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Did you know the ACA was going back to being like it was 20 years ago with prices of Cadillac plans?

Posted by on Apr. 3, 2014 at 7:22 AM
  • 35 Replies

"I think there will be a lot of people very happy and satisfied with what they have," said Joel Ario, formerly the director of the Office of Health Insurance Exchanges at the Department of Health and Human Services and now a managing director at Manatt Health Solutions. "But there may be those who say, 'Nobody told me about the deductible on the bronze plan.' People are going to say the cost-savings measures are too high, particularly around some of the drug plans."

Ario and others who helped create and implement the law said they knew it was a move toward consumers having "more skin in the game," because they will have to weigh the costs and benefits of medical procedures.

"For people who think the ACA takes care of everything for you, you'll find it's more like 20 years ago, where it takes care of the serious things," Ario said. "But they're not going to go bankrupt anymore. It's far better to owe $5,000 in the deductible than have a bill from the hospital saying you owe $100,000 or more."

People will also continue to question the limited networks, he said. Some of the plans keep their costs down by saying consumers may only see certain doctors, or else pay more, and consumers need to understand that better both while shopping for plans and while seeking treatment.

LINK

Bronze Plan – Affordable Care Act (Obamacare)

What Is the Bronze Plan?

The Affordable Care Act, otherwise known as Obamacare, requires insurance companies in 2014 to offer new categories of health insurance plans to consumers: Bronze, Silver, Gold, and Platinum. These plans will all offer a minimum standard of benefits determined by the government. This minimum standard is known as the plan’s "essential health benefits."

Generally speaking, the Bronze Plan is intended to have the lowest premium of the 4 new categories of plans but charge the highest out-of-pocket costs for healthcare services. For people without group insurance from an employer or other group, the Bronze plan is the minimum health insurance plan in which they can enroll that will satisfy the Affordable Care Act’s mandate for people to purchase health insurance.

What Are The Bronze Plan’s Out-of-Pocket Costs?

Bronze Plans are designed so that insurance companies will pay 60% of covered healthcare expenses with the remaining 40% to be paid by consumers. The consumer’s expenses will be in the form of out-of-pocket fees over and above the cost of the plan’s monthly premium. Out-of-pocket expenses in 2014 are capped at $6,350 for individual plans and $12,700 for family plans.

The 40/60 percentages are based on projected use of healthcare services by plan members. The actual out-of-pocket expenses of any single beneficiary may work out to be more or less than this ratio but should remain within the range. Those people whose out-of-pocket limits reach the annual maximum could see their share of healthcare costs fall until a new calendar year begins and the annual limit reset.

Out-of-pocket expenses include fees like deductibles, copayments, or coinsurance. Different plans will approach the 40/60 split in various ways (see the table below) so it is important to research the financial details of a specific plan before deciding which one to purchase. For example, a person who has frequent medical expenses may want a Bronze Plan with a lower deductible (depending on premium) while a healthy person may want the opposite.

Below are the average out-of-pocket cost-sharing expenses for medical services and prescription drugs found across bronze plans.

Cost-Sharing CategoryAverage for a Bronze Plan
Deductible for an individual enrollee$5,081
Deductible for a family$10,386
Doctor Visit30% of doctor visit expense charged to patient as coinsurance fee* (coinsurance fees used for doctor visit in 54% of plans studied)
Generic drugs32% of generic drug expense charged to patient as coinsurance fee
Preferred brand drugs35% of preferred brand drug expense charged to patient as coinsurance fee
Non-preferred brand drugs36% of non-preferred brand drug expense charged to patient as coinsurance fee
Specialty drugs34% of specialty drug expense charged to patient as coinsurance fee
Specialist visit30% of specialist visit expense charged to patient as coinsurance fee
Annual cap on out-of-pocket costs for an individual$6,267
Annual cap on out-of-pocket costs for a family$12,569

* Doctor visit charges vary based on length and whether you are an existing patient or new patient. For reference, a cost estimate for a doctor visit in the Boston area by an established patient is $138.1

Below is an illustration of how costs could differ among Bronze plans for an individual enrollee.

 Bronze Plan Example #1Bronze Plan Example #2Bronze Plan Example #3
StateCaliforniaNew YorkOhio
PlanAnthem Blue Cross of California - Bronze Plan (PPO)United Healthcare - New York Standard Bronze (EPO)Aetna - ADVANTAGEPLUS 5500 PD
Deductible$5,000$3,000$5,500
Doctor Visit Fee$6050% of cost10% of cost
Coinsurance Fee30% of cost50% of cost10% of cost
Annual Limit on Out-of-Pocket Expenses$6,350$6,350$6,350

For some plans, the consumer’s share of expenses may come in the form of large deductibles (e.g. above $5,000) with low out-of-pocket costs for services received after the deductible is satisfied. For other plans, the deductible might be low but the consumer would be responsible for 40% of the cost of every covered medical service he or she receives.

The examples above show significant differences between deductibles and coinsurance even though the plans offer the same essential benefits and cap the maximum out-of-pocket expenses at $6,350 in 2014. It’s also important to remember that coverage depends on you using the plan’s approved healthcare providers. Using a doctor or hospital outside of that network could result in significantly higher costs.

It is estimated that the Bronze Plan requires higher cost-sharing for consumers than the typical employer-based plan. Moreover, people who are insuring family members along with themselves will have higher out-of-pocket limits as well as higher premiums. However, with respect to families, the income limits for government subsidies are also higher.

Bronze Plan Premiums

Bronze plans have the lowest premium rates of the four new types of metal plans since they charge the highest out-of-pocket costs. However, there may be instances where the Silver Plan for one insurance company may charge a lower premium than the Bronze Plan of another insurance company. Comparison shopping will be essential for anyone who wants to minimize their healthcare expenses. HealthPocket’s health insurance comparison tool allows people to compare all the plans available in their area.

Below are the average monthly premiums found for 30, 40, 50, and 60-year-old individuals in Bronze plans across 34 different states.

Age 30Age 40Age 50Age 60
$263$296$413$627

The Affordable Care Act caps deductibles on small business health plans at $2,000 for individual enrollees and $4,000 for families. However, in February 2013 the Department of Health and Human Services permitted small group health insurance plans to exceed the deductible caps if it was necessary to maintain the appropriate percentage of out-of-pocket costs for enrollees. HealthPocket found the following average out-of-pocket costs for bronze plans in the small business market.

Cost-sharing categoryAverage for a Bronze Plan
Medical deductible for individual enrollee$4,216
Medical deductible for family$8,667
Primary care visit33%
Specialist visit33%
Annual cap on out-of-pocket costs for an individual$6,224
Annual cap on out-of-pocket costs for a family$12,518

The average deductibles for Bronze plans exceeded both the $2,000 individual and $4,000 family deductible caps. In fact, nearly all Bronze plans exceeded the deductible caps for both individuals and families.

Did this really help anyone besides insurance companies? How many people will truly benefit from a major medical policy with high deductibles and high monthly payments? 

by on Apr. 3, 2014 at 7:22 AM
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Replies (1-10):
btamilee
by Silver Member on Apr. 3, 2014 at 8:25 AM
4 moms liked this

The MAJOR winners in this...without a doubt, will be the insurance companies.

Avarah
by Member on Apr. 3, 2014 at 9:03 AM
2 moms liked this
I'm a SAHM and my husband is self insured. We had to get insurance through the ACA. Our new plan with BCBS is about $200 per month less expensive and it covers WAY more than our old insurance with lower deductibles and about the same for co-pays.

We do not have this insurance because we are poor. We are not on any public assistance. We have it because this is the very best option, and I am personally extremely grateful to have better insurance than the insanely expensive crap we were handed before by the insurance companies.

As to this article, I have worked since I was 15 yrs old. In every insurance policy I've had in that time, either through an employer or purchased privately, there has been a lower cost/higher deductible option. This is true of car insurance and home owner's insurance, as well.
stormcris
by Christy on Apr. 3, 2014 at 9:31 AM

While that is great for you, I am not sure that is the standard experience. Just before this came into the picture my insurance was 1/2 as much for an 80/20 with an $1800 per year deductible and a $25 office visit copay. Now I am to pay double for less and a $5000.00 deductible. Taking a higher deductible does not get me significantly cheaper rates as they can hardly up them much more and meet the requirements. I have also never had an employer that offered a lower cost higher deductible policy. You either payed the standard or you didn't take it. However, my original policy had to be dropped as it skyrocketed soon after they started debating ACA. As for home owners, they are going to the point of discontinuing many policies so that you are forced onto a state plan with no options, a higher payment and larger deductible; so yes I would say it is fairly similar. I pay way less for my cars with a low deductible and will likely see far more benefit out of the car insurance. 

Quoting Avarah: I'm a SAHM and my husband is self insured. We had to get insurance through the ACA. Our new plan with BCBS is about $200 per month less expensive and it covers WAY more than our old insurance with lower deductibles and about the same for co-pays. We do not have this insurance because we are poor. We are not on any public assistance. We have it because this is the very best option, and I am personally extremely grateful to have better insurance than the insanely expensive crap we were handed before by the insurance companies. As to this article, I have worked since I was 15 yrs old. In every insurance policy I've had in that time, either through an employer or purchased privately, there has been a lower cost/higher deductible option. This is true of car insurance and home owner's insurance, as well.


nelopyma
by Bronze Member on Apr. 3, 2014 at 9:38 AM


Quoting stormcris:

While that is great for you, I am not sure that is the standard experience. Just before this came into the picture my insurance was 1/2 as much for an 80/20 with an $1800 per year deductible and a $25 office visit copay. Now I am to pay double for less and a $5000.00 deductible. Taking a higher deductible does not get me significantly cheaper rates as they can hardly up them much more and meet the requirements. I have also never had an employer that offered a lower cost higher deductible policy. You either payed the standard or you didn't take it. However, my original policy had to be dropped as it skyrocketed soon after they started debating ACA. As for home owners, they are going to the point of discontinuing many policies so that you are forced onto a state plan with no options, a higher payment and larger deductible; so yes I would say it is fairly similar. I pay way less for my cars with a low deductible and will likely see far more benefit out of the car insurance. 

Quoting Avarah: I'm a SAHM and my husband is self insured. We had to get insurance through the ACA. Our new plan with BCBS is about $200 per month less expensive and it covers WAY more than our old insurance with lower deductibles and about the same for co-pays. We do not have this insurance because we are poor. We are not on any public assistance. We have it because this is the very best option, and I am personally extremely grateful to have better insurance than the insanely expensive crap we were handed before by the insurance companies. As to this article, I have worked since I was 15 yrs old. In every insurance policy I've had in that time, either through an employer or purchased privately, there has been a lower cost/higher deductible option. This is true of car insurance and home owner's insurance, as well.

I love how everyone claims it's ACA that's causing skyrocketing premiums.  The year we had a substantial leap in our premium share was 2 years BEFORE the ACA mandates went into effect.  Since then, our portion of the premiums has still increased, but not a giant leap like that one time.

For very small businesses, yes, you might only get one plan to take or leave.  For businesses that employ more people, it's common to get a choice.  DH works for the gov't now, and we had a choice of about a dozen plans.  At his previous job, a private company that employed a few hundred, we had 3 options.

Roxygurl
by Bronze Member on Apr. 3, 2014 at 9:46 AM
I benefit greatly from it.

I am a nanny so I don't get healthcare through my employer. I've been buying my own insurance since I turned 26 and was no longer allowed to stay on my dads plan.

I've watched my plan premium skyrocket while my benefits haven't changed. At one time I was paying over 300 bucks for a plan with a deductible of 5000 plus 80/20

I also found out the hard way that even though I paid my premiums faithfully every month it didn't cover things like maternity and in the state of Texas there was no way to buy a maternity rider so I had no choice but to sign up for Medicaid.....even though I had health insurance.

I went to my pcp for a headache once when I was a teen thinking it was a migraine and because he prescribed me meds blue cross considered it a pre existing condition and refused to cover anything related to headaches.

I also need a tonsillectomy but under the old plan I would've had to pay 5000 PLUS 20%.

I signed up for a new plan under aca and although I'm paying more it covers more so I'm extremely happy. I pay 334 a month and I have a 3250 deductible but once I meet that deductible everything minus office visits and meds are covered at 100%

They can not deny me maternity benefits. They can not refuse to pay for something because they deem it a pre-existing condition and now I can have the tonsillectomy and not have to worry about how I'm going to pay for it all.

I also didn't sign up for a bronze plan, I believe I signed up for a silver plan and I don't think I was offered a platinum plan....I assume because of my age
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DSamuels
by Gold Member on Apr. 3, 2014 at 9:48 AM


Quoting nelopyma:


Quoting stormcris:

While that is great for you, I am not sure that is the standard experience. Just before this came into the picture my insurance was 1/2 as much for an 80/20 with an $1800 per year deductible and a $25 office visit copay. Now I am to pay double for less and a $5000.00 deductible. Taking a higher deductible does not get me significantly cheaper rates as they can hardly up them much more and meet the requirements. I have also never had an employer that offered a lower cost higher deductible policy. You either payed the standard or you didn't take it. However, my original policy had to be dropped as it skyrocketed soon after they started debating ACA. As for home owners, they are going to the point of discontinuing many policies so that you are forced onto a state plan with no options, a higher payment and larger deductible; so yes I would say it is fairly similar. I pay way less for my cars with a low deductible and will likely see far more benefit out of the car insurance. 

Quoting Avarah: I'm a SAHM and my husband is self insured. We had to get insurance through the ACA. Our new plan with BCBS is about $200 per month less expensive and it covers WAY more than our old insurance with lower deductibles and about the same for co-pays. We do not have this insurance because we are poor. We are not on any public assistance. We have it because this is the very best option, and I am personally extremely grateful to have better insurance than the insanely expensive crap we were handed before by the insurance companies. As to this article, I have worked since I was 15 yrs old. In every insurance policy I've had in that time, either through an employer or purchased privately, there has been a lower cost/higher deductible option. This is true of car insurance and home owner's insurance, as well.

I love how everyone claims it's ACA that's causing skyrocketing premiums.  The year we had a substantial leap in our premium share was 2 years BEFORE the ACA mandates went into effect.  Since then, our portion of the premiums has still increased, but not a giant leap like that one time.

For very small businesses, yes, you might only get one plan to take or leave.  For businesses that employ more people, it's common to get a choice.  DH works for the gov't now, and we had a choice of about a dozen plans.  At his previous job, a private company that employed a few hundred, we had 3 options.

The year they passed the ACA is the year that hubby's employer went from paying our whole premium to us paying part of it. It started at $88 every two weeks to $102 to $124 and this year $164. Our deductible jumped from $100 to $1000. As of last year ER went from being covered 100% to being covered at 80% AFTER the deductible and $200 copay. 

We have 3 options and we have the middle plan. The higher plan has a deductible $250 less, but the increase in premiums would be larger than $500 a year, the copays aren't that much cheaper either.

stormcris
by Christy on Apr. 3, 2014 at 9:50 AM

Do you believe they didn't know this would come into play before it happened? That two years before was when everything went to changing in insurance. The change overs occurred not only in prices but also in limiting doctors and setting up the prescriptions available. Many banks stopped private student loans prior to the signing of the government taking them over prior to it happening. There have been other instances as well of things being affect by bills not yet signed into law but it affecting the market none the less. Of course this affected premiums. It was written for insurance companies and they know they can charge more for something that is required. The companies I worked for employed at least 500 employees. They offered one standard, plus Afflac, plus disability at each. The insurance I had right before this came into play was a self insured policy though under self employed.

Quoting nelopyma:


Quoting stormcris:

While that is great for you, I am not sure that is the standard experience. Just before this came into the picture my insurance was 1/2 as much for an 80/20 with an $1800 per year deductible and a $25 office visit copay. Now I am to pay double for less and a $5000.00 deductible. Taking a higher deductible does not get me significantly cheaper rates as they can hardly up them much more and meet the requirements. I have also never had an employer that offered a lower cost higher deductible policy. You either payed the standard or you didn't take it. However, my original policy had to be dropped as it skyrocketed soon after they started debating ACA. As for home owners, they are going to the point of discontinuing many policies so that you are forced onto a state plan with no options, a higher payment and larger deductible; so yes I would say it is fairly similar. I pay way less for my cars with a low deductible and will likely see far more benefit out of the car insurance. 

Quoting Avarah: I'm a SAHM and my husband is self insured. We had to get insurance through the ACA. Our new plan with BCBS is about $200 per month less expensive and it covers WAY more than our old insurance with lower deductibles and about the same for co-pays. We do not have this insurance because we are poor. We are not on any public assistance. We have it because this is the very best option, and I am personally extremely grateful to have better insurance than the insanely expensive crap we were handed before by the insurance companies. As to this article, I have worked since I was 15 yrs old. In every insurance policy I've had in that time, either through an employer or purchased privately, there has been a lower cost/higher deductible option. This is true of car insurance and home owner's insurance, as well.

I love how everyone claims it's ACA that's causing skyrocketing premiums.  The year we had a substantial leap in our premium share was 2 years BEFORE the ACA mandates went into effect.  Since then, our portion of the premiums has still increased, but not a giant leap like that one time.

For very small businesses, yes, you might only get one plan to take or leave.  For businesses that employ more people, it's common to get a choice.  DH works for the gov't now, and we had a choice of about a dozen plans.  At his previous job, a private company that employed a few hundred, we had 3 options.


stormcris
by Christy on Apr. 3, 2014 at 10:15 AM

The pre-existing inclusion is a great thing, no doubt. However, that was the selling point. The position was that this would be affordable health care. There was supposed to be something similar to gap insurance that would take the inbetween people who could not get medicaid but were still too poor to afford the exchange without burden. However, that program requires rules that have yet to be dictated and as such is not available yet.

On a side note: Affordable is a tricky word.

For now, low-income Americans who aren't eligible for Medicaid must rely on the financial help that is available to them on the health insurance exchanges.

Determining how much that amounts to is a computational labyrinth. According to the ACA, a family of three whose annual income is at 133% of the federal poverty level (an annual income of $24,352), should have to pay no more than 3% of their household income in annual premiums, or $731. In that case, the federal government would pay the insurance company the difference between $731 and the actual premium.

The percentage an individual or family is expected to pay rises at higher income levels, up to 400% of poverty. At that income level, paying up to 9.5% of household income on health insurance is considered affordable. So, a family of three making $73,240 would receive a subsidy to cover premium amounts above $6,958.

People making between 133 and 250% of the poverty level also can get help with their out-of-pocket medical expenses, such as co-payments for visits to the doctor, providing they purchase at least a "Silver" plan on the exchange. The exchanges offer up to four different tiers of health insurance plans: "Bronze," "Silver," "Gold" and "Platinum." Bronze plans have the cheapest premiums, but leave policyholders with the highest co-payments and deductibles. Platinum plans have the highest premiums but the lowest co-pays and deductibles.

Under the Silver plans, people making more than 250% of the poverty level can expect to contribute an average of 30% for their medical costs, with their insurance company paying the rest. But those with incomes below 250% of the poverty level can get federal assistance with their out-of-pocket expenses. At 133% of the poverty level, an individual or family could contribute as little as 6% to the cost of their medical bills with the insurance company and the federal government picking up the rest.

Those cost-saving breaks, however, are only available for those selecting Silver plans, apparently to entice people away from Bronze plans with their high deductibles and co-pays.

Despite all of this assistance, health insurance still may not be "affordable" for some. Affordability, like beauty, is a matter of opinion. "What it means for something to be affordable or not affordable is totally debatable," said Sherry Glied, dean of New York University's Robert F. Wagner Graduate School of Public Service. "It isn't like there's a fixed definition of affordability."

That's particularly true in the U.S., where the cost of living varies so strikingly. "What's poor in Mississippi is different from what's poor in New York state," said Elisabeth Benjamin, an executive with the Community Service Society of New York. "People have so little disposable income in New York City and other urban areas, but the law doesn't do geographic indexing."

Using cost of living data on the Albuquerque area from the Economic Policy Institute, Kelsey Heilman, a former staff attorney with the New Mexico Center on Law and Poverty, showed that a single mother of two making 200% of the poverty level would have virtually no money left for health care premiums or health care expenses after paying for housing, food, transportation and other necessities. That mother, Heilman said, might decide to go with the cheaper Bronze plan, but then she would forgo the cost-sharing help the federal government makes available for Silver plan policyholders. As a result, she might pay as much as 40% of her medical expenses out of pocket, instead of the 13% she would have to pay with a Silver plan. That difference could amount to more than $3,000 a year.

Those who decide to forgo insurance can ask for hardship exemptions from the financial penalty. But getting medical care is likely to become increasingly difficult for them because the federal government is cutting its payments to hospitals that provide charitable care to the poor.

Other possible solutions to the affordability problem have also surfaced. Massachusetts, which enacted its own health care reforms in 2006, won federal permission to use Medicaid dollars to provide premium and cost-sharing assistance for those with incomes below 300% of the poverty level who purchased private insurance on the Massachusetts exchange. Other states could apply for permission to do the same, but it is a months-long process.

States also might seek to raise eligibility for Medicaid above the 133% threshold. Manne, with the New Mexico Center on Law and Poverty, said some businesses and hospitals have talked about voluntarily undertaking sponsorships to help those unable to pay premiums or meet out-of-pocket obligations.

But, Manne said, broad relief seems months away, if not longer. In the meantime, she predicts that policymakers will be hearing about legions of Americans who still can't afford health care—no matter the title of the Affordable Care Act.

Quoting Roxygurl: I benefit greatly from it. I am a nanny so I don't get healthcare through my employer. I've been buying my own insurance since I turned 26 and was no longer allowed to stay on my dads plan. I've watched my plan premium skyrocket while my benefits haven't changed. At one time I was paying over 300 bucks for a plan with a deductible of 5000 plus 80/20 I also found out the hard way that even though I paid my premiums faithfully every month it didn't cover things like maternity and in the state of Texas there was no way to buy a maternity rider so I had no choice but to sign up for Medicaid.....even though I had health insurance. I went to my pcp for a headache once when I was a teen thinking it was a migraine and because he prescribed me meds blue cross considered it a pre existing condition and refused to cover anything related to headaches. I also need a tonsillectomy but under the old plan I would've had to pay 5000 PLUS 20%. I signed up for a new plan under aca and although I'm paying more it covers more so I'm extremely happy. I pay 334 a month and I have a 3250 deductible but once I meet that deductible everything minus office visits and meds are covered at 100% They can not deny me maternity benefits. They can not refuse to pay for something because they deem it a pre-existing condition and now I can have the tonsillectomy and not have to worry about how I'm going to pay for it all. I also didn't sign up for a bronze plan, I believe I signed up for a silver plan and I don't think I was offered a platinum plan....I assume because of my age


Sisteract
by Whoopie on Apr. 3, 2014 at 11:34 AM

I do think there is one thing correct about this article. The people who seem to be most up-in-arms about the ACA are those who had Cadillac plans and found out that they can no longer have that plan unless they pay far more. Remember the lady here with the 2 SN kids whose CP was cancelled? The ACA has allowed ICs to cut off those who had CPs, were paying little for the coverage AND were high users-meaning they were costing boatloads of money.

Many of us have been dealing with insurance issues for years, well before the ACA.

I also agree that the ICs are the real winners.

SunshneDaydream
by Silver Member on Apr. 3, 2014 at 11:58 AM

Not to mention the fact that if you are offered insurance through work--regardless of whether or not you can afford it--you may not be eligible for subsidies at all.  This is the situation I am in, and I have not yet figured out if I am eligible or not.  Insurance through my work is too expensive, so I don't get it.  Insurance through the ACA is also too expensive.  I tried to sign up last minute (I know, my fault, I'm a procrastinator lol!) and of course the call center was too busy to help me, so they will call me back sometime in the next WEEK.  We'll see if I'll be able to get subsidies, or if I'll have to pay the penalty and go yet another year without insurance.

Quoting stormcris:

The pre-existing inclusion is a great thing, no doubt. However, that was the selling point. The position was that this would be affordable health care. There was supposed to be something similar to gap insurance that would take the inbetween people who could not get medicaid but were still too poor to afford the exchange without burden. However, that program requires rules that have yet to be dictated and as such is not available yet.

On a side note: Affordable is a tricky word.

For now, low-income Americans who aren't eligible for Medicaid must rely on the financial help that is available to them on the health insurance exchanges.

Determining how much that amounts to is a computational labyrinth. According to the ACA, a family of three whose annual income is at 133% of the federal poverty level (an annual income of $24,352), should have to pay no more than 3% of their household income in annual premiums, or $731. In that case, the federal government would pay the insurance company the difference between $731 and the actual premium.

The percentage an individual or family is expected to pay rises at higher income levels, up to 400% of poverty. At that income level, paying up to 9.5% of household income on health insurance is considered affordable. So, a family of three making $73,240 would receive a subsidy to cover premium amounts above $6,958.

People making between 133 and 250% of the poverty level also can get help with their out-of-pocket medical expenses, such as co-payments for visits to the doctor, providing they purchase at least a "Silver" plan on the exchange. The exchanges offer up to four different tiers of health insurance plans: "Bronze," "Silver," "Gold" and "Platinum." Bronze plans have the cheapest premiums, but leave policyholders with the highest co-payments and deductibles. Platinum plans have the highest premiums but the lowest co-pays and deductibles.

Under the Silver plans, people making more than 250% of the poverty level can expect to contribute an average of 30% for their medical costs, with their insurance company paying the rest. But those with incomes below 250% of the poverty level can get federal assistance with their out-of-pocket expenses. At 133% of the poverty level, an individual or family could contribute as little as 6% to the cost of their medical bills with the insurance company and the federal government picking up the rest.

Those cost-saving breaks, however, are only available for those selecting Silver plans, apparently to entice people away from Bronze plans with their high deductibles and co-pays.

Despite all of this assistance, health insurance still may not be "affordable" for some. Affordability, like beauty, is a matter of opinion. "What it means for something to be affordable or not affordable is totally debatable," said Sherry Glied, dean of New York University's Robert F. Wagner Graduate School of Public Service. "It isn't like there's a fixed definition of affordability."

That's particularly true in the U.S., where the cost of living varies so strikingly. "What's poor in Mississippi is different from what's poor in New York state," said Elisabeth Benjamin, an executive with the Community Service Society of New York. "People have so little disposable income in New York City and other urban areas, but the law doesn't do geographic indexing."

Using cost of living data on the Albuquerque area from the Economic Policy Institute, Kelsey Heilman, a former staff attorney with the New Mexico Center on Law and Poverty, showed that a single mother of two making 200% of the poverty level would have virtually no money left for health care premiums or health care expenses after paying for housing, food, transportation and other necessities. That mother, Heilman said, might decide to go with the cheaper Bronze plan, but then she would forgo the cost-sharing help the federal government makes available for Silver plan policyholders. As a result, she might pay as much as 40% of her medical expenses out of pocket, instead of the 13% she would have to pay with a Silver plan. That difference could amount to more than $3,000 a year.

Those who decide to forgo insurance can ask for hardship exemptions from the financial penalty. But getting medical care is likely to become increasingly difficult for them because the federal government is cutting its payments to hospitals that provide charitable care to the poor.

Other possible solutions to the affordability problem have also surfaced. Massachusetts, which enacted its own health care reforms in 2006, won federal permission to use Medicaid dollars to provide premium and cost-sharing assistance for those with incomes below 300% of the poverty level who purchased private insurance on the Massachusetts exchange. Other states could apply for permission to do the same, but it is a months-long process.

States also might seek to raise eligibility for Medicaid above the 133% threshold. Manne, with the New Mexico Center on Law and Poverty, said some businesses and hospitals have talked about voluntarily undertaking sponsorships to help those unable to pay premiums or meet out-of-pocket obligations.

But, Manne said, broad relief seems months away, if not longer. In the meantime, she predicts that policymakers will be hearing about legions of Americans who still can't afford health care—no matter the title of the Affordable Care Act.

Quoting Roxygurl: I benefit greatly from it. I am a nanny so I don't get healthcare through my employer. I've been buying my own insurance since I turned 26 and was no longer allowed to stay on my dads plan. I've watched my plan premium skyrocket while my benefits haven't changed. At one time I was paying over 300 bucks for a plan with a deductible of 5000 plus 80/20 I also found out the hard way that even though I paid my premiums faithfully every month it didn't cover things like maternity and in the state of Texas there was no way to buy a maternity rider so I had no choice but to sign up for Medicaid.....even though I had health insurance. I went to my pcp for a headache once when I was a teen thinking it was a migraine and because he prescribed me meds blue cross considered it a pre existing condition and refused to cover anything related to headaches. I also need a tonsillectomy but under the old plan I would've had to pay 5000 PLUS 20%. I signed up for a new plan under aca and although I'm paying more it covers more so I'm extremely happy. I pay 334 a month and I have a 3250 deductible but once I meet that deductible everything minus office visits and meds are covered at 100% They can not deny me maternity benefits. They can not refuse to pay for something because they deem it a pre-existing condition and now I can have the tonsillectomy and not have to worry about how I'm going to pay for it all. I also didn't sign up for a bronze plan, I believe I signed up for a silver plan and I don't think I was offered a platinum plan....I assume because of my age


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