Don't know whether to laugh or cry. As a disabled Veteran, my health care is covered by the VA which good...when you can get it and with cuts and vacancies in the staff, that's a real adventure. Anyhow, back to my point. Indeed, Biden was able to get and extension with retroactive coverages. But, and it's a big but, he had not gutted the agency if people capable of implementing it! Do we still have that capacity? Hey MAGA, when was the "great" you want back, and what did it consist of? Do you honestly believe we're working towards anything that resembles "great"?
Incidentally, comparative-developed-country wise, it can't hurt to remind us here in the U.S. that our problem with fear over health insurance is rather unique.
The YouTube algorithm brought me something from DW (in Germany) where a U.S. expat in Germany says paying for healthcare is just completely different over there vs. here, and people just don't worry much about being unable to pay for it.
To represent the U.S. side in the comparison, we have this Jonathan Cohn post, the comments here, and about half of the other Jonathan Cohn posts, and the comments on those.
Nonetheless, I don't mind beating a dead horse, and being redundant with a sarcastic comment of mine down below:
In the U.S., for many, no matter what happens, and it will be more so if the expanded subsidies are allowed to lapse, or One Big Beautiful Bill (OBBB, Hakeem Jeffries now uses "One Big Ugly Bill") holds:
"I mean, people have access to health care in America. After all, you just go to an emergency room.".
Reminder: The emergency room will treat you to the point of medical-stabilization only, which they have to do because of the Reagan-era EMTALA law. (You are still legally-responsibly for the bills, and many hospitals will collect on that debt.)"
This comment is for an important completeness, and at the risk of distracting us from the current task that the Republicans have brought on us, which is to not go backwards, and have the U.S. health insurance system get worse.
(The current task is to reverse both the expiration of the expanded subsidies, which expanded subsidies included a fix of an initial ACA defect--the 400% of Federal Poverty Level (FPL) "subsidy cliff", and to reverse the provisions of the recent One Big Beautiful Bill (OBBB), which actually is larger in both numbers of people to become uninsured, and number of dollars, than the expiring expanded subsidies, but has been less-clumsily timed by the Republicans to start Jan 1, 2027 instead of Jan 1, 2026.)
There are other problems with the ACA that also need mending. They are state-specific problems, that is, they depend on how each state implements the details of the ACA, both on its own exchange (if it has one) and at the state Medicaid department (which all states have).
One problem needing to be fixed is that, in many states, there is an estate recovery of expanded Medicaid for people 55 or older when they had the coverage.
A second is that there can be poorly-thought-through administration of the ACA and/or Medicaid and expanded Medicaid, with various problems, including frequent thrashing of people up and down between the ACA on-exchange and expanded Medicaid.
I describe these in more detail here:
--
Problem 1) The fixable problems with the current ACA, least discussed in the media, even the New York Times and Washington Post, is that, in some states, ACA expanded Medicaid (and other non-long-term-care Medicaids) can be estate recovered, at least for people who were 55 and over when they had the coverage.
I’ll cut and paste a bulleted item from just a bit of the ways down, which should make the precise issue clear:
“For individuals of any age, medical assistance paid by MassHealth for long-term care in a nursing home, Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID), or an Institution for Mental Disease (IMD). For former MassHealth members with a date of death before August 1, 2024, MassHealth is required to recover the total cost of care it paid for members after they turned 55.”
Within that quoted two sentences, that last sentence is the issue, fairly precisely stated.
In Massachusetts (that’s my state) there was a change, 10 years late (in my opinion) in 2024. They trimmed back the estate recover on Medicaid to the minimum federally required.
But the pre-2024 status in Massachusetts is the issue. (Think of it is that a state now is following the Massachusetts recovery rule, but it’s currently the one that Massachusetts was following between 2014 and 2023).
(Note MassHealth means Medicaid, including ACA expanded Medicaid.)
We don’t know if the state will go after a capitation, or all medical bills paid out. If it’s the latter, the person doesn’t have insurance at all, but rather they have a loan until death for medical expenses.
(In Massachusetts, at the other end of the phone when I had expanded Medicaid, a person told me an insurance company would decide the network and the amount of the bill to pay, but the payment would be made directly by the state. If that's true, then I had no insurance at all, but a loan until death for medical expenses.)
So, this can be fixed by federally prohibiting the estate recovery of non-long-term-care Medicaids.
(I am, frankly, not sure the economists who designed the ACA were aware of this issue, and even are now. I don't know if the two economists who wrote the newsletter post above are aware of the issue, or haven't dismissed it, in my opinion quite erroneously, as unimportant.
One might dismiss it as unimportant by saying, oh, it's only poor people with no assets to lose. But, besides the discounting of the savings of poor people being a problem, it's not just poor people. Expanded Medicaid has no asset test. People with substantial assets frequently wind up on expanded Medicaid. For example, early retired, or while pausing working for a bit. Especially since some Medicaid agencies apparently re-evaluate income frequently, and may use income for a period much shorter than annual.
As well, the notice of the estate recovery can be missing or inadequate. In Massachusetts, it was buried in the middle of a list of 20 items, which all seemed benign--like "we'll check with your employer to make sure you are not cheating...".
In the end, when I finally found out about the estate recovery, I was able to switch to paying full price for on exchange. Because eligibility for expanded Medicaid precludes eligibility for a subsidy on on-exchange. That was OK for me, due to my own finances, and the relatively low raw premiums in Massachusetts, due to the pooling of small-group and on-exchange. But, in some states, it's like $40,000 a year for a couple, and that would be a big problem for many people.)
I do know that in 2014, the Obama administration asked the states not to estate recover expanded Medicaid, but many, including Democratic ones, chose not to comply. (See:
Though, after early coverage in 2014 in some newspapers, leading to many states fixing the problem, many did not, and I believe even some Democratic states, such as NJ and MD, do still recover expanded Medicaid. And Massachusetts took 10 and a half years to fix it! Actually, only by the accident of one state legislator having to leave office because of a sort of a scandal, and another one replaced him, and saw the problem, and worked to get it fixed. (Sen. Comerford, the person replacing the one who had to leave, working with Rep. Barber.)
References on problem (1):
I point to an archived version of the Wikipedia article on Medicaid Estate Recovery, from around 2020, when yours truly (me), put the info in.
(I believe the live article still has the same content. But I gave the archived link just in case.)
(The link may or may not show up at bottom—I don’t know what substack will do)
Note the article is not up to date, so, for example, it is missing the Massachusetts repair in 2024.
(It has those flags in their from one other Wikipedia editor. I had a lot of trouble with Wikipedia from two other "editors" (who knew not a thing about health insurance), and even though a flag on unreliable sources is no longer applicable -- I had had some blog articles giving the flavor from some "The Democrats want to confiscate poor peoples" stuff assets", those are out. But I didn't want to remove the flag on unreliable sources, for fear that the whole article might get pulled from Wikipedia.)
Note that every assertion in the article is supported by references, though you may have to go to the Wayback archive for some of the references, whose live links have disappeared.
(I am allowing long-term care recovery as O.K. because the ACA does not attempt to fix our serious long-term-care financing problem. The ACA has left long-term-care as a problem for another day. But, for other than long-term care, it should be providing (real) health insurance with affordable premiums and copays to everyone. "Real" means not just a loan!)
--
Problem (2): Some states, including Massachusetts, seem to thrash people up and down between expanded Medicaid and on-exchange plans, based on the state insisting on income rederminations or FPL adjustments.
This was my experience in Massachusetts, with my 9 years of ACA coverage from 2014 to 2022.
So, for example, one time, in about April, I get about 5 days notice that my on-exchange plan was being terminated, and I would then be on expanded Medicaid. What was the trigger? It took a lot of work to find out, but it was that the number they were using for my income, just a tiny bit over 138% of FPL, had become just a tiny bit below 138% of FPL, owing to changed FPL cutpoints, which changed midyear.
This same thing happened a second time, one year, around Nov 1 at open enrollment time. New income. It was either a quick thrashing up or down between the parts. I forget which. Then, they tell you send in proof of income. They will estimate next year's income however they choose, and they won't tell you in advance how they will estimate it. Another potential thrashing.
(On the Massachusetts ACA site, responsible for both on-exchange and expanded Medicaid enrollment, there is a big notice saying something like "tell us in the future any time your income changes".)
I don't know how often they might redetermine income in Massachusetts. Perhaps, if you had non-steady work, and did what they told you, and told them whenever your income changed, they might thrash you up and down as often as every month. Or even more often. Don't forget: new medical network each time!
(For my latter thrashing, I actually had a serious illness, and might have needed to be hospitalized. I didn't appreciate the changed network at all.)
Maybe there is some what to fix this in a changed ACA law, or with regulations and standards?
I've had to add a bit more as reply to this comment, owing to comment length limit.
I have a suspicion, besides that some of the policy people at the top of both designing and maintaining the ACA may not know about these problems (because they are a bit down in the weeds) and may feel it is administrative stuff, a job for people at the state level. Not their job.
No, it is their job. The states, many of them, at least, have, and will continue to screw it up unless you make it damned near impossible to screw up.
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Additional reference about both issues in Massachusetts:
I have kept around a reference to the paper version of the Massachusetts joint on-exchange ACA and expanded Medicaid application for 2019, which is a period when I was using that coverage, and when the estate recovery on expanded Medicaid was in effect.
On adobe pp. 22-23, there is a long list of conditions, that, on the Massachusetts exchange website, popped up on a screen after you put in all of your household information.
So, in that list, way down at items 9 and 10, past other benign-looking items if you're not going to cheat,
"9. To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If MassHealth puts a lien against such property and it is sold, money from the sale of that property may be used to repay MassHealth for medical services provided.
10. To the extent permitted by law, and unless exceptions apply, for any eligible person age 55 or older, or any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth will seek money from the eligible person’s estate after death."
So, I think I've made my point about the estate recovery on expanded Medicaid, and other non-long-term-care Medicaids, having been easy to miss.
I might as well add another point: with that "to the extent permitted by law" business, it means after you've gone through putting your information into the exchange website, you have to stop. Find a specialist attorney, and pay them figure out what, exactly, is the extent permitted by law. Before the end of open enrollment.
As well, my other point about the exchange requesting you notify them as soon as there is any change in your income is well made by item 11:
11. "Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons can make changes by calling (800) 841-2900, TTY: (800) 497-4648 for people who are deaf, hard of hearing or speech disabled. A change in information could affect eligibility for such persons or for persons in their household."
By George, with this addition, I think I've done a very good job of documenting the two problems, if I am allowed to say so myself!
I will be happy, of course, to answer any questions posed in the comments.
I look forward to millions of red state Republicans losing access to health care, and even more importantly having to make difficult choices between their health and being able to afford housing and food. I am looking forward to this because I believe in a democracy the people deserve to get what they voted for, and get it good and hard.
I equally look forward to millions of American farmers explaining to their neighbors why they got billions of dollars in subsidy because Trump vaporized their farms profits, but their neighbors lost their healthcare because it was more important to hurt everyone else.
Today was the last day to enroll (or change) for Jan. 1st coverage, and I had to change my plan (in a red state.) Last year the ridiculously high subsidy was $2200, which covered the cost of my "silver" HMO plan. It went up to $3000 for 2026, and my plan went up $1500! So I would have to pay $700 per month for health care!
Wow!
I live on Social Security, a very modest income. No other pensions. So $700/month is a lot.
Fortunately there were two providers with "bronze" plans which came in under the $3000 subsidy. I'm sure I'll be paying a lot more in copays and out-of-pocket expenses, but I'm sure even going without medical insurance, my costs would be less than $700/month.
Welcome to America, where we may have the worst health care system in the developed world, but at least we can take pride in it being the most expensive!
The subsidies help a lot of people, but they hide the real problem, which is that health insurance should never cost anyone $3,000 a month. As a U.S. citizen living in a country with single-payer, I can tell you that even services paid entirely out of pocket are 60 to 90 percent cheaper than the equivalent in the U.S. There's an "affordability crisis" for you. Maybe the silver lining of the subsidies ending is that things will get so absurdly bad that the U.S. will finally be forced to scrap the system and rebuild it from scratch instead of wallpapering over it every couple of years.
1000%. The truth is that the insurance industry has been profiteering from the ACA, and the enhanced subsidies. We have to see that. The R's are not wrong in that assessment. And I agree, it may take this crisis to understand the fundamental problem. We have to come to terms sooner or later that healthcare should not be a profit making industry. Once we've finally swallowed that concept, the rest may be relatively smooth sailing. But too many are choking on the entire notion of healthcare for all, as a human right. That's the thing we just cannot agree on.
This is the whole reason that the insurance industry bribed Manchin, Biden and others to deep six the public option in the ACA. The point of the public option was that it would ensure that the insurance companies couldn't simply profiteer off of the ACA, and Biden killed it. Which is why you don't let the old white guy from Delaware negotiate your signature legislative achievement after he bailed out the banks and left the rest of the country to lose their houses.
This should be a major problem for Massachusetts. Everyone must be enrolled in a plan, and proof of insurance is required with tax returns. A lot of people are going to take the lowest plan, which the state offsets with Medicaid money. Insuring all these people will be a massive drain on the stat’s budget.
Thanks for your info on the do-ability of an extension retroactively, based on the mid-year 2021 example of when the expanded subsidies initially were passed into law. (I had not realized they were mid-year.)
(I had assumed an extension now would take many months, given especially that there are 21 state exchanges, some of which have much less resource than the much-larger federal exchange would have.
For people who actually are short the cash to pay in full for a policy at very-much-higher non-extension rates, say some people in the over-the-400% FPL subsidy cliff case, I imagine there could be a number of months of a coverage gap, still.
Thinking about the terror a coverage gap would cause for me, I hope those could somehow be avoided. And, of course, we need the extension first!)
It isn't just the subsidy people who are getting slammed! We make too much as a family to get any subsidy. However, as a retiree, my corp. backstop Medicare Advantage Plan premium given as a benefit by the company I worked 30 years for, my share of the premium going up 38% this year. My younger spouse, self-employed so must buy plan on the ACA, and two kids, our plan is going from $18k to 27K this year, again up 38%. While they also increased the family out of pocket max from $7 to $14k! Thanks so much! We have one F-ed up healthcare system in the US! We are lucky as a family to be able to afford all of this! (for now)
There are plenty of issues with how healthcare is administered in the US. The ACA fixed multiple problems, including "denials or high cost with pre-existing conditions", "risk pools", and reducing some of the opacity of the entire supply chain. It also recognized the primary concept of insurance -- the bigger the pool of the insured -- premium payers -- the more resilient coverage can be -- the individual mandate. (That concept tossed by the Tax Cuts and Jobs Act in December 2017).
There are meaningful reforms that could improve coverage, reduce costs, ferret out fraud, and reduce products and services pricing opacity. Discussed in some circles since before the ACA was passed, and certainly in the past year. Much of what is proposed by the GOP is just chipping away at the edges when the larger issues still remain. For one, cutting IRS staffing and budget? (For anyone who receives APTCs the annual tax return is where the real action takes place with adjustments for income over the poverty line calculations).
Mike Johnson? This from October 28, 2024: “Health-care reform’s going to be a big part of the agenda,” Johnson said, wearing a personalized jacket emblazoned with the Trump-Vance campaign logo. He added that a caucus of Republican physicians has shared proposals with him and that GOP leaders hope “to take a blowtorch to the regulatory state” and “fix things.” “No Obamacare?” an attendee asked the speaker, invoking the term popularized by Republicans to describe the health law. “No Obamacare,” Johnson responded. “The ACA is so deeply ingrained, we need massive reform to make this work, and we got a lot of ideas on how to do that.”
So the only real thing on the GOP radar is to cripple or repeal the ACA. It can be easy to maintain the tax credits for a year or two (also politically expedient!) while working on improvements. Over and over, the GOP has shown they are not serious people working on serious issues of concern to their own constituents.
They could, but they won’t, because they’ve wanted to kill the ACA for 15 years and their ideology is to kill every other social program as well. Social Security and Medicare are next.
I look forward to watching Republicans pour Social Security into the crypto market and then pump and dump it themselves. The funniest part is that their voters will still vote for them after they steal billions from them.
Waste, fraud and abuse. Isn’t that what the regime said animated its “cost-saving” measures? Well, we all know that the real waste, fraud and abuse come from this regime. Throw in chaos and cruelty and you have its playbook.
Even if Congress manages, somehow, to pass retroactive legislation, millions of Americans will not be made whole. They may recoup some (badly needed) money. But the needless worry and anxiety they experience at the hands of an abusive regime will leave lingering effects. How can the Republicans not see that their inaction will result in major backlash in the midterms? Well, some of them apparently do get it. It’s just too bad they are too timid to introduce—and ensure passage of—a meaningful approach to fixing the problem at hand. They can argue for their so-called “reforms” later. In the meantime, they need to put an end to this torture of the American people, many of them their constituents.
Mr. Cohn brings up that there just might be some resolution extending the expanded subsidies, possibly before Xmas, knocking out those cases of like a couple, age 62 with an income a bit over the returning 400% of Federal Poverty Level (FPL) "subsidy cliff" of say $88,000 a year
having a premium jump from about $6,000 a year for 2025, to $25,000, $30,000, $35,000, $40,000 (WY) or $50,000 (WV) a year with higher deductibles and out-of-pocket maxes as well.
Let's hope for that quick resolution.
Just in case it doesn't happen, I bring up that I have been poking around the various websites where tips, comments, and ideas are exchanged for the coming Xmas gatherings of family and friends.
Apparently, there is some realization that some of the guests present will be facing a loss of health insurance less than 7 full days after the gathering. There has been some discussion on the websites of what special things, in light of this, might be appropriate to have for the gathering.
I'm looking for ideas on this, and if I see any good ones in reply to me here, I will certainly get them on the Xmas-celebration sites.
I have also, from the sites, found some I can offer for people reading here:
1) Medium-sized bowls of quick-acting antidepressant drugs ,
2) Large bowls of heavily-spiked bunch, with a paper sign attached to the bowl, with, written in festive glitter, "Forget About Today Until Tomorrow" ,
3) Notes at each place setting, hand-written before the dinner, by the children at the event, in crayon on the front, saying
' "I mean, people have access to health care in America. After all, you just go to an emergency room.".
-George W. Bush, 7/10/07 ' ,
with, on the back of each one, in type (pre-printed by the hosts the day before the event):
Reminder: The emergency room will treat you to the point of medical-stabilization only, which they have to do because of the Reagan-era EMTALA law. (You are still legally-responsibly for the bills, and many hospitals will collect on that debt.)"
Can I recommend a nitrogen bottle (from your local welding supply) with a CPAP machine attachment, for when you are in pain and something is clearly wrong with you but you can't afford to go to the hospital?
This is what I sent to my US Rep and Senators: "Hello, I am a member of the gig economy. As a professional classical musician, I've always worked multiple jobs and worked very hard to make a living and be a responsible person. The ACA allowed me to get affordable health insurance. I anticipated that there would be a huge increase because of the roll-back on the Covid subsidies. But I did not expect that the ACA subsidies would be completely GONE. My Silver basic plan went from a monthly premium of $64.45 to nearly $900 per month for 2026. I looked up my IBX Silver basic plan to see what it would cost if I bought it directly from IBX and it was about $900 per month.
So I have downgraded to the Bronze plan, but that is still nearly $600 per month. I am 56 years old. I'm not sure where I'm going to get an extra $7000 this year - PLUS my doctor visits and medications will be much more expensive.
It is clear that the Trump Administration and the GOP in Congress hate me and all constituents like me. I still can't believe that this is the same USA that I grew up in. What's the plan to help Americans like me??? Thank you."
Just remind them that its people like you that protect them from people like Luigi who rightly believe that guillotines are a more effective solution to their problems with American politics than letters to their representatives. It would be a shame if more people realized that their representatives are profiting from the misery of their constituents and started believing that the American Revolution was founded on actual representation and human rights and decency, and it might be time to remind our government officials of that.
Jackie, Please share any responses you receive. I am so sorry for what the controlling edifices of government has decided to do - or more correctly, not do for their citizenry.
The Republicans don't want people to have job security, claiming that a flexible and job-mobile workforce is the thing to make an economy efficient. Gig workers and contractors would seem to be their ideal, and yet they're opposing the ACA, and especially it's provided reasonable coverage over the returning 400% of FPL "subsidy cliff", which enables Gig workers.
Tacking on a little bit on a particular set of Gig-economy people and the extensions:
There is a case I found interesting about Gig economy people, illustrated in a podcast involving substack mostly-healthcare wonk Charles Gaba (who was interviewed), and two people who do the podcast.
I listened to the podcast (about an hour long), and noted that all three participants were self-employed Gig-economy people.
And, they brought up in the interview that, since there are humongo premium jumps for many people around the returning 400% of Federal Poverty Level (FPL) "subsidy cliff" (which had been repaired for 5 years under Biden), a strategy they were heavily reliant on was trying to keep their income under the "subsidy cliff".
So we can see that this cliff, coming back, and a kind of standard feature of much U.S. sharp-edged "means testing with various "cliffs", certainly discourages work in many cases. (Make a few bucks too much, and you have to pay $15,000, $20,000, $30,000 or more extra, (after taxes!) for health insurance.
I believe all three participants do their Gig work through corporations. In that case, they would seem to have an option of not actually working less, but staying under the cliff, by having their corporation retain some of the money that came in to them, but only paying out as salary an under-the-cliff income. (This is the kind of complicated machinations that this causes.)
I'm not an accountant, but I did have my own company at one time (myself really a Gig worker, before I retired) and I believe it has to be a C-corporation, not an S-corporation. So, observing that one of the podcast hosts indicated his corporation was an S, I chimed in in the comments that I think it has to be a C corp: https://charlesgaba.substack.com/p/past-due-podcast-wana-marie-cox-and/comment/182097821 .
Oh, what a byzantine healthcare system we have created!
Incidentally, Charles Gaba did, weighing his privacy loss vs. benefit to others, lay out his own healthcare and financial situation, talking in some detail about his own "subsidy cliff" issue. If interested:
Don't know whether to laugh or cry. As a disabled Veteran, my health care is covered by the VA which good...when you can get it and with cuts and vacancies in the staff, that's a real adventure. Anyhow, back to my point. Indeed, Biden was able to get and extension with retroactive coverages. But, and it's a big but, he had not gutted the agency if people capable of implementing it! Do we still have that capacity? Hey MAGA, when was the "great" you want back, and what did it consist of? Do you honestly believe we're working towards anything that resembles "great"?
Incidentally, comparative-developed-country wise, it can't hurt to remind us here in the U.S. that our problem with fear over health insurance is rather unique.
The YouTube algorithm brought me something from DW (in Germany) where a U.S. expat in Germany says paying for healthcare is just completely different over there vs. here, and people just don't worry much about being unable to pay for it.
That's here:
https://www.youtube.com/watch?v=MNzJkMUowsI
--
To represent the U.S. side in the comparison, we have this Jonathan Cohn post, the comments here, and about half of the other Jonathan Cohn posts, and the comments on those.
Nonetheless, I don't mind beating a dead horse, and being redundant with a sarcastic comment of mine down below:
In the U.S., for many, no matter what happens, and it will be more so if the expanded subsidies are allowed to lapse, or One Big Beautiful Bill (OBBB, Hakeem Jeffries now uses "One Big Ugly Bill") holds:
"I mean, people have access to health care in America. After all, you just go to an emergency room.".
-George W. Bush, 7/10/07 ' ,
"(From here: https://web.archive.org/web/20100423045051/https://georgewbush-whitehouse.archives.gov/news/releases/2007/07/20070710-6.html
At about the 17th paragraph.)
Reminder: The emergency room will treat you to the point of medical-stabilization only, which they have to do because of the Reagan-era EMTALA law. (You are still legally-responsibly for the bills, and many hospitals will collect on that debt.)"
This comment is for an important completeness, and at the risk of distracting us from the current task that the Republicans have brought on us, which is to not go backwards, and have the U.S. health insurance system get worse.
(The current task is to reverse both the expiration of the expanded subsidies, which expanded subsidies included a fix of an initial ACA defect--the 400% of Federal Poverty Level (FPL) "subsidy cliff", and to reverse the provisions of the recent One Big Beautiful Bill (OBBB), which actually is larger in both numbers of people to become uninsured, and number of dollars, than the expiring expanded subsidies, but has been less-clumsily timed by the Republicans to start Jan 1, 2027 instead of Jan 1, 2026.)
There are other problems with the ACA that also need mending. They are state-specific problems, that is, they depend on how each state implements the details of the ACA, both on its own exchange (if it has one) and at the state Medicaid department (which all states have).
One problem needing to be fixed is that, in many states, there is an estate recovery of expanded Medicaid for people 55 or older when they had the coverage.
A second is that there can be poorly-thought-through administration of the ACA and/or Medicaid and expanded Medicaid, with various problems, including frequent thrashing of people up and down between the ACA on-exchange and expanded Medicaid.
I describe these in more detail here:
--
Problem 1) The fixable problems with the current ACA, least discussed in the media, even the New York Times and Washington Post, is that, in some states, ACA expanded Medicaid (and other non-long-term-care Medicaids) can be estate recovered, at least for people who were 55 and over when they had the coverage.
In case you or readers are not familiar with the issue, I link to the Massachusetts estate recovery page https://www.mass.gov/info-details/massachusetts-medicaid-estate-recovery
I’ll cut and paste a bulleted item from just a bit of the ways down, which should make the precise issue clear:
“For individuals of any age, medical assistance paid by MassHealth for long-term care in a nursing home, Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID), or an Institution for Mental Disease (IMD). For former MassHealth members with a date of death before August 1, 2024, MassHealth is required to recover the total cost of care it paid for members after they turned 55.”
Within that quoted two sentences, that last sentence is the issue, fairly precisely stated.
In Massachusetts (that’s my state) there was a change, 10 years late (in my opinion) in 2024. They trimmed back the estate recover on Medicaid to the minimum federally required.
But the pre-2024 status in Massachusetts is the issue. (Think of it is that a state now is following the Massachusetts recovery rule, but it’s currently the one that Massachusetts was following between 2014 and 2023).
(Note MassHealth means Medicaid, including ACA expanded Medicaid.)
We don’t know if the state will go after a capitation, or all medical bills paid out. If it’s the latter, the person doesn’t have insurance at all, but rather they have a loan until death for medical expenses.
(In Massachusetts, at the other end of the phone when I had expanded Medicaid, a person told me an insurance company would decide the network and the amount of the bill to pay, but the payment would be made directly by the state. If that's true, then I had no insurance at all, but a loan until death for medical expenses.)
So, this can be fixed by federally prohibiting the estate recovery of non-long-term-care Medicaids.
(I am, frankly, not sure the economists who designed the ACA were aware of this issue, and even are now. I don't know if the two economists who wrote the newsletter post above are aware of the issue, or haven't dismissed it, in my opinion quite erroneously, as unimportant.
One might dismiss it as unimportant by saying, oh, it's only poor people with no assets to lose. But, besides the discounting of the savings of poor people being a problem, it's not just poor people. Expanded Medicaid has no asset test. People with substantial assets frequently wind up on expanded Medicaid. For example, early retired, or while pausing working for a bit. Especially since some Medicaid agencies apparently re-evaluate income frequently, and may use income for a period much shorter than annual.
As well, the notice of the estate recovery can be missing or inadequate. In Massachusetts, it was buried in the middle of a list of 20 items, which all seemed benign--like "we'll check with your employer to make sure you are not cheating...".
In the end, when I finally found out about the estate recovery, I was able to switch to paying full price for on exchange. Because eligibility for expanded Medicaid precludes eligibility for a subsidy on on-exchange. That was OK for me, due to my own finances, and the relatively low raw premiums in Massachusetts, due to the pooling of small-group and on-exchange. But, in some states, it's like $40,000 a year for a couple, and that would be a big problem for many people.)
I do know that in 2014, the Obama administration asked the states not to estate recover expanded Medicaid, but many, including Democratic ones, chose not to comply. (See:
https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-14-001.pdf and
https://www.healthaffairs.org/content/forefront/implementing-health-reform-medicaid-asset-rules-and-affordable-care-act )
As well, it was caught by Andrew Sprung a few times relatively recently, such as:
https://xpostfactoid.blogspot.com/2021/01/the-117th-congress-should-end-medicaid.html
Though, after early coverage in 2014 in some newspapers, leading to many states fixing the problem, many did not, and I believe even some Democratic states, such as NJ and MD, do still recover expanded Medicaid. And Massachusetts took 10 and a half years to fix it! Actually, only by the accident of one state legislator having to leave office because of a sort of a scandal, and another one replaced him, and saw the problem, and worked to get it fixed. (Sen. Comerford, the person replacing the one who had to leave, working with Rep. Barber.)
References on problem (1):
I point to an archived version of the Wikipedia article on Medicaid Estate Recovery, from around 2020, when yours truly (me), put the info in.
https://web.archive.org/web/20250824223703/https://en.wikipedia.org/wiki/Medicaid_estate_recovery
(I believe the live article still has the same content. But I gave the archived link just in case.)
(The link may or may not show up at bottom—I don’t know what substack will do)
Note the article is not up to date, so, for example, it is missing the Massachusetts repair in 2024.
(It has those flags in their from one other Wikipedia editor. I had a lot of trouble with Wikipedia from two other "editors" (who knew not a thing about health insurance), and even though a flag on unreliable sources is no longer applicable -- I had had some blog articles giving the flavor from some "The Democrats want to confiscate poor peoples" stuff assets", those are out. But I didn't want to remove the flag on unreliable sources, for fear that the whole article might get pulled from Wikipedia.)
Note that every assertion in the article is supported by references, though you may have to go to the Wayback archive for some of the references, whose live links have disappeared.
(I am allowing long-term care recovery as O.K. because the ACA does not attempt to fix our serious long-term-care financing problem. The ACA has left long-term-care as a problem for another day. But, for other than long-term care, it should be providing (real) health insurance with affordable premiums and copays to everyone. "Real" means not just a loan!)
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Problem (2): Some states, including Massachusetts, seem to thrash people up and down between expanded Medicaid and on-exchange plans, based on the state insisting on income rederminations or FPL adjustments.
This was my experience in Massachusetts, with my 9 years of ACA coverage from 2014 to 2022.
So, for example, one time, in about April, I get about 5 days notice that my on-exchange plan was being terminated, and I would then be on expanded Medicaid. What was the trigger? It took a lot of work to find out, but it was that the number they were using for my income, just a tiny bit over 138% of FPL, had become just a tiny bit below 138% of FPL, owing to changed FPL cutpoints, which changed midyear.
This same thing happened a second time, one year, around Nov 1 at open enrollment time. New income. It was either a quick thrashing up or down between the parts. I forget which. Then, they tell you send in proof of income. They will estimate next year's income however they choose, and they won't tell you in advance how they will estimate it. Another potential thrashing.
(On the Massachusetts ACA site, responsible for both on-exchange and expanded Medicaid enrollment, there is a big notice saying something like "tell us in the future any time your income changes".)
I don't know how often they might redetermine income in Massachusetts. Perhaps, if you had non-steady work, and did what they told you, and told them whenever your income changed, they might thrash you up and down as often as every month. Or even more often. Don't forget: new medical network each time!
(For my latter thrashing, I actually had a serious illness, and might have needed to be hospitalized. I didn't appreciate the changed network at all.)
Maybe there is some what to fix this in a changed ACA law, or with regulations and standards?
I've had to add a bit more as reply to this comment, owing to comment length limit.
(Continuation)
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I have a suspicion, besides that some of the policy people at the top of both designing and maintaining the ACA may not know about these problems (because they are a bit down in the weeds) and may feel it is administrative stuff, a job for people at the state level. Not their job.
No, it is their job. The states, many of them, at least, have, and will continue to screw it up unless you make it damned near impossible to screw up.
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Additional reference about both issues in Massachusetts:
I have kept around a reference to the paper version of the Massachusetts joint on-exchange ACA and expanded Medicaid application for 2019, which is a period when I was using that coverage, and when the estate recovery on expanded Medicaid was in effect.
That's here:
https://web.archive.org/web/20220814230835/https://www.bmc.org/sites/default/files/Programs___Services/Services/aca-3-english-3-21-19.pdf
On adobe pp. 22-23, there is a long list of conditions, that, on the Massachusetts exchange website, popped up on a screen after you put in all of your household information.
So, in that list, way down at items 9 and 10, past other benign-looking items if you're not going to cheat,
"9. To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If MassHealth puts a lien against such property and it is sold, money from the sale of that property may be used to repay MassHealth for medical services provided.
10. To the extent permitted by law, and unless exceptions apply, for any eligible person age 55 or older, or any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth will seek money from the eligible person’s estate after death."
So, I think I've made my point about the estate recovery on expanded Medicaid, and other non-long-term-care Medicaids, having been easy to miss.
I might as well add another point: with that "to the extent permitted by law" business, it means after you've gone through putting your information into the exchange website, you have to stop. Find a specialist attorney, and pay them figure out what, exactly, is the extent permitted by law. Before the end of open enrollment.
As well, my other point about the exchange requesting you notify them as soon as there is any change in your income is well made by item 11:
11. "Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons can make changes by calling (800) 841-2900, TTY: (800) 497-4648 for people who are deaf, hard of hearing or speech disabled. A change in information could affect eligibility for such persons or for persons in their household."
By George, with this addition, I think I've done a very good job of documenting the two problems, if I am allowed to say so myself!
I will be happy, of course, to answer any questions posed in the comments.
I look forward to millions of red state Republicans losing access to health care, and even more importantly having to make difficult choices between their health and being able to afford housing and food. I am looking forward to this because I believe in a democracy the people deserve to get what they voted for, and get it good and hard.
I equally look forward to millions of American farmers explaining to their neighbors why they got billions of dollars in subsidy because Trump vaporized their farms profits, but their neighbors lost their healthcare because it was more important to hurt everyone else.
Today was the last day to enroll (or change) for Jan. 1st coverage, and I had to change my plan (in a red state.) Last year the ridiculously high subsidy was $2200, which covered the cost of my "silver" HMO plan. It went up to $3000 for 2026, and my plan went up $1500! So I would have to pay $700 per month for health care!
Wow!
I live on Social Security, a very modest income. No other pensions. So $700/month is a lot.
Fortunately there were two providers with "bronze" plans which came in under the $3000 subsidy. I'm sure I'll be paying a lot more in copays and out-of-pocket expenses, but I'm sure even going without medical insurance, my costs would be less than $700/month.
Welcome to America, where we may have the worst health care system in the developed world, but at least we can take pride in it being the most expensive!
The subsidies help a lot of people, but they hide the real problem, which is that health insurance should never cost anyone $3,000 a month. As a U.S. citizen living in a country with single-payer, I can tell you that even services paid entirely out of pocket are 60 to 90 percent cheaper than the equivalent in the U.S. There's an "affordability crisis" for you. Maybe the silver lining of the subsidies ending is that things will get so absurdly bad that the U.S. will finally be forced to scrap the system and rebuild it from scratch instead of wallpapering over it every couple of years.
You will get no argument from me on the overall problem — ie, underlying cost of American health care
The international comparisons are also important
Stay tuned for more on this very topic!
I have a saying, and you are welcome to use it (but you read it here first!)
We may have the worst health care in the developed world, but at least it's the most expensive!
1000%. The truth is that the insurance industry has been profiteering from the ACA, and the enhanced subsidies. We have to see that. The R's are not wrong in that assessment. And I agree, it may take this crisis to understand the fundamental problem. We have to come to terms sooner or later that healthcare should not be a profit making industry. Once we've finally swallowed that concept, the rest may be relatively smooth sailing. But too many are choking on the entire notion of healthcare for all, as a human right. That's the thing we just cannot agree on.
This is the whole reason that the insurance industry bribed Manchin, Biden and others to deep six the public option in the ACA. The point of the public option was that it would ensure that the insurance companies couldn't simply profiteer off of the ACA, and Biden killed it. Which is why you don't let the old white guy from Delaware negotiate your signature legislative achievement after he bailed out the banks and left the rest of the country to lose their houses.
Knock it off with what the Dems should do. ALL CONGRESS SHOULD DO WHAT IS RIGHT
This should be a major problem for Massachusetts. Everyone must be enrolled in a plan, and proof of insurance is required with tax returns. A lot of people are going to take the lowest plan, which the state offsets with Medicaid money. Insuring all these people will be a massive drain on the stat’s budget.
Let the Trump voters feel the pain. Yeah, sucks for the normies, but they have to experience the consequences of their actions someday.
Thanks for your info on the do-ability of an extension retroactively, based on the mid-year 2021 example of when the expanded subsidies initially were passed into law. (I had not realized they were mid-year.)
(I had assumed an extension now would take many months, given especially that there are 21 state exchanges, some of which have much less resource than the much-larger federal exchange would have.
For people who actually are short the cash to pay in full for a policy at very-much-higher non-extension rates, say some people in the over-the-400% FPL subsidy cliff case, I imagine there could be a number of months of a coverage gap, still.
Thinking about the terror a coverage gap would cause for me, I hope those could somehow be avoided. And, of course, we need the extension first!)
It isn't just the subsidy people who are getting slammed! We make too much as a family to get any subsidy. However, as a retiree, my corp. backstop Medicare Advantage Plan premium given as a benefit by the company I worked 30 years for, my share of the premium going up 38% this year. My younger spouse, self-employed so must buy plan on the ACA, and two kids, our plan is going from $18k to 27K this year, again up 38%. While they also increased the family out of pocket max from $7 to $14k! Thanks so much! We have one F-ed up healthcare system in the US! We are lucky as a family to be able to afford all of this! (for now)
There are plenty of issues with how healthcare is administered in the US. The ACA fixed multiple problems, including "denials or high cost with pre-existing conditions", "risk pools", and reducing some of the opacity of the entire supply chain. It also recognized the primary concept of insurance -- the bigger the pool of the insured -- premium payers -- the more resilient coverage can be -- the individual mandate. (That concept tossed by the Tax Cuts and Jobs Act in December 2017).
There are meaningful reforms that could improve coverage, reduce costs, ferret out fraud, and reduce products and services pricing opacity. Discussed in some circles since before the ACA was passed, and certainly in the past year. Much of what is proposed by the GOP is just chipping away at the edges when the larger issues still remain. For one, cutting IRS staffing and budget? (For anyone who receives APTCs the annual tax return is where the real action takes place with adjustments for income over the poverty line calculations).
Mike Johnson? This from October 28, 2024: “Health-care reform’s going to be a big part of the agenda,” Johnson said, wearing a personalized jacket emblazoned with the Trump-Vance campaign logo. He added that a caucus of Republican physicians has shared proposals with him and that GOP leaders hope “to take a blowtorch to the regulatory state” and “fix things.” “No Obamacare?” an attendee asked the speaker, invoking the term popularized by Republicans to describe the health law. “No Obamacare,” Johnson responded. “The ACA is so deeply ingrained, we need massive reform to make this work, and we got a lot of ideas on how to do that.”
https://www.washingtonpost.com/politics/2024/10/30/mike-johnson-trump-aca-obamacare/
So the only real thing on the GOP radar is to cripple or repeal the ACA. It can be easy to maintain the tax credits for a year or two (also politically expedient!) while working on improvements. Over and over, the GOP has shown they are not serious people working on serious issues of concern to their own constituents.
They could, but they won’t, because they’ve wanted to kill the ACA for 15 years and their ideology is to kill every other social program as well. Social Security and Medicare are next.
I look forward to watching Republicans pour Social Security into the crypto market and then pump and dump it themselves. The funniest part is that their voters will still vote for them after they steal billions from them.
Waste, fraud and abuse. Isn’t that what the regime said animated its “cost-saving” measures? Well, we all know that the real waste, fraud and abuse come from this regime. Throw in chaos and cruelty and you have its playbook.
Even if Congress manages, somehow, to pass retroactive legislation, millions of Americans will not be made whole. They may recoup some (badly needed) money. But the needless worry and anxiety they experience at the hands of an abusive regime will leave lingering effects. How can the Republicans not see that their inaction will result in major backlash in the midterms? Well, some of them apparently do get it. It’s just too bad they are too timid to introduce—and ensure passage of—a meaningful approach to fixing the problem at hand. They can argue for their so-called “reforms” later. In the meantime, they need to put an end to this torture of the American people, many of them their constituents.
They lied. Its what Republicans do. Its even how you can tell Republicans are lying, because they are talking.
Mr. Cohn brings up that there just might be some resolution extending the expanded subsidies, possibly before Xmas, knocking out those cases of like a couple, age 62 with an income a bit over the returning 400% of Federal Poverty Level (FPL) "subsidy cliff" of say $88,000 a year
having a premium jump from about $6,000 a year for 2025, to $25,000, $30,000, $35,000, $40,000 (WY) or $50,000 (WV) a year with higher deductibles and out-of-pocket maxes as well.
Let's hope for that quick resolution.
Just in case it doesn't happen, I bring up that I have been poking around the various websites where tips, comments, and ideas are exchanged for the coming Xmas gatherings of family and friends.
Apparently, there is some realization that some of the guests present will be facing a loss of health insurance less than 7 full days after the gathering. There has been some discussion on the websites of what special things, in light of this, might be appropriate to have for the gathering.
I'm looking for ideas on this, and if I see any good ones in reply to me here, I will certainly get them on the Xmas-celebration sites.
I have also, from the sites, found some I can offer for people reading here:
1) Medium-sized bowls of quick-acting antidepressant drugs ,
2) Large bowls of heavily-spiked bunch, with a paper sign attached to the bowl, with, written in festive glitter, "Forget About Today Until Tomorrow" ,
3) Notes at each place setting, hand-written before the dinner, by the children at the event, in crayon on the front, saying
' "I mean, people have access to health care in America. After all, you just go to an emergency room.".
-George W. Bush, 7/10/07 ' ,
with, on the back of each one, in type (pre-printed by the hosts the day before the event):
"(From here: https://web.archive.org/web/20100423045051/https://georgewbush-whitehouse.archives.gov/news/releases/2007/07/20070710-6.html
At about the 17th paragraph.)
Reminder: The emergency room will treat you to the point of medical-stabilization only, which they have to do because of the Reagan-era EMTALA law. (You are still legally-responsibly for the bills, and many hospitals will collect on that debt.)"
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Any other suggestions, chime in here please! (😊)
Can I recommend a nitrogen bottle (from your local welding supply) with a CPAP machine attachment, for when you are in pain and something is clearly wrong with you but you can't afford to go to the hospital?
This is what I sent to my US Rep and Senators: "Hello, I am a member of the gig economy. As a professional classical musician, I've always worked multiple jobs and worked very hard to make a living and be a responsible person. The ACA allowed me to get affordable health insurance. I anticipated that there would be a huge increase because of the roll-back on the Covid subsidies. But I did not expect that the ACA subsidies would be completely GONE. My Silver basic plan went from a monthly premium of $64.45 to nearly $900 per month for 2026. I looked up my IBX Silver basic plan to see what it would cost if I bought it directly from IBX and it was about $900 per month.
So I have downgraded to the Bronze plan, but that is still nearly $600 per month. I am 56 years old. I'm not sure where I'm going to get an extra $7000 this year - PLUS my doctor visits and medications will be much more expensive.
It is clear that the Trump Administration and the GOP in Congress hate me and all constituents like me. I still can't believe that this is the same USA that I grew up in. What's the plan to help Americans like me??? Thank you."
Just remind them that its people like you that protect them from people like Luigi who rightly believe that guillotines are a more effective solution to their problems with American politics than letters to their representatives. It would be a shame if more people realized that their representatives are profiting from the misery of their constituents and started believing that the American Revolution was founded on actual representation and human rights and decency, and it might be time to remind our government officials of that.
Jackie, Please share any responses you receive. I am so sorry for what the controlling edifices of government has decided to do - or more correctly, not do for their citizenry.
Gig-economy workers are an excellent point.
The Republicans don't want people to have job security, claiming that a flexible and job-mobile workforce is the thing to make an economy efficient. Gig workers and contractors would seem to be their ideal, and yet they're opposing the ACA, and especially it's provided reasonable coverage over the returning 400% of FPL "subsidy cliff", which enables Gig workers.
Tacking on a little bit on a particular set of Gig-economy people and the extensions:
There is a case I found interesting about Gig economy people, illustrated in a podcast involving substack mostly-healthcare wonk Charles Gaba (who was interviewed), and two people who do the podcast.
You can get to the podcast from here:
https://charlesgaba.substack.com/p/past-due-podcast-wana-marie-cox-and
if interested.
I listened to the podcast (about an hour long), and noted that all three participants were self-employed Gig-economy people.
And, they brought up in the interview that, since there are humongo premium jumps for many people around the returning 400% of Federal Poverty Level (FPL) "subsidy cliff" (which had been repaired for 5 years under Biden), a strategy they were heavily reliant on was trying to keep their income under the "subsidy cliff".
So we can see that this cliff, coming back, and a kind of standard feature of much U.S. sharp-edged "means testing with various "cliffs", certainly discourages work in many cases. (Make a few bucks too much, and you have to pay $15,000, $20,000, $30,000 or more extra, (after taxes!) for health insurance.
I believe all three participants do their Gig work through corporations. In that case, they would seem to have an option of not actually working less, but staying under the cliff, by having their corporation retain some of the money that came in to them, but only paying out as salary an under-the-cliff income. (This is the kind of complicated machinations that this causes.)
I'm not an accountant, but I did have my own company at one time (myself really a Gig worker, before I retired) and I believe it has to be a C-corporation, not an S-corporation. So, observing that one of the podcast hosts indicated his corporation was an S, I chimed in in the comments that I think it has to be a C corp: https://charlesgaba.substack.com/p/past-due-podcast-wana-marie-cox-and/comment/182097821 .
Oh, what a byzantine healthcare system we have created!
Incidentally, Charles Gaba did, weighing his privacy loss vs. benefit to others, lay out his own healthcare and financial situation, talking in some detail about his own "subsidy cliff" issue. If interested:
https://charlesgaba.substack.com/p/sigh-ok-here-goes-how-about-my-own