I knew everything about the ACA, lost my insurance, and got sick

Become a Patron!Since I've been self-employed almost as long as the Affordable Care Act has been law, I've had lots of opportunities to learn the finer points of the law. At its best, the ACA works as the gentlest possible nudge for folks who rely on employer-provided health insurance to start their own businesses, knowing they'll have access to affordable, comprehensive health insurance, without exclusions for pre-existing conditions.In the past I've written about triggering "special enrollment periods" by moving to a different zip code. In Wisconsin, which under Scott Walker refused to expand Medicaid, I paid $0.12 per month in premiums for a Silver plan with no co-pays or deductibles.The District of Columbia has what I call "Super Medicaid," which covers adults earning up to 233% of the federal poverty line, far higher even than in other Medicaid expansion states. Enrolling was a bit of a hassle, but after harassing them on Twitter about their terrible IT, I was eventually enrolled and received my insurance card in the mail a few days later.Besides a couple of teeth cleanings, I never used my insurance, but knowing I was insured meant I knew an accident, injury or illness wouldn't bankrupt me. Since it's Medicaid, it wouldn't even cost me anything.

I lost my insurance — 6 months ago

At the beginning of the year we all receive a slew of tax documents. At a minimum we expect W-2's for wage income, 1099's for interest, dividend, and miscellaneous payments, and health insurance verification documents to prove we were insured the entire preceding year.Imagine my surprise when, a few weeks ago, I received my health insurance verification document from DC and the little black X's abruptly stopped in July. I'd been uninsured for the last 6 months and no one had told me.After some research, I eventually started to piece together what had happened. Like most states, the ACA is administered in DC through two separate programs, the "ACA (or Obamacare) exchanges," which we call "DC Health Link," and Medicaid, which we call "DC Healthy Families." I was enrolled in Medicaid — DC Health Families. But since I had started my enrollment — all the way back in 2016 — through DC Health Link, my renewal material was being sent to that website, instead of to the Medicaid website. Since I wasn't enrolled in an exchange health plan, I never logged into that site, and never got the renewal notification. Since I never completed the renewal application, my insurance was cancelled, and the notification of that was also sent to the DC Health Link website — again, a site I have not used since August, 2016.

Enrolling again was easy

Fortunately, since I know how the law works, it wasn't a big deal to complete another application. Since I'm earning a bit more these days, and in order to avoid this mayhem in the future, I decided to enroll in an exchange plan this time, estimated my income at the level to maximize the possible subsidy, and selected a plan for coverage to begin March 1. I'd still rather be on Medicaid, but private coverage won't be the end of the world, and it might get me into a better hospital if something serious happens to me.

Then I got sick. Then I got sicker.

About three weeks ago I started to develop a pretty unpleasant cough. It wasn't horrible, but it was certainly annoying. I started warning people on the phone that I might have to go on mute if I had a particular nasty fit. It would come and go, I tried to stay hydrated, drank a little Robitussin here and there to see if I could bring up whatever was irritating my lungs.Then it started keeping my partner up at night. I thought as long as I felt fine, and it was just a cough, it would have to clear up eventually. I promised I'd go to the doctor as soon as my insurance kicked in on March 1.Then it started keeping me up at night. I couldn't sleep for more than a few hours without waking up trying to cough up something I couldn't cough up. I couldn't sleep at night and I was useless during the day.And on Wednesday, something finally clicked. I didn't "have a cough," I was sick. I knew I needed medical care. But where on Earth was I going to get it? I don't have insurance, I don't have money, and I didn't know what the hell I'd contracted. I (half-) jokingly started praying it was coronavirus so the National Guard would quarantine me and treat me for free.So, like any right-thinking millennial, I started Googling free health clinics.

There are no free health clinics in DC

My mom volunteers at a couple of free health clinics, and my brother runs a network of community health centers, so I had vaguely assumed in a large, diverse, working-class city like DC there would be 20-30 walk-in clinics around town and I just needed to find which ones were open on Wednesday mornings. I knew I'd be waiting around for a few hours, but since my body was rapidly shutting down, I figured I didn't have anything better to do.It turns out, there are no free walk-in clinics in DC (or if there are, they keep a pretty low profile). This is partly a consequence of how successful Medicaid expansion has been: since all low-income people are covered by Medicaid, and all high-income people are covered by exchange plans or their employers, there are relatively few uninsured people in the District.I just happened to be one of them.

So I went and stole some healthcare

My mom has always told fond stories about living in DC and working at the Columbia Road Health Services clinic, which was a Christian mission attached to the nearby Potter's House and Christ House. The clinic now belongs to a big health insurance chain, but since it's just down the street, I thought I'd try my luck. I walked in, said I was sick, and asked if they could help me.As it turned out, they took really good care of me. It's not "fun" seeing a doctor, but they took my vitals, listened to my chest, listened to me describe my symptoms, gave me something called "breathing therapy" (not highly recommended) and diagnosed me with "community-acquired pneumonia." The doctor called in a prescription for antibiotics and gave me a "GoodRx" discount card (I ended up paying $17 for a five-day supply at the CVS down the street).Then I walked out of the clinic. They didn't ask for money and I didn't offer.

Interlude: "Walking Pneumonia"

In September, 2016, there was a brief round of news coverage when Hillary Clinton had to be helped into her vehicle after attending a memorial service at Ground Zero. She was later diagnosed with pneumonia; she had simply continued to campaign until she was finally sidelined by it for a few days.This almost exactly mirrors my own experience. I kept working for the last few weeks through a "nasty cough" until the moment when it clicked for me that I needed help. And at that moment, it was inescapable.I realized the real issue was giving myself "permission to be sick." It's a funny way to describe the feeling, since obviously most people don't want to be sick — why would they give themselves permission to feel bad? But the second I acknowledged I was really sick, I realized I wasn't "just coughing." My body hurt, my head hurt, I was sweating and freezing, and I was exhausted. Basically, once I gave myself permission to be sick, I finally started putting myself in a position to recover (the drugs helped).

What's next?

I'm a bit curious about this myself. I assume eventually the clinic is going to send me a bill, but since healthcare prices are completely imaginary, I simply have no way of guessing how much it's going to be: $200 or $10,000?Besides the obvious (money is expensive), one reason it's relevant is that Medicaid allows retroactive coverage for medical expenses up to 3 months before enrollment. That means if I can manipulate my income sufficiently, I could apply for Medicaid once I get the bill and have them cover the expense "as if" I were insured when I received treatment. That would be exceptionally annoying since I just completed my ACA exchange enrollment, but it's one option.Another option is simply declaring bankruptcy in order to discharge the medical bill. Financially speaking this wouldn't be a big problem since virtually all my assets are in retirement accounts that are protected in bankruptcy, but it would obviously be a big inconvenience, if for no other reason than that I earn a lot of rewards with my credit cards, which would presumably be closed after a bankruptcy filing.

Conclusion: Medicaid for All

The Affordable Care Act was a remarkable achievement in a country that has given up on remarkable achievements: it virtually eliminated uninsurance among low-income people in Medicaid-expansion states (and would have eliminated it entirely if not for the Supreme Court's intervention); it gave entrepreneurs and sole proprietors access, for the first time, to affordable comprehensive health insurance; and it provided important guarantees of care to workers covered by employer-provided insurance (guarantees that would be even more valuable if the Supreme Court hadn't proceeded to undermine them).But the fact is, despite knowing every nook and cranny of the law, the ACA left cracks big enough for even me to fall through. The law has provisions for people who earn more money to transition from Medicaid to the exchanges. It has provisions for people who earn less money to transition from the exchanges to Medicaid. But it has no provisions for someone unknowingly disenrolled from Medicaid, who enrolls in an exchange plan, and needs medical care in the intervening 20 days. How could it?The answer, the next step, has always been as simple and obvious as it sounds: Medicaid for All. No premiums, no deductibles, no co-pays. No retroactive enrollment, no prospective enrollment, no income verification, no residence verification, just Medicaid. For. All.Become a Patron!

Regulatory uncertainty, business confidence, and entrepreneurship

The driving force behind this site is promoting a culture of entrepreneurs and entrepreneurship.As I like to say: not everyone should be an entrepreneur because not everyone wants to be an entrepreneur, but a lot more people should be entrepreneurs than are currently entrepreneurs, and I'm here to do a little hand-holding along the way.On Tuesday night, I was thrilled to see Democrats win back the House of Representatives, and tweeted "If you like your comprehensive affordable health insurance, you can keep your comprehensive affordable health insurance (for 2 more years)." In fact, the title of this blog post was going to be, "you have two more years to start a business and receive affordable, comprehensive health insurance."And then I remembered, isn't there still a Republican lawsuit trying to destroy the Affordable Care Act? There sure is!

Does regulatory uncertainty matter or not, and why?

There has, historically, been a straightforward argument made by business-oriented politicians on both sides of the aisle: private enterprise is discouraged when people are unable to make reliable predictions about the future.Of course, nothing is entirely predictable (ask the dwindling number of stable owners in New York City), but a steady policy hand is best suited to encourage the private sector to put its capital to work in an inherently risky world, and constant policy gyrations scare off anyone trying to make long-term plans. You can find this argument deployed whenever a city tries to raise the minimum wage, enact fair scheduling laws, or provide paid family leave to employees.But today, the Republican Party has adopted a completely different view towards business formation. Entrepreneurs are extended health insurance one year at a time and one (shrinking) open enrollment period at a time, while a legal effort is coordinated across the country to make sure that this is the last year they'll have access to affordable, comprehensive health insurance. Or if not this year, next year. Or if not next year, the following.How could anyone make plans under these conditions? How could anyone start a business? How could anyone start a family?

We only see the businesses that are created

In the finance industry one of the most important red flags to watch for is "survivorship bias." In the most flagrant cases, a mutual fund company might only report the 10-year performance of its funds that are still operating after 10 years, concealing the lackluster results of all the funds that have already been closed due to underperformance.The decade-long sabotage of the Affordable Care Act has left us with a version of the same problem. We see all the businesses that have been created by entrepreneurs who have had the confidence to strike out on their own, knowing they'll have access to affordable comprehensive health insurance whether they succeed or fail, but we don't see the businesses that would have been formed if the entire country hadn't been subjected to the Republican deluge of lawsuits, appeals, and legislative attempts to strip that protection from entrepreneurs.

Even employees should root for entrepreneurs

When I write about this problem there's always a commenter or two who insists that it's actually good that only young, healthy single men start businesses, and that the old, the sick, the pregnant, or the female should just keep working at their jobs and forget about entrepreneurship. So let me make a case to the employees, as well.You don't have to ever start a business to benefit from other folks starting businesses.Maybe you'll be a customer: if one of your coworkers quits to start a secondhand jewelry store, maybe you'll buy some jewelry from her.Maybe you'll be an employee: if the jewelry store gets successful enough, your former coworker might hire you away.And even if you never see your former coworker again, maybe you'll be able to extract a raise from your employer sooner if they see your coworkers leaving to strike out on their own.

Conclusion

The media sometimes has a deliberately blinkered view of private enterprise. The so-called "small businesses" you sometimes see interviews with are inevitably Midwestern jet-ski dealerships or insurance salesmen with dozens of employees, while the "entrepreneurs" are Silicon Valley startups with millions in venture capital.But those cliches are not what entrepreneurship has ever really looked like. Entrepreneurs are mostly just normal people trying to make a little more money than they spend, day in and day out. Some of them succeed spectacularly and some of them fail miserably, but in a world without universal access to affordable, comprehensive health insurance, we're never going to have the opportunity to find out what we're missing.

The rhetorical confusion between the administrative and regulatory states

On the occasion of a new Federalist Society nominee to the Supreme Court, I thought it'd be worth explaining a set of issues that are going to repeatedly come before the Court in the coming decades, and explain a confusing set of terms that arises from those issues.

The "Administrative" Procedure Act is about regulation, not administration

The Administrative Procedure Act lays out the rules executive agencies have to follow when creating new, legally binding regulations. So, for example, Congress might pass a law saying the EPA has to regulate pollution of the air and water, and to create corresponding regulations. The Administrative Procedure Act sets the rules by which the EPA is allowed to create those rules.This is, manifestly, a terrible way to run a regulatory state. The EPA has to pretend to collect "input" from anyone and everyone, then they have to pretend to judge the input, then they get to enact the regulation they wanted to enact in the first place.Then the people affected by the regulation get to sue and spend years working their way through the courts arguing that the EPA didn't properly take their input into consideration, or that Congress didn't have the EPA's regulation in mind when they passed the law, or that the head of the EPA wasn't properly confirmed by the Senate, or whatever else the Federalist Society comes up with next week.

Congress ought to pass more, better laws

The Administrative Procedure Act has let Congress off the hook for decades. For example, the entire legal doctrine of sexual harassment has arisen from one sentence in Title VII of the Civil Rights Act of 1964. Instead of passing additional laws specifying what kind of behavior constitutes sexual harassment and what the consequences of it should be, Congress has been happy to let the courts and the Justice Department wander all over the place, interpreting the law however they please.But we know there's a better way. When the Supreme Court threw out Lilly Ledbetter's sex discrimination claim, Nancy Pelosi led Congress in passing the Lilly Ledbetter Fair Pay Act that simply spelled out the legal framework Congress had in mind for assessing sex discrimination claims. If a future Congress wants to assess sex discrimination claims differently, they can pass another law, but it's no longer up to the Department of Labor or the Supreme Court to fantasize about Congress's intentions.

We (still) need a well-functioning administrative state

This brings me to the rhetorical confusion I mentioned above: the Administrative Procedure Act is bad, and in my opinion should simply be repealed, but a regulatory state that is explicitly designed and endorsed by Congress will still require administration.If, instead of the EPA, in consultation with scientists, activists, and lead manufacturers, determining the level of lead that's acceptable in municipal drinking water, Congress determines and sets into law the level of lead that's acceptable in municipal drinking water, people will still have to be employed to administer the law: they'll have to take testing equipment out to Flint, fill up some test tubes, run some tests, and report whether Flint is in compliance or not.Likewise, the so-called "carried interest loophole" is not a product of any congressional action, it's the product of the IRS's interpretation of certain terms within the laws passed by Congress. But even if Congress finally passed a law specifying whether hedge fund management fees should, or should not, be treated as capital gains, the law would still have to be administered by an army of auditors swarming across the nation's hedge funds making sure they complied.

Don't leave it up to the judges

In college I fenced in the foil weapon category, which leaves a lot of discretion to referees. They're asked to determine, in real time, who initiated an offensive action, where on the weapon a defensive move lands, and whether a counteroffensive move is a riposte or a counter-attack. This, naturally, leads to a lot of hurt feelings when you feel the judges don't give your efforts enough credit.But my coach, an ornery old Russian lady, never let me mope about the judges. She told me, "don't leave it up to them." If you leave it up to the judges, you may as well be flipping a coin. If you want to win, make sure there's nothing left for the judges to decide.

The worst equilibrium is a dysfunctional Congress and an amateur judiciary

In the Supreme Court's 2012 hearing over the constitutionality of the Affordable Care Act's individual mandate, the original amateur justice, Antonin Scalia, drew laughs from the usually staid audience when he suggested that Congress should simply pass another law fixing the defects in the original Act.Of course, at that point Republicans had taken control of the House of Representatives, so striking down the Affordable Care Act would have meant another generation of Americans without access to affordable health care.That is, of course, the situation we're being set up for today: a Congress that is so deeply gerrymandered that it's incapable of representing the popular will, and a Supreme Court that stands ready to strike down any legislation that is able to pass through Congress.You don't need to be a Democrat, or a liberal, or a leftist, to appreciate that a country congenitally unable to pass laws governing itself, that turns itself over to executive agencies and then resigns itself to years or decades of court battles over the slightest minutiae of statecraft, is not a country well-suited to addressing the challenges of this or any other century.

It's not too late to enroll in health insurance

As an independent businessperson, I've been enrolled in health insurance through the Affordable Care Act practically since it went into effect. Due to an unprecedented buildup of bile, the current administration radically shortened the open enrollment period for plans offered on the ACA marketplaces, which will lead to somewhat fewer people enrolling in time for their coverage to begin January 1, 2018, despite an accelerated pace of enrollment during the shortened open enrollment period.So, this being the last day of the open enrollment period, I wanted to give a quick, practical breakdown of all the options available.

Enroll today

If you're self-employed or don't get qualifying health insurance through your employer, then head to healthcare.gov right now and submit an application. If you estimate your 2018 income between 138% and 250% of the federal poverty line, you'll likely be best off choosing a Silver plan, so you can take advantage of cost-sharing reductions. If your estimated income is up to 400% of the federal poverty level, you'll still be eligible for a (decreasing) amount of advance premium subsidies.Note that despite the current administration's refusal to pay the cost-sharing reduction subsidies to insurance companies in a timely manner, the insurance companies themselves are still forced to honor them.If you think you're unlikely to use non-preventive medical services during 2018, another option is to use a premium subsidy to purchase a Bronze plan. Such plans don't qualify for cost-sharing reductions, but still provide the preventative services offered by all ACA-compliant plans.

Enroll later

For most people, most of the time, the open enrollment period is the appropriate time to sign up for health insurance coverage for the following year. However, there are a range of exceptions which allow people to signup for ACA-compliant health insurance throughout the year.Besides getting married or having children, the easiest exceptions to the open enrollment period are changes in residence. From healthcare.gov, such changes include:

• Moving to a new home in a new ZIP code or county
• Moving to the U.S. from a foreign country or United States territory
• A student moving to or from the place they attend school
• A seasonal worker moving to or from the place they both live and work
• Moving to or from a shelter or other transitional housing

While it may sound strange — and it is strange — to move your residence to a new ZIP code in order to trigger a special health insurance enrollment period, the reason it's strange is because we don't offer our citizens universal, comprehensive, affordable health insurance coverage.

Enroll in Medicaid

If you live in a Medicaid expansion state, you can enroll in Medicaid at any time if your income is or drops below the Medicaid eligibility threshold. That's usually 138% of the federal poverty level, although Medicaid enrollment is administered by the states so enrolling can be as easy or hard as your state chooses to make it.

Conclusion

Health insurance isn't about staying healthy. If you want to stay healthy, you should eat mostly vegetables, cooked mostly in olive oil (not too hot though!), get a moderate amount of exercise, and pray.Enrolling in health insurance is about paying for all the things that lightly sautéed vegetables and cross-country skiing won't prevent. So get covered — or at least have a plan to get covered.If you end up needing medical care, you'll thank me then. If you don't end up needing medical care, I'll thank you. Do we have a deal?