Considering the latest threat to the Affordable Care Act

As an income-less medical student, I would be one of the now 7.1 million people who have signed up for Obamacare for this year. Except I live in Texas, one of nearly half of all states that elected to not expand Medicaid. At the same time, I don’t have enough of an income to qualify for federal subsidies, making insurance from the Marketplace unaffordable.

As such, the individual mandate — the part of the law that taxes those without insurance as a motivator to get insured — does not apply to me. Putting aside the irony of the medical student unable to pay for medical insurance, nearly 5 million people also fall in the same coverage gap.  Now, that coverage gap faces a very real risk of growing to a coverage Grand Canyon, engulfing those who qualify for federal subsidies.


A group of small business owners funded by the conservative nonprofit public policy organization the Competitive Enterprise Institute, is fighting a battle in courts that would deny the federal subsidies that are the main driver of the ACA, affordable insurance, to 12.5 million Americans that qualify for the subsidies of an average of $5,290 per person.

The case ostensibly supports the cause of small business who face penalties if they don’t provide employee insurance, and thus they argue, economic development. They claim that the IRS did not have the rights to extend the federal penalty nor subsidy, a federal tax credit, to states which did not create their own state run health insurance marketplace. The case is made on the wobbly stalk of evidence that the Congressional intent was only for the subsidy to be available to the states because of one quote from the law that authorizes federal subsidies for coverage from an “exchange established by the State under section 1311.”

Only 14 states have managed to do so, which would leave the majority of states with hollow shells of a federally managed insurance marketplace if there were not a federal subsidy. On top of that nonsensical establishment of an exchange which offers no subsidy, 87% of federal exchange participants in 34 states are receiving federal financial assistance. If the case were to ruled in favor of the plaintiffs, these millions of people would lose the assistance, joining me in the group of people pondering what a waste of time this political maneuvering is when effectively no new options are on the table.

Although the federal subsidies survived the first round of litigation in a district court this January where the court ruled in favor of the IRS, the fate of the ACA now rests in the hands of the three judges of the D.C. Court of Appeals. A ruling is expected later this spring.

Never mind that the fate of the massive investments of political willpower to overhaul the biggest health system in the world rests in the hands of 3 district court judges.  Never mind the polarizing ideologies of the groups behind the case: that the owner of the plaintiff restaurant companies is president of the San Antonio Tea Party. Never mind that amidst the years of confusion about the legality, implementation and rumors, the majority of the uninsured and likely missed the enrollment deadline. Never mind that we now live in an age when our elected officials are quoting the Machiavellian puppet master of House of Cards when referencing the disingenuous Congressional mishandling of Medicare reimbursement.

What we should mind is that while the chaos of health system reform stymies the country, the powers continue to rest on their laurels with the notion that America has the best health care in the world.  But really what they should say is that they will not rest until the bounty of America’s health care remains restricted solely to those with money.

The author is an anonymous medical student who blogs at Policy Prescriptions.

Comments are moderated before they are published. Please read the comment policy.

  • http://frugalnurse.com/ Frugal Nurse

    My niece, a second-year med student, came to me in January with the same dilemma. Turning 26 in Feb., she could no longer have coverage through her parents. But she lives off student loans, of course, and can’t afford the $200-plus monthly premiums that are the average for her age group in our state (Wash.). She asked me what to do. I told her the only affordable option, since she did not have enough income to qualify for a subsidy, was to sign up for expanded Medicaid.

    She did not like the idea one bit. “I wasn’t raised to take a government handout! Isn’t there an inexpensive plan that just covers an emergency, like a car accident?”

    “Sorry, honey, those plans are no longer considered adequate. You either pay a high premium (with a $3,000 deductible), go without insurance, or take Medicaid.”

    Luckily, she is smart enough to know going uninsured was a poor choice. She swallowed her pride and signed up for Medicaid (as did many of her classmates). The irony was not lost on us, either, that even future doctors don’t have access to affordable, quality health insurance.

    • querywoman

      I doubt that my state, Texas, would have Medicaid. She would have had to use her county or public system.
      Now, in your state, had she gone to an ER without Medicaid, and ran up a costly bill, then the hospital would have sent someone in to sign her for Medicaid.

  • John C. Key MD

    This is an exciting time to be alive–a brave new world where being on the dole and supported by others is considered wise and noble, where being responsible for oneself and standing on one’s own two feet is deemed “foolish”.

    The widely disparate opinions expressed on this site bear ample witness to this. From what I’ve seen of the PPACA it is less than worthless: the typical 18-to-35 blue collar male with a bronze plan can expect to make hefty, though affordable, monthly premium contributions for a year and thanks to a sky-high deductible, expect to receive absolutely no benefit in return…except for the satisfaction of having to become a collectivist.

    It’s pretty clear that in the next couple of decades a lot of choices are going to shake out in our country, and how that ultimately comes down will decide what the future of the nation will look like. As my alloted span ends, I probably won’t be around to see it.

    • Dr. Drake Ramoray

      The current crop of medical students are more beholden to the government than they realize. Medicaid beneficiaries when students, paid residency salary via Medicare when residents (in all fairness so was I, but they weren’t cutting the funding at the time), and then when they finish practice they can check little boxes on their government mandated EMR for meaningful use and accountable care.

    • Patient Kit

      This kind of judgmental attitude is why I initially hesitated to tell my personal story here on KMD. But I decided my story was worth telling because there are many others like me out here struggling to survive in our heathcare system.

      So, I revealed (or should I say confessed or admitted?) that I have been on Medicaid for this last year. Prior to this year on Medicaid, I have worked hard and paid taxes for my whole life since I was 18. I don’t feel like Medicaid “gave” me any free handout. I am in my 50s now and was diagnosed with ovarian cancer after I was laid off from a job I had for 18 years and lost the insurance that was attached to that job. This was a year before the pre-existing condition clause of the ACA kicked in. So, no new insurance would cover me for the cancer, even if I could afford to buy insurance at that point, which I couldn’t.

      After contributing to the system for my whole life, do you think I should apologize for turning to my government for help for the first time in my life? Nothing else was going to pay for my surgery but Medicaid. Do you think I deserved to just die because I couldn’t afford treatment on my own? I spent my life savings trying not to become homeless during this time, which is why I was broke enough to qualify for Medicaid for the first time in my life.

      Plenty of hardworking people in this country don’t make enough money working to amass enough wealth to weather this kind of storm. I’ve met many people on Medicaid during this last year who formerly worked hard in all sorts of good middle class jobs.

      Let me tell you, living on any kind of public assistance is not easy. I can’t wait to get off this “free ride” and get beyond this. I had two job interviews last week that went very well. Neither job comes with health insurance or would pay enough for me to afford to buy my own. Nobody is more disappointed in the exchange plan options than me. If I get one of those jobs, I will have to stop seeing doctors and discontinue being monitored for cancer recurrence but I’ll be able to keep a roof over my head.

      There is light at the end of the tunnel. Eventually, I wil have Social Security and Medicare (I hope) and a decent private pension, all of which I worked hard to earn. In the meantime, I have to survive for the next ten years. But first, I had to do whatever it took to survive cancer this year. I’m thankful that the safety net of Medicaid helped save me.

      Your judgmental attitude toward me for being on Medicaid really has me amazed at myself for how sympathetic I am about doctors’ financial woes. I guess you don’t treat any undeserving cashless patients like me?

      • EmilyAnon

        Kit, if I could give 10 upticks for your comment, I would. A heartfelt reply to critics who will probably never be in your shoes.

        • Patient Kit

          Thanks, Emily. I appreciate your support. In talking about policy, legislation, politics and our healthcare system, I think we always have to remember that there are real people out here caught in various parts of it. It’s not abstract theory to real people who are seriously ill and unable to access the medical care they need. I hope telling my personal story will make us more real to some readers who don’t live in our shoes or our economic circumstances. I guess I have a short fuse for contempt for the poor coming from people who have everything they need.

          The disparate opinions expressed on KMD, that Dr Key apparently laments, is what makes KMD the great site it is. Coming from different backgrounds and experience, we can all learn from each other if we’re willing to keep our minds open.

          • Ava Marie Wensko George

            I support you Kit. I’ve traveled to several countries who have single payer health care systems. There is such a small percentage of uncovered citizens in those countries, it puts our country to shame. I agree with Emily. It’s a matter of health care public policy in our country that is lacking added to the total ignorance of many of our fellow citizens who lack access and ability to pay for health care. It is a travesty, and we should be ashamed.

          • Patient Kit

            Thank you. In the 1.5 years since we first found my cyst/tumor that turned out to be cancer, I’ve been in 3 different insurance situations. Private Blue Cross when it was first found, then 4 months of being uninsured and not being able to get any follow up medical care. My private practice GYN told me I needed to “find the money” for surgery and that I shouldn’t delay too long. Then she stopped seeing me after I lost my BC. Then 6 months after my tumor was initially found, I qualified for Medicaid and had major surgery.

            I just past my first cancerversery since the surgery and official dx and, going forward as I try to get back to work, I could potentially be in 3 more different insurance situations before I reach my second cancerversery — uninsured again, possible stopgap exchage plan and, hopefully at some point, a new employer-based insurance.

            It goes without saying that everytime a patient’s insurance situation changes, the patient potentially has to start over with new doctors. Our system is just insane and inhumane.

          • B Viner

            I hope that you stay well Kit. We had Medicaid for our first child when I was in medical school and even 21 years ago, it was hard to find a doc that took it. The paediatrician had 70 patients a day booked.
            The problem from my standpoint is that it doesn’t pay well enough to support a practise and most of the people you encounter do nothing beneficial for their health. Typically they were overweight, smoked, and abused prescription drugs. It’s really sad and it can burn you out pretty quick.

          • Patient Kit

            Thank you. I’m doing everything I can to both stay well and get off Medicaid. This Friday, I have a GYN ONC checkup in the morning and a job interview in the afternoon. I totally agree that docs need to be paid better by both Medicaid and Medicare. I’d prefer a single payer system in which all docs are paid fairly and all patients are treated well. In the meantime, as a temporarily cash-free person with cancer, I have no choice but to deal with our current healthcare system instead of my dream system.

            As for finding docs who take Medicaid, I’m lucky I live in NYC and have some good choices. I’m so thankful for the teaching hospitals and their docs. I’ve had excellent specialist care there, especially from my wonderful GYN ONC. It will be a much bigger problem to access medical care once Medicaid cuts me off and I’m uninsured again.

            I realize that the Medicaid patient stereotype comes from real experience, but it annoys me since I eat healthy, don’t smoke and get plenty of exercise, including swimming a mile 5x a week. I’m not giving up a few margaritas here and there though. ;-). Life is short. Gotta find ways to enjoy it, no matter what.

  • John C. Key MD

    Whatever. That was more gobbledygook than I can follow.

    • Dr. Drake Ramoray

      I’m with you. I tried, didn’t really get me anywhere.

  • Dr. Drake Ramoray

    “I imagine from the 10 yr policy standpoint, the reforms aimed at the system in terms of accountability and reporting ( for instance linking govt payments to ‘performance’), collaboration through PCMH and ACOs will slowly help the medical community financially police itself.”

    If by police itself you mean drop Medicare/taking insurance and or moving out of underserved, poor, and rural areas (you know where transportation might have an influence on outcomes) or the fact this demographic is less healthy in the first place than yeah, sure. We will “police” ourselves, whatever the he#$ that means.

    Or perhaps you love big business? Shop at Wal-Mart much? These mandates and ACO/PCMH are really only pushing individual doctors who use individual face to face patient care into a system that is faceless, more bueracratic and more expensive. Let me introduce you to the facility fee, and what is really happening in the ACO/PCMH model.

    http://www.publicintegrity.org/2012/12/20/11978/hospital-facility-fees-boosting-medical-bills-and-not-just-hospital-care

  • ninguem

    Do the medical schools and training programs no longer provide medical coverage to the students and residents?

    They did when I was a student, has it changed?

  • Dr. Drake Ramoray

    ” I think these ‘quality checklist’ style changes will catalyze change that will ultimately free up patient care time.”

    Thanks. I just shot some of my after dinner wine out my nose. Its always good to end the day with a laugh. I do hope you have a good night.

  • QQQ

    Many people have found that they can now get on Medicaid but are not aware of the “Medicaid Estate Asset Recovery Act” that came about in 1993. From the government web site: “State Medicaid programs must recover certain Medicaid benefits paid on behalf of a Medicaid enrollee. For individuals age 55 or older, states are required to seek recovery of payments from the individual’s estate for nursing facility services, home and community-based services, and related hospital and prescription
    drug services.” So your kids can kiss good-bye the inheritance they thought they would be getting.

    • http://frugalnurse.com/ Frugal Nurse

      Washington state passed emergency legislature in Dec. to address this problem. They changed the wording of the policy so that estate recovery efforts will be limited to long-term care costs, not medical costs. Of course, state lawmakers only became aware of this problem after it was highlighted by an article in the Seattle Times. Just one more unintended, overlooked consequence of the ACA.

    • Lisa

      Quite frankly, I don’t undertand what is wrong with recovering of payments from the estate of people were covered by medicaid. Of course, most people who have been on medicaid have very few assets.

  • Eric W Thompson

    Interesting comments. From what I have seen, if a person is poor, they will only afford the cheaper plans which have deductibles as high as 7 or 8 thousand dollars. Most will never reach that level. Essentially a lot of money for catastrophic insurance. Most money paid in will be from the young and healthy to cover the old and sick. A tax on the young for the old since the disparity in costs are capped by age.

  • querywoman

    The Medicaid coach probably does it for the benefit of the hospitals. Without Medicaid, they just eat the bills, or write them at huge inflated rates.
    That tells you right there that the hospitals are more powerful than the doctors.

  • querywoman

    The ACA has done very little for people below the mysterious middle middle income limit.