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).
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.