“…An eligible employer-sponsored plan is affordable for a related individual if the portion of the annual premium the employee must pay for self-only coverage does not exceed the required contribution percentage…” (Federal Register, Feb 1, 2013. 78-22, p. 7265)
Once upon a time I was an enrollment assister in rural West Virginia, helping community members get signed up for ACA-compliant health insurance coverage. I have hundreds of success stories under my belt, and hopefully not as many failures. Most frequently, I can say with confidence, those failures could be attributed to the family glitch. Most Americans have never heard of the family glitch unless it has affected them personally. Actually, even if they’ve experienced this glitch, they may not understand what it is. It’s complicated, but important to understand when you’re parsing through all the new ACA-fix bills circulating out there. A family glitch fix is essential to allowing more people to access affordable health coverage.
I’ll start with an example:
Maria comes to me hoping to purchase a subsidized Marketplace plan for her husband who is a stay at home dad. She is working a full time job making $53,000/year. Maria has coverage through her employer for $175/month (about 4% of her income). However, to add her husband to her plan it would cost her $575/month (about 13% of her income) which she cannot afford. At $53,000/year for a family of 3, Maria’s husband should qualify for a healthy tax credit to help him pay for his coverage. So what’s the glitch? In this case, Maria’s husband is not eligible for a tax credit to help him pay. Here’s why:
An individual may not receive a tax credit to purchase Marketplace coverage if s/he has an offer of affordable employer-sponsored insurance coverage (ESI). “Affordable,” in 2019, according to the ACA/IRS, means the total cost of self-only premiums must equal no more than 9.86% of an individual’s total household income. “Self-only” is the key term. While Maria’s ESI cost for her family is well over 9.86% (at 13%), the cost of her self-only coverage is well under 9.86% (at 4%) and is thus deemed affordable. Therefore, her husband has an offer of “affordable” ESI and is not eligible for a tax credit.
How can this be? Turns out, it’s not a glitch. The IRS and the GAO have decided to interpret the law in such a way so as to cut costs. Fewer people eligible for tax credits means less money the government has to dole out. It all comes down to the interpretation of the phrase “required contribution.” Because the law states that the required contribution, as it relates to the individual mandate, will be calculated based on self-only cost, the IRS determined that “required contribution” as it relates to tax credit eligibility should also be calculated based on self-only cost, though the law does not explicitly state this.
Two to four million people are stuck in the glitch, with no options for affordable coverage. Back in 2014, Senator Al Franken first introduced the Family Coverage Act to fix the family glitch. His bill went nowhere because of concerns over- you guessed it- cost. But here we are in 2019, with a plethora of ACA-fix and health system reform ideas filling our inboxes and bungling our brains. Most notable, for the sake of this issue, is HR 1884: The Protecting Pre-Existing Conditions and Making Healthcare More Affordable Act, better known in health policy circles as ACA 2.0 thanks to the unsurpassable Charles Gaba. The upside is it passed the House in May, which is quite a feat given previous pushback. The down side is, well, Mitch McConnell will never let it come to a vote in the Senate. It is also worth it to check out Senator Sherrod Brown’s (D-OH) reintroduction of the Family Coverage Act, introduced in June, which specifically targets the family glitch. This bill would allow families to access Marketplace tax credits if the cost of employer-sponsored family coverage is greater than 9.86% of income, providing access to affordable coverage to millions of individuals.
So, what is there to do if you have found yourself in the family glitch? The hard answer is “not much.” Here are some true but maybe unhelpful answers:
What you should actually do:
The “family glitch” is essentially health policy jargon, so families may have experienced this without even realizing. They just know that the ACA hasn’t helped them, and they are owed an explanation.
Let’s educate, enlighten, and demand change for those who deserve access to affordable health insurance coverage.
This weekend marks the second anniversary of the Senate vote to repeal the ACA. This vote was a culmination of a contentious battle on Capitol Hill and around the country, with protesters in the halls of Congress being arrested, protests, town halls demanding lawmakers protect the law and the health care of millions of Americans, office protests and petition deliveries to those lawmakers who refused to hold town halls or meet with their constituents. Prior to the Senate vote we witnessed a callous and childish celebration on the grounds of the White House by certain members of Congress and the current President chortling with glee at their successful vote to rip protections and somewhat affordable access to health care from tens of millions of Americans (complete with a purported keg party in the halls of the House).
Those of us who had been advocating and calling, protesting, marching, exhorting our lawmakers to do the right thing sat riveted. Millions who had been sleeping poorly in terror of losing health insurance, in horror of losing protections for those with medical histories that were preventing insurance companies from denying coverage awaited the final vote anxiously. The millions of Americans who finally could access health insurance either through the exchanges or through Medicaid expansion sat on tenterhooks when the final vote came in the Senate. That vote, a party-line vote showing the distinct ideological differences and implacable indifference of some lawmakers to the wishes and desires of those who elected them over the support of special interests, lobbyists, and the like - that vote signified a moment of sanity and a breath of relief. Some lawmakers stood up to the barrage of party pressure and voted for the greater good, despite potential campaign backlash. Just enough Senators voted to stop the juggernaut of inebriation brought on by finally controlling the executive and legislative branches of our government.
And, just like two years ago, this weekend starts the August recess for Congress. A time for lawmakers to go back to their districts and states, to meet with constituents, to hold town halls (or not), march in parades, kiss babies, and get their photos in the paper during the dog days of summer.
While this year has not been as fraught with tension and fear, it has had its own terrors and its own Sword of Damocles dangling over the state of health care in this nation. A current lawsuit, called spurious and ridiculous by experts on both sides of the aisle, awaits decision and eventual appeal to the Supreme Court. Our department of Health and Human Services is issuing rules changes to strip nondiscrimination protections from women, immigrants, and members of the LGBTQ community, with the potential aim of stripping racial discrimination protections from patients seeking care, not to mention a rule which would allow medical providers to refuse medical treatment that they felt went against the provider’s moral beliefs.
Debate ranges on Capitol Hill to help address the out-of-control prices of life saving medications, as well as prescriptions that allow people to live the best lives they can. Bills have been passed in the House to address the so-called premium subsidy cliff, which if passed and signed, would allow millions of Americans who make over 400% of the federal poverty level to access premium tax subsidies to help them afford plans on the exchanges - many of these between the ages of 50 and 64, who see significant premium increases due to age-rating (or charging those in that age range up to 3 times the premiums of someone who is 26). A bill has been introduced to address the so-called ‘family glitch,’ which prevents family members with access to employer-based benefits that cost more than 9% of the family income from accessing less expensive plans on the exchanges. Other bills have been introduced to help states create their own exchanges, to codify protections for those with ‘pre-existing conditions,’ a term created by the insurance industry to justify denying insurance to those with medical histories they find objectionable.
We are once again hearing how if the ACA is struck down by the courts, GOP leadership will protect those with medical histories, but we have seen no such legislation from them. It is all still a nebulous concept that they will get to if and when needed. We are seeing that while there is a bipartisan bill to address prescription pricing, the lobbyists for the pharmaceutical and insurance industry meet at the White House to push against any regulations or laws that may impede their ability to seek excess and uncontrolled profit from the suffering of their fellow citizens. We are seeing large hospital associations sue the poorest patients for bills, seeing people being charged up-front for treatment and testing above and beyond a patient’s copay, we are seeing more social funding appeals for those hit with surprise bills totaling tens or hundreds of thousands of dollars, and we are seeing bankruptcies due to health expenses once again on the rise.
One thing that makes this year different from two years ago is the sheer number of bills and plans that have been introduced to address the problems with health care in this country. One could say there are too many plans to keep track of. Some call for a wholesale overhaul of our nation’s health care system, others call for modest steps toward an eventual goal of universal affordable, comprehensive, equitable, and quality health care. Find one that you like, or support all of them. Steps to fix the current system make sense while we work to see what happens next November. A complete sea-change in our nation’s health care is predicated on a change in Washington and could not be implemented for at least 3 years, but incremental fixes have been proposed, and some have passed the House and are just waiting to be brought up in the Senate.
So, this weekend once again marks a period where we, the People, must take up our signs, our phones, our keyboards, and make sure that the lawmakers in Washington hear from us when they are home. Now is the time to write letters to the editor to demand lawmakers stop holding the health care of this country hostage. Now is the time to gather friends and family, go to town halls, coffees on the corner, office open houses, and yes, even candidate fundraisers if you can. Now is the time to discuss your personal stories, explain what health care means to your family, put a face to the issue with your lawmakers. If you don’t like your lawmaker’s position, seek out their campaign opponent and talk with them.
By all means, go to the beach, see friends, enjoy the flowers and concerts. But, wear a pin at the concerts that says #ProtectOurCare or another health care slogan, join with others who want to protect and defend the health care of everyone you know, get involved, write letters to the local paper, join local grass roots functions. Together we can make some noise and remind lawmakers that we expect them to do the jobs they were elected to do. Remind lawmakers that we are watching and will support them if they are supporting us. Remind them that some lawmakers were brave two years ago, and that we expect them to continue being brave until doing the right thing - on both sides of the aisle - is no longer a thing of political bravery, but an expectation of the position they sought, a position which requires them to protect and defend the Constitution of this great country, and its people.
Words matter. Language is important in communicating ideas and positions. It is critical to use clear, concise language to convey exact meanings and avoid misunderstandings and confusion. Utilizing terms that were crafted by those who oppose one’s position help to undermine one’s position or argument. To that end, I propose we stop using the term ‘pre-existing conditions’ immediately.
In many other countries, previous diagnoses and health issues, chronic conditions, and injuries are simply referred to as an individual's medical history.
We seem to have accepted the concept that a 'pre-existing condition' is a perfectly reasonable and normal reason for someone to be denied health insurance coverage. Even though the ACA actually outlawed insurance companies from using PECs to deny insurance in qualified plans under the law, we have allowed ourselves to be convinced that being sick or injured is a justifiable reason for not being eligible for health insurance in the future. This is fundamentally wrong, and it must stop.
The term pre-existing condition was created by the U.S. insurance industry to identify conditions and diagnoses that would allow them to exclude insurance coverage for individuals who had purchased health insurance. This was done with the ultimate goal of realizing greater and greater profits for insurance companies, their executives, and their shareholders.
There is no comprehensive industry-wide list of PECs. Each insurance company has their own internal list. These lists change and have even been expanded when consumers, who had faithfully paid their monthly premiums, became ill. There have been documented cases where consumers received a diagnosis or experienced a critical accident and the insurance company would work to find anything, no matter how specious, that would allow them to exclude coverage for that individual retroactively - coverage that individual had paid for in good faith, and leaving the individual on the hook for sometimes hundreds of thousands of dollars.
In addition, PECs are used by short-term and so-called unqualified plans under the ACA - those that still require underwriting - to preclude medical conditions from coverage, up to and including gender. One case documented in the past year noted a young woman who had experienced incredibly heavy menstrual cycles. One month, she hemorrhaged and needed surgery and several blood infusions to save her life. The short-term insurance company declared that simply being a woman, and therefore subject to potential complications from menstruation, was a pre-existing condition and denied coverage for any of her treatment.
There is a significant difference between so-called PECs, which again are a wide category of insurance company-identified reasons for declining insurance coverage, and chronic medical conditions. Unfortunately, over the last couple of years, they have come to mean the same thing, or be used interchangeably. Many PECs have nothing to do with chronic medical conditions. A broken ankle is not the same as arthritis or multiple sclerosis.
Further, the fear of having a potential PEC become part of a one’s medical history has led some people to avoid or delay medical treatment. In case the ACA protections are stripped away and we lose them altogether, some people are delaying treatment until their care can no longer be ignored for fear of having a diagnosis on their medical record that could be used to deny future insurance coverage. These delays frequently result in much higher costs than if they had been treated earlier.
The longer we continue to use the expression PEC, or ‘pre-existing condition,’ the longer we are allowing the health insurance industry in this country -- a for-profit industry focused on their bottom line and keeping their shareholders and Wall Street happy -- to dictate the discussion. It is time to simply stop using their terminology. It is time to stop letting them dictate what constitutes comprehensive medical care and coverage.
It is past time for us to retake the narrative, and begin working for a comprehensive, equitable, affordable, quality, universal health care system on our own terms - for the benefit of the people.
It is past time to simply state that we are all more than our medical history.
It is past time to declare that our health is no one’s commodity.
It is past time that we agreed that every single person deserves quality affordable care based on the concept of humanity and decency, and on the core precepts of our country - that all are created equal and all are endowed with the unalienable rights of life, liberty and the pursuit of happiness, which includes universal, affordable, comprehensive, equitable, quality health care.
It is past time we stopped calling our medical history ‘pre-existing conditions.’