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obamacare

Obamacare? Isn’t That Socialized Medicine?

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A recent trip up the East Coast to visit family and friends presented a brief but intense glimpse into the debate that still rages around the Patient Protection and Affordable Care Act, now often referred to as Obamacare, even by the President himself.

Some aunts were very enthusiastic, some suspicious, some entirely opposed, and everyone confused. Many people I talked to — friends, family, and brief acquaintances — had some facts that they were holding onto firmly, which often informed their overall opinion. Some facts were more factual than others, but given the scope of the legislation and the broader health care debate, this is hardly surprising. A representative of the Kaiser Family Foundation health news branch was on NPR this morning, and she pointed out that many of those that the law is likely to benefit most don’t even know that they will soon be eligible for coverage.

If you have concerns about your own eligibility and how to move forward, I recommend Leanne’s post, A Guide to Shopping for Health Exchange Insurance Plans, that ChangeEngine published earlier this week. She links to several other resources that could also help further your understanding. But a more cerebral question has now been kicking around in my head for the past 48 hours: if clever, well educated people with lots of resources have a hard time grasping the basic elements of this law, and the implications that will soon be forthcoming, how on earth will someone who has a limited social support network, perhaps limited internet access, and other limitations fare?

I believe that the roll-out of the ACA will have a net societal benefit, but on the individual level, many questions remain. Questions of access, for instance, as I just mentioned, or of equity for those caught in between economic categories: too ‘wealthy’ to qualify for Medicaid, too ‘poor’ to access high quality insurance products. There are answers out there to these questions, and I plan to devote myself to finding as many of them as I can between now and the beginning of October, when the open enrollment begins on state exchanges and Healthcare.gov, the federal portal.

If you have burning questions that you would like to have answered, please put them into the comments section at the bottom of this post. If there are a sufficient number of questions to warrant it, the next edition of this column will be devoted to answering them. If not, I will endeavor to answer the most pressing concerns that I have heard from friends and family over the past week, since I am confident they will apply to just about all of us.

In the meantime, please stay healthy!

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].

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].

Burkina Bound

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I was bitten by the travel bug a long time ago, but ever since I found out I’ll be leaving for Burkina Faso in October with the Peace Corps, I haven’t really been able to hide my excitement. So I wanted to dedicate this post to my future home.

Burkina Faso is a landlocked country  in West Africa about the size of Colorado. Despite all the turmoil that affects nearby countries, Burkina Faso is relatively peaceful as they don’t have any coveted natural resources. They grow peanuts and mangoes rather than raw minerals or oil fields. The country has been described as poor even by African standards. A low blow, but nonetheless true — the United Nations ranks it 181 out of 187 on the Human Development Index.

But what the Burkinabe people lack in resources they make up for in personality. It is known as one of the friendliest countries in the world and I hear they live up to their country’s name, meaning “The Land of the Upright People.” They also take fashion, arts and music very seriously. Ouagadougou (pronounced wah-gah-doo-goo, and so much fun to say), the country’s capital, is home to the African equivalent of the Cannes film festival and many other famous music festivals. They also have one of the world’s best soccer teams.

Plus, Burkina Faso actually has somewhat of a structured health care system. In the years following its independence from the French in 1960 their system was managed by the government, but with no support from the local level, meaning there wasn’t really outreach to Burkinabe who still today rely on traditional or folk medicine. Then, about 25 years ago at the African Ministers of Health conference, the Burkina government decided it was time to provide more primary care services to its people. They started the Bamako Initiative which allocated more medical resources and money to the community level and pushed for a bigger emphasis on primary care.

Today, the health care system is organized into three institutional tiers. The first is the Ministry of Health, which has three national hospitals throughout the country and manages all health care policies and public health programs. The second tier is made up regional directors who enforce the policies set by the ministry and provide assistance to the third tier – the local health districts, which contain emergency care centers, dispensaries and clinics. I’ll be working in one of these local clinics as a Peace Corps volunteer. Each health district has a health team that manages the resources and makes sure minimum services are available. The health team is hired by the government but they have to share managerial power with a committee elected by the community. This sharing of power makes the administrative doings of the clinics more transparent, so clinic staff become more accountable and will better allocate funding.

Even though Burkinabe are expected to live until only about 52, I think there’s something very attractive about their health care system. What I love most about the Burkina health care system is that they include the community in the management of the local health districts. If we had something like this with our hospitals, there wouldn’t be all this sneakiness about billing and service fees.

We could also use more community health educators in our hospitals, clinics and doctor’s offices. Somebody could counsel you about insurance (much of what Health Leads does) or talk you more thoroughly about diabetes, high blood pressure, smoking cessation or whatever else instead of getting a little pamphlet about it. If I come in with diabetes, and someone from my community who also has the disease comes in to talk to me about managing it and encourages me to be proactive about my health– that gives so much more motivation than a doctor suggesting you do such and such.

If our clinics and hospitals got this kind input and support from the community level, we would see a lot more people using preventative care and get a lot more out a visit to the doctor.

IMAGE CREDIT. [Wikimedia Commons].

Domo Arigato Mr. Abe

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If France can brag that they have the healthiest health care system, Japan can brag that they have the healthiest people. At a life expectancy of 82 years, the Japanese live the longest and have four full years of life on us Americans. Some people may think it’s because of their diet full of fish and low on fried foods but it could be that the Japanese have their hands-on government to thank.

First of all, even if the traditional Japanese diet is lower in fat and sugar than a lot of countries around the world, the Japanese government doesn’t care. They will still make you take nutrition classes if your waistline is over a certain amount of inches because of the Waistline Law. To Americans this may seem strange because the United States has more than three times the amount of obese people. Bloomberg and public health officers are green with envy — they can’t even ban large sodas.

In addition to the government’s heavy hand in public health, they also control most of private health matters. Every two years the Ministry of Health sets the prices for all health care services. Hospital stays cost roughly $10 a night whereas it runs in the thousands for a U.S. patient.  Doctors may get paid way less, but they also don’t have to pay for medical school and their malpractice insurance for the whole year is less than what doctors here pay in a month.

Although the Japanese government severely controls prices, the patients have all the freedom of choice. They don’t need a referral to see a specialist and they can see any doctor they please — there’s no in or out of network for insurance. And the Japanese are taking advantage of this freedom too. They see a doctor about three times more than Americans do.

Good for them, as the Japanese will always have health insurance and it doesn’t cost that much either. That’s because all health insurance companies in Japan are not-for-profit and if the company comes in the black one year, they subtract it from your premiums the next. Most Japanese people get health insurance through their employer, which helps pays for the already low-cost premium, or through the government.

So how does our reformed health system compare? Well, soon all Americans will have the opportunity to have health insurance. Though people are grumbling about a rumored increase in insurance premiums, all insurance companies must run them by the government first. And a lot of the speculations of high cost premiums don’t take into account the subsidies for people up to 400% of the Federal Poverty Level (roughly $45,000/yr). For a more realistic estimate of what insurance will cost in the exchanges, Washington D.C. recently released proposed rates. But as far as the other highlights of Japan’s health care system, particularly public health measures and cost control, it’s not looking too good. It would help if states would consider expanding Medicaid to include people making up to 133% the poverty level but so far only 23 states have taken that step.

Perhaps we don’t want our government policing our waistlines, but when it comes to providing a low-cost, equitable healthcare system for all, Japan is, quite literally, years ahead of us.

 

IMAGE CREDIT. [Ko Sasaki for The New York Times].

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.