Our current president has a well-documented problem with lying about easily verifiable facts. One of his favorite things to lie about is the Affordable Care Act, also known as Obamacare. Last month at a public Cabinet meeting, Trump told the following lie: "Obamacare is finished. It's dead. It's gone. … Obamacare does not exist anymore."
Trump may wish that to be true. But for Americans making important decisions about health care and tax filings, Obamacare remains the law of the land. It's easy to be confused about some aspects of the ACA – that's why we've compiled this guide to 2018 Health Insurance Marketplace sign-ups in Central Texas, which began Nov. 1 and will run through Dec. 15. Because one thing is still clear: Obamacare hasn't gone anywhere.
Elizabeth Colvin, director of Insure Central Texas, a project of the nonprofit Foundation Communities that helps locals navigate the complex health insurance system, is out to set the record straight. Since 2013, the organization has signed more than 22,800 people up for health care. "There is a tremendous amount of confusion this year," Colvin said. "We have done considerably more outreach than we've done in previous years, because of the confusion that exists in our community about what people's rights are and what they have access to."
Colvin says many Central Texans erroneously believe that their pre-existing conditions might make them ineligible for health insurance in 2018. Real news: Insurance companies cannot discriminate based on pre-existing conditions. That protection still stands, like all protections codified in the ACA under Obama. Likewise, if customers purchase plans in the current open enrollment season, they'll be covered until the end of 2018, no matter what happens in Washington. "They're signing a contract with the insurance company to have insurance for all of 2018, and their prices and plans are set," Colvin explained. "That is not going to change for the entire year. We have to reassure people of that fact."
The mandate for most Americans to purchase health insurance or pay a hefty penalty still stands, too. Because of that and other, more serious implications for people who don't insure themselves against expensive or potentially deadly health problems, application helpers at Insure Central Texas have been hard at work this month, giving people the free assistance they need to sign up quickly and knowledgeably. (Full disclosure: I attended a brief Insure Central Texas volunteer training this fall, but have not yet volunteered.) Thanks in part to their efforts, nationwide HealthCare.gov sign-ups in the first week of open enrollment were well ahead of previous years, despite attempts to confuse.
Although Trump and his colleagues in Congress were unable to repeal the ACA, there are various new wrinkles that HealthCare.gov users should be on the lookout for during open enrollment heading into 2018. We called on Colvin to get the lowdown on how to be a savvy shopper this enrollment season.
One limited way that Trump has found to screw with the ACA is by shaving a full month off the enrollment time, from two-and-a-half months to six weeks. Getting carpal tunnel from writing too many postcards to your representatives? One effective way to #resist is by spreading the word to sign up now for health insurance. Said Colvin: "The decrease in the advertising budget of the federal government has made it more important than ever that we get the word out locally, and that Central Texans let their neighbors and friends know that if they don't get insurance through work, Medicaid, or Medicare, this is their chance, between now and December 15th, to get health insurance for 2018."
If you wait until after Dec. 15 to sign up, you may not be able to access affordable health insurance in 2018 – even if you get very sick. There are exceptions to this rule, like if you lose a job, move to a new area, have a baby, or change your marital status. If at any point in the next year you need what's called a "special enrollment period" for HealthCare.gov, you can ask someone at Insure Central Texas about your eligibility. They do this year-round.
One measure of the ACA's robustness in Central Texas is the fact that our local marketplace didn't lose any insurers this year. In fact, we gained one: Oscar Health, a tech-flavored insurance start-up with ties to the family of presidential son-in-law Jared Kushner. (His brother Josh, a self-described liberal and ACA supporter, co-founded the company.) In recent years, we've greeted other less-familiar names to the local marketplace, including Ambetter and Sendero.
It can be scary to put your family's health in the hands of an unknown company, but Colvin advises it's in your best interest to make a side-by-side comparison of what each plan has to offer. "People often are not familiar with the insurance companies that are in the marketplace, so we have to assure them that these are real insurance companies," she said. "These are not fly-by-nights that are going to disappear, because they are regulated by the Texas Department of Insurance. This is all real, legitimate, comprehensive health insurance that has to meet certain requirements to be in the marketplace."
The ACA requires all insurance plans offered on the marketplace to cover a robust set of medical needs. If they don't, the law has mechanisms to back you up.
This isn't to say that these insurers hold your best interest at heart. You should always be prepared to advocate for yourself against your insurer's denials if necessary. But don't dismiss a newer insurance company just because you don't know how they work. The law determines how they work.
Some plans look different this year in terms of either how you pay or which providers they work with. According to Colvin, some of these changes could mean more expenses for consumers, depending on how much they go to the doctor. "This year, there are some Silver plans where you have to meet the deductible first, and then coinsurance kicks in," she said. "So it's not based on copays, which is what we're used to seeing with Silver plans."
Several plans have scrambled their affiliations with local providers. For instance, one Sendero plan has added Austin Regional Clinic and Texas Oncology, but is no longer in-network with Austin Diagnostic Clinic. If it's important to you to see a specific doctor, make sure to use the search tool on HealthCare.gov to check if your doctor is included in each plan.
That said, even if your preferred doctor or hospital is not in-network, the ACA has adequacy requirements that each plan must meet. "We work with people who need transplants to be able to live, who have very serious medical conditions," said Colvin. "If we are able to figure out how to work the system and make the plan work for those folks, it can likely work for you."
It's a complicated story with a simple summary: Trump tried to undermine the subsidies that help low-income people afford to buy insurance, and he failed. For 2018, low-income people will see costs that are similar to what they saw on the marketplace last year.
To tell it in full, know that there are two kinds of federal support for low-income people – cost-sharing reductions (CSRs) and premium tax credits (PTCs) – and Trump only had executive discretion to stop payments on one of them. He defunded CSRs, which help lower deductibles and out-of-pocket maximums for low-income people. He couldn't defund PTCs, which are more clearly accounted for within the ACA. Because of how the law is written, consumers aren't on the hook for the missing federal CSR money; insurance companies are. So, to avoid going broke, insurance companies jacked up the prices of premiums in the Silver category, where PTCs come into play. That way, the federal government still has to shell out a similar amount of money in 2018.
"When the word came down that the administration was going to stop making the CSRs, insurance companies were prepared for that," said Colvin. "When I talked to the different insurance companies that morning to see what was going to happen, they all said, 'Business as usual.'"
In 2018, Silver premiums are higher than last year – but they're also more highly subsidized by the federal government. If you qualify for premium tax credits, things will look pretty similar to 2017. If you don't, Silver premiums will look strangely high. You can thank your orange overlord for that.
According to Colvin, the number-one overlooked benefit for ACA customers are the dozens of free preventive services included in each plan sold on HealthCare.gov. These services range from diabetes, HIV, and blood pressure screenings to contraception, mammograms over age 40, and various immunizations and screenings for babies and kids. The services are free only if used in-network.
Colvin's number-two overlooked benefit is the fact that there remains a regulatory structure in place to support appeals when drugs or medical services are denied by an insurer. It can be exhausting for patients to advocate for ourselves, but it's something we'd have to do under any conceivable health-insurance regime. The hardest part is getting the law on the patient's side to support appeals and active regulation.
Besides the marketplace, Central Texans have a few other limited options for support with health insurance bills. Texas does not have a generous Medicaid program. Our conservative state government continues to refuse Medicaid expansion money offered through the ACA, contributing to dismal statewide health outcomes including the highest maternal mortality rate in the developed world. But many low-income children applying on the marketplace will qualify for the Children's Health Insurance Program ("CHIPs Are Down," Nov. 3).
If you are currently enrolled in the Medical Access Program but also qualify for federal subsidies for the marketplace, or if you are a qualifying musician who is a member of the SIMS or Health Alliance for Austin Musicians programs, Central Health has a premium assistance program to bridge the gap and help you enroll. HAAM offers a walk-in "one-stop shop" for members and prospective members during open enrollment. The organization also offers its membership health, dental, and vision benefits, while SIMS connects Austin music professionals and their families with affordable mental health and addiction care. Locally and nationally, some disease-specific organizations also offer special funding for people facing those diseases.
Another evergreen reminder: Immigrants should not be scared off by misinformation about the ACA or concerns of family members' statuses being revealed to authorities. Legally present noncitizens (except DACA recipients) can apply, just like citizens, to buy insurance through the ACA marketplace and get help paying for it. Undocumented persons and DACA recipients are not eligible to use the marketplace, but they can apply on behalf of children or other family members. You will not be asked for your immigration status unless you are applying for health insurance for yourself.
Does choosing a plan on the ACA marketplace feel like a pop quiz in a foreign language? Use this quick refresher.
Minimum essential health benefits: To be listed on HealthCare.gov, plans must cover outpatient care, emergency care, hospitalization, maternity and newborn care, mental health and substance abuse services, labs, preventive care, chronic condition management, and pediatric care, including oral and vision care for kids. If a plan is on the marketplace, it covers these things.
Marketplace: This term describes both the menu of insurance plans on HealthCare.gov, and the federally run system for applying for and receiving help paying for insurance and medical care. Also known as "the exchange."
Premium: The amount you pay each month just to stay insured, even if you don't use any health care.
Copayment: The flat fee you pay for simple things like seeing your doctor or buying non-specialty meds; often deeply discounted right off the bat.
Deductible: Until you've spent this amount of money on health care in a calendar year, you will have to cover most of your expenses (besides things that qualify for copays). After you've spent this amount, your insurance will help with more of the costs.
Out-of-pocket maximum: This is the most you'll ever have to pay (of your own money) for health care in a single year, so long as you use in-network providers.
Coinsurance: Often, after you've hit your deductible but before you hit your out-of-pocket maximum, you'll owe coinsurance on medical costs incurred in-network, a percentage of the amount that is billed to your insurance company.
Appeal: If you are denied coverage that the ACA guarantees – such as the essential health benefits above, or other treatments and services that are essential to your health – you and your doctor can appeal that decision to your insurance company and/or the Texas Department of Insurance.
Penalty: If you don't enroll in an insurance plan that meets minimum standards laid out in the ACA, you will owe the federal government a hefty fine: $695 for a typical adult. If you have a very low income, are a DACA recipient, have experienced hardship, or have certain tribal or religious affiliations, you may be able to apply for exemption from the penalty. Do ask!
North: 5900 Airport (HAAM also located here), 737/717-4001
Mon.-Thu., 9am-7pm; Fri.-Sat., 9am-4pm; Sun., 1-5pm
South: 2600 W. Stassney, 737/717-4000
Mon.-Wed. 10am-7pm; Thu., 10am-4pm; Fri.-Sat.: 9am-1pm
1) Username and password for HealthCare.gov, if available.
2) Immigration documents for those seeking insurance.
3) Cost and details of insurance offered by your employer.
4) Knowledge of current income information and names of doctors and medications you need covered.
Latino HealthCare Forum is also offering in-person assistance by appointment at four Southeast and Northeast Austin locations. Call 211 to make an appointment.
Copyright © 2020 Austin Chronicle Corporation. All rights reserved.