Second Opinion: Does Obamacare Give Employees More Choice Over Coverage?

Second Opinion: Does Obamacare Give Employees More Choice Over Coverage?

Photo by Megan Burks

Scripps Ranch health care advocate Sylvia Hampton says the Affordable Care Act won't help her friend, who doesn't like his employer's insurance options.

Second Opinion is a weekly Q-and-A series that answers questions from San Diegans on the Affordable Care Act. Ask yours here.

The Question: What is an employer’s responsibility if one of its workers opts out of its group plan?

Sylvia Hampton is an advocate. She was entered into the San Diego Women’s Hall of Fame in 2008 for her work protecting women’s rights. She’s a member of the League of Women Voters. And she pushes for improved access to health care through San Diegans for Health Care Coverage, a nonpartisan coalition of nonprofits, businesses and health care providers.

This week, she’s advocating for a friend. Her Second Opinion question is really for him.

He recently switched jobs and his new company doesn’t offer coverage through his preferred provider, Kaiser. It says his only option is to leave his Kaiser doctor and find a new one through the company plan.

Video by Megan Burks

Here’s Hampton’s question:

“They are consumers who want to keep their doctor. And the employer is saying, ‘Sure, keep your doctor, keep Kaiser, but we’re not going to pay for it.’ What is the responsibility of the employer to pay that share, or the normal share of the cost that they would pay for another employee who is going on the plan that they have contracted?”

Hampton called the situation “unfair,” especially for people undergoing a special course of treatment or who have a chronic illness.

“These are problems we’ve had all along with health care. It’s one of the reasons we needed reform,” Hampton said. “But this is an area where reform is not happening for the consumer the way it should.”

The Takeaway: Choices are limited for individuals with access to employer-based plans.

Under the Affordable Care Act, a large employer’s responsibilities start and stop when it offers affordable coverage.

feature_inline-second_opinion500The law defines that as plans with premiums falling within 9.5 percent of an individual’s income and covering at least 60 percent of his or her medical expenses.

The company is not obligated to offer a stipend if its employees seek coverage elsewhere, nor will it be fined by the federal government, said Linda Keller, the executive vice president of San Diego-based insurance brokerage Intercare.

And if the employees go on to the state’s insurance market, Covered California, to shop for alternative coverage, they will not qualify for subsidies. Covered California doesn’t offer premium assistance to people who have affordable coverage options elsewhere – whether it’s through work, Medi-Cal or Medicare.

The Orders: Start looking for a new doctor.

The subsidy rule for people with access to a group plan doesn’t mean they can’t buy a plan through Covered California. But it means they’ll be paying the full premium without help from the federal government or an employer.

Check out last week’s Second Opinion: Does Obamacare reduce costs for people with pre-existing conditions?

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Megan Burks

Megan Burks

Megan Burks is a reporter for Speak City Heights, a media project of Voice of San Diego, KPBS, Media Arts Center and The AjA Project. You can contact her directly at meburks@kpbs.org or 619.550.5665.

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37 comments
BVBailey
BVBailey

To my knowledge, depending on the size of the employer, insurance companies often require a certain level of participation in the selected plan and the employer may not have the option to offer a choice to employees even if they'd like to. Wouldn't some employers have to abandon their existing (and possibly superior) plans completely and use the ACA exchanges in order to offer a "choice" to some employees?

BVBailey
BVBailey subscribermember

To my knowledge, depending on the size of the employer, insurance companies often require a certain level of participation in the selected plan and the employer may not have the option to offer a choice to employees even if they'd like to. Wouldn't some employers have to abandon their existing (and possibly superior) plans completely and use the ACA exchanges in order to offer a "choice" to some employees?

Carrie Schneider
Carrie Schneider

This same thing happened to me a few years ago. I lost Kaiser and my doctors because of a change in employment. If this happens to you, call and make an appointment with a new doctor asap. It took me a couple months to get an appointment as a new patient.

Carrie Schneider
Carrie Schneider subscribermember

This same thing happened to me a few years ago. I lost Kaiser and my doctors because of a change in employment. If this happens to you, call and make an appointment with a new doctor asap. It took me a couple months to get an appointment as a new patient.

amy roth
amy roth

Did any of you read the Daily Beast piece entitled, "I laughed at Boehner until the mail came" (or words to that effect.)

amy roth
amy roth subscribermember

Did any of you read the Daily Beast piece entitled, "I laughed at Boehner until the mail came" (or words to that effect.)

Don Blucher
Don Blucher

The only thing Obummercare gives is more choices of crummy, higher cost insurance that most doctors won't want to accept without governmental arm-twisting. People will have insurance coverage, but no doctors available to accept it.

Don Blucher
Don Blucher subscriber

The only thing Obummercare gives is more choices of crummy, higher cost insurance that most doctors won't want to accept without governmental arm-twisting. People will have insurance coverage, but no doctors available to accept it.

Mark Giffin
Mark Giffin

Companies will tend to make the decisions on finances for the most part.. If it is less expensive to pay the fine, switch employees to part time or to provide coverage on a different plan to save money. Employee retention will play a role but will not be the over riding criteria. If people want to keep their existing coverage they will have to pony up and pay for it.

Mark Giffin
Mark Giffin subscribermember

Companies will tend to make the decisions on finances for the most part.. If it is less expensive to pay the fine, switch employees to part time or to provide coverage on a different plan to save money. Employee retention will play a role but will not be the over riding criteria. If people want to keep their existing coverage they will have to pony up and pay for it.

Chris Brewster
Chris Brewster

The intent of the Affordable Care Act was to cover those who were not covered under good quality employer provided plans and to improve aspects of all plans such that they include free preventive care and caps on out of pocket fees. The situation described may seem like a continuation of the status quo, but an option for this employee might be to try to negotiate with the employer. That is, for example, to propose receiving 2/3 of the cost of the employer provided plan and then to self-insure using those funds. It may or may not work, but it might be worth a try if greater choice is particularly important. The employee might also contact their Congressional representative and propose that Congress amend the law. (OK, I'm kidding.)

Chris Brewster
Chris Brewster subscribermember

The intent of the Affordable Care Act was to cover those who were not covered under good quality employer provided plans and to improve aspects of all plans such that they include free preventive care and caps on out of pocket fees. The situation described may seem like a continuation of the status quo, but an option for this employee might be to try to negotiate with the employer. That is, for example, to propose receiving 2/3 of the cost of the employer provided plan and then to self-insure using those funds. It may or may not work, but it might be worth a try if greater choice is particularly important. The employee might also contact their Congressional representative and propose that Congress amend the law. (OK, I'm kidding.)

Chris Brewster
Chris Brewster

This is actually from a San Jose Mercury News article, aspects of which have been cherry picked by various conservative news sites. Reading the entire article provides some further perspective. The article does not indicate whether the writer independently verified the increases claimed by the subjects of the article.Obamacare's winners and losers in Bay Areahttp://www.mercurynews.com/nation-world/ci_24248486/obamacares-winners-and-losers-bay-areaPosted: 10/05/2013 04:52:50 PM PDT Updated: 10/07/2013 12:37:59 PM PDT Click photo to enlarge Cindy Vinson and Tom Waschura are big believers in the Affordable Care Act. They vote independent and are proud to say they helped elect and re-elect Presid...

Chris Brewster
Chris Brewster subscribermember

This is actually from a San Jose Mercury News article, aspects of which have been cherry picked by various conservative news sites. Reading the entire article provides some further perspective. The article does not indicate whether the writer independently verified the increases claimed by the subjects of the article.Obamacare's winners and losers in Bay Areahttp://www.mercurynews.com/nation-world/ci_24248486/obamacares-winners-and-losers-bay-areaPosted: 10/05/2013 04:52:50 PM PDT Updated: 10/07/2013 12:37:59 PM PDT Click photo to enlarge Cindy Vinson and Tom Waschura are big believers in the Affordable Care Act. They vote independent and are proud to say they helped elect and re-elect Presid...

Chris Brewster
Chris Brewster

Mr. Blucher: Let's not speak in extremis. I do not advocate efforts to legislate perfect equality to all members of our society or the human race as a whole. The concept of this legislation is to make health insurance available and affordable to everyone. Whether it will ultimately accomplish that remains to be seen. In any case, there remain myriad levels of coverage available through employers, on the private market, and through the exchanges.

Chris Brewster
Chris Brewster

Mr. Jones: You said, "I call BS on that one." Not possible to have a considered debate if you presume the other person is a liar. There was, indeed, insurance for people with preexisting conditions in California, but the numbers they accepted were limited. Regarding your statement that, "You want preexising conditions not to be an issue? That's a 5 page law, not obamacare." If insurance companies are prohibited from refusing people with preexisting conditions, then they would likely go bankrupt, as people might wait until they need it to get insurance, which defies the very concept. It's why mandating health insurance is necessary to economically avoid denial of insurance. Finally, I am not suggesting outlawing medical bankruptcy. What I am pointing out is that people have been forced into bankruptcy for medical reasons because of no caps on out of pocket spending. That won't happen anymore I would expect.

Chris Brewster
Chris Brewster

Mr. Jones: One of my closest friends was completely unable to purchase health insurance in California due to, no kidding, a history of cystic acne. My sister in law, a doctor, was unable to purchase health insurance in another state due to a prior bout with cancer. It wasn't an issue of cost. It was an issue of no. As for caps, insurance companies in many cases used to have lifetime caps of $1 million or similar. That is unaffordable for all but the most affluent. A cap of $12,000 is a very, very different situation. Whether this program is a disaster or not is arguable. There seem to be few moderate opinions. Aspects of the program though, like being able to insure kids up to 25 on your plan are factual. These are benefits that need to be considered in discussions about any detriments. The bottom line from my perspective is that the system previously locked some people out of insurance and exposed many to unbelievably high costs if they were unlucky enough to contract an expensive disease. That won't happen anymore. Are those benefits worth some of the trade-offs? That depends on whom you talk to. As for the Forbes piece, it's basically an interesting opinion piece wherein the author postulates the noted increase over an eight year period. (The headline makes it seem like this is in a one year period.) Others say he's blowing smoke.

Chris Brewster
Chris Brewster

Apparently, Mr. Blucher, you don't know anyone who has been unable to purchase insurance due to a pre-existing condition; or anyone who has been bankrupted by a health condition. Regardless of what you think of the rest of it, that won't happen anymore.

Chris Brewster
Chris Brewster subscribermember

Mr. Blucher: Let's not speak in extremis. I do not advocate efforts to legislate perfect equality to all members of our society or the human race as a whole. The concept of this legislation is to make health insurance available and affordable to everyone. Whether it will ultimately accomplish that remains to be seen. In any case, there remain myriad levels of coverage available through employers, on the private market, and through the exchanges.

Chris Brewster
Chris Brewster subscribermember

Mr. Jones: You said, "I call BS on that one." Not possible to have a considered debate if you presume the other person is a liar. There was, indeed, insurance for people with preexisting conditions in California, but the numbers they accepted were limited. Regarding your statement that, "You want preexising conditions not to be an issue? That's a 5 page law, not obamacare." If insurance companies are prohibited from refusing people with preexisting conditions, then they would likely go bankrupt, as people might wait until they need it to get insurance, which defies the very concept. It's why mandating health insurance is necessary to economically avoid denial of insurance. Finally, I am not suggesting outlawing medical bankruptcy. What I am pointing out is that people have been forced into bankruptcy for medical reasons because of no caps on out of pocket spending. That won't happen anymore I would expect.

Chris Brewster
Chris Brewster subscribermember

Mr. Jones: One of my closest friends was completely unable to purchase health insurance in California due to, no kidding, a history of cystic acne. My sister in law, a doctor, was unable to purchase health insurance in another state due to a prior bout with cancer. It wasn't an issue of cost. It was an issue of no. As for caps, insurance companies in many cases used to have lifetime caps of $1 million or similar. That is unaffordable for all but the most affluent. A cap of $12,000 is a very, very different situation. Whether this program is a disaster or not is arguable. There seem to be few moderate opinions. Aspects of the program though, like being able to insure kids up to 25 on your plan are factual. These are benefits that need to be considered in discussions about any detriments. The bottom line from my perspective is that the system previously locked some people out of insurance and exposed many to unbelievably high costs if they were unlucky enough to contract an expensive disease. That won't happen anymore. Are those benefits worth some of the trade-offs? That depends on whom you talk to. As for the Forbes piece, it's basically an interesting opinion piece wherein the author postulates the noted increase over an eight year period. (The headline makes it seem like this is in a one year period.) Others say he's blowing smoke.

Chris Brewster
Chris Brewster subscribermember

Apparently, Mr. Blucher, you don't know anyone who has been unable to purchase insurance due to a pre-existing condition; or anyone who has been bankrupted by a health condition. Regardless of what you think of the rest of it, that won't happen anymore.

Chris Brewster
Chris Brewster

Mr. Giffin: I don't think that responds to the issue at hand. She's referring to a situation that was long-standing and doesn't seem to have been affected one way or another by the new law.

Chris Brewster
Chris Brewster subscribermember

Mr. Giffin: I don't think that responds to the issue at hand. She's referring to a situation that was long-standing and doesn't seem to have been affected one way or another by the new law.

gcabrahm
gcabrahm

I think much was done through ACA to cut the costs of delivering care, eventually. Exchanges should serve as a catalyst to change the way health insurance is purchased. In the longer term, they will transform the entire health care system. http://www.forbes.com/sites/robertpearl/2013/10/01/4-ways-new-exchanges-will-radically-alter-health-insurance/4 Ways New Exchanges Will Radically Alter Health Insurancehttp://www.forbes.com/sites/robertpearl/2013/10/01/4-ways-new-exchanges-will-radically-alter-health-insurance/When the next phase of the Affordable Care Act (ACA) kicks into gear January 1, 2014, each state will be required to offer its residents access to health care insurance through an online marketplace, often referred to as a "health insurance exchange....

Bill Bradshaw
Bill Bradshaw

Congratulations, Mr. Brewster. You didn't include in your description of the "intent" of ACA that it was supposed to cut health care costs, a claim the president repeatedly made that was patently ridiculous on it's face. In fact, he now claims it's already saving the country money. Some individuals will certainly benefit mightily from this plan, particularly the old with serious disabilities that make the cost of care prohibitive or are simply unable to get coverage at any price. But the younger and healthier are going to get a huge sticker shock as they end up subsidizing the old geezers like me. Nothing new here, just like Social Security and Medicare. It's a shame nothing meaningful was done to cut the costs of actually delivering care, which is the major driver of the problem as we approach 20% of GDP spent on it, roughly twice the cost of other advanced societies. And please, don't tell me how all the new taxes are going to control costs or how they'll require doctors to take less or tax medical devices to pay the freight. Ain't gonna happen!

Bill Bradshaw
Bill Bradshaw subscribermember

Congratulations, Mr. Brewster. You didn't include in your description of the "intent" of ACA that it was supposed to cut health care costs, a claim the president repeatedly made that was patently ridiculous on it's face. In fact, he now claims it's already saving the country money. Some individuals will certainly benefit mightily from this plan, particularly the old with serious disabilities that make the cost of care prohibitive or are simply unable to get coverage at any price. But the younger and healthier are going to get a huge sticker shock as they end up subsidizing the old geezers like me. Nothing new here, just like Social Security and Medicare. It's a shame nothing meaningful was done to cut the costs of actually delivering care, which is the major driver of the problem as we approach 20% of GDP spent on it, roughly twice the cost of other advanced societies. And please, don't tell me how all the new taxes are going to control costs or how they'll require doctors to take less or tax medical devices to pay the freight. Ain't gonna happen!

Jim Jones
Jim Jones

Chris, there is PCIP and high risk pools for people without coverage, it's easy to make false claims but insurance is there, granted it can be very expensive so most people with preexisting conditions don't try. Cystic acne? I call BS on that one. For most people who gain from Obamacare, $12k is bankruptcy. The middle class and above are hurt by Obamacare, the poor who get massive subsidies paid for by the rest of us gain, but they are already milking the system and their EBT card doesn't have $12k on it. For a family making $30k a year $12k is not affordable. It means bankruptcy, because that is the tool used to forgive that medical debt that they won't pay. It might as well be $12 million. All Obamacare does is add anywhere from 1% to 5% additional cost to our health insurance system. It doesn't save lives, its just more bloat, a massive tax increase. It also allows the NSA easier access to your health information. That is why it is overwhelmingly despised by a majority of americans, it's bad law. You want preexising conditions not to be an issue? That's a 5 page law, not obamacare. You want to stop medical bankruptcy? Just outlaw it, but that will hurt a lot of people, because bankruptcy is a tool that helps people. Obamacare isn't health care, it's not even real reform, it's a lousy, intrusive, expensive way to get government involvement in health insurance and add subsidies that redistribute wealth with very low efficiency and no overall positive benefit to society, it drives up the cost to the consumer and it doesn't hurt the insurance industry even a little, it bakes the big insurers into the cake, stifling innovation and guaranteeing lack of competition. Its a freaking disaster. It keeps the lower class down, discouraging success that would eliminate subsidies like all welfare does, paying people to stay poor and It drives up cost for the majority of people, either reducing insurance benefits or increasing expenses. All without saving a single life or making one person healthier.

Don Blucher
Don Blucher

Mr Brewster, Try as Progressives are want to do, one cannot, nor never will be able to, legislate perfect equality to all members of our society or the human race as a whole. The effort to press for better care for our masses is noble but the way in which THIS bill was slammed through was subjective, poorly thought out, and poorly crafted. The result is a boondoggle for everyone's pocketbook INCLUDING those it was intended to help. Sure, the Taxpayer was previously on the hook for emergency room care for those that had to go that route, or for those that sought care then couldn't pay the bill. NOW, everyone must pay MUCH more and we now will have to pay for a bunch of irresponsible Government Bureaucrats and a huge soon-to-be-bloated new governmental department. Progressive emotional decision-making has, again, trumped common sense and good planning.

Don Blucher
Don Blucher

Mr Brewster- As nice as it is to be able to have insurance, "There ain't no such thing as a free lunch". SOMEONE will always wind up having to pay the bill sooner or later. The ill person will eventually have to pay the bill either directly or via much higher premiums for the rest of their lives. you don't get nothin' for free in this life.

Jim Jones
Jim Jones

Anyone could purchase health insurance with a preexisting condition, it just cost more. It's important to note that now people wh have taken care of themselves, or are young, are paying for people who have abused themselves. In some cases the increase is a huge and crippling burden to healthy people: http://www.forbes.com/sites/theapothecary/2013/09/23/its-official-obamacare-will-increase-health-spending-by-7450-for-a-typical-family-of-four/ As far as being bankrupted by a health condition, Obamacare does nothing to stop that.if you are on the heavily subsidized low tier plans you won't be able to afford the cap, which can be around $12k, Most people who take medical bankruptcies have insurance. It's important to note that bankruptcy is not undesirable, it's a tool used to restart. Obamacare increases costs for medical care. That reduces the overall amount of medical care. The insurance industries response is almost always to reduce treatment in order to reduce costs, and that kills people. Obamacare is a disaster. It has a huge and real cost that is way out of proportion to its benefit, that will be tragic for many people, and it's few good points are easily passed without the burden that Obamacare brings. Obamacare Will Increase Health Spending By $7,450 For A Typical Family of Four [Updated]http://www.forbes.com/sites/theapothecary/2013/09/23/its-official-obamacare-will-increase-health-spending-by-7450-for-a-typical-family-of-four/It was one of candidate Obama's most vivid and concrete campaign promises. Forget about high minded (some might say high sounding) but gauzy promises of hope and change. This candidate solemnly pledged on June 5, 2008: "In an Obama administration, we...

Jim Jones
Jim Jones subscriber

Chris, there is PCIP and high risk pools for people without coverage, it's easy to make false claims but insurance is there, granted it can be very expensive so most people with preexisting conditions don't try. Cystic acne? I call BS on that one. For most people who gain from Obamacare, $12k is bankruptcy. The middle class and above are hurt by Obamacare, the poor who get massive subsidies paid for by the rest of us gain, but they are already milking the system and their EBT card doesn't have $12k on it. For a family making $30k a year $12k is not affordable. It means bankruptcy, because that is the tool used to forgive that medical debt that they won't pay. It might as well be $12 million. All Obamacare does is add anywhere from 1% to 5% additional cost to our health insurance system. It doesn't save lives, its just more bloat, a massive tax increase. It also allows the NSA easier access to your health information. That is why it is overwhelmingly despised by a majority of americans, it's bad law. You want preexising conditions not to be an issue? That's a 5 page law, not obamacare. You want to stop medical bankruptcy? Just outlaw it, but that will hurt a lot of people, because bankruptcy is a tool that helps people. Obamacare isn't health care, it's not even real reform, it's a lousy, intrusive, expensive way to get government involvement in health insurance and add subsidies that redistribute wealth with very low efficiency and no overall positive benefit to society, it drives up the cost to the consumer and it doesn't hurt the insurance industry even a little, it bakes the big insurers into the cake, stifling innovation and guaranteeing lack of competition. Its a freaking disaster. It keeps the lower class down, discouraging success that would eliminate subsidies like all welfare does, paying people to stay poor and It drives up cost for the majority of people, either reducing insurance benefits or increasing expenses. All without saving a single life or making one person healthier.

Don Blucher
Don Blucher subscriber

Mr Brewster, Try as Progressives are want to do, one cannot, nor never will be able to, legislate perfect equality to all members of our society or the human race as a whole. The effort to press for better care for our masses is noble but the way in which THIS bill was slammed through was subjective, poorly thought out, and poorly crafted. The result is a boondoggle for everyone's pocketbook INCLUDING those it was intended to help. Sure, the Taxpayer was previously on the hook for emergency room care for those that had to go that route, or for those that sought care then couldn't pay the bill. NOW, everyone must pay MUCH more and we now will have to pay for a bunch of irresponsible Government Bureaucrats and a huge soon-to-be-bloated new governmental department. Progressive emotional decision-making has, again, trumped common sense and good planning.

Don Blucher
Don Blucher subscriber

Mr Brewster- As nice as it is to be able to have insurance, "There ain't no such thing as a free lunch". SOMEONE will always wind up having to pay the bill sooner or later. The ill person will eventually have to pay the bill either directly or via much higher premiums for the rest of their lives. you don't get nothin' for free in this life.

Jim Jones
Jim Jones subscriber

Anyone could purchase health insurance with a preexisting condition, it just cost more. It's important to note that now people wh have taken care of themselves, or are young, are paying for people who have abused themselves. In some cases the increase is a huge and crippling burden to healthy people: http://www.forbes.com/sites/theapothecary/2013/09/23/its-official-obamacare-will-increase-health-spending-by-7450-for-a-typical-family-of-four/ As far as being bankrupted by a health condition, Obamacare does nothing to stop that.if you are on the heavily subsidized low tier plans you won't be able to afford the cap, which can be around $12k, Most people who take medical bankruptcies have insurance. It's important to note that bankruptcy is not undesirable, it's a tool used to restart. Obamacare increases costs for medical care. That reduces the overall amount of medical care. The insurance industries response is almost always to reduce treatment in order to reduce costs, and that kills people. Obamacare is a disaster. It has a huge and real cost that is way out of proportion to its benefit, that will be tragic for many people, and it's few good points are easily passed without the burden that Obamacare brings. Obamacare Will Increase Health Spending By $7,450 For A Typical Family of Four [Updated]http://www.forbes.com/sites/theapothecary/2013/09/23/its-official-obamacare-will-increase-health-spending-by-7450-for-a-typical-family-of-four/It was one of candidate Obama's most vivid and concrete campaign promises. Forget about high minded (some might say high sounding) but gauzy promises of hope and change. This candidate solemnly pledged on June 5, 2008: "In an Obama administration, we...

Chris Brewster
Chris Brewster

Mr. Bradshaw: To my understanding, people like yourself were already benefitting from free care. I disagree with your assessment. I think the ACA will reduce healthcare costs. For example, it caps profits of insurance companies. In any case, we will see.

Chris Brewster
Chris Brewster subscribermember

Mr. Bradshaw: To my understanding, people like yourself were already benefitting from free care. I disagree with your assessment. I think the ACA will reduce healthcare costs. For example, it caps profits of insurance companies. In any case, we will see.