Health Care Decision A Victory For Everyone, Except Millions Of Poor People Maybe
Good news, liberal-arts majors with Internet connections! Now even though you don't have a "real job" but are making a livable amount of money by cobbling together three blogging gigs and so don't have health insurance, starting in 2014 you will be able to (and also required) to stone-cold buy health insurance from whoever you want -- even if you have a pre-existing condition (i.e., herpes, we are going to guess that herpes is what you have). But wait, do you only have one blogging job, or maybe no blogging job and you work in a Wal-Mart, or as one of Newt Gingrich's janitors or something, and so you can't even afford to buy insurance through the subsidized exchanges and you were kind of counting on the expansion of the Medicaid to cover you? Well, we've got good news! Oh, do you live in a state with a Republican governor and/or legislature? Then we mean "bad news."UPDATED WITH MAYBE SLIGHTLY LESS BAD NEWS?
One of the parts of the law that was not talked about so much by the chattering Internet classes (most of whom are able to more or less afford health insurance, but are often freelancers who are denied it, because of their VD) is that Medicaid would be radically expanded. You probably think of Medicaid as "health insurance for poor people" but in actuality it's "health insurance for people who are disabled, blind, old, or extremely poor and also have children." This leads to awesomely depressing stories like this one , where a uninsured lady with cervical cancer considered getting pregnant specifically so she could get on Medicaid and not die.
Medicaid is also a state-federal joint program administered by the states, which now have a lot of leeway about setting the standards for who is eligible and what kind of care they get. Obamacare changes the Medicaid program so that it has to cover literally everybody who is a human and who earns up to 133 percent of the federal poverty level (still pretty low, but higher than the current threshold), in every state; it also mandate a minimum threshold for what diseases and whatnot Medicaid covers ( cough Arizona cough ). Yay for poors, right?
Well, sorry poors, because that's the only part that John Roberts didn't agree with! Medicaid is technically a voluntary program that states don't have to participate in if they don't want to -- Arizona didn't implement it until 1982 (seriously, Arizona, WTF). Up until this point, Medicaid has been an all-or-nothing proposition, which means that either you accept the Federal monies and run it the way King Nobama says, or you get nothing and you let all your old/blind/disabled/poor-with-kids people die. And that was supposed to be the way expanded Medicaid works, except now it won't, because Congress was tricky.
See, even though the program is still called "Medicaid," it's essentially an entirely new program, and by forcing all the states to sign up for it, the Feds are essentially "coercing" the states, by giving them money. And the Feds will give them money! 100% of the Medicaid expansion is paid for by the Feds for several years and then 90% thereafter. But it's the principle of the thing! So whatever states (Arizona) decide that expanding Medicaid (Arizona) is a savage affront (Arizona) to Freedom will just (Arizona) stick with the old system, the one that Congress repealed. This system will apparently still live on in some kind of zombie existence for states that want it (Arizona).
Now, the whole point of expanding Medicaid in the first place was so that people who couldn't afford even the newly subsidized insurance exchanges could still get the insurance that they were legally mandated to have. So -- and sorry so long but here's the punchline -- in Arizona and other Republican-run states that will opt out of expanded Medicaid because it's the one way they can spit in Obamacare's eye, poor people won't be able to get on Medicaid, but they'll still be required by the 100% Constitutional individual manda-tax to buy health insurance. That they probably can't afford. Because they're poor. And now they're screwed! Sorry poor people! Maybe you can make some extra money by claiming that you won a Bronze Star and Navy Cross when you fought in the Invasion of the Moon? Because that's totally legal now . [ The actual decision, read this and tell us if we're wrong, we're not fucking lawyers or anything ]
UPDATE: Slate sez "But ideological zeal may well lead some states to turn it down. In that case, substantially more people than the law's authors expected might find themselves eligible for either hardship waivers from the mandate or subsidies to buy insurance on exchanges," so maybe the poors will have other avenues to not get screwed by this! Meanwhile, Bloomberg cannot believe that any state would really turn down that sweet, sweet Federal cash just to make a point. Have you met our states, Bloomberg?
UPDATE 2: Aaaand Nebraska is first up in saying they won't expand Medicaid! Take a bow, Nebraska!
Repub. state senator is a drooling moron.
There was never any compulsion to set up an exchange, but there was the provision that wherever states opt out of creating exchanges, the Federal government will step in and create one the state has no control over. In other words, you can have it how you want it, or how we want it, your choice, but you're fucking getting it.
Anyone for whom their contribution to the cheapest plan in the Exchange is over 8% of household income is exempt from the penalty.
The amount of the penalty if you are not exempt is at least $95 per year per non-covered person* in 2014, ramping up to at least $695 per year per non-covered person by 2016 and inflation-linked thereafter. If your income is sufficient that 1% (in 2014) of income exceeds the fixed amount, ramping up to 2.5% of income by 2016, you will pay that fraction of income.
However, if you would've been eligible for Medicaid, you should never pay the penalty (except maybe in 2014 or 2015, depending on exact income level). Your income would've been no more than 133% of Federal Poverty Level, so let's look at what that means in terms of Exchange subsidies. In the Exchange, you'd receive a subsidy of the difference between the second-cheapest silver level plan (plans are bronze, silver or gold) and 2% of your annual income - in other words, you'd have to pay no more than 2% of income to get a decent level of coverage, and that's less than the penalty will be in 2016. What's more, because the subsidy is based on the silver level, there's a good chance that you'd be able to get a bronze-level plan fully covered by the subsidy.
Now, bronze-level coverage leaves you having to foot quite a lot of the bill if you ever actually <em>use</em> it, probably more than you can afford if your income is low enough you would&#039;ve qualified for expanded Medicaid if your state wasn&#039;t run by jackasses, so it might not be a tremendous value to you, but at least it&#039;ll prevent you from being penalized.
If you&#039;re in the window where the subsidy doesn&#039;t cover the full cost of bronze care and you can&#039;t afford to pay <em>anything</em> in premiums, you&#039;ll have to write the Secretary of HHS and beg a hardship exemption. Better hope there&#039;s a Democrat in office, or the response will be &quot;you have a refrigerator, don&#039;t you?&quot;