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| FILE - In this March 23, 2010 file photo, Marcelas Owens of Seattle, left, Rep. John Dingell, D-Mich., right, and others, look on as President Barack Obama signs the health care bill in the East Room of the White House in Washington. |
WASHINGTON
(AP) -- Having health insurance used to hinge on where you worked and
what your medical history said. Soon that won't matter, with open-access
markets for subsidized coverage coming Oct. 1 under President Barack
Obama's overhaul.
But there's a new wild card,
something that didn't seem so critical when Congress passed the
Affordable Care Act back in 2010: where you live.
Entrenched
political divisions over "Obamacare," have driven most Republican-led
states to turn their backs on the biggest expansion of the social safety
net in a half century. If you're uninsured in a state that's opposed,
you may not get much help picking the right private health plan for your
budget and your family's needs.
The
differences will be more glaring if you're poor and your state rejected
the law's Medicaid expansion.
Unless leaders reverse course, odds are
you'll remain uninsured. That's because people below the poverty line do
not qualify for subsidies to buy coverage in the markets.
"We
are going to have a new environment where consumers may be victims of
geography," said Sam Karp of the California HealthCare Foundation, a
nonprofit helping states tackle practical problems of implementation.
"If I'm a low-wage earner in California, I may qualify for Medicaid.
With the exact same income in Texas, I may not qualify."
The
health care law is finally leaving the drawing boards to become a real
program with citizens participating. But in many parts of the country
the decisions of Republicans opposed to the law will trump the plans of
Democrats who wrote it.
Still, there is a new
bottom line. Health insurance marketplaces in every state will provide
options for millions of people who don't have job-based coverage, who
can't afford their own plan or have a health problem that would get them
turned down. The feds will run the markets in states that refused to do
so.
The coverage won't be free, even after sliding-scale subsidies keyed to your income.
That's
significant because starting next year most Americans will also have a
legal obligation to get covered or face fines. Some people who now
purchase bare-bones individual plans will complain the new ones cost too
much. Others, in good health, may resent the government telling them to
purchase insurance they don't think they need.
Nonetheless,
the number of uninsured people is expected to drop markedly, bringing
the United States closer to other economically advanced countries that
guarantee coverage.
The combination of
subsidized private insurance through the new markets, plus expanded
Medicaid in states accepting it, could reduce the number of uninsured by
one-fourth or more next year. Current estimates of the uninsured range
from around 49 million to well over 50 million.
As
Americans get more familiar with the law - and if more states accept
the Medicaid expansion - millions more should gain coverage. Many of the
remaining uninsured will be people living in the country illegally.
They are not entitled to benefits.
In Texas,
Republican Gov. Rick Perry has vowed not to facilitate "Obamacare." But
Cecilia Fontenot of Houston is looking forward to the opening of that
state's federally run insurance market.
A
part-time accountant in her early 60s, Fontenot is uninsured and trying
to stay healthy while coping with diabetes, high blood pressure and high
cholesterol. She walks twice a day, early in the morning before it gets
hot, and in the evenings.
Also on her mind is
a breast lump detected about a year ago. Her doctor recommended a
digital mammogram, but she has not been able to afford the more involved
test.
"I try not to worry and just pray on it," said Fontenot.
Because
of her pre-existing conditions, Fontenot would have a tough time
finding affordable individual coverage today. But starting Jan. 1,
insurers will no longer be able to turn away people with health problems
or charge them more.
And the government will
provide sliding-scale tax credits that can make premiums more affordable
for households earning between 100 percent and 400 percent of the
federal poverty line. That's $11,490 to $45,960 for an individual,
$23,550 to $94,200 for a family of four.
People on the low end of the income scale get more help, as will older people, whose premiums are higher.
With
an annual income of about $23,000, Fontenot makes too much to qualify
for Medicaid. And her state decided not to expand the program, an option
the Supreme Court granted last year as it upheld the rest of Obama's
law.
But she would qualify for subsidized
private coverage in the federally run Texas marketplace. She could apply
online, through a call center, by mail or in person.
After
the government verifies her identity, legal residence and income,
Fontenot would be able to take her tax credit and use it to pick an
insurance plan. Coverage takes effect Jan. 1.
She'd
have up to four levels of coverage to choose from: bronze, silver, gold
and platinum. All cover the same benefits, but platinum has the highest
premiums and lowest out-of-pocket costs, while bronze has the lowest
premiums and highest out-of-pocket costs.
Fontenot's
share of premiums would be capped at 6.3 percent of her income, or
$1,450 a year for a benchmark silver plan. She'd have to squeeze about
$120 a month out of her budget, and that doesn't include her annual
deductible and copayments.
"If I want to stay alive, I'm going to have to budget that in," said Fontenot.
With
insurance, she'd switch to a brand-name diabetes drug that does a
better job of controlling her blood sugars - and get that mammogram.
"I am not asking for free stuff," she added. "I am willing to do my part."
Like Fontenot, many of the people who'll access the markets Oct 1 will have health problems. It's where the greatest need is.
But
two other groups are critical to the program's success: Healthy
uninsured people, many of them in their 20s and 30s, and insured people
who will switch over from existing individual policies.
Healthy individuals are needed to help pay for the sick.
And
with instant feedback via social media, reviews by people switching
from existing individual plans could define early consumer sentiment.
Some
of those transitioning will be looking for better deals. Others will be
there because their insurers canceled policies that didn't meet the
law's minimum standards, and they may be upset.
Consumers
don't have to decide on Oct. 1. You have until Dec. 15 to sign up if
you want coverage by Jan. 1. And you have until next Mar. 31 if you want
to avoid penalties for 2014. Fines start as low as $95 the first year
but escalate thereafter.
Procrastinate beyond
Mar. 31, and you'll have to wait until the next open enrollment period
in Oct. 2014, unless you have a life-changing event like job loss,
divorce or the birth of a child.
Former
Medicare chief Mark McClellan, who oversaw the rollout of seniors'
prescription drug benefits for Republican President George W. Bush, says
his advice is not to sign up right away, but not to wait too long
either. In other words, check things out. Buying health insurance is not
as simple as shopping on Amazon.
"This is a
milestone along the path but by no means the end of the road," said
McClellan. "There's a lot more of a journey to see if it can really
succeed."
Three key things to watch for are premiums, choice and the consumer shopping experience.
Premiums
so far are averaging lower than what government experts estimated when
Congress was debating the law. That's important for policy types, but it
may not mean much to consumers. Current low-cost individual market
policies are difficult to compare with the new plans, which offer better
financial protection and broader benefits.
Plan choices seem adequate, but networks of hospitals and doctors may be tightly restricted to keep premiums low.
The
biggest unknown is how consumers will feel about the whole experience.
Many will be unfamiliar with health insurance basics, and applying for
subsidies may feel like plodding through tax forms.
Still,
after years of polemic debate and a Supreme Court decision - and even
as congressional Republicans keep trying to repeal it - "Obamacare" will
finally be in the hands of American consumers.
