Individuals to determine fate of ACA


WASHINGTON — On the day in 2010 that he put his signature to the biggest domestic achievement of his presidency, President Barack Obama declared: “After a century of striving, after a year of debate, after a historic vote, health-care reform is no longer an unmet promise. It is the law of the land.”

Now, we get to see whether it works.

Starting Oct. 1, more than 40 million Americans who lack medical insurance will have their first chance to sign up for coverage under the new system created by a law formally known as the Affordable Care Act. That sets the gears in motion to begin what the president has promised will be a transformation of the nation’s entire health system — making it fairer, less costly and more effective at providing care.

But while Obama might have thought that signing the new law would begin a political healing process, the divisions three years later are as deep as ever.

Poll after poll has shown Americans remain skeptical and confused about the new health-care program. And on the day enrollment opens, the federal government may shut down as part of a budget battle tied to a Republican effort to block the law’s implementation. But the law will move forward, in any case.

Having passed a test of its constitutionality before the Supreme Court, the law now faces an even more critical judgment — one that will be written in millions upon millions of individual stories.

Among the winners will be the uninsured, assuming the coverage they get proves to be affordable and adequate. Businesses facing a new requirement to provide insurance say they could be losers. Some people who buy their own insurance may pay more, while others may pay less. Hospitals and doctors welcome the fact that more patients will be able to pay their bills but worry the government will demand more say in what kind of care they provide.

“The law is entering a new phase where it becomes real,” Drew Altman, president of the Kaiser Family Foundation, said. “A lot is going to turn on how smooth the process is, whether people get coverage and whether they like the coverage they get.”

In coming months, clues will emerge on whether the system will succeed or fail: Will the new insurance marketplaces work as designed? Will enough Americans — especially young, healthy ones — sign up? Will patients be able to find enough primary-care doctors and specialists — and see the ones they trust?

“We’re now seeing that a lot of the exchanges probably will have very limited networks and very low reimbursements to providers” compared with the large employers’ plans, said Douglas Holtz-Eakin, a former head of the Congressional Budget Office who now heads the conservative American Action Forum think tank. “This is the Medicaid story: Sure, I’ve got insurance, but no one wants to see me, and so I go to the emergency room for regular care.”

Most Americans will continue to get coverage through work; beginning in 2015, companies with more than 50 people will need to cover employees who work at least 30 hours a week.

Many of America’s poorest uninsured won’t be helped by the law. Currently, many low-income people, including childless adults, are ineligible for Medicaid in many states. The health law sought to change that by expanding Medicaid to include anyone with an income at or below 138 percent of the federal poverty level ($15,400 for an individual).

However, the Supreme Court ruled that states could opt out of the expansion and about half have done so. Under the law, subsidized insurance on the marketplaces won’t be available to those below the federal poverty level ($11,490).

“We’re going to have an upside-down social program in these states” that do not expand Medicaid, said Massachusetts Institute of Technology economics professor Jonathan Gruber, who advised the administration on the law. “If you’re poor, you get nothing. If you cross the poverty line, you can get subsidies and buy into the exchanges.”

In Southern Maryland, Greater Baden Medical Services estimates that 40 percent of the patients at its community health facilities are uninsured. It will be working feverishly to help them sign up for coverage. But providers there have no idea how many more patients to expect, once the law kicks in Jan. 1.

“Nothing this big is going to happen without glitches,” said Sarah Leonard, who is about to retire as Greater Baden’s chief executive. “We know there’s a long line of people needing care. But how soon will they enroll? What will they expect or need? What other providers will there be for them? Those are some of the great unknowns.”

The health law’s success rests on Americans buying coverage en masse. Low enrollment could cause premiums to spike. But some young people already are planning on paying the penalty, rather than buying coverage by Jan. 1, as required.

Premiums have, so far, come in below government forecasts. But because of new rules, some young, healthy people with low rates may pay more than they do now, while some older, ailing consumers might pay less. And premiums are only part of the story. Some low-premium plans have high co-pays and deductibles.

Experts say it hasn’t been clear how consumers will react.

Now, America is about to learn.

IRWIN HOENIG, 63, Laurel, Md.

Hoenig will pay the fine rather than buy insurance

Hoenig voted for Barack Obama in 2008, but he is adamantly opposed to the health-care law, especially the individual mandate requiring that almost all Americans have health insurance beginning Jan. 1.

Hoenig has gone without insurance since 1997 and won’t start buying it now, he said. He’d rather pay the fine, which for the first year would be $95, or 1 percent of his income, whichever is greater. The penalty increases in subsequent years.

A self-employed health-care practitioner, Hoenig specializes in craniosacral therapy, which involves touching the skull and other points to relieve tension.

He said he has gone to the doctor just twice in the past decade and is happy to pay out of pocket for medical services.

In a sense, Hoenig is an older version of the “young invincible.” That was a term coined during the health-care debate to describe people in their 20s who supposedly believe they are so healthy they don’t need insurance.

“Health insurance is kind of like betting against your own health,” Hoenig said. “If you pay a certain amount, you feel like you should collect on that.”

Hoenig said he would consider signing up for Medicare when he turns 65.

Right now, though, Hoenig doesn’t worry about getting sick.

“I try to eat organic,” he said. “I try to stay away from chemicals. And I’ve actually outlived quite a few people who I believe could have not ended up the way they did.”

ARIANNA GRIFFIN, 30, Silver Spring, Md.

For a moderately priced plan, total monthly premium: $189. Federal subsidy: $0. Griffin would pay: $189

For the cheapest plan, total monthly premium: $121. Federal subsidy: $0. Griffin would pay: $121

A few years ago, Arianna Griffin got her life on track. She landed her first desk job after slinging coffee and peddling books at Borders. She owned a car and didn’t have to worry about making rent.

Today, she’s uninsured, unhappy about it and far from sure the health-care law will solve her problem.

Her concerns started when she focused on the coverage being offered by her employer, a temporary-employment agency. The “mini-med” health plan had a high premium and offered skimpy benefits.

Griffin turned it down and applied for a private plan but was rejected. The insurer cited a “pre-existing condition” — she was 30 pounds overweight.

“I felt like I took my lumps and worked really hard, and now I can’t even insure myself,” she said she thought at the time. She bought a pair of running shoes and lost 15 pounds but remained uninsured.

Now, unless Griffin’s employer offers a better health plan, she’ll likely browse Maryland’s online marketplace, where the benefits will be more robust.

But she might not be able to afford it. Because she earns about $47,000 a year, she won’t qualify for a federal subsidy to pay part of the premium. (The subsidy cutoff for a single person is about $46,000.) A bargain-basement plan would cost her $121 a month.

“I was hoping it would be less than that,” said Griffin. “It would take a lot of re-budgeting and hoping for a raise.”

TONY BERNARDO, 31, District of Columbia

For a moderately priced plan, total monthly premium: $198. Federal subsidy: $54. Bernardo would pay: $144.

For the cheapest plan, total monthly premium: $136. Federal subsidy: $54. Bernardo would pay: $82

After stints raising organic vegetables and selling kale and tofu at a local market, Tony Bernardo settled on a new career path: music. He didn’t worry much about health insurance, even though he wasn’t 100 percent healthy.

“I’ve sort of taken my health for granted a little bit throughout my 20s,” said Bernardo, the lead singer of a local band called Juneau Sky.

But Bernardo has since become uneasy about his lack of coverage. He has Crohn’s disease, a chronic condition that could flare up at some point. And he worries that an accident could bring financial ruin.

“It’s always a little unnerving,” he said. “I guess especially now that I’m starting to get a little older, it would be nice to have something.”

Despite his illness, which he manages with a careful diet, Bernardo is the kind of person the administration hopes will sign up for coverage. Assuming he keeps his illness under control, he is unlikely to need much medical care anytime soon, so his premiums will help offset the cost of the older, sicker people expected to flood the insurance exchanges in the coming year.

Bernardo earns about $25,000 a year, most of it from playing cover songs at weddings and local bars. If he buys coverage on the District of Columbia’s marketplace, he’d get a $54 subsidy. As a result, he would pay $144 for a moderately priced plan and $82 for the cheapest plan.

His reaction: “It sounds affordable, definitely,” he said. “I would be curious as to what it covers.”

EMILIA ROSA, 51, Takoma Park, Md.

For a moderately priced plan, total monthly premium: $311. Federal subsidy: $203. Rosa would pay: $108.

For the cheapest plan, total monthly premium: $198. Federal subsidy: $198. Rosa would pay: $0.

For Emilia Rosa, who came to the United States from El Salvador nearly three decades ago and earns about $22,000 a year cleaning houses, health-insurance premiums have been marching steadily upward.

In July, she learned her monthly premium would jump to $601 in September, an increase of more than $100. She canceled the policy and bought another one for $332 a month.

Now Rosa is planning to peruse Maryland’s new health-insurance exchange. She recently heard about the new health-care law for the first time, while listening to a Spanish-language radio program.

According to census data, about 30 percent of Latinos are uninsured. Many are young and healthy, an appealing demographic group avidly sought by the insurance industry.

Rosa is neither young nor free of ailments. She has fibromyalgia, a debilitating condition that keeps her awake at night. She takes four kinds of medicines for joint pain.

Nevertheless, she might score significant savings on Maryland’s exchange. The main reason: She would be eligible for a federal subsidy of $203 a month, and could apply it toward the premium of a moderately priced plan or the cheapest one.

In the latter case, her premium would be zero. “I’m waiting for October,” she said.

KING LABULE, 23, Silver Spring, Md.

LaBule will be eligible for Medicaid under Maryland’s expanded program.

Two years ago, King LaBule lost his health insurance when his father got sick and stopped working. His parents couldn’t afford to buy a plan on their own.

“Right now, I guess I’m just winging it,” said LaBule, who is a bouncer at a lounge near Washington’s Dupont Circle neighborhood and works as a dishwasher at another restaurant.

So far, he has been lucky; he hasn’t had any serious illnesses.

“The only thing that’s happened to me since I’ve been uninsured is I dislocated my thumb,” he said.

Next year, LaBule expects to make less than $10,000. That would make him eligible for Maryland’s expanded Medicaid program.

Most state Medicaid programs have traditionally excluded childless adults. But the health-care law called for anyone with an income at or below 138 percent of the federal poverty level (about $15,400 for an individual or $31,400 for a family of four) to be covered by the Medicaid expansion.

So far, about half of the states and the District of Columbia have chosen to take part in the expansion.

LaBule said he’s eager to enroll. Though healthy, he said he worries about what would happen if he were in a serious accident.

After his girlfriend got insurance through her school, he said, some of her medical expenses dropped.

“She was paying $250 for a prescription and now it’s $10,” he said. “She’s pretty stoked.”


For a moderately priced plan, total monthly premium: $454. Federal subsidy: $350. Russo would pay: $104.

For the cheapest plan, total monthlypremium: $291. Federal subsidy: $350. Russo would pay: $0.

Aniela Russo vividly remembers how it felt to have a heart attack: It was January 2012 and she was working as a makeup artist at a charity benefit.

“I wasn’t feeling well, I had numbness in my right arm, I felt really fatigued,” she said. “I was one of the senior makeup artists there, and my boss said to tough it out.”

The single, middle-aged mother of three had heart bypass surgery that Valentine’s Day, and since then has had multiple surgeries for a genetic heart condition. Russo is unemployed, and her family is covered by Medicaid.

But Russo is about to go back to work as a self-employed real estate agent, and her income will probably rise enough to render her ineligible. That means she’ll turn to the Maryland marketplace to buy private insurance. Before the Affordable Care Act, she said, she likely would have been rejected because of her medical history. She figures she never would have passed an insurer’s physical.

“If they look at me, they’re going to see I have all these scars,” Russo said.

The health law, however, bans insurers from rejecting people with pre-existing medical conditions, or charging them more.

If Russo earns about $30,000 next year, as she’s expecting, she would qualify for a $350 monthly subsidy to purchase family coverage on the exchange.

She would pay $104 a month for a moderately priced plan, and have no premium at all for the cheapest one.

Besides cost, she has another big question: Will she be able to see her same doctors? That answer isn’t in.

FATIMA ABUKAR, 63, Alexandria, Va.

Abukar will not be eligible either for Medicaid or for federal subsidies to buy insurance on the new health exchanges.

Fatima Abukar has not had health insurance since arriving in the United States from Somalia a decade ago. The health law won’t change that. She is one of millions of people too poor to benefit from the Affordable Care Act.

Abukar, a legal resident, used to work at a nonprofit thrift store, but now relies on her children, with whom she lives, for financial support. She takes 10 medications, paid for by her family and nonprofit organizations, for chronic conditions including asthma, gastric ulcers, high cholesterol and knee and back pain. She wears five-year-old glasses with scratched lenses and a broken hinge.

Abukar’s doctor says she needs knee surgery, but Abukar said she can’t afford it.

To ease the pain, she wears a tattered blue brace. Abukar doesn’t qualify for Medicaid; Virginia has one of the strictest Medicaid standards in the country. And she won’t benefit from the Medicaid expansion. About half the states, including Virginia, have declined to take part.

About 8 million people who under the law would have been eligible for expanded Medicaid live in states that have decided not to participate, according to the Urban Institute.

Abukar won’t be permitted to buy subsidized insurance in the exchanges. Individuals with incomes below the federal poverty level ($11,490) aren’t eligible for subsidies. The law assumed these people would be covered by the Medicaid expansion. Abukar said she’ll continue to make do without insurance.

“I don’t have it,” she said. “But I’m not crying.”

JAN STRUCKER, 59, Arlington, Va.

For a moderately priced plan, total monthly premium: $550. Federal subsidy: $465. Strucker would pay: $85.

For the cheapest plan, total monthly premium: $455. Federal subsidy: $455. Strucker would pay: $0.

Two decades ago, Jan Strucker, an intensive care nurse, injured her back on the job and had to stop working. Since then, she has lived on $20,000 a year in workers’ compensation payments and hasn’t been able to afford insurance. That’s likely to change under the health law.

Strucker, who has skin cancer, has had four heart surgeries. Her medications, she said, cost $300 a month and her medical debt has climbed to $350,000. She said she sometimes has to choose among paying for food, medicine or rent.

“I’m on the edge of losing my home,” she said.

At times, she added, she has considered moving to Europe to try to get free health care.

But Strucker and other pre-Medicare baby boomers are among the biggest winners under the health law. Many will qualify for subsidized health coverage on the new insurance marketplaces. They can’t be denied coverage because of bad health. And while they will undoubtedly pay higher premiums than younger people, the gap won’t be as wide as it used to be.

The guarantee of coverage could be liberating for some, experts say. Some in the pre-Medicare crowd would like to stop working because of medical problems, while others want to try something new such as starting a business. Fearful of losing insurance, many have been afraid to make any moves until they reach the Medicare age of 65.

Strucker would qualify for a hefty $455 subsidy on the exchange. It would sharply reduce her cost for a moderately priced plan and cover the entire premium for the cheapest plan.


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