Anecdote: in the South

January 20, 2014

I recently spoke to a number of friends and family members about the ACA during a trip back east to Georgia. Most of these Southerners were either highly skeptical or outspokenly critical of health reform. Several were uninsured, but disinterested in enrolling in the Exchange.

I had a long conversation with a close family member (“Chris”) about what the ACA has to offer. I explained that the cost of his monthly premiums would depend on his income and that he would have numerous choices of plans that varied in price, provider network, prescription drug formulary, and benefit structure. Chris had lots of questions – “Does the income of my fiancé count? Do I have to pay more since I used to smoke? What happens if I get a new job with insurance?” Some of the answers prompted confusion and irritation (“What do you mean the penalty is not $95?!”), but luckily he was pleasantly surprised by many responses (“You’re saying I don’t pay anything extra for being diabetic?”)

Chris had figured out how to treat his health conditions from day to day without insurance; he had a payment agreement for visits with a specialist and paid for his prescriptions with a drug membership program sponsored by the manufacturer. But Chris lacked access to preventative care, and confided in me that he had been putting off a special test that would cost hundreds or thousands of dollars. If faced with a serious diagnosis or an accident, the costs could ruin him.

Back in the Golden State, I received a call from Chris, who had just completed the application for coverage through

“It says $200 a month. I can’t pay that.”

My internal panic mode kicked in. “That can’t be right – that’s substantially more than my calculation based on your income.”

Twenty minutes of fishing around on his account yielded some confusing results. After the application was completed, his income was verified, and an eligibility determination letter was generated. letter blacked out

The letter stated that Chris qualified for a premium subsidy and should select a plan. Yet when he moved to the plan selection phase, only $20 of the subsidy was applied. The system had apparently defaulted so that only a portion of the subsidy was applied to premiums monthly, saving the rest to be received as a tax credit at the end of the year. I was able to disable this setting, allowing him to take the full subsidy each month, but the option was challenging to find, hidden deep in the application.

Now the plan selection page showed the right amount of subsidy and thus real costs. His response at the prices: “I’m impressed.” Chris has yet to select a plan, but I have high hopes that he will soon.


While Chris was able to successfully get through fairly quickly, I felt grateful for some of amenities that come with living in California. The primary difference between coverage options in Georgia vs. California: plan structure. Only three carriers participate in metropolitan Atlanta, yet they each offer multiple plans in each tier with widely varying structures. Yes, that’s right; the bronze/silver/gold/platinum structure essentially has no meaning. Bronze plan deductibles varied from $6,300 to $4,000, while deductibles for gold plans went from $0, $750, $1,000, or $2,500. The choices were overwhelming, with 12 bronze plans, 10 silver plans, and 7 gold plans to choose from, yet only 2 platinum plans (offered by 1 company).

Plan Bronze Deductibles
BlueCross/BlueShield #1   $6,300
BlueCross/BlueShield #2   $5,750
BlueCross/BlueShield #3   $5,550
BlueCross/BlueShield #4   $5,550
BlueCross/BlueShield #5   $4,300
BlueCross/BlueShield #6   $4,000
Humana #1   $6,300
Humana #2   $6,300
Humana #3   $4,850
Kaiser #1   $5,000
Kaiser #2   $5,000
Kaiser #3   $4,500

While this may provide more choices to customers, it is very confusing. Given that most people don’t understand basic health insurance concepts like deductibles and coinsurance, this is likely far too much for the average consumer to handle.

The entire experience reaffirmed three things in my mind:

1)   Glitches are inevitable and will persist. We must do everything possible to prevent them from discouraging and/or misleading consumers.

2)   If it takes considerable effort and inquiry from a health policy professional to mitigate application issues, imagine the obstacles faced by everyday consumers.

3)   California, where our Exchange is relatively simple and our state government isn’t actively fighting progress, is truly the promised land.