f13.net

Per request, I'm happy to talk about the ACA and how it will work/ramifications of it as it comes into implementation in the next year.  This is not about the politics of it, just the actual nuts and bolts.

I don't claim to be an expert but I am involved in the implementation from the employer's side so know a fair amount about its practical effects and also get to sit in meetings with our consultant who does know a lot about it.

So, feel free to ask any questions and I will do my best.

My overall opinion is that it will be very interesting to see how all this will shake out. It will both squeeze employers, shift how hours are handled in any employer subject to the Act, and broaden the insurance pool. The real test is whether costs come down which no one knows yet although there are some encouraging signs.

What I'm curious about is what it means for somebody looking to not work for a while.  I've been toying with taking a year or two off to pursue personal projects, see if they evolve into something startup-ish or not, or so on for a while now, and I'm definitely spoiled by getting reasonable health care through my employer without much hassle (certainly many people are not so well off, but California tech companies tend to be reasonable to their employees, thankfully).

It sounds like the private exchange thing should allow for some choice of plans where costs vary based on coverage level (deductible and so on) and coarse demographics (age, location, etc), but otherwise work more like the employee-provided plans I'm used to (don't have to jump through a lot of hoops to get coverage, just pick one that has the features I want, sign up, make my payments, and off I go).  Does that line up with reality?

Obviously, COBRA has me covered for a year and a half, but it's nice to have options, especially should I decide I like working on my own or have difficulty finding a job down the road, and the cost of the health care my employer provides is non-trivial when I'm paying all of it, instead of 10% or whatnot.

Let's say I don't have medical insurance right now. Would it behoove me to wait until this starts and if so/when does it?

If you want an idea of what's available and how it's organized, you can look at the Mass exchange that's been up for several years.

Mass HealthConnector (http://www.mahealthconnector.org)

Pretty much.  The exchanges are designed to act more like employer plans then the current private market (which are basically shit because of waiting times, pre-existing exclusions, etc.) and also you can get subsidized based upon income level.

Well, if an exchange gets up and running in your area and you want insurance, then its a decision as to whether you want to buy insurance as far as timing goes. The subsidized plans have to be in place by 10/1/13 so you might want to wait until then if your income is low enough to be subsidized (for a single person that is around 42k of income)  On 1/1/14 though, which isn't that far off, you are required to have insurance or you have to pay the penalty. The penalty ramps up from 2014 to 2016.

EDIT: I should also say that your employer may be required to offer you insurance next year and if they do offer an "affordable" plan (which is based upon a percentage cap in relation to income) then you have to take it rather than hitting the exchange.

Friend of mine is self employed, has been for years, owns the business ( Employee of one, but supports himself and his wife ). He has no health insurance of any kind. Quite sure he makes bellow the poverty level for this area, even if he lives comfortably by his standards.

Whats the outlook look like for him, and what kind of subsidies are we talking about. Can things like the money he pays out for health care impact his taxes on a business or personal level?

The subsidies are a sliding scale and depend upon the number of family members in his household.  The way it is present is a bit backwards as the tables don't show the subsidy but rather the maximum premium, so any cost over and above that is basically a subsidy. Federal poverty level for a two person household is approx 15k, so the subsidy will vary up to 60k in household income.

(http://i6.photobucket.com/albums/y222/Abagadro/800px-PPACA_Premium_CRS_zpsfd920c4b.jpg)

In some cases, no... because the majority of providers are trying to lock people into a "cheaper" plan before they raise rates.  i.e. they're threatening to.

Though, I caught myself laughing in an agent's face when she gave me that spiel.  I basically told her she wasn't paying much attention in economics class; because the reality is, with the increased competition and downward cost pressures, there's NO way insurance will become more expensive due to ACA.  They're really just using that tactic to get people signed up and semi-committed.

Anyways, most plans are month-to-month (quit or switch whenever) so your question is kind of moot.  The key is not letting yourself go un-insured for more than 6-months and making sure you stay vigilant with picking the right insurer.
I just picked up a cheapo preventative plan for $30/month while I wait for the exchanges to go online in October.

That chart does not seem helpful.

:rofl:

Lots of good info in this thread, thank you Abagadro.

This may not be as simple a question as I think it is. What is the penalty for going uninsured? For instance, if you can't even afford insurance at a subsidized rate.

It starts out in 2014 as the greater of 95 dollars or 1% of your household income over $9,750, per person in the household.  So if you make $25,000 and are single, the annualized penalty (it is assessed based on the number of months uninsured) would be $152.50.  If you are married it would be a total of $110 (25k-19.5k*.01*2).

In 2015 it goes to the greater of $325 or 2 percent. In 2016 it is 695 or 2.5 percent.

There are some caps and such for number of people in household, but that is the basics.

It's a government chart. You expect it to be helpful?

The real penalty for going uninsured is having to pay heftier fees for insurance since you're likely pretty unhealthy and/or a much riskier claimant.  I'm not sure of the exact metrics on that though.  Odds are it mostly applies to folk over 35, and moreso still for retirees. 

This is why I opted to at least get SOMETHING before the exchanges open.  This way I know where I stand (after physicals, bloodwork, stress tests, etc.) before shopping.

Generally speaking, will signing up for ACA be cheaper than the healthcare provided by my work?  I'm single and paying $80 a month on medical alone. 

Also, what's to stop my employer from dropping our health care? 

Nope, all that was swept away. Rate setting is based on age and tobacco use and these have relatively strong controls on how much extra can be charged. Sex and other health conditions are no longer allowed as criteria for rate setting.

The penalty for non-insurance is $95 the first year, $325 the second, and $695 the third. There are waivers for the non-insurance penalty if insurance costs more than 8% of your income.


It's extremely unlikely it would be cheaper. Even for a 20 year old, the cheapest plan locally in the exchange is $180 a month. $80 is lol cheap. I seem to remember something about being able to drag your employer subsidy to buy insurance in the exchange if your insurance sucks, but I can't find the details. (Or it might be part of the Mass system and different in the ACA.)

Right now, there's nothing stopping an employer from dropping insurance. Under the ACA there will be a $2000 penalty for each full time worker who isn't covered. A lot of people are predicting that employers will stop offering insurance, but they predicted that here in Mass too and it just didn't happen.

So, if you've never had insurance and at age 42 decide to suddenly get some...  your cost will be the same as a fully preventive-PPO insured 25 yr. old who just decides to switch carriers?  I find that hard to believe.

Well they aren't doing it out of the goodness of their hearts. It's part of the law.

Through the Mass health connector: 25 year old $227/month -- 42 year old $280/month. Difference is for age only, not previous coverage. That's for a "bronze" low end (Pay 20% hospitalization up to $5k out of pocket annual limit) It could go up to $394/$485 for a Gold plan (no deductables, $150 hospitalization copay)

There are also special plans for age 26 and under that would go as low as $180 without prescription coverage or $207 with.

Subsidies for an individual start with an income below 34,000.

As I understand it, the whole point of the "individual mandate" of the ACA is to move towards a model where everybody is insured (it's required, there are subsidies, there are penalties, etc), at which point (in theory) there aren't people who've had no health coverage for significant portions of their life, etc.   Obviously there is a transition period, but it seems like a reasonable step in the direction of universal healthcare, something people take for granted in much of the civilized world these days.

Numtini -- that Mass exchange site is pretty good.  The better silver plans or cheaper gold plans seem in line with or are a bit less expensive (for similar coverage) than what I'd be paying for the healthcare provided by my employer if I left and took advantage of COBRA. 

My wife and I struggle to pay for insurance on our son. A couple hundred extra a month would strangle us. I am hoping competition really does make it more affordable. Otherwise It looks like the penalties will be cheaper.

If you have "affordable" care from your employer (which is defined as less than 9.5 percent of your income) you most likely won't be eligible for the exchange.

As stated above, the employer gets hammered by penalties. All employers over 50 employees have to offer affordable coverage to their employees or get fined (it is more than 2k a year last I heard. The number I've seen thrown around is 250 per month).

They removed individualized rating (well, more like severely restricted it), so that goes a long way to eliminating those types of differences.

The non coinsurance bronze plan is better and cheaper than what I get as a municipal employee. (Of course not cheaper than my share of the employer provided plan.)  

Wow, I thought when our rates jumped to $360/mo (half subsidized by employer, so $720/mo) and they slashed benefits, we were getting screwed. Turns out it's 'affordable'. About twice as expensive as the last plan and copays went from 0/20 to 30/50 (and little things like only two dental visits a year covered vs four under teh old plan, I go 3x a year, so it's another $120 or so out of pocket). And it went from covereage through retirement to nothing after retirement. That when I sat my boss down and told her we were going to have a talk about unionizing.

I know this isn't about the politics, but I don't post in the politics forum :) Our personal plan is to move to a country with socialized health care at the first possible opportunity. We're just in a general disgust of the idea of for-profit health care and consider it a basic human right more important than say, gun ownership. Sure, it would raise taxes, but would it raise them more than what you pay for insurance? Would the abolition of insurance companies (another abhorrent concept, people paid to find ways of not paying for your health care...ghoulish) not be the first step toward better healthcare?

Sorry, as I said I don't post 'down there', but this issue so is extremely repellent I can't help it.

It becomes a trade-off, Sky.  Affordable routine care vs access to specialized care.  While I'm not a huge fan of health care being a for-profit industry, it does have a few benefits... particularly if you are wealthy enough to afford the best services.

I also want to thank Abagadro for doing this.  I've read the ACA twice and much of the language makes it tough for me to wade through.  I can see some good in the intent of the bill, but the compromises made along the way to passing it made for an overly cumbersome mess.

That's not that bad. We are self-insured (so there is a very low admin fee and no "profit" involved) and our insurance is over 1k per month per employee.  A lot of employers on private group plans are paying 1100-1500 per month per employee.

Nebu's right. There's no question that if you can afford the best of American health care it's better than what you would get in Canada.  Not necessarily because the US gets better outcomes but because that extra money pays for way nicer rooms with lots of attentive nurses and half decent food.  In Canada if you don't have a family member around to make trouble things can get kind of awful.  That's why so many of the Canadian 1 percenters go down to the States for surgery.

On the other hand the worst Canadian health care is a hundred times better than what an uninsured American would get.

I forgot we had so many wealthy people on f13.

Maybe I'm not 1% enough (and this is probably political), but I took care of a Canadian friend who had cancer and the care was superior to anything I've experienced in the US.

Really? Maybe things have changed. I visited an aunt down in the US (Arizona) twenty years ago and her care was awesome. Dozens of nurses on her floor, a nice bright private room and what seemed to be good care. At least she recovered and lived 15 more years after. My experience in a Canadian hospital was much more recent and much more dire. Horrendous food, not enough nurses, grey dismal rooms etc. My mom recovered so I have no complaints about her actual cancer treatment but if my brother and I hadn't been around to make trouble she'd have been totally ignored except for a daily diaper change.  Even with us trying to make sure she got attention she came home with a bedsore that hasn't healed to this day.

But maybe that particular Canadian hospital was just shitty.

edit: Sorry. I'm taking this thread way off topic. I'll shut up now.

Stay on target!

I didnt. Donation drive is still below goal.

Not sure if serious but..

We do have a good number in the upper 75% (even if they don't realize it) and a few of the 1%.

Bear in mind, that 80 dollars a month may or may not be the actual, full cost of your healthcare. Because they get a tax break for it, employers often more generously fund benefits rather than offer higher salaries.

I think my company pays some sizeable percentage of my insurance for me -- so the rate I see (the X a month I pay) is actually not the full cost. Which is why going on COBRA (Is it COBRA? CORBA?) can be such a sticker shock,

Before this thread goes the wrong way, I wanted to thank Abagadro for taking the time to share information with those of us that had trouble understanding the ACA. By us, I mean mostly me, because I didn't understand any of it.

All this thread makes me think is I need to start asking for job advice and get out from under the poverty line.

Weren't we over goal last year?

That was to fund the servers.  This is to fund Schilds coke habit redesigning F13.

And has already been noted, the 1% here might have donated more if Schild hadn't so effectivly convinced a large amount of people to drop half a grand on a vaporware fake internet card game shortly before asking for donations.   :awesome_for_real:

FWIW, most of my friends who are in the dirt poor young person category just get insurance--in both cases I can think of they were also signed up when they went to the emergency room right on the spot. That's the medicaid expansion part. The subsidized plans are supposed to be for "middle class" people who may not be able to afford the entire thing, but if you can't afford any of it, you don't get saddled with a fine. Again, this is Mass where the state government was dedicated to making the plan work, not scuttling it YMMV. But for what it is, it's really worked out well in Mass. It hasn't seemed to turn into any sort of burden.

The burden will be on the healthcare industry itself when the countless masses all of a sudden start showing up to have their health problems addressed because they can't be barred at the door anymore. 

But that's a topic for the next presidency  :why_so_serious:

Again, we've had the system for several years. It really has been a non-event. It covers more people, but it's not perfect and people still end up in bankruptcy for medical problems.

The timing of Hex was... depressing.

Yup. Hence why we do not need a donation drive for servers this year. They're paid through next September.

My fucking pissant backwards state is trying everything they can think of to not set up an exchange, so finding out any goddamn information on our particular situation is MADDENING. I think we'll end up with a federal exchange (which I'm actually ok with since it means these backwoods inbred wookiefuckers don't do everything they can to scuttle it) but my biggest problem is finding out any real information on the subsidies we'll get for buying on the exchange. According to my tax preparer, we should get enough that it'll be totally paid for by tax subsidies, but who the fuck knows? Certainly not the assholes in charge of setting the goddamn thing up.

It could be just me not knowing where to look, but information here in Florida has been extremely scarce if not hostile when calling around for information.

They complicate it even more than that.  If you have more than 50 full time equivalent (actuall full time, or part timers adding up) then you qualify for penalties if you don't offer insurance.  However, you only pay penalties on actual full time employees, part timers don't count for that calculation, and you get to not count the first 30 or so full-timers.

Then, there's two options on the penalty.  The easy to understand one is just $2000/year (in monthly installments) per full time employee, flat rate, with upward adjustments probably every year.  The other I can't remember the details, it's something like $3000/year per employee but some employees may not count.

As an employer, I'd rather offer insurance but I'm going to wind up paying the penalties instead.  We've looked into it, but the rates are just too high.  Hopefully if our state is kicked in the ass hard enough to stop dragging its feet on the exchanges, the rates will wind up at a reasonable level rather than the obscene shit we've been quoted.

So the part I do not understand is if a employer pays the penalty fee rather than providing insurance for the employees. Do the employees by default get discounted / free insurance from the state / federal exchange? Or is it the case where both end up paying? Thankfully my employer is paying for my insurance but I know a few people that are going to fall into the above situation.

If they don't create an exchange, one will be created by the feds. That's gotten delayed because so many states fiddled and diddled about deciding whether or not they were going to do their own.

Unfortunately, the small business aspect of the federal exchange seems to be something that's going to be partially delayed. As I understand it, there will be a variety of options, but you will need to choose one plan for all your employees, where the eventual aim of the small business exchange is you can offer a variety of plans for the employees to choose from on an individual basis. There's also tax credits up to 50% of the employer part of the cost.


Such a person can buy insurance in the exchange as an individual and they'll get whatever subsidies their income and family status qualifies you for. If they don't choose to do so, they are subject to the individual penalty. So yes, both would pay the penalty.

Thanks,

I figured it might be the case but I have not seen anything explicitly saying that.

Current plans are to review options, but a corporate split is definitely on the table so as to remain under the 50-employee limit.  The real question would be if the larger corp could fit under 50.

I clearly live in a Silicon Valley / Tech Industry bubble, because this talk of companies opting to pay penalties instead of insuring people immediately makes me think "who in the world would accept a job offer from a company that didn't provide health insurance?" 

People who have unemployed for a long time and just want some kind of income?

Basically 99% of the employees of my in-law's company.  They are the sort of people that opt for short-term wins.  The company had health insurance in the past, but the employees generally preferred to opt out and keep the cash so the program was discontinued.  My wife uses my insurance, and the rest of the office workers are self-insured.

To be clear, I totally understand that insurance coverage is not a given and that the vast majority people don't have the luxury of picking and choosing jobs (like I said, I'm clearly living in a bubble here), but just the idea that insurance would not be part of the standard package seems kinda crazy to me -- I'm not sure how a tech startup out here could survive and manage to hire people if they didn't offer insurance -- I've worked for tiny companies (smaller than 20 people) through pretty enormous ones (30k+ on staff) and that was never something up for debate.

I guess the "why the hell haven't we fixed this yet" debate is more politics forum territory.

 

Wikipedia'ing it quickly, 39% of workers aren't covered by employer provided insurance.

It boils down to price differences between large company-wide groups and individual insurance.  As the spread gets more and more negligible, there becomes less and less a reason to use/have company-insurance.  This ACA is the 1st step towards getting rid of bulk rates altogether I assume... and hope.  

Seriously, why should "x" person live healthier because he's got an affordable group policy as opposed to "y" person that doesn't?  The whole ideal needs to go away.

Silicon Valley has had a long history of generous employee benefits. HP was probably the first but there were other companies known for their benefits as well like Rolm and Tandem. Lockheed, which at one point was the largest employer in the valley, also had amazing benefits for employees. Things sort of stayed at that level for a while and then Google came along and raised things to a whole other level. Other companies here still can't compare to what Google provides its employees though some are trying to close the gap.

That was the idea behind the exchanges - they'd basically be a massive pool of those who just didn't happen to be a part of any of the other pools available which were usually available only because businesses wanted "offers health insurance" as a reason to want to work there.

Thing is, that's not really the business' fault.  That's the fault of unregulated free enterprise.  Broker sits down with HR and salivates over possibly getting commission on 100 employees signing up for "x" plan, offers them steep discounts as to what they'd offer joe shmo individual in his cubicle (with maybe a free trip to Tahiti for the HR gal), then HR passes that info. onto joe shmo job applicant.  Govt. comes in and is all like "oh, that's cool" let's now require businesses to do that so we can all be happy with our perceived discounts!  Now the 30%+ price gap shoots to 35% and so forth.  And upward price pressures continue.

Meanwhile there a like five brokers (including HR itself) between the applicant and the doctor, all making money off your plan.   :oh_i_see:

We provide services for developmentally disabled kids & adults, and get our reimbursement from the state for 90% of everything we do.   Medicaid doesn't reimburse us enough to pay more than $200-250/month in premiums before we lose money on the deal, and it was only after the state got sued last year that they started reimbursing at a rate high enough to allow for that.

Right now, some of those funds go to employees to help defray insurance costs if they have their own insurance, the rest is in a pool (and getting taxed) while we figure out where to go from here.  If the costs get down into that $250ish range, then it's insurance time for all.  As it stands, we've got employees who would cost anywhere from $300 to $1000 a month in premiums.

Edit to add:  the irony is thick on this one; the people we serve all have coverage.

 :heart:

I worked for KenO, he was such an awesome guy.

Man you are old (in Silicon Valley years) :awesome_for_real:

There are so many variables and wild theories flying around that I frankly have not the slightest clue what the end result is going to be for our medical system.  On the one hand, I hate the everloving fuck out of insurance companies.  On the other, anything done by the government is riddled with idiocy and corruption.  While my hope is that this leads to a new, more reasonably priced healthcare system where hospitals don't charge $90 for aspirin, I'm having a hard time working up much optimism.  Judging from Abagadro's chart thing, my premium should decrease somewhat, but that still leaves the question about just what quality service I'd be getting under the federally mandated price plan.  I managed to get screwed badly last year by picking a 1500 deductible/30% copay plan and developing a kidney stone the very next month; got stuck with a $3000 bill that I'm still paying for the treatment.

Since the federally mandated price plan is administered and controlled by a private insurance company, you'll likely get the same shitty HMO style health insurance service you would have gotten before this law was passed, only they can't cancel your policy when you get sick or deny you coverage because you are overweight or have some pre-existing condition.

But they can certainly charge you 2 or 3 times as much as before.   :awesome_for_real:

The plans offered in the exchange have to meet certain requirements and are basically exactly the same plans from the same insurance companies that you'd get from an employer.

The big thing with me is if I'll be able to hop onto plans put together by independent unions/groups in other states, such as the big one up in NYC that single-mom started (I forgot the name of it).  Under current laws I'm wedded to my state's rules, which is to fuck over labor as much as possible especially if you're self-employed.  With ACA, will I be able to latch onto these big self-insured groups??

No, I think you still have to buy it in the state you live in. I don't think you are allowed to venue shop.

This is true, but it's been pretty commonplace to see those premiums and deductibles rising as well.  Some of my staff who have policies with their husbands' work have seen their deductibles and monthly fee rise by 50-100%.

Well I didn't work for him at ROLM. Although, I do have a certification lying around somewhere in my office to support ROLM phone switches.  :why_so_serious:

So, I pay something like $43 per pay period - I have no idea if this is good or what, but I was pretty much forced to buy a premium plan in order to handle things like translating foreign medical bills and such.

If you aren't paid weekly, it doesn't sound like a bad deal.

--Dave

Hell, even weekly that is spectacular for a premium plan with a reasonable deductible.

Whats Premium? What is your pay period?

Last job I had that offered insurance it was like $130 a month for the shittiest of shit coverage. Like $50 co-pays on routine visits, 80/20 for most services, 5k deductible, and that didn't include vision/dental. This is off the top of my head from paging through the flyer 3 years ago, so I could be way off.

But yeah. You probably have a god tier price to service ratio.

The deductible is a huge issue.  A 5K deductible is going to destroy 85% of the US working population financially.

Yeah, however they are much more affordable (assuming you don't actually use it :why_so_serious:) than the low deductible plans.

Here in Silicon Valley the trend for small startups is to switch to these high deductible plans for employees but then setup HSA accounts for employees that the company funds. In many cases that turns out to be cheaper for the company than going with a low deductible plan and no HSA.

Here's what I expect: Young, healthy people will opt for high deductible plans or bypass the system by paying the penalty (if it's less than a high deductible plan) if they aren't covered by workplace insurance.  This will defeat the purpose of mass coverage as it won't provide the necessary buy-in to reduce the costs of care for everyone.  It's a design flaw in the ACA brought about by compromises required to get the thing passed.

It's a steaming pile of shit. 

Sorry, I misquoted myself - it's about $86 every two weeks, pre-tax.

Here is my plan - I'll let one of you more-enlightened folks tell me how much I'm getting ripped: http://www.fepblue.org/benefitplans/standard-option/medical-benefits.jsp (http://www.fepblue.org/benefitplans/standard-option/medical-benefits.jsp)

It provides revenues, which flaw or not is better than nothing.  Cost reductions will be determined by how those revenues are spent of course.  Which in GOP talk means cut taxes to make up the difference.   :oh_i_see: