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health insurance

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].

Where Obamacare Fails

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I shy away from criticizing Obamacare too much because I think it provides some major improvements to our health care system. Personally, the law has positively impacted me — more free preventative care, more services covered and longer coverage. But lately I’ve become a bit fed up with my own health insurance and doctors’ visits, and it’s hard not to ignore all the negativity surrounding the law. Obamacare isn’t the problem here. It’s definitely not the solution either. Rather, Obamacare is kind of like a band-aid that distracts you from the real problem — a health care system that perpetuates inequality.

Ironically, this past year I met a lot of bright-eyed Johns Hopkins students who came to be a part of the “best” health care system in the world. And our medical education is arguably the best in the world (thanks to the 1910 Flexner Report that set Johns Hopkins Medical School as the gold standard for medical education and compared all other schools to it.) There’s no doubt our doctors can do amazing things. A news report stated that a Chicago suburban hospital has a 97% survival rate for gunshot wounds that enter the ER. Considering that a bullet can enter your upper torso and exit in your lower torso, damaging every organ in between, that is a spectacular rate. It’s the long-term care after the fact where we drop the ball.

Here’s an all-too-typical story: a patient is admitted to the hospital, can’t get out of bed for weeks on end and when it’s time to leave,  they no longer have the strength to walk. Patients lie in their hospital bed for weeks eating crappy hospital food and their only option for exercise is to be the creepy person walking up and down the hallway in their hospital gown dragging the IV stand. Healthcare in the United States is amazing at the quick-fix, but when it comes to helping a patient overcome root causes of illness, we don’t really try. There’s rarely any sufficient patient education or measures taken to prevent re-admittance to the hospital.

What’s even worse is what can come after the hospital — a nursing home. No one wants to be in one. Not even the workers like being there. If you can’t afford at-home help, off you go to spend most of your time eating more crappy food and watching more TV in bed.

Patients at all hospitals should be receiving holistic care. Take the New York program that allows doctors to prescribe vegetables, for instance. Instead, many patients are being subjected to a long-standing though theoretically taboo practice called “patient dumping” where patients at one health facility are forced to another, usually because of their insurance status. Though hospitals are required to treat whoever enters their doors under the Emergency Medical Treatment and Active Labor Act of 1986, patient dumping still occurs, even as horrible as busing people to another state.

Soon about 30 million more people will have health insurance, but it’s scary to think that “patient dumping” might still occur even if the majority of Americans are insured. Will you be referred to a crappier facility if you have the cheapest health insurance? That’s the thing with our health care system — if you have more money, you receive better and faster care. There will be minimum benefits thanks to Obamacare, but people with more money will still be able to afford better health insurance even with the “Cadillac” tax for the more exhaustive insurance plans. In Germany, health insurance will cover spa days and yoga if your doctor prescribes it. Why can’t everyone have benefits that would get a “Cadillac” tax? If only we could take a step back and realize the care we’ve been delivering is actually not the best in the world, then maybe we could start on the path to the equal holistic care we all need and deserve.

IMAGE CREDIT. [robcares.com].

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].

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.

Obamacare Keeps Calm and Carries On

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The final count is in! The federal government will be providing health insurance exchanges for 26 states. On February 15th, states had their last chance to opt for a federal partnership to run an exchange – essentially an online marketplace for health insurance. States will always have the option to take control of the exchanges themselves (which the feds would prefer), but for now only the other 24 states have chosen to set up their own and have them running by October 1st of this year.

Some states were skeptical that they would have the funds and manpower ready to meet that deadline. But many Republican-led states simply refused to run their own exchanges because they didn’t want to be a part of Obamacare, despite the fact that most Americans agree that exchanges will work best under state control. The department of Health and Human Services ideally wanted all of the states to take control of the exchanges and will have to work hard to adjust its original plans, as has so often been the case for Obamacare. The story of the president’s signature reform has been one of change.

Indeed, that we have exchanges at all is the result of a shift in position. The basis for the exchanges is the individual mandate, which requires all U.S. citizens (with certain exceptions) to have health insurance by January 1, 2014. Originally, President Obama was against the individual mandate – a topic hotly debated in his primary battle with Hilary Clinton. Once president, he saw that there was no other choice. Without the mandate, the government couldn’t require insurers to turn away sick people as some people might wait until they were sick to buy insurance.

As of now, uninsured people with pre-existing medical conditions have been able to enroll in the government’s Pre-Existing Condition Insurance Plan, but the Obama administration announced Friday that they had to cap the plan due to financial restrictions. Other changes have been made since Obama originally proposed his vision for health reform. Obama had wanted to include a public option or a publicly-run insurance plan (similar to Medicare, which is government-run) to compete with the private insurers in the exchanges. This would potentially drive down insurance premiums and lower administrative and medical service costs.

But a public option would be tricky to get right since it wouldn’t work if too many people were enrolled, or too few. If enrollments in a public option were too numerous, providers wouldn’t be able to “cost shift” – currently, by charging higher premiums to private, fee-paying patients, doctors and hospitals gain back losses from providing services to Medicare patients, Medicaid patients and the uninsured. Conversely, if there were severe enrollment restrictions and too few people were enrolled in a public option, it would most likely be those with a high risk. This would leave the public option bankrupt and private insurers rolling in the dough from having so many healthy people enrolled.

And of course a public option is considered by conservatives to be a first-step toward a single-payer health system (a health system in which one entity pays for all health services), which liberals would cheer, but which they believe to be dangerous government intrusion on the workings of the market.

As a compromise on the public option, the Senate offered a Medicare expansion to enroll people at the lower age of 55. Neither this nor the public option could get passed so the Consumer Operated and Oriented Plan (CO-OP) was born. A CO-OP is a non-profit insurance plan controlled by the patients it insures and must be included in all state exchanges. The government is offering low-cost loans to both new groups and existing ones. Twenty-four states have received loans and their CO-OPs will be highly monitored to make sure they will repay loans and are meeting goals.

Even after clearing so many obstacles, many are still skeptical the plan for Obamacare can be carried out. Will a federal exchange be ready by October? For one, it’s an enormous feat of information technology and logistics that will need to connect many government departments such as Homeland Security (to verify citizenship) and the IRS (to determine subsidy eligibility). By July, insurance plans for the exchanges are expected to be chosen, but will HHS have and choose the best plans?

Could the federally-run exchange look like a public option?

Will states eventually take over their own exchanges?

Will people even know about the exchanges by next year?

Will the exchanges really provide competitions for insurers?

And will policymakers be forced to make yet more changes to address these questions?

As America’s great experiment with healthcare reform unfolds, only time will tell.

IMAGE CREDIT. endthefedusa.ning.com.

 

Obamacare – Exchanges, Optimism and Irony

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The New Year brings us optimism, good spirits and hope that America will be one step closer to equality in health care. Over the holidays, states and the Department of Health and Human Services were hard at work developing the health insurance exchanges, or in other words, an easier way for certain individuals and small business owners to purchase health insurance.

The exchanges must be ready by October 2013 for enrollment and be fully operational by January 2014. Yes, that’s optimism at its finest. In mid-December 2012 states had to decide if they were going to run the exchanges themselves or use the government plan. Though, until February 15, 2013 states can still opt for a federal partnership. So far, 19 states decided to operate the exchange themselves, seven decided to receive some help from the government and 25 have defaulted to a federal exchange.

Basically, exchanges are going to be organizations (either a government agency or a non-profit) that will help make finding health insurance simple and straightforward and will keep prices competitive among plans. Massachusetts already has had a great functioning exchange since 2007 called Health Connector. Utah also has had a functioning exchange since 2009 for small businesses but will need to expand to individuals.

All exchanges, state-run or not, will need to meet minimum standards set by the Affordable Care Act which includes hiring ‘navigators’ for assistance, client education, basic health benefits, maintaining a website, and rating health insurance plans. All exchanges must offer two plans and one must be from a non-profit. Ideally, if you are looking for insurance you’ll be able to go onto a website, browse plans, have all your questions answered either online or by phone and be enrolled with an affordable plan that fancies you within 30 minutes. Good thing it’s January so we’re all feeling extra optimistic! By 2014 people who don’t have employer health insurance (those with lower incomes will receive subsidies) and small business with up to 100 employees will be able to find health insurance plans through an exchange.  By 2017, states can decide if they want to offer exchanges to larger employers.

Originally, the intent was for exchanges to all be state-run since state legislatures probably know what works best for them as far as setting eligibility, plans and funding. It was expected that only states with small populations would default to a federal exchange, but the two most populous states with 20 percent of the nation’s uninsured, Texas and Florida, have opted for the default.

Most states that chose to have a federal Exchange did so early in advance claiming that the exchanges would be too expensive or to try to sabotage Obamacare since they don’t agree with the law. All but four states received grants to help offset costs which mainly went to hiring IT work. The states with partnership exchanges will be able to manage plans and customer service and the hope here is that the Department of Health and Human Services will try to work with states as much as possible to individualize the exchanges so that all states will have the opportunity to move to a state-based model in the future.

The irony here is that the Republican states that chose a federal exchange are going against their fundamental Republican ideals. They complain that Obamacare is big government but they certainly don’t seem to have a problem making government’s role bigger in this case. I’m staying optimistic though, the world didn’t end, Obamacare is in full effect, Republicans can still flip-flop on exchanges and I’m hoping people will remember once again George Washington’s warning in his farewell address of damaging divides due to partisan political spirits.