Is Obamacare the destruction of the American healthcare system or baby steps toward making it better for everyone?
From its inception, critics and supporters alike have seen what they wanted to see in President Barack Obama's signature first-term policy achievement. The right views the Patient Protection and Affordable Care Act as a "government takeover" and "socialized medicine," even though it leaves private insurance and private hospitals firmly in place. The left only wishes the claims of socialism were true.
The polarized perceptions persist to this day. Earlier this month the Wisconsin Office of the Commissioner of Insurance put out a news release claiming insurance premiums would skyrocket once the federal government's new "health exchange" -- a state-by-state clearinghouse where uninsured consumers and small business employers can purchase health insurance policies -- takes effect Oct. 1.
Within hours, Wisconsin Citizen Action, the progressive activist group that has become the state's leading defender of the federal health reform package, was rebutting OCI's claims. The group noted that the report ignored tax credits that would lower the premium cost and failed to make important distinctions among the plans being compared, including how much consumers would pay out of pocket under a given plan.
Whoever turns out to be right on that one, this much is certain: After years of being little more than an ideological Rorschach, the Affordable Care Act will finally rise off the paper and take three-dimensional form.
Hospitals are getting ready. Insurers and employers are, too. To help the rest of us prepare, here are 15 things you need to know come Oct. 1.
Do I have to carry health insurance?
Yes. The Patient Protection and Affordable Care Act has many moving parts. But in its simplest terms, the act boils down to these principles: Everyone has to have health insurance; all employers with 50 or more full-time workers or the equivalent must offer health insurance; health insurance must be easier to get and harder to lose.
The requirement for everyone to carry health insurance was one of the Act's flashpoints, and many were surprised when the United States Supreme Court did not find it unconstitutional.
The reason for the so-called individual mandate is simple: Requiring that everyone be insured is one way to keep the cost of insurance down. If only people who are sick or at risk of illness buy insurance, it's a sure way to break the bank.
Mandating coverage spreads that cost over a larger group, keeping the individual cost per person lower. To help fulfill the mandate, the Act also creates a way to make it easier for the uninsured to get coverage.
That's where the health exchange comes in.
What is a health exchange?
The exchange is a centerpiece of the Affordable Care Act. Starting Oct. 1, every state is required to have an operating exchange in which uninsured individuals can purchase a policy from private companies approved to offer plans.
States were allowed to create an exchange on their own, but Gov. Scott Walker's administration, which opposes the ACA, opted to leave it to the federal government.
The health exchange will also be a place where employers can shop for coverage for their employees.
The exchange sets a minimum standard for what health insurance covers and what it costs. The Act's architects expect plans offered on the exchange will be more affordable than private health insurance has been for individuals in the past.
Is Wisconsin's exchange ready to go?
Yes, says Elizabeth Surgener, a spokeswoman for the U.S. Dept. of Health and Human Services' Chicago-based region, which includes Wisconsin. "We remain on track to open the marketplace on time on Oct. 1. We are working hard to ready this consumer tool, which will allow consumers to shop from October to March for affordable insurance in a way that was never before possible."
Once implemented, the exchange will be called a "marketplace," which arguably conveys its purpose more accurately.
Wisconsin's federally operated marketplace has approved 13 insurers to offer plans in part or all of the state. (There are actually two exchanges; one for individual consumers and one for small businesses to buy plans for their employees.)
The state insurance commissioner's office released a list Sept. 18 showing that of the state's 72 counties, 59 will have at least two insurers offering plans on the exchange. In the other 13 with only one insurer, at least two plans are offered, which was a requirement to join the exchange.
How much time do I have to sign up?
Until March 31, this first year. Next year, the open enrollment period will be from Oct. 15 to Dec. 7.
What if I lose my job, have a child, or something else changes in my life?
Open enrollment in the marketplace will be similar to open enrollment with an employer that offers health insurance: Under certain circumstances, you can make a change in your plan outside of the usual enrollment period.
How can I access the marketplace?
The health insurance marketplace is optimized for the Internet. At www.healthcare.gov, interactive question/answer screens steer consumers through the process of applying for insurance and picking a policy.
Surgener boasts that it will employ "online commercial best practices, include integration of social media, shareable content, and engagement destinations for consumers to get more information." Users can visit a live web chat system for help.
What if I don't have Internet access?
Individuals can also apply to the marketplace by phone, mail or in person. A toll-free call center -- 1-800-318-2596 -- will include access to interpretation and translation services for speakers of more than 150 languages in addition to English and Spanish.
Operators are already answering questions. Starting Oct. 1 they can help people complete the application process. The number for hearing-impaired people who need to use TTY/TDD technology is 1-855-889-4325.
In states with a federally run marketplace, "navigators" are being contracted to work directly with people needing extra help in accessing the system. Wisconsin received $1 million of some $67 million in federal grants for navigator groups, and the state's share is being divided among six organizations: Partners for Community Development, Inc.; Northwest Wisconsin Concentrated Employment Program, Inc.; Legal Action of Wisconsin, Inc.; National Council of Urban Indian Health; National Healthy Start Association; and R&B Solutions.
How long can I leech off my parents?
If your parents' plan covers children, you can stay on it until you are 26. That is regardless of whether you are married; a student; independent of your parents; or living apart from them. You can also stay on their plan even if you qualify for your employer's plan.
People under 30 with limited incomes can also opt for a catastrophic plan that has very high deductibles and some provisions for free preventive care.
What if I'm poor?
Coverage will increase for low-income individuals, but it could have cost state taxpayers less if Walker had accepted federal funds to expand Medicaid, as he was implored to do by activists, healthcare providers and a number of counties. The counties are key players in administering Medicaid, which is called BadgerCare in Wisconsin.
But Walker turned down the money, limiting BadgerCare to people at or below 100% of the poverty line instead of extending it to those at 133% or lower.
Social service agencies say that means some on BadgerCare will have to shift to the private health insurance marketplace. Federal subsidies are supposed to be available for people who can't on their own afford health insurance purchased in the marketplace, but who don't qualify for BadgerCare.
At the same time, agencies expect some people now uninsured will be eligible for BadgerCare.
Access Community Health Centers, a network of low-income clinics in the Madison area, has identified about 6,000 patients who either will lose BadgerCare or who will now be able to enroll in the health insurance program for the poor.
"Our biggest initiative is helping our patients understand what they might be eligible for and helping them apply for whatever that is," says Tammy Quall, chief strategy officer for Access.
Where can I find help in Dane County?
On Sept. 18, Access and Dane County officials announced plans to connect with as many eligible people as they could, in cooperation with the Capital Consortium. The consortium, consisting of Dane, Adams, Columbia, Dodge, Juneau, Richland and Sauk counties, was formed after passage of the 2011-13 budget to help counties manage their income maintenance programs, including BadgerCare.
The Capital Consortium is sponsoring a call-in center (1-888-794-5556), to be housed at the Dane County Job Center. The call center has hired and trained 34 additional staff primarily to help people enroll in BadgerCare. Staff will also refer people to the health insurance marketplace, but they won't be able to directly enroll them, says Casey Becker, spokeswoman for Dane County Executive Joe Parisi.
Dane County Human Services will hold weekly fairs at the job center, located at 1819 Aberg Ave., to enroll people in the health insurance marketplace "for many months to come," says Lynn Green, director of the county's human services department. County officials say a schedule of the enrollment fairs will soon be posted to the Dane County Job Center website.
In addition, staff from Access Community Health will post temporary staff members at the job center to help people who want to enroll in the marketplace.
Public Health-Madison and Dane County, meanwhile, will be doing outreach at community centers, libraries and other public spaces to educate people about their options, says agency director Janel Heinrich. Public Health will also have a link to the insurance marketplace web page from its own website.
The message everyone is trying to send is, "Don't panic," says Green. "You have time " reach out and you will get the help you need."
Will my boss drop health benefits?
Remember the warning that Obamacare would drive employers to dump their health plans?
In 2011, McKinsey and Co., citing survey data and its own research, confidently forecast "a radical restructuring of employer-sponsored health benefits." As many as 30% of employers "will definitely or probably stop offering" health benefits after 2014, McKinsey claimed, and more than 50% of "employers with a high awareness of reform" would.
Last year, Congressional Republicans pushed the same scenario.
This year's answer is beginning to look like, "not so much."
The International Foundation of Employee Benefit Plans, based in the Milwaukee suburb of Brookfield, researches trends in benefits on behalf of public and private employers, tracking what employers are experiencing, what they're offering and what they're paying.
The foundation's 2013 survey found that, as the effective date for the ACA draws closer, employers have been backing off from canceling health benefits.
At least 69% of employers "stated they will definitely continue to provide employer-sponsored health care" as the law takes effect, the foundation said in its report summary. (In the 2012 survey, just 46% of employers surveyed were that upbeat about keeping their plans.) And another 25% said they were "very likely" to keep their benefit programs.
In a Midwest Business Group on Health survey, 90% of employers said they would not move their workforce over to the marketplace or even to an emerging group of so-called private exchanges that work with employers to offer a menu of health insurance alternatives.
Will I pay more for health care?
In August, the International Foundation of Employee Benefit Plans reported that 14% of organizations that tracked their cost trends saw no change or even a decrease in their costs because of the Affordable Care Act. For the rest, among medium and large employers, most reported the costs were going up less than 5%.
Smaller employers reported being hit harder. Of those with fewer than 500 employees, nearly one in five said their 2013 health costs were up more than 15% due to the new health care law. Among very small employers of 50 or fewer workers -- who won't be mandated to provide benefits -- over one in four said their costs have risen more than 15%.
More than 90% in the survey said as a result of the Act they're trying to further rein in health care costs. That includes charging employees more and moving to so-called high-deductible health plans, where workers put aside funds in tax-free health savings accounts to pay those deductibles and other medical bills not covered by their insurance.
Can I go to the same doctor?
Yes, but it's likely your doctor's office will probably become part of a larger group.
Dr. Peter Newcomer is an internist who oversees all outpatient care at UW Health, which encompasses both the University of Wisconsin hospital as well as the clinics affiliated with it. He acknowledges that all of the changes brought by ACA tend to favor larger healthcare organizations.
If your family doctor isn't already working for a larger organization like UW Health, Aurora Healthcare or Meriter Health Services, that's likely in the future. The amount of coordination among various parts of the system makes that all but inevitable. So does the increasing demand to keep more electronic records and comprehensive data, which the federal government plans to use to award bonuses or assess penalties under the Medicare program.
"That's really hard to do if you're an individual or in a small practice," Newcomer says.
What about hospital care?
ACA has a number of new hospital regulations. Generally they focus on Medicare; they're aimed at lowering the costs while improving the outcomes for patients covered by the federal health insurance plan for seniors.
As Newcomer points out, though, when hospitals change their practices to comply with those rules, they generally apply them to all patients, regardless of how they are covered.
Under ACA, hospitals have a greater incentive to make sure that Medicare patients don't return for the same ailment. Nationally, 20% of Medicare patients go back to the hospital within 30 days.
"That number is too large, and we all think it should come down," says Newcomer.
With the act, hospitals with higher-than-average readmissions for Medicare patients will be penalized in their Medicare reimbursement, says Newcomer. So institutions like UW Health are paying more attention to how they send people home in the first place.
"We're trying to improve the discharging process," Newcomer says.
They're redesigning the paperwork so patients going home understand more clearly what they're supposed to do to stay well. They're following up more closely in the subsequent days and weeks; hospital personnel contact the patient's primary care doctor, but they also call the patient at home after a hospital stay. And patients know where they can call if symptoms reappear.
"Not only can we prevent the readmission, but we can optimize your health," says Newcomer.
What if I don't get insurance?
Your doctor and your hospital won't rat you out if you don't have insurance.
That will fall to the Internal Revenue Service, which will enforce the requirement through federal income tax returns.
"We've dealt with people without insurance for quite some time," Newcomer says. "I don't think we have any plans" to start calling up federal officials to report them.
Quall, of Access Community Health Centers, agrees.
"We would never do that," she says. "As a provider, we want to provide you with services."
But individuals who ignore the "individual mandate" to carry health insurance will pay a penalty. Tax returns for 2014 to be filed in 2015 will include lines to document coverage, any exemption, and calculate the penalty for non-coverage into the taxpayer's total bill. After Jan. 1, 2015, employers who ignore their requirement also will pay a penalty. That was originally effective Jan. 1, 2014, but the administration recently pushed it back a year.
