A THCB Reader in Maryland writes:

“I realize many individual health insurance policies are being cancelled because they are not in compliance with the ACA’s new requirements. 

Do the new ACA requirements effect all individual plans sold or just those available in the exchanges?

In other words, if I am a self employed, single 50 year old male who does not want maternity, pap smears and mammograms; can I solicit an individual policy outside of the exchanges that meets these needs? For that matter, could I find a policy in the exchanges that meets these needs?”

If you’ve had a bad or good experience attempting to buy health insurance on the state or federal exchanges, we’d like to know about it. Drop us a note.

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62 Responses for “I’m Male. A Non-Smoker. And in My Fifties. Can Somebody Please Explain Why I Have to Pay for Maternity Coverage?”

  1. HIT Geek says:

    Insurance is composed of a pool of people. The larger the pool, the lower the cost due to shared risk. That;s the way insurance works.

    Insurance is not all about you. It is about society, sharing risks.

    So, if you want it to be all about you, establish a savings account for your medical care. Don’t get insurance if you don’t want to share risks. Of course if you get sick and it costs more than you’ve saved, that’s just your problem. Other people don’t have to pay for your illness since they don’t have it.

    • MD as HELL says:

      Pap smears and mammograms are not about insured risk. They should not be covered by insuance. Neither should any screening test. Wellness medicine is for the worried well. Let them write a check.

  2. Insurer says:

    Look, us executives must be able to take down more than $10 million in compensation, and we need suckers like you to bend over and pay to cover those sicker than you and at higher risk. Welcome to America, where they rob from the poor and give to the wealthy.

  3. Fireplug says:

    How about I’m a woman why should I pay for a man’s prostate surgury,I don’t have a prostate,the list could go on and on,how about I ‘m not mentally ill never plan on being mentally ill why should I have to pay for it.Lets let all the dangerously mentally Ill out on the street so they can shoot us in the movie theaters,or in the airport,oh never mind we already do that.Its about taking care of people for the betterment of society as a whole not he individual.Healthy well educated children become better tax payers,benefiting the senior citizens they will support with their payroll taxes.If you want to get angry how about the 90 year old stroke victim kept on a ventilator for 10 months with no brain activity to the tune of 5 million dollars,just read in the news about that one,the son was suing the hospital to keep her on the machines.Bet if the 5 mil came out of his pocket he’d pull the plug fast.

  4. Sundae Driver says:

    It used to be that most insurance was a voluntary purchase. Now we have those who argue that insurance is a societal obligation. Yet, the reason that healthcare costs have increased is that we fund it with insurance instead of paying as we go. No one cares about how much care costs as long as somone else is paying for it.

    Now that we mandate that we have insurance and what it should cover, it will become even harder to control costs. It’s easy to say that men should pay for maternity costs if women have to pay for prostate surgery. Yet, in many cases, pregnancy is voluntary. Prostate troubles tend not to be voluntary. So how do we decide what costs are covered and what are not? More importantly, who decides?

    We had a healthcare system that worked quite well but needed some tweaks. The ACA doesn’t fix what needed fixing. It breaks what was working and replaces it with more problems.

    • Fireplug says:

      Yes pregnancy is voluntary,but unless it’s artificial insemination having a baby involves a man and a woman,therefore men of childbearing age have half a financial stake as well,it just happens a woman’s womb has to do the carrying,if we were seahorses the male would have the burden of carrying the offspring.Then we could have the arguement men should pay for maternity care.

    • MD as HELL says:

      It is a tax.

      Your coverage will suck no matter what. Put your assets in a trust and get the cheapest coverage you can. Pay for the care you want. Save your money. Get self-sufficient. Have a doctor in the family.

      • June says:

        You assume he is not self-sufficient. This implies either that he is accepting government subsidies, or that your definition of “self-sufficient” is “wealthy enough to pay cash for a kidney transplant.” The former is offensive. The latter is ridiculous.

        Creating a trust requires an attorney to draw-up a document dozens of pages long at a cost of thousands of dollars. This does not seem like a reasonable replacement for health insurance. It seems like a silly suggestion.

        “Have a doctor in the family” is just a snarky add-on.

        If you are, indeed, an actual physician, it would be helpful for readers if you would provide suggestions and information that are reasonable and based on your inside knowledge, rather than just spewing snark. Snark doesn’t help anyone.

        • MD as HELL says:

          Thousands in co-pays and coveraing half is not coverage. There is no rational way through this.

          This must stop now.

          • Jen says:

            If you really are an MD, you would understand the rising cost of med school and that not all families can afford that. Therefore, not everyone is lucky enough to have an all knowing MD in the fam.

  5. legacyflyer says:

    Allow me to offer an explanation which is (hopefully) not as judgemental as some of the above answers.

    So let us assume that it cost 5 million dollars to cover OB services for 1 million people (obviously not the right number). Therefore everyone (including you) contributes 5 dollars. But you are a man and don’t need OB services. So if we pull you out of OB coverage, you would save 5$. But if you start pulling out all the people that don’t need OB services – the majority – then the insurance company needs to raise premiums on women in the childbearing years. Discrimination?

    Similarly, (as someone above pointed out) if women were pulled out of paying for prostate cancer, you would need to be charged more for coverage for prostate cancer – maybe $5. There goes you savings.

    And then people with pre-existing conditions would need to be charged more for dialysis, diabetes treatment, etc. And pretty soon the whole ball of yarn starts to unravel.

    And the ACA is not only insurance, but a cross generational subsidy program that transfers money from young to old. And you as a 50 YO male are being subsidized by a 25 YO – who has to be forced to buy insurance with penalties.

    • Fireplug says:

      I’d like to point out my daughters are both around 25 years old,subsidizing all you childless couples in your old age.

      • June says:

        And I would like to point out that me and my husband, who are childless, subsidized the education of your two daughters. I’d much rather subsidize someone’s health than their education.

    • Lisa says:

      The young are not subsidizing the old. Check the website. Young people can buy catastrophic insurance for under $50/month while the old (greater than 49) must pay a minimum of $450/month. If anything, the big losers in this game are old people who were foolish enough to stay healthy and save for retirement.

      • legacyflyer says:

        Don’t know where your numbers come from.

        It is my understanding that as part of the design of the ACA rates were “compressed”. In other words, the rates for young people were raised and those for older people were lowered. This was part of a conscious attempt to cross subsidize older, less healthy people by younger healthier people.

        Perhaps someone who is more familiar with the rate structure can add more.

        • Lisa says:

          My quote is directly off the website. It’s my lowest option. Anybody who wants to kick the tires can log on to HealthCare.gov and check for themselves. You should try it instead of propagating false information.

          For real grins, check the price differences of different states. I’m thinking of moving to North Dakota. ;)

          • Peter1 says:

            “It’s my lowest option.”

            With or without a subsidy?

            “Anybody who wants to kick the tires can log on to HealthCare.gov and check for themselves.”

            You mean we can log on just like Amazon, browse, compare, roam, in under 10 seconds? No need to spill your personal profile and register first?

          • Lisa says:

            Answers to Peter1 (below)

            All of my quotes are without a subsidy because I’m using the website without logging in and have not created a profile yet.

            Yes, you can browse, roam, and compare without spilling your personal information.

          • Peter1 says:

            “Anybody who wants to kick the tires can log on to HealthCare.gov and check for themselves. You should try it instead of propagating false information.”

            Lisa, you are right you can just kick the tires, but the pricing information is useless. This was discussed earlier. “Quotes” are only for two age ranges, under 49 and over 50. The estimates for under 49 are based on a 27 year old and the over 50 is based on a 50 year old. (Or thereabouts)

            Commonly called teaser rates in private business.

  6. martingop says:

    I don’t plan on having any car accidents. Or a workman hurting themselves working on my home. Or someone suing me because I’ve made an error or omission in my work for them.

    But I buy insurance to protect me against all of these. And my premiums pay for those that incur losses.

    Such is the nature of insurance. Get over it.

    • MD as HELL says:

      You do that by paying a premium.

      This has been ruled a tax. As such it is not voluntary.

      Furthermore, since you must buy something,they will sell you crap, because you must buy it.

    • Lisa says:

      Martingop, I agree with you — if catastrophic insurance were available to everybody then the ACA would be a very good thing. Rates are already set by age, but the option of buying insurance with a very high deductible is only available to the under-30 people.

  7. Sundae Driver says:

    There are some interesting responses here. Before the ACA, we had a fairly functional healthcare system. Most got by on employer-provided insurance. Some had government provided insurance. And about 15 million purchased individual insurance policies that provided coverage they deemed necessary.

    In the first meaningful wave of the ACA is individual mandate. Most of the 15 million are learning their coverage doesn’t fit the standards determined by government. They are told that their current coverage is substandard. So now they must abandon their current coverage for coverage that exceeds what they want. Of course, no one asked them. Had they wanted more coverage, the insurance companies would have been happy to sell it to them.

    The stated goal of the ACA was to provide insurance coverage to the 45 million who lacked insurance coverage. The CBO projects that only 15 million will gain coverage after the full implementation of the ACA. Why must we disrupt or destroy the coverage of the 15 million who have individual policies to extend coverage to 15 million who do not?

    Why not develop an insurance plan that provides coverage to those who don’t have it but want it while leaving the rest of us alone? Weren’t we promised that if we like our coverage, we could keep it? Period.

    In other words, why should someone purchase insurance coverage they do not ask for? Especially since they were explicitly promised they wouldn’t need to?

    • Peter1 says:

      “Before the ACA, we had a fairly functional healthcare system.”

      Are you talking about the employer provided system or the individual market?

      “And about 15 million purchased individual insurance policies that provided coverage they deemed necessary.”

      Deemed necessary or what they could afford which may or may not have provided “necessary” coverage.

      Considering costs and rising premiums this has never been a “functional” system, it has been a system heading for the cliff.

      Tell us how you pay for your own coverage?

  8. t says:

    Yep, costs like these disproportionately falls on people on the individual market. I’m female, older, have no kids. My premiums went up a $1000/yr, my deductible will be way too high for me to ever meet it and get any care. And if I go to an Exchange plan, I lose access to every single one of my doctors because of the thin networks.

    Why? So I can have maternity coverage. I get no real coverage at all unless I’m catastrophically sick.

    If the whole society paid, the cost would be more evenly distributed. That is not what is happening here.

    • Peter1 says:

      “If the whole society paid, the cost would be more evenly distributed.”

      Support single pay.

      t, will you get subsidy?

      “I lose access to every single one of my doctors because of the thin networks.”

      How many doctors do you require?

      • t says:

        I get subsidy if I accept an Exchange plan, but not, if I don’t go outside of the Exchange. However, the Exchange plans have narrow networks and in our area, the networks exclude all research hospitals and specialty centers. Thus, I don’t consider them insurance, since insurance is about minimizing financial catastrophe — providing a safety net for the most serious illnesses. When you’re seriously ill, you need specialty centers.

        I support single payer, 100% The administration had an opportunity to move in that direction. They instead opted for high insurance company profits. We won’t see single payer in my lifetime.

        • Peter1 says:

          t, I do not support these narrow networks, but in insurance mentality they keep costs lower. If we had access to all providers, regardless of cost, we’d all choose the most expensive.

          Would you get access in out-of-network extra cost? Agree single-pay not in our lifetime, so pester your congressman, especially if Republican, to improve rather than dump ACA.

          For once Republicans seem to be newly converted consumer advocates.

  9. Sundae Driver says:

    About 5% are covered in the individual insurance market. Of those, 62% do not have policies that cover maternity, or a 3% of people. While we don’t know how many of the 3% do not have maternity coverage by choice, but it’s safe to assume that a larger percentage do not.

    So we essentially destroy the private, individual insurance market (and soon, the employer-provided insurance market) to force 3% to purchase maternity coverage? Doing so will result in a number of those who currently have low-cost, affordable coverage to forgo insurance altogether since the ACA exchange policies are costlier. The math simply won’t work no matter how much we hope it will.

    The question still remains, why do we destroy a system that has proven to be fairly effective in exchange for a system that will not expand coverage, will not lead to healthier patients, and will not lower costs?

  10. Bob Hertz says:

    The drafters of the ACA looked out on the individual market and saw some very clear deficiencies, such as no maternity coverage and relatively low lifetime limits.

    So they created a law that would force those mean insurance companies to step up and provide more coverage.

    They may have known that those insurance companies would then raise premiums. But the subsidy program was supposed to cushion the blow for many thousands of insured.

    Frankly I do not remember if the subsidy program started out more generous than it is now. It might have been cut back to meet CBO scoring assumptions, I am not sure.

    The one thing that puzzles me about the anecdotes of the last two weeks is this:

    where did these very cheap pre-ACA individual policies come from? When an angry person testifies that their existing premium is $370 a month for a decent family policy with a $3000 deductible, I am stumped. I have sold health insurance in MN and hhave almost never seen such a policy, and certainly not after regular rate increases.

    • Fireplug says:

      From what I’ve been hearing many of these cheap plans had no coverage for inpatient hospital care and no prescription medicine coverage.Some people are disputing that but I’ve always found the old adage you get what you pay for is usually true,the policies were worthless.

  11. Bob Hertz says:

    To Fireplug — I think you are wrong. The cheap plans did provide decent coverage, perhaps with more recissions than group coverage but on the whole they did pay claims.

    Instead, they relied on tight underwriting to suppress the volume of large claims for 3-5 years. I have done life insurance underwriting and this is how we worked also. If you examine people closely for blood sugars, cholesterol, etc., then you will of course get some car accidents in the first few years but you will not get too many chronic disease claims until the underwriting “wears off.”

    The elimination of underwriting by the ACA shoots down this method of making profits, so the insurers are retreating but charging high premiums as they retreat.

  12. Fireplug says:

    I had one of these plans back in the day,they capped my prescription drug plan at $1000 a year,my daughter was on human growth hormone shots for a growth deficiency ,it was $2000 a month.Fortunantly my husband was retired from the military and we were able to go back to his champus plan,it had no cap but paid claims so low we had to go to the one public hospital in the middle of the ghetto for primary care,never had a doctor for more then a few months before they dumped my plan.After the Iraqi war started I think the local hospitals got shamed into accepting what is now called Tricare,I now have Cleveland Clinic doctors,but it’s to late for my kids.This was an employee based plan before the Clinton administration forced comprehensive coverage on large employees,I worked for an airline with 80,000 employees at the time.

  13. legacyflyer says:

    This is an excellent discussion about the re-arrangement of the deck chairs on the Titanic.

    We need to do something to drastically reduce the cost of Medical care in the US. And anything authored by lawyers won’t do that.

    We also need to provide every American with BASIC medical care. And once the lobbyists for all the special interests sign in that won’t happen either.

    Watch the downward spiral continue. (Is that optimistic enough?)

  14. MD as HELL says:

    You are paying a tax. Same as all taxes.

    The “coverage is really an illusion. You will have nothing covered . You will demand single payor. You will still have nothing covered that you want in a time and manner that you expect.

    Hope it will Change.

  15. Mr James says:

    The answer: Because the government said so. It is the same reason you also will have to pay to cover “free” preventive care and birth control and all sorts of other little add-ons.

    It is one thing if people voluntarily form/join a risk pool with risks covered that they wish to include. However, in this case, the government has stepped in and demanded, in effect, that every Happy Meal comes with a side of broccoli.

    You get it whether you want broccoli or not. You pay for it, too.

    You will see more things added as every interest group with a lobbyist seeks to get an automatic pipeline to profit via mandated benefits. Chiropractics, acupuncture, quack hormone replacement and “detox” allergy treatments, whatever…

    What is covered and not covered have become political decisions.

    • Peter1 says:

      Mr James. do you oppose pre-exist pooled coverage, women paying for mens prostate cancer, erectile disfunction; men covering women’s breast and uterine cancer and so on and so on?

      • Mr James says:

        You are asking the wrong question. I am perfectly fine with any voluntary arrangement between those who buy insurance and those who sell it. My problem is when government intervenes and demands that certain benefits become mandated or provided for “free”.

        The inevitable trade-off is higher costs.

        Once this takes root, the list of what is required or “free” starts to grow as every interest group under the sun hires a lobbyist and runs to their legislature.

        I know about lobbying for mandated coverages because I was an insider to the process at a state capital.

        Should chiropractors be mandated? Acupuncture treatments? Alternative medical treatments? Rest assured that every one of these and more has their lobby team working lawmakers.

        • Peter1 says:

          “Should chiropractors be mandated? Acupuncture treatments? Alternative medical treatments? Rest assured that every one of these and more has their lobby team working lawmakers.”

          Let them show medical benefits and overall cost savings. While I certainly understand the financial rewards of being mandated, it must at least pass the smell test. Can’t stop people from lobbying and any politician who votes for this will have to stand for election and be judged.

          “If one wished to handle those who literally couldn’t get insurance at any price (a small group), there would have been a lot cleaner ways to do it than this monstrosity of a law.”

          What cleaner way would there be which would not cost the rest of us?

          • Mr James says:

            Trust me, every group that wants to get on the list comes armed to the teeth with their claims for benefits and savings. Nobody shows up at the door saying their service/product/specialty/scan will hurt patients and cost more money.

            The issue is that they cannot convince the insurance market (and those with existing coverages) that this is worth the cost. So, they make an end run around it by going the mandate route.

            Insurers have motivation to cut costs of care, so why would they not jump on things that actually worked? Do they want to make LESS money?

            It would be great if the general public could make the connection between “free” stuff added to their policies and the rising costs. It would be even better if they held elected officials accountable. However, a scary number of people can’t even name their national elected officials (or their state ones), let alone know their voting records.

            Given how badly ACA is flopping (and the full negative impacts are not even here yet), I can’t think of any option that WOULDN’T have cost less and done better.

            I would point to the Hippocratic oath for those who legislate in the field of health care: First, do no harm.

          • Peter1 says:

            “Given how badly ACA is flopping (and the full negative impacts are not even here yet), I can’t think of any option that WOULDN’T have cost less and done better.”

            For sure the sign up process is a disastrous mess designed by idiots, but we don’t know if the ACA is “flopping” yet as not enough people can actually get it to work, other than a couple of state exchanges. Getting the cost of insurance down is not getting the cost of care down – which should be the ultimate goal. Can’t say if ACA will ever do that given the large and wealthy corporate lobby for providers and insurance.

            Including pre-exist and no maximums is something that can visit anyone. Preventive no costs will hopefully catch disease early. The problem is with those who had insurance that did not meet ACA standards and with insurance companies deciding that many policies be cancelled with new policies required. It’s hard to say how many of those policies were junk policies and how many were legitimate.

            Obama did not make the proper pitch as to why everyone in the individual market should shoulder those costs alone. But limiting these policy mandates to just the individual market has made that market more costly than it would have been if the load was spread over larger pool.

            This country continues to segment health care into unnecessary political pools – Medicaid, employer, Medicare, individual. Until we have full universal coverage under one pool we will not get this right.

  16. Stan_1036 says:

    I’m not sure the bulk of the premium increases come from mandated benefits. Don’t they mainly come from eliminating insurance companies’ ability to exclude preexisting conditions? Put differently, sick people can now buy individual coverage, not just healthy people. That means average costs rise for current, relatively healthy enrollees. Ezra Klein wrote something very clarifying on this subject recently.

    The other big issue in insurance reforms is making coverage real — eliminating annual and lifetime limits, for example, so that people don’t discover, to their horror, that insurance doesn’t cover them if they get hit by a car or develop a serious illness. Then the costs get passed on to others.

  17. Mr James says:

    “Then the costs get passed on to others.”

    The costs still get passed on to others if the person is mandated entry into a risk pool. In this case, the “others” will be the other insured members of the same pool.

    If one wished to handle those who literally couldn’t get insurance at any price (a small group), there would have been a lot cleaner ways to do it than this monstrosity of a law.

  18. Bob Hertz says:

    Note to Stan: you are correct that most of the mandated benefits add only one or two percent each to the cost of policies. Even ten mandated benefits would add 10 or 15 per cent to premiums, and the insurers have been raising premiums that much anyways for years.

    You are correct that guaranteed issue is the big item. Some insurers cannot make money in such a market, so they are dropping out but cjharging high premiums on the way out (an old tactic)

    Note to Mr James: You are correct that a full fledged high risk pool would be a much cleaner solution. The high risk persons could just be added to Medicare, which would take no new computers or bureaucracy anywhere.

    But that would require an on-budget expenditure of $100 billion or so.
    That would require a tax increase of less than 2% of payroll.

    But both parties shy away from such honesty.

  19. MD as HELL says:

    Most healthcare spending is for discretionary stupid stuff. Why cover that?

    • ernesto says:

      Most healthcare spending is for discretionary stupid stuff.

      Please provide us with the facts to back up your statement.

  20. 2cents says:

    A 50 year old man may not need maternity care, but his 30 year old wife might or his college age child still remaining on his insurance might. What makes you think that a provider on the exchange will not allow you to use your doctors? Do you have knowledge of that? Why couldn’t you or wouldn’t you be able to shop for the policy that your doctors take?

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