SUMMARY: Health care is a top 2020 political issue. Democratic candidates are debating whether to build upon the Affordable Care Act, or 'Obamacare,' or replace it with Medicare for All. Meanwhile, President Trump wants to dismantle the ACA entirely. As millions of Americans enter the time of year when they choose their health plans, Amna Nawaz gets the latest from Margot Sanger-Katz of The New York Times.
SUMMARY: As consumers rush to enroll in the insurance exchanges, one change that's complicating signups is that more than half of the state-run health co-ops -- an alternative to private insurers -- were forced to shut down this year. The government was supposed to offset the costs, but Congress sharply curtailed that money. Special correspondent Mary Jo Brooks reports on the effects in Colorado.
GWEN IFILL (NewsHour): But, first, the demand for health insurance and concerns over choice.
The federal government reported higher demand this year for people trying to enroll on insurance exchanges for coverage. Six million had signed up by last week for coverage that begins next month. More than two million of them were new customers.
But, in 11 states, there’s one change that’s complicating the picture this year: Half of the state-run health co-ops were forced to shut down.
Special correspondent Mary Jo Brooks looks at what happened in Colorado.
MARY JO BROOKS (NewsHour): It’s been a tough year for 36-year-old Jessica Peck, a Denver attorney and divorced mother of two. Peck suffers severe vascular and neurological ailments which over the years led to soaring medical bills.
In 2014, she signed up with a brand-new health insurance company called Colorado HealthOP.
WOMAN: The co-op provides health insurance that is built around all needs.
MARY JO BROOKS: It was a nonprofit co-op formed under the Affordable Care Act and funded with loans from the federal government. Peck says she chose it because the price was right.
JESSICA PECK, Colorado HealthOP member: At least 50 percent in terms of premiums and out-of-pocket co-pays from the year before.
MARY JO BROOKS: Fifty percent.
JESSICA PECK: Fifty percent. So this cost saving was a difference. When I was at my sickest of being able to pay my bills, to be able to put gas in my car, and at one point having the difference in premiums was probably the only thing that kept me afloat.
MARY JO BROOKS: At her sickest last year, Peck was forced to have her right leg amputated and was hospitalized for more than 23 days. Peck is the first to admit that the co-op wasn’t perfect, including some billing errors she is still trying to sort out. But she was dismayed when she heard the news that the co-op was being shut down.
JESSICA PECK: Now I have to go back into a marketplace of players that I have worked with before, the big, big guys out there, who hurt me before, who sent me to collections on bills, who denied care that was absolutely 100 percent essential. And I have to go back into that marketplace and pay twice as much as what I’m paying right now.
Colorado HealthOP was one of 23 co-ops started around the country as a concession to Democrats who wanted the ACA to include an alternative to private insurers.
Michele Lueck heads up the policy research group Colorado Health Institute.
MICHELE LUECK, Colorado Health Institute: There were a number of politicians and legislators who wanted to have a government choice, something like Medicare that people could opt into.
And when that wasn’t politically feasible, an olive branch essentially that was offered to the left was this idea of creating co-ops, that this would be something that was owned and operated by the people who needed it the most.
SUMMARY: Dr. Devi Prasad Shetty, one of the world's most prolific heart surgeons, is the founder of a for-profit medical chain in India that offers top-notch surgery at very low prices. It serves wealthy patients and some medical tourists, but their goal is to bring the latest advances to the poor. Special correspondent Fred de Sam Lazaro reports.
GWEN IFILL (NewsHour): Next, the story of a man who’s been called the Henry Ford of heart surgery.
Fred de Sam Lazaro reports from India. It’s part of his ongoing series Agents for Change.
A warning: Some images may be disturbing.
DR. DEVI PRASAD SHETTY, Founder, Narayana Health: Hole in the heart. It’s one of those standard procedures.
FRED DE SAM LAZARO (NewsHour): It is especially standard for 62-year-old Devi Prasad Shetty, one of the world’s most prolific heart surgeons.
DR. DEVI PRASAD SHETTY: I do now about one or two surgeries a day, and we work six days a week. My colleagues, some of them do four surgeries, five surgeries a day.
FRED DE SAM LAZARO: Anywhere from 25 to 35 open heart operations are performed in the theaters here every day, many on babies, making this by far the largest cardiac care facility in the world.
It’s part of a fast-growing for-profit chain called Narayana Health, offering top-notch surgery, like this complex valve replacement, at rock-bottom costs.
DR. DEVI PRASAD SHETTY: This patient would have paid us about $2,500 to about $3,000, but in the U.S., an operation of this nature would cost, I guess, more — anything from $30,000, $100,000.
FRED DE SAM LAZARO: Dr. Shetty founded Narayana Health 15 years ago. It serves wealthy patients and some medical tourists. But he says the goal is to bring the latest advances in cardiac surgery to the poor.
DR. DEVI PRASAD SHETTY: It’s pointless we’re talking about huge developments in cardiac surgery or a brain operation or a complex cancer surgery if the common man cannot afford it. If a solution is not affordable, it is not a solution.
SUMMARY: Under the Affordable Care Act, the expected health care price spikes for coming year range from 20 to 85 percent. Those who are covered by their employers are also paying more out of pocket. What’s behind the increases? Gwen Ifill talks to Dr. David Blumenthal, president of the Commonwealth Fund, and Larry Levitt, Senior Vice President of Kaiser Family Foundation.
GWEN IFILL (NewsHour): If it feels like you are spending more for health care through higher deductibles or premiums, you may be right. Under the Affordable Care Act, insurers are required to post rate increases if they exceed 10 percent, and, in many cases, the price spikes for the coming year range from 20 percent to 85 percent.
And another study shows people who are covered by their employers are also paying more through higher out-of-pocket costs that leave as many as 31 million people underinsured.
Larry Levitt studies this for the Kaiser Family Foundation, and Dr. David Blumenthal is the president of the Commonwealth Fund, which released a second survey on out-of-pocket costs.
Larry Levitt, could you explain to me why these price hikes are going up all of a sudden? Or is it not all of a sudden?
LARRY LEVITT, Senior Vice President, Kaiser Family Foundation: Well, first, I would say that it’s hard to generalize from what we have seen so far.
I mean, as you said, insurers are only required to report right now increases of 10 percent or more. So, not surprisingly, those are all in double digits. But that said, reading the tea leaves, it does look like premiums are heading upwards.
And it’s for a combination of factors. I mean, first of all, health care costs, which have been growing very slowly recently, are increasing faster, particularly for prescription drugs. And insurers are for the first time under Obamacare setting premiums based on actual experience with enrollees.
Up until now, they were guessing at how much health care people were using. Now they have actually some experience under their belts and in many cases people are — look to be sicker than insurers expected.
You know it's going to be one of those days when one of the first tweets on vacation (in UK) inquires about the closest hospital.
Victor, one of my 11-year-olds, had something in his eye courtesy of a big gust of wind outside of Westminster Abby. He was complaining enough to let me flip his eyelid and irrigate his eye on the square in front of Big Ben. (I'm sure several people thought I was torturing him). Despite an extensive search and rinse mission no object or relief was to be found. I fretted about going to the hospital. It wasn't the prospect of navigating a slightly foreign ER, but simply the prospect of the wait. While I am a staunch supporter of the British NHS in the back of my mind I envisioned a paralyzingly full emergency room and an agonizing 18 hour wait only to find he had nothing in his eye (the basic antechamber of Hell scenario). To ensure we really needed to go I gave Victor a choice between the emergency room and a toy store (Gunter's third rule), but he declined the toys so off we went to St. Thomas hospital, conveniently right over the bridge.
The hospital was on the aging side and a little drab, but clean and well-marked. I didn't have to ask anyone for directions. We had to take a number to be registered, but waited less than five minutes. I gritted my teeth a bit in preparation for the we-are-not-from-the-UK conversation, but it wasn't an issue at all. I offered my US insurance number for billing, but was told they didn't need it. The clerk was, however, impressed with the fact that I flipped his eyelid and irrigated his eye before coming. "Well, you did all the right things," and looking at his red and watering eye she smiled and said. "Looks like you are in the right place."
Registration completed, we waited to be seen by the children's part of the ER. A registrar (resident) did a quick triage within five minutes of our registering (also impressed with the eye irrigation) and then a nurse did his vitals and took a history. After that we waited less than 15 minutes for the registrar to do a formal assessment. He wanted ophthalmology to do the evaluation. I was a bit surprised the ER doc wouldn't do it, but every facility is different and when they found out that Victor was born at 26 weeks and had retinopathy of prematurity they got a bit jumpy. Everyone does. I was OK with ophthalmology checking him out. What I have learned from years of medicine is don't mess with the local order.
We were walked over to the urgent care clinic and were warned that the ophthalmology registrar was covering the whole hospital so it might be a while. This was our longest wait, about 20-30 minutes. She was very nice (also working on her PhD). Dr. Katie Williams (she gave me permission to use her name and her photo) diagnosed Victor with a corneal abrasion and easily snagged the offending speck of dirt wedged under his eyelid. Once removed Victor exclaimed, "It's gone!," and within a minute or two the redness cleared up. She put in antibiotic ointment and gave us a tube to use at home.
"So where do I pay?" I asked Dr. Williams.
The answer, you don't. Perhaps they might bill us, she just wasn't sure.
I was about as dumfounded at her answer as she was at my asking.
I protested that it wasn't fair. We had used services and I was very prepared to pay. I also have insurance that covers emergencies when out of network, so I was pretty sure I would be reimbursed at least some of the visit. However, we were just sent away. They do have my address so it is possible I will get a bill in the mail.
I am very curious what similar care would have cost in the US. The saddest commentary of all is that it is really impossible to tell as billing practices are so bizarre and opaque. My guess is it would be a minimum of $1000 in America for cash (which is egregious). If I ever get a bill from the UK, I'll post a follow-up. If anyone has had similar care in the US and received a bill please do post in the comments.
But what of this idea that national health care means DMV-purgatory worthy waits, Dementor-staffed death panels, Saxon-age medical equipment, and incompetent care? Well, I can tell you we had great care at St. Thomas and Dr. Williams was fantastic. The slit lamp wasn't brand new, but it worked just fine. Sure it's an N of one, but I've been to the ER more times than I can count with my other son and this was as smooth as the best care we've had in the United States.
We could have hit the ER at an opportune time, but to expand my N I've also asked many people about their medical care while I've been in the UK. Not one person wanted to abandon the NHS. I've heard of excellent care and some care that was lacking, but the bad care has nothing to do with the "national" part. Rather it was diagnostic errors or a full hospice unit, things that I hear about with the same incidence back in the world of commercial insurance. Take away the accents and I could easily have been listening to a group of Americans discussing their care. With one exception, no one in the UK is left wondering what the price will be or gets an egregious bill.
It makes you wonder exactly what frightens Americans about the NHS?
Evidence is spreading that health-care costs are growing much more slowly than before. Now, it's not just a flattening in Medicare spending; the deceleration has spread to employment, too.
Last fall, in a generally skeptical analysis of the apparent slowdown in health-care costs, Harvard University economist Amitabh Chandra of Harvard University and co-authors noted that, because 57 percent of overall health-care expenditures are labor costs, "it seems unlikely that we would expect to see a permanent bending of the cost curve without a commensurate shift in employment rates.” And at that point, they didn’t see any such shift.
Now, a few months later, the accumulating data show that we are indeed experiencing a noticeable decline in health-care employment growth. From 1990 to 2005, according to the Bureau of Labor Statistics, employment in health care grew by an average of 2.8 percent per year. But over the past year, it has grown by only 1.4 percent. And in the past two months, it has barely changed at all -- and that is something that hasn't happened since data collection began.
“We have noted since first publishing on the health care spending slowdown that health labor would eventually need to follow suit," said Charles Roehrig, director of the Altarum Institute’s Center for Sustainable Health Spending. "We have apparently finally reached that point.”
Within health care, employment is still expanding rapidly in some areas but has slowed sharply in others. The most notable trend is that hospital jobs, which account for a third of employment in the sector, have basically stopped increasing. On the other hand, in some outpatient care services (freestanding emergency medical centers and kidney dialysis centers, for example) the number of jobs has risen about 6 percent over the past year. These patterns reflect the broader shift toward outpatient care.
What does this all mean both for the broader economy and for health care? Given the weak state of the labor market, will sluggish job growth in the health-care sector be a problem? Consider that, if the job growth rate in health care after 2010 had continued at its historical average of 2.8 percent per year, the sector would employ some 650,000 more people today than it actually does.
While that seems like a lot of jobs, however, it would represent only about one-half of 1 percent of the workforce, even assuming the additional jobs in health care did not displace jobs in other sectors. The way to strengthen the overall labor market this year is not to perpetuate inefficiencies in health care. (By the way, some good news for workers in the sector: The share of labor compensation in total health-care income has remained roughly constant over time. That stands in stark contrast to the economy as a whole.)
JUDY WOODRUFF (Newshour): Let's focus on an issue the president was asked about at length today, the health care law.
Mr. Obama acknowledged the rollout of it was probably his biggest mistake of the year. But he defended the law overall, and pointed to a big increase in enrollment in the exchanges this month as evidence of his efforts to turn things around.
His remarks came after the administration responded last night to the problem of canceled insurance policies with a special exception. Those affected can buy cheaper, bare-bones catastrophic coverage if new plans are more expensive.
Mary Agnes Carey watching all this for Kaiser Health News, an independent news organization.
Welcome back to the program.
MARY AGNES CAREY, Kaiser Health News: Thank you.
JUDY WOODRUFF: So what exactly did the administration announce last night?
MARY AGNES CAREY: What they said is for these folks in the individual market who may have had their policies canceled -- we're not sure exactly how many have had that. The estimates are maybe three to four million.
If they have not been able to find a policy that they think is affordable, they can qualify for something called the hardship exemption in the health law. Typically, this is for some sort of event, like you're homeless or you have been evicted in the last six months, that sort of hardship. But they're saying that by qualifying for the hardship exemption, there's two things.
Number one, they won't face the individual mandate penalty in 2014, and they would be allowed to buy something called a catastrophic health care policy, which is usually just open to people under the age of 30.
With just a handful of prescriptions to his name, psychiatrist Ernest Bagner III was barely a blip in Medicare's vast drug program in 2009.
But the next year he began churning them out at a furious rate. Not just the psych drugs expected in his specialty, but expensive pills for asthma and high cholesterol, heartburn and blood clots.
By the end of 2010, Medicare had paid $3.8 million for Bagner's drugs — one of the highest tallies in the country. His prescriptions cost the program another $2.6 million the following year, records analyzed by ProPublica show.
Bagner, 46, says there's just one problem with this accounting: The prescriptions aren't his. "All of that stuff you have is false," he said.
By his telling, someone stole his identity while he worked at a strip-mall clinic in Hollywood, Calif., then forged his signature on prescriptions for hundreds of Medicare patients he'd never seen. Whoever did it, he’s been told, likely pilfered those drugs and resold them.
"These people make more money off my name than I do," said Bagner, who now works as a disability evaluator and says he no longer prescribes medications.
Today, credit card companies routinely scan their records for fraud, flagging or blocking suspicious charges as they happen. Yet Medicare’s massive drug program has a process so convoluted and poorly managed that fraud flourishes, giving rise to elaborate schemes that quickly siphon away millions of dollars.
Frustrated investigators for law enforcement, insurers and pharmacy chains say they don’t see evidence that Medicare officials are doing much to stop it.
“It’s kind of a black hole,” said Alanna Lavelle, director of investigations for WellPoint Inc., which provides drug coverage to about 1.4 million people in the program, known as Part D.
Lavelle said her team routinely refers doctors and pharmacies to the contractor Medicare hires to pursue fraud. "Oftentimes we never hear back, positive or negative."
Since it started in 2006, Part D has been lauded for its success in getting needed medications to more than 36 million seniors and disabled enrollees.
But over the past year, ProPublica has detailed how Part D is beset by weak oversight. Medicare doesn’t analyze its prescribing data to root out doctors whose inappropriate drug choices endanger patients. Nor has it flagged those whose unchecked devotion to name-brand drugs, instead of generics, adds billions in needless expense.
For this story, ProPublica again scrutinized Medicare’s data, this time to identify scores of doctors whose prescription patterns bore the hallmarks of fraud. The cost of their prescribing spiked dramatically from one year to the next — in some cases by millions of dollars — as they chose brand-name drugs that scammers can easily resell.
Sometimes the doctors claimed they were unwitting victims of identity theft. In other cases they were paid for writing bogus or inappropriate prescriptions.
Over the past few years, Washington state’s liberal voters have been on quite a roll. Same-sex marriage? Approved. Assisted suicide? Check. Legalized pot? That too. Strong abortion protections? Those have been in place for decades.
Now, though, the state finds itself in the middle of a trend that hardly anyone there ever saw coming: a wave of mergers and alliances between Catholic hospital chains and secular, taxpayer-supported community hospitals. By the end of this year, the ACLU estimates, nearly half of Washington’s hospital beds could be under Catholic influence or outright control.
Many of the deals have been reached in near secrecy, with minimal scrutiny by regulators. Virtually all involve providers in Western Washington, which voted heavily for same-sex marriage last November and the Death with Dignity Act in 2008. The cultural divide between the region’s residents (Seattle recently edged out San Francisco as the area with the largest proportion of gay couples) and the Catholic Church (whose local archbishop led the effort against marriage equality and is overseeing a Vatican crackdown on independent-minded American nuns) couldn’t be wider. And yet more and more hospitals there — sustained by taxpayers, funded by Medicare, Medicaid, and other government subsidies — could be bound by church restrictions on birth control, sterilization and abortion, fertility treatments, genetic testing, and assisted suicide.
In affected communities, the news is not going over well.
“It’s the perfect storm here,” said Kathy Reim, president of Skagit PFLAG (Parents, Families and Friends of Lesbians and Gays) north of Seattle, where four area hospitals have been in merger talks this year. “We are the only state that has all these rights and privileges available to our citizens. Yet many of our hospital beds are being managed by a system that, for the most part, cannot and will not honor these rights and laws.”
Meanwhile, the deals just keep coming. Earlier this month, hospital commissioners approved a letter of intent between Skagit Valley Hospital and PeaceHealth, a Catholic enterprise that runs nine medical centers and dozens of clinics in three states. The week before, Franciscan Health System (which already has six hospitals in the region) said it would affiliate with an acute-care facility in the sprawling suburbs south of Seattle. In mid- September, UW Medicine, which includes the University of Washington’s teaching centers, signed a “strategic collaboration” with PeaceHealth to provide advanced specialized in-patient care.
In all, Washington has seen at least 10 completed or proposed Catholic-secular affiliations in the past three years, more than anywhere else in the country, says Sheila Reynertson of MergerWatch, a New York-based nonprofit group that tracks hospital consolidations. Three of the state’s five largest health-care systems are Catholic.
Catholic providers have actually been an integral part of Washington state’s health-care infrastructure since the late 1800s, when nuns from the East Coast and Europe braved rain and worse to minister to loggers and miners in remote outposts around the region. A century later, those historical ties — and their relative robustness — have made them attractive partners for community hospitals for whom the choice is: affiliate or get crushed.
“It’s harder than ever before for independent health-care organizations to thrive without alliances,” said PeaceHealth spokesman Tim Strickland. One of the main reasons: health-care reform. “It’s happening all over the country, with all kinds of providers,” he said. “We don’t perceive this trend as a Catholic scenario so much as a health-care scenario.” (Indeed, the consulting firm Booz & Company predicts that a fifth of the nation’s 5,000 hospitals could merge over the next few years.)
In some places — including big swaths of Western Washington — Catholic providers are becoming the only source of health care for an entire region. (Approximately 8 percent of what the federal government calls “sole community hospitals” are Catholic.)
The dilemma is that Catholic hospitals — there are 630 or so in the United States, representing 15 percent of all admissions every year — are not independent entities. They are bound by a 43-page document called the Ethical and Religious Directives for Catholic Health Care Services, which have been around in some form since 1921 and were last revised by the U.S. Conference of Catholic Bishops in 2009.
A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.
Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.
Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.
People shopping for insurance on the health exchanges are already discovering this bitter twist.
“How can somebody in poverty not be eligible for subsidies?” an unemployed health care worker in Virginia asked through tears. The woman, who identified herself only as Robin L. because she does not want potential employers to know she is down on her luck, thought she had run into a computer problem when she went online Tuesday and learned she would not qualify.
At 55, she has high blood pressure, and she had been waiting for the law to take effect so she could get coverage. Before she lost her job and her house and had to move in with her brother in Virginia, she lived in Maryland, a state that is expanding Medicaid. “Would I go back there?” she asked. “It might involve me living in my car. I don’t know. I might consider it.”
The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.
“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”
The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.
Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.
SUMMARY: The health care reform law was designed to help give people without health insurance an affordable avenue to buy it. But how does it affect Americans who get their insurance through their workplace? NewsHour analyst Susan Dentzer joins Ray Suarez to help answer frequently asked questions about how companies are affected.
JUDY WOODRUFF (Newshour): Tonight, we are looking at the changes that start taking effect when new online insurance marketplaces known as public exchanges open next month. One big question: how employers may respond.
Just today, Walgreens announced that it will move 160,000 of its employees into a private exchange where they can choose an insurance plan, but with company subsidies. Executives cited generally rising health care costs as one reason, but said expenses associated with the new law were a factor as well. Time Warner, Sears and Trader Joe's have announced similar moves.
That brings us to our series in which we try to answer some of your more frequently asked questions.
And to Ray Suarez.
RAY SUAREZ (Newshour): The law was designed to provide coverage for many who don't have health insurance now. But there are still many concerns and questions about what it may mean for employer-sponsored coverage and whether some businesses may change what they offer as the law takes full effect.
The workplace is our focus tonight.
And, once again, we're joined by NewsHour regular, analyst Susan Dentzer.
JUDY WOODRUFF (Newshour): .....the health care reform law and its impact on insurance coverage.
New insurance marketplaces, called exchanges, are getting set to open in October. But there's still much frustration and confusion about the law. A new poll finds 53 percent of the public is opposed to it. Just 25 percent say they have a very good understanding of it. And only about half of the uninsured Americans surveyed are supportive of it, with many questions about how it works.
We're starting a series tonight in which we will try to answer some of your more frequently asked questions.
Ray Suarez is in charge.
RAY SUAREZ (Newshour): The exchanges are intended to provide new insurance options for those who are uninsured or in some cases need to change their coverage.
What we have heard online and from people we have interviewed are basic questions: Who can sign up and what's covered? That's where we start tonight.
Julie Rovner from NPR is with us again to help us walk through this.
And, Julie, we have been hearing about the exchanges for a really long time. The window finally opens up on October 1. What is an exchange and who are the customers?
Wondering how much insurance premiums will cost under the upcoming insurance exchanges? In many states, information is now becoming available.
One of the biggest questions about Obamacare is whether its new consumer protections might lead to higher costs for some people buying coverage on their own -- or through small groups -- when they purchase it via the online insurance marketplaces that open for enrollment Oct. 1.
A growing number of states have released approved 2014 premiums and other details about individual and small group insurance plans that will available on the marketplaces, also called exchanges. Those rates do not take into account the federal tax credits that many people will be eligible for. In addition, the federal government must give final approval to the plans in September.
Some states such as Arkansas, Illinois and New Hampshire have approved their rates but have not released any information about premiums and say they don't plan to do so until Oct. 1.
States that are running their own exchanges, such as California, provide details about the benefits in each state-approved plan in each region of the state.
States who have declined to run their own and who will have federally-run exchanges, still must have the premiums approved by the Obama administration.
The following are links to publicly released data from states that have made their information available. KHN will add links to other states as they are published.
Rep. Louie Gohmert is wrong when he says a “poor guy out there making $14,000? is “going to pay extra income tax if he cannot afford to pay the several thousand dollars for an Obamacare policy.” In fact, that “poor guy” will be eligible for Medicaid coverage or heavily subsidized private insurance, depending on where he lives, without fear of being penalized if he cannot afford insurance.
Under the new law, an individual earning $14,000, which is currently 122 percent of the federal poverty level, would be eligible to receive:
- Medicaid if he lives in a state that expands Medicaid to include coverage for individuals and families earning up to 138 percent of the federal poverty level. A provision of the Affordable Care Act funds the Medicaid expansion, at the state’s discretion.
Gohmert, a Texas Republican, made his comment on ABC’s “This Week.” He was criticizing President Obama for delaying implementation of the health care law’s employer mandate but not its individual mandate. Under the law, most Americans will be required to purchase health insurance or pay a penalty, beginning at $95 per person or 1 percent of income in 2014, whichever is higher, and rising to $695 per person or 2.5 percent by 2016.
- A significant federal subsidy to help pay for private insurance, if he doesn’t live in a state that expands Medicaid. But he doesn’t have to buy insurance, because he is also eligible for a “hardship exemption” that would exempt him from any tax penalties.
Gohmert, Aug. 11: What about the poor guy out there making $14,000? He’s going to pay extra income tax if he cannot afford to pay the several thousand dollars for an Obamacare policy. Who’s caring about him?
Well, a lot of us do, but it’s not this president because he didn’t let the individual mandate have a year off. He — that only goes to big business. That’s not fair.
Gohmert has repeatedly expressed concern about the guy making $14,000, as he did in a July 17 statement and in an interview on the “Sean Hannity Show” on Aug. 6 (at the 4:47 mark).
Gohmert, July 17: To force higher income tax rates on people making as little as $14,000 or so a year is grossly unfair by any standards, no matter how badly he wants to force Americans into ultimate government healthcare control.
Gohmert, Aug. 6: We’re doing this for America, for the guy that’s making $14,000 that would ultimately have an extra two and a half percent tax because Obama went after the little guy in Obamacare. We’re doing it for those people.
But Gohmert is wrong, for several reasons. Let’s start with the fact that the federal poverty level currently is $11,490 for one individual, so $14,000 is 122 percent of the federal poverty level. A person earning that little would qualify for Medicaid next year in at least 23 states. That’s because the ACA expands Medicaid to include those earning up to 138 percent of the federal poverty level, which is $15,856 a year for 2013. The Medicaid expansion will not occur in every state, because the Supreme Court’s June 2012 ruling gave states the option not to expand it. As of July 1, 23 states and the District of Columbia support the expansion, while 21 are opposed and six are still considering it, according to the nonpartisan Kaiser Family Foundation.
So what happens to the “poor guy out there making $14,000? in, let’s say, Gohmert’s home state of Texas — one of the states that so far has opted not to expand Medicaid? He can buy a qualified health plan through an insurance exchange that will be set up under the law, beginning Oct 1. But it is not a requirement that he buys insurance. That’s because he will be eligible to receive a “hardship exemption” to the individual mandate and its tax penalty, under a final rule published July 1 by the Department of Health and Human Services. (See page 39525 under “eligibility standards for exceptions.”)
Federal Register, July 1: Ineligible for Medicaid based on a state’s decision not to expand. The Exchange must determine an applicant eligible for an exemption for a calendar year if he or she has been determined ineligible for Medicaid for one or more months during the benefit year solely as a result of a State not implementing section 2001(a) of the Affordable Care Act;
The Centers for Medicare and Medicaid Services announced the final rule in a June 26 press release. That release provided a list of reasons why a person would qualify for an exemption to the individual mandate — including this one: “Individuals who are ineligible for Medicaid solely based on a state’s decision not to implement the Medicaid expansion under the Affordable Care Act. This rule will protect individuals in states that, pursuant to the Supreme Court decision, choose not to expand Medicaid eligibility. …”
So, Gohmert’s guy making $14,000 won’t be penalized even if he lives in a state like Texas. But he would be eligible to receive a significant tax credit subsidy to help him buy insurance on the exchange, because the law also provides a sliding scale of subsidies to people with annual incomes between 100 percent and 400 percent of the federal poverty level, as the Kaiser Family Foundation explains.
Someone with a modified adjusted gross income of $14,000 would receive a significant tax credit to help pay for insurance. How significant? A 27-year-old nonsmoker who has no children and earns $14,000 might expect to pay only $280 a year for insurance on the exchange. That’s because he would receive a tax credit subsidy of $2,883, covering 91 percent of the estimated $3,163 annual premium, according to the Kaiser Family Foundation’s (KFF) “Health Reform Subsidy Calculator.”
KFF estimates the subsidy would be even larger for a 57-year-old nonsmoker. That person — who, again, has no children and earns $14,000 — also would pay just $280 a year toward his insurance premium, even though the cost of his plan is estimated at $7,355.
(The calculator is for illustrative purposes only to give people an idea of how much they can expect to pay for insurance and receive in subsidies. Premiums on the exchanges are still being set. KFF assumes that the average premium for a single adult before subsidies would be $4,827, which is then adjusted based on a person’s family size, age, tobacco usage and income.)
The new federal law allows insurance companies to charge higher premiums based on age and tobacco use — up to a point. Older policyholders can’t be charged more than three times the rate for younger policyholders and smokers 1.5 times more than nonsmokers. It’s under this scenario that someone earning as little as $14,000 — and living in a state that chooses not to expand Medicaid — might have to pay “several thousand dollars for an Obamacare policy,” as Gohmert said. KFF estimates, for example, that a 57-year-old smoker would have to pay nearly $4,000 even after receiving federal subsidies. But, as we said, that person isn’t required to buy insurance and won’t get hit with an extra income tax if he doesn’t — despite what the Texas congressman says.
Even low-income individuals who are not eligible for Medicaid because they earn above 138 percent of the federal poverty level — currently $15,856 a year for 2013 — are eligible for subsidies and possibly a hardship exemption. That’s because the eligibility standards for exemptions also state that a person must be granted an exemption if “[t]he expense of purchasing a qualified health plan would have caused him or her to experience serious deprivation of food, shelter, clothing or other necessities.”
HARI SREENIVASAN (Newshour): There are more than three million registered nurses in the U.S., and that will not be nearly enough in the coming years, as baby boomers begin to need more assistance and the Affordable Care Act kicks in.
A new book called "The American Nurse" looks behind the numbers in a very personal way, through portraits and essays of more than 75 men and women in several different care-giving capacities.
Photographer and documentarian Carolyn Jones spent the last two years chronicling the changes in the health care system and the compassion of those on the front lines. She interviews nurses who care for prisoners at Angola prison in Louisiana, the coal miners in Kentucky, to wounded soldiers in California, and hospice patients in Florida, among many others.
Carolyn Jones joins me now, along with Rhonda Collins, who is a registered nurse and vice president of Fresenius Kabi USA, the health care company that funded the project.
Television commercials have already run suggesting that buying health coverage through the state’s new insurance market, Connect for Health Colorado, will feel like winning the World Series.
The market’s employees are traveling the state to explain how it will work, often in electric yellow T-shirts with the message, “Got Insurance?” In the coming weeks, 400 guides will be trained to help the uninsured sign up for coverage, with some targeting groups like Hispanics, gay and lesbian citizens, and even truckers.
This is Colorado, five months before the central provisions of President Obama’s health care law take effect: a hive of preparation, with a homegrown insurance market working closely with state agencies and lawmakers to help ensure the law’s success. Gov. John W. Hickenlooper, a Democrat, is a firm supporter, and the state legislature, controlled by Democrats, has not thrown up any obstacles.
When the legislature voted to allow a state-based insurance market in 2011, Republicans controlled the House of Representatives, but many supported the bill, contending that it would give Colorado more control over how the health care law played out here. This spring, state lawmakers voted along party lines to approve an expansion of Medicaid, which is encouraged but not required under the law.
The law does have opponents in Colorado, but they can do little to stop the Democrats from carrying it out. In February, Republicans even helped kill a bill that would have repealed the law allowing the insurance market.
“There’s politics everywhere these days,” Mr. Hickenlooper said in an interview, “but for the most part, we’ve really been focused on how to do this right, and trying to make sure that people have affordable health care.”
Connect for Health has received about $180 million in federal money to be up and running by Oct. 1 and to cover the first year’s operating costs.
Much of the work involves building the Web portal through which people who do not get insurance through their job can buy coverage. Colorado residents will be able to shop for insurance plans and compare them on www.connectforhealthco.com, and determine whether they qualify for federal subsidies to help with the cost.
The portal has to be able to exchange information in real time with insurance companies, state agencies and the federal government, which is building a “data hub” through which it can verify income and citizenship.
Looking for the new health insurance marketplace, set to open in this state in two months, is like searching for a unicorn.
The marketplace, or exchange, being established by the federal government under President Obama’s health care law has no visible presence here, no local office, no official voice in the state and no board of local advisers. It is being run like a covert operation, with no marketing or detailed information about its products or their prices.
While states like Colorado, Connecticut and California race to offer subsidized insurance to their citizens, Missouri stands out among the states that have put up significant obstacles. It has refused to create an insurance exchange, leaving the job to the federal government. It has forbidden state and local government officials to cooperate with the federal exchange.
It has required insurance counselors to get state licenses before they can help consumers navigate the new insurance market. And, like many states, it has refused to expand Medicaid.
“It’s like running an obstacle course every day of the week, but the course changes from day to day,” said Herb B. Kuhn, president of the Missouri Hospital Association, a strong advocate of expanded coverage.
State Senator Rob Schaaf, the Republican author of a 2012 ballot measure that prevented the state from setting up its own insurance exchange, said: “We can’t afford everything we do now, let alone provide free medical care to able-bodied adults. I have a philosophical problem with doing that, and I’m also worried about our country’s financial situation.”
Over 850,000 Missouri residents, including low-income people in St. Louis and Kansas City, family farmers and small-business employees, are uninsured. Many could qualify for coverage through the exchange, which encourages competition and offers subsidies to reduce costs.
Kenneth L. Schmidt, an insurance broker in St. Louis who intends to sell insurance products offered on the exchange, said: “We have not seen any evidence of the federal exchange — how it will be run, how it will be structured in Missouri. Will it be run from Jefferson City? Will it be run from Washington? Who will watch over it? No clue.”
David R. Griggs, who owns a carpet store with 15 employees in Columbia, Mo., said he was hungry for information about the exchange. But, he said, “I have not seen or heard a word about it.”
Kat Cunningham of Columbia, the president of Moresource, a firm that handles payroll and benefits for more than 600 employers, said she had been deluged with questions from clients and was struggling to provide guidance.
Reuters reports this morning, in a matter-of-fact sort of way, that when it comes to implementation of federal health care law, Republicans and their allies "are mobilizing ... to dissuade uninsured Americans from obtaining health coverage."
I hope folks will pause to let that sentence sink in for a moment. Unlike every other industrialized democracy on the planet, the United States -- easily the wealthiest nation on earth -- tolerates a significant chunk of its population to go without basic health care coverage. These Americans and their families can't afford to see a doctor and are one serious illness from financial ruin.
After nearly a century of politicians talking about the problem, President Obama actually signed the Affordable Care Act into law three years ago, giving working families a level of health-care security they've never had before, and throwing a life preserver to the uninsured. Now, Republicans aren't just actively trying to sabotage the law, they're telling struggling Americans it's better to drown than accept the life preserver.
Writing in National Journal overnight, Norm Ornstein accurately describes the GOP efforts as "contemptible" and "spinning out of control."
It is important to emphasize that this set of moves is simply unprecedented.... For three years, Republicans in the Senate refused to confirm anybody to head the Centers for Medicare and Medicaid Services, the post that McClellan had held in 2003-04 -- in order to damage the possibility of a smooth rollout of the health reform plan. Guerrilla efforts to cut off funding, dozens of votes to repeal, abusive comments by leaders, attempts to discourage states from participating in Medicaid expansion or crafting exchanges, threatening letters to associations that might publicize the availability of insurance on exchanges, and now a new set of threats -- to have a government shutdown, or to refuse to raise the debt ceiling, unless the president agrees to stop all funding for implementation of the plan. [...]
What is going on now to sabotage Obamacare is not treasonous -- just sharply beneath any reasonable standards of elected officials with the fiduciary responsibility of governing.
For the unhinged right, there's apparent confusion over these criticisms. "We hate the health-care reform law," they argue, "so it's hardly outrageous for us to try to stand in its way."
This might help Republicans live with themselves, but it's a lousy argument.
More from Ornstein:
When a law is enacted, representatives who opposed it have some choices (which are not mutually exclusive). They can try to repeal it, which is perfectly acceptable -- unless it becomes an effort at grandstanding so overdone that it detracts from other basic responsibilities of governing. They can try to amend it to make it work better -- not just perfectly acceptable but desirable, if the goal is to improve a cumbersome law to work better for the betterment of the society and its people. They can strive to make sure that the law does the most for Americans it is intended to serve, including their own constituents, while doing the least damage to the society and the economy. Or they can step aside and leave the burden of implementation to those who supported the law and got it enacted in the first place.
But to do everything possible to undercut and destroy its implementation -- which in this case means finding ways to deny coverage to many who lack any health insurance; to keep millions who might be able to get better and cheaper coverage in the dark about their new options; to create disruption for the health providers who are trying to implement the law, including insurers, hospitals, and physicians; to threaten the even greater disruption via a government shutdown or breach of the debt limit in order to blackmail the president into abandoning the law; and to hope to benefit politically from all the resulting turmoil -- is simply unacceptable, even contemptible.
It's worth emphasizing that Ornstein isn't some liberal firebrand. When folks like, say, me write about Republican efforts to sabotage federal health care law, hoping to make millions suffer out of partisan spite, it's largely expected. Ornstein, however, is a celebrated and respected figure of the Washington establishment, an independent political scientist, and a scholar at the American Enterprise Institute.
In other words, when he writes columns like these, even the laziest both-sides-are-always-to-blame-for-everything Beltway talking head should take note.
And finally, let's also not forget that the sabotage-governing strategy is not the radical vision of the fringe; it's the official position of the elected Republican leadership in both the U.S. House and U.S. Senate. No further proof of the radicalization of GOP politics in the Obama era should be necessary.
A variety of adjectives come to mind to describe Republican efforts on this issue, but as this is a family blog, "contemptible" is as good a word as any.
JEFFREY BROWN (Newshour): Much of the public remains skeptical or unaware, an important component has been delayed, and Republicans continue their attempts to derail it.
But President Obama again today offered a strong defense of his signature health care reform law. His remarks came as deadlines approach for its implementation.
President Obama ratcheted up his campaign to sell the health care law today in a speech in the East Room of the White House.
PRESIDENT BARACK OBAMA: The Affordable Care Act is doing what it's designed to do; deliver more choices, better benefits, a check on rising costs, and higher-quality health care.
JEFFREY BROWN: The president highlighted a relatively obscure part of the law, which he himself now regularly refers to as Obamacare, that requires insurers to spend 80 percent of premium dollars on medical care or send rebates to their customers.
BARACK OBAMA: I bet, if you took a poll, most folks wouldn't know when that check comes in that this was because of Obamacare that they got this extra money in their pockets. But that's what's happening.
JEFFREY BROWN: Today's speech was part of a broader effort to sell the law. It comes amid continuing criticism from Republicans and worry from some supporters about its implementation.
Health Insurance Exchanges, one of the law's central components, begin to open Oct. 1.
JEFFREY BROWN: Jonathan Gruber, starting as a sort of general starting point, is there a simple answer as to whether the health reform law will lower or raise premiums?
JONATHAN GRUBER, Massachusetts Institute of Technology: There's never a simple answer with something as complicated as health care, but there's a three-part answer.
The first part is, for most Americans who have private health insurance who get it from their large employers, nothing changes.
The second part of the answer is, for the second largest groups, those who get insurance from small employers, what they're going to see is increased premium certainty. They won't see their premiums jump 50 percent in the year because someone gets sick.
And on average, they are going to see rates basically stay the same. Some will go up some, some will come down some, but basically stay the same. The third group is individuals.
Now, the effect on individuals is going to vary a lot across states, because -- depend on how regulated the individual market was before this law.
But what we are going to see is on average the premiums individuals face will go up, but that will be offset by the fact that the Affordable Care Act includes tax credits to cover the cost of health insurance. After you factor in tax credits, premiums will go down on average.
HARI SREENIVASAN (Newshour): Medicaid is a crucial piece of the health reform law and its goal of providing new coverage to 30 million Americans.
Roughly 13 million of them are expected to receive coverage by expanding eligibility to the program, which provides health care to the poor. But the calculus changed after the Supreme Court decided states could opt out, even though the federal government would pick up 100 percent of the new costs for the first three years.
So far, 23 states, mostly led by Democratic governors and the District of Columbia, have said they plan to expand eligibility starting next year. Eighteen others with Republican governors are opposed. Those states could be passing on billions of dollars. Now some Republican governors who have been opposed to the health care law are pushing to expand Medicaid. That includes Florida, Michigan, Ohio, and Arizona, where Governor Jan Brewer signed a bill to do so today.
We look at what's behind these changes in two of these states.
Mary K. Reinhart is with The Arizona Republic. And Karen Kasler is with Ohio Public Radio.
