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Perspectives DIAGNOSIS: CONFUSION A HEALTH CARE SYSTEM IN TRANSITION

A MULTIPART SERIES ON HOW THE LOOMING HEALTH CARE REFORMS WILL CHANGE THE LIVES OF MID-MISSOURIANS.

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Columbia Daily Tribune Sunday, September 29, 2013 www.columbiatribune.com

COMING TUESDAY: Who are the navigators and enrollment assistants who are helping people enroll in the health insurance marketplace?

COMING WEDNESDAY: How do the health insurance marketplaces work, and how much does insurance cost?

Q&A

Nick Schnelle/Tribune

Jen Bersdale, executive director of Missouri Health Care for All, speaks Tuesday during a panel lecture aimed at providing tips and tools to communicate about the new health care exchanges during the 2013 Cover Missouri Summit at the Holiday Inn Executive Center.

A dose of uncertainty Although 75 percent of Obamacare has already been implemented, sweeping changes ahead pose a myriad of unanswered questions. By Jodie Jackson Jr. | jjackson@columbiatribune.com | 815-1713

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bamacare. Few words trigger as much emotion as the nickname for the Patient Protection and Affordable Care Act, which was signed into law by President Barack Obama in March 2010. Critics and proponents both use the term — it started as a pejorative but was embraced by Obama — yet the law itself continues to divide. Supporters believe the law will deliver on its promise to provide affordable insurance and consumer protections for millions of uninsured Americans, and opponents warn of unknown, unintended consequences, including crushing costs to taxpayers. The law has been dissected and debated through three national elections, Congress has voted 40 times to repeal it and the U.S. Supreme Court — by a slim 5-4 margin — upheld the bulk of the law last summer. Despite the rancor and contentious debate, Obamacare is the law of the land, and while congressional efforts to repeal or defend the law continue, roughly 75 percent of the law already has been implemented.

A rule that allows dependents to stay on a parent’s insurance until the age of 26, prohibition against denying coverage to children for pre-existing conditions, and removing the cap on lifetime coverage limits are just a few of the more than 70 provisions already in place. At least 17 more will be phased in between 2014 and 2018. ■ Tuesday’s scheduled launch of a six-month enrollment period for coverage through Missouri’s federally run health insurance exchange, or marketplace, is one of the biggest hallmarks of the health reform law. Policies purchased through the online marketplace will begin Jan. 1. Failure to purchase insurance could result in a fine, although many health policy analysts have said that most people won’t feel or see any change on Jan. 1 because 80 percent of the nation’s non-elderly population already has insurance. In addition, the Congressional Budget Office estimates that most people who remain uninsured will be young or poor or both and won’t have to pay the penalty. Missouri is a different creature altogether when it comes to Obamacare and its provisions to expand Medicaid and launch the online marketplace. The General Assembly has rejected Medicaid expansion — even with the feds dangling the carrot of covering 100 percent of the expansion cost for three years — and the state also refused to put

together its own marketplace, forcing the feds to take on that task. Medicaid expansion was seen as the key to helping an estimated 32 million Americans find affordable health coverage. The Medicaid debate is expected to be front-andcenter once again when the General Assembly convenes in January. Darin Preis, executive director of Central Missouri Community Action and a member of the Columbia Board of Education, said CMCA will have a staff of six consumer assistance counselors, funded by a grant from the Missouri Foundation for Health, to help people enroll in the online marketplace. The counselors will be aiming to enroll people who fall between 100 percent and 400 percent of the federal poverty level. People with incomes less than 100 percent of the federal poverty level will have to buy insurance on the marketplace because the Medicaid program was not expanded. “They’re falling through a crack that our state legislature chose to put in place,” Preis said. “I’m sincerely hoping they’ll come back in the next legislative session and take a look at that … so the people who most need preventative care can access it.” CONTINUED ON 4C

Q: I am 78 years old, and my husband is 80. Do we have to sign up for the new Obamacare since we have paid into Medicare for years? … We do not understand this law and do not understand what we have to do to sign in. This is confusing. Thank you for answering my question. Sincerely, M.L., Glasgow A: Your Medicare benefits are not changing under the Affordable Care Act (Obamacare). If you get your health care through a government plan such as Medicare or Medicaid, you do not need to enroll for insurance through the online marketplace that launches Tuesday. “We want to reassure Medicare beneficiaries that they are already covered, their benefits aren’t changing and the marketplace doesn’t require them to do anything different,” said Julie Bataille, spokeswoman for the Centers for Medicare and Medicaid Services. She said call centers for the state exchanges are already fielding questions from Medicare recipients and rerouting them to the Medicare line. Another reason for the confusion is the overlapping enrollment periods for Medicare and Obamacare. Medicare open enrollment starts Oct. 15 and closes Dec. 7, while enrollment for the new state exchanges for people 65 and younger launches Tuesday and runs through March. Many of the same insurance companies offer coverage for both. ■ Be aware of possible Medicare-related scams that are adding to the confusion. Joyce Jones of Columbia said she received a phone call from a person who told her she was going to get a new Medicare card in the mail. The man then asked her to confirm her phone number and address. “He said he was going to have to ask me more personal questions to verify I was who I said I am,” Jones reported. “I knew right then and there it was a scam.” She knows Medicare officials do not ask for information over the phone. At that point, the caller hung up. Jones reported the phone call to the Missouri Attorney General’s Office and to the Department of Health and Human Services Office of Inspector General, which confirmed the call did not come from HHS or the Centers for Medicare and Medicaid Services. “They were the ones who told me they were well-aware of this scam,” she said.

THE FACES OF HEALTHCARE | WHO WILL BE AFFECTED?

Advocate for disabled hopes for improvement BY JODIE JACKSON JR. jjackson@columbiatribune.com | 815-1713 heryl Price knows all too well the public’s misperception that individuals with disabilities automatically qualify for services or financial assistance. “ ‘There’s programs out there for all you folks, so why don’t you go get it?’ ” she said, repeating the sentiment she often hears. But Price laughs it off, shaking her head and smiling. As the president of the board of directors for Services for Independent Living, Price — who uses a wheelchair — is a tireless advocate for people with disabilities and SIL’s mission of maximizing independence for people with disabilities. She is waiting to see how SIL consumers — the organization doesn’t call them “clients” — will fare under the online health insurance marketplace, which is a primary feature of Obamacare. Enrollment is set to begin Tuesday. “Are people really going to be able to

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Don Shrubshell/Tribune

afford it? Is it truly going to be less expensive?” she asked. Price, 63, is a retired federal employee and has a BlueCross/BlueShield Anthem plan through the government, combined with Medicare for her disability. She is not unhappy with the plan but wouldn’t mind saving money. “I have what Congress has,” she said. “I just have to pay for it. They don’t.” Most of her needs are met. She pays about $200 per month for medications, and most hospitalizations and doctor’s visits are paid for. “It’s going to be a real struggle for me … to decide if I want to give that up” for a health plan on the marketplace, also known as the exchange. “It basically covered everything I needed.” Almost everything. Price longs to have a personal care attendant for tasks that now are done by her husband, who has chronic back problems and diabetes. The attendant would cost at least $20 per hour, and at six hours a day, “that’s more than I

CHERYL PRICE AGE: 63 OCCUPATION: Retired CURRENT MEDICAL SITUATION: Disabled INCOME: Price makes $17 too much each month to qualify for Medicaid

make” in a month. If she qualified for Medicaid — or if the Missouri General Assembly agreed to expand Medicaid, with the feds covering 100 percent of the expansion cost for three years — Price could get the attendant she needs. Instead, her monthly retirement and disability income is $17 more than the threshold to receive Medicaid. “Seventeen bucks makes all that difference in your life,” she said. “Our state legislature really needs to buy into Medicaid expansion.” Price’s “new birthday” — the term

some individuals with disabilities use for the date of injury or disability — was June 19, 1980. She fell and suffered a traumatic brain injury while she was between shifts as a nurse at Truman Memorial Veterans’ Hospital. She broke all the bones in her face. A medical condition related to her brain injury was treated with high doses of steroids, which caused osteoporosis, eventually requiring Price to begin using a wheelchair in 1998. Price also is eager to see how the marketplace and new insurance regulations might help her husband gain insurance. He could buy insurance now for around $1,200 per month, but that will likely change. “Before Obamacare, most of the Medicare supplement policies wouldn’t accept him because of pre-existing conditions,” she said. That discrimination is outlawed effective Jan. 1. At that point, people can be charged more but can’t be denied coverage if they have a pre-existing mental, physical or medical condition.

JOHN DARKOW

OPINIONS

SPEAK YOUR MIND

Darkow cracks Ted Cruz’s “Green Eggs” exposition.

Hank Waters likes administrator’s community school idea. Terry Schlemeier knows where rodeo clown can find work. Ron Leone takes issue with push for ethanol increase in fuel.

Comment on any story or column at www. columbiatribune.com.

EDITORIAL, 2C

EDITORIAL and OPINION, 2C and 3C


4C www.columbiatribune.com COLUMBIA DAILY TRIBUNE Sunday, September 29, 2013

DIAGNOSIS: CONFUSION A HEALTH CARE SYSTEM IN TRANSITION

A dose of uncertainty FYI

WHAT DOES THAT WORD MEAN? Obamacare has many terms — some old, some

CONTINUED FROM 1C

Medicaid expansion has been a regular topic of conversation at numerous Obamacare-related conferences and seminars over the past few months. Amy Whitcomb Slemmer, the director of Health Care For All in Massachusetts, recently called for Medicaid expansion during an event in Columbia. “I understand you don’t have a wildly supportive legislature,” Slemmer said, telling representatives of not-for-profit and social service agencies that they will have important voices in modifying the state’s federally run exchange “as you go.” “I know there are still people trying to defeat this law, but it is the law of the land,” she said. The Family Health Center of Boone County also has hired staff to help people enroll, and two Columbia-based statewide groups — Primaris Healthcare Business Solutions and the Missouri Association of Area Agencies on Aging — received sizeable federal grants to hire navigators to help educate and enroll people in the marketplace. ■ Insurance plans on the marketplace will range in price at bronze, silver, gold and platinum levels. Bronze will have the cheapest premiums and highest out-of-pocket costs. On the other end, platinum has the highest premiums but the lowest out-of-pocket costs. Despite the cost differences, insurance companies no longer can set higher premiums for women, and each plan must provide a list of 10 basic benefits, including maternity care, prescription drug coverage and mental health care. In addition, many of those who shop on the online marketplace will be eligible for a subsidy or tax credit based on their income and family size. Meanwhile, even with the marketplace enrollment just days away, confusion about the law continues to abound. “There are so many unknowns as far as what it’s going to entail and cost, and what benefit you get from it,” said Mike Kinkead, owner of Kinkead Pharmacy/RadioShack in Centralia. “Everybody, including me, is trying to play catch-up as far as finding out all the ins and outs.” People with Medicare coverage are wondering how the marketplace might affect them. It won’t. Business owners are anxious to learn the specifics of mandates for them to provide coverage to employees. Health care professionals worry that simply providing affordable insurance won’t have a real impact for people who’ve never had insurance and who typically wait for a health emergency to see a doctor or go to the emergency room. Kinkead said he’s not well-versed enough to answer peoples’ questions, but he’s not hearing many. “At this point, we’re not really getting many questions” from pharmacy customers, he said. “The few people I’ve talked to” who had concerns “don’t even know which questions to ask.” Tom Kayser, benefits division manager at Sundvold Financial in Columbia, said his job for 25 years has been helping individuals and businesses develop plans and benefits, to negotiate prices, maintain compliance with insurance and financial regulations, and provide ongoing claim support. That approach is now preceded by “a 1½- to 2-hour conversation just getting them up to speed” on Obamacare “before we can even strategize,” Kayser said. He added, “Unfortunately, this law is making me spend probably 70 percent of the time to make sure that people aren’t in a position to pay exorbitant penalties and fines.” ■ Even in the midst of the confusion, however, it’s clear that additional taxes and fees are going to be part of the new health care landscape. The new taxes include a medical device tax, health insurance industry tax and changing the threshold on itemized health and medical deductions from 7.5 percent to 10 percent of adjusted gross income. “The sad thing is so many employers don’t know what’s about to hit them,” Kayser said.

Sait Serkan Gurbuz/St Joseph News Pressvia AP

U.S. Sen. Roy Blunt of Missouri, right, arrives in May at Heartland Health in St. Joseph to speak about the Affordable Care Act. Blunt has been critical of so-called Obamacare and wants to defund the law.

“Small employers are going to have an extreme surprise when it comes to their 2014 renewal.” One of the potential surprises for employers will be the transitional reinsurance program, also known as the “belly button tax.” The tax, assessed on each covered individual in a health plan, will last for three years and is intended to stabilize the insurance market in case sicker and previously uninsured people flood insurance risk pools without a corresponding influx of young, healthy people. The belly button tax is estimated to cost Boone County, Columbia city government and the University of Missouri system a combined $2.59 million in 2014. The coming public blitz of Obamacare and marketplace education also will target young Americans. The need for younger, healthier people to join the marketplace risk pool is “crucial to making this work,” said Ryan Barker, vice president of health policy for the Missouri Foundation for Health. “You can’t understate the importance of lots and lots of young, healthy people signing up,” he said. Twenty-six percent of people ages 18 to 34 are uninsured — the largest population of uninsured Missourians, Barker said. Kayser is skeptical about the prospect of young people signing up to receive a monthly health insurance bill. Not buying insurance, however, will mean a penalty of $95 or 1 percent of income, although the amount grows substantially larger over the next few years. At least for now, “the likelihood is those people will remain uninsured because the penalty, the tax, is virtually nonexistent,” Kayser said. “You’ve got a lot of 20-somethings that don’t buy insurance now,” he said. They’ll be faced with the option of paying several hundred dollars per month versus 1 percent of income. “The polling is showing that a lot of those people are still going to opt out of the plan.” Obamacare proponents point out that those 20-somethings likely will qualify for subsidies to reduce the premium. ■ Some of the lingering confusion in Missouri about Obamacare likely is a result of statewide elections in 2010 and 2012, when voters resoundingly approved anti-Obamacare measures. However, those votes were basically symbolic because they did not stop the federal health care law from being implemented, although Proposition E, approved last November, certainly put up a barrier to starting the online marketplace. Prop E, a statutory change proposed by the General Assembly, prohibits the governor or any state agency from establishing or operating a statebased health insurance exchange “unless authorized by a vote of the people or the legislature.”

The law gives the General Assembly or any citizen the right to sue the governor or any state agency — or its workers — that attempts or helps to get the exchange going. As a result, Missouri became one of 35 states where the federal government is operating the exchange either alone or in partnership with the state. Proposition C, approved by 71 percent of Missouri voters in 2010, marked the first time a state had successfully challenged Obamacare. Prop C was a rejection of the individual mandate of Obamacare that everyone must purchase health insurance or pay a fine, but the state law cannot trump federal law, so the provision — which was ruled constitutional by the U.S. Supreme Court — is still in effect. Analysts who consider the effects of repealing Obamacare point to the myriad parts of the law already in place and the Supreme Court’s endorsement — although narrow — as factors that make a complete repeal highly unlikely. Still, other delays have slowed implementation of the mandate for large employers and a new limit on out-of-pocket costs. A report last November by the partisan Congressional Research Service, an arm of Republican Sen. Tom Coburn’s senate office, said the Obama administration had missed as many as one-third of the deadlines established by the new health care law. And on Thursday, administration officials were quietly telling key interest groups to expect initial glitches signing up online for coverage. Sources told The Associated Press that small businesses will not be able to enroll online in the Small Business Health Options Program, or SHOP, starting Tuesday. Instead, business owners initially will have to mail or fax their information so that they can enroll. Kayser predicted that development back in June when he answered “yes and no” to a question about whether he thought the exchanges would begin enrollment on Oct. 1. “SHOP will happen, but not in the virtual marketplace,” he said in June. Also on Thursday, the Department of Health and Human Services told Hispanic groups that the Spanish-language version of its healthcare.gov website will be not be ready to handle enrollments for a few weeks. An estimated 10 million Latinos are eligible for coverage. In Boone County, from the halls of city and county government and hospitals and health clinics, to the businesses and coffee shops, there still seem to be more questions about Obamacare than answers. “The scariest part for me as a health care person is all the unknown factors that have not come to light yet,” said Kinkead, the Centralia pharmacist. “At this point, there’s so much misinformation out there. The last thing we want to do … is give the wrong information.”

new — that are worth becoming familiar with. Employer mandate: A federal requirement that companies with 50 or more workers pay a penalty to the government if one of its workers obtains taxpayer-subsidized coverage through the law. Delayed one year to Jan. 1, 2015. Intended to keep companies from “dumping” employees into public coverage. Employer-sponsored insurance: Insurance coverage purchased through the employer. Enrollment period: The dates when consumers or their dependents are allowed to enroll in an insurance plan. For the initial enrollment in Obamacare, the period starts Tuesday and ends March 31. Federal poverty level: A measure of income level issued annually by the U.S. Department of Health and Human Services. Federal poverty levels are used to determine eligibility for certain programs and benefits. Formulary: A list of drugs that a health plan will cover, either fully or in part. Formularies vary by health plan. Also called a preferred drug list (PDL). Individual mandate: A requirement that individuals buy health insurance or face fines. There are exemptions for financial hardship and religious objections. Marketplaces: Online health insurance markets in each state where consumers can get private health insurance, subsidized by the government. They used to be called “exchanges,” but the feds decided that was too confusing and started calling them “marketplaces.” Marketplaces can be accessed online through healthcare.gov. Small businesses will have their own marketplaces. Medical Loss Ratio (MLR): A requirement that helps make sure your monthly payments (premiums) go further in covering your health care. Health plans sold to individuals and small business employers must spend at least 80 cents of each premium dollar on health care and as much as 20 cents on administrative costs. Plans sold to large employers — generally more than 50 employees — must spend at least 85 cents of every premium dollar on health care and just 15 cents on administrative costs. Metal levels: The four levels of coverage available through exchange plans, called bronze, silver, gold and platinum. Bronze plans feature the lowest monthly premiums but cover only 60 percent of average costs. Platinum plans have higher premiums and cover 90 percent of expected costs. Navigators: People who will help you understand the new health coverage options, give you information on how to enroll and help you select a plan. Pre-existing condition: An ongoing or past health problem. Insurers now can use pre-existing conditions to deny or restrict coverage or charge more. Those practices will be barred by federal law starting Jan. 1, and insurers will have to accept all applicants. Premium tax credits: An amount that can be subtracted from the amount of income tax a person or business owes. Premium tax credits will be offered to some individuals and small businesses that purchase health coverage through Health Insurance Marketplaces to help pay for the cost of coverage. You can have the tax credit applied to your premium over the course of the year or wait until you file your taxes to claim the full amount. SHOP: Small Business Health Options Program, a new program designed to simplify the process of finding a health plan for a small business, generally those with 50 or fewer employees. SHOPs are competitive marketplaces where small employers can go to find health coverage from a selection of providers. The small business tax credit is available only through a SHOP. Tax credits: Government health insurance subsidies for individuals will come in the form of tax credits. The money will be paid directly to the consumer’s health plan to help cover premiums. The subsidies are on a sliding scale based on income. Each year, people will have to “true up” with the Internal Revenue Service to make sure they got the right amount. People who receive too generous a tax credit might owe money back to the government. Tax penalty: The fine levied on individuals who disregard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. Thereafter, it’s adjusted for inflation. Sources: Department of Health and Human Services, Blue Cross Blue Shield, The Associated Press, Kaiser Family Foundation, younginvincibles.org

A CLOSER LOOK | THE AFORDABLE CARE ACT TIMELINE

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resident Barack Obama on March 23, 2010, signed into law the Patient Protection and Affordable Care Act. The U.S. Supreme Court, in a 5-4 decision, upheld most aspects of the law in a ruling on June 28, 2012. To date, at least 71 major provisions of the law have been implemented, with 17 more to come from 2014-20. Here are some highlights:

2010-2012

씰Provides Provides a tax credit for small businesses for as much as 35 percent of their contribution to purchasing health insurance for their employees. Estimated at $40 billion over 10 years. 씰Provides Provides for increased federal taxpayer funding for community health centers totaling $11 billion over five years. 씰Obamacare Obamacare closes the Part D Medicare Coverage Gap, or “doughnut hole,” that forced seniors to pay out of pocket for drug costs. It also includes a 50 percent discount on brandname drugs. Seniors now get a rebate to cover the costs, and Obamacare closes the Medicare coverage gap for good in 2020. 씰Health Health insurance companies can’t drop your coverage when you are sick. 씰Children Children younger than 19 can’t be classified as having pre-existing conditions. 씰Children Children younger than 26 can stay on their parents’ insurance. 씰Creates Creates a high-risk pool for individuals with pre-existing conditions. These individuals can still get treatment but at higher rates. The highrisk pool disappears in 2017, at which point high-risk individuals will buy the same insurance as everyone else. 씰Rate Rate hike review is implemented. Insurers no longer can increase your premiums to increase profits. They must justify rate hikes of more

than 10 percent to the state and then display them on their website and a government website the same day. 씰The The 80/20 rule is implemented. Insurance companies now have to tell their customers how their money is being spent. If insurers don’t spend at least 80 percent of the premiums on health care, they have to give customers a rebate for the difference. To date, Americans have received $1.1 billion in rebates. 씰Increased Increased reimbursement to physicians, mostly in rural areas. 씰Employers Employers must list employee benefits on their tax forms. This helps to determine whether the company will get tax breaks or credits for insuring employees. 씰All All new plans must provide free preventive care. 씰Obamacare Obamacare establishes state consumer assistance programs to help consumers file complaints and appeals, and enroll in health care and other consumer-related assistance to better understand trouble spots that need oversight. 씰The The hospital “pay-for-quality” program begins. This is part of an overall effort to promote quality not quantity in the health care industry. A portion of Medicare payments is withheld from hospitals that don’t meet readmission criteria. 씰There There is a 3.8 percent tax increase on capital gains, unearned income, interest, dividends, annuities, rent, royalties and inactive businesses.

2013

씰Health Health Insurance Exchanges open. Those making more than 400 percent of the federal poverty level can shop on the exchange but will

not receive tax credits or discounts. The insurance purchased on the exchange doesn’t go into effect until Jan. 1, 2014. 씰Tax Tax credits, discounts on out-of-pocket costs, tax breaks and other subsides are available on the exchange. The assistance is directly related to gross adjusted income. 씰There There is a 0.9 percent Obamacare Medicare tax on those making more than $200,000 as an individual or $250,000 as a business or family. This applies to between 1.5 to 4.2 percent of taxpayers. 씰New New rules about the amount that can be contributed to a Flexible Spending Account. A cap of $2,500 is applied to reform FSAs and prevent individuals from overpaying and then needing to rush to use the money. 씰Part Part D coverage gap, or “doughnut hole” reduction, goes into effect. 씰Increases Increases from 7.5 to 10 percent the threshold at which medical expenses, as a percentage of income, can be deductible from federal taxes.

2014

씰Individuals Individuals can’t be denied coverage for preexisting conditions. 씰For For those who do not purchase health insurance, there is a tax starting at 1 percent of your income to a maximum $95 and increasing to 2.5 percent of your income or a maximum of $685 by 2016 for individuals. For a family, it’s capped at $285 in 2014 and rises to $2,085 by 2016. It cannot exceed these amounts. 씰Congress Congress must shop on the health insurance exchanges. 씰Many Many states expand their Medicaid programs to insure more low-income individuals, with the feds paying 100 percent of the expansion

cost for three years, then 90 percent of the additional cost after that. Missouri is among the states that opted out of Medicaid expansion. 씰Employers Employers will be able to shop on the health insurance exchanges for employee insurance.

2015

씰Doctors’ Doctors’ income is based on quality of care, not quantity of care. This provision, also known as “pay for performance,” replaces the current “fee-for-service” payment model.

2017

씰States States have the flexibility to allow businesses with more than 100 employees to purchase coverage in the SHOP (Small Business Health Options Program) exchange. 씰No No more exceptions for pre-existing conditions for anyone, including high-risk customers.

2018

씰All All health care plans — including plans held since before preventive care was required — must now offer preventive coverage. 씰The The “Cadillac” tax for higher-quality coverage for individuals and employers purchasing insurance for employees is put in place.

2020

씰Obamacare Obamacare fully eliminates the Medicare Gap instead of just offering rebates to seniors. Sources: Obamacarefacts.com; Kaiser Family Foundation; Center for Health Policy Studies Heritage Foundation Young Leaders Program; and the Department of Health and Human Services


6A www.columbiatribune.com COLUMBIA DAILY TRIBUNE Wednesday, October 2, 2013

DIAGNOSIS: CONFUSION A HEALTH CARE SYSTEM IN TRANSITION

■ Compared to its neighbors, Missouri has fewer insurance carriers to choose from, fewer qualified health plans to compare and higher premiums.

■ Coverage tiers range from bronze plans, which cover about 60 percent of medical costs, to platinum plans, which cover about 90 percent of costs.

■ Estimates indicate the average monthly premium for a middle-of-the road policy in Missouri is $334, slightly higher than the national average.

Missourians have limited options on the marketplace BY JACOB BARKER jbarker@columbiatribune.com | 815-1722 ow that the health insurance exchanges are open, all you have to do is shop. In Missouri, that might not take as long as it will in neighboring states. As the final outlines of Obamacare come into focus, there’s still a lot left to learn. But early indications from a U.S. Health and Human Services preview last week indicated Missouri, compared to its neighbors, has fewer insurance carriers to choose from and fewer qualified health plans to compare, as well as higher premiums. The bigger problem now might be accessing a workable website to actually compare the plans. The launch of the exchanges yesterday was dogged by glitches. Tribune reporters were unable to log on throughout the day. Regardless, the biggest provisions of the health care law signed by President Barack Obama three years ago are finally taking effect. Like any major policy overhaul, there are winners, losers and a learning curve. People with pre-existing medical conditions no longer can be barred from purchasing insurance. Women can’t be charged more for insurance than men. People who got by without insurance on a bet they wouldn’t get sick or hurt will have to purchase it or pay a fine starting next year. Some companies are shaking up how they provide benefits, pushing spouses or other dependents off company insurance plans. However, most Americans receive insurance through their employers, and for them, the change is expected to be minimal. “I don’t think we’re going to have a mass exodus of employers providing coverage if they were providing it before,” said Debra Mathes, an accountant and owner at MidMissouri accounting firm Williams Keepers. But there are big uncertainties surrounding Obamacare. One is whether it will do anything to tame the rising costs of medical care. Experts are skeptical, but they admit it does begin to move the system toward one that pays based on outcomes, not on the number of services rendered. Another question is whether the ranks of the uninsured will be able to afford the new requirement to purchase health insurance. People earning between 100 percent and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual) will qualify for government subsidies to help pay their monthly premiums. But that raises another question: How much will those subsidies eventually cost? In the first year, at least, the estimate is $16 billion, according to the Robert Wood Johnson Foundation. Individual subsidies will vary, and they are calculated for you when you sign up for health insurance on the individual exchange. “It’ll be paid directly to the insurance companies,” said Kit Wagar, a communications official at U.S. Health and Human Services, or HHS, who spoke at a Cover Missouri conference in late August. “So the consumer doesn’t even have to worry about it.” Despite the recent focus on the individual insurance exchanges, the law is designed to keep employer-sponsored insurance as the lynchpin of the American health care system. Starting in 2015, many employers will be required to offer insurance or pay a fine. But for many people, there’s a steep learning curve ahead. The biggest challenge will be learning how to navigate the new exchanges — once they start working.

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THE EXCHANGE The health insurance exchanges, unique to each state, are online marketplaces where consumers can shop for insurance

Danny Johnston/AP

Anne Lyon, left, talks yesterday with Brandi Hawkins about different types of health insurance at the University of Arkansas Clinton School in Little Rock, Ark. State officials yesterday marked the launch of Arkansas’ insurance exchange, set up under the federal health care law.

WHO ARE THE PROVIDERS? There are two confirmed insurance carriers that cover Mid-Missourians on the health insurance exchange. Aetna/Coventry will not participate in the small business health insurance exchange, or SHOP, in 2014, but it will offer eight insurance plans on the individual exchange. Anthem Blue Cross Blue Shield will include all of the health systems below in its SHOP network, but Boone Hospital Center and Lake Regional Health System will not be in its network on policies sold on the individual exchange. 씰University University of Missouri Health Care (University Hospital and Capital Region Medical Center in Jefferson City): Coventry and Anthem 씰Boone Boone Hospital Center: Coventry 씰SSM SSM Health Care (St. Mary’s Health Center in Jefferson City and Audrain Medical Center in Mexico): Coventry and Anthem 씰Moberly Moberly Regional Medical Center: Anthem. Coventry unknown. 씰Lake Lake Regional Health System: Coventry

plans and easily compare prices — a new level of transparency in at least one portion of the opaque health care services market. Answer a few questions about your age, where you live and lifestyle behaviors such as smoking, and you’ll be able to look at premiums (monthly payments for insurance) and deductibles (the out-of-pocket costs you pay before insurance kicks in) for health insurance plans offered in your state. To better help consumers compare plans, they are supposed to be divided into easily comparable coverage tiers: bronze, silver, gold and platinum. Those plans range from covering about 60 percent of medical costs in a bronze plan to as much as 90 percent in a platinum policy. In Missouri, relatively few insurers have signed up to sell policies on the exchange, which will primarily serve those who don’t get coverage through their employer. Only two have said they will sell plans, but that could change depending on how popular the exchanges become. “The biggest incentive is going to be the success of the program,” Gary Cohen, a deputy administrator and director for the Centers for Medicare and Medicaid Services, said in a conference call with reporters last week. “This is a marketplace. This is private commercial companies deciding whether they want to be a part of it or not.

Some have decided to sit back and see how it goes. Others have decided to jump in with both feet.”

THE PREMIUMS While technical problems on Missouri’s federally run health exchange made it difficult to compare plans, prices and provider networks yesterday, a report from HHS last week gave an early indication of what the state’s residents can expect. Insurers can still charge different rates depending on age, and in Missouri, the average monthly premium for a middleof-the road health policy — the secondlowest-costing silver plan — was expected to cost around $334, slightly higher than the national average. Comparing that price to existing premiums is difficult because health insurance plans offer different levels of coverage. Here’s a rough comparison: In 2011, the average monthly premium paid for employee coverage in Missouri was $400, according to a report released in April by the University of Minnesota and the Robert Wood Johnson Foundation. Employees typically paid only about 20 percent of that. But that average takes into account all plans while the HHS estimate is for a middle-of-the-road policy that covers 70 percent of health care costs. Data for average premiums that include those who buy on the individual market

are more difficult to find on a state-bystate basis. The National Conference of State Legislatures says no federal agency releases those figures on an annual basis. It cites a 2007 report from the Joint Economic Committee of Congress for recent state figures. That report says Missouri’s average annual premium in 2006 was $4,186, or about $349 a month. That number has no doubt risen, but even in 2006, it was still higher than the average estimate for a silver plan on the new insurance exchange. The estimates released by HHS tell only a portion of the story. While premiums might appear comparable, it’s still unknown how affordable the plans will be when taking into account deductibles and co-pays and the provider network of each plan. Some news reports suggest the lower-than-expected premiums are a result of smaller provider networks. Missouri seems to have higher premium costs than all of its neighbors except Arkansas. Average premiums for a silver benchmark plan in Illinois and Iowa are around $285. Kansas is at $260, and Oklahoma is at $266. All of those states have more insurers participating in the exchange. In Illinois, some regions have as many seven insurers and 80 plans to choose from. Kansas has only three insurers in some regions of the state and two in others, but even in the places with two insurers, consumers will have as many as 36 plans to choose from, according to a report released by HHS last week. Missouri, by contrast, has at most 23 plans to choose from (in the St. Louis area) and only two insurers expected to participate in each of the state’s 10 regions. “It’s just going to be really different state to state, even in regions of the state,” said Ryan Barker, vice president of health policy at the Missouri Foundation for Health.

THE PROVIDERS In Mid-Missouri, choices seem to be more limited and premiums higher than in many areas of the state. Residents in

Boone, Cole, Callaway and other MidMissouri counties can expect to choose from only 18 plans from two insurers initially, according to HHS. One of those insurers is Anthem Blue Cross Blue Shield. It will include many Mid-Missouri health systems on its network, including University of Missouri Health Care, Moberly Regional Medical Center, Audrain County Medical Center and St. Mary’s Health Center. It will not include Boone Hospital Center, operated by St. Louis-based BJC HealthCare, on its individual exchange plans, a spokeswoman confirmed. Nor will it include Lake Regional Medical Center in Osage Beach in its network for individual policies sold on the exchange. However, both health systems will be included in the small business marketplace, or SHOP. A spokeswoman for Aetna, which owns Coventry Health Care, said Coventry of Missouri will provide eight plans in the region: four bronze plans, two silver plans and two gold plans. Coventry’s network will include Boone Hospital Center as well as University of Missouri Health Care. In Mid-Missouri, a benchmark silver plan monthly premium for a 40-year-old would cost around $307 a month. In St. Louis, it would run about $263, and in Kansas City and Springfield it would be $238. There are fewer lives to cover in MidMissouri and fewer providers to negotiate with than in the state’s more populous areas, said Thomas McAuliffe, a heath policy analyst with the Missouri Foundation for Health. “They can’t bargain for the rates they can in the urban areas,” he said. More insurers that jump in as the exchanges mature might drive down health insurance rates. That might be the only way because it doesn’t look likely that new hospitals are going to start up in Columbia anytime soon. “If there’s fewer providers in a given area, then there’s less to negotiate on because you have to have that provider,” Barker said.

HOW THE ENROLLMENT PROCESS IS SUPPOSED TO WORK

STEP ONE: A person decides to enroll in health insurance through the marketplace. You can apply online, in person, by mail or by phone.

STEP TWO: Fill out application for insurance. The online form for a single person takes approximately 30 to 60 minutes to complete.

STEP THREE: Information is entered into the computer system to determine eligibility. This could be determined in real time or could take longer, depending on a number of factors.

STEP FOUR:

 ; :

UNDECIDED: Additional information is needed to determine eligibility. APPROVED: Applicant is eligible to use health care exchange system. DENIED: If not eligible, DENIED: the applicant applies for coverage under Medicaid.

STEP FIVE:

STEP SIX:

If determined eligible for a federal tax credit, the applicant can shop and compare available health care plans available on the exchange.

Enroll in a health care plan and potentially begin paying for premium. Full coverage under the plan would begin Jan. 1.


Wednesday, October 2, 2013 COLUMBIA DAILY TRIBUNE www.columbiatribune.com 7A

„ YESTERDAY: How does the

„ COMING TOMORROW: The Missouri General Assembly continues looking at Medicaid expansion. What are the prospects?

TODAY: How many newly insured people will there be, and does MidMissouri have enough providers to meet demand?

health insurance marketplace work, and what coverage options do Missourians have?

„ COMING SATURDAY: Even though the exchange for small businesses was delayed, business owners face tough choices.

Q&AHOW DO THE SUBSIDIES WORK If you make between 100 percent and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual), then you could qualify for subsidies from the federal government to help you pay for health insurance. The subsidies would be paid directly from the government to the insurance company. To qualify, you must purchase insurance on an exchange and not be offered insurance from your employer that is considered “affordable” (the coverage must not cost more than 9.5 percent of your income, and it must cover 60 percent of health benefits). Calculating your benefit is a little tricky, but it’s best to think of it as the difference between a mid-level health plan and a percentage of your income that you will be responsible for paying for health insurance premiums.

INCOME COMPARED TO THE 2013 FEDERAL POVERTY LEVEL FAMILY SIZE:

100% of FPL

YEARLY: 400% of FPL

MONTHLY:

HOURLY:

100% of FPL

400% of FPL

100% of FPL

400% of FPL

1

$11,490

$45,960

$958

$3,832

$5.52

$22.10

2

$15,510

$62,040

$1,293

$5,172

$7.46

$29.83

3

$19,530

$78,120

$1,628

$6,510

$9.39

$37.56

4

$23,550

$94,200

$1,963

$7,850

$11.32

$45.29

5

$27,570

$110,280

$2,298

$9,190

$13.25

$53.02

6

$31,590

$126,360

$2,633

$10,530

$15.19

$60.75

WHO QUALIFIES FOR A SUBSIDY AND HOW MUCH? Income level as percentage of federal poverty level

Premium costs as a percentage of income

Less than 133 percent of poverty level

2 percent of income

At least 133 percent but less than 150 percent

3 to 4 percent of income

At least 150 percent but less than 200 percent

4 to 6.3 percent of income

At least 200 percent but less than 250 percent

6.3 to 8.05 percent of income

At least 250 percent but less than 300 percent

8.05 to 9.5 percent of income

At least 300 percent but less than 400 percent

9.5 percent of income

EXAMPLE 1: A SINGLE 24-YEAR-OLD WITH NO DEPENDENTS EARNING $28,725 A YEAR

EXAMPLE 2: A FAMILY OF FOUR EARNING $50,000 A YEAR

You are a single person, age 27, with no dependents who makes $28,725, (two times the poverty rate for a family of one). 1. Take 6.3 percent of your income, or $151 per month. 2. The federal government calculates your subsidy against a middle-of-the-road plan, or the second-lowest-costing “silver” plan, which covers at least 70 percent of health costs. In Mid-Missouri, the second-lowest costing silver plan is estimated to cost about $252 per month for a 27-year-old. 3. Subtract $151 from $252. Your subsidy is $101 per month and will be sent directly from the government to the insurer. 4. You can purchase that silver plan for $151 a month, or you can apply that $101 subsidy to another plan, such as a lower-premium bronze plan that will only cover about 60 percent of your health costs or a higherpremium gold plan that will cover 80 percent. 5. The lowest-costing bronze plan in MidMissouri runs about $195 for a 27-year-old, so you could buy that for $94 a month. A gold plan would cost $298 without the subsidy, but at your income, you could buy it for $197 a month.

Your household (a 40-year-old, a 38-year-old and two kids younger than 18) makes $50,000 a year, or just more than twice the poverty rate. 1. A benchmark silver health plan costs $798 a month in Missouri. 2. Take 6.8 percent of income, or $282 a month. 3. Your credit would be $516 per month, the difference between the second-lowest-costing silver plan and 6.8 percent of your income. 4. The average lowest-costing bronze plan in Missouri would run $588. If you used your tax credit, you could buy it for $72 per month.

State opposition set roadblocks to health insurance exchange BY JACOB BARKER jbarker@columbiatribune.com | 815-1722 Obamacare has arrived in the Show-Me-State — despite the best efforts of many of its residents. Some provisions have already started, such as allowing young people to stay on their parents’ insurance until they’re 26. Others the state rejected, such as expanding Medicaid to cover people with incomes of as much as 138 percent of the federal poverty level. But the law’s centerpiece, the establishment of online health insurance marketplaces where consumers can shop and compare insurance policies, officially opened yesterday. Missouri is one of 36 states where the federal government will have a role operating the insurance exchange. Unlike some states that partnered with the federal government, Missouri was one of the states that ceded all control to the feds. It also put up roadblocks to the law’s implementation, including a voter-approved measure that barred state officials from any involvement in getting the exchange up and running. As a result, spreading the word about Missouri’s exchange has been put in the hands of private groups. While other states distribute swag such as sunscreen that says “get covered” to promote their exchanges, Missouri’s government has stayed silent. “The Department of Insurance is not promoting the exchanges in

FYI

Missouri agencies, their h i employees and officials are exposed to potential litigation if they assist, cooperate or provide any resources to any department, agency or employee of the federal government related to a federal exchange or a federally facilitated exchange.” — BRIDGET KEVIN-MYERS, MU assistant research professor

any way, shape or form,” said Bridget Kevin-Myers, an assistant research professor and senior legal analyst in the University of Missouri’s Institute of Public Policy. In January, Kevin-Myers authored a legal brief on Proposition E, which was passed by the Republican-controlled General Assembly and approved by Missouri voters in November with 62 percent of the vote. “Missouri agencies, their employees and officials are exposed to potential litigation if they assist, cooperate or provide any resources to any department,

agency or employee of the federal government related to a federal exchange or a federally facilitated exchange,” she wrote. Missouri regulates insurance within its boundaries, and the law could keep the Department of Insurance from approving new insurance plans to be sold on the exchange out of fear they will be sued, Kevin-Myers argues. That likely means the carriers participating will be those already operating in the state. Getting the word out has fallen to private groups. The main one, Cover Missouri, is a coalition of community and health care provider groups put together by the Missouri Foundation for Health. It became clear earlier this year that the foundation would have to step up and take the lead to let Missourians know what resources and financial aid was available, who qualifies for insurance on the exchange and how to access it, said Ryan Barker, the foundation’s vice president for health policy. But the Missouri Foundation for Health doesn’t have the clout state government does, and it has relied more on a grass-roots campaign to raise awareness of the changes Obamacare is bringing to Missouri. “Even, like, Kansas, the insurance commissioner — the Republican insurance commissioner — she’s been out there” promoting the Kansas exchange, he said. “A lot of people go to government for information. None of that’s available in Missouri.”

Early indications show that Missouri will have fewer insurance carriers than many states selling insurance on the exchange — just two in most areas of the state. Many of Missouri’s neighbors have more insurers offering plans, and on average, they’re cheaper. Has the lack of outreach and legal questions about the ability of Missouri’s insurance regulators to approve new plans discouraged some insurers from selling on the exchange? It’s hard to tell. “If we didn’t have Prop E, would we have seen more” insurance carriers? “I don’t know,” Barker said. Proposition E could be playing a part in the small number of insurance carriers interested in Missouri. But, more likely, it is the health of Missouri’s residents, Kevin-Myers said. Missouri has some of the highest smoking and obesity rates in the country. “It could be” Proposition E, she said. “It could also be more so the health status. Colorado has a lot. They have 11 carriers, but it’s also one of the healthier states.” There have been no lawsuits — that she knows of — filed using Proposition E, Kevin-Myers said. In any case, federal law trumps state law, and any lawsuits likely would be decided in favor of state officials following federal law. Still, it would cost Missouri time and money defending against them. “Missourians may be required to fund futile litigation to defend a statue that is likely to be struck down,” she wrote in her brief.

WHAT DOES THAT MEAN?

Obamacare has many terms — some old, some new — that are worth becoming familiar with. Premium tax credits: An amount that can be subtracted from the amount of income tax a person or business owes. Premium tax credits will be offered to some individuals and small businesses that purchase health coverage through Health Insurance Marketplaces to help pay for the cost of coverage. You can have the tax credit applied to your premium over the course of the year or wait until you file your taxes to claim the full amount. SHOP: Small Business Health Options

Program, a new program designed to simplify the process of finding a health plan for a small business, generally those with 50 or fewer employees. SHOPs are competitive marketplaces where small employers can go to find health coverage from a selection of providers. The small business tax credit is available only through a SHOP. Tax credits: Government health insurance subsidies for individuals will come in the form of tax credits. The money will be paid directly to the consumer’s health plan to help cover premiums. The subsidies are on a sliding scale based on income. Each year, people will have to “true up” with the Internal Revenue

Service to make sure they got the right amount. People who receive too generous a tax credit might owe money back to the government. Tax penalty: The fine levied on individuals who disregard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. Thereafter, it’s adjusted for inflation. Sources: Department of Health and Human Services, Blue Cross Blue Shield, The Associated Press, Kaiser Family Foundation, younginvincibles.org

Ryan Henriksen/Tribune

Vanessa Hall does not pay for health insurance because of the cost. She has found out that she does not qualify for subsidies under Obamacare, but she’s a fan of the program anyway and sees it as a good “first step” toward a singlepayer system.

Grandmother sees law as step on way to further reforms BY JACOB BARKER jbarker@columbiatribune.com | 815-1722 For the past 20 years, Vanessa Hall has been without health insurance. It was a financial decision, and a good one, she said, to stop paying for a plan that cost a lot and provided little in the way of coverage. It hasn’t stopped her going to the doctor. She regularly gets preventative exams and buys generic prescriptions out of pocket. “It’s reasonable,” she said. “It’s not much more than a co-pay in all reality.” She pays with cash, and doctors give her a steep discount. Because the money is upfront, they don’t have to go through insurance company middlemen that are a mainstay of the American health care system and will be even further embedded by Obamacare. “That discount tells you how much overhead and profit is involved,” Hall said. It has been affordable, Hall said. But she worries that soon, it won’t be. In her home off Route WW, just over the line into Callaway County, she stands in her kitchen with the help of a cane. Several years ago, she hurt her back when a swivel chair “swiveled one way and I swiveled another.” Sliding down the stairs with her grandson on her lap — a game they called “bump bump” — probably didn’t help, either. “I miss sitting on the floor because I can’t do that anymore,” Hall said. “And it’s very hard to work in the garden. But I’m so much better off than most people.” She has managed to pay for services to manage pain out-ofpocket. But she knows if it keeps getting worse, she won’t be able to afford a major service such as an operation. And she also knows that Obamacare requires her to purchase insurance starting Jan. 1. If she doesn’t, she’ll pay a fine of at least $95 the first year; the penalty quickly rises to at least $695 by 2016. Hall’s husband works. He has a good job, and they live comfortably with their 12-year-old grandson, Matthew. When Matthew came into their care 12 years ago, Hall stopped substitute-teaching to raise him. They had enough to live as a one-income household. Hall’s husband’s job provides insurance for him and Matthew. It’s pretty good insurance and affordable for them, Hall said. But if she wanted to be included on the policy, it wouldn’t be. She

VANESSA HALL AGE: 57 OCCUPATION: None. Hall stays at home to raise her 12-year-old grandson CURRENT INSURANCE SITUATION: Uninsured; husband is covered under a policy offered by employer HOW WOULD AFFORDABLE CARE ACT AFFECT HER: It doesn’t. Obamacare provides subsidies to purchase insurance on the exchange if a family isn’t offered “affordable” care. Insurance her husband can purchase qualifies as affordable, meaning she won’t get any help from Obamacare.

estimated premiums for coverage that included her would cost close to 20 percent of the household’s income. Obamacare provided Hall with the prospect of help. The law offers subsidies to help families making as much as 400 percent of poverty buy health insurance. A family of three making less than $78,000 a year would be eligible for help. Hall said her family would qualify. But Obamacare only provides subsidies to purchase insurance on the exchange if a family isn’t offered “affordable” coverage from an employer. “Affordable” is defined as less than 9.5 percent of family income. But that calculation is based on what it costs a single employee to buy coverage, not what it would cost a family to purchase insurance. The insurance her husband can purchase would qualify as affordable, meaning she won’t get any help from the new law. Hall knows she could go hunt for a job, but she doubts she would find a very good one after being out of the workforce for more than a decade and nearing 60 years of age. With her back problems, she could probably qualify for disability, but she doesn’t want to draw taxpayer funds her family can afford to live without. After all, she is only eight years away from Medicare eligibility. Personally, Hall is a supporter of health care reform, even though she found out it won’t help her to afford insurance. The best answer Hall sees is singlepayer, and she hopes Obamacare eventually leads to more reform of the health care system. “I’m for this because it’s a step forward,” Hall said, “but it’s a first step.”

| WHOM TO CONTACT

Information from the federal government about Missouri’s marketplace can be found at www.healthcare.gov or by calling 800-318-2596. Primaris Health Business Solutions: For individual counseling in Mid-Missouri, call 573-817-8300 or log on to www.primaris.org/counseling. Program director: Jeremy Milarsky Central Missouri Community Action’s health care/Obamacare hotline: 855-612-2259 Family Health Center of Boone County, 1001 W. Worley St., Aaron Swaney, 877-677-4342 Central Missouri Area Agency on Aging, 1121 Business Loop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.net Also: www.ma4web.org/health-insurance-marketplacemissouri/local-resources


6A www.columbiatribune.com COLUMBIA DAILY TRIBUNE Thursday, October 3, 2013

DIAGNOSIS: CONFUSION A HEALTH CARE SYSTEM IN TRANSITION

LOOKING TO THE WEST | IMPLEMENTATION IN KANSAS

■ Various agencies in Columbia are training specialists to help people shop and compare insurance policies, and they reported some inquiries about the new health insurance marketplace.

■ Although many of the peo help the uninsured compare on the exchange were ready site used to enroll people wa

Are we read Technical problems block access to health insurance marketplace. John Hanna/AP

Kansas Insurance Commissioner Sandy Praeger answers questions from audience members Sept. 17 after a town hall meeting on the federal health care overhaul at the University of Kansas satellite campus in Overland Park, Kan.

Tim Goessman/The Hutchinson News, AP

Rogena Johnson, left, chief medical officer at PrairieStar Health Center in Hutchinson, Kan., answers questions for Jennifer Garcia after an examination at the center Sept. 25. PrairieStar will have certified application counselors to help people who need assistance in applying for health care on the marketplace.

Kansas officials urge patience as glitches abound WICHITA, Kan. (AP) — The online insurance marketplace for Kansas could not fully handle the crush of consumers who hit the federally run exchange when enrollment opened Tuesday, but the technological glitches were expected as not only the website but the program itself tried to keep up with demand. On the first day of the sixmonth open enrollment period, advocates in Kansas were struggling to implement their own portion of the nation’s biggest health care coverage expansion in 50 years. The latest U.S. Census bureau estimates are that about 358,000 Kansans have no health insurance. The Kansas Association for the Medically Underserved, the lead agency for the rollout in Kansas, said it had 60 health care navigators or certified application counselors — the program’s front-line guides for the new system — across the state ready to work on the first day of enrollment. Another 200 to 225 more were still undergoing training to work, said KAMU spokeswoman Katrina McGivern. Six of those were bilingual in Spanish, and one person knew sign language. At GraceMed Health Clinic in Wichita, a steady stream of people showed up for one-on-one sessions with Juven Nava, one of the clinic’s two navigators. The clinic has a grant that will allow it to hire two more navigators. By mid-day Tuesday, Nava had seen eight people at the clinic and taken about a dozen calls from people seeking to enroll in the state’s exchange. But Nava has been unable to sign up a single person for insurance coverage. Sometimes he can’t even log into the website to sign them up; sometimes the online exchange kicks him off. “We tell them that with everything there is going to be some glitches,” he said. “There is always going to be some bumps, but it is going to get better.” GraceMed’s chief executive, Dave Sandford, said that when he tried to get access to the site, he got a message to wait because of the high volume, but after waiting 10 minutes, he was kicked off. He does not think anything could have been done to handle the significant volume of calls the site was going to get on Day One. “There are probably a lot of folks like me, who already have health insurance, that are

just trying to log on to see how it works,” Sandford said. “I am probably compounding the problem.” At the Shawnee County Health Agency in Topeka, enrollment coordinator Paige Ashley said she, too, couldn’t obtain the online login she needed to purchase coverage on the site. She was advising people who were calling her to set up appointments to wait until at least next week. Consumers won’t start incurring tax penalties for not having coverage until after March 31 of next year and have until Dec. 15 if they want their coverage to start in January. U.S. Rep. Tim Huelskamp, a Republican who has been a vocal critic of the health care overhaul, said he tried unsuccessfully 20 times to get into the exchange. Huelskamp, who represents the sprawling and GOP-leaning First District of western and central Kansas, said he has been unable to even create the account that would allow him to purchase insurance. Members of Congress are required by the Affordable Care Act to use the exchange. The federal government is running Kansas’ exchange because Republican Gov. Sam Brownback and the GOP leaders of the Legislature have resisted implementing the Affordable Care Act since its passage three years ago. They have argued that it represents a costly expansion of government. Manuela Oroteza, a 48-yearold cook at Wichita State University, said she was eager to see if she could afford health care through the new exchange. Her family lives off her $10-per-hour salary and can’t afford the coverage the school offers its employees. “The thing is, I don’t make that much money, and then between taxes and the insurance, my paycheck will not be enough to cover my expenses,” she said. As has been the case in many other Republican-led states, Brownback and Kansas’ Republican legislative leaders have left it to the federal government to set up the Kansas exchange. In 2011, Brownback refused a $31.5 million federal grant that would have gone toward setting up the infrastructure for Kansas’ exchange. It also would have funded a $10 million public education campaign Insurance Commissioner Sandy Praeger had planned.

BY JACOB BARKER jbarker@columbiatribune.com | 815-1722 any of the people who are supposed to help the uninsured compare health coverage options on the exchange are ready to go. The exchange, however, isn’t. Technical problems with the new health insurance marketplaces persisted into this morning. Tribune reporters were unable to create an account and log on to healthcare.gov, which is necessary to view plan options and costs. Various agencies around Columbia are training specialists to help people shop and compare insurance policies, and they reported some inquiries about the new exchanges. One agency said calls from reporters outnumbered those from people seeking information about health insurance. But for those who did call inquiring about new options from the Affordable Care Act, the Central Missouri Area Agency on Aging is having them wait until next week to meet with one of their enrollment specialists. The agency’s parent group, the Missouri Association of Area Agencies on Aging, was awarded a $750,000 grant in August to train enrollment specialists — dubbed navigators — and organize outreach events. “We learned from Medicare Part D you don’t want to be the first one out there,” Jean Leonatti, CEO of the Central Missouri agency, said yesterday. About 10 people called, a few sent emails and three walked into the Family Health Center of Boone County on Tuesday seeking information and help with the new insurance exchange, said Aaron Swaney, an outreach and enrollment specialist at the health center. But because the site wasn’t working, there wasn’t much he and his staff could do except tell people they would contact them when the system was working. “We’re just taking down people’s contact information,” he said yesterday morning. ■ At Primaris, a Columbia health consulting not-forprofit, more than 70 navigators began the required training for the job, and 27 are already through the process, said Jeremy Milarsky, the navigator program manager. Primaris is coordinating a statewide navigator program with 10 other partner agencies with the help of a $1 million federal grant. The few navigators who are already working in Columbia have had steady inquiries about the exchange, Milarsky said. “I think people are still trying to feel out the system,” he said. “We’re not getting inundated with calls. There’s a steady stream of them.” People were mostly patient despite the technical issues, and he did have a breakthrough: “As of” yesterday

M

Monica Craig, insurance counselor, works yesterday at Primaris, a Columbia hea train counselors to help people enroll in health insurance through the new mar steady stream of inquiries about the exchange.

BY THE NUMBERS | UNINSURED IN BOONE COUNTY

17,859 4,001 The number of uninsured people in Boone County in 2012, according to the U.S. Census Bureau’s American Community Survey.

The number of uninsured people who will not qualify for premium subsidies (those below the poverty line)

“afternoon, I was actually able to get an account created for one of my clients,” Milarsky said. Even before the official launch of the health insurance

exchanges, a centerpiece o signed into law three years ag cups were likely.

Woman doesn’t qualify for s BY JACOB BARKER jbarker@columbiatribune.com | 815-1722 Outside the Family Health Center of Boone County on Worley Street, Kelly Camp was walking out after having her hand examined for what she thinks might be carpal tunnel. Her other hand was full of informational pamphlets on the new health insurance marketplaces created by Obamacare. “I may look into it and speak with someone,” she said. But Camp, like many Missourians, might be out of luck. The 51-year-old was laid off from 3M last month, and even though she doesn’t have any income right now, she was already told she wouldn’t qualify for Missouri’s Medicaid program. Missouri’s current Medicaid system doesn’t offer coverage for low-income adults without dependent children. Despite an offer from the federal government to pay the full cost for three years, Missouri legislators declined to expand Medicaid to cover people earning as much as 138 percent of the federal poverty level, or $15,862 for a household of one.

KELLY CAMP AGE: 51 OCCUPATION: Unemployed. Camp was laid off from 3M last month. CURRENT INSURANCE SITUATION: No insurance. Camp does not qualify for Missouri’s current Medicaid system. HOW WOULD AFFORDABLE CARE ACT AFFECT HER: Without a source of income, Camp does not qualify for subsidies to purchase health care on the exchange. In addition, Missouri’s current Medicaid system doesn’t offer coverage for low-income adults without dependent children, such as Camp.

Obamacare was designed to provide insurance for low-income people via Medicaid while helping those with more moderate incomes purchase private health insurance on the online exchange with federal subsidies. A Supreme Court ruling last year upheld the law but said the federal government couldn’t force states to expand Medicaid. As a result, many

states led by Republicans opposed to Obamacare didn’t expand it, leaving a big hole in the near-universal insurance coverage the law envisioned. To qualify for subsidies to help purchase insurance on the exchange, you have to make more than the federal poverty level. There are approximately 245,000 uninsured Missourians below the poverty line, according to the U.S. Census Bureau’s 2012 American Community Survey released last month. In Boone County, about 4,000 people make less than the federal poverty rate and have no health insurance. They have little hope of getting insurance unless they find a higher-paying job or the General Assembly expands Medicaid. When they seek help from one of the various agencies aiding those looking to buy insurance, there’s little to be found. “It’s an unfortunate message of, ‘There’s not much we can do,’ ” said Ryan Barker, vice president of health policy for the Missouri Foundation for Health. Camp, though, has more pressing worries

Q&A WHO CHOOSES YOUR DOCTOR? FYI Q: I’VE HEARD THAT THE FEDERAL GOVERNMENT WILL CHOOSE THE DOCTORS FOR PEOPLE WHO PURCHASE HEALTH INSURANCE THROUGH THE ONLINE MARKETPLACE. IS THAT TRUE?

A: First of all, the marketplace features health insurance plans offered by a variety of private insurance companies. It is not government-run health insurance, though the government sets the standards the plans must meet. Whether you have the same doctor as you have now depends on which plan you purchase and which plans your doctor participates in. The marketplaces, or exchanges, could include plans that re-

duce the number of doctors or hospitals covered in certain networks. The American Medical Association suggests that people check out plans on the exchanges before buying to make sure their preferred docs are included. Navigators and enrollment counselors, as well as insurance agents and brokers, are trained to help you avoid that possibility and to help you maintain continuity of care.

WHAT DO

Obamacare has many terms — som some new — that are worth becom with. Premium tax credits: An amount t be subtracted from the amount of tax a person or business owes. Pre credits will be offered to some ind small businesses that purchase he age through Health Insurance Mar to help pay for the cost of coverag have the tax credit applied to your you over the course of the year or wait file your taxes to claim the full amo Tax credits: Government health in subsidies for individuals will come of tax credits. The money will be p to the consumer’s health plan to h


Thursday, October 3, 2013 COLUMBIA DAILY TRIBUNE www.columbiatribune.com 7A

„ YESTERDAY: How does the health insurance marketplace work, and what coverage options do Missourians have?

„ TODAY: How many newly insured people will there be, and does MidMissouri have enough providers to meet demand?

„ COMING TOMORROW: The Missouri General Assembly continues looking at Medicaid expansion. What are the prospects?

■ Some officials are urging people to wait before trying to sign up for insurance on the marketplace. “You have until Dec. 15 to purchase insurance to begin on Jan. 1,” one said. “Why not wait until Nov. 1?”

ople who are supposed to e health coverage options y to go Tuesday, the webas not.

„ COMING SATURDAY: Even though the exchange for small businesses was delayed, business owners face tough choices.

LOOKING TO THE EAST | IMPLEMENTATION IN ILLINOIS

dy for this?

Ryan Henriksen/Tribune

alth consulting not-for-profit that received a federal grant of $1 million to ketplace. The navigators who are already working in Columbia have had a

12,431 5,579 Uninsured people between 100 percent and 400 percent of poverty, potentially qualifying for subsidies to purchase insurance on the exchange

of the Affordable Care Act go, officials warned that hic-

Boone County residents earn less than 138 percent of poverty and are uninsured. (These people would have qualified for Medicaid expansion, excluding most students who likely still have coverage from their parents)

“We anticipate that our experience will mirror that of other large-scale implementation efforts,” Julie Bataille, director of communications at the Centers for Medicare

and Medicaid Services, said in a conference call with reporters last week. It might be best to wait a month or so before trying to sign up for insurance, said Thomas McAuliffe, a policy analyst at the Missouri Foundation for Health. Not only will that give time for the federal government to fix glitches in the exchange system, but it will give the navigators time to get better at their jobs. “You have until Dec. 15 to purchase insurance to begin on Jan. 1,” he said. “Why not wait until Nov. 1?” ■ There are a lot of Missourians who will have to purchase insurance or pay a fine starting next year. Of the roughly 850,000 uninsured Missourians, about 245,000 are below the poverty line and will not be required to purchase insurance. They also won’t qualify for subsidies to help them purchase health insurance on the exchanges because the law envisioned all states expanding Medicaid. Missouri did not. Most of the uninsured making more than the poverty level will qualify for subsidies to help them buy coverage on the exchange. Anyone who isn’t offered affordable insurance from an employer and makes between 100 percent and 400 percent of the poverty level, or $19,530 to $78,120 for a family of three, would qualify for subsidies. Of the roughly 18,000 people without health insurance in Boone County, about 12,000 could qualify for subsidies, according to U.S. Census data. Whether the new exchanges will lead to a crush of new patients at doctors’ offices is unknown, but many think it will be more of a trickle. The largest portion of uninsured Missourians are young, and they tend to be healthier. “More importantly, it’s going to be getting those patients enrolled,” said University Physicians Executive Director Scott Hofferber. The physicians group estimates it could see as many as 7,000 new patients because of insurance expansion, Hofferber said. He thinks it will be gradual, and at any rate, University Physicians has beefed up its staff, especially primary care doctors, just in case. “We’ve added primary care over the last couple of years, so I think we’re ready for that,” he said. ■ Until the feds fix the exchange website, the uninsured will almost surely obtain coverage in a trickle. Those frustrated by the system could give up. But even before the problems were evident, Gary Cohen, a deputy administrator at the Centers for Medicare and Medicaid Services, told reporters on a conference call that initial problems aren’t a good indicator of The total number of uninsured from surpopularity. rounding counties, accord“What Mid-Missouri I like to remind people of is what happened ing to U.S. Census Small Area Health when we introduced Medicare Part D,” he said. “There Insurance Estimates were really significant problems in the early days and weeks and months.” Today, it’s not remembered as “the program that had all the problems,” he said. Seniors like it. The new exchanges, like any software or system, can be updated and improved over time. “Any big IT project, there are always going to be things you can improve on and make better,” Cohen said.

subsidies than getting health insurance. Her biggest problem now is getting unemployment insurance to kick in while she looks for work. Camp drove trucks for more than 10 years, and she has been unemployed before. She knows it sometimes takes a few weeks before unemployment checks start coming. She was laid off in 2008 when Dana Corp.’s Columbia factory cut more than 100 jobs as its customers — Detroit automakers — faltered that year. She struggled to find a job after that, even being told that she was overqualified when she applied at Watlow Electric’s local factory. “They told me I’m overqualified even though I’ve been in a distribution warehouse for years,” she said. Camp worked at 3M for a little more than a year, she said, but even then, she couldn’t afford the health insurance the company offered. She lived paycheck to paycheck, and she needs to find her next one quick. “I don’t have four to six weeks to wait,” she said. “The rent man ain’t gonna wait. Boone Electric isn’t gonna wait. And neither is Ameren UE.”

Don Shrubshell/Tribune

Kelly Camp, 51, was in the Boone County Family Health Center yesterday to receive treatment. While there, she got information about the new health insurance marketplace. Camp, who recently was laid off, doesn’t qualify for Medicaid, and she makes too little to qualify for federal subsidies on the health insurance exchange.

OES THAT MEAN?

me old, ming familiar

that can f income emium tax dividuals and ealth coverrketplaces ge. You can r premium t until you ount. nsurance surance e in the form paid directly help cover

premiums. The subsidies are on a sliding scale based on income. Each year, people will have to “true up” with the Internal Revenue Service to make sure they got the right amount. People who receive too generous a tax credit might owe money back to the government. Tax penalty: The fine levied on individuals who disregard the individual insurance mandate. It starts small and gets bigger in subsequent years. In 2014, it’s $95 or 1 percent of taxable income. By 2016, it’s $695 or 2.5 percent of taxable income, whichever is greater. Thereafter, it’s adjusted for inflation. Sources: Department of Health and Human Services, Blue Cross Blue Shield, The Associated Press, Kaiser Family Foundation, younginvincibles.org

| WHOM TO CONTACT

Information from the federal government about Missouri’s marketplace can be found at www.healthcare.gov or by calling 800-318-2596. Primaris Health Business Solutions: For individual counseling in Mid-Missouri, call 573-817-8300 or log on to www.primaris.org/counseling. Program director: Jeremy Milarsky Central Missouri Community Action’s health care/Obamacare hotline: 855-612-2259 Family Health Center of Boone County, 1001 W. Worley St., Aaron Swaney, 877-677-4342 Central Missouri Area Agency on Aging, 1121 Business Loop 70 E., Jean Leonatti, 800-369-5211, www.cmaaa.net Also: www.ma4web.org/health-insurance-marketplacemissouri/local-resources

John Dixon/AP

Awais Vaid, right, helps Mandy Wyatt sign up for health insurance Tuesday through the Affordable Care Act at the Champaign Urbana Public Health District in Champaign, Ill.

David Mercer/AP

Patrick Lamanske works Tuesday with Amanda Ziemnisky, right, to try to get health coverage for his wife, Ping, left, at the Champaign Urbana Public Health District office.

Thousands visit Illinois exchange on the first day CHICAGO (AP) — More than 71,000 people visited Illinois’ new health insurance marketplace by late Tuesday, the first opportunity to comparison shop for coverage through a system that’s a key piece of President Barack Obama’s signature health care law. But people hoping to enroll weren’t getting much further, as the federally run website experienced glitches and delays. At a health center on Chicago’s west side, workers said their goal for the day was to get just one person enrolled, but none of the people who came in was able to do so. The same was true at the Champaign Urbana Public Health District office in Champaign. Deborah Mitchell, 57, waited about an hour at Chicago’s West Side Health Authority before giving up and making an appointment for next week. Mitchell and her 62-year-old husband have insurance but wanted to see if she could get a better rate. She also wanted to try so she can report back to the congregation at the church where her husband is a pastor. Mitchell took the delay in stride. “It’s the first day,” she said. “I’m looking for the whole week to be kind of jammed.” Gyung Min Choi, 33, and his wife, 32-year-old Minyoun Ham, were trying to find coverage for her at the Champaign Urbana health district. She’s about five weeks pregnant, he said, and has no health care coverage, so she hasn’t yet seen a doctor. “We want to get some coverage for the baby’s” birth, said Choi, a materials science student at the University of Illinois from South Korea. He explained that their only other option would be private insurance, something he probably would struggle to afford on his $24,000-a-year income. They hadn’t been able to enroll, though, after about a halfhour of trying. Gov. Pat Quinn said the problems with the website were understandable given the magnitude of the program. “We understand with any new program there will be glitches and bumps along the way,” he said at a news conference. “That’s what happens with any endeavor.” The Chicago Democrat called it a “historic” day that will change the lives of hundreds of thousands of Illinois residents by helping them get health insurance. An estimated 1.8 million people in Illinois don’t have coverage; officials hope at least 300,000 of them will enroll through the marketplace by March 31. Illinois residents wanting to shop for coverage start by visiting

a new website, Get Covered Illinois, where they can determine if they’re eligible for Medicaid or to buy insurance on the marketplace. Consumers who don’t qualify for Medicaid based on income are directed to the marketplace, where they also can find out if they’re eligible for federal tax subsidies. The site is run by the federal government because Illinois lawmakers did not vote to have the state create its own system. The state couldn’t say Tuesday how many people were able to enroll. But officials said about 2,200 people were directed to the Medicaid site and submitted applications. Illinois also opened a call center where staff fielded questions from more than 350 callers Tuesday, which also marked the launch of a $33 million advertising campaign to inform residents about Get Covered Illinois. Still, officials were expecting a slow rollout. Although the law requires almost everyone to have health insurance, consumers have until the end of March to do so and avoid penalties for 2014. People who want their coverage to begin Jan. 1 must enroll by Dec. 15. Patrick Lamanske and his wife, Ping Lamanske, 59, came to the Champaign Urbana Public Health District office to sign up for coverage for her. But after almost two hours of sitting in front of a laptop with a staff member, they hadn’t managed to get through the federal website. Patrick Lamanske, who is 66 and retired, said he has coverage through Medicare, but his wife does not. “It’ll help me sleep better, knowing my wife’s got some kind of coverage,” the Champaign resident said as he waited at one of the half-dozen laptops set up in the office. She’s healthy, he said, but “you never know — you break a leg, you sprain an ankle.” Julie Pryde, health district administrator, said she was “very frustrated” that people weren’t able to sign up. But she said people were being really patient. Pryde said her office had been doing outreach to younger employees of small businesses, people with pre-existing conditions and others, including to a local halfway house where she found middle-age men who had never had access to health care other than when they were in prison. Tuesday’s launch came the same day as shutdown of the federal government led by congressional Republicans who want to block the health care law. However, the shutdown had no immediate effect on the marketplaces.


Diagnosis Confusion