The ACA saved his life. Its subsidies saved his finances. Its enemies almost killed him

The Philadelphia Inquirer's Robert Calandra has a great story about a death's-door ACA conversion experience for a certain Dean Angstadt:

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.
That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Read more at http://www.philly.com/philly/health/healthcare-exchange/20140427_Hs1obamacare27xxxxxxxxx.html#E8pxpMvPEBLcEwee.99

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.
That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Read more at http://www.philly.com/philly/health/healthcare-exchange/20140427_Hs1obamacare27xxxxxxxxx.html#E8pxpMvPEBLcEwee.99

 He's a self-employed, self-sufficient logger who has cleared his own path for most of his 57 years, never expecting help from anyone. And even though he'd been uninsured since 2009, he especially wanted nothing to do with the Affordable Care Act.

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.

That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Angstadt's conversion was complete almost immediately following his online signup for a private plan in late January. ", "All of a sudden, I'm getting notification from Highmark, and I got my card, and it was actually all legitimate," he said. "I could have done backflips if I was in better shape."

At that point in the story I did wonder whether this jubilation would be tempered when the gentleman had a full accounting of his share of out-of-pocket costs. ACA plans tend toward high deductibles -- an average of almost $3,000 for silver plans, which is the level he chose -- and out-of-pocket maximums that often hit the allowable per-person limit of $6,350.

Good news: HealthCare.gov's shop-only feature is now all you could wish

In the darkest days of HealthCare.gov's dysfunction, I was preoccupied for a time by the partial workarounds enabled by third-party informational sites like ValuePenguin and HealthSherpa. ValuePenguin in particular offered (and still offers) a near-complete and accurate substitute for the informational functions of HealthCare.gov: it will calculate your subsidy and show you all available plans, accurately priced, with plan summaries.

HealthCare.gov at first, famously, had no pre sign-in informational feature allowing users to scope out options if they could not register, as most couldn't. When that feature was hurriedly added, it at first referred people to the Kaiser subsidy calculator, rather than incorporating its own subsidy calculation. It also gave out misinformation, at least for me in New Jersey: failing to query about age, the site quoted prices at a middle-range age without disclosing that it was doing so. In my case, the quoted prices were half to two-thirds of the actual prices, which I found on ValuePenguin and confirmed with the insurers.

Young, self-employed and seeking health insurance via the ACA exchanges? See an accountant

A good number of Americans who will be shopping for health insurance on the ACA exchanges are self-employed.  A 2007 Commonwealth Fund study found that 34% of buyers on the individual market for health insurance were self-employed (p.3). In 2012, about 15 million Americans were self-employed.

Doubtless many of the younger Americans subject to "rate shock" on the ACA exchanges are self-employed and earning enough to qualify for only small subsidies or none at all. For those who have not learned to max out on allowable deductions to reduce their taxable income -- e.g., everything from paper clips to home office space to computers, auto expenses and retirement fund contributions  -- the ACA adds new incentives -- in some cases powerful ones.

The ACA offers subsidies not only for premiums but for deductibles and maximum out-of-pocket (OOP) expenses. While the premium subsidies shrink at a steady rate per $1000 of income (and fade gradually to zero for a single young person), the break points for deductibles and OOP are sharper.  At some break points, a $1000 difference in reported income can mean a difference of thousands in medical expenses covered in a given year.

A caveat for Ezra Klein

[updated, with a rather large caveat to the caveat...]

..who has a cogent set of questions about how well HealthCare.gov will be working as of Dec. 1 and going forward.  On one key question I think there's a moderating factor:

9. Where the Dec.1 deadline really matters is for people who've already had their plans canceled and who need to be able to sign up for a new one in time for it to start on Jan.  1. If the Web site isn't working smoothly for these people in the next week or so it'll be an utter disaster when 2014 comes and many of these people find themselves uninsured and some get sick.

Most people subject to policy cancellations in the individual market are probably not eligible for subsidies, since they've already found insurance affordable. That means they don't really need HealthCare.gov.  They can easily get complete information about their options on ValuePenguin and then sign up directly with an insurer. [UPDATE: I'm afraid my premise here is severely compromised; William Ocasio reminds me that a recent Families USA study found that 71% of those currently in the individual market are below 400% of the Federal Poverty Level, and thus potentially eligible for subsidies. In practice, though, many people above about 270% FPL are not subsidy-eligible -- you only get a subsidy if the full cost of the benchmark silver plan exeeds a benchmark percentage of your income, and plan prices vary pretty widely from market to market. Still, probably more than half of those subject to cancellation are in fact eligible for at least some subsidy.]

Those who have received policy cancellations and are eligible for subsidies will need to get a subsidy application processed by hook or crook (that is, by online, phone or print application to the federal government) by Jan. 1. If they can't, I would imagine that some kind of retroactive subsidy payment will have to be worked out, after a lot of angst. For what it's worth, the subsidy-eligible probably won't be subject to rate shock, unless they're at the very top end of the scale, where the subsidy can shrink to near nothing.

Related:
Bypassing HealthCare.gov, cont.
Who needs HealthCare.gov?

Bypassing HealthCare.gov, cont

In prior posts, most recently here, I have explored the possibility that shoppers for health insurance on the ACA exchanges might bypass the still-balky HealthCare.gov with the help of information-only comparison sites ValuePenguin and HealthSherpa. Customers ineligible for a federal subsidy can already easily get all the information they need on these sites and then enroll directly with an insurer. For those whose incomes entitle them to subsidies, however, the subsidy application has been the roadblock, as it must be submitted directly to the federal government, either through HealthCare.gov or via phone or print application.

That may be about to change. Kaiser Health News' Julie Appleby reports, "Insurers and the Obama administration are testing fixes to healthcare.gov designed to allow insurers and web-based brokers to directly enroll consumers who qualify for subsidies under the health law."  It appears, though that the fixes require insurers themselves to route the customer's application through HealthCare.gov -- that is, in the 36 states that have forced the federal government to run their exchanges.  Direct insurer processing of the subsidy application is still only an ask:

Who needs HealthCare.gov?

[updated and corrected 11/22, per notes at bottom]

HealthCare.gov may be obsolete before it's fixed.

Purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. ValuePenguin provides plan details.  (Shopping without a login or completed application is also possible on HealthCare.gov, but there are limitations and inaccuracies.*)

The missing link has been the subsidy application. That has had to be done through HealthCare.gov, or through phone or print applications, both of which can be started by calling the number posted on HealthCare.gov.  That application is the black box from which it's unclear how soon a completed application will emerge. As I've noted before, some insurers at least will take an application for a specific plan from a user who's started a subsidy application with the government, but that's a two-track and perhaps unsettling process

Now, though, the government is poised to let the insurers -- and online brokers, which also enable some comparison shopping -- take the subsidy application, according to HuffPost's Jeffrey Young:

Now these insurance issuers and brokers are about to get what they want. The Centers for Medicare and Medicaid Services is close to providing insurers with the technological capability to also take subsidy applications, as well as sell plans to customers, spokeswoman Julie Bataille said during a conference call with reporters Tuesday. ..

Online brokers eHealth, Go Health and about 30 others also will soon have this capability, Bataille said. "We believe that they are on track to begin their transactions as soon as possible. This is something that, obviously, they will make determinations about individually as they see how their system is interacting with ours, and they make their own assessments about the fixes necessary for them to begin their work." 

[Update: fixes currently being tested  have the insurers route their customers' subsidy applications through healthcare.gov.  It remains unlikely that insurers will gain direct access to the federal data hub that enables subsidy determinations.] 

The brokers could be a useful intermediary for some. eHealth  offers comparison shopping, with plan details for each posted choice, though in many locations it's far from covering all options on the exchanges. Within its own universe, however, eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, hold information for any plan you select and notify you when enrollment is available on eHealth -- that is, when the site can initiate the subsidy application. A user should check their choices against ValuePenguin or HealthSherpa, however (I have found ValuePenguin's price quotes to be more accurate than HealthSherpa's in New Jersey).

If you want to eliminate the middleman, once the government allows third parties to process the subsidy application, you can use a non-transactional comparison site like ValuePenguin and then apply directly through the insurer offering the plan you choose. Many (I suspect most) insurers on the exchanges provide plan summaries online and enable online applications.

Once the government does outsource the subsidy application process, who needs HealthCare.gov? Its front end, that is. All that really matters is the back end: whether an application can be processed accurately in reasonable time. That of course is the rub, and allowing third parties to initiate subsidy applications won't make the technological challenge* go away. But perhaps the insurers and brokers will be able to expedite the process on behalf of their prospective customers -- and enable a smooth shopping process. If insurers and brokers can take the complete application, all the government needs to do on the front end is refer users to functioning online brokers and the informational sites.

At present, those who are not eligible for subsidies can easily make an informed choice from among policies available on the exchanges and complete the transaction through the insurer or an online broker.

One caveat: "informed" choice is a relative term. Online (and print brochure) plan summaries are not insurance contracts, which are complex, though less prone to booby-trapping than before ACA coverage rules took effect. If I were buying on the exchanges (as I might, next year), I might still seek the advice of a real live human broker to scope out how the co-pays, deductibles etc. might play out.

* You can comparison shop on HealthCare.gov without filling out an application. But subsidy information won't be incorporated in the price quote (they refer you to the Kaiser calculator for that). And the price quotes I got for my wife and I in New Jersey did not take our age into account and so were way off.

** Not to mention the yet-unbuilt systems to process subsidy payments to insurers.

Update, 11/21: just recalled that eHealth has been somewhat notorious for poor customer service:  it gets two out of five stars on epinions.com, and Rick Ungar spotlighted some customer horror stories when Avik Roy used the site to spotlight rate shock. Among the complaints: signing up at one price, getting enrolled at another. That should not be possible under the ACA. But the experiences do highlight possible pitfalls to using a middleman. Of course HealthCare.gov and the state websites should function at the least, in William Ocasio's  phrasing, as "public options to private marketplaces."   The point here is that complete effective workarounds while HealthCare.gov is still balky may soon be imminent, and that private online gateways may remain an important part of the landscape.

Update 2, 11/22: An earlier version of this post assumed that one could effectively ACA shop on eHealth. Prompted by the Anon comment below, I further tested eHealth and found that in many locations it does not include most of the plans available on the exchanges. I have amended the post accordingly. For the record, here is the original lead paragraph:

Online health insurance brokers like eHealth and purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. eHealth and ValuePenguin provide plan details. eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, and, for now, hold the the plans you select in a kind of provisional shopping cart. [Update: management/healthcare scholar William Ocasio of Northwestern tweets that eHealth omits some insurers. So results should be checked against ValuePenguin or other brokers.] 

Low-tech glitches on HealthCare.gov

I get that fixing HealthCare.gov dysfunction is a massively complex tech project.  But there are informational flaws on the site -- sins of omission and commission -- that would be easy to fix. I've encountered two.

For the first, call me stupid. There's a hole either in my tech savvy or my reading about ACA implementation -- or both.  But stupidity is rarely rare, and the designers of heatlhcare.gov should have anticipated my need for one really basic piece of information.

From October 1 to November 15, I tried to create a login at healthcare.gov at least 40 times.  For perhaps too long, I assumed that my failure was just the core failure of the site. Gradually, recently, it dawned that whatever the site's functional failures, most people by now could at least log in -- and were encountering further glitches when they tried to complete applications (see comments on this HHS posting). So I went on live chat and quickly learned the cause of failure: if you've blocked access to pop-ups, you have to turn off the pop-up blocker. I did so, and lo, my login is created.

Working around healthcare.gov: summary

To distill the takeaway from my last two posts (1, 2): anyone with computer access seeking to buy insurance on the ACA exchanges can easily get all the information they need to select a plan while bypassing healthcare.gov by visiting window-shopping sites ValuePenguin and HealthSherpa, as well as the individual insurers' sites once one has honed in on a single plan or a handful of top contenders.

Both sites prompt you for your location (zip code or state/county), the number and ages of people in your household, and your household income, and then give you specific quotes for all the exchange plans in your area. These quotes incorporate your subsidy if you qualify for one.  ValuePenguin provides plan details, and HealthSherpa provides contact information for each plan, including the identifying name of the plan in question. I appear to have gotten inaccurate price information in one location (Essex County, NJ) from HealthSherpa, but not from ValuePenguin, and the two provide identical price info at other locations I tested. The information on the two aggregator sites can in any case easily by checked against the insurers' own sites. The big insurers, if not all exchange participants, also offer subsidy calculators on their websites.

The catch is that as of now, the actual subsidy application has to be processed by the federal government, and the application process through the healthcare.gov website has proved broken for many if not most users (I have not been able to establish a login myself). You can, however, apply over the phone by calling the number listed at healthcare.gov and providing information orally, or you can ask the phone rep for a print application, which they'll mail. I reached a live person quickly, and he was ready to take a subsidy application from me, or so he said. Once you have an application case number, which can be sent by email if you apply over the phone, an insurer will let you apply for a specific plan, but you cannot seal the deal until the subsidy application comes through. 

The great unknown, I believe, is whether the federal government can process a phone or print application in reasonable time.  If so, the process need not be particularly onerous even if you cannot apply through the healthcare.gov site.

P.S. Healthcare.gov should be able to perform the ValuePenguin/HealthSherpa function even if you can't log in.  It does not provide age-specific price information, however -- at least, it hasn't in my three attempts. And it sends you to the Kaiser Family Foundation  for a subsidy calculator.  The Kaiser calculator is a great tool, and has been around for a while, but it doesn't provide plan-specific information.

Working around HealthCare.gov, cont.

[updated]

On Nov. 10 I spotlighted two public service websites, ValuePenguin and HealthSherpa, that appear to offer workarounds to the dysfunctional healthcare.gov for people hoping to buy health insurance on the ACA exchanges.

Both sites take your location (zip code or state/county), the number and ages of people in your household, and household income, and give you specific quotes for all the exchange plans in your area.  ValuePenguin links to plan details, and HealthSherpa provides contact information.

To what extent do these tools provide a workaround the broken Healthcare.gov website? They provide all the information needed to make an informed choice, at least when checked against the insurers' sites.  One still has to go through the federal government to apply for a subsidy, but that can be done by phone or snail mail. The main question, for those eligible for subsidies, is how long the subsidy determination will take.

A shopper who is not eligible for subsidies can buy a plan directly from the insurer of her choice, with all the information that should have been available on healthcare.gov easily obtained elsewhere. Below the jump, my experience initiating the shopping process.  I presented myself on the phone as someone planning to apply for a subsidy.