Obamacare 101

If you receive health insurance under the Affordable Care Act (“ACA”), Obamacare, you already know that it has all of the elements of a corporate scam.  If not, the jury would seem to still be out.   I’m here to tell you that the verdict is in.

I have a politically progressive friend who reads the Wall Street Journal every day.  He argues that the ACA has been a great step forward.  It covers millions more uninsured Americans than ever before and is beginning to rein in runaway medical costs.   As a participant in the ACA, and no fan of the Wall Street Journal, I can tell you from direct experience how closely Obamacare resembles an insurance industry scam.  

On the plus side first, it can’t be denied that eliminating the loophole of “pre-existing conditions”, the term that enabled American health insurance companies to deny insurance if you were ever sick with a particular disease, was welcome, and long-overdue.   There are other good features, no doubt. The perfect should never become the enemy of the good, as the president has said, but for the most part the ACA, that great free market compromise with comprehensive health care reform written primarily by and for the insurance industry, profits mainly that industry.   Like many other boons applauded by the Wall Street Journal, it involves large profits for the canny few at the expense of the clueless many.  

The opacity of the 900 page ACA is one of its most notable features.  If your rights and remedies are hard to discover, most people pay the bills they are sent and kiss their rights and remedies goodbye.

New York State set up a Health Care Marketplace at the earliest possible date.   We were all in for Obamacare.  Visit the New York State of Health website and you will marvel at the opacity of the consumer-friendly system.  From the difficulty of signing in (that’s called Get Started, by the way, no matter how many times you’ve already gotten started), to the lack of easily navigable plan details, to the absence of a clear statement of what the ACA is, or what it guarantees, to the almost completely useless help number (“we are experiencing more than the usual volume of callers, your business is very important to us”) you will see enough to discourage the casual seeker of health insurance from persisting there.  Also, enough to deter anyone looking for the rights guaranteed by the law in clear, unequivocal language.

“Preventative services are 100% covered,” the helpful woman at the NYS of Health assures me, after only 35 minutes on hold.  I ask her where I can see a list of these covered services, since I’ve already paid $150 in co-pays towards my recent colonoscopy and am being dunned, and threatened with collection letters, for an additional $281 connected with this preventative service.   She isn’t sure where I can find that language, the NYS of Health Marketplace only sells the plans, they don’t actually administer them or oversee the individual insurance companies.  

This particular woman is great, sympathetic, smart.  I kick myself that I did not get her name.  We look together for language that says I’m entitled to have my colonoscopy paid for 100% under the ACA, for my $471 monthly premium.  I find, several screens later, in only 4 or 5 clicks, this page, under Resources, and on the pull-down menu there’s a link for Using Your Plan, that eventually takes me to this, at the bottom of that page:    

Sep 26, 2013

Covered Benefits and Out-of-Pocket Costs for 2014 Standard Health Plans

And I read, under What Are Essential Health Benefits, number 9, the closest I will find to any kind of confirmation of this seemingly simple yes or no fact that preventive services are not subject to any deductible, to wit:  

Prevention & wellness services and long-lasting disease management

“You are entitled to be repaid that $150 you already paid for a covered service.  If your insurance company is making you pay any fee in connection with a colonoscopy they are not in compliance with the ACA and you should hold their feet to the fire,” this bright woman, a former health insurance industry appeals expert, tells me firmly.  

She informs me, in answer to my question, that the Department of Financial Services (“DFS”) is the state agency that holds insurance companies accountable for compliance issues.  She gives me their 800 number (800-842-3736  M-F 8:30-4:30).   I ask why there is no information about that on the NYS of Health webpage. They are discouraging frivolous complaints, she explains, since so many people are having problems with the ACA.  Not publishing the complaint number reduces the amount of angry callers making unfounded complaints before they have followed up with their individual insurance plans to make sure the insurers are out of compliance before calling DFS to lodge a complaint.

Makes me think of President Obama’s laudable campaign promises about transparency in government, protection of whistle blowers, and robust protections for consumers. Clear knowledge of one’s rights, after all, is a precondition to exercising them.   Few things are more important to the proper functioning of a just and accountable democratic republic than government transparency.   Few things are more useful to exploiters, despots and profiteers than the secret concealment of devilish details that might galvanize righteous opposition.

I recall the president’s campaign rhetoric and think of the Obama administration, the most opaque in our history, whatever else one might say about it, and my jaws clench. And I have to say, between Obama and Bush, dealing with the latter is much less soul crushing to an idealistic citizen than listening to the glib eloquence of the Equivocator in Chief, great lover of justice and defender of the common citizen that he is.




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