Mama's Got a Plan:

Maternity Care, Health Insurance, and Reproductive Justice

Obamacare, Again


Image Credits


Oh, Obamacare

As we were creating a cartoon about the complexity of the current health care payment system, we noticed media reports on common misunderstandings of the Affordable Care Act (ACA). The most recent was in the Michigan news weekly Bridge, which noted, “In Michigan, some counties with the highest Medicaid expansion and ACA usage gave Trump some of his largest victory margins …”
People have been known to vote against their own interests for the sake of broader principles, a tendency that politicians are happy to exploit. However, on the chance that voters were misled on simple facts, we bring you the following educational cartoon, put together lickety-split to be of service before the ACA can be repealed!



A few slightly more detailed facts:

  • Obamacare is the Affordable Care Act (ACA). Strictly speaking, it’s the Patient Protection and Affordable Care Act.
  • The ACA was the result of a series of compromises, but its goal was to provide health insurance coverage, either public or private, for anyone who did not have coverage through an employer-provided plan. In the past, options for the planless who were not eligible for public insurance (Medicaid, Medicare, TRICARE, etc.) included buying “individual” insurance on the private market at great cost, paying for COBRA through a recent employer at great cost, paying for care in cash at great cost, or going without.
    The ACA succeeded in insuring 20 million Americans. Of the 27.2 million (non-elderly) Americans who remain uninsured, 11.7 are eligible for financial help. For information about health insurance for the elderly, see the final bullet point below on “Medicare.”
  • The ACA bans insurers from refusing coverage to people with pre-existing conditions. In the past, people were refused insurance for reasons ranging from the tragic (had suffered from cancer) to the ridiculous (tested negative for a medical problem).
  • Because young and/or healthy people would naturally wait until they needed care to buy insurance, the ACA mandates that everyone have coverage. This ensures that the risk pool is not made up solely of very sick people who need expensive care.
  • In the past, only the poorest of the poor were eligible for Medicaid, except for certain special (and temporary) categories, like children or pregnant women. The ACA required states to expand Medicaid to people whose income was at 133% of the federally-determined poverty line or below. Following a challenge, the U.S. Supreme Court conceded that states did not need to expand Medicaid. Many states (green on our map) nevertheless did so because generous federal subsidies are offered for the purpose. But states that did not expand Medicaid caused many of their residents to remain trapped in the “donut hole” that existed pre-ACA: their income was too high for Medicaid, but too low to afford private insurance. It is worth noting that the decision to expand now rests solely with the states; those who blame the feds for the donut hole are blaming the wrong government.
  • The ACA reduces premium costs up front, by providing tax credits for households whose income is 400% of the federal poverty level. If an applicant’s income is considered too low for tax credits, that person is funneled toward their state’s Medicaid program.
  • Many people insured by public plans were unaware they were benefiting from Medicaid expansion, because their plans bore state-specific names that did not include the word “Medicaid.” Some examples: Husky Health Connecticut, MassHealth, Healthy Michigan Plan, Washington Apple Health, and many more. These state plans are Medicaid.
  • The ACA allows children to remain on their parents’ plans until the children reach the age of 26. William Shatner’s 1978 Saturday Night Live skit is referenced here purely for the nostalgic amusement of your cartoonist.
  • The ACA requires that free preventive care be included in all insurance plans.
  • We can identify and acknowledge many drawbacks to the ACA, many of which are continuations of problems that existed pre-ACA or resulted from compromises made in response to opposition challenges. But even political opponents who have been fighting like cats and dogs can agree on what’s wrong and how to fix it. Insurance premiums do keep increasing, just as they did in the past; however, the absence of an ACA cap on premium increases exacerbates the problem. Correspondingly, tax credits arguably should be adjusted to accommodate unaffordable higher premiums. This is purely a political problem and should be addressed accordingly. High-deductible plans are a reasonable choice for people who do not expect to use much care, but can be financially devastating for those who find themselves in need of medical attention. The answer, again, is to adjust the tax credit and premium caps to make better plans affordable to more people. Insurance does not guarantee health care, it is true. While the ACA contains provisions to increase access from the provider side, those preparations will require years to bear fruit. More immediate creative solutions are clearly needed. Finally: big government. This is a philosophical objection that begs for its own cartoon. Stay tuned!
  • Where is this all leading? Medicare for all. Medicare is the federal health insurance program for people who are 65 or older. “Medicare for all” suggests extending this insurance program to all Americans in a national single-payer health insurance plan – the kind favored by a majority of Americans. This proposal does not necessarily involve a centralized authority that employs providers and directs all medical care. Rather, it proposes combining the entire population into one insurance risk pool in order to take the greatest advantage of potential savings, particularly from administrative spending, which currently accounts for one of every three health care dollars spent in the U.S. Much more information on single-payer systems is widely available. We suggest starting with Physicians for a National Health Program.

We hope that The Affordable Care Act/Obamacare 101 has been useful to you. Please respond on our Facebook page if you have ideas for future cartoons on this subject – or any other!

Image credits

News and links, May 4, 2014

Please follow the Facebook page for Mama’s Got a Plan!

My children on MIChild … and meditations on the purpose of government

I did not need to apply for marketplace health insurance for my children, because they already receive coverage through the federal Children’s Health Insurance Program (CHIP), know in Michigan as MIChild.

Before MIChild, my children were covered for a short time under Medicaid, implemented in Michigan as the “Healthy Kids” program. What’s the difference? Medicaid is the public health insurance program for low-income people, run under a state-federal partnership. In Michigan, children are eligible to receive coverage under Medicaid if their family income is under 150% of the federal poverty line. New figures should be out soon for 2014, but under last year’s guidelines, the poverty line for a family of four in most states was $23,550. MIChild/CHIP, on the other hand, is a program funded entirely by the federal government, available to children whose family incomes fall between 150-200% of the poverty line.

Is it too embarrassing to talk about?

Considerable stigma attaches to receiving direct assistance from government programs, especially when it’s in the form of health insurance. This piece by an anonymous writer provides an excellent portrayal of the stigma, including its racial dimensions. Besides indignation surrounding “socialized medicine” – that don’t seem to apply to politicians, other government employees, armed services members, or senior citizens, by the way – many of our fellow citizens seem to feel that it’s shameful to be the recipient of this or other forms of assistance.

I disagree about the need for shame, based both on policy considerations and on our family’s experience. For us, having the children receive public health insurance was beneficial and sensible because it removed the need to worry whether the children were sick enough to warrant care. At that time, on our very minimal insurance plan, we paid out-of-pocket for all care aside from two doctors’ visits a year. So if, for example, a child ran a fever for five days (not unheard of for small children), we had to decide whether it could possibly be the sign of something much more serious that would warrant the $100 doctor’s visit – or wait and see. To pay $100 to be told the fever was the result of a common virus, and that the child should be given OTC painkillers and kept hydrated, was a disaster. But waiting to see whether something worse developed was equally dreadful. Once the children were on Medicaid and then later on MIChild, this scenario never arose. If we were worried about the children’s condition, they got evaluated. The shame, to my mind, attached to the earlier need to delay the care.

From a public policy perspective, public health insurance for children is a reasonable trade-off: the government pays money up front for children to receive care so their illnesses don’t become more serious. It’s bad policy to create incentives for parents to wait for illness to progress until their children get care – not least of all when we remember the traditional public health rationale of protecting society against the spread of contagious disease. Frankly, I think we should extend public health care to all inhabitants of our country, not just children, for that reason alone.

Health policy rationale and the means of delivery

That dream aside, I find that the real policy rationale for providing insurance – and consequently, one hopes, health care – to those who cannot afford it lies in the responsibility we have to each other. Noam Chomsky spoke eloquently on this topic when opposing the political push to dismantle Social Security through privatization, but his answer works just as well as a rebuttal to those questioning the need for public health insurance. This passage is taken from a transcript of a 2011 interview on Democracy Now!:

Social Security is based on a principle. It’s based on the principle that you care about other people. You care whether the widow across town, a disabled widow, is going to be able to have food to eat. And that’s a notion you have to drive out of people’s heads. The idea of solidarity, sympathy, mutual support, that’s doctrinally dangerous. The preferred doctrines are just care about yourself, don’t care about anyone else. That’s a very good way to trap and control people. And the very idea that we’re in it together, that we care about each other, that we have responsibility for one another, that’s sort of frightening to those who want a society which is dominated by power, authority, wealth, in which people are passive and obedient. (Emphasis added.)

I would like to think that it matters to others whether my children are healthy, and vice versa. In smaller civic organizations, we show this concern by bringing meals to parents of sick children, donating our time – if we’re health care professionals – to work at free clinics, holding fund drives through our houses of worship for children’s special medical needs, and much more. While these attempts are laudable, by their very nature they are limited to certain families, clinics, and congregations. We have a way to make these changes systematically and on a larger scale: that method is called government. We can embody the virtues of charity, kindness, generosity, fairness, and social justice through the use of our shared resources (yes, through taxation!) to make sure all children get the care they need.

Takeaways from my experience

Enough with the pronouncements! What useful tips can I supply regarding  MIChild/CHIP and Medicaid/Healthy Kids? These will be most helpful to Michigan parents, but parts may also be applicable to other states.

  1. Billing. My experience with Medicaid billing was delightful – there was none! MIChild was a little more complicated, but not much.
  2. Dental care. During our experience on Medicaid, dental care was effectively unavailable – no private dentist in the entire state accepted Medicaid, as far as I could make out. Since I have children with mercifully few medical needs, but who have inherited my fragile teeth (sorry, kids!), this was a hardship. Since then, Medicaid has improved its dental program for several counties. However, a look at this map shows that the counties containing and surrounding Detroit still lack coverage.
  3. Choice of providers. Another reason I wanted to get the children on MIChild was its broader choice of physicians. My children’s long-standing doctor does not take Medicaid patients – presumably because of its low reimbursement rate and high paperwork burden, particularly for a solo practitioner. I was thrilled to return to him on MIChild, but am now less thrilled; seven months in, MIChild has changed its plan and we must look for a new doctor.
  4. Surveillance. The sense of surveillance while on Medicaid was not overwhelming, but it was palpable. In the presence of health care providers and program administrators, I felt a presumption that because we qualified for Medicaid, our ability to parent could be called into question. I was able to combat this impression with my professional, class, and race privilege, but of course that’s not a satisfactory answer to the problem. For a scholarly examination of this kind of surveillance in the context of maternity care, I highly recommend The Reproduction of Race: An Ethnography of Pregnancy as a Site of Racialization, by Khiara M. Bridges. reproduction of race
  5. Funding. While this has little to do with our health care delivery experience, I must say I was happy to know that receiving MIChild coverage meant my children were pulling much-needed federal dollars into our state.
  6. Application tip! Finally, this one very useful hint: If you have determined you meet the income eligibility requirements for MIChild, do NOT fill out a paper application. These seem to get funneled automatically into Medicaid. Instead, fill out the online application. I wish I had known this before applying; our income seemed to fall in the MIChild range, but we were twice assigned to Medicaid.

What’s new with the ACA?

With regard to MIChild and Medicaid – not much. Michigan residents use the federal marketplace to apply for insurance, since our state declined to establish its own exchange. The marketplace should currently advise applicants whether their children are eligible for Medicaid or MIChild, but according to federal Medicaid documentation, will continue to refer qualified applicants to the state application process.

Michigan’s Medicaid expansion, planned to take effect in April 2014, changes the eligibility requirements only for adults: those whose income is under 133% of federal poverty guidelines will be eligible. However, the federal government recently granted Michigan a waiver to include previously prohibited conditions for Medicaid coverage, including limited premiums and co-pays as well as “Healthy Behavior Incentives.” Until I can locate waiver details on the CMS website, you can read about them as described by this management and communications firm.


Success! I greet the new year with new health insurance ID cards in hand. Many of them, in fact. How did that happen?

Pre-Affordable Care Act

Until December 1, I was covered by an insurance plan purchased on the individual market. This fall, I received notice that the plan would be discontinued because it did not comply with the ACA. I did not mourn this plan. As mentioned in an earlier post, the only thing going for it was its merely moderately high premiums.

My insurance carrier repeatedly urged me to buy an alternate “Keep Fit” plan. However, I knew  that my federal tax credit would almost certainly make a plan purchased through the Marketplace a better bargain. The Keep Fit plan’s other disadvantage was its notice of “lower deductible and fitness reward if you meet certain health standards.” Translation: your fitness activities and health standards count for nothing if you’re fat. Much has been written about the discriminatory nature and lack of evidence basis of such a restriction, both by the Health at Every Size and Size Acceptance communities as well as those critical of the Workplace Wellness provisions included in the ACA. I hope to return to this topic in a future post; for now, let me simply say that I knew the “Keep Fit” plan was not for me.

Temporary Insurance

To cover the gap from December 1 to January 1, when I expected to obtain Marketplace coverage, I purchased temporary insurance. This is a tactic I’ve used in the past; I mention it here because it can be a useful stop-gap. I did not expect to need any medical care in December, and I made sure to take care of any existing dental problems beforehand. The temporary insurance, which I obtained from the agency that provides our car and property insurance, was simply a hedge against catastrophe. If, for example, I slipped down the stairs and needed brain surgery, the insurance would kick in after a certain amount to ensure that our family did not lose all assets in a medical emergency – a reasonable fear, given that a majority of U.S. personal bankruptcies are precipitated by a medical emergency. The temporary insurance doesn’t pay for any routine care, so it is not suitable for everyone. But it bought me peace of mind for a month.

Enrollment – check! Payment – uh…

As reported before, through the federal Marketplace I successfully enrolled in a new plan from my earlier insurer and was told to expect a bill within a week. But when I opened the bill that arrived several days later, I was surprised to see a premium 50% higher than the one I had been quoted. Some small portion of this was due to federal and state taxes, but the remainder still constituted quite a large difference. I immediately got in touch with by online chat, was referred to the special hotline – only to learn that once I purchased a plan from the Marketplace, I was essentially on my own. I tried to imagine what it would be like if I bought a plane ticket from Orbitz, for example, and then found that the airline had raised the price of my ticket 50%.

Next stop: the insurance company. After I waited a very long time on hold, the customer service representative easily explained the problem. I had missed the reference to “Keep Fit” on my bill. Remember Keep Fit? The plan I did not purchase? Apparently the insurer decided to enroll me without my permission and then billed me for it.

The problem was easily remedied: I was instructed to simply ignore the bill. Imagine, however, that I had dutifully paid it. Now multiply this error by however many former customers the insurer mistakenly enrolled in this plan. I’m sure reimbursement would have been possible after considerable time and effort, but the insurer would have had the use of money not its own for some time – and presumably reaped the benefit in interest.

My many cards

The problem is solved. I eventually received a bill for the plan I actually selected, and I set up monthly payments through my bank account. My premiums are considerably lower now than they were for my pre-December high-deductible plan. With the money I’m saving in premium payments, I plan to pay off debts to various health care providers, all of whom have been remarkably patient. I look forward to scheduling an appointment with my doctor – the first in over a year. For the moment, life is good.

The insurer sent me four different sets of ID cards, including ones for the mistakenly-assigned “Keep Fit” policy. The cards have now been dealt; I look forward to seeing how the game plays out.

Leave a comment

Michigan Senate Bill “Legalizes Breastfeeding in Public”? No, Even Better!

The recently passed Michigan Senate Bill 464 received a warm but somewhat confused reception from local media. The voices of the internet – not surprisingly – jumped at this new opportunity to sermonize on public breastfeeding. But what is the bill really about? What is it not about? What is its public policy basis?

What it is

The bill amends Michigan’s Elliott-Larsen Civil Rights Act to include breastfeeding as a right whose exercise may not be prohibited by discriminatory practices. Such rights currently consist of religion, race, color, national origin, age, sex, and marital status. The Elliott-Larsen Act, like the federal Civil Rights Act of 1964, prohibits discrimination by private actors in the context of public accommodation. These federal and state laws were originally enacted to address race-based discrimination in public accommodation.

Michigan S.B. 464 and its companion House Bill 4733 do the same for breastfeeding. The act of breastfeeding in public is already protected by statutes that prevent breastfeeding women from being charged under indecent exposure laws. However, this constrains the behavior only of law enforcement and fails to forbid privately-owned establishments from refusing to accommodate breastfeeding women. The new legislation, if enacted, would permit breastfeeding in all places the mother herself has the right to be.

What it is NOT

Nursing mothers vs. formula-feeding mothers

This is not an opportunity for media flame wars on whether mothers should breastfeed or formula-feed. Although science has established breastfeeding to be largely beneficial to mothers and children, there are women who should not or cannot breastfeed. Before we start throwing stones, it would be prudent to review the minimal accommodations for women who want to, but cannot, breastfeed. We have no national policy on parental leave, save the very limited, unpaid leave available under the Family Medical Leave Act. It was  only under the Affordable Care Act that the federal government granted women working outside the home the right to take unpaid time to pump breast milk in a private place that is not a bathroom – but as breastfeeding legal expert Jake Marcus points out, these provisions may be less effective than they appear. In any case, the ACA provision covers only the right to pump milk, not to the right to actually breastfeed.

Breastfeeding also comes with real costs. While the milk itself bears no price tag, that very fact obscures the considerable costs in time and labor to the mother. Until we can support and subsidize these costs, we must affirm the decision of the mother who weans a child in order to take care of other responsibilities, not least of which may be getting an education, caring for other children, or making a living.

Every mother’s experience of breastfeeding is unique; indeed, one mother’s experiences can vary from pregnancy to pregnancy. We can continue to improve circumstances for mothers who wish to breastfeed and make sure that unbiased information about risks and benefits is available to them, but we must trust mothers to make the right decision for themselves and their children.

The sexy breast vs. the nursing breast

Likewise, this should not be our cue to reopen the quarrel about whether breasts are for sexual partners’ gaze or for nursing our children. This line of argument makes it sound as if breasts were pets kept on leashes rather than being actual attached body parts. Our breasts are “for” whatever we say they are for –  and they are far from having only two functions.

The fact that sexualized breasts are frequently visible in public is often used to suggest that these sexy breasts somehow contaminate nursing breasts with sexiness, thus making nursing breasts in public unacceptably sexual. However, following the thinking of sociologist Linda M. Blum, I believe it is the other way around: In our society, the chief acceptable public use of breasts or other female body parts is for sexual display. Nursing breasts in public are transgressive, because they are used for the non-sexual purpose of nourishing children. Urging nursing women to be “discreet” by covering up their nursing breasts aims to banish the offensively non-sexy breast from public view.

Again, each woman must make her own decision about the manner in which she wishes to nurse in public, if at all. Some women follow religious guidelines about display of the body in public; others may suspect that such a display may put their personal safety at risk; still others may be embedded in our country’s racist history in which some women’s bodies and reproductive capacities were used by others against their will. We must respect every woman’s capacity to decide what is best for her.

Policy basis

Public health policy and law, at least according to some authorities, seek not to badger people into behaviors that some privileged segment of the population thinks everyone should adopt, regardless of other priorities. Rather, their role is to move obstacles out of the way for the benefit of those people who wish to adopt practices that are widely held to be beneficial to the public health.

Breastfeeding is one of those practices. In order to make a path for people who wish to breastfeed their children in public, the bill gives a right and a remedy. The right is the liberty to breastfeed children in public any place the breastfeeding woman herself is entitled to be. Remedies (as already outlined in the Elliott-Larsen Act), should this right be denied, are the ability to seek a judicial injunction against the offending party, to pursue legal action through the state Civil Rights Commission, or to bring suit against the offending party in a civil suit.

What happens next and how to help

Now that S.B. 464 has passed the state Senate, its companion bill must also be given a committee hearing, receive a favorable vote, and be voted upon on the House floor. Should that happen, once the governor signs the bill, it will become law.

If you wish to support these bills and this cause, you can follow through with these actions:

  1. Thank Senator Rebekah Warren for sponsoring S.B. 464. I am very proud to be her constituent – thank you, Sen. Warren!
  2. Encourage the chair of the House Judiciary Committee, Rep. Kevin Cotter, to schedule a hearing on H.B. 4733.
  3. Especially if your representative is a member of the House Judiciary Committee, encourage him or her to support H.B. 4733. You can identify your representative here.

Finally, easiest of all, we can help mothers to breastfeed in public simply by speaking out on the spot. If someone asks a mother to cover up, or to leave, we can object. When I was a new mother nursing my first child in public, strangers would occasionally come up to me and murmur approvingly, “I nursed my child for three years, or “I nursed two children.” I can’t tell you how supported this made me feel! Now I try to carry on this tradition by telling women how nostalgic I feel when I see their beautiful little nurslings. But a simple smile and a nod also does the trick.


Leave a comment

Time served

Governments manage to build roads, regulate air quality, invade countries – however imperfectly and occasionally inappropriately. So I am moderately hopeful that my new health insurance plan, purchased through the marketplace set up by the Affordable Care Act, will be an improvement, even if only because of the generous tax credit that subsidizes my premiums.

That said, if time spent could be parlayed into dollars, I might be able to forgo the tax credit. Although my search for insurance for the adults in our family was neither quick nor easy, I can’t blame the ACA or even Much of the complexity was the result of my family’s economic circumstances and the structure of private health insurance.

Essential tool: crystal ball

I was surprised when asked me for proof of income for 2014 – frankly, I would like proof of income for 2014 too. Neither, the federal exchange, nor a local navigator were able to tell me what documentation I could reasonably provide for income not yet earned – or even conceptualized! [Time spent on phone calls and internet chats: approximately 2 hours.]

Out of necessity, I invented a solution: I will submit my final pay stub from this year, even though it is not a reflection of my income for next year, as evidenced by the fact that I will also submit a letter from my employer confirming that I am no longer receiving paychecks. My husband will submit a “self-employed ledger”; because no one is able to tell us exactly what that means, we will concoct a spreadsheet of business income and expenditures and hope that it suffices. I give credit for not requiring that documentation be uploaded before selecting a plan. [Time spent gathering documentation so far: 1 hour.]

What’s my point? The ostensible purpose of the ACA is to provide affordable care by means of health insurance to people who would otherwise lack access. It’s not a long shot to say that a large number of people in this situation are those whose employment is sporadic, variably paid, or simply unpredictable. Demanding proof of future income defeats the purpose of providing easier access to care for this population.

Dental …

Our family is blessed with relatively good health, with the notable exception of My Teeth. Thanks to genetics and my tendency to send stress directly to my jaw – and believe me, I’m grateful it doesn’t go to some other body parts – I am very familiar with dental care. Health insurance, on the other hand, has always considered dental care to be a separate, alien entity. When I searched for plans within my price range that also included dental care, I found one, for which our out-of-pocket cost for the premium would be higher than we’re currently paying, even taking the tax credit into account. Naturally, I wanted to be sure this costly plan was worth it, so I carefully examined the dental benefits. While I was on hold with the insurer, I also hopefully text-chatted with, to no avail. The insurer was finally able to clarify several of the “Benefit Explanations” regarding frequency of coverage of fillings. For anyone who’s wondering: “1x per 48 months for permanent teeth” means as many teeth as need to be filled in 48 months  (subject to plan maximums, of course), just not more than once in any given tooth during that time. Perhaps I was overly suspicious of that language; however, I have forked over plenty as a result of past misunderstandings of policy language. [Time spent on hold: 1 hour.]

After looking at the numbers again, I decided to investigate dental riders available directly through the insurer. I reasoned that if such a rider cost only about $50 a month, as it did in our pre-ACA individual plan, we could easily buy one of the more cost-effective health care plan without dental benefits. I had questions regarding:

  1. My dentist’s participation in a provider network, the meaning of which was far from clear on the insurer’s website;
  2. Whether as a result of my dentist’s possible participation, I would or would not be charged for the difference between the insurer’s approved amount and my dentist’s charges;
  3. Whether the deductible on the dental rider worked as a group or individual deductible.


After another long wait, I was connected with a customer service representative who was apparently puzzled by my questions. His answers included the word “probably” and once directly contradicted a benefits summary document, which itself was careful to state that it was not a contract – the legal equivalent of crossing your fingers behind your back. I was far from reassured. [Time spent on hold: 1 hour.]

However, I was gratified to discover that I could purchase the dental rider through I am almost certainly overestimating the scope of government oversight on private plans, but I felt that going through the exchange would provide me a layer of protection against the excesses or obfuscations of the insurer. We’ll see how that plays out when I deal with my first claim.

What’s my point? I am thrilled that it is possible to purchase a separate dental care rider through the exchange, but knowing that from the start would have saved me a number of steps. Better-informed customer service representatives staffing insurer phone lines would also be helpful, but I am under no illusion that this falls under government dominion.

… and mental

Mental health care has traditionally been as alien to the average insurance plan as dental care. The Mental Health Parity Act of 1996 sought to address this problem, but in the end did little to require plans to offer routine mental health care.

My hope was that our new health care plan would pay the mental health care professional seen regularly by our family. I found, however, that our provider was out of network for all of the plans available to us. In order to receive any coverage at all for her services, we needed to buy a plan with premiums more expensive than our recently expired plan. When I did the math, the best of those plans would cost us $200 more a month than the less expensive plan we were considering, and due to deductibles, coinsurance, co-pays, and a maximum 50% reimbursement, would save us at most $400 a year. This was the final impetus for us to discard that plan. [Time spent examining provider networks and crunching numbers: 40 minutes.]

What’s my point? Plans continue to prioritize coverage for inpatient mental care over outpatient care, and reimburse providers accordingly, thus providing less incentive for providers to participate. While inpatient care is more expensive and thus especially deserving of coverage, it is a mistake to neglect coverage for outpatient care, for the simple reason that regular outpatient care can significantly reduce the possibility of needing inpatient care. When outpatient coverage requires substantial out-of-pocket expenditure, patients are less likely to continue that care.

Just the facts – but where are they?

I haven’t described the process of sorting through possible plans, seeing whether our providers participated in those plans, constructing a spreadsheet to compare the plans, running through various health care needs scenarios to test the numbers, or any of the other tasks required to make a decision of this importance.  [Time spent: 6 hours.]

What’s my point? I am struck again and again by how unlike other purchases it is to buy health insurance. Consumers must predict what they will need to spend, in a market where costs are for the most part indiscernible. Customers must predict what they can afford to spend. Customers must decide whose services they will need should some of their scenarios come to pass.

Time and again

I’m grateful for the ACA and the chance to buy health insurance that actually allows us to receive medical care. Under our old plan, the deductible was so high that it was hardly even worth getting an annual physical: had an exam unearthed issues that needed further study or treatment, it would have been too expensive to follow up. The only answer would have been to buy a lower deductible plan – one that charged unaffordable premiums. The ACA cut through that problem to some degree by aligning income eligibility with insurance costs through the tax credit.

But the problem it didn’t solve was the vast amount of time needed to organize insurance. I’m an educated, privileged person with a computer, a fast network, and enough free time to make endless phone calls and sift through the benefits – or lack thereof – of various plans. Even so, getting coverage has taken weeks and is not yet completely resolved.

What’s my point? If I were an economist assessing citizens’ productive labor capacity, it would concern me that so many of us are must use our time to get something that other developed nations take for granted: access to affordable health care. After watching several British TV medical dramas, I reported to my family that I couldn’t get over how every patient expected care – and got it! I hope the ACA will make a dent in our nation’s problems that are responsible for this sort of amazed perception on my part, for the obvious public health reason that populations are healthier when they can access quality health care. However, setting aside health outcomes, I can’t help imagining the things I might have accomplished in the time I spent identifying and purchasing a workable health insurance plan. Multiply that by everyone buying plans on the exchange, and we potentially have the 21st century equivalent of Sputnik – some giant leap we might have made as a nation, but didn’t.

Furthermore, I am under no illusion that my work is done; past experience tells me that each time I have contact with the health care system, six months of phone calls and paperwork with my insurer ensue. It is in the financial interest of insurers to avoid reimbursing care and they count on the inability of most of their customers to take the time to vigorously pursue claims. I do not relish the prospect of disproving their expectations, but I cannot afford not to. When I had employer-based health care, I could count on my H.R. department to wage some of these battles for me. Now it’s just me against the insurer.

All this time! In which, perhaps, I could have written another article, looked for a new doctor for my children (due to their change of health plan – more about that in another post), lobbied legislators, done more laundry – you name it. Let’s hope it will have been worth it.

With luck, my next post will mark the beginning of my new health insurance plan.