As we hoisted champagne flutes in the first seconds of 2014, my partner and I toasted all the usual things people do as they look ahead to the coming year. Health. Happiness. Love. Optimism. Hope.
To that traditional list, we added one more: Obamacare. My husband, Miles, was enrolled in what appeared to be an excellent, affordable plan at the stroke of midnight. Celebration seemed in order.
It had been a tough slog, of course. We’d worried the GOP would succeed in defunding it or undermining it in some other way that would put affordable coverage further out of our reach. Then we’d wrestled with that horrific website, struggled to understand the choices before us and waited nervously after we did so to see if the insurance card would actually materialize. It did.
On Jan. 1, we rejoiced. And on Jan. 10, we gave up.
Ten days in, we decided to cancel Miles’ Obamacare plan, swallow hundreds of dollars we’ll probably never recover and buy him a private policy away from the Federal Health Insurance Exchange Marketplace. His new plan does benefit from many requirements of the Affordable Care Act as well, so that’s good.
But even the administrators at Obamacare’s headquarters have agreed this is the best option. Really.
That’s not how it was supposed to be. After dozens of hours of phone calls that displaced my usual work obligations this week, only one thing is clear: Nobody can give anybody a straight or consistent answer to anything.
Our troubles may strike some as trivial and particular, although they wouldn’t if it happened to them. And anyone who wants a successful system – as we do – must understand that these nightmares are happening across the nation to the very people who want Obamacare to work.
Most just don’t have a way to tell the world.
In the summer of 2013, Miles and I, both 41 years old, quit our jobs in Washington. Miles was a producer at WJLA, the ABC affiliate in Washington D.C., but he longed to return to school for a new degree and a different career. I was at POLITICO realizing that my life as a freelance journalist was far more engaging, empowering and lucrative than chronicling the petty, overly intertwined worlds of D.C. politics and journalism.
Even a year earlier, it would have been unthinkable for Miles to walk away from a proper job. He has pre-existing conditions. None are life-threatening or unmanageable, but one requires expensive medication.
This is one of the promises of Obamacare we most appreciated, the idea that unshackling health decisions from employment can liberate people to leave unsatisfying jobs and engage their entrepreneurial sides. How many people have been prevented from pursuing careers that would make them more productive and passionate out of fear that a health calamity could ruin them?
Obamacare helped to embolden Miles to change his life. It is why we left Washington and headed back to the Midwest, a region we came to love while I had an academic fellowship at University of Michigan in 2011 and 2012. I wanted to freelance, write books and teach, and he wanted to go back to school.
We made our move when we did because the academic year was coming, figuring we could shoulder a few months of COBRA coverage for Miles – about $420 a month – until Obamacare began.
(With no important pre-existing conditions, I got a very good private plan right away through Aetna for about $210 a month. It’s evidently Obamacare-compliant, because I liked my plan and, as the applause line goes, I was able to keep it.)
Shortly after midnight on Oct. 1, we hopped onto healthcare.gov to see what the federal exchange had for Miles. As you may have heard, that didn’t go so well. When I wrote about that first-day misadventure of glitches and unhelpful phone assistance for New York Magazine, my liberal friends attacked me for judging too soon and providing anti-Obamacare fodder to the haters.
But to us, this really is not about politics. It’s about our lives. Miles and I support health reform because we believe that, executed correctly, it can liberate people to pursue their highest and best purposes. As recently as a week ago, that was the angle of a piece I pitched to Time.Com, where I regularly contribute.
And then Jan. 3 happened.
We struggled with the healthcare.gov website for months. Every so often, we’d return to find Miles’ application for eligibility stuck in some “pending” netherworld. The Phone People said to wait a few weeks and try again. Nothing ever happened, except that the site said at varying times the application was “in progress” or “incomplete.” I lost count of how many times I re-entered the same information because some Phone Person told me to try that.
The deadline to sign up was Dec. 23, so by Dec. 20 we were frantic. I finally broke down and called the Obamacare navigators in our region, the folks supposedly deputized to guide helpless souls to the finish line. Only two of the five I reached out to even responded, one to say she’d be on vacation for the rest of the year (?!?) and the other to say she was booked solid with other desperate customers. I guess we were supposed to know that the website would never, ever work and plan ahead for that.
The second lady did help, though. She suggested we create a whole new account for Miles because the old one, created in the earliest days of the troubled site, might be corrupted and stuck in some digital purgatory. I did that — and, gosh darn it, it worked. Well, sort of.
It turned out that Miles, despite planning to be a student and not expecting to have much income, did not qualify for any subsidy. We received a document supposedly explaining why, but it looked like this to us:
We kept asking the Phone People why. They suggested we download it again or log out and log in again or wait an hour and try again or reboot our computers. I was surprised nobody recommended a little club soda.
On Dec. 21, with two days to go, we shrugged off the perplexing notion that the ACA actually does not provide help for people who have low incomes. Maybe we could figure out an appeal or, perhaps, our accountant could figure it out later.
Subsidy or no, Obamacare offered Miles a seemingly terrific deal: $246 a month for health insurance with a $1,650 deductible through the Blue Care Network, a Michigan subsidiary of Blue Cross Blue Shield. This was comforting; Miles’ COBRA policy from his WJLA job was under BCBS and our coverage at University of Michigan was under Blue Cross Blue Shield of Michigan. His doctor was in the plan, the price was good, the benefits and co-pays seemed adequate. At long last, he had his coverage. Done.
We should’ve known new problems lurked, but it was Christmas and we wanted to be merry. Then, on Dec. 27, I realized the $30 per month dental plan I chose for Miles offered no dentists within a 20-mile radius of our home. When I ventured back into the morass of healthcare.gov to pick another one, the site wouldn’t let me. A Phone Person explained that if I changed the dental plan, it would also invalidate Miles’ medical plan, too, and he wouldn’t be able to start any coverage until Feb. 1. I left the dental plan as it was; the Phone Person told me I could come back in January and change it.
The Phone Person lied. They lie a lot. And this would become very important later.
Three days into 2014, Miles took his Obamacare out for its maiden drive. His stop at the doctor went fine. At the pharmacy, it crashed.
His medication — which has cost us a co-pay of between $10 and $30 under every other plan he’s had since 2004 including one under Blue Cross Blue Shield of Michigan — would not be covered. At all.
That’s $438 out of pocket. Every month. And it won’t even go against the plan deductible.
In other words, this nifty $246 Obamacare plan would actually cost $686 a month.
Miles put the $438 on a credit card, all the while wondering what someone without a credit card would have done in the face of going without important medication. He, like most Americans, assumed the insurer’s word, via the pharmacist, was final. Also, it was late on a Friday, a blizzard and epic cold snap bore down on us and he couldn’t know when he’d be able to go get it again.
The Pollyanna in me was sure this was some mistake. We spent a lovely weekend watching the snow pile up, confident that the matter would be handled in a call or two whenever business resumed after the storm and polar vortex.
Instead, it turned out to be all I did all last week. My work deadlines got pushed back, interviews rescheduled, emails unreturned. Day after day, I found myself on lengthy calls with countless Phone People trying to understand why this very common medication, covered under every plan Miles has ever had, was now about to become a significant monthly expense. Every time I hung up believing I understood something, it would be contradicted by something else in my notes or some lapse in logic. So I’d call again, and I’d get some other Phone Person who would blindfold me, spin me around a few more times and let me grope for the donkey’s tail yet again.
One thing remained consistent: Miles’ medication was not in the “formulary” anymore. I’d never heard that term, either, but it’s the document in which insurers state what they will cover and at what level.
From there, the situation made progressively less sense. The Obamacare Phone People offered no information or explanation, only a mild scolding that I should have checked the formulary before I signed Miles up for this plan. They couldn’t have been nicer — or more useless.
The Blue Care Phone People, however, were aggressively obnoxious and unhelpful. Time and again, they came up with different answers I would later learn to be wrong: that Miles had exceeded his lifetime limit of a component of the medication (creative, but false), that the Affordable Care Act forced the medication off the formulary (mostly false), that the FDA had pulled the medication from use (made up out of thin air), that no insurer was allowed to cover it anymore (big fat lie).
One Blue Care Phone Lady read off a list of other medications for the same condition that the doctor could prescribe, including the same medication in a different form. That was a possibility, but that wasn’t what Miles’ doctor wants him to take.
Much more troubling than the fact that we received so much worthless and conflicting information was that there was nobody to appeal to, nobody to trust.
For days, I attempted to obtain a credible, consistent answer as a “normal” person. Then, realizing how futile that was, I contacted the public relations offices of both Blue Care Network and the Centers for Medicare and Medicaid Services, the Health and Human Services division administering the Affordable Care Act. I explained I was chronicling this experience because thousands of people must be encountering similar frustrations.
The CMS folks promised to gather the information I requested, and I did get some. I sent one spokeswoman the illegible eligibility document that showed only pages of weird symbols; she opened it on her computer just fine. I sent her screenshots of what I saw, she acknowledged that this was weird and faxed me the actual document. It did explain that Miles didn’t qualify for a subsidy because his expected student income was so low that he should apply for Medicaid. That seems like an easy enough, perhaps even reasonable, answer. Why couldn’t any of the many Obamacare Phone People have told us that? And is it really possible I was the only one having trouble opening the document properly?
Nobody from Blue Care Network responded to my request for information or an interview.
When the Blue Care Phone People claimed the FDA and/or Obamacare had banned this form of Miles’ medication, I became skeptical. If that had been so, it would’ve been a gigantic medical news story given the millions who take this medication, but it wasn’t. So I logged onto my Aetna account to check if my policy covered it. I learned it was considered generic and would cost not $438 but a whopping $15. Huh. I called Aetna; a Phone Person confirmed this. Their “formulary” still included the drug. We were more baffled than ever.
Aetna had plans on the federal marketplace as well, so I returned to HealthCare.gov to seek out a different plan for Miles. The site, however, incorrectly — surprise! — believed Miles hadn’t yet enrolled in the plan he was in.
Thus, I found myself back on the line with an Obamcare Phone Person. This time, however, I was told that once someone is enrolled in a plan via the marketplace, they cannot change it until the next open enrollment period in November. The only time to change plans, I learned, was before we paid the first premium.
This was news. In late December, remember, I had asked about changing the dental plan. I had been told then that I couldn’t do so without canceling the medical plan as well and postponing coverage to February. All we could do, they said, was cancel our plans. We were stuck.
All of this was passed along to CMS’s publicists, who vowed repeatedly to provide answers. They promised, that is, until they changed their minds. On Wednesday, I received some boilerplate information and a note: “Unfortunately, nobody is available for an interview.” The material they sent was clearly cut-and-pasted off HealthCare.gov — an explanation of why we couldn’t change our plans and how we should have known that this common medication would not be covered in our plan. There was a line in there about a three-day appeals process when a medication is denied; this was the first time in countless phone calls or emails that anyone even suggested there was such a process. Shouldn’t that have been the first thing the Obamacare Phone People said?
It was time to get out of the Obamacare fun house.
Our math had changed. Initially we hoped to get Miles a plan for less than the $421 cost of his COBRA. Now Miles was stuck in an Obamacare plan for $246 plus $438 out of pocket for his medications. Anything less than $690 a month was now a bargain.
Miles hadn’t been able to get covered independently in 2013 because of his pre-existing conditions, but the ACA now prohibits that exclusion. And I knew from earlier research that Aetna covers his medication. So I called Aetna. They had an excellent plan for Miles for $335 a month that we could start in February. It was outside the federal exchange and wasn’t eligible for any subsidies but, at this point, so what?
Knowing this restored a modicum of confidence in the ACA. Without it, Aetna wouldn’t — as we learned in 2013 — offer Miles any plan at all. So we were grateful, at least, for that.
But I still needed answers, so we held off on signing on with Aetna. Why did Aetna cover the drug but Blue Care didn’t? Why didn’t Blue Care cover the drug when every other Blue Cross Blue Shield plan Miles had had did? Why were we told we couldn’t change the dental plan and still have coverage on Jan. 1? How do we cancel our Obamacare plan?
After CMS’s no-comment email, I offered a respectful but pointed reply: “Thanks for trying. This system, which I toasted on Jan. 1 and had such high hopes for, is unraveling. I hope you understand that. If you with your access can’t obtain actual answers to these very common problems, there is no hope for it.”
That actually dislodged something. The next morning, Tony Dawson, a specialist from CMS’s Center For Consumer Information and Insurance Oversight division called. He listened to the whole story. His conclusion was startling: He agreed that our best course would be to dump our Obamacare plan and buy the Aetna one.
Dawson was sympathetic and, dare I say, honest. He reiterated that we couldn’t change plans in the exchange, but he said he would see about getting special permission to switch dental plans because I had tried before the deadline and had received incorrect information.
He also offered a plausible answer to the mystery of the formulary. Insurers write their own formularies. Neither the FDA nor the Affordable Care Act forced them to remove this medication. It was likely, however, that Blue Care made the change in part during negotiations with CMS regarding what plans would be made available on the exchange.
Dawson said he would find out why the drug had been dropped. I asked how fast he could do so; he said it would take a quick email. I explained I had a Jan. 15 deadline to enroll Miles with Aetna and be covered for February.
The most refreshing part of the conversation with Dawson was his acknowledgement that normal people, buying health insurance, usually don’t think to request the formulary to check on whether a common drug is covered. The boilerplate material that had been provided by CMS suggested the formulary had been easily accessible when we were browsing for plans, but I went back and saw that it actually is still not available on HealthCare.gov. (In mid-December, Forbes writer Scott Gottlieb wrote that the formularies were usually not available as people chose their plans, and he warned people with certain chronic conditions in need of expensive medication might face sticker shock at the pharmacy.)
Anyhow, Dawson promised to get back to me, and he did. He called Monday to confirm this form of the medicine wasn’t covered and our best choice was, in fact, to dump our plan.
On Jan. 10, I signed Miles up for the Aetna plan and called Blue Care to cancel. A Phone Person said they can’t do it, that policies created through the exchange had to be canceled through the exchange.
I called the Obamacare line. This Phone Person apologized at the outset because the “system is down,” so he wouldn’t be able to access Miles’ account. Nonetheless, how could he help me?
“We want to cancel this policy,” I told him.
“Oh, we can’t do that,” he said.
“I can’t cancel policies,” he said. “I suggest you call the insurance company. They’re the only ones who can do it.”
“But they just told me to call you.”
“I’m sorry, that’s not something we can do here.”
I know it’s rude, but I just hung up without saying goodbye. It was all I could do to avoid saying something cruel and regrettable to a poor soul who may or may not be right.
I figured if Dawson ever called me back, maybe he could straighten this out. Otherwise, Blue Care will drop us sooner or later when they realize we’re not giving them our money anymore.
Some may boil our misadventures down to its core, a bratty dirge by privileged whiners who don’t even need Obamacare and are sore they couldn’t get their medication covered. But that’s just it — we, too, need and want more affordable health care. We are precisely the kind of folks they need to make these exchanges work. If it’s all poor, very sick people, Obama can kiss his legacy goodbye.
What’s more, we have the time and initiative to dig for answers. As journalists, we could tap on the shoulders of people who ought to know, but that failed, too. Even with the looming prospect of being subject to this sort of publicity, nobody could give us complete, prompt or useful information. How are people who don’t badger public figures for a living, people who have no other option than to contend with Phone People, supposed to work it out?
But this isn’t merely a failure of government — though it is that. It’s also a failure of the private sector in the form of the insurance industry. They’ve received an unbelievable gift, a government-backed money-minting machine on an epic scale. Nobody really likes them, either. This is their chance, too. And their Phone People are no better despite being significantly more experienced. Their media spokespeople were even less responsive than the government’s, and that’s a pretty low bar.
Come November, we’ll check back and see what Obamacare plans are available for 2015. We want the ACA to work; the previous status quo certainly did not.
Right now, though, it’s time to move on. It’s easy to shrug that these are the expected growing pains of a massive new system. That’s probably true. But in real time, it is destructive to our finances and potentially bad for our health.
The president promised a system that would make obtaining insurance as easy as buying a book on Amazon.com. Instead, he gave us – so far, anyhow – one that’s about as easy as getting the NSA to stop listening to our phone calls.