Obamacare, a True Look at the Program

Obamacare rocks, if you have absolutely no idea how insurance actually works, what it does or what it is supposed to do. If you know even a little about insurance you know it is awful. People either love or hate Obamacare but the reality is most have zero idea what they are talking about. My wife is a user of the NY state exchange, I am the former director of insurance markets, I consulted, wrote studies, etc. I am also a sickly person who has used his insurance on a massive level. All of this gives me tremendous advantage that all of the talking heads simply don’t have and, likely, never will. I have reached out to them, sent emails, etc., but who am I… too smart for them I guess? Who knows.


The Idea

In a utopian society everyone lives in bliss with no sadness or evil. There are sugar plums and apples as far as the eye can see and no one goes without. Unfortunately, utopia doesn’t exist, never will.

I suspect this is the world Obama and the democrats are trying to create, but they just have no idea what they are doing. Their first stab at creating this make believe world was Obamacare, can we agree they deserve to be fired over this yet? They did everything they thought they should, spoke to liberals and academic professionals who know everything there is to know, from their ivory towers.

My suggestion for the first try at getting the uninsured insured would have been to simply do premium support in conjunction with expansion of Medicare and Medicaid. Forget the mandates like free birth control, my God it is $20 a month, so what, an concentrate simply on coverage. They didn’t do that, obviously, they recreated the marketplace which was dumb as the marketplace took a century to build! All they needed to do was open Medicare or Medicaid up to those who are uninsured, use a sliding scale to calculate premiums, i.e. free for the poor and the more you make the more you pay, no mandates and simple. Of course the preexisting and cap limits are fine, kind of as eventually that will cause premiums to spike, hard.

With my system you conquer 2 goals, it makes all the left wing whack jobs happy because it looks like a “public option” and there is no mandate to buy insurance, or pay a tax, fine or whatever it is now. The third true benefit is you are not destroying and rebuilding something that works… we know insurance works, contrary to what politicians say because if insurance doesn’t work why expand it with Obamacare. However, we have what we have and over time you will hate it, trust me. The idea was good and noble, the direction was straight down the tubes.

What we Have

What we have is a mess an absolute mess and the longer we have it the more obvious it will be. If you are uninsured and in the exchange you can now buy “affordable” health insurance in 3 different varieties, bronze, silver, gold or platinum. In each category the policies all basically do the same thing, deductibles are standardized and the benefits are standardized, but you have a choice of HMO, PPO, POS(point of service not the other thing) which allows you the perception of more choices. Sadly, all Obamacare policies are basically HMOs because they needed more control to make it “cheap”. So think of the different versions of policies in terms of how big the network is, co-pay costs, do you need referrals, maximum out of pocket costs instead of real choices in policy types.

What everyone doesn’t understand is that these policies all have zero out of network coverage, do you understand that? If your insurer isn’t in Florida where you are vacationing and you get hurt or sick, you pay. Therefore the claim this will reduce bankruptcies is partially true, but mostly not. What the co-pays for surgeries because these policies allow for separate co-pays to every doctor in the surgery, the hospital and after care, these can add up to thousands of dollars, I know from experience and we have a platinum Obamacare policy.

Pre-authorizations are a big part of these plans as well. Do you have injections for back pain? Pre-authorization and only a set number of injections are approved at a time. Do you get 240 pills in your prescriptions? Well, their formulary is different and they only approve up-to 180 without preapproval. This is how they reduce the costs of these policies and, after a while, you will get similar care it expands the work you doctor has to do and headaches for you is they forget to reauthorize something. We just went through this with my wife’s new platinum policy and we have had it for 2 months, oh joy!

Premiums

The insurers used Obama’s enrollment figures to calculate this year’s premiums and if those projections are wrong they will readjust the premiums, drastically, next year, after the mid-term elections I might add. Think about this, every major thing with Obamacare is implemented, or postpones, until AFTER the next election, always after, never before, why? Because everything they told you wasn’t true, it’s that simple.

Think about this, we were told 35-48 MILLION people were uninsured and Obamacare fixes this, OK, fine. However, another 5-8 MILLION lost their policies, we were one of them but we had Healthy New York and this wasn’t a junk policy. Anyhow, we have had 3 MILLION paying customers of which only 11% are new customers, i.e. the 30-48M uninsured people, that is awful. A note on Medicaid, Medicaid sign ups are garbage, they aren’t in the exchanges and therefore do nothing to impact the premium pricing so ignore those figures, plus they are made up.

WHERE ARE THE UNINSURED?? If we redesigned the whole system for these people that needed insurance and wanted insurance where the hell are they? We have 10% of the “official” uninsured figure buying insurance, but most of these people, we know this from Aetna and a study, are replacing policies they lost so where are the rest of them? Without this new blood, and a healthy mixture of young healthy people, the pricing scheme will collapse. Only in government can politicians pat themselves on the back for being at 10% of goal…

In all seriousness, without new blood and healthy people these exchanges have their product too cheap. Remember, there are no caps, annual or lifetime, on what they have to pay and an insurer cannot drop sick people, ever, unless they don’t pay. Basically, insurers had to increase their risk to an unlimited amount with no way to ever thin the herd of the most expensive users and they had to do this on the cheap. This is not a good thing to do, unlimited risk, can’t drop people and you can’t raise premiums without the HHS secretary approving it, it can’t work especially when you based your premiums off of lofty projections. My point is these carriers figured they would have 3-to-4 times the current number of exchange customers and that is how they determined their pricing model.

If they don’t get more people in the exchanges, especially young people, there is no way premiums don’t go up 30%, or more, next November, after the election. This isn’t partisanship here, its mathematics, basic mathematics to boot. Don’t you think I want good cheap insurance? Of course I do, but I understand adverse selection and risk management which makes me nervous.

It’s too Expensive, but the Subsidies

In Syracuse NY our exchange has 4 carriers, maybe 5 I can’t recall exactly at the moment, which is fine. The companies range from someone I never heard of before to Blue Cross. Now, the prices shocked me at first, my Healthy NY policy was $427/month with no deductible, low co-pays, just great insurance and was offered through the state so I don’t care about government offered plans, unbiased. In order to replace what we lost we had to go platinum, my wife uses the doctors a lot as well. I needed to figure out our subsidy though, which is a pain to find out what you are eligible for, but I found it.

I know we needed the platinum plan so I went there first and was stunned at the first policy. The price was so cheap, $400ish a month, but I never heard of the company before. I looked at their website and was, again, shocked. This is a co-op from NYC that offers policies in NYC, Albany, Syracuse, and some of Western NY with wide gaps in the coverage within the state. That doesn’t sit right with me, too good to be true usually means it’s too good to be true. I called our doctors and asked them if they take the carrier, they didn’t. I called our specialists to see if they take this carrier, they didn’t. Great, a cheap plan that no one takes so I had to move up the price ladder, but tell me my subsidy…

We had to move up to the $500+ a month policy, but Obama said he will help me pay for this, after all, I am disabled with limited income, their poster child, right? Wrong. Our subsidy was $28 a month, I don’t command the income I used to make since I am on disability. Granted, my SSDI is capped out to the most you can get, but it doesn’t cover the extra $100 a month I needed to pay for the Obamacare policy which is 20% more expensive than what we had before, even with the $28 a month subsidy.

How they determine the subsidy is simple, kind of, they look at the second cheapest silver health policy and base it off of that. Well, our name brand silver policies all cost between $300-400/month, but the no name policy no one takes was $200/month. The policy no one will use in my area and shouldn’t even be in our exchange is creating substandard subsidies for our area which is wrong. I am wondering if this is being done in other areas, but have no way to find out. So, the insurers cut costs by their little tricks and Obama is cutting costs by policy stuffing cheap policies in order to reduce the subsidy amount. Nice, huh?

Like I said, the longer we have this program the more we will hate it. Hell, look at the 30-48M uninsured running to sign up for Obamacare! It’s a failure and is going to hurt us, all of us, moving forward. No one in their right mind should re-elect a democrat who created this thing, seriously. It has caused havoc in the individual market, most of the plans cancelled was not junk policies, look at ours, and redesigned the marketplace into something unworkable. I have reservations as to how the carriers will make it under this new system.

This raises the question, was this the democrats plan all along? Destroy insurers and move towards single payer? I used to think that was conspiracy theory stuff, but now, I don’t know. The evidence is compelling they knew this plan was flawed. You can’t have that many eggheads in a room and not figure out these huge flaws, sorry, it’s not possible. Sure, the ivory tower guys screwed up on the practicality of the plans, no surprise there, they have union insurance, but if they spoke to me, for example, or someone similar we would have told them about the inefficiencies and problems this would create. When will politicians learn, us little people know stuff and probably a lot better than the politician. Good luck, enjoy the premium hikes!

Obamacare, a True Look at the Program