WASHINGTON — As the politicians fuss and fight over the merits of the biggest overhaul of the health insurance system in this country, you may be wondering, “What does this all mean to me?” Here’s what we know so far about what’s up with your healthcare.
It’s all about me
The Affordable Care Act, or Obamacare, as it is now commonly known, went into effect in 2010 and was affirmed by the U.S. Supreme Court in 2012, despite the 42 times the House Republicans tried to repeal it.
It will have the most dramatic impact on the 48 million Americans who don’t or haven’t been able to get insurance. By 2014, everyone — with a few exceptions — has to have insurance or face a penalty.
I get insurance through work. Why should I care?
More than half of Americans get health insurance through work. For those keeping score at home, that’s 55.1% of the population, or about 149 million non-elderly people, according to U.S. Census data.
If that’s you, news about Obamacare marketplace computer problems and people getting letters saying they’re losing their coverage — that doesn’t affect you.
What you do have to worry about is that e-mail reminder your company sends you this time every year telling you about open enrollment season.
You may notice that information packet is a lot easier to read and the different plans are a lot easier to compare. You’ve got Obamacare to thank for that, since it is now mandatory that these companies communicate clearly about what they have to offer.
If your child is under the age of 26, under Obamacare, they can stay on your insurance. It doesn’t matter if they live with you or not or whether they’re married or single. As long as they don’t get insurance anywhere else, you can keep them covered.
Also because of Obamacare, many health plans must offer you free preventative care services. You can get your blood pressure or cholesterol checked, get a colonoscopy or a mammogram, ask for a flu shot, seek counseling for alcohol or smoking, find out if you are depressed and seek other preventative screenings. Since studies show 70% of all healthcare conditions are considered preventable, in theory this should keep a lot of people healthier.
If you are a woman, you no longer need a referral to see a gynecologist. Maternity care is provided. So is birth control, which would come at no cost in most plans.
Now if you are denied a payment new rules give you a chance to appeal a decision and if that doesn’t work Obamacare lets you take your appeal to an outside independent review panel. The law now says the insurance company has to let you know why your claim was denied and they have a time limit in which they have to answer your appeal.
Will I pay more for my insurance?
Your plan will probably take a little more out of your check next year, but really that’s nothing new.
Some companies, such as UPS and Delta, did blame Obamacare for rising insurance costs, but experts say employees will pay more for their policies because the economy is improving. When people feel more secure financially, they go to the doctor more and get test and procedures they put off when they felt less secure, according to Tim Nimmer, the chief healthcare actuary at Aon Hewitt an employee benefits administrator.
Aon Hewitt’s research on the cost of insurance predicts employees will spend just under $5,000 on premiums and out-of-pocket expenses next year. That’s up 9.5% from the year before — higher than the increases for 2013, which were more in the 5% range. Over the past 10 years, average premiums for a family have kept going up a whopping 80%, according to a Kaiser Family Foundation report.
Another reason you’ll pay a little more is because employers are continuing to shift the cost of insurance to employees, studies show. There are also new fees on employers and insurers to help cover insurers with new high-risk enrollees.
“I think they key point is to recognize that victory in healthcare is not that the cost of your healthcare is going up, it is that it is going up more slowly,” said Jonathan Gruber, one of the architects of both the Massachusetts and Obama healthcare plans and the author of a graphic novel that simply explains health care reform.
What happens when I use my benefits?
When you do use your benefits and go to the doctor, you may have to wait a little longer for an appointment since you’ll be competing with more patients who now have insurance.
You may have already been waiting a bit, since there is a primary care physician shortage according to the Association of American Medical Colleges. We’re down about 20,000 now, and the number is expected to get worse as physicians age. And it’s not just doctors who are in short supply; we also need more nurses, according to the Institute of Medicine.
“Keep in mind, the Affordable Care Act didn’t create this crisis,” said Dr. Reid Blackwelder, president of the American Academy of Family Physicians. “We’ve got an aging population that needs more care and a growing population.”
If you do go to the hospital, in theory you should be leaving it healthier. The ACA penalizes hospitals that see patients return after treatment, and facilities have started a number of innovative programs to try and keep patients well and out of the hospital.
If something catastrophic happens to you and it’s expensive, that’s also where Obamacare will make sure your insurance continues to cover you. In the past, insurance companies could dump you if you spent too much. Those costs are capped under the ACA and there are no lifetime spending limits.
The one thing that was supposed to change under the ACA that has been delayed is a mandate that all companies with more than 50 full-time employees get benefits. Companies will eventually face fines if they don’t offer insurance. That doesn’t go into effect until 2015.
What if I own — or work for — a small business?
A giant part of the small business community, 96% of small businesses have fewer than 50 workers. If you own that kind of business, you don’t have to worry about that employer mandate. If you work for one, you will be able to buy a policy in the new Obamacare marketplaces.
If you do employ more than 50 people, chances are you already offer insurance to your workers — 90% do — and business owners who are happy with their insurance plan can stick with it. In fact, many insurance companies are offering discounts to clients who renew their policies.
If you are in that 3% with more than 50 workers and you do not provide insurance, you will have to start — or you’ll have to pay a penalty starting in 2015.
The government has opened a small business marketplace, also known as the Small Business Health Options Program (SHOP). It is meant to provide an easier and cheaper venue for business owners to shop for insurance for their employees. SHOP’s website lets business owners compare plans.
The government offers tax credits to these smaller business to help pay for this insurance. These are worth up to 50% of your premium costs. Small businesses can still deduct the rest of their premium cost not covered by the tax credit. It is only available for plans bought through SHOP.
Is anyone directly impacted by all this Obamacare talk?
If you don’t have insurance or haven’t qualified for insurance in the past, you’ll need to have it by March 31 of next year. If you don’t, you’ll be fined up to 1% of your income or $95, whichever is greater.
You can buy a plan from a broker at any time. If you want to buy through the new Obamacare marketplaces, open enrollment stretches through March 31. You’ll only get a tax break/subsidy if you buy a policy through the marketplaces.
If you are like Jeff Jones in Lexington, Kentucky, who wants a policy to start on January 1, you’ll have to make up your mind on which plan is right for you by December 15.
Jones lost his job with the University of Kentucky and is unable to get on his partner’s policy. “I’ve been shopping around online but haven’t decided on which policy yet,” he said.
Jones has been comparison shopping through Kentucky’s state marketplace website. There have been some technical hiccups, but he’s been able to see what he’d qualify for based on his expected income. A diabetic, he says he is grateful this is an option now. Currently, insurance companies could deny him a policy since he has this pre-existing condition. Obamacare ends that practice next year.
If you can get into the website, you can sign up for a policy through Healthcare.gov. There’s also a phone number to call: (800) 318-2596 (TTY: (855) 889-4325). The number is staffed round the clock. Information is available in more than 150 languages.
There will also be specially trained advisers in communities. These “navigators,” as they are known, can help you in person. If you would like to find the closest navigator, go to Localhelp.healthcare.gov. Plug in your ZIP code and it will give you the closest location to get help.
So bottom line, what does this cost?
Costs of plans vary, depending on where you live in this country and your age; the White House says you should be able to buy a plan for less than a $100 a month. If you want to see what your bill may look like, check out the Kaiser Family Foundation’s calculator. The nonpartisan foundation’s tool provides an estimate of your costs, depending on where you live and the plan you pick.
The bronze level is basic, silver is midrange and gold and platinum are higher-end. There is also a catastrophic option. Catastrophic insurance covers three doctor visits per year at no cost and preventive care such as screenings and vaccines. This plan will carry a higher deductible.
What do I get for my money now?
All plans bought through the exchanges must offer the same coverage benefits. Mental health is covered, behavioral health is covered, maternity care, emergency care, hospitalization, newborn care, prescription drugs, rehab, lab services, and pediatric services. All offer free preventive care. Nearly all cap out-of-pocket costs to $6,350 and $12,700 per family. No one can be turned away. No one will be penalized because of their gender (women often paid more in the old insurance system). Only smokers may be penalized in some plans and some older people may pay more.
Dental is covered for kids, but it is not for adults. You’ll have to buy a separate policy for that or find a policy that offers it.
There are more limited doctor and hospital networks offered in these plans. That’s how insurance companies have been able to keep costs down and offer all these benefits. Insurance brokers advise you look to see if your doctor or favorite hospital is considered in-network with whatever plan you buy. Otherwise, you will have to switch doctors or pay a higher fee for seeing him or her.
Didn’t Obama say I can keep my policy?
Some people who do buy their own insurance have been getting letters from their insurance companies saying their plan has been canceled. That’s because their old plans don’t qualify under these Obamacare rules that mandate insurance cover all these benefits.
With these plans you will pay a monthly premium, and may also have a co-pay or be asked to meet a deductible when you go to the doctor or hospital.
Is there help to pay for all this new insurance?
The good news is, if you go through the exchanges rather than buy directly from an insurance company, you will likely be eligible for tax breaks and subsidies to pay for your insurance. The assistance is available to those with incomes of up to four times the federal poverty level — this year, that’s $45,960 for an individual or $94,200 for a family of four — and will be calculated on a sliding scale.
You can take this subsidy as a tax credit or the government will pay the insurance company directly.
You may also want to check to see if you will qualify for Medicaid. So far, 26 states are moving toward expanding who is eligible for the federal government-funded health program for lower income families and individuals.
I’ve got Medicare. Does Obamacare change that?
You are in a group that doesn’t need to worry about Obamacare. Medicare doesn’t change with Obamacare.
So then, why the fuss?
Studies show people are politically riled up about all this change in health insurance, but when it comes down to it, Gruber said the sky won’t fall next year and things should get better.
“Once people experience it and go through this initial transition, which is going to be rocky, then they’re going to realize the benefits of having a system like this,” Gruber said.
“Yes, if you are young and healthy it will be more expensive, but right now this is an insurance market which not only is discriminatory, but the typical person who buys their own insurance has a very weak insurance plan. (Under Obamacare) everyone will have will have guaranteed, real insurance that’s fairly priced.”