How Many of Obamacare’s New Enrollees Were Uninsured Last Year? Why It Doesn’t Matter

Charles Gaba, the enrollment guru who has been tracking Obamacare sign-ups since October, now estimates that by April 15, some 17 million Americans will have purchased their own insurance policies either in the Obamacare Exchanges (8 million) or off-Exchange (9 million)

But how many of them were uninsured and how many were simply replacing policies that Obamacare had forced insurers to cancel?  This is the question conservatives ask.  After all they argue, if most of these folks already had coverage, we have just wasted a great deal of time and money moving them from a policy they chose to one that President Obama prefers.

There are two answers to their question. The first is that while we don’t have an exact number as to how many of the new enrollees were uninsured, we do know that, thanks to Obamcare,  the percent of Americans who are “going naked” has declined. New Gallup data shows that the uninsured rate fell from 18.1% in the third quarter of 2013 to 15.6% in the first quarter of 2014.

That said, Gaba offers a second, even better, answer: “It doesn’t really matter.” 

I agree. As he explains:

“It doesn’t matter because every one of those new policieswhether on-exchange or off-exchange; whether it went to someone who didn’t have insurance before, someone who had their old policy cancelled or went to someone who voluntarily made the switch to a new one…which  . . is a LOT of people, by the way…is still a fully ACA-compliant, full-coverage healthcare plan.”

Gaba points out that “the primary point” of his website (ACASignups.net) “is to track how many people are now enrolled in a “QHP certified” plan regardless of whether they had insurance before or not. Some moved from no plan at all to a QHP. Others moved from a ‘junk’ policy to a QHP (some have argued that there aren’t that many of these, but there were still a lot of them). Still others yet (myself included) have moved from a decent plan to a QHP. . . . The point is, they’re all ACA QHPs now.” [his emphasis]

This is critical to understanding the purpose of health care reform. From the beginning the goal of the Patient Protection and Affordable Care Act (PPACA) was not simply to insure the uninsured, but to protect the under-insured by making certain that everyone has comprehensive coverage.  Whether a carrier is peddling policies in a state marketplace or off-exchange all plans now must comply with the ACA’s rules by:

–covering the ten essential benefits

–offering free preventive care, and

–capping how much a patient can be asked to pay out-of-pocket.

In addition, carriers can no longer discriminate against customers suffering from pre-existing conditions by charging them exorbitant premiums, and they cannot set a limit on how much the insurer will pay out, over the course of a year or a lifetime.

The second goal of the Patient Protection and Affordable Care Act is to make sure that the price of such high quality insurance is not beyond reach. Government subsidies help low-income and median-income families, but the only way to make sure that everyone else can afford policies that meet the ACA’s high standards is by asking all of us to share in the cost.

This is why the ACA mandates that everyone purchase insurance. When more people pay into the risk pool, the costs decline for everyone. It is only then that universal coverage becomes possible

 

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Next Year, Will Your Employer’s Insurance Cover 62 Services and Products with No Co-Pay or Deductible? How Much Will You Save?

Under the ACA,  some 62 preventive services and products will be free: no copays and the deductible will not apply. The list includes vision checks for children, birth control, and more than a dozen vaccines.

This rule will hold true not just for plans sold in the exchanges, but for most employer-sponsored plans. Under Obamacare, they, too, must offer preventive care without cost-sharing – unless they are “grandfathered.” (Grandfathered plans are policies that existed before the ACA was passed in 2010, and that have not made substantial changes to benefits or cost-sharing since then.)

This year, just 36 percent of Americans who have health benefits at work are enrolled in a grandfathered plan,, down from 48 percent in 2012 and 56 percent in 2011. Each year, more plans will lose their grandfathered status. 

The ACA’s list of preventive services and products covers most of the reasons that many of us visit a physician – for blood pressure checks, cholesterol checks, flu shots, mammograms, tetanus shots, Pap smears or colorectal cancer screening.

Some of us go to the doctor because we want help losing weight, or quitting smoking. Counseling and smoking cessation products – including nicotine patches – all make the list.

If we feel sad, and don’t know why, we may want to be screened for depression. Under Obamacare, this is a free preventive service. If you are a new mother who is feeling blue – or a 60-year-old man who just doesn’t want to get up in the morning – and your primary care physician (PCP) determines that you are depressed, he will send you to a someone who can provide counseling andor medication. The initial consultation with your PCP is free.

Preventive care for kids

As parents, we take our children to doctors for a host of reasons – often because we want advice. “What should I feed a plump six-year old?” “My 14-year-old doesn’  like to leave his room-and he is being teased at school. Should I be worried?”

The ACA lists 25 preventive services for children, including diet counseling, depression screening for adolescents, , oral health risk assessments for children under age 11, behavioral and developmental assessments,  vaccines to protect against 12 diseases, obesity screening and counseling, flu shots and tetanus shots.

      How Much Will You Save? Why Should Men Pay for Contraception?

A woman who uses birth control m”ay save up to $600 a year.

Some men are not happy that part of their insurance premium will pay for contraception. “I’m single and I never plan to have children” one HealthBeat reader grouses. “Why should I pay for it?

There are many answers. But here is an easy one: Women use more preventive services when they are younger, but as men age, the fact that they didn’t go to the doctor for blood pressure screening – or help losing weight – catches up with them. According to the Health Cost Institute, healthcare spending for women exceeds spending for men until age 60. At that point men’s healthcare becomes more costly.  

This is when healthy women begin subsidizing men. Of course, much depends on how long an individual lives. If a fit 70-year-old woman survives until she is 95, she may, in the end, cost society more than an overweight man who has a knee replacement, suffers from diabetes, and dies of heart disease at age 75.

But over the long run, these things even out. Different people need more care at different points in their lives. This is how insurance works: over time, we subsidize each other.

I originally wrote about preventive care on Healthinsurance.org. To  find out more about how much you will save, and how free preventive care affects the maximum that you will ever be expected to lay out under Obamacare click here  and scroll down to “Most Won’t Exceed Their Deductibles.”

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HHS Announces How Much Insurance Will Cost in 36 State Exchanges

These are the numbers we have been waiting for. This week the Department of Health and Human Services (HHS) published a report revealing what insurers will be allowed to charge in the largest cities in 36 states, when selling policies Americans buying their own coverage in the state “Exchanges.” The report also shows the size of the subsidies that Exchange shoppers  will receive. Previously, we had hard numbers for only 14 states.

In addition, HHS announced averaged premiums, state-wide, for Bronze and Silver plans in those 36 states. (We will be getting more information on rates in other cities very soon.)

Fear-mongers should blush.

It turns out that, on average, rates are 16% below the Congressional Budget Office’s projection—and that is BEFORE factoring in the subsidies.

I found what the report has to say about premiums in Texas particularly interesting. Many observers had suggested that while rates in the Blue States might be surprisingly low, Red States would let carriers charge far more.

I’ve written about the report—and the media’s reaction to it—here on healthinsurance.org. 

You can comment there, or return here to comment.

If you use Facebook, you may want to put a link on your Facebook page. More people need to hear the facts about Obamacare.

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Under Obamacare, Will You Receive a Subsidy to Help You Buy Your Own Insurance? We Now Have Real Numbers That Will Let You Calculate How Much You Will Receive

 

Note to Readers: A longer version of this post appeared yesterday on HealthInsurance.org.

Up until now, when Obamacare’s supporters and reform’s opponents squabbled over what insurance will cost in 2014, they had to rely on estimates and national averages. But now we have real numbers.

Eleven states have announced the rates that insurers will be charging in their Exchanges-marketplaces where individuals who don’t have employer-sponsored coverage can shop for their own insurance.

Subsidies Will Be Based On the Cost Of A Silver Plan Where You Live,

Middle-income as well as low-income people buying coverage in the Exchanges will be eligible for government subsidies that will come in the form of tax credits. Anyone earning between 100 and 400 percent of the federal poverty level (FPL) (now $11,490 to $45,960 for a single person, and up to $126, 360 for a family of six) will qualify.

Most people who are forced to buy their own insurance earn less than 400% of FPL. More affluent Americans usually work  for companies that offer comprehensive coverage.

The graph below shows average Silver plan rates in the eleven states that have disclosed premiums. (Note that these are only state averages. Premiums vary widely within a state: In some cities and counties silver plan rates will be much lower, even before you apply the subsidy.

Silver plan premiums

It’s worth noting that in these 11 states the least expensive Silver Plan costs 18% less than the non-partisan Congressional Budget Office projected last year. 
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Boehner Asks: “Why A Break for Businesses Only?”

 That House Speaker John Boehner would ask this question shows either:

a)    how little he understands about the Affordable Care Act; OR

b)    how committed he is to making sure that the American public  does not understand the purpose of health care reform.

I would pick “b”.

Republicans are now suggesting that if the employer mandate (requiring that businesses offer benefits to their workers or pay a penalty) is being postponed until 2015, the Obama administration should postpone the individual mandate as well.

“Is it fair for the president of the United States to give American businesses an exemption from his health care law’s mandates without giving the same exemption to the rest of America?” Boehner asks.

What he ignores, of course is that under the Affordable Care Act, .middle-income as well as low-income citizens would receive generous tax credits to help them purchase insurance. Not long ago, I wrote about those subsidies, and a new “subsidy calculator” that will let an individual estimate how large his subsidy would be).

More than 26 million Americans will be eligible for these tax credits next year–though most dont know it. And by attempting to delay the individual mandate, the GOP is trying to make sure that they don’t find out.

       The Individual Mandate and the Employer Mandate Are Not Connected

Meanwhile Boehner pretends that the two mandates are somehow connected, In fact, they have nothing to do with each other. 

 The individual mandate exists because, under Obamacare, insurers are required to cover people suffering from pre-existing conditions. Aetna will no longer be able to shun the sick, nor will it be able to slap them with sky-high premiums.

This part of the law is extremely popular. Most Americans understand that any one of us could be diagnosed with cancer tomorrow. The goal of the law is to protect all of us against the vicissitudes of fate by ensuring that we have access to affordable insurance.

But if there were no individual mandate requiring that we all purchase insurance (or pay a penalty), a great many people would wait until they became ill, and only then buy insurance.As a result the insurance pool would be filled with folks who need expensive care, and everyone’s premiums would spiral.

If we want to insist that insurers cover the sick, we also must insist that everyone join the insurance pool. We all share in the risk of becoming sick, and so all must share in the cost. Ultimately, insurance is all about “pooling the risk.”

(Those who believe that they shouldn’t have to join the pool because they are young or  because they don’t smoke, exercise regularly and generally “take care of themselves” are ignoring the most basic fact about the human condition:  ”all flesh is grass”. )

The requirement that insurers must cover a 30-year-old suffering from MS cannot be separated from the individual mandate. We cannot have one without the other. The architects of health care reform understood the connection

By contrast, the employer mandate has little to do with the individual mandate. The phrases sound alike, that’s about it. The individual mandate and the employer mandate do not depend on each other.

If some employers decide that they will wait until 2015 before offering comprehensive, affordable health benefits, their employees will be eligible for subsidies to help them purchase their own coverage.  Postponing the employer mandate in no way affects their ability to obtain coverage at a cost they can afford. Alternatively, if an individual decides not to purchase insurance, next year, he will be asked to pay a penalty of just $95.

This is what Fox News calls “a hefty fine.”

 

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The Affordable Care Act and the Smokers’ Penalty

Under the ACA smokers  buying insurance in the Exchanges will have to pay a 50% “Premium Surcharge.” For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. http://news.yahoo.com/penalty-could-keep-smokers-health-overhaul-205840155.html Does this mean that Americans who smoke won’t be able to afford coverage?

No. In the end, most smokers should be able to get health insurance without paying a stiff penalty.

For one, it’s up to individual states as to whether they want to let insurers charge smokers more. By early April of 2013, Rhode Island, Vermont, Massachusetts and D.C. had voted to eliminate smoking premiums in their health care exchanges:  The American Cancer Society, which is opposed to the surcharge, is working to persuade other states to ban it. (The ACS explains: “We’re anti-smoking, not anti-smoker.”)

I agree with the ACS that the penalty is counter-productive.  If it makes insurance unaffordable for some smokers, this means that they won’t have access to smoking cessation programs, nicotine patches and other drugs that could help them quit.  Keep in mind that most smokers want to quit, and these programs have proved extremely successful.

The good news is that many Americans who are addicted to nicotine will be eligible for Medicaid. In the U.S. 39 percent of adult smokers live below the poverty level. . Many more live below 133 percent of the poverty level. As states expand Medicaid, they, too, will become eligible for the program. Since Medicaid charges no premiums, they will not pay a premium surcharge.

Meanwhile, new research by the George Washington University School of Public Health and Health Services indicates that including comprehensive tobacco cessation benefits in Medicaid insurance coverage can result in substantial savings for Medicaid. The study found that every dollar spent on tobacco cessation program costs resulted in an average program savings of $3.12, which represents a $2.12 return on investment. 

Under the Affordable Care Act all state Medicaid programs are required to cover tobacco cessation medications, beginning in 2014.

Finally smokers who receive health benefits from their employer are likely to find that they don’t have to pay the premium if they join a smoking cessation program.

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Navigators: The Folks Who Will Help You Surf the New Insurance Exchanges

Over at Healthinsurance.org, I’ve addressed some “frequently asked questions” about the “navigators” who will help individuals and small business find the coverage they want in the new Exchanges. 

– Who Will Become Navigators?

–  Can Insurance Agents and Brokers Apply to Be Navigators? (Wouldn’t that create a conflict of interest?)

–  Just How Will Navigators Help People Sort Out Their Options in the Exchanges?

–  How Much Training Will They Receive?

–Finally, many people worry that the “navigators” just won’t be able to handle the heavy traffic. Giving the American public the information it will need about Obamacare is an enormous task. Will these navigators be up to it?

The answer to that last question is that the navigators will have help.  Patient advocacy groups, the states, and county health agencies will pitch in.  The federal government  also is launching a marketing program, “Enroll America” that will urge mothers to nag their uninsured 20-something and 30-something sons. (Seriously– and I expect that in many cases, this will be effective.)

Meanwhile insurers will be eager to draw young, healthy customers into the Exchanges. This means that they will invest in marketing campaigns designed to let 20-somethings and 30-somethings know that the vast majority will be eligible for generous government subsidies.

Just one example: Blue Cross and Blue Shield of Illinois already has launched a “Be Covered Illinois” campaign. The campaign is being funded by the insurer, and carried out by various community groups:  

Keep in mind that if insurers mislead customers about their offerings, those customers will have an opportunity to pick a different plan a year later. And under the ACA, they will have “navigators” to help them make a better choice.

Insurers know this. They  also are well aware  that under the new ACA rules that regulate them, a health insurance company will have to draw—and keep—a large share of the market’s customers in order to survive financially. For that reason, I suspect that savvy insurers will make a major effort to provide information about specific plans that will attract customers who will want to stick with those plans.

For my answers to the first four questions above, go to Health Insurance.org, click on the question and the answer will pop up.

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Problems with Health Insurance? Under the Affordable Care Act You Will No Longer Be Alone

If you sent in your health insurance payment on time, and paid it the way you always have (as a direct withdrawal from you checking count), but made a mistake when you put the checking account number on your payment,  would you expect that your insurer would drop you?

What if your insurer sent you an email a few days after you sent in your payment saying “Your payment has been received? Wouldn’t you assume that you were still insured?

Mike Holden did. He was wrong.

Yesterday, he sent an email explaining his story.  

 “On March 16, I paid my family’s monthly health insurance bill to United Healthcare (UHC) the same way I have for almost a year now. But I was using a new bank account that we set up after a recent move. Unfortunately, I entered the account number incorrectly. It turns out I left off three digits that are part of the account number but listed separately on the checks.”

Holden had no idea that he had made a mistake. On March 20, he received an email from UHC saying “Your payment has been received.”

Yet in April, when he went online to pay his family’s April bill, he was told his coverage had been terminated. He then talked to a customer service representative at UHC and received a letter explaining that he had until March 31 to correct his mistake.

Unfortunately, the letter, which was postmarked March 27, went to his old address. .

He appealed to UHC, explaining the problem and asking that his insurance be reinstated,

He then received a letter telling him that his appeal had been denied:  “United Healthcare Benefit Services follows the guidelines for payments and grace periods defined by the Department of Labor. Your account has been reviewed and the termination remains, as payment was not received within the guidelines provided.”

                          How the Affordable Care Act Brings Us Together

Beginning in 2014, people like Mike Holden will no longer be alone, trying to stand up to insurance companies. Individuals and families who buy their own insurance will be able to purchase coverage in “Exchanges”—marketplaces where insures will be regulated and individuals and families who purchase their own insurance will become part of a large group. There, they will have far more clout than they do now.
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A Doctor Confides, “My Primary Doc is a Nurse”

Last week I interviewed a doctor who told me that his primary care doc is a “physician assistant”  who has been trained to deliver primary care.   He said it casually, dropping the fact into a long conversation.

Dr. David Kauff is an internist at Seattle’s Group Health Cooperative (GHC), an organization that has a fabulous reputation–both among patients and among physicians—for its primary care program.  One reason is that at Group Health, doctors, physicians assistants and nurse practitioners work together in teams. “The success of our model is based on the fact that everyone in this together; we are corralled by a common purpose,” says Kauff, who also serves as GHC’s  Medical  Director for Practice and Leadership. 

I’ll be writing more about Group Health Cooperative in a few days.

 In this post, I would like to focus on the growing role of Nurse Practitioners (NPs) and Physician Assistants (PAs) as clinicians.  NPs are registered nurses who have gone on to earn a master’s or a doctorate. Some specialize in areas such as anesthesiology, pediatrics (pediatric nurses) or Ob-Gyn (certified nurse-midwives). NP’s can run clinics; some run their own practices.     

By contrast, physician assistants (PAs) don’t usually work alone. While physicians may not be on-site, typically doctors oversee their work.  

PAs are formally trained to provide diagnostic, therapeutic, and preventive health care services.  They take medical histories, examine and treat patients, order and interpret laboratory tests and X- rays, and make diagnoses. In many cases, they did not begin their careers as nurses. They may have been  paramedics, respiratory therapists, or emergency care technicians (EMTs) before becoming PAs.  

Currently, 17 states, plus the District of Columbia, let nurse practitioners operate independently.  In 33 states regulations vary. As this map  reveals, in some places NPs are not allowed to prescribe medication. In others, they may have to consult with a physician when treating patients.

It’s worth noting that NPs enjoy greater freedom in the Northwest, the Upper Middle West, and Northern New England (areas that some healthcare reformers refer to as “Canada South” because these states are in the vanguard of reform) as well as in the Southwest, where many NP’s started working in group practices, and they went out and established their own clinics. Nationwide, about 6,000 nurses operate independent primary-care practices.                                               

                                              Why Physicians Object

Today, 14 states are debating whether NPs should be allowed to practice on their own.  Many emphasize the difference in education and years of training. Though in truth, the length of training is not so different. Becoming a primary care doctor requires four years of medical school plus three years of residency. A nurse practitioner  attends nursing school for four years, then spends two to three years in graduate school, depending on whether he or she is getting an M.A. or a Ph.D. (In 2015, all nurse practitioners will be required to earn a Ph.D.) 

Most NPs also have nursing experience. At the University of Michigan, for instance, the average candidate admitted to the NP program has 7 years of hands-on experience as a nurse.  But while the number of years spent training are not so different, as I explain below, traditionally ,the nature of that training has been very different.   

Doctors say that they are worried about patient safety. “I see it as physicians being true to their oath “  Dr. Adris Hoven, president-elect of the American Medical Association recently told Marketplace Health Care’s Dan Gorenstein.   Hoven insists that doctors are “not threatened” by NPs.  “At the end of the day what they want to do is deliver the best healthcare possible.”  

Dr. John Rowe, a professor of Health Policy and Management at Columbia’s School of Public Health, doesn’t buy the argument.  As he points out, nurse practitioners are already working without primary care doctors: “The fact is this is going on in 16-17 states,” he told Gorenstein, “and there is no evidence that it’s not good for the patient.”  A recent Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation backs him up: “studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar.”

At the same time, Rowe understands why doctors are uncomfortable. “The physicians feel they have something special to offer,” he explains. “And being told there are individuals who are less well trained can do it as well as they could is a very difficult lesson for them.”                                    

When I last wrote about nurse practitioners, back in 2010, one physician/reader (“Sharon M.D.”) was exceptionally candid on this point:

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Who is Douglas Holtz-Eakin and why is he saying such terrible things about health reform?

Today, the House Energy and Commerce Committee’s Subcommittee on Health will hold a hearing entitled: Unaffordable: Impact of Obamacare on Americans’ Health Insurance.  (Always nice to know that our elected representatives are keeping an open mind.)

Prominent on the list of witnesses: “Douglas Holtz-Eakin.” Even before reading his testimony, I knew what Holtz-Eakin would say: young, health Americans should brace for “sticker shock.”  Conservatives like Holtz-Eakin tend to stay on script. However stale the rhetoric, they firmly believe that if you repeat a sound-bite often enough, people will believe it.                                     

                                        Who is Douglas Holtz-Eakin?

If you recognize the name, it’s probably because Holtz-Eakin has become a familiar figure in the mainstream media, quoted in the New York Times, writing Op-eds for Reuters and Politico.com, and appearing, not only on Fox Business News, but on CNN and the PBS’ Newshour.

Alternatively, “Holtz-Eakin” may ring a bell because he served as a member of George W. Bush’s Council of Economic Advisers (CEA), and as Director of Bush’s Congressional Budget Office (CBO.)

In a remarkably candid 2011 interview, Holtz Eakin recalled his tour in the Bush administration:

“Going into the summer of 2001, things were getting worse. . . When we first went in and talked to the President, Glenn [Hubbard] and Larry Lindsey said, ‘Mr. President . . . We’re probably not going to run a surplus on budget.  We’re going to run a deficit.”

Bush’s reply: “We’re not going to run a deficit. If you come in here with a deficit, you’re both fired. Go fix it.’”

We ended up running a budget surplus of one billion dollars,” Holtz-Eakin confided, “driven by gimmicks of remarkable proportions.”
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