Eligible for a "catastrophic" plan?

I read last night that the twenty million people whose individual health insurance plans terminated because they didn't meet ACA requirements for a "comprehensive" health plan can now qualify for a "catastrophic" health plan - if they are "having trouble paying for a new plan".

Previously there were twelve criteria for "catastrophic coverage" eligibility listed at https://www.healthcare.gov/exemptions/:

1. You were homeless.
2. You were evicted in the past 6 months or were facing eviction or foreclosure.
3. You received a shut-off notice from a utility company.
4. You recently experienced domestic violence.
5. You recently experienced the death of a close family member.
6. You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property.
7. You filed for bankruptcy in the last 6 months.
8. You had medical expenses you couldn't pay in the last 24 months.
9. You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.
10. You expect to claim a child as a tax dependent who's been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you do not have the pay the penalty for the child.
11. As a result of an eligibility appeals decision, you're eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren't enrolled in a QHP through the Marketplace.
12. You were determined ineligible for Medicaid because your state didn't expand eligibility for Medicaid under the Affordable Care Act.

These criteria are bizarre! Note that some of them might be due to carelessness (utility shut-off notice) or not involve actual financial stress ("increases in necessary expenses").

But the new announcement adds a thirteenth and most bizarre criterion - bizarre because it acknowledges that ACA itself can create hardship from which only ACA exemptions can grant relief, and because the exemption hinges on an individual's belief:
    13. Your individual insurance plan was cancelled and you believe other Marketplace plans are unaffordable.

"You believe other plans are unaffordable"? The ACA has turned into a faith-based initiative? Are thought police going to investigate beliefs?

My Kaiser coverage terminates at the end of the year because it doesn't meet ACA standards. I signed up for a new plan with Anthem Blue Cross and just mailed the check for my first premium. But I emphatically believe that Marketplace plans are unaffordable. I also think they are poorly designed and provide perverse incentives. But how can I block the plan I just paid for and switch to a "catastrophic" plan?

And just who is running this show, and how on earth do they think they can arrange things this way?

Update: I just received an e-mail from Representative Anna Eshoo trumpeting this latest enhancement to ACA. She included a link to the Hardship Exemption Form.

This form has somewhat different langugage: "You may qualify for a hardship exemption if you experienced one of the following:" ... "13. You received a notice saying that your current health insurance plan is being cancelled, and you consider the other plans available unaffordable." "Consider" rather than "believe." What kind of criterion is that for granting an exemption?

Predictably this form asks you to identify yourself as Hispanic/Latino (Mexican, Mexican American, Chicano/a, Puerto Rican, Cuban, or Other) or White, American Indian or Alaska Native, Filipino, Vietnamese, Guamanian or Chamorro, Black or African American, Japanese, Other Asian, Samoan, Asian Indian, Korean, Native Hawaiian, Other Pacific Islander, Chinese, or Other. This is beyond offensive! What does this have to do with deserving a hardship exemption?
 

Letter to my Representative about the Affordable Care Act

270 Fulton Street
Palo Alto, California 94301
November 13, 2013

The Honorable Anna G. Eshoo
698 Emerson St
Palo Alto, California  94301-1609

Dear Representative Eshoo,

Thank you for your letter of November 8 and your e-mail of November 11, 2013. I am impressed by your emotional commitment to the Affordable Care Act, but I repeat my observation that it is an economic and medical disaster.

The new "comprehensive" plan I am now required to purchase costs $4100 per year more than my old plan, which had a maximum annual out-of-pocket of $5000. There is no scenario in which I personally am not damaged - by thousands of dollars a year. You repeat the patently false assertion that "nothing in the ACA required your insurer to cancel your insurance policy." But mine was exactly the kind of plan that ACA was designed to ban - my old plan gave me an incentive to look for value in my medical care, and take responsibility for my own health. It was very precisely ACA-mandated modifications than canceled plans like mine and drove my premium from $295 per month to $637.

You make many claims in defense of ACA - but if you think about them, none make any sense:

• A ban on lifetime caps is a barrier to a robust, affordable health care system - exactly the opposite of what you suggest.
• Banning discrimination based on pre-existing conditions invites adverse selection, and is an incentive to not get a health plan - exactly the opposite of what you suggest. Healthy people - most of the population - can now join the health insurance system only if they get sick.
• Bankruptcy is the appropriate outcome for people who accept medical care they can't afford. It clears the books and allows them start afresh. Making that a general obligation provides yet another perverse incentive to not save, to not buy health insurance, to not be a responsible person.
• Preventive medicine (like cholesterol screening) is a waste of money: the scientific evidence on this is clear. Also, preventive care and screening do not have the characteristics of insurable expenses. Mandating this coverage for all people is an example of how the ACA unnecessarily raises health care costs, increases demand without regard to supply, and encourages wasteful overtreatment. Removing copays makes this mistake even worse.
• Pediatric dental care involves small and predictable expenses, and is a direct result of a decision to have children. It has none of the characteristics of an insurable risk. I raised three children and their dental bills were just one of many predictable costs. In contrast, cancer treatment is relatively rare and expensive, and thus suitable for insurance protection and risk-sharing. I am surprised that you confounded these two very different problems.
• Your statement that the ACA "requirement" that people have "comprehensive health insurance… makes insurance more available and affordable for people who are likely to have such costs while creating incentives for people who might have high-cost health needs in the future to get coverage" is nonsense. In fact, "comprehensive" health plans are a priori less affordable. The ACA creates incentives for people who don't need insurance now to avoid expensive coverage and instead pay (or not pay) a modest penalty. This will make coverage less and less affordable in the future as adverse selection dominates the insured population.
• The requirement that "insurers have to spend at least 80 percent of your premiums on actual care, not overhead costs" is merely protection for incumbent insurance companies (whose shares have been climbing steadily thanks to your largesse). It is a throttle on innovation and investment, and a long-term guarantee that health plan costs will rise. I wish you would promote the wonderful American economic system, rather than attacking it. And if you are going to attack business profits, I hope you will be fair about it and also attack Apple and Intel and Google.
• The ACA doesn't offer any new "investments in public health." Indeed, it has many clauses that will reduce investment - by taxing medical equipment and by capping profits.

I hope you will take some time to defend the substantial marriage penalty and extraordinary effective marginal tax rates imposed by the ACA. If two single people each earning $20,000 per year marry, they lose a healthcare subsidy of $1269 per year - and that's on top of various other marriage penalties that fall particularly heavily on families struggling to climb the economic ladder. It is monstrous to promote a system where people are actually better off keeping their income low - but that's exactly what the ACA does, in too many cases.

The ACA will be the direct cause of huge increases in health care costs. It arms more and more people with third party reimbursement. It punishes the poor. It discourages high deductible health plans which gave consumers an incentive to seek value for our healthcare dollars. It has cut worker hours and eliminated jobs.

Here are some ideas for sensible health care reform:

• Give individuals the same favorable tax treatment for insurance premiums that employers have.
• Require employers to list health care benefit costs on the W-2, so employees can decide whether they actually want their compensation to go to gold-plated health plans.
• Give Alabama, California, and New Jersey incentives to harmonize HSA tax treatment with Federal law.
• Allow insurance companies to cap coverage. If we have the moral and political will to fund extreme and tragic cases, then let the government explicitly reinsure these risks.
• Require hospitals to post price lists and quote firm, all-in prices.
• People who pay cash in advance for health care should always get the best price.
• Require significant copays and coinsurance in all health plans - including Medicaid - so all consumers have an incentive to seek value. Apply the copays to check-ups and screening; let consumers decide if those are worth the money. Exempt only public health benefits like vaccinations. Apply excise taxes to "comprehensive health plans" to discourage their use.
• Strengthen the old "guaranteed issue" rules where anyone with continuous "creditable coverage" is guaranteed an affordable policy subject to cohort-based underwriting.
• End the mandate requiring insurers to allow children to stay on their parents' health insurance plan after age 18. We as a society want to encourage young people to form their own households and take responsibility for their own lives.
• Pediatric dental care and normal maternity care offer important societal benefits - but these do not have the characteristics of insurable expenses, and they should not be mandated coverages. Any subsidies should be provided through tax credits or a comprehensive welfare system.
• End coverage mandates for acupuncture, experimental therapies, talking psychotherapy, chiropractic, on-patent drugs, and other medical treatments that are not essential to good medical care. Allow these items to be covered optionally. Also, encourage optional coverage with separate pricing for expensive therapies with marginal benefit, like left ventricular assist devices, bone marrow transplants, and so on.
• Remove the marriage penalties and discontinuities in subsidies to low-income people. There should always be a positive financial incentive to marry (and never a positive incentive to divorce), and no person with below-median income should ever face an effective marginal tax rate higher than 40%.

Over the next few years we will all see how your changes to our health care system work out. You as a Member of Congress have exempted yourself from the system you created. I am very sad that I was not able to do the same, and I am quite certain that my grandchildren and yours will not get good medical care unless the horrific "Affordable Care Act" is reversed.

Thank you for your consideration.

Obamacare and the war against the poor: marginal thinking

I just visited the Kaiser Family Foundation's subsidy calculator at http://kff.org/interactive/subsidy-calculator/ to see what effect PPACA ("Obamacare") does to marriage incentives.

• A single parent with one child who earns $30,000/year gets a $2,688 subsidy. Two parents with two children who earn $60,000/year get $3,719. By marrying, they lose $1,657 a year in after-tax dollars.
• A single parent earning $15,000 qualifies for Medicaid, a subsidy of roughly $4000. A single parent earning $45,000 gets a $341 subsidy. By marrying, they lose more than $4000 in non-taxable subsidy dollars.

This is on top of the hundreds of other marriage disincentives built into the Federal income tax system, the welfare system, food stamps, and every other government program designed to "help" the needy.

How T-Mobile pushed me out

I've been a T-Mobile subscriber since Google sold me an unlocked Nexus One in the spring of 2010, and I've been mostly satisfied.

By my calculations I've come out ahead buying my two unlocked GSM phones outright and getting a lower-cost monthly plan. An unlocked GSM phone lets me get cheap service when I travel to foreign countries - my SIM collection includes the UK, Spain, Cambodia, and Germany. Not being tied to a contract frees me to try Walmart and Solavei and Simple Mobile and other cheap mobile virtual network operators. And on principle I prefer not to borrow money at high rates of interest -- the reality of a phone subsidy.

I have a few complaints with T-Mobile. There's a big dead spot in Atherton right in the middle of my daily commute. I can be certain that I will get completely incorrect information from store personnel - they didn't know that you can only program "forward on ring-no answer" with a postpaid plan, and they told me that number porting always meant paying a termination fee. They have no knowledge of unusual or complicated procedures. But you can't get your hopes up about cellphone companies, and the T-Mo network has generally been fast and reliable with coverage that works pretty well for me.

I was mostly satisfied with my T-Mobile deal of $50/month for 500 minutes of talk, unlimited texts, and 2GB of "high speed" "4G" data. But I also thought it would be nice to have a little more flexibility... So I decided to port my number to Google Voice. In that way, I could instantly change cellphone carriers without having to port my number again. And I could get a prepaid plan - cheaper than postpaid, without the hassle of a credit check - and save a few more dollars. Two agents at the T-Mobile call center (I double checked) assured me that if I did this I could keep my current plan without termination fees or any other inconveniences. I just had to visit a store and get a new SIM and new phone number within sixty days of porting the number away.

So I ported my number to Google Voice. The many horror stories about GV porting failures worried me but mine went smoothly and took just three days. In my lunch hour on the Thursday the port completed, I hopped on my bike and pedaled three miles to the local T-Mobile store. Here's what I found when I got there at 12:20pm:

Confused - and bemused, like several passers-by - I decided to wait. After twenty-five minutes, "Daniel M" unlocked the door. I told him (rather testily, I admit) how long I'd been waiting. Annoyed with me, he replied - completely seriously! - "The sign says thirty minutes, and I cut my lunch hour short to help you."

He had no idea how to set me up with a new SIM, so he called customer service to go through the procedure. Along the way he read off my SIM number.  He assured me I'd have cell service again "within two days."

At 4:00pm that day I still didn't have service. I called T-Mobile and got the correct SIM number entered in the system - and my phone immediately came back to life. But the agent told me that, contrary to what I'd been told, I could not keep my old plan and had to take a new, current one - with unlimited talk, unlimited messages, and 500 MB of data. While it wasn't as attractive a combination as my old plan (which had 2GB data) it was OK and I accepted the deal.

A couple of weeks later I got a text from T-Mobile asking me to rate their service on a scale of 1 to 10. I replied "2". A few days later I got a call from another customer service specialist who said he was following up on my dissatisfaction. I told him about the "back in 30 minutes" sign, and explained that if the web site had mentioned lunchtime closing, or the sign had said, "Back at 1pm" I'd have been able to work around it. (I didn't mention the botched activation.) Anyway, he apologized and after some discussion agreed to give me my old 2GB plan back.

But he didn't. When I left my office (and its WiFi) I discovered I had no data service at all. The agent had deleted data from my plan altogether. I dialed 611, and after a few minutes on the phone the agent gave me 2GB data.

Peeved by all these hassles, the next morning I shopped around. I went through all the GSM MVNOs (mobile virtual network operators, resellers of ATT or T-Mobile) and discovered that I can get unlimited talk, texts, and 2.5GB of "3G" "high-speed" data on the T-Mobile network from Walmart (!) for $39.88/month plus $25 to sign up.

That evening I checked my T-Mobile account online and discovered that I had no text messaging plan, either! The agent had deleted my SMS plan, too - and I was 105 SMS messages over my plan limit of zero! Another call to T-Mobile, and this time "Jackie" fixed it, retroactively.

Now back to my baseline $50 for 500 minutes of voice, unlimited texts, 2GB data reinstated, I asked if they'd match the Walmart deal. Jackie patiently and politely pointed that the Walmart deal is prepaid, and that there are many customer service advantages with a postpaid plan. I told her that the only benefit I could think of was that I could roam internationally - and laughed as I said that any customer service advantages would need to be demonstrated some other time.

That conversation pushed me over the line. The cumulative hassles really got to me. I decided to cancel my T-Mobile account. Strangely, I felt guilty about it, as if I had somehow failed, or was being disloyal. But they'd botched their side of the deal again and again, repeatedly inconveniencing me. The next day I met a friend in Mountain View for lunch, and on the way home stopped at Walmart where I paid $25 for a "FamilyMobile" SIM.

When I called T-Mobile to cancel, I was treated to a truly amazing, virtuoso customer service performance by "Andrea" who pulled out all the stops to try to keep me. "Do you really want to end a four year relationship because of what's happened in just one month?" What a great line!  What a scriptwriter! "I understand your frustration but maybe I can make everything right for you." 

And the stick: "That Walmart plan is only 3G." 

I replied, "But my phone doesn't have an LTE radio - it's just HSPA+ - are you telling me that Walmart doesn't get access to LTE? Or to the highest HSPA+ speeds? Because my phone can't use them." 

"Gee, I don't know - I've never heard those terms." 

I checked - T-Mobile 3G is UMTS or HSPA+ at up to 7.2Mbps, while their "4G" is really a souped-up 3G HSPA+42. But their HSPA 3G at 7.2Mbps is plenty fast, and my phone can't receive T-Mobile's "4G", and anyway it's not clear to me that it would make any difference. Most of the time I seem to be in a T-Mobile dead spot or at a WiFi access point. Today, for example, the fastest rate I could get on T-Mobile was 1.3Mbps which definitely is a "3G" speed or maybe even 2G.

So I stood fast and my T-Mobile service will be disconnected on August 4. Even though I am awed by their retention effort, this final act reflects the fatal flaws that have always been in our relationship. I was willing to contribute $600 annually to their fixed costs. All I wanted was that things be simple, easy, and fast. I prefer to do everything myself online (further reducing their costs). I don't want them to screw up or nickel-and-dime me. But it was exactly their desperation to to maximize yield that turned every interaction into a nightmarish comedy. Reaching for that extra $50/year cost them the whole $600 annuity, which had a present value of several thousand dollars. 

When I ported my number to Google Voice, they should have recognized that I was an at-risk customer. When I mentioned Walmart Family Mobile, they had to know I was serious and in my opinion at that point they should have offered to match the $39.88/month figure.

The irony is that Walmart Family Mobile runs on the T-Mobile network, so the effect of their yield maximization is to cut their revenue from me by (I estimate) 40%.

Wednesday night at home

Train home. Changed both tires on my road bike after noticing that the belt fibers were peeking through the rear wheel tread. Laurie called to suggest a rendezvous at Town & Country so we caught the end of a Detroit-style blues band, and then pedaled home.  Tabbouleh, salad, brussels sprouts for dinner. I started the laundry (rags left by the maids) and we walked downtown for milk...  When we got back, I threw the rags in the dryer and sat down to clear up a few loose ends. First, the New York Times crossword puzzle in 6:19...

The MythTV box is down again. It's recording but not playing back. It looks like Catalyst Control Center v.12.6 disagreed with Ubuntu 12.04 and whatever MythTV rev is installed, and it uninstalled itself. So no sound (again) and images don't get scaled. The answer seems to be to backup the database, upgrade to Ubuntu 13.10, install Catalyst 13.6, and maybe a MythTV upgrade too.  I don't know when that will happen. I just tried running the Catalyst installer and it failed (predictably), complaining that a proprietary AMD driver was already installed. I really ought to set up regular backups, and fix the infrared remote (which Really Needs an Esc function), too.

I'm investigating the Magento e-commerce system for my brother, who needs some customization on his gift basket site. I wrote some code to explore the SOAP APIs and to load arbitrary customer data files. But the next step for me was to set up my own Magento test system...  This took about ten minutes - download the file, unzip it, edit the Apache extra/httpd-vhosts.conf file, edit drivers/etc/hosts, start MySQL, start Apache, go to the setup URL - except the initial startup transaction (run through Apache) requires 90 seconds - so it crashed because of the PHP timer. I edited php.ini, dropped and recreated the database, and it all looks good.  More on that tomorrow.

And then there are the telephones. Porting my T-Mobile number to Google Voice meant that I no longer had a separate voicemail-only Google Voice number. So to use GV with my home SIP phones, I had to reconfigure them with my VOIP provider. But for some reason, the changes just didn't take. I couldn't get to the new voicemail system to set the outgoing message. It only took me about ten minutes to figure out that long ago - maybe before I discovered the rich feature set of the VOIP system - I had programmed the the Cisco/Linksys/Sipura SPA2102 analog telephone adapter (ATA) box to forward to my GV number on ring-no-answer. That was still active... Clearing those fields got me right to the voicemail system and I recorded a nice outgoing message.