Still murky on how federal health care reform affects you and your pocketbook? You’re not alone. To help sort out the details, we assembled a Fact Squad of local health care experts to explain the Patient Protection and Affordable Care Act and tell you what you need to know.
The Fact Squad responded to the following beliefs about the health law.
1. Due to federal health care reform, my insurance plan benefits will change.
Erin Hoeflinger, president, Anthem Blue Cross and Blue Shield in Ohio: IT DEPENDS. If you have an employer-sponsored health plan, it will depend on what your company offers in 2014. Many companies change their health benefits on an annual basis regardless of health care reform; but the Affordable Care Act will impact different size companies in different ways.
For companies with more than 50 employees, they have to offer minimum coverage to employees or pay a penalty — although this mandate is not in effect until 2015. Employers with 25 or fewer employees may be eligible to get some financial help in the form of tax credits, as long as they offer coverage through an exchange.
For people purchasing their own coverage, those plans are changing in 2014. Also, preventive care, like screenings, shots and exams are covered at no cost to employees/individuals. That means you don’t pay a copay, coinsurance or deductible as long as your doctor is in the health insurer’s network.
For seniors, the new health care reform regulations do not directly impact them. They will continue coverage as they have in the past and will not be required to purchase through the exchange.
Dr. Gary LeRoy, associate dean for student affairs and admissions, Wright State University Boonshoft School of Medicine: PARTLY TRUE. Each year employers offer open enrollment for employee insurance. This will not change when the ACA begins. Each individual will have the option of either staying with their current insurance plan and doctors (with the usual annual updates to premiums and benefits) or elect other offered insurance plans. What employees may see is a wider array of new options.
2. Everyone will have to buy health insurance on new online health exchanges that begin enrollment in October.
Bryan Bucklew, president and chief executive officer, Greater Dayton Area Hospital Association: FALSE. The exchanges are for people who don’t have insurance or who buy their own insurance. If you qualify for Medicaid, Medicare or receive health insurance from your employer, you do not need to buy from the exchange.
The Congressional Budget Office estimates that only about 7 million people are going to sign up for the exchanges out of more than 300 million Americans.
James Haubrock, shareholder and chairman of employee benefit plan services, Clark Schaefer Hackett: FALSE. You will only need to purchase from the public health exchanges (federal or state) if you do not have health insurance. If your employer does not offer health insurance, you have the option to purchase from an exchange.
3. The Affordable Care Act will cause premiums for all plans to rise, including employer and government plans.
Hoeflinger: PARTLY TRUE. While the ACA will help millions of people get coverage for the first time, new insurance taxes, requirements for higher-cost benefits, community-rating and age-rating restrictions will drive up the cost of coverage for many. For instance, beginning in 2014, the ACA will impose a new health insurance premium tax that will exceed $100 billion over the next 10 years. For those who have trouble paying for their coverage and qualify, government subsidies will be available on the exchange to help make the products more affordable.
While the ACA does not directly affect benefits for people in Medicare, experts have cited concerns that budget cuts may force (private) plans and providers to charge higher premiums and cost-sharing, exit the market, or stop serving Medicare members. Only time will tell.
Bucklew: FALSE. There will be many different plans available in the exchanges and some people could be paying less for the same or similar coverage. One would need to look at an identical benefit package pre-ACA implementation and post-ACA implementation to see if their particular plan is costing them more or less. One also has to realize that insurance costs have risen before the passage of the ACA and one of the main tenants of the ACA is to attempt to slow down the rate of increase for health insurance and health care delivery.
Haubrock: FALSE. Some insurance premiums will go up and others may go down. There are a lot of factors that will play into the price of insurance costs, such as: the type of plan offered by your employer, the demographic mix of employees and claims history in your plan. For example: An employer with a younger pool and a good (claims history) may end up paying less than what they are currently paying.
Michelle (Mickey) Sweeney, insurance broker, Wallace & Turner Inc.: PARTLY TRUE. The additional required coverage, community rating and full coverage for pre-existing will increase most premiums. However, for those who cannot get coverage due to health conditions or now have to pay much a higher premium than standard rates, a decrease in premium will happen.
Medicare recipients are benefiting on drug coverage, with the donut hole, or coverage gap, decreasing each year. The volume of people initially coming into coverage will cause premiums to increase at first, then should level out after a couple of years. More people in the covered pool will help spread the risk — the very basis of insurance — and you’ll have choice of plans.
4. The new health law is going to cancel my Medicare plan.
Scott Streator, vice president of the health insurance marketplace product line, CareSource: FALSE. The ACA protects and guarantees Medicare benefits and the policy specifically states that no cuts in guaranteed benefits will occur. Under the ACA, benefits will expand to include more preventative services and more branded prescription drug choices.
5. The law is a government takeover of the health care system.
Bucklew: FALSE. If this was the case, then there would be no private insurance available. Estimates from the Kaiser Family Foundation, Ohio Department of Insurance and the U.S. Department of Health & Human Services range from 48 to 52 percent of Americans will get their health insurance from their employer during the first year of the Affordable Care Act. This is comparable to numbers in the past three years. The public also needs to be aware that the baby boomers are becoming Medicare eligible, which will greatly increase the percentage of individuals on that government health program.
Streator: FALSE. The U.S. government is already one of the largest payers of health care in the market. As a result of the ACA, the government will stimulate new competition and promote private sector health plans.
6. The health care law is putting companies out of business and is causing other businesses to cut work hours.
Haubrock: PARTLY TRUE. The Affordable Care Act is not putting companies out of business, but it is causing some companies to cut back on employee work hours. Some companies, especially in the retail and food service industries, are reducing employee work hours to below 30 hours a week so they can get below the 50 full-time employee mark to be classified as a small employer. As a small employer, they are not subject to the pay-or-play provision.
Sweeney: PARTLY TRUE. The economy is putting some companies out of business and this extra expense for small employers may be what puts them over the edge, but the ACA isn’t the only thing. True, it is causing some businesses to reduce work hours in order to still be competitive. The business model that has worked for years in some industries will not continue to do so with having to count full-time as a 30-hour work week.
7. I can’t afford health insurance now and the Affordable Care Act will force me to buy something I don’t have the money to pay for.
Bucklew: PARTLY TRUE. One of the main goals of the Affordable Care Act is to make health insurance options more available and affordable to those who previously did not have access to any health insurance. The health exchanges will be a resource point to compare various health plans, policies and costs. The ACA did impose a penalty for individuals who do not have health insurance, which was upheld by last year’s Supreme Court decision. An individual can decide to pay the penalty instead of having health insurance.
Sweeney: FALSE. Many low to middle income individuals and families may be eligible for the government to pay all or part of your premium and possibly even your deductibles and co-pays. Right now, only those who are Medicaid eligible get help. The ACA will allow help for up to four times the Federal Poverty Level — which would mean annual incomes of $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four this year.
If you decide to not buy coverage, you’ll pay a tax of the greater of 1 percent of income or $95 per person for 2014. That increases to 2 percent of your income or $325 in 2015, and it adjusts upward each year. You have to pay a tax for not having coverage, but you don’t have to buy coverage. You decide whether it’s better for you to pay the tax or pay for coverage.
8. The government through the health law will control the doctors I see, and medications and services I buy.
Haubrock: FALSE. The control will still lie with the insurance carrier, or the exchange, and is based on the level of coverage you elect to buy.
Sweeney: FALSE. The plan you choose coverage through will have networks of doctors/hospitals/other providers, as well as prescription programs, just like you have a choice of plans now. Some will be more restrictive than others to keep the price down. All must cover the “essential benefits,” which most plans already cover. Be prepared to take more responsibility for taking care of yourself, by the choices you make in smoking or not, eating and drinking in moderation, keeping physically fit.
9. The law establishes government “death panels” that encourage the elderly to opt-out of life extending treatment as a way to reduce Medicare expenses.
Hoeflinger: FALSE. Plans are not incented to withhold care under ACA. In fact, they are encouraged to reduce spending by coordinating care to prevent avoidable hospitalizations.
Streator: FALSE. The Independent Payment Advisory Board or the “death panel” is tasked with reducing growth rate (not spending) by improving quality. The Patient Outcome Research Institute, which is an independent nonprofit, non-government entity whose purpose is to advance the quality and relevance of medical evidence for informed decisions, states that this board is tasked with making recommendations around slowing net growth in Medicare spending. It can’t ration health care, raise premiums or revenues.
Any proposal to reduce expenses must contain key considerations around improving health outcomes, protect access and beneficiaries, and consider effects and needs of consumers.
10. Appointments and wait times will be longer to see a doctor in the future due to health reform.
LeRoy: FALSE. There is currently a shortage of primary care physicians. There are provisions in the ACA to encourage more medical students to go into primary care specialties (family medicine, primary care internal medicine and pediatrics). There is also a modest financial reimbursement (a 10 percent fee increase for preventative primary care services through 2014) for primary care services under the ACA.
If your doctor’s daily schedule is already full the ACA cannot mandate that he/she see more patients. True, there will be many more people seeking primary care services, and the pipeline of primary care professionals has not been filled enough to accommodate the anticipated national need. This will certainly be a challenge for the system for the next several years. We will need to become more aware of these system limits, more efficient in providing service, and utilize more of the talents of physician extenders, such as physician assistants and advance practice nurses.