It’s now February, and the Affordable Care Act, aka “Obamacare” is here. The law, as everyone knows, has become a political football, subject to endless spin and distortion. Yet many people, including some colleagues, do not know what the law entails. This week, I decided to take a closer look at how it could affect some of our patients …
The first is 18-year-old Mina, who just graduated from high school last year and has a part time job working, 20-30 hours a week at a pizza shop while she’s preparing to start college next fall. She makes about $10,000 a year. Mina (names have been changed to protect patient privacy) got dropped from the Pennsylvania Children’s Health Insurance Program (CHIP) when she turned 18 and her parents have no insurance, so she is uninsured.
The second is the Bankole family. The parents are immigrants from Africa and recently became citizens. They clean offices at night in Center City and as contractors have no health insurance. Policies that they would have purchased on their own were expensive and would not have covered expenses due to Mrs. Bankole’s diabetes, a pre-existing condition. Their two children are insured through CHIP. Their income, through a lot of overtime is about $60,000. They are both worried that Mrs. Bankole will need to cut back her hours because she has been feeling unwell from the untreated diabetes.
So, can any of these folks benefit from the ACA? First, a quick review of ACA. The goal was to create 1) affordable options of health insurance for those who were uninsured because of cost or were uninsurable because of pre-existing conditions and 2) a system to easily purchase those plans on exchanges where consumers could comparison shop. Federal guidelines would delineate essential benefits that must be included to ensure that shoppers would be comparing apples to apples and it would be presented in a user friendly interface.
For those with incomes above 100% poverty level ($11,490 for an individual, $23,550 for a family of four) up to 400% of poverty level ($45,940 for an individual, $94,200 for a family of four) the federal government would provide financial assistance to purchase insurance on these exchanges (now called Marketplaces) with tax subsidies. For those in poverty, Medicaid would be expanded to include anyone with incomes up to 100% poverty level. Currently, in Pennsylvania, childless adults are not eligible for Medicaid and parents are only eligible with incomes up to $8,953 for a family of four. The Kaiser Family Foundation estimates that 715,000 Pennsylvanians, 400,000 New Jersians, and 29,000 Delawareans are eligible for tax subsidies.
However, after the Supreme Court Ruling in 2012, the Medicaid expansion decision was left up to states. In our region, New Jersey, Delaware, Maryland, and New York expanded Medicaid. Pennsylvania, however, has not expanded, and while an alternative proposal has been drafted, it is being revised and has not yet been submitted to the federal government. So the old Medicaid eligibilities are in place. That leaves approximately 20% of uninsured Pennsylvanians in the gap.
Individual states were also left to decide whether they set up their own Marketplaces, or as they are or to participate in the federal marketplace, as Pennsylvania and New Jersey have opted to do. What resulted is the infamous www.healthcare.gov
Mina was only vaguely aware of Obamacare and the Bankoles had heard negative things on television, so had not even tried the website. I encouraged them to use our computer and certified insurance counselor to check out their options.
Mina is a childless adult so is not eligible for Medicaid and does not make enough to qualify for buying insurance on the Marketplace with a subsidy, so will remain uninsured. One option is to move to Camden to live with a cousin, so she’ll qualify for New Jersey Medicaid Expansion and she is contemplating that choice, but had everything all lined up to start Philadelphia Community College and prefers not to move.
For the Bankoles, they have better options because their income is at 255% poverty level. Mrs. Bankole’s diabetes is no longer an issue. She can get insurance and cannot be charged extra because of her health status. Going on the Marketplace, they find that they have multiple choices for insurance companies and plans, including Aetna, Keystone, and Blue Cross. Plans are offered in tiers from Bronze to Platinum, with premium costs lower for the bronze plans but also with higher deductibles, co-pays, and out-of-pocket maximums.
Because of the diabetes and having neglected their preventive health needs, they anticipate that they will need to access healthcare frequently, so opt for a Gold plan. For them, that means a plan with a monthly premium of $608, but a $0 deductible and out of pocket maximum of $11,000 for the couple. Without the subsidy, that they would have paid $772 per month. The least expensive bronze plan for a similar family who didn’t anticipate having high health needs would have been $291 per month ($455 without the subsidy). They have a drug formulary and wide provider choice the same as a plan not purchased on the exchange.
While the cost of the Gold Plan is about 10% of their monthly income, they feel affordable healthcare increases the likelihood that Mrs. Bankole can continue to work full-time. Their hope is that on enrollment at the end of the year that they can potentially chose a lower price plan for next year once health issues are under better control.
Back tracking for a minute, a word on CHIP. Mina until recently was the beneficiary of years of good healthcare including on time immunizations, regular screenings, treatment for ear infections when she was younger, dental care, and family planning services financed through CHIP. The Bankole children, ages 5 and 8, both have asthma, but have been well controlled because they received regular health provider visits and low cost prescriptions. CHIP has functioned successfully for years in a model similar to how the ACA will function. Mina’s CHIP was free because of her mother’s income and family size. The Bankoles have been paying around $100 per month premiums.
Try going on Healthcare.gov (it’s easy to access these days). There’s a calculator there for you to try out various scenarios for your family and friends without committing or giving personal information. What would happen if you lost your current healthcare coverage and/or income and needed to shop for insurance? Do you already purchase your own insurance but want to see if there are cheaper options—or options with more coverage than you have?
For more on the ACA, there are excellent resources at the Kaiser Family Foundation website. The large health reform section includes state-by-state analyses; the Pennsylvania analysis was used to develop this article.
Pennsylvania posts information about its Children’s Health Insurance Program, including specific income eligibility guidelines.
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