An overwrought look at what the Affordable Care Act amendments will mean for Massacusetts

“I didn’t need that fourth glass of wine,” Cassandra St. James grumbled to herself as she slammed off her wailing alarm. Her headache from last night’s binge was beyond splitting, making her simultaneously grouchy and grateful that, thanks to federal health reform, her health insurance plan was banned from putting annual limits on essential services –  lately, she’d been going through her prescription migraine pills like they were Skittles.

“Uggghh…I cannot face another day at work!”

Cassandra had been feeling the heat at her job lately, perhaps sparking this new interest in multiple glasses of wine per evening. Being a customer service representative at a Boston-based health insurance company during the advent of federal Health Reform was stressful to say the least. But tension at work wasn’t the only reason for Cassandra’s hangover.

Cassandra was engaged to a man she hardly knew, even though she was still heartbroken over the loss of her true love, Dr. Lance Jones. It’s been almost three years since the freak boating accident that took Dr. Jones’ life along the Cape, but his body was never found, leaving Cassandra without closure. Maybe that’s why she’d agreed to marry Chip Montebello.

To be sure, Chip had a good heart, but his health insurance situation left something to be desired. His decision to defy the state’s individual mandate left him with a greater tax burden and no health benefits.

What’s more she had financial woes coming at her in every direction. It didn’t help that the health insurance available to her through her employer was all but affordable, with over 9.5% of her income put towards her premium each month. In more desperate moods, Cassandra fantasized about having the freedom to buy insurance over the Health Connector, but that fantasy was too farfetched even for her. Massachusetts law prohibits anyone with insurance available to them through their job to seek coverage elsewhere, regardless of its affordability.

But it wouldn’t matter even if she could stray to the Connector. Ever since her so-called “big promotion” her salary was boosted to $45,960 and with her household size of one, that boost put Cassandra at 400% of the federal poverty line. With an income at that level, she wouldn’t even qualify for any of the state subsidies for purchasing insurance on the Connector, available only to those with incomes between 133 – 300% of the federal poverty line.

“And then there’s my mother,” Cassandra said under her breath as the phone rang.

“Hello?”

“Where’s my money?”

“Speak of the devil.”

“I said, WHERE IS MY MONEY?”

“Mother – it’s coming. I’ve had a lot on my mind. I — I forgot.”

“Life’s not a permanent vacation, Cassandra. Don’t tell me these convenient memory lapses of yours were plaguing you between July 1st and August 15th . I didn’t raise you to forget about the Health Connector enrollment period that’s been in place ever since Massachusetts health reform!”

“Mother – you know I get insurance through work. Besides, once Obamacare kicks off, the Health Connector will have an extended enrollment period from October 1st, to March 31st. So relax, okay?”

“You think you’re so smart, don’t you? Well, you better not get used to taking your sweet time deliberating about how you should enroll during that initial extended enrollment period. After March 31st, 2014, all future enrollment periods in the state will be from October 15th until December 7th. Now get me my money…or else!”

“You’ll get your money, mother!” said Cassandra between clenched teeth, and slammed down the phone.

Ever since her mother, Elaine St. James, blew out the 65th candle on her diabetic-friendly birthday cake earlier this year, she’d been cashing in on her Medicare benefits. Elaine burned through her prescription drug coverage privileges fast, hitting the coverage gap, or that infamous “donut hole”, within months of becoming eligible for Medicare. Subsumed by a gnawing filial guilt, Cassandra had been footing the bill for her mother’s pricy alpha-glucocide inhibitors ever since.

Cassandra popped one of her migraine pills as she ripped off yesterday’s date from her page-a-day calendar.

“October 1st, 2013?” gasped Cassandra. “It can’t be!”

Not only was this the official onset of Obamacare across the country, but it was also her wedding day.

“I’ve got to get to the church! I’m going to be late!” cried Cassandra as she grabbed her wedding dress, the one she had originally bought when she was going to be Mrs. Dr. Lance Jones…..

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At the Church

With her dress half on and stocking runs too extensive to be passed off as high fashion, Cassandra bolted through the church doors. She raced down the aisle, past what resembled more of an angry mob than a wedding party and to the altar that, besides one highly peeved Father Mortlock, was unoccupied. Cassandra covered her mouth in disbelief, smearing her lipstick into a vibrant red halo circling her lips. Had she been stood up?

“Where’s Chip?!” Cassandra yelped at Father Mortlock, who was glaring at her as he tapped his watch.

“Mr. Montebello will be late,” scoffed Father Mortlock, rolling his eyes. “He’s taking advantage of the new seamless enrollment experience on the Health Connector that has come with today’s initiation of Obamacare. He wanted you to know that he’s opted out of health coverage for so long because he found the enrollment process so infuriating, but now that there’s a standardized, one-stop shop situation for everyone purchasing insurance on the Health Connector, Mr. Montebello will be able to apply for coverage and determine his eligibility for assistance in one sitting.”

As Father Mortlock finished, Cassandra felt a tap on her shoulder. It was Chip!

“Hey, babe, sorry I’m late. You look, uhhh, great?” he said through a grimace.

“Chip! Why on earth did you decide to look into getting health insurance on our wedding day?”

“Listen, with Obamacare coming to town today, I was getting anxious. I knew that opting out of health coverage this time around I would be breaking both state and federal individual mandates.Come tax time, I would be forced to pay the higher of the two penalties for my non-compliance so I wanted to enroll as soon as I could.”

Cassandra couldn’t believe this was the man she was about to marry, but she liked that he was thinking about the future.

“All right,” huffed Cassandra, “you’re here now. Let’s just get this over with. Father Mortlock, would you mind doing the honors? And make it snappy – my migraine medication hasn’t kicked in!”

“Fine by me,” said Father Mortlock, raising his bible. “I’ll get right to the good stuff. If anyone objects to this union, speak now or forever hold your pea-”

“I OBJECT!”

(Gasps from the audience.)

Cassandra’s heart almost stopped. That voice! She’d recognize it anywhere! But it couldn’t be….

“Dr. Lance Jones?! But how? You died three years ago!”

“Well, I’m back from the dead and I object to this union! Back away from the bride, Montebello.”

“Lance! Lance my darling!” Cassandra cried, running to him. “I don’t understand! Where have you been?”

“Let me explain, “declared Dr. Jones, pushing Cassandra aside dramatically. “Back in the early days of 2010, I was finally getting used to all of the changes with health reform in Massachusetts, when all of a sudden it was announced that Obamacare was to become the law across the country. This got my blood pressure surging. How could there be more changes to state health insurance laws when Obamacare was modeled after Massachusetts health reform? What would this mean for me, someone who provides health care and consumes health insurance?

“This sent me head-first off a proverbial cliff into an abyss of uncertainty, causing me severe professional and existential angst. So I did what any overwhelmed physician would do. I staged a boating accident, faked my own death and have been living on Nantucket for the past three years. At the time, this was the path with the greatest number of options for me.”

(More gasps from the audience)

“Greater options?” blurted Chip. “What do you think you are? The Mass Health Connector after Obamacare?”

“What are you talking about?” bellowed Dr. Jones.

“The PPACA requires that the Mass Health Connector add a fourth metallic “Platinum” tier to its product shelf – right now there are only three,” Chip quipped, growing increasingly agitated. “When you combine that with the new Co-op plan that’s coming to this state’s insurance market in 2014, we’ll be seeing plenty of new coverage options by January. But right now, Jones, it looks like your only option is to explain why you’ve chosen to come back from the dead today, or be prepared to feel the wrath of a Chip Montebello knuckle sandwich! ”

“I-i-it’s October 1st!” sputtered Dr. Jones. “Obamacare kicks in across the country and will be in even greater effect come January 1st, 2014! I’ve had nothing but time on Nantucket and I’ve been following the news in detail. Some project that with the increased number of federal dollars coming into the state to assist with the expansion of Medicaid, Massachusetts taxpayers may see some savings in the coming years. What’s more, increased federal funds are available to health care workers who experiment with innovative ways of providing comprehensive care at lower costs. I had to come back now so I could finally realize my dream of operating an Accountable Care Organization!”

(Still more gasps.)

“Wait a minute!” chimed in Cassandra. “You’re a pediatric surgeon. The money for innovations in health care delivery is only available through Medicare. Plus, Massachusetts was already giving these types of financial incentives before you…er, died.”

“Yes, but there are even more federal dollars available for health care innovators now that Obamacare’s the law of the land. But more importantly, I’ve seen the light!” exclaimed Dr. Jones throwing his hands into the air. “Providing coordinated care to the elderly is my calling!”

“Something fishy’s going on here,” said Cassandra to herself.

“Ya think?” croaked a rather caustic voice from the back of the church. It was Elaine! But, Cassandra knew her mother wasn’t at the church to wish her a happy wedding.

“Now Cassandra, I’ve had just about enough!” Elaine barked as she stormed down the aisle. “Someone with the kind of chronic conditions I have can’t wait forever to buy her medication. Where is my money?!”

“That voice!” beamed Dr. Jones. “It’s like a choir of laughing angels! Oh! I can’t hold it in any longer! I’ve come back because my heart belongs to your mother, Cassandra. I’m in love with Elaine St. James!”

(Yet more gasps.)

“I knew it!” spat Cassandra. “I could sense you had a wandering eye when we were together before your death…or whatever. But my mother?! Well, it all makes sense. You knew she was turning 65 this year! Now you’ve come back to start your ACO that will receive funding through Medicare as part of some sick ploy to seduce her! Well fine! Now you can cover her donut hole expenses!”

“It’s true. That’s why I have come back,” said Dr. Jones, staring, bewildered, out towards the sea of dropped jaws occupying the church pews. “But pay for Elaine’s pharmaceuticals? The coverage gap for some medications covered by Medicare has been shrinking since 2011.  By 2020, the donut hole could be but a distant memory and seniors won’t see any change in their pharmaceutical coverage once they hit that level of spending.”

“What?” screeched Cassandra. “Mother! You’ve had pharmaceutical coverage all along? You’ve betrayed me! All that money I’ve been dolling out to you! For what?”

“Fine,” growled Elaine, brow furrowed and lips clenched. “You’ve caught me. But I can explain. I’ve been trying to get out of this good-for-nothing town for 65 years. Ever since I was a tot I’ve known I have what it takes to be famous. A Hollywood contract is my ticket out of here! But the only thing between me and world fame is….my teeth! Look at them!”

Elaine’s unveiling of her ghastly grin was met with a chorus of horrified screams.

“All right, all right,” Elaine began. “So I scammed my own daughter. How else was I going to come up with money for dental insurance? I knew it was my big chance when the Health Connector announced that for the first time ever, they’d be offering stand alone dental insurance plans as per new Obamacare regulations.”

“Well this is just great!” screeched Cassandra, throwing off her veil and crumpling to the floor. “What a wonderful life I’ve got! My fiancé would rather shop for health insurance than show up to our wedding on time, the love of my life, whose alleged death I’ve been mourning over for the past three years, has been hiding from the world on Nantucket, all the while pining for my two-faced mother who has been actively ripping me off! With you lot in my life, I ought to seek professional help! I would get myself a psychiatrist, but my employer covers less than 60% of my health benefits, and I just can’t afford that! Hey, Obamacare! You think you’re so great, but can you help me now?!!”

“Actually, yes it can.”

“Father Mortlock?” whimpered Cassandra. “How – how do you know?”

“Well,” said Father Mortlock, “I actually took an interest in this federal health reform business when the Church community was in a huff about the contraceptive mandate. From what I know about the law, come January 2014, if the insurance your employer offers isn’t affordable to you, you’ll be allowed to purchase coverage on the Health Connector. Affordability is determined using a federal measure, so if your employer’s insurance premiums are greater than 9.5% of your income, or if it covers less than 60% of the cost of the benefits on your insurance policy, then your insurance is considered to be unaffordable and you are free to wander the tiers of the Health Connector in search of coverage.”

“That’s good to hear, Father,” sighed Cassandra, “but my income is 400% of the federal poverty line. I won’t be eligible for government subsidies, so even insurance on the state exchange would be a financial strain for me.”

“Don’t you jump to conclusions like that in my church!” Father Mortlock scolded. “It just so happens that Obamacare shifts the income bracket for subsidy eligibility from 300% of the federal poverty line to 400%. You might want to follow the lead of Mr. Montebello and check out the new streamlined enrollment on the Health Connector.”

“Hallelujah!” cheered Cassandra, jumping to her feet. “Mother! You can have Lance. The two of you deserve each other. Chip – I never loved you. Besides, I don’t think I can be with a man who hasn’t seen the value in having health insurance until now. Goodbye, Father Mortlock, and hello, therapy!”

THE END

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