# U.S. Affordable Care Act ("Obamacare") Opens October 1, 2013: Time to Enroll



## BBCWatcher (Dec 28, 2012)

*U.S. Affordable Care Act ("Obamacare") Opens October 1, 2013: Time to Enroll*

October 1, 2013, is an important milestone in the U.S. Patient Protection and Affordable Care Act ("Obamacare"). On that date the new health insurance exchanges will open to help individuals and families enroll in new insurance plans. This brief guide summarizes the PPACA, how it may affect you, and what actions (if any) you should take. This thread is not for political discussions about Obamacare -- just the facts, as apolitically presented as possible.

Please note that, at this writing, Congress is debating whether and how to continue U.S. federal government funding past September, 2013, and related issues. However, even if there is a shutdown in certain federal government services (similar to what occurred in the 1990s), implementation of the PPACA will proceed since its funding sources are already allocated and mandatory.


*Quick Summary: What Essential Information Do I Need to Know?*

If you are a resident of any of the 50 U.S. states or of the District of Columbia, starting in 2014 you must either have adequate health insurance or you will likely face a penalty (tax) that you must pay to the IRS. Most people will continue getting their health insurance through their employers, Medicare, Medicaid, TRICARE, and other existing programs. If you already have health insurance and will continue to have health insurance, you will see few changes.

However, for those U.S. residents that don't have health insurance and/or who need health insurance, the PPACA is introducing new "health insurance exchanges" for all 50 states and the District of Columbia. The exchanges will open on October 1, 2013, to start accepting enrollments for insurance coverage that begins on January 1, 2014. You can find your state health insurance exchange by visiting Healthcare.gov starting on October 1. Due to the high demand on October 1 and over the next several days you may experience some Web site delays or other issues. If so, don't forget to visit again later in October or in November. You'll still have plenty of time to enroll to begin your coverage on January 1, 2014.

The new health insurance exchanges should offer better, more affordable health insurance options than in the past. Also, there are new government subsidies available that may help pay for all or part of your insurance premiums depending on your income level.

In many states Medicaid is expanding to cover more individuals and families. Healthcare.gov will be able to advise you on whether you and your family qualify.


*More Details and Fine Print*

1. If you are not a resident of any of the 50 U.S. states or of the District of Columbia then you are not subject to the new health insurance requirements in the PPACA. (For purposes of determining whether or not you will owe a penalty if you do not have adequate health insurance, the IRS will generally look at whether or not you could qualify for the Foreign Earned Income Exclusion -- regardless of whether you actually take the FEIE. Residents of Puerto Rico, the U.S. Virgin Islands, Guam, and other parts of the U.S. outside the 50 states and D.C. are not subject to the PPACA.)

2. Some PPACA reforms have already been introduced, including a requirement that children (young adults) can stay on their parent's/s' policy until age 26, elimination of lifetime benefit caps, and early introduction of better coverage options for those with preexisting conditions.

3. Although 2013/2014 is the biggest milestone in the implementation of the PPACA, there are other provisions of the PPACA that will be introduced in the coming years. For example, the PPACA gives the U.S. Department of Health and Human Services additional latitude to grant waivers to states beginning in 2018 as long as they achieve the same or better public outcomes. The State of Vermont is applying for a waiver to switch to a single payer coverage system which would begin on January 1, 2018.

4. If you're shopping for health insurance on the exchange, all the policies you are offered must meet new minimum quality standards for coverage. As examples, all the policies will have no lifetime benefit caps, all must cover medically necessary procedures (across a broad range of services), and all will have well-defined appeals processes with independent adjudication if your claim is denied. Policies will vary according to selection of doctors and amount of co-payments among other factors. Usually you will be able to choose from policies that will cover about 70%, 80%, or 90% of your total medical bills at various monthly premium costs. Preexisting conditions are no problem -- that's new in the individual and small group insurance markets. You should read all the policy information carefully and also look carefully at customer ratings. (Are other policyholders happy with that insurance company?)

5. Thinking about going without health insurance in the United States? That's an option, but unless you qualify for an exemption there will be a penalty (tax) that you'll owe the IRS. For the first two years (tax years 2014 and 2015) the penalty will be $95 or 1% of household income per year, whichever is larger. Starting in 2016 the penalty will increase to $695 or 2.5%. Moreover, if you have to pay for medical services on your own you'll be at a significant disadvantage compared to health insurance companies and the government which are able to negotiate much lower rates for medical services. It's not uncommon in the U.S. for private individuals purchasing medical services on their own to be charged multiples what the same facility charges insurance companies for exactly the same services. And, if the penalty and higher prices for medical services aren't bad enough, the potential loss of refundable tax credits for buying health insurance is another negative.

_In general_ high income individuals who might otherwise be tempted to self-insure should still purchase minimum acceptable insurance because of the 1% (rising to 2.5%) penalty. For example, an individual with $1,000,000 in annual income would face a penalty of $10,000 rising to $25,000 if he/she does not purchase at least a minimally acceptable health insurance policy. That sort of penalty would be greater than the premium cost to purchase the least expensive health insurance on any exchange. However, if you are an individual with a large amount of wealth but little income, it _might_ make financial sense to self-insure. Or, alternatively, if health insurance is still unaffordable, even with the new subsidies, then there may be no other choice but to pay the penalty. For most people, though, it will make financial sense to buy health insurance.

6. Do you have Medicare, Medicaid, TRICARE, employer-provided health insurance, or some other adequate coverage? Not much changes for you that hasn't already changed. However, what might happen over the next few years is that there should be less "cost shifting" in the U.S. medical system. Right now if you have insurance coverage you're helping to pay for those who don't (and who frequently visit hospital emergency rooms, which is expensive). The PPACA should get many more U.S. residents covered, and those individuals and families will have access to preventive services. That increased coverage _should_ reduce costs for everyone. Exactly how much is yet to be determined.

Another possible impact is that there will probably be somewhat more demand for primary care physician services, so you may see somewhat longer delays in getting an appointment, for example. There are some PPACA provisions to help take the edge off the spike in demand -- more funding for clinics, for example -- but don't be too surprised if your typical 3 day wait increases to 4 days (or your 3 week wait increases to 4 weeks). Hospitals and medical providers will adjust to the shift in demand -- they already are -- but it'll take some time. On the other hand it'll probably be somewhat easier and quicker to get attention if you need to go to a hospital emergency room, and obviously that would be a plus.

Another change, particularly if you have employer-provided coverage, is that it should be easier to change jobs, including starting your own small business. One of the major reasons many Americans keep working at jobs they don't like is to maintain their health insurance. If the individual insurance market functions better -- and it should with the PPACA -- then it's a much more realistic option for maintaining coverage even if you have a preexisting medical condition.

Another change coming starting in 2018 is that so-called "Cadillac" employer-provided health insurance plans will face an excise tax. It's a steep 40% excise tax on the value of the plan above a certain threshold. If your employer provides you with a wonderful, super-expensive health insurance plan then you might see that plan get somewhat less generous in the future as employers adjust to avoid the excise tax.


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## stormgal (Sep 30, 2009)

BBCWatcher said:


> If you are a resident of any of the 50 U.S. states or of the District of Columbia, starting in 2014 you must either have adequate health insurance or you will likely face a penalty (tax) that you must pay to the IRS.



The US government should not be telling people what to buy. It's really a form of fascism.


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## Bevdeforges (Nov 16, 2007)

stormgal said:


> The US government should not be telling people what to buy. It's really a form of fascism.


Gee, most other countries in the world actually do require people to have health insurance in some form or another. Even Australia.
Cheers,
Bev


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## twostep (Apr 3, 2008)

It looks great on paper until you get faced with it. Or better until your checkbook gets confronted by it.

So far every insurance company has increased premiums by 10% and more, providers have restructured their networks to decrease services and insurances accepted, some actually shut down. 

I know firsthand how difficult it is in Germany especially for retired people to get medical attention not to mention an MRI, see a specialist or even preventive care. LOL - mother is third generation cancer patient and was told she is too old to get a mammogram at 65!


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## BBCWatcher (Dec 28, 2012)

twostep said:


> So far every insurance company has increased premiums by 10% and more, providers have restructured their networks to decrease services and insurances accepted, some actually shut down.


No, that's not correct. The Kaiser Family Foundation took a look at the new health insurance exchange premiums. They're lower than expected. Moreover those with preexisting conditions can now actually buy insurance at the lower rates whereas they couldn't before.

And, if the insurance companies have set their rates too high, the PPACA requires them to refund premiums if they don't meet minimum medical loss ratio standards. Thus the exchange premiums are maximums for the year (2014) but not necessarily also minimums.

The PPACA is objectively imperfect -- USA Today has an article explaining some coverage gaps -- but the exchange premiums are much better than the status quo and better than even the CBO forecasts.


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## twostep (Apr 3, 2008)

Premiums went up everywhere at the first mentioning of Obamacare:>)


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## BBCWatcher (Dec 28, 2012)

twostep said:


> Premiums went up everywhere at the first mentioning of Obamacare:>)


Medical insurance premiums have been rising at faster than the rate of inflation since at least the 1990s. Within the past 4 years or so the medical inflation rate has slowed. And now the exchange premiums will be (in most cases) lower.

Let's stick to the facts, and these facts are well established and easily verified.


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## BBCWatcher (Dec 28, 2012)

The U.S. Department of Health and Human Services (HHS) will be operating the new health insurance exchanges for 36 states, and they've just issued a report summarizing the expected insurance costs on the exchanges based on near-final data available as of September 18, 2013.

The news is much better than expected, thank goodness. In nearly all cases (about 95%) premiums are coming in lower than the Congressional Budget Office (CBO) forecasted -- an average of 16% lower, even before counting the new tax credits (subsidies). HHS provides some specific examples such as a 27 year old in Texas earning $25,000 per year (approx. U.S. individual median) who will now be able to buy a bronze plan for $83 per month after subsidies. Or a family of four in Texas earning approximately the median U.S. household income ($50,000) who will now be able to buy a bronze plan for only $57 per month. And they won't be excluded due to preexisting conditions.

Why is the bronze coverage $26/month cheaper for the family of four? It has to do with the way the subsidies/tax credits are calculated. The subsidies depend on financial need versus insurance costs, and that hypothetical Texas family of four gets a bit more subsidy than the single Texan. To translate those costs into percentages of gross income, that hypothetical 27 year old Texan's medical insurance would cost less than 4% of annual gross income, and for that family of four it's less than 1.4%. These are the sort of numbers that are getting healthcare "wonks" excited about the premiums and plans that will be available through the new exchanges. Naturally when the premiums come in lower than expected more people should enroll than expected, and that would be great news, too.

"Bronze," "silver," etc. refer to the actuarial categories for the insurance plans. A "bronze" plan has an actuarial value of about 60%, for example. All of the PPACA plans always provide catastrophic coverage, meaning they always cap out-of-pocket costs and with no lifetime maximum on benefits. The actuarial values primarily vary based on co-pays and deductibles, with more generous plans reducing the co-pays and deductibles. Also, regardless of actuarial value the plans provide generous coverage of preventive services to try to reduce medical costs and future claims. Plans range from (in order of least generous to most generous actuarial values) catastrophic, bronze, silver, gold, and platinum.

Most individuals and families buying health insurance through the exchanges will probably buy "bronze" plans. The bronze plans provide excellent catastrophic coverage (as all PPACA plans do), excellent coverage for preventive services (ditto), and decent but somewhat barebones non-catastrophic coverage. However, the PPACA subsidies are calculated based primarily on the second lowest cost "silver" plan. Consequently it'll be interesting to see how many households buy the higher actuarial value plans. There are some forecasts, but nobody really knows for sure. Since the premiums are coming in lower than expected it's likely that more households will buy higher actuarial value plans than previously forecast. And if that happens, more households will be paying lower co-pays and deductibles than expected.

HHS also provides premium figures for a single 27 year old pre-subsidies across the 36 states where they'll be running the health insurance exchanges. The highest lowest cost catastrophic category plan -- in other words, the lowest amount (without subsidy) a 27 year old could pay in the highest cost state to avoid paying the IRS penalty -- would be in Wyoming at $259/month. For perspective, even in Wyoming (which will have the highest lowest cost exchange policy among the 36 HHS states) buying insurance will be cheaper than the IRS penalty in tax years 2014 and 2015 for a 27 year old with income of $311,000 or higher. The naive "break even" point drops to $124,320 in tax year 2016 (assuming that same $259/month premium). As I described upthread, if you're a high income earner you might think you'd be better off self-insuring. No, not usually. _Even pretending catastrophic medical insurance coverage has no value_ (which is not true), you're objectively financially better off buying insurance in most cases if you don't already have it. The new IRS penalty makes it essentially financially mandatory for all relatively well-to-do (and better) individuals to buy at least minimal catastrophic health insurance.

Another piece of very good news is that, since the premiums are coming in lower than forecast, federal government subsidies should be less expensive than forecast per individual and per household. That also means the subsidies will be stretched to cover more individuals/households than originally forecast. While the PPACA was already funded (and is forecast to require less federal government spending than the pre-PPACA status quo), this is even better news than expected on the federal spending front.

I see one potential problem in the report, which was expected and now confirmed. The PPACA has state-level exchanges. States that run their own exchanges are allowed to pool together if they agree, but the HHS-run exchanges can't do that as I understand it. (It's an odd quirk in the law, one of at least a few such quirks.) So those of you living in, for example, Wyoming will have to pay somewhat higher insurance premiums than a comparable individual/family living in, say, Virginia. Maybe that's as it should be -- it's probably more expensive to provide medical care in predominantly rural Wyoming than it is in more urbanized Virginia -- but it's important to note there will be some fairly big differences in healthcare costs between states. There already are big differences, and the PPACA doesn't affect that reality too much, although the differential subsidies will help. For those of you deciding where to live in the U.S. (or where to relocate within the U.S.), you'll still want to include healthcare costs as one factor in your decision.


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## twostep (Apr 3, 2008)

Have you ever been to Wyoming?


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## stormgal (Sep 30, 2009)

Bevdeforges said:


> Gee, most other countries in the world actually do require people to have health insurance in some form or another. Even Australia.
> Cheers,
> Bev



Who cares what Australia or other countries have? Australia or other countries is not America! The US government should not be telling people what to buy, period, end of story. That is highly unconsitutional as the government is using a penalty or a “tax” to compel the enforcement of this mandate.


In addition, "Obamacare" will force all of us to buy insurance, when half of us are already getting this benefit from our jobs. Our employers would probably prefer to pay the tax (which is much cheaper) than the benefit itself (which is much more expensive) and roll out the cost to us employees - decreasing our take-home pay. 

Do you even have an idea how freaking expensive healthcare is around the US? A professor of mine had a heart attack and had to stay at the hospital for two days - when the bill came back, it was $90,000 - just giving you an idea, you know. A complete disaster, which the US government could not afford with heart disease as the number one cause of death here, but I digress.


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## Bevdeforges (Nov 16, 2007)

You indicate with your flags that you are an expat (or potential expat) in Australia. If you want to move there, you're going to have to have their health insurance.

And I am well aware of health care costs in the US - being from there and having to purchase health care insurance for any visits I make back there. Travel insurance that includes time spent in the US is much more expensive than regular travel insurance for a country that has reciprocity with the health care systems in other countries.

Obamacare "forces" you to buy nothing if you already have health insurance through your employer. In most European countries, you are required to have health insurance (state and/or private) as part of your employment - even if you are working only part-time. It's the cost of doing business under the public system of registering and running a business so that businesses are recognized as "legal persons."

Frankly, it's about time a big country like the US started requiring health insurance coverage among its residents. Long overdue.
Cheers,
Bev


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## BBCWatcher (Dec 28, 2012)

I'm just going to stick to the facts here as best I can. There's been way too much political discussion about the PPACA. The law passed, and the federal government is implementing it, so whatever you think of the law here it is.



stormgal said:


> The US government should not be telling people what to buy, period, end of story.


The U.S. government does not tell anybody specifically what to buy. Starting on January 1, 2014, U.S. residents must have minimum standard catastrophic health insurance for themselves and their children obtained in any of myriad ways, or qualify for an exemption, or pay a higher income tax rate. Those are the three options, and the U.S. Supreme Court has ruled there's no problem whatsoever with those three choices.

The government requires drivers to buy auto insurance, young men to register with Selective Service, and practically everybody to file U.S. tax returns, among other requirements. You have to put kids in car seats, wear seat belts, wear motorcycle helmets, wear clothes when you present yourself in public, dump your garbage only where it belongs.... The list is practically endless. The PPACA at least offers choices. Most legal requirements offer only one choice, i.e. no choice at all.



> That is highly unconsitutional as the government is using a penalty or a “tax” to compel the enforcement of this mandate.


The U.S. Supreme Court decides what is constitutional or not, and the U.S. Supreme Court ruled in 2012 that the PPACA is constitutional. That question has already been litigated, and there's no appeal.



> In addition, "Obamacare" will force all of us to buy insurance, when half of us are already getting this benefit from our jobs.


No. If you obtain health insurance through your employer (or Medicare, TRICARE, etc.) you're done. You've fulfilled your PPACA requirements.



> Our employers would probably prefer to pay the tax (which is much cheaper) than the benefit itself (which is much more expensive) and roll out the cost to us employees - decreasing our take-home pay.


What the PPACA does is increase the tax on most (but not all) large employers who do not provide health insurance to their employees from today's $0 to $2,000 per employee starting in 2015. That's it. Any employer that isn't providing health insurance today _might_ be encouraged to start providing health insurance to employees to avoid the tax. Any employer that's currently providing health insurance to their employees is unaffected (except that the PPACA is highly likely to better control health insurance costs, making it less expensive than otherwise for the employer to keep providing health insurance).

Yes, if your employer chooses to pay the $2,000 tax instead of providing health insurance, that fact alone is not good. (Your pay won't go down $2,000 -- that's not how labor markets work -- but it could go down some.) However, the PPACA also provides lots of subsidies, and those start a full year earlier than the $2,000 penalty. The vast majority of people working for such (less than stellar) employers start receiving PPACA subsidies (or free Medicaid) starting on January 1, 2014. That's real money, too.



> Do you even have an idea how freaking expensive healthcare is around the US?


Yes. And it's much less expensive than expected starting on January 1, 2014. The cost-related news is all moving in the right direction at least for now.



> A professor of mine had a heart attack and had to stay at the hospital for two days - when the bill came back, it was $90,000 - just giving you an idea, you know. A complete disaster, which the US government could not afford with heart disease as the number one cause of death here, but I digress.


I gather that the "alternative" of leaving your professor untreated and letting him die of a heart attack in order to save the $90,000 is not what you're recommending. Unfortunately that's the all-too-common reality in the U.S. medical system. People die, lots of people, solely because they cannot pay for medically necessary care and nobody else will.

And unfortunately that will still happen in 2014. Some people will still die in the U.S. because they won't get the medical care they need. However, that will happen _substantially less often_. Lives will be saved, literally. Lots of people -- many millions -- who don't have health insurance today because they can't afford it or because they have a preexisting condition (who doesn't?) will be able to get decent health insurance. Thank goodness.

The ongoing challenge, one the PPACA is just starting to tackle, is making U.S. medical care more affordable and more effective. I won't bore you with the details, but there are lots of provisions in the new law to try to do that. It will be _better than the status quo_ in terms of controlling medical costs and improving effectiveness -- through much greater emphasis on prevention, in particular. That much is clear already based on all the evidence coming in. Better is better, but better still may not be as good as Americans want or need. So let's hope Americans keep pushing to improve their medical system: to make it truly universal, even more affordable, and even more effective.


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## stormgal (Sep 30, 2009)

Bevdeforges said:


> You indicate with your flags that you are an expat (or potential expat) in Australia. If you want to move there, you're going to have to have their health insurance.


Yes, this is correct, but Australia doesn't have the same type of democracy that the US has. They are two totally different countries and I am not going to hold Australia to US standards or vice versa. Health insurance in and by itself is not the issue that I am debating, but the fact that the government in the US is mandating for its residents to "buy or be fined/ thrown in jail" 




> Obamacare "forces" you to buy nothing *if* you already have health insurance through your employer. In most European countries, you are required to have health insurance (state and/or private) as part of your employment - even if you are working only part-time. It's the cost of doing business under the public system of registering and running a business so that businesses are recognized as "legal persons."



There should be no conditional statements when it comes to a person's rights. People should not be forced to buy health insurance or anything else regardless of their circumstances. 

And trust me when I tell you, if the poor cannot afford the monthly payments on health insurance *now* (which averages between $500 - $1700 per month) then they won't be able to afford Obama care either. What will Obamacare do? Provide everyone with a check to pay for *half* of the monthly costs. (As if the US isn't already in enough debt but I digress). Point is, it forces people to spend money and if the poor doesn't come up with their premiums - after paying the fines, they will eventually be thrown into prison. 


Here's an example: 

• _Remember if you make less than 400% of the Federal Poverty Level you and your family may be eligible for reduced premium rates and lower out-of-pocket costs through the marketplace._

Are they serious? So if you're below 400% poverty level you still have to pay for insurance?? _ Even 50 bucks a month is a lot for a person who's at 400% below the poverty level. These people may not even want to buy health insurance, they may want to spend their 50 bucks on food!_ 



> Frankly, it's about time a big country like the US started requiring health insurance coverage among its residents. Long overdue.
> Cheers,
> Bev



If done right. It would be nice if we weren't forced to buy expensive insurance. Countries like Canada and Australia just take the taxes from your paycheck. 

In the US, the government sends you a letter telling you that your Social Security fund may not be available after you've retired (for lack of funding), but tells the public that there's enough money for ObamaCare while they still tax you on social security. If that's not LMAO, I don't know what is.


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## Longford (May 25, 2012)

twostep said:


> Premiums went up everywhere at the first mentioning of Obamacare:>)


That's either false, or an exaggeration - if one speaks of employer-sponsored healthcare plans which I am covered by. My own experience has been that for this year and next, my premium has declined ... it didn't increase.


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## stormgal (Sep 30, 2009)

From Obamacare website:

_A recent study showed the price for a 21-year-old buying a mid-range policy will average about $270 a month before cost assistance. With cost assistance that 21-year-old could pay much less. Over 80% of 21 year olds in the US will be eligible for cost assistance, meaning they will be paying up to 1/10th of that $270 cost per month for quality health insurance and many may even get it for free_


Oh yeah, a 21 year old can have a lot of fun paying part of those $270 a month - say good bye to that car you wanted or the new pad you wanted to rent out. :wave:


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## BBCWatcher (Dec 28, 2012)

stormgal said:


> ....the fact that the government in the US is mandating for its residents to "buy or be fined/ thrown in jail"


That's not a fact, that's a falsehood. U.S. residents cannot be thrown in jail for failure to obtain health insurance or pay the IRS penalty. That's not part of the PPACA, and any representation otherwise is a fabrication.

The IRS _may_ have limited powers to collect the penalty for failure to obtain health insurance, but jail time is not one of those powers. Go read the law.



> There should be no conditional statements when it comes to a person's rights. People should not be forced to buy health insurance or anything else regardless of their circumstances.


They are not. You're making that up. U.S. residents who do not obtain at least minimum standard catastrophic health insurance through whatever means (employer, Medicare, TRICARE, Medicaid, exchanges, wherever) and who do not qualify for an exemption simply pay a slightly higher income tax rate, with the tax increase not subject to a prison penalty if they refuse to pay it.

There are three categories of choices provided in the PPACA, and all three are realistic and viable.



> Are they serious? So if you're below 400% poverty level you still have to pay for insurance??


You may have to pay _something_. Or pay the higher income tax, or qualify for an exemption.

They already do pay! A lot! If they don't have health insurance (including Medicaid, Medicare, TRICARE, etc.) they have to pay for every medical expense 100% out of pocket. Right now, today, with zero help. That $90,000 heart attack you mentioned? That's instant bankruptcy and destitution for the vast majority of people earning below 400% of the federal poverty line. That's the U.S. medical "system" today. Or did you somehow forget that? Right now, today, well over 40 million Americans are one heart attack or one bout of cancer away from utter financial ruin. That's just fact.



> If done right. It would be nice if we weren't forced to buy expensive insurance. Countries like Canada and Australia just take the taxes from your paycheck.


Yes, they do, but you're all over the map. I thought you want individuals to have choice? The PPACA provides far more individual choice than Canada and Australia do. One of those many PPACA choices is not even getting health insurance.



> In the US, the government sends you a letter telling you that your Social Security fund may not be available after you've retired (for lack of funding)....


No they don't. You're making stuff up again.

The Social Security Administration's trustees estimate that Social Security can pay 100% of promised benefits (including cost of living increases) through 2033 or later (using the most pessimistic model) and about 75% of promised benefits thereafter _absent any changes whatsoever to contributions_. Not zero, not even close. As it happens (and as the trustees will tell you), simply eliminating the payroll tax cap would probably take care of 2034 to infinity (or at least as far as anyone can forecast).



> but tells the public that there's enough money for ObamaCare while they still tax you on social security. If that's not LMAO, I don't know what is.


ObamaCare is _cheaper_ than the status quo. The Congressional Budget Office says that, and they're almost always right. (As it turns out they were a bit too pessimistic -- ObamaCare premiums are coming in lower than expected.) Paying to treat people in emergency rooms and having more Americans die due to lack of medical care (and thus not pay taxes) is _expensive_ for the federal government.

The United States spends over 16% of its GDP on medical care. The U.S. federal government alone spends a greater percentage of GDP on medical care than the Canadian government, to pick an example. It's actually not too hard to come up with a medical system that costs less, covers more people (or everyone), and yields better medical outcomes. Pick any other medical system from any other developed country in the world. ObamaCare is fundamentally the Massachusetts system extended to the nation, and the Massachusetts system is a timid version of Switzerland's healthcare system (Europe's most expensive, per capita). It's as simple as that.

Could we please deal in actual facts from this point forward? Goodness knows I'm trying, and I wish everyone else would.


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## Bevdeforges (Nov 16, 2007)

BBCWatcher hit most of the rebuttal points I was thinking of making, and more eloquantly than I could have done. (I'm not all that interested in the whole US health care fiasco these days, given that it doesn't affect me - though I still have friends and family back there trying to deal with what currently exists.)

But you don't get any options at all about paying for US style "Social Security" - that's basically how the health care system works in France, Germany and most other countries where I have had any dealings with the system. You pays your money and you are covered by the system as it exists. You may have the option to purchase additional cover to fill in where the national system doesn't pay (or reimburse) but you have to pay for the basic system if you are working at any level.

One thing they didn't do with the US system, which I find remarkably practical in the French system, is to make the basic insurance "premiums" a simple percentage of your salary. But even without that feature, the residents of Massachusetts have been living with "Romneycare" for some years now, and people here really seem to LIKE the system. It ain't perfect, but it sure beats what there was before, and I suspect the national system will turn out the same way. Once it's in place, they can tweak things but at least give it a chance.
Cheers,
Be


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## stormgal (Sep 30, 2009)

BBCWatcher said:


> That's not a fact, that's a falsehood. U.S. residents cannot be thrown in jail for failure to obtain health insurance or pay the IRS penalty. That's not part of the PPACA, and any representation otherwise is a fabrication.
> 
> The IRS _may_ have limited powers to collect the penalty for failure to obtain health insurance, but jail time is not one of those powers. Go read the law.


The Supreme court itself has determined that Obama care is a TAX. What usually happens to people who don't pay taxes? (Hint, Go read the law)



> They are not. You're making that up. U.S. residents who do not obtain at least minimum standard catastrophic health insurance through whatever means (employer, Medicare, TRICARE, Medicaid, exchanges, wherever) and who do not qualify for an exemption simply pay a slightly higher income tax rate, with the tax increase not subject to a prison penalty if they refuse to pay it.


I am not making up facets of a free market - it's basic economics. * In a free market, the government cannot force you to buy products*. Now, since US residents are under Common Law, we have opened up a can of worms: Insurance companies can now mandate us to buy liability insurance for automobiles and make the argument that since the law regarding insurance for "the good of the people" has already been passed in Supreme Court, then why not pass a mandate to make everyone obtain liability insurance as well?





> There are three categories of choices provided in the PPACA, and all three are realistic and viable.


Three, four, five, 10, 100 - the government is still making people buy products from the private sector. Whether the court ruled it as not, we both know that people who didn't buy health insurance before will have to buy it now.



> You may have to pay _something_. Or pay the higher income tax, or qualify for an exemption.
> 
> They already do pay! A lot! If they don't have health insurance (including Medicaid, Medicare, TRICARE, etc.) they have to pay for every medical expense 100% out of pocket. Right now, today, with zero help. That $90,000 heart attack you mentioned? That's instant bankruptcy and destitution for the vast majority of people earning below 400% of the federal poverty line. That's the U.S. medical "system" today. Or did you somehow forget that? Right now, today, well over 40 million Americans are one heart attack or one bout of cancer away from utter financial ruin. That's just fact.


Thankfully, most people are not sick every single day, but when they do get sick, they go to the doctor. True, it may be expensive, but it is a risk you take if you decide - key word "decide" - not to get the insurance (under a normal free market).

For some people, choosing to pay every single month when they cannot afford to do so will only strain the poor, not give them relief. Some of these people would prefer (key word "prefer") to spend the little money that they have a month on food and education, not on a health plan they may need once every five years, as an example.

Regardless, *they should have the option to choose*. I think this is where you and I differ. You are making a decision for all, saying that they should buy the insurance or else they'll file for bankruptcy if they get sick. But in a free market, you're supposed to choose that for yourself. The US is supposed to be a free market not a socialist/fascist one where the government is baby feeding the people in what to buy, how to live and what they need to pay.

Also, let me point out that with your logic, I can easily make a case that everyone should also pay automobile liability insurance, home insurance and credit insurance, because if God forbid any of us were to go through any terrible event concerning any of the above, we could all be forced into bankruptcy!



> The Social Security Administration's trustees estimate that Social Security can pay 100% of promised benefits (including cost of living increases) through 2033 or later (using the most pessimistic model) and about 75% of promised benefits thereafter _absent any changes whatsoever to contributions_. Not zero, not even close. As it happens (and as the trustees will tell you), simply eliminating the payroll tax cap would probably take care of 2034 to infinity (or at least as far as anyone can forecast).


You can be as "fancy" as you want with your statistics, estimates and language. But I know what I saw - a letter directly to *me* from the Social Security administration, basically telling me to invest in other forms of retirement because the funds for Social Security may not be available by the time that I retire. (At least I was warned - you seem like you're still asleep on that one - did you not get the same letter? It's the one that shows your whole work history and the contributions you've made to SS) 




> ObamaCare is _cheaper_ than the status quo. The Congressional Budget Office says that, and they're almost always right. (As it turns out they were a bit too pessimistic -- ObamaCare premiums are coming in lower than expected.) Paying to treat people in emergency rooms and having more Americans die due to lack of medical care (and thus not pay taxes) is _expensive_ for the federal government.


Cheaper for who? For the tax payer who'll inherit the current trillions of dollars in deficit plus the Obamacare? 

Regardless, whether it's cheaper, more expensive, - I should be allowed to choose what I want to spend my hard-earned cash on. If I want to go into debt by buying a Jaguar XKR-S GT and not a used Toyota corolla because it's "cheaper", then that is my American-given right.



> The United States spends over 16% of its GDP on medical care. The U.S. federal government alone spends a greater percentage of GDP on medical care than the Canadian government, to pick an example. It's actually not too hard to come up with a medical system that costs less, covers more people (or everyone), and yields better medical outcomes. Pick any other medical system from any other developed country in the world. ObamaCare is fundamentally the Massachusetts system extended to the nation, and the Massachusetts system is a timid version of Switzerland's healthcare system (Europe's most expensive, per capita). It's as simple as that.
> 
> Could we please deal in actual facts from this point forward? Goodness knows I'm trying, and I wish everyone else would.


What is your point? If the US spends 16% of its' GDP on medical care, how will Obama care reduce this expense? The fact that Canadians don't spend that much just shows that we're just sicker and that all we're doing is pushing debt around - it's not going to make people less sick. The real solution would be to watch our diets, go to a gym, get our asses from up the computer and enjoy life a little more- you know, that kind of thing that makes us less sick and reduces our personal health expense. But once again, that is a personal decision, not one the government should make for us.


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## BBCWatcher (Dec 28, 2012)

stormgal said:


> The Supreme court itself has determined that Obama care is a TAX. What usually happens to people who don't pay taxes? (Hint, Go read the law)


Yes, _usually_. Go read the law. Congress specifically curtailed IRS enforcement powers to collect the noncoverage penalty. Prison time is not an option if you owe that particular tax and refuse to pay it.



> I am not making up facets of a free market - it's basic economics. * In a free market, the government cannot force you to buy products*.


OK, then healthcare is not a free market. The government isn't forcing anybody to buy insurance. (Your repeating that falsehood doesn't make it true.)

Also, yes of course the government can and does force you to buy types of products. If you walk in public the government forces you to wear clothing (which presumably you must buy somewhere). As another example, if you excrete human waste the government can and does force you to buy a suitable disposal device, most often a toilet connected to an approved septic system or municipal sewer (which you must also buy). And that's just barely scratching the surface of municipal building codes.



> Thankfully, most people are not sick every single day, but when they do get sick, they go to the doctor. True, it may be expensive, but it is a risk you take if you decide - key word "decide" - not to get the insurance (under a normal free market).


And anybody can still decide to do that.

Let me restate the PPACA for you in exactly the same financial, mathematical, completely factually accurate way. The federal government just raised everyone's income tax by 1% in 2014-2015 and a total of 2.5% in 2016. Everyone. Clearly the government is allowed to tax. It's in the Constitution. The federal government is also now providing a new tax credit starting in 2014. If you qualify for the tax credit -- if you have practically any health insurance or fit into one of several other qualifying categories -- you get the tax credit. Exactly like if you buy an electric car or take public transportation to work you qualify for tax credits -- exactly the same. This new PPACA tax credit (if you qualify) is a minimum of 1% in 2014-2015 and 2.5% in 2016 and beyond. The tax credit is higher for those with moderate or low incomes who face high medical insurance costs, exactly as today's high unreimbursed medical expenses are tax deductible.

There is nothing -- nothing at all -- that is in any way breaking new legal ground in what I just described which is all that the PPACA is on the tax side. In the late 1700s the U.S. raised taxes to fund health insurance. It was legal then, and it's legal now. And the U.S. Supreme Court is the sole final authority on that question, not either one of us.

As another example, practically everyone in America has been paying Medicare taxes since the 1960s. It was legal then, and it's legal now. The government can give you a tax credit for installing a more water efficient toilet, waive or reduce your taxes if you're a nonprofit, reduce your tax rate by 1.2% if you adopt a child from Bangladesh -- all normal, all legal. To argue otherwise is both absurd and polemical.



> Cheaper for who? For the tax payer who'll inherit the current trillions of dollars in deficit plus the Obamacare?


Go back and read what I wrote, but I'll repeat it. The CBO projects that ObamaCare will reduce the U.S. federal budget deficit compared to the alternative status quo scenario. Sick people getting inferior treatment too late at emergency rooms is much more expensive than simply giving them more financial support to get insured, fundamentally. And this is utterly obvious to anyone who has even studied developed economy medical systems for at least a few minutes.



> Regardless, whether it's cheaper, more expensive, - I should be allowed to choose what I want to spend my hard-earned cash on.


Go for it! Go without health insurance if you wish. Unlike France, Canada, Australia, and most other developed economies, in the U.S. you have that choice.

Exactly like buying a Jaguar instead of a Tesla -- you picked a car analogy not me -- your choice will determine the types and amounts of federal tax credits you do or do not qualify for. But you have the choice, exactly as you do when choosing a car.

The toilet and clothes requirements I can't help you with.


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## BBCWatcher (Dec 28, 2012)

Here are a few more updates on the PPACA health insurance exchange rollout that begins on October 1, 2013 (in no particular order):

1. The District of Columbia's PPACA health insurance exchange's Web site reportedly may not have all the subsidy calculations available until early November. As mentioned in the first post, if you have any difficulties using any of the health insurance exchange Web sites when they open for business on October 1, just check back later. There's plenty of time to get enrolled after October 1 to start your new insurance coverage on January 1, 2014.

2. To start your insurance coverage on January 1, 2014, your first month's premium will be due on December 15, 2013. If you're eligible for a subsidy then your subsidies start right away, too.

3. Small businesses generally are welcome and encouraged to participate in the new health exchanges to get health insurance coverage for their employees (and owners). That's especially true if your small business does not presently offer health insurance. There are major tax and other advantages available to small businesses that cover their employees, so it's well worth seriously investigating at the very least.

4. U.S. citizens living overseas generally should not purchase health insurance through a PPACA exchange. The exchange health insurance plans are much better geared to U.S. residents, and some plans do not cover medical expenses outside the U.S. However, U.S. citizens living overseas are perfectly welcome to visit the exchange Web sites in order to get estimates -- for example, if planning a move back to the U.S. and expecting to buy a health insurance plan.

5. If you want to buy PPACA exchange health insurance coverage for 2014, you have to buy it during the enrollment period. This year's enrollment period runs from October 1, 2013, to March 31, 2014. Obviously if you buy health insurance after December, 2013, you're not going to be able to start your policy coverage until later in 2014. If you don't buy a plan by March 31, 2014, then you may not be able to get coverage through the exchange until next year (for coverage starting January 1, 2015).

However, you can buy health insurance on the exchange outside the enrollment period (October 1, 2013-March 31, 2014) if you have a "qualifying event." To pick one example, when you have a baby, you have the opportunity to go to the exchange to buy health insurance even if that's outside the annual enrollment period.

6. Exchange premiums are fixed per year -- the premiums cannot vary month-to-month unless your circumstances change (such as adding a new baby to your health insurance) or unless your subsidies change (because of a change in income). In fact, as mentioned, it is possible you could get a partial premium refund if your health insurance company did not spend at least 80% of the premiums on medical care.

7. If you are receiving subsidies to buy health insurance and your income changes substantially, it's a good idea to go back to the exchange Web site and update your income information. That will make sure you get the right subsidy every month. If you've received too much subsidy because your income increased, you will have to pay back the extra subsidy to the IRS. (Not the end of the world, but it's better to get the right subsidy every month.)

8. To clarify, the most basic "catastrophic" plans are available in the exchanges only for those in their 20s. Even these low cost plans pay for many preventive services, and they're often good choices if you're an "indestructible 20-something." If you're older, the minimum coverage plan available is "bronze" level. Silver, gold, and platinum plans are also available.

9. All the exchange plans provide coverage for many mental health services including free testing for depression. The PPACA is putting a lot of emphasis on identifying and treating mental health issues as early as possible since these issues are among the most expensive to treat if left to fester -- not to mention the qualify of life impacts. Read the plan details carefully to learn about coverage of mental health services.

10. If you're a student and getting health insurance through your university, that counts and fulfills your PPACA requirement -- no problem.

11. If your income is at or below the federal poverty line, or if health insurance would be "unaffordable" (i.e. more than about 9% of your income after subsidies), you will not have to pay the $95/1% additional tax (increasing to $695/2.5% in 2016) if you do not have health insurance. These are a couple of the major exceptions described above that qualify you for the tax break even if you don't have health insurance, and there are some others. (But everybody should have at least catastrophic health insurance, honestly, if at all possible.)

12. In most states with most exchange plans you will pay less for health insurance if you do not smoke. Of course it's a good idea to quit smoking -- nothing new about that.

13. Yes, you can still buy health insurance outside the PPACA exchanges. However, the plans offered may not provide the same level of coverage and benefits, and you cannot get any subsidies you're entitled to unless you buy through the exchange.

14. At least some of the exchange plans offer HSA (Health Savings Account) options. HSAs are a way to save money (and save taxes) for medical care that isn't fully reimbursed by your health insurance policy. HSAs are especially popular combined with basic catastrophic health insurance plans. Details on HSAs will also be available through the PPACA exchange Web sites, and you can read through that information to decide whether you want to set up an HSA.

15. The PPACA is funding more public clinics, and you're welcome to take advantage of those facilities and their services if available in your community. They're a good way to get affordable care and can help reduce your out-of-pocket medical expenses.

16. I probably should have mentioned this earlier, but if you are visiting the U.S. (as a foreign tourist) nothing really changes. It's of course very wise to have at least basic emergency medical and medical repatriation insurance coverage when visiting any foreign country, but that's especially true when visiting the U.S. where medical services are extremely expensive if you have to pay for them out of pocket without an insurance company to negotiate better prices. Also, if you are staying in the U.S. without authorization then you won't be able to use any of the publicly supported health insurance programs (Medicaid, Medicare, PPACA exchange plans, etc.) That includes the foreign family members of U.S. citizens and U.S. permanent residents who are staying in the U.S. without authorization.

At this point in time I'm not aware of any reciprocal agreements between the U.S. and other countries in terms of providing limited health insurance coverage for visitors between the two countries (except for extremely limited coverage in Canada). Maybe that will happen in the future, but the PPACA does not change that situation. The U.S. does not honor European Health Insurance Cards (EHICs), for example.


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## BBCWatcher (Dec 28, 2012)

Healthcare.gov and the PPACA health insurance exchanges are now open for business.

As a reminder, if you are _lawfully present_ in the United States -- citizen, national, legal permanent resident, or lawful resident for tax purposes -- you are generally required to have at least catastrophic health insurance coverage starting on January 1, 2014, or face a higher rate of income tax (the greater of $95 or 1% in 2014-2015 rising to $695 or 2.5% for 2016 and beyond). If you are not/will not be getting that health insurance coverage through your employer, a government program, another family member, your university, etc. then you can get coverage (often with subsidies) through the new exchanges.


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## Bevdeforges (Nov 16, 2007)

Just a note: I'm just back from a couple weeks in the US, and there have been numerous articles in the newspapers over there saying that certain aspects of the health insurance exchanges may not be fully functional for the next few weeks yet. Don't be surprised to encounter a few glitches in the system, but things should be up and running as of today.
Cheers,
Bev


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## twostep (Apr 3, 2008)

As for "up and running" - one of the largest hospitals in North Texas (mainly Neuro/Spine) completely shut down out patient MRI processing for all but one insurance carrier.


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## overmyer (Aug 15, 2013)

twostep said:


> As for "up and running" - one of the largest hospitals in North Texas (mainly Neuro/Spine) completely shut down out patient MRI processing for all but one insurance carrier.


That's been pretty much the experience with all the State exchanges.


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## BBCWatcher (Dec 28, 2012)

twostep said:


> ....one of the largest hospitals in North Texas (mainly Neuro/Spine) completely shut down out patient MRI processing for all but one insurance carrier.


I'm hard pressed to think how that would have anything to do with the PPACA itself. It might have something to do with the State of Texas not expanding its Medicaid program starting on January 1, 2014, as the PPACA provides and fully funds. Hospital and other medical providers in Texas have been heavily lobbying the state government to accept the PPACA's Medicaid funding, but thus far the governor has refused. That means a lot of people in Texas below 138% of the federal poverty level _still_ won't be getting MRIs in 2014, and -- I hate to say it, but it's just simply true -- some of those people are going to die prematurely for lack of medically necessary MRIs and subsequent care.


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## BBCWatcher (Dec 28, 2012)

I tried using Connecticut's state-run health insurance exchange Web site, and it worked at least as well as the best non-exchange health insurance Web site. I was mighty impressed, actually.

HHS's Web site for 34 of the states is still having some demand problems. This is not really a surprise. Nobody thought so many states would refuse to run their own exchanges -- remember the PPACA funded this stuff -- but HHS had to take on more than it expected. No surprise, they're still trying to satisfy the Web demand and iron out the problems completing an enrollment. They will, I'm sure, so try again in a few days if you're having problems.

I'm seeing quite a few reports of individuals saving a lot of money, so that's good. That's not always the case, though. Sometimes you can find non-exchange health insurance that's cheaper. That's because most often the non-exchange policy is crap. For example, when I shopped in Connecticut the "bronze" policy offered in the exchange is very good and very simple. Basically every medical expense totaling under $6,500 out of pocket per person per year I would have to pay (except for several preventive services which are free), and everything over the annual deductible the insurance company would pay. That's a good policy. Then I checked the non-exchange insurance market. Assuming no preexisting conditions, yes, I found cheaper insurance. And it's crap. The cheapest policy had zero coverage for prescription drugs. That's right, zero. (Is that even health insurance?)

So you have to really look at this stuff carefully and decide what's right for you. The Obamacare exchange policies are regulated, and none of them are crap "insurance" riddled with exceptions and loopholes. That sometimes makes the premium higher, particularly if you are not eligible for subsidies. But that's not really the point. The point is how much you'd be out of pocket for medical care, and if you have crap insurance you'd (for example) have no prescription drug coverage. Another non-exchange carrier had zero maternity coverage and was prepared to sell that policy to a hypothetical woman of childbearing age. There's a lot of crap insurance available in the U.S. health insurance market, so be careful you're comparing things on an equal basis.


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## mtlve (Oct 3, 2013)

BBCWatcher said:


> I tried using Connecticut's state-run health insurance exchange Web site, and it worked at least as well as the best non-exchange health insurance Web site. I was mighty impressed, actually.
> 
> HHS's Web site for 34 of the states is still having some demand problems. This is not really a surprise. Nobody thought so many states would refuse to run their own exchanges -- remember the PPACA funded this stuff -- but HHS had to take on more than it expected. No surprise, they're still trying to satisfy the Web demand and iron out the problems completing an enrollment. They will, I'm sure, so try again in a few days if you're having problems.
> 
> ...


I too looked at some of the exchange policies for my former states. They seemed a lot cheaper than what I saw in the market in the past. I did not look too in depth at the actual coverage though. 

Obamacare is a step in the right direction. Our healthcare system was totally screwed up and one serious illness would bankrupt most middle and lower class, and this was an extremely common issue. This hurts the economy too. I considered going into medicine for a long time, but I eventually decided that I did not want to this under the American system that did not view medical care as a right of all people. When a 3yr old cant get a simple but expensive life-saving procedure because his parents had no medical insurance and did not make a lot of money, we have serious issues with our system.

We need some additional changes soon though before this new system is in place too long. Everyone thinks that this will decrease physician stipends. This will result in them spending less time with patients (more mistakes and decreased quality of care) and/or people leaving this field. Physician training in the US is extremely expensive (most people leave school with like 500k debt), and they need higher incomes to pay this off. With these decreased stipends due to Obamacare, they need to drop the price of medical education significantly. They also need some sort of loan forgiveness type system for those that already graduated. The malpractice system also really needs to be changed. All of these factors have helped increase the costs of medical care in the states


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## BBCWatcher (Dec 28, 2012)

mtlve said:


> The malpractice system also really needs to be changed.


I'm going to disagree with you on that one since the U.S. is already running that experiment. There are states that have severely limited malpractice damage awards and others that have not. And...medicine isn't materially less costly in the states with limited malpractice damages. It just isn't a cost driver.


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## twostep (Apr 3, 2008)

mtlve said:


> I too looked at some of the exchange policies for my former states. They seemed a lot cheaper than what I saw in the market in the past. I did not look too in depth at the actual coverage though.
> 
> Obamacare is a step in the right direction. Our healthcare system was totally screwed up and one serious illness would bankrupt most middle and lower class, and this was an extremely common issue. This hurts the economy too. I considered going into medicine for a long time, but I eventually decided that I did not want to this under the American system that did not view medical care as a right of all people. When a 3yr old cant get a simple but expensive life-saving procedure because his parents had no medical insurance and did not make a lot of money, we have serious issues with our system.
> 
> We need some additional changes soon though before this new system is in place too long. Everyone thinks that this will decrease physician stipends. This will result in them spending less time with patients (more mistakes and decreased quality of care) and/or people leaving this field. Physician training in the US is extremely expensive (most people leave school with like 500k debt), and they need higher incomes to pay this off. With these decreased stipends due to Obamacare, they need to drop the price of medical education significantly. They also need some sort of loan forgiveness type system for those that already graduated. The malpractice system also really needs to be changed. All of these factors have helped increase the costs of medical care in the states


If you do not compare actual coverage and copays you are comparing apples and oranges.


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## stormgal (Sep 30, 2009)

Here's an article on a bit of what I was discussing a while back on this thread. 

Http://investigations.nbcnews.com/_...ns-could-not-keep-their-health-insurance?lite


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## BBCWatcher (Dec 28, 2012)

If you're having trouble with the Healthcare.gov Web site, and if you reside in one of the ~36 states served by the Healthcare.gov-managed insurance exchange, you can get information on health insurance plans and enroll by telephone. Just call 1-800-318-2596. The Healthcare.gov call center seems to be doing a very good job providing information and getting people enrolled even if the Web site is having some problems.


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## twostep (Apr 3, 2008)

Have you had a chance to look at the number and quality of hospital systems opting out?


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## Davis1 (Feb 20, 2009)

i love my medicare


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## BBCWatcher (Dec 28, 2012)

twostep said:


> Have you had a chance to look at the number and quality of hospital systems opting out?


I don't follow your question. The exchange policies are private (or co-op) insurance, and private insurance companies pay more for services than Medicare and Medicaid. Exchange policies can have preferred and non-preferred networks (with more generous coverage for the former), but that's been true for decades and nothing new. And, as before, that still means you should pick the health insurance policy with the provider coverage that you prefer.

What has changed in terms of networks is that it's much, much easier -- and possible! -- to switch to another plan if you don't like a particular plan's provider network. If you have a preexisting condition -- and everybody does eventually -- then it was difficult or impossible to switch to another plan. No more. So the only news on the provider selection side is good news.


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## jsharbuck (Jul 26, 2012)

Sorry BBCWatcher. You sound like an Obama ad


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## BBCWatcher (Dec 28, 2012)

Do I think the PPACA is a substantial net positive development for U.S. healthcare consumers? Yes, I do. That's based on facts, not emotion or politics. Whether any particular politician benefits from these facts or not is a separate issue and not my concern.


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## twostep (Apr 3, 2008)

BBCWatcher said:


> Do I think the PPACA is a substantial net positive development for U.S. healthcare consumers? Yes, I do. That's based on facts, not emotion or politics. Whether any particular politician benefits from these facts or not is a separate issue and not my concern.


I have yet to hear from one person who actually benefitted from Obamacare.


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## BBCWatcher (Dec 28, 2012)

OK, I have, so here's an example for you. My health insurance was required to abolish its lifetime limits, and so it did. My insurance coverage materially improved due to the minimum quality standards mandated in the PPACA, and there was no increase in cost nor offsetting dimunition of coverage.

My step sister also has benefitted. She enjoyed the option to remain on her parents' policy until age 26, an option which the PPACA mandated. She exercised that option, and it dramatically reduced her out-of-pocket costs until she could get decent employer-provided coverage. (The other alternative was to go without insurance, which is very risky.) Again, her coverage had zero impact on other family members' costs -- and even if it did that'd hardly be the worst thing in the world compared to the ugly alternatives.

So there you go, two PPACA-delivered improvements in my extended family alone. And both occurred before the bulk of the PPACA goes into effect in 2014. (You can't benefit from a provision that hasn't yet been put into effect.)


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## jsharbuck (Jul 26, 2012)

We could trade horror stories versus good all day long. For me it is about government's intrusion in our lives. It's about lack of accountability. It is also a major reason that I am an expat. All I want from America is my social security( which I earned). That too is in question. I would invite others to look around the world and see how other countries handle healthcare. In New Zealand we have been well pleased with the care we receive. how do you justify a 50 yr old man being forced to have OB coverage. How do you explain to a family that their deductible is now 4,000 and that they have to find hundreds of more $$$$ a month from their salaries to pay for this great plan.

We will see 5 yrs down the road what shape America is in as a result of Obama Care. PS. At 26, you should be totally self supporting anyway


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## Bevdeforges (Nov 16, 2007)

Doesn't New Zealand have a national health care system that you are obliged to be part of?

The issue here is that the US is the only "advanced" country that doesn't have some form of national health care coverage. Obamacare is definitely flawed, but it's a first step toward providing some sort of basic coverage for all. Give it a chance, at least.
Cheers,
Bev


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## jsharbuck (Jul 26, 2012)

Yes Bev, you are correct, New Zealand does. Here are the highlights and perhaps differences

1. Free medical care. Non of my friends have every had issues with getting care they need in a timely manner. They might require an overweight person who needs a knee replacement to meet with a dietitian to loose weight first, but the care is available.

2. Pre scripts are 5$ for. 3 month supply irregardless of which medicines. A family cap of 20 prescriptions per year and the they are free.

3. Preventative care is stressed here. A doctor here will not prescribe multiple medicines like in the US. You feel like your doctor has the time to spend with you. 70 is much healthier here than In the US

4. You don't have to worry about paying for ER or surgery, cancer are, hospice are because it's all covered. In the US, one bad illness or accident can impact you financially. 

5. Related but separate industry. Life insurance, if terminal illness, policies pay out immediately upon diagnosis, to help while you are still alive.

Bev it's not perfect here. Dental care is so expensive that many of us fly to Thailand to, get our dental care done, enjoy a short vacation and then return back. I wonder about the average American family who in a still struggling economy, who have to pay a $4,000 deductible as well as hundreds of dollars monthly for insurance.


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## BBCWatcher (Dec 28, 2012)

jsharbuck said:


> 1. Free medical care.


Ah, no. It's never free. In New Zealand (and in all other developed countries, including the U.S.) medical care is heavily subsidized via tax revenues.



> 2. Pre scripts are 5$ for. 3 month supply irregardless of which medicines. A family cap of 20 prescriptions per year and the they are free.


The PPACA requires policies to cover prescription drugs, although copays and deductibles can be higher if you choose. Previously (through 2013) it was legal to sell health insurance in the U.S. with zero or capped prescription drug coverage. Which is, of course, crap coverage. Get cancer, AIDS, an organ transplant, or another drug-treated disease and, without prescription drug coverage, you are either bankrupt or dead (or both).



> 3. Preventative care is stressed here.


The PPACA requires all policies to cover a simple but very important set of preventive services. The PPACA also boosted funding for public health clinics in an effort to reduce more expense/less effective emergency room visits.



> 4. You don't have to worry about paying for ER or surgery, cancer are, hospice are because it's all covered. In the US, one bad illness or accident can impact you financially.


No longer. The PPACA largely fixes that, or at least improves the situation. You cannot be turned down due to preexisting conditions, so you are always insurable at community rated prices. Your benefits are unlimited -- no lifetime coverage maximums any more -- and your annual out-of-pocket costs must be capped for comprehensive covered services.

The PPACA changes all of the above, to be more like New Zealand -- and more like every other developed country. (The PPACA most closely resembles the Swiss and Dutch systems, albeit in more tentative form. It also very closely follows the healthcare system in Massachusetts, so it had a "pilot.")



> Bev it's not perfect here. Dental care is so expensive that many of us fly to Thailand to, get our dental care done, enjoy a short vacation and then return back. I wonder about the average American family who in a still struggling economy, who have to pay a $4,000 deductible as well as hundreds of dollars monthly for insurance.


The "average" American family is better off -- the PPACA reduces both their costs for healthcare and their risks of medical bankruptcy. The American household earning up to 400% of the poverty line receives subsidies so they don't have to pay high or even (in many cases) any premiums.

In other words, the PPACA adopts a progressive subsidy/funding system for healthcare. U.S. residents don't pay European-style regressive VAT rates, which are one of the primary sources of healthcare funding outside the U.S. Instead, the PPACA "taxes" by raising tax rates on those who don't insure and subsidizes the insurance of those who earn less than the median, with the subsidies more generous the lower your income. The insurance "product" is the same, meaning that lower income households aren't shunted to a public provider network.

I much prefer the PPACA's progressivity on the funding/financing side. It may actually have many European systems beat on that score. I'm not a fan of high VAT rates which disproportionally hit the poor.


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## BBCWatcher (Dec 28, 2012)

jsharbuck said:


> At 26, you should be totally self supporting anyway


The PPACA agrees in principle. It simply mandates that insurers include children until age 26 (i.e. under age 26). This is the cheapest, most sensible way to insure young adults. Previously medical insurers were knocking 18 year olds off their parents' policies. And if that 18 year old had a preexisting condition he/she was uninsurable. No more -- the PPACA fixed all that pretty well.


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## jsharbuck (Jul 26, 2012)

BBCWatcher. I admire your zeal and resect our difference of opinion. Have no wish to debate the merits of Obamacare. Best of luck to you. It will be interesting how this program is seen in 5 yrs from now.

Cheers


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## BBCWatcher (Dec 28, 2012)

I don't know what the difference of opinion is. You like New Zealand's healthcare system. The PPACA (factually, quite simply) moves the U.S. healthcare system closer to New Zealand's.

If you didn't like New Zealand's system and instead prefer the pre-PPACA U.S. healthcare system then we'd have a difference of opinion.


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## Bevdeforges (Nov 16, 2007)

BBCWatcher has made most of the same points I was going to do. 

"Obamacare" is nothing but the delivery system to try to make health coverage available to all (or nearly all). They made lots of mistakes (IMO) in how they set it up, but it's a noble first attempt in a country that has gone far too long with no national health care program at all. 

Your health care program in New Zealand sounds very good - but it is hardly "free" - you pay for it somehow, whether through your general taxes or through dedicated social insurance payments (or both). 

I've got my quibbles with the French system and with how the medical profession here operates (no pun intended), but IMO it's far, far better than the mess they have back in the US. With any kind of luck, the ACA will start to address some of those long-standing problems, but I give Obama credit for at least making a start at addressing the problem.
Cheers,
Bev


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## jsharbuck (Jul 26, 2012)

Yes it's not free but everyone here pays taxes with a minimum of 10%. That fact alone makes it seem fair compared to the US.


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## BBCWatcher (Dec 28, 2012)

The PPACA is simple in principle, but practically any new law has unintended consequences. Here's one of the very few examples. Somehow, miraculously, a California couple in their late 50s/early 60s managed to buy a decent (but not great) health insurance plan on the individual market starting in 2011 (after the PPACA was passed, importantly). Their health insurance company is required to cancel that policy. It doesn't meet the minimum PPACA quality standards which apply to policies that began after the PPACA was passed. (Older policies are "grandfathered," though even they must make a few quality changes without cancellation.) So, this couple got a cancellation letter, and now they have to shop for a new policy.

The most likely best policy will be available through the new health insurance exchange, and California has its own state-based exchange. It's a good one. However, if you somehow got a really fantastic deal on health insurance on the individual market (both in terms of quality and premium), and if you earn above 400% of the poverty line, and if you are older, then you might be looking at a premium increase. This particular combination describes about 5 people in California, metaphorically speaking, but there are a few such lucky people. (Maybe their insurance carrier made a mistake in calculating their premiums on their current policy? Who knows.)

Anyway, this couple demonstrates _*an important lesson if you are right around 400% of the poverty line in income*_, particularly if you are older (pre-Medicare age). There's a weird "bubble" in the PPACA at this income level. If the normal price for a "silver" plan on the exchange is greater than 9.5% of your income, then federal subsidies will drop that price down to 9.5% (or lower) if you are below 400% of poverty line income. If you are even $1 above that 400% magic number, the subsidies disappear. That can be a very expensive dollar of income!

So, what can you do about it? Well, there are at least a couple options if you're right around 400% of poverty line:

1. Reduce your income. Take an unpaid vacation, work less overtime, etc. It might actually make financial sense for you to reduce your income to stay within that 400% of poverty line in order to qualify for federal health insurance subsidies.

2. Contribute your excess (400%+) income to a Health Savings Account. Due to another quirk in the PPACA it appears that HSA contributions are taken out of your income in order to calculate subsidies, so an HSA contribution can drop you below 400% if you're above 400%.

Again, these little quirks only apply if you're buying health insurance on the individual market (i.e. through the new exchanges), and if you happen to be in a situation (primarily age-based) where your policy is expensive relative to your income, and your income is above but relatively close to 400% of the federal poverty line. If all three of those conditions are true, you should take an even more careful look.

Ask for help. Find a so-called "health navigator" who can help you understand your options and the subsidies available depending on your circumstances. And browse the policies available on the exchanges. Do a little bit of research before you make a decision. The best time to make your decision is later this month or early next month (December, 2013) so that you can get your coverage in place for 2014.


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## twostep (Apr 3, 2008)

https://www.ijreview.com/2012/06/9466-mugging-soldiers/


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## jsharbuck (Jul 26, 2012)

While I respect every persons right to post a d certainly their opinion on Obama Care, I have to wonder why this person is taking such time and effort to try to educate us on how great it is. I will never change my opinion no matter what this person writes. In my opinion, just like politics, this type of sermonizing has no place here in this forums.


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## Guest (Nov 10, 2013)

A forum is just the place for voicing your opinion and values. An anonymous where you can spout till your heart is content so long as it stays within the forums rules. Where your neighbours, friends, colleagues are not going to get into a barny with you face to face which is much more vicious and likely to cause upset as you know them. 

Personally I think obamacare is wonderful. It really is about time that a country with so much wealth, power and standing in the world did something to bring about healthcare to the masses.


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## overmyer (Aug 15, 2013)

_shel said:


> A forum is just the place for voicing your opinion and values. An anonymous where you can spout till your heart is content so long as it stays within the forums rules. Where your neighbours, friends, colleagues are not going to get into a barny with you face to face which is much more vicious and likely to cause upset as you know them.
> 
> Personally I think obamacare is wonderful. It really is about time that a country with so much wealth, power and standing in the world did something to bring about healthcare to the masses.


They've just gone about it in their usual inept way!


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## BBCWatcher (Dec 28, 2012)

I don't really give a damn whether the PPACA is better or worse than something else. (Not much, anyway.) It's the law in the U.S., and I'll try to be helpful and utterly factual in helping people understand how to take best advantage of the new healthcare provisions in the U.S. (And how to work around any imperfections in the PPACA, and there are some. I just described one upthread.)

The PPACA is a heck of a lot better than the pre-PPACA status quo if you have a preexisting condition(*), you are not tremendously wealthy, you reside in the United States, and you do not have continuous employer-provided health insurance(*). That's just fact. Sorry if you're "offended," but I don't consider expanding (somewhat more affordable) healthcare to non-wealthy individuals with preexisting conditions to be the work of the devil. On the contrary, I consider it a part of the definition of a civilized society.

If that's "political," then I guess I'm guilty.

(*) And practically everybody eventually has a preexisting condition and/or loses a job at some point.


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## Bevdeforges (Nov 16, 2007)

The only thing to remember in considering the pros and cons of the ACA (aka Obamacare) is that, for most expats to the US, it's more or less irrelevant. Those who are covered by their employer's medical insurance don't have to worry about signing up for policies, etc. 

The state or federal insurance exchanges are pretty much for those who don't have insurance through an employer. Given that 85% of the US population already has health insurance, I just question how relevant this is for an expat oriented forum. (And, the ACA does not apply to US citizens living outside the US at all.)

But, no reason not to discuss the issue. Carry on.
Cheers,
Bev


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## BBCWatcher (Dec 28, 2012)

Bev, this section is primarily for expatriates inbound to the United States. And yes, healthcare is a huge issue for residents of the United States. The PPACA's requirements and benefits apply to the vast majority of U.S. residents, as described at the very top of this thread.


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## Bevdeforges (Nov 16, 2007)

Inbound expats to the US only have to get concerned about the ACA and health care exchanges if they don't have a job lined up that offers health insurance. Given the requirements for most visas that include work privileges, the uninsured arriving expat is likely to be a rare commodity. 

I must say they seem to have managed to make this program incredibly complicated. In most countries with a national health care program, health insurance is a prerequisite for getting a visa in the first place - at least for any non-work visa.
Cheers,
Bev


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## BBCWatcher (Dec 28, 2012)

In my (somewhat limited) experience observing the posts to the America forum, most people aren't asking about employer-supported work visas (the "expat packages"). There seem to be a lot more questions about sponsoring spouses and other family members without any particular employer involvement.

It's a big issue, actually. A very large proportion of currently uninsured U.S. residents are non-citizens. The PPACA is quite interesting in treating all legal residents the same, which (in my view) is quite enlightened.


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## BBCWatcher (Dec 28, 2012)

Still having trouble with healthcare.gov? The telephone and postal mail services work fine, and Medicare and Medicaid ran for decades without Web sites. However, if you want to do a quick check via the Web to find out what exchange policies are available and their costs to you, there are some new, unofficial alternatives popping up.

The President has proposed allowing insurance companies to continue underwriting existing noncomforming (i.e. usually low quality, riddled with loopholes) health insurance policies into 2014, and he can apparently do that with a regulatory change. The insurance industry doesn't actually like that idea. The real reason they're canceling these policies is mostly because they want to, and Obamacare is a convenient excuse. (Insurance companies have been canceling policies for as long as they've been in business -- this is nothing particularly new. It's part of how they've been maximizing profits.) Meanwhile, Congress has been considering legislation to make some changes, but I would not predict any agreement on any legislation. I think you can safely ignore the debates in Congress right now.

In other news, Alaska's governor has now refused to expand Medicaid in his state, leaving 40,000+ low income (mostly working) Alaskans without health insurance, many Native American. The federal government fully funds Medicaid expansion, and consequently/simultaneously the federal government is cutting aid to hospitals and medical facilities (primarily emergency rooms). So, as with other states that have refused to expand Medicaid, everybody loses: more people don't get the treatment they need (especially preventive care), hospital emergency rooms are flooded with non-emergency cases, state governments have to pay more for this emergency room care, and more people die sooner. It's one of the stupidest public policy decisions a state governor can make right now, but there are lots of governors that are putting politics ahead of the health of their constituents. Hospitals in these states are livid, as you can imagine, but here we are.

As I said upthread, I am not at all interested in the politics. The bottom line questions are simple. Providing decent, affordable, universal healthcare is what I (and most people) consider to be a necessary core function of every civilized society. Yet there are still many (Republican) politicians in the U.S. that don't agree with that statement and are still actively trying to prevent poor and middle class U.S. residents from receiving non-bankrupting medical care, especially as early (and less expensive) intervention. I just cannot understand that philosophy from any moral angle. It's fundamentally amoral, in my view -- and the insane thing is the status quo is way more expensive. In other words, the cheap thing to do is to have universal healthcare. Emergency rooms and prematurely dead people are terrifically expensive!


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## jsharbuck (Jul 26, 2012)

The Affordable Care Act is law and cannot be changed by the President. The Legislative Branch is responsible for drafting and passing laws. The Executive branch is tasked with seeing those laws are followed. There is no Constitutional basis for Obama to change anything, that can only be done by Congress. Besides all He and the vote on the Upton Bill passed by the house does, is extend this by 12 months.

This whole situation is unconstitional. We did need a better healthcare system, but not this. I still believe BBC Watcher that you are either a progressive idealog or someone who is being paid to blog about Obama cre.


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## BBCWatcher (Dec 28, 2012)

Rubbish. Congress passes laws all the time which delegate regulatory responsibility to the Executive Branch, and it has done so in the PPACA. And the Clean Air Act, the Clean Water Act... every nontrivial piece of legislation grants rule making/regulatory authority to the Executive. The President and his HHS Secretary are granted a lot of regulatory discretion in the PPACA.

If there is any question of the Executive Branch exceeding its regulatory discretion then Congress has three choices (not counting "complain but do nothing"):

1. Pass a new or amended law addressing the question. The President can veto this legislation, but Congress can override if it can muster 2/3rds majorities in both houses.

2. Seek redress in the courts (Judicial Branch), which are generally reluctant to interfere in political questions.

3. Impeach and possibly remove from office the official(s) they don't like.

That's it.

I'm neither. Seriously, do you believe a developed country's government (i.e. the government of a country with ample wealth) must assure that its citizens have decent, affordable, universal healthcare or not? Yes or no? If no, why not? Simple question, and in my view (and in the overwhelming consensus view around the world) it has a simple answer: yes.


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## BBCWatcher (Dec 28, 2012)

Surprise! There are insurance companies trying to scam people into paying for crappy insurance.

If you buy this crap insurance you won't get anything resembling adequate coverage, you'll have to pay the IRS penalties starting in tax year 2014 because you don't have adequate coverage, and you cannot receive federal subsidies to help you pay for health insurance. Unfortunately these insurance industry scams are still legal.

Every policy you buy from the official Obamacare health insurance exchanges -- whether you buy on the Web, by phone, or by mail -- must meet minimum guaranteed quality standards for coverage. These are called PPACA (or ACA) compliant policies. If your health insurance policy is not ACA compliant, it's probably crap -- and you'll probably have to pay a tax penalty because you don't have adequate coverage. The exchanges are also the only way to receive federal help to pay for your insurance if you qualify.

I'm talking about the individual private insurance market here and those that participate in that market, not employer-provided coverage or other coverage programs such as Medicare, Medicaid, TRICARE, etc.

Be very careful out there, folks. There are a lot of scammers right now trying to dupe people.


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## jsharbuck (Jul 26, 2012)

ACA compliant policies include having a 68 yr old man having to carry OB/GYN or Pediatric coverage, something that will definitely be of benefit to him. That is what I call a "crap insurance plan.". What it mandates is that he pays for someone else's coverage. That is simply redistribution. It is hard to stomach an increase in premiums for Obama Care because you are having today for someone else. My sister has MS and lives in a farming community and a steadfast supporter of Obama Care. Now she finds out that she can no longer go to the doctor that she has used for 15 yrs and.... Yes her premiums have increased. Hers is sadly not the only story like this.

There are many issues in US Healthcare. Let's take a look at the pharmacy industry for example. Why do we have our seniors on multiple mess that surely interact and affect their health. So many I know are on more than 10 meds. Talk about drug interactions! But the pharmacy companies are getting rich. The average senior here in New Zealand is far healthier and very few are on meds. When my father in law died, we discovered 23 meds and that is sadly the Norman America.

Placing the responsibility on the individual should be stressed. If you eat at McDonalds, if you eat unhealthy food, you will have health issues. If you are overweight, you will have health problems. Yes BBC Watcher America needed a better plan but not the ACA.


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## BBCWatcher (Dec 28, 2012)

jsharbuck said:


> ACA compliant policies include having a 68 yr old man having to carry OB/GYN or Pediatric coverage, something that will definitely be of benefit to him. That is what I call a "crap insurance plan."


No, that's called _community rating_.

The alternative is that women must pay higher insurance rates than men simply because they had the random happenstance of being born with two X chromosomes instead of an X and a Y. Are you suggesting that women should pay more for health insurance than men? If yes, how many risk pools do you want? Do you want a separate risk pool for people born with other genetic propensities and differences?

Most Americans get their health insurance through their employers. Employers have community rating. Are you suggesting that female employees should pay more for their health insurance than men? Are you suggesting that younger employees should receive higher salaries than older workers, because the actuarial value of employer-provided health insurance is higher for older workers than it is for younger workers?

Methinks you don't understand the concept of "insurance" if you think there ought to be separate risk pools.



> What it mandates is that he pays for someone else's coverage.


Yes, that's a little something called "insurance." If he has homeowner's insurance, for example, he's paying for other peoples' tornado damage to their homes. And he's paying for their pool accidents, even if he doesn't have a pool (uterus). That's called risk pooling, risk sharing...you know, insurance.



> That is simply redistribution.


Yes. Insurance companies collect premiums and redistribute those premiums to pay claims. Shocking!



> My sister has MS and lives in a farming community and a steadfast supporter of Obama Care.


Should we have a separate risk pool for women with multiple sclerosis? Another for men with MS?



> Now she finds out that she can no longer go to the doctor that she has used for 15 yrs and....


Yes, and this has been true forever. Insurance companies have been free to add and remove doctors from their networks, and Obamacare doesn't change that.

What Obamacare does change is that your sister now has the ability to select an alternative insurance plan which includes her preferred doctor. She has portability of coverage. She cannot be denied insurance through the exchange because she has a preexisting condition (MS). In short, she has options. Previously, she was screwed. If her doctor left (or was kicked out) of her insurance network, there was absolutely nothing she could do about that except pay for her preferred doctor out-of-pocket if she could afford it. Now, Obamacare provides her with more protection. Not unlimited protection -- she'll have to shop for a new policy on the exchange to reacquire her doctor -- but some protection she didn't have before.



> Yes her premiums have increased.


Perhaps not after subsidies if she qualifies. They might go down. However, (1) since when have health insurance premiums _not_ increased in the last 20+ years? The price of gasoline has increased, too. It's called inflation. It happens. (2) The relevant question isn't whether her _premiums_ have increased it's whether (and how much) her _out-of-pocket medical costs_ have increased. She has MS! She has medical bills! Obamacare provides ACA compliant exchange policies, and that means they're high quality. They actual pay a lot of medical bills, and lifetime benefit caps are now illegal. (She has MS, so she could easily have run through her lifetime maximum previously.)

You mention prescription drugs. ACA compliant policies must include prescription drug coverage. Previously in the U.S. it was legal to sell "health insurance" policies without prescription drug coverage. Which isn't actually health insurance. Obamacare is an improvement. It's not perfection -- stipulated -- it's improvement.



> Placing the responsibility on the individual should be stressed. If you eat at McDonalds, if you eat unhealthy food, you will have health issues. If you are overweight, you will have health problems.


Yes. And if you have health problems you will pay your deductibles and co-payments, and that won't be free. If you smoke you'll pay a higher rate for insurance in most states. Insurers on the exchanges can even do things like provide gym memberships and rebates if you exercise, reduce your blood pressure, etc., etc. The PPACA mandates that insurance companies provide a core list of preventive services free of charge. (Previously insurance companies didn't do that because they typically didn't carry their customers very long, so it was "somebody else's problem" that their customers didn't get preventive services.)

There is ample individual responsibility in the PPACA -- more than there's ever been in U.S. healthcare, and too much, many would argue. You have to shop for a policy on the exchange now if you have no coverage, otherwise you have to pay a higher tax rate to the IRS.

Now, contrast that with Medicare, America's most popular medical coverage system. Medicare has less "individual responsibility." Is that a problem? Do you think Americans should give up Medicare?

I have less than zero patience for political grandstanding on this issue. If someone has a better idea on how to get U.S. residents covered and healthier, great, let's do it. But going backwards from the PPACA is absurd and amoral in my view, which is what you seem to be suggesting on multiple fronts.


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## jsharbuck (Jul 26, 2012)

BBC Watcher . You border on sarcasm on your comment about whether I understand the concept of insurance....of course I do. I will not argue about needed reform in US healthcare delivery but I think this is wrong. 

I guess history will judge the success or disaster of Obama Care and all it entails. You have one opinion, I have another and I respect that.


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## BBCWatcher (Dec 28, 2012)

As a reminder, the last day to enroll in an "Obamacare" exchange policy for coverage to begin on January 1, 2014, is *December 23, 2013*. You then must make your first premium payment to your insurer no later than January 10, 2014.

The deadline to get coverage to avoid the tax year 2014 IRS penalty is *March 31, 2014*. If you don't have PPACA-compliant health insurance coverage for yourself and your dependents by then (through your employer, Medicare, Medicaid, TRICARE, the Obamacare health insurance exchange, or some other route), and if you are a U.S. resident, you may see a tax increase unless you qualify for one of the limited exceptions. March 31, 2014, is also when the Obamacare open enrollment period ends. Unless you have a "qualifying event" (e.g. loss of a job and coverage, birth of a child) you won't be able to get exchange coverage for 2014. You'll have to wait for late 2014 to sign up for coverage that begins in 2015. This also means you can't wait until you get sick -- a bad idea for your health anyway -- then sign up for coverage when you want.

People seem to have no particular problems now using Healthcare.gov to learn what options they have and to get enrolled. You can also apply by phone, postal mail, or in person with a certified "navigator." Pharmacies are even helping people get signed up.

Now is the time to maximize your coverage (start on January 1), your 2014 subsidy (if you qualify -- for many people insurance is now free), and avoid the 2014 tax increase if you don't get covered. If you haven't signed up yet, do it now.


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## twostep (Apr 3, 2008)

This is a forum where immigrants and expats can exchange information, mostly q&a. The option to purchase medical insurance through the so called Obamacare has been discussed and those interested in more details can obtain details based on their personal situation through official channels.


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## BBCWatcher (Dec 28, 2012)

*Update*: There's a little Christmas present from HHS. They've extended the Healthcare.gov enrollment deadline by 24 hours, so you've now got until Tuesday, December 24, to get enrolled for coverage that starts on January 1 at 12:01 a.m.

Have a happy (and healthy) New Year, everyone!


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## BBCWatcher (Dec 28, 2012)

Reminder: The open enrollment period for all of calendar year 2014 ends on March 31, 2014. That's the deadline to get health insurance coverage (unless you have some "qualifying event" that allows enrollment at another time). However, if you don't have PPACA-compliant health insurance coverage in place by March 31, and you don't qualify for an exception (for example, a hardship exception), you'll likely be subject to a tax penalty for tax year 2014 when you file your tax return next year. The penalty for tax year 2014 is $95 or 1% of income, whichever is greater.

So, this is the last call to avoid the tax penalty.


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## BBCWatcher (Dec 28, 2012)

We've now reached the annual open enrollment period for 2015. If you enroll in a new/different medical insurance plan by December 15, 2014, then your new/different coverage can start on January 1, 2015. Even if you already have an exchange policy in 2014, and even if you are thinking of just renewing your existing plan, you should visit the medical insurance exchange marketplace to see if you can get a better deal (better policy and/or better subsidies if qualified) for 2015.

Please note that the tax penalty increases in tax year 2015 if you do not maintain adequate, PPACA-compliant medical insurance for your family (and if you do not qualify for an exemption). The penalty will rise to $325 per person ($162.50 per child under 18, up to $975 per family) or 2% of your income above your filing threshold, whichever is higher.

Visit Healthcare.gov for more information.


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## twostep (Apr 3, 2008)

Well, it is all over news here that premium hikes of up to 20% should be expected.

Personally - loos and lab work plus explanation used to be part of office visits. 2015 it will be separate copays for each.


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## BBCWatcher (Dec 28, 2012)

twostep said:


> Well, it is all over news here that premium hikes of up to 20% should be expected.


That'd be America's sensationalist "news" media. (Well done.)

The average premium increase is zero, which is really quite remarkable since average medical insurance premium increases haven't been zero for...well, I can't remember the last time they haven't gone up. But yes, if you do nothing (don't change plans), have a particular plan level most affected by an increase, live in the one county in the United States with the nation's #1 highest premium increase, and don't qualify for federal subsidies (which absorb premium increases) or don't apply for a subsidy recalculation -- if all of that is true -- then you might see a 20% premium increase.


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## Bevdeforges (Nov 16, 2007)

From today's NY Times: http://www.nytimes.com/2014/11/15/u...n-region&region=top-news&WT.nav=top-news&_r=0

Apparently, for those who rely on the exchanges for their coverage, rates are going up "as much as" 20%. But your mileage will probably vary, as they say. 

However, the vast majority of folks aren't getting their insurance from the exchanges, but rather from their employers. The point is, if you are on the exchange you may want to check to see if you're still getting the best deal available before just accepting a renewal of what you bought last year.
Cheers,
Bev


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## twostep (Apr 3, 2008)

Bevdeforges said:


> From today's NY Times: http://www.nytimes.com/2014/11/15/u...n-region&region=top-news&WT.nav=top-news&_r=0
> 
> Apparently, for those who rely on the exchanges for their coverage, rates are going up "as much as" 20%. But your mileage will probably vary, as they say.
> 
> ...


Back to business as usual))


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## BBCWatcher (Dec 28, 2012)

Even the New York Times failed to note that the federal government absorbs any premium increase if you're receiving subsidies -- subsidies that didn't exist before 2014 and the Patient Protection and Affordable Care Act ("Obamacare"), by the way. (The subsidies are tied to the second least expensive silver plan.) But I suppose New York Times readers don't qualify for subsidies because they're too wealthy. 

The New York Times also failed to mention that, in Mississippi, premiums are _decreasing_ an average of 19 percent. The Times just wanted to cherrypick, apparently. I leave it as an exercise to the reader to figure out why. (Maybe New Yorkers can't find Mississippi on a map? )

From 2008 to 2010, before the PPACA went into effect, premium increases for individual medical insurance policies averaged over 10 percent per year, and _nobody_ got any federal government help to pay for those premiums or to handle those increases. Lots of people that qualify for Medicaid today didn't back then.


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## Bevdeforges (Nov 16, 2007)

I thought I had read that about the decrease in Mississippi rates in that article. Hm, maybe I read another article somewhere else.

But the point remains that most people in the US still get their health insurance through their employers. (Just for the record, however, the NY Times has been running a number of articles about how successful the ACA has been and how this is being overlooked by those more interested in creating "rhetoric.")
Cheers,
Bev


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## BBCWatcher (Dec 28, 2012)

According to the Kaiser Family Foundation, at any one time less than half the U.S. population (48%) has medical insurance coverage through an employer-sponsored plan. Moreover, according to the U.S. Bureau of Labor Statistics, employees participating in such plans pay 21% of total premiums.


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## Bevdeforges (Nov 16, 2007)

And according to Wikipedia: 



> According to the United States Census Bureau, roughly 55% obtain insurance through an employer, while about 10% purchase it directly. About 31% of Americans were enrolled in a public health insurance program: 14.5% (45 million – although that number has since risen to 48 million) had Medicare, 15.9% (49 million) had Medicaid, and 4.2% (13 million) had military health insurance (there is some overlap, causing percentages to add up to more than 100%).


Point being, however, that expats in the US are probably in a somewhat different statistical situation from the US as a whole. It would be interesting to know how many (legal) immigrants in the US are eligible to go through the various health exchanges.
Cheers,
Bev


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## BBCWatcher (Dec 28, 2012)

I would trust the KFF data since it's more current, and (as I've said over and over) the U.S. medical system is profoundly different than it was just a couple years ago. KFF's number is also a slightly different number (potentially): percentage of the population. There is a percentage that's uninsured.

One of the important points discussed in this very thread (and elsewhere) is that the PPACA makes it possible now for older individuals moving to the U.S. who are ineligible for Medicare to obtain medical insurance.


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## twostep (Apr 3, 2008)

BBCWatcher said:


> I would trust the KFF data since it's more current, and (as I've said over and over) the U.S. medical system is profoundly different than it was just a couple years ago. KFF's number is also a slightly different number (potentially): percentage of the population. There is a percentage that's uninsured.
> 
> One of the important points discussed in this very thread (and elsewhere) is that the PPACA makes it possible now for older individuals moving to the U.S. who are ineligible for Medicare to obtain medical insurance.


Be so kind and pull a premium range for female, 78, GC, retirement and investment income.


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## BBCWatcher (Dec 28, 2012)

OK....

A hypothetical 78 year old female non-smoker living alone in Miami, Florida, who has total income of $30,000 per year (and any level of wealth) would have the following medical insurance plans available for 2015 via HealthCare.gov (picking the lowest premiums in each "metal" category) inclusive of federal subsidies:

1. "Ambetter Essential Care 1," a bronze level plan, for $88 per month with a $6500 annual deductible and the same annual out-of-pocket maximum.

2. "Ambetter Balanced Care 1," a silver level plan, for $206 per month with a $5000 deductible/out-of-pocket maximum.

3. "Molina Marketplace Gold Plan" for $305 per month with a $500 deductible and $6600 out-of-pocket maximum.

For perspective, Option #1 is actually less expensive than plain vanilla Medicare Part B ($104.90 per month). Medicare would be better in certain ways overall, but it's pretty amazing to have a nice, catastrophic medical insurance option (plus free wellness services) for $88 per month for a 78 year old.

In the event this hypothetical female has a much higher income and does not qualify for any subsidies then Option #1 is still less than $600 per month, which is still pretty amazing. Before 2014 this hypothetical female probably wouldn't be able to find medical insurance at all, especially if she has a preexisting condition -- which most 78 year olds have.

Anyway, as you can see, this is really transformative for older immigrants to the United States who do not qualify for Medicare. It's become much more possible for their families to sponsor them to come join them in the United States. There's still exposure with long-term care, as before, but acute and chronic care coverage has been well addressed for this cohort.


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## Bevdeforges (Nov 16, 2007)

For a newcomer to the States, however, there is the "culture shock" of how the US works - particularly those high deductibles and the large "out of pocket maximum" figure. For anyone coming from a country with a standard sort of national health care coverage, the co-pays, deductibles and out-of-pocket charges can still sabotage the old budget. (Plus, I've seen some discussion elsewhere on how the "out of pocket" is determined, and it's not always what you'd expect.)
Cheers,
Bev


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## shortcols (Jan 12, 2015)

The whole healthcare system in the US is a mess. The only people that benefit from Obamacare are the insurance companies and the very low earners. I was hoping for so much more from Obama on healthcare. I think he failed big time on this one. I can't wait for the 'affordable' part of the affordable care act to kick in.


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## BBCWatcher (Dec 28, 2012)

shortcols said:


> The only people that benefit from Obamacare are the insurance companies and the very low earners.


That's factually, objectively incorrect.


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## BBCWatcher (Dec 28, 2012)

Here's a gentle reminder that the open enrollment period for calendar year 2015 ends on February 15, 2015. You'll need to visit Healthcare.gov and enroll in a PPACA-compliant medical insurance policy on or before that date to get coverage (including federal subsidies to help you buy medical insurance, if you qualify). After that date you won't be able to enroll unless you have a qualified "life event," for example the birth of a new child in your family.

Moreover, if you don't have PPACA-compliant medical insurance you may be subject to a tax penalty. The non-coverage penalty rises in tax year 2015 to the greater of $395 per person or 2% of your income above your filing threshold.

It's best not to wait until the last minute before the deadline when the Web site might be slow.

Over one year into the bulk of the PPACA reforms and the news is nearly 100% good. The Congressional Budget Office has revised government expenditures on healthcare downward again. The percentage of U.S. residents uninsured has fallen by several percentage points. Over 10 million people have enrolled in PPACA exchange policies for 2015, and there's still over one week to go for the open enrollment period (as I write this). Premium rate increases for 2015 have been almost nonexistent, so healthcare inflation seems to be at least temporarily held in check. Despite the Supreme Court hiccup more states are expanding their Medicaid systems, as the PPACA intended.

What hasn't worked, at least not yet? Well, Vermont dropped its plans to adopt a single payer healthcare system from 2017. Though the PPACA allowed states to apply for exceptions such as that one, Vermont determined that the PPACA wasn't designed well enough to provide sufficient funding to make their funding mechanisms realistic. It also seems tougher to adopt a single payer system at a state level given the unfortunate reality that states compete against each other in a zero sum game. A couple other states are still seeing what they can do, and Vermont will likely make another attempt if they get a couple federal changes. Also, the Republican-controlled Congress cut the IRS's funding -- a terrible idea already (the federal government will lose much more legally owed tax revenue than the cut to the IRS), but it's a particularly terrible idea when taxpayers are now having to deal with the tax-related aspects of the PPACA in its first major tax year (2014). There are also some new or at least newly invigorated insurance company and medical provider frauds that have surfaced, notably drug formulary shenanigans (such as reducing or eliminating coverage for all drugs available to treat certain whole diseases, such as HIV treatments) and out-of-network doctors (and lab technicians) descending like vultures on patients, even in supposedly in-network medical facilities. (Many insurance plans don't cover or only partially cover out-of-network providers.) Any system built on the "good faith" of profit-maximizing actors was bound to run into such problems, so the regulators have some work to do to eradicate the fraud. (And I call it fraud because it is, in any colloquial interpretation if not legal.) That's not to say these problems weren't already occurring -- they were. It's really a byproduct of the fact the PPACA is _starting_ to squeeze some inefficiencies out of the system, and so the grifters are trying to find ways to keep grifting. Then there's the fact there's an entire political party (the Republican Party) still devoted to destroying what progress has been made in providing at least basic medical care to more people -- that hasn't changed. You'd think by 2015 there'd at least be consensus on the core principle that all Americans deserve to have medical care no matter what their income level, even if there's an argument over the way to get there. Sadly, no. The Democratic Party said, "Fine, we'll do it your way." They passed and implemented the PPACA, a clone of the Massachusetts program that then-governor Mitt Romney presided over and that the conservative Heritage Foundation championed. That's all the PPACA is -- there's literally nothing left from the Democrats' wish list. Now the Republican Party officially hates their own proposal. Go figure.

Anyway, here we are, in 2015, and it's a lot better than it was in 2013. Congratulations, America. Keep improving.


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## BBCWatcher (Dec 28, 2012)

*"Obamacare" Open Enrollment for 2016*

For those of you who do not have sufficient medical insurance through your workplace, through Medicare, or through Medicaid (as notable examples), the "Obamacare" open enrollment period for 2016 has started. Legal residents of the 50 U.S. states and the District of Columbia, including non-citizen residents, can now sign up for medical insurance for 2016 and receive federal government subsidies to purchase insurance if qualified. Visit Healthcare.gov for more information or to enroll. It's also an extremely good idea to visit Healthcare.gov to compare new medical insurance options (and their premiums) to what you have now, even if you previously purchased medical insurance through Healthcare.gov. You could save some money, so it's well worth rechecking every year during open enrollment.

The open enrollment period for 2016 runs from November 1, 2015, through January 31, 2016. However, you must enroll by December 15, 2015, if you want coverage that begins on January 1, 2016. If you do not sign up for medical insurance by January 31, 2016, then you'll have to wait until the next open enrollment period unless you have a qualified status change (such as birth of a child, loss of a job, etc.)

As a reminder, it can be very dangerous to your health (medical and financial) to go without adequate medical insurance, especially in the U.S. Moreover, you could be subject to a higher U.S. income tax rate (called the "Shared Responsibility Payment") if you fail to carry adequate medical insurance. The Shared Responsibility Payment for 2016 rises to the greater of $695 per adult in your household (and $347.50 per child), or 2.5% of your household income. That's a lot of money to pay, _and_ you wouldn't have medical insurance -- bad idea!

If you're confused about what the various medical insurance terms mean, read through this guide first.


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## twostep (Apr 3, 2008)

Let's forget about the shortcomings of Obama Care such as more and more physicians especially specialists not accepting it or limiting the number of patients been seen.


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## BBCWatcher (Dec 28, 2012)

Nobody is forgetting anything. Both those problems existed before Obamacare, and both those problems exist in _every_ medical system except perhaps systems that incorporate state monopoly provision of medical services.

The guide linked to in the previous post carefully explains "in network" and several other terms that describe limitations _all_ medical insurance policies have. There is no such thing as medical insurance that can promise services from specific medical providers. Medical providers in most countries, including the U.S., have the freedom to choose whether to accept you as a patient or not, what prices to set, and consequently whether your insurance will cover their services or not. There's nothing that should be surprising about that. Syndicated TV's Dr. Oz and CNN's Dr. Gupta are not accepting every patient who wants to see them.

You can and should evaluate medical insurance based on coverage, including the medical providers that insurance covers and their quality of service. That should not be a surprise.


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## BBCWatcher (Dec 28, 2012)

Here's a quick tip. If you're shopping for a new medical insurance plan on the health insurance exchange (Healthcare.gov) -- and you should at least check! -- you should pay close attention to the deductibles and co-pays. In particular, if your annual income is between 100 and 250 percent of the federal poverty line ($11,770 to $29,425 for a household with one individual), there's something called the Cost Sharing Reduction (CSR) available. But the CSR is only available if you choose a "silver" plan. The CSR reduces your deductibles and co-pays even beyond what the standard silver plan does (versus "bronze").

The CSR can be a bit confusing at Healthcare.gov, but watch for it. To make things relatively simple: even if the premium (after your federal government subsidy) is slightly higher for the silver plan, you're better off picking a silver plan if your income is at 250% of the federal poverty line or below. The CSR and silver level benefits make a big difference in the quality of your medical insurance.

Or, said another way, be an informed consumer and shop around, and take advantage of the CSR (also) if you qualify.

For example, with a bronze plan you might have a $5,500 deductible, a $6,840 out-of-pocket maximum, a doctor co-pay of $40, and a hospital co-pay of $1,500. A silver plan without the Cost Sharing Reduction could drop that to a $750 deductible, a $1,450 out-of-pocket maximum, a doctor co-pay of $30, and a hospital co-pay of $1,500. With CSR added that same silver plan would probably drop to a $250 deductible, a $1,450 out-of-pocket maximum, a $15 doctor co-pay, and a $250 hospital co-pay. That's a big difference with the CSR and almost always well worth choosing the silver plan.


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