It’s time to get real about how affordable insurance will be in the exchanges—not just for the young turks, the prize catch for the insurance jungle—but for everyone else. The average man or woman on the street who needs insurance doesn’t care one whit what the Congressional Budget Office or Avalere Health or Kaiser have to say about premiums. They don’t care about the prognostications of bloggers on the left or right. They will decide to buy or not buy based on their pocketbooks, a point that’s been grievously overlooked in the media rush to report the spin from insurance departments or from policy wonks who have pretty much tried to downplay any hint that insurance might be costly in the exchanges, which it will be for millions who want decent coverage. By that I mean a gold plan, the old Blue Cross model that historically has provided decent coverage for Americans, paying 80 percent of an individual or family’s medical costs and offering a good choice of doctors and hospitals. After all, wasn’t choice one of the battle cries during the debate over Obamacare?
Instead, government and media focus has been on the bronze variety that covers just 60 percent of medical costs or the second-lowest cost silver plan on which subsidies are based and covers 70 percent of medical costs. Even with limits on out-of-pocket expenses ($6,350 and $12,700 in 2014, a provision delayed until 2015), families in the middle face substantial costs for health insurance. It seems that when you count subsidies, a.k.a. tax credits, families will get for buying insurance, those at the low end of the income ladder (but not the lowest in states not expanding Medicaid) will do okay, but those in the middle may think twice about buying coverage. In a recent Washington Post Wonkblog post, Sarah Kliff, questioned whether premiums would be affordable—putting that query to Kaiser senior vice president, Larry Levitt. “I don’t know,” he admitted.
“On the one hand, all the cry about rate shock may be unfounded,” Levitt continued. “On the other, we’re still talking about a pretty significant purchase. Unless you’ve had to go out and buy insurance, you have no idea what it’s supposed to cost or whether it’s a good deal.
In a bulletin to clients, insurance consultant Robert Laszewski suggests buying a policy may not be such a good deal for many families. Using numbers from Covered California, California’s exchange, he shows that a family of four making $59,000, a bit more than the median income, could expect to pay $4,739 for a policy after subsidies are applied—about 10 percent of their take-home pay. That would buy the second lowest-priced silver plan with a $2,000 deductible and a cap of $12,700 on out-of-pocket expenses. He writes:
For so many individuals and families 10% of their take home income is a huge issue. This is the marginal income left at the end of the month, after taxes, rent, and car payments that is so critically important to them. The dirty little secret for Obamacare is that the subsidies aren’t enough to assure us that we will attract a good cross section of risk.
He means: Will middle income and potentially healthy families judge the policies of sufficient value to spend their walking around money on? Will they jump into the risk pool? It’s wishful thinking that subsidies will get larger any time soon. The story is the decisions people are making, not the latest study from another policy shop.
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