Obamacare - practical discussion

I think it’s worth separating the Obamacare / ACA speculating on the future and political discussion from the more narrow, practical discussion. This thread is for the latter, i.e. my insurance company is the last good one in my area and is discontinuing all service for 2018, so do I self-insure or buy a mediocre plan? What about using an address somewhere else that still has better options, or starting a company to get group coverage? Sadly, this is not a hypothetical question and I have looked into lots of these options.

I will probably start a single separate thread for discussing the future of healthcare, news coverage, and predictions of things like future rates and quality/availability of care, etc, so if you want to discuss those types of more general and more political ACA topics, please wait for that thread. I want to double check with the admins here before starting it to make sure they’re ok with something like that.

So without further ado, here’s my post from the FWF Obamacare thread with lots of links to FWF and BH threads, many of which are now locked or archived, but often had fairly long and useful discussions. If/when FWF goes away, I will try to replace the links with archived versions for the old FWF material (which is saved, but not yet online).

Loss of choice / coverage
My Obamacare plan is being closed; most ins cos have pulled out of my state for '18; I may have to move states

Another insurance co. likely to pull out in 2018 hope you are not in Colorado, Kentucky, Missouri and Ohio

Aetna will withdraw from several states (ACA)

Received a letter that health insurance company is closing (IL)

discussing new ACA plans
Preview of 2017 ACA plans now active

What are your health insurance stats (cost, coverage, etc)

2017 ACA plan reviews

Limitations of ACA coverage, small networks / out of network woes
Out of network issues

New health insurance rules cap surprise billing (out of network charges at in network places)

general speculation on ACA and effects
What realistically is going to happen to ACA in Q1’17

Individual health premiums tripled. Why?

Future of ACA / health insurance

personal costs / strategies
Is ACA making your wallet slim?

Should young healthy people buy insurance?

Importance of high deductible insurance

healthcare costs and self funding

ACA renewals, shop around

Individual ACA-related decisions
Various ACA vs COBRA decisions

PPO/EPO/HMO choices

If you have personal type ACA questions, post them here and I’ll do my best to answer.


They say Trump is preparing an executive order allowing the marketplaces to sell across state lines. I think a lot of things are about to change.


I hope so. Our COBRA (which is cheaper than NY marketplace prices) runs out in about two years. I hope by then, more competition lowers prices, and we can buy reasonable healthcare on the market.


With Price now gone, God help those hoping for relief from the ACA. Price was crucial to that effort. He knows where all the bodies are buried. One wonders whether the Senate will confirm a replacement for Price any time soon. I doubt it. And beside that, there really IS no replacement for Price.

Trump has been POTUS for more than Eight months. Still over half the key spots in his administration remain occupied by Obama holdovers. That is not what I call getting the job done. Pity.


we’ve had a few years of 30-50% increase per person. I remember when kid premiums were less than $50. now it is approaching $200 - and that is with higher deductible!

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if your just worried about the tax penalty of self insuring I recommend medishare with a big deductible.

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Is that really going to help though?
A couple years ago my state had several insurance companies selling on the marketplace. A few big (national companies like Anthem, United Healthcare, etc), and several local/regional insurance companies.

The Big Guys already sell in multiple states, so how is this any different? The subscribers premium is still based on age/sex/location.

The Small Guys (local / regional companies) have such a limited group of Doctors, unless you live in that regional you’re just wasting your money. You really want to drive 200+ miles to see your family doctor?? And if they sell this policy across state lines now you may have to travel 500 + miles to see your family doctor? Oh, but my premium is $100 less a month!! I just have to buy a plane ticket and a day off from work each time I need to see the Doctor.

But then again maybe I’m missing something with this “across state lines” thing, but I just don’t see how that is going to help any…


It is a bit misleading to call it “selling across state lines”, when it is really creating/expanding insurance risk pools across state lines.

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Persons who favor Obamacare do not like the idea of using the ERISA law as a can opener. Nevertheless, such an outcome could be very close:

ERISA may become the key

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Things just got interesting…following this thread now.

“Based on guidance from the Department of Justice, the Department of Health and Human Services has concluded that there is no appropriation for cost-sharing reduction payments to insurance companies under Obamacare,” White House press secretary Sarah Huckabee Sanders said in a statement.


There will be lawsuits and the insurers are still required to offer Silver 93 and Silver 87 plans. This will put things in flux for a few weeks but I expect the courts to resolve it in favor of the insurance companies.

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The insurance companies in some states had put in 20% higher premium requests anticipating this risk, and it looks like they were right (actual requests were higher than this for cost increases, adverse selection risk, etc, but they attributed 15-20% for the risk of this change alone).


This is really going to force the healthcare issue politically since now lots of people will have to pay their real cost for ACA coverage rather than getting subsidies. The unsubsized rates have been going up like crazy, and it’ll probably be a 30%+ hike for 2018 everywhere that the companies can still change their premium requests.

No way it gets resolved any time soon in the courts and the marketplace plans are basically dead without the subsidies - now they will be unaffordable for all, not just those unlucky people who are gainfullly self employed or retired.

Apparently these subsidies under the ACA didn’t get Congressional authorization per some of the legal challenges, but the Obama administration didn’t care and made them anyway. Now Trump can throw this ball back at Congress and tell them to get some reform done. And the health insurers are going to lose a bunch of money without the subsidies and will probably all quit without reform by next year. The real rates are going to be so high that almost no one will pay them, and without a core subsidized group of low income profitable customers, I think the whole ACA market is unsustainable.

Here’s something about possible new options under Trump’s less restrictive rules.


Thursday’s executive order directs a trio of federal agencies to take action that would weaken the effect of ACA regulations. It could lead to the lifting of ACA restrictions on a type of short-term insurance policy, for example, that could provide fewer health benefits than mandated under the ACA, also called Obamacare.

The Obama administration limited those policies to less than three months, with no ability to renew after that time, because of concerns they were siphoning off healthier consumers from the ACA marketplaces. The short-term plans don’t have to meet the ACA’s minimum benefit requirements, such as covering maternity care, and they can refuse people with pre-existing conditions.

The executive order also could boost “association health plans,” which let small businesses and possibly individuals band together to buy insurance. Association plans would also be exempt from the requirement that they offer a specific set of benefits, and they, too, would likely attract those with limited health needs, leaving sicker people in the ACA exchanges. The Labor Department has already spent weeks working on a regulation at the White House’s request, administration sources said.

The order would also let more people with “health reimbursement arrangements,” which employers fund to help workers meet their health needs, use those accounts to buy their own insurance. Republicans say this will give people greater choices, while some insurer groups say it will prompt more employers to stop offering coverage.

Sounds like there may be better choices coming for healthier indivuduals seeking cheaper options. I’m not sure they’ll arrive in time for 2018 however.

My take was that this would be best solved with congressional action on the subsidies.

Congress doesn’t like to do anything until they absolutely have to, then they’re able to do it in a few days. Maybe this will force their hand.

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Bogleheads had some discussion of the changes, but the mods expunged it. The internet doesn’t forget though.

http://archive.is/XyafM (Page 1)
http://archive.is/6V7l1 (Page 2)

Issues raised include possibly higher premiums for 2018 (and definitely for 2019 if no healthcare compromise is reached to restore the Fed subsidies), possible insurers withdrawing at the last minute from the 2018 marketplace, and a bunch of new alternatives like short term policies that are being encouraged by laxer regulation but those are all TBD at this point and may not come in time for 2018. They would likely be good and much cheaper for healthy people.

Is this correct? Then it’s not too bad, but I see my monthly rate even with the subsidies will more than double for 2018 and go from PPO to HMO.

Subsidies to buy insurance are unaffected. “Cost Sharing” subsidies are also unaffected. The ACA requires “cost sharing” subsidies for low income people. However, it does not specify who pays for the subsidies. Under Obama, it was the federal government. Now, it will be the insurance companies paying for the cost sharing subsidies. This is the reason that there will is a big spike in ACA premiums.

Since cost sharing subsidies are only available on silver plans, California and a few other states mandated that all premium increases due to the federal government not paying the cost sharing subsidy be restricted to the silver plan. This way it will not affect people who buy insurance without a government subsidy, they just can not buy the silver plan. The silver plan will then be used strictly by people who are using a government subsidy to buy insurance. So the federal government will be paying for the cost sharing subsidy either way, through a direct payment to the insurance company like they do now or through higher subsidies due to higher premiums.


So here is a nice matrix for what you should do based on how your state insurers have/will react to the CSR costs. They will typically have ignored this risk (bad for the insurer, fine for you unless they quit), or will spread the CSR cost over some group. That group could be all individual plans, just Silver ones, or just Silver exchange ones. Here some discussion and a summary of what you should consider doing for 2018 based on your personal status and what is happening in your state for allocating the CSR costs.

Here you can find the details about your state:

some observations - there are cases where if you don’t get CSRs (<100% or >200% FPL), you need to switch away from Silver, either to Bronze or Gold, or from Silver on exchange to Silver off. The old Silver plan is often going to be a clearly worse choice, so whatever you do, double and triple check your options this enrollment period.

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The stupid part about removing CSR subsidies is that all the folks that benefit from CSRs now will not pay any more - they’ll get the same coverage for the same money in the form of premium subsidies (which means the ‘evil’ insurance cos still get their money). The folks that get screwed, yet again, are the ones that don’t get subsidies because they make too much money. They’re the ones that have been yelling loudest about the ACA, with good reason.

Many of these folks are Trump voters, and the ones I know all blame the ACA for their situation. But there is no alternative now, they’re just going to get reamed or go without coverage.