The Ultimate Guide to Obamacare

The voting and posturing and Supreme Court validation are all over and done with, and Obamacare is the law of the land. So, what does that mean for you and your family? We turned to dozens of local experts—doctors, nurses, hospital administrators, public-health advocates, insurers—and asked them to help us explain it all to you.

Philadelphia magazine's Ultimate Guide to Obamacare (aka the Affordable Care Act)
Question 12: Guide to Obamacare

Why’d I get a check from my insurer last year—not that I’m complaining?
Lucky you! You’re one of more than 575,000 Pennsylvanians who got insurance rebates in 2012, totaling more than $51 million in recouped cash. The ACA requires that insurers spend at least 80 cents of every premium dollar on actual subscriber benefits and no more than 20 cents for administrative costs in individual and small-group plans. For large employer-based health plans, the ratio is higher: at least 85 cents on benefits. If your insurance company falls below those benefits levels, you’re entitled to a rebate. “This isn’t about faulty bookkeeping,” says Scott Post, lead health-care-reform executive at Independence Blue Cross. “When you’re setting rates for an insurance product, you’re trying to predict the future: How much money is this population of people going to spend in the next 12 months? Sometimes you get it right; sometimes you don’t.”

Question 13: Guide to Obamacare

My friend’s birth control pills are free and mine aren’t. What gives?
The ACA’s contraception coverage provision went into effect last August, with insurance companies obligated to offer birth-control measures such as oral birth-control pills, emergency contraceptives (i.e., the morning-after pill) and sterilization at no cost to consumers. It applies to most insurance plans, except those offered through certain religious organizations. (The Obama administration and faith groups have been fighting over the religious exemption.) But the ACA didn’t mandate that all pills and methods be free; your insurer decides which prescriptions are covered. If your pills still require a co-pay and you don’t work for a religious organization, chances are your brand isn’t among those your insurer covers at no cost. Get a list of your insurer’s no-cost pills, then talk to your doctor about switching.

Question 14: Guide to Obamacare

I smoke. I’ve tried to quit, but I just can’t. Will Obamacare help me?
Yes and no. The ACA requires your insurer to cover tobacco cessation as a no-cost preventative service. But if you don’t quit, your insurer can levy a penalty, charging up to 50 percent more for your premiums starting in January. And if you qualify for a low-wage tax credit for an individual plan through the exchange, you can’t use it to offset the smoking penalty—just the premium. Experts worry many smokers will be priced out of health coverage.

Question 15: Guide to Obamacare

I’m young and single. I don’t get sick. I’m not going to buy insurance. What can the government do to me?
It depends. If buying insurance would cost you more than eight percent of your income even with the tax credits, you’re exempted. But if you can afford coverage and choose not to buy it, you’ll owe penalties when you file your taxes. Starting with your 2014 return, you’ll owe the greater of $95 or one percent of your taxable income; this maxes out in 2016 at $695 or 2.5 percent. (Penalties are higher for families.) Although it’s unclear what the IRS can do if you don’t pay those penalties—the ACA forbids using aggressive tactics to collect them—it can withhold tax refunds from you.

Question 16: Guide to Obamacare

I really hate my job. But I have diabetes, and if I quit, I won’t be able to get health insurance—right?
Wrong. There must be a lot of people with preexisting conditions who hate their jobs, because so many of the experts we talked to mentioned this point. “People stay at jobs they hate because they’re afraid they won’t be able to get insurance,” says advocate Carol Rogers. As of January 1st, you’ll be able to tell your boss to shove it and still afford coverage through an exchange, since charging more for those with preexisting conditions will be banned. “This provides a safety net,” says Penn’s Daniel Polsky. “There will be no gap in coverage” while you look for another job.

Question 17: Guide to Obamacare

My six-year-old was born with a heart defect. We’re already bumping up against our lifetime limit to pay for her care, and the doctor says she needs three more operations. Is there help for us?
So long as your plan isn’t grandfathered, rejoice: The ACA abolished both annual and lifetime coverage limits as of January 1, 2014—a change that Jefferson pediatric nurse and nursing prof Mary Lou Manning calls “amazing” for her patients’ health.

Question 18: Guide to Obamacare

The government does a crappy job of running Medicare and Medicaid. Why should I think it will do a decent job with Obamacare?
“There’s a lot of fraud and not a lot of innovation” when it comes to the government’s health-care programs, acknowledges Jefferson’s Mary Lou Manning. But the new Center for Medicare and Medicaid Innovation, set up by the ACA, should help. It tests new service delivery and payment models and evaluates results, and is already paying off; Penn bioethicist Zeke Emanuel recently noted in the New York Times that in 2012, Medicare spending per beneficiary increased just 0.4 percent—and those costs have trended downward for the past three years. What’s more, the Congressional Budget Office (CBO) just slashed its projections for year 2020 Medicare and Medicaid spending by 15 percent, because the programs have seen their lowest rates of growth since the government started keeping records in 1960. And DOJ/DHHS investigations of Medicare and Medicaid fraud racked up $4.2 billion in fines last year, up from $4.1 billion in 2011. Eighty percent of all seniors agree that “Medicare is working well.”

Question 19: Guide to Obamacare

My ob/gyn stopped de­livering babies; her malpractice insurance costs too much. Does Obamacare do anything about tort reform?
No, and it’s one of the main problems a lot of doctors see with the act, including Einstein ob/gyn Arnold Cohen, who points out that only three private obstetricians are still delivering babies in the City of Philadelphia. “We’re one of the states with the most hostile malpractice atmospheres,” he says. Besides driving up costs, malpractice suits have a chilling effect on the doctor/patient relationship, says Einstein radiologist Debra Copit: “All those ads you see on TV, saying, ‘Have you been hurt by your doctor?’—they make patients more suspicious. They ask, ‘Do I need this, or is this to make money?’”

Question 20: Guide to Obamacare

Don’t lie: Are there death panels in the act?
Nope. No death panels. What there is, according to Penn health-policy guru Daniel Polsky, is a new, independent not-for-profit organization called the Patient-Centered Outcomes Research Institute. The institute evaluates and conducts research with the goal, Polsky says, of figuring out when more expensive care options work better and when they don’t. It offers guidance; it doesn’t pull any plugs. The panel is explicitly forbidden to use criteria that discount the value of a life because of a disability in recommending treatments—a major difference from the system employed in the U.K.

Question 21: Guide to Obamacare

Is there any chance in hell that the economics of this thing will work out?
That’s the almighty question—and the answer depends on whom you ask. Says Einstein chair of medicine Steve Sivak: “The ACA is an attempt to completely change the paradigm of health care, from volume-based to value-based. Hospitals will be rewarded for admitting fewer patients.” Everyone agrees that’s a good and lofty goal. But the ACA is one big balancing act; the idea, as with all insurance, is that widening the pool of those covered will lessen costs, or at least hold down the rate of increase. But there’s a lot of disagreement about whether the penalties for not buying insurance are draconian enough to compel healthy young people to sign up; meantime, everybody with preexisting conditions is expected to flock to sign on. The bill is full of incentives for hospitals and doctors to reduce costs, as well as for small-business owners to join in pooled plans. But employers are scrambling to find ways to get more expensive workers off their policies and onto exchanges, and the federal government is slated to pay for the 16 million people being added to state Medicaid rolls.

At the same time, boomers are being added to Medicare at a rate of three percent more per year. How will it all shake out? Sivak cautions: “Some of the bill’s provisions will result in good things. Some will have unintended consequences.” Fox Chase Cancer Center physician-in-chief Richard Fisher is hopeful: “There may be an initial spike, but as the system adapts and adjusts, I think costs can go down.”

Question 22: Guide to Obamacare

My wife has suffered from depression for years. Does Obamacare do anything for her?
They’re not officially a part of Obamacare, but Department of Health rules issued in connection with the ACA have clarified what insurers must provide in the way of mental health coverage—clarification that patients and a­dvocates have been waiting for ever since passage of the 2008 Mental Health Parity and Ad­diction Equity Act. The changes will provide access to mental-health coverage for 32 million people who never had it before, and improve coverage for another 30 million. Insurers are now required to treat mental health serv­ices the same way they do services for physical health, with comparable co-pays, benefits and deductibles.

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