If this dramatically-titled post hit your inbox, you’re one of the 1,100 who’ve followed my writing this past year — thank you, it means a lot. It’s time I told you why.
Your story is compelling, and many will be able to relate to it from their own experience.
1) I (now retired) once worked for one of those big corporations. As many people find, there is in many of those big corporations a required social compliance and brainwashing that some people can't take.
In my case, it really wasn't that bad. Certain important and very true things could not be said, though. So, every day I had the feeling I was going into a little Communist country.
Many people, I have found, have a similar reaction. They often wind up being contractors, to minimize the entanglements with corporate nonsense.
--
2) A very good example of real valuableness of a person who has chosen your path is a one Charles Gaba ( https://charlesgaba.substack.com/archive ). I don't know what exact path got him to where he is now (at about 55 years of age), but he is very competent and has a lot of energy, and gets out these very important things in his Substack (mainly around the ACA) that you just can't find elsewhere.
The fact that you can't find them elsewhere is indicative of how the institutions are failing our democracy. We are hanging by a thread. So, we have this one guy filling in so much.
(I'm now retired, myself, and put a little bit of healthcare stuff in Substack, nowadays. I find myself extremely reliant on Charles -- he is the source of most of my information. You might think it could be the New York Times, but they are woefully under-resourced, and as well sometimes have an evident bias in what they choose to report, so I am reliant on Charles!
Thus, with the ACA expanded subsidy lapse on 1/1/26, I learned from Charles that CMS did not released some data at a point when they usually did in the past, and then that there was a leak from inside CMS that CMS knows of large coverage drops and was preparing a false claim that the drops were due entirely to the administration's successful crackdown of fraud.
And then, last Friday, 6/26/26, Charles reports, same day, that some data has been released by CMS, accompanied by that expected claim about the cause of the drops being fraud reduction.
So, only due to Charles, I had sufficient material to go through the CMS report and establish that the claim is false, which I did, here:
not possible without the invaluable Charles Gaba. Who, incidentally, was not long ago referred to as "kind of a cult figure"--in a good way-- by Paul Krugman .)
--
3) You and your subscribers undoubtedly are also aware of a repentant former health insurance executive Wendell Potter, who has also taken an anti-system stance. This was long ago, and I remember him on Bill Moyers around the time the ACA was under consideration. He has, as most will already know, his own little Substack: https://healthcareuncovered.substack.com/
--
4) Best of luck on your newish path. It sounds like a good decision to me.
Thank you so much Norm for this rich and thoughtful comment - it's good to know other folks have experienced the kind of thing that wore me down.
Good tip on Charles Gaba as well (I'm not familiar!), but the fact that so much essential reporting rests on a few dedicated individuals says a lot about where the institutions are falling short. Thanks for reading, and for the kind words on the path ahead.
"Sec. 71305: Recapture of Excess Premium Tax Credits
Background
Currently, if an enrollee receives excess premium tax credits because their estimated income was lower than their actual income, they must repay the excess. However, for most enrollees, there is a repayment cap that varies based on household income. For enrollees with household incomes at least 400% of the federal poverty level (FPL), there is no limit. They must repay the entirety of their excess tax credit. Other repayment limits vary from $375 for a single person with an income that is 100% FPL up to 200% FPL to $3,250 for families with an income between 300%-400% FPL for tax year 2025.
Description
Requires that all premium tax credit recipients repay the full amount of any excess, no matter their income.
Effective date: taxable years beginning after December 31, 2025."
--
So, onto the question.
Background:
In the Medicaid non-expansion states, we already know people below 100% of FPL are in serious trouble, unless they become dirt poor in both income and assets to qualify for old-fashioned standard Medicaid. (I think there are 2.7 million such people.)
That's not the question.
The question is, is, in a Medicaid expansion state, if a person mis-estimates over 138% FPL on the exchange, and winds up under 138% or under 100% of FPL at reconciliation time, do they have to repay the APTC?
(I hope the answer is no, and that the summary, which I have clipped above, is incorrect, or I have misread it.)
Anyone who knows, can you respond with the answer in a comment?
Honestly, Norm, I don't know the answer to this one with any confidence - it feels pretty crunchy to me too. My gut says it likely depends on the state, and there's also the wrinkle that once someone drops below 100% FPL they'd generally need to enroll in Medicaid rather than stay on exchange subsidies, so it's not obvious to me why a repayment would even apply in that scenario. But I'm genuinely not sure, and I don't want to guess on something with real dollars attached. Hoping one of the wonkier readers here can give you a solid answer.
Thanks for attempting it. I don't know who actually might know. Perhaps somewhat like Katie Keith, at Health Affairs, who is a lawyer with her eye on the ACA details and the legal issues around that. (And, I might add, a good head for understanding, and foreseeing, all of the complexities.)
It may be that the issue is unclear in the law, even.
I don't think it can depend on the state, because it's a reconciliation on the federal tax form (filed by April 15, the year after the coverage).
--
The issue is coming up in my mind partly because I used the ACA for myself in Massachusetts, from about 2014 to 2022, before aging into Medicare-for-Me.
I happened to be in an unusual situation, which was retired but not drawing Social Security or cashing IRAs, so in that situation, I was hovering around the 138% FPL level in Modified Adjusted Gross income.
Massachusetts has its own exchange, and, of course, all states have their own Medicaid agency.
Now, in terms of the technical things to manage, the ACA, particularly with its division at 138% of FPL between expanded Medicaid and subsidized on-exchange, can get quite complicated and too much to manage without screwing up when the factors of people are using an estimated future income on the exchange (and a bit for expanded Medicaid), and throw in that expanded Medicaid may be based on a short period, like a month (depending on the state), whereas the federal subsidy I think is based on annual.
As well, incomes may jump around, especially as each state uses its own income determination, based on whatever estimating method, and whatever period of time it chooses.
So, this kind of thing (pre-OBBB) is a recipe for disaster, and so, in the 8 years I had the ACA, twice I was rapidly, on a few does notice, moved up or down mid-year between the two halves of the ACA, with a full provider change each time.
(One time it was because my FPL level was a teeny tiny bit above 138% FPL, and a mid-year update in FPL cutpoints nudged me a teeny-tiny bit below. This was where I had about 5 days notice of a complete network change because of moving to expanded Medicaid from on-exchange.
The other time it happened, I was actually a bit sick, and was possibly to be hospitalized, and I was in a limbo state for a few days as the state had to get my Medicaid sub-network in place in its computer systems. This was after me having to research, while fairly sick, to find the one Medicaid subnetwork to choose which accepted by my current GP. Lots and lots of phone calls for this finding that Medicaid subnetwork. Bad data encountered required lots of troubleshooting and effort to finally figure that out. )
Now, a point about that 138% FPL crossover: as best as I could tell, the state made it its goal to rapidly change you to the correct of expanded Medicaid and subsidized on-exchange as soon as it detected your short term income crossed 138% FPL, and it also requested you (you had to sign to agreen you would) tell the state within 10 days of your income changing.
Thus, it seemed Massachusetts could potentially thrash a person up and down between the two ACA halves as often as every two or three weeks, changing their whole provider network each time.
(For my last two or three years with the ACA in Massachusetts, I actually switched to on-exchange, without any APTC, which the MA Health Connector ombudsperson told me, correctly, would keep me from the thrashings. I took the PTC (not advanced) on my 1040, but was not sure always that eligibility for a Medicaid wouldn't disqualify me from it. The risk, and cost, was affordable to me, to save the thrashing.*)
--
So far, I'm all pre-OBBB. However, what I observed indicates the magnitude of the complicatedness, even with the original ACA, which maintains the byzantine complexity of our system, and is subject to all kinds of malfunctions, which each state will have prepared its own custom version of things likely to go wrong on its citizens.
So, the issue I'm trying to get at with my question, is, has the OBBB, even forgetting the work requirements, screwed up the ability of even the 41 Medicaid expansion states to provide coverage to the low-income group, by making it so that an honestly estimated income on the exchange above 138% FPL, followed by an income actually winding up below 138% FPL or below 100% FPL, will make people have to pay back up to tens of thousands of dollars? (The extreme case: $40,000 for a 62 year old couple in Wyoming.)
--
Of course, many wonks will not know the answer. I had no expectation that you would happen to know the answer. I though perhaps some reader of your 1000+ might, though, which is why I posted it, once I thought of the issue the other day. (I also posted the same question in a few other Substacks that health policy wonks might visit. So far, no answer, but I got a few likes!)
Perhaps the answer cannot be known until some legal case or cases makes it all the way up to the Supreme Court, in about 7 years or so!
--
Incidentally, the complexity of handling the work requirements themselves by 51 Medicaid agencies, has me separately worried about what could go wrong. Based on my experience.
On that, I am not alone, and I think the New York Times and Jonathan Cohn, and maybe KFF, have posted something.
--
* Actually, there was a second reason that made the declining the APTC and doing on-exchange, possibly forgoing a subsidy and paying full cost, a no-brainer.
And that is that, in some states, people 55 or or older when they have expanded Medicaid (or really, the problem is any non-LTSS Medicaid) are subject to an estate recovery, which could even mean all bills paid out have to be paid back by a person's estate. (The person don't have insurance! They have a loan, until death, for whatever medical expenses occur.)
When I first stumbled on this knowledge, in 2019, I tried to get it publicized and fixed, and had a little interaction with the xpostfactoid blog, as Andrew there caught the issue, and tried to get it fixed, federally, or state-by-state, I think including in his New Jersey.
My own MA, incidentally, did manage to fix it, but only in mid 2024. (That would be 10.5 years late. Even later if the same issue afflicted some part of Romneycare. I haven't looked into whether it afflicted some part of Romneycare.)
(At this point, your readers who are unaware of the issue may be saying, do you have a reference on this, for us to look at?
(There are sufficient links to reliable reference places that everything I have asserted should be verifiable. In certain cases, you might have to go to the Wayback machine archive to find a page now gone from the live web, but I think mostly not.)
Bonus Material: On that thrashing that I was talking about, based on the Massachusetts agencies at the time thinking their most important duty in the world was to track every little income change as quickly as possible, and then immediately carry out the consequences of that change, I have the paper-version .pdf of the ACA application for 2019:
There you got your item (11) on the page numbered 20, from which I quote:
"Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change."
On that other Medicaid estate recovery thing, which was in effect at the time, you might also note items (9) and (10), which, buried in the midst of innocuous-looking things indicating mostly "don't lie--we're gonna check", you've got these things telling you that the coverage you wind up getting might not be insurance at all. Only a loan until death for whatever medical expenses happen to have been incurred.
(I, and most people, used the on-line exchange. Not the paper application.
For that, the full set of conditions popped up after you entered all of your income and other information, and before you agreed to take your plan. So, at that point, you're supposed to, if you caught the items (9) and (10), supposed to stop everything, contact and pay for a specialized attorney to figure out what the heck they're talking about.)
As I have indicated, the Medicaid estate recovery problem was finally fixed in 2024 in Massachusetts. My guess is the continuous thrashing potential is still going on, and who knows whatever else very goofy and causing much misery will be added when the new OBBB provisions go into effect start of 2027. (In just this one state.)
Healthcare, like life, is messy as you and I have discussed. The challenge is as you have found it is incredibly hard to impact the whole machine.
I think I have shared with you previously, my own particular take on this is it’s incredibly difficult to say how you change the world other than one person at a time. I guess that is why my own writing has a few lanes that I jump around between. They are all connected by me and my experiences, but they are absolutely connected.
I love that you have the courage to take this step, and you know I have got your back in anyway you want me there. I’ve loved our short collaborations, and I’d love to continue them.
Andrew I understand how you feel both about work in Healthcare and about the healthcare non-system in the US. I retired at 71 after 20+ years in healthcare software for the same reasons. I wish you well and if I can help you find a way forward for the healthcare system, I am willing to work free to achieve that end.
Thank you David, it means a great deal to hear this from an industry veteran in the space - it's actually reassuring to hear about other folks who arrived at the same place!
I appreciate your gracious offer and am eager to do the work and make an impact
Say, Andrew. I just tried to paid upgrade my subscription. I got this:
"This Connect account cannot currently make live charges. The `requirements.disabled_reason` property on the account will provide information about why this account is currently disabled. If you are a customer trying to make a purchase, please contact the owner of this site. Your transaction has not been processed."
Too much info, but I put www.healthisotherpeople.com on Stripe but didn’t have the www DNS record up, so they couldn’t verify I had a blog. Tested it out and all good now
Thanks so much for your support! Also, thanks for giving me a heads-up about the upgrade issues - I looked into it and it was because I put www on my domain at Stripe but I didn't add the DNS record yet. Fixing it now, will let you know when it's all good!
Andrew, read your letter and appreciated it. Sharing your ideas and your point of view without the handcuffs of the big company logo is liberating. And it’s hard….but oh so rewarding. You’ve done the hardest part: overcoming the fear. Now do the work: create a formal business strategy and plan for yourself. On paper. With all the discipline you had in your $200k/ye job. Next chapter starts now.
I recently left an executive role at a large payer and your words really hit home for me. There is so much that is broken about the healthcare system and the only solutions offered are either impractical because of naïveté (“let’s launch a digital health app that will solve everything!” or they fail to address the core issues of that brokenness (“let’s use ambient AI to submit claims!”). For many in the industry, it just is what it is. But it’s deeply frustrating if you know it can be better, want it to be better, and believe we all deserve better.
Your story is compelling, and many will be able to relate to it from their own experience.
1) I (now retired) once worked for one of those big corporations. As many people find, there is in many of those big corporations a required social compliance and brainwashing that some people can't take.
In my case, it really wasn't that bad. Certain important and very true things could not be said, though. So, every day I had the feeling I was going into a little Communist country.
Many people, I have found, have a similar reaction. They often wind up being contractors, to minimize the entanglements with corporate nonsense.
--
2) A very good example of real valuableness of a person who has chosen your path is a one Charles Gaba ( https://charlesgaba.substack.com/archive ). I don't know what exact path got him to where he is now (at about 55 years of age), but he is very competent and has a lot of energy, and gets out these very important things in his Substack (mainly around the ACA) that you just can't find elsewhere.
The fact that you can't find them elsewhere is indicative of how the institutions are failing our democracy. We are hanging by a thread. So, we have this one guy filling in so much.
(I'm now retired, myself, and put a little bit of healthcare stuff in Substack, nowadays. I find myself extremely reliant on Charles -- he is the source of most of my information. You might think it could be the New York Times, but they are woefully under-resourced, and as well sometimes have an evident bias in what they choose to report, so I am reliant on Charles!
Thus, with the ACA expanded subsidy lapse on 1/1/26, I learned from Charles that CMS did not released some data at a point when they usually did in the past, and then that there was a leak from inside CMS that CMS knows of large coverage drops and was preparing a false claim that the drops were due entirely to the administration's successful crackdown of fraud.
And then, last Friday, 6/26/26, Charles reports, same day, that some data has been released by CMS, accompanied by that expected claim about the cause of the drops being fraud reduction.
So, only due to Charles, I had sufficient material to go through the CMS report and establish that the claim is false, which I did, here:
https://normspier828307.substack.com/p/the-administrations-claim-in-the
after, also Gaba-only-possible, reporting on the earlier fishy stuff before the actual false claim came from CMS here:
https://normspier828307.substack.com/p/loss-of-aca-coverage-after-republicans .
(I also tried my hand at a little health-policy-wonk-only satire, here:
https://normspier828307.substack.com/p/a-proposal-for-a-major-revamping ,
not possible without the invaluable Charles Gaba. Who, incidentally, was not long ago referred to as "kind of a cult figure"--in a good way-- by Paul Krugman .)
--
3) You and your subscribers undoubtedly are also aware of a repentant former health insurance executive Wendell Potter, who has also taken an anti-system stance. This was long ago, and I remember him on Bill Moyers around the time the ACA was under consideration. He has, as most will already know, his own little Substack: https://healthcareuncovered.substack.com/
--
4) Best of luck on your newish path. It sounds like a good decision to me.
Thank you so much Norm for this rich and thoughtful comment - it's good to know other folks have experienced the kind of thing that wore me down.
Good tip on Charles Gaba as well (I'm not familiar!), but the fact that so much essential reporting rests on a few dedicated individuals says a lot about where the institutions are falling short. Thanks for reading, and for the kind words on the path ahead.
came here to say a big hi from me!
Dude! We have a lot of catching up to do! Congrats, and hopefully I can get organized to chat soon. /Jamie
Maybe Andrew or one of his readers knows the answer to this. (I've put the question in a few wonk-oriented places.)
QUESTION -- QUESTION--QUESTION -- NOT A COMMENT --DOES SOMEONE KNOW THE ANSWER?
This is not a comment. It's a question. Someone here may know the answer, among the wonkyinsh visitors.
On the ACA APTC repayment limits, now in effect (which are basically no repayment limits), I think from OBBB,
From here:
https://www.kff.org/medicaid/health-provisions-in-the-2025-federal-budget-reconciliation-law/#11b14007-9dd9-4b35-8c5a-31fb55714cc9:~:text=Sec.%2071305%3A%20Recapture%20of%20Excess%20Premium%20Tax%20Credits
I pull the text:
"Sec. 71305: Recapture of Excess Premium Tax Credits
Background
Currently, if an enrollee receives excess premium tax credits because their estimated income was lower than their actual income, they must repay the excess. However, for most enrollees, there is a repayment cap that varies based on household income. For enrollees with household incomes at least 400% of the federal poverty level (FPL), there is no limit. They must repay the entirety of their excess tax credit. Other repayment limits vary from $375 for a single person with an income that is 100% FPL up to 200% FPL to $3,250 for families with an income between 300%-400% FPL for tax year 2025.
Description
Requires that all premium tax credit recipients repay the full amount of any excess, no matter their income.
Effective date: taxable years beginning after December 31, 2025."
--
So, onto the question.
Background:
In the Medicaid non-expansion states, we already know people below 100% of FPL are in serious trouble, unless they become dirt poor in both income and assets to qualify for old-fashioned standard Medicaid. (I think there are 2.7 million such people.)
That's not the question.
The question is, is, in a Medicaid expansion state, if a person mis-estimates over 138% FPL on the exchange, and winds up under 138% or under 100% of FPL at reconciliation time, do they have to repay the APTC?
(I hope the answer is no, and that the summary, which I have clipped above, is incorrect, or I have misread it.)
Anyone who knows, can you respond with the answer in a comment?
Thanks.
(Reason for me asking may be obvious.)
Honestly, Norm, I don't know the answer to this one with any confidence - it feels pretty crunchy to me too. My gut says it likely depends on the state, and there's also the wrinkle that once someone drops below 100% FPL they'd generally need to enroll in Medicaid rather than stay on exchange subsidies, so it's not obvious to me why a repayment would even apply in that scenario. But I'm genuinely not sure, and I don't want to guess on something with real dollars attached. Hoping one of the wonkier readers here can give you a solid answer.
Thanks for attempting it. I don't know who actually might know. Perhaps somewhat like Katie Keith, at Health Affairs, who is a lawyer with her eye on the ACA details and the legal issues around that. (And, I might add, a good head for understanding, and foreseeing, all of the complexities.)
It may be that the issue is unclear in the law, even.
I don't think it can depend on the state, because it's a reconciliation on the federal tax form (filed by April 15, the year after the coverage).
--
The issue is coming up in my mind partly because I used the ACA for myself in Massachusetts, from about 2014 to 2022, before aging into Medicare-for-Me.
I happened to be in an unusual situation, which was retired but not drawing Social Security or cashing IRAs, so in that situation, I was hovering around the 138% FPL level in Modified Adjusted Gross income.
Massachusetts has its own exchange, and, of course, all states have their own Medicaid agency.
Now, in terms of the technical things to manage, the ACA, particularly with its division at 138% of FPL between expanded Medicaid and subsidized on-exchange, can get quite complicated and too much to manage without screwing up when the factors of people are using an estimated future income on the exchange (and a bit for expanded Medicaid), and throw in that expanded Medicaid may be based on a short period, like a month (depending on the state), whereas the federal subsidy I think is based on annual.
As well, incomes may jump around, especially as each state uses its own income determination, based on whatever estimating method, and whatever period of time it chooses.
So, this kind of thing (pre-OBBB) is a recipe for disaster, and so, in the 8 years I had the ACA, twice I was rapidly, on a few does notice, moved up or down mid-year between the two halves of the ACA, with a full provider change each time.
(One time it was because my FPL level was a teeny tiny bit above 138% FPL, and a mid-year update in FPL cutpoints nudged me a teeny-tiny bit below. This was where I had about 5 days notice of a complete network change because of moving to expanded Medicaid from on-exchange.
The other time it happened, I was actually a bit sick, and was possibly to be hospitalized, and I was in a limbo state for a few days as the state had to get my Medicaid sub-network in place in its computer systems. This was after me having to research, while fairly sick, to find the one Medicaid subnetwork to choose which accepted by my current GP. Lots and lots of phone calls for this finding that Medicaid subnetwork. Bad data encountered required lots of troubleshooting and effort to finally figure that out. )
Now, a point about that 138% FPL crossover: as best as I could tell, the state made it its goal to rapidly change you to the correct of expanded Medicaid and subsidized on-exchange as soon as it detected your short term income crossed 138% FPL, and it also requested you (you had to sign to agreen you would) tell the state within 10 days of your income changing.
Thus, it seemed Massachusetts could potentially thrash a person up and down between the two ACA halves as often as every two or three weeks, changing their whole provider network each time.
(For my last two or three years with the ACA in Massachusetts, I actually switched to on-exchange, without any APTC, which the MA Health Connector ombudsperson told me, correctly, would keep me from the thrashings. I took the PTC (not advanced) on my 1040, but was not sure always that eligibility for a Medicaid wouldn't disqualify me from it. The risk, and cost, was affordable to me, to save the thrashing.*)
--
So far, I'm all pre-OBBB. However, what I observed indicates the magnitude of the complicatedness, even with the original ACA, which maintains the byzantine complexity of our system, and is subject to all kinds of malfunctions, which each state will have prepared its own custom version of things likely to go wrong on its citizens.
So, the issue I'm trying to get at with my question, is, has the OBBB, even forgetting the work requirements, screwed up the ability of even the 41 Medicaid expansion states to provide coverage to the low-income group, by making it so that an honestly estimated income on the exchange above 138% FPL, followed by an income actually winding up below 138% FPL or below 100% FPL, will make people have to pay back up to tens of thousands of dollars? (The extreme case: $40,000 for a 62 year old couple in Wyoming.)
--
Of course, many wonks will not know the answer. I had no expectation that you would happen to know the answer. I though perhaps some reader of your 1000+ might, though, which is why I posted it, once I thought of the issue the other day. (I also posted the same question in a few other Substacks that health policy wonks might visit. So far, no answer, but I got a few likes!)
Perhaps the answer cannot be known until some legal case or cases makes it all the way up to the Supreme Court, in about 7 years or so!
--
Incidentally, the complexity of handling the work requirements themselves by 51 Medicaid agencies, has me separately worried about what could go wrong. Based on my experience.
On that, I am not alone, and I think the New York Times and Jonathan Cohn, and maybe KFF, have posted something.
--
* Actually, there was a second reason that made the declining the APTC and doing on-exchange, possibly forgoing a subsidy and paying full cost, a no-brainer.
And that is that, in some states, people 55 or or older when they have expanded Medicaid (or really, the problem is any non-LTSS Medicaid) are subject to an estate recovery, which could even mean all bills paid out have to be paid back by a person's estate. (The person don't have insurance! They have a loan, until death, for whatever medical expenses occur.)
When I first stumbled on this knowledge, in 2019, I tried to get it publicized and fixed, and had a little interaction with the xpostfactoid blog, as Andrew there caught the issue, and tried to get it fixed, federally, or state-by-state, I think including in his New Jersey.
My own MA, incidentally, did manage to fix it, but only in mid 2024. (That would be 10.5 years late. Even later if the same issue afflicted some part of Romneycare. I haven't looked into whether it afflicted some part of Romneycare.)
(At this point, your readers who are unaware of the issue may be saying, do you have a reference on this, for us to look at?
Fortunately, yes, I do:
https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing
(There are sufficient links to reliable reference places that everything I have asserted should be verifiable. In certain cases, you might have to go to the Wayback machine archive to find a page now gone from the live web, but I think mostly not.)
Bonus Material: On that thrashing that I was talking about, based on the Massachusetts agencies at the time thinking their most important duty in the world was to track every little income change as quickly as possible, and then immediately carry out the consequences of that change, I have the paper-version .pdf of the ACA application for 2019:
https://web.archive.org/web/20220814230835/https://www.bmc.org/sites/default/files/Programs___Services/Services/aca-3-english-3-21-19.pdf
There you got your item (11) on the page numbered 20, from which I quote:
"Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change."
On that other Medicaid estate recovery thing, which was in effect at the time, you might also note items (9) and (10), which, buried in the midst of innocuous-looking things indicating mostly "don't lie--we're gonna check", you've got these things telling you that the coverage you wind up getting might not be insurance at all. Only a loan until death for whatever medical expenses happen to have been incurred.
(I, and most people, used the on-line exchange. Not the paper application.
For that, the full set of conditions popped up after you entered all of your income and other information, and before you agreed to take your plan. So, at that point, you're supposed to, if you caught the items (9) and (10), supposed to stop everything, contact and pay for a specialized attorney to figure out what the heck they're talking about.)
As I have indicated, the Medicaid estate recovery problem was finally fixed in 2024 in Massachusetts. My guess is the continuous thrashing potential is still going on, and who knows whatever else very goofy and causing much misery will be added when the new OBBB provisions go into effect start of 2027. (In just this one state.)
Healthcare, like life, is messy as you and I have discussed. The challenge is as you have found it is incredibly hard to impact the whole machine.
I think I have shared with you previously, my own particular take on this is it’s incredibly difficult to say how you change the world other than one person at a time. I guess that is why my own writing has a few lanes that I jump around between. They are all connected by me and my experiences, but they are absolutely connected.
I love that you have the courage to take this step, and you know I have got your back in anyway you want me there. I’ve loved our short collaborations, and I’d love to continue them.
Kudos my friend. See you on the ‘Stack!
Andrew I understand how you feel both about work in Healthcare and about the healthcare non-system in the US. I retired at 71 after 20+ years in healthcare software for the same reasons. I wish you well and if I can help you find a way forward for the healthcare system, I am willing to work free to achieve that end.
Thank you David, it means a great deal to hear this from an industry veteran in the space - it's actually reassuring to hear about other folks who arrived at the same place!
I appreciate your gracious offer and am eager to do the work and make an impact
Say, Andrew. I just tried to paid upgrade my subscription. I got this:
"This Connect account cannot currently make live charges. The `requirements.disabled_reason` property on the account will provide information about why this account is currently disabled. If you are a customer trying to make a purchase, please contact the owner of this site. Your transaction has not been processed."
Maybe you have to fix something on your end?
Please let us know when you think you have it fixed, if it indeed is on your end.
It works now!
Too much info, but I put www.healthisotherpeople.com on Stripe but didn’t have the www DNS record up, so they couldn’t verify I had a blog. Tested it out and all good now
Thanks so much for your support! Also, thanks for giving me a heads-up about the upgrade issues - I looked into it and it was because I put www on my domain at Stripe but I didn't add the DNS record yet. Fixing it now, will let you know when it's all good!
It's so nice to see a person going out with their real feelings in this Instagram shaped world.
I am subscribing and wishing you all the best.
You are a kind of a 'new age warrior',
and sometimes people like you do change the system.
I'm crossing my fingers for this!
Thank you so much Zohar - that really means a lot, and welcome aboard!
"Warrior" might be a bit generous, but I'll happily take the vote of confidence. Grateful to have you along for the ride!
Andrew, read your letter and appreciated it. Sharing your ideas and your point of view without the handcuffs of the big company logo is liberating. And it’s hard….but oh so rewarding. You’ve done the hardest part: overcoming the fear. Now do the work: create a formal business strategy and plan for yourself. On paper. With all the discipline you had in your $200k/ye job. Next chapter starts now.
Thanks so much Archelle for the words of support! Like all things, overcoming my own fear is the biggest thing to me living a fulfilled life.
Best way to do that is to take a step forward. Once that's done, take another step and repeat. Consistency and hard work!
I recently left an executive role at a large payer and your words really hit home for me. There is so much that is broken about the healthcare system and the only solutions offered are either impractical because of naïveté (“let’s launch a digital health app that will solve everything!” or they fail to address the core issues of that brokenness (“let’s use ambient AI to submit claims!”). For many in the industry, it just is what it is. But it’s deeply frustrating if you know it can be better, want it to be better, and believe we all deserve better.