What I've learned as an ACA assister

This Open Enrollment period I've been volunteering a few hours per week as a Certified Application Counselor (CAC) for the ACA marketplace, at an office in Newark, NJ. I haven't had as much experience as I would have liked, but here, very generally, are a few things I've learned.

• The government could save a lot of money by opening Medicare and Medicaid to all legally present immigrants*.  Marketplace premiums for Medicare-age immigrants are sky-high -- and often paid entirely by the federal government. Oddly, marketplace plans may actually be better than traditional Medicare for elderly immigrants -- if they stay in network, e.g., if their middle-aged children can find them in-network providers. That's because marketplace plans, unlike traditional Medicare, have an out-of-pocket maximum. Then again, dual eligibles would be better of Medicare/Medicaid.


• Similarly, legally present immigrants with Medicaid-eligible income but subject to the 5-year bar for Medicaid eligibility cost the government more in marketplace plans than they would in Medicaid (as does anyone; see Private Option, Arkansas). They would also be better off in Medicaid -- the out-of-pocket costs attached to silver plans, even with strong Cost Sharing Reduction attached, are a high bar for people with Medicaid-eligible incomes.


• Deductibles and copays for silver plans with medium-strength Cost Sharing Reduction can look prohibitive to people with incomes in the 150-200% FPL range. In my neck of the woods, the cheapest silver plan with mid-level CSR has an $800 deductible and a $500 copay for ER and other hospital visits after the deductible is met. For an older enrollee or someone in poor health, $1300 for any hospital admission can seem prohibitive. Midlevel CSR raise the actuarial value of a silver plan to 87%, better than the average employer-sponsored plan. But the OOP is still high for low income people.


• More generally, people with incomes below 200% FPL belong in Medicaid, or a program with out-of-pocket costs comparable to or slightly higher than Medicaid (hello, Basic Health Program).


• Narrow networks and drug formularies can get low income people in deep trouble. Many doctor's practices, presented with an insurance they don't participate in, may say "we'll put the claim through" -- and then balance-bill, and then send the bill to a collection agency, with late fees piling on. If a drug is not covered, or if a pharmacy the person uses habitually is not in network, in the absence of careful explanation a person may conclude she has no options (such as get a generic alternative or go to another pharmacy).


• Our healthcare system is a barbaric mess.  We all know it. The ACA provided significant benefit to 20-25 million people and improved public health and a lot of poor people's economic and psychological well-being. But under Trump/Republican sabotage, those benefits are eroding, and access to benefits is riddled with gaps and pitfalls. That was true before the ACA was implemented, it was true as the ACA took hold, it's more true now, and it's likely to be far more true for however many years Republican domination lasts, and possibly well beyond.

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* Or maybe not, because I suspect far fewer Medicare/Medicaid-ineligible seniors sign up for marketplace plans than would sign up for the two Ms.  Per person, though, the marketplace is more expensive.