hat do you need to know about the Affordable Care Act, aka Obamacare, the health-reform law or the “federal health-care overhaul”?
It’s big, it’s far-reaching and, despite what you may have heard, it’s happening.
And it will change many things about the way you get health care, whether or not you are one of the more than 1 million state residents currently uninsured, many of whom may benefit directly.
Basically, the ACA’s aim is to begin to pull, push and persuade everyone to pile into the big “pool” — the insured. In short, that’s because some of those who study health-care systems have come to believe it’s crazy to have health “insurance” that evaporates if you become too sick to work. And of course if you don’t work — and even if you can, for many low-paying jobs — you likely can’t afford insurance in the first place.
Nobody ever tried to argue that having no health insurance somehow magically keeps people from getting sick. They get sick, and they seek care in emergency rooms, or in “free” clinics, which depend on grants, taxes and donations.
This “cost-shifting” — getting someone else to pay the bills — has increased costs in many ways. The “someone else’s” have often been employers, and their steeply rising health costs have prompted pushback.
A fairer way to do this, the proponents of the health-care law argued, is spreading the burden more widely. To do that, there are bits and pieces of tax hikes in the law.
The picture of the near future isn’t all rosy. Bringing a lot of people into the system, many worry, will create its own problems. Are there enough primary-care doctors to care for everyone? Or will health-care systems adapt, perhaps using other skilled workers such as nurse practitioners to full advantage?
And cost remains one of the biggest issues — and one of the most serious criticisms of the federal law. With pharmaceutical companies, doctors, hospitals, device manufacturers, insurers and others all jockeying to keep their income, will costs just keep rising?
As a country, we haven’t yet settled on the best way to get a grip on costs — one that’s politically acceptable, anyway.
One of the biggest challenges, many ACA advocates say, is helping people understand the value of health care and having insurance when you need it.
So what is this ACA thing and what should you know? Here are 20 things to know as you try to understand the new law and the wave of change that is just beginning.
1 Next year, you must have health insurance, one way or another, or pay a penalty. There are exceptions, but they won’t apply to most people.
2 Very likely, you already have insurance, so don’t panic. If you are covered by an employer-sponsored plan, Medicare or Medicaid, military or veterans programs, an individual plan or other group plans, you’re golden. If it’s very skimpy or unaffordable, you can buy on the state’s exchange marketplace, where you might get financial help.
3 If you have an individual plan, you’re considered covered, but your plan is likely going to change, and you’ll have to pick a new one. You’ve probably already received a notice from your insurer. At least one insurer selling plans in Washington’s exchange, LifeWise, will keep some older plans.
For most people, new plans will cover more. For older people, they may cost less. Younger people may pay more. There won't be lifetime limits on these “essential services,” and your yearly out-of-pocket expenses will be capped.
4 Insurers can no longer reject you or charge you more because you have a health condition. Trouble getting coverage because you have a pre-existing condition or a chronic illness is now a thing of the past. The “high-risk pool” insurance plans will dry up.
5 Your kids can be on your policy until they’re 26. Which is pretty much a blessing, because if they got hurt or seriously ill, you’d probably pay their health-care expenses anyway, wouldn’t you?
6 You can’t sign up for insurance coverage all year long. So if you don’t have insurance, it’s not a good idea to think: Oh, I’ll just pay the penalty and wait until I’m sick or injured or rich to sign up. You’ll be able to sign up only during specified open-enrollment periods.
This year, a special six-month period lasts from Oct. 1 to the end of March 2014. Later enrollment periods will be shorter.
7 If you’re a mom, you’re the most-trusted adviser to over-26 kids. So you’re the one who needs to explain that, yes, they can pay the penalty and skip insurance. But if they break an arm or a shoulder in a bike crash they could end up with a big honking hospital bill — and a lousy credit rating — that could dog them well into the next phase of their life.
8 There is a new way to compare and sign up for individual insurance. In Washington, the insurance-exchange marketplace will appear Oct. 1 as the Washington Healthplanfinder, a one-stop shopping site that will take care of a lot of messy details for you.
If you make less than $15,856 ($32,499 for a family of four) you likely will qualify for Medicaid, the federal-state plan that has been greatly expanded.
If you make up to $45,950 ($94,200 for a family of four) you may get a subsidy that will reduce your premiums.
If your income is low enough, you can qualify for a second type of subsidy to help with cost sharing (out-of-pocket costs). It also will link you with various other services, if you qualify.
10 The exchange isn’t the only way. You’ll still be able to buy individual insurance through a broker, or through the insurer the same way you signed up before. Some insurers, including LifeWise, will offer some “grandfathered” plans left from the good old days.
And there will be other choices, just as there are today.
But there are no subsidies for purchases outside the exchange.
11 If you work for a big, self-insured company, you won’t see many changes. At least not right away. Expect more emphasis on wellness programs, some pressure to select a health savings account (HSA) or health reimbursement arrangement (HRA) plan, and some squeezing when it comes to choice of health networks.
12 Expect new arrangements between insurers and doctors and hospitals. In general, they may lead to better coordination of care, but you may also see fewer choices of doctors, clinics and hospitals.
You may hear about “ACOs” — accountable care organizations. Think of them as health-maintenance organizations “lite.” They are moving away from paying for each health-care service — “fee for service” — toward incentives that reward both insurers and providers for keeping patients healthy.
13 You might want to call way ahead of time to make that doctor’s appointment. If it turns out that more people are insured, there just might be a few more patients in the waiting room.
14 Don’t expect costs to go down soon. If there is anything systematic about our “system” of health care and insurance, some experts argue, it is this: It has kept costs down, such as they are, by keeping sick people out, or limiting their access.
Once most people are in the pool, though, expect some slow ratcheting down of costs as businesses, insurers and health systems find ways to reward care that works and discourage care that doesn’t. According to a recent Institute of Medicine analysis, fully a third of the $2.6 trillion spent in 2010 on health care went for care that didn’t make patients healthier.
15 Expect more pressure from every direction to adopt healthful habits and choices. It may come as an incentive — lower premiums or gift cards — or not. Once we’re all in the same boat, it’s hard to argue that one person’s actions don’t affect others.
16 Businesses aren’t required to insure workers this year. The federal government in July delayed the mandate for business coverage for a year. But in 2015, employers of more than the equivalent of 50 full-time workers will have to insure or pay a penalty.
17 Undocumented immigrants won’t get any subsidies. Immigrants here illegally will continue to try to patch together care in community clinics and emergency rooms. But legal immigrants can buy insurance on the exchanges and qualify for subsidies, if their income qualifies them for help.
Legal immigrants here for five years or more can qualify for Medicaid with the same income limits as others.
18 Watch as hospitals pull out all the stops to sign up patients for insurance. The only really open door in health care is the emergency room. So how cool would it be if the hospital could make sure everyone who comes there is signed up?
UW Medicine hospitals will be doing just that, with enrollment kiosk stations at various areas, personnel trained to help patients enroll, and newsletters to reach out to potential patients.
Look for distinctive buttons or lanyards to identify people who can provide information.
19 Soon, there will be information everywhere. There will be assisters and seminars and advertisements and info packets about the exchange and the ACA everywhere you turn. Even so, not all questions will have answers yet. Think of it as a good first date: Promising, but there are still some mysteries.
20 Despite what you may have heard, Obamacare doesn’t change the world as we know it. There will still be hospitals, and doctors and insurance companies. Employers will still offer insurance to workers. Brain surgeons will still make a lot of money.
The ACA isn’t communism or socialism, and the “free” market will still be alive and kicking — perhaps more vigorously than it’s done in the past. In fact, some predict we’ll find that more choices, more “shopping” and more decisions aren’t really what we all want, after all.
Carol M. Ostrom: email@example.com or 206-464-2249. On Twitter @costrom