The New York Times Bestirs Itself to Report on ObamaCare Problems Naked Capitalism Readers Have Known About for Years

By Lambert Strether of Corrente.

The normally reliable Elizabeth Rosenthal, “a New York Times correspondent who is writing a book about the health care system,” has produced a shockingly agnotological and tendentious article on ObamaCare and its “growing pains.” I’m going to go through the article — “Sorry, We Don’t Take Obamacare” — and juxtapose Rosenthal’s reporting with material familiar to Naked Capitalism readers, often from two or even three years ago. We’ll find that Rosenthal’s article is disinformant in three ways: It’s dilatory, incomplete technocratically, and incomplete in terms of public policy. (Long-time Naked Capitalism readers will find the material an easy read, and newer readers may find ways to apply it to campaign 2016 and Medicare for All.)

Dilatory Coverage

Here’s Rosenthal’s summary of the state of play; I’ve added numbers for the individual points:

Some early studies of the impact of the Affordable Care Act plans are proving patients’ grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients’ home states, [1] require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a [2] narrow network policy. And while employers tend to offer their workers at least one plan that allows them [3] coverage to visit doctors not in their network, patients buying insurance through A.C.A. exchanges in some states do not have that option, even if they’re willing to pay higher premiums.

(I like “grumbling”; I mean, it’s not like access to health care can avoid suffering or death.) And to be fair, most NC coverage focuses on the intrinsic absurdity, unfairness, or unaffordabilty of ObamaCare policies as such, rather than comparing them directly to employer-based plans, as Rosenthal does. That said, let’s take those points in order

[1] Pharmaceuticals. On higher patient outlays, “Obamacare’s Drug Coverage Minefield,” December 5, 2013:

[Quoting the Wall Street Journal:] In a study of 22 carriers in six states, Avalere Health found that 90% of bronze plans (with generally the lowest premiums) require patients to pay a percentage of costs, 40% on average, for drugs in tiers 3 and 4, compared with 29% of employer-sponsored plans that most Americans currently use. Most silver plans also require patients to pay 40% for the highest-tier drugs, although some have flat fees of $70 to $270, the study found….

Now let’s not kid ourselves. Current private insurance plans often put a lot of the burden of pricey drugs on the patient. But the bronze plan v. employer-sponsored plan comparison above shows that patients will often face bigger financial charges than their peers who are on the corporate meal ticket.

[2] Narrow Networks. On the limited number of doctors and hospitals, “ObamaCare Roundup: Random Rates and Narrow Networks,” June 14, 2014:

What’s in and out of network really matters, because — whoopsie! — you can be on the hook for everything if you go out of network. But as Kevin Drum explains, nobody’s looking out for you but you, and in the nature of the case, you’re stressed, sick or injured, possibly even disoriented, and prone to error. Error that’s profitable for the insurance companies, naturally.

[Narrow networks have] been a growing problem with private insurance plans for years…. [I]t gets worse with Obamacare in some states because of the narrow networks supported by nearly all ACA insurers. For example, [one reader] confirmed to me that he had a Blue Shield plan, but that’s not the whole story. “The blood lab in question is in network for Blue Shield, but not for Blue Shield CoveredCA [whoopsie!] plans, as per everyone I’ve spoken to about it.” …

[I]’s really hard to be alert enough all the time to avoid this. You have to remember to ask every time. You have to ask every doctor, and you have to ask for every lab test. And most doctors don’t know, and don’t really want to be bothered finding out. So you have to be very, very persistent.

And most of us aren’t very, very persistent. Especially if, say, we’re in an ER worried that chest pains [whoopsie!] might be an indication of an oncoming heart attack.

How big a deal is this? I don’t have any way of knowing.

Not only does Drum have no way of knowing, I don’t think ObamaCare itself has any way of knowing; everything is siloed by insurer. They have no reason to make themselves look bad, and there’s no way to aggregate the data for problems like this for ObamaCare as a whole.

[3] Balance Billing, or what happens when you “visit doctors not in their network.” “Another Lurking Obamacare Problem: Balance Billing,” November 19, 2013:

One of the proofs that Obamacare is really about helping insurers and Big Pharma rather than ordinary Americans is its failure to do much about the seamy practice known as balance billing.

Say you have a scheduled procedure, like getting a stent. Like most Americans who have health insurance, you are in an HMO or a PPO. Your doctor, who is in your network, schedules you for the operation at a hospital in your network. You assume the only thing you need to worry about is a fairly minor co-pay and recovery.

But weeks later, you find that the anesthesiologist wasn’t in your network, and you are hit with a $12,000 bill for his services. And this sort of scamming (hospitals knowingly putting people on a surgical team that they can bill at huge premiums to negotiated rates) is routine. And of course, if the ambulance takes you to an emergency room that is not in your network, the outcome can be catastrophic.

Finally, Rosenthal mentions the impact of narrow networks on cancer patients in particular.

Some of the problems may have been predictable. When designing the new plans, for-profit insurers naturally tended to exclude high-cost, high-end hospitals with whom they had little clout to negotiate discounts. That means, for example, that as of late last year none of the plans available in New York had Memorial Sloan Kettering Cancer Center in their network — an absence that would be unacceptable to many New York-based employers buying policies for their employees.

“Obamacare Narrow Networks: How They Affect Doctor Specialties,” October 12, 2013:

As we venture into the world of narrow health care provider networks, I thought I would take some time to study what they really mean, in terms of how the new networks might affect patients’ access to specialty care services. To do this, I compared the current landscape of provider networks with those that will be available on the Exchanges. I used Washington State as a case study.

As you can see from my results, the most under-represented specialties (on the left) are the ones that typically provide services to truly sick patients, such as oncology, cardiology, internal medicine, neurology. And no doctor specialty has more than about 75% representation on the Exchange provider networks. Hospitals are also included on the right of the graph. Their numbers are diminished in the Premera Exchange plan network via excluding specialty hospitals that are crucial to good care in this region, such as Children’s Hospital and the Seattle Cancer Care Alliance.

I’m just a little amazed that Rosenthal, and her readers, have to be treated to a potted summary of these issues in 2016 when all these problems were investigated in 2013 by people who were actively evaluating the polices available on the the exchanges, some directly seeking care. What kind of bubble do these people live in?

Incomplete Coverage of the Story (Technocratic)

Rosenthal mentions, without naming them, “early studies,” but oddly doesn’t cite two studies from the well-known National Bureau of Economic Research (NBER), both of which undermine ObamaCare’s ideological foundations. Remember that ObamaCare is a neoliberal, market-based program that assumes buying health insurance is like buying a wide-screen TV, and that people will comparison shop (which will ultimately bend the cost curve down). Unfortunately, these assumptions are false.

Here’s how Rosenthal presents the ObamaCare shopping experience:

When Sara Hamilton of New York was shopping on the exchange for a plan to cover her and her two young-adult children — who live in distant states — she discovered that none of the plans covered doctor visits in those places. When notified that the plan would double its monthly premium the following year, to nearly $1,000, she went shopping again on the state exchange and chose a Blue Cross silver plan for $500.

Notice the key point: Rosenthal shows shopping, but not comparison shopping. In Rosenthal’s telling, all Hamilton did was cut back on price. Rosenthal does not show that Hamilton received equivalent value, which conforms to consumer behavior in the first study she did not cite. From NBER Working Paper No. 21632, October, 2015 (cited by Naked Capitalism January 12, 2016):

We find no evidence of consumers learning to price shop after two years in high-deductible coverage. Consumers reduce quantities across the spectrum of health care services, including potentially valuable care (e.g. preventive services) and potentially wasteful care (e.g. imaging services).

And from NBER Working Paper No. 21565, September 2015 (cited by Naked Capitalism October 19, 2015):

[E]ven under the most optimistic assumptions, close to half of the formerly uninsured (especially those with higher incomes) experience both higher financial burden and lower estimated welfare; indicating a positive “price of responsibility” for complying with the individual mandate. The percentage of the sample with estimated welfare increases is close to matching observed take-up rates by the previously uninsured in the exchanges.

In other words, 50% of the unenrolled believe ObamaCare would decrease their welfare, making it highly unlikely that ObamaCare will ever provide universal coverage, and those enrolled don’t comparison shop to reduce costs, but simply pick a cheaper policy, often at the risk of their health. From the technocratic perspective, ObamaCare is failing because its neoliberal conceptual foundations are false, not because of any lack of transparency, as Rosenthal later speculates. You’d think these studies would be part of the narrative?

Incomplete Coverage of the Story (Public Policy)

First, Rosenthal describes variations between ObamaCare coverage as follows, seemingly without noticing the intrinsic injustice of disparate access to health care:

Many of the problems may well be the growing pains of a young, evolving system, which established only broad standards for A.C.A. plans and allowed insurers — a large majority of them for-profit — considerable leeway in designing their exact offerings. The specific requirements and policing mechanisms vary by state, and are still works in progress.

The legislation created four tiers of insurance — bronze, silver, gold and platinum. … But within each tier there are dozens of plan designs that give buyers the choice of different premiums, deductibles and networks of doctors, among other things. And the options are different in each state.

(I like “work in progress.” ObamaCare was passed in 2010! How long do the “growing pains” continue?) But as we demonstrated in exhaustive detail in a six-part series of posts in 2013:

In a six-part series on “ObamaCare’s relentless creation of second-class citizens,” I showed how people seeking health care through ObamaCare’s exchanges get randomly varying access to care because of age, geography (state and county), income, employment status, banking status, internet access, existing insurance status, language, demographics, and by CMS marketing category (1, 2, 3, 4, 5, and 6. In addition, people “on the bubble” for income eligibility are incentivized to corrupt the system by gaming it.)

These variations are in great contrast, both morally and economically, to single payer’s “everybody in, nobody out” model.

So, from the public policy perspective, not only does Rosenthal accept the inequity of differential treatment for people who are situated similarly, she gives specifics on only one (“by each state”) of the multiple ways in which this inequity can occur.

Second, Rosenthal ignores or suppresses solutions that are not market-based (that is, are not neo-liberal). She begins by pushing the shibboleth of transparency, which is a good thing only if a market is not broken:

In order to make smart choices, patients need far clearer and more accurate information about the plans’ restrictions as well as which doctors and hospitals are in the network. Yet such information is rarely available, and early research suggests that only a fraction of the doctors listed in some directories are available to see new patients.

But as we have seen from the NBER studies, the “smart choices” model isn’t working in the real world; consumers don’t comparison shop. (Rosenthal might have argued that they would, were the market more transparent, but that assumes what needs to be proved, and also assumes that insurance companies won’t game the system. Just because the physician directory is correct doesn’t make a network any less narrow, or prevent a hospital from balance billing).

Rosenthal goes on to mention the “public option”[1]

This disappointment is fueling renewed interest in a “public option” that would supplement current offerings. That idea found support from both Senator Bernie Sanders and Hillary Clinton as the Affordable Care Act was making its way through Congress. It was taken up again last week by Mrs. Clinton, when she suggested allowing people 55 and over to buy into Medicare, the government-run insurance for people 65 and over, which is accepted by virtually all hospitals.

Of course, this isn’t a serious proposal by Clinton, because she doesn’t address the issue of how subsidies would work, or even if there would be any. But did you notice Rosenthal suppressing anything? Of course you did: Single payer Medicare for All. (I mean, it’s not like there’s a whole single payer system called Medicare 60 miles north of Burlington. That’s science fiction stuff! And it’s not like there’s a presidential candidate who’s made Medicare for All a centerpiece of their campaign.) And ironically, a new poll on single payer appeared two days after Rosenthal’s article:

Most Americans want to replace Obamacare with a single-payer system — including a lot of Republicans

Well over half of Americans want to replace Obamacare with a single-payer system. That figure, amazingly, includes 41 percent of Republicans and Republican-leaning independents — even though the wording of the question specifies that the program would be “federally funded.”

Maybe Rosenthal will do a follow-up?


I can only speculate why this article is so dilatory. Perhaps the introduction to the story provides a clue:

“Anyone who is on these plans knows it’s a two-tiered system,” said Ms. Moses, describing the emotional sting of those words to a successful entrepreneur.

Many say they feel as if they have become second-class patients.

I’m guessing that when entrepreneurs get affected, as opposed to poor shlubs like the rest of us, the Times sees a problem, not merely a situation, rather like one of those genre pieces they run about how hard it is for a struggling family to live in Manhattan on $250K a year.

And if you really want to experience “a two-tiered system,” wait until you’re over 55 and, based on its eligibility requirements, ObamaCare forces you into Medicaid and then claws back any health care expenses you incur from your estate, like the house you’d hoped to pass on to your kids, should you have that privilege. Yes, I want Ms. Moses to be covered by Medicare for All, like everyone should be, but I really don’t think she, or Rosenthal, have any idea what being a “second-class citizen” is really like.

Oh, and read Naked Capitalism so you don’t have to wait for the mainstream to take its own sweet time getting to stories that affect you.

[1] One of the many reasons the “public option” is a terrible idea is that it puts a public service into the marketplace, subordinating it (which is the neoliberal program in a nutshell). One excellent way to gut Social Security would be to make it the “public option” in a “Retirement Exchange” organized like the ObamaCare exchanges.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. Pavel

    Ha ha, Lambert — I thought of you, NC, and your excellent Corrente series on the Obamacare clusterf*ck as soon as I read the NYT piece.

    More details from the Gallup poll:

    A majority of Americans are in favor of a federally funded healthcare system that provides insurance to all Americans, according to a new Gallup poll.

    Some 58 percent of respondents support replacing ObamaCare with a universal healthcare system, while 37 percent oppose that plan.

    A majority — 51 percent — also supports simply repealing the Affordable Care Act, while 45 percent oppose the idea. Americans were divided over the idea of leaving ObamaCare as is: 49 percent oppose the idea, and 48 percent support it.
    The three scenarios were meant to correspond to the proposals of the three presidential candidates.

    The Hill: Poll: Majority of Americans support universal healthcare

    Always money for war (Obama’s and Hillary’s included), but god FORBID the government pay for proper health care!

    And wait until the next Obamacare increases kick in just a week or so before the election. The gift that keeps giving, or something like that.

    1. fds

      THere is no ‘smart’ choice here. All plans are over priced and offer few services vis-a-vis pre-Obamacare.
      Shopping smart in this context is like saying people should shop intelligently to maximize two fast food joints.

  2. Pavel

    Here is more anecdotal evidence from Phil Girardi on ObamaCare price increases and its unintended consequences, in a piece on Obama’s foreign policy:

    Obamacare is something more serious and, in my mind, disastrous. In my own experience, working for a non-profit foundation, I saw health insurance for our three employees go from less than $1,000 per month to nearly twice that in 2013 the first year Obamacare was introduced then to more than $3,200 per month in 2014 with a warning that it would go up again by at least 25% in 2015. At that point we were compelled to drop the insurance. Now it appears that several large health insurance companies are also refusing to participate in the program because of the losses that they are sustaining.

    Obamacare might make sense for that proportion of the population that cannot afford healthcare at all unless it is paid for in full by the government or heavily subsidized, but what about the rest of us? The concept of providing mandatory insurance coverage bothers me somewhat constitutionally speaking but it is the failure to make any attempt to control prices while turning the system over to for profit insurance companies that resulted in a plan that was guaranteed to fail. At what point will healthcare become unaffordable for most people? That point might soon be here.

    Philip Girardi: The Obama Legacy: War is peace

    But wait, remember — “If you like your health plan, you can keep your health plan”!

    For all of these reasons, PolitiFact has named “If you like your health care plan, you can keep it,” the Lie of the Year for 2013. Readers in a separate online poll overwhelmingly agreed with the choice. (PolitiFact first announced its selection on CNN’s The Lead with Jake Tapper.)

    For four of the past five years, PolitiFact’s Lie of the Year has revolved around the health care law, which has been subject to more erroneous attacks than any other piece of legislation PolitiFact has fact-checked.

    Obama’s ideas on health care were first offered as general outlines then grew into specific legislation over the course of his presidency. Yet Obama never adjusted his rhetoric to give people a more accurate sense of the law’s real-world repercussions, even as fact-checkers flagged his statements as exaggerated at best.

    Instead, he fought back against inaccurate attacks with his own oversimplifications, which he repeated even as it became clear his promise was too sweeping.

    The debate about the health care law rages on, but friends and foes of Obamacare have found one slice of common ground: The president’s “you can keep it” claim has been a real hit to his credibility.

    Lie of the Year: ‘If you like your health care plan, you can keep it’ (2013)

    Watch the video at the link above to see Obama repeat that “promise” multiple times. What a frigging disingenuous jerk he is. Either he knew he was wrong, or he had no idea what his beloved “health care plan” really would do — unlike, e.g., Lambert who documented and predicted what would happen all these years running.

    1. Pavel

      Via Mish (Mike Shedlock), more anecdotal evidence for consideration from the comments section. I also know several US physicians who say the increased paperwork is costly, stressful, and basically is driving them insane. One psychiatrist says he has gone “cash only” (no insurance of any kind accepted) and he is doing much better. (That approach is not applicable to all medical specialties, of course).

      My girlfriend went on COBRA this spring; a continuation of employee based health insurance, but at full premium. She received a letter indicating premiums would be increasing 20% in August. Insurance companies are in really bad shape when they have to raise rates THAT much.
      My health insurance costs have gone from $8’600 a year for a family of 7 the year Obama was elected, to $36’000 including a $5’000 HSA now, for the 5 remaining at home. I don’t have issues with doctors or out of state coverage – but THAT is why the bill is so high, so we could keep our doctors and our coverage.
      Don’t you dare think I will EVER vote for a Democrat.
      The original plan called for the taxpayers to reimburse these companies for their losses but it died in congress. Just like medicare and even worse medicaid doctors can choose not to take Obamacare.
      I know there are some greedy doctors but when talking to my friends they would take the plans if it wads not for the mountains of paperwork to just get reimbursed for care they provide. Bob told me he had to hire another lady to submit the new paperwork and it takes about 4 to 6 months to get his money and the lady spent 4 months trying to file. She is very good at filing but regulations change al the time. Now Bob no longer takes Obamacare or Medicaid. Paperwork is killing the host as well.

      MishTalk: As Insurance Losses Mount So Do Refusals: “Sorry, We Don’t Take Obamacare”

      1. NotTimothyGeithner

        The Bernie Bros will be sorely missed when Democrats start to run in a few weeks. June 1st is coming up. When Democrats don’t have answers beyond “Bill Clinton,” I don’t expect their numbers to do very well.

        If only there was some kind don’t of warning.

      2. reslez

        Wow, those Mish commenters are stomach turning. Hair-on-fire about the evils of socialism, Denmark, VA medical care, the post office, and anything else the government has ever done, aside from bombing Middle Easterners.

        Thoroughly propagandized against the danger of government ever helping working people.

        Incapable of empathy until sickness strikes themselves or someone they care about (when it comes out of their own pocket… the government better pay for it then).

        Hooray for “personal responsibility”. Sick people they’re not related to or dislike can go die.

        This is why I skip extended family Thanksgivings.

  3. Disturbed Voter

    Obamacare = Health insurance corporate welfare + Solyndra => Obamafail

    At least the Solyndra failure was limited to Solyndra. The mandate of Obamacare is the entire US.

    Government subsidy produces higher participation, but also higher prices … like the cost of everything near DC. It is like trying to live on sugars and other carbohydrates. Corporate subsidy produces economic diabetes.

    1. Pavel

      Well it seems even some of the Big Insurance companies are losing money on ObamaCare. Perhaps they’ll be bailed out by Mr & Ms Taxpayer (just add it to the tab) but the real winners are the typical gang of consultants, lobbyists, and other crony capitalists e.g. the Canadian company that got $2 billion for a broken web site.

      It seems like:

      –if you had previous coverage you liked, you either lost it or it got much more expensive and you may no longer have access to the same docs
      –if you didn’t have coverage you now have CrapCare™ which is hard to figure out, has lots of extra fees, and changes every year, using different web sites in each state, and taking endless amounts of time

      Otherwise it’s all good!

      1. Disturbed Voter

        It is unfortunate, even for well intentioned policies, that so much failure is produced. I am not sure this Obamacare thing was even well intentioned … but it needs a redo, or be replaced by “single payer” like Medicare. But the people who are “invested” in it, don’t want to admit they are wrong, so they will resist improvements to Obamacare.

  4. jgordon

    LSD and/or mushrooms is like an engine flush for the mind. People really have no idea how much useless crap that builds up in their heads from day to day until they get the chance to look at life from another perspective–with level-headed friends and the right setting of course. While it’s not going to end all wars and stop people from joining corporations as Timothy Leary enthused in the linked video, it’s still worthwhile as a reality check once or twice a year for anyone.

    Using psychedelics is like graduating from the self-involved juvenile thinking into adult thinking for the first time, and I suddenly understood why a lot of indigenous cultures use psychedelics in their coming of age ceremonies. Considering society, religion, money, government etc while using psychedelics quickly reveals just how limited and wrongly categorized/compartmentalized these concepts are. Worth the experience.

    Caveat: nearly everyone I know who uses drugs regularly, including psychedelics, is a flaky and unreliable idiot. I can appreciate why these substances illegal; the people who take them regularly inspire disgust. But with that said psychedelics are certainly appropriate and useful for level-headed people who otherwise have no experience with drugs. Once or twice a year.

    1. John Zelnicker

      @jgordon – You are correct about the usefulness of psychedelics. However, it must be emphasized that these are powerful drugs and are most certainly not for everyone. And novices should always have a guide during the trip.

      In other news… There is new research looking into clinical uses of psychedelics to treat a number of mental issues. Mushrooms (psilocybin) appear to be quite effective in treating depression, for example.

  5. Roy Morrison

    MA my wife is psychiatric clinician in private practice. People who have insurance with MASS Health, the model for Obamacare developed by Mitt Romney often have high deductibles that effectively mean no mental health coverage until they pay 5k out of pocket a year which of course they don’t have. Unless you are poorest of poor. You are screwed, as are clinicians.

  6. Cat Burglar

    Just got a letter from Anthem Blue Cross, my provider under Covered California.

    They’re informing me of a proposed settlement of a class action lawsuit against them for misrepresenting which providers were in-network: “Some providers listed as ‘in-network’ were not participating in-network for ACA plans and as a result some Class Members incurred higher costs. The settlement is designed to allow consumers to recover 100% of their extra costs.” Perhaps they’ll maintain their lists now — after all, I hear they do it for a living.

  7. DG

    Newbie here (couldn’t resist that!) – The best thing that came out of this election cycle was me running across this blog and the amazing commenters. Of course, there’s Bernie, but he’ll probably be crushed by the HRC machine by the Dem convention.

    Just feels nice to know that I’m not alone. Keep up the great work guys!

  8. Knifecatcher

    Ah, networks.

    A few weeks ago my 4 year old managed to shove a stick into his eye. Don’t ask. Fortunately as an informed health care consumer I was aware of the importance of locating an in network ER. If I went to the wrong one it could cost me thousands of dollars out of pocket – and that would be my fault, of course!

    So with my little boy bleeding profusely from his eye socket I calmly (ha!) pulled up my insurance company’s web site to locate the nearest in-network ER. I live close to the center of a metro area of around 3 million souls so surely there would be one to my zip code. Sure enough – after a desperate search for my ID card to determine exactly which of the 50 or so different plans we belonged to – one came up on the screen. It was 20 miles away as the crow flies, easily 45 minutes by car.

    That couldn’t be right, and sure enough it wasn’t – apparently there was a glitch in the web tool and by trying several nearby ZIP codes I finally found an ER within reasonable distance. I still have no idea what this will end up costing out of pocket.

    I say burn it down. Burn. It. All. Down. Everything. Obamacare, the insurance companies, everything. Nothing could be worse than the system currently in place.

    Coda: the stick didn’t pierce his eyeball and just tore the conjunctive tissue in the socket, causing some scary bleeding but no long term effects. Within a day or so he was excited to show off his shiner to the little girls in his pre-school class.

    1. jrs

      I don’t think that’s actually how ER care works with most healthcare plans. Most seem to allow you to go to any emergency room. Now there are caveats, like suddenly a non-plan radiologists or something shows up on the hospital bill, yea it could cause issues, but ER is often covered at any hospital even with HMS. Are you sure that is what your plan says – that for ER care you need to only go in network?

      1. Lambert Strether Post author

        Too pressured to dig out the links, but I am 100% certain there are policies and documented episodes of out-of-network ER care costing a fortune and the patient only finding out when they opened the bill.

      2. Knifecatcher

        It’s a high deductible plan so it effectively comes out of my pocket. The difference is that the plan has negotiated rates with in-network hospitals and not so with out of network so the prices I’ll have to pay – before I’ve met my deductible anyway – would be much higher.

        Or maybe not. Hell, I don’t know. Is there any real way to know? Either way I was worried enough about the cost impact to spend the time to try to pick the “right” hospital even with my boy’s eyesight potentially at stake.

        I hate myself for doing it, and I hate the system for making me do it.

        1. reslez

          What a horrible situation! I feel so much sympathy for what you had to go through. Ultimately I think you did a wise thing, but what if the injury had been life threatening? You would have been at the mercy of whoever was driving the ambulance. An injury to your little boy is bad enough, but the prospect of it destroying your family financially for years to come is the ultimate “f**k you” from our demonic health care system. I agree — burn it to the ground.

        2. rexl

          It is not a bad system until you need to use it, until you get hurt or sick, then watch out. We have difficulty even talking to, it is like no one knows you ever called and your call can be dropped right in the middle of a long explanation, and they never call you back. Burn it down.

    2. Sammy Maudlin

      Lousy situation made worse by the idiotic requirement that, when you or your loved ones’ health is at immediate risk, you need to take the time necessary to be a wise and educated “consumer.”

      “Insurance” is generally defined as a contract by which a person regularly pays money in exchange for indemnification against a “loss.” Your “loss” in that situation the cost of treatment. The actual cost of the treatment should be about the same whatever hospital you choose to “patronize.” All these variations in out of pocket responsibility are not due to variations in the cost of providing you treatment, but in the contracts extant between providers, facilities, and insurers.

      How can we possibly be expected to be educated consumers when there is little to no chance we can possibly understand all of the factors affecting our choices? Even when there is no immediate need for medical treatment? The whole premise is fallacious.

      Most importantly though, glad to hear your boy’s OK.

  9. RUKidding

    I had what is considered one of the better health insurance plans out there via the CalPers extended network. I stayed in the same system I’ve been in for years, but now it’s simply a nightmare of trying to figure out what I may or may not owe. Calling the Insurance company ends up being a joke because often the staff I speak to also don’t have a clue, although they are usually very polite and appear to be trying to figure things out.

    Recent incident: went for very routine cataract surgery. Called Ins Co. The opthamogist was in network. Even so, somehow for reasons never really explained clearly, I was still on the hook for over $800 for the dr’s time doing the surgical procedure. Luckily for me, I can afford this, but why? Especially as I was told that I wouldn’t have to pay a fee like that.

    Tried to find out if the anesthesiologist was in network – because I had been reading about these issues here at NC. It was hard to determine bc the opthamologist couldn’t guarantee who I’d get. I had to call in several names. Lucky me, I was only billed an “extra” $94 for his services.

    The kicker is that the opthamologist’s staff had a tussle with the Ins Co over whether they’d cover the procedure at all due to where the out-patient surgery happened. It was at an out-patient clinic, but apparently the billing occurs through a hospital with which it is connected. The Ins Co finally told both me and the dr’s staff that, yes, they would accept this as an out patient surgery and would cover most costs, although I’d still be on the hook for $1100 (why? I don’t know. But I have another insurance policy that covered this).

    So initially the Ins Co billed the surgery as discussed with me getting an initial bill for the expected $1100, which I paid. THEN the Ins Co retracted that coverage and issued me with a different bill for something like $3500!! Their reason: because the out patient surgery was billed through a hospital. The Ins Co LIED and said they never told me/the dr’s staff that I would only be on the hook for the $1100. but I had some smidgeon of “proof” with the two different billings indicated by the Ins Co.

    We are still fighting this ridiculous attempt at ripping me off SIX months later. Luckily the dr’s staff is fighting this with me. I have another process I can follow IF the Ins Co denies the dr’s staff current fight.

    It’s simply ludicrous that people have to go through sh*t like this over simple and very common procedures like cataract surgery. I duly note that NOW the Ins Co customer service line begins with a recorded message saying something like “If you are having cataract surgery, we will not cover most of it if you do it at an outpatient clinic that bills via a hospital.” It did NOT have this message last Fall.

    Absurd. I have no way to know, but my bet would be that these kinds of nonsensical shenanigans didn’t happen as frequently prior to ObamaCare. It’s just the worst.

    1. fresno dan

      I feel for you.
      You know, we should be greatful Obama didn’t “reform” fire insurance. They would not cover the pumper truck, charge you extra for water supplied from a water district not in your “network,” and the driver of the firetruck is a specialty that is out of pocket, and all yeah, wooden structures have 100,000$ deductible…

    2. Punxsutawney

      Great example of friction within the system. All this hassling with billing from both the doctor’s and patieint’s perspective adds unnecessary costs to the healthcare outcome. Is it any wonder we have the highest costs / outcome in the developed world.

      I suppose the insurance company wins here if the claim is eventually denied. How many doctors/patients just give up and pay it?

      1. reslez

        I would rather have no insurance at all than deal with this garbage. A product so terrible the government has to force you to buy it. I guess that’s why they are coming out with those new “medical treatment” consumer loans, because health care providers won’t provide you care unless they know they will be paid. Neoliberalism: “Go die.”

        They say medical bills are the leading cause of bankruptcy but you can actually wipe them out that way, unlike student debt which you are shackled to forever.

        I would like to see some figures on how many years of lifespan we lose from the stress alone.

        1. Punxsutawney

          See my post below, about how we are consumers, not citizens, or human beings. Loans for medical bills, exactly! How long before congress makes them non dischargeable? I agree it’s garbage unless you are close to indigent.

          I’m getting to an age where the body starts failing, no matter how “healthy” your lifestyle and the one way the system will be sure to impoverish me is medical bills. Otherwise I try not to play the game, but not get sick at some point, not gonna happen.

  10. fresno dan

    Lambert: “Not only does Drum have no way of knowing, I don’t think ObamaCare itself has any way of knowing; everything is siloed by insurer. They have no reason to make themselves look bad, and there’s no way to aggregate the data for problems like this for ObamaCare as a whole.”

    Addendum – …”I don’t think ObamaCare itself has any way of knowing …..They have no reason to make themselves look bad”…. – AND EVERY REASON IN THE WORLD TO PURPOSEFULLY NOT KNOW – and not just “not know” but willfully, stridently, obnoxiously NOT KNOW…to keep from making themselves look bad…

    Lambert: “What kind of bubble do these people live in?”
    Dare I say it – A PURPOSEFUL BUBBLE. They know, but it is the cover to argue that they don’t know. And to digress, Clinton makes the point of doing things and reform. I would ask, what law and/or reform in the last 30 years has made anyone IN THE 99% better off? I would say most reform is to screw the 99% while using the soft, silky words of the elite, always professing kindness and concern, while f*cking you in a non good way.

    And a word on “comparison shopping” Honestly, with regard to health care, is there any concept more idiotic and illogical??? It’s like Sophie’s choice on steroids.
    I have a number of aliments. How exactly am I suppose to check availability (ACTUAL – not 500 miles away) of every kind of doctor, formulary, and OH YEAH – FUTURE possible condition????? NONE of the information provided by insurers lists every possible service and the price.
    AND I CAN’T know what may happen to me in the future – I don’t have HIV now, but if I were to somehow get it, I sure as hell would want to be treated AS WELL AS I COULD BE.

  11. mk

    Thanks to NC for your coverage on ACA/Obamacare. I signed up for ACA on the CA Covered website and was forced into the Medicaid program (Medi-Cal in California, I am between 55-65 yrs old). Then I read one of Lambert’s posts here on NC about the clawbacks. Then I learned California is a 100% clawback state – our legislators submitted a bill to fix this problem and Governor Jerry Brown vetoed it. EFF THIS!! My estate, if there is anything left, goes to the grand daughter, even if it means I die early.

    The worst thing about it is that they don’t tell you so you can make an informed choice, they just sign you up! It took lots of phone calls and letters to politicians and others, but I finally got them to clawback my application.

    “It is shocking that Gov. Brown has chosen to single out low-income seniors by forcing them into an involuntary loan for their health insurance,” Campbell resident Anne-Louise Vernon, 60, a new Medi-Cal enrollee, said through tears Thursday night. “This is unconscionable, and the governor’s decision not to sign Senate Bill 1124 is penny-wise, pound-foolish and frighteningly hardhearted.”


    1. Lambert Strether Post author

      I believe the workaround, if you can afford a lawyer, is to get the house out of your name into a trust of some sort. More expert readers please correct!

      1. reslez

        It can differ state by state. I’m not an expert but I’ve recently been dealing with these issues for my parents and myself/sibling. In Michigan, Medicaid has a 5 year look-back period for all gifts (including trusts). Trusts don’t protect you unless they were established more than 5 years before entering Medicaid, same as any other gift. (There can be other reasons to establish a trust, consult an eldercare professional etc etc.) You don’t receive benefits until the full amount is paid back.

        Payback begins when the applicant enters Medicaid. (Note that in order to be eligible for Medicaid you must have almost zero assets already.) Let’s say you gave your kid $15,000 for college 4 years ago and you now enter Medicaid to assist with long term care. The $15,000 “gift” will be clawed back month by month according to the DHS formula for the average price of long term care. Medicaid does not kick in until then.

        There’s no minimum gift amount (you can’t stagger it in small sums), no maximum penalty for what you have to pay back, no partial payback, no exceptions or exclusions for the type of gift or reason the gift was made. If the gift was stock or real estate and the market crashed, you’re on the full hook for the original value.

        Different states can handle it slightly differently. Here’s some info I found for Maine. Good luck living in the right place.

  12. Punxsutawney

    Seems to me that healthcare here in the US is just another example of how we are viewed as consumers who need to have every dollar extracted from us, our dry husks tossed aside when there is nothing left; or to be re-inflated with consumer debt. Not citizens or human beings with rights, health care being one of them in my opinion.

    My employer’s plan was too costly to put my wife and children on after her job went to China, so even though the benefits were better, the 12k a year less in buying through the open market was well worth the risk of higher deductibles and co-pays. If all got seriously ill or hurt, then we could be out a significant amount more than the 12k, but all of them were healthy with no pre-existing conditions, though god knows what the insurance company could have come up with given enough incentive. When the ACA went through, well guess what, WE COULDN’T KEEP our plan that we did LIKE! We couldn’t keep our doctor, and quite frankly the network sucked. Fortunately at this point, the rest of a family is now on an union plan.

  13. Russell

    Thank you Lambert, Yves and all of NC contributors.
    Medicaid and Medicare for all represents the way out. Or correct me.
    Sanders points that way. (No excuse for unruly behaviour.)
    Did he really say that?
    He left something out!
    Obama? Charming guy.
    Sanders is abrasive.
    Should I get a license plate tattooed on my butt? You are required to be insured on the road, and I don’t read as much horror stories.
    Then,well it is different.
    700 is the number I estimate it will take as minders in Wash. DC shadows of gov. Equipped with a checklist to increment on.
    But by fix date coasts will be 125 miles further West.
    Written with the FIRE, so best time for

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