Doing the Math for Obamacare, Year Two
Andrea Wachholtz had a bumpy signup in the New York State of Health exchange last year that led to four months in early 2014 with no coverage and several more months in medical limbo.
The doctor she wanted to see was not sure if he would be in-network with her insurer, Emblem Health. When it became clear she would need to find another physician, Wachholtz initially had trouble finding someone near her home on the southern shore of Staten Island, and eventually Emblem assigned her to a practice.
Although it wasn’t her choice, she ended up being very pleased with the outcome.
“It’s a nice facility, and they also have emergency care, so you can go to them Monday through Friday, 9 a.m. to 9 p.m., without making an appointment,” said Wachholtz, who owns a children’s dance studio. “I like the convenience of it, because if I wake up and I don’t feel well, I can go there and get taken care of and just pay my copay.”
Wachholtz wasn’t planning to comparison shop for a new plan for 2015, but last week a state health exchange customer service representative warned her that her coverage and doctors network could change.
“I finally get health insurance, finally get a doctor, find great place, I’m really happy with it, and now you’re telling me when I re-certify, now I have to pick a new plan, it doesn’t just roll over?” she said.
Wachholtz and all health exchange plan-holders have the option of doing nothing and automatically re-enrolling, but the “same plan” from 2014 could include significant changes in costs, payments and the selection of doctors.
Subsidies change every year under Obamacare, because they’re pegged to the premiums of the second lowest Silver Plan in an area. Every year, those premiums shift, changing the benchmark. And subsidies also fluctuate individually as plan-holders’ incomes increase or decrease.
If people do not auto-reenroll and opt to shop around, they must pick a new plan by December 15th in order to have coverage in place by January 1st.
Advocates are encouraging everyone to look closely at their current plan’s details for 2015 and compare them to other offerings.
After the initial scare, Wachholtz this week learned the monthly premium on her Emblem Silver plan will increase from $385 to $407, a 6 percent hike. Wachholz gets a subsidy from the state to make it more affordable, but the subsidy is getting smaller, because her income has increased. So her net monthly payment will go from $61 to $94.
"I re-upped, because I don't have time to shop around," said Wachholtz, whose life is consumed in the late autumn getting her dancers ready for The Nutcracker.
Another Obamacare enrollee WNYC has been following, Brooklyn taxi driver Mahmoud Khanfour, said he does not have any immediate plans to comparison shop his Fidelis Silver plan with competitors' offerings, because he is pleased with his coverage, its price tag and the doctors it allows him to see.
After 17 years of being uninsured, he recently went to a primary care doctor, who referred him to a cardiologist, Dr. Chaim Levine. Overall, Khanfour, 62, feels fine, but he told Levine that his heart races whenever he exerts himself.
Earlier this month, Levine spent a half-hour with Khanfour, taking a detailed history, examining him, listening to his heart and chest and administering an electrocardiogram. Levine, who is affiliated with Maimonides Hospital, prescribed a stress test, an echo-cardiogram and a follow-up visit to work up an exercise regimen for Khanfour.
"My deductible is minor and the premium is not so bad," said Khanfour, who pays $132 a month and has to pay for $250 worth of medical services with his own cash, before his Fidelis plan kicks in. "To get a doctor of this caliber [for that] — I’m grateful to have the Obamacare."
For plan-holders with little or no subsidies, the costs are much higher, and so is the imperative to shop around.
Drew DeMaio, an apartment rental broker in Brooklyn, has a Bronze Plan with Health Republic that costs him around $300 a month, with a $6,000 deductible. He used it all up this year on procedures to locate and remove the source of severe neck pain — a growth that a surgeon eventually operated on.
Now that his deductible has been spent, DeMaio is going to see what other healthcare he can get in the remaining weeks of 2014: maybe a trip to the gastroenterologist for a colonoscopy or to the ophthalmologist for an eye exam.
He is going to look at other plans, albeit reluctantly. Like Khanfour and Wachholtz, DeMaio has been impressed with the doctors he has been able to see so far this year. He said that ideally he would just stay with one insurer and remain in the same network. But he said that does not seem like the best strategy for Obamacare coverage.
"Don’t just sign up for an insurance plan and stick with it. Keep on it. See what’s new. Continually shop around," DeMaio said. "I think that onus is going to be on us, to be in charge of our own healthcare."
DeMaio used to work for Apple, where he pretty much got the same coverage every year, and that was that. Now, he’s an independent worker, and things are less predictable – in his health coverage, just like in his paycheck. He accepts that as the price of professional freedom, but hopes that over time using Obamacare to buy insurance and get medical care will become a little more stable.
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