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Affordable Care Act

A Guide to Shopping for Health Exchange Insurance Plans

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In just two short weeks the online exchanges or health insurance marketplaces will open and millions of people will have the opportunity to begin shopping for various health insurance plans. Coverage won’t begin until January 1, 2014, but it is super important to know what you are getting into before choosing a plan.

The online exchanges are intended for small business owners and people who don’t receive health insurance through their job. If you are unsatisfied with your employer’s health insurance, you probably won’t be able to get a different plan through an exchange unless it costs you more than 9.5 percent of your income or if it doesn’t cover the required essential health benefits.

The first thing to consider when shopping for a plan is that all health insurance plans in the exchanges will be categorized into four tiers: bronze, silver, gold and platinum. Although all plans are required to cover essential health benefits, they differ in how you pay for them. The bronze plans have the lowest premiums but the highest out-of-pocket costs whereas the platinum plans are the opposite with the highest premiums and lowest out-of-pocket costs. In the bronze plans, the individual is expected to pay about 40% of health service costs with each tiered plan covering about 10% more ( so, silver: 30%; gold: 20%; platinum: 10%). The idea behind this is that if you are a generally healthy person who rarely needs more than preventative care, a bronze plan may work best for you. If you are someone who gets sick a lot and seems to need a lot of health services, a platinum plan may work best for you.

It may be easy to choose between a bronze and platinum plan, but maybe not between bronze and silver or silver and gold. One consideration is that the out-of-pocket costs for the bronze plans will be capped at $6,350. If you think the bronze plan monthly premiums are still too expensive for you, you may be able to apply for a Catastrophic Health Plan if you are under 30 or get a “hardship exemption.” In this type of plan, your monthly premium will be a lot lower but you’re only covered for 3 yearly primary care visits. If you’re have a medal plan however, you may be able to add benefits to your coverage.

Another huge consideration is the subsidies on your premiums for which you may qualify. The Advance Premium Tax Credit will be applied directly to your premiums, so you save immediately. Incomes up to 400 percent of the Federal Poverty Level will qualify for these tax credits with the lowest incomes receiving the largest credit. A general range for individual households receiving credits is an annual income between $11,490 – $45,960. If you want more specifics, you can try out the Kaiser Family Foundation’s Subsidy Calculator until October 1st.

So if you have an idea by now of what plan you’d like to go with, the last thing to do is pick an insurance company. Here is a list of estimated premiums for plans in the Baltimore area (many other states/areas can be found here). Each company will differ in the specifics on how much you pay for certain services. For example, one plan may cover completely your prescription drugs but charge you a little more for dental services. Besides price, you may want to consider how the health insurance company is run. I encourage people to check out the CO-OP insurance plans since they are non-profit and will probably put you, the patient, first.

Still confused? Don’t worry, once the exchanges open, many clinics and online/telephone support services will provide trained “Navigators” who will help you decide which plan is the best for you.

IMAGE CREDIT. [www.protocol.gov.hk].

To Be Young and Invincible

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After a year of AmeriCorps, living in poverty while dealing with Hopkins staff and students and Baltimore city youth (all intimidating in their own way), I do feel quite powerful and invincible. I’m moving to Africa and the world is mine for the taking! According to Joel Stein’s The Me Generation such narcissism and self-confidence is beneficial since it causes myself and others born between 1980 and 2000 to think that we can change the world for the better. At the same time, such traits are becoming a barrier to the success of the Affordable Care Act.

The Department of Health and Human Service recently announced a video contest, pioneered by the non-profit The Young Invincibles, that will give up to $30,000 in prizes to winners who convince the millennials to sign up for health insurance. A little bit of peer education – smart idea. Getting people ages 18-30 is an integral part of making Obamacare work and keeping critics at bay. Having healthy people to pay for insurance (or medical care of the poor) is a sacrifice that all other countries with national health care consider a no-brainer. And it should be. Getting young healthy people to pay for insurance means keeping insurance costs lower for everyone else (ideally).

Most critics have already been complaining about higher premiums costs under the ACA. But all premium increases (whether it’s an increase to an already existing plan or a comparison of the new plans in the exchanges) will have to be approved and out-of-pocket costs will be capped, eventually (unfortunately this requirement will also be delayed another year). Another consideration is that all health insurance plans will have to have minimum benefits so even if you’re paying more, you may be receiving more too. Slowly but surely states are releasing estimates of health insurance rates from the exchanges, and depending where you live it could be more or less. Plus people up to 400% of Federal Poverty Level will be receiving subsidies for health insurance.

So if you’re young and invincible and will very soon need to start thinking about purchasing health insurance, the government has given over $67 million to organizations that will help people navigate the exchanges. United Way and Planned Parenthood are two of the most popular organization to receive grants while University of South Florida Association of Community Health Centers and United Way of Metropolitan Tarrant County (Texas) were among those to receive the highest amounts. Or if you want to start taking things into your own hands (feeding into those self-reliant stereotypes) these pointers from Kaiser Health News will serve you well. And if you’re still hesitant about even considering health insurance, this article from New York Magazine describing how vulnerable we truly are might change your mind.

Introducing: Evergreen Health Co-Op!

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In less than two months, health insurance exchanges around the country will be helping people to enroll in health insurance. In Maryland, you can get all your questions answered at Maryland Health Connection, our online exchange. Or you can sign up for Evergreen Health Co-Op, Maryland’s first non-profit health consumer oriented and operated plan.

One of the best things about Co-ops, besides the intent of offering affordable and comprehensive health insurance is that they will be partly managed by members. Evergreen will open positions to members on its board of directors which will make costs and operations transparent to the customers. It’s the first time that the American people will have a say in how their health insurance is run. Currently there are 24 states that have state-run co-ops, all of which have been given grants from the government.

Although Evergreen is a brand new organization, most of their insight comes from the current president and former officer of the Healthy Howard Health Plan which gives low-cost health insurance to residents of Howard County who aren’t eligible for Medicaid. The program also focuses on social determinants of health such as education, housing and employment.

It’s a common misconception that Medicaid serves all low-income individuals. But it doesn’t. It serves people with children, with disabilities or the elderly. If you’re a low-income childless adult, where do you turn? For the residents of Howard County they have their awesome comprehensive plan. For other Maryland residents they can turn to the Primary Adult Care (PAC) program which basically will hook you up with a primary care doctor but nothing else, and only if you make less than $2,000 a month. Otherwise you could turn to The Access Partnership (for people living near Johns Hopkins Hospital), the Maryland General Financial Assistance or a free health clinic such as Shepard’s Clinic. Starting January 2014, PAC will be no more, but what will happen to free health clinics?

Some clinics such as the Esperanza Center, which primarily serves the immigrant population, will continue as normal. Others may have to reconsider their purpose completely. Maybe we will see more health resource centers that focus on improving the social determinants of health. And others still might begin charging insurance companies for their services. It’s almost scary to think that free health care may become extinct but we shouldn’t have to have these non-profits filling in the gaps in the first place… right?

IMAGE CREDIT. [www.bernardhealth.com].

Obamacare Mash-up Model

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If an alien came to America today and asked you to describe our health care system, could you?

I certainly doubt you would be able to fit it into one sentence.  It’s a smorgasbord of private insurance, government programs (Medicare and Medicaid), non-profits and a lot of things in between. Lucky for some other countries, they don’t have this problem. And two in particular, Germany and Britain, are seen by experts as two of the best models for health care.

The Bismarck Model

For 130 years the Germans have been using this model of health care. Adopted by the French and many other countries, including the U.S. to some extent, this system uses insurance or “sickness funds” to pay for medical care. Employers and employees contribute to the funds through payroll and the government sets budgets and prices. This model works really well for a lot of countries despite the doctors who often exercise their right to strike and protest for higher wages.

The Beveridge Model

This is the epitome of the single-payer system. The government, through taxes, is the sole payer of medical care in Britain and other countries such as Spain and Cuba who’ve adopted the model. The government keeps costs low and patients never see a bill.

The Obamacare Model?

The other week I had the privilege of seeing Wes Moore speak (author of The Other Wes Moore, a true story about two boys from Baltimore with the same name who grew up to have very different lives — a must read). He said one of the smartest things I’ve heard in a while. His definition of a good politician was someone who sees what’s already working and helps to make it work bigger and better. To me, I think that is what the Obama administration tried to do when it came to health care reform.

For example — and Obama has said this many times — they looked at Mayo Clinic and Kaiser Permeante for inspiration on the Accountable Care Organizations that have been popping up in Medicaid. In these organizations, multi-disciplinary groups of health care providers are accountable for the quality and cost of care to the patient. This could be a shift from the old fee-for-service model of payment and is one of the few cost-control initiatives in the affordable care act.

On a less popular note, what had been working (or more like had created a market so big that it couldn’t be shut down, cough, cough Blue Cross Blue Shield) were private insurance and employer-based insurance. Since the turn of the 20th century this is what has been “working” and is most popular in the country, for better or for worse.

In this way and many others, Obamacare tried to improve on our current mash-up health care system. But will Obamacare be known as a model for health care? It certainly is the first reform and health care system that advocates for the market-based approach. Even though the Affordable Care Act itself isn’t popular, most of the provisions on their own are.

 

IMAGE CREDIT. [www.transatlanticacademy.org].

Obamacare’s Delayed But Not a Disaster

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It’s been a rough week for Obamacare. Last Tuesday the White House announced it would delay the employer mandate of the Affordable Care Act until 2015, giving businesses with 50 or more employees an extra year to figure out how to provide health insurance. Because of this the law has been under major scrutiny since many critics believe this is proof of failure. Though this delay is definitely a huge setback for morale, there could be some good that comes out of it.

But first, the cons.

Besides all the remarks about how Obamacare is now a disaster and will never work, the delay will probably make the law more expensive next year. Those who don’t receive health insurance from their employer will now have to turn to the exchanges to find it. Plus these people are more likely to be lower-income workers meaning that many of them will be eligible for subsidies (incomes up to 400 percent of the Federal Poverty Level) which cost the government (and us) a lot more. And it gets a little worse than that too. When you apply for an exchange, the government is no longer requiring proof of income to qualify for the subsidies (I guess just try to keep that on the down-low). Paying for subsidies is one of the biggest expenses for Obamacare. And to help pay for them, businesses were going to help out, not just by providing insurance, but from fees for not following the employer mandate.

And there’s more. The national health insurance exchanges are falling behind schedule which are supposed to be ready by October 1st. The law requires at least two insurance companies for the exchange and at least one that’s not-for-profit. This is supposed to create more competition in order to lower premiums. So far, only the Blues (Blue Cross Blue Shield) have applied for the national exchange. But they already dominate the country without much competition.

Okay, deep breath — now the pros. I like to find the light in any negative situation.

First, this delay is a relief to many businesses and mostly those who are right on that 50 employee border. A lot of businesses revealed plans to cut workers or workers’ hours to offset costs of buying more insurance. Now they have extra time to figure out how to make the law work efficiently for them. Yes, you can argue that the Obama administration is once again being swayed by big business, but like it or not, businesses are made up of people too.

Second, the employer mandate doesn’t really affect that many people (relatively speaking). Most large businesses already provide health insurance (about 95 percent of them in fact) — it’s pretty much the backbone of the American health insurance system. And of the companies that do not provide insurance, about 10,000 out of six million, they employ only 1 percent of American workers.

Third, delaying a somewhat significant part of the law shows that there is room to adapt and reflect on what is working and what does not. Taking a year to reconsider and revise the employer mandate, in my opinion, leaves room to consider other options that may work better — reconsidering a livable wage (to make health insurance more affordable)? Reconsidering a public option? Reconsidering more comprehensive plans for medical cost control? Hey, a girl can dream.

All-in-all, the employer mandate delay is an eye sore for the image of Obamacare. Is it a complete disaster and train wreck? I don’t think so. If you look at it this way, the main goal of Obamacare is to expand coverage and non-insured employees at large companies will still be able to purchase insurance through the exchanges. Cost control was never a priority but maybe now the Obama administration will see that it should be.

IMAGE CREDIT. [www.golocalworcester.com].

What’s in a Name?

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One of the biggest criticisms of the Affordable Care Act is that health insurance premiums will rise. The cost of premiums has already increased up to 4 percent in the past year. So is the ACA living up to its name? Let’s take a closer look.

Last Tuesday, the Maryland Insurance Administration released rate proposals from insurers for the new exchange in October. In the proposals, from a wide variety of insurers, new plans are the only ones that see a rate increase. This is because insurers are expecting the newly insured people in 2014 to be sicker so they plan to charge more. This also represents one of the major faults of our current health care system — those who are sicker are less likely to have access to care. Fortunately, many of the people who will be buying new plans (about half of the newly eligible in Maryland) will be able to receive subsidies to help pay for care.

Though insurers are saying the additional 12 percent of currently uninsured Marylanders is going to cost them more, the individual mandate was what insurance companies negotiated for in the first place in return for accepting people with pre-existing conditions and giving up recessions of coverage. Plus, the current rate proposals are not just estimates, but they also must be approved by the insurance administration. A major regulatory rule of the ACA (also known as the Medical Loss Ratio) requires 85 percent of group plan costs (80 percent for individual) must be spent on medical coverage or quality improvements instead of administrative cost. If they don’t follow this, they must give customers a rebate.

The newly 32 million people who will be getting health insurance in 2014 may be sicker yes, but that doesn’t mean they won’t be relatively easy to care for. Most of these people don’t have insurance because their job doesn’t provide them with it, not because of deathly pre-existing conditions. Most of these people will most likely be sick with diabetes or cardiovascular disease — two of the most common causes of morbidity and two illnesses that are relatively easy to control with proper medication. This thinking just comes from my experience as an EMT and as a volunteer with Charm City Clinic.

What’s more is that the ACA has provisions that target increases in premiums. For the first three years of the exchanges, the reinsurance program will help pay for the higher cost of newly insured sicker patients and the temporary risk corridors program will help protect inaccurate rate-setting. The law also sets limits on cost-sharing or charging healthy young people more to pay for the sick older people. Previously, the difference had been 6-to-1 but now will be at most 3-to-1. It’s true that some people may start paying more for health insurance, but they are also more likely to receive better insurance too since Obamacare mandates minimum required benefits.

As I’ve said before, Obamacare focuses on access to care rather than cost control, which makes its official name  — the “Affordable Care Act” — very misleading. In addition to increasing medical prices, the biggest obstacle so far for Obamacare is getting the word out about eligibility for insurance and subsidies. The exchanges are supposed to ready to go in October, so pretty soon we better start seeing some kind of major outreach. So much of what Obamacare promises is still just speculation; it’s hard to know where it will end up. But we do know one thing is for certain —  Obamacare gives the opportunity for millions more of the neediest people to have access to care when they otherwise wouldn’t.

The Perils of Step-by-Step Healthcare

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Medicare represents some of the greatest and worst qualities of our health care system. The positive is that it provides coverage for people over the age of 65 no matter what. After your 65th birthday you receive a little red, white and blue card in the mail that guarantees you can go see a doctor for little cost. The program serves many of our most vulnerable populations and has helped to bring many elderly people out of poverty.

On the other hand, Medicare is the foremost example of our fractured, piecemeal health care system that attempts to fix problems after they’ve occurred instead of trying to prevent them. Instead of having a simple, unified health care system, we rely on Medicare, Medicaid, non-profits and other charity groups to fill in the pieces when people don’t have employer health insurance. Medicare was built one part at a time, just as our health care system and just as Obamacare are being phased in year by year.

When Medicare was introduced into the Social Security Act by President Johnson in July 1965, the program consisted of two parts – A and B. Part A covers 80 percent of hospital costs. Part B covers 80 percent of inpatient and primary care. This type of payment is referred to as cost-sharing. President Reagan tried to implement catastrophic coverage (Medicare paid for services up to a certain amount, depending on your income). So many protests resulted that he switched back to cost-sharing.

But, as you can imagine, paying for that extra 20 percent can get pretty costly. So Part C was introduced in 1997 to help both the elderly and private insurance. If you decided to enroll in part C, or Medicare Advantage, you would choose to pay a higher monthly premium instead of that 20 percent. During this same time, the Sustainable Growth Rate was implemented, which was intended to limit the increase in cost of doctor’s services, but has been suspended every year since 2002.

This lack of control added to Medicare spending, and so did the last part of the program, Part D, which covers drugs. But even this provision left coverage incomplete, with many people trapped in a “doughnut hole” with high out-of-pocket costs. So even with these four parts in Medicare coverage, you’re still paying quite a bit for your comprehensive coverage. Fortunately, if you’re low-income you can apply for more assistance or even qualify for Medicaid which will pay that 20 percent.

If you’re living with a disability, you also qualify for Medicare, but if you have a work history you may have to wait for up to two years. If you don’t, you will also qualify for Medicaid. Either way, you’ll need to lawyer up.

Yet, one of the greatest parts about Obamacare, is minimizing the out-of-pocket costs for Medicare beneficiaries. The law phases in rebates for drug costs, free primary care services and ways to improve quality of care. The biggest benefit is drug coverage as eventually, it will be 75 percent covered and will save people a lot of money since those pills can add up.

Nonetheless, since the law was enacted, Medicare has still been subject to changes because of sequestration by capping reductions to payments and limiting out-of-pocket expenses.  Fortunately in Obama’s plan, the “doughnut hole” will be closed by 2015 instead of 2020 and (unfortunately for hospitals) teaching hospitals and hospital debts will be paid less. Another controversial new provision is having wealthier Medicare beneficiaries pay more. Others have proposed Medicare changes but none offer Obamacare’s biggest addition to the program – the elimination of the “doughnut hole.”

All these changes and back-and-forth make it even harder for Medicare beneficiaries to understand. Drug coverage for this vulnerable population could mean saving an extra few hundred dollars a month, or more importantly an ER scare. I doubt most Medicare beneficiaries follow health reform closely and if they do, I bet they’re still confused about what pieces are going to be implemented that will affect them. Like our health care system, we need a concrete plan that will curb costs and improve quality of care in place of making changes step-by-step as things go wrong. Step-by-step, day-by-day doesn’t work. What we need is a fresh start!

IMAGE CREDIT. seniorjournal.com.

Happy Birthday, Obamacare!

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Happy Belated Birthday Obamacare! In just three little years the Affordable Care Act has made some big changes but has a whole lot more to do. All of the law’s provisions won’t be in full effect until around 2020 but that doesn’t mean the law hasn’t made a big impact already.

Most of us have heard that the law has put a tax on using tanning beds, provides free preventative services, lets young adults stay on their parent’s insurance until the age of 26, will require everyone to buy health insurance, and will create health insurance marketplaces called “exchanges.” Most people don’t know the bulk of what the law has done, so in celebration of the birth of Obamacare, here’s just some of what this ambitious law has accomplished. A full list of the ACA timeline can be found here.

Prevention is worth a pound of cure…

A lot of what Obamacare has focused on in the past three years is preventative services. In its first year the law created the National Prevention, Health Promotion and Public Health Council which passed the National Prevention Strategy and the law required any new health insurance plans to include minimum prevention services. It’s been a good few years for primary care doctors too, as their programs have received billions of dollars in funding and new residencies were added for primary care in an attempt to draw more pre-meds to a sorely under-staffed field. In the past few years the ACA has also focused on workplace wellness as it provided grants to small employers with a wellness program, and tax credits to large employers who invested in certain treatment projects.

While all this has been going on, the only thing that the average person might have noticed is new nutritional info on vending machines and at chain restaurants. But even more monumental changes have been made to the two heavyweights of America’s healthcare system – Medicare and Medicaid. A massive assessment of services is underway with the creation of the Medicaid and CHIP Payment Advisory Board. More immediately, the federal government has allowed states to begin to offer home and community-based services through Medicaid, which means more senior centers, transportation, home health aides, meal delivery or anything else that can help someone remain independent living at home.

Closing the doughnut hole…

As for Medicare, one of the biggest changes was tackling the prescription “doughnut hole.” In 2003, when the Bush administration added Medicare Part D to provide for certain types of drug coverage, the provision did not help pay for annual drug expenses between $2,250 and $5,100. Starting in 2010, Medicare patients started receiving $250 in rebates for brand name drugs, and then the following year they could get a 50 percent discount plus federal subsidies for generics. This year they can receive federal subsidies for brand-name drugs. Doughnut hole closed!

Figuring out how we pay for it all…

A lot of the ways in which the ACA is being funded (about 50 percent of it) is through Medicare and many of these funding changes occurred within the past three years. Some of this is funding received through trying out other models of payment instead of fee-for-service such as bundled payment programs and Accountable Care Organizations, which have recently been piloted. Other funding comes from an increase in Medicare Advantage premiums and a decrease in federal subsidies for this program, as well as a reduction in payment for Medicare patients who have been recently re-admitted to the hospital. This year too, wealthy elderly had a Medicare tax increase of 0.9 percent to help pay for the law.

And what it means for you…

For the future, a big obstacle will be getting the word out! The changes that affect everyone (the individual and employer mandate, exchanges, tax credits, Medicaid expansion) begin next year. Don’t delay! Now’s the time to educate yourself about how you’ll be affected and what your options will be. For all of Obamacare’s limitations, you’re sure to find it’s more than a party favor.

IMAGE CREDIT. Foxnews.com.

Birth Control, Religion and Medicine

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Religion and medicine were born together. From Asclepius, the Greek god of medicine, to Jesus to Christian Science to John Wesley to the Baptist Church. Few, I think would disagree that spiritual health is a key determinant in overall well-being. And religious groups have  often provided health care in their mission to serve the helpless. Recently, however, with the passage and upholding of the Affordable Care Act, religious values have clashed with medical reform, with the issue of birth control at the fore.

This past Friday, the Obama administration revealed a new proposal that would exclude religious employers from having to provide insurance plans with contraceptive coverage. The controversy will rage on; but it’s worth taking this moment when the issue is so forcefully in the public mind to explore the interwoven history of medicine, birth control and religion.

Pregnancy was one of the first non-diseases to be hospitalized and medicated. It supported the growth of the hospital and the authority of medicine (giving rise to the idea that “doctor knows best”).  The transfer of the birth to a hospital is thought by some medical historians to have been the beginning of our over-medicated society. That theory makes even more sense now that birth control is officially labeled as preventative medicine and can be covered by insurance. Medical authority in this regard has reached its apex.

But with that authority have come abuses. In the mid-1950s, clinical trials in Puerto Rico were held to test the efficacy of the first birth control pill. Most of the women had no idea they were partaking in a clinical trial or of the horrible side effects. In the 1960s, the women of this tiny island would again be coerced into population control, but this time through sterilization. Puerto Rican officials distributed media to encourage women to get “la operacion.” But ill-informed consent on sterilization happened on America’s mainland too. Around this same time, ten Mexican-American women sued the Los Angeles County General Hospital for giving them unwanted sterilizations. In the 1978 case, Madrigal v. Quilligan, the judge ruled in favor of the hospitals because the doctors “acted in good faith.”

Ironically, though, faith has been at the heart of the American medical system for decades, albeit religious faith. Indeed, beyond birth control, religious groups have been both a spur and a barrier to universal health care. It started at the turn of the twentieth century when hospital administrators usually gave away beds to wealthy friends or socialites. Religious and racial discrimination prompted faith groups such as Catholics and Jews to form their own hospitals, yet they still served the population at large and not solely their own denomination.

But as historian of medicine Paul Starr notes, “the denominations that do build their own schools and hospitals tend to be those that see themselves as deeply at odds with the dominant culture.” Because of this strong “cultural heterogeneity” or culture clash, hospitals in the United States have been harder to control by one entity, such as the government, as most universal health care systems are. In fact, in countries where there is one dominant religion, hospitals are far more likely to be run by the state.

And as the United States moves to a somewhat more state-controlled medical system, the age-old debate over the bounds of contraception still raises barriers to universal care. Even the Ancient Greeks struggled with the question of abortion – Aristotle countenanced abortion within forty days of conception for a male, and eighty for a female (women taking longer to gain a soul), but many Greeks opposed it completely because they conceived of embryos as nothing more or less than tiny people.

No doubt the controversy will persist long into the future. The Obama administration’s proposed amendment currently includes only non-profit faith employers, meaning the religious owner of a private company or the devout executive officer of a corporation will have no such exemption. So expect more exceptions to be made. For many women, birth control will continue to be free, but lower-income women working at religious institutions will be denied that access, meaning that our health care system will fall short once again of being universal.


 

IMAGE CREDIT. The Rag Blog.

 

Medicaid Matters

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The fiscal cliff is looming and debates are raging about whether or not to tax the rich, but starting January 2013 individuals and couples with incomes over $200,000 and $250,000 respectively are going to have to pay more in taxes anyway. These new payroll taxes will help pay for the expansion of Medicaid starting in 2014, which is projected to newly insure about 16 million people and is one of the major foundations of the Affordable Care Act. But things aren’t that simple.

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