing, cost shifting, and that puts walk-in care in the realm of “imaginary prices” (couldn’t agree more how crazy this is). Still, this is caused by price discrimination and administrative “cost cutting procedures” that continuously take from the doc and give to the behemoth of a hospital (including the handsome admin salaries). That’s where all the services are rolled up and no particular entity is held accountable, so there’s no feedback to be affordable.
Basically, it’s too much system, not too little. Involving the government doesn’t make that better – that’s “fixing” something that’s broken by breaking it farther, which only sounds good if you’ve got nothing to lose, or you’re an accelerationist.
In contrast, the cheapest services are things like Lasik precisely because it’s elective. Everywhere else, there’s no resemblance free market and it’s growing worse the more we distort it.
I know we’ll never agree, but it confounds me that someone with good business sense cannot see that “business” CAN be good for the patient, if we’d let it bring costs down. True, we still need a way to reliably provide some tier of care for people below means – that are particularly lousy at compliance and showing up. But contrary to what’s popular, I think that’s a different issue. Conflating it leads us to a solution you might like, but I want no part of. If it was a state level, I’d say go ahead do as you please.
Anyway, truly glad you got the care you need.
Great article, glad that you were able to suss it all out. This might be a weird request but would you be willing to do a paid consultation re: appropriate health care coverage? I’m using a Christian Health Ministry membership to avoid the tax penalty and just enrolled my girlfriend in Medicaid ($0 income full time student) but I get the nagging feeling that I’m leaving a lot on the table. I’m a reader from the beginning of this blog and from your posts over the years I feel like you have the best granular understanding of the healthcare system of anyone I’ve come across. Thanks for your consideration.
Fredeeb,
I don’t think you need a paid consultation, but I’m happy to help. Your absolute first priority should be getting off this health ministry nonsense, since it’s not insurance and will leave you in the lurch if you become seriously ill. Getting on Medicaid would obviously be ideal, but if your income is too high to qualify, the next best option is to apply for exchange subsidies reporting an income just above the Medicaid qualifying line. That will get you the maximum subsidy and “cost sharing reductions” which will reduce your deductible and out-of-pocket maximums, if you enroll in a Silver plan (you may have to repay part of the subsidy at tax time if your income is high enough, but there’s no mechanism to claw back cost sharing reductions).
Unfortunately at this point it’s a bit late to apply to the exchanges without a change in status. The obvious options are marrying your girlfriend, moving zip codes, quitting your job or getting fired, having a kid, etc. If you have relatives in the same state, or if your girlfriend’s dorm is in another ZIP code, reporting a change in address is one easy solution.
Happy to help with any other questions that come up as you proceed.
—Indy
You forgot one other no…no way to afford it.
Mark,
Why not use the 6% revenue increase from the TCJA?
—Indy