The Obamacare problem that Democrats don’t want to talk about and Republicans don’t know how to talk about!

14702444_1001294410000218_7240752846434689031_nBill Clinton criticized President Barack Obama’s signature policy reform a few Mondays ago while on the stump for his wife, Democratic presidential nominee Hillary Clinton, calling Obamacare “the craziest thing in the world.” But he attempted to temper his criticism the next day at a Tuesday rally.

Speaking at a Democratic rally in Flint, Michigan, the former president ripped into the Affordable Care Act (ACA) for flooding the health care insurance market and causing premiums to rise for middle-class Americans who do not qualify for subsidies.

“So you’ve got this crazy system where all of a sudden 25 million more people have health care and then the people who are out there busting it, sometimes 60 hours a week, wind up with their premiums doubled and their coverage cut in half. It’s the craziest thing in the world,” Clinton said.

On Tuesday, he tried to clean up his criticism. “Look, the Affordable Health Care Act did a world of good, and the 50-something efforts to repeal it that the Republicans have staged were a terrible mistake,” Clinton said at a rally in Athens, Ohio. “We, for the first time in our history, at least are providing insurance to more than 90% of our people.”

“But there is a group of people — mostly small business owners and employees — who make just a little too much money to qualify for Medicaid expansion or for the tax incentives who can’t get affordable health insurance premiums in a lot of places. And the reason is they’re not in big pools,” Clinton said. “So they have no bargaining power.”

Sarah Kliff wrote that Bill Clinton’s very specific critique of Obamacare a few week s ago is one that most Democrats won’t. discuss. “The people that are getting killed in this deal are … individuals who make just a little too much to get any of these subsidies,” Clinton said while campaigning in Flint, Michigan. “People are out there busting it [and] wind up with their premiums doubled and their coverage cut in half.” This was not just some off-the-cuff riff. Clinton was addressing a serious problem with Obamacare. It’s one that people like Julianna Pieknik know all too well.

Pieknik is a 37-year-old PhD student in Maryland, who shares a house with four roommates. She earns $42,000, which is just slightly too much to qualify for tax credits where she lives. This year, she paid a $250 premium for a plan with no deductible. Next year, to keep same level of coverage, she needs to pay $450 — and she doesn’t think she can afford that.

So right now she’s facing a choice: Pay a lot more money, or scale back her level of coverage. “I am still in panic mode,” Pieknik says. “I haven’t decided whether to switch to an ultra-risky plan and hope for the best.”

The Obama administration often describes unsubsidized enrollees like Pieknik as a relatively small part of the individual market. Health and Human Services Secretary Sylvia Mathews Burwell recently told reporters that in the marketplace, “85 percent of folks receive subsidies.”

This is true, but it also leaves out something important: that there are millions of people buying their own coverage outside of the marketplace. And none of them receive subsidies. So they don’t have any financial cushion to protect against the larger premium increases most observers expect to see in 2017.

“They are the red-haired stepchildren of American health reform,” says Kevin Coleman, head of research and data at HealthPocket. “They don’t have strong sympathy within the government and have typically been ignored.”

We don’t know exactly how many people buy unsubsidized coverage off the marketplaces — estimates range from about 7 million to 12 million — but we do know it’s a large group that, when open enrollment begins in a few years, is likely to face bigger premium increases than ever before.

He pointed out that millions of Americans don’t get subsidized coverage through Obamacare Much of Clinton’s remarks centered on a very specific group of Americans: those who are uninsured and earn too much money to qualify for subsidized coverage — and who are exposed to double-digit premium increases.

“The people that are getting killed in this deal are small-business people and individuals who make just a little too much to get any of these subsidies,” Clinton remarked in Flint.

A bit of background is helpful here. The Affordable Care Act provides subsidies to purchase health insurance to people who earn less than 400 percent of the poverty line — $47,520 for an individual or $97,200 for a family of four.

These subsidies limit how much an individual has to pay for coverage. For example, someone earning $47,000 won’t have to spend more than 9.6 percent of her income on midlevel coverage. The government will kick in subsidies to cover the rest.

““THEY ARE THE RED-HAIRED STEPCHILDREN OF AMERICAN HEALTH REFORM,” ONE EXPERT SAYS OF THOSE WHO BUY UNSUBSIDIZED OBAMACARE COVERAGE”

(The reason that Pieknik, who earns $42,000, does not qualify for subsidies is that a midlevel plan where she lives only costs 8.6 percent of her income. So the government considers her under the affordability threshold and doesn’t provide a subsidy. But committing 8.6 percent of income to premiums, as Pieknik has found, can still be a pretty big strain on a budget.)

There are many people who earn too much to qualify for subsidies, and they don’t have any sort of protection against high premiums.

This is becoming especially important this year, with premiums expected to rise, on average, by 9 percent — significantly higher than prior years. Last year, for example, the average increase was just 2 percent. And many increases are much higher. If an insurance plan jacks up rates by 25 percent (the average in Connecticut this year) or 62 percent (Blue Cross Blue Shield’s approved increase in Tennessee) — as many are this year, after losing money on the marketplaces — then a person who doesn’t qualify for subsidies will have to pay that full increase.

How bad is the problem? Nobody really knows.

We have really great data on who has health insurance through the marketplaces because those are government-run entities that keep track of each and every sign-up. So the government knows, for example, that 8.5 million people bought coverage through the Healthcare.gov marketplace in 2016 — and 7.1 million of those people got a subsidy.

But finding data on people who sign up outside of the marketplace is actually pretty tough. These people don’t go through one central clearinghouse to buy plans. Instead, they might be going to a local insurance broker’s office or signing up through an individual insurance plan’s website. So the best we have is a handful of estimates on how big this market is. The Obama administration thinks there are 6.9 million people buying coverage off the marketplace. It thinks 2.5 million of those people would be eligible for subsidies if they switched to the marketplace.

““I AM STILL IN PANIC MODE. I HAVEN’T DECIDED WHETHER TO SWITCH TO AN ULTRA-RISKY PLAN AND HOPE FOR THE BEST.”

Charles Gaba of ACA Signups estimates it to be 9.1 million. And a survey of Blue Cross Blue Shield plans — which dominate the Obamacare marketplaces — shows that about half of the enrollees aren’t subsidized. Among those on the marketplace, only 17 percent did not receive a subsidy in 2016. But when you include all these people estimated to be buying outside the marketplace, that figure jumps to 31 percent, according to a report from the consulting firm McKinsey.

The premiums off marketplace can be expensive, particularly for those who earn just a little too much to qualify for any subsidies. But expensive, some enrollees argue, is better than not having any coverage at all.

Rebecca Barston, a 39-year-old consultant in Washington, DC, says her unsubsidized premium is “probably my second biggest cost after housing.” She pays $420 per month for her plan, and that’s a big line in her budget. And she’s a bit worried about how that rate might change next year. But $420 doesn’t seem that expensive to Barston — because when she shopped for insurance before the health care law, in 2008, insurance plans wanted to charge her premiums over $1,000 due to a preexisting condition. “It’s a concern, that my rate will be going up,” Barston says. “But at least I know it won’t be going up to $1,000.”

The subsidized Obamacare population is guaranteed affordable premiums. But that’s not the case in the unsubsidized market, which means the unsubsidized market creates winners and losers. It’s true that there are more people buying coverage outside the marketplace than we usually acknowledge — and that their premiums are higher than the people in the subsidized markets. But whether that feels affordable can hinge a lot on what the marketplace looked like before Obamacare launched — and that will vary a lot from person to person.

For some, like Pieknik, it’s creating tough decisions. Pieknik doesn’t use much health care — she estimates that she goes to the doctor about three times a year or so — but she prefers buying the protection against a catastrophe. This year, she might not get that option. “It only takes one thing to happen to you, unless you have decent coverage, to go thousands of dollars in debt,” Pieknik says. “It’s hard to think how I would come up with that money, if my coverage weren’t as good and something did happen.”

Look at Kate Ashford’s review of Out-Of-Pocket Hospital costs-up 37% in the study that she reviewed. She stated that if you think you’re spending more on healthcare costs, you’re right. And if you’ve been hospitalized in the past few years, you’ve definitely felt the burn. The average patient with private health insurance paid more than $1,000 in out-of-pocket costs for an inpatient hospitalization in 2013, according to research from the University of Michigan. That’s a rise of 37% since 2009—from $738 to $1,013. Most of this increase was due to a jump in the amount applied to deductibles, which rose 86% from 2009 to 2013, and secondly by increases in coinsurance, which went up by 33% in the same period.

“There’s not a lot out there about how much people with private insurance are spending on hospitalizations or out of pocket generally,” says Emily Adrion, a research fellow at the University of Michigan and lead author of the study. “It was really a black box. We didn’t have any idea whether it would be really high or really low.”

As it turned out, it was really high. “We were really surprised,” Adrion says. “It was pretty surprising that it was that much higher and that it was also higher than premium growth.” Premiums, according to a recent Kaiser Family Foundation survey, rose by about 4% in the previous year, while this study’s findings point to a 6.5% annual increase in out-of-pocket costs.

“There definitely seem to be more high-deductible plans available,” Adrion says. “Whether that’s what’s driving this or whether there’s a general trend toward greater percentages of coinsurance and patients being responsible for more coinsurance, it’s hard to say.”

Since 2010, deductibles have risen a whopping 67% for employer-sponsored health plans, according to the Kaiser Family Foundation. And more people are enrolled in high-deductible health plans—24% of all workers 2015, compared to 8% in 2009. The deductible is the amount a consumer must pay out of pocket before an insurance company will start covering anything. One issue may be that despite the rise in high-deductible plans, consumers focus on a health insurance plan’s premium without understanding what other costs they may be responsible for.

“Patient education is a huge issue,” Adrion says. She pointed to a 2013 study that found that only 14% of people surveyed understood the concepts of coinsurance, copayments, deductibles and maximum out-of-pocket costs. “People don’t have a good understanding of different forms of coinsurance and what they’ll owe.”

Another survey found that 51% of U.S. adults couldn’t accurately identify at least one of the following terms: premium, deductible or copay. One in eight didn’t realize a deductible is the money a consumer owes before an insurance company will start making payments.

This is particularly frightening at a time when a recent Federal Reserve report found that 46% of Americans would struggle to meet an emergency expense of $400. The University of Michigan’s study analyzed medical claims for 7.3 million hospitalizations using 2009-2013 data from Aetna, UnitedHealthcare and Humana insurance companies.

These last studies are a few years old but the recent data supports the same analysis, concerns, and conclusions. And the other part of the problem or equation is that due to the cost of care, huge deductibles and the large outlay of personal funds for their care we are finding more and more patients delaying their diagnoses and therefore care. Sometimes this leads to even larger cost to the patient, now including expensive chemo or immunotherapy, where if the patients were seen at an earlier stage of disease health care would be less costly and there would be a higher success rate of treatment and cure.

There must be a better system where we can actually care for our patients and improve long-term survival and the quality of care that we give to each and every patient, present and in future.

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