Amy Ball, right, counsels Wanda Perry, 48, left, about possible options for health insurance in Delaware once the new exchanges open on Tuesday. Christiana Care Health System in Wilmington, Del., is providing marketplace "guides" to help consumers navigate the system. Perry is currently unemployed and her husband is self-employed. Neither has health insurance now.
The new health-insurance exchanges open for enrollment on Tuesday, but a new Kaiser Family Foundation/NBC survey shows most Americans are still worried and confused about what it all means. The battle in Congress over shutting down the federal government -- something that could also happen Tuesday -- has people even more perplexed. Here’s what you need to know before day one of Obamacare:
Why bother? Isn’t the government going to shut down and stop this? Won't Congress delay Obamacare anyway?
Even with a government shutdown, the exchanges will open as scheduled on Oct. 1. The money the federal government is using to run them doesn’t rely on appropriations from Congress. The Republican-controlled House of Representatives has deliberately linked the Affordable Care Act to the continuing resolution -- the law that keeps the federal government funded. They want Democrats in Congress and President Obama to agree to delay or even repeal the law in return for keeping the government running. Not going to happen, say the Democrats and Obama. It's far more likely that the government will shut down for a few days and then both sides will agree to keep cash flowing without bringing the health-reform law into it.
And it’s very unlikely the Republicans in Congress who have vowed to repeal the health-reform law can succeed, because all laws have to pass the Senate and Democrats who support the law control the Senate. And President Barack Obama would veto any such repeal, of course. Even some Republicans point out that the Supreme Court has ruled Obamacare constitutional and it is now the law of the land.
Got insurance already? You don’t need to worry
Most of us -- 58 percent of non-elderly Americans -- get health insurance through an employer, and 32 percent get government-sponsored insurance such as Medicare or Medicaid. The U.S. Census Department says about 15 percent of Americans don’t have health insurance and these are the people who should be either buying health insurance on the new exchanges, or getting it through Medicaid in the states that are offering it to more people.
The opening of the exchanges doesn't affect anyone who already has insurance. The law does change some of the rules regarding health insurance, but the only thing happening Tuesday is the opening of the exchanges. Other changes go into effect Jan. 1.
Some news reports have highlighted the cases of employers who have decided their workers will be better off buying insurance on the exchanges. This may be because the federal subsidies would actually lower costs for them. If you have workplace-sponsored insurance, your employer must give you a letter detailing what your options are.
What are these exchanges?
The exchanges are a new way to buy health insurance that let people compare the plans available to them and to also see, within minutes, whether the federal government will pay for part of the premiums. They’ve been compared to online sites such as Travelocity or Expedia, where people can compare the prices of airline flights across different carriers. At the same time, the sites check to make sure people are telling the truth about their income and employment.
How much will it cost?
The prices vary based on the different plans -- a lot like employer-provided insurance works now. There are four tiers of coverage: bronze, silver, gold and platinum. The bronze plans usually charge lower premiums, but then you’ll be charged a higher co-pay, which means you pay each time you see a doctor or other provider, each time you fill a prescription, or each time you have a procedure. The platinum plans charge the highest premiums but provide much more care before the patient has to pay a share. In some places, young adults can also buy bare-bones catastrophic insurance for people who really think they’ll only need health care if they have an accident.
A lot depends on where you live. In some counties, a family of four with an income of $50,000 may pay $11 a month for a low-level silver plan. In other places a similar family might pay $280 a month for the same plan. This is because care costs more in different places. You can give the federal government site a run now at www.healthcare.gov although you cannot actually enroll until Tuesday.
Will the plans be expensive -- more than plans cost now?
Some of the bare-bones plans are likely to cost more than the minimal-coverage plans on the market now, but that’s because you get much more coverage. Many of the plans available now don’t provide much coverage, and can stop paying for services once patients start running up bills. The Affordable Care Act requires insurers to provide a basic level of care, which includes free preventive services such as vaccines, mammograms and wellness checkups. They cannot cap your coverage and they can’t charge you more just because you are a woman, for instance.
Can people get help paying for the insurance?
Many people can get a federal government subsidy. It depends on how much you make and your family size, but the subsidies can be very generous. It’s a complicated formula but families with incomes of up to $94,000 might get a subsidy. There’s a calculator here that you can use to estimate what it might cost.
There’s a big exception for people who make very little money. The law assumed that states would expand Medicaid to cover people who earn less than 138 percent of the federal poverty level, which works out to $16,000 for an individual or $32,500 for a family of four. But the Supreme Court ruled that states don’t have to, and many states won’t. These people also don’t qualify for subsidies if they make less than the federal poverty level, and right now they are stuck. They’ll either have to pay full price on the exchanges, or go without insurance.
If your employer offers adequate insurance but you decide to go to the exchanges to buy some anyway, you can’t get a subsidy. But you may qualify for one if the insurance you have now isn’t adequate.
What if I don't want to pay?
Technically, you'll have to pay a fine, which varies depending on your income. The argument is that people without health insurance cost everyone money because they do get sick or hurt and they do go to emergency rooms and someone has to pay in the end. The Supreme Court says it's a tax. The IRS can take the money out of any refund you have coming. In reality, it's not clear how hard the federal government will go after holdouts.
What if I’m already sick?
That’s called a pre-existing condition. Right now, insurance companies can refuse to cover you if you’re sick, or they can refuse to pay for care for some condition, such as diabetes, if you had it before you bought insurance. Not any more. Now insurers have to cover everyone, regardless of their health or previous illnesses.
What about if people are too busy to sign up Oct. 1?
Tuesday’s just the first day that the exchanges are open for business. People have six months to sign up for health insurance during what’s called open enrollment. If you get signed up by Dec. 15, you can start using your insurance on Jan. 1, 2014.
So where do I go to get started?
Anyone can go online and sign up at https://www.healthcare.gov/. You can find a person or place to help you by entering your zip code here. States that are offering health insurance have their own sites, too, like Delaware and California. Various privately funded groups like Enroll America also have websites to help people sign up.
First published September 30 2013, 2:03 AM