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> The "logic" there (from reading discussions of the cutoff) is that, "well, if you're below the poverty line, you should be on Medicaid and not on the ACA exchanges at all, silly!" Okay, but if you have wildly varying income, and a high income from previous years, you don't know that you'll be "in poverty" this year, and won't qualify because of the past year.

This wasn't setup this way because it was thought to be a good design, but as a political compromise. At the time, it was seen as important to keep the headline cost of the bill below some arbitrary threshold and for it to be revenue neutral (the wisdom of this is questionable in hindsight since the moderate Dems that supported the bill mostly got wiped out anyway and it never got any Republican support). Medicaid is cheaper for the government than ACA subsidies (at least for low income people given the way the subsidies are structured), partly because the government has a lot of negotiating power and partly because Medicaid is stingy.

This was made worse when the Supreme Court ruled that the federal government couldn't make receiving existing Medicaid funding conditional on Medicaid expansion (Medicaid is partially funded by the federal government, but the program is administered by individual states) so whether the Medicaid expansion is even available to you largely depends on whether your state is run by Democrats or Republicans (with a few notable exceptions).

People like me are an extreme edge case, I doubt this was a big factor in any debate.

I would consider just taking the medicaid for a year.

Medicaid can actually be very good quality healthcare, if you're located say, near a very good research hospital in a city with a structural oversupply of medical care due to having a lot of med schools.

I'd rather have medicaid living next to a high quality (non profit) health system, than "nice" insurance living in a shithole. All the insurance in the world can't materialize doctors that aren't there

> I would consider just taking the Medicaid for a year.

ACA subsidy eligibility may be annual, but Medicaid eligibility is based on current monthly income, and if you have a change that makes you ineligible, you lose it. You can’t just decide to “take Medicaid for a year” because you aren’t subsidy-eligible based on prior-year income.

So? Isn't losing medicaid an ACA qualifying event? Your income goes up, you lose the medicaid but now qualify for ACA.

That said, in my secondhand experience across multiple states I won't name, the medicaid office probably won't actually find out or do anything before 12 months are up.

Also, a few states are starting to officially enact "continuous eligibility" and intentionally not check your income for 12 months -- mostly for children[1] right now, but some states for adults[2] too.

[1] https://www.medicaid.gov/medicaid/enrollment-strategies/cont...

[2] https://www.commonwealthfund.org/publications/issue-briefs/2...

ACA subsidy eligibility is not annual. "Income changed" is a qualifying event.

A reminder to anyone reading that there is no actual "opposite problem" to yours (which I'm very disturbed to hear about, hope things work out).

For now, there is no income level cut off for ACA premium subsidies, just a limit that says you should never spend more than 8.3% of your AGI (more or less) on health insurance (more or less).

This may change next year and/or in the future.

I had a friend in that situation one year. He reported some imaginary income that brought him up over that limit. Paid the tax on it, received the subsidy, and was able to continue with his existing ACA healthcare plan (and doctors, and etc).

Oh wow, good to know about other people who went that route. I was also considering getting a friend to pay me "consulting fees" for their business, and then I'd silently gift back the money ... but, as above, ick.

> (Which, I know, being retired on crypto, I also feel ick about taking the subsidies to begin with, but that's a different issue.)

One qualifies for subsidies regardless of how much wealth they have? Sounds like US welfare system is a joke.

Well, remember, any time you have cutoffs like that, you can introduce the kind of welfare traps and discontinuities that the article focuses on. But yes, Congress definitely wasn't even asking "wait, do we want the subsides for high NW, choose-your-income people?"