In George Orwell’s Animal Farm, the farm animals, after hearing of many upbeat statistics on enormous increases in crop yields, simply wished they had “less figures and more food.” I am reminded of that passage as defenders of healthcare “reform” tell us how popular the new exchanges are or how healthcare costs have been driven down. I am one among those cheery statistics.
This year I purchased insurance on the exchange for the first time, adding force to the numerical case for the success of reform; yet like those characters in the Orwell novel I find that I just wish we had fewer statistics and were free to return to our old “substandard” insurance.
Although I do not pretend to be any kind of expert on health insurance, and for reasons that I will make clear soon enough I am hardly the poster child for the damage done to health insurance by “reform,” I am able to view how the new law has affected many other insured people in New York State from multiple perspectives. My perspective changes each year because each New Year’s Day since 2012, I have been forced out of my plan. I started out with an employer plan, then moved to a group plan through a professional association, and, as my range of options has dwindled over the last few years due to the new law, I have now essentially been forced into the individual market.
In the first year I got a glimpse of how reform reduced coverage for the many on the group health plans offered by large corporations to their employees. In the second year I saw how it had similar effects on the owners and employees in small businesses that obtain group plans through professional or trade associations. In the third year I would see how individuals who lost group insurance coverage were affected when forced into the individual market. My personal experience with these three sectors of the health insurance market allows me to put myself in the shoes of a great many people subject to the new law’s strictures, and to see how the law affects them, not in some lofty academic theory, but right here on the ground.
I also surveyed the field of options available to me before deciding whether to take an early retirement in 2012, forming a mental snapshot of the outlines of the pre-“reform” health insurance menu of options in my geographic area.
I based my plans on this survey because no one I spoke with about obtaining insurance could answer my questions, at that time, about how reform would affect those options as it went into effect and health insurance was the key final issue I considered carefully before deciding to retire. I must admit that at that time, I was opposed to the new law primarily because of concerns about the long-term fiscal impact of adding a new entitlement when Social Security and Medicare are still expected to run out of money; but I thought that I, a middle-aged early retiree, would be the kind of person the law was intended to benefit—that I personally would gain one additional option for obtaining health insurance. I had no reason to expect that the most important impact of this new law would be to outlaw those options available to me that offered the best coverage at the least cost one-by-one, year-after-year, until I was finally dependent on government subsidies, which I otherwise would have had no need for, just to try to stay within my budget.
Hasta la vista, policy!
As soon as my insurers began to adjust their policies to the new law it was as if the Health Insurance Terminator had come to town.
At the end of 2012, just a few months after my retirement, my employer canceled my continuation plan, replacing it with the now familiar “gold, silver, bronze...” options in an apparent effort to conform its plans even before the most important “reforms” took effect in 2014. The new plans had a deductible that applied very broadly to services formerly covered with a small fixed co-payment, such as doctor visits, x-rays and cat-scans. Notwithstanding the scaled-back coverage, there was also a premium increase even if I chose the “silver” plan with a deductible that was not only broader but also higher.
My range of choice within my former employer’s program was also severely constricted. Before 2013, under its “Build Your Own Plan” feature, I could mix and match different choices such as deductible, prescription coverage and copayments. Now there was just a limited set of prepackaged plans. It was as if you were used to choosing separately an entrée, a couple side dishes, and a salad or soup, as you would at a restaurant, and then suddenly your menu were reduced to just a few TV dinners.
Instead of selecting from the new menu offered by my former employer, in 2013 I moved to a group insurance plan with the Monroe County [of New York State] Bar Association (MCBA). For many years this kind of group insurance offered by professional or trade associations has been a haven for people seeking affordable insurance with good coverage. Reportedly the Freelancer’s Union offered such plans not limited to a particular profession. “We’re lawyers and nannies, … graphic designers and temps,” their website reads.
The coverage of the plan I obtained from MCBA had not changed much from 2012. Like the new silver plan offered by my former employer it also had a high and broadly applicable deductible, even a bit broader in covering prescription drugs. In addition, by switching I would lose some coverage for routine eye exams, which would become subject to my large deductible and coinsurance. However, notwithstanding its high-teens percentage premium hike that year, it was cheaper than my hollowed-out continuation plan and so it now made sense to switch to what had formerly been my second-best alternative. My coverage was clearly going to be inferior and it was a very bad start to healthcare reform, but it was only the beginning.
When the most important health insurance reform changes occurred in 2014 I saw Excellus Blue Cross, my new insurer under the MCBA program, terminate its offered plans in that program and replace them with its own “gold, silver, bronze...” options. In their offered default replacement plan I again saw a premium increase combined with major reductions in coverage.
The out-of-pocket maximum would increase over 80% compared to my second terminated plan; so in the very situations when insurance is needed most, it would pay less of the bills for both in- and out-of-network care. The deductible also would increase by over 35%. Although in my prior experience such deductible increases had led to huge savings in premiums the new law had somehow vacuumed up all the premium savings and then some. I also would again lose some preventive care coverage, as my PSA (Prostate Specific Antigen) blood test for cancer was no longer fully covered, but instead subject to the high deductible as well as the coinsurance percentage. As with my employer plan the prior year, I would be paying more for a lot less coverage. This was important confirmation of the effects I’d seen the year before. My former employer was a large corporation that self-insured employees in more than one state and may not have been typical of other New York State employers—however my MCBA coverage, as will be detailed more fully below, was clearly governed by New York law, and suffered similar changes. It didn’t appear to be just one insurance company, or one employer, or just one state that was causing the deterioration in my coverage. The common thread was the change in federal law.
Disturbed by the changes I again looked for alternatives, but this time there was no escape. To borrow an old metaphor, out of context, running from Obamacare was like running from a long driving rain in a wilderness; sooner or later I, and every place I might reasonably try to take shelter from it, would be soaked. My only practical alternative after the reform changes effective for 2014 was the New York health exchange and the plans there were even worse.
There was one advantage to the plans on the exchange: the federal subsidies. I knew I might get a premium tax credit by buying through the exchange, but I decided it wasn’t worth it, primarily because I found no plan that would provide out-of-network coverage at an unsubsidized price close to what I would pay for my group plan. The New York Times would later report that with the exception of “a small part of western New York,” in 2014 there were no plans on my state’s exchange with out-of-network coverage at any price. I decided at that time that quality insurance that allowed me to choose my doctor or hospital in even the most dire circumstances was more important to me than the possible tax credit, so after a long process of applying on the New York exchange website (which, contrary to news reports, functioned quite poorly in 2013), a number of phone calls with long waits to answer questions, and an investigation of the available plans, I abandoned my exchange application and chose to default into the new MCBA group plan which still covered out-of-network care. Even though MCBA coverage had become much more expensive or had been severely degraded both years of the reform transition it still allowed me to choose any doctor, so I decided the new individual market was even worse.
What no one told me at that time was that New York State had already prohibited my group coverage with the MCBA and I was continued in the plan only by being “grandfathered” for just one more year. Only in June of 2014 did I receive a letter telling me my coverage was ending, this time not because my plan was being terminated, but because a legal requirement of healthcare reform required the group plan to drop coverage of self-employed individuals with no employees. The MCBA offered replacement plans to people like me in the individual market for 2015, but those replacement plans would not replace the out-of-network coverage I would lose and for which I had chosen my group plan in 2014 (with limited exceptions such as emergency and prenatal services). In addition, I was losing yet even more preventive care coverage. My old group plan at least still offered me some coverage for routine vision checkups, albeit subject to the deductible and coinsurance. In the individual market I would have to pay for this routine preventive care entirely out of my own pocket, and because it was now uncovered what I paid would not count toward meeting my deductible and, like out-of-network care, would be on top of my out-of-pocket maximum; in other words, my cap on out-of-pocket expenses, a key factor in my retirement planning, had now been shot full of holes by “reform.” For the third time in three years I’d lost my coverage at year’s end and the replacements offered were much worse--it was “déjà vu all over again.”
I was assured by phone that I would have been allowed to continue with group coverage but for the new law. I would later learn that Excellus Blue Cross/Blue Shield had cited an amendment made to a New York statute (NY Ins L § 4317(d)), enacted as part of the state’s implementation of healthcare reform, as the sole reason for terminating my coverage.
In late 2013 when people discovered they would lose their plans it was explained away as an exercise of discretion by insurance companies, or necessary to eliminate those “substandard” plans. However, the third annual termination of my insurance coverage was the unkindest cut of all, both because it was so gratuitous (the group plan I would lose was a replacement plan that was compliant with the coverage mandates of the new law and group coverage would continue to be offered to those self-employed persons who had employees), and because it was clearly the act of the government caused by the enactment of the Affordable Care Act; not an exercise of discretion by the insurance company. I was losing my insurance, yet again, because of “reform” and clearly for no other reason. It has been reported that the plans offered by the Freelancers’ Union have also been discontinued under the new law, along with group plans offered by other similar associations.
Just to make this, as much as possible, an apples-to-apples comparison, let’s assume I chose and stayed with the MCBA plans from the beginning of my early retirement in 2012 always switching to the default replacement when my coverage was taken away during the transition period, and ending up with an MCBA offered 2015 plan in the individual market. By the end of that three-year period of Obamacare phase-in I would have seen an over 50% increase in deductible, a 67% increase in the out-of-pocket-maximum, a loss of all or almost all out-of-network coverage as I was moved to an exclusive provider network, meaning essentially no limit to how much I would pay if I became seriously ill and in need of out-of-network care; and for all these cuts in benefits I would be rewarded with a more than 40% increase in premium. This is not the actual path I took, but it may well have been the path of others who had no chance of qualifying for subsidies; and it illustrates the extraordinary toll exacted by the new law from working people in group plans--far beyond the 10% allowance I made for health insurance premium inflation in planning my retirement.
In the Monty Python insurance skit an insurance agent named Mr. Devious tells one of his clients, “Reverend Morrison, … in your policy it states quite clearly that no claim you make will be paid.” Obamacare, for those forced out of group coverage and currently without subsidies, now has a similar flavor. Between huge deductibles that require people to pay for all of many day-to-day diagnostic tests and medical services and, at the other end of the scale, a possible loss of out-of-network care that might be needed for catastrophic illnesses, people would face increased out-of-pocket expenses both coming and going, and pay more in premiums for the privilege, leaving them to merely hope they do more coming than going. This is worse than the now abolished missing hole in Medicare prescription coverage, and more like someone cut a hole in the coverage and by mistake threw away the doughnut instead of the piece from the middle.
I am a middle-aged early retiree who does a little freelance writing in retirement. I am the kind of person this law should have helped. Nancy Pelosi said it would help freelance writers along with photographers and artists. Perhaps I’m not sufficiently grateful for the government’s efforts to look out for the welfare of early retirees and freelancers such as myself, but I’d appreciate it greatly if the federal government would just stop doing me all these wonderful favors before I end up bankrupt, which could happen even now if I suffer from a serious health problem that requires the kind of quality insurance that I am now legally prohibited from buying.
Shortsighted regulations
As I noted in the summary of my serial health coverage terminations one of the striking aspects of the Obamacare three-year phase-in was my loss of coverage for routine preventive care. For many years I’ve been accustomed to having full coverage of regular eye exams. In fleeing from my former employer’s greatly shrunken yet more expensive coverage in 2013 these exams became subject to a high deductible and coinsurance, causing me to delay my most recent eye exam for months until my deductible was reached. With the implementation of the coverage regulations of 2015 I was forced out of my group plan and into the new individual market where I would lose such preventive care coverage entirely.
I wondered how my preventive care coverage could be disappearing under what was supposed to a reform law. After all Obama and Biden had committed themselves to reform that would serve the goals of “promoting prevention and strengthening public health to prevent disease.” Nevertheless, when I looked at the contract for my current policy purchased on the new health insurance exchange, I found the federal government’s fingerprints on my degraded coverage for routine preventive care:
Preventive services are not subject to Cost-Sharing (Copayments, Deductibles or Coinsurance) when performed by a Participating Provider and provided in accordance with the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”), or if the items or services have an “A” or “B” rating from the United States Preventive Services Task Force (“USPSTF”)…
The reference to HRSA guidelines and the top two ratings from the U.S. Preventive Services Task Force tracks the Obamacare requirements. Although the government may not have expressly required the degrading of my coverage, the hidden taxes of Obamacare, perhaps combined with either market forces or regulations limiting premium increases, created a strong and foreseeable business reason for insurance companies to abandon or reduce coverage for a variety of preventive care services not specifically required just to save money. Before Obamacare I needed no mandates of coverage, but now my preventive care apparently has been “crowded out” by the government taxes and regulations.
The HRSA guidelines referred to have nothing to do with vision or prostate screening. Only the U.S. Preventive Services Task Force appeared to have even looked at either topic and its members appear to be a very skeptical lot.
At least three of my relatives, two related by blood, have suffered with macular degeneration, both in its “wet” and “dry” forms, and one of my relatives has managed to avoid impaired vision in her one good eye only with an evolving regimen of multiple supplements that appear to have at least greatly slowed the progression of the disease, which was diagnosed 25 years ago without her then suspecting any problem. For many years one eye supplement seemed to be preserving her eyesight, but then, as her eyesight began to deteriorate rapidly and she seemed almost resigned to eventual blindness her ophthalmologist suggested an additional supplement specifically for macular health. After she began taking this new supplement the deterioration seems to have stopped, or nearly so, and apparently just in time to keep her from becoming visually impaired in both eyes. Naturally I would want to know as soon as possible if I will face the same fate. Losing vision is a major life-changing event and I would have thought routine vision exams for early detection of such serious problems would be on a short list of the most important forms of preventive care--but apparently not.
The U.S. Preventive Services Task Force gave routine exams for visual acuity, even for those patients over 65 years of age, an “I” rating, indicating that there was insufficient data to recommend routine testing. It stated in its full recommendation statement:
The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and AMD [age-related macular degeneration] improves or prevents loss of visual acuity. Although the USPSTF found adequate evidence that treatment of refractive error improves visual acuity, there was inadequate evidence that these improvements improve functional outcomes.
Elaborating as to cataracts and driving a vehicle, it expressed skepticism that vision degraded by cataracts would affect driving ability:
Evidence shows that cataract surgery improves vision-related quality of life and function, but evidence from observational studies on effects on motor vehicle accidents and death is sparse and inconclusive...
Demanding evidence that cataracts might degrade one’s ability to drive a car is not something I would think required empirical evidence, notwithstanding that alleged psychic Uri Geller supposedly drove a VW while blindfolded in the early 1970s. How can one begin to imagine an empirical study that could prove the relationship? Perhaps one would have a large group of people in need of cataract surgery drive vehicles with half doing so after corrective surgery and the “control group” doing so with cloudy lenses while scientists count up how many auto accidents, serious injuries and/or deaths result? Do we let them keep driving for years with further deteriorating eyesight until we reach that “Eureka moment” when we find the point at which a statistically-significant number of people have been injured or killed so as to demonstrate that further-advanced cataracts do indeed need detection? Is this practical and might such a study ever be done? I certainly hope not, but if not, are we condemned to “insufficient evidence” of the need for preventive eye care for all eternity?
The New York State Department of Motor Vehicles has not demanded similar empirical proof of the correlation between vision and vehicular accidents. If a driver fails to demonstrate 20/40 vision in at least one eye a driver’s license will not be renewed. That is the only “double-blind” experiment it requires. Even if the Task Force took notice of the impact losing a driver’s license might have on a person’s functionality, it still isn’t clear that would be enough. The Task Force also noted:
Many older adults may not perceive sensory deficits as a problem and may alter their daily lives to adapt to the sensory deficits. This fact creates a challenge to researchers and decision makers to determine whether interventions to improve sensory deficits, such as vision, are beneficial when there is evidence on improvements in objective measures but a lack of evidence of improvements of subjective measures.
If I’m reading this right, and frankly it strikes me as enough to make just about anyone doubt their eyes, the Task Force would need evidence that older people care whether or not they lose their senses. This Task Force may not be the much prophesied “death panel” but the more banal reality of Obamacare is sobering enough. One wonders if patients who unnecessarily lose their eyesight might wish they were dead as the Task Force demands empirical proof even of whether there is any need for good health in the aged.
At the end, the recommendation statement does note that both the American Academy of Ophthalmology and the American Optometric Association Consensus Panel on Comprehensive Adult Eye and Vision Examination both recommend regular eye exams for older people--but not the Task Force, and under Obamacare it is what those skeptical folks on the Task Force say that counts.
Gathering all the evidence they need in order for the Task Force to recommend, even just for those over 65, let alone those of us younger, the routine eye exams, which my health insurance fully covered for those of all ages before Obamacare, could take a very, very long time indeed. In fact, a draft update to the recommendation has already been posted and still gives an “I” rating.
The Task Force appears to have looked only at visual acuity testing for those over age 65, not younger people, and was not convinced such testing would even detect AMD or cataracts. Perhaps it did not consider an ophthalmological examination of the retina to detect AMD, the manner in which my relative’s AMD was discovered. However, that only raises further questions, such as why not look at those forms of preventive care as well, and why not look at routine checks for younger people? The Task Force at least does not dispute that there are effective treatments, even as its members sit on their hands and watch our routine preventive eye care coverage disappear.
Indeed such further questions about recommending other preventive measures may be pointless in view of the absurd standards of proof required to recommend any preventive vision care. Somehow, I suspect the rating would be “I” for insufficient evidence all over again and again.
Some confirmation of my suspicion can be found in the separate treatment of glaucoma screening. It too received an “I” rating: “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma (POAG) in adults.” To sum up, it seems that the “I’s” have it; but the eyes do not.
The American Optometric Association referred to Glaucoma in a 2013 article as the “sneak thief of sight” (the Association placing the phrase in quotes because the disease is so commonly described in this way) and warns it “may strike without pain or other symptoms,” recommending “regular, comprehensive eye exams,” among other preventive measures.
Years ago the actor Dana Elcar, perhaps most well known for his role as a co-star with Richard Dean Anderson in the popular 1980s television show, MacGyver, became blind near the end of the show’s run. A report at the time, based on an interview, said he’d been diagnosed with Glaucoma 25 years earlier and had “maintained excellent eyesight through treatments and medication,” but also that he admitted that in the few years during which his eyesight was reduced 90% he had not visited his eye doctor as often as he should have. Interviewed on camera he said, “I can’t drive anymore.” (Task Force please take note!) As he was losing his eyesight, his fictional character on MacGyver, Pete Thornton, would too as Elcar’s medical condition was written into the script.
When Thornton finally admitted his problem to MacGyver he said, “I let it go too long.” When asked why he let it go too long, he said, “denial.” Both Elcar, and his fictional character, went through surgery in a desperate effort to save eyesight from a disease Elcar had failed earlier to treat adequately. Elcar had limited success and became legally blind. Public service announcements at the end of the program warned viewers of the need to be checked often for the disease. Of course, avoiding surgery and other late-stage more expensive and sometimes futile efforts to treat conditions which could have been more effectively and easily treated earlier is a reason that was given for why Obamacare promised to improve routine preventive care coverage. The reality, however, is that the Task Force which has been made our “decider” on preventive eye care coverage seems to think that evidence to support those television public service announcements of decades ago is still not sufficient to justify such a recommendation, even today. Perhaps the Task Force has the same problem as Pete Thornton: denial.
My relative who has battled with AMD for two and a half decades checks her eyes for further deterioration by looking at a grid of horizontal and vertical straight lines known as the “Amsler Grid.” Notwithstanding the vigilance required to find new ways to forestall visual impairment in her last remaining good eye and her inability now to see those straight lines as clearly as in the past, I dare say that even at her current age she can still see straighter than the folks on the U.S. Preventive Services Task Force or the ones who are responsible for the state of current law in this area.
As for my reduced coverage for prostate cancer screenings the Task Force gives the prostate-specific antigen [PSA] test a much worse “D” grade: “The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen-based screening for prostate cancer.” Why? It thinks these screenings have little or no benefit and are dangerous.
To be fair, some forms of preventive screenings actually do have significant physical risks. Some forms of electro-magnetic radiation can harm the patient and the risk must be weighed against any health benefits, but the PSA test just involves drawing a small quantity of blood. I usually had mine along with many other blood tests before or after a routine physical exam so my blood was being drawn anyway. The risk that the Task Force refers to, however, is not a physical risk. The danger it used as a justification lies solely in the knowledge of the test result, which it says could easily be a false positive or an indication of a cancer that does not require treatment and might cause unnecessary treatment or biopsy. In other words, it recommends against prostate cancer screening because it thinks here ignorance is bliss (I paraphrase, of course). It certainly is a conclusion bound to save money for insurance companies, in the short run at least.
This conclusion was not reached without controversy. In the preface to the 2013 book he edited, Prostate Cancer Diagnosis: PSA, Biopsy and Beyond, J. Stephen Jones said the Task Force recommendation created a “firestorm.” He disputed the claim of little or no benefit and stated that tens of thousands of men’s lives were being saved by “early diagnosis and improved treatments.” He went on to say, “That fact won’t go away with a dismissive remark by a group of people that interprets the data differently from most experts in the field…” noting that the Task Force was composed of individuals who had “never had primary responsibility caring for patients with the second most common cause of cancer death in men.” Indeed the website on which the Task Force conclusions are posted admits in its FAQ that “The Task Force does not have any members who are urologists,” (although it does say some did provide peer review).
I would not suggest that medical specialists know it all and I appreciate the dangers of medical intervention. I have disobeyed doctors orders, including those of specialists, on more than one occasion, but I do not appreciate the paternalism of the Task Force inherent in their twin assumptions: first, that I am not the one best able to decide for myself, after consultation with one or more doctors, whether the test’s benefits are worthwhile when the only risk is I will be more informed; and second, that I will somehow make better decisions when less well-informed. My old insurance made no such assumption before the federal government began issuing mandates on my routine preventive care.
At least for now the government can’t stop us from obtaining routine preventive care if we pay for it, in whole or in part, out of our own pockets, but the loss of coverage for routine preventive care after massive regulations were imposed reminds me how things can go awry when we surrender our freedom and allow the government to place the most important decisions in our lives in the hands of people who just don’t care about what becomes of us as much as we do. I was far better off and had more useful health insurance coverage when there were no federal mandates governing my insurance, when I was offered choices of more robust coverage, and when I was the one who decided what forms of routine preventive healthcare I needed.
In the area of preventive care, as in so much of Obamacare, it is as if we have entered the “Bizarro World” where up is down, as described in a Seinfeld episode. “Bizarro Superman,” as Jerry referred to him, was a comic book nemesis of Superman. Unlike the defender of truth (not to mention “justice, and the American way”), his nemesis from the Bizarro World always said the opposite of whatever he meant. If he had been describing Obamacare to us before it was enacted his descriptions would have matched those we heard from the supporters of the law on many key points.
Speaking of comics, Jonathan Gruber actually created a comic book to extol the virtues of Obamacare but don’t look for the Bizarro character or his Bizarro world in that comic book. When it comes to healthcare reform the Bizarro world is no fictional location limited to comic books--it is the world in which we now live.
Unsafe at any price
Although the premium and cost-sharing subsidies may make healthcare cheaper for some, they only seriously address the added costs of premiums and noncatastrophic care. Subsidized insurance may sometimes be cheaper for those who do not become seriously ill, and with good health I might now become one of those people, but the Monty Python “never-claim policy” was also “very worthwhile” for those who didn’t need to make any claims. At least in the comedy skit the victim chose to roll the dice with his cheap policy. For those forced out of the group market in New York State, bankruptcy may become more likely because the law took away our freedom to choose insurance that protects us with out-of-network coverage, even in a worst case scenario. It is remarkable nothing has been done about this and so little has been reported about how reform turned out to be the opposite of what the public was told it would be in so many respects.
The attempt by an article in New York Magazine to put a good face on the yet still unrepaired broken promises of Obamacare, in advising its readers how to deal with the loss of group plans with out-of-network coverage through the Freelancers’ Union and choose among exclusive provider networks, reads like a how-to manual for putting Humpty Dumpty back together again:
Make a list of the high-priority doctors and specialists you might already have and see which plans they're taking. Also, make a God-forbid list. If you get cancer, do you want to go to Memorial Sloan Kettering or NYU or Beth Israel?
Before reform I wasn’t relying solely on God to forbid the worst, I also had reasonably good insurance coverage. In 2015, without the freedom to buy the quality coverage I’d elected in the past, I could find only four providers to choose from on the New York exchange available in Monroe County and I ruled out two because they didn’t cover the primary care physician I’ve had for decades.
Was this article in New York Magazine (which was pointed out to me by a representative of either the New York exchange or my insurer in response to my questioning) suggesting I would be expected to anticipate every serious disease from ALS to Leukemia to Parkinson’s to you-name-it and research in advance where I would want to be treated for every such major disease in the medical encyclopedia, then look at my two remaining insurance providers and try to connect all those dots in just one of the two networks I have to choose from?
Are we to believe that no matter who we are or what health problems we might confront, the adverse consequences of lost freedom to choose an out-of-network provider can somehow miraculously be erased by careful advance planning in the selection between a couple of exclusive provider networks?
Should we also wish upon a star?
The importance of freedom of choice was why many rejected HMOs in the private sector and, as many have pointed out, why Hillarycare failed in the public sector years ago. The over 20-year-old Harry and Louise commercial, predicting how choice would be severely limited by the government to plans people didn’t want, has proven quite prophetic if you apply it to Obamacare. Louise began that commercial saying, “This was covered under our old plan.” Later she says, “Having choices we don’t like is no choice at all.” It did far more to warn us what the future would hold than the president did.
Ezekiel Emanuel, a key White House adviser in the design of Obamacare, contended that if people are willing to pay enough, they could keep their doctors under Obamacare, so the president never broke his promise. Setting aside the fact that Obama also promised that people would not have to pay more, Emanuel’s argument still fails. I couldn’t find my old out-of-network coverage in New York State at any price on or off the exchange in late 2014 after being forced to search for insurance in the individual market by “reform.” Although I was provided a replacement group plan in 2014 with out-of-network coverage this partial relief only lasted for one more year. Whether Emanuel was aware of it when he was interviewed in late 2013 or not, by 2015 I and many others would lose all out-of-network coverage as we were forced out of group insurance entirely. Emanuel’s statement could only be true for an out-of-network doctor if paying more means paying the doctor bills out-of-pocket without any insurance coverage at all. Of course, we can all keep our doctors if we pay for them entirely out of our own pockets. If that’s all health insurance reform was about maybe we all need a review of what the meaning of the word “reform” is from Monty Python’s Mr. Devious.
The promise land
Even considering that my experience losing my plan and searching for new insurance every year for three years sheds considerable light on the kind of problems the law has created for many others, I have merely been in an opportune position to get a small taste of some of the many bitter pills the prohibitions and hidden taxes of this complex piece of legislation have forced down the throats of many other patients. Although I will not know the full impact of the law on my situation for several more years, at least, so far my problems are trifling compared to the many, especially those in poor health, who were hit much harder by the new law. According to reports some pay much more than I do, have lost their current doctors, or hospitals, or have to travel long distances for treatment. In one notable case, a woman in La Jolla, California lost coverage for some of the doctors who treated her for cancer and might have to use her own resources if she needed follow up.
The world described in these reports is a far cry from the promise land we were told reform would take us to. Remember when the individual mandate would control the problem of free riding, which was driving up costs for everyone? Remember when the President told us reform would “cut the cost of a typical family’s premium by up to $2,500 per year,” that “no one will take [your health plan] away, no matter what,” that reform would “build on what works,” and later in a television interview shortly before the law was passed “that for the vast majority of people, their healthcare is not going to change, because right now they’re getting a better deal. The only thing that is going to change for them is … they’ll have more security.”
The trout in our milk
What is far more troubling than the broken promises is the failure to make more than token efforts to repair the damage done by those broken promises. If you buy a product that doesn’t come remotely close to living up to the vendor’s promises you might not assume bad faith if the vendor offers a refund, repair or replacement. However, if when you complain about these problems the vendor just gives you a blank look you might reasonably conclude you were simply cheated.
Years after the law was passed it seems that those who supported it have given little more than lip service to the task of fixing it. If Congress has done anything significant to fix these problems I must not have noticed. Fred Upton’s bill only addressed people losing insurance in the individual market and it was a Republican effort that was passed only in the House. The president in November of 2013 offered permission for insurance companies to restore canceled plans, but only for a limited period of time, and New York State was allowed to reject this offer and leave people in the lurch even in 2014. The President also permitted those whose plans were canceled to claim a hardship exemption and obtain a “catastrophic policy” for a limited time period. However, I investigated this option and the catastrophic policy is not much less expensive than some options on the exchange; in addition, I was told it does not qualify for the premium tax credit, and is not HSA-eligible, notwithstanding its high deductible. I was also told over the phone that it has no out-of-network coverage, so this “catastrophic” plan not only offers little in the way of premium savings, but it also doesn’t cover the out-of-network care you might need most in the case of a catastrophic illness. The President might just as well have said, “Let them eat cake.”
Even apart from the videos of Jonathan Gruber’s statements, the failure to make any authentic effort to repair the law’s admitted and continuing failures year after year to keep the president’s promises was already strong circumstantial evidence the promises were made, or left broken, or both, in bad faith--essentially Thoreau’s trout still flopping around in our watered-down insurance coverage.
Although Gruber suggested taxation hidden from the insured, but felt by them in their premiums and/or coverage, was to help the sick, the watering-down I would see in my own plans was not to guarantee coverage for those with pre-existing conditions. In my research prior to retirement I learned that New York State had already addressed denials due to “pre-existing conditions.” People were permitted 60 days after losing coverage to obtain a new policy and with a certificate of coverage their pre-existing conditions would not be taken into account. I provided such a certificate when I switched to the MCBA plan. Those who failed to obtain coverage for more than 60 days could still obtain coverage on the same terms, but pre-existing conditions would not be covered until after the expiration of a waiting period--apparently to discourage free-riding; which is similar to the current requirement that people wait for the next open enrollment period. Further, the New York Times reported in April of last year that New York had previously guaranteed coverage for those with pre-existing conditions and children of policyholders to an even higher age than federal law now does. In addition, although New York’s own version of reform had already driven up rates in the individual market there was the Healthy New York program, which provided insurance at very affordable rates for those with lower middle-class incomes. Those with higher incomes or who did not want a subsidized plan could seek refuge in association group plans as I had. The fact that I would see serial cancelations, with large reductions in replacement coverage accompanied by premium hikes in both an employer-provided plan and a professional association plan and a further deterioration, upon termination of my group coverage, in the default replacement plan in the individual market are all the more striking, because in New York State these enormous costs imposed on existing policyholders could not have been caused by, nor be justified by, the need to solve problems that had already been largely addressed by state law. It may well be true that the subsidies for some among the lowest of the middle class are even more generous under Obamacare than under the former Healthy New York program and some may benefit from those mandated benefits that were not previously required by state law. However, the legislation was not presented as some kind of a trade-off to impose taxes or regulations that would result in seriously degraded coverage or higher premiums for many in the full range of middle-class incomes in order to provide more generous subsidies for some, but not all, of those in the lower middle class range, or for any other purpose.
More fundamentally, if it was true that before reform people were already paying for the uninsured, because the uninsured were already getting free services and driving up the medical bills of those who paid for their services, as advocates of reform contended, then why hasn’t the individual mandate brought down the cost of comparable health insurance; and if Obamacare brought new efficiencies why aren’t those savings showing up in coverage and/or premiums, as promised, instead of driving the cost of insurance up or putting quality insurance with out-of-network coverage entirely out of reach?
The pretense of transparency
The New York Times defended the administration by saying:
There was no lack of transparency. Two Senate committees and three House committees held extensive public hearings on versions of the bills and debated them for days on the floor. Republicans sat in on all the committee meetings and were well aware of what was in the bills.
Earlier the president had said something similar:
By the time the vote has taken place, not only I will know what’s in it, you’ll know what’s in it, because it’s going to be posted and everybody’s going to be able to evaluate it on the merits.
Anyone, we have been told, whether a Republican in Congress, or John Q. Public, could read the bill posted online and know what was in it; yet, the president later would explain away his broken promise, that people could keep their plans, by saying that he just didn’t realize how the law was going to affect people. He had to say this or admit to either lying, or having made his promise in bad faith, or both. So are we to believe that everyone knew what was in the law except the president who signed it?
His comments at that time indicate he focused only on how it would affect the small percentage of people in the individual market and miscalculated that effect, yet even as he did his mea culpa he still ignored any possible effect on the much larger number of people in group plans. My experience demonstrates that the problems with the law adversely affected far more than just a tiny sliver of the population in the individual market. All three of the plans I lost were group insurance. My former health insurance options, along with much of their benefits, have been destroyed one-by-one all while I was in the group market. The group market is enormous. Even employees at Harvard have seen their choice of providers narrow because of healthcare reform.
The new law was so complex it was virtually impossible for me to intelligently plan my retirement, even in 2012 long after the law was signed. In fact, even a very basic question on my eligibility for the premium tax credit would stump the representative at the New York exchange phone help line in late 2013 and required me to do my own research.
I wasn’t the only one confused. At an MCBA meeting regarding insurance coverage for “sole proprietors” we were told that different insurance companies in the state had reached different conclusions about whether they were required to deny group coverage to such persons in 2015 and I would later learn that different lawyers had formed different opinions about whether my insurer was required to remove persons like me from the group market. Further, two cases have divided the U.S. Supreme Court on the validity and interpretation of critical provisions of the Act, one of which would hold that a provision which might otherwise appear to be clear in its meaning had to be construed contrary to “it’s most natural reading” in the context of the overall scheme of the Act of several hundred pages. The three dissenters would reach an entirely different interpretation but would “wholeheartedly agree” that context mattered and applying this same holistic approach cited various provisions from the Act to reach the opposite conclusion.
Albert Einstein famously said that the income tax was “the hardest thing in the world to understand.” However, in his day there was no Affordable Care Act. If I, a licensed attorney with some experience in both federal tax law and employee benefits, could not plan accurately, and if an insurance company could not tell me what the new law would do to my options before I retired in 2012, I can only begin to imagine the impact of this fog of transitional uncertainty on the average working person.
The simple truth is that the average American did not read the bill, and any who did read the entire bill so as to be able to interpret each provision holistically in context would still not be sure exactly what a number of provisions meant. Most Americans likely relied on the statements of those who wrote, or voted on the bill and the president who signed it--and those statements could hardly have been more misleading. In light of the complete mischaracterization of the nature of the law to the American public, the claims of transparency are nothing more than a thin pretense.
Statistical misdirection
Kaiser Family Foundation statistics say premium increases have been modest in recent years, but most people understand that when a box of cereal gets smaller its unit cost goes up even if the price stays the same, and, similarly, health insurance has become far more expensive as coverage has shrunk drastically, even if the Obamacare shell game has in some cases kept much or even all of the increased cost from showing up in premiums. Further, it doesn’t help if the same plan has only a small increase in premium if you can’t keep the same plan but must instead move to a new far more expensive plan. The ways in which Obamacare has made insurance more expensive may be off radar for many statisticians but not those who pay the bills. For example, the new law prevents me from keeping my less expensive group insurance, and if I had taken the default MCBA replacement in the individual market my quoted rate would have been about 18% higher, my deductible would have increased over 10% and, most importantly, I would pay for all this while losing all or virtually all out-of-network coverage--a lost benefit that also makes the insurance more expensive with potentially devastating impact in cases where insurance is most needed. The commonly reported statistics, however, would show only the smaller increase, of several percentage points less, for those who were able stay on the MCBA group coverage, not the apples-to-oranges comparisons forced on those who lost their insurance. As long as the commonly reported statistics fail to capture the way people are being harmed and how their insurance has become more expensive the statistics are worthless.
Rick Ungar, a Forbes contributor, mocked those who claim to have been harmed by this law citing a McKinsey study that examined only premiums for the relatively small number of people on the individual state exchanges and didn’t even address the harm caused by the law to the group market, much less those forced out of their group plans.
No choice
As I mentioned, I very reluctantly entered the individual market in 2015. Although I did not request the premium tax credit in advance and my income from investments in retirement, which depends on interest rates and other factors, is not something I will know for certain until year’s end; my income in 2015 may qualify me for the premium tax credit when I file my tax return. In addition, I am also currently receiving cost-sharing reductions in my deductible and coinsurance. As a result I can see the law from both sides. I have, through 2014, been among the many paying its heavy costs through reduced coverage, and now will apparently join the few receiving both of these generous subsidies. If I were still free to do so, I would choose to have neither reduced coverage nor subsidies and simply return to a pre-reform group plan.
Before “reform” I needed no government subsidies because I still had the freedom to choose affordable unsubsidized insurance with much better coverage. Group plans still exist with such coverage, albeit seriously diluted by the new law, but by law those group plans can now only be offered in New York State to businesses with employees. A law supposedly to help individuals actually discriminates against them in practice. At the same time we have lost the freedom to decline insurance some of us also lost the opposite freedom to choose quality insurance that provides a choice of any doctor or provider. The little people lose out and must accept lost freedom of choice and dependency on government just to recover some of what was unnecessarily taken from them by the new law.
This denial of freedom of choice on a matter of great importance to an aging public may lead to costs in future years that can be accurately calculated by no one, not even that unimportant man behind the curtain, Mr. Gruber. In all too many respects, the law does just the opposite of what we were told it would do, primarily because it treats with contempt the value of personal choice on matters of health and gratuitously insinuates the government between patient and doctor and between patient and private insurer.
Bait and switch
That the Times editorial board would rush to the President’s defense in spite of all the facts to the contrary is hardly surprising, considering how it has spun the new law in its news reporting. In its April 2014 news article it had said that New York State’s “hard choices” had made its exchange a “success.” For example, it attributed its success, in part, to the state’s decision not to reinstate terminated plans after the president said states could do so. More than 100,000 people were left without their old plans, according to the article. “Thousands more freelancers and other ‘sole proprietors’ were barred from banding together for group insurance rates, a change in longstanding practice that almost certainly pushed more consumers to buy insurance on the exchange.” Note the use of the word “pushed” rather than “attracted.” Instead of people beating a path to the exchange, the government beat up on the people until they followed its path. The article admitted, in passing, before an upbeat ending, that the “sickest customers tend to be the most upset,” like a long-time cancer patient paying $3,600 per year more to keep her cancer doctors. This is not the cancer patient from California mentioned earlier; a cancer patient struggling to pay more to keep her doctors because of “reform” seems to be a recurring theme of our new quasi-insurance from coast to coast.
Were these hard choices breaking promises viewed as a failure? No. As long as by breaking promises, destroying alternatives, hurting those who are the most ill, and coercing people onto the exchange, the State raises its enrollment figures it is deemed by the Times a success. A private business engaging in such tactics might be charged with unfair competition or antitrust violations, but when the government is behind it all the Times thinks better statistics and less insurance coverage “spell success.” A smashing success, actually, achieved by smashing pre-existing insurance even when it complied with new coverage mandates.
Of course, those of us who lost our insurance and/or saw coverage degraded, who were forced unnecessarily into government dependency, or the women mentioned in news reports who saw coverage for cancer treatments disappear or become more expensive under “reform,” may not spell success quite the way the Times does; but, to paraphrase a line from the Billy Wilder movie, apparently we just can’t spell.
A glimpse of the future
As this is about to be published I have begun the process of renewing my application for 2016 insurance on the New York exchange. I can only give some impressions based on an initial review at this point, my research being hampered somewhat by long wait times, as high as one hour and twenty-five minutes, on the exchange help line and an exchange website which can become overloaded due to “overwhelming interest in the New York State of Health.” However, it is clear there are some changes coming and the themes seem to be more pain, in the form of larger deductibles and out-of-pocket maximums on some unsubsidized plans; and some gain for those with subsidized plans in the form of an increased premium tax credit for those on the familiar exchange plans and a new set of plans with a premium of $0 to $20 per month, each called “the Essential Plan,” which take the place of the familiar gold, silver and bronze options for those above, but not too far above, Medicaid eligibility. The Essential Plan does not have an unsubsidized version, so its features conflate the twin effects of Obamacare in driving up the underlying premiums and out-of-pocket costs of unsubsidized insurance then subsidizing that cost for certain persons. Otherwise, however, it appears to be a more highly subsidized variant of prior subsidized insurance on the exchange. The Essential Plan is also not HSA-eligible, which fits the trend toward fostering less self-sufficiency and more government dependency.
With my insurer the new changes do not appear to give back lost routine vision or prostate preventive care coverage, except under the Essential Plan at an additional fee if the provider offers it; nor do these changes address the loss of out-of-network coverage for those migrated to the individual market. However, that is damage already done in my case. The story in 2016 may not be about further damage done to my coverage--I was already “a statistic”--but more likely about damage done to that of others.
Perhaps, after I have learned more about the 2016 developments, I will follow up with an update on my experience and what I have learned in the 2016 open enrollment, if it seems warranted.
Treatment without diagnosis
My personal experience with health insurance is not limited to the transition to Obamacare. In the 1990s I was one of those who faced losing my health insurance when I was out of work following the expiration of a one-year judicial clerkship in the State of Oklahoma. I had to apply for insurance in the individual market and answer a lot of health questions. However, my disability policy was not affected by either my move from New York State to Oklahoma to take the job, nor by my subsequent unemployment. It was an inexpensive noncancelable insurance policy, issued in the individual market, with good coverage and a fixed payment, that I bought when I was healthy, under which I would never lose insurance moving from job-to-job or because I decided to become self-employed. Instead of creating a massive and expensive new entitlement that destroys our village of health insurance in order to save it I would suggest we might have asked the question Robert Kennedy asked; to imagine things as they might be “and ask why not?” Why couldn’t health insurance be more like my old disability insurance?
A good doctor would first diagnose a cause of an illness, then treat the cause, rather than treat the symptoms and let the disease fester. Similarly, a good reformer of our health insurance system would have first diagnosed the cause of the problems and addressed those causes first.
If all along people could have bought a noncancelable health insurance policy when they were young the way they buy life or disability insurance, take it with them from job-to-job and state-to-state, and obtain the same tax treatment as is provided for employer-sponsored group plans our system would not have been forcing conscientious people who pay their premiums on time to lose insurance when they lose a job or move out-of-state, precisely the problem Obama cited in support of the new law. Instead of creating new laws we could have repealed laws that hampered the marketplace from healing itself. Repealing laws is a lot less expensive than a massive new entitlement; and tax laws written when a great many people never switched employers in an entire career can wreak havoc in our modern economy.
Such changes would not solve all the problems but any good physician knows that a patient must ultimately heal himself or herself and the role of medical intervention is to help the patient to heal. Similarly, a better approach to reform would remove the legal impediments to portability and noncancelability, allow the market to heal itself as much as possible, and address through intervention only those problems that remained for those who cannot reasonably be expected to help themselves. Not only would such an approach show due regard for individual freedom of choice on private healthcare decisions, it also would show due regard for the limited ability of people on group plans to pay for massive legislative overkill, not to mention due regard for the limits of expensive governmental intervention in a nation deep in debts both public and private.
President Obama in a different context offered a similar metaphor when in his first presidential debate with John McCain he famously said he would use a scalpel instead of a hatchet to cut the budget. It is a great irony that when it came to medical care, the very field that gave us the tool of such a metaphor, Obamacare would take, not a scalpel, to the problem of unaffordable health insurance, but rather a hatchet to our entire health insurance system--destroying millions of policies. It is said that “an ounce of prevention is worth a pound of cure.” In turn, a pound of diagnosis and cure may well be worth more than a ton of treating the symptoms. If we had eliminated the cause of much of the problem, laws that inhibit or prohibit portability, then those harmed by those repealed laws would be a finite group, which would shrink in size as time passes. Instead we have another typical entitlement program like Medicare or Social Security, which will likely grow, become unwieldy, and need further reforms as time passes. The failure to use that scalpel where it was needed most leaves one to wonder, with apologies to Churchill, if ever so many have sacrificed so much for so few.
Our health insurance system needed both prevention and cure of its economic ailments. What we got was treating the symptoms and, for most of us, the treatment was worse than the disease. It was also a treatment for which the patients never gave their informed consent, because they were not told the truth. It is as if Doctor Obama promised to remove a polyp and instead performed a colectomy.
Instead of building on what worked and letting people keep their plans, we destroyed the pre-existing health insurance options. Instead of permitting people to get noncancelable insurance they could take from job-to-job with the same tax treatment as employment-based plans the new law requires employees to use any available employment-based group plans or lose all tax breaks. As I have discovered by seeing the law from both sides, the new law would seem to burden many lower middle-class working persons with employment-based insurance who are likely to be hurt by the hidden taxes yet don’t qualify for any new tax benefits, even if they have plans just as poor as my current insurance on the new exchange; while an early retiree like me living primarily off of savings and a small investment income, by contrast, is eligible for subsidies paid for, in part, by those very working people with similar incomes--subsidies I wouldn’t even need and would gladly give up if I could return to my old insurance plan. If such arbitrary and capricious tax laws represent a blow for “social justice” then I need lessons in more than just spelling.
Both the destruction of higher quality plans and the dual-track tax treatment of “reform” make people less able to provide for their own future and make them more dependent on the government to bail them out of situations they otherwise might have been willing and able to take care of on their own at no cost to taxpayers.
To be fair, the new law does contain a provision for healthcare choice compacts next year that could allow policies to be sold in multiple states. However, these are left to the discretion of the several states; the law that has mandates for all kinds of things has no mandate requiring the states to give us back our freedom to choose.
Unless insurance companies have some Jekyll and Hyde transformation when they sell health insurance, the key to why health insurance is so much worse than other forms of insurance must be the element of increased government coercion limiting the competition and choices we would have with other forms of insurance.
The next time you see statistics on how many people have signed up for insurance on the exchanges, remember, I have become one among those statistics. I am part of the building case for the success of the program; but I have a voice of my own. By the enactment of this law I have no more been set free than were the drivers who encountered lane closures on the George Washington Bridge; and like one of those many drivers, I am most certainly not alone.
Fooled once
By the most charitable interpretation of the president’s motives he honestly had a completely mistaken impression of how the law would affect Americans, yet the process--or so we are told--was transparent to everyone except the president, his legal counsel, other experts, and advisors.
Even setting aside the patent implausibility of this charitable explanation, the failure of the President to attempt anything more than a token fix alone would still cast a long shadow of doubt upon it. Also casting doubt is the long list of statements that presented a program virtually the exact opposite of what was delivered. Not just to (1) “keep your plan;” to (2) “keep your doctor;” to (3) lower the average family’s premiums by thousands of dollars; to (4) make people more secure when many would actually lose out-of-network coverage due solely to the law, making it more likely medical bills will result in bankruptcy. Reform was also supposed to (5) expand routine preventive care coverage and yet I’ve seen what I use contract, just the opposite of what was promised; and (6) to cap healthcare expenses when losing out-of-network and routine care coverage means the cap I’ve always had has become porous with more expenses that now must be paid for in addition to any maximum. We see just the opposite of what was promised time and again, and again, and again ... It looks like a pattern and a pattern suggests more than just an inadvertent oversight. Not to mention Obama’s insistence that the law is “working.” If he thinks it is working as it should and refuses to fix broken promises how can anyone believe he didn’t intend to break his promises all along?
The far more plausible alternative explanation, that the promises have been left broken because they were never intended to be kept--perhaps because they simply cannot be kept if the numbers are to add up--is consistent with the candid remarks of Jonathan Gruber, the man who added up all those very numbers. As the Wall Street Journal reported back in 2013, even before more recent reports made him a widely known figure, Jonathan Gruber said the effect of Obamacare on pre-existing insurance was "a social policy decision the government made,” and the statements by the president to the contrary were "pretty low on the totem pole of political overstatements."
Gruber’s word, “overstatements,” seems an understatement of the extent to which people were misled. Whether or not the President, or his team, knew the President’s statements were untrue and his promises were made to be broken, the process could only be characterized as transparent in the sense that the truth had become virtually invisible, or, as Nancy Pelosi put it so well, they had to pass the law so we could find out what was in it.
Abraham Lincoln famously said, “you can’t fool all of the people all of the time.” I can only hope that it is Abraham Lincoln’s estimation of the voting public, and not that of Jonathan Gruber and those whom he observed erecting healthcare “reform” by misleading the American public, that is ultimately proven right.
