Reader questions were edited for typos and remain in their original format.
Gloria Gevirtz: What will happen with the ACA if the next president is a Republican?
Geoffrey Cowley: If the GOP wins the White House and both houses of Congress (unlikely!), we’ll no doubt see new efforts to scale back the health care law. But it’s hard to imagine lawmakers repealing the Affordable Care Act in 2017. By then, according to the Congressional Budget Office, 25 million previously uninsured people will have gained coverage. The CBO projects that 24 million Americans will buy their insurance through the exchanges in 2017, and 12 million will benefit from the Medicaid expansion. Politically, taking health care away from 36 million people would be a hard sell.
@DWAT8002: I currently do not have healthcare coverage. I just started a new job that offers healthcare benefits, but I will not be able to sign up until April 1. Since the deadline to sign up for health insurance and avoid the tax penalty is March 31, will I have to pay the penalty fee even though I will have coverage on April 1?
Geoffrey Cowley: No one who enrolls in a health plan by March 31 will face any penalties this year, even if the coverage takes a while to kick in. By waiting until April 1 to enroll, you would cross the three-month threshold and incur a penalty for the part of the year you spent uninsured (details here).
The penalty for going uninsured all year is $95 (or 1% of your income if you make more than $95,000). The baseline fine for three uninsured months would be a fourth of that amount, or $23.75. If you want to save the money, maybe your employer will move up your start date by a day.
Ademocrat: My husband and I rarely have need for doctors but because he is self-employed and makes an average of $150k, we will have to pay over $500 per month for "affordable" health coverage with a large deductible to boot. Yes, we can afford the cost, but why should we pay for something we have no need of? We paid so much less for the few times we did need a doctor as self-pay patients. Please explain to me what is "affordable" for those of us that would rather keep our money instead of lining the pockets of these insurance monsters??!!
Geoffrey Cowley: There’s a difference between not needing something and not needing it at this moment. We require drivers to insure themselves because some will have accidents and the costs they can’t cover will fall upon others. The argument for mandatory health coverage follows the same logic. Self-pay may work well while you’re healthy, but few of us could pay cash for the care we would receive when mortally injured or seriously ill. Since we’re all likely to require serious care at some point, we owe it to each other to pay our share of the cost. Conservatives used to champion that idea, but something has eroded their sense of shared responsibility.
As for affordability, health care is expensive and often wasteful. The health care law includes many provisions to make it more efficient and to help people who truly can’t afford it. Fortunately for those who can afford coverage, health care costs are now rising more slowly than they have in decades.
Tom Kruse via Facebook: Dental health is health. Why wasn't dental insurance included in ACA?
Geoffrey Cowley: The health care law treats dental care as an essential health benefit for children and youth less than 19 years old. Any health plan offered to that age group will include dental coverage, but Obamacare makes dental coverage optional in adult health plans. Some offer it, some don’t, and consumers can choose the level of coverage they want. There’s no tax penalty for skipping dental coverage, but you’re right that it’s worth having. Untreated cavities and gum disease can foster everything from pregnancy complications to heart disease.
KaitlynK: For unknown reasons, many doctors are not accepting ACA exchange insurances. If this trend continues, can't the government compel physicians to accept these insurances so that Americans can continue to have access to affordable care?
Geoffrey Cowley: Doctors can refuse any form of payment they don’t like. Many refuse Medicaid because of its traditionally low reimbursement rates, and some refuse all insurance to avoid being second-guessed by claims adjusters. It’s hard to imagine any doctor caring whether a patient’s health plan was purchased through an insurance exchange. Thanks to the Affordable Care Act, those policies provide the same coverage as the policies people get through their jobs.
@LLeno22: My 88-year-old mother has Medicare through her former employer, the state of Michigan, where she retired as a teacher 30 years ago. The prescription coverage thru Catamaran is horrible, only allowing for old generic meds which have not helped her issues with diabetes and neuropathy and they offer no therapeutic meds for dementia. Can the ACA help my mother or supplement her prescription coverage?
Geoffrey Cowley: It sounds like your mom is using Medicare Part D, the prescription drug plan that President George W. Bush signed into law in 2005. The program is administered by private insurers, through Medigap or Medicare Advantage plans. Different insurers charge different premiums and cover different collections of drugs, so you should shop around for the right plan. Medicare has an online plan finder you may find helpful.
Under federal law, all Medicare Part-D plans must provide a minimum level of coverage. The law also limits the deductibles and copays insurers can impose. This year’s maximum deductible will be $310 (down from $325 in 2013), and copays will be capped at $2,850 (down from $2,970 in 2013).
The Affordable Care Act doesn’t restructure Medicare Part D, but it does close a big gap in coverage. Because of a quirk in the 2005 law, Part-D benefits fall off sharply after a subscriber’s total drug bills reach a certain threshold ($2,970 last year) and resume only after the subscriber crosses a “catastrophic” threshold ($4,750 last year). For more details on this “doughnut hole,” see this fact sheet from the AARP.
The Affordable Care Act is slowly closing the hole, both by shifting its boundaries (to $2,850 and $4,550 this year) and by helping people pay for their medications while they pass through it. Last year, between federal subsidies and drug-company discounts, people in the doughnut hole paid 48% of the retail price for brand-name drugs and 79% of retail for cheaper generics. Obamacare ensures that by 2020, no one in the gap will pay more than 25% of a drug’s retail price.
AltaAndy (sent via email): In your recent article on Arkansas’ approach to Medicaid expansion (A red state breakthrough on health care reform), you mention a graduate student who “earns too little to qualify for a discount on private health insurance.” I don’t get that. Are you saying he has to earn MORE to qualify for help?
Geoffrey Cowley: Yes, it’s strange but true. Here’s the back story. As signed into law four years ago, the Affordable Care Act extended Medicaid coverage to everyone living below 138% of the federal poverty level (roughly $16,100 a year for a single adult)—and it used tax credits to help people with moderate incomes buy private insurance through the new health insurance exchanges. Those subsidies are available to anyone earning 100% to 400% of the federal poverty wage ($11,670 to $46,680 for a single adult).
Just about everyone would have been covered if that formula had stuck. But two years ago, the Supreme Court ruled that states could opt out of the Medicaid expansion, and 23 of them have done just that. If Arkansas had turned down its Medicaid expansion funds, that grad student would be out of luck. His $9,000-a-year internship would make him too rich for traditional Medicaid (he would have to earn less than $2,000 a year to qualify for that). But his $9,000 salary would make him too poor for a marketplace subsidy.
Some 5 million low-income people have fallen into that coverage gap in the Medicaid refusal states. Congress could fill the gap by lowering the floor for marketplace subsidies, but no one expects that to happen as long as the GOP controls the House of Representatives.
SocialmedicToo: I would like to know why crippling student loan debt is not taken into account when figuring how much a person is able to pay. Student loan debt payments are not exactly optional or dischargeable through bankruptcy and do rob the individual of discretionary income.
Geoffrey Cowley: Means testing is generally based on your income and assets, not your obligations. Without that distinction, anyone—even the rich—could qualify for benefits by loading up on debt. People living on fixed assets sometimes opt into Medicaid by paying down debts until they they’re poor enough to pass the means test. As you point out, the monthly payment on a student loan can have the same effect. Unfortunately, social programs just aren’t set up to take that into account.
Here’s the upside. The ACA subsidizes health coverage for anyone earning between 100% and 400% of the federal poverty wage ($11,490 to $45,960 for an individual), and the biggest subsidies go to those with the lowest incomes. If a student-loan payment is taking a significant chunk out of your paycheck, chances are you fall into that range. To learn more, check out this primer on eligibility and this guide to checking your own status.
@cjkid1964: Section 18115 of the Affordable Care Act is titled “Freedom not to participate in Federal health insurance programs.” Can you tell me more about this?
Geoffrey Cowley: Sure, this section simply tells insurers that they don’t have to sell their plans through the exchanges or take part in other Obamacare programs. Here’s the full text:
No individual, company, business, nonprofit entity, or health insurance issuer offering group or individual health insurance coverage shall be required to participate in any Federal health insurance program created under this Act (or any amendments made by this Act), or in any Federal health insurance program expanded by this Act (or any such amendments), and there shall be no penalty or fine imposed upon any such issuer for choosing not to participate in such programs.
Mathies Gorm Jensen: As the ACA goes forward and becomes, as Mr. Boehner has called it, the law of the land, my question concerns the projects that individual states will start running in 2017. Do you feel these may lead to more states running single payer systems if, for instance, Vermont is successful? We have seen how other states are jumping in on legal marijuana after Colorado was successful with it. Do you feel a similar parallel could be drawn to health care? Thank you.
Geoffrey Cowley: I suspect legal weed will prove more popular than single-payer health care, at least in the short term. But yes, states are exploring a lot of interesting variations on Obamacare. So far, only 10 have embraced all three of the law’s main provisions (state-run exchanges, and Medicaid expansion and insurance-industry reforms). But nearly all states have embraced parts of the law—and several are using Obamacare funds to pursue novel approaches to health care reform.
Arkansas and Vermont are both good examples. Last year, the feds approved Arkansas’ bid to spend its Medicaid expansion funds on commercial insurance policies rather than government benefits. As a result, nearly 100,000 poor Arkansans now enjoy the same coverage as other private consumers, and 150,000 are still eligible.
Vermont is pursuing the opposite tack—hoping to pool private, state and federal resources to create its own single-payer system. To succeed, the state would have to reallocate all of its federal health funds, not just those earmarked for Medicaid expansion. The feds can’t legally approve that request before 2017, and some experts—even those who favor a single-payer solution—doubt the experiment will work at the state level. But all of these experiments will hold valuable lessons for the rest of the country. And like Romneycare, the successful ones are likely to spread.
Fred Orth: What is going to happen to medical facilities in states that do not accept Medicaid expansion? I understand that federal payments will be reduced to reflect the compensation they would have received if their states had expanded coverage. What will the ensuing cost-shift mean to charges for those insured outside of ACA?
Geoffrey Cowley: Hospitals could suffer huge losses in states that refuse to expand Medicaid, because they’re the provider of last resort for people who lack health insurance. Under a 1986 law called EMTALA, hospitals that receive federal funding have to attend to dangerously sick or injured patients regardless of their ability to pay. Hospitals have traditionally recouped their losses from “uncompensated care” by shifting the cost onto paying patients and by drawing on a federal account called DSH, which provides partial reimbursement.
It’s more efficient to give people routine care than to rescue them from medical crises, so the Affordable Care Act moves money out of the DSH program and uses it to help states expand their Medicaid programs. In states that refuse to expand Medicaid, uninsured people will continue to rack up unpaid hospital bills, but the hospitals will stop getting DSH payments from the feds. That’s one reason the hospital industry is pleading with recalcitrant states (e.g., Florida, Georgia and Texas) to stop boycotting the Medicaid expansion.