Picturing the Winners and Losers from Obamacare
Jonathan Cohn has a useful, comprehensive summary of what we now know about premiums under Obamacare, and does a very good job of keeping his temper in the face of the obscurantists. As I read it, however, I found myself hankering for a simple way to characterize what’s going on. So I’d like to throw out a stylized diagram, which looks like this:
Remember the three-legged stool: the same policies available to everyone, regardless of preexisting conditions, the mandate, so that almost everyone (we hope) joins the risk pool, and subsidies to make insurance affordable to those with lower incomes. Who loses under this system — that is, who is better off with the present non-system? Well, if you’re very healthy you might be able to get a cheap policy now, or feel reasonably secure going without insurance. Under Obamacare, someone blessed with good health might find his (or, more rarely, her) premiums going up, and if he’s wealthy as well as healthy he might not get much if anything in the way of subsidies (and if he’s very wealthy he’ll face new taxes). So we’ve know all along that there were going to be at least some people in the northeast corner of my box, doing worse under the new system. The question has always been, how many?
It’s not an easy question to answer, even now — but all the evidence coming in suggests that my dotted line is further up and to the right than previously believed, implying fewer losers and more winners from Obamacare.
How have the right’s health pundits responded? Not with contrary evidence, but by telling us things we already knew, and pretending that they are startling and destructive revelations. Some of it simply amounts to saying that there are indeed some people in the northeast corner of my box. Not everyone wins from the policy! Well, duh.
But at least that’s a valid comparison. The other main argument is that if you look at average premiums under Obamacare, they will be higher than the premiums currently paid by young, healthy people in states without community rating. Again, well duh: insurers are now going to be covering people with health problems who weren’t covered before, so it would be a miracle if the premiums they charged were the same. It is, as Ezra Klein has said, a comparison of apples with oranges you might not even have been allowed to buy.
The thing is, supporters of Obamacare could have been negatively surprised by the premium results. Some people were clearly going to win, but if the bids had come in high both the number of losers and the cost of the subsidies would be looking uncomfortably high. As it turns out, however, the news is looking pretty good.
The Wonk Gap
By PAUL KRUGMAN
On Saturday, Senator John Barrasso of Wyoming delivered the weekly Republican address. He ignored Syria, presumably because his party is deeply conflicted on the issue. (For the record, so am I.) Instead, he demanded repeal of the Affordable Care Act. “The health care law,” he declared, “has proven to be unpopular, unworkable and unaffordable,” and he predicted “sticker shock” in the months ahead.
So, another week, another denunciation of Obamacare. Who cares? But Mr. Barrasso’s remarks were actually interesting, although not in the way he intended. You see, all the recent news on health costs has been good. So Mr. Barrasso is predicting sticker shock precisely when serious fears of such a shock are fading fast. Why would he do that?
Well, one likely answer is that he hasn’t heard any of the good news. Think about it: Who would tell him?
My guess, in other words, was that Mr. Barrasso was inadvertently illustrating the widening “wonk gap” — the G.O.P.’s near-complete lack of expertise on anything substantive. Health care is the most prominent example, but the dumbing down extends across the spectrum, from budget issues to national security to poll analysis. Remember, Mitt Romney and much of his party went into Election Day expecting victory.
About health reform: Mr. Barrasso was wrong about everything, even the “unpopular” bit, as I’ll explain in a minute. Mainly, however, he was completely missing the story on affordability.
For the truth is that the good news on costs just keeps coming in. There has been a striking slowdown in overall health costs since the Affordable Care Act was enacted, with many experts giving the law at least partial credit. And we now have a good idea what insurance premiums will be once the law goes fully into effect; a comprehensive survey by the Kaiser Family Foundation finds that on average premiums will be significantly lower than those predicted by the Congressional Budget Office when the law was passed.
But do Republican politicians know any of this? Not if they’re listening to conservative “experts,” who have been offering a steady stream of misinformation. All thoseclaims about sticker shock, for example, come from obviously misleading comparisons. For example, supposed experts compare average insurance rates under the new system, which will cover everyone, with the rates currently paid by a handful of young, healthy people for bare-bones insurance. And they conveniently ignore the subsidies many Americans will receive.
Missed MaineCare rides drive health agency losses
Clients who don't show up for medical appointments cost health care providers both time and money.
By MATT HONGOLTZ-HETLING Morning Sentinel
When an out-of-state company began brokering rides for MaineCare patients in August, thousands of patients began complaining that they no longer could access the medical services they depend on.
While the patient's health is the primary concern when a person can't make a medical appointment, the transportation companies and other medical care providers also pay a price.
When Coordinated Transportation Solutions, a Connecticut firm, won a $28.3 million contract to coordinate rides to most of the MediCare patients in the state, it became the middleman between the patients scheduling the ride and the transportation companies.
While the company has pledged to fix problems, patients continue to complain about confusing and burdensome paperwork and long wait times. At the same time, transportation companies say that continuing confusion has led to rides not showing up for patients who have scheduled them.
Agencies in Maine, many of which are dealing with other financial constraints, are struggling to cope with the effects.
Maine hospitals get big payments, still squeezed
About $490 million in overdue Medicaid reimbursements won't make up for the millions in other revenue drains, officials say.
By CLARKE CANFIELD, The Associated Press
PORTLAND - Hospitals this month will feel relief when they receive nearly $500 million from the state, but the payments don't provide a remedy for higher taxes that hospitals are paying and lower reimbursements they're receiving for medical services, hospital officials say.
Half-a-billion dollars sounds like a lot of money and hospitals are certainly grateful for it, but it doesn't mask that they're paying more in other ways, said Jeff Austin, vice president of the Maine Hospital Association.
State taxes on hospitals have gone up, costing them about $20 million a year, he said, and the Legislature cut outpatient reimbursement rates for Medicaid by 10 percent, costing them an additional $15 million to $20 million a year. On top of that, mandated federal budget cuts that went into effect this year cut Medicare reimbursement rates by 2 percent, costing another $20 million or so annually, he said.
Some hospitals also are losing other federal Medicare payments they've received for years.
"It's not all roses," Austin said.
$490 MILLION IN HOSPITAL PAYMENTS
Maine plans to send out $490 million this month in payments it owes to 39 hospitals for unreimbursed Medicaid bills.
The top 10 payments are:
• Maine Medical Center: $81.8 million
• Eastern Maine Medical Center: $74.7 million
• MaineGeneral Medical Center: $47.6 million
• Central Maine Medical Center: $38.2 million
• Mercy Hospital: $23.7 million
• St. Mary’s Regional Medical Center: $23.7 million
• Southern Maine Medical Center: $23.1 million
• Franklin Memorial Hospital: $16.6 million
• Mid Coast Hospital: $16.3 million
• Penobscot Bay Medical Center: $14.5 million
Source: Department of Health and Human Service
Millions fall through Obamacare cracks
Even after the Affordable Care Act takes effect, demand for care in free clinics will remain high.
By SARAH KLIFF and LENA H. SUN The Washington Post
ARLINGTON, Va. - Every month, a hundred or so people crowd the lobby of the Arlington Free Clinic, clutching blue tickets to enter a health-care lottery. Uninsured and ailing, they hope to be among the two dozen who hit the jackpot and are given free care.
Some might think the lottery's days are numbered, given that the insurance expansion under President Obama's health-care law will take effect in January.
But clinic officials say the lottery will remain, because demand for services is likely to be as high as ever.
"We will be business as usual," said Nancy Sanger Palleson, the clinic's executive director.
The Affordable Care Act, the most sweeping health-care program created in a half century, is expected to extend coverage to 25 million Americans over the next decade, according to the most recent government estimates.
But that will leave a projected 31 million people without insurance by 2023. Those left out include undocumented workers and poor people living in the 21 states that have declined to expand Medicaid under the statute, commonly called Obamacare.
"The law will cut the number of the uninsured in half," said Matthew Buettgens of the Urban Institute. "This is an important development, but it certainly isn't the definition of universal."
Groups race to hire, train Obamacare guides
Deploying the guides for the uninsured is one the first hurdles for the new health system as it transitions from an abstract political debate in Washington to a real-life process in communities.
By Carla K. Johnson / The Associated Press
CHICAGO — With the program known as Obamacare only weeks away from its key launch date, hectic preparations are in motion in communities across the country to deal with one of its major practical challenges: hiring and training a small army of instant experts who can explain the intricacies of health insurance to people who've never had it.
More than 100 nonprofits and related organizations, which specialize in everything from running soup kitchens to organizing farm workers, have been recruited by the federal government to sign up "navigators" to help the 30 million uninsured people who can now gain coverage.
Many of the groups have little expertise in health insurance. And the timeline for training the workers is tight. According to the new health law, people can begin shopping among the new policies on Oct. 1. The enrollment period lasts six months. Coverage begins in January.
"I think there's a lot of concern about whether, with all these state requirements, they are going to be ready to go," said Katie Keith, a former research professor at Georgetown University, who has been tracking the heath care legislation. "You want people out there educating consumers."
Deploying the guides for the uninsured is one the first hurdles for the new health system as it transitions from an abstract political debate in Washington to a real-life process in communities. It is one of the steps government officials are concerned about as critics warn that the Affordable Care Act could become a "train wreck."
An ACA glossary
Posted Sept. 09, 2013, at 5:59 a.m.
Catastrophic plan: You’re young, poor and feel invincible — this is the plan for you. Offers low monthly cost, high yearly deductible, limited benefits. Basically, it’s there in case you’re in a major car accident, get cancer or suffer some other major medical problem. You know, a catastrophe. Thus the name.
Co-insurance: Your share of the medical bill after you have paid your annual deductible. Usually shown in a percentage, as in 20 percent paid by you and 80 percent paid by the insurance company.
Co-op: A new kind of nonprofit insurance company run by members for members. Think credit union. Maine has one co-op: Maine Community Health Options in Lewiston.
Co-pay: That money you plunk down at the receptionist’s window when seeing the doctor.
Deductible: How much you’ll pay each year before the insurance company starts kicking in its share.
Exchange/marketplace: Are you an individual or small business or group? If so, you can buy insurance here. Insurance will be sold elsewhere, sure, but this is the only place where individuals can use their federal subsidy to help pay the cost. It’s also the only place small business owners can get a tax break for buying insurance for their employees. Originally dubbed the “exchange,” it’s now officially the “marketplace.”
Government-sponsored insurance: Insurance paid by the state or feds. Includes Medicaid and Medicare.
Grandfathered plan: Insurance bought before March 2010. If you have a grandfathered plan, your costs and benefits don’t have to meet ACA requirements.
Individual: You. Or you-and-family.
In-network: The doctors and hospitals your insurance company will happily pay for. (It may pay for out-of network care, but not as much.)
Medical loss ratio: This kicks in when your insurance company spends too much on the corporate jet and not enough on flu shots. If the insurance company doesn’t spend at least 80 or 85 percent of overall premiums on medical care, you get a rebate.
Metal levels: Bronze, silver, gold and platinum. Like medals in the Olympics, these metals help you tell the difference between good, better and best insurance plans.
The lowest insurance levels, bronze and silver, cost less each month, but you’ll get fewer benefits and will pay more when you go to the doctor. The highest levels, gold and platinum, cost more each month, but they offer better benefits, and you won’t have to pay a lot when you see the doctor. (FYI: No one is offering a platinum plan in Maine yet.)
Narrow network: Want to see Dr. Smith? Go for it, because your insurance company likes her. Dr. Jones? Nope, sorry (unless you want to pay the bill all by yourself). When an insurance company strictly limits the doctors and hospitals a patient can see in an effort to control costs, it has a narrow network.
Open enrollment: You can buy individual health insurance only during this time unless you lose your job, get married, have a baby or something else big happens in your life. Right now, open enrollment will last from October 2013 to March 2014. In future years it will go from October to January. (FYI: This is the rule for insurance bought on or off the exchange/marketplace.)
Out-of-pocket maximum: The most you’ll have to pay for your health care in a year. Have a $6,350 out-of-pocket maximum with your insurance company? Everything after that is free until the new year rolls around again.
Plan factor: The things about you that can raise the price of your insurance. Typically your age, where you live and whether you smoke.
Premium: How much you pay each month for insurance. Think of it as the price tag.
Preventative care: Shots, colonoscopy, depression screening, counseling for alcohol abuse, diet counseling and a bunch of other services designed to keep you healthy or catch an illness before it gets to the crisis point. Preventative care is free, with no co-pays or co-insurance, even if you haven’t met your annual deductible.
Private insurance: If it’s not government insurance, it’s private. This includes insurance paid by you or your employer. All plans on the exchange/marketplace are private plans, even if you get a subsidy for it.
SHOP: Small Business Health Options Program. It’s where small groups can buy health insurance and get a tax break for it over the next two years. (FYI: Only the employer gets this refundable credit, not employees.) In Maine, SHOP is the same as the exchange/marketplace.
Small group: Fifty or fewer people. Usually means a small business. The definition will change to 100 or fewer people in 2016.
Subsidy: Money the federal government will give to people who need to buy their own insurance (because an affordable plan isn’t offered through their job) and who earn between 100 percent and 400 percent of the federal poverty level. You can get the subsidy in a tax credit or have it paid directly to the insurance company to lower your monthly bill. If you earn less than 250 percent of the poverty level, you can also get a subsidy to discount your out-of-pocket expenses. How big of a subsidy? Depends on your salary. It’s a sliding scale.
An ACA glossary
Posted Sept. 09, 2013, at 5:59 a.m.
Catastrophic plan: You’re young, poor and feel invincible — this is the plan for you. Offers low monthly cost, high yearly deductible, limited benefits. Basically, it’s there in case you’re in a major car accident, get cancer or suffer some other major medical problem. You know, a catastrophe. Thus the name.
Co-insurance: Your share of the medical bill after you have paid your annual deductible. Usually shown in a percentage, as in 20 percent paid by you and 80 percent paid by the insurance company.
Co-op: A new kind of nonprofit insurance company run by members for members. Think credit union. Maine has one co-op: Maine Community Health Options in Lewiston.
Co-pay: That money you plunk down at the receptionist’s window when seeing the doctor.
Deductible: How much you’ll pay each year before the insurance company starts kicking in its share.
Exchange/marketplace: Are you an individual or small business or group? If so, you can buy insurance here. Insurance will be sold elsewhere, sure, but this is the only place where individuals can use their federal subsidy to help pay the cost. It’s also the only place small business owners can get a tax break for buying insurance for their employees. Originally dubbed the “exchange,” it’s now officially the “marketplace.”
Government-sponsored insurance: Insurance paid by the state or feds. Includes Medicaid and Medicare.
Grandfathered plan: Insurance bought before March 2010. If you have a grandfathered plan, your costs and benefits don’t have to meet ACA requirements.
Individual: You. Or you-and-family.
In-network: The doctors and hospitals your insurance company will happily pay for. (It may pay for out-of network care, but not as much.)
Medical loss ratio: This kicks in when your insurance company spends too much on the corporate jet and not enough on flu shots. If the insurance company doesn’t spend at least 80 or 85 percent of overall premiums on medical care, you get a rebate.
Metal levels: Bronze, silver, gold and platinum. Like medals in the Olympics, these metals help you tell the difference between good, better and best insurance plans.
The lowest insurance levels, bronze and silver, cost less each month, but you’ll get fewer benefits and will pay more when you go to the doctor. The highest levels, gold and platinum, cost more each month, but they offer better benefits, and you won’t have to pay a lot when you see the doctor. (FYI: No one is offering a platinum plan in Maine yet.)
Narrow network: Want to see Dr. Smith? Go for it, because your insurance company likes her. Dr. Jones? Nope, sorry (unless you want to pay the bill all by yourself). When an insurance company strictly limits the doctors and hospitals a patient can see in an effort to control costs, it has a narrow network.
Open enrollment: You can buy individual health insurance only during this time unless you lose your job, get married, have a baby or something else big happens in your life. Right now, open enrollment will last from October 2013 to March 2014. In future years it will go from October to January. (FYI: This is the rule for insurance bought on or off the exchange/marketplace.)
Out-of-pocket maximum: The most you’ll have to pay for your health care in a year. Have a $6,350 out-of-pocket maximum with your insurance company? Everything after that is free until the new year rolls around again.
Plan factor: The things about you that can raise the price of your insurance. Typically your age, where you live and whether you smoke.
Premium: How much you pay each month for insurance. Think of it as the price tag.
Preventative care: Shots, colonoscopy, depression screening, counseling for alcohol abuse, diet counseling and a bunch of other services designed to keep you healthy or catch an illness before it gets to the crisis point. Preventative care is free, with no co-pays or co-insurance, even if you haven’t met your annual deductible.
Private insurance: If it’s not government insurance, it’s private. This includes insurance paid by you or your employer. All plans on the exchange/marketplace are private plans, even if you get a subsidy for it.
SHOP: Small Business Health Options Program. It’s where small groups can buy health insurance and get a tax break for it over the next two years. (FYI: Only the employer gets this refundable credit, not employees.) In Maine, SHOP is the same as the exchange/marketplace.
Small group: Fifty or fewer people. Usually means a small business. The definition will change to 100 or fewer people in 2016.
Subsidy: Money the federal government will give to people who need to buy their own insurance (because an affordable plan isn’t offered through their job) and who earn between 100 percent and 400 percent of the federal poverty level. You can get the subsidy in a tax credit or have it paid directly to the insurance company to lower your monthly bill. If you earn less than 250 percent of the poverty level, you can also get a subsidy to discount your out-of-pocket expenses. How big of a subsidy? Depends on your salary. It’s a sliding scale.
Health reform anxiety? Here’s 6 things to know
Posted Sept. 09, 2013, at 6:01 a.m.
Here’s something you probably never thought you’d hear: Health insurance is about to get interesting.
New discounts. New benefits. New rules.
And a new place to buy.
Come Oct. 1, people can start signing up for health insurance in the new Affordable Care Act marketplace, or exchange. All individuals, families and small businesses can use it, some getting money to do so.
So, are you ready to buy? Maybe? You’re not really sure?
Here’s what you need to know.
Here’s your deadline
The ACA health insurance mandate starts Jan. 1, 2014, requiring almost all Americans to have health insurance or pay a penalty. There’s a three-month grace period before the penalty kicks in, however, so if you don’t have insurance right on Jan. 1, you’re OK. But don’t be an April fool.
People who are very poor (those under the federal poverty level) and who live in a state that didn’t expand Medicaid (like Maine) are exempt from the penalty. You can also get an exemption if:
— Your religion prevents you from accepting insurance benefits.
— You’re part of a health care sharing ministry.
— You are a member of a federally recognized Indian tribe.
— You lack insurance for less than three months in a row.
— You have suffered a certified hardship.
— You can’t afford coverage because you’d have to pay more than 8 percent of your household income for it.
— You’re behind bars.
— You are not a U.S. citizen, a U.S. national or an alien lawfully present in the U.S.
If you have affordable insurance through your employer, you’re all set. Likewise if you get health care through the military, Veterans Affairs, Medicare, Medicaid or some other insurance program.
If you don’t have health insurance, the act wants you to get some. Like, soon.
Insurance can still be bought and sold the regular way, through agents. But starting Oct. 1, it will also be sold through the marketplace, a virtual shopping center where people and small businesses can compare prices and benefits. Think online shoe shopping — it’s all about what fits, what suits your needs and how much you can afford.
Although insurance can still be bought elsewhere, federal subsidies and tax breaks will only be available for insurance bought through the marketplace. (Except for catastrophic plans. No subsidy for those.)
You, Dr. McDreamy and the ACA: 6 case studies on Obamacare eligibility
Posted Sept. 09, 2013, at 5:56 a.m.
What are your options under the Affordable Care Act? Here are some examples — with the help of some (slightly re-imagined) characters from “Grey’s Anatomy.”
Izzie, 24, single, no kids, doesn’t smoke. Lives with mom and dad in Bangor while she saves up money for medical school. She makes $16,000 a year working part-time for a modeling agency that doesn’t offer insurance.
The options:
— Because she’s under 26, Izzie can stay on her parents’ insurance.
— Because she’s under 30, Izzie can buy a low-cost, high-deductible catastrophic insurance plan. If purchased through the marketplace, it will cost her $184 a month with Maine Community Health Options or $209 a month with Anthem Blue Cross and Blue Shield. If Izzie takes up smoking, Anthem’s price will jump to $271 a month. (Should she move out of Penobscot County, those prices could change.)
— Because Izzie earns between 100 percent and 400 percent of the federal poverty level, she can get a subsidy from the federal government to help pay for her insurance. (However, it can’t be used for a catastrophic plan. If she wants a subsidy, she’ll have to buy a more comprehensive bronze, silver or gold-level plan from the marketplace.) The Kaiser Family Foundation’s online calculator puts her subsidy at $2,479 a year, or about 82 percent of her annual premium.
And, because Izzie earns less than 250 percent of the federal poverty level, she can also get a subsidy to lower her out-of-pocket expenses.
— She can go without insurance and pay the penalty. For a single woman, that will be $95 or 1 percent of her income, whichever is greater, for 2014. The penalty increases in future years.
An Affordable Care Act timeline
Posted Sept. 08, 2013, at 12:14 p.m.
March 23, 2010: President Barack Obama signs the Patient Protection and Affordable Care Act.
- Coverage required for children with pre-existing conditions and young adults under 26.
- Insurers prohibited from placing lifetime limits on coverage and arbitrarily canceling coverage.
- Insurers must cover certain preventive health services for free, with no copays or deductibles, such as colonoscopy screening, Pap smears and mammograms, and flu shots.
- Small business tax credit kicks in.
- Temporary coverage for adults with pre-existing conditions.
2011:
- Prescription drug discounts for seniors.
- Free Medicare preventive services for seniors.
- The “80/20 Rule” requires insurers to use at least 80 cents out of every premium dollar to pay for medical claims, instead of overhead costs.
- Insurance companies must publicly justify any rate increase of 10 percent or more before raising premiums.
2012:
- Most health plans must cover additional preventive health services for women, such as breast cancer screenings.
- Consumers must be provided easy-to-understand summaries about a health plan’s benefits and coverage.
2013:
- Oct. 1: health insurance marketplaces open for enrollment.
2014:
- Jan. 1: Coverage purchased in the health insurance marketplace takes effect.
- March 31: Open enrollment on the health insurance marketplace ends.
- All Americans, with few exceptions, must have health insurance or face a penalty.
- Insurers can’t deny people with pre-existing health conditions.
- Consumers shopping on the marketplace can save on monthly premiums and out-of-pocket costs with federal subsidies and tax credits.
- Nearly all plans, sold through the marketplaces and otherwise, must cover a basic set of health benefits, including emergency care, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs and pediatric dental and vision care.
- The Medicaid expansion takes effect (not in states including Maine that opted out).
- Insurers can’t set yearly limits on what they spend on your coverage.
- Small business tax credit expands.
2015:
- Employers with at least 50 full-time workers must offer health insurance to their employees or face a penalty.
Make it happen: The step-by-step guide to the ACA
Posted Sept. 09, 2013, at 5:58 a.m.
Need insurance? Here’s what you should do:
Step 1. Check with your employer to see if health insurance will be offered. If it will, find out how much your share of the monthly premium will be. If it’s unaffordable (more than 9.5 percent of family income to insure you), poor quality or doesn’t exist at all, you might be able to get a subsidy to buy insurance from the upcoming marketplace.
Step 2. Go to Healthcare.gov or call 1-800-318-2596 (for individuals) or 1-800-706-7893 (for small businesses) to find out more about the marketplace. Online you can also plug in you age, employer coverage information, income and other information and find out what material you should gather now to be ready to sign up for coverage on Oct. 1.
Step 3. After Oct. 1, contact the marketplace or a local federally designated “navigator,” certified application counselor or other expert approved to help you learn about your options within the marketplace. Some are listed in our info box. All will be listed at Healthcare.gov and through Maine Health Access Foundation’s coming site www.enroll207.org.
Step 4. Sign up for marketplace insurance through Healthcare.gov, over the phone at the toll-free numbers listed above or with one of those approved experts.
Step 5. Use your new insurance starting Jan. 1, 2014.
http://bangordailynews.com/2013/09/09/health/make-it-happen-the-step-by-step-guide-to-the-aca/print/
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