Cat Flag’s Health Insurance Misadventure, Part 2

Stethascope image from The Health Care Blog

Now that 2014 is in full swing, millions of Americans are now adjusting to a new health care reality brought about by the Patient Protection and Affordable Care Act, better known my most Americans as “Obamacare”. Since it was first proposed in Congress in 2009, I have never seen a law so polarizing and controversial in my life.

The law was intended to address a major problem in the United States. As the only developed and industrialized country with no universal government-backed guarantee of health coverage for all, those Americans who weren’t old enough to qualify for Medicare, had too high of an income to qualify for Medicaid, didn’t participate in an insurance program they got from their employer, and couldn’t pay for private health insurance out-of-pocket had to simply make do without. This meant that millions of Americans would be stuck paying doctors, pharmacists, and hospitals thousands of dollars for their medical treatments. This problem was even worse for patients who had some sort of pre-existing health condition, who could be turned down for insurance or forced to pay more to get insured.

The new law prohibits insurance companies from turning down or charging more to people with pre-existing health conditions, allows college students under the age of 26 to keep health coverage through their parents’ insurance plans, and sets up low-cost insurance exchanges subsidized by the government for individuals who are too poor to afford ordinary private insurance but not poor enough to qualify for Medicaid. In particular, these exchanges try to make insurance more affordable by having the government pay a part of each participant’s monthly insurance bill, based on their income. For this plan to work, millions of healthy people would have to sign up to the program, with their monthly payments helping to spread the cost of caring for those who actually need medical care. Otherwise, the program would just get too expensive. To make sure as many people signed up as possible, the law set up a penalty for anyone who didn’t get health insurance – they would have to pay $95 or 1% of their annual income (whichever is greater) each year they are not covered until 2016, or $695 or 2.5% of their income (whichever is greater) each year they are not covered thereafter.

Health care is such a complicated issue, with a million possible variables and nearly infinite unique situations, that the law itself had to be one of the most insanely long documents you have ever seen (you can read it here) just to cover any scenario or problem the lawmakers could think of. The law is so long and complicated, that entire websites devoted to explaining how the law works in plain English and debunking misconceptions about it have started to crop up.

The law has plenty of critics. I have heard plenty of ordinary people on the street discussing the relative merits and drawbacks of the law. Nothing has galvanized the Republican Party in recent years like Obamacare has, as Republicans have made “repeal and replace” their rallying cry for the past four years. Just yesterday, Senate Republicans formally proposed their own “Obamacare alternative” law.

Not only is the law itself controversial, but its implementation has been, as well. The original plan was for each state to either create a health insurance exchange of its own, or to partner with the federal government to do so. Thanks to a Supreme Court ruling, the states got a third option: do neither, and force the federal government to set up an insurance exchange to cover residents of those states. As of this writing, 27 states have chosen this third option. Thus, the federal government had to set up its own website for people to use to buy insurance from the exchange, and when the federal website was opened to the public, it was buggy and crashed a lot.

That problem was eventually fixed, but now the White House is bracing for even more complaints and problems as patients try to use their new insurance to pay for doctor visits and medicines. That’s not even beginning to mention those families who received letters from their existing health insurers that told them “We’re sorry, but the new laws make it way too expensive to insure you, so we’re dropping your coverage and cancelling your policy.” Here in my home state of California, there are 900,000 people who lost their health insurance in this way. Not only that, but the new exchanges have come nowhere close to covering all of the 45 million uninsured Americans, or even merely the 5.5 million uninsured Californians. Only 3 million people nationwide have signed up for insurance through these exchanges, and many of these are people who were already insured and were simply switching their coverage. Here in California, only 424,936 people enrolled in the program as of January 1.

Even those who actually are enrolling are not necessarily the kind of patient that the exchanges need. Only about a quarter of the program’s participants are under the age of 35. More than half are between the ages of 45 and 64. This is a real problem for the program, as younger patients tend to be healthier and need less medical care than older patients. If too few young patients sign up, the administration fears, those private insurance companies that participate in the exchanges may have to raise their rates.

Many of you probably read my last discussion on health care, where I described my own journey through the complexities of trying to get health insurance. As I explained in that article, I am young, healthy, and have no long-running health problems. I haven’t been in a doctor’s office in more than a year. I am exactly the kind of patient that Obamacare is looking for. Since I figured it couldn’t hurt to find out if I could save money by applying, I decided to give Obamacare a shot. Here’s what I found out.

Californians Get a Different “Obamacare” Experience than Other States

CoveredCalifornia logo from KQED

The first thing I did was… I waited. I had been reading headlines about how was constantly crashing and giving people problems, and decided I’d rather wait until the bugs were fixed. When the news reported that the bugs were mostly fixed and the website was working, I finally decided to check it out, only to discover that it didn’t matter.

The first thing that happens when you type “” in your web browser is a prompt asking if you want to apply for health coverage. Then, it asks you what state you live in. When you select “California”, it tells you that California is one of those states that chose to set up its own exchange, and redirects you to a different site.

Welcome to “Covered California”, a program set up by the state’s Department of Health Care Services to try to insure everyone in the most populous state in the nation. The website lets you compare the different health insurance options available with a surprisingly convenient and intuitive “shop and compare” tool. You just enter your income, how many people you are trying to cover and their respective ages, and where you live. Then, based on your income, it will tell you one of three things. If your income is at or below 133% of the Federal Poverty Level, it will tell you that you might qualify for Medi-Cal, California’s version of Medicaid (more on that in a minute). If your income falls between 133% and 400% of the Federal Povery Level, it will tell you that you may get a subsidy to help you pay for one of the state’s approved insurance plans. If your income is more than 400% of the Federal Poverty Level, it will tell you that you don’t qualify for any subsidy and must pay the full price for you insurance.

Covered California is served by only two companies: Anthem Blue Cross (a subsidiary of the for-profit health insurance company WellPoint) and Blue Shield of California (a non-profit insurance provider). These insurance companies offer four tiers of coverage, based on how much you are willing to pay per month. The lowest or “Bronze” tier is the cheapest, but only pays about 60% of your medical expenses (doctor’s visits, hospital visits, medications, surgeries, and so on). You have to pay the rest. The next tier, “Silver”, is a bit pricier but covers 70% of your expenses. “Gold”, as you may expect, is pricier still but pays 80% of your expenses. The priciest tier is “Platinum”, which will foot 90% of your medical bills.

If you buy one of these insurance plans and you qualify for a government subsidy, then when you pay your monthly bill, the amount that Uncle Sam pays is automatically deducted from your premium. Then, when you go to file your taxes for the year, those subsidies are taken into account when calculating your tax refund or payment. You also have the option to “opt-out” of this automatic deduction and just pay the full premium every month, and get the entire year’s tax credit as one big refund at tax time. Be warned, though, that there are plenty of things that could change the amount of your subsidy: a raise, a marriage, a new baby, a lost job, and so on. You have to keep Covered California updated on these changes and adjust your subsidy accordingly, or else you may end up owing a significant sum at tax time.

The Application Process is Simpler

Signing form image from Florida A&M

When I applied for private health insurance in my last adventure, I had to go through what seemed like pages and pages of digital check-boxes and text-boxes to give the insurer as complete of a picture of my health as I could give. I had to check “no” to a barrage of questions about whether or not I had had various types of cancers or heart diseases, I had to tell them I had never been diagnosed with mental disorders and never undergone any surgeries, and I had to reassure them that I hadn’t been on any prescription drugs for the past six months. At least it was fairly easy for me to just check “no”, “no”, “no” over and over again. If I had to answer “yes” to anything, I imagine it would have made filling out the form much harder, because I would have had to explain the circumstances to them. This video by somebody much older than I am and with a more colorful medical history shows just what I mean.

That video also shows just how much easier applying for an Obamacare plan is. When I applied through Covered California, I had to create an account, answer a few questions about who I was trying to cover (just myself), and tell them about my income. I had to send them a digital copy of my ID card and tax return to prove I wasn’t lying, and then I was done. The website asked me how I would like to be contacted, and then told me that my application would be reviewed by an actual person for final approval. It was easier than applying for student financial aid for college.

To illustrate just how much easier to get insurance through Covered California was, let me tell you a little story. A few days after my last health insurance misadventure, after submitting my application for private insurance, I got a phone call asking about my weight. I had made an error on my application, and they thought I was medically underweight. I told the lady my mistake, and she corrected the application for me so I could get approved. When I applied for insurance through Covered California, they didn’t even ask me my weight. Or any medical questions at all.

Medi-Cal has Changed Since I Last Applied

Healthcare image from SocialInnovationMN

I had to wait for weeks to hear back after I submitted my application. I assumed the people who were reviewing these applications probably had a crush of work to do after the holiday break as Californians tried to get their applications in before the end of the year. When I did hear back, I got a letter telling me that, based on my income, I didn’t qualify for Obamacare, but did qualify for Medi-Cal. They would send my application over to Medi-Cal for approval.

About a week later, I received my Benefits Identification Card in the mail, a piece of plastic that I needed to use to access any Medi-Cal benefits when I go to a doctor, hospital, or pharmacist. The strange thing was that the card came with an explicit warning that just because I have a card doesn’t mean I actually have any benefits. Instead, the letter told me to keep the card whether I qualified or not; if I reapply and get benefits at a later time, it said, I could still use that card. I guess it saves the state money to not have to keep printing new cards?

In any case, I found out about a month after my application that I had been approved for Medi-Cal and was enrolled. This was a huge improvement over the last time I applied for Medi-Cal, when I had to wait for hours, drive around town, and find out that I didn’t qualify for anything. This time, I just had to fill out an online application and then sit around and wait for a month. And this time I got approved.

Now that I am on Medi-Cal, I decided to figure out what next steps I need to take, so I asked someone who was familiar with how the program works. I learned that Medi-Cal, on a functional level, works just like an HMO. I have to visit specific, approved doctors, and I have to have a “primary care physician” as my main doctor to approve any specialized care I may need. One advantage to Medi-Cal, though, is that there is a fall-back plan for patients without a primary care physician. The Community Health Centers are a network of non-profit urgent care clinics located throughout the California Central Coast that take Medi-Cal patients and are listed as an approved primary care provider. I was warned, though, that it is best to go to whatever doctor or CHC clinic I choose right away, and fill out the forms I need to get registered as a patient. Otherwise, it could take months for me to get an appointment if I am sick.

I hope that my writing all of this down will be helpful to someone who may feel lost and confused with all the new health insurance changes. I sure could have used some of this information while I was applying for coverage. If you haven’t applied for Obamacare yet, but are considering doing so, you had better apply soon. Covered California is only taking applications until February 15 for plans that start in March, and only until March 15 for plans that start in April. For the rest of the country, open enrollment in Obamacare ends March 31.