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    Obamacare and Us


    It has been over three years since the Patient Protection and Affordable Care Act was passed. It is often called the Affordable Care Act (ACA) or more commonly, Obamacare. It is undeniably the most significant change in the United States health care system since Medicare’s enactment in 1965. There are still challenges to parts of the legislation and regulations are still being worked out. It is due to take effect January 1, 2014, and the open enrollment process begins October 1, 2013.

    What does this 20,000-page legislation mean for us, as an LGBT community, or as individuals with or without children or same-sex partners? And what if we are married to that partner?

    As a disclaimer, I am not a health care policy expert nor do I pretend to understand all aspects of this law. As a provider, I am always aware of patients’ insurance coverage. I do not provide care on that basis, but I certainly am considerate of the challenges patients face with co-pays and deductibles. With Obamacare around the corner, I was curious how things would change. I was especially curious about its affordability.

    If you currently have health insurance through your employer, that may not change, although it might, mostly in the form of higher premiums or deductibles (nothing new there). The so-called “Cadillac Tax” for “good” plans will not go into effect until 2018, we think. If you currently have Healthy San Francisco, it is expected that most plan members will be moved to Covered California or
    Medi-Cal. These new options may improve your coverage allowing you to access care beyond the borders of San Francisco. You can go to for more information or call 415 615 4555. There is a penalty for not buying insurance. It is the greater of $95 or 1% of annual income. However, the penalty does not apply to people who would pay more than 8 percent of their income for health insurance, and that threshold may not be uncommon.

    How does one enroll in Obamacare? There are Health Insurance Marketplaces. In California it is called “Covered California” and can be found at or call 1-800 300 1506.  For our readers outside California, try the 24-hour government help line, 1-800-889-2596, or go to

    I tried the Covered California plan, with several scenarios of income. At first glance, the numbers may be frightening. But there are subsidies for premiums and share of costs. They help to reduce or eliminate costs for many lower income people. However, the magic number where subsidies disappear is $45,000. If your income falls above that, even by a small amount, your share of cost will be the same as someone earning $100,000. For one mid-range plan, the monthly premium (for a single individual age 51) was $550 with a maximum out-of-pocket expense of $6,350 (this does not include the premium). So the individual earning $46,000 can pay up to $12,950 or nearly 25% of their income. By whose definition is this affordable?

    For a lot more information than can be covered in this short article, see The Best Obamacare Guide: For you, your family, and your business by Don Silver. It is available only as an ebook, but it comes with updates. For example, I purchased the book today, wrote for updates and immediately was told that the recent IRS ruling regarding legally married same-sex couples means that their combined income will be used to determine eligibility for Obamacare subsidies. You can run the numbers to determine if you are financially better off married or not, just like the straight folks.

    I would have preferred a kinder, gentler Obamacare (disclaimer #2, yes I preferred a one payer system). Obamacare does have its good aspects, however. Those include required coverage for mental health care, the end of penalties for pre-existing conditions, preventive services, integrative medicine, and basic health coverage for millions of previously uninsured Americans, including, of course, many in our own LGBT community.

    Dr. Naomi Jay is a nurse practitioner in the department of Infectious Disease at UCSF.