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Times special report: Is the health act affordable?

Health insurance ‘marketplace’ set to launch Oct. 1

POSTED: September 22, 2013 12:06 a.m.

Barring congressional attempts to derail it, the fiercely debated and legally tested Patient Protection and Affordable Care Act is poised to take a major step toward full implementation on Jan. 1.

Beginning Oct. 1, Americans can go online at government-regulated insurance “marketplaces,” or exchanges, and shop for insurance plans as an option to complying with the law’s “individual mandate,” a main focal point of the health care reform law and one that has passed U.S. Supreme Court review.

Under the law, all Americans are required to have insurance or face IRS penalties that will escalate year to year.

For many people, little will change, as half of Americans will continue to get insurance through their jobs, according to the Henry J. Kaiser Family Foundation.

Those who fall into this category still can check out the exchange, but any job-based plan must have “minimum essential coverage,” such as free preventive checkups and prescription drug coverage.

Also, “be aware that you may not qualify for lower costs on your monthly premiums and out-of-pocket costs, even if your income would qualify you otherwise,” according to a website set up by the U.S. Centers for Medicare & Medicaid Services to help set people on the path toward enrollment.

“With most job-based health insurance plans, your employer pays a portion of your premiums,” the site states. “If you choose a Marketplace plan instead, your employer does not need to make a contribution to your premiums.”

The health care law’s requirement that companies with 50 or more employees cover full-time workers has been postponed until 2015, but companies already are reacting to that provision — like UPS, which is ending health coverage for thousands of employees’ spouses, starting in 2014.

One third of Americans will get coverage through Medicare, a federal health program that pays for some of the medical and hospital expenses of people older than 65 using Social Security money; and Medicaid, a public health program funded by the U.S. and state governments for people who meet low-income guidelines.

The Supreme Court threw out the law’s requirement that states expand Medicaid, covering anyone in homes earning up to 138 percent of the federal poverty level, or face losing federal support.

As the dust settled from that ruling, states had the choice to expand Medicaid, and Georgia Gov. Nathan Deal opted out, saying he was concerned the expansion would lead to a deeper funding crisis for Georgia. Such an expansion would add about 620,000 people to Georgia’s current enrollment of 1.5 million.

Finally, Kaiser further estimates that 1 in 10 Americans will buy their own insurance, while 30 million or so will remain uninsured. According to the U.S. Census Bureau’s American Community Survey, 22 percent of Hall County’s population was uninsured in 2012.

The exchanges

For those interested in checking out the exchange, specific plans and prices won’t be available until Oct. 1. However, information about what to expect is available through the U.S. Centers for Medicare & Medicaid Services site, www.cms.gov.

Basically, insurance plans on the exchanges offer four levels of coverage: bronze, silver, gold and platinum. On average, bronze plans cover 60 percent of enrollees’ total costs; silver, 70 percent; gold, 80 percent; and platinum, 90 percent.

In general, more comprehensive plans have higher premiums, but also have lower out-of-pocket costs.

Kaiser offers a “subsidy calculator” on its website, allowing users to enter personal information to determine whether they are entitled to a tax credit.

Tax credits are available for anyone whose income is between 1 and 4 times the federal poverty level and if the amount of the insurance premium exceeds 9.5 percent of their income. Insurance policy amounts vary according to various factors, including age and size of household.

For some, depending on income and family size, monthly premiums for a silver plan could cost as little as $100 per month.

Families USA, a Washington-based consumer advocacy group, estimates that 803,000 Georgians will be able to receive financial help for insurance. In an April report, the group stated that Hall County has 16,360 residents whose income falls below four times the poverty level — 14,560 of those holding full- or part-time jobs.

The organization also estimates there are 4.3 million Georgians affected by the law’s provision that, starting in 2014, “health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition.”

“Our nation will soon take a giant step toward making high-quality health coverage affordable for all Americans,” said Ron Pollack, Families USA executive director, in a Sept. 11 press release.

Gainesville-based Northeast Georgia Health System will participate in the Alliant Health Plan through the state exchange, said Steve McNeilly, director of NGHS’ Health Partners Network.

The hospital also is working with Humana and Blue Cross and Blue Shield of Georgia “and we hope we’re going to be in those networks when they roll out later this year,” he said. “We’re in those discussions now.”

“We do want to support the exchange strategy,” McNeilly said.

He added, however, that “it’s still a little unclear how that’s going to look in this market.”

The other insurance companies participating in Georgia’s exchange are Kaiser Foundation Health Plan and Peach State. In July, state Insurance Commissioner Ralph Hudgens announced that Aetna and Coventry had pulled out of the exchange.

“Obamacare has created great uncertainty in the health insurance market, and I am not surprised,” he said at the time.

The politics

The Affordable Care Act, signed into law March 23, 2010, has stirred controversy since President Barack Obama rolled it out in 2009 as one of his signature initiatives. Most politicians have agreed that reform is needed to deal with health care’s rising costs, but how it should happen, to what extent and how to pay for it are thorny issues.

In some ways, the law was spurred by the Great Recession, which began in December 2007 and ended 18 months later.

“In meetings at the White House in March and April 2009, businesses, academicians, providers representatives ... got together and said something has to be done to stop the dramatic increases in health insurance premiums that we receive every year,” said Rich Sanders, an Atlanta lawyer who has served as vice chairman of the American Health Lawyers Association’s Health Reform Task Force.

“It was an either-or thing. We’re either going to survive or we have to do something about health insurance.”

One of the most polarizing provisions that emerged from the law was the “individual mandate,” which survived a constitutional challenge in the Supreme Court. Under the law, those who don’t have insurance face “fees” of 1 percent of yearly income or $95, whichever is higher, to be imposed through federal taxes.

The fee rises each year; by 2016, the penalty is 2.5 percent of income or $695 per person, whichever is higher.

IRS involvement has only fueled criticism of the law, already derided by some critics as moving the U.S. closer to a single-payer system in which the government, rather than private insurers, pays for all health care costs.

In a series of events resembling last year’s “fiscal cliff,” Congress is debating whether to pass a federal 2013-14 budget, which would take effect Oct. 1, with health care reform intact.

The Associated Press reported that House Republicans on Friday passed a continuing resolution 230-189 to keep the government going but with a measure that would block the health care law.

The Democratic-led Senate promises to strip the “defund Obamacare” provision from the bill this week and will challenge the House to pass it as a straightforward funding bill that Obama will sign.

The White House promises Obama would veto the measure in the unlikely event it reaches him, the AP also reported.

A government shutdown could take place without a resolution by Oct. 1, the start of the new federal fiscal year.

U.S. Rep. Doug Collins, R-Gainesville, who voted for the measure that passed Friday, said late Thursday that speculation on the budget bill’s future, at this point, is “fruitless.”

“No one can say House Republicans are attempting to shut down the government. We’re fully funding it,” he said. “We are simply listening to Democrats, who have said over time the health care law is a bad law. So, we’re saying we’re going to defund it, put it off, because it’s not ready.”

The Congressional Budget Office estimates that the law will cost $940 billion over the next 10 years. It will be funded through a variety of sources, including an annual fee on health insurance providers and a tax on indoor tanning services.

“Is the Affordable Care Act financially sustainable?” said David Miller, associate professor at Brenau University, at a chamber-sponsored forum last week. “Will it eventually collapse under its own massive bureaucratic weight?”

He also raised other questions about the law, including the Republican push to defund it and whether “Americans will radically modify their lifestyles and make necessary changes for sustainable health.”

The effects

McNeilly said doctors and hospitals have been conferring about the law and its potential impacts.

“One of the challenges for providers is that we have to be able to improve the outcomes and quality of patients we serve at a lower cost,” he said. “We’re in an environment called fee-for-service, which means if a physician or hospital bills for a service, they expect to be paid for that service.

“It doesn’t really matter if it’s an appropriate service or whether we have had three of the same services done in the same week, we get paid. And that’s flawed. There’s a lot of waste and duplication in our health care system today.”

Overall, the 906-page Affordable Care Act and believed-to-be even deeper set of rules and regulations has created confusion in many corners, from health care providers to patients.

“I don’t think anybody knows how this is ultimately going to look like,” said Dr. Jeff C. Reinhardt with The Longstreet Clinic’s Center for Women’s Health in Gainesville. “It’s sort of that law of unintended consequences — you think you’re doing one thing and you find out you’re doing another.

One of his patients, Justa Martin, 28, of Dawsonville, is on Medicaid now and her baby — due Sept. 30 — will be insured through that program for a year. Martin said she is getting married soon and hopes to get on her husband-to-be’s insurance.

“I’ll be put on that, eventually, sometime after the baby, whenever we can afford it, really,” she said. “If that wasn’t available, I would be depending upon some kind of Obamacare, state (insurance) or something.”

Jackie Wallace, president and chief professional officer of United Way, said she has put together a group of interested parties to see if there are ways to better inform the public about the Affordable Care Act. The group includes representatives from Good News Clinics, Northeast Georgia Medical Center, The Longstreet Clinic, Georgia Legal Services and District 2 Public Health.

“We know those phones are going to start ringing Oct. 1,” she said.

One idea that has been floated in the group is a community forum.

“There is so much information out there that it is all overwhelming,” Wallace said. “Depending on who you’re reading, you can read (the law) differently.”

Speaking at last week’s forum, McNeilly expressed optimism that the Hall County community won’t wilt under the new law.

“I truly believe that our effort has to be one where we work together and we openly communicate about the issues affecting all the stakeholders in this,” he said.

“We don’t have all the answers and I know you don’t have them either, so together we might be able to rise to this challenge.”


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