Obamacare 101

To judge from recent headlines out of D.C., you might think the Patient Protection and Affordable Care Act (aka "Obama­care") is on the ropes, just waiting for yet another repeal vote from the U.S. House, or another grandstanding filibuster from Sens. Rand Paul or Ted Cruz to force it to its knees. Despite all the brinksmanship of the last few weeks, on Tuesday – October 1 – the enrollment process begins for the "Health Insurance Marketplace" (aka "health exchanges"), and those who qualify will begin receiving coverage Jan. 1, 2014. (See "What Happens When?" below.) All the huffing and puffing of Cruz et al. will not end the law, although it will somewhat obstruct implementation.

In Texas, for example – where Gov. Rick Perry has done his best to prevent or stall any expansion of health care in any way, despite the fact that Texas leads the nation in uninsured residents – Texans must rely on nonprofit assistance and direct federal government administration to enter and use the new Marketplace. In the latest wrinkle, Perry (echoing other GOP governors) is attempting to impose onerous requirements on the nonprofit "navigators" hired to help people access the Marketplace and enroll for coverage – even though similar counselors, with little controversy, have assisted Medicare enrollees for years. U.S. Health and Human Services Department spokesman Fabien Levy described Perry's move as "a blatant attempt to add cumbersome requirements to the navigator program and deter groups from working to inform Americans about their new health insurance options and help them enroll in coverage." Perry's office defended the new regulations as protecting the rights and privacy of enrollees – and then added that the new rules – some of which would violate federal law – won't be ready before January, when coverage is supposed to begin.

Whatever else happens politically, the obstructionism will undoubtedly continue, leaving the task of explaining the law to the feds, the overstretched nonprofit groups, and the Texans who simply believe that more of their neighbors getting health insurance helps us all: in more preventative care, in lower premiums and fewer co-pays, in less demand on publicly financed emergency rooms, in healthier people overall – in short, the common good.

In that spirit, what follows is a primer on what to look for in the new law, how it works, who is most encouraged to apply, and the up- and downsides of the law. It is not exhaustive, by any means – the resources listed below provide a great deal of additional information – but it should serve as a basic introduction to the largest expansion of national health care since the 1965 creation of Medicare.

We hope this information may help some of our neighbors to acquire health insurance, and be less unprotected against catastrophic illness and its personal and financial consequences. And for those of us already with access to health care – perhaps the following will help dispel some of the misleading hysteria over the law.

What is Obamacare? – Basic Principles

• Shared risk: The Affordable Care Act addresses the national shortfall of health insurance by expanding the risk pool -- that is, more people buying insurance means more people sharing both the benefits and the costs, requiring less emergency care and creating downward pressure on medical costs.

• Personal mandate: In principle (much like vehicle insurance) the new law requires everyone to purchase health insurance (or pay a penalty), either through existing systems (e.g., employer-provided plans), or the new health insurance exchanges, or other public programs.

• Those who cannot afford to buy insurance on their own will be eligible for a federal subsidy.

• Employer mandate: Companies with more than 50 full-time employees will be required to offer basic insurance plans meeting a coverage standard (the full implementation has been delayed until 2015).

• Since most people already have health insurance (usually through their jobs), for most people, very little will change; however, in Texas, only about half the population gets insurance through their jobs, making the ACA more urgent here.

What Happens When? – Major Dates

• Oct. 1: Formal opening of the "Health Insurance Marketplace" through which applicants can compare, price, and apply for health insurance plans being offered in their states; some will be run by the states themselves in collaboration with the federal government, some (e.g., in Texas) will be run solely by the feds.

• Dec. 15: In order for coverage to begin on Jan. 1, 2014, people will need to apply by mid-December.

• March 31, 2014: First period of open enrollment in the Health Insurance Market­place closes.

What Changes Will There Be? – Early Benefits

• People can no longer be denied coverage because of pre-existing conditions.

• Insurance plans must provide plain-language summaries of coverage in standard, comparable formats.

• Children are eligible under parents' insurance until age 26 (already in place).

• All insurance plans must include coverage for: outpatient and emergency services; hospitalization; maternity and newborn care; mental health disorders; prescription drugs; rehabilitation services and devices; lab services; preventive and wellness services and chronic disease management; and pediatric services.

• Insurance plans purchased under the new law must cover a wide range of preventive care without co-payment, including a wide range of standard tests and lab work, specialized women's care (including birth control), and screenings and immunizations for children.

• No cost discrimination based on gender.

• No yearly or lifetime limits on coverage – if you reach your "out-of-pocket maximum" in a year, you pay no more for necessary additional treatment.

• New protections against "frivolous cancellations" – insurance companies can no longer cancel policies for application errors (applies to existing and new policies).

Who Should Apply?

• You should explore the Marketplace if you don't have health insurance through an employer or other group plan, and if you haven't been able to purchase health insurance directly.

• Young people (between 19 and 29) may find that under Obamacare, they can buy affordable health insurance for the first time; within certain income limits, they can receive lower premiums or tax credits to offset the cost.

• People can opt out of the requirement to have health insurance by paying a tax: In 2014, it will be 1% of income or $95 (whichever is higher) with some income-based exemptions, escalating in following years. Parents must see that their children are insured or also pay a tax. Those choosing to opt out and pay the tax (aka "fee" or "penalty") will not have health insurance, and will remain responsible for 100% of their medical costs.

• Applicants eligible for Medicaid, Medicare, or the Children's Health Insurance may be directed to those or other alternative programs for less expensive coverage.

How Do I Begin? – Navigating the Marketplace

• The most basic resource for enrollment is the federal government website: www.healthcare.gov. While it won't begin accepting applications until this Tuesday, Oct. 1, it's been online and updating for some time – interested people should begin exploring the site now, to answer a range of basic questions and learn how the Marketplace and the available levels of insurance will work.

• For those without web access, the federal help phone line is 800/318-2596, available 24 hours a day, 7 days a week (TTY: 855/889-4325).

• Applicants will also be assisted by local "navigators" – aides trained by local nonprofits to help people in the application process; several organizations have received grants in Texas; in Austin, a federally approved navigation agency (more may be added) is People's Community Clinic (2909 N. I-35; 512/478-4939); www.austinpcc.org; alexb@austinpcc.org.

• Beginning Oct. 1, Foundation Communities will begin a program called Insure Central Texas, and open two free "enrollment supersites" staffed by certified navigators: Commun­ity Financial Center, 2600 W. Stassney, and Highland Mall, 6001 Airport Blvd. Other sites may open later. See www.foundcom.org.

Design Flaws: Pending Problems

• It ain't single-payer: As a massive compromise with both private insurers and conservative opposition – effectively designed by a committee of the whole – the Affordable Care Act system offers broader coverage by expanding the private insurance market, somewhat simplified by regulation but still overcomplicated and burdened with excess administrative costs; it should be subject to regular Congressional oversight and amendment, but exclusive GOP focus on "repeal" has meant no consistent approach to revision or amendment.

• The delay of the large-employer mandate (more than 50 full-time employees) to 2015 means one more year of argument over coverage and reporting requirements.

• Some spouses and children may not be able to afford job-based coverage, yet be excluded from the Marketplace because of that theoretical access to job-based coverage: a Catch-22 that could leave many people still uninsured.

• Some large employers have been restricting the hours of part-time employees (below 30 hours/week) to avoid offering health insurance, presuming they'll instead be covered in the government-subsidized Marketplace – or not at all.

• Certain aspects of the ACA incentivize employers to "game the system" – offering diminished coverage or else moving insurance costs onto their employees.

The Politics: Especially in Texas

• Republican opposition to Obamacare ranges from rhetorical obfuscation to active sabotage; in the latest Texas action, Gov. Rick Perry has imposed additional regulation on Marketplace "navigators," demanding fingerprinting and background checks, and imposing additional training not required under the federal law. Some Texas requirements may violate federal law.

• Fledgling Texas Sen. Ted Cruz has built his brief national career on pandering to the hard right of the Republican Party, demanding that Obamacare be defunded and threatening filibuster, selective repeal, a government shutdown, even defaulting on federal debts.

• There's an air of real desperation (40 pointless negative votes in the U.S. House) and infighting in the GOP response to the law; they do not have the votes to repeal it, nor certainly to override a presidential veto, so much of the recent headline-grabbing is just posturing.

• However, the rabid, hysterical opposition has greatly contributed to public opposition and exaggerated misunderstanding of the law; for example, national polls reflect majority opposition to the law itself, but stronger support for the actual provisions of the law (see "What Changes Will There Be?" above); moreover, whatever their thoughts on the law, both Demo­crats and Republicans oppose shutting down the government to undermine it.

Resources & Links

Federal Marketplace site: www.healthcare.gov (800/318-2596)

Texas nonprofit health care coalition: www.texaswellandhealthy.org

Center for Public Policy Priorities: www.forabettertexas.org

Foundation Communities: www.foundcom.org (211)

People's Community Clinic: www.austinpcc.org

CommUnityCare: www.communitycaretx.org (512/978-9015)

Lone Star Circle of Care: www.lscctx.org (877/800-5722)