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Health care is no game, but will your family win or lose under Obamacare?

Published: Thursday, March 27 2014 5:30 a.m. MDT

  • The “individual mandate" requires people to buy insurance unless they qualify for one of 14 exemptions, such as being in jail or financial hardship. Fines for noncompliance grow each year.
  • Requirements that employers provide insurance have been pushed back — employers with 100 or more full-time workers have until 2015 and those with 50-99 workers to 2016 — but individual workers must still obtain insurance. Experts predict many will choose the relatively small penalties this year over purchasing insurance, said Rachel Reimann, ACA specialist for SelectHealth, which insures individuals in Idaho and Utah. Penalties may have to grow before some people choose insurance.
  • The end of this enrollment period on March 31 is the last chance for new coverage until the next enrollment period unless a person has a qualifying life event, like birth of a child or a lost job. With five days to go, though, the Obama adminstration said it would allow those unable to complete enrollment by the deadline to apply for a brief extension. They must check a box on Healthcare.gov to show they tried to enroll before the deadline.
  • The only factors that matter for setting rates are tobacco use, age and geography. Insurers can charge more for tobacco users and for being older, though both have proportional caps. They can no longer charge more because of gender. Insurers cannot ask about medical history, which is good news for the 50 million to 129 million non-elderly individuals that a 2011 Health and Human Services study said have pre-existing conditions.
  • Families may qualify for subsidies to help pay. A sliding schedule tops out at 400 percent of the poverty level, or $94,200 for a family of four. Still, there is what Jason Stevenson of Utah Health Policy Project calls a “cruel joke” in the subsidies. The law was written expecting Medicaid expansion; the Supreme Court then said states could each decide, and only half have chosen to expand. In states that didn't, that means people making less than $11,490 don’t qualify for help, while those making a few dollars more get free insurance. States must decide how to fix that.
  • Obamacare mandates 10 essential benefits: ambulatory services, prescription drugs, emergency care, mental health services, hospitalization, rehabilitative and habilitative services, preventive and wellness care, laboratory services, pediatric care and maternal and newborn care.

“I don’t think everyone has to be an expert or understand all the ins and outs of this, but they do need to be smart and look at resources and ask questions,” said SelectHealth spokeswoman Carrie Brown. It doesn’t cost more, adds Reimann, to ask questions or use a broker or agent. The law also created two new types of helpers: navigators and certified application counselors who are tasked with helping individuals who ask for help to enroll for insurance.

“There's still some chaos,” said Judi Hilman, advocate and community engagement officer for Arches Health Plan. “We spend much of our time showing different groups the subsidy calculator. Regardless of how they feel about the law, folks’ eyes light up when they see how much help they can get buying insurance. Most people, when they stop and think about it, understand the importance of insurance.”

Winners, losers and keeping score

When the question of who loses or wins under health reform arises, conversations get animated — though not necessarily less confusing — for families trying to make actual health coverage decisions.

David Hogberg said that to keep track of losers under ACA, “you’d need a score card. But to keep track of winners, you’d need a search party.” Hogberg is a senior fellow at the National Center for Public Policy Research, a free-market conservative think tank. His list of possible winners includes those with pre-existing conditions who were previously priced out of coverage and “maybe hospitals with Medicaid expansion.” He thinks politicians might be able to use some of the subsidies as election talking points, although it’s not an electoral winner, he said.

His biggest worry, he said, is that a big expansion of government over any system tends to benefit politicians and those with political clout, something sick people usually lack.

Hogberg said the biggest losers in the individual markets are those who lost plans and can’t find one that isn’t far more expensive. Plans also may not include someone's preferred doctors and hospitals. Doctors are being pushed into bigger and bigger practices, which he said won’t be good news for sole practitioners.

Hogberg predicts that as businesses are required to provide insurance, some will try to keep more employees to 29 hours or less, as 30 is the threshold for providing coverage.

Jonathan Gruber, an economist at MIT, found three winners for every loser. Christopher Conover at Duke University found four losers for every winner.

Young people are winners as they get to stay on their parents’ coverage longer, said Alan Weil, executive director of the National Academy for State Health Policy, a nonprofit, nonpartisan, independent research and policy institute. But they should expect that once they’re off the parental policy, costs for the youngest and healthiest will be higher for them initially. As they grow older, they’ll reap the same benefit they are bestowing as younger people help lower prices for them.

“If you supported the law because you thought it would solve all your problems, it’s a disappointing result. If you opposed it because you thought all would find harm, you’re disappointed about that,” Weil added. “This is a more incremental law than most people think. We can all pull it apart into 1,000 pieces, but you have to keep it in perspective."

The success of the ACA will hinge on the health distribution, not the age, of those who sign up. Nichols said it needs healthy people buying policies and not using too many services in order to balance those who are sicker. But those who are middle-aged and older are most likely to recognize how important health coverage is for their families.

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