Published December 18, 2017|4 min read
Katherine recently picked a health insurance plan for her 24-year-old son Josh. The Hampton, Virginia, resident hates it.
"It's just pointless," she said. "It's like car insurance that only covers your muffler. We have no options."
Katherine (a pseudonym — we're not using her or her son's real names to protect their privacy) did not enjoy shopping on HealthCare.gov either. The 51-year-old found it time-consuming. She had to spend hours on the phone with insurers. It was not an easy process, she said.
That's partly why she didn't get her son health insurance for 2017. Her children were on Medicaid until they turned 19, but went without insurance after. But Josh needs treatment for issues with addiction and mental health.
The problem is, Katherine hasn't found an inpatient facility in Virginia that will treat both addiction and mental illness. She hasn't found an insurer that will cover a facility outside of Virginia either.
Virginia didn't expand Medicaid, as former President Barack Obama's health care law originally required. A Supreme Court verdict overturned that mandate. So now states can provide health coverage to anyone making an income equal to or below 133% of the federal poverty level, but they don't have to. A low income isn't enough to qualify in Virginia. To get Medicaid in the state, for the most part, one needs to be a parent or caregiver, pregnant, under 19 or disabled.
Katherine gets Medicaid as a parent, but Josh doesn't qualify. Plus, his addiction has led to legal problems. While Katherine was shopping for a plan for him, Josh was arrested.
Katherine is getting a generous subsidy for the plan she selected on the federal marketplace from Optima Health. The premium normally costs more than $500 a month. She'll pay $68. The deductible is just $100 because of cost-sharing reductions, another discount for low-income people. She'll have to pay a 5% coinsurance on most services, but her out-of-pocket maximum is fairly low, $1,800; marketplace plans can have out-of-pocket limits as high as $7,150.
She still considers the plan a waste of money. But her son needs treatment.
Katherine is unsure whether her subsidy will hold steady. She listed Josh as a dependent when applying so she could use her own income information. As a real estate agent, Katherine's income isn't always constant, making estimating it difficult.
To qualify for premium tax credits and cost-sharing reductions, her income has to stay between $16,240 and $40,600. Even within that range, if her income rises or falls, it will affect her health care costs.
The plan is cheaper than what she had in 2016, when she paid a $189 monthly premium with a $6,000 deductible. But despite the savings Katherine is getting, she still worries about the 5% coinsurance adding up. After all, she said, her family is on Medicaid — they don't have much money.
Katherine feels she has to choose between paying for a plan that doesn't offer what her son needs or paying a tax penalty. Without this rule, known as the individual mandate, she believes more people would opt out of health insurance altogether. Her theory will potentially get tested — Republicans have included a repeal of the individual mandate in their tax bill.
"If you can't afford insurance, how can you afford the penalty?" she said.
She knows she and her children need health care. Her daughter has asthma. Another son gets migraines.
"But not everybody can afford it," she said.
Josh will remain in jail until his trial. Katherine hopes a judge sends him to a drug treatment program in Richmond for six weeks, after which he can go to a private mental health facility in Salem. It's out of network, so she'll have to get pre-authorization from her insurer.
"I really think it's a horrible thing," Katherine said of the health care law. "It's almost like communism. We have zero options. We are forced to do what they tell us to do. We can't just shop and do what we want to do."
This is the eighth in our series profiling real people who use 'Obamacare'. We're hoping to put a face to the controversial law and provide an up-close look at its impact, whether harmful or helpful. We'll feature someone new each week until federal open enrollment ends on Dec. 15, so check back for more stories. If you're looking for help signing up for Obamacare 2018, visit our HealthGenius section.
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