Miami (AFP) – Some Americans are overjoyed with Obamacare. Others say it is a nightmare.
To understand why, here are two men’s opposing experiences with US health insurance since Obamacare, known formally as the Affordable Care Act (ACA), became law in 2010.
– ‘I love it’ –
Johann Ali, 40, actually giggles when he talks about his health insurance.
“I love it,” says the self-employed environmental consultant.
First, he raves about his son, Kyle, who is 19, works part-time, and has been able to find a good insurance plan for $99 per month. His annual earnings of about $16,000 allowed him to get a federal discount, slashing the cost from the list price of $199 per month.
Ali, too, found an affordable plan by purchasing an individual policy directly from an insurer for $233 per month.
Before the Affordable Care Act, Ali says he had employer group coverage and his monthly cost was around $900.
Preventive care, such as his annual checkup, now costs him nothing extra. Gone are the co-pays, and the occasional denials of coverage when an insurer did not think certain tests were merited, he says.
He also benefits from a key provision in Obamacare that makes it illegal to discriminate against people by refusing to insure them, or charging them more for pre-existing conditions.
Even though Ali does not have asthma, he has a prescription for a brand-name asthma medication that helps with an allergy-like condition. As a result, his monthly payments, or premiums, used to rise 10-15 percent per year, he says.
Those price hikes no longer happen, he says.
There is one common downside to Ali’s plan: It carries a high deductible, meaning he must pay about $5,000 out of pocket before many insurance benefits kick in.
But Ali also has a friend who was an insurance agent, and urged him to get an additional “accident policy” for $150 per year.
That policy paid off — literally — when Ali broke his ankle two years ago. The hospital bills totaled $90,000. He filed his accident claim and got a $10,000 check, which more than covered his deductible. He paid nothing out of pocket, he says.
“I was lucky enough to have somebody to educate me,” says Ali.
“Insurance is set up in this country to confuse you. That is how they keep you in the dark about maximizing your benefits.”
– ‘Nobody takes it’ –
Todd Ulmen, 50, runs a retail clothing business in Miami.
He provides health insurance for his two full-time workers, but must make sure his part-timers work fewer than 25 hours per week, or he would have to pay for their coverage as well.
“If you had to provide insurance for everybody, you couldn’t be in business,” he says.
Ulmen’s own insurance did not change the first year after Obamacare became law. The second year, his insurer said his policy, which cost about $400 per month, would no longer be available.
“I said OK, fine, give me your best policy. And they did not tell me they were putting me in the Obamacare program,” says Ulmen.
Ulmen was stunned when he went for a checkup “and they told me, ‘we don’t take Obamacare.’”
Ulmen paid for that visit out of pocket, but then needed to see an eye specialist, and a cardiologist.
“You cannot find a specialist in Miami that will take that insurance,” he says.
Ultimately, Ulmen realized he had been given a health insurance plan from the ACA marketplace, or exchange, that did not meet his needs.
So, he chose to purchase a private plan directly from a major insurer for about $600 per month.
“I tell people if they have Obamacare, just go to the emergency room because that is the only way you are going to get decent care,” he says.
“Insurance is fine and dandy but if you can’t get anyone to take it, it doesn’t do any good.”
– An expert explains gaps –
So what is happening here?
“People are finding their doctors are dropping out of their plans,” says Steven Ullmann, an expert in healthcare policy at the University of Miami.
“Insurance companies are moving to very narrow networks where you have just a selection of a few doctors in each specialty, and a few hospitals. That is a huge trend.”
The price of health insurance is rising, in part, because many healthy young adults have not signed up. Therefore the overall risk pool has not fallen enough, he explains.
An additional 20 million people have become insured since the passage of Obamacare, but they “tend to be people over 35 or over 45 and are more prone to illness.”
About another 20 million people “are uninsured and those are mainly the ‘young invincibles,’ in their 20s and early 30s.”
If money is tight, there is little incentive to sign up. The tax penalty for not being insured is $695 for the entire year, about half the cost of buying insurance, which runs at least $1,500 per year.
Finally, there is “the gap.”
Ali’s son Kyle avoided it, because he earns just enough over the poverty line that he qualifies for a federal subsidy.
But many find that they make too much to qualify for Medicaid, which insures the poor, and not enough to earn a government-issued discount.
Initially, Obamacare called for expanding Medicaid to 133 percent of the poverty level, but it was rejected by the Supreme Court.
About half of states have opted not to expand Medicaid, including Florida.
That means individuals who earn less than Kyle, say between $11,800-15,800 per year, “fall in a hole,” explains Ullmann.
“They do not have access to health insurance, except for the full, extremely high-priced health insurance. So they continue to be uninsured.”