Health Insurance Exchanges

Transcript for: 
Health Insurance Exchanges

MS. DIANE REHM

10:06:55
Thanks for joining us. I'm Diane Rehm. On Oct. 1, open enrollment begins for uninsured Americans as part of the new health care law. Health insurance will be offered through small business or individual exchanges. Health advocacy groups have stepped up efforts to educate people about their options. We talk about those options and whether states will be ready to begin implementing the new programs.

MS. DIANE REHM

10:07:29
Joining me here in the studio: Ron Pollack of Families USA and Enroll America, Julie Rovner of NPR and Joseph Antos of the American Enterprise Institute. I invite you to be part of the program with your questions and comments. Join us, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or Twitter. Good morning, everybody. Thanks for being here.

MR. RON POLLACK

10:08:06
Good morning, Diane.

MS. JULIE ROVNER

10:08:06
Good morning.

MR. JOSEPH ANTOS

10:08:06
Good morning.

REHM

10:08:07
And, Julie, I'll start with you. Everybody's been talking about Oct. 1. What happens?

ROVNER

10:08:15
Well, on Oct. 1 is when enrollment begins for these new health exchanges. There will be one in every state. Some of them will be run by the states. Many of them will be run by the federal government. That should be invisible to most people. They will go online and it will say, welcome to your exchange, depending on what state you live in. But...

REHM

10:08:31
Suppose you don't go online.

ROVNER

10:08:35
Well, there will be people who -- to help you. There are a number of different types of people who can help you.

REHM

10:08:41
Where?

ROVNER

10:08:41
Believe me, you'll -- by Oct. 1, you will know there is an enormous effort that is just getting underway. It actually launches this weekend called Get Covered America.

REHM

10:08:53
OK.

ROVNER

10:08:53
There will be all kinds of publicity around that will tell people where they can go to get help if they are not online themselves.

REHM

10:09:03
And for the most part, most people are not gonna be affected?

ROVNER

10:09:08
That's right. And I think that's the most important thing to start with. We're really only talking about people -- not only people who don't have insurance, but people who don't have insurance and are not eligible for other things. Although you can -- if you go online to the exchange and you're eligible for Medicaid, for instance, it should then kick you over to how you enroll in the Medicaid program or if your children are eligible for the CHIP program, it should then -- it's something called no wrong door.

ROVNER

10:09:36
Wherever you show up to sign up, it will send you to what you are eligible for. But generally, these health exchanges are for people who have income over 100% of poverty, do not -- are not eligible for employer-provided insurance. So it's a fairly narrow window of people. It's about 30 million people who will be eligible. For the people who need it -- very important, these are people who are in the individual market now who buy they own insurance, people who don't have access to insurance at work, people who've not been able to get insurance because they have pre-existing health conditions.

REHM

10:10:09
OK.

ROVNER

10:10:09
Starting Jan. 1, insurers will no longer be able to discriminate against those people. So a lot of people have been waiting a very long time for this.

REHM

10:10:18
All right. So tell me about this GAO report, what it said and its relevance to Oct. 1.

ROVNER

10:10:29
Well, it said and we -- this is not a great surprise. It's said that states and the federal government are behind in getting ready.

REHM

10:10:35
They're not ready.

ROVNER

10:10:36
They're not ready. Now, remember one important thing, and we just saw this GAO report yesterday, the day before I forget...

REHM

10:10:43
Right.

ROVNER

10:10:43
...this was as of May -- takes a while to get these reports out -- and it said -- and the GAO was very, you know, careful in what it said. As of May, they were behind. They might catch up by October, but everybody's been worried about whether things will be ready on Oct. 1. And, of course, opponents are saying, look, they're not ready, and the administration is saying, we're gonna catch up.

ROVNER

10:11:05
I think everybody agrees that it's been a big push. There's a lot to do. There are probably gonna be glitches. But probably, I mean, on Oct. 1, I think everybody agrees there are gonna be exchanges to go to.

REHM

10:11:15
One more important fact and that is they have, from Oct. 1 to March 1...

POLLACK

10:11:23
March...

REHM

10:11:23
...to sign up.

POLLACK

10:11:24
March 31.

REHM

10:11:25
March 31. So they've got a good period of time.

ROVNER

10:11:29
And coverage doesn't begin until Jan. 1.

REHM

10:11:32
Jan. 1.

ROVNER

10:11:32
It's the enrollment that begins Oct. 1.

REHM

10:11:34
OK. So, Ron Pollack, why is there so much confusion about all this? And are you going to -- and Enroll America be able to help people understand?

POLLACK

10:11:51
Well, there are lots of organizations that are working to make sure that we actually move the discussion from a political discussion...

REHM

10:11:59
Right.

POLLACK

10:12:00
...to a personal discussion.

REHM

10:12:01
OK.

POLLACK

10:12:02
And, you know, despite all the rhetoric and the contentiousness, the vast majority of Americans, particularly those who can benefit from it, are unaware of it. You know, for example, of the folks who are uninsured who can get tax credit subsidies though the exchanges, over three out of four are unaware of it. 78 percent are unaware of it. There's even a higher percentage of those who are eligible for Medicaid who could get real big help though the Medicaid program who don't know about it.

POLLACK

10:12:36
83 percent don't know about it. So there are many organizations across the country. Enroll America is playing a key role in this, and there are many organizations that are diverse. They range from those that were strong supporters of the Affordable Care Act to even those that were opponents of different parts of the Affordable Care Act or even the entire thing. But they think it would be a good thing if we get everybody enrolled.

POLLACK

10:13:02
Now, mind you, we have 49 million people in the country who are uninsured today. All but those who are not legally in the country can now get some form of coverage. So it's close to 40 million. That's -- I'm not saying we're gonna see 40 million people enrolled in the coming year. But the overwhelming majority can get some help. And so it's really important that we help to explain in such a way that people understand how it will affect their lives, their family's lives. And as that happens, I think we're going to see, incrementally, a very large number of people get coverage.

REHM

10:13:46
All right. And to you, Joseph Antos. In the meantime, you still got members of Congress putting forth bills to try to overturn Obamacare. Is that going to continue? Or is there finally a realization that come Oct. 1, something is going to happen?

ANTOS

10:14:14
Plenty of bills are introduced in Congress every day. Most of them go nowhere. The, you know, this is something that Republicans in the House regularly do, not because they think that such legislation would actually be enacted but as a sign...

REHM

10:14:32
Just to make a point.

ANTOS

10:14:33
It's to make a point. But...

REHM

10:14:36
Thirty-seven times.

ANTOS

10:14:38
But as John Boehner said the day after the election, the ACA is the law of the land. OK? So the leader of the House is well aware of what's going on here. They're -- none of them are unconscious about this. They know that things are changing. What Boehner also meant, though, was that we're gonna live with the warts and the problems that were built into the law in the first place.

REHM

10:15:07
And what do you expect to happen on Oct. 1?

ANTOS

10:15:11
Well, I think that's a good question. There's gonna be a lot of variation. I think that...

REHM

10:15:18
Is variation another word for confusion?

ANTOS

10:15:21
Well, yeah, there will be confusion. I think the biggest part of the confusion will be that the target audience, those who are uninsured or those who buy their own coverage, they probably don't really understand health insurance world. It's a tough topic. Most of us don't, right?

REHM

10:15:37
It's hard. Yeah.

ANTOS

10:15:39
You know, what is a deductible, for example. It's hard to know what this means.

REHM

10:15:40
Right, right.

ANTOS

10:15:42
And so I -- what I -- my big concern is that we can raise consciousness, but what we really need is one-on-one conversations with people between the uninsured and people who actually understand what the products are. And we won't know what the products are probably until sometime in September. But even then, this is a tough topic for everybody, so I think that's really the challenge.

REHM

10:16:05
And, Julie, how is that going to be met, that challenge of basic education about what's going to be offered?

ROVNER

10:16:17
There is a lot of -- there is actually money in the law that is going out, and there are a number of people. They are called navigators. They're called assisters. There's still a role for brokers -- for insurance brokers to help people and to sit down indeed, one on one, explain their options. One of the things that the law does is it simplifies within the exchanges what can be offered.

ROVNER

10:16:37
We have, you know, standardized plans -- platinum, bronze, gold, silver -- and then there's a catastrophic plan for young people because there was a concern that young people didn't wanna have terribly comprehensive insurance. And, of course, you need young people in the pool to help...

REHM

10:16:51
Absolutely.

ROVNER

10:16:53
...you know, sort of equalize the cost. So there is a catastrophic plan for young people. But there's really only those, you know, what is it, four -- five different possibilities and, you know, you can have sort of cheaper premiums and then more expensive -- your premium can be less expensive and your deductibles can be higher. That's the tradeoff. And that -- so that's basically what you're looking at. They've standardized your options. That makes it a little bit simpler.

ROVNER

10:17:16
But there will be people available to help you, and that's what this sort of education is about, is matching up people who need insurance with people who can help explain it to you. But Joe's right. It's going to have to be one on one. I mean, it's...

REHM

10:17:29
Right.

ROVNER

10:17:29
There's gonna be portals. There's gonna be, you know, ways to -- things online that will simplify the application process. But yes, there is going to be a need for people to actually have -- sit down with a person who can help walk them through this.

REHM

10:17:41
I would think the great challenge that you face, Ron, in encouraging people to become part of this is to draw those young people into a mindset that even though they're healthy now, things do change.

POLLACK

10:18:04
I'm very encouraged of what I think the prospects are for getting young adults covered. Now, you're right to highlight that as an issue. Young adults are the age cohort that is most likely to be uninsured. Part of it is because some of them feel invincible and they won't need health care, but another part of it is they feel they can afford health coverage. They are gonna get disproportionate help, and we can go over how they're going to get that disproportionate help that will bring them into coverage.

REHM

10:18:38
Ron Pollack of Families USA. He's also board chair of Enroll America. Short break here. We'll deal with your questions when we come back.

REHM

10:20:05
And we have many questions, as you can imagine, on the Affordable Health Care Act, which will begin enrollment Oct. 1. And that enrollment will run until March 30. Ron Pollack, just before the break, you were talking about young people and why you believe that ultimately they will want to become part of the program.

POLLACK

10:20:37
The key to this, Diane, is that if you get coverage in these new exchanges, if you have income below 400 percent of poverty -- now, that means for family of four, that's $94,200. For an individual living alone, that's about $46,000. So it reaches pretty well into the middle class. Those -- you will get very significant tax credits subsidies in the thousands of dollars. Now, what's critical with respect to young adults is that these subsidies are going to be provided on a sliding scale. And what that means is the lower your income, the higher the subsidy you're going to receive.

REHM

10:21:21
OK. All of a sudden, what strikes me is: Are the educators being educated? Julie.

ROVNER

10:21:31
Well, one of the interesting findings -- the Kaiser Family Foundation does this monthly tracking poll. And they actually talked to -- sort of, I guess, oversampled young people this month. It just came out yesterday. And they found, I think, to their surprise that 70 percent of young people said that it's very important to have health insurance.

ROVNER

10:21:49
And, you know, everybody assumes that young people are not gonna be interested in having this insurance, that they'd rather spend their money on other things. And interestingly, two-thirds said that they worried about not being able to pay medical bills if they had a serious illness.

REHM

10:22:00
'Cause they've seen what's happened to perhaps their own parents.

ROVNER

10:22:04
Yeah. I mean, I think, you know, some of this information is kinda getting through. And we saw this in Massachusetts. Remember Massachusetts, it's kind of laboratory for this. They passed this requirement for people to have health insurance back in 2006. They had a very successful marketing campaign. They got the Red Sox involved. They reached out to young people. And they did get, you know, quite a number of young people to sign up.

ANTOS

10:22:25
And since these young people are in entry-level jobs, or they may not have a job yet, they will get the largest subsidies. They will get the disproportionate help. And that's why they are going to find it much more valuable because they won't have to pay as much out of pocket for those insurance premiums.

REHM

10:22:43
Julie, you didn't answer my other question about educating the educators. You know, you've got to have, in these one-on-one conversations, people who know the full range of options and are good communicators.

ROVNER

10:23:03
That's one of the things that's been going on. There has been money through the Affordable Care Act to train the trainers, if you will. And it's -- now, this is one of the places...

REHM

10:23:12
How many trainers have we got?

ROVNER

10:23:14
I don't know exactly the number of trainers, but I do know -- this is one of the places where it's going...

REHM

10:23:17
It's got to be in the thousands.

ROVNER

10:23:19
This is where it's going to be uneven, though, because in the states that are doing their own exchanges, there has been money. There's been a fair bit of money laid out for -- that states have been drawing on to train, as I said, these navigators and assisters. In states where the federal government is doing the exchanges, there has been less money for that...

REHM

10:23:39
I see.

ROVNER

10:23:39
...and less effort. So I think you're going to see -- this is where there maybe, yes, a differential that, you know, that when you go to the exchange itself, it will look, you know, the same. But the amount of backup that you have, I think, will be different in those states.

REHM

10:23:53
Joe Antos, you look a little skeptical.

ANTOS

10:23:57
Well, more than a little skeptical. The HHS standard for training for these people is that they have to know about the mechanics of signing somebody up for coverage, not what people really need to know, which is what do the options actually mean. So there is no training in that.

ANTOS

10:24:15
Now, ideally, the states for the people that they're responsible for will not follow HHS' guidance here. And they will, in fact, do the right thing, which is invest their own money, which they're gonna have to, in order to train their people about their specific options. But, in fact, all of these volunteer organizations that say we're gonna help, it's very unlikely that they're gonna have a consistent level of information to give to people, which I think is a big, big concern.

POLLACK

10:24:48
You know, Joe, I got to take a little issue here. We at Families USA are actually providing training in the District of Columbia for the folks who are going to be navigators. There is going to be a very systematic process of training people. And it's not just on process, it'll be on substance. We have had -- we've had half a dozen staff people crashing on putting together careful educational program so that the people who are going to be doing this work can be proficient.

POLLACK

10:25:18
Now, at one point, though, I wanna underscore that Julie said a moment ago. There are going to be differences from one state to the other. And Julie is absolutely correct in saying that those states where the federal government is running the exchanges, they have -- the federal government has less money for administering the exchanges in the states that it has responsibility for than the states have received.

REHM

10:25:42
Why is that?

POLLACK

10:25:43
Because Congress, you know, in its efforts to repeal and to obstruct, has said, in effect, we're not going provide appropriations.

REHM

10:25:51
We're not gonna give you any money.

POLLACK

10:25:53
And so as a result, in the 33 states where the federal government is going to be running the exchanges, the total amount of money for these navigators is $52 million. This includes states like Texas and Florida. In Connecticut alone, which is running its own exchange, they have $17 million. And I think you're about to have Rebecca Pearce from Maryland. I think Maryland has about $45 million. So it is uneven. Over time, this is going to change. But there are going to be people on the ground.

POLLACK

10:26:26
One other thing I should say is that there a lot of other groups that are going to be providing help. For example, community health centers. Right now, there are 4,000 outreach workers in community health centers across the country. The community health centers have now received $150 million so that there'd be more outreach workers. And so there are going to be total of 8,000 outreach workers. They will be adequately trained and they will be able to do this work.

REHM

10:26:53
All right. We've got lots of questions. Let's start in Lammi, Finland, with Pamela. Good morning to you.

PAMELA

10:27:05
Good morning. Thank you for taking my call.

REHM

10:27:07
Surely.

PAMELA

10:27:08
I'm calling, as you said, from Finland. I'm an American citizen, and I was -- that's my parrot in the background. You know, I put him completely opposite part of the house from me.

REHM

10:27:18
That's the first time we've had a parrot on the program.

PAMELA

10:27:21
Well, maybe he wants to do that, I don't know.

REHM

10:27:25
Sure.

PAMELA

10:27:25
Anyway, I know that you have lots of callers. But, as I've said, I was recently diagnosed with MS, and my husband and I were thinking about moving back to the United States. But now, because of all the health care conundrum, we can't decide if we should -- if it's better to stay in Finland where I have my health care -- I've been on the system with -- the Finnish health system for five years -- or is better to go back to the United States...

REHM

10:27:47
Wow.

PAMELA

10:27:47
...because I don't have previous coverage -- and I had previous coverage in the United States, but I haven't lived there in five years. So, you know, it lapsed.

REHM

10:27:53
Yeah. Right. Let's...

PAMELA

10:27:55
So what do you think is in the works for people like me?

REHM

10:27:59
Yeah. Julie, what's your response?

ROVNER

10:28:02
Well, actually you will, starting Jan. 1, be able to get coverage regardless of your MS. So that -- that's a, you know, something that you would not...

REHM

10:28:10
Because no pre-existing condition can deny you

ROVNER

10:28:11
Because -- right. No, you will not be able to be denied because -- or charged more...

REHM

10:28:16
Right.

ROVNER

10:28:16
...or because you're a woman, actually. That's another change. So those are all sort of changes.

REHM

10:28:20
But is she better off in Finland, or is she better off in the United States. That's the question.

ROVNER

10:28:26
That I can't say.

REHM

10:28:29
Ron Pollack.

POLLACK

10:28:30
So I can't say that I'm an expert on the Finland heath care system.

REHM

10:28:35
I'll bet the Finnish ambassador calls in this morning.

POLLACK

10:28:40
Right. But I will say that as the Affordable Care Act matures -- and it's gonna take a while. Any new program, it takes a while. You know, we had this expansion...

REHM

10:28:50
But wait a minute, Ron. I wanna get specifically to Pamela and her situation. Pamela, how good is your coverage in Finland?

PAMELA

10:29:04
Hundred percent.

POLLACK

10:29:06
She's not gonna get 100 percent...

REHM

10:29:09
All right.

POLLACK

10:29:09
...here in the United States. But we're going to -- we're gonna come closer and closer to having everyone covered.

REHM

10:29:15
OK.

POLLACK

10:29:15
But it's gonna take some time.

REHM

10:29:16
Go ahead, Joe.

ANTOS

10:29:17
You know, the first thing I'd think about is not the 100 percent, but the quality of care. I think that's the issue for you. And...

PAMELA

10:29:23
Right.

REHM

10:29:24
And Finland has superb quality of care.

ANTOS

10:29:26
Well, like every other place, including the United States, it depends on what part of the health system you enter, who your physician is, how you're connected to the specialist and so on. It's a very, very complicated issue.

REHM

10:29:40
Pamela, you clearly have some research of your own to do. I wish you all success. Let's go to Cape Cod, Mass. Good morning, Tanya.

TANYA

10:29:53
Good morning, Diane. It's such a pleasure to be on your show.

REHM

10:29:55
Thank you.

TANYA

10:29:55
I listen every day.

REHM

10:29:57
Good to have you.

TANYA

10:29:58
Listen, for families who live in Massachusetts, as you all know, we have MassHealth. My family luckily qualified, which was a savior last year. What's gonna happen to us being on MassHealth? Is that gonna change for us here in Massachusetts? Am I gonna start having to get onto the national plan?

REHM

10:30:17
Julie.

POLLACK

10:30:17
No -- yeah.

ROVNER

10:30:18
Oh, go ahead, Ron.

REHM

10:30:19
Go ahead, Ron.

POLLACK

10:30:20
The program in Massachusetts will continue. Actually, it'll be augmented somewhat, and one of the things that Massachusetts is doing is that when people get subsidies that will help them pay premiums, Massachusetts will actually provide a supplement to make sure that that subsidy is even larger. So Massachusetts is building on what it already has, and now that the -- national, we're gonna see this nationwide, Massachusetts is building on that and is improving further what Massachusetts has already on.

REHM

10:30:56
OK. But does she have to switch from Massachusetts to the national plan, Julie?

ROVNER

10:31:04
No. I'm -- no.

POLLACK

10:31:06
No.

REHM

10:31:06
She stays on the...

ROVNER

10:31:07
Yes, yes.

REHM

10:31:08
OK. Does that answer it, Tanya? I guess she...

TANYA

10:31:13
It did. And one more follow-up. Next year -- because I'm a realtor, I change my income every year. Should I not qualify for MassHealth next year? Would there be a program for me?

ANTOS

10:31:28
Well, of course, there is, as Ron said, there is this subsidy program through the exchange in the federal program, and that depends on your income. So, you know, once again, you have to find out the specifics...

REHM

10:31:43
OK.

ANTOS

10:31:43
...and that applies equally in terms of the subsidy, irrespective of what state you're in. Except in Massachusetts, it would provide a supplement.

POLLACK

10:31:48
Well, but...

ANTOS

10:31:50
Massachusetts may have different standards.

REHM

10:31:52
All right. Let's go to Athens, Ohio. Rebecca, good morning.

REBECCA

10:31:59
Hi.

REHM

10:31:59
Hi.

REBECCA

10:32:01
My question is -- actually, we -- my husband and I are self-employed professionals, and we have three children, one of which was born with multiple health issues. This was over five years ago. You know, in the past, his health insurance was denied before this health care law passed. We were not able to get him insurance at all based on his pre-existing conditions. Once the health care law passed and incorporated children, they couldn't deny him, but they offered us a premium plan for him, which cost $1,200 a month, just for him.

REBECCA

10:32:41
That's more than our mortgage. The plan they offered for my two daughters and myself is less than one-third of what they offered for him. They denied my husband altogether. As a result of that, we are no longer self-employed. I have now a job with a company that offers health insurance in order to cut that cost 'cause we can't afford $1,200 a month. You know, we've never asked for it to be free, but that seems like a really outrageous price.

REBECCA

10:33:10
I'm concerned for other people like us who are self-employed. Now going into this system, are they gonna be offered health insurance at some outrageous cost and then, because they're offered this health insurance, excluded from programs run by the state that would offer them insurance?

REHM

10:33:29
All right. Rebecca, let's see if we can address your questions. You're listening to "The Diane Rehm Show." Julie.

ROVNER

10:33:39
You know, this was -- you know, when the health law first went into effect, there was an immediate ban on excluding children who had pre-existing conditions. But as the caller mentioned, there were a lot of cases where they were charged very high premiums even though they could no longer be excluded. That's what's going to end on Jan. 1, is the idea of charging -- you can not only not exclude people with pre-existing conditions. You can't charge them more.

ROVNER

10:34:05
Everybody's going to be in the same pool. Everybody's going to be charged the same. That's what's leading to what we keep hearing about, this rate shock, because everybody is going to be in the same pool. And so people with pre-existing conditions who -- will be more expensive, and the concern is that the healthy people are gonna have to pay more to make up for the -- right.

REHM

10:34:23
Well, of course. Joseph.

ANTOS

10:34:25
But, you know, the other part of this is not specific to this family. But the other part of this is that they've also changed the rules about age rating. In most states, older people -- say over 55 or so -- paid eight times the amount that people, say, 25 would pay. Now it's down to 3-to-1. What that means is that the average premium for younger people will be much higher than it was before, and for older people, much lower than it was before relative to the coverage they used to have.

ANTOS

10:35:05
Now, the other problem is that the coverage is also richer. So that means that the average cost of the premium will go up for everybody. It's a very complicated story, but what it boils down to is, once again, if you don't have somebody guiding you with your specific information, it's hopeless.

REHM

10:35:21
All right. To Michael in Kalamazoo, Mich. Good morning.

MICHAEL

10:35:27
Good morning. How are you all?

REHM

10:35:29
Fine. Thank you. Go right ahead.

MICHAEL

10:35:30
Thank you very much. I'm the coordinator of benefits for a very small nonprofit. We have four full-time employees. And what I'd like to know is where do we go or what path do we follow for information or guidance through the affordable health care system?

POLLACK

10:35:48
Well, it's going to be different depending on what state you're in. So...

REHM

10:35:52
He's in Kalamazoo, Mich.

POLLACK

10:35:55
Yeah. So Michigan is one of the states where the federal government will be running the exchange. And the key source of information will be a site called healthcare.gov. That's currently online. But there's gonna be a whole lot more information provided through healthcare.gov, and there'll be a 1-800 number. That's the way you're going to get much of your information. I just wanna add one thing to what Joe was saying before in response to Rebecca's question.

POLLACK

10:36:29
You know, it is true that when you reduce the disparity in premiums between those who are older and those who are younger, it does mean that for younger people, the premiums come up. But that's only half the story. The other half of the story is that since these young people tend to be in lower paid jobs or may not have a job, they're going to qualify for the largest subsidies.

POLLACK

10:36:55
And ultimately, what a young adult is going to be concerned about is not what's the overall premium. It's gonna be what do I have to pay out of pocket? And with those subsides, the overwhelming proportion of young adults will be paying a whole lot less.

REHM

10:37:10
All right. We're gonna take a short break, and we've got lots of callers waiting. I hope you'll stay with us. We'll be right back.

REHM

10:40:05
And as we talk about the new Affordable Health Care Act, joining us now by phone, Rebecca Pearce. She is executive director of the Maryland Health Connection and that is Maryland's state-based exchange. Good morning, Maryland.

MS. REBECCA PEARCE

10:40:28
Good morning. Thank you for having me.

REHM

10:40:29
Good to have you with us. Forgive me, Rebecca. Tell me why Maryland decided to set up a state health insurance exchange and not go with the federal option.

PEARCE

10:40:46
Well, Maryland has always been committed to health care reform, and I think the Affordable Care Act gave us a new set of tools to be able to take that further. So on the day after the Affordable Care Act was signed, Gov. O'Malley signed an executive order to put in place a committee to determine exactly what pieces of health care reform we would move forward with in the state.

PEARCE

10:41:07
And the state determined, stakeholders included, determined that the exchanges is an important place to be able to move forward for us, to be able to implement and exchange this right for all of Maryland and Marylanders as opposed to something that that the federal government would set up for all of the state.

REHM

10:41:24
And tell us briefly just what your own exchange is going to look like. What choices people will have?

PEARCE

10:41:35
Sure. So Maryland Health Connection currently will have about 13 medical and dental carriers offering up to 300 medical and dental plans. We'll also have nine managed care organizations offering Medicaid plans. People will be able to see quality data for each of their plans, and they're also gonna be able to pare down their specific choices based on the provider that they're interested in using.

REHM

10:41:59
And how much money has been allocated to education, to provide guidance for individuals who are trying to sort out the option?

PEARCE

10:42:14
So we are actually still in our procurement process for our training vendors, so I can't give you the actual number. But what I can tell you is that we're anticipating training over 5,000 people in the state. We have about 2,000 to 3,000 brokers that we're gonna be working with, and they'll be getting about eight to 10 hours of training from us, all the way to navigators who are gonna be getting about 120 hours worth of training from us. So across the board -- it will range across the board, but we anticipate about 5,000 people.

REHM

10:42:48
You know, what strikes me is that already this morning, we've heard from a number of different people with different kinds of problems. Will those trainers be able to train people to handle that broad variety of issues and personal problems?

PEARCE

10:43:15
Well, I certainly -- I mean, that's our goal. We certainly have -- we're going to be doing scenario-based training, so that people understand specific scenarios for people and are able to answer those questions. We anticipate that there will be some people that will be training to about 80 percent and be able to answer about 80 percent of the questions. And then we'll have to be training a next set of people to be able to answer every single question there is.

REHM

10:43:39
I see. What snags have you run into along the way?

PEARCE

10:43:45
Well, timing, of course. We're setting up something that's brand new in a short period of time.

REHM

10:43:51
Sure.

PEARCE

10:43:52
So it's really a timing issue more than anything else.

REHM

10:43:54
Will you be ready on Oct. 1?

PEARCE

10:43:56
Of course. Yes, Maryland will absolutely be ready.

REHM

10:44:01
Rebecca Pearce. She is executive director of the Maryland Health Connection and that is Maryland's state-based exchange. Thanks for joining us.

PEARCE

10:44:14
No problem. Thank you.

REHM

10:44:15
All right. And here's an email from Josh in Lake Wales, Fla. He says, "I look forward to having the opportunity to purchase health insurance. My problem is the unknown cost. Will coverage be $250, or will it be $1,000? I need to know. And are there price ranges available? A ballpark figure would be great." Julie.

ROVNER

10:44:48
Of course. This has been the question since the day the law was passed.

REHM

10:44:51
Sure. Of course.

ROVNER

10:44:52
And it's getting close. And, of course, you know, everybody's frustrated because we still don't know. But so far, we have nine states who have reported. And there's a new analysis from Avalere Health -- they crunch a lot of numbers. And they're looking at the second lowest cost silver plan because that's what the subsidies will be based on. And they have found a range so far of that second lowest cost silver plan, from $205 a month to $433 a month.

REHM

10:45:18
OK.

ROVNER

10:45:19
So that's basically the range that we're looking at. Now, this can, you know, can very dramatically -- it depends on the area of -- not just the area of the country, it depends on the area of the state. It depends how much competition there it's gonna be. So, you know, it could, you know, things depend on where you live. It depends not just on what's gonna happen in Florida but what part of Florida. But again, that seems to be the range that we're looking at, you know, sort of between $200 and $400 for that kind of mid-level plan.

REHM

10:45:45
All right.

ROVNER

10:45:46
Again, that's a pretty -- as Joe pointed out, that's a pretty comprehensive plan. It's got pretty -- it's got more benefits. People in the individual market have tended to buy plans with pretty spare benefits because, again, this has been a not very functional market. It's been where people go who really tended to need insurance, so they tended to be sicker, so they tended to have sort of lower premiums but very, very high deductibles and not a lot of benefits.

ROVNER

10:46:10
So these are more benefits than people in this market are used to. On the other hand, there probably gonna have higher premiums than people in this market used to.

REHM

10:46:17
All right. To New Orleans, La. Good morning, Jason.

JASON

10:46:24
Good morning. This is Dr. (word?), a physician in Louisiana. My question is, I know you have mentioned increasing access, especially for low income as well as poor people were mostly my patients. In the state of Louisiana where they are not expanding Medicaid, what -- which I have to say, I believe, is unethical, but what options do we have in our state under the Affordable Care Act for those low-income patients that I see?

JASON

10:46:55
What I have noticed is that they have less options now with the Affordable Care Act because at least before we were getting federal moneys for uncompensated care.

POLLACK

10:47:07
So what's gonna happen with respect to the Medicaid program, which is the Safety Net program, excuse me, will differ from one state to the other. So in half the states, the states are opting into expanding the Medicaid programming...

REHM

10:47:27
But Louisiana is not.

POLLACK

10:47:29
He is in Louisiana, and the governor, Gov. Jindal, has said he's not going to do it. What that means is that the people who need help the most, those below the poverty level, they are not going to get help.

REHM

10:47:44
This is crazy.

POLLACK

10:47:46
It is crazy. It is crazy, but increasingly, states are opting into this. We got now half the states. We've got eight Republican governors, who are strong opponents of the Affordable Care Act, who have said, we're going to expand the Medicaid program. And these are very conservative governors who rushed to the courthouse door to challenge the constitutionality of the Affordable Care Act. You've got governors in states like Arizona, Ohio, New Jersey, New Mexico...

REHM

10:48:18
But not Louisiana.

POLLACK

10:48:19
But not Louisiana.

REHM

10:48:20
Joe Antos.

ANTOS

10:48:21
So there has been a law on the books for at least a decade until -- I can't remember what is...

ROVNER

10:48:27
Oh. It's in 1986.

ANTOS

10:48:28
1986 that says that public hospitals have to accept all patients, no exceptions. So, in fact, what we're really talking about is payment. We're not talking about access to care. I think the doctor really got those two things mixed up. He's really talking -- we're really talking about payment.

REHM

10:48:49
He's a physician perhaps not operating in a hospital but maybe on his own.

ANTOS

10:48:59
Right. It's entirely possible.

REHM

10:49:01
Yeah.

ANTOS

10:49:01
And so he is concerned about getting paid for the services he provide.

REHM

10:49:04
Sure.

ANTOS

10:49:05
Then that's a legitimate thing. But the fact is that it's not that his patients have no place to turn. Now, that's...

POLLACK

10:49:14
Wait a minute. I think it's very important to...

ANTOS

10:49:16
Wait, wait, wait, wait. May I finish statement?

POLLACK

10:49:18
Sure.

REHM

10:49:18
All right. Finish.

ANTOS

10:49:20
That doesn't mean that eventually Louisiana and other states -- Ohio is one of the great one -- aren't going to...

REHM

10:49:31
Eventually.

ANTOS

10:49:32
...recognize. Yeah. This is a political matter. In the case of Louisiana...

REHM

10:49:36
It's a humane matter. It's not just a political matter.

ANTOS

10:49:41
Of course, it's a humane matter, but there is -- Louisiana has a particularly difficult fiscal problem. They were effectively bankrupt as a state. And so, you know, we're not discussion their general bankruptcy, but decisions have to be made. If the citizens of Louisiana wanted it to change, it would change.

POLLACK

10:50:06
So I wanna just make one, you know, clarify one thing. Joe properly cited this so-called EMTALA statute. But the way it's characterized is if you need help, you go to a hospital, you gonna get care. Well, that's not quite true. The EMTALA statute is very limited. What it says is if you are at an immediate risk of life or limb, then you are guaranteed to get coverage in the hospital.

REHM

10:50:34
But if you're sick with a flu or pneumonia?

POLLACK

10:50:36
But if you got something that is not an immediate risk of life or limb, you don't have the right to get hospital care.

REHM

10:50:42
Julie.

ROVNER

10:50:42
Well, if you have cancer -- let's go back. EMTALA stands for Emergency Medical Treatment and Active Labor. Those were the only things that are covered by that. So one of the big problems, if you show up at the emergency room and you have cancer, you don't get treatment. You have to literally be at death's door or in active labor in order to be covered by EMTALA. So what's this doctor in Louisiana is saying, I have patients who come to me and need care.

ROVNER

10:51:06
They are not going to be eligible unless they're over the quirk of this because of what the Supreme Court did last year in making this Medicaid expansion optional. The law was written so that the expansion would go up to 100 percent, actually 233 percent, and everybody else would be picked up by the subsidies and exchanges.

REHM

10:51:24
Right.

ROVNER

10:51:25
Well, no one over 100 -- no one under 100 percent is allowed into the exchanges. So in states like -- many states like Louisiana, you can't qualify for Medicaid if you're an adult if you have income over some tiny percentage of poverty.

REHM

10:51:35
So what's gonna happen to this people?

ROVNER

10:51:38
None -- these people are not eligible for anything.

ANTOS

10:51:41
So you have to ask why did they put that cut off there. If the exchanges were good for somebody at 134 percent of poverty, why wasn't it good for somebody at 133?

POLLACK

10:51:51
Well, remember, when the Affordable Care Act passed, we assumed every state, because it was a requirement, was going to implement the Medicaid expansion to 138 percent. And as Julie mentioned, last June, when the Supreme Court ruled on the Affordable Care Act, while it held that the act is constitutional, it changed this Medicaid expansion from a mandate to an option.

POLLACK

10:52:18
And so as a result, the people who need health care the most and are least capable of paying for it are gonna be left out in the cold unless the state decides to implement the expansion.

REHM

10:52:28
All right. Let's go to Cincinnati, Ohio. Good morning, Randall.

RANDALL

10:52:34
Good morning. Thank you for taking my call.

REHM

10:52:36
Sure.

RANDALL

10:52:38
So I actually fit right into what you guys are talking about. I am 25, turning 26 in October. And luckily, I'm fortunate enough to be under my mother's health insurance. But, you know, after I turn 26, I will not. My question is, I do not fit into the category that I make. You know, I think it was -- the statistic was 400 percent times the poverty level. So my question is what options are there for me to get health insurance when I can't even afford, you know, to pay for it nor do I qualify for these new mandates?

REHM

10:53:18
I gather you make a salary in the 20,000.

RANDALL

10:53:24
On good years. Yes, ma'am.

REHM

10:53:26
On good years.

POLLACK

10:53:26
So he actually will qualify 'cause an individual living alone -- 400 percent of poverty is approximately $46,000. And so since he is below 400 percent of the federal poverty level, he will be eligible for a tax credit subsidy that's worth thousands of dollars.

ROVNER

10:53:47
400 percent is where the subsidies stop. That's -- it's -- the people who are eligible for subsidies -- anybody can get into the exchange if they make poverty or above. Four hundred percent is where the subsidies stop. You can get into the exchange no matter how much you make, you just won't get a subsidy if you get -- if you earn more than 400 percent of poverty.

REHM

10:54:03
And you're listening to "The Diane Rehm Show." But he -- Randall says he makes in the 20s in a good year. Now, how much is he going to get back in tax credits?

ANTOS

10:54:20
Well, I think a better way to answer this is not how much is he gonna get back in tax credits but what's the maximum that he would have to pay.

ROVNER

10:54:27
Yeah...

ANTOS

10:54:28
We know that, and the answer is at -- in the $20,000 range, it's probably around 5 percent. It's probably about $1,000.

POLLACK

10:54:35
And, by the way, these tax credit subsidies, it's not that you're going to get them when you file your IRS forms the following April 15. What happens is you sign up for a plan, and as premiums fall due, the IRS will pay these subsidies to your insurance company...

REHM

10:54:53
OK.

POLLACK

10:54:54
...so you don't have money out of pocket for that.

REHM

10:54:56
All right. So...

ROVNER

10:54:56
It's like...

REHM

10:54:57
...Randall, how does that sound to you?

RANDALL

10:55:00
Oh, thank you all so much for helping my education in this matter. I really appreciate it.

REHM

10:55:04
OK. Thanks for calling. What do you wanna say, Julie?

ROVNER

10:55:08
It's like an automatic discount. I mean, basically...

REHM

10:55:09
Yeah.

ROVNER

10:55:10
...when you go to sign up, it's sort of -- it's a discount off your premium as you sign up.

REHM

10:55:13
One last question from San Antonio, Texas. Tom, you're on the air.

TOM

10:55:19
Hi. Thank you. I love your show, Diane.

REHM

10:55:21
Thank you.

TOM

10:55:22
I have a weird situation. I was work -- I was making about close to $5,000 a month, and so I was on the insurance by myself. Our company paid for most of my insurance cost, so I only paid about $30 a week. Now, I decided to get my family on, and now I'm paying almost about $250 a week for my insurance. All of the sudden, my workload gets cut back and I lose about $2,500 a month.

TOM

10:55:52
Now, I could barely pay my rent and my bills, and I can no longer back out of my insurance because I have already signed on with the company. Is there anything that I could do about that situation?

POLLACK

10:56:05
If you have an offer through your employment of health insurance, that's what you -- you're going to wind up...

REHM

10:56:13
You're stuck with.

POLLACK

10:56:15
You are stuck with it turns out that it's too expensive for you as an individual, which means if you're spending more than 9.5 percent of your income on premiums...

REHM

10:56:25
I see.

POLLACK

10:56:26
...then you can get out of employer-sponsored insurance and go into the exchange and get coverage. But it's only in that limited circumstance.

REHM

10:56:34
Joe.

ANTOS

10:56:35
But here is the problem. The way HHS interpreted the law -- this does not apply to his family. And he mentioned that he added his family.

REHM

10:56:42
Right.

ANTOS

10:56:43
So, in fact, there is this disconnect, which is going to be very disruptive to people like him.

REHM

10:56:50
You know what, in the next few months, I sure wanna have you all back and talk about how this is moving along and talk about whether they've been able to straighten out these stupid curly cues that don't work for anybody. Ron Pollack, Julie Rovner, Joseph Antos, thank you all so much.

POLLACK

10:57:17
Thanks for having us.

ANTOS

10:57:17
Thank you.

ROVNER

10:57:18
You're welcome.

REHM

10:57:18
And thanks for listening all. I'm Diane Rehm.
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