100 Days and Counting; 10 Things You Need to Know About Obamacare

In fewer than 100 days, the Obamacare insurance exchanges will be open for business.  Fifteen states will be running their own exchanges.  Thirty-five will be relying on the federal exchange.

Vangent, which is running the federal call center, is preparing for 200,000 calls per day between now and the first of October.

The federal government has also re-tooled its site, www.healthcare.gov, to provide up-to-date information about the exchanges.

These are parts of a massive consumer education campaign, which is badly needed.  Because as of two months ago – three years after its enactment and a year after the Supreme Court affirmed almost all of it – according to a Kaiser Family Foundation poll, 42 percent of Americans did not even know that Obamacare was the law of the land.

Obamacare is and will remain the law of the land.  And here ten things you need to know today as you prepare for it to take full effect.

One, if you are part of a family of four and your household income is between approximately $24,000 and $92,000 per year, and you have to buy your own health insurance, you will be eligible for a tax subsidy beginning on January 1.  Small employers already are, but most are not taking advantage of the credit. If you are insured through your employer, very little will change for you. 

Two, a family of four with a household income of $50,000 will receive a subsidy so large for an average insurance plan that the net cost of the premium for family coverage will be only $280 per month.  And if that is too much, there will be a less expensive choice.  A lower cost “bronze” plan will cost only $140 per month.  You can calculate your own costs by using the Kaiser Family Foundation calculator.

Three, if you are under the age of 26, then as of January 1, 2014 you will have the option of remaining on your parents’ insurance – even if your own employer offers you coverage.  But if you stay on your parents’ plan and can only pick up your employer’s during an open enrollment period, you may need to enroll in the year before you turn 26 or risk a lapse in coverage and a possible tax penalty.

Four, if you earn less than 138% of poverty and your state has expanded Medicaid, then you will have Medicaid coverage.  But if you live in one of the 20+ non-expanding states and have an income that is at or just above the poverty level, then you will be eligible for a “bronze” plan at no cost to you.  (I have an updated list of where states stand on expansion on my State Rankings page.)

Five, under Obamacare you will still get your health insurance from companies you recognize – not from the government.  Blue Cross Blue Shield will be participating in exchanges throughout the country.  United and Aetna will each be participating in a dozen or more states.  Smaller local companies will also be offering plans.

Six, pre-existing conditions will no longer disqualify adults for insurance.  The transitional health insurance program for adults with pre-existing conditions, called PCIP, has ended.

Seven, mental health benefits will finally be on a par with physical health benefits.  This isn’t just because of Obamacare.  The administration has promised that the Mental Health Parity Act of 2008 will finally take full effect before the end of the year.

Eight, soon everyone will know what an “accountable care organization” is, and chances are that at least one of your providers will be participating in one.  Although it is hard to summarize what this means in one sentence, the bottom line is that you’ll see more emphasis on preventive services, and your providers will get paid more for keeping you healthier.

Nine, the number of uninsured people will begin a march downward from over 50 million to between 25 and 30 million, and then remain at that level.

Ten, widespread opposition to Obamacare will die down over the next two years.  Part of the reason is that years of Obamacare-bashing have set the success bar pretty low.

And by 2016, the opposition may be effectively gone.  Most people will be used to paying lower net amounts for health insurance, most states will be reaping the benefits of the expanded Medicaid program, and young people coming of voting age will have never known a time when Obamacare was not a part of the national landscape.

We will be ready to move on.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The Disintegration of Health and Mental Health Care

How will the Supreme Court respond to an argument next week that might lead to the disintegration of health care in America?

In recent years, we have been making slow policy progress in better coordinating and integrating primary and specialty care, and health and mental health care.  Two milestones were the passage of the federal Mental Health Parity Act in 2008 and the Affordable Care Act provisions in 2010 that prohibit insurance discrimination against people with pre-existing conditions, both in coverage and in cost.

These are opening more primary care doors to people with mental illnesses. 

80% of all mental health problems are first seen in a primary care office.  And it now pays for a primary care clinician to screen for mental health problems.  According to one recent projection completed by the Mental Health Association of Palm Beach County (available on request from that organization), a primary care practitioner can generate in excess of $100,000 in insurance payments for every 2,500 behavioral health screenings he or she completes.

Integration also appears to pay off for patients in earlier and more effective care.  Between 2006 and 2009, the number of primary diagnoses of mental illness in general hospitals dropped from 2.4 million to 1.6 million, as more clinicians recognized the need to treat health and mental health symptoms – which are often indistinguishable – together.

Now the Supreme Court is being asked to weigh in on the question of integration.

Next Wednesday, on its third day of oral arguments about ACA, the Court will hear arguments about whether the individual mandate is “severable” from the rest of the Act.  How it responds may well determine whether the recent progress we’ve made to integrate care will stall.

Here’s why. 

The Obama Administration is arguing that the individual mandate is intertwined with two other provisions – the mandate to provide coverage without regard to pre-existing conditions and the mandate to provide coverage at no additional cost to those with chronic conditions.

These are important consumer protections, but the Administration’s view is that without the individual 

mandate healthy people will choose not to purchase insurance that covers expensive chronic conditions.  Instead, they will just wait until they get sick and then buy the coverage that will still be guaranteed to them if the other mandates remain.  This will in turn force up the price of insurance for everyone. 

The Administration supports ACA, but most ACA opponents also agree with the Administration on this point, as have some judges who have already ruled on the law.

If the Supreme Court finds the individual mandate unconstitutional, and then also agrees that it is not severable from the other provisions, it would overturn these two additional mandates.  This would result in a worst-case scenario for people with mental illnesses – a return to the private insurance market we’re just now leaving behind, where premiums are too high for them to afford, and coverage is too low for them to obtain effective treatment.

It won’t help people with other chronic conditions, either, as they head back out of primary care settings and into hospitals for treatment.  We’ll all lose out, because properly diagnosing and treating chronic conditions early means less cost down the road, more effective care, and better patient outcomes.

The historical pressure against integration in the health care delivery system isn’t philosophical or constitutional, but is often the product of increasing specialization among health care providers.  In 1960, there were approximately 7.5 primary care physicians and 7.5 specialty care physicians in the United States for every 10,000 citizens.  Fifty years later, in 2010, there were just under 7 primary care physicians per 10,000 citizens, but over 13 specialists. 

Specialists by training know a narrow area of medicine well.  As a result, we have grown to think about chronic diseases one at a time, and we often treat them this way, too. 

But this isn’t very efficient or effective, because patients usually bring more than one problem at a time to their primary care clinicians.  And by the time they are in care, almost two-thirds of patients with at least one chronic condition have at least one more.

That’s why we need integrated health and mental health services, and fair coverage for chronic diseases.  And that’s also why – if policymakers aren’t ready with an alternative – the disintegration of health and mental health care could result from the Supreme Court’s decision about severability.

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.