MILWAUKEE -- Please don't use my name, the self-employed businesswoman said. Customers might worry that her business is on shaky ground if they knew her situation.
Even though she earns a solid middle-class income ranging from $60,000 to $75,000 a year -- and she likes being her own boss -- she's wondering if she'll have to find a new job.
The reason: the cost of her health insurance.
She pays $606 a month, or $7,272 a year, for her current plan. And because she must take an expensive prescription drug, she hits her out-of-pocket maximum of $5,600 each year. The total: almost $13,000 a year.
Next year, premiums for that same plan will increase to $12,204, potentially raising her total costs to almost $18,000.
"When I got my notice in September, I kind of freaked out," the woman said. "It's not just an increase, but an increase that could put me out of business."
She may have the option of buying a less expensive plan Nov. 1, when the marketplaces set up through the Affordable Care Act open. But if she goes that way, she'll be paying as much as or more than she's paying now -- for less coverage.
The situation stems in large part from a decision by President Donald Trump to stop paying insurance companies for the additional coverage they are required by law to provide to people with low incomes.
That decision also is certain to cause additional turmoil in the already fragile market for insurance sold directly to individuals and families.
That's paradoxical for two reasons:
First, it's expected to end up costing the federal government more money.
Second, the people being hurt the most are the very ones who opponents of the Affordable Care Act have cited as evidence of the law's failure.
The law expanded coverage by an estimated 20 million people and required health insurers to cover people with pre-existing health conditions. But flaws in the law's design and implementation sharply increased premiums for many people who are not eligible for federal subsidies.
They are people solidly in the middle class, many of them self-employed, who have incomes above $48,240 for an individual and $98,400 for a family of four this year.
Most states have put in place a workaround that will lessen the effect of the Trump administration's decision. But those folks still will take a hit.
People who receive federal subsidies, in the form of tax credits, will be shielded from the increases. That's because what they have to pay for health insurance is capped at a percentage of their income, ranging from 2.04 percent to 9.69 percent this year.
Trying to explain all this, though, is making life difficult for insurance agents and brokers.
"Repeated, unpleasant conversations" is how Corrine Bultman of Bultman Financial Services in suburban Milwaukee characterized it.
One client, a 61-year-old lawyer, was paying $974 a month, or $11,688 a year, for a plan with a $3,000 deductible. He got a renewal letter from Common Ground Healthcare Cooperative that the premium next year would be $1,608 a month, or $19,296 a year -- and that's for single coverage.
"It's a horrible conversation to have with a client," Bultman said.
She expects him and most people to move to health plans in the so-called bronze tier, which will have much lower increases in their up-front premiums but less coverage with higher deductibles.
"It didn't have to happen," Bultman said.
Here's what happened:
The Affordable Care Act requires health insurers to provide additional coverage to offset deductibles and other out-of-pocket expenses for people with low incomes -- less than $30,150 for an individual this year.
The law did not clearly appropriate money for the subsidies, and congressional Republicans sued the Obama administration, contending that Congress must fund the subsidies each year. They prevailed, but the court order was stayed pending appeal.
Congress hasn't funded the subsidies, and the Trump administration announced this month that it would stop paying them.
The only way that insurance companies -- which, again, must provide the additional coverage by law -- can offset the cost of the subsidies is by raising rates.
The Wisconsin Office of the Commissioner of Insurance and its counterparts in most states put in a place a partial solution.
Here's how it works:
State regulators allowed health insurers to allocate the costs of providing the additional coverage to people with low incomes to health plans sold in the "silver" tier.
That lessens the rate increases for health plans sold in the lower-cost "bronze" tier, with its higher deductibles, and the top-of-the-line "gold" tiers, which have lower deductibles.
Some people eligible for a subsidy may even be able to get better coverage for less money or get coverage for free. That's because the subsidy, or tax credit, is pegged to the second-lowest-cost plan in the silver tier but can be used to buy a bronze or gold plan.
Adding to the confusion, Molina Healthcare, which had the most customers in the state's marketplaces, and Anthem Blue Cross and Blue Shield are pulling out of the ACA market in Wisconsin.
For most people not eligible for subsidies, the only realistic option will be to buy a plan in the bronze tier.
One exception is Security Health Plan, an affiliate of Marshfield Clinic, which is offering the equivalent of a silver plan outside the marketplaces set up through the Affordable Care Act.
The plan, which doesn't include the cost of providing the additional coverage for people with low income, will be an option for the roughly 1,000 people not eligible for subsidies who are covered by Security Health silver plans this year, said Marty Anderson, chief marketing officer of the company.
Others are in for a shock.
In the Green Bay area the cost of a silver plan is doubling, for example, and Common Ground Healthcare is the only insurer in the market.
Todd Catlin of Transition Health Benefits in suburban Milwaukee has a self-employed client with four children in the Green Bay area. He now pays $1,240 a month, or $14,880 a year, for family coverage. The same coverage next year will cost $2,600 a month, or $31,200 a year, and that doesn't include the deductible.
"When you talk about those numbers, it's ridiculous," Catlin said.
But Common Ground Healthcare, he said, is in a box.
"I don't blame them at all," Catlin said.
The costs of health plans also are increasing because of the turmoil and uncertainty in the market.
One concern is that healthy people who have heard of the rate increase will opt not to buy health insurance, said Cathy Mahaffey, chief executive officer of Common Ground Healthcare.
They are needed to offset the cost of people with health problems.
Another concern is that the Trump administration will not enforce the penalty that people must pay for not having health insurance -- and those most likely to go without insurance are young and healthy.
Common Ground Healthcare also doesn't know anything about the thousands of new customers it will pick up because of Molina leaving the market.
"We have to price our plans accordingly to account for all the risk factors," Mahaffey said.
Wisconsin in some ways is lucky given the number of health insurers that remain in the market. That's because the remaining insurers, with the exception of Common Ground Healthcare, are owned by nonprofit health systems.
The Milwaukee market, for example, will have three insurers in its ACA marketplace for 2018: Common Ground Healthcare, Network Health, owned by Ascension Wisconsin and Froedtert Health, and Children's Community Health Plan, owned by Children's Hospital of Wisconsin.
Their nonprofit status, though, hasn't lessened their frustration.
"It's maddening to me," said Coreen Dicus-Johnson, president and chief executive officer of Network Health.
Adding to the frustration is the talking point of Trump and other opponents of the Affordable Care Act that funding subsidies for people with low incomes would be a "bailout" of the insurance companies.
The contention, Dicus-Johnson said, is an "absolute mischaracterization."
By law, insurers are required to provide the additional coverage.
Yet earlier this month, Trump tweeted: "I can never support bailing out ins co's who have made a fortune w/ O'Care."
Health insurers have lost billions of dollars on the health plans sold on the Obamacare marketplaces. The Office of the Commissioner of Insurance estimates that insurers in Wisconsin alone have lost $400 million.
For that matter, if insurers have made a fortune on Obamacare, why have many of them abandoned the market?
National organizations, such as the American Hospital Association and the American Medical Association, state organizations, such as the Wisconsin Hospital Association and Wisconsin Medical Society, and individual health systems have all called on Congress to fund the subsidies.
Even if Congress does eventually do that, though, it is too late to affect rates for next year.
"The Affordable Care Act was imperfect, but everyone knew that," said Linsey Sieger, a self-employed graphic designer. "It is better than what we had before. So why not put all our resources into addressing what's wrong with it?"
Sieger, whose firm is called Third Sector Creative, has been self-employed since 2005. Her premiums have increased under the Affordable Care Act. But for her, the additional cost was worth the trade-off of not having to worry about pre-existing conditions or the fine print in an insurance policy.
Her son was born prematurely and she understands the value of health insurance.
"It can completely wipe you out if you don't have insurance," Sieger said.
She knows that she is going to have to change insurers and buy a health plan in the bronze tier for 2018. She's prepared for that. But she also is tired of the political gamesmanship that's threatening American entrepreneurship.
"In American culture, there is this alleged value for striking out on your own, pursuing your own dreams," Sieger said. "Yet your health insurance is tied to employment."
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