Natalie Powell (not her real name) is sitting across from me at a sushi restaurant. She’s just recovered from a 48-hour pain episode brought on by trouble afflicting her neck.

“I get them about every two to three weeks,” she says. “Treating them means lots of bed rest, ibuprofen, Tylenol, and sleeping pills.”

She’s contemplating having an operation, something that is, naturally, causing her anxiety.

But she’s anxious for another reason. By the end of the year she may lose her insurance, which she has had since 2008, and her primary-care physician whom she has been seeing since 2003.

The cause of this is, not surprisingly, Obamacare.

Natalie, a Washington, D.C., resident, first began experiencing neck pain after a truck rear-ended her car in July of last year. The whiplash she received herniated one of the discs and altered the bone structure in her neck.

“My neck was not in great shape before the accident, although I was largely asymptomatic. Since then not only do I have pain, but I’ve lost much of the curve in my neck. It’s much more straight up-and-down now,” Natalie said.

Her troubles worsened in October when the D.C. Health Benefit Exchange Authority, which runs the Obamacare insurance exchange in D.C., decided that individuals and small businesses with fewer than 50 employees would not be allowed to purchase insurance outside the exchange.

Natalie, who has had her current policy through Blue Cross, doesn’t know if her policy will be sold on the D.C. Exchange. She’s contacted Blue Cross and, thus far, they have not given her a definitive answer.

If it’s not, then she’ll have to purchase a different policy. And there’s the rub: her primary-care physician is no longer accepting new insurance.

“She’s a very popular doctor,” Natalie said. “She had all but stopped taking new HMO [health maintenance organization] policies when I managed to get my first appointment with her. Now, she’s booked. She’s not even taking any new patients.”

Natalie has an HMO policy from Blue Cross that is coupled with a $1,200 deductible. She likes it because it costs her about $150 per month in premiums. As it is in an HMO, the doctors she sees have to participate in the HMO’s network and her primary-care physician must approve any visits to a specialist. That’s not a problem for Natalie, though, since she has such a good relationship with her primary-care physician.

Natalie desperately wants to keep her policy, even if it means buying it off the exchange (that means she won’t qualify for any tax credits, but she earns too much to qualify for those anyway).

But the D.C. Exchange may take that option away. Mohammad N. Akhter, the exchange’s chair, reasons that if people can buy outside the exchange, not enough people will participate in the exchange to make it viable. “For the exchange to be sustainable, it has to have approximately 100,000 people,” Akhter said.



Right now the D.C. Exchange is running off grant money from the federal government. That ends in 2015. After that, the exchange will be responsible for funding itself. The legislation passed by the D.C. City Council authorizing the exchange enables it to charge user fees, licensing fees, and other assessments on insurers who participate in it.

The problem for D.C. is that so many of its residents work for the federal government and, hence, get their coverage from the Federal Employee Health Benefits Program. Thus, the individual market available for an exchange in D.C. is quite small.

In a study of D.C.’s health insurance market, Mercer Consulting estimated “there are approximately 19,100 District residents (12,800 uninsured and 6,300 direct purchasers) that would be primary candidates for coverage through the exchange.”

The federal government has decided to charge a user fee to insurers who participate in a federal exchange. The user fee will amount to about 3.5 percent per premium. If that user fee is applied to the D.C. Exchange and it is assumed that the average policy will cost $6,000, with 19,100 participants, the exchange will only gross about $4,011,000 annually. That may seem like a lot, but running an exchange apparently cannot be done on the cheap. Between 2010 and 2012, the federal government gave D.C. over $82 million to get an exchange up and running.

Mercer also identified about 125,000 people who get their insurance from small employers (businesses with fewer than 50 employees). Add in another 15,700 people who buy insurance on the individual market but are not “primary candidates” for the exchange (i.e., like Natalie they don’t qualify for tax credits) and you now have about 159,800 people that can be forced into the D.C. Exchange. Doing the math again, that yields an annual budget of over $33.5 million. Now we’re talking real money.

This forced inclusion of small businesses in the D.C. Exchange didn’t go unchallenged. A letter to the exchange signed by over 150 small businesses warned:

… by dismantling and recasting the separate health insurance marketplaces that serve small employer groups and individuals in the District, D.C. policymakers would take away the option of keeping the health plan that they now have. Rather, to continue to offer health benefits to employees after 2013, small employers like us would have no choice but to go to an undefined, untested, more expensive entity to obtain coverage. … In addition, many of us have long-established relationships with health insurers we know and are guided by broker advisors who understand our unique needs. We do not want to be forced to buy the standardized, cookie-cutter coverage that would be offered through a government-run Exchange.

Ultimately, the D.C. City Council will have the final say on the exchange’s decision. Whether councilmembers will decide to allow D.C. residents to purchase insurance outside the exchange is anybody’s guess at this point.

For Natalie, the exchange’s decision means tremendous uncertainty surrounding how her present medical issues will be resolved. She especially doesn’t want to lose her primary-care physician.



“Right after the accident, I was experiencing some pain and some numbness in my right fingers,” Natalie said. “I didn’t think it was a big deal, but I called my physician anyway. She insisted that I come see her.”

After an evaluation, Natalie’s doctor referred her to an orthopedic surgeon. The orthopedic surgeon ordered an MRI that showed extensive damage to Natalie’s neck. He said she will need surgery that will involve replacing one of the discs in her neck with an artificial disc. It will also involve fusing some of the vertebrae by inserting titanium rods into them.

Natalie wasn’t sure about the surgery, so her primary-care physician referred her to a physical therapist. The physical therapist has helped Natalie manage her pain so that she now only has major pain episodes every two to three weeks. Her primary-care physician also referred her to a neurosurgeon for a second opinion. The neurosurgeon told Natalie that there might be ways she could manage her pain, but in all likelihood she would still need the operation.

“I’ve become very partial to physicians and my physical therapist,” Natalie said. “I want them to continue in their care.”

Natalie increasingly thinks that she’ll have the surgery. However, she notes that if she could keep her insurance and her medical team indefinitely, she’d have the luxury of waiting a year or two to see if she could get the pain under control (or at least live with the pain she has) and avoid an operation. Now, she may have to decide on an operation within a few months so that her current physicians can treat her.

Unfortunately, Natalie’s travails may not end there. Fusing two vertebrae often puts pressure on the disc underneath the two vertebrae, causing it to weaken. More treatment — possibly even another operation — could be down the road if that happens.

At times, Natalie feels her trust in progressive leadership was betrayed.

“I voted for Obama in 2008 because I couldn’t stand McCain,” she said.

During the debate over Obamacare, President Obama assured the American people, “No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what.”

Natalie may lose both.

“I can’t say how disappointed I am because I believed him,” laments Natalie.

David Hogberg is a senior fellow for health care policy at the National Center for Public Policy Research. Follow him on Twitter.