In early August, several weeks before my COBRA insurance was due to expire, I began shopping for replacement coverage with two health insurance companies in my area that I will call Company A and Company B. I met with a Company A sales representative, and she helped me complete an application that included my medical history. She was reassuring about my ability to obtain medically underwritten insurance through Company A.
Medically underwritten insurance is less expensive than other coverage health insurers offer, but for that reason insurers are highly selective about who qualifies to receive it. Because I am in good health, do not smoke, am not overweight and exercise regularly, I thought I would be a shoo-in for this coverage.
Silly me. A few days later, I was subjected to a grueling, 90-minute telephone interview by a researcher for Company A, during which she (to her credit, apologetically) asked me in minute and often humiliating detail about my medical history. One question that particularly floored me: “Have you been treated or seen by a health care professional for any conditions in the last five years?” At the end of the interview, I was shaking with anger, indignation and embarrassment. I was even more angry when I received an email five days later informing me that, in part because of my answers in the telephone interview, Company A was denying my application for medically underwritten coverage.
I decided to try my luck with Company B, which was already providing the coverage I had through my former employer. Again I worked with a sales rep to submit an application for medically underwritten coverage. This process went somewhat better; Company B agreed to cover me under a medically underwritten plan, but at a high “Tier 6” (the second-highest tier) premium rate because of concerns about three medical conditions, including an April wrist fracture that had fully healed by August.
This assessment struck me as so ludicrous that I decided to request a reconsideration of my rate. I asked the orthopedist who set my wrist to write to Company B, and I made the same request of the doctors who had treated me for the other two medical conditions, which were also now resolved. In addition, I wrote my own letter to Company B describing my good physical condition and my history of regular exercise. As further proof, I included the summary of my vital signs from my most recent doctor’s visit. (Blood pressure: 114/78! Pulse: 67! Body Mass Index: 20.8! Who could argue that I am not a picture of health?)
One week later, my Company B representative called me with good news: Company B had reviewed my letter and those from my doctors and decided to place me in the Tier 2 category for their medically underwritten insurance. Their reclassification reduced my premium by more than $200 a month.
This felt like a major victory: The pen is mightier than the underwriter! In accepting Company B’s medically underwritten coverage, however, I also agreed to the terms of their pre-existing condition clause. This meant that for 12 months Company B would not cover medical expenses for a recurrence of any medical condition I had had in the past five years.
I agreed to this Draconian clause for two reasons: I had not had a life-threatening illness in the past five years, and I knew I would be signing up for new coverage under the Affordable Care Act that would begin Jan. 1. Because the Affordable Care Act prohibits insurers from writing policies with pre-existing condition exclusions, I would be risking going without coverage for any pre-existing conditions for just a few months.
As fate would have it, in mid-November I began to see small flashes of light in my right eye. I visited my eye doctor, who assured me that this was not a detached retina, but instead was a benign condition common to extremely near-sighted individuals. My left eye had developed this same benign condition in September 2009, so I was familiar with his diagnosis. Nonetheless, I was surprised when Company B rejected my $78 claim for this visit, citing their pre-existing condition clause. I had explained in writing to Company B that the 2009 episode involved my left eye and the current episode involved my right eye, but this explanation did not persuade them. As the billing specialist in my doctor’s office said to me, with great sympathy, “They don’t look at it per eye. They think of it as a disease.”
All of this may seem like an exceptionally long preamble to my experience with HealthCare.gov. However, my impression from hearing and reading the countless criticisms of the Affordable Care Act before and after its passage is that many, many people in this country—including the members of Congress who still oppose the act—have no idea just how difficult it has been for people who are not covered by an employer’s health insurance plan to get coverage. At up to several hundred dollars a month—and in some cases more than that, the cost of the premiums alone put insurance out of reach for many. And the pre-existing condition exclusions made medically underwritten plans hazardous for those who had had serious illnesses, assuming they could even qualify for coverage.
I was alarmed enough by what I had heard about the HealthCare.gov website’s multiple technical failures to wait until early December to make my first visit—after the Dec. 1 date by which the website was expected to be in better working order. In the meantime, I perused the materials about health insurance under the Affordable Care Act that I had received from Company B, which was offering plans through the federal website. I learned that, in order to qualify for income-based premium tax credits and cost-sharing benefits, I needed to limit my search to the Silver plans offered by the insurers in my area. (Shoppers on the website can choose from plans at four premium levels—from least-expensive Bronze through Silver and Gold to most-expensive Platinum.)
When I ventured on the site for the first time, I encountered no delays and I was both surprised and pleased by how user-friendly it was. I did a preliminary search for the Silver plans offered in my area, and I was startled to see that I had 23 plans to choose from. During several visits to the site, I carefully examined the plans to compare premiums, deductibles, prescription drug coverage, office visit co-payments, out-of-pocket maximums and other expenses. In all of my visits, by the way, I encountered only one red-letter message asking me to please visit the site another time.
I should note again here that another crucial advantage of insurance offered through the Affordable Care Act is that medical underwriting does not exist in this universe. In other words, insurers can no longer set premium prices for customers—or deny them coverage altogether—based on their health history. Premiums for smokers are higher than for non-smokers, and age is also a factor: Older consumers pay higher premiums than their younger counterparts. But past illnesses cannot be used to deny applicants coverage.
As part of my research I met—free of charge—with a counselor from a local hospital system who was helping explain the Affordable Care Act to the community. From her I verified that my method of comparing plans on the website was appropriate. She also helped me decide to use all, rather than part, of my income-based premium tax credit, a choice the website offers. (If my income increases in 2014 beyond my current estimate, I must notify the website. My premium tax credit will be decreased and my premium cost correspondingly increased.)
Next, I completed my application on HealthCare.gov. Using my estimated 2014 income, along with my decision to take all of my premium tax credit, the site calculated my actual premium rates for each of the Silver plans available to me. I was happily stunned to see how reasonable the premiums were—far less than I was currently paying or had been paying under my COBRA plan. After more cost-comparing, I narrowed my choices to three Silver plans. By coincidence, all were offered by Company B, my then-current insurer.
I still had questions about the plans, however, so I took the old-fashioned step of calling the company. A representative spent a solid hour on the phone with me, patiently explaining the differences among the plans and what I should consider. She could not have been more helpful, and the same was true of the two representatives of the dental insurance company I called to ask about the plans that company was offering through the site.
The end result of my research, website visits, price comparisons and phone calls was that I officially signed up for health and dental insurance through HealthCare.gov on Dec. 16, and I paid my first month’s premiums to the companies online moments later. My monthly premiums for both health and dental insurance will be one-third the cost of the health insurance premiums I have been paying for the past few months—and let me repeat that my new insurance has no pre-existing condition exclusion.
On Oct. 21, three weeks after HealthCare.gov made its awkward debut, The New York Times ran a story about the website and the Affordable Care Act titled “Obama Pushes Health Law But Concedes Web Site Problems.” Among the 1,175 online responses to the story was an eloquent comment from Alan, a reader in Hawaii. He beautifully stated what I think of the Affordable Care Act, and what I hope Americans will come to understand in greater numbers as the months and years pass. Here is Alan’s comment:
“I’m in my early 60s, self-employed and was denied health insurance because of a pre-existing condition (my job covered me before). So Oct. 1 was a pretty big day for me. I eagerly went online, but couldn’t even set up an account. An inauspicious start.
“Here’s the thing, though.
“Being told you won’t be able to get health insurance feels something like getting a death sentence. A private company is telling you, tough luck, nothing personal, it’s just not profitable enough for us. I think my life has value, but from their perspective, it’s time for the trash heap. The worth of my life to them? $0.
“That’s why the Affordable Care Act, to me, is a godsend. It’s not just being able to go to a doctor without breaking the bank, although that’s a big part. It’s also a feeling that my life counts, that every citizen’s life has intrinsic value, that in this country we look out for each other. And for that, thank you, America.
“So this software problem? Yeah, it could have gone smoother. But I’ll wait. It’s nothing compared to the benefits that will be available soon. And I know if healthcare reform doesn’t happen now, it’s probably not going to happen in my lifetime. Costs will get more obscene and eventually only those with gold-standard policies will be able to get proper care. And that’s just wrong.
“We need to cut out all this political jabbering, and just get back to basic decency. If we reach out a hand to help another, we are headed in the right direction.”
Copyright © 2013 By Susan Hooper